Public health preparedness in a time of budget cuts

Last week, the House of Representatives Committee on Homeland Security Subcommittee on Emergency Preparedness, Response and Administration held a hearing on the National Preparedness Report released earlier this year by the Federal Emergency Management Administration. Subcommittee Chair Gus Bilirakis noted in his opening remarks that it’s the start of hurricane season, and cited the response to Hurricane Irene and the Joplin tornado as evidence that preparedness in the US has improved since the days of September 11, 2011 and Hurricane Katrina.

The first witness was FEMA Deputy Administrator Timothy Manning, whose written testimony highlights some of the ways preparedness has improved nationwide, including better communications systems, networks of specialized teams that respond quickly to hazards or conduct search and rescue operations, and improved “strategic and tactical communications planning and coordination” by government agencies at all levels. He explained that the US now has a National Preparedness Goal that involves 31 core capabilities needed to “prevent, protect against, mitigate, respond to, and recover from the threats and hazards that pose the greatest risk to the Nation” as well as a National Preparedness System to achieve the goal. But, he reminded the Subcommittee, “preparedness is not an end-state, it is a process.”

Just as it’s essential to keep evaluating and strengthening response capabilities, it’s important to sustain progress that’s been made toward the goal of preparedness. And witness Georges Benjamin, executive director of the American Public Health Association, highlighted and expanded on a section of FEMA’s report that warns “The Nation has built a highly respected public health capacity for managing incidents, but recent reductions in public health funding an personnel have impacted these capabilities.” In his written testimony, Benjamin explains:

There are core functional capacities you want in a public health preparedness system. You want to know when a disease syndrome first enters a community, the ability to rapidly identify the cause of the disease and how it is contracted, the ability to conduct accurate new case findings and tracking, the ability to communicate effectively to a range of stakeholders (including the public) and disease containment and treatment ability. In a terror attack the forensic component of these efforts magnify the importance of these requirements.

I’ve written before (e.g., here and here) about the importance of having labs, epidemiologists, and other elements of a public-health system that can conduct surveillance and respond quickly to an increase in cases of a particular disease. But these are exactly the kinds of facilities and positions that have been falling victim to budget cuts over the past several years. Benjamin’s testimony includes some troubling figures:

Since 2008, more than 52,000 public health jobs have been lost at local health departments and state and regional health agencies. These numbers represent 17 percent of the state and territorial public health workforce and 22 percent of the local public health workforce.

State and territorial health agencies continue to report ongoing job losses and budget cuts to critical public health programs. According to the most recent survey of state health agencies conducted in March 2012 by the Association of State and Territorial Health Officials, between July 1 and December 31, 2011, 30 percent reported staff layoffs, 41 percent reported the loss of staff through attrition, 24 percent reported cutting entire programs and 46 percent reported a reduction in services provided. Cumulatively, since 2008, the numbers are even greater with 56 percent reporting layoffs, 62 percent cutting entire programs and 91 percent reporting a reduction in services provided.

The situation is just as dire among local health departments. According to a January 2012 survey of local health departments conducted by the National Association of County and City Health Officials, 57 percent of local health departments reduced or eliminated at least one public health program in 2011, with emergency preparedness activities taking the biggest hit. Twenty three percent of local health departments reported cuts to emergency preparedness programs in 2011. The effects of the recession continue to be felt among local health departments with 41 percent of departments reporting that their current year’s budget is less than the previous year and 41 percent reporting that they expect additional cuts in the coming fiscal year.

Benjamin offers an example of how quickly and dramatically a public-health system needs to ramp up in a crisis: the 2001 anthrax attacks, which hit the East Coast when Benjamin headed Maryland’s department of health (emphasis added):

Our disease surveillance staffs were superb but we were often challenged to keep up with our day-to-day responsibilities before the attacks. When the attacks occurred, we utilized many other staff from across the agencies that were in programs unrelated to public health preparedness to use their skills in support of this emergency response. In this way, chronic disease epidemiologists, maternal child health epidemiologists and HIV/AIDS workers were recruited to help. Often working 18 to 20 hours a day, sleeping on the floor or on cots in their offices these heroic public servants did what was required to respond to this effort. Erosion in other programs unrelated to preparedness has a negative impact on the ability of a public health agency to scale up when a disaster occurs.

… Maryland is fortunate to have had one of the best public health laboratories in the country. A public health laboratory is very different from a hospital or clinical laboratory. We served as the reference lab for many lab samples, the prime testing lab for many clinical and nonclinical samples and the link to the FBI for forensic samples. Our laboratory was swamped with samples from sources all over Maryland and the District (as their laboratory did not have appropriate equipment to do the testing at the time). Over 300 samples a day came into the lab for several weeks. All of the positive samples required follow up with the sender and had to follow a chain of custody to be sent to the FBI. This relatively limited and small, but serious incident (five letters), completely inundated our system. It was a massive undertaking for months and a staffing and logistical challenge. The federally supported laboratory response network played a critical role in our response activities.

A strong public health system isn’t important only when something like anthrax attacks or SARS happens, although that’s when people tend to appreciate it the most. It’s important to identify and respond to the kinds of disease outbreaks that happen fairly regularly, like foodborne illnesses or vaccine-preventable diseases in communities where vaccination rates have fallen. (For more on what public health laboratories do on a day-to-day basis, read about Kim Krisberg’s visit to her local lab.) Most of us are probably grateful to first responders and law enforcement officials, even if we don’t benefit from their services directly in a given year. It can be hard to envision what public health workers might do for us as individuals, but their work does have an impact on our communities’ health.

To a great extent, the US has taken to heart the lessons of 9/11 and Katrina and invested substantial resources into preparedness. But budget cuts are undoing some of these achievements, especially when it comes to public health systems. Let’s hope we’re able to re-invest in these important systems before the next massive disaster strikes.

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Let me be more blunt. This nation has failed to protect the public’s health and, in recent years, had made a bad situation worse.

While we spend enormous amounts of money on health care, we spend next to nothing on prevention and public health. Our priorities are wrong. The public’s relatively poor health, as measured absolutely or relative to other nations, reflects those wrong priorities.

It is not just about the threats of diseases, risks in the environment, or threats to our drinking water, it is about a nations that smokes too much, abuses alcohol and drugs too much, and has a poor and deteriorating diet (too much obesity being just one consequence).

The time is long overdue to redo our priorities and re-build and reinvigorate a strong public health system at the local, State and national levels. Then and only then can we achieve a healthy and thriving future for all people and for the nation.

Gary Christopherson, Founder, HealthePeople
Former Defense Health Affairs Principal Deputy Assistant Secretary and CMS Senior Advisor

By Gary "Chris" C… (not verified) on 15 Jun 2012 #permalink

Well said.

The tough thing about re-priortizing is that it's much harder to take away something people have come to expect -- like expensive surgical procedures or cancer drugs -- than it is to set the right priorities from the start.

And as we've seen with the Prevention and Public Health Fund, any time there's a chunk of money dedicated to public health, Presidents and Members of Congress will be quick to suggest other uses for it.

Massively increasing prevention investments is too worthwhile a goal to abandon just because it's hard, but I can see why it hasn't happened yet.