A bill making it’s way through the state legislature would allow for changes to the way public health is organized in North Carolina. County commissioners argue it would streamline county government and save dollars. Public health practitioners worry the bill would undermine the ability of officials and workers at the local level to protect the public’s health.

By Rose Hoban

Don Yousey remembers the day almost two decades ago when he heard a local hog farmer had run a pipe from an overflowing waste lagoon on his farm into the bottom of a nearby stream bed, and was draining hog feces into the waterway.

“In those days, they were spraying hog manure across roads, and across other people’s property. There were no rules,” said Yousey who was the Bladen County health director at the time. “I went out and videotaped it.”

“I was told I couldn’t do it, but I had protections,” he said.

Mosquito taking a blood meal
Boards of Health in NC are responsible for activities such as responding to outbreaks of mosquito borne illnesses. Photo courtesy, CDC, James Gathaney Credit: James Gathany, CDC

Yousey refers to the fact that in most of North Carolina’s local and county health departments, health directors are hired by local boards of health under the State Personnel Act, a set of rules that apply to state employees.

“Workers in the health department are mandated to enforce public health laws,” explained Yousey, who retired as the Brunswick County health director last year. “But they’re also protected in enforcing those laws under the State Personnel Act.”

“The SPA also gives you sovereign immunity,” he continued. “If you’re working as an agent of the state and you’re sued, as long as you’re following the law, the attorney general protects you. If you don’t follow the law, the protection goes away.”

But a bill making its way through the General Assembly could change much of how public health is organized in North Carolina. County commissioners want the law because they say it would streamline the public health infrastructure in counties, reduce costs, and simplify lines of authority.

The law would also allow counties to remove health department workers – including health directors – from under the SPA, would allow county boards of commissioners to disband local boards of health, and would allow small counties to form consolidated human services departments. That has Yousey, and others, concerned.

“The SPA sets up qualifications for types of employees, their education and experience,” said Beth Lovette, director for the four-county Appalachian District health department.

“When we get ready to hire someone, we have to get their college transcripts, background checks, all of it,” said Lovette, who said that weakening the standards could lead to lowering the quality of hires.

The proposed bill does not include require hiring someone with experience in public health to lead the consolidated departments.

“If we take the expertise out of the local governance, we change the way the public’s health is protected,” Lovette said.

Consolidation in some places

“What commissioners want is to have the option to consolidate human services administration,” said Todd McGee, a spokesman for the NC Association of County Commissioners.

Currently only three counties – Mecklenburg, Wake and Guilford – have the option of melding together social service and public health departments into one consolidated human service agency because they have populations greater than 425,000. Wake and Mecklenburg have adopted the model, Guilford has not.

“Commissioners in other counties want to see if it’s something that would benefit their communities,” said McGee. “We’re just of the belief that if something is looking good in a couple of counties, it ought to be available in all counties. We’re not looking to mandate it. we’re just trying to get that authority for any county that wants it.”

More than 33 counties have adopted resolutions in support of the change in the law, according to McGee.

“We’re not looking to usurp existing rules and guidelines,” McGee said. “The hope is that it could help counties save some money that could go back into services for citizens.”

Map of Local Public Health Agencies in North Carolina, FY2011–2012
Map of Local Public Health Agencies in North Carolina, FY2011–2012. Image courtesy of UNC-CH, School of Government

With the exception of Cabarrus and Hertford counties, most other areas of the state have either a single-county health department. But nothing in the current law prevents the formation of district departments; the state already has six multi-county departments.

A recent study by the School of Government at the University of North Carolina – Chapel Hill showed that health outcomes differed little between the types of agencies used around the state. The study also found a wide range of costs to counties, even among counties of similar size and organization.

“We saw a correlation with money, and size, and full time employees, though” said Aimee Wall, who co-authored the study. “As the size of the population increased, the number of FTEs per 1,000 decreased.”

The bill currently being discussed would provide incentives for counties to create more multi-county arrangements. Focus groups interviewed for the study said that for multi-county arrangements to succeed, departments need strong leaders who can be entrepreneurial.

Boards of Health could disappear

In late 2010, several bar owners in Pitt County sued the county after they were fined for allowing smoking in their bars, after the state passed a law banning smoking in bars and restaurants in 2009.

Initially, a Pitt County district judge agreed with the bar owners. Members of the county’s mostly volunteer board of health wanted to appeal the decision, but the county board of commissioners told the county attorney she could not defend the board of health, which eventually prevailed using a volunteer attorney.

This kind of politicization worries Gene Matthews, an attorney specializing in public health law who works at the Gillings School of Public Health at UNC-CH.

NC restaurant inspection grades.
Local public health departments inspect restaurants for safety. Image courtesy Forsyth County Environmental Health

Matthews said abolishing the volunteer boards of health – which include physicians, dentists, nurses and engineers, among others – would be a mistake, because they have expertise, and do more things than most people realize.

“They have things like regulatory authority for restaurant inspections, and other public health matters: where you put a septic tank, should you close a school if there’s an outbreak of flu,” said Matthews.

He explained in situations such as the one in Pitt County, if someone has a dispute over how a health ordinance is being enforced, that goes to the appointed local board of health, not elected officials on the county commission.

“Most savvy political operatives as well as public health people understand there’s a real value in having a local public health board to deal with the local controversial local public health issues, and not throw that completely into a political firefight,” said Matthews, who was chief legal adviser for the Centers for Disease Control and Prevention for 25 years.

County commissioners approve board members. Then boards of health hire and fire local health directors, something county commissioners say they would like to be able to do.

“I personally find this to be a plausible argument in reasonable local governance,” Matthews said. “But it’s important not to strike out that professional board that gives good, sound, long-term guidance on breastfeeding, or water pollution, or an outbreak of viral encephalitis, or whatever.”

But Don Yousey said being separated from county commissioners was key to him resisting them when he needed to (Yousey recently ran for county commissioner in Brunswick, but lost in the May primary).

As a case in point, Yousey said he had heard from friends who are still health directors that they had been instructed not to publicly speak about the proposed bill.

“I’ve had county managers and county commissioners ask me to do illegal things,” he said. “And I looked the commissioners in the eye and said “no.” Now, what would a guy do if he served at the pleasure of the commissioners, and those protections weren’t there?”

Mervin Dieckmann, a retired Navy doctor who volunteers on the Warren County board, was more blunt.

“We have health expertise, they don’t,” Deickmann said. “We assess what the county needs and try to provide it, they’re trying to get re-elected.”

“It would just give commissioners more power, something they don’t need,” he said. “And if there’s a public health emergency, like a flu epidemic, they wouldn’t know what to do.”

Correction: The story has been corrected to reflect the correct number of district health departments in North Carolina. The Appalachian District Health Department contains four counties.

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...