Last week The US Department of Health and Human Services (HHS) released a comprehensive pandemic flu guidance document for states, accompanying it with a web presentation, the first of three. I haven't seen the Web Seminar and only quickly perused the document, so I am commenting on the basis of a description in CIDRAP News, a reliable source. You can find the Web presentation and document at pandemicflu.gov. It is always best to see the original, so this is my take from a second hand source. Even so, I don't think our take is likely to be wildly off kilter (assuming you don't think we are always off kilter on this subject; if you do, you'll probably think so again).
The federal government role is to tell the states that they are on their own -- sort of. It is clear the federal government can't be the cavalry riding to the rescue when everywhere needs rescuing at once, including the federal government whose employees will be as affected as anyone. So their role reduces to helping the state and local public health systems. Realistic and fine as far as it goes. Where it heads, though, is problematic:
Christa-Marie Singleton, MD, MPH, associate director for science in the division of state and local readiness at the US Centers for Disease Control and Prevention (CDC), said states, territories, and the District of Columbia are required to submit their pandemic plans to HHS so that the agency can establish a baseline for each state's pandemic preparedness and help each identify gaps in planning. The guidance walks states through each issue to consider and includes details on how to format and submit their plans to the HHS.Singleton said the federal government might withhold some 2009 funding for states that don't submit their pandemic plans. The guidance document says the plans are due on Jun 16.
Webinar participants said federal officials would be available to help states prepare their pandemic plan submissions. (Lisa Schnirring, CIDRAP News)
Ouch! We're from the Federal Government and we're here to help you. Start by filing paperwork and we'll tell you exactly what the paper work has to have in it. Or we don't feed you.
There is something unredeemingly controlling about this that is discouraging and counterproductive. It might work for some things, but not for this. Localities differ and will solve their problems in specific, perhaps idiosyncratic ways. We need to get them resources, mainly money in the form of Block Grants, and let them use it to make their public health and social service systems fit for duty, functioning properly and working effectively at the community level. Few if any places in the US meet this basic requirement now. The goal is not to fulfill some pre-envisioned planning sequence but to make the community sufficiently robust to function during a pandemic.
One of the overarching goals is to assure the continued functioning of critical infrastructure. Unfortunately much of that infrastructure is outside public control, in the hands of private companies (many water companies, almost all utilities) and there is no guidance as to who will do what and for what reason. There is now widespread recognition of the many problems a serious pandemic would bring. That's a step forward. But unless those problems have solutions, it's not where we need to be. At the same time there is considerable lack of clarity about roles the Federal government might decide to play if it felt it necessary "to protect Americans." We've seen a lot of what this administration would like to do to protect us and many of us feel we want to be protected from our own government instead. The coercive role the Feds might play in all this is a blank page that needs to be filled in with limits and boundaries. Somehow many of us suspect that the federal government is more likely to try to enforce a quarantine order than to take over a utility. It's all about choices.
Some of this is good and goes in the right direction. Planning, in itself, is a big step forward. But the plan on paper will go out the window in the first week (the old military saying applies: no battle plan survives the first engagement with the enemy), even while the planning is valuable by envisioning what is ahead, meeting your counterparts in other agencies, thinking it through, all tremendously valuable. States and localities need to be strongly and forcefully encouraged to do this. But most states and communities are also fully engaged in the desperate business of trying to keep people alive day to day and until they can get out from the falling debris of a system disintegrating about their ears. In those circumstances, pandemic planning is a luxury, even harmful to the extent it pulls people away from other urgent business.
Isolating pandemic planning from the overall health of the system isn't going to work, no matter how detailed the plan.
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Revere:
I wholeheartedly agree with you, even as we usually tend to disagree on issues of public health preparedness.
The idea of submitting plans -- or else -- doesn't seem to make sense in this case. SNS planning, on the other hand, does, as the states will be depending entirely on CDC resources, so it makes sense that the CDC signs off on those plans.
Pandemic planning documents, which will not depend on CDC resources, as they themselves have noted, have no business getting "approved." If states want help fleshing plans out, CDC should have an ongoing open-door policy of "we'll review and help with your plans - for free," not just before the deadline. Or better yet, they should develop regional coordinator meetings similar to what they do for SNS planning. Get state and local pandemic planners together for a two-day meeting twice a year to review best practices and innovative plans.
And to threaten to cut off funding because a state didn't submit a plan seems rather counter-intuitive, don't you think? Especially since, to date, there's been no help in developing these plans. Unless you think it's possible to write a comprehensive pandemic preparedness plan for an entire state in three months (which it's not). Unless, of course, you don't really care what the plans say... Wait, maybe this is starting to look like something we've seen before... a bit of public health security theater?
-Jimmy
Umm, I have a question, for both revere and Jimmy. Apologies if I'm a little unsure of the facts. I don't know about block grants and other more esoteric terms, and I don't know how you guys would define 'help', but there's this thingie called CDC Cooperative Agreement Guidance for Public Health Emergency Preparedness which looks to me that a) it has funding that comes with it, and b) has had 'benchmarks' on pandemic preparedness since 2004.
Personally, I'm not too sure how well benchmarks work, but if I turn the argument the other way round, I can imagine how it would be reasonable for someone giving out the money to spell out how they want the money to be spent, and expect to be able to check on whether it has indeed been spent the way the states promised when they signed the agreement to receive the check!
At least in theory...
Incidentally, I had a really interesting encounter with DHS who are supposed to be in charge of critical infrastructure preparedness. Here's how the question and answer went
Very astonishing, and very sobering.
Susan: Block Grants are for large programmatic areas (e.g., Family Health) where the recipient uses them more or less as they see fit. They were phased out in most areas (although I think there are still some). The point I was making that resources should have far fewer strings attached then now required -- more flexibility and less transaction costs.
thanks, revere.
Yes, I agree. More flexibility and less transaction costs, definitely. And more public participation.
A thought occurred to me a I read your blog Revere. Perhaps the carrot and stick approach is a way to hurry up and ensure the process is actually being done? The article(http://en.rian.ru/world/20080318/101628539.html) stated there had been at least one co-infection between H5N1 and H3N2 in an Indonesian girl last April. I understand the Indonesians never looked for co-infections while testing for H5N1 cases. Now, they are taking another look at A/H3N2 Brisbane to see if it had bf polymorphisms. This scenario might have just put a fire under the Bush admin to do more for pandemic preparedness. It's a thought anyway.
Shannon: I drafted a post about this for tomorrow a.m.
I have seen Dr. Singletary speak in other venues and this is her standard view of the world. The CDC is the parent and the rest of us need to be the good little children and do what they say. I find it more than a little scary (as a local planner) that someone who is supposed to be in a liason position to work with locals, and in fact comes from a local, has decided to completely block out the mantra that "all response is local" and instead has adopted "we know best, you know nothing"
I haven't read any prior grant guidance documents that CDC has put out for their previous pandemic flu grants, but I have read about 90% of this new federal document and think it provides much better guidance and tools for preparing for a pandemic than most other federal document's I've seen.
It's up to states and locals whether they want to use all the recommendations (states will put into their grant proposal what they want done in their state when they submit it to CDC); certainly some items are more relevant than others. But as a person working on our local plan, I thought the guidance was quite valuable--not for the purpose of getting CDC grant money, but for the purpose of improving our local plan.
There are certainly gaps that the CDC guidance doesn't address, but most of what's there was pretty useful, I thought.
It sounds like state will be penalized for not submitting a plan AT ALL, rather than not accepting all the CDC guidance.
Just my 2 cents.
BC that is correct. They have milestones they have to start meeting and thats with matching federal funds. Its the states problem and that was agreed to by Congress. Revere would simply chuck the system to the Federal government and its one of the reasons that UHC will never come to pass. If there is a pandemic, look only to N. Zealand and Australia last year. That wasnt even a killing pandemic and it just about took them down. Its not that I begrudge anyone healthcare, I only want everyone to pay for it. Under our system it wont be that way and something like 1/3rd of the people will end up paying for 2/3rds. I could add in waiting times, the problems in the UK, problems in Canada, N. Zealand, Australia, etc.
But you add a pandemic to a health care system run by the government and it takes all liability out of the system. There are people in Canada who want people who leave to get care outside of the country... arrested. The same for people inside the country. It is a crime in Canada to get care for a condition that is covered. Sounds to me like big brother found a home. All encompassing government. You are fabulously rich in Canada, or you are fabulously lower middle class. Very little in between.
Randy: I would not chuck the system to the feds. On the contrary, I want the Feds to provide resources to the state and locals, via Block Grants, so they can make their systems work again. The Bush approach is three fold:
1. Procurement of antivirals and vaccine stockpiles: translation, privatize my money into the hands of their cronies in Big Pharma and Biotech
2. Organize Federal "assets" for coercion of the population via quaratine, containment, possible civil disorder that ensues
3. Provide "guidance" to the states on pandemic planning that includes (2) and other advice (much of it good) that doesn't provide any resources to get it done and actually makes things worse by taking down a tottering system.
Won't work. But Grover Norquist will finally be able to drown it in a bathtub.
Revere, I understand your frustration about the paperwork requirements/federal financial threats. However, in the relationships between the states and the feds, the states finally comply with federal requirements not because of the carrot, but because of the threat that the carrot will be taken away. Unfortunately, many state government agencies don't really believe that Dad is serious until he actually takes the car keys away. The money is really the only thing that the feds have to use if they want to mandate state compliance with federal legislations. I could quote you quite a few examples of various states violating civil rights regulations (yes,specifically racial discrimination) by state agency staff in the administration of federal U.S. DHHS funds meant for handicapped adopted and foster children--to the point where you'd think this was 1954, not 2008. (Yes, and in northern states.) Personally, I'm grateful for the feds' action in this manner. Where I live, the state-level staff administering those funds are so crooked that they openly converse with judges before and during legal actions, and have openly instructed judges to violate federal laws, so that they don't have to pay state-matching funds. We've even caught one judge erasing evidence from hearing tapes. It was an investigator at the federal office for civil rights who actually clued us in to the fact that this was all race-related. Now, the feds are finally coming down hard.
I think it's very appropriate. Although the need for it is absolutely pathetic. AnnieRN
Annie: I think there are differences between kinds of federal programs and difference between states and within states, state agencies. They are not all the same. This administration uses the stick to enforce certain programs good for its cronies and in line with its ideology and abandons others (e.g., environmental and civil rights/liberties statutes). So this was a comment about how it uses its carrots and sticks in public health. Block grants used to be common and the health of agencies was far better than now, when the federal government uses them to put health departments in a box and pull the strings in ways that have nothing to do with improving the health of the community. I see it up close every day.