The California Department of Public Health’s (CDPH) was spun off from its predecessor (Department of Health Services) in 2007 as a direct response to the terrorist attacks of September 11, 2001. The state wanted a department focused on threats to the public from bioterrorism, as well as emerging antibiotic-resistant diseases and environmental threats, that was not bogged down with responsibility for tending to the health needs of low income and uninsured Californians. And that is what it got. A department with physician leadership guided by an expert advisory panel devoted to shoring up a public health system that was identified by the independent Little Hoover Commission in 2003 as the “weakest link in California’s homeland defense.” Its programs support the activities of local health agencies in controlling environmental hazards and address a broad range of health issues including, cancer and other chronic diseases, communicable disease control, environmental and drinking water quality, inspection of health facilities and care for maternal and child health. The department, which is in the Health and Human Services Agency, also administers certain statewide programs, such as licensing and certification of health facilities. It has a special focus on health care emergency preparedness.

California was the second state in the nation (after Massachusetts) to establish a Board of Health, in 1870. It wrestled with an outbreak of bubonic plague in San Francisco in 1900 and a re-outbreak of the plague after the 1906 San Francisco earthquake, experiences that solidified the role of a public health system in government. By the mid-1900s the state had built a world-class science-based operation with significant funding and regulatory power. Throughout the century, the agency dealt with a series of health issues including air pollution, sanitation, water purity and disease. It also took on chronic ailments, infectious disease and smoking.

But eventually the emphasis shifted nationally to an allocation of resources toward specific disease programs (such as HIV/AIDS) and acute care for the poor. The State Board of Health was eventually dissolved and the network of connections between the states and localities was diminished. In time, the Department of Health Services, which had dual responsibilities for serving the poor and needy as well as the general health concerns of the state, became the lead agency for health care.

In 1991, the state enacted a major realignment that shifted responsibility for a range of public health programs from the state to local health jurisdictions (LHJs) with dedicated state tax revenues and federal funds to pay for it. LHJs were administering more than 30 categorical programs by 2008, many of them targeting specific populations with particular needs. Although LHJs are required to meet certain reporting functions, much of their spending was unmonitored by the state leading to fragmentation of the state’s public health effort.

After the September 11, 2001, attacks, California formed a terrorism response team representing 22 agencies of state government, including the Department of Health Services. As early as 2002, a steady drumbeat began to establish a separate health department not burdened with ever-growing responsibilities for indigent citizens. The Department of Public Health was spun off in 2007 from its former parent, which was renamed the Department of Health Care Services (DHCS).

The creation of a separate Department of Public Health was intended to elevate the visibility and importance of public health issues. It was also intended to result in increased accountability and effectiveness of CDPH and DHCS programs by allowing each department to administer a narrower range of activities and focus on their core missions.

Getting Ready for New and Uncertain Dangers (Little Hoover Commission) (pdf)

Rebuilding California’s Public Health System (Little Hoover Commission) (pdf)

Analysis of the 2007-08 Budget Bill (Office of the Legislative Analyst)

Analysis of the 2008-09 Budget Bill (Office of the Legislative Analyst)

California Department of Public Health (U.S. Department of Health & Human Services)

CDHS Has Reorganized (DHS website)

History of Public Health in California (by Dr. William L. Halverson, director of California Department of Public Health) (pdf)

The department is the lead agency in California providing detection, treatment, prevention and surveillance of public health and environmental issues. Some of these programs complement and support the activities of local health agencies; others are solely state-operated programs, such as those that license health care facilities.

Its Office of Emergency Preparedness oversees statewide public health disaster planning and distributes funds to local health departments for that purpose. The office coordinates planning for the storage of large quantities of medicine and medical supplies at the Strategic National Stockpile, and has developed a disaster planning website to help Californians prepare for catastrophic threats to public health.

The department also administers programs through five centers:

Center for Chronic Disease Prevention and Health Promotion deals with cancer, cardiovascular disease and diabetes. It also works on the prevention and control of occupational and environmental diseases and injuries.

Center for Environmental Health focuses on unsafe drinking water, medical waste, low-level radioactive waste. It has a separate division for handling food, drug and radiation safety.

Center for Family Health administers programs for low income families who are generally at risk for poor health, including comprehensive newborn and prenatal genetic screening, supplemental nutrition assistance and family planning.

Center for Health Care Quality has administrative oversight of health facilities and professionals. It evaluates laboratories, investigates complaints and certifies facilities for compliance with state and federal laws. It also oversees the training of nursing home administrators, certified nurse assistants, home health aides and laboratory scientists.

Center for Infectious Diseases helps investigate and diagnose disease outbreaks, including STDs, HIV/AIDS, tuberculosis, viral hepatitis and emerging infectious diseases. It plans for emergencies, helps local health departments, provides diagnostic laboratory services and conducts and studies to define, prevent and control disease.

The department compiles birth, death, marriage and divorce records through its Vital Records office, and maintains a database of communicable, infectious and chronic diseases.  The department closely monitors any spread of the West Nile virus, which first appeared in California in 2003. The sometimes deadly disease is transmitted to humans and animals by mosquito bites and has spread to every county in California.

After the 2011 earthquake and tsunami in Japan crippled some of that country’s nuclear reactors, releasing radioactive gases, the department worked in tandem with California’s Emergency Management Agency to observe whether there might be any radioactive impact on the state from the Japanese fallout.

The CDPH also penalizes hospitals when it finds that the “facilities’ noncompliance with licenses requirements caused, or was likely to case, serious injury or death to patients.”  By mid-year of 2011, the department had fined 12 California medical facilities with penalties ranging from $25,000 to $75,000, mainly for failing to follow safe patient surgical policies and procedures.  Under legislation that took effect in January 2009, fines begin at $50,000 for the first violation; $75,000 for the second; and $100,000 for the third.  The $25,000 fines were for incidents that occurred prior to 2009.

Strategic Plan 2008-2010 (CDPH website) (pdf)

California Department of Public Health Programs (CDPH website)

West Nile Virus (CDPH website)

Radiation Safety (Joint statement from Governor Brown and CDPH director)

The Fukushima Dai-ichi Nuclear Power Plant Incident (CDPH Radiologic Health Branch) (pdf)

The proposed $3.5 billion budget for 2011-2012 represents a 3.2% increase over the previous year, due mainly to an increase in federal funding for the Women, Infants and Children program and health care reform. Most of its budget, 81%, is for local assistance while the rest pays for state operations. Although the 2001 terrorist attack may have been the impetus for establishing a separate department devoted to public health, the lion’s share of its budget is spent on public and environmental health. Only 3.1% is spent on public health emergency preparedness.

Almost 55% of the department’s funding comes from the federal government and 8.9% from the state’s General Fund. The rest comes from special funds and reimbursements.

Governor’s Budget Highlights Fiscal Year 2011-2012 (CDPH website) (pdf)

Reducing State Government (pdf)

HIV/AIDS Statistics

The department’s Office of AIDS is responsible for coordinating state programs, services and activities relating to HIV/AIDS. It works with the national Center for Infectious Disease to collect high quality surveillance data, interpret the data and disseminate its findings. But unlike many states, California’s HIV/AIDS reporting structure is not centralized. Its laboratories and health care providers forward HIV-related reports directly to 61 local health jurisdictions (LHJs) rather than to California’s state health department.

As a result, 35,350 outstanding paper lab reports had piled up by 2010. No reports were published on HIV/AIDS between April 2009 and September 2009 and annual published figures for that year underestimated the scope of the disease. The Office of AIDS embarked upon a two-stage plan to eliminate the backlog by the end of 2011 and utilize a new electronic laboratory reporting tool developed by the Department of Public Health (CalREDIE) to facilitate up-to-date filings.

HIV/AIDS reporting in California has experienced problems for years. In August 2008, when the national Centers for Disease Control released its revised estimates for HIV infections in recent years, one state was conspicuously missing from the report: California. The state had stuck to its guns on refusing to associate patient’s names or other ID in its reporting regulations and consequently the HIV rate was nearly impossible to accurately determine. The state made the switch to a names-based reporting system in 2006 but its efficacy was complicated by other reporting problems.

HIV/AIDS Surveillance (pdf)

HIV/AIDS Surveillance Update (Office of AIDS) (pdf)

HIV Incidence Surveillance ( Office of AIDS)

CA HIV Stats: Up, Down or Stable? (by Michael Petrelis, blogger)

Blogging the Office of AIDS (by Michael Petrelis, blogger)

Dead Patients

In the first half of 2011 alone, 12 medical sites were fined by the Department of Public Health for mistakes that killed four patients or threatened the health of others.  The medical errors occurred between 2008 and 2010 and included medication mistakes and surgical tools left inside patients during surgery.

The department issued a total of $650,000 in fines. The medical facilities were required to work with the department to change procedures, according to Pam Dickfoss, the acting deputy director of the agency’s Center for Health Care Quality.

One patient was a 62-year-old woman with metastatic cancer who died in February 2010  after receiving 33 times the correct dosage of morphine.  Another patient, who suffered from chronic obstructive pulmonary disease, died in December 2009 after being left unattended while on a ventilator in Santa Cruz. A patient admitted at Sharp Memorial Hospital in San Diego after suffering a heart attack died in June 2008 from an overdose of a medication used to treat congestive heart failure. And a patient with a history of confusion died at Pomerado Hospital in Poway in February 2010 after he got out of bed, fell down and fractured his skull.

The department also noted a number of accidents where surgical material was sealed up inside of patients. A fetal scalp electrode used to monitor fetal distress was left inside a woman who during a cesarean section at San Francisco’s Kaiser Foundation Hospital in 2008.  A piece of surgical sponge was left in the eye of a patient who had eye surgery in 2009 at Mills-Peninsula Medical Center in Burlingame. A foot-long metal retractor was overlooked inside a 66-year-old woman who had abdominal surgery in 2010 at Scripps Memorial Hospital in Encinitas. And a 28-inch-long guide wire used for a cardiac catheterization on an 82-year-old patient at Scripps Memorial Hospital in La Jolla was left in the femoral artery in 2009. It was discovered 29 days later during a second catheterization.

Calif. Fines 12 Hospitals for Endangering Patients (by Robert Jablon, Associated Press)

Public Health Controversies: Common Characteristics  (by Rajan R. Patil, Journal of Global Infectious Diseases)

Public Health and Civil Liberties (by Reinhard Kurth, Embro Reports)

More Independence

The Little Hoover Commission played a major role in laying out the arguments for creation of the Public Health Department in 2006, but in a generally positive review of the department one year later it continued to advocate for more change.

While the commission applauded creation of a department solely focused on public safety rather than comingled with Medi-Cal-dominated insurance program concerns, it would have prefered a department that reported directly to the governor instead of the Health and Human Services Agency secretary.

The commission wanted a department dominated by science rather than politics, led by an independent advocate (a surgeon general) for the public. But in its review found that health-related legislative positions were dictated by the governor’s administration policy and that the department, while led by doctor, is dominated by professional public health officials.

The commission also recommended creation of a volunteer, part-time scientific public health board to provide expert input into development of policies, regulations, and programs. The department does have a public health advisory committee, but the scope of its powers is limited.

First-Year Checkup: Strategies for a Stronger Public Health Department (Little Hoover Commission) (pdf)

Changes at the Local Level

California’s administration of public health programs at the local level is “fragmented, inflexible and fails to hold local health jurisdictions accountable for achieving results.”  That is the observation of the state’s independent Legislative Analyst’s Office, which recommends shifting more responsibility, along with funding through block grants, to local jurisdictions. However, it points out that barriers exist to efficient health care funding because many programs are supported with a combination of state and federal money.

The Analyst’s office also found that the Public Health Department is behind in implementing and enforcing state laws and is also unresponsive to requests for information outside the department.  The analyst’s office has recommended that the department report at budget hearings on the status of regulations to ensure the state Legislature is aware of what laws and regulations have not been implemented.

 Analysis of the 2008-09 Budget Bill (Office of the Legislative Analyst)

DNA Testing

It seemed like a good idea at the time. A student DNA-testing project at University of California, Berkeley was designed to teach incoming freshmen about personal genetics by giving them their personal results for three genetic markers. The students at UC Berkeley’s College of Letters and Sciences were going to be invited at orientation to voluntarily submit swabs to be returned for genetic testing. Geneticists would analyze each sample for three genes: metabolism of folate, tolerance of lactose and metabolism of alcohol, all relatively innocuous and perhaps useful in students' daily lives. Students might find out more about their relationship to leafy green vegetables, milk products and booze.

Results would be available at a lecture to be given by genetics Professor Jasper Rine a week later. But before the project got off the ground, a very public debate ensued. The Legislature tried to pass a law blocking it, bioethicists weighed in and the public buzzed. After much ado, the Department of Public Health put an end to the controversy when it ruled in August 2010 that the project violated state regulations regarding clinical diagnostic tests which require a doctor to be actively involved in the testing, and that the testing be done in a federally certified laboratory. That put the department in the middle of a national debate over the ethics of personal DNA testing.

Public Health Department Should Butt Out

Critics of the decision by the health department point a finger at overzealous bureaucrats, hamstringing scientific inquiry and interfering with student education, while denying people the basic right to know if they are at risk of a  medical problem. For many it’s a bioethical or legal issue, but for some it’s about education.

 “This is a very participatory way to get them to engage in the conversation, to have something to talk about with their fellow students and with the faculty,” said Alix Schwartz, director of academic planning for the college's undergraduate division.

Professor Rine explained what he was trying to accomplish with the project. “We want to get people to appreciate that there are things you can do that enhance your health based on the genes you have. There are concrete, actionable, specific steps that do enhance quality of life. This is the message of the post-genomic era.”

Rine’s colleague, associate professor of molecular and cell biology Michael Eisen, said critics of the project were “genetic Luddites who seem to emerge any time they hear the word ‘genetic test’ to screech about terrible risks of learning about one’s own DNA and demand that testing be suspended.” He called the whole uproar “absurdly paternalistic.”

Lawyers at the University of California worried that the ruling by the Department of Public Health could have broad legal ramifications for research and studies nationwide. Auburn K. Daily, a university lawyer, warned of “a deeply chilling effect on many types of legitimate and valuable activities that are currently undertaken at academic institutions every day throughout the country.” The fear was that researchers who conduct studies on genetic material would be prevented from reporting results to participants, even if they revealed risk of a serious medical condition.

Hank Greely, a Stanford University bioethicist who had been critical of the Berkeley DNA program, nonetheless wondered if the health department had gone too far. “If the DPH takes the view that for us to tell you anything like that, it has to be done in the clinical lab, that could be a little disconcerting,” Greely said. What if some genetic study obtained DNA samples with no intention of giving the results to its subjects but researchers noticed that a research subject had a genetic variation that puts that person at a high risk for colon cancer. He found it problematic that the researcher might be constrained by the guidelines that apply to medical testing.  

Public Health Department Did the Right Thing

It’s the law. And “total foolishness” to say otherwise, according to Jeremy Gruber, president of the Council for Responsible Genetics. “It has been long and well-established policy at the state and federal level that if you are going to test DNA and report individual health results back to an individual, you need a CLIA-certified lab, and you need a medical professional at some level involved in the program,” Gruber said.

That’s the way the Public Health department interpreted the law and Kevin Reilly, its chief deputy director of policy and programs, said it was to ensure that test results are accurate and reliable. That echoed the sentiment of the Food and Drug Administration when it stopped Walgreen’s from selling DNA kits in its drug stores. And that sentiment resonated with Center for Genetics and Society associate executive director Marcy Darnovsky: “In effect, it puts the university's seal of approval on products that have not been, and may never be, approved by federal regulators.” 

Darnovsky disagreed with Berkeley professors Rhine and Eisen that the project would be educational. “Catalyzing discussion and debate about the future of genetic technology is a wonderful idea,” she said “But this is the wrong way to do it. This project could fuel common misperceptions about the importance of genetic information.”

Some worried that students would feel pressured to participate in a project that their peers were joining at the outset of their college experience. Privacy advocates expressed concern about whether the personal information of participants could be properly protected. Some bioethicists complained that it was an unprecedented and disturbing use of genetic data by a university.

One commenter on a MetaFilter blog wondered if the university could be entrusted with the DNA of students. He cited the story of the Havasupai Tribe of Grand Canyon that won a $700,000 settlement from Arizona State University after the school used samples ostensibly taken to test for Type II diabetes, which was ravaging the tribe, for research on mental illness and the tribe’s origin. Unfortunately, the ASU findings contradicted the tribe’s own legend of its origin. The tribe also won the return of its blood samples.

And yet another commenter at the same blog suspected the project could become this generation’s “posture photos,” a reference to the nude pictures that were taken of incoming freshmen for decades at certain Ivy League and Seven Sister colleges, ostensibly to document the prevalence of rickets, scoliosis and lordosis in the population.

Berkeley Offers Free DNA Testing to Students (by Kim Carollo, ABC News Medical Unit)

DNA Test Replaces Summer Reading Project at UC-Berkeley (by Jennifer Epstein, Inside Higher Ed)

Geno-Luddites and Berkeley’s On the Same Page Program (by Associate Professor Michael Eisen)

Unwinding Berkeley’s DNA Test (by Jennifer Epstein, Inside Higher Ed)

Wider Debate Swirls Over Ruling That Curtailed Berkeley's DNA Program (by Josh Keller, The Chronicle of Higher Education)

UC Berkeley Adjusts Freshman Orientation’s Gene-Testing Program (by Larry Gordon, Los Angeles Times)

Genetic Material and Informed Consent (MetaFilter)

The Great Ivy League Nude Posture Photo Scandal (by Ron Rosenbaum, New York Times)

Ronald Chapman, 2011-2015

Howard Backer, 2011. Named interim director early in Governor Brown’s term.

Mark Horton, 2007–2011. Served under Governor Arnold Schwarzenegger as the first director of the newly created Public Health department.  Was relieved of his position by Governor Jerry’s Brown’s newly appointed Health and Human Services secretary, Diana Dooley.

Beverlee A. Myers, 1978–1983. First woman and first non-physician to become director of the California Department of Health Services, which pre-dated the Department of Public Health and is now a separate agency.  Myers died at 56 of pancreatic cancer in December 1986.

Thomas Logan,  1870–1876. First director of the California Board of Health, the predecessor to the Department of Public Health.