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Public Health And National Security: The Critical Role Of Increased Federal Support
Protecting the public’s health historically has been a state and local responsibility. However, the growing threat of bioterrorism has highlighted the importance of a strong public health infrastructure to the nation’s homeland security and has focused increased attention on the preparedness of the public health system. As a result, federal public health funding has increased exponentially since the anthrax attacks of late 2001, and Congress has passed sweeping new federal legislation intended to strengthen the nation’s public health system. This heightened level of federal interest and support should yield important public health benefits. Most recognize that after years of neglect the public health infrastructure cannot be rebuilt overnight. As we implement a comprehensive strategy to increase the capabilities and capacity of our nation’s public health system, it is essential to address a series of important policy questions, including the appropriate level of ongoing public health investments from local, state, and federal sources.
The anthrax attacks of October 2001 heightened America’s awareness of bioterrorism and focused attention on the important role of our nation’s public health system in responding to such emergencies. This paper discusses the state of the public health infrastructure before the fall of 2001 and the initial legislative initiatives to begin the rebuilding process. It highlights the special nature of bioterrorism and the federal response to it. The paper also examines some of the key political and policy considerations raised by recent federal investments in public health preparedness; illustrates the historical role of local, state, and federal funding of national public health efforts; and cites examples of public health benefits achieved by this funding and gains that can be expected from the dual use of bioterrorism funds. A cautionary note is added about what Congress can expect from increased federal support, and the difficulties states may face in achieving the desired outcomes.
The risk of a bioterrorist attack is increasing. Terrorists around the world, including Al Qaeda, have often expressed their desire to use biological weapons against the United States. We know that more than a dozen nations, including Iraq, North Korea, Libya, and Syria, have the capability to produce chemical and biological weapons. We know that thousands of Soviet scientists who have the expertise to develop biological weapons are unemployed and potentially available to the highest bidder.1 An unclassified memo from the National Intelligence Council warns: "The biological warfare capabilities of state and non-state actors are growing worldwide. This trends leads us to believe that the risk of an attack against the United States, its interests and allies will increase in the coming years."2 For example, Iraq launched a robust biological weapons program in 1985 and has admitted to producing large quantities of agents and weapons, including 19,000 liters of botulinum toxin (10,000 into munitions) and 8,500 liters of anthrax (6,500 into munitions). During the Gulf War, Iraq armed 100 bombs and 15 missile warheads with botulinum toxin and 50 bombs and 10 missile warheads with anthrax. Iraq also has demonstrated the capability to deliver biological agents from crop sprayers and may also have remote-controlled helicopters for spraying aerosol agents such as anthrax.3 Nonstate actors are also a threat. CIA director George Tenet recently was quoted in the New York Times as saying that "documents recovered from Al Qaeda facilities in Afghanistan show that [Osama] bin Laden was pursuing a sophisticated biological weapons research program." U.S. forces discovered a facility in southern Afghanistan near Kandahar that was being built to produce anthrax and other deadly agents.4 The current reality of terrorist threats means that we can no longer afford to neglect the public health system. As we know from the October 2001 anthrax attacks, the United States is vulnerable. As significant as last fall’s anthrax attacks were, they could have been much worse. The attacks killed five people, infected twenty-two, and exposed hundreds more. Yet had the spores been aerosolized in a crowded public area; had the public and private health professionals responded more slowly; or had a communicable organism or more sophisticated delivery method been used, many more people could have died or become ill.5 Indeed, preparing for potential bioterrorist attacks involves unique considerations that are distinct from the emergency and disaster preparations necessary for other forms of terrorism, such as those that use conventional, chemical, or, possibly nuclear weapons. Bioterrorism does not announce itself with a large explosion. One cannot smell, taste, or see biological agents. The attack will not be known until sick patients begin arriving in hospitals and doctor’s offices, usually days later—long after the terrorist has left the scene. First responders will often not be firefighters and policemen, but emergency room doctors and nurses. If the organism used is one that occurs naturally in the environment, it may initially be difficult to discern that the resulting disease pattern is from an intentional attack.
The nation’s public health infrastructure is not fully prepared to meet this growing challenge. Over the past two decades the infrastructure has greatly deteriorated. A lack of focus, funding, and national attention have combined to reduce the physical structures (such as laboratories) and workforce capabilities necessary to collect and analyze data, conduct epidemiology and disease surveillance, communicate effectively, and implement interventions to respond to threats to the health of the entire community. Recent grant announcements by the Centers for Disease Control and Prevention (CDC) outline six focus areas essential to the core public health mission required to respond to a bioterrorist threat: (1) preparedness planning and readiness assessment, (2) surveillance and epidemiology capacity, (3) laboratory capacity, (4) communications and information technology, (5) risk communication and health information, and (6) education and training. These six "core capacities" outline crucial public health elements required for appropriate prevention to, preparedness for, and response to any act of bioterrorism or another public health emergency.6 Surveys and studies conducted before 11 September 2001 found that many communities lacked adequate laboratories or epidemiologists trained to detect infectious disease outbreaks. Even the CDC, the nation’s premier public health agency, relied heavily on antiquated laboratories constructed in the 1960s and 1970s. Furthermore, prior to 1999 one-third of public health departments serving fewer than 25,000 people did not have access to the Internet or electronic mail, and almost 20 percent of all local health departments had no e-mail capacity at all.7 More than nine of ten public health departments lacked staff trained in bioterrorism preparedness, and only one in five hospitals had a response plan in place to deal with biological attacks. Ironically, the seeds of this decline were sown in part by scientific progress and public health’s successes: improved sanitation and nutrition and the discovery and widespread use of vaccines and effective antimicrobial agents. These agents have reduced the public’s fear of deadly, naturally occurring infectious disease outbreaks and simultaneously diminished the importance of traditional public health functions. At the same time, as the danger posed by infectious diseases has subsided, the public health community has become focused on more controversial areas, such as violence prevention, family planning, environmental issues, and chronic diseases, and broad support among federal policymakers for public health efforts has declined. In recent years federal funding has tended to focus on individual health services (Medicare and Medicaid) and categorical public health programs, while the more controversial programs became targets for funding reductions.
In the late 1990s a handful of members of Congress and federal officials grew increasingly concerned about the state of the public health infrastructure and the growing threat of bioterrorism. The Clinton administration began gradually increasing funding for bioterrorism preparedness (although much of this focused on areas other than improving the capabilities of the state and local infrastructures). Also, landmark federal legislation designed to improve the public health system passed in November 2000. The Public Health Threats and Emergencies Act of 2000 (P.L. 106-505) was the first federal law to comprehensively address the public health system’s preparedness for bioterrorism and other infectious disease outbreaks. It authorized $540 million in the first year (fiscal year 2001) to help improve public health agencies’ response capabilities and core public health capacities. Its goal was to deliberately increase state and local capacity by establishing a process for gradually improving preparedness by (1) requiring the development of a core set of public health capacities to be implemented by states and localities; (2) establishing a state grant program to allow states to evaluate their public health capacity; and (3) authorizing increased funding for state and local planning and implementation of those capacity-building goals. The law represented an important milestone, with the recognition of the need for an increased federal role in securing public health preparedness as well as creating goals for improvement. Symbolically, the legislation marked the beginning of a return to the national vision of the role of public health as a protector of the entire community (against pathogens that could attack anyone) that had not been present since the early twentieth century. Practically, the law formed the foundation for an even larger expansion of the federal commitment to improving the nation’s public health infrastructure in June 2003. Little fanfare accompanied the law’s enactment in December 2000. Only eight Senators cosponsored the act, and it passed too late in the congressional session to receive consideration by appropriators that year. All indications during the early phases of the 107th Congress suggested that the act would receive only partial funding in the subsequent fiscal year as well. Clearly, prior to the anthrax attacks of late fall 2001 there was little political support at the federal level for substantial new investments in local public health activities. In fact, it would take the most serious biological attack on American soil for federal policymakers to fully recognize the connection between the public health infrastructure and national defense.
The fall 2001 anthrax attacks served as a catalyst, not merely for increased attention but also for federal legislation authorizing sweeping new initiatives and providing new funding for long-neglected public health activities. Congress appropriated a record $3 billion in December 2002 for antibioterrorism activities, including more than $1 billion dedicated to upgrading state and local public health capabilities and hospital preparedness.8 This represented a 600 percent increase over the previous year’s funding levels for antibioterrorism activities. Moreover, in June 2002 President Bush signed into law the Public Health Security and Bioterrorism Preparedness and Response Act (P.L. 107-188), which authorized even greater funding, while providing a host of new measures to (1) improve public health capacity, (2) upgrade health professionals’ ability to recognize and treat diseases caused by bioterrorism, (3) speed the development of new vaccines and other countermeasures, (4) improve protections for our water and food supplies, and (5) track and regulate the use of dangerous pathogens within the United States. Bioterrorism continues to be a focus of federal attention, and preparedness plans feature prominently in the Bush administration’s proposal to create a Department of Homeland Security.9 A strong public health infrastructure is important not only to safeguarding and improving the public’s health but also to the nation’s security. Therefore, the federal government must work with states and localities to ensure these capabilities. State and local governments must shoulder their fair share of financial obligations for these functions, but it will require an enhanced and prolonged strategy for America to regain and maintain the capacity necessary to respond to today’s increased bioterrorist threats. Moreover, if we achieve the level of preparedness necessary to respond to these challenges, we will simultaneously strengthen our public health system’s ability to combat naturally occurring infectious disease outbreaks and other public health threats and emergencies. As Congress discusses future funding sources for public health, it is important to examine funding trends from a historical context. Given the shared responsibility of federal, state, and local governments in securing the public’s health, a mix of federal, state, and local revenues fund public health agencies, but the relative contributions have changed with time.
Historically, most public health responsibilities have been carried out at the state and local levels, and, as a result, most public health funding has come from states and local governments. In the eighteenth century, what little public health programmatic activity existed pertained to isolation and quarantine functions intended to prevent or halt epidemics.10 In the second half of the nineteenth century, states and cities once again led the way by establishing local boards of health and initiating programs to address sanitation problems. New York City established the first Department of Health in 1866. By 1900 forty states had established health departments, and several also ran their own public health laboratories.11 However, funding for these activities was modest, with only two states spending more than two cents per person in a given year.12 During that time the federal public health role was remained limited, and states resisted attempts to increase federal involvement in disease control and quarantine activities. For example, the National Board of Health and Quarantine, founded in 1879, was terminated in 1883.13 Local and state health departments expanded and continued to lead the nation’s public health efforts through the early part of the twentieth century, as the federal role in public health also began to expand. The Food and Drug Act was passed in 1906; in 1912 the Marine Hospital System became the U.S. Public Health Service (PHS), the position of surgeon general was created, and the PHS began to investigate the spread and causes of diseases. The PHS assumed the responsibility of examining immigrants upon their entry into the country and in 1918 began efforts to control venereal diseases in the general population. In 1922 the Sheppard-Towner Act was passed, creating the Federal Board of Maternity and Infant Hygiene, funding the Children’s Bureau, and providing funds to states for maternal and child health programs. This was the first federal public health program that provided grants to states.14 The federal role in health continued to expand during the 1930s as part of the New Deal. Between 1930 and 1940 the National Institutes of Health (NIH) was established, while the Social Security Act provided more funding to states for public health services, training of public health professionals, and venereal disease control. The precursor to today’s CDC, the Communicable Disease Center, was founded during World War II to work with state and local health officials against malaria, typhus, and other communicable diseases.15
Fortunately, more complete data are available with respect to public health funding during the past few decades. One of the best sources for data for examining public expenditures for health is the National Health Accounts (NHA). This data source has been compiled consistently using a standard set of definitions for more than forty years; here we present data through 2000. Not all programs that many would consider related to public health are included within the NHA. For instance, nutrition programs such as the Women, Infants, and Children (WIC) Food Supplemental Program; sanitation and water programs; other environmental health programs; and federal research support are not included. Therefore, the following analysis is not intended to be a comprehensive look at the funding levels of all activities many would consider to be in the realm of public health. Rather, it illustrates trends for those funding sources that have been collected regularly and consistently. In the NHA, "government public health activity" includes funds spent to organize and deliver services or to prevent or control health problems. These funds are delineated between federal (predominantly the CDC and the Food and Drug Administration, or FDA) and state and local funds. Federal passthroughs are subtracted from the state and local funds to avoid double counting. It is difficult, if not impossible, to cleanly separate personal health care services from public health activity. For instance, when a vaccine is administered at a clinic, this is a public health activity occurring in the context of personal health care. In an attempt to include only funding for essential (that is, population-based) public health services and not personal health care services, we adjusted the state/local NHA data by multiplying by 0.31, based on a study of nine states that determined that only 31 percent of public health spending was for population-based public health services.16
Total health expenditures rose from $26.7 billion in 1960 to $1.3 trillion in 2000, while total public health expenditures increased from $192 million to $17 billion (Exhibit 1
In 1960 federal and state/local spending on public health was nearly equivalent (with the federal amount slightly above the state/local amount). The federal contribution increased at a greater rate than the state and local contribution in the early 1960s, so that by 1968 the federal contribution accounted for 75 percent of the total funding for public health (Exhibit 3  ). Federal spending stagnated through the 1970s until the late 1980s and then grew slowly through 2000. The state and local contribution continued to grow through this time period, so that by 2000 state and local spending was 2.5 times the federal level. Local and state governments now account for more than 70 percent of spending for those public health services included in the NHA. The trends in the proportion of federal public health spending illustrated in Exhibit 4 are indicative of the movement to state and local responsibility for public health that began in the mid-1970s.
Historical trends of spending on public health should also be analyzed by taking into account the effects of inflation and population growth. This adjustment involves using (1) the gross domestic product (GDP) inflator for the year 2000 to adjust to year 2000 dollars, and (2) the annual population estimates from the Census Bureau to adjust for population differences.
Between 1960 and 2000 the inflation-adjusted per capita amount spent by state and local governments on population-based public health services (Exhibit 3 The recent increases in federal spending for national, state, and local public health activities, intended to address the threats of bioterrorism and other public health emergencies, amounted to $1.1 billion in FY 2002 alone; President Bush has proposed an additional $1.2 billion in FY 2003. Although this is an increase of 25 percent in the federal contribution to public health spending, it changes only marginally the federal share of funds spent for public health (from 29 percent to 34 percent), assuming that state or local spending does not change dramatically.
There is little doubt that investments in public health—whether at the federal, state, or local level—have paid off handsomely. Infectious disease deaths declined dramatically during the twentieth century.17 At the beginning of the century the leading U.S. causes of death were infectious diseases; pneumonia, tuberculosis, and diarrhea caused one-third of all deaths. In 2000 the three leading causes of death were chronic diseases: heart disease, cancer, and stroke.18
Vaccines alone have prevented millions of illnesses and hundreds of thousands of deaths (Exhibit 5
Public health efforts have led to a safer and healthier food supply by way of pasteurization, improved food preparation and storage practices, and food product fortification with vitamins and minerals. A number of nutritional deficiencies, including goiter and rickets, have been effectively eliminated, in part because of food fortification and government assistance programs.20 Although heart disease is still the leading U.S. cause of death, public health efforts have led to major improvements. The age-adjusted death rate from heart disease of 307 per 100,000 in 1950 was reduced to 134 per 100,000 in 1996. This has resulted in large part from the reduction in risk factors (hypertension, smoking, and high cholesterol) discovered through epidemiological studies. Mortality from stroke has also declined (from 89 per 100,000 in 1950 to 26 per 100,000 in 1996) for the same reason.21 The effects of tobacco use on morbidity and mortality remain high, but public health efforts have contributed to a decline in the prevalence of smoking. In 1965, 42 percent of adults smoked; by 1997 the rate was 24 percent.22 Although this is just a sampling of the illness and death prevented by public health efforts, it demonstrates the large improvements that can be achieved by investing in basic public health interventions. As we strengthen our public health infrastructure and improve our capability to prevent and respond to bioterrorism, we can expect additional improvements by using these improved capabilities for additional public health activities. Examples of "dual use" of the infrastructure needed for bioterrorism preparedness include (1) enhanced detection and prevention of foodborne disease outbreaks; (2) increased capacity to prevent HIV/AIDS; other sexually transmitted diseases; hepatitis A, B, and C; waterborne diseases; and enteric pathogens; and (3) better ability to monitor and prevent environmentally related diseases.
To be prepared for bioterrorism, it is imperative that we develop a cohesive and comprehensive system of ongoing surveillance and case investigations for early detection; laboratory capabilities for immediate confirmation; public health medical expertise for rapid assessments and recommendations for prevention and treatment; preventive response teams to implement needed interventions; and a communication network for providing updates to physicians, health facilities, and the public. These are capabilities needed for basic disease control, and they constitute a strong public health infrastructure at the federal, state, and local levels. In addition, we must invest in research and development of bioterrorism countermeasures, such as vaccines and new antibiotics. This will require a federal investment as well as a collaborative effort with private industry. The traditional public health agencies at the federal, state, and local levels will need to collaborate with each other and with other federal agencies involved with homeland security to find new, creative ways to conduct surveillance and disease control. Equally important, we will need to train and support an adequate public health workforce. To the extent that these efforts are seen in Congress as a response to a threat to the public and the national security, continued support will be more likely. If funds are used by states and local public health agencies to supplant their current funding or to create dual use for more controversial programs that do not enjoy broad support, ongoing funding will be jeopardized. We can also expect increased congressional scrutiny to hold states and localities, as well as public health officials, responsible for achieving results. The challenge for public health will be to use the money wisely to address the concerns for which it was intended. The Public Health Security and Bioterrorism Preparedness and Response Act of 2002 is a good start. It establishes a cohesive and comprehensive framework for improving our public health system and reducing our vulnerabilities. As our resources and capabilities improve, new questions will arise. For example, a major public policy debate is occurring about who should be vaccinated with newly available smallpox vaccine.23 What public health emergency powers are needed at the state and national levels is also being debated in many states.24 Discussion of these and other issues will continue. One of the most critical issues remaining is the appropriate federal, state, and local shares of funding for the public health infrastructure. Given the increasing risk of bioterrorism, the importance of a strong public health infrastructure in responding appropriately to potential bioterrorist attacks, the remaining vulnerabilities in our public health system, and current federal public health funding relative to its historical levels, it is clear that enhanced federal support is necessary. There is a strong national-security interest in developing and maintaining a strong public health system. And while states and local governments must continue to shoulder a large portion of future investments, the federal government will have to sustain an elevated level of support for the overall public health system if we are to strengthen our preparedness as a nation and meet the growing threat of bioterrorism.
Sen. Bill Frist (R-TN) is board-certified in both general and cardiothoracic surgery. He is the first practicing physician elected to the U.S. Senate since 1928. He is ranking member of the Subcommittee on Public Health of the Senate Health, Education, Labor, and Pensions Committee. The author gratefully acknowledges the contributions to this paper by Douglas Campos-Outcalt and Dean A. Rosen.
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