The proposed House budget makes critical cuts to the Department of Health's general funds and the Tobacco Settlement Special Fund.

Of the proposed 300 position cuts in the House budget, 251 (84 percent) are from the Department of Health. The Tobacco Settlement Special Fund — which provides the only funding for primary prevention for physical activity, nutrition, obesity and the majority of funding for tobacco prevention and control — would be reduced by an amazing 77.8 percent, given fund diversion and addition of programs and positions reallocated from other sources.

These cuts would have a substantial impact on the health of the people of Hawai'i. We have been admired as the Health State and have enjoyed the longest lifespan in the U.S. This is now in peril. If the proposed cuts are enacted, public health in Hawai'i may never recover. Ten years after the closure of the School of Public Health, only a small program, the fraction of the size of the old school, remains. Public health is often the first to be cut and the last to be invested in. These decisions have lasting and important effects on the health of our people and the cost of medical care.

Physical inactivity, poor nutrition and tobacco use account for about two-thirds of the premature deaths in the U.S. Healthcare costs are growing at a rapid rate with the medical plan, Medicare, retiree health benefits and worker's compensation accounting for almost 20 percent of the fringe benefits paid to state employees.

Luckily, prevention works. A recent study from Eric Keuffel of the University of Pennsylvania showed that physically activity adults used up to $200 less in medical care per year and had 17 percent fewer sick days than sedentary adults. A 2004 study calculated adult-obesity attributable medical expenditures in Hawai'i to be $290 million dollars. Continued funding of effective programs could greatly reduce this number.

California's state tobacco control program saved $86 billion — in 2004 dollars — in personal healthcare costs in its first 15 years, a 50-to-1 return on investment. The Hawai'i program, which is modeled after California's program, should be realizing returns close to this shortly.

Prevention programs also save lives. Tobacco use, lack of physical activity and poor nutrition have been strongly linked to heart disease, cancer and diabetes. Numerous studies have shown the strong, comprehensive prevention programs change behavior.

Successful programs include social marketing, changes in policy to create walkable and bikeable communities, healthy school policies and programs, physician education and training, community-based coalitions and strong surveillance and evaluation. These programs have a direct, measurable effect on health. However, when prevention programs end, there is a quick return to previous behaviors.

The general fund cuts to the Department of Health will greatly reduce its ability to respond to public health threats. Public health is a wide-ranging field and includes restaurant sanitation inspections and food safety, outbreak control and investigation for diseases like SARS and avian influenza, monitoring the health status of populations, monitoring air and water quality, immunizations, recycling, collecting vital statistics and informing and educating the population on a variety of health topics. All of these areas would be greatly affected given the proposed budget cuts.

In the next few weeks, the Senate and a conference committee will develop a budget with less money than needed to fund all of the competing priorities. This will be an arduous task with many tough decisions to be made. Choices made in this fiscal year will have reverberations that will be felt for generations.

The already crumbling public health infrastructure will be tested and I hope not decimated. Other areas to generate revenues, such as taxes on tobacco, liquor, junk food and gasoline, should be explored.

With the rise in childhood obesity, the ongoing threat of emerging infectious diseases, the possibility of bioterrorism and the closure of the School of Public Health, Hawai'i is at a perilous crossroads between protecting the health of our population and utter chaos. Let's hope lawmakers choose wisely.

Jay Maddock is the director of the Office of Public Health Studies, UH-Manoa, and vice chair, state Board of Health. He wrote this commentary for The Advertiser.

Reach Jay Maddock at (Unknown address).