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Preparedness Funds Undermines Readiness Efforts

A major reprogramming of federal bioterrorism preparedness funds in June resulted in about a $1 million funding decrease per state, according to public health advocates, many of whom say the move is resonant of the government's long-time undercommitment to public health.

The millions being shifted were originally part of fiscal year 2004 bioterrorism funds that were allocated for states to continue funding preparedness projects and revitalizing public health infrastructures. A total of $54.9 million of 2004 funds were redirected away from state projects and into activities such as upgrading quarantine abilities at the Centers for Disease Control and Prevention; accelerating CDC's BioSense surveillance initiative; and developing the Cities Readiness Initiative, which will shore up preparedness capacities in 21 U.S. cities. The funding shift is also coupled with President Bush's proposed $105 million cut in state and local public health preparedness funds, which is included in the administration's fiscal year 2005 budget request.

"We have made significant progress in preparing for bioterrorist attacks, but to continue to improve our preparedness, sustained commitment is needed - and that starts with money," said Georges Benjamin, MD, FACP, APHA's executive director.

Although the new city initiative is being praised by public health advocates, its funding mechanism has garnered widespread criticism from groups ranging from APHA to the National Governors Association. While city readiness is key to overall preparedness, it should be funded with supplemental funds, not with funds sorely needed by states, according to APHA member Shelley Hearne, DrPH, executive director of Trust for America's Health.

"These new initiatives may be very important ones - I don't want to minimize their role and need - but this shouldn't be an either/or proposition," Hearne told The Nation's Health.

In a May letter about the redirection of preparedness funding, U.S. Health and Human Services Secretary Tommy Thompson wrote that a reason for reinvesting the almost $55 million was the "slow rate at which states are expending available federal funds to improve homeland defense." But Hearne maintained that states have done "extraordinarily well in attempting to rebuild and revitalize a very antiquated health defense." Spending bioterrorism funds is not a quick or easy process, she said, pointing to public health laboratories as a prime example. Beefing up laboratory capacity requires ordering equipment, training the work force, finding qualified scientists and much more - "there are many layers and it takes a while," Hearne noted.

And unfortunately, many states are choosing not to make long-term public health commitments, such as hiring full-time workers, out of fear that the federal government will cut or pull funds and states will get stuck with the bill, Hearne said. However, state governments also need to be held accountable for years of "starving (public health) agencies to death," she said.

"This is what happens all the time in public health," Hearne said. "We just started up a critical program and lo and behold, the money disappears."

According to the Association of State and Territorial Health Officials, more than 90 percent of fiscal year 2002 preparedness funds have been spent or obligated, and states still have until November to report their fiscal year 2003 spending. Geoffrey Wilkinson, executive director of the Massachusetts Public Health Association, which signed onto an APHA-initiated letter to Congress opposing the funding shift, said money was spent slowly in his state, as some efforts are being built from the ground up. MPHA leads a coalition that helps bring local public health officials to the table with state officials in making emergency preparedness plans.

Massachusetts doesn't have a county health system, so much of the state's preparedness funds were spent slowly in the first year developing regional public health infrastructures, Wilkinson said.

"The funds had a very important value that went beyond the direct purchases that Thompson was concerned were happening," he told The Nation's Health. "It's important to recognize that strengthening our preparedness includes building and rebuilding our infrastructure in a lot of ways. It's not just about buying hazmat suits and indestructible laptops."

Wilkinson also noted that regularly changing preparedness funds - either by redirecting or decreasing funds - directly compromises the ability of public health workers to improve preparedness and exacerbates a pattern of regularly changing expectations.

"Each time the (Bush) administration develops a new set of priorities, it requires that people at the state and local levels adjust accordingly and that is disruptive of consistent planning and implementation of local plans," Wilkinson said.

Thompson's decision to redirect the funds did not go unchallenged by members of Congress. Among those opposing the decision was Sen. Tom Harkin, D-Iowa, ranking member of the Senate Appropriations Committee, who urged Thompson to look toward other options to fund the Cities Readiness Initiative. Harkin's state lost more than $1 million dollars in preparedness funds, and because Iowa isn't home to a Cities Readiness Initiative locality, the state won't receive any returning funds.

"If the (Bush) administration has found it needs money for additional threats, it should ask for it instead of robbing Peter to pay Paul," Harkin said.

Unfortunately, the current administration seems to be addressing public health preparedness issue by issue, never stating what activities will be left unattended when funding is withdrawn or redirected, according to Patrick Libbey, executive director of the National Association of County and City Health Officials. Libbey said that although federal officials are doing a better job of getting resources to the local level, he agreed that additional preparedness projects should be funded with additional resources - not by taking money from state and local efforts.

"What's missing is a clear sense of a systematic approach to assuring that communities are appropriately prepared," Libbey told The Nation's Health.

Libbey noted that with reductions in funds, it's even more critical that a "cooperative planning process becomes the hallmark between state and local health officials when making their plans." He added that a lack of federal preparedness standards is also problematic in the planning process.

CDC is currently working on a set of performance standards for public health preparedness - which is being piloted in a few states - but data coming from a variety of sources reflect that the nation is far from prepared for a bioterrorism event, said Hearne. According to a 2003 report from Trust for America's Health, states are only modestly better prepared to handle a health emergency than they were before the terrorist attacks of Sept. 11, 2001. Also, a 2003 report from the U.S. General Accounting Office, Congress' investigative arm, found that most U.S. urban hospitals were not ready for a bioterrorist attack.

"By not having a long-term, sustained and strategic commitment to strengthening our public health defenses, we are guaranteeing that we will leave critical areas vulnerable," Hearne said.

In May and June, HHS awarded $849 million in public health preparedness funds to states, territories and four metropolitan areas as well as $498 million to improve hospital response.

For more information, visit http://www.tfah.org/ or http://www.hhs.gov/.

Kim Krisberg
Reprinted with permission from The Nation's Health, APHA

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