Statement from Paul E. Jarris, MD, MBA, Executive Director of the Association of State and Territorial Health Officials (ASTHO) on the Need for Sustained Commitment to Public Health
(Arlington, VA) May 20, 2009 - States and territories have made significant progress in pandemic planning, as evidenced by our effective response to the ongoing novel H1N1 epidemic. Despite the challenges of the current economy, federal, state, territorial, and local governments have come together to serve the American people as a unified enterprise. During the last three weeks, the Centers for Disease Control and Prevention (CDC), ASTHO, state, territorial, and local public health departments have stood up their emergency operations centers to coordinate planning and response issues and share practices among states for the benefit and use of every agency. But we cannot sustain this response without further resources.
In FY 2006, Congress invested $600 million in state and local pandemic influenza supplemental funding to support three years of preparedness activities. This funding was fully expended in August 2008. The federal investment enabled state and territorial health departments to lead the development of comprehensive pandemic influenza operational plans that have linked health agencies with agriculture, homeland security and emergency management, education, justice, labor, transportation, treasury and commerce, and other state and federal agencies to drill and refine plans to meet the goal of continuous state operations during a pandemic or other disaster.
At this moment, states and territories are carefully considering, and carrying out community mitigation strategies such as closing schools as recommended by federal guidance. Prior to the current outbreak, all states and territories had their operational plans assessed by a team of U.S. Government experts and their findings were reported to the Homeland Security Council. The comprehensive, effective, and integrated response between states and the CDC to H1N1 is a result of the investment Congress made in state and territorial public health preparedness.
State and Territorial H1N1 Response
State and territorial health agencies are on the front line of our nation’s response to this influenza epidemic. Disease investigators are on the ground 24 hours a day, seven days a week to detect infectious disease outbreaks. Our state laboratories stand ready to test specimens to identify new and seasonal influenza strains. Our top priority is to protect the public’s health, no matter what the situation. State and territorial public health officials prepare for and respond to all health threats including infectious disease outbreaks, natural or man-made disasters, and food borne illnesses. Public health agencies also understand the complex and devastating effects of pandemics.
However, the current epidemic is occurring during a period of economic hardship. State, territorial, and local health departments are suffering the same effects of the current recession as other sectors of the economy. State, county and municipal budget shortfalls have resulted in the loss of over 11,000 public health workers in the past year, and additional job losses are expected during the remainder of this year. As more public health professionals are laid off to balance state and local budgets, health departments will become even more strained in the fall, should H1N1 turn out to be more lethal. There is no dedicated public health emergency reserve fund states can draw from to pay for the response.
We need to build our workforce now so that we can sustain the current response and prepare for the future. Health departments are stretched to the limit working long and extra shifts, while remaining ever vigilant to handle other emergencies as they occur. State, territorial and local health departments do not have the personnel and financial capital to continue this level of response over a long period.
Right now these health departments must also be prepared to respond to other public health threats arising from flooding, hurricanes, tornadoes, and wildfires. Sustained investment is needed. But, federal public health emergency preparedness funding for states and localities declined approximately 25 percent since 2005 and state budget cuts prevent us from absorbing these losses. Further, state and territorial health departments are committed to carrying out mandated essential functions such as conducting restaurant inspections, maintaining a safe water supply, providing maternal and child health services, screening newborns, giving immunizations, and numerous other activities critical to the public’s health. Even before the outbreak, over 60 percent of health departments had reduced public health services, and 30 percent had eliminated entire programs.
It is essential that the state and local public health workforce and infrastructure be reinforced to enable enhanced influenza surveillance, case detection, epidemiological investigation, laboratory testing, medical surge capacity, fatality management, and disease control measures in the event that this novel virus returns with increased deadliness in the fall of 2009, as occurred in 1918. The federal government can purchase enormous quantities of new H1N1 vaccine, but without the public health workforce to distribute and administer it, the vaccine will do no good.
The effective federal, state, territorial, and local response to H1N1 virus over the last several weeks was made possible with previous federal investment. Nevertheless, the current epidemic is stressing our diminished public health workforce after only three weeks of response. A severe epidemic or pandemic will require a three to six month mobilization. Sustaining a response of this magnitude is not possible given the current human and financial resources available to state, territorial, and local public health agencies. Moreover, during the Fall, public health will need enhanced surveillance to detect influenza outbreaks and sort out illness caused by seasonal influenza versus illness caused by a return of the novel H1N1 virus.
We must be prepared to sustain a public health response should we face a severe pandemic requiring rapid dispensing of antivirals to millions of sick or exposed individuals, a national vaccine campaign for hundreds of millions of Americans, and professional medical attention in the face of an overwhelmed health care system.
Allow me to mention three key areas where we can improve our readiness:
Disease Surveillance – We need more epidemiologists on the ground to identify outbreaks, monitor the spread of a disease, and inform our response as the outbreak continues. We recommend investing in standardized electronic reporting systems and centralized databases to analyze and respond to geographically widespread outbreaks. It is essential that we have real time capabilities to monitor the prevalence of diseases and identify which populations are most susceptible to certain illnesses whether it is pregnant mothers, children, young adults, or the elderly.
Laboratory Capacity – During this recent response, public health laboratories quickly exceeded testing capacity. Not only were there not enough laboratorians to maintain three shifts, seven days a week, but states also needed additional reagents and other resources and equipment to run the large number of tests required throughout this outbreak. Going forward, state health laboratories would benefit from increased investment in electronic health information infrastructure. We recommend increasing our nation’s investment in bi-directional data exchange of laboratory test orders and results with CDC. Our country would also benefit from interoperable regional electronic laboratory information sharing networks among state laboratories and health departments. Stronger laboratory capacity will speed our detection of potential cases and enhance our understanding of the characteristics of novel viruses.
Public Health Nursing – State and territorial public health nurses make up 25 percent of the public health workforce. They are a critical component of our public health infrastructure providing expert advice and guidance to the public and health professionals. Public health nurses frequently oversee crucial emergency response activities such as the mobilization of mass immunization clinics and are instrumental in overseeing and training volunteer nurses on the safe administration of antivirals and vaccines. During emergencies, public health nurses ensure that vaccines are distributed efficiently, administered correctly, and are properly handled (i.e. refrigerated). We applaud Congress for including funding for nursing workforce development programs in the American Recovery and Reinvestment Act of 2009; however, additional investments are needed to reduce the serious public health nursing shortage in our state, territorial, and local health departments.
We cannot be complacent. We cannot let our guard down. We must redouble our investment in the nation’s public health system. Protecting America’s health and effectively responding to emergencies, whether pandemics or terrorist attacks, requires sustained federal commitment and financial support.
Contact: Paula Steib 571-527-3173; 703-439-8259 (cell); psteib@astho.org