As public health funding and staffing continue to decline, communities are left more vulnerable to the next catastrophic public health emergency. The United States is failing in its public health preparedness efforts. The nation’s resilience depends on the government and public health making critical changes to reverse this downward trend.
When, not whether, the next biological incident of national significance occurs, it will rival other historical mass casualty events. Since the United States is not heeding its own lessons learned – for example, the 2009 H1N1 pandemic or even the domestic Ebola incidents – it is time to motivate government leaders to rethink the nation’s posture on public health preparedness, using the 2014 domestic Ebola response as a point of measure. A catastrophic public health emergency is defined as an emerging or a re-emerging infectious disease outbreak with a high fatality rate, an ability to quickly spread, and few or no available pharmaceutical interventions. In the event of such emergencies, public health response will falter and struggle to contain the outbreak in a timely manner.
Poor Investments With Significant Consequences
Instead of the positive outcomes expected from lessons learned and best practices inherited from the international Ebola epidemic, a future, deadly infectious disease epidemic (or pandemic) would result in a high fatality rate, a coinciding high morbidity rate, a crippled healthcare system, and an unstable economy. The reason for this argument is based on three assumptions:
- The return on investment from the hundreds of millions of dollars spent, and still being spent, on the Ebola epidemic and on improving healthcare response capabilities overall have been shortsighted and marginally effective.
- The public health security structure, which includes public health, emergency management, behavioral health, and social services, remains vulnerable and unable to meet community needs in order to save the maximum number of lives, which is exacerbated by receding funding levels.
- Sensible investments are replaced by financially consuming and ineffective applications. A window of opportunity is closing to instill, for example, a culture of clinical astuteness in current and future healthcare professionals to be able to quickly identify an unusual, but potentially deadly, case of disease presentation that might be indicative of a deadly disease outbreak.
The point here is not to criticize public health officials who suffer from many chronic handicaps while heroically trying to save lives; rather, the lack of focus and poor understanding of government officials about the importance of appropriate public health investments – that is, providing stable and sustainable funds – is draining essential resources. Fatigue is also setting in because public health agencies have been waiting anxiously for another biological attack while public resonance with this issue is waning.
At the same time, political rhetoric is crowding out substantive risk communications to the public on the importance of public health preparedness. It is not helping that, in instances where a robust public health response is needed to provide sensible mitigation strategies, the public endures an awkward approach intended to provide short-term political gains through costly activities, which ultimately result in irrational expectations of the public. There are three key examples that underscore weaknesses within preparedness resulting directly from this flawed approach.
Example 1 – Ineffective Strategies & Other Lessons Not Learned
Implementing ineffective and costly response and recovery methods drains resources and limits effective mitigation strategies. The government’s responses to public health emergencies (i.e., those that garner attention from the public) generally involve an automatic, nonstrategic reaction in terms of providing solutions – for example, conducting surveillance on passengers arriving from West Africa. What many learned over the past year, but experts had known for years, is that costly surveillance methods at ports of entry are ineffective and provide no more than a placebo effect to the public.
More than 30,000 travelers entering the United States at five international ports of entry screened for Ebola since October 2014 did not result in any detection of Ebola and missed a case of Lassa fever – another virus that similarly results in viral hemorrhagic fever. This lesson could have been learned previously from attempts to screen travelers during the 2003 Severe Acute Respiratory Syndrome (SARS) virus epidemic or the 2009 H1N1 Influenza Pandemic.
Instead of calling for more funding for such inefficient programs, better individual monitoring programs should be implemented using state-of-the-art technologies and requiring automatic opt-in procedures for all travelers returning from areas of ongoing epidemics. The key is to provide realistic surveillance practices for monitoring individuals, while limiting the burden on strapped health departments. This approach can be accomplished through mobile applications, similar to other crowdsourcing technologies already in use for many different aspects of disaster response and recovery operations.
Example 2 – Unrealistic Expectations & Ineffective Communication
Succumbing to the hype and fear on the implementation of nonpharmaceutical interventions – for example, quarantine and isolation strategies, infection control measures, decontamination, and waste management – is resulting in unrealistic expectations when responding to a biological incident. Media reports and imperfect forecasting of the Ebola epidemic raised anxiety levels without a solid foundation to back them. That hype led to increased pressure on public health officials and government representatives to react excessively. Case in point: the Ebola response and recovery efforts in Dallas, Texas, resulted in hundreds of thousands of dollars spent disproportionately on a few individuals.
Nobody should expect that level of investment, especially in the case of a true catastrophic incident. Similarly unsustainable and unrealistic are the solutions for recovery – for example, decontamination and waste management of the apartment where the Dallas Ebola patient lived. In the event of a real public health emergency of national significance, each apartment that houses a person who contracts a deadly disease would not be equipped with 140 drums for waste disposal. The current approach to a biological incident reflects a poor job of the government to deescalate hyped coverage by the media and public health’s inability to reduce the public’s anxiety about diseases and infection control.
To remedy these issues, notes should be taken from the playbook on radiation emergency preparedness to develop clear and simple messages – on a complex issue – that resonate with the public. Simply providing basic hygiene recommendations is not good enough. Public health officials and government representatives need to:
- Manage expectations
- Better explain the characteristics of a biological incident
- Not just quote exaggerated case fatality rates, which can raise fears
- Describe what an emergency response to a biological incident would look like
- Reveal the challenges that exist
- Explain how the public can help mitigate these challenges
- Emphasize how a timely response would save many lives
A radiation emergency is a low-probability, high-consequence event for which agencies drill at the highest level of preparedness. An emerging, naturally occurring, catastrophic biological incident has a much higher probability of occurring – with potential high-consequence outcomes – yet agencies lack fundamental communication strategies to inform the public about their concerns related to the biological incident.
Example 3 – Funding Gaps & Ignored Burdens
Poor return on investment, or cost/benefit analysis, and underfunded/unfunded mandates with high expectations are a default setting for failed public health emergency response and recovery efforts. It can be difficult to measure success in public health, but not impossible. Examples that have taken a page from economic cost-benefit analysis – such as Marcozzi et al.(2015), “An Economic Analysis and Approach for Health Care Preparedness in a Substate Region” – find only little improvements, are not acceptable, and would be seen as a catastrophic failure for the investor under any other standard.
Compounding this effect are continued reductions in public health preparedness funding, whereas expectations remain high that the front line defenders are able to protect their communities. With few resources in its toolkit, limited staffing, and unfunded mandates, the public health system is bound to break under continued pressure. The increasing burden that communities bear for emerging infectious disease – with increased mortality and morbidity rates – can no longer be ignored. The solution is maintaining sustainable funding levels, requiring concrete outputs to measure the success of investments, investing heavily in public health professionals and healthcare workers, and institutionalizing the ability to identify extraordinary threats and raise concerns about other potential threats.
The pieces are all there, but the proper approach to make sound investments has been lacking. Like the aging infrastructure of interstate highways and bridges or the miles of neglected rail lines, an ongoing disregard for a strong foundation would continue to weaken the public health infrastructure and leave gaping holes, resulting in catastrophic outcomes measured in terms of unnecessary lives lost.
Patrick P. Rose
Patrick P. Rose, director for pandemic and catastrophic preparedness at the National Association of County and City Health Officials, holds a Ph.D. in infectious diseases and is a subject matter expert on national security issues related to public health security. He works with federal and local stakeholders to address requirements and gaps that produce vulnerabilities in public health security. In addition, he supports efforts domestically and internationally in the field and at the policy level to reduce the proliferation of biological weapons and to increase public health security awareness. These efforts include promoting greater engagement in the Global Health Security Agenda. He is an alumnus of the Emerging Leaders in Biosecurity Initiative and serves as an adjunct assistant professor at the University of Maryland Department of Epidemiology and Public Health.