For the Sake of National Security, Fix the Public Health System

With the looming threat of avian flu and the increased concerns over bioterrorism, the United States faces a credible possibility of a biological disaster. Although over $10 billion has been appropriated for bioterrorism preparedness since the anthrax attacks of 2001, and President Bush has recently requested another $7.1 billion to combat avian flu, the U.S. is not adequately prepared for a biological threat. These preparedness efforts fail to address the deeper, systemic problem that leaves the United States vulnerable: the degraded state of our public health system, composed of hospitals, community health clinics, epidemiological labs, and research centers.

The public health infrastructure is a fundamental component of the United States’ biodefense, providing services essential to mitigating a biological disaster, such as monitoring health status, surveying the nation for disease threats, providing diagnosis and treatment, and educating and informing the public= A strong public health system can quickly identify a biological outbreak, contain and treat victims, communicate and calm the public, and work towards long-term recovery.

Unfortunately, for the last 30 years the public health system has been drastically under-funded and underappreciated. Policymakers diverted resources originally designed to combat infectious diseases to other areas as America declared victory over polio, tuberculosis, and other diseases. The drain of critical resources has left public health in disarray; as a 2005 Government Accountability Office report reviewing public health bioterrorism preparedness concludes, “serious challenges remain in ensuring national preparedness for public health threats.”

Despite redoubled efforts to bolster biodefense, the public health infrastructure has been starved of attention and funds. As federal funding for bioterrorism preparedness infused state budgets (increasing from about $4.3 billion in 2004 to over $5 billion in 2005), many states slashed funds for broad-based public health services, further weakening the already fragile public health infrastructure. Because much of the bioterrorism preparedness funding appropriated to states is earmarked for narrow bioterrorism programs—such as supporting labs that can detect only a small number of “bioterror” agents—the additional funds did not benefit the public health infrastructure. In fact, programs shifted their focus to bioterrorism preparedness from broad-based social programs in order to take advantage of the earmarked funds. While these biodefense efforts improve our protection against a limited range of conventional threats, our stultified public health system lacks the capacity to respond to broader and more likely national security threats, such as pandemics (e.g., avian flu), national disasters, or bioterrorism using an unanticipated agent.

The reliance on vaccines to combat biological threats must be balanced with broader efforts to improve the public health infrastructure. The United States has spent billions of dollars to identify and manufacture vaccines against a range of agents, including the plague, smallpox, and now avian flu. However, the Centers for Disease Control and Prevention (CDC) lists nearly 30 potential bioterrorism agents; no more than five have vaccines and, of these, three are still in advanced research or are not commercially available in the United States. Because the development of a single vaccine is estimated to take between five and ten years and cost billions of dollars, it is impossible for us to be prepared for a biological disaster by relying on vaccines. Even improved vaccines will be ineffective without a sound public health system to educate the public and distribute the vaccines.

In order to improve our preparedness, we must give public health a greater role in the coordination and planning for biological threats. Fewer than ten states have finalized and distributed plans that establish concrete coordination between public health agencies and other agencies involved in emergency response. Without effective coordination procedures, the public health system is unable to respond to biological threats with the necessary speed and precision; emergency response requires the coordination of multiple agencies acting on multiple fronts. Recent emergency response simulations such as Dark Winter and TOPOFF found that inter-agency coordination was muddled to the point that important information was not shared, resources were allocated inefficiently, and the overall response was significantly weakened. By leaving out important response agencies, such as public health, the overall effort to mitigate disaster is severely impaired. Coordination between agencies with different procedures, resources, and responsibilities is a major challenge, but it is essential to effective preparation and response.

In the event of an emergency the public health response is supposed to take place mainly at the state level. But according to the Institute of Medicine, many states have inadequate technology—lacking up-to-date computers, high-speed Internet access, secure information systems, and integrated communications systems—and insufficient training for employees. The best laid plans are useless if the public health system lacks the technology essential for coordinating emergency response with other agencies (e.g., FEMA and the National Guard) and with the public.

Disease surveillance systems, which collect and analyze data throughout the country to determine the location of outbreaks and other abnormal epidemiological events, need to be integrated so that large data sets can be compiled and used to detect imminent biological threats. The CDC alone maintains more than 100 different surveillance systems and throughout the country there are more than 3,000 local health departments, state departments, and large municipalities, all of which use different surveillance systems. The inability to integrate these systems is a significant hindrance to accurate and timely epidemiological information, which is critical for detecting and combating a biological threat.

Most importantly, the public health system needs more resources for broad-based services. President Bush’s request for additional funding for the public health infrastructure is not enough; his request would grant only $500 million for improving the public health system, while dedicating almost $5 billion to new vaccines. More highly qualified employees need to be hired, communication networks need to be improved, information systems need to be updated and integrated, physical facilities need to be repaired and improved, and better leadership needs to be attracted from the private sector.

The notion that funds allotted for bioterrorism preparedness would automatically improve the public health infrastructure has not been realized. Rather than misallocating our resources for limited defense purposes, we must recognize that a viable public health system is a necessary element of our national biodefense.