Intelligence in Homeland Security

Public Health And National Security: The Critical Role Of Increased Federal Support Although responsibilities are shared at the local and state levels, U.S. public health improvements require federal direction and support.

by Bill Frist

ABSTRACT: Protecting the public’s health historically has been a state and local responsi- bility. However, the growing threat of bioterrorism has highlighted the importance of a strong public health infrastructure to the nation’s homeland security and has focused in- creased attention on the preparedness of the public health system. As a result, federal pub- lic health funding has increased exponentially since the anthrax attacks of late 2001, and Congress has passed sweeping new federal legislation intended to strengthen the nation’s public health system. This heightened level of federal interest and support should yield im- portant public health benefits. Most recognize that after years of neglect the public health infrastructure cannot be rebuilt overnight. As we implement a comprehensive strategy to in- crease the capabilities and capacity of our nation’s public health system, it is essential to address a series of important policy questions, including the appropriate level of ongoing public health investments from local, state, and federal sources.

T he anthrax attacks of october 2001 heightened America’s aware- ness of bioterrorism and focused attention on the important role of our na- tion’s public health system in responding to such emergencies. This paper

discusses the state of the public health infrastructure before the fall of 2001 and the initial legislative initiatives to begin the rebuilding process. It highlights the special nature of bioterrorism and the federal response to it. The paper also exam- ines some of the key political and policy considerations raised by recent federal in- vestments in public health preparedness; illustrates the historical role of local, state, and federal funding of national public health efforts; and cites examples of public health benefits achieved by this funding and gains that can be expected from the dual use of bioterrorism funds. A cautionary note is added about what Congress can expect from increased federal support, and the difficulties states may face in achieving the desired outcomes.

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©2002 Project HOPE–The People-to-People Health Foundation, Inc.

Sen. Bill Frist (R-TN) is board-certified in both general and cardiothoracic surgery. He is the first practicing physician elected to the U.S. Senate since 1928. He is ranking member of the Subcommittee on Public Health of the Senate Health, Education, Labor, and Pensions Committee.

The Growing Threat And Special Nature Of Bioterrorism The risk of a bioterrorist attack is increasing. Terrorists around the world, in-

cluding Al Qaeda, have often expressed their desire to use biological weapons against the United States. We know that more than a dozen nations, including Iraq, North Korea, Libya, and Syria, have the capability to produce chemical and biological weapons. We know that thousands of Soviet scientists who have the expertise to develop biological weapons are unemployed and potentially available to the highest bidder.1 An unclassified memo from the National Intelligence Coun- cil warns: “The biological warfare capabilities of state and non-state actors are growing worldwide. This trends leads us to believe that the risk of an attack against the United States, its interests and allies will increase in the coming years.”2

For example, Iraq launched a robust biological weapons program in 1985 and has admitted to producing large quantities of agents and weapons, including 19,000 liters of botulinum toxin (10,000 into munitions) and 8,500 liters of an- thrax (6,500 into munitions). During the Gulf War, Iraq armed 100 bombs and 15 missile warheads with botulinum toxin and 50 bombs and 10 missile warheads with anthrax. Iraq also has demonstrated the capability to deliver biological agents from crop sprayers and may also have remote-controlled helicopters for spraying aerosol agents such as anthrax.3

Nonstate actors are also a threat. CIA director George Tenet recently was quoted in the New York Times as saying that “documents recovered from Al Qaeda facilities in Afghanistan show that [Osama] bin Laden was pursuing a sophisti- cated biological weapons research program.” U.S. forces discovered a facility in southern Afghanistan near Kandahar that was being built to produce anthrax and other deadly agents.4

The current reality of terrorist threats means that we can no longer afford to ne- glect the public health system. As we know from the October 2001 anthrax at- tacks, the United States is vulnerable. As significant as last fall’s anthrax attacks were, they could have been much worse. The attacks killed five people, infected twenty-two, and exposed hundreds more. Yet had the spores been aerosolized in a crowded public area; had the public and private health professionals responded more slowly; or had a communicable organism or more sophisticated delivery method been used, many more people could have died or become ill.5

Indeed, preparing for potential bioterrorist attacks involves unique consider- ations that are distinct from the emergency and disaster preparations necessary for other forms of terrorism, such as those that use conventional, chemical, or, pos- sibly nuclear weapons. Bioterrorism does not announce itself with a large explo- sion. One cannot smell, taste, or see biological agents. The attack will not be known until sick patients begin arriving in hospitals and doctor’s offices, usually days later—long after the terrorist has left the scene. First responders will often not be firefighters and policemen, but emergency room doctors and nurses. If the

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organism used is one that occurs naturally in the environment, it may initially be difficult to discern that the resulting disease pattern is from an intentional attack.

Public Health Before September 11, 2001 The nation’s public health infrastructure is not fully prepared to meet this

growing challenge. Over the past two decades the infrastructure has greatly dete- riorated. A lack of focus, funding, and national attention have combined to reduce the physical structures (such as laboratories) and workforce capabilities neces- sary to collect and analyze data, conduct epidemiology and disease surveillance, communicate effectively, and implement interventions to respond to threats to the health of the entire community. Recent grant announcements by the Centers for Disease Control and Prevention (CDC) outline six focus areas essential to the core public health mission required to respond to a bioterrorist threat: (1) prepared- ness planning and readiness assessment, (2) surveillance and epidemiology capac- ity, (3) laboratory capacity, (4) communications and information technology, (5) risk communication and health information, and (6) education and training. These six “core capacities” outline crucial public health elements required for ap- propriate prevention to, preparedness for, and response to any act of bioterrorism or another public health emergency.6

Surveys and studies conducted before 11 September 2001 found that many com- munities lacked adequate laboratories or epidemiologists trained to detect infec- tious disease outbreaks. Even the CDC, the nation’s premier public health agency, relied heavily on antiquated laboratories constructed in the 1960s and 1970s. Fur- thermore, prior to 1999 one-third of public health departments serving fewer than 25,000 people did not have access to the Internet or electronic mail, and almost 20 percent of all local health departments had no e-mail capacity at all.7 More than nine of ten public health departments lacked staff trained in bioterrorism pre- paredness, and only one in five hospitals had a response plan in place to deal with biological attacks.

Ironically, the seeds of this decline were sown in part by scientific progress and public health’s successes: improved sanitation and nutrition and the discovery and widespread use of vaccines and effective antimicrobial agents. These agents have reduced the public’s fear of deadly, naturally occurring infectious disease out- breaks and simultaneously diminished the importance of traditional public health functions.

At the same time, as the danger posed by infectious diseases has subsided, the public health community has become focused on more controversial areas, such as violence prevention, family planning, environmental issues, and chronic diseases, and broad support among federal policymakers for public health efforts has de- clined. In recent years federal funding has tended to focus on individual health services (Medicare and Medicaid) and categorical public health programs, while the more controversial programs became targets for funding reductions.

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Initial Federal Efforts To Rebuild In the late 1990s a handful of members of Congress and federal officials grew in-

creasingly concerned about the state of the public health infrastructure and the growing threat of bioterrorism. The Clinton administration began gradually in- creasing funding for bioterrorism preparedness (although much of this focused on areas other than improving the capabilities of the state and local infrastructures).

Also, landmark federal legislation designed to improve the public health system passed in November 2000. The Public Health Threats and Emergencies Act of 2000 (P.L. 106-505) was the first federal law to comprehensively address the pub- lic health system’s preparedness for bioterrorism and other infectious disease out- breaks. It authorized $540 million in the first year (fiscal year 2001) to help im- prove public health agencies’ response capabilities and core public health capacities. Its goal was to deliberately increase state and local capacity by estab- lishing a process for gradually improving preparedness by (1) requiring the devel- opment of a core set of public health capacities to be implemented by states and localities; (2) establishing a state grant program to allow states to evaluate their public health capacity; and (3) authorizing increased funding for state and local planning and implementation of those capacity-building goals.

The law represented an important milestone, with the recognition of the need for an increased federal role in securing public health preparedness as well as cre- ating goals for improvement. Symbolically, the legislation marked the beginning of a return to the national vision of the role of public health as a protector of the en- tire community (against pathogens that could attack anyone) that had not been present since the early twentieth century. Practically, the law formed the founda- tion for an even larger expansion of the federal commitment to improving the na- tion’s public health infrastructure in June 2003.

Little fanfare accompanied the law’s enactment in December 2000. Only eight Senators cosponsored the act, and it passed too late in the congressional session to receive consideration by appropriators that year. All indications during the early phases of the 107th Congress suggested that the act would receive only partial funding in the subsequent fiscal year as well.

Clearly, prior to the anthrax attacks of late fall 2001 there was little political support at the federal level for substantial new investments in local public health activities. In fact, it would take the most serious biological attack on American soil for federal policymakers to fully recognize the connection between the public health infrastructure and national defense.

Enhanced Federal Public Health Preparedness Efforts The fall 2001 anthrax attacks served as a catalyst, not merely for increased at-

tention but also for federal legislation authorizing sweeping new initiatives and providing new funding for long-neglected public health activities. Congress ap- propriated a record $3 billion in December 2002 for antibioterrorism activities, in-

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cluding more than $1 billion dedicated to upgrading state and local public health capabilities and hospital preparedness.8 This represented a 600 percent increase over the previous year’s funding levels for antibioterrorism activities.

Moreover, in June 2002 President Bush signed into law the Public Health Secu- rity and Bioterrorism Preparedness and Response Act (P.L. 107-188), which autho- rized even greater funding, while providing a host of new measures to (1) improve public health capacity, (2) upgrade health professionals’ ability to recognize and treat diseases caused by bioterrorism, (3) speed the development of new vaccines and other countermeasures, (4) improve protections for our water and food sup- plies, and (5) track and regulate the use of dangerous pathogens within the United States. Bioterrorism continues to be a focus of federal attention, and preparedness plans feature prominently in the Bush administration’s proposal to create a De- partment of Homeland Security.9

A strong public health infrastructure is important not only to safeguarding and improving the public’s health but also to the nation’s security. Therefore, the fed- eral government must work with states and localities to ensure these capabilities. State and local governments must shoulder their fair share of financial obligations for these functions, but it will require an enhanced and prolonged strategy for America to regain and maintain the capacity necessary to respond to today’s in- creased bioterrorist threats. Moreover, if we achieve the level of preparedness nec- essary to respond to these challenges, we will simultaneously strengthen our pub- lic health system’s ability to combat naturally occurring infectious disease out- breaks and other public health threats and emergencies.

As Congress discusses future funding sources for public health, it is important to examine funding trends from a historical context. Given the shared responsibil- ity of federal, state, and local governments in securing the public’s health, a mix of federal, state, and local revenues fund public health agencies, but the relative con- tributions have changed with time.

Funding For Public Health Through The Mid-1900s Historically, most public health responsibilities have been carried out at the

state and local levels, and, as a result, most public health funding has come from states and local governments. In the eighteenth century, what little public health programmatic activity existed pertained to isolation and quarantine functions in- tended to prevent or halt epidemics.10 In the second half of the nineteenth century, states and cities once again led the way by establishing local boards of health and initiating programs to address sanitation problems. New York City established the first Department of Health in 1866. By 1900 forty states had established health

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“A strong public health infrastructure is important not only for the public’s health but also for the nation’s security.”

departments, and several also ran their own public health laboratories.11 However, funding for these activities was modest, with only two states spending more than two cents per person in a given year.12 During that time the federal public health role was remained limited, and states resisted attempts to increase federal involve- ment in disease control and quarantine activities. For example, the National Board of Health and Quarantine, founded in 1879, was terminated in 1883.13

Local and state health departments expanded and continued to lead the na- tion’s public health efforts through the early part of the twentieth century, as the federal role in public health also began to expand. The Food and Drug Act was passed in 1906; in 1912 the Marine Hospital System became the U.S. Public Health Service (PHS), the position of surgeon general was created, and the PHS began to investigate the spread and causes of diseases. The PHS assumed the responsibility of examining immigrants upon their entry into the country and in 1918 began ef- forts to control venereal diseases in the general population. In 1922 the Sheppard- Towner Act was passed, creating the Federal Board of Maternity and Infant Hy- giene, funding the Children’s Bureau, and providing funds to states for maternal and child health programs. This was the first federal public health program that provided grants to states.14

The federal role in health continued to expand during the 1930s as part of the New Deal. Between 1930 and 1940 the National Institutes of Health (NIH) was es- tablished, while the Social Security Act provided more funding to states for public health services, training of public health professionals, and venereal disease con- trol. The precursor to today’s CDC, the Communicable Disease Center, was founded during World War II to work with state and local health officials against malaria, typhus, and other communicable diseases.15

Funding Of Public Health, 1960–2002 Fortunately, more complete data are available with respect to public health

funding during the past few decades. One of the best sources for data for examin- ing public expenditures for health is the National Health Accounts (NHA). This data source has been compiled consistently using a standard set of definitions for more than forty years; here we present data through 2000.

Not all programs that many would consider related to public health are in- cluded within the NHA. For instance, nutrition programs such as the Women, In- fants, and Children (WIC) Food Supplemental Program; sanitation and water programs; other environmental health programs; and federal research support are not included. Therefore, the following analysis is not intended to be a comprehen- sive look at the funding levels of all activities many would consider to be in the realm of public health. Rather, it illustrates trends for those funding sources that have been collected regularly and consistently.

In the NHA, “government public health activity” includes funds spent to orga- nize and deliver services or to prevent or control health problems. These funds are

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delineated between federal (predominantly the CDC and the Food and Drug Ad- ministration, or FDA) and state and local funds. Federal passthroughs are sub- tracted from the state and local funds to avoid double counting.

It is difficult, if not impossible, to cleanly separate personal health care services from public health activity. For instance, when a vaccine is administered at a clinic, this is a public health activity occurring in the context of personal health care. In an attempt to include only funding for essential (that is, population- based) public health services and not personal health care services, we adjusted the state/local NHA data by multiplying by 0.31, based on a study of nine states that determined that only 31 percent of public health spending was for popula- tion-based public health services.16

Total health expenditures rose from $26.7 billion in 1960 to $1.3 trillion in 2000, while total public health expenditures increased from $192 million to $17 billion (Exhibit 1). The proportion of total health spending dedicated to public health rose from 0.72 percent in 1960 to 1.32 percent in 2000. Public health spending as a proportion of total health spending peaked in the early 1970s. It declined in the 1980s and then returned to its 1970s peak level in the late 1990s. Exhibit 2 further illustrates these trends.

In 1960 federal and state/local spending on public health was nearly equivalent (with the federal amount slightly above the state/local amount). The federal con- tribution increased at a greater rate than the state and local contribution in the early 1960s, so that by 1968 the federal contribution accounted for 75 percent of the total funding for public health (Exhibit 3). Federal spending stagnated through the 1970s until the late 1980s and then grew slowly through 2000. The state and local contribution continued to grow through this time period, so that by 2000 state and local spending was 2.5 times the federal level. Local and state governments now account for more than 70 percent of spending for those public health services included in the NHA. The trends in the proportion of federal pub- lic health spending illustrated in Exhibit 4 are indicative of the movement to state and local responsibility for public health that began in the mid-1970s.

Historical trends of spending on public health should also be analyzed by tak- ing into account the effects of inflation and population growth. This adjustment involves using (1) the gross domestic product (GDP) inflator for the year 2000 to adjust to year 2000 dollars, and (2) the annual population estimates from the Cen- sus Bureau to adjust for population differences.

Between 1960 and 2000 the inflation-adjusted per capita amount spent by state and local governments on population-based public health services (Exhibit 3) in- creased by a multiple of 18.4, from $2.41 to $44.29. During the same time period

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“It is difficult, if not impossible, to cleanly separate personal health care ser vices from public health activity.”

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EXHIBIT 1 Spending For Public Health, In Millions Of Dollars, 1960–2000

Year

Total national health spending

Total federal health spending

Adjusted total public health spendinga

Federal public health spending

Adjusted state/local public health spendingb

Adjusted total public health spending as percent of total health spendingc

1960 1961 1962 1963 1964 1965

$ 26,679 28,553 31,032 33,817 37,682 41,012

$ 2,826 3,238 3,687 4,141 4,448 4,674

$ 192 200 238 301 334 340

$ 102 108 140 208 226 214

$ 90 92 98 93

108 126

0.72% 0.70 0.77 0.89 0.89 0.83

1966 1967 1968 1969 1970

45,128 50,691 57,460 64,587 73,056

7,431 11,895 13,988 15,786 17,589

430 544 626 753 830

294 401 471 564 594

136 143 155 189 236

0.95 1.07 1.09 1.17 1.14

1971 1972 1973 1974 1975

80,952 90,674

100,540 113,730 129,841

20,365 22,738 25,108 30,166 36,108

1,065 1,191 1,248 1,472 1,631

791 893 854 969

1,043

274 298 394 503 588

1.32 1.31 1.24 1.29 1.26

1976 1977 1978 1979 1980

148,826 169,403 189,412 213,935 245,758

42,484 47,225 53,828 60,805 71,311

1,799 2,068 2,315 2,512 2,942

1,110 1,152 1,155 1,109 1,235

689 916

1,160 1,403 1,707

1.21 1.22 1.22 1.17 1.20

1981 1982 1983 1984 1985

285,092 321,006 353,532 390,123 426,832

82,769 91,922

101,853 112,577 122,167

3,255 3,524 3,775 4,035 4,496

1,216 1,141 1,232 1,298 1,325

2,039 2,383 2,543 2,737 3,171

1.14 1.10 1.07 1.03 1.05

1986 1987 1988 1989 1990

457,242 498,025 558,090 622,653 695,999

131,509 142,815 154,062 172,387 192,669

4,824 5,325 6,039 6,972 7,825

1,321 1,520 1,786 2,024 2,256

3,503 3,805 4,253 4,948 5,569

1.05 1.07 1.08 1.12 1.12

1991 1992 1993 1994 1995

761,826 827,043 888,063 937,225 990,264

221,678 251,114 274,373 298,454 321,970

8,749 9,713

10,607 11,804 12,262

2,595 2,914 3,144 3,626 3,650

6,154 6,799 7,463 8,178 8,612

1.15 1.17 1.19 1.26 1.24

1996 1997 1998 1999 2000

1,039,975 1,091,163 1,149,781 1,215,554 1,299,463

343,930 358,800 367,655 384,770 411,453

12,821 13,715 14,533 15,733 17,089

3,752 3,934 4,033 4,442 4,892

9,069 9,781

10,500 11,291 12.197

1.23 1.26 1.26 1.29 1.32

SOURCE: Data compiled from Centers for Medicare and Medicaid Services, National Health Accounts (NHA), 1960–2000. NOTE: The NHA breaks down health spending by source of funding and by activity and type of service provided. a Adjusted total public health expenditures, including expenditures at both the federal and state/local level. State/local public health expenditures are adjusted in an attempt to include only funding for essential (that is, population-based) public health services and not personal health care services. This column is the sum of columns 4 and 5. b State/local health spending, adjusted to include only spending for essential public health services. c Adjusted total public health spending (federal plus adjusted state/local), as a percentage of total national health spending.

federal per capita spending on public health increased by a multiple of only 6.5, from $2.72 to $17.77. Federal per capita spending on public health began declining in 1974 and continued its downward trend until 1986. Not until 1992 did it return to its mid-1970s level. These trends illustrate the point made earlier about declin- ing federal support for public health as infectious threats to the public subsided and more controversial public health programs became the focus.

The recent increases in federal spending for national, state, and local public health activities, intended to address the threats of bioterrorism and other public health emergencies, amounted to $1.1 billion in FY 2002 alone; President Bush has proposed an additional $1.2 billion in FY 2003. Although this is an increase of 25 percent in the federal contribution to public health spending, it changes only mar- ginally the federal share of funds spent for public health (from 29 percent to 34 percent), assuming that state or local spending does not change dramatically.

Benefits From Public Health Investments There is little doubt that investments in public health—whether at the federal,

state, or local level—have paid off handsomely. Infectious disease deaths declined dramatically during the twentieth century.17 At the beginning of the century the leading U.S. causes of death were infectious diseases; pneumonia, tuberculosis, and diarrhea caused one-third of all deaths. In 2000 the three leading causes of death were chronic diseases: heart disease, cancer, and stroke.18

Vaccines alone have prevented millions of illnesses and hundreds of thousands of deaths (Exhibit 5).19 In 1900 vaccines were available to combat only five infec- tious diseases, and they were not widely used. Now there are vaccines against twenty-six infectious diseases, and their use has rendered many of the leading causes of mortality in infants and children completely preventable.

Public health efforts have led to a safer and healthier food supply by way of pas- teurization, improved food preparation and storage practices, and food product

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EXHIBIT 2 Federal And Adjusted State/Local Public Health Spending, As A Percentage Of Total Health Spending, 1960–2000

SOURCE: Data derived from Centers for Medicare and Medicaid Services, National Health Accounts, 1960–2000.

1.4

1.2

1.0

0.8

0.6

Percent

1960 1970 1980 1990 2000

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EXHIBIT 3 Federal Public Health Spending As A Percentage Of Total Spending, And Per Capita Public Health Spending, 1960–2000

Year

Federal public health spending as percent of total federal health spending

Federal public health spending as percent of adjusted total public health spendinga

Real per capita federal public health spendingb

Real per capita adjusted state/ local public health spendingc

Real per capita adjusted total public health spendingd

1960 1961 1962 1963 1964 1965

3.61% 3.34 3.80 5.02 5.08 4.58

53.07% 53.90 58.83 69.10 67.69 62.91

$ 2.72 2.80 3.53 5.12 5.40 4.96

$ 2.41 2.40 2.47 2.29 2.58 2.92

$ 5.13 5.20 6.00 7.40 7.98 7.88

1966 1967 1968 1969 1970

3.96 3.37 3.37 3.57 3.38

68.41 73.77 75.28 74.86 71.55

6.55 8.57 9.55

10.80 10.67

3.02 3.05 3.14 3.63 4.24

9.57 11.62 12.69 14.42 14.91

1971 1972 1973 1974 1975

3.88 3.93 3.40 3.21 2.89

74.29 74.98 68.45 65.84 63.96

13.36 14.31 12.84 13.24 12.91

4.62 4.77 5.92 6.87 7.28

17.98 19.09 18.76 20.12 20.19

1976 1977 1978 1979 1980

2.61 2.44 2.15 1.82 1.73

61.70 55.71 49.90 44.14 41.98

12.88 12.44 11.52 10.09 10.18

8.00 9.89

11.56 12.77 14.06

20.88 22.32 23.08 22.87 24.24

1981 1982 1983 1984 1985

1.47 1.24 1.21 1.15 1.08

37.36 32.38 32.63 32.17 29.47

9.07 7.94 8.17 8.23 8.07

15.22 16.58 16.87 17.35 19.32

24.29 24.52 25.04 25.58 27.39

1986 1987 1988 1989 1990

1.00 1.06 1.16 1.17 1.17

27.39 28.54 29.57 29.03 28.83

7.80 8.64 9.73

10.52 11.17

20.69 21.62 23.16 25.71 27.56

28.49 30.26 32.89 36.23 38.73

1991 1992 1993 1994 1995

1.17 1.16 1.15 1.21 1.13

29.66 30.00 29.64 30.72 29.77

12.26 13.30 13.86 15.51 15.14

29.08 31.02 32.91 34.98 35.72

41.34 44.32 46.77 50.49 50.86

1996 1997 1998 1999 2000

1.09 1.10 1.10 1.15 1.19

29.26 28.68 27.75 28.23 28.63

15.13 15.41 15.46 16.65 17.77

36.56 38.31 40.26 42.31 44.29

51.69 53.72 55.72 58.96 62.06

SOURCE: Data compiled from Centers for Medicare and Medicaid Services, National Health Accounts (NHA), 1960–2000. NOTE: The NHA breaks down health spending by source of funding and by activity and type of service provided. a Federal public health spending as a percentage of adjusted total public health spending (federal plus adjusted state/local). b Inflation-adjusted per capita spending on public health (federal spending). Amounts are in 2000 dollars, adjusted using the 2000 gross domestic product (GDP) deflator. U.S. population estimates are from the U.S. Bureau of the Census. c Inflation-adjusted per capita spending on public health (adjusted state/local spending). d Inflation-adjusted per capita spending on public health (federal plus adjusted state/local). This column is the sum of columns 3 and 4.

fortification with vitamins and minerals. A number of nutritional deficiencies, in- cluding goiter and rickets, have been effectively eliminated, in part because of food fortification and government assistance programs.20

Although heart disease is still the leading U.S. cause of death, public health ef- forts have led to major improvements. The age-adjusted death rate from heart dis- ease of 307 per 100,000 in 1950 was reduced to 134 per 100,000 in 1996. This has re- sulted in large part from the reduction in risk factors (hypertension, smoking, and high cholesterol) discovered through epidemiological studies. Mortality from stroke has also declined (from 89 per 100,000 in 1950 to 26 per 100,000 in 1996) for the same reason.21 The effects of tobacco use on morbidity and mortality remain high, but public health efforts have contributed to a decline in the prevalence of smoking. In 1965, 42 percent of adults smoked; by 1997 the rate was 24 percent.22

Although this is just a sampling of the illness and death prevented by public health efforts, it demonstrates the large improvements that can be achieved by in- vesting in basic public health interventions. As we strengthen our public health infrastructure and improve our capability to prevent and respond to bioterrorism, we can expect additional improvements by using these improved capabilities for additional public health activities. Examples of “dual use” of the infrastructure needed for bioterrorism preparedness include (1) enhanced detection and preven- tion of foodborne disease outbreaks; (2) increased capacity to prevent HIV/AIDS; other sexually transmitted diseases; hepatitis A, B, and C; waterborne diseases; and enteric pathogens; and (3) better ability to monitor and prevent environmen- tally related diseases.

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EXHIBIT 4 Federal Public Health Funding As A Percentage Of Adjusted Total Public Health Spending (Federal Plus State/Local), 1960–2000

80

70

60

50

40

30

Percent

20

1960 1970 1980 1990 2000

SOURCE: Data derived from Centers for Medicare and Medicaid Services, National Health Accounts, 1960–2000.

Future Policy Challenges To be prepared for bioterrorism, it is imperative that we develop a cohesive and

comprehensive system of ongoing surveillance and case investigations for early de- tection; laboratory capabilities for immediate confirmation; public health medical expertise for rapid assessments and recommendations for prevention and treat- ment; preventive response teams to implement needed interventions; and a com- munication network for providing updates to physicians, health facilities, and the public. These are capabilities needed for basic disease control, and they constitute a strong public health infrastructure at the federal, state, and local levels.

In addition, we must invest in research and development of bioterrorism coun-

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EXHIBIT 5 Baseline Twentieth-Century Annual Morbidity And 1998 Provisional Morbidity From Nine Diseases With Vaccines Recommended Before 1990 For Universal Use In Children, United States

Disease

Baseline twentieth- century annual morbidity

1998 provisional morbidity Percent decrease

Smallpox Diphtheria Pertussis

48,164a

175,885b

147,271d

0 1

6,279

100.0% 100.0c

95.7

Tetanus Poliomyelitis (paralytic) Measles

1,314e

16,316f

503,282h

34 0g

89

97.4 100.0 100.0c

Mumps Rubella

Congenital rubella syndrome Haemophilus influenzae type b

152,209i

47,745j

823k

20,000l

606 345

5 54m

99.6 99.3 99.4 99.7

SOURCE: “Impact of Vaccines Universally Recommended for Children—United States, 1900–1998,” Morbidity and Mortality Weekly Report 48, no. 12 (1999): 245, Table 2. a Average annual number of cases during 1900–1904. F. Fenner et al., Smallpox and Its Eradication (Geneva: World Health Organization, 1988). b Average annual number of reported cases during 1920–1922, three years before vaccine development. c Rounded to nearest tenth. d Average annual number of reported cases during 1922–1925, four years before vaccine development. e Estimated number of cases based on reported number of deaths during 1922–1926 assuming a case-fatality rate of 90 percent. f Average annual number of reported cases during 1951–1954, four years before vaccine licensure. g Excludes one case of vaccine-associated polio reported in 1998. h Average annual number of reported cases during 1958–1962, five years before vaccine licensure. I Number of reported cases in 1968, the first year reporting began and the first year after vaccine licensure. j Average annual number of reported cases during 1966–1968, three years before vaccine licensure. k Estimated number of cases based on seroprevalence data in the population and on the risk that women infected during a childbearing year would have a fetus with congenital rubella syndrome. Batelle Medical Technology Assessment and Policy Research Program, Centers for Public Health Research and Evaluation, A Cost Benefit Analysis of the Measles-Mumps-Rubella (MMR) Vaccine (Arlington, Va.: Batelle, 1994). l Estimated number of cases from population-based surveillance studies before vaccine licensure in 1985. S.L. Cochi and J.I. Ward, “Haemophilus influenzae Type B,” in Bacterial Infections of Humans, ed. A.S. Evans and P.S. Brachman (New York: Plenum, 1991). m Excludes 71 cases of Haemophilus influenzae disease of unknown serotype.

termeasures, such as vaccines and new antibiotics. This will require a federal in- vestment as well as a collaborative effort with private industry. The traditional public health agencies at the federal, state, and local levels will need to collaborate with each other and with other federal agencies involved with homeland security to find new, creative ways to conduct surveillance and disease control. Equally im- portant, we will need to train and support an adequate public health workforce.

To the extent that these efforts are seen in Congress as a response to a threat to the public and the national security, continued support will be more likely. If funds are used by states and local public health agencies to supplant their current funding or to create dual use for more controversial programs that do not enjoy broad support, ongoing funding will be jeopardized. We can also expect increased congressional scrutiny to hold states and localities, as well as public health offi- cials, responsible for achieving results. The challenge for public health will be to use the money wisely to address the concerns for which it was intended.

The Public Health Security and Bioterrorism Preparedness and Response Act of 2002 is a good start. It establishes a cohesive and comprehensive framework for improving our public health system and reducing our vulnerabilities. As our re- sources and capabilities improve, new questions will arise. For example, a major public policy debate is occurring about who should be vaccinated with newly available smallpox vaccine.23 What public health emergency powers are needed at the state and national levels is also being debated in many states.24 Discussion of these and other issues will continue.

One of the most critical issues remaining is the appropriate federal, state, and local shares of funding for the public health infrastructure. Given the increasing risk of bioterrorism, the importance of a strong public health infrastructure in re- sponding appropriately to potential bioterrorist attacks, the remaining vulnera- bilities in our public health system, and current federal public health funding rela- tive to its historical levels, it is clear that enhanced federal support is necessary. There is a strong national-security interest in developing and maintaining a strong public health system. And while states and local governments must continue to shoulder a large portion of future investments, the federal government will have to sustain an elevated level of support for the overall public health system if we are to strengthen our preparedness as a nation and meet the growing threat of bioterrorism.

The author gratefully acknowledges the contributions to this paper by Douglas Campos-Outcalt and Dean A. Rosen.

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“We can expect congressional scrutiny to hold states, as well as public health officials, responsible for achie ving results.”

NOTES 1. A.H. Cordesman, Defending America: Asymmetric and Terrorist Attacks with Biological Weapons (Washington: Cen-

ter for Strategic and International Studies, 24 September 2001).

2. National Intelligence Council, “The Biological Warfare Threat” (Unclassified memo, 2 January 2001).

3. A.H. Cordesman, Iraquis’ Past and Future Biological Weapons Capabilities (Washington: CSIS, February 1998).

4. D. Johnston and J. Risen, “A Nation Challenged: Weapons; U.S. Concludes Al Qaeda Lacked a Chemical or Biological Stockpile,” New York Times, 20 March 2002.

5. T.V. Inglesby et al., “Anthrax as a Biological Weapon, 2002: Updated Recommendations for Management,” Journal of the American Medical Association 287, no. 17 (2002) : 2236–2252.

6. Centers for Disease Control and Prevention, Cooperative Agreement Award Notice and Grant Guidance, Guidance for Fiscal Year 2002 Supplemental Funds for Public Health Preparedness and Response for Bioterrorism, Announcement no. 99051—Emergency Supplemental, 15 February 2002, www.bt.cdc.gov/ planning/coopagreementaward/index.asp (30 September 2002).

7. National Association of County and City Health Officials, “Information Technology Capacity and Local Public Health Agencies,” Research Brief (Washington: NACCHO, July 1999).

8. The Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, P.L. 107-116, 107th Cong., 1st sess. (10 January 2002).

9. White House, draft legislation to establish a Department of Homeland Security, 2002, www.whitehouse. gov/deptofhomeland/bill/index.html (10 September 2002).

10. For an overview of the U.S. public health system’s history since the 1700s, see E. Fee and T.M. Brown, “The Unfulfilled Promise of Public Health: Déjà Vu All Over Again,” in this volume of Health Affairs. See also In- stitute of Medicine, “A History of the Public Health System,” in The Future of Public Health (Washington: Na- tional Academy Press, 1988), chap. 3.

11. IOM, “A History of the Public Health System.”

12. S.W. Abbott, The Past and Present Conditions of Public Hygiene and State Medicine in the United States (Boston: Wright and Potter, 1900).

13. Ibid.

14. IOM, “A History of the Public Health System”; Fee and Brown, “The Unfulfilled Promise of Public Health”; and R.A. Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850–1929 (Baltimore: Johns Hopkins University Press, 1990).

15. CDC, Office of Communication, CDC Timeline, 22 October 2001, www.cdc.gov/od/oc/media/timeline. htm (10 September 2002).

16. Public Health Foundation, Measuring Expenditures for Essential Public Health Services (Washington: PHF, 1996).

17. CDC, “Achievements in Public Health, 1900–1999: Control of Infectious Diseases,” Morbidity and Mortality Weekly Report 48, no. 29 (1999): 621–629.

18. Ibid.

19. CDC, “Impact of Vaccines Universally Recommended for Children—United States, 1900–1998,” Morbidity and Mortality Weekly Report 48, no. 12 (1999): 243–248.

20. CDC, “Achievements in Public Health, 1990–1999: Safer and Healthier Foods,” Morbidity and Mortality Weekly Report 48, no. 40 (1999): 905–913.

21. CDC, “Achievements in Public Health, 1990–1999: Decline in Deaths from Heart Disease and Stroke— United States, 1900–1999,” Morbidity and Mortality Weekly Report 48, no. 30 (1999): 649–656.

22. CDC, “Achievements in Public Health, 1900–1999: Tobacco Use—United States, 1900–1999,” Morbidity and Mortality Weekly Report 48, no. 43 (1999): 986–993.

23. A.S. Fauci, “Smallpox Vaccination Policy—The Need for Dialogue,” New England Journal of Medicine 346, no. 17 (2002): 1319–1320.

24. G.J. Annas, “Bioterrorism, Public Health, and Civil Liberties,” New England Journal of Medicine 346, no. 17 (2002): 1337–1342. See also L.O. Gostin, “Public Health Law in an Age of Terrorism: Rethinking Individual Rights and Common Goods,” and three Perspectives, in this volume of Health Affairs.

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