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CDC Public Health Preparedness Report

March 7, 2008

Chlorine Spill Like it or not, one of the goals of the CDC is to protect folks from terrorism.  To that end, in 2002, Congress authorized funding for the Public Health Emergency Preparedness cooperative agreement.  This agreement was intended to support preparedness activities in the states, territorial, tribal and local health departments.  Developed in the shadow of the Fall of 2001, and after an IOM report that stated that the public health infrastructure suffered from

vulnerable and outdated health information systems and technologies, an insufficient and inadequately trained public health workforce, antiquated laboratory capacity, a lack of real-time surveillance and epidemiological systems, ineffective and fragmented communications networks, incomplete domestic preparedness and emergency response capabilities, and communities without access to essential public health services.

Um, can you say scathing?

The cooperative agreement was intended to increase collaboration between all levels of public health agencies, research universities and first responders; increase the speed at which biological and chemical agents could be identified by public health labs; fix the communication problem; enhance public health programs through planning and exercises; protect the health of the community and first responders during an emergency; and helping communities to recover from emergency.

Now, I know that different people will read that previous paragraph in different ways.  The person who thinks that preparedness activities are draining money from traditional public health see only the bioterrorism words and worry how the government can continue to pile roles on public health before the whole thing collapses.  I, however, prefer to read it as each of those activities are proxies for supporting and improving traditional public health.  I mean, really, we’ve all written grants where you shoehorn your project into some RFP that it doesn’t really fit saying that your project will help to increase our knowledge of this completely unrelated project that the grant is supposed to be dealing with.  And then it’s up to you to make it work – figure out the links.  This is exactly the same thing.  The money’s there, the support is there – now, figure out how to support public health with it.  And some places have figured that out, and are doing just that (you can read about those stories on my delicious page, under the goodnews tag).

So, now that we’ve established that I’m a cheerleader, what does the Public Health Preparedness: Mobilizing State by State report, released by the CDC, say?  Basically that progress has been made, but we’ve still got work to do.  HHS Secretary Mike Leavitt has been credited with saying something along the lines of, “We’re better prepared than we were yesterday.    We have to be better prepared tomorrow than we are today.”

The report is divided into three sections: Disease Detection and Investigation, Laboratory Testing, Response: Communication and Coordination.

No one in the field would argue that improving disease detection and investigation is anything but of paramount importance, both for preparedness and public health reasons – so it’s appropriate that this is dealt with first.  This is one area where you can’t fix the problems with better technologies, better coordination or fancy new plans.  Better disease investigation and epidemiology requires bodies – people who can do the job.  And public health has been recognized as facing a huge personnel shortage as the older folks retire and the younger folks get jobs that actually make money.  Well, the CDC funding has, according to the report, paid for more than 500 epidemiologists in 2006.  Yeah, but c’mon Jimmy, they’re BT epi folks, all they do is sit around and wait for the big one, right?  Nope, by and large, these folks increase the day to day capacity of public health surveillance and disease detection systems (see my post on telephone-reporting systems).  The agreement has also been used to increase coordination among the different health agencies through tools like Epi-X.

I saw that one blogger dismissed this report saying that all that money paid for a few more labs, big whoop.  I got a laugh out of that, because in my mind, that’s the least of the preparedness activities that’ve been going on.  I think that what’s been going on in the labs front is the least impressive.  This is where the largest problem of a lack of recruitment resides, and not much has been done to rectify it.  Almost half of the state labs can’t effectively or securely transmit electronic data.  What agents or conditions can be tested for is a patchwork quilt of state labs; with no one lab outside of CDC being able to do everything.  And the ongoing problems at the BSL labs like the one in Boston and at Texas A&M, or should be, a crime.

The most telling statistic of the improvement in this area has to do with the Health Alert Network (HAN), as implemented by the CDC.  In 2001, there was no coordinated way to distribute messages on health and medical issues to the health care community outside of panicked calls.  Today, all 50 states, four cities, and a number of unsanctioned and paid for counties have established HANs to do just that.  Messages can be delivered from the CDC to a huge portion of the healthcare community in literally minutes now.  Every state has developed a public health emergency response plan, though how good they are remains to be seen.  According to the report, on 73% of the states scored above a 69 (out of 100) on the most recent SNS planning review.  Pretty poor, if you ask me.  And Pennsylvania just squeaked by, if I remember correctly.

So, where does that leave us?  With a lot of work to do, unfortunately.  And a dwindling budget.  My three pet theories about improving public health preparedness are actually represented in the “Moving Forward” section of the report, which I take to mean that they’re on the right road.

First, and most importantly, is standards development.  The majority of people working in public health preparedness planning are learning on the job.  The programs and trainings and best practices coming out of DHS and CDC are random at best.  Now, I understand that it takes time to develop standards for developing best practices, but these things should be much further along than they are, in my opinion.  And it’s not just about developing plans, either.  Standards for data transfer, interoperable communications, public health labs, and exercises are all areas that need to be developed.

The next logical step after developing standards is measuring health departments efforts against those standards and constantly improving the standards themselves over time — making them tougher to reach.

Finally, there is communicating with the public.  And I don’t mean “communicating with the public” communicating, either.  I mean involving the public in our planning.  One of the biggest problems with government communications in emergencies these days is the complete lack of trust in government spokespeople (no thanks to the wonderful disaster responses we’ve seen recently).  By making the public stakeholders in the process, letting them know about our plans in disaster situations will help rebuild their trust in government response.  Hell, it might even make our plans better.  So many times I have to respond to questions about why the government just doesn’t tell regular folks about the plans, let them know what they can do to help.  We live in an age when people gain power with information — keeping them in the dark is basically shutting them out of the process and ignoring them.  Thinking that way, can you really blame them for criticizing the government’s “lack” of plans?

In sum, we’re getting there is my best interpretation of the report.  I realize that it serves as a nice counter-point to the TFAH report,  so it looks like (yet another) reaction to bad news, but I really don’t think (read: hope) that it’s like that.  I guess we’ll see with time.

Photo credit: CDC promo

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