AWAKE, BUT RUNNING LOW ON FUEL

Abstract

Frieden asserts that “local health departments [need] to wake up to the challenge”1(p2061) that chronic diseases now pose to US mortality and morbidity. He maintains that chronic diseases are neglected by local public health agencies and that “the foremost reason may be the assumption that chronic diseases are not meaningfully amenable to public health action.”1(p2059) Frieden has misinterpreted the reason for this inaction. The problem is not at the switch, it is in the fuel tank. For at least a decade, local public health agencies have recognized the (often unequal) burden of chronic disease on communities and have undertaken creative and effective surveillance and intervention efforts. For example, the decline in rates of smoking and related disease reflects the successful application of traditional public health strategies such as surveillance; community health education; and clinical, regulatory, and environmental interventions to a noninfectious public health problem. Local health departments were major actors in this national success, which was funded in large part by proceeds of the tobacco Master Settlement Agreement. That agreement was the result of successful public health advocacy. The problem is lack of resources, not lack of understanding of what we could and should be doing. Where resources exist to do so, local health agencies have mounted effective campaigns to address a variety of cancers and chronic diseases and their underlying risk factors. The National Association of City and County Health Officials maintains an active national advisory group on tobacco control and chronic disease prevention and supports model practices and publications on local strategies for chronic disease control. Regrettably, local health officers are often forced to operate these programs with tenuous categorical microgrants, dwindling tobacco settlement dollars, or funds from a core public health infrastructure that has been eroded by unfunded demands for local emergency preparedness capacity. I am certain that the nation’s local health officers would readily agree with Frieden’s call for “the federal government [to] greatly increase its support for local activities in these areas.”1(p2061) It is important to understand that we are not asleep at the switch; we are simply running out of gas.