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Issue: November 2015
ByJeffrey S. Duchin, MD
November 19, 2015
4 min read
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The next outbreak: Public health emergency prevention, preparation and response

Issue: November 2015
ByJeffrey S. Duchin, MD

Preventing, preparing for, and responding to infectious disease outbreaks demands a sustained and forward-looking investment in public health. Over the past few years, threats like the influenza A(H1N1)pdm09, Middle East respiratory syndrome coronavirus and the recent Ebola virus disease outbreak have highlighted challenges faced by the public health system related to infectious disease preparedness and response while also reminding us that deadly pathogens will respect no borders. Meanwhile, HIV/AIDS, tuberculosis, hepatitis C virus, seasonal influenza and foodborne illnesses infect millions of Americans each year, leading to preventable illnesses, hospitalizations, deaths and staggering health care and societal costs. They are draining resources that could otherwise be used to build sustainable response capacity and prevention programs.

Perhaps most alarming is the rapid increase of highly antibiotic-resistant bacteria, which threatens to reverse more than a century of remarkable medical advancements in the treatment of infectious diseases. Antibiotics are quickly losing their effectiveness, and there are few promising replacements in the pipeline, making it difficult, if not impossible, for physicians to treat many patients.

Jeffrey S. Duchin, MD
Jeffrey S. Duchin

If we are to be adequately prepared to respond to these emerging and re-emerging infectious threats, we need to transform not only the health care delivery system but also our nation’s public health system. This will require dynamic and effective leadership at the national, state and local levels as well as robust, long-term and stable investments of resources.

Strong local public health systems are the foundation for ensuring community health both during and between health emergencies. As evident during the U.S. Ebola response, it is difficult, if not impossible, to develop new systems, resources and capacity in the midst of an infectious disease emergency. That is why it is important to establish core elements of a strong public health emergency response in advance. These include:

  • clear lines of authority and accountability;
  • governance systems that are flexible/situational and transparent;
  • proactive engagement of both governmental and nongovernmental stakeholders in governance, preparedness and response activities;
  • recognition of the importance of incident management as a framework for effective emergency response;
  • strong and culturally appropriate communication and risk communication systems; and
  • a solid foundation of community resilience and effective community engagement in formulating response strategies.

To adequately address the many health problems our country is facing, including infectious disease threats as well as other major health problems, a robust “foundational public health capacity” is needed in communities across the country. Such a foundation would comprise adequate numbers of trained public health professionals and corresponding modernized infrastructure in the fields of epidemiology and surveillance, disease investigation, public health nursing, environmental health, zoonotic diseases, toxicology, policy development, data management and informatics, and communication.

Once an expert workforce has been diminished, it cannot be rebuilt overnight to respond to an emergency. In order to ensure that the U.S. public health system achieves these capabilities, we must invest in a stronger infrastructure at the federal, state and local levels. At the federal level, the CDC leads national ID surveillance and administers and coordinates ID preparedness and response grants to state and local public health departments, hospitals and communities. When a crisis like Ebola virus disease or pandemic influenza erupts, we count on the CDC to respond quickly and effectively.

Despite this essential role, the agency’s funding has been relatively flat over the past several years. The CDC was funded at $6.87 billion in fiscal year 2015, barely above the $6.84 billion it received in fiscal year 2011. The CDC also has lost purchasing power, reducing funds for state and local health systems. This is particularly damaging for state and local health departments because federal revenue sources account for roughly half of their funding. Both state and local health departments have cut back critical infectious disease programs and the public health workforce is shrinking. According to a recent analysis from the Trust for America’s Health, 22 states and Washington, D.C., decreased their public health budgets from fiscal year 2012-2013 to fiscal year 2013-2014. In all, state funding for public health was cut $1.3 billion when adjusted for inflation. A 2012 report from the National Association of County and City Health Officials documented that 44,000 jobs were cut at local health departments between 2008 and 2012.

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We cannot continue to rely on emergency funding from Congress every time a new or unexpected infectious disease threat arises. Instead, a long-term investment is needed to create a robust local public health system capability and capacity to promptly detect, investigate, report and respond to outbreaks and health emergencies. In addition to modernizing our existing public health infrastructure, new initiatives are needed to build public health infrastructure for specific ID threats. For example, the President’s Combating Antibiotic-Resistant Bacteria initiative would build surveillance infrastructure by expanding the Emerging Infections Programs and setting up regional laboratory centers. However, this initiative can only be fully implemented, and its potential benefits only realized, if Congress and the Obama administration are able to allocate sufficient resources to this effort.

Congress is currently working on a plan to provide some relief from the sequestered spending caps imposed by the Budget Control Act of 2011. Such a plan is critical to securing additional public health funds and preventing steep proposed funding cuts to public health. Members of the House and Senate committees charged with appropriating funds to federal agencies and programs have articulated an understanding of the important role that CDC plays in promoting public health, particularly with regard to infectious diseases. However, current overarching spending caps leave them little ability to provide necessary investments in CDC and other agencies critical to public health.

A well-financed and sustainable public health infrastructure at federal, state and local levels is our strongest asset to secure Americans against past, present and future microbial threats. We cannot afford to continue to pass on a public health investment now that would save lives and taxpayer dollars in the near future.

  • For more information:
  • Jeffrey S. Duchin, MD, is chair of the Infectious Diseases Society of America’s Public Health Committee; health officer and chief of the Communicable Disease Epidemiology & Immunization Section, Public Health – Seattle and King County; professor of medicine, division of infectious diseases, University of Washington; and adjunct professor at the University of Washington School of Public Health.