by Kim Krisberg
It only takes a few minutes of talking with Scott Becker to realize just how passionate he is about public health. In fact, his enthusiasm is contagious. Maybe that's why he isn't mincing his words.
"What keeps me up at night is how we are going to maintain the core and critical services we have," said Becker, executive director of the Association of Public Health Laboratories. "If the question is 'how low can we go?' My answer is 'we're there.' I used to be on a more hopeful note, but I can't do that anymore."
Becker is talking about the worrisome state of public health preparedness funding and its effect on the nation's network of public health laboratories, which Becker describes as the "hidden jewel within the public health system." Public health labs and their highly skilled workers are frontline defenders of the nation's health, protecting the public against disease and providing critical support in the wake of natural and manmade disasters.
When a foodborne illness outbreak occurs or a chemical release exposes a local population to fumes, public health officials need to be able to quickly determine who's affected and how the exposures are happening in order to treat victims promptly and prevent more people from being harmed. Labs play a crucial role in this process. For example, during the 2001 anthrax attacks, public health laboratories tested more than 1,200 specimens a day. Ultimately, they ended up conducting more than one million laboratory analyses in response to the anthrax attacks. Now, the ability of public health labs to quickly respond at that same level of capacity is truly on the line.
"As the dollars shrink, public officials can't expect the same response," Becker told me. "Labs are somewhat intense in terms of budget because we deal with things like supplies, instrumentation, equipment maintenance...but right now, we're struggling just to keep the infrastructure going."
And public health labs aren't alone. According to a December 2011 report from the Trust for America's Health (TFAH), federal funds for state and local public health preparedness declined by 38 percent from fiscal year 2005 to 2012, with many core preparedness activities and programs at further risk of declining funds or elimination.
The influx of preparedness funds as well as the renewed focus on public health preparedness began in earnest after the Sept. 11 terrorist and anthrax attacks -- "these tragedies marked the first time public health was considered central to the nation's emergency preparedness -- marking the beginning of a significant transformation," the TFAH report states. Since then, more than $7 billion in preparedness funding has been provided to states and some major cities, resulting in a tremendous build up of public health's capacity to respond to emergencies. And such capacity not only kicks in during crises, it has strengthened the public health system's overall ability to protect the nation's health on a daily basis. Unfortunately, advocates warn that the recent declines in preparedness funds coupled with cuts in federal, state and local public health budgets are threatening to turn back the clock on years of investment and capacity building.
"We're clearly better off than we were before," said Albert Lang, TFAH's communications manager. "But there's a legitimate and real fear that we'll slide back to 2001 levels of preparedness."
Public health's ability to respond in an emergency "isn't just something you pick off the shelf," Lang told me. It takes constant training to do it right, and a major concern is that "people are just disappearing," he said. According to the TFAH report, more than 49,000 state and local public health department jobs have been lost since 2008 due to layoffs and attrition. So, while a state may have a modernized public health lab, it's losing the highly trained people to staff it, he noted, and "you can't train someone in the midst of a disaster."
"The country has failed to create level and sustained funding streams," Lang said. "It's hard to plan (emergency) responses if you can't count on resources down the road."
The faces of funding cuts
Creating an effective public health response system takes more than training; it takes research too. That's why the Centers for Disease Control and Prevention has invested millions in creating university-based Preparedness and Emergency Response Research Centers (PERRCs) and Preparedness and Emergency Response Learning Centers (PERLCs). These are the places where effective, evidence-based public health response practices are born. According to the TFAH report, funding for a number of the research and learning centers is at risk for being reduced or eliminated in 2012.
"You need to prepare for the worst and hope for the best," said Andrea Hickle, associate director of the University of Minnesota's Simulations and Exercises for Educational Effectiveness Preparedness and Emergency Response Learning Center. "There's a constant need for people to be trained in areas of preparedness... you need refreshers. It's not like you're trained once and you're set to go."
The University of Minnesota's PERRC launched in 2008 and its PERLC began in 2010. Hickle said the two centers are closely linked, with the learning center acting as a live platform for applying the work conducted at the research center. The work being done, however, is hardly confined to the university campus and its students -- the university has become a critical training resource for public health departments in Minnesota, North Dakota and Wisconsin. Over the years, the university has trained thousands of state and local public health workers in effective preparedness and response via face-to-face training as well as distance-based learning, Hickle told me. The first responders are trained in a variety of topics, such as hazardous materials exposure, how to use personal protective equipment and field survey instruments, and risk communication. They can also take advantage of online emergency simulations. If federal funds disappear, it would be a "real challenge" to continue and a number of training and learning opportunities could end, Hickle said.
"State and local health departments are pretty limited for resources, so we're a key resource for them," she said. "We really need to have research about public health preparedness systems in order to know what's worth the resources and what works."
Another area at risk is the Cities Readiness Initiative (CRI), a federally funded program aimed at the nation's largest cities and metropolitan areas and which primarily focuses on enhancing public health's ability to rapidly distribute and administer medications and vaccines in an emergency. According to TFAH, 51 of the 72 cities participating in the initiative face a possible elimination of funds. One of those cities at risk is Baltimore, one of three Maryland regions involved in the initiative.
"It's important for people to understand that training staff to do these kinds of things is a time-consuming process -- you don't train people overnight," said Sherry Adams, director of the Office of Preparedness and Response within the Maryland Department of Health and Mental Hygiene. "When you invest the time and energy and money to train people who are committed and then you lose them, you don't just reinvent them on the spur of the moment...we are talking about the capability throughout the state of Maryland of being able to get life-saving medicines to more than five million people in a very short period of time."
CRI funds in Maryland have supported extensive planning, training and exercises; partnership building with critical community partners such as hospitals; policy development; equipment needs; and the development of effective crisis communication channels between first responders as well as between local officials and the public, Adams said. While the federal initiative was developed to respond to a bioterrorist attack, Adams said the training and skills building are applicable to a variety of public health emergencies. For example, she said, the training was successfully employed during the 2009 H1N1 flu outbreak. If CRI funds start disappearing, it will likely result in job losses and make it difficult to maintain and update preparedness plans -- "it will stress our system considerably, especially at the local level," Adams told me.
"We've built a system to answer that emergency call; we've built the expectation among the residents that we're going to be there," she said. "But will we be there at full capability? That's the question."
The decline in public health preparedness funds will likely result in the erosion of the field's ability to respond to all kinds of threats, said Becker at the Association of Public Health Laboratories. For labs, in particular, TFAH reported that all 10 state labs with "level 1" chemical testing status are at risk for losing top-level capabilities, which would leave CDC with the nation's only public health lab with the full ability to test for chemical terrorism and accidents. If multiple chemical events did happen at one time, it could overwhelm CDC and force the agency to prioritize one region over another, Becker said. Like most public health efforts, he said, the "local response is crucial."
"We're at a critical point in this country," Becker said. "We can't go any lower than we are (in funding) and still be able to say to the public, 'you're protected.'"
For a copy of TFAH's report, "Ready or Not?: Protecting the Public from Diseases, Disasters and Bioterrorism," visit www.tfah.org.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for almost a decade.