Cuts could harm health emergency preparedness
February 25, 2013
by Brett Norman
The Centers for Disease Control and Prevention has put out a new game called Solve the Outbreak that allows would-be medical sleuths to track dangerous diseases in a frightening cyber world.
But if the sequester takes effect, CDC’s actual disease detectives may be a lot less prepared for an epidemic in the real world.
“Fundamentally, CDC’s ability to protect the health of Americans would be severely compromised,” CDC Director Tom Frieden told POLITICO. “It would impact every CDC program. It would make us less able to find and stop outbreaks.”
Frieden and other experts say that even before the automatic budget cuts that are set to go into effect Friday, the nation’s public health system was stretched dangerously thin. Recession-driven cuts in federal, state and local spending since 2008 have culled the ranks of public health workers nationwide by about a fifth — 46,000 fewer positions.
More than two-thirds of the CDC’s core budget of about $6 billion goes to state and local health departments to fund positions and programs that extend a network of public health partnerships that can deliver early warnings of emergencies and a coordinated, rapid response.
Those CDC-funded partnerships are the key to saving lives, Frieden said in an interview, whether the threat comes from E. coli in spinach, a whooping cough outbreak, tainted steroids, a scary new virus — or worse. That system is “at the breaking point,” as Washington state Secretary of Health Mary Selecky testified at a hearing on the sequester last week.
And Frieden said the sequester could cut funding “for literally thousands” of CDC-trained disease detectives. Experts and public health advocates say that’s a cause for alarm — although the consequences may not hit home on Day One.
“When there’s a foodborne outbreak, we want to know the source,” said Jeffrey Levi, executive director of the Trust for America's Health and chairman of a presidential public health advisory council. “We want to know the cause, we want to know it quickly, and we assume that CDC and the state health authorities are adequately staffed. And we get angry when they’re not.”
Under the sequester, the cumulative impact of cuts upon cuts could significantly hamper the ability to quickly respond to problems — or ferret them out before they become full-blown crises, Levi said.
And given the timing of the sequester, midway through the fiscal year, a cut of about 5 percent of the CDC’s annual budget squeezed into the second half of the fiscal year translates into the loss of $350 million or more.
Nationwide, that means the agency would be unable to buy 540,000 vaccines against diseases including the flu, measles and whooping cough; could support about 25,000 fewer breast and cervical cancer screenings for poor, high-risk women; and provide more than 400,000 fewer HIV tests, Health and Human Services Secretary Kathleen Sebelius estimated.
Five percent may not sound like much, but packed into six months, it would be closer to an effective cut of 8.5 percent or 9 percent, said Paul Jarris, executive director of the Association of State and Territorial Health Officials.
At the state and local level, entire programs could go belly-up. Last year, Jarris said, the CDC cut 4 percent from its injury-prevention funding, and those programs “just shut down in eight states.” Expect more of that on a much larger scale post-sequestration, he said.
“The misperception is that the sequester will shrink the size of the federal government,” said Laura Hanen, director of government affairs for the National Association of County and City Health Officials. In fact, she said, the cuts — and the jobs lost — will hit hardest locally.
And that directly affects emergency preparedness — the first line of defense for the real life disease detectives.
In rural areas, emergency preparedness may mean that one lonely public health worker coordinates drills among hospitals and first responders. They train for natural disasters, terrorist attacks, severe weather, foodborne illnesses or disease outbreaks — the full gamut of calamities. Their vigilance and quick thinking matter.
Some funding has already been shifted from rural areas on the rationale that they are less likely than cities to be struck by bioterrorists. Combine that with rollbacks in total emergency preparedness funding nationwide, and the rural areas are hard-hit, Hanen said.
“For smaller, rural areas, if they get cut again, there will be no one,” she said. “Public health emergencies occur every single day. Hurricane Sandy does not just skip the rural areas.”
The strained workforce on the front lines in Washington state, for instance, struggled last year to contain the worst whooping cough epidemic in 50 years, afflicting more than 4,800 people, including 370 babies. Nationwide, the CDC recorded more than 41,000 cases last year, including 18 deaths, all in infants.
Selecky, the top health official in Washington state, said the sequester cuts public health capabilities — but it doesn’t cut the threats. Vaccines can’t prevent epidemics if they aren’t given.
And under the sequester, the CDC says it will probably be able to supply a half million fewer vaccines for poor or underinsured kids and adults. And fewer immunized people creates more openings for outbreaks to begin.
“Already we’re in a situation where we never have adequate money for vaccines,” said Georges Benjamin, executive director of the American Public Health Association. “We’re adding more and more vaccines to the vaccination schedule, and it’s always a challenge. But [the sequester] will absolutely result in less kids getting vaccinated."
The fungal meningitis crisis last fall is a textbook case of how the public health system — a widely distributed collection of agencies and capabilities, many paid for at least partly by the CDC — can work. And how it could be damaged by spending cuts.
The outbreak linked to contaminated steroid injections last fall has so far included 707 documented cases and 47 related deaths, and the CDC’s Beth Bell and Rima Khabbaz detailed the response in a recent article in the Journal of the American Medical Association.
In the early days of the fungal meningitis outbreak, before the public health gears had started to turn, about half of those diagnosed with infections linked to the steroid injections were dying within a month.
That rate dropped to nearly zero — not because someone invented a miracle cure, but because a smart local equivalent of the CDC’s “disease detective” in the Tennessee health department made the connection between the infection and the injection. Then, CDC scientists identified the fungus, rarely seen in humans, developed diagnostic techniques and best treatments, and distributed the information to state and local health departments nationwide. Nearly 14,000 people in 23 states were potentially exposed and nearly all of them — and their physicians — were tracked down and notified.
The response drew on the combined resources of the distributed public health system, the CDC-trained laboratory scientists and epidemiologists in Tennessee and in Virginia, the FDA and Massachusetts officials who went into the suspect compounding pharmacy, Jarris said.
“It meant sending national park rangers walking into the woods to find campers who were exposed,” he said. “It’s a national response. And that’s what we’re going to lose with the sequester — the ability of all of those players to step up to the plate and do their part.”
The CDC’s iPad app makes the disease detectives’ job look relatively easy.
“Do you quarantine the village? Talk to people who are sick? Ask for more lab results?” teases the preview of the game. “The better your answers, the higher your score — and the more quickly you’ll save lives.”
But unlike the free game, disease detectives in the real world need expensive training and infrastructure. And that means money.
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