Doyle McCallister weighed 420 pounds when he walked into the Madison County Health Department a year ago.

“My dad had five heart attacks, two open heart surgeries, diabetes and high blood pressure.  I don’t want to go through that,” said the 42-year-old Jackson County corrections officer.

Borderline diabetic and between jobs, McCallister was temporarily without health insurance and couldn’t afford his medication. So he seized an offer made by the local health department’s Stroke and Heart Attack Prevention Program (SHAPP). If he lost an initial ten pounds and continued to lose five more every three months, he would pay nothing to have his diabetes treated.

With the help of counseling on exercise and weight loss and motivated by the risks of uncontrolled diabetes, McCallister far exceeded the goals set by the health department. He lost 100 pounds in a year and continues to lose. At its highest, McCallister’s blood sugar was 120. Now it is under control at 104.

SHAPP helps clients at high risk for four of the five leading causes of death in Georgia – stroke, heart attack, hypertension and diabetes. McCallister is fortunate that his district has a fully functioning program. SHAPPs in many districts have been whittled away to almost nothing, while cancer prevention programs, women’s health, and child and adolescent programs have also been cut dramatically.

“As a whole, public health prevention programs are under-funded, so we aren’t able to 100 percent meet the needs of all those that are eligible,” said Kimberly Redding, M.D., director of health promotion and disease prevention for the Georgia Department of Community Health, Division of Public Health (DPH).

A result of the state’s budget woes, public health spending in Georgia is plunging. For fiscal year 2010, state funds for health promotion were reduced by $1,136, 228.

The hardest hit program was one that could save the state the most money. SHAPP funding was cut by $916,038.

Return on investment

Obesity, associated with all the conditions that SHAPP addresses, costs the state a total of $2.4 billion per year, a combination of the direct costs of doctor visits and medicines and the indirect costs of lost productivity and contribution to the economy, according to Redding.

Tobacco use, which SHAPP helps reduce, costs the state $1.8 billion in health care costs for people over 18 and $3.4 billion in lost productivity costs among adults 35 and older, Redding said.

“Skyrocketing health costs are not sustainable,” Redding said. “Prevention really is the answer to bringing down healthcare costs long term.”

An annual investment of $10 per Georgian in programs shown to increase physical activity, improve diet, and reduce tobacco use could save the state $426 million annually within five years, according to a 2009 report published by the Trust for America’s Health and the Georgia Budget and Policy Institute.

This amounts to a return of $4.77 on every dollar spent.

Public and private employers and employees, and all who purchase health insurance or services, would see the biggest savings at a return of $3.02 on every dollar, while additional returns would come to state and federal tax payers in the form of savings on state and federal Medicaid and Medicare spending.

McCallister’s 100-pound weight loss may soon account for some of these savings. “There’s a possibility that if I continue to lose weight, I could come off my medication,” McCallister said.

He’s not the only one who’s gained by losing: since McCallister committed to changing his habits and losing weight, his wife has dropped from a size 20 to a size 16. It’s not unusual for an individually focused health program to actually benefit a whole family.

Georgia public health districts

While the Northeast district’s SHAPP is alive and well, many other districts report crippling cuts to funding.

Cardiovascular disease is the number one cause of death and illness in Clayton County, as in the rest of Georgia, but budget cuts forced the county to eliminate SHAPP more than two years ago. “It’s always been under-funded and has never been to the level it should be in Georgia,” according to Alpha Bryan, M.D., director of the Clayton County health district and president of the Georgia Public Health Association.

Other parts of the state with little or no SHAPP funding include Valdosta’s South district, Gainesville’s North district, and Rome’s Northwest district.

Cardiovascular health programs are not the only ones to suffer.

Cancer – ‘calling and crying’

Gladys Long, who was treated for cancer 30 years ago, knows all too well the limits on public health resources for mammograms. As an outreach coordinator for the Georgia Cancer Foundation, Long educates African American and Latina women in Gilmer County on the importance of mammograms and refers them to providers.

“I saw that lots of minority groups were being diagnosed with cancer,” she said. But Long scrambles to find other resources when under-funded health departments can’t accept all the women referred for their Breast Test and More program.

This program is meant to improve access to breast and cervical cancer screening for low-income, uninsured women, but many districts ran out of funding for the program early this year.

“In Lowndes County they’ve got 200 women calling and crying, but I don’t have the money to run that program if the state can’t help us,” said Lynne Feldman, M.D., South district director.

Statewide, the program tests 19,000 women for breast cancer and 90,000 for cervical cancer each year, “but that’s still a very small percent of eligible women,” Redding said. In 2009, 14 percent of eligible women were screened for breast cancer through the program; 21 percent were screened for cervical cancer. “We do a lot, but there is never enough money to screen every woman who needs to be screened.”

Health districts including LaGrange, Cobb-Douglas, Coastal, North, and South have either suspended the programs or instituted wait lists for mammograms until funding is available. Shifting patients to the next fiscal year, however, guarantees that the next year’s budget will be depleted even faster, said Feldman.

In Feldman’s district, mammography funding ran out in late March even though the district had already switched women from annual to biannual screening.

The story is the same for women in other parts of the state. “That happens every year. We’re typically out of money by early spring for those programs,” said David N. Westfall, M.D., director of the North district.

Women’s health takes a hit in other areas as well.

Reducing teen pregnancy risk and cost

Most of the young mothers who attend “Cabbage Patch” classes will tell you that if not for the program they might not have breastfed.

Cabbage Patch is a series of free classes on prenatal health and infant care at the Madison County health department offered to women with high-risk pregnancies.

“They taught you how to breastfeed and when the baby is latched on correctly,” one mother explained.

Breast milk decreases infants’ risk for conditions from ear infections to asthma and obesity. Nursing mothers lower their risk for type 2 diabetes, breast and ovarian cancer, and postpartum depression. The combined benefits for mother and child improve quality of life, lower healthcare costs and create a more productive workforce, not to mention the savings on formula of $1,160 to $3,915 a year.

Teen mothers are especially unlikely to breastfeed, and early childbearing is a major public health concern in Madison County.  Cabbage Patch has had success in addressing this and other risks associated with teen pregnancy.

Teenagers are more likely to give birth prematurely and have low birth-weight babies, whose early days of life are enormously expensive. A low-birth weight infant increases the cost of a birth in Georgia from $3,000 to $40,000.

Infants are born underweight all too often in Georgia. In fact, the state surpasses the national average for low birth-weight as well as those for births to teenagers and premature births.

In Madison County, about 15 percent of all babies arrive ahead of schedule. But only 5 percent of Cabbage Patch participants, who are considered higher-risk than average, went into pre-term labor last year.

The county has also had success preventing unwanted pregnancies. In 2008, before the Teen Matters clinic arrived, 62 percent of sexually active teens were on an effective hormonal method of birth control. In 2009, that number had risen to 84 percent.

Preventing unwanted pregnancies saves money. In Georgia, 50 percent of births are paid for by Medicaid, according to The March of Dimes Data Book for Policy Makers: Maternal, Infant, and Child Health in the United States 2010. Yet family planning programs are often vulnerable when money is tight.

The North district recently lost its full-time adolescent educator and three family planning positions, greatly limiting the health department’s ability to provide birth control and to educate teens on abstinence, contraception and STDs.

Teen pregnancy brings a greater need for prenatal and newborn care. Yet in the North district, funds for obstetrician visits and Babies Born Healthy were exhausted early this year. The Northwest and Coastal districts were also forced to cut back on home visits that help parents keep babies healthy and developing on schedule.

Teen pregnancy also highlights the importance of programs that teach adolescents good decision making skills and self esteem.

Pregnancy is the number one reason girls drop out of high school. Daughters of teen moms are at an elevated risk of dropping out and becoming teen mothers themselves, which mires generations of women in poverty.

Outreach programs like the South district’s Adolescent Health & Youth Development (AHYD) program and the North’s Niyelo, an adventure activity-based youth prevention and counseling program, may help. AHYD has lost some funding and participating teens have been required to pay a registration fee. The North’s Niyelo program was eliminated completely due to budget cuts.

‘Measuring something that doesn’t happen’

“Public health isn’t just about treating poor people, it’s about protecting the public on a day-to-day basis,” Clayton County’s Alpha Bryan said. Pool, restaurant, and hotel inspections are public health safeguards many people take for granted.

Teaching Americans to wash their hands more often, to prevent the spread of colds and flu, was the work of public health prevention programs as well. “It seems like a small thing to do, but training an entire nation to cough into their elbow instead of their hand, it took public health to make that happen,” said Kathryn Martin, Ph.D., of the Chatham County Board of Health.

“Without prevention,” Martin said, “we’re going to see a disparity in healthy versus unhealthy employees. Prevention can affect your bottom line.”

Redding recognizes that investment in prevention will require a shift in thinking. “It’s easier for people to see the immediate result of treatment versus prevention.” Measuring the result of prevention is different, she said, because “you’re measuring something that doesn’t happen.”

With so much political attention focused on healthcare costs, and more public discussion about the value of addressing problems before they worsen, Redding is optimistic. “The pendulum seems to be swinging towards understanding. If people were willing to commit to that investment, it would take us a long way.”

This article is the third of a series developed by the Public Health News Bureau, a project funded by Healthcare Georgia Foundation. The Bureau is staffed by graduate students from the health and medical journalism concentration in the University of Georgia’s Grady College of Journalism and provides information about the state’s public health system that is distributed via the Partner Up! For Public Health advocacy campaign.

Sonya Collins

Sonya Collins

Sonya Collins is an independent journalist whose recent stories about public health, medicine and biomedical research have appeared in Yale Medicine magazine, [email protected], and print and online publications served by the Georgia Public Health News Bureau.  She has also contributed news stories, columns, features and travel pieces to local and regional publications in New York, Georgia, and Brazil.  While earning an M.A. in Health & Medical Journalism at the University of Georgia, Sonya was a two-time science writing fellow at research conferences sponsored by the National Academies of Science and held in Irvine, CA.

Before becoming a journalist, Sonya earned an M.F.A. in creative writing at The New School, where she was a teaching fellow. She has also taught writing at Hunter College of the City University of New York, where she earned her B.A., and at the University of Georgia. During her teaching stint at UGA, she contributed an article on author Elizabeth Gilbert (Eat, Pray, Love) to the Encyclopedia of Contemporary American Fiction published in 2010.

Fluent in Portuguese, Sonya has translated literary and scholarly texts for publication.  She lived in Brazil for two years, where she wrote a collection of essays about life on the island of Florianópolis.