SARS, West Nile virus and bioterrorism are the big scares. But the greater threat is the gradual erosion of public health services.
When Seattle received $2 million in federal money last year to prepare for a possible biological, chemical or radiological attack, public health director Alonzo Plough was relieved. Along with his counterparts around the country, Plough had watched new health threats multiply while public health budgets stagnated. Finally, he thought, the city would have funds to work out emergency procedures with area police departments, fire officials and other "first responders." He'd be able to hire new staff to help combat naturally emerging diseases as well.
Things haven't worked out as he planned. No sooner had he launched a terrorism-planning effort than he had to drop it because the federal government ordered its sweeping smallpox-vaccination program. That task tied up so much of Plough's staff that they were slow to detect a new outbreak of tuberculosis among Seattle's homeless population. As officials scrambled to catch up with that problem, SARS, or severe acute respiratory syndrome, emerged in China. Almost immediately, the mysterious disease started showing up in travelers returning from Asia. Plough had to divert staff from the unfinished smallpox and tuberculosis efforts and put them to work to keep the new disease from spreading in Seattle.
Plough's job has become a continuous exercise in triage. The reason: His department has too much to do and too few resources. "In my 20 years in public health, I have never seen such a layering of challenges, all with fairly equal urgency and all drawing on diminishing core funding," he says. "We aren't providing anything near the web of protection that's needed."
The problem isn't unique to Seattle. All over the country, local public health departments are struggling to keep on top of a growing list of health threats. Terrorism may turn out to be the least of their concerns. Changing patterns of land use are bringing people into contact with dangerous new microbes such as the West Nile virus and the coronavirus, which is believed to be the cause of SARS. Globalization is spreading these diseases more rapidly than human immune systems or modern science can build defenses. And many see a scenario in which the familiar influenza virus abruptly morphs into a deadly pandemic that the U.S. Centers for Disease Control and Prevention estimates could kill as many as 300,000 people. On top of that, old maladies such as tuberculosis have started appearing in drug-resistant strains; sexually transmitted diseases such as HIV and syphilis are on the rise because many people have become complacent about them; and chronic diseases such as asthma and diabetes are becoming more prevalent due to environmental and behavioral factors.
Local public health leaders widely agree with Plough that their tools and budgets haven't kept pace with these challenges. Despite the growing threat from communicable diseases, for instance, state health agencies employ fewer epidemiologists today (1,400) than they did in 1992 (1,700). When a professional association this fall and winter asked state health laboratory directors to rate their preparedness to handle a terrorist chemical attack, half scored their own facilities "1" or "2" on a scale of 1 to 10, with 1 being the poorest mark. And a Little Hoover Commission in California declared in April that the state's "public health infrastructure is in poor repair, providing less protection than it should against everyday hazards and unprepared to adequately protect us against the remote but substantial threats we now face." The commission noted, among other things, that only 20 percent of reportable diseases and conditions were actually reported to public health officials, and that at one key health laboratory, only 60 of 100 positions were filled.
As California goes, so goes the nation. Updating a 1988 report that concluded the country's entire public health system was in "disarray," the National Institute of Medicine said last fall that the system is plagued by "outdated and vulnerable technologies, lack of real-time surveillance and epidemiological systems, ineffective and fragmented communications networks, (and) incomplete domestic preparedness and emergency response capabilities."
STARVING THE SYSTEM
Policy makers are aware of the holes in the public health system. Last year, the U.S. Congress provided $940 million to help local health departments cope with emerging threats. Local health officials hoped to use the funds not only to prepare for terrorist attacks but also to improve their ability to conduct general surveillance and cope with natural outbreaks such as SARS.
The federal smallpox-vaccination program has absorbed nearly all of the funds so far, however, making "dual use" largely a chimera. Indeed, many local officials say the federal government hasn't even provided enough money for them to prepare adequately for possible terrorist attacks, let alone cope with naturally occurring diseases that already are killing people. In particular, the preoccupation with smallpox has set back efforts to plan defenses against a host of other potential biological weapons, including plague, tularemia, botulism toxin, and viral hemorrhagic fever; chemical agents such as ricin and sarin gas; and a possible "dirty bomb" laden with radioactive materials.
Many public health officials such as Plough also say they lack secure communications networks linking them with other first responders. On top of that, public health officials have received no money to start educating the public about what people should do if there is a biological or chemical attack. "We are writing plans, but plans by themselves don't automatically translate into increased capacity," says Jeffrey Duchin, chief of the Seattle health department's Communicable Disease Control, Epidemiology and Immunization section. "We aren't committing the resources needed to turn them into living documents."
Federal officials counter by saying that state and local agencies would have trouble absorbing many more funds than Congress has provided. But the increased federal funding has had an unintended side effect: Fiscally strapped states and localities have seized on it to cut their own public health spending. In Colorado's Larimer County, for instance, a $700,000 slash in state funds for public health more than erased a gain of $100,000 in federal money. Even with new federal funds, the Boston Public Health Commission has been forced to cut scores of positions.
"Overall, we are losing money in the public health budgets in the 50 states, despite funds for terrorism preparedness," says Dr. George Benjamin, executive director of the American Public Health Association. Benjamin formerly was health director for Maryland, which has received federal funds to increase its epidemiological staff but has been forced to cut its state-financed food safety program.
Perhaps more troubling, public health departments have had to rely increasingly on revenues that come with many strings attached. For years, they have sought wherever possible to support programs with grants or with user fees, such as charges for restaurant inspections. But you can't charge a mosquito when you test it for West Nile virus, and while you can persuade public and private grant-makers to provide funds for programs aimed at recognized ills such as breast cancer, nobody seems to want to pay for ongoing operations or general preparedness. "There is a much greater investment in public health and public health programs now than there was a decade ago," notes Mary Selecky, Washington State's secretary of health and president of the Association of State and Territorial Health Officers. "But there is far less flexibility in how the dollars are spent. We are driven by categorical funding."
Seattle's health department, considered by many to be dynamic and forward-looking, illustrates the problem. Its overall budget has grown impressively, reaching $187.9 million this year from $77.5 million in 1993. But almost all the increases have been in programs supported by user fees and grants. County government gives it $28 million to run its emergency medical services; a federal program provides $5 million to support AIDS victims (but not to help prevent spread of the HIV virus that causes AIDS); and the Robert Wood Johnson Foundation donated money for the development of a program to deal with asthma.
None of these funds pay for basic public health operations, including surveillance to detect new disease outbreaks, investigators to track the spread of diseases and a host of prevention-oriented activities. This year, funding for "core" activities totaled $30.9 million, barely up from $30.1 million 10 years ago. The current West Nile virus and TB outbreak alone would more than eat up that increase this year. And that doesn't take inflation or Seattle's substantial population growth into account. Per capita, core funding has dropped from $21.34 in 1997 to $16.67 today.
Behind those numbers lies a slow deterioration in the department's ability to address long-term problems or react quickly to changing conditions. When SARS hit this spring, for instance, the department couldn't follow up on a number of hepatitis B cases. The rate of childhood immunizations has fallen since 1998, while cases of measles and pertussis (whooping cough) have increased, and new TB cases are at a 30-year high.
When a team belatedly began combating the TB outbreak, it moved ahead in fits and starts. The key to stamping out such an outbreak is painstaking detective work: Investigators interview known victims, identify places they frequent and other people with whom they have come in contact, and then follow up those leads with additional screening and information-gathering. Eventually, such searches enable them to track a disease's movements, isolate it and stamp it out. By this spring, investigators had collected more than 50 pieces of information on each of some 528 actual or potential carriers. But the information lay unanalyzed for precious weeks because the outbreak team couldn't find an epidemiologist to work on it.
"Somewhere in there is the answer to where and how this got kicked off, and where it's going next," says Linda Lake, a consultant who leads the outbreak team and also chairs the Washington State Board of Health. "But the department is too busy dealing with SARS or other things. When you find somebody to help, it's always part-time, it's always for a short period of time, and it always takes them away from something else."
Outbreaks don't occur on a neat schedule, and there inevitably will be times that are busier than others. Even the most ardent public health advocates don't expect voters to pay to have public health workers waiting around for the next outbreak the way firefighters are paid to be available at all times. But there's a backlog of tasks that could keep the public health workforce busy when there are no emergencies.
Currently, the Seattle department can afford just 10 public health nurses for an intensive counseling program called "Best Beginnings," which has been proven to reduce a wide range of health problems affecting children of first-time teenage mothers. That's enough to reach only about one fourth of the mothers who need the service. Meanwhile, a strategy for working with schools to encourage teenagers to drink less soda and get more exercise--keys to reining in a near epidemic of juvenile diabetes--remains on the drawing boards for lack of funds, as does a major initiative to help Seattle's health providers incorporate ideas about safer behavior, better diets and exercise into their daily interactions with patients.
Although public health departments could make good use of additional funds, public skepticism about government and taxes usually trumps proposals to increase their resources. In Washington State, public health advocates were optimistic early this year after the Republican and Democratic leaders of the Senate co-sponsored a bill that would ask citizens to vote on whether to raise property taxes by $151 million to support local public health agencies. But health advocates lost heart after a poll commissioned by the Washington State Association of Counties and others showed the idea was far from assured of winning voter approval.
The lack of support demonstrates, in part, how reliance on categorical funding has become a political trap for public health agencies. Victims of specific illness often lobby tirelessly and effectively for funds to address their afflictions, but it's hard to find citizens who feel the same degree of passion for quiet government activities that keep people healthy. Public health workers have the passion, but it doesn't get them very far. "People think they're just asking for a handout." says Pat Libbey, executive director of the National Association of County and City Health Officials.
Clearly, voters expect more than they are willing to pay for. The Association of Counties poll showed, for instance, that 96 percent of Washington voters believe the services public health agencies provide are "very important." Yet the state Department of Health estimates that total public health spending in the state--about $507 million annually--amounts to only one third of what public health agencies need to do the job they currently are expected to do. The department says only one half of local public health agencies are doing reasonably well in meeting 202 performance measures developed for them.
For Carolyn Edmonds, a member of the county council for Seattle's King County and a former state legislator, the disparity between expectations and reality represents a political quandary. On one hand, she wonders whether advocates should present the budget situation in starker terms--by warning voters, for instance, that the current stringency is forcing public health officials to put fighting infectious diseases ahead of making sure children are immunized. "Public health has shied away from doing that," she says, "but maybe we're going to have to be more blatant" about what the trade-offs are.
On the other hand, Edmonds fears that voters won't believe leaders who say current budget and tax policy require such decisions: "People go to restaurants expecting that the food will be cooked properly. They go to a drinking fountain expecting that they won't get sick from the water. There is a built-in assumption that they will be taken care of."
Eventually, she says, the assumption will be disproved--maybe not in dramatic ways but slowly and less noticeably. "Response times will be slower. There will be fewer prevention measures," she says. "More people will get sick. People will die."
The end result, in Edmonds' view, may not be as shocking as, say, terrorists detonating a dirty bomb in a baseball stadium. Nevertheless, it will be very real and might have been avoided.
NO SIMPLE TASK
Washington State's public health system is trying to meet five basic standards:
--Promote understanding of health issues--by assessing community health and disseminating findings.
--Protect people from disease--by maintaining surveillance and reporting systems, developing plans for handling communicable disease outbreaks, and establishing procedures for disease investigation and control.
--Assure a safe and healthy environment--by educating the public, tracking environmental health risks and illnesses, enforcing health- related environmental regulations, and being prepared to respond to environmental disasters.
--Promote healthy living--by providing prevention, early intervention and outreach services, and involving the community in efforts to prevent illness.
--Help people get needed services--by providing information to the public on existing health services, analyzing what factors affect access to critical services, and developing plans to reduce specific gaps in access.