While attempting to gauge California's readiness to deal with a bioterrorism attack, an independent oversight agency has found that the state's basic public health system is so disjointed and neglected that residents are just as seriously threatened by an epidemic of commonplace diseases such as the flu.
In a report scheduled for release next month, the state's Little Hoover Commission describes a 30-year erosion of a health system that has left Californians vulnerable to disease outbreaks, new germ strains, hospital-acquired infections and widespread poisoning.
Government officials and private experts interviewed by the independent agency over the past year testified that the network for tracking disease and treating mass illness or injury has "deteriorated to the point that lives are at risk," according to the draft report, a copy of which was obtained by The Times. That deterioration, it said, partly reflects a shortage of money, but also is the result of unfocused state agencies and a lack of centralized leadership in the health-care system.
Some of the commission's findings reflect long-standing concerns about the state's public health system, but the new warnings include a call for creation of a state public health department and come at a particularly delicate time, as California is grappling with a huge budget shortfall and a weak economy.
A deputy to Gov. Gray Davis said administration officials had not yet received the report, but that California's public health system has improved over the past year as it has attempted to brace for the possibility of terrorist attacks.
The report, scheduled for public release in early April, will be considered by the 13-member commission next week and could be amended. Among its conclusions:
* A key agency -- the Department of Health Services -- focuses more on insuring poor people than guarding the population against contamination and infection.
* California's laboratories for analyzing disease are too few and outdated. Sophisticated analyses must be done on the East Coast.
* No single government agency is responsible for making sure hospitals can handle a surge in patients triggered by an epidemic or attack.
* State authorities learn of only roughly 20% of the diseases and conditions that doctors and nurses must legally report, in part because the reporting system is slow, cumbersome and paper-based.
* In contrast to the governor and other state officials who believe California is well-prepared for health emergencies, county officials and private experts on the front line of disease control are far more pessimistic.
"Early in this study, the Commission was confronted by conflicting testimony: State leaders expressed confidence in a system that local leaders and private partners described as severely broken and not improving," according to the report.
The 41-year-old agency -- officially known as the Commission on California State Government Organization and Economy, but informally referred to as the Little Hoover Commission -- investigates state government and recommends improvements. Its staff is overseen by a panel of lawmakers and citizen appointees of the governor and Legislature.
The commission investigated California's homeland defense readiness after the Sept. 11 terrorist attacks and concluded in a January 2002 report that the public health system was by far California's weakest link. The commission then launched a more detailed study of the state's disease-control network.
In six public meetings between June and November 2002, the commission took testimony and advice from dozens of government officials, university researchers, medical industry representatives and security experts. The commission staff, with advice from the commissioners, drafted the report and its recommendations.
The researchers found a system ill-suited to deal with drug-resistant tuberculosis, contaminated juice and influenza epidemics, let alone an intentional release of anthrax or smallpox.
"The public health infrastructure is in poor repair," states the draft report, "providing less protection than it should against everyday threats, and unprepared to protect us against what is possible."
One contributing problem, according to the researchers, is the time and expense of administering California's Medi-Cal program, the state's health insurance program for the poor. Ninety percent of the Department of Health Services' budget is dedicated to Medi-Cal, and that job overwhelms officials who otherwise might be able to spend more energy responding to health problems, the report states.
Davis administration officials said they had not yet seen the Little Hoover Commission report. But they defended their efforts to strengthen the state's public health system, particularly in response to the threat of terrorism.
"There's no question that the state is better prepared than we were a year ago and progress is being made," said Daniel Zingale, the governor's deputy chief of staff.
Although the commission report focuses on areas far beyond the threat of terrorism, some state officials say that threat actually has helped the state hone its health systems.
For one thing, they say, California has received more than $100 million from the federal government to bolster public health since the Sept. 11 attacks. Los Angeles County received more than one-fourth of that money, which was intended to thwart the risks of terrorist attacks, but which serves other purposes as well.
"There have been hundreds of additional hires at the city and county level using these funds," said Kevin Reilly, a Department of Health Services deputy director in charge of the agency's prevention programs.
The newly hired doctors, nurses and public health advisors can help people with childhood obesity and flu prevention, he said, besides training them to use radiation pills or build an emergency kit.
"It's a new challenge," said Reilly of bioterrorism, "but the basic approaches to public health are going to be the same."
In Los Angeles and elsewhere, however, health officials have complained that the federal money was not enough to cover new responsibilities handed out to local agencies. Among other things, those agencies were given responsibility for smallpox vaccinations, which are expensive to administer.
Health as a Priority
In confronting California's many public health issues, the Little Hoover Commission report recommends that the governor and Legislature make public health protection as high a priority as fire and police services. It suggests creating a corps of deputized, uniformed officers who track and treat illness. And it recommends that California install a Web-based, confidential disease-reporting system.
The commission also urges the governor and Legislature to carve out a new Department of Public Health from existing agencies -- a move that it says would not require more money but merely a realignment of existing programs -- and appoint a physician to the new position of state surgeon general. Such a post, the commission argues, would strengthen the critical link between the state and the 61 county and city health officers who are expected to respond first to a disease outbreak or bioterrorist attack.
But Zingale, Davis' deputy, warned against moving too quickly to expand government programs in response to the health concerns. Davis and the rest of the state's elected leadership are grappling with a budget shortfall of as much as $35 billion between now and the spring of 2004.
"We would consider any ideas for being yet better prepared," Zingale said, "but you can't automatically assume that a new or expanded bureaucracy is the best response to every threat."
Many other states have a top health officer. For 100 years, so did California. But that post, as well as the Department of Public Health and Board of Health, was eliminated in 1970. The duties of disease tracking and prevention in California were scattered to the Department of Health Services and at least three other agencies.
One of dozens of experts interviewed by the commission argued that California's system has become "de-professionalized" and too decentralized.
"We need to have something like we had in those days," said Lester Breslow, the former dean of the School of Public Health at UCLA and one of the last directors of the California Department of Public Health before its elimination. "Namely, a state Board of Health, which is an independent body that can base its determinations on scientific and expert information and advice."
Reilly, the Department of Health Services deputy director, disagreed. Decentralizing certain services has advantages, he said, because it allows each county to target local health problems such as smoking or sexually transmitted diseases -- which are far more serious problems in some parts of the state than others.
"There are a lot of perspectives on better ways to do things," Reilly said. "We're not a perfect system yet. But we have a very strong system. We recognize areas for improvement and we're working on those areas."
Assemblyman Keith Richman (R-Northridge) testified before the commission as it studied the state's health system and already has introduced legislation intended to speed up California's preparations for a possible bioterrorism attack. His bill, AB 206, would create a special commission to make plans for public health crises, and it also proposes new rules for handling public health emergencies, including those that would govern the use of quarantines.
A physician with a master's degree in public health, Richman carried a similar bill last year, but it was killed in a legislative committee.
"I felt last year that many people in both the Legislature and administration were sticking their heads in the sand," he said. "I was and continue to be very concerned about our lack of preparedness. Not only are we not prepared for a public health emergency or a bioterrorist attack, we're not even prepared for a bad flu season."