Homeland Security Watch

News and analysis of critical issues in homeland security

August 5, 2009

Public health: unilateral disarmament

Filed under: Biosecurity,Budgets and Spending,State and Local HLS — by Philip J. Palin on August 5, 2009

Yesterday the New York Times editorial board highlighted an urgent homeland security threat.  I am not pointing to their second piece, Chemical Plants Could be More Safe.  While undoubtedly a real risk, as far as we know there is no actionable intelligence on plans to attack US chemical facilities.

Tuesday’s lead editorial in the Times is entitled, “States in Distress.”  It outlines consequences of $143 billion in state budget cuts.  In twenty-one States public health funding has been among the biggest losers.

There is actionable intelligence, known vulnerabilities, a specific threat sequence, and potentially ominous consequences for an Autumn pandemic.  Despite this we are accelerating a process of public health disarmament.

The Illinois public health budget has been cut 25 percent and further cuts are threatened.   At one point in late July the Illinois budget  had zeroed out funding for infectious disease surveillance.   Heroic last minute efforts restored the money, but there is still a huge budget deficit to close and the public health budget is still at risk.

In Sacramento County, California the public health department’s budget has been reduced from $9.8 million in 2007-2008 to $5.1 million this year.  The number of county  public health positions has been reduced by one-fourth.  More cuts are possible as the County attempts to adjust to  reduced State funding.

On July 27 the Chief Justice of the West Virginia Supreme Court noted in a judgment against the State’s Department of Health and Human Resources, “I conclude that DHHR’s ability to adequately comply herein with its legal obligation was caused not by any desire of a DHHR employee or administrator to do so, nor by the best efforts of DHHR employees and administrators, but rather by the continuing lack of requisite resources which DHHR receives to meet its mission. There is only so much that dedicated DHHR personnel can accomplish without adequate resources. I am deeply troubled and concerned about this continuing resource problem _ a problem which I sense may be worsening and may be becoming systemic.”

The same could be said for a whole host of public health departments and functions across the United States.  Committed professionals are doing their best with less and less.  But  budget reductions, staff cuts, and distraction undermine the fundamental capacity of even the most dedicated professional organization.

Yesterday Secretary Napolitano highlighted the lag-time and increased vulnerability between the beginning of school — late this month — and the hoped-for availability of an H1N1 vaccine in mid-October. Yesterday news reports suggested a possible pattern of H1N1 resistance to Tamiflu in Southern Texas. (See possible correction from CIDRAP).  Yesterday other news reports seemed to confirm that H1N1 had evolved a resistance to Relenza.

 Perhaps H1N1 will ultimately prove to be no more than a tweak of the seasonal flu. It could also be considerably worse.  We don’t know.  There is no way to be certain.  But H1N1 is not the only threat  requiring ongoing care by public health professionals.

Precisely because of the uncertainty, this is the time  to reinforce our front lines of surveillance and defense.  Instead we are reducing our troop levels, withdrawing our artillery, grounding our planes, and moving our ships into drydock.

In considering the current situation of our State and local public health capacity the analogy of a bio-medical Munich  — or at the very least, a kind of summer Sitzkrieg — is hard to avoid.


Inside the fight against a flu pandemic (TIME)

California nurses say swine flu training, protections inadequate (Mercury News)

Some measures won’t help prevent flu pandemic: report  (Reuters)

Public Health and Medical Responses to the 1957-58 Influenza Pandemic (UPMC-Center for Biosecurity)

WHO sees swine flu vaccination from next month  (Reuters)

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Comment by William R. Cumming

August 5, 2009 @ 1:58 pm

Okay how about just federalizing Public Health efforts in the good old USA? Reason–public health issues don’t respect state lines! What we have learned in last 100 years is that the Public Health system is too expensive for the states to maintain except when really needed. Hey let’s abandon flood insurance and disaster relief for second homes and those earning more than $250,000 then plenty to spare for public health. Or just adopt the policy of federal government pays for maintenance on all federal highways. No more state share. And yes collect those clunkers and sell to CUBER! Some hard public health lessons are about to be learned in the current PANDEMIC FLU situation this fall and winter. How about the FEDS paying for condoms and STD testing in all public high schools? How about federal liscensing for doctors who flee from state to state killing patients? The Health Care Financing administrartion should just bypass the current intermediaries and issue vouchers to all citizens for various visits to any doctor or nurse practicioner they want to go to? Then Health Reform not needed. All covered and all insured by the federal government. How about a tax on all health care intermediaries to support public health administration and costs? How about no federal insurance for any medical procedure unless the medical profession itself recognizes it as the STANDARD of CARE under STATE Tort regimes. Or that is to correct and modify the Tort regime for public health to reflect best practices nationwide. Money saved from malpractice can be used to support Public Health best practices. A portion of every judgement would go to Public Health requirements. Community service for health practioners who are found in violation of best practices.

Comment by bluecollarkid

August 5, 2009 @ 9:00 pm

How about we just do away with “Public Health Services” altogether and let people fend for themselves? I find that to be a compelling resolution to the funding problem and the lawsuits. Neither the State or the Government has a responsibility to provide health services to its citizenry. Rather, why not enable private entities such as non-profits and practitioners to fulfill that role by easing regulations on the provision of their services – such as categorizing them as “insurers” when they provide basic health services at a flat monthly rate?

Comment by Clinton J. Andersen

August 5, 2009 @ 11:08 pm

Yea, my wife and I are not huge fans of the Department of Health and Human Resources, at least the one in Nebraska. My wife and I had a daughter in day care. It was the first time and we were new so we, especially my wife, took great pains to make sure that my daughter was at a good facility. After a while, however, my daughter started exhibiting some disturbing behavior, such as coming home and screaming and hitting her dolls and putting them in corners, etc. After a little research we discovered we could request information from the state regarding the day care, which was no where published previously. We requested the information and much to our dismay our daycare provider had a track record, which included locking children up in the kitchen, they had a registered child abuser watching children, they had 30 children with one underaged staff member, the didn’t lock up their poisons, etc. etc. etc. After making a complaint to the state and watching nothing happen, my wife called until they scheduled a meeting with her. When she asked why they haven’t taken more severe action, to include shutting down such a facility before people got hurt, the state representative told her that they oversee doctors too and if they shut down every doctor that has killed somebody through a mistake then people wouldn’t have options as there would be a lot less fewer doctors to choose from (yes, that was her example). I don’t know about the rest of the world but we would rather have a few good doctors then a bunch of crappy ones. However, if they fall under the branch of the main DHHR, then I’m sure this behavior is tolerated everywhere.

It certainly changed our opinion… probably permanently.

Comment by Clinton J. Andersen

August 5, 2009 @ 11:09 pm

P.S. – William, no worries about the last name. It’s not the first, nor the last time it will happen. I do appreciate the corrective note, however. :-)

Comment by Philip J. Palin

August 6, 2009 @ 6:03 am

In the comments by William R. Cumming and BlueCollarKid we have examples of radically centralized and radically privatized solutions. In Clinton J. Andersen’s comment we are reminded that the problems-needing-solved are not abstractions.

A question for WRC,BCK,CJA,and others at large: How do you define the role of government and when you place limits on that role, how and why do you mark the boundaries?

Comment by Clinton J. Andersen

August 6, 2009 @ 12:21 pm

Good question, but definitely a hard one. From the initial growing up point I saw and learned what the government was, and has been, involved in since its inception, and over 90% of that is understandable and accepted as just the standard way of doing business. After this point, the role of government is most likely defined by an individuals background and belief system, the most of which being political. At this time one takes something, compares it with their beliefs and understandings, and makes a determination as to whether or not the government should be involved; for instance, the president and car dealerships.

I view car dealerships as a private entity. They started off small and have, over the years, grown to enormous sizes. Now that the car companies are in trouble, the government steps in to bail them out and come up with new car programs instead of just allowing them to file for bankruptcy. Sure, many people will be affected and layed off, etc. But that is an inherent risk no matter were one works. Without making this a conversation about car dealerships, many major institutions, most notably airlines, have had to cut back on individuals, cut back on locations, and file for bankruptcy many times before they finally started getting things right. That’s the price of business when leaders get too greedy or complacent.

In this case, I have based my line primarily on the fact that I don’t think that the government needs to have their hands in private companies and two, I think there are a million other important things out there they could be doing other than the president holding a conference about cars. (Another great example were the congressional hearings on major league baseball steroid use. That is what the MLB commission is for. The government should not be involved). But because others believe and perceive differently, again in large part due to politics, the role of government will be defined differently.

Comment by William R. Cumming

August 9, 2009 @ 10:06 am

To respond to Phil’s question. My assumption was federal funding, standards, training and support systems (including info sharing) but the old saw “delegate or die” seems appropriate. It is a first principle of Emergency Management [but not apparently of Homeland Security] that you don’t let command and control authoritarian systems permeate the response to a crisis! Why? Several reasons! First if you delegate both authority and accountability you expedite solutions to whatever the problems created by the crisis! Second, you local the damage caused by an inappropriate response because you have created an organization that has an information flow smoothly going up and down the system with analysis of flaws in decisions even though not second guess the first on the scene. Thus, corrective action can be recommended or adopted by those facing similar situations in that crisis or others. There are in fact even more important reasons including the fact that a system that purports to have command and control over a response force in a country as large as the US is a complete fiction and deludes none but the designers as to its potential performance. Hey! The US is a really big country and many right solutions are possible and assuming proper training all will be examined and those completely wrong discarded. This is definitely an iterative process though so that data and metrics on what happened can be collected, and analyzed and even better protocols and solutions can be designed. Just as you want to give the decision-makers options to the extent possible [and avoid “The Guns of August” rollout of preplanned responses] you never want to disconnect the ‘Mind” from the response. No two situations are alike and that is why training, education, experience and most of all judgement are so very important. To assume that only those atop the federal heap have judgement is in itself a complete failure of judgement. Pretty much so far demonstrated by the lawyers who have led DHS! From a profession that when it makes a mistake largely breaks paper not lives [criminal justice system one major exception] perhaps expecting these trained legal analysts to perform in a actual real-world [not a paper]crisis is the real failure of judgment. Don’t bother to ask why there are so many unemployed or underemployed lawyers.

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