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:
Earl
Fox, Director, Urban Health Institute, Johns Hopkins University,
and former Administrator, Health Resources and Services Administration
(HRSA), U.S.
Department of Health and Human Services
Barbara
Levine, Public Health Advocacy Consultant and Director
of Legislative Affairs, Association
of State and Territorial Health Organizations (ASTHO)
Nancy
Rea, Program Manager, Health, Mental Health and Substance
Abuse, Metropolitan
Washington Council of Governments (WASHCOG)
:
Beryl
Radin, NAPA Fellow and Professor of Government and Public
Administration, School of Public Affairs, University of Baltimore
Spurred by the threats
of bioterrorism and the strain that the September 11 attacks
and the anthrax incidents have placed on public health systems,
NAPA Fellows Beryl Radin and Earl Fox organized a panel to
consider the structure of the public health system, the extent
of collaboration between local, state, federal, and other
related organizations, and the nature of intergovernmental
challenges of homeland security.
In preparing for the session, Radin noted
that she had found very little about public health in the
February 2001 Hart-Rudman report (the Phase III report of
the United States Commission on National Security/21st Century,
Road Map for National Security: Imperative for Change). The
commission talked about science and the budget for scientific
research, but did not anticipate the many issues related to
preparing the infrastructure and delivering assistance in
the event of bioterrorism or a catastrophic outbreak of a
deadly disease requiring widespread and immediate treatment.
The interdependence of the various levels
of government-federal, state, and local-is reflected in all
the major public health issues associated with terrorism:
responding to the effects of the terrorist attacks, including
anthrax issues; identifying and treating bioterrorism threats,
particularly the issues related to the availability of data;
and preparing, distributing and administering the smallpox
vaccine.
The panel included people with experience
in public health at the local, state, and federal levels of
government, as well as in the private and non-profit sectors.
(A representative from the current staff of the U.S. Department
of Health and Human Services Center for Disease Control and
Prevention in Atlanta was invited but was not able to attend.)
The moderator proposed a set of issues for
the panel to discuss including
- their roles and
experiences to date with public health and homeland security
issues
- coordination issues in dealing with federal,
state, and local government
- their points of contact in the federal
government
- strategies used by federal programs and
officials for dealing with public health and homeland security
(proactive or reactive)
- the Department of Homeland Security plans
to form a Policy Coordination Committee on Medical and Public
Health Preparedness
whether the concept of "first responders" is helpful
to them
PANEL PRESENTATIONS
Barbara Levine, Public Health Advocacy Consultant
and Director of Legislative Affairs, Association of State
and Territorial Health Officials (ASTHO)
Public health people often don't talk to
other than public health people. Many citizens still seem
to believe that "public health" means health care
for the poor. Before September 11, 2001, ASTHO worked hard
to get Congress to pass legislation on public health infrastructure
for bioterrorism, but the issue just didn't have the urgency
to command their attention.
When anthrax was found in the mail after
September 11, public health suddenly became a concern. Almost
no state was prepared to do testing for anthrax. The Maryland
testing lab was flooded requests. People started to understand
what public health meant.
Congress moved quickly to appropriate $1
billion for public health. Now state public health officials
face a new challenge: All the people who have been waiting
for years for funding think the money should go to them.
At that point, the states didn't even have
a plan for public health and terrorism. They had to bring
together all the relevant state agencies, local public health
officials, the National Guard--people who had not been meeting
and in some cases had never been in touch with each other
before. Invariably someone feels left out; there are tremendous
expectations and it is unlikely everyone will ever be happy.
It is a monumental task and the states have
made a good start, though experiences vary by state and community.
In Oregon, the general feeling is that things are working
well; in other states, the small communities are happy and
the large cities are not. The thing to remember is every community
and every local public health department is different: "If
you have seen one local health department, you've seen one
local health department."
The states know they
have to:
- show some short-term progress
- work toward long-term improvements in
public health infrastructure and response capacity
- train public health employees expeditiously
and cost effectively
"You don't just
go out and find qualified epidemiologists on the street."
In the federal government, the responsibility
for public health is focused in HHS, including the Health
Resources and Services Administration (HRSA) and the Centers
for Disease Control (CDC). They have a lot of new people working
on homeland security issues, most of them in jobs that never
existed before this year. They are putting together new information,
writing grants, and trying to gear up at once. "For the
first year, they've done a good job. It is hard when things
are changing."
There are many public health coordination
issues across levels of government, including distribution
of the appropriated federal funds. The most frequent complaint
is that local communities aren't getting funding. In fact,
some states have no local public health departments, while
others have more than 200. With such disparities, it wouldn't
make sense to try to give the same funding or responsibility
to the local communities in every state.
ASTHO sees three
general categories of activities and funding: some funds should
go to the state, some should go to the local agencies, and
some cover "shared services" where benefits accrue
to both state and local public health. Although the funding
may be counted as "state" spending, in some cases,
actions taken by the state health department serve local public
health interests:
- In Maryland, the state put in place
a Health Alert system for local health departments, which
they can use to be in touch with others in the community,
but the control of the system is at the state rather than
local level.
- Iowa prepared a flyer on public health
threats such as smallpox and provided $100,000 for local
agencies to distribute it to citizens.
- A state lab that tests for anthrax or
other biothreats strengthens every local community's capacity
for testing at a lower cost than if they each developed
a lab.
There are still improvements
to make in state and local coordination but ASTHO has seen
good coordination to date. ASTHO also has been producing guidance
on actions to take at local levels before and after a terrorist
attack.
Nancy Rea, Program Manager for Health, Mental
Health, and Substance Abuse, Washington Council of Governments
(WashCOG)
WashCOG had a bioterrorism task force 18
months before September 11, 2001. The task force report, "Planning
Guidance for the Health System Response to a Bioevent in the
National Capital Region" was finalized on September
9, two days before the terrorist attacks. "We still flunked
on anthrax," in terms of who would be in control, state
and local coordination, and working with the CDC. After that
experience, the region's public health officials were asked
to develop a "concept of coordination" plan.
There are two key challenges for COG in
coordinating on public health:
1. disease surveillance
2. getting federal agencies to wear a separate hat, not only
as an umbrella oversight and policy authority for the nation
but also as a local employer, when something happens in the
Washington area. If federal agencies send their employees
home or suggest they use Cipro [antibiotic prescribed to fight
anthrax], that has a major effect on the local community.
"HHS has been wonderful to work with
. . . They are functioning as a fourth state health department
in the Washington region." Federal health officials have
been put into COG's Regional Incident Communication and Coordination
System (RICCS). COG has relied on Jerome ("Jerry")
Hauer, currently Acting Assistant Secretary for Public Health
Emergency Preparedness at HHS, to coordinate between COG and
all the public health related federal officials and agencies.
COG works with health care professionals in private practice,
hospitals, medical societies, as well as physicians at the
U.S. Capitol, the Public Health Service and other parts of
HHS, the Federal Emergency Management Agency (FEMA), and Department
of Defense (DOD).
"Federal funding streams go
to states but most problems are regional so we may end up
with three incompatible systems especially with grants, for
example in disease surveillance. If we could develop funding
streams that go across state lines . . ." then COG would
have an easier time developing effective strategies and response
to health challenges.
"Most federal agencies are not used
to working with local governments. They usually work with
states, whereas COG has not worked as much with states. COG
officials have already begun meeting with the official in
charge of anti-terrorism in the new administration in Maryland.
COG has a communications system that reaches across state
lines in the Washington area, so it can be used to link Maryland
to Virginia and the District of Columbia in an emergency.
COG is hoping to have a tabletop exercise
for health emergencies, to allow all the relevant local, state,
and federal officials and agencies to test and practice their
approaches to communications and response. These exercises
are usually developed to deal with a military or paramilitary
event, not a public health emergency, which may develop slowly.
In a bioterrorism incident, there may be a question of who
should be in charge. For example, if a crime is involved,
would FEMA coordinate, or would a law enforcement agency have
the lead?
Regional health issues are not new to COG:
West Nile virus and malaria threats in the last two years
have required regional coordination. Loudon County borrowed
Spanish-speaking public health officials from Montgomery County
to deal with malaria among Hispanic residents in northern
Virginia. This presents some legal issues. For example, state
law requires that personal medical information cannot cross
state lines.
There are also liability and workers' compensation issues,
if state employees work in other states. COG has been asked
to lend a staff person to HHS to provide expertise in these
areas.
One federal program COG has worked with
is the National Pharmaceutical Stockpile. In the event of
an event requiring large amounts of medication very quickly
to avert a public health crisis, the stockpile sends a "push
pack" of the needed medications within 12 hours. Only
one "push pack" is sent to a region, which then
must be distributed. There is a question of who will get it
in the Washington region--state or local officials. Then it
must go to the appropriate hospitals or health care providers.
"First responders are mostly not government
people, they are in the private sector. After the [attack
on] the Pentagon, we discovered that most people don't go
first to the hospital, they go to a clinic or to their doctor."
In an emergency, public health officials
sometimes have to reach beyond their own region for assistance.
On September 11, 2001, domestic airline flights were suspended
and it was not possible to obtain skin from the usual supply
centers to treat the burn victims at the Pentagon. Volunteers
agreed to drive to Texas to bring the skin to Washington,
DC.
The week before the panel meeting, COG had
a conference call in which officials discussed the model they
should use for future emergency response. The response to
the discovery of anthrax was not considered effective. It
was not clear who was in charge, or who would receive the
region's "push pack" of medications from the National
Pharmaceutical Stockpile. For future incidents, the officials
recommended following the model of the response to the sniper
incident in the area in the fall, with one spokesperson and
one control center, perhaps in the jurisdiction first affected.
In the area of medical surveillance, COG
currently has a research project at Johns Hopkins University,
funded by DOD, called "Essence," but it is only
targeting syndromes associated with bioterrorism, and it is
only funded for one year. Rea suggested it would be useful
to have an ongoing project to develop surveillance for a variety
of diseases, not just those related to homeland security threats.
"If we're not looking, we may not see the next crisis
coming until it's too late."
Claude ("Earl") Fox, Director,
Urban Health Institute, Johns Hopkins University, Baltimore,
MD
Earl Fox, newly elected a NAPA Fellow in
2002, has served in local public health agencies, as state
health agencies, and in federal government, where he served
as HRSA Administrator until 2002.
"A lot has happened at the federal,
state, and local levels [to improve the public health infrastructure]
since 9/11 but a tremendous amount still has to be done by
the feds." Though not as widely known as CDC, HRSA has
twice the budget of CDC and unlike CDC, HRSA has regional
offices that work with state and local health departments
and community health centers.
HRSA has funded public health training centers
for state and local public health departments through distance
learning. CDC later started funding its own bioterrorism training
centers through a different grant. There was a lost opportunity
on the part of both HRSA and CDC to coordinate their training
efforts with schools of public health. Some universities including
Johns Hopkins are trying to coordinate the two programs but
the funding is probably not sufficient to do either. "We
should coordinate . . . Even if you put people in the same
organization, they still may not talk. It is the same challenge
we face with the Department of Homeland Security."
The President has called for 1,200 new community
health centers (funded mostly by HRSA) but they don't always
talk to the state health departments. The nation now has approximately
3,000 local public health departments, 50 state health departments,
and 3,500 community health centers, for a total of between
6,500 and 7,000, and they are not all talking. The states
can help by providing coordination.
"We don't even know where the public
health workforce is." There is a tremendous opportunity
to improve that knowledge base, particularly with a new federal
project to give funds to states for that purpose. HRSA gave
a grant two years ago to the State University of New York
to develop a database on public health workers across the
United States. "There is no common taxonomy; no one even
knows the total, where they are, and the demographic trends
on where they should be."
The nation also has a huge shortage of environmental
epidemiologists--probably only a handful is working in the
entire country. Many public health departments don't have
anyone trained in environmental health issues; they need to
identify the need and develop and train people to do that
work.
In earlier years, before Medicaid shifted
to managed care, there was an increment of funding above basic
needs and most public health employees in local communities
were funded by Medicaid, including public health nurses. Sec.
1115 of the Social Security Act http://www.nhpf.org/pdfs_ib/IB777_1115Waivers_6-13-02.pdf
allows states to apply for waivers from the federal requirements
in order to initiate pilot, experimental, or demonstration
projects to try innovative and more flexible health care programs
but for the most part, Medicaid funding has been so tight
that the increment of funding available for public health
has not been available. The Clinton health care reform proposal
included some funding for preventive medicine, but that was
not adopted. "We've got to get preventive medicine on
the radar screen. The federal government has no more than
$2 million in the budget for preventive medicine programs.
Not that many schools teach it. An infusion of $10-12 million
would make a huge difference in training and getting people
into local public health organizations.
On the issue of intergovernmental coordination,
rural health departments talk to community health centers
and public health agencies. When he was at HRSA, it gave a
grant to a local agency to look at all the HRSA grants to
organizations within the local jurisdiction. That knowledge
is very helpful.
Currently, Fox's organization has an Institute
of Medicine grant to look at food safety and report to Congress
by summer. With the threat of bioterrorism that could affect
water or food, it will be a problem if state and local health
departments, EPA, USDA, and the Food and Drug Administration
(FDA) don't talk. Though GAO has recommended consolidating
some of those agencies and programs, they each have their
own systems and missions and constituencies and don't want
to consolidate. But there are many opportunities to coordinate
programs and they need more coordination.
Fox also expressed disappointment that when
communities wanted to obtain Cipro to protect workers against
anthrax, no one mentioned the federal 340B drug pricing program
created in the Veterans Health Care Act of 1992 (U.S. Public
Law 102-585), which allows health care providers certified
as "covered entities" by HHS to purchase prescription
drugs at reduced prices. A half dozen institutions are covered
in the Baltimore area alone, and none of them used the 340B
authority, which would have allowed Cipro to be purchased
at lower cost. More than 9,000 institutions serving 10 million
people across all 50 states are already certified as "covered
entities." www.ncsl.org/programs/health/drug340b.html
COMMENTS AND QUESTIONS
Nancy Rea commented that one of the biggest
problems is information sharing; it is difficult to get individuals
and agencies to share what they know, particularly if they
are afraid that it might put them in a bad light or if they
are uncertain what others may do with the information.
Earl Fox recalled that even within HHS,
the individual agencies such as HRSA, HCFA (Health Care Financing
Administration, now known as the Centers for Medicare and
Medicaid Services or CMS), Administration for Children and
Families (ACF), and the Centers for Disease Control (CDC)
all had different methods of communicating with states and
local governments. Many communications systems have been or
are being developed that could be shared. For example, USDA
installed satellite downlink capacity in every state, which
HRSA tapped into.
In HHS, he recalled that the Regional Health
Officer reports to the Regional Director, who is a political
appointee with no formal power over the HHS regional offices,
which are part of HRSA, HCFA, etc. But he noted that even
without unified organizational structures or procedures, agencies
in a region can at least communicate and get together for
planning.
Paul Posner: We often hear the term "picket
fence federalism" (where each agency and level of government
does its own thing without knowing or coordinating with others
that have parallel or overlapping missions). There are many
federal agencies that don't communicate with each other. For
example, FEMA probably has centers that are not part of the
health system.
Health issues are very regional. We hear
some examples of the federal government promoting coordination,
for example Metropolitan Planning Organizations (MPOs, which
are charged with developing transportation improvement plans
for investing federal funds for highways and transit). Maybe
the National Pharmaceutical Stockpile "push packs"
are another case where the federal government can promote
coordination across a region.
Barbara Levine: The states would say they
are already doing a lot of those things. Virginia and Maryland
were practically camped out together during the recent terrorist
and sniper incidents. A lot of infrastructure is in place
already, though some of it should be changed. I wouldn't say
set up new infrastructure.
Paul Posner: Should New Jersey have 200
local health departments?
Barbara Levine: I'm not the one to say.
Southern states provide a lot of health care. There are some
areas where more money would help. There is new funding in
the President's proposed FY2004 budget for more coordination,
for example, for surveillance systems.
People talk about bioterrorism preparedness,
but most people still die of chronic disease and heart attacks,
we still have trouble with tobacco and alcohol abuse, and
children are susceptible to accidents, poor nutrition, and
lack of good health care. [A GAO staff person noted that the
rate of sexually transmitted diseases (STDs) has been reported
to be down since September 11, when what is probably happening
is not that there are fewer cases of STDs but just that they
aren't being counted, because the resources for monitoring
them have been diverted to fighting bioterrorism.)
Nancy Rea: Bioterrorism is stealing money
from those other areas. It is classic "displacement."
COG's traffic safety person was taken off those issues to
deal with anthrax. There is no more money for public health
education, which was the reason I left Montgomery County to
work for COG.
Barbara Levine: All health areas are underfunded.
We have huge public health issues that are not being addressed.
Beryl Radin: Should the coordination on
public health issues be done at the federal level, the state
level, the local level?
Earl Fox: Almost all statutory authority
in public health (allowing us to do what we do, such as quarantine)
is at the local level. Sometimes the state level authority
is delegated to local governments. Everyone talks about expanding
the public health system but very little money is available
for hiring and training people.
Nancy Rae: That is a good point. The state
of Virginia used almost all of its emergency funding to put
epidemiologists and public health experts in localities. That
was all they could do. And you have to have those people;
you have to have epidemiologists at the local level because
that's where a disease is going to show up.
Enid Beaumont: This is a huge and very significant
problem. We are a huge country and we are very good at creating
units of government. We have 87,525 local government units
at last count, not counting private services. We cite that
as a great example of energy and creativity in our system
of governance, but . . . I had a graduate student who looked
at food safety and concluded that the agencies have got to
get together.
Beth Kellar: It takes a new way of thinking.
Beryl Radin: And also not creating new structures
but working through networks and virtual organizations.
Nancy Rea: We don't know what others are
doing. It's the "Mom" model, to see a need and say,
"I'll do it." Then you realize how many others are
doing the same thing, so many that it's impossible even to
find them all.
Earl Fox agreed and offered the example
of the Vice President's committee on telemedicine, including
distance-based learning and consultation.
Costis Toregas: This is depressing, but
it is an opportunity for the Federal System Panel. We assume
the federal system is not working as well as it could, and
that there's room for improvement. We need more cross-boundary
leadership: the imperative for each leader is not only do
well in his or her stovepipe, but also in other sectors. What
are the incentives, standards, metrics, and other learning
that can contribute to this? Public Technology Inc. is working
with National Defense University on this.
We see many things that are going wrong,
but maybe we can also identify things that are going right.
There are many technological opportunities: video, satellite,
computer, streaming. Most of us grew up in a "command
and control" system. The problem for the Department of
Homeland Security is that the people in the organization are
still geared to command and control.
We need to think about "dual use"
if we are going to be fighting Al Qaeda in the back streets
of Wichita. Maybe we can do something that will have other
benefits.
Earl Fox: The WIC program and USDA's Cooperative
Extension Service are two examples of programs that might
have dual uses (serving their own missions and also helping
to communicate information that can help people improve their
protection against potential bioterrorism threats).
HRSA explored a wireless uplink at the same
time that CDC was looking at something different using the
Internet. Neither one was using new money, they were going
to spend it anyway, but they could have gotten together. Only
a few federal agencies deal with state and local health departments
so maybe they could get together.
Paul Posner: What it takes is to understand
what needs to be done. How can the federal government contribute
or get out of the way?
Beryl Radin: Both state and local representatives
on the panel have been relatively positive about how things
are going [on the public health infrastructure, homeland security,
and federalism]. Maybe FDA or USDA need some changes in law?
Earl Fox: Most of the changes that might
be needed are not in statute but in regulations and policy
decisions. Costis's comments remind me that there are no incentives
to coordinate because agencies compete for their budgets;
they each have their own funds and accountability. If we could
figure out incentives, not punishments, to combine and integrate
these systems . . .
Nancy Rea: If we could put the authority
for talking for your agency down at a lower level in the federal
government. Frequently federal people are held back by the
necessity of going through clearance processes before they
can speak for the agency, and getting approval from people
who may not have that much knowledge. The tendency in the
federal government has been to centralize.
Beryl Radin: The middle level people have
the knowledge and they are doing the job because they think
it's important; they don't have any other incentives.
Costis Toregas: An article in PAR (Public
Administration Review) 3-4 months ago reported on a survey
several professors did of local officials in Kansas City,
about how much time they spend talking to people outside their
jurisdiction. When I saw it, I thought, "I hope the city
manager doesn't see this!" But there was quite a bit
of interchange at the lower levels. And a Public Manager article
more recently indicated that a majority of city managers realize
they need to communicate with others in the profession, so
maybe there is some hope.
Barbara Levine: When ASTHO is involved in
a discussion of a local public health issue, we often tell
the local public health officials they need to get others
in on the call. Do you offend them by saying you won't participate
if they don't do that? Cardiologists need to have nutritionists
in the mix, but no one will reimburse them for the costs,
so there's no incentive. Do we give them money to create incentives
to do it? Or withhold money if they don't do it? What can
you do to push agencies to do these things, when they know
they should?
Earl Fox: Maybe these things could be included
in training, for example, joint training by CDC and HRSA.
Nancy Rea: We have the same issues with
disease surveillance. Are all the jurisdictions going to develop
their own systems, which will not be compatible?
Marcia Crosse, GAO: What do you see as the
role of Gerry Hower's office, the Office of Health Preparedness
in the Office of the Secretary of DHS?
Nancy Rea: When I talked about HHS functioning
as a fourth state in working with COG, he is the one we work
with. We've asked him to coordinate COG's dealings with all
the feds.
Earl Fox: They're taking away the authority
of the individual programs. The HHS regional office role has
been transferred to a central office to monitor grants. All
the funds have been taken away for AIDS.
Paul Posner: Collaboration has got to be
inspired from the bottom but homeland security is a national
challenge, so the federal government should provide some incentive.
Beryl Radin: Rural Development Councils
are an example where federal funding spurred cooperation.
Beth Kellar: The federal government is in
the driver's seat because state and local governments are
facing such huge deficits. The federal government is the only
one that has money.
Earl Fox: One thing the federal government
can do is to ask ASTHO and NACCHO (National Association of
County and City Health Organizations) to look at a few areas
such as WIC where federal agencies could coordinate. State
and local governments will know which areas might be constructive
for coordination. They will be able to tick off the programs
and areas of funding that could be targeted.
Nancy Rea: There's a small example of what
you are talking about in the area of substance abuse. Under
the name "Exchange," a number of local, state, and
federal organizations and individuals come together to share
information, and they know about all the funding streams in
the different agencies and what they are doing.
Barbara Levine: It would be hard for ASTHO
and NACCHO to come out and make any recommendations, but it
might work if GAO or the Institute of Medicine interviewed
people and prepared a report with those recommendations.
Earl Fox agreed it would be preferable to
present the recommendations in a non-attributed manner, because
every state and local health department reports to someone.
Barbara Levine: You have a moment in time
to achieve something in the public health area. With the state
and local deficits, public focus on homeland security, food
safety concerns, and Bill Frist as majority leader, people
will pay attention.
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