Public health system still is not ready for terrorist attacks

More than two years after the terrorist attacks in New York City and Washington, DC, and despite $1.8 appropriated by Congress to revitalize the country’s public health system, some progress has been made, but not nearly enough, according to a report prepared by Trust for America’s Health (TFAH). The question the organization asked was simple and direct: Two years and almost $2 billion later, are we better prepared to respond to public health emergencies?

Despite a perception that the federal investment in public health preparedness over the last two years has brought rapid and substantial improvements to a long-neglected public health system, TFAH says it found "a more complicated and, at times, unsettling picture."

To assess the current level of emergency preparedness, TFAH worked with an advisory committee of state and local officials and public health experts to define 10 key indicators that express the fundamental capabilities every state should have.

"Collectively," the report says, "these indicators provide a snapshot of improvements that have been made and ways in which the public health system is still vulnerable. The indicators do not present a full measure of preparedness, but they do represent a first step toward providing the level of accountability and transparency that should be expected of publicly funded programs, particularly those that allow communities to understand what has been done and what remains to be done to improve homeland security.

"The study demonstrates that while states have made important advances in certain critical preparedness functions, many essential improvements have not yet been achieved. The indicators, while pointing out progress, also reveal that state public health agencies are facing fundamental, structural problems that threaten the nation’s ability to respond to a large-scale public health emergency."

TFAH put together a state-by-state assessment on the 10 indicators to provide a picture of each state’s preparedness to handle a public health emergency. States received one point if they had achieved an indicator and zero points if they did not achieve the indicator.

California, Florida, Maryland, and Tennessee received the highest scores, achieving seven out of the possible 10 indicators. With two out of a possible 10 points, Arkansas, Kentucky, Mississippi, New Mexico, and Wisconsin had the lowest scores. More than 70% of the states received scores of three, four, or five. The report’s authors say the fact that a majority of states have scores in the lower range depicts a trend: While states have achieved piecemeal progress, the full-scale effort to comprehensively fix the nation’s public health system is falling short.

TFAH concludes that despite a surge in federal funds, states are only modestly more prepared to respond to health emergencies than they were before Sept. 11. "Overall," it says, "the preparedness effort has been severely compromised by the impact of state budget crises, the lack of priority placed on addressing underlying systemic problems, and the failure to eliminate bureaucratic obstacles."

In response to what it found, TFAH recommends these actions:

1. Public health agencies must be battle-ready for all hazards and not just bioterrorism. The Centers for Disease Control and Prevention (CDC) must authorize states to use federal preparedness funds for an all-hazards approach to preparedness that simultaneously addresses the potential for biological, chemical, radiological, and natural disease outbreaks. In consultation with state and local health officials and outside experts, the CDC should define measurement standards for comprehensive preparedness that all states and major local health departments should meet. And Congress should provide long-term commitment and oversight to ensure the nation achieves adequate and sustainable public health security.

2. Establishment of health security requirements in terms of mandates and accountability will ensure that all citizens are adequately protected. The CDC should be required to track state and local funding and expenditures on critical public health functions, especially those involving federal support, and should independently verify that health emergency performance standards are being met at the federal, state, and local levels. The CDC also should establish rules for ongoing federal funding by requiring that state or local governments maintain core public health funding levels.

3. Staging a summit on the future of public health will develop a cohesive, national approach to public health protection. Such a summit, TFAH says, should develop a vision for the future of the American public health system and the resources needed to make the vision a reality. The summit would consider how the country can best build a robust, integrated, 21st century infrastructure.

In a similar effort, the General Accounting Office (GAO) was asked to examine improvements in state and local preparedness for responding to major public health threats and federal and state efforts to prepare for an influenza pandemic. In testimony earlier this year before the House of Representatives Committee on Government Reform, the GAO said that although states have further developed many important aspects of public health preparedness since April 2003 (when the GAO last briefed the Congress on this issue), no state is fully prepared to respond to a major public health threat.

"States have improved their disease surveillance systems, laboratory capacity, communication capacity, and work force needed to respond to public health threats," a GAO report said, "but gaps in each remain. Moreover, regional planning between states is lacking, and many states lack surge capacity — the capacity to evaluate, diagnose, and treat the large numbers of people that would present during a public health emergency."

The GAO concluded that while states have taken many actions to improve their ability to respond to a major public health threat, no state has reported being fully prepared, and state efforts to develop their plans have been complicated because federal plans for the purchase, distribution, and administration of vaccines and drugs in response to an influenza pandemic still have not been finalized. "States are more prepared now, but much remains to be accomplished," the GAO added.

Responding to the studies, American Public Health Association executive director Dr. Georges Benjamin tells State Health Watch that TFAH wanted to be sure people knew that while some progress has been made, it has been uneven among the states.

"While there have been improvements in some important areas, the basic infrastructure has been eroded because of state fiscal problems," Mr. Benjamin says. He notes that when the anthrax scare broke, Maryland was able to pull people from other programs to work on that issue. But state budget cuts have reduced the capacity for such response and have made the overall system weaker.

According to Mr. Benjamin, it’s important that the federal and state governments understand and accept the need to continue to invest in public health. "We need to have some kind of rational plan," he tells State Health Watch. "We need to decide what we want our protection systems to be like and then adequately fund them."

Officials must recognize that their plans will always need to be updated in response to changing conditions, Mr. Benjamin says. For instance, some states are planning to use their National Guard troops to move stockpiled supplies to where they are needed. But if those troops have been called to active duty and are serving outside the country, the plan calling for them to be involved may need to be revised.

One problem Mr. Benjamin sees is a lack of recognition generally of the importance of the broad protective role of the nation’s public health system. "Studies indicate that citizens don’t believe they have been affected by the public health system," he says. "They don’t see it operating in their daily lives. We need a federal-state partnership in an educational effort so that public health and what it does will become a household word. It’s good to see increased leadership at the federal level to push for a better understanding by the public of what public health is."

[For more information, go to: To see the GAO report, go to: Contact Georges Benjamin at (202) 777-2742.]