Newsletter - February 2004

Editor: Virginia Dato

AAPHP News

1) AAPHP's 50th Anniversary meeting is 2/18/2004 at the Caribe Royale in the Hibiscus Room in conjunction with Prevention 2004 in Orlando, Florida (preliminary details below)
2) Fifty Years after Leaving Medical School by CMG Buttery M.B., B.S., MPH.

2)
Fifty Years after Leaving Medical School.
CMG Buttery M.B., B.S,, MPH
Presentation upon the 50th anniversary of the founding of the AAPHP

In addition to the 50th anniversary of the AAPHP, this year is also my 50th anniversary of graduation from Guy's Hospital Medical School in London, part of the University of London. This medical school, along with St. Thomas's medical school has been incorporated into King's College Medical School as the number of people allowed into medical school has been curtailed in the U.K., to meet population need, rather than the desires of people to use them. This material is written at our president's request to give members who have less longevity then I have an idea of what can be accomplished in a lifetime of public health service. I just hope I have emulated my role model, Ben Freedman.

After an internship and 1 year of internal medicine I started a Family Medicine Practice in 1956. I spent 10 years in practice, until an overview of my patients, the problem's seen, and my analysis of the practice content convinced me I could do more for people by practicing preventive medicine.
These were interesting times. Other doctors in the community were disturbed that I allowed all my patients to enter through the same door and occupy the same waiting room. I never had a complaint from any of my patients, black or white. From the day I started practice I kept a Royal McBee punch card on each patient. It was punched to indicate age, sex, race, main problem, and additional problems. I sorted these cards every 6 months to look at my practice content and determine what CME I needed. I used the data on the cards to compare results of therapy and try to make my intervention more effective. I wrote three papers based on these cards which were published in the Virginia Medical Monthly. I also developed a comprehensive laboratory in my office at a time when family doctors rarely did more than urinalysis and hemoglobin tests. After being approached by some CDC staff and then by one of the senior staff of the state health department I went the Fairfax Health Department in Northern Virginia for two years training followed by an MPH at Johns Hopkins.

Over the years I heard a lot of people talk about the MPH as a method of ticket punching to a career in public health. I found it a valuable commodity and used what a learned from the very start of my career.

I have been fortunate to always report to senior managers who allowed me to try new ideas with minimal guidance allowing experiments to improve the public's health.

During the almost forty years of public health and Academic practice I had the opportunity to stretch the boundaries of public health.

For example while I was the director in Portsmouth, Virginia from 1968 (after graduating from JHU) I collaborated with CDC to develop the first machine readable input forms to manage Tuberculosis (it was written up in an article in one of the major business journals) and became the standard for most public health agencies. Another grant from CDC with the assistance of the then community public health program - Ruell Waldrop MPH, I developed the first community analysis by socio demographic areas, which result in a paper at the annual CDC conference in 1972 and led .to my long term interest in GIS linkages for public health programs. I assisted the city in developing animal control programs after I asked my sanitarians to measure the coliform content of our rivers and streams after rains, for three months. This showed the pollution from animal feces washing into rivers, streams and ponds. We actually measured the amount of dog feces produced in the city daily, it resulted in a pile 40 feet high with an angle of repose of 45 degrees and weighed about 10 tons! Another opportunity was to develop the fist housing hygiene ordinance in Virginia the City Manager and council were concerned about the poor quality of housing for low income families.
We used the APHA and BOCA housing standards to develop minimal standards for rental housing. All housing was inspected upon rental turnover and withheld from the market by my staff the owner brought the house into code compliance or demolished it. In three years we went from 40% of rental housing meeting
the code to 95% meeting the code. Another important issue I dealt with in
Portsmouth was integrating the public health clinics into the outpatient department of our local hospital, using the Alexandria, Virginia model. It worked well and has since become part of the Family Medicine residency program at the Norfolk medical school.

In 1975 I moved across the river into Norfolk as one of the founding faculty of the new Eastern Virginia Medical School, now the Medical College of Hampton Roads. I taught preventive and family medicine developing the first required community clerkship in combined family medicine and public health.
The study and results were published in Teaching Preventive Medicine in Primary Care, edited by Bill Barker, in 1983. It has been exciting to see part students become officers and eventually presidents of the State Medical Society. While at the medial school my major research was in analysis of the first iteration of the NAMCS (National Ambulatory Medical Care Survey).
I used this study to analyze the content of Primary care and suggest a curriculum for our primary care residency program. This study was discussed at the 1979 NAOPGRG program and used by a Canadian Medical school to develop their training for medic al students.

In 1980 I moved to Corpus Christi Texas as director health and Welfare services. I managed to spin off the welfare program into its own department. It was an area I did not believe I had the skills to manage. In Corpus I also had a number of fascinating opportunities, more in environmental health, although we had active clinical programs, as both stand alone programs and associated with our three local hospitals.
Although I had some involvement in occupational health in Portsmouth I became much more involved in Corpus by managing the City's occupational health program for its several thousand employees, developing wellness, disability management, and EEO programs for employees, as well as serving as an OH consultant (part of my reserve duty) to the Army Helicopter rework depot where all military helicopters in the US are sent for maintenance.

The major program which came out of my sojourn was an innovative ordinance to improve food service without increasing the city budget. When I arrived in Corpus I found food handlers physical exams were being performed on anyone who asked for them. The major use seemed to be that prostitutes showed a clean exam to the police and escaped arrest! I discussed this with the restaurant association and we moved to a program whereby all establishments, of any size, profit or non profit, ecumenical or religious had to have food service overseen by a certified food manager. The food service license fees fully funded the program. The program was monitored by a community board equally split between citizens and food establishment owners. All the sanitarians were certified in food handling. Our inspection standards went up from 55% to 85%+.

Another program involved animal control management with careful drawn standards for capture and use of dart guns, and development of a zoological ordinance for exotic animals. Because of the predominance of the oil industry we had to perform a number of epidemiologic examinations to show that people were not getting sick from airborne chemical fumes. We also had to enhance programs to prevent equine encephalitis vectored by quinquefasciatus mosquitoes. We had to stay aware on dengue at the US/Mexican border. We had a major measles outbreak in a well immunized population of school children. Early intervention and research resulted in the national Immunization Committee recommending booster doses of measles vaccine in middle school. This was published in the NEJM on March 26, 1987.
We had the state's major hazardous chemical disposal site in our county and frequently had to perform epidemiologic investigations to try and assure cattlemen and others that the chemicals were not harming the livestock.

Further, while in Corpus I wrote a computer program to print epidemiologic maps of disease, acute and chronic, by census tract and socio-economic areas, carrying on the work I started in Portsmouth. Examples of these maps, which were used successfully to motivate the City and County Councils to appropriate additional funds, were published in the 12th & 13th editions of Maxcy Rosenau.

In 1986 I returned to Virginia as State Health Commissioner serving 5 1/2 years until I had a significant dispute with our cabinet secretary about programs he wanted that I thought would be harmful to older citizens in the community. When I arrived back in Virginia I had the only PC in the Virginia state government. Working with Governor Baliles I set up three major missions, review the Certificate of Public Need Program, develop an access study for primary care, and enhance our MCH program, while trying to bring our data and financial systems in from the 1950 'green eyeshade' era to the 21st century.

Our study of COPN showed that no assertions could be made that there was any different in performance with or without it. Working with our State Board of Health (a Governor's advisory board) I developed them into a political force that got the health department a $45 million increase for MCH and environmental services (a 15% increase in funding which had never happened
before.) By the time I left I had started to move the staff into computer use, development of anticipatory budgets, and the use of GIS software for community assessment. My biggest regret was the time I spent on non health issues. The health department did develop a primary care assessment that resulted in new laws to support primary care residencies, funds to assist location in underserved areas, improve Medicaid payments for delivery, and development of a Virginia Health Care Foundation which brought together public and matching funds from business and industry. The project has developed more than 35 local primary centers for the indigent as well as developing a statewide pharmacy to support these programs, using gifts from pharmacy companies. About 85% of my time was spent on personnel issues. A strategic development board I developed with the Governor's assistance died on the vine after his successor took office, and the state faced a major budget deficit. While Commissioner I had a textbook, the 'Handbook for Health Directors' published by Oxford University Press in 1990. A Japanese edition was published in 1993. One major issue as Commissioner, working with legislators, was sitting on a commission to review how to manage HIV infections in Virginia. Some of our legislators wanted us to test all persons about to be married, for HIV infection. It was quite a problem explaining the epidemiology of HIV and issues of false positives and their deleterious effects on those so identified..
In 1991, after I left as Commissioner I had planned to develop a software company to promote GIS and public health, but the Richmond City Manager offered me an opportunity I could not resist, which was to stay with the city for 4years, from 1991 to 1995 and develop a program to ensure access to primary care for all citizens in Richmond. I would also accept an appointment to MCV's department of preventive medicine and assist in development of the department and develop an introductory course on public health for the new MPH program. While I did this I managed to obtain several large grants from DC, HRSA, and the Robert Wood Johnson Fund to develop a model program to track immunizations (one of twelve nationally), to start one the 10 National Healthy Start programs, and to develop a primary care center (including building a facility located in an underserved
area) transferring public health clinical staff to MCV, for a defined population so we could measure the value of the intervention over the years.
This turned out to be one a group of nationally recognized public health/academic centers cooperatives. The community primary care program has continued and is one of the Virginia Models.
Since 1996, in semi-retirement, I have managed your web site, as well as my department's web site. I have developed the medical school's first distance learning graduate course. I chair the department's admission's committee and serve on with faculty's internet facilitating committee. The handbook is now way out of date. As part of the distance learning course I have a set of essays, initially drawn from the handbook, but rewritten with hyperlinks to web sites, and revised every 3 months with additional links added to ensure that the site is up to date. Prior to each class additional links are added or substituted... Our students have found these essays particularly useful