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SPECIAL REPORTLeveraging The Nation’s Anti-Bioterrorism Investments: Foundation Efforts To Ensure A Revitalized Public Health System
The emerging potential threats of bioterrorism combined with critical existing epidemics facing the United States call for immediate and urgent attention to the U.S. public health system. The foundation world is helping to answer that call and is sounding the alarm that our health defenses must be able to do "double duty" to protect us from the full spectrum of modern health threats. This Special Report presents a selective sample of recent and ongoing grant activities designed to revitalize and modernize the public health infrastructure, which is vital to protecting the nation’s health and ensuring its safety.
The need to revitalize and modernize the nation’s public health system has never been more urgent. We are facing a wide range of epidemics—from obesity to severe acute respiratory syndrome (SARS) to potential threats posed by chemical and biological terrorism. We need a truly effective and comprehensive public health defense to protect Americans from the full spectrum of preventable modern health threats. The September 11 terrorist attacks and the subsequent anthrax incidents illuminated what the public health field has long known: The current U.S. public health system is poorly focused, underfunded, and therefore often ill prepared to provide an effective health defense system. A 2001 Centers for Disease Control and Prevention (CDC) report described the U.S. public health system as "structurally weak in every area." The report called for a system of "public health armaments," including a "skilled professional workforce, robust information and data systems and strong health departments and laboratories.1"
As the United States marshals resources to prepare communities for possible acts of chemical and bioterrorism, we have a unique opportunity to put these homeland health security dollars to work to do "double duty": that is, to help revitalize the entire public health system. In most cases, the same public health resources and professionals used to protect us from terrorist threats also are responsible for protecting communities from other health threats. For instance, staff involved with the smallpox vaccination efforts could augment resources for childhood vaccination programs. As a first step toward improving our ability to prepare for possible bioterrorist attacks, the federal government invested more than $1 billion in 2002 and again in 2003 to enhance federal, state, and local health departments.2 Unfortunately, these initial investments already face serious challenges. First, just as states are receiving these federal grants, they are encountering major budget gaps. Traditionally, when state finances have been tight, public health departments have often received disproportionate cuts. Second, funding for terrorism preparedness could divert resources from vital public health programs, such as cancer prevention or responses to new crises like SARS or West Nile Virus. While terrorism preparedness is crucial, we must be particularly vigilant to ensure that investments in these programs are not affecting our ability to fight other emerging and existing health threats.
During this time of limited resources and competing requirements, foundations can provide leadership to help make sure that terrorism preparation efforts also help to modernize the nation’s public health infrastructure. In the past, public health rarely registered on major foundations’ radar screens. One notable exception is Turning Point: Collaboration for a New Century in Public Health. This initiative was originally a partnership between the Robert Wood Johnson Foundation (RWJF) and the W.K. Kellogg Foundation to enhance the nation’s public health partnerships and performance. Turning Point has reported many lessons learned; for instance, it released a 2003 report on performance management.3 Overall, however, health grant making in the past predominantly targeted health care quality and access issues, not public health. In late 2002 Grantmakers In Health (GIH) convened experts in philanthropy, health, and government to help identify opportunities for funders to strengthen and advance public health in a new era of terrorism. As a result, GIH produced an issue brief on strengthening the public health system, which provides an excellent overview of public health infrastructure, its weaknesses, and foundations’ experiences with strategic response.4 A recent Institute of Medicine (IOM) report provides a framework for areas within the governmental public health system that need attention, including a workforce that needs revitalizing, agency legal authority, information and communications systems, laboratories, and accountability systems.5 This report serves as a roadmap to guide foundations’ activities. The following is a selective sample of projects funded by private foundations that are helping to address these gaps in public health. These efforts are helping to show how positive synergies can be created between terrorism preparedness and improved responsiveness to everyday health threats.
Public health professionals have traditionally been guardians of community health. One of their most important tasks is to prevent disease epidemics. A 2002 IOM report, funded by the RWJF, outlines the challenges and makes recommendations for enhancing public health education, research, and practice.6 The recent immediate needs for bioterrorism staffing further heighten concerns about workforce gaps and dwindling numbers of professionals trained in a specialty. These shortages severely impair public health departments’ ability to protect the communities they serve. To better understand these issues, the Nuclear Threat Initiative, an international operating foundation based in Washington, D.C., supported the Center for Infectious Disease Research and Policy at the University of Minnesota to develop a bioterrorism preparedness framework. The group created a set of strategies for enhancing the public health workforce and improving federal, state, and local public health agency collaboration and infrastructure. The strategies are listed on the center’s Web site.7 The anthrax crises highlighted the critical role of state health officers, yet this workforce is perpetually challenged because of leadership tenure that averages less than two years. To help rapidly prepare health leaders, the RWJF recently reauthorized for three years its collaboration with the National Governors’ Association and others on the State Health Leadership Initiative (SHLI). The SHLI is widely credited for better preparing new health officers for the full spectrum of their duties, from effective management to emergency response.
Through the Turning Point initiative, the RWJF funded the Public Health Statute Modernization Collaborative, an effort to create a model state public health act to be used by governments to assess, update, and revise public health statutes and regulations. This innovative project brought together experts from multiple disciplines to make recommendations, which are scheduled for release in fall 2003. The Alfred P. Sloan Foundation has also been supporting efforts to develop model legislation, via a grant to the Center for Law and the Public’s Health, based at Georgetown and Johns Hopkins Universities. This approach is already yielding strong results. As of February 2003 the center’s Model State Emergency Health Powers Act had been introduced in whole or in part through bills or resolutions in thirty-six state legislatures and the District of Columbia.8 In almost all cases, these actions have improved states’ emergency powers, but concerns have been raised about adequate due-process protection.
Federal, state, and local health departments face unprecedented challenges and aggressive timeframes for designing and installing sophisticated systems for bioterrorism preparedness and response activities. The situation is complicated by the fact that similar tools are needed to support core public health functions. Several foundations have made critical investments to advance these vital public health informatics. The RWJF funded the Public Health Informatics Institute, a program of the Center for Innovation in Health Information Systems, in Decatur, Georgia. The institute "fosters collaboration among public health agencies in the conception, design, acquisition, and deployment of software tools," according to the center’s Web site. "The goal is to eliminate redundant efforts, speed up development processes, and reduce costs."9 The Sloan Foundation has made a series of grants on bioterrorism detection and early warning systems. The New York Academy of Medicine, in collaboration with the New York City Department of Health and the University of Connecticut, developed and disseminated a syndromic surveillance software package "to help provide early warnings of a bioterrorist attack or disease outbreak," Sloan’s Web site explained. The software package, a product of a 2002 Sloan grant, is now available as a freely downloadable program on the National Cancer Institute’s Web site.10 As an example of double duty, these techniques also can be used for cancer cluster analysis. The Kansas Health Foundation has been steadily investing over the past few years in building a national model for an integrated public health information system—the Kansas Integrated Public Health System. By linking all caregivers to a central data warehouse, the system allows individual health information to be located in one site that is accessible to multiple providers. That information also could be made available for public health purposes. More than half of Kansas’s county health departments are involved in this effort. Several other states, including Washington, Oklahoma, and Wisconsin, are following this model. The Pew Charitable Trusts, with support from the Bauman Foundation, Joyce Foundation, and Benjamin Spencer Fund, funded a public education campaign at the Trust for America’s Health (TFAH), which focused on advancing the need for a Nationwide Health Tracking Network (NHTN) to improve the nation’s disease prevention efforts, including early warning systems for chemical terrorism. To help quickly raise attention and awareness, TFAH launched newspaper advertisements, conducted town hall meetings, and generated reports that urged policymakers to make a sustained commitment to revitalizing all components of public health infrastructure. Congress recently appropriated $27 million to the CDC to launch the NHTN in more than seventeen states and cities.11
Public health labs are on the front lines in diagnosing a full spectrum of threats, from anthrax to food contaminants. Recent reports by the U.S. General Accounting Office and the Association of Public Health Laboratories have indicated that laboratories are underprepared and underfunded to manage both their ongoing, routine tasks and their emergency-response responsibilities.12 The 2001 anthrax crises revealed the fragile condition of public health laboratories, which were overwhelmed by the demand to analyze thousands of samples. In 2002 the New York Community Trust (NYCT) awarded a grant to the Public Health Research Institute to develop new lab testing methods for anthrax. The institute has a long history of working with local health departments to improve the methodology for rapidly testing infectious agents, which can now be augmented for bioterrorism preparedness. The goal of this NYCT-funded project is to produce an anthrax assay that will identify infections within three hours. As part of the RWJF’s investment in the Public Health Informatics Institute, another project has been launched to address gaps in laboratory data management. In collaboration with the APHL, the institute is working with state and local agencies to modify information systems to improve bioterrorism readiness and laboratory management. To date, sixteen state and local public health laboratories have jointly defined requirements for an information system to help manage large volumes of specimens, and to process and report results.
Traditionally, there has been a lack of standards and accountability for what constitutes an adequate public health infrastructure or appropriate capability to respond to public health emergencies. One valuable project recently launched by the California Endowment through a grant to RAND is a quantitative gap analysis of California’s public health system. RAND has been developing a framework that creates concrete, quantifiable performance measures for core public health functions. This project could have important national implications, including looking at ways to assure effective coordination among all community, state, and local agencies involved in public health, as well as finding ways to improve the system. In 2003 the RWJF awarded a grant to a TFAH public education campaign to bring attention to the critical need for strengthening public health infrastructure so that the system can protect all Americans from a range of health threats—from chemical terrorism to cancer. With states facing severe budget cuts, a series of national reports will be produced that will evaluate the status of key public health programs, such as cancer registries, public health laboratories, and states’ preparedness for emerging infectious diseases (such as SARS). These reports will serve as accountability tools to ensure that the nation is committed to the core functions of public health for better detection of, response to, and prevention of all health threats. Because of the urgency of potential threats of bioterrorism combined with America’s existing health epidemics, a critical opportunity exists for smart and leveraged investments in modernizing our nation’s public health programs. The philanthropic sector can seize this moment to repair our public health defenses in a way that protects every community. The grant-making community has made some important strides post–September 11 to provide necessary leadership for the needed effort to improve the nation’s public health system. As public health is becoming more widely recognized as a national priority, foundations are increasingly supporting initiatives and projects that serve essential functions, including convening thought leaders who bring different perspectives and expertise to help move ideas into action; bringing independent, strategic, high-quality thinking and measures for accountability into needed efforts to modernize and revitalize public health infrastructure; and bolstering advocacy activities to encourage real improvements and change in the nation’s policies and practices.
Shelley Hearne is executive director of Trust for America’s Health (TFAH), in Washington, D.C. She is also a visiting scholar at the Johns Hopkins University’s Bloomberg School of Public Health and chair of the American Public Health Association’s executive board. Laura Segal is director of communications at TFAH. The authors appreciate the assistance of Laure Lesperance and Lee-Lee Prina.
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Opportunities For Double Duty
Bioterrorism Preparedness/Public...
