In many ways, the situation demonstrates the good and the bad about America’s public health system in an era of budget cuts and reduced government resources. Undoubtedly, many public health professionals have reacted admirably, contacting providers who may have received contaminated injections from the Massachusetts compounding pharmacy blamed for the outbreak and providing critical information to those who received them or are worried they may been exposed. As many as 14,000 people may be at risk, according to official estimates.
But the frank truth of the matter is, at this moment, the public health system is likely spread as thin as it can be. A second scenario—something as routine as a severe seasonal flu wave—could have a devastating effect, says Paul Etkind, director of infectious diseases at the National Association of City and County Health Officials (NACCHO).
"I think we've seen a lot of the good, a lot of the professionalism, the training. But I think if we had a second emergency happening at the same time, we would see just how frayed the system is, just how the tenuous the safety net really is,” he says. “We are so lucky that we're not dealing with competing emergencies, because I think then we would see the worst and just how threadbare the system has become."
It’s a warning bell that’s been sounded loudly in recent years. Public health advocates often cite one figure: 34,000, the number of local government health jobs that have been cut since the economic downturn. Earlier this year, Trust for America’s Health, a non-partisan think tank, released a report with a number of disconcerting statistics: In FY 2011, 40 states cut their public health funding—29 for the second consecutive year and 15 for the third consecutive year. Based on the budget proposed by President Barack Obama for FY 2012, federal public health emergency preparedness grants will have been cut by $72 million over the last two years.
"If we have further reductions, I think it will have serious consequences for our ability to detect and respond to future public health events," said Mel Kohn, state health officer for the Oregon Health Authority, at the time.
It’s a matter of expertise and resources, Etkind explains. Responding to an outbreak of a disease as rare as fungal meningitis requires an ability to quickly assimilate oneself to the facts and then vigorously engage in the kind of public outreach and counseling that’s needed. If someone suspects they’ve been exposed, a representative from the health department has to check in with them one or two times a week to make sure they don’t develop symptoms. If that person ends up requiring hospitalization, the check-ups are increased and follow-ups are necessary after they’ve gone home.
That process can be mentally and emotionally draining, Etkind says—and now cities and counties are trying to accomplish it after thousands of people with prior experience have been let go.
“This is hitting local health departments at the worst time,” he says. “We have fewer people who are qualified to do this kind of work. You can’t just give the job to people who don’t have training. They could potentially make it worse.”
By and large, though, local health offices have risen to the challenge, Etkind stresses. In all likelihood, they’ve saved lives by contacting those who have been connected with the contaminated injections and educating the public about what early symptoms to watch for. But flaws in communication and protocol, exacerbated by dwindling resources, have still showed themselves and made it more difficult for local health officials to do their jobs.
Etkind declined to name specific situations, but said NACCHO has heard concerns from some of its members. Here’s an example: a person received a contaminated injection at a major medical center in one county, but they live in another county. It could take days for health officials, after contacting the health-care provider, to figure out that one or more of the patients live in a different jurisdiction and then inform their peers in the neighboring county. For a disease that can appear as quickly as a few days (though the average is closer to two weeks), that elapsing time is critical.
More broadly, because there are fewer people funneling information from the federal to the state to the local level, it simply takes longer for those on the ground to be alerted about an ever-changing scenario. Just this week, federal officials announced that other medications from the same pharmacy may have been contaminated. The new information now has to trickle down to the local level, where officials will likely have more clinics to call and more patients to track.
"This is an ever-moving target. Sometimes, you don't have all the details,” Etkind says. “There are sags and there are delays. That’s one of the complications that arise in a crisis like this.”
