Dollars for disaster readiness, bioterrorism tricky to spend

Victor Freeman, MD, an internist and past president of the Medical Society of the District of Columbia, is frustrated with the local efforts regarding bioterrorism and disaster preparedness. He knows that physicians are a key element of any such response plan, but the local public health department has proven so difficult to work with that he and other MSDC members have considered disbanding their emergency preparedness committee.

"We're quite disappointed, almost to the point of being demoralized," said Dr. Freeman.

His frustration results from an emerging reality that, despite increased federal support for shoring up public health readiness, this money has not always been easy to spend.

According to a series of eight reports issued in the past year by the Dept. of Health and Human Services Office of Inspector General, a significant portion of the billions of dollars directed to the public health system since the 2001 terrorist attacks was unspent as of August 2004.

More OIG reports analyzing how states used money from the Centers for Disease Control and Prevention and from the Health Resources and Services Administration for disease surveillance, laboratory capacity, and upgrades to hospitals' disaster response ability are expected in the coming months.

For now, though, what is clear is that each state along with the District of Columbia has its own unique set of issues in utilizing these newfound riches and most feel the hurdles faced thus far are a result of the difficulties that come with rapid growth. CDC preparedness funding, for example, was $40 million in 1999 but jumped to $982 million in 2002.

"The OIG is looking at a very new program, and it certainly takes some time to get a new program up and running," said Georges Benjamin, MD, executive director of the American Public Health Assn. "And there have been some barriers to being able to spend these dollars."

This circumstance has meant that, although the money to rebuild the public health infrastructure has been much welcomed, it hasn't always been easy to rapidly determine how to use it. One report found that, as of August 2004, Massachusetts had failed to utilize 65% of the money it received from HRSA, but this was blamed on efforts to establish a coordinated regional system. Much of this money was expected to be spent by the end of 2005.

According to two of the reports, as of August 2004, 48% of CDC funds in the District of Columbia had not been spent; just over 46% of HRSA money hadn't been used either. These cash balances were blamed on the District's complex bureaucracy that is linked to the federal budget.

"Spending money in D.C. is really tough," said Dr. Benjamin, who was the District's health officer from 1990 to 1991. "It's a challenge being in the nation's capital, and it's a little different planning process. There are regional issues to consider, and there's a complexity that doesn't exist in other places."

Work-force issues

For many jurisdictions, it also hasn't been easy to hire staff to spend this money. Public health departments in states with budget problems have been strapped by hiring freezes. Those that have been allowed to hire new staff have found that it isn't always easy to find the right people, particularly when most public health departments are unable to provide salaries that can compete with the private sector. Additionally, public health advocates have long expressed concerns about work-force availability, with lab staff and epidemiologists being in particularly short supply.

"We are in many cases cannibalizing ourselves by hiring good people from other public health areas," said Steve Cline, DDS, MPH, chief of epidemiology at the North Carolina Dept. of Health and Human Services and the principal investigator for CDC and HRSA grants in his state. "There's a lot of turnover. It's a real problem."

Public health officials also say that leftover money is not necessarily a sign that they don't know what to do with it. It may be a sign of efficiency.

In North Carolina, the OIG found that the state had either spent or committed all of its bioterrorism budget for 2004, though that may not be the case for 2005, when the budget included money for laboratory information management and electronic disease reporting systems. Both cost less than expected.

Officials are also unconcerned that they may lose the money they have been given. So far both the CDC and HRSA have allowed states to carry forward leftover money, and most state officials intend to spend the money, if they haven't already.

"In the end we have not lost any money. It's about when it gets spent, and we have spent more of the total available each year," said Steve Wagner, MPH, assistant chief for preparedness at the Ohio Dept. of Health. The OIG found that, as of the end of August 2004, 15% of Ohio's HRSA and CDC funds were still unspent.

Officials say, however, that spending has become easier as programs mature. There is also great variability from state to state, and overall states have spent just over 87% of the money allocated, according to a survey by the Assn. of State and Territorial Health Officials.

"This is a young program, but we see big improvements in how states spend this money," said Alison Johnson, director of the CDC's Division of State and Local Readiness.

The biggest concern of public health advocates, though, is that any evidence of unspent funds may be interpreted as a sign that the resources are not needed. Both CDC and HRSA faced cuts in the proposed 2006 federal budget, which was still being finalized in Congress at press time.

"Because a state has not spent what was allotted is not a reason to not continue to fund states for this kind of work," said James J. James, MD, DrPH, MHA, director of the American Medical Association's Center for Disaster Preparedness and Emergency Response.