Waiting for Bioterror
A Public Health 'Train Wreck'
On taking office, President Bush eliminated the health position from the National Security Council, arguing that health, while in the national interest, was not a national security concern. In the wake of the anthrax attacks last year, he changed his tune, declaring, "We have fought the causes and consequences of disease throughout history and must continue to do so with every available means." Next year's budget for biodefense is up 319 percent, to $5.9 billion. States, newly flush with $1.1 billion in biodefense funds, have gone on shopping sprees for emergency equipment like gas masks, hazmat suits and Geiger counters. Newly drafted to fight the war on bioterror, doctors and public health officials are now deemed vital to national security, and their hospitals are even under threat, according to an alert released in mid-November by the FBI.
And yet this flurry of interest and concern has not begun to address America's greatest public health vulnerability: the decrepit and deteriorating state of our healthcare system. In states from Nevada to Georgia, dozens of health officials and doctors told The Nation that anemic state funding, overcrowding and staff shortages may be greater problems in responding to bioterror than lack of equipment or specific training. "We don't have enough ER capacity in this country to get through tonight's 911 calls," said Dr. Arthur Kellerman, chairman of the emergency medicine department at the Emory University School of Medicine in Atlanta. Two decades of managed care and government cuts have left a depleted system with too few hospitals, overburdened staff, declining access for patients, rising emergency-room visits and an increasing number of uninsured. The resulting strain is practically Kafkaesque: How do you find enough nurses to staff enough hospital beds to move enough emergency-room patients upstairs so that ambulances with new patients can stop circling the block?
The infusion of cash for bioterror defense without consideration of these fundamental problems is like "building walls in a bog," where they are sure to sink, said Dr. Jeffrey Koplan, the recently departed head of the CDC.
Between 1980 and 2000, the number of hospitals declined by 900 because of declining payments and increased demands for efficiency, according to the American Hospital Association, leaving almost four-fifths of urban hospitals experiencing serious emergency-room overcrowding. Burnout and low pay have left 15 percent of the nation's nursing jobs unfilled, and the staffing shortage has led to a drop in the number of hospital beds by one-fifth; in Boston by one-third, according to the Center for Studying Health System Change in Washington.
Meanwhile, emergency room visits increased by 5 million last year, according to the American College of Emergency Physicians. One in eight urban hospitals diverts or turns away new emergency patients one-fifth of the time because of overcrowding, the American Hospital Association reports. And the costs of health insurance and medical malpractice premiums continue to soar.
In public health, chronic underfunding has closed training programs and depleted expertise. According to a recent CDC report, 78 percent of the nation's public health officials lack advanced training and more than half have no basic health training at all. During the anthrax crisis inexperienced technicians in the New York City public health laboratory failed to turn on an exhaust fan while testing anthrax samples and accidentally contaminated the laboratory.
A government study of rural preparedness this past April found that only 20 percent of the nation's 3,000 local public health departments have a plan in place to respond to bioterror. Thirteen states have had no epidemiologists on payroll, said Dr. Elin Gursky, senior fellow for biodefense and public health programs at the ANSER Institute for Homeland Security. Meanwhile, 18 percent of jobs in the nation's public health labs are open, and the salaries create little hope of filling them. One state posted the starting salary for the director of its public health laboratory program--a PhD position--at $38,500, said Scott Becker, executive director of the Association of Public Health Laboratories. Becker calls the combination of state cuts and work-force shortages a "train wreck."
Amid this crisis, clinicians have a new mandate: to be able to fight a war on two fronts simultaneously. They must care for the normal volume of patients and track the usual infectious diseases while being able to treat mass casualties of a terrorist event. They now have some money for the high-concept disaster, but with many states in dire financial straits, there is less money than ever for the slow-motion meltdown of the healthcare system, in which 41 million Americans lack health insurance. In the event of a smallpox attack, the tendency of the uninsured to delay seeking treatment could be catastrophic.
Hauer hopes that the "dual use" of federal resources could herald a golden age in public health, with tools for tracking anthrax or smallpox being used also to combat West Nile virus or outbreaks from contaminated food. But politicians of all stripes continue to propose beefing up biodefense in isolation from more systemic problems. In October, Al Gore argued in a speech that the problem of the uninsured should take "a back seat" temporarily to the more urgent matter of biodefense. And Bush has proposed shifting key public health and biodefense functions into his proposed Department of Homeland Security, a move likely to weaken daily public health work like disease surveillance and prevention, according to the General Accounting Office. A bipartisan report recently issued by the Council on Foreign Relations warned that America remains dangerously unprepared for a terrorist attack, with its emergency responders untrained and its public health systems depleted.
The solution, say doctors, is to tackle the systemic and not just the boutique problems. "If you have a health system that is chaotic and has no leadership and is not worried about tuberculosis and West Nile and just worried about these rare entities, you'll never be prepared," said Dr. Lewis Goldfrank, director of emergency medicine at Bellevue Hospital Center in New York City. "To be useful, money has to be earmarked for public health generally, so that it will prepare you for terrorism or naturally occurring events."
President Bush strongly resisted federalizing airport security until it became clear as day that private security companies and their minimum-wage workers would continue to let a flow of box cutters, knives and handguns through the metal detectors. Some clinicians now say that the specter of bioterror raises a similar question, which almost nobody in Washington has yet begun to address: Has healthcare become so vital to national security that it must be centralized, with the federal government guaranteeing basic healthcare for everyone?
"Forget about paying for the smallpox vaccine," said Dr. Carlos del Rio, chief of medicine at Atlanta's Grady Memorial Hospital. "Who's going to pay for the complications of the vaccine? With what money? We haven't even addressed that. As you look at bioterror issues, it's forcing us to look at our healthcare delivery."