Congresswoman Eddie Bernice Johnson Introduces the National Nurse Act of 2013

Since the issue first came to my attention several years ago, I have strongly supported the passage of the National Nurse Act and the establishment of a National Nurse for Public Health. The following is a press release distributed on February 4th by the National Nursing Network Organization Board of Directors. It is reproduced with their kind permission.

The Demise of the Public Health Nurse

Back when H1N1 was on the rise, the city of Worcester, Massachusetts laid off all but one of its public health nurses, much to the consternation of the public health community. Public health has rarely been understood by Americans in general, and perhaps the H1N1 pandemic has brought the benefits of the public health infrastructure into the spotlight for both the public and politicians.

Back in October when I left my position as a public health nurse for a small college town in Western Massachusetts, I felt guilty that I was leaving at a time when I was needed the most. Luckily, I was quickly replaced by a skilled and capable nurse who was able to pick up the gauntlet and lead the town through the maze of H1N1 prevention and immunization clinics.

Now I have learned that the public health nurse position in that particular town has been eliminated, and the new director---a former public health nurse for the town---will fulfill the responsibilities of both nurse and department head, a monumental task that seems altogether untenable, no matter how capable and earnest this individual can be. From the surveillance of infectious disease to the management of tuberculosis, public health nurses need time and resources to fulfill their duties, and more and more nurses are being asked to decrease their hours and the scope of their practice, significantly limiting their overall effectiveness.

Public health is often seen as an expendable expense by politicians and bureaucrats, and the signs all point to the fact that public health---and public health nurses---are still not appreciated for the ways in which they safeguard the health of the population and work to prevent the spread of infectious disease.

The gutting of public health programs around the United States is a travesty, and when the ability of a local public health department to fulfill its responsibilities is emasculated in the interest of saving money, everyone loses.

A Replacement Cometh

Today was the day when we interviewed the four top candidates to replace me in my position as Public Health Nurse. Without disclosing anything specific about the interviews or the interviewees themselves, it was a relief to realize that, yes, there are a number of qualified candidates who are interested in taking my place and assuming all of my responsibilities. Even more encouraging, our #1 choice is available to start on October 1st, which would afford a two-week overlap before I gracefully exit, stage left.

In prior blog posts (see "Stirrings of Nursely Guilt"), I have discussed the feeling of being indispensable as a nurse, carrying my nursing positions like crosses that I alone can bear. That's complete hogwash, of course, and I continue to process the emotions that lay beneath the nursely guilt complex.

Leaving my current position---at a time when the public health infrastructure is facing its greatest challenge in a generation---is truly a test of my personal resolve, and the guilt underscores for me the fact that I truly want to leave my position in qualified and well-prepared hands.

Today, it seems that the capable and qualified hands for which I have been waiting may well be ready to relieve me of my occupational burden (and guilt!), and I am only now beginning to see glimmers of light at the end of the tunnel.

Personally, these are exciting times as my wife and I ready ourselves for the cross-country trip of a lifetime. Wresting ourselves from our occupational shackles is one of the final acts that we must mindfully commit prior to stepping off of the precipice into the Great Unknown. And knowing that we may very well have found the person to whom I can pass the public health torch is a feeling of relief beyond measure. Now, as I wait to hear that the offer of employment has been accepted, I dare not to hold my breath........

Finding a Successor

This week, we will interview four potential successors, intrepid nurses who are willing (and hopefully able) to pick up where I leave off on October 15th. The one who is chosen to take my place will inherit my office, my files, my newly written Public Health Nurse training manual, my many responsibilities, and the certainty that this flu season will be a doozy.

In preparation for my departure, I will continue to write the training manual, purge and organize files, order supplies, and administer as many flu shots as I can before my successor takes over. Now, the problem is that production and distribution of the seasonal flu vaccine is now slowing to a trickle as manufacturers try to cope with the ramped up need for H1N1 vaccine. So, plan as we may, how can we hold successful and far-reaching flu clinics if the flu vaccine is in short supply? Woe to the public health nurse who wants to be ahead of the 8-ball for a change.

So, we prepare, we strategize, and we hope---with multiple fingers crossed---that one of the interviewees is indeed intrepid, ready, willing, and able to pick up the torch and run with it into the crashing waves of flu season.

H1N1: Many Questions and Stormy Days Ahead

The questions about H1N1 are coming fast and furious now, and I often don't know what to say.

Seniors feel slighted because they're lowest on the priority list for the new H1N1 vaccine. Middle-aged people who are otherwise healthy who would like the vaccine notice that they do not meet the criteria for being in the first wave of recipients, if at all. There are the many health care workers who usually don't receive a flu vaccine and are reluctant to get the H1N1 vaccine, even if it means protecting their patients from illness. Meanwhile, pregnant women are afraid to receive this newly formulated vaccine, even though they are top priority for receiving it in order to protect their gestating children, and parents of school age children are also afraid. And then there's the conspiracy theorists who feel it's all a government ploy to poison, sicken, and subjugate us.

What's an earnest Public Health Nurse to do, anyway?

The concerns, the worries, the misgivings, the fears, the suspicions---they are all rising to the surface as the flu season kicks into gear. There is certainly confusing information out there, and some of it even seems contradictory. We can rest assured that many media outlets will undoubtedly get it wrong along the way, further adding to the confusion that so many people feel.

So I answer calls, assuage fears, refer people to the most reliable websites about H1N1, and I cross my fingers that we find a qualified replacement for me before I leave my position on October 15th. It's a wild influenza world out there, and something tells me the weather's about to get rougher.

H1N1 Creeps Along

The H1N1 virus, otherwise known as Swine Flu, is creeping along at a slow but steady pace, and my work as a public health nurse amidst the outbreak of a novel influenza virus has certainly ebbed----for now.

As predicted by many, the virus is currently no more virulent than your average seasonal influenza, and while more cases and deaths are indeed expected, the rate of the spread of H1N1 is slow and steady rather than rapid and diffuse.

Still, there is a great deal of uncertainty as to what will happen when H1N1 goes somewhat underground over the summer, only to resurface in the Autumn, mutated and ready for the seasonal flu season. Epidemiologists are concerned due to the fact that the 1918 influenza pandemic began with a novel virus emerging in the Spring, spreading slowly but steadily, diminishing in the summer and reemerging in the Autumn, hundreds of times more virulent. Only time will tell.

Another novel aspect of this virus is that, unlike seasonal influenza---which predominately impacts older adults and those with chronic illnesses---the majority of H1N1 cases are those between the ages of 5 and 20, with the vast preponderance being between the ages of 11 and 15. The assumption is that those generations of children have never been exposed to this virus before, whereas the rest of us were alive in the 1970s during the last H1N1 outbreak. And whereas most children and young adults are healthy enough to fight off the infection, there are concerns about children with weakened immune systems and chronic illnesses. When children die from otherwise benign infections, people take notice, and this is an eventuality we all want to avoid.

Be that as it may, the H1N1 scenario is relatively calm for now, and those of us working in public health and other sectors of the health care industry watch, wait, listen, and hope that nothing more comes of this outbreak of a novel virus making its inexorable way around the world.

Public Health Layoffs During Public Health Week

At a time when it is universally agreed that the fight against communicable and infectious disease is an absolute necessity, right here in New England the city of Worcester, Massachusetts is choosing to dismantle its public health infrastructure, laying off its public health nurses during the celebration of Public Health Week.

Public health nurses provide case management for patients with active tuberculosis, provide crucial surveillance of communicable and infectious disease, and perform a myriad of tasks that help to protect citizens from harm and injury. Worcester's short-sighted decision is seen as potentially catastrophic, and I share with you below the text of a press release from the Massachusetts Nurses Association:

FOR IMMEDIATE RELEASE

WORCESTER, MASS — As the City of Worcester prepares to celebrate National Public Health Week, the city manager has recently announced the elimination of nearly all funding for public health services and the layoff of nearly all the nurses who provide public health protection to the state's second largest city.

The public health nurses serve all the people of Worcester, providing vital preventive services to immunize against, track and manage over 150 infectious diseases, including tuberculosis, hepatitis, salmonella, the flu and West Nile Virus. The cuts in services and staff leave the city vulnerable to the unwarranted spread of infectious diseases. It will also deprive the city's most vulnerable children and adults of access to immunizations and other health screening services.

The decision by the City of Worcester to lay off all six of its public health nurses, along with the chief public health nurse and secretary for the department, is a shortsighted and dangerous decision that will shred the health care safety net for the city's 172,000 residents. The layoffs, which were announced last week, will take effect on April 17.

While everyone understands we are in a fiscal crisis, this decision places hundreds, if not thousands, of our residents at risk for harm and leaves the most vulnerable in our city stranded without necessary care," said Anne Cappabianca, chair of the bargaining unit of the Massachusetts Nurses Association, which represents the Worcester public health nurses. "The public has a right to know what they are losing and what they will be exposed to as a result of these cuts."

Fact Sheet on Public Health Nurses

► A public health nurse is a special type of registered nurse who focuses on providing health promotion and protection to an entire community or population. There are currently six public health nurses serving a population of more than 172,000 residents in the City of Worcester.

► During the past year the nurses investigated 300 communicable disease cases, including tuberculosis cases at local colleges and high schools, requiring tuberculosis skin testing of hundreds of individuals.

► The nurses track at least 100 residents each month that may have been exposed to TB and are now living in the community. They make more than 35 visits each month to the homes of those residents with active TB to ensure they are receiving proper care and are taking their medication. In so doing, they prevent the spread of this highly infectious disease while at the same time assist those infected in getting well. Without the services provided by the public health nurses, these patients are less likely to follow their treatments, and are therefore at much greater risk to become more seriously ill, and much more likely to spread this disease throughout the community.

► In preventing the spread of disease, public health nurses are responsible for immunization of vulnerable segments of our population against the spread of disease. For example, more than 2,000 vaccines were administered to children and adults during the last 10 months by the public health nurses.

► The nurses also provide all varieties of childhood immunizations to those who can not afford them, such as children living in family homeless shelters, etc.

► Worcester public health nurses also play a vital role in the city's disaster response plans. During the ice storm in December 2008, the nurses staffed the shelters at Burncoat High School and Doherty High School to provide care to victims, including fragile elderly residents.

"In addition to the loss of existing services, the elimination of the public health nurses prevents the city from initiating a number of health and wellness programs planned for the recently established wellness clinic in the department. These programs included screening services for diabetes, hypertension, kidney disease as well as obesity.

"In the long run, all of these programs save money and save lives, while increasing the wellness of all our citizens," Cappabianca said. "Those who suffer the most from these cuts are those in our community for whom these services matter most. In abandoning these programs, particularly all our services related to disease surveillance, we jeopardize everyone in our community unnecessarily."

Founded in 1903, the Massachusetts Nurses Association is the largest professional health care organization and the largest union of registered nurses in the Commonwealth of Massachusetts. Its 23,000 members advance the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Legislature and regulatory agencies on health care issues affecting nurses and the public.

Tuberculosis Rears Its Head

So, my learning curve continues to veer upwards as different aspects of my job ebb and flow. This week, it's tuberculosis case management.

According to our state Department of Public Health, every patient with active or latent TB who lives in the community must have a nurse case manager, and the local Public Health Nurse (if there happens to be one, that is) usually fits the bill. Thus my work is cut out for me.

Things have been pretty quiet on the TB front in my little town for the last few months, with a few patients finishing treatment and sent on their merry way. Now, without divulging any important details, I will say that a new case has emerged that involves complicated and multiple social contacts, a language barrier, sensitive cultural issues, and the potential for a media and public backlash due to the frequency of tuberculosis among immigrants from outside the United States.

When a new case of TB comes to light and is reported by a medical provider to the state, a great epidemiological and bureaucratic machine is set in motion. There are contacts to investigate, families and friends to test for TB, complicated medication regimens to dispense, and an investigation that can easily consume the time of an erstwhile Public Health Nurse who has many other duties with which to contend. Tuberculosis is serious business, and it is taken very seriously by state and federal agencies that seek to contain it wherever it surfaces. And surface it does.

In these days of global air travel, an individual with undetected (and untreated) tuberculosis can sit on a transatlantic flight for many hours as nearby passengers breathe in the recirculated air carrying the potential for infection. While not everyone on a plane may be at great risk, close contacts who have shared the same air space for a number of hours are indeed suspect, and testing and close monitoring are crucial in order to catch new infections. If the infected individual attends school, works in a restaurant or hospital, or lives in a dormitory in close proximity with others, contact investigations are key to ascertaining who is at greatest risk of infection.

My TB case load has been light these last months of winter, and for that I'm very grateful. Now, an interesting and compelling case begins to draw my attention, and I will be put to the test as I summon my communication skills, cultural sensitivity, and ability to tease out the details of what may be a complex investigation.

Welcoming Spring!

Well, here in New England, the colder days are slowly being outnumbered by the warmer ones, (emphasis on slowly). The mornings can be quite nippy and the nights still drive the mercury down. However, the crocuses are up, the birds are returning, windows are opening and people are out with their bicycles and running shoes in droves.

With my new job being right downtown, I plan to take advantage of the warm weather by doing outreach to local businesses, visiting churches, and making inroads to various groups within our community. I find that many individuals and organizations have no idea what the local Health Department does, and most people don't even know that our town has a Public Health Nurse. In fact, some nearby towns have no nurse to call their own, so we are especially blessed to have such a well-funded Health Department.

Our Medical Reserve Corps (MRC) chapter has historically been relatively small, usually between 30 and 40 members, only a fraction of whom are actively involved on a regular basis. Although our title emphasizes the medical aspect of our mission, all MRC chapters welcome laypeople and non-medical professionals into our midst, since a diversity of talents and strengths is indeed important in emergent situations. Thus, we are actively recruiting veterinarians, clergy, business owners, IT professionals, HAM radio operators, and any other people who are simply interested in being of service when the proverdial feces hits the fan.

While members of the MRC are all trained to respond to emergencies and lend a hand when police, fire and other entities are overwhelmed (MRC's have assisted in hurricanes, floods, fires, and other incidents), we also like to do community outreach and emergency preparedness education. Thus, some of my Springtime efforts will include outreach to seniors, church groups, civic organizations (like the Knights of Columbus), and private and public groups of all sizes and persuasions.

Beyond that, working in town also gives me a route by which to take the "pulse" of the town, talk to people about my work, and enlist community partners in improving public health in its myriad aspects.

Spring has certainly sprung, and I want to take advantage of the pervasive feeling of optimism in the air, reaching out to those who might be willing to contribute to improving the overall health of our community.

Surfing the Learning Curve

I spent today sitting in a conference room with public health nurses, people from our state Department of Public Health, and other professionals who focus their professional lives on the surveillance and prevention of infectious and communicable disease.

As dry as this topic may seem, there is a passion that people in the public health world feel for this work, and many people have dedicated entire careers to this avenue of work. As a newcomer, I listen, watch, and feel my way through this maze of information, and I consider the many decades of human effort that have led us to this point in history.

The 20th century was very much focused on the control and eradication of communicable diseases like polio and measles. We've done a pretty good job in that arena, and vaccine-preventable diseases have been on the run for some years, at least in the industrialized world.

Now, multidrug-resistant TB, HIV/AIDS, malaria and other diseases have us on the run, and the fight is raging around the world. Billions of dollars are being spent every year, and philanthropic organizations like The Gates Foundation feed a great deal of private capital into some of the larger public health engines that drive the action.

For myself, I'm a very small cog in a series of multilayered wheels that turn in combinations still beyond my comprehension. While I see my actions as very small when compared with what's happening "out there", I also recognize that my interventions on a local scale---counseling a patient with TB, vaccinating a child, preventing illness---are part of a wider web that is made even more meaningful (and, in fact, effective) based on the very small, local actions of a multitude of individuals.

Prevention, surveillance and protection of the public is a year-round and frequently thankless job. Public health happens in the background, if you will, and the public and the media generally only think about such things when something goes wrong. This is understandable, and if the price of such vigilance is relative anonymity in a world made more healthy and safe by their diligence, most public health professionals would probably accept that outcome with a knowing smile.

I am still surfing on the learning curve, gleaning what I can from every day on the job, and relishing the lessons that bring new personal and professional meaning and importance to my work. It's an interesting ride, and I'm often impressed by the multifaceted nature of the field into which I have so recently stumbled.

Collaboration and Relationships

In my current position as a Public Health Nurse, I am seeing so clearly how the building of collaborative relationships is the key to success. Whether I am creating wellness programs for municipal employees, writing town-sponsored blogs, developing emergency preparedness protocols, fostering communication with other town health departments, or working with the local university and colleges, my work revolves around positive relationships and a collaborative spirit of cooperation and mutual benefit.

As I delve deeper into the areas for which I am responsible, there is precious little that I can satisfactorily accomplish without some form of collaboration. If I want employees of the town to exercise, then I have to develop positive relationships in order to motivate employees to take part in my programs. If I want to move forward with our emergency preparedness plans, then I have to work closely with town officials and school department personnel in order to conduct surveys of potential emergency shelter sites and Emergency Dispensing Sites. When there's a case of tuberculosis or salmonella in town, I have to use my contacts at the state Department of Public Health to fully undertake my investigation.

Every step I take here in my work is collaborative on some level. Every initiative I undertake suggests a way in which I might get the "buy in" of a key individual or group of individuals. With each idea I have or new program I wish to launch, some connections must be made, relationships must be fostered, and alliances forged.

This position of mine is not one in which I can thrive as a lone agent. Sure, I could act on my own, burning bridges as I run rough-shod over my colleagues and other innocent bystanders. But in order to truly create public health programs and initiatives of any intrinsic and lasting value, collaboration and relationship building is key.

I am building such alliances every day, feeding relationships, fostering connection, finding common ground, and building confidence within and without. I am gathering my forces and lining up my allies. And with these elements in place, success is assured.

Social Justice, Public Health, and the Pursuit of Happiness

The health department where I am currently employed is the recipient of a three-year social justice grant from a large national foundation. Despite a steep learning curve vis-a-vis emergency preparedness, the coordination of our local Medical Reserve Corps, and developing wellness programs for town employees, the social justice mission of our little health department is one of the most intriguing aspects of my new workplace.

When one generally thinks of public health, one thinks of communicable and infectious diseases, vaccinations, disease surveillance, and epidemiology. But I am learning that access to health care, food insecurity, and access to adequate housing can all be seen under the umbrella of public health, especially when looking at these issues through a social justice lens.

In addition to our social justice grant, our health department also boasts a Cambodian outreach worker who is responsible for outreach to the Cambodian refugee community in our area, a sizeable cohort which has varying levels of need vis-a-vis health care access and other social issues.

For American-born citizens, refugees and immigrants alike, free and equal access to adequate health care is indeed a privilege in this country, but it is a privilege that many of us prefer to view as a basic human right.

Along with housing, employment and education, my progressive heart wants to see every American have free and unfettered access to as much education as his or her heart desires; comfortable and affordable housing; gainful employment; sufficient quality and quantity of food; and high-quality and accessible health care. Call me a bleeding heart, but my personal vision of social justice includes what I see as essential components of "life, liberty, and the pursuit of happiness."

In terms of my work as a Public Health Nurse, I want to remind myself that the "public" aspect of my job entails my responsibility to the public, the people who live within the geographic area of my jurisdiction. The Human Rights Commission in our town is very active, and I see part of my duty as the PHN to reach out to this group (and others) who spend their time assuaging the suffering of our homeless, hungry, and uninsured.

Aside from the nuts and bolts (and syringes) of my work, I want to delve into the area of social justice wholeheartedly. There is nothing more worth fighting for in my book, so why not start right here at home?

So, What Does A Public Health Nurse Do, Anyway?

This is a question that has already been posed to me several times, and coming up with answers helps me to define what it is I'm actually supposed to accomplish in my new job.

Public health nursing has a long and illustrious history which I will not illustrate here, but in terms of my new position, there are a number of things for which I am directly responsible:

-Tuberculosis case management: I closely monitor and follow any cases of active or latent tuberculosis in my community, assuring that patients take their medications as prescribed and follow up with the regional TB clinic as required.

-Emergency preparedness: it is my job to actually make sure that our town has protocols and plans in place for emergency preparedness, whether it be for natural disasters, terrorist attacks, pandemic illness, or other public health emergencies. I will cooperate with other regional agencies and serve as coordinator of our local Medical Reserve Corps.

-Immunization clinics: I will hold monthly immunization clinics for immigrants and other citizens in need of urgent immunizations. Influenza clinics are also an important part of our work in the late Autumn and early Winter.

-Infectious disease surveillance and investigation: I am responsible to track, report, and investigate infectious and communicable diseases in our community.

-Resources and referrals: I will provide the general public with resources, referrals and advice vis-a-vis medical issues, psychosocial issues, and other needs as they arise.

-Employee wellness: on some level, I am supposed to provide employee wellness resources for employees of our town. I'm not sure what this is supposed to look like, and only so much can happen in thirty hours each week. Still, I see this as a potentially interesting aspect of the job if there's any time to actually do it.

There is so much to learn and so much to know. Infectious disease surveillance in general is an enormous area of expertise and I feel ill-prepared to take it on.

The learning curve is indeed quite steep, but in exchange for my own sunny office, a great cafe next door, and excellent health insurance, I think I made the right choice.

Public Health and Me

So, I have officially accepted a position as the Public Health Nurse for my town, and my hours were approved by the town government just yesterday. While I've been filling in as the Interim Public Health Nurse for ten hours each week over the last several months, I will begin working thirty hours a week beginning on Monday.

After ten months of being a free agent, consultant, and general slacker, having a job to responsibly report to four days a week is indeed a wake-up call. While consulting and working per diem jobs has allowed me a great deal of flexibility and self-determination, the need for high-quality health insurance and a more steady income have also reared their heads. Thus, my decision is propelled by economic need as well as the realization that this will certainly be an interesting and growthful career move on many levels.

As a Public Health Nurse for a town of approximately 40,000 people, I will be responsible for emergency preparedness (including the management of the local Medical Reserve Corps), infectious disease surveillance and reporting, tuberculosis case management, a monthly immunization clinic, influenza clinics each fall and winter, fielding questions and calls from citizens and town employees, and other important responsibilities.

I am honestly slightly overwhelmed as I realize the steep learning curve involved in this undertaking, but I also realize that my desire to work for Partners in Health, Doctors Without Borders, or a similar organization in the future will be even more likely with significant public health experience under my belt. While public health is not necessarily hands-on nursing, it is a crucial part of the healthcare infrastructure of the country, and many of my new skills will certainly be transferable to other countries and societies.

Stay tuned for developments as I dig in to my new position, and I surmise that issues of public health will become an even more intrinsic part of the regular conversation here on Digital Doorway.

Public Health and Me

Tomorrow, I begin my position as interim Public Health Nurse right here in my own New England hometown. Having never worked in my town (after almost fifteen years of residence in the area), it will be an interesting experience to actually be a "public figure" for the first time.

While my position is indeed interim, I'm coming on board just at the beginning of flu season, and since I'm the individual who literally holds the key to the town's flu vaccine supply, I have an idea I am about to become very popular.

Understandably, everyone is anxious to get their flu shot. The elderly residents of the town see the annual flu clinic and make-up flu clinic as an inalienable right, and the government's push for the majority of Americans to be vaccinated this year has driven this point home quite widely. Town employees, police, EMTs and firefighters also need to be vaccinated quickly and efficiently in order to decrease the likelihood of such essential personnel being sickened over the winter.

With the CDC and other government agencies expecting this year's vaccine to be more effective than last year's, I'm expecting a great deal of interest in and around town vis-a-vis the influenza vaccine. Our clinics will most likely be very busy events, and I'll need to champion that cause and do it well.

Meanwhile, I'll be taking care of daily infectious disease surveillance, TB case management, as well as other sundry responsibilities that I guess I'll figure out tomorrow.

I start this new job knowing that I'm standing on the shoulders of Lillian Wald and other famous nurses who had the vision of actually creating the institution of public health nursing in the first place. It's an honor to enter this new arena of my profession/vocation, and I look forward to growing personally and professionally throughout the process.