Bioterror blowback

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Americans tend to think of public health only during times of crisis. With debates about smallpox vaccination and bioterrorism preparedness and the outbreak of anthrax, SARS and monkeypox, recent memory has given Americans plenty of occasions to see the nation's public health community in action.

The success that health officials had in containing these health emergencies gives the impression of a robust public health infrastructure. These recent successes belie the reality that the nation's public health is in a fragile, precarious state after years of financial and political neglect.

Although controlling infectious diseases and responding to acts of bioterrorism have garnered the most public attention, they are only two of the functions of state and municipal public health departments.

In the post-September 11 climate, bioterrorism preparedness has received significant funding from the federal government. In January 2002, the Department of Health and Human Services announced $1.1 billion in grants to state and municipal health departments to shore up their capabilities to respond to bioterrorism. The 2004 budget proposes to give HHS $3.6 billion to prevent and to combat bioterrorism.

The infusion of federal funds and its well-meaning emphasis on bioterrorism is, however, having unintended consequences. The availability of federal funds has become an excuse for cash-strapped states to cut their funding for public health programs. And these state cuts stand to immediately affect more people than the federal funds will help.

The emphasis on bioterrorism has compromised the overall effectiveness of the public health system by forcing it to divert funds, resources and manpower from chronic diseases and health promotion programs.

For instance, the rural Larimer County, Colo., health department gained $100,000 in federal bioterrorism funds but lost $700,000 in state funds. The result? It gained 1.4 positions to fight bioterrorism but had to cut 15 other positions that affected family planning and child immunization programs, leaving 200 women without access to birth control and more than a thousand children without their needed immunizations. In a referendum in the November 2002 election, the county asked its residents to consider a tax increase to offset the state funds lost by the health department. The proposal was voted down.

Small towns are not the only ones affected. Los Angeles received $28 million for bioterrorism preparedness in 2002, but it still expects to run an $800 million deficit for the next three years. It has already closed 16 health centers and school clinics, and has considered shutting two of its six public hospitals, eliminating more than 455,000 patient visits. Only a taxpayer-backed bailout in the November 2002 election keeps the two hospitals operating.

At a time when public health departments are being asked to do more, they are losing much needed funds and resources, and the funds that are available are not being directed to the programs where they are most urgently required. Adrienne LeBailly, the director of the Larimer County health department, told the American Medical Association, "It would have been nice to have the bioterrorism money to enhance the services that we used to have. ... At this point, I feel like we've been hurt more. I certainly wasn't expecting to have a weaker public health infrastructure than we had before 9/11."

While bioterrorism preparedness can serve as a catalyst for the reform of the U.S. public health infrastructure, there has to be a recognition that public health work also involves the protection of community health, the prevention of disease and injury, the promotion of health, and the surveillance of disease incidence and health factors.

In studying the nation's public health efforts, the Institute of Medicine described the system as ready for a major overhaul that would recognize the many determinants of good health, that would strengthen the governmental structure of public health, that would recognize more than just government efforts can contribute to public health, and that would enhance communication across all of the many contributors to the public health enterprise.

The recommendations might sound very different from preparing for a bioterrorist attack. And they are. These recommendations are meant to create an effective and responsive public health system for the long term. The provision of funds for bioterrorism preparedness addresses a short-term need, but neglects the pressing, systematic reforms that can not be delayed any longer.

D. George Joseph studies the history of public health at the Yale School of Medicine.