Crisis vs. chronic: Paying the price of public health

When Wisconsin had a large pertussis outbreak last summer, Jonathan Temte, MD, PhD, a family physician in Madison, treated cases while public health workers struggled to trace contacts and reduce further spread.

"The state was swamped," said Dr. Temte, associate professor of family medicine at the University of Wisconsin Medical School -- describing how quickly the infrastructure can become taxed. "I would have loved to see sufficient funding to fully fund a public health system by a factor of 100%."

Just a few years ago, this idea seemed more a promise than a dream.

After the terrorist attacks of Sept. 11, 2001, and the anthrax scare that followed, it seemed that the nation's public health system, shabby from decades of neglect, finally might get its due. These two incidents did what numerous reports from esteemed institutions -- including the Institute of Medicine and the Centers for Disease Control and Prevention, as well as frequent declarations of need from the American Medical Association -- could not.

In a sense, public health had found not only the limelight but also a seeming pot of gold. Millions since have flowed from the federal government to state and local health departments.

"We're putting money in the hands of states and local communities so they can start building strong public health systems for responding to a bioterrorism attack," said then-Health and Human Services Secretary Tommy Thompson in a statement issued Jan. 31, 2002, that announced $1.1 billion in funding for bioterrorism preparedness.

Three years later, many physicians and public health officials are viewing the glass as both half full and half empty -- with new emphasis placed on crisis response but sometimes at the expense of chronic conditions.

"It was our hope that a lot of the money that was put aside for bioterrorism would be used for improving the infrastructure of public health," said Robert Pallay, MD, chair of the American Academy of Family Physicians' Commission on Public Health and vice chair of the Dept. of Family Medicine at Robert Wood Johnson Medical School in New Jersey. "I can't say I'm terribly happy. There's been improvement in the infrastructure, but not to the extent that we would have liked. And the money is already starting to dry up."

Experts say new funds generally streamed into some programs, especially those involving new technology and infectious disease control. And though federal funds were earmarked for emergency preparedness, this windfall was diminished by cuts at the state and local levels for more traditional public health work.

"With the initial funding, at least for bioterrorism, we've taken a step in the right direction," said Georges Benjamin, MD, executive director of the American Public Health Assn. "For those things that deal with the 10 leading causes of death and the most prevalent diseases in our country, we've taken three or four steps back."

A report issued annually by the Trust for America's Health, a Washington, D.C.-based public health advocacy group, found that 32 states cut funding for public health in fiscal year 2003. The situation in fiscal 2004 was marginally better with 15 states cutting funding and 11 maintaining funding levels or increasing them by less than 1%. These investments, however, were accompanied by, on average, a $1 million cut per state in federal support.

The money that did surface built new labs and telecommunication systems, bought fax machines and developed surveillance systems. But many officials complain that they don't have the staff to use these tools or to educate physicians and the public about what the new technologies can do and what actions need to be taken.

Case in point

Take, for example, the Dutchess County (N.Y.) Health Dept. It has technology to map out clusters of Lyme disease and areas with a high prevalence of ticks. But there is no money to communicate this information to residents.

"We have wonderful maps of our county and where, specifically in ZIP codes, Lyme disease cases are, and where we're finding a lot of ticks," said Michael C. Caldwell, MD, MPH, president of National Assn. of County and City Health Officials and director of the local health department. "But education on Lyme disease is being cut."

The emphasis on technology over people is in part due to budgetary constraints and fears that bioterrorism money would not continue to flow -- making it practical to invest in hardware.

"There are enormous pressures on the budget, including tax cuts and huge deficits," said AMA Trustee Ronald M. Davis, MD. "And public health is often the program left with the short straw."

Some complain that President Bush's proposed fiscal year 2006 budget continues to favor technology investment. For example, it calls for the Strategic National Stockpile to be increased by 51%. Meanwhile, funding to state and local health departments for bioterrorism preparedness could be cut 14%.

"The stockpile is something that has been underdeveloped," said Shelley A. Hearne, DrPH, executive director of Trust for America's Health. "[But] you could have the greatest stockpile in the world. ... If you don't have anyone who knows how to deliver it and distribute it in a rapid-response method, what's the point?"

As for priorities, many officials see their efforts as becoming an either-or proposition, with infectious disease and emergencies taking precedence over many more traditional functions. In their view, the initial promise, which some interpreted to mean a public health infrastructure that could respond to all health threats, is not quite emerging. Chronic disease, in particular, appears to be getting short shrift.

"If you line up everyone who has had morbidity or mortality from bioterrorist agents and compare it to the burden and life years lost due to diabetes, gosh, I wonder which one is going to win?" Dr. Temte asked. "There's an epidemic of diabetes coming on, and if we don't address it from a public health model, we're going to be inundated. We're going to see the falling back of life expectancy in this country."

This change in emphasis is particularly clear in the proposed budget, which calls for a 7% decrease in CDC funding for chronic disease and health promotion.

"This is alarming when you consider the fact that the obesity prevention program resides there," Dr. Davis said. "The obesity epidemic is going to take our best efforts to turn around."

The Preventive Health and Health Services Block Grants, flexible money that states could use to address their own priorities, would be completely eliminated.

Finding benefits

But it's also clear that the public health system needs more than just money. It also needs a strategy to ensure long-term viability, particularly around work-force issues. Even those who have money for personnel say they have a hard time finding qualified people, and several reports have found that the public health work force is aging and closer to retirement than the general population.

"Public health nurses, public health lab directors, epidemiologists are in serious short supply," said Babatunde A. Jinadu, MD, MPH, director of the Kern County Health Dept. in Bakersfield, Calif. "Everybody thinks throwing money at something like this is a panacea."

Federal officials respond to these types of complaints by saying that rebuilding the infrastructure was a nice idea, but only likely to happen as a welcome byproduct of the new emphasis on bioterrorism preparedness. They admit that bioterrorism money certainly has helped infectious disease response and note that much of it has not been useful for chronic-disease prevention.

"It pains me when I hear people quoted as saying the promise has not been fulfilled," said William Raub, PhD, HHS deputy assistant secretary for public health emergency preparedness. "Public health is receiving more money than at any time in its history, but it was appropriated for preparedness for bioterrorism and for other public health emergencies. We're at war, and we're at risk. There are many multipurpose benefits of these investment, but we would be misleading if we contended that every aspect of public health was going to benefit. Chronic disease, by and large, is not a beneficiary."

Still, there are some public health officials who maintain that the resulting new systems also can help response to chronic disease issues -- it just takes a bit of creativity. For example, Andrew Dennis McBride, MD, MPH, director of the Milford (Conn.) Health Dept., has been using his department's new geographic information system to map out antibiotic distribution centers that might have to be set up in case of a natural or man-made infectious disease outbreak. He's also using the system to plan and map out food sources and recreation areas to help tackle his jurisdiction's obesity challenges.

"We can use the same mapping technology to look at how we can better plan for walking routes and access to food and nutrition. It's one thing to tell a mother, 'Make sure your kid has all the food pyramid.' It's another thing to know there's no food markets within walking distance," Dr. McBride said. "We can use those technologies to benefit long-term preventive health."