Huge advances in controlling infectious diseases, tracking foodborne illnesses and purifying the water supply have vastly improved public health over the past century. More recently, closer communication between emergency managers and public health officials has created the possibility of more coordinated responses to public health emergencies — as well as better prevention.
However, there is much work to be done in all of these areas and recent cuts to public health funding may be jeopardizing the progress.
A report, called Outbreaks: Protecting Americans from Infectious Diseases, released in December 2013 by Trust for America’s Health and the Robert Wood Johnson Foundation identified numerous reasons for concern. Among them:
- Just one-quarter of states vaccinated at least half of their population against the seasonal flu, even though the U.S. Centers for Disease Control and Prevention recommends the vaccine for all Americans 6 months and older.
- Only Connecticut, Delaware and Washington, D.C., met the federal government’s goal of vaccinating 90 percent of preschoolers against whooping cough.
- About half of public health laboratories did not test their emergency plans through either a drill or a real event in the previous year.
- Two-thirds of states cut funding for public health from 2011-12 to 2012-13.
“We found, not surprisingly, that after some pretty severe budget cuts at the state and federal levels, a majority of states had decreased public funding for public health,” said Rich Hamburg, deputy director of Trust for America’s Health. “There are states that have had their public health budgets cut three and four years running.”
Where To Go From HereThe report Outbreaks: Protecting Americans from Infectious Diseases recommended steps for shoring up infectious disease control and prevention in the U.S. Among them: Maintain an expert public health workforce and give it state-of-the-art tools. Rich Hamburg, Trust for America’s Health’s deputy director, said an all-hazards approach is best: “You need the resources that will help you conduct investigations to detect, control and treat disease outbreaks — whether from diseases or acts of bioterrorism.” Improve vaccination rates, which Hamburg called the “most effective way” of reducing infectious disease. Modernize disease surveillance and ensure public health laboratories can test not only for routine problems like foodborne illnesses but also for large-scale threats like bioterrorism or a pandemic. IT for the health-care field plays an important role here, Hamburg said, since it can help track disease outbreaks. Improve global coordination to prevent and contain emerging illnesses while still defending against longstanding threats like malaria and tuberculosis. To reach these goals, funding needs to be adequate. “Policymakers and citizens need to understand the importance of public health protection services to a community. We have to have some way of maintaining health protection capabilities and services in all of our communities,” said Paul Kuehnert of the Robert Wood Johnson Foundation. |
“Public health professionals will do anything it takes to try to protect the health of the population that they serve,” Hamburg said. “It’s amazing what they can do even in times of decreasing resources. But you reach a point where you have to say there are certain things you just won’t be able to do.”
For example, if laboratories are not adequately staffed and there is an outbreak of a foodborne illness, it could take five days to detect the outbreak instead of two. The result is that more people get sick while experts try to track down the source of the illness.
In addition to the hard economic times of the past several years — which are clearly a driving force behind the cuts — there’s the issue of complacency. Public health officials see this in demand from the public for flu shots, which spikes when there’s a serious outbreak and declines when the flu isn’t viewed as such a big concern. But governments can act the same way when it comes to deciding how to spend money, especially when difficult choices must be made.
“The resources will be provided after an emergency,” Hamburg said, often through emergency appropriations by the government. So if an earthquake or fire damages a local water treatment plant, the government will be sure it gets fixed. It’s important to provide these funds, he said, but in some cases, the outcome could have been better if there had been more money invested in prevention before the emergency. When governments have to cut their budgets, big-ticket items like preparedness are often among the first to go.
One of the costs of these funding cuts is the ability of public health officials to detect food- or water-borne illnesses and infectious diseases, which could be critical in the case of a bioterror attack.
“The role of public health in these situations is working closely with doctors and nurses and really understanding when something is unusual, when the pattern is changing or the symptoms are coming together in ways that haven’t been seen before,” said Paul Kuehnert, team director and senior program officer with the Robert Wood Johnson Foundation, as well as a registered nurse who has spent his whole career in public health. “That’s something that is really key not only to managing and containing these routine things like foodborne illnesses, but to biosecurity.”
To make these determinations, public health officials need to: maintain relationships with local clinical care providers; receive electronic reports of illnesses and outbreaks; and be able to analyze the data quickly and work with emergency management officials if necessary. All of these tasks are made more difficult without enough staff and equipment.
“These critical services in health departments across the country are being threatened,” Kuehnert said.
One of the areas where complacency is a great concern is in infectious diseases.
“We are looking at huge advances that have been made over 50 years in preventing and controlling infectious diseases,” Hamburg said. “The majority of Americans can live longer lives.”
But those gains are not guaranteed to be permanent. With most states not meeting the U.S. goals for vaccination, for example, the threat of some infectious diseases is increasing.
Certain infectious diseases are always around, though they vary from year to year in intensity. Flu is a good example, with its potential for an epidemic. HIV and tuberculosis are also among the infectious diseases that public health officials monitor and try to prevent from spreading.
“Ten years ago, measles and whooping cough wouldn’t be on that list,” said Jennifer B. Nuzzo, senior associate with the UPMC Center for Health Security. “They are now because people aren’t vaccinating. Now we’re seeing large outbreaks, which is a big drain on resources for public health departments to investigate and control them.”
In addition, the U.S. is seeing some mosquito-borne illnesses, like dengue, that had not been present in the country in recent years but seem to be seeing a resurgence.
This is an ongoing concern due to climate change, Hamburg said. “Some of it is just temperatures,” he said. If the temperature changes, mosquitoes, ticks and other animals that carry disease may start living in places where they didn’t previously inhabit. “Weather patterns have an effect on some outbreaks.”
The Centers for Disease Control and Prevention estimates that each year about 1 in 6 Americans gets sick from foodborne diseases and 3,000 die. Foodborne illnesses have been found to be transmitted by foods as diverse as frozen pizza snacks, salads, ground beef and tahini sesame paste.
The U.S. has worked hard over the last two decades to build a surveillance system that can detect foodborne illnesses, Nuzzo said. When doctors suspect a foodborne illness in a patient, genetic analysis of his or her stool samples can link the illness to what other patients are experiencing. When public health officials know where the victims are, they can more easily find the source of the illness and, if it’s a food that is still being sold, get it off the shelves.
However, Nuzzo said, this system is threatened, ironically, by advances in health care. Newer, faster tests may give doctors the information they need to treat the patient, but they may not provide as much detail as public health officials need to establish links between cases. “It’s good for the patient, but not necessarily good for public health, which relied on having much more detailed testing,” Nuzzo said.
Budget cuts are also an issue. “Important programs have had to do more with less, but you get less with less,” Nuzzo said. “It’s really worrisome.”
“These are mostly illnesses that can be prevented,” Kuehnert said. This means that even though in most cases the illnesses are not life threatening, preventing them should be a goal. “They have a significant impact on our health-care system in terms of dollars spent and lost productivity.”
A related issue is that while officials in the United States have become good at detecting outbreaks, it can still be very difficult to determine what caused them. In one salmonella outbreak, for example, officials first thought tomatoes might be the culprit, Nuzzo said. Ultimately they realized the problem was with jalapenos, which were being eaten with tomatoes. By that time, though, the outbreak was mostly over and the tomato industry had lost millions of dollars. Other cases have involved contamination of food from just one processor, but consumers get the message that they should avoid a particular product entirely.
Although it’s important to keep people from getting sick, Nuzzo said, “We don’t want to cause undue economic losses or to have people lose confidence in foods that are safe.”
Waterborne diseases are also a threat. Because breakdowns of the U.S. system for protecting drinking water are rare, most come from recreational water use, Nuzzo said, such as swimming pools or water parks.
“Waterborne and foodborne illnesses were a major cause of death before we got sanitation systems in place in the early 20th century,” Kuehnert said. “That’s particularly true of our drinking water. Today in our country, we have great infrastructure in place that protects our water supply for drinking.”
There are still occasional problems with the water supply, however. Big rainstorms can wash solids into the water, for example, and intentional contamination is always a concern.
The relationship between emergency management and public health departments continues to evolve.
“Prior to 2001, I think that public health and emergency management were very separate from each other,” Kuehnert said. “Like many public agency departments, everybody was kind of comfortable in their silos.” There were a few exceptions, he said, primarily in places with frequent natural disasters.
Communication between the departments started improving in the late 1990s and picked up markedly after 2001, as the federal government increased its funding for public health emergency preparedness and response.
Public health departments have received funding in recent years to respond to disasters, such as bioterror threats, which has led to increased collaboration and cross-training between agencies.
The level of communication still varies a lot by jurisdiction, Kuehnert said, but public health is seen as one of the real resources for a jurisdiction in emergency preparedness, response and recovery and has been integrated much more into the state, county and city emergency response framework.
