Monday, October 6, 2014

Are We Ready? No!

I am talking about Ebola of course. And yes I am exaggerating, because Ebola cannot break out and ravage communities in the US the way it can in Africa. But in a larger sense it is true we are not prepared. Many people would be shocked to learn how weak and fragmented our public health system has become (expect to see more of the kind of Ebola-bungles that have recently occurred in Texas). Even fewer people realize this is the result of policy choices we have made that have turned out badly.

First some basic facts. The CDC’s budget was $6.5 billion in 2010. It is $5.9 billion now. I am happy to say that some of these cuts are likely to be restored next year, but we are still expecting a $54 million cut from emergency preparedness. State and local public health depend on the CDC for much of their budgets, so cuts at the federal level trickle down and affect the ability of public health to respond to local problems. The chart on the right shows the budget trends for the Mid-Michigan District Health Department for the past five years.  According to the National Association of County and City Health Officials, local health departments have laid off 48,300 people since 2008. That’s a huge reduction in our ability to respond. Cuts at the CDC affect hospitals, too, which have taken a 33% whack to funding for hospital emergency preparedness activities.

Another fact that would surprise many people is that we do not have a strong, vertically integrated public health system. The CDC is a federal agency accountable to Congress. State public health is accountable to governors, and local public health in most places is a local agency, like a sheriff’s department. Each level of the system is accountable to a different authority and it is difficult to coordinate their work or get them to communicate effectively and efficiently.

This state of affairs isn't an accident. It is the result of policy choices made in the past. Obviously we could have a more unified system if we wanted it and worked together to make it happen, but in many places in America we do not want that. Some states reject or refuse to participate in some public health activities proposed by the federal government—think of the states that refused to expand Medicaid. And in some state’s public health codes local units of government may be able to refuse to participate in many statewide activities.

It is interesting to compare public health in Michigan with public health in Texas. In Michigan, local public health is part of county government. But instead of letting things go flying off in all directions, Michigan’s public health code mandates that local government provide a basic set of standard public health services, directs the State to fund those services (sort of), and evaluates their effectiveness through Michigan’s Local Public Health Accreditation Program. Compare this with the situation in Texas as reported by Kaiser Health News:

Public health experts argue that the state’s response system is “fragmented” and vulnerable to local budget cuts, which they say could hamper crisis-response efforts in the case of diseases that are more easily transmitted…  “In the event of a public health emergency ... the resources necessary to adequately respond to that are not all in the control of the health department,” Sanchez [Dr. Eduardo, the former commissioner of the Texas Department of State Health Services] said. “You have to have the money and the authority — whether it’s informal or formal — to actually lead a response and take care of business.”

Even in Michigan with it's integrated system, the effects of budget cuts show themselves all the time. Recently we got a call from a school about a mercury spill but we could not respond because our employee who was trained on mercury had moved on to another job. We lack the resources to have redundancy in that position. On another occasion we called the State after hours for assistance with a meningitis case, but the person staffing the 24/7 hotline didn't know how to direct our call.  The State is short-staffed, too. Both of these issues were ultimately resolved, but when you work inside the system you see the potential for serious breakdown.

Both Texas Governor Rick Perry and CDC Director Tom Frieden are telling us that we are prepared for Ebola and everything is going to be OK. But Tom Frieden also warns about the consequences of further budget cuts and reductions in capabilities, and Dr. Frieden understands the importance of global public health. We have underfunded public health locally and feel the consequences of that, but we have also allowed many other counties in our world to languish with almost no public health infrastructure at all, and this is a huge threat to all of us.

The biggest threat to this country from Ebola is not it spreading here. It is an Ebola outbreak spreading in Pakistan or Indonesia or other south Asian counties that do not have the public health capacity to stop it. If Ebola gets into south Asia and starts to spread, be prepared for serious consequences for the global economy.