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Lab Matters Spring 2009 Cover - Unstaffed Laboratories Threaten Public’s Health 
Unstaffed Laboratories Threaten Public's Health

Radioactive slurry from Moab Tailings, a uranium mill waste pond in southeastern Utah, is believed to be leaching into the Colorado River. A hundred miles down US 191, Ute tribal members are worried about possible contamination from radioactive waste at the White Mesa Uranium Mill. As these cases suggest, the toxic legacy of Utah’s long mining history—and an estimated 5,000 abandoned uranium mines—will not go away anytime soon.

But what has disappeared is the state’s ability to perform radiation testing. The last of Utah’s radiation chemists was laid off February 2, when the state public health laboratory shut down its radiation chemistry unit, a victim of state and federal budget cuts.

The work is now being outsourced to labs in California, placing a critical public health service hundreds of miles away. Said laboratory director Patrick Luedtke, MD, MPH, "It means we’re not able to respond to environmental catastrophes that are naturally occurring or manmade."

The closure has inevitable consequences beyond Utah. The Colorado River, for example, is the primary source of drinking water for millions of households in downstream Arizona and Southern California.

"We are part of that greater safety net in the US," said Luedtke. "And that safety net has a lot of holes in it, because there are only 20 or so radiation labs in the entire US... And we just made another hole."

With uranium mining on the verge of a comeback in Utah and radiological terrorism a continuing national concern, the timing could scarcely be worse.

Alarmingly, Luedtke’s former chemist is but one of hundreds of state and local laboratory workers nationwide whose jobs have been lost or are now at risk owing to recessionary budget cuts. Based on a member survey, APHL estimates about 430 state and local laboratory positions were either eliminated or left vacant in 2008 and another 250 or so will likely be eliminated or unfilled this year.

Altogether, APHL estimates state and local government laboratories have seen their budgets cut by about $39 million.

Coming on the heels of a significant long-term laboratory workforce shortage, this erosion of staffing and funding now threatens fundamental public health services across the country. The Maryland Laboratories Administration is struggling to maintain its newborn screening program. And the Louisiana Public Health Laboratory, which once tested all types of raw and cooked foods for bacterial contamination, now tests only molluskan shellfish.

After losing 29 of 112 positions, Louisiana’s public health laboratory director, Stephen Martin, PhD, said, "Everything is run on a shoestring. I wouldn’t say we have any surge capacity at this point."

Peter Kyriacopoulos, APHL’s public policy director, said the association’s most important priority is "to find funding that will help our members retain the highly qualified and highly trained staff they have."

APHL joined other public health advocates in supporting a tripling of the Preventive Health and Health Services Block Grant—a previous source of federal funding for laboratories in public health—in the House version of the president’s stimulus package. A small group of Republican senators was instrumental in nixing that increase, which would have hiked funding from about $100 million to $296 million.

"Sadly," said Kyriacopoulos, "it does not look like there will be a huge increase in the block grant in fiscal year 2010." The omnibus appropriations bill for 2009 had a marginal increase.

APHL is now trying out new ways to articulate the impact of laboratory testing on the population’s health. Kyriacopoulos said, "We want to find ways to collaborate with all of the people who use the data the laboratory generates." One effort is a survey to capture information about specific tests that might be eliminated.

The association has found that some jurisdictions are faring worse than others. For example, while state public health laboratories in Texas and New York so far remain unscathed by the recession, those in Utah, Michigan and California have been hit hard.

Utah: 'Another Hole in the Safety Net for the Whole Country'

In Utah, Luedtke said, "Our real problems began last summer." His laboratory not only suffered a major cut in federal bioterrorism funding (which also supports routine disease surveillance) but the state reversed its funding formula for state and local health departments from 60% state–40% local to 40% state–60% local. "That resulted in four people being riffed over the course of just a few weeks," he said.

Overall, the Utah public health laboratory has lost 10 positions since the start of its fiscal year last July, and those losses now impact everything from the testing of drinking and swimming pool water to support for law enforcement investigations and the state medical examiner.

Consider the difference one person can make. In February, Luedtke let go the toxicologist responsible for virtually all blood alcohol testing in Utah. That duty was shifted to other forensic scientists, on top of their customary workloads, and immediately the turnaround time for DUI tests shot up 20%.

"If you look at the way the court system works," said Luedtke, "when somebody is suspected of driving under the influence, they have to show up in court as part of the due process. And if we don’t have the test result back at their first court date—and we think we won’t—those people are going to go back out on the road. That’s a concern to us."

At the same time, the turnaround time for routine cause-of-death tests has lengthened from 21 to 28 days and continues to drift upward, delaying the payment of life insurance benefits to survivors. "We’re potentially keeping someone in extremis if the deceased was the primary breadwinner," said Luedtke.

Come August, the laboratory’s Level 2 chemical terrorism laboratory will drop to Level 3, meaning it will no longer meet funding and staffing requirements to test for agents like arsenic, ricin and toxic industrial chemicals. Instead, the laboratory will pack and ship suspect samples out of state—"another hole in the safety net for the whole country."

Michigan: 'The Hemorrage Has To Stop'

Frances Pouch Downes, DrPH, director of the Michigan Public Health Laboratory, is at ground zero of the US recession. Michigan’s economic struggles began with the recession of 2001 and have continued unabated. Now, with the meltdown of the state’s core automotive sector and a 12% unemployment rate—the highest in the nation—Downes expects the downturn here will be "deeper and longer" than in any other state.

The effect on the laboratory has been harsh. "In general, the ability of the lab to fulfill its mission gets increasingly more tenuous," said Downes.

The laboratory lost 17 of 150 positions in the past six years, including five since January 2008. Infectious disease testing, which relies on state and federal support, has suffered a disproportionate share of cuts.

Among the most recent staff departures are an IT specialist working on the lab’s information management system and the program advisor heading up efforts to build a statewide clinical laboratory system.

A TB technician slot is now being held open. "We don’t have approval to fill it," said Downes, "and there’s no guarantee we will in this environment."

In the face of repeated budget cuts, Downes has been experimenting with several strategies to preserve as much testing as possible. More aggressive Medicaid billing has enabled the laboratory to switch a few technicians’ salaries from state funding to fee-for-service funding. This move allowed the lab to maintain its blood lead testing program and some STD testing despite a loss of general funds.

The lab has also reduced the volume of hazardous waste generated on-site to decrease disposal costs and instituted a robust cross-training program, so employees are able to perform multiple functions.

Staff work schedules and pay have been subject to any number of adjustments; some voluntary, some not.

"We’ve done the concessions," said Downes. "No cost-of-living increases, and unpaid hours are not new to us at all. We have been doing that for years."

From 2006 to 2008, the state instituted a mandatory program of "bank leave hours," in which staff accrued unpaid hours that could be added to vacation leave or reimbursed as an equivalent contribution to employee 401(k) plans upon retirement. The program was discontinued after the Internal Revenue Service found it problematic.

Pay-for-performance incentives for executive staff have not been available for at least five years. Downes said, "I’ve got people in this executive management system who are not getting even routine salary increases that you would expect as they acquire experience."

The state now has a voluntary work reduction program in place. "At first I didn’t approve those because of our workload and the vacancies we carried," said Downes. "Now I’ve started to approve them because of the cost-savings. We’ve had to rethink that approach."

Where innovation and sacrifice have reached their limit, the laboratory has been forced to pare services. The public health laboratory no longer performs routine species identification of non-TB mycobacteria; physicians must request the service if they suspect a novel pathogen. "If we had a new strain or new species of mycobacteria emerging in an unexpected niche, we wouldn’t recognize it rapidly," said Downes.

The laboratory’s physical infrastructure is also hurting: "We’re not replacing old equipment. We’re cutting back on replacing outdated computers. We’re abrogating some service contracts... We’re taking a risk."

The loss of resources, said Downes, is "going to lead to, at least for me, a process of reevaluating what we’re doing. And if this continues, we’re going to have to eliminate services."

She said, "I would rather do 10 things well as opposed to doing 12 things not as well. There’s only so much we can do. The hemorrhage has to stop."

California: 'We Don't Know What's Going On' 

As a hub for sub-prime mortgage lenders, Southern California was at the leading edge of the global financial crisis. Today, the state has double-digit unemployment and an empty treasury.

The California State Public Health Laboratory (CSPHL), along with the rest of state government, has already shed student workers and "retired annuitants," a category of employees who have retired from state service and returned to work on a part-time basis.

Since last fall, all California agencies have been subject to a two-day/month furlough, amounting to a 2-3% employee pay cut. At first, government offices were closed the first and third Fridays of each month, for all except emergency work. In March, Governor Arnold Schwarzenegger remanded that order and asked agencies to stagger employee furlough days to keep government doors open.

The biggest hit, though, is still pending.

In January, the governor instituted mandatory, across-the-board lay-offs of the least senior 10% of the entire state workforce. CSPHL Director Paul Kimsey, PhD, explained that "the bottom 10% was calculated and those people received layoff letters; they were put on notice that they were declared surplus and a layoff process was initiated."

However, because it takes about six months for authorities to work through all the civil service rules and regulations governing lay-offs, those "surplus" workers are still on the job, and Kimsey said the governor’s office is now rethinking the layoffs.

"If you’re an employee and you’ve received one of those letters, you’re wondering what’s going on," he said. "We don’t know what’s going on."

The one certainty is that such a huge loss—amounting to dozens of employees from essential support staff to scientists with highly specialized training—would devastate the laboratory.

Because the least senior 10% of the public health laboratory workers are distributed unequally across laboratory units, some units would lose few employees, while others would lose as much as 75% of their staffs.

The Food and Drug Laboratory Branch microbiology section, for example, would likely be so understaffed that it would cease all food regulatory testing and nearly all work to support foodborne illness investigations and traceback investigations of food products with microbial contamination. Such a development would reverberate well beyond California, a state that is, after all, home to an agricultural corridor popularly known as "The Salad Bowl of the World" and that exports more produce and tree nuts than any other US jurisdiction.

[A California spinach farm was the source of the E. coli O157:H7 outbreak that killed three people and sickened hundreds across the US and into Canada in 2006.]

Other Food and Drug Laboratory Branch staff losses would hinder the analysis of foodstuffs for chemical contaminants, such as melamine, potentially delaying product recalls and endangering health.

In the CSPHL’s Environmental Health Laboratory, layoffs would disrupt the development of new analytical methods and halt research on nanoparticle emissions from laserjet printers, as well as measurement of formaldehyde and other volatile organic compounds off-gassed by building materials.

Other CSPHL branches would suffer similar consequences.

Given that the California budget bill enacted in February has already fallen out of balance, with plunging state revenue creating a new, multi-billion dollar shortfall, Kimsey said the likelihood of proposed layoffs taking effect is "still very unclear" as of early April.

Concrete Losses, Questionable Gains

The piecemeal dismantling of laboratory units is undoing years of effort and millions of dollars of government investment in sophisticated public health testing. Often, this substantial sacrifice does not even bring expected cost-savings.

Luedtke noted a domino effect. He said, "Some of these state-funded positions do work for other state agencies for free. Now the state will have to pay someone else to do the work, probably for more money than it cost us to do it."

Government scientists also do fee-for-service work for private entities and other government jurisdictions. Overall, Luedtke reckons that for every $100,000 cut in state funds, the Utah public health laboratory foregoes an additional $30,000 to $50,000 in fee-for-service work that it will no longer be able to deliver. He estimates his total forfeited fee-for-service income at about $250,000.

In California, the proposed downsizing of the lab’s Food and Drug Laboratory Branch would leave it with insufficient staff to meet its obligations under three federal emergency preparedness grants, amounting to a potential loss of nearly a million dollars in annual federal funding. Elimination of the grant programs, in turn, would impact national emergency preparedness, since California would no longer assume its role as a key member of the Food Emergency Response Network, coordinated by the USDA and FDA.

Proposed staff losses in California’s Environmental Health Laboratory would endanger a $3 million/year CDC grant supporting a new state biomonitoring program, a groundbreaking effort to monitor residents’ exposure to select pollutants.

Once gone, some programs will be hard to resurrect.

Certain types of scientists are extremely difficult to recruit, especially in predominately rural states. Radiation chemists are so hard to find that Luedtke said, "We have a sense that radiation chemistry may be gone forever."

The piecemeal dismantling of laboratory units is undoing years of effort and millions of dollars of government investment in sophisticated public health testing.  Often, this substantial sacrifice does not even bring expected cost savings.

Other types of scientists, such as water microbiologists, must undergo extensive training and achieve federal certification before they can assume senior positions.

But there are other obstacles as well. Michigan’s Downes explained, "The bigger challenge is administrative approval to reinstitute a position once it’s eliminated and removed from the organizational chart. Then it’s considered a new position. And having to justify a new position is much, much, much more difficult than filling a vacant position."

The Colorado Department of Public Health and Environment’s Laboratory Services Division (CDPHE-LSD) is one of only two state public health laboratories receiving no state funding at all. Since 2002, the CDPHE-LSD has relied on user fees as its main source of income.

Said Director David Butcher, MBA, MT(ASCP)SM, "It worked as long as we could supplement it with adequate grant funds, because you can’t run a total fee-for-service shop."

The problem, he said, is that it is often impossible to identify a willing payer for public health testing: "If a potentially rabid dog’s running loose, everybody wants to be sure they’re not exposed to it, but if you ask someone to pay a fee to test that dog, you don’t have as many people stepping forward."

After winning department and governor support to petition the state legislature, Butcher has preliminary approval for a resumption of some state funding next year. If the funding comes through and a statewide hiring freeze is lifted, he will begin to refill 10 positions that he is holding vacant to balance his budget.

California’s Kimsey noted that the collective impact of state and local laboratory downsizing is akin to placing blinders on the health and safety officials tasked with crisis management. He said, "Inevitably, erroneous decisions will be made. There will be greater reliance then on federal laboratories, and states will have far less capacity to make public health decisions."

As one example, Kimsey said, "If you look at the information authorities used during the investigation of Salmonella tainted peanut butter, that’s all local information. The federal government isn’t capable of providing that level of local and state data for national outbreaks."

Without that rich collection of data—including the identification of specific patients known to be contaminated with the outbreak strain of Salmonella Saintpaul—Kimsey said the source of the outbreak "may not have been figured out." If current trends continue, he said, "We’ll just have a higher level of disease burden and mortality and just not know why."