Saturday, April 10, 1999

Illustration by Bryant Fukutomi, Star-Bulletin

After years of shrinking budgets and neglect
from the UH administration, the School
of Public Health is barely breathing.
It may lose its accreditation in June
unless heroic measures are
undertaken to revive it.

By Shirley B. Gerum
Special to the Star-Bulletin

How can the workers in an underground mine determine if the oxygen supply is diminishing imperceptibly? They watch for the canary to die. When there is not enough oxygen to support the life of a small bird's body, it is not safe for humans.

At extremes, this is the way a community gauges the effectiveness of its public health efforts in prevention, education and intervention. If systems are in place with personnel trained to monitor, recognize and remediate problems, interventions taking place around the clock are hardly fodder for the evening newspaper. You'd never see the headline, "No one contracted dengue fever today."

It's when systems aren't in place, with personnel trained to recognize the problems and the actions necessary for correction, that we begin to lose our battles.

The University of Hawaii School of Public Health could be perceived as the canary for the health of our state. Graduates from the school's maternal/child health, epidemiology, environmental health, nutrition, gerontology, health administration, and community health development/education programs are part of the work force now protecting Hawaii's population.

They can be found preparing people for disasters and biological terrorism; administrating at island hospitals, clinics, community health centers and nursing homes; overseeing air and water quality; and training Hawaii epidemiologists for the outbreak we hope never materializes.

This continuity has been ongoing since the school turned out its first graduates 39 years ago. As they reach retirement, though, what next? What happens if there is no School of Public Health to train those who quietly work to maintain the health of our islands?

If those making administrative decisions on the future of the school don't fully "get it," it's understandable. It took exposure to the core of required classes -- in epidemiology, environmental health concerns, human growth and development, informal health education, etc. -- for me to get it, to understand the scope of what an ounce of prevention means in terms of a pound of human life.

I went from not getting it at all to thinking that all public administrators should be required to complete part of their training at the School of Public Health.

Had our elected officials, who have proposed going from twice-weekly to once-a-week trash collection, taken Dr. Lee Goff's public health class, they would realize that collection days must interrupt the life cycles of insects breeding in trash cans. These insects rapidly reproduce themselves and the infectious diseases they carry.

How does it affect a community when it loses the systems in place to prevent problems?

For a pregnant mother who does not get the proper education -- for example, on nutrition for her developing keiki -- it could determine whether that child lands at UH or in Oahu Prison 20 years down the line.

It could determine how much businesses save in workers' compensation insurance when occupational safety measures and return-to-work modifications are in place.

Pristine beaches aid economy

For the visitor industry, it could determined whether pristine shores have "Beach Closed: Water Unsafe" signs to greet conventioneers or film-location scouts.

Many are not aware that such scouts are looking for island streams with the least reports of leptospirosis. They set out to find the safest work areas for their highly paid actors and film crew.

They seek out Hawaii because they can drink the water, speak the language, use U.S. currency and not worry about malaria, cholera and a whole slew of tropical diseases they cannot pronounce. Illness is extremely expensive when filming so far from home.

No visitor destination wants the media attention that Fiji experienced a few weeks ago. Tabloid headlines screamed news of "Tom Hanks' Battle with Deadly Bacteria" while he was filming in Fiji. Had they flown Hanks to a medical center in Hawaii instead of St. John's Hospital in Santa Monica, the story would not have focused on the agonizing pain that the actor suffered while "baffled" doctors tried to figure out what was wrong.

In general, doctors and microbiology lab personnel in Hawaii are more familiar with tropical diseases than their peers in California. Public health students sit with researchers and physicians from all over the world in UH tropical medicine classes.

It's not that Hawaii has escaped association with high-profile health disasters. TV viewers around the world can catch frequent re-runs of "Understanding Bacteria" on The Learning Channel or its web site, and see the graphics-enhanced re-enactment of the infamous 1994 Honolulu-bound flight with one ill passenger who was later diagnosed with active tuberculosis. Fictional re-runs of a "One West Waikiki" episode, which illustrate how this might have played out in an ill-prepared Hawaii, are still broadcast on the USA Network.

Island residents need go no further than their own newspaper headlines to see how health disasters could occur in the islands when staff are untrained to watch for signs of trouble: unlabeled lab samples infected with dengue fever arriving in Hawaii labs, hepatitis from catered food at Washington Place, HIV-infected blood samples from Guam leaking onto baggage handlers, the preventable food poisoning at a marathon carbo-loading party. Epidemiology professor Al Katz brings up experiences like these in his UH lectures.

Not everyone realizes that students in the master's in public health program in the school are required to do field work in their specialties within our islands or the Pacific community.

This not only provides free short-term labor in a down-sized economy, but valuable hands-on experience and training for students to work with professionals in the field. Our own state health director, Bruce Anderson, garnered experience this way.

It would be a loss to Hawaii and the Pacific if the UH School of Public Health closed and Hawaii residents had to obtain their health training on the mainland, far from the very people and agencies they seek to serve. Booming mainland economies would receive free internships and cash-strapped Hawaii would lose an amazing number of free hands.

Knowledge of isles is priceless

Another major thread that would be lost is Hawaii's connection with long-term public health professors, who are familiar with previous epidemics and environmental mishaps. The thought of losing this bank of knowledge is frightening.

In the course of researching a book on Hawaii's epidemics and the administrative responses to them, I have become more aware of how our island leaders must have knowledge of Hawaii's long-term decisions -- good, bad and fatal -- and how they have far-reaching consequences:

Queen Regent Kinau will be remembered for taking the earliest documented public health measure in Hawaii in 1836 during the reign of Kamehameha III. She directed Honolulu Harbor pilots to determine if smallpox or other pestilent diseases were aboard ships entering the harbor. If cases were present, Kinau demanded that a yellow flag be raised and the ship quarantined, long before scientific proof of how diseases were transmitted. Following her initiative, a group of concerned individuals pressured Kamehameha III to create a board of health. This was accomplished in 1850, 10 years after the queen regent's death. It was the first board of health in what is now the United States.

On the other hand, in 1826, the captain of the Wellington will be remembered for his decision that resulted in larvae from the ship's water hold being introduced into Hawaii and bringing the first mosquitoes to the islands.

Then there was the board of health member who lifted the quarantine for loading and unloading of boats, shore leave, etc. in 1899, after it was determined that no additional cases of bubonic plague had been reported. In retrospect this was a serious error, Goff says, as the incubation period for the disease is six to eight days, and only seven days had elapsed.

A black eye for 'Health State'

Recently, Governor Cayetano admits to finally "getting it" after golfing with a visiting Asian head of state, who was scheduled for an annual physical at Stanford. Cayetano rattled off Hawaii's competitive advantages that mirror those that public health folks speak of -- a multi-ethnic, multi-cultural society where people from all over the world feel comfortable; a spectacular environment, year-round tropical climate and a high quality of life; and good hospitals and advanced telecommunications infrastructure. At some point, all of these pieces of the puzzle will come together.

But one of the most important pieces of the puzzle could be lost, if the UH School Public Health loses its accreditation because of a lack of funding and support from the UH administration. How can Hawaii be the "Health State" if it cannot even sustain a School of Public Health?

To be sure, health experts in Hawaii and around the world will have their eyes focused on the canary in the Biomedical Sciences building on the UH-Manoa campus. Its survival could tell us a lot about our own future.

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Shirley Gerum

Shirley B. Gerum has a master's in environmental
health from the School of Public Health and teaches environmental
science and ethnobotany at Chaminade University.