A Public Mess

By Jeffrey Kluger

The plague unfolded like one of those pre-9/11 bioterrorism war games. It started with a simple case or two that quickly grew to dozens, then hundreds. Local health officials, who had tracked the epidemic's course through Asia and Europe, sprang into action. Hospitals were set up in schools, banks and offices. Incoming ships were stopped 300 yds. offshore; vehicles were blockaded a mile outside of town. Health officials swept through the city, cleaning up streets, distributing medicine and imposing strict guidelines on food preparation. Eventually, the disease went into retreat, but not before 3,000 people had died.

This was no contemporary war game, however. It was New York City in 1832, when the town was struck by a devastating cholera epidemic. That the city fought back as hard and effectively as it did was a tribute to a health system honed by floods of immigrants and the diseases they carried. New York's response to its great plagues, in fact, became a model for the rest of the country. In the decades to follow, the city's lessons were to be institutionalized in the creation of new federal health agencies, new public hospitals and, in 1870, the brand-new office of national Surgeon General.

But a public-health system that had become the envy of the world has fallen into disrepair. The drive to lower health care costs and the reforms of managed care have taken their toll. Government laboratories are running out of funding and equipment; emergency rooms are running out of staff and beds; emergency-preparedness plans have become moldy and outdated. Many of the labs at the Centers for Disease Control and Prevention are crumbling, a fact that outgoing Surgeon General David Satcher believes Americans should consider "a national disgrace."

The system still does many things well, but how serious its shortcomings have become was made abundantly clear last fall, the moment the first anthrax case surfaced. The government did a passable job of controlling the anthrax spores but a terrible job of dispensing medical advice. Frozen in the bright lights of the 24-hour news cycle, Health and Human Services Secretary Tommy Thompson and Homeland Security chief Tom Ridge often looked flummoxed and misinformed, learning medicine on the go and winging it when they didn't know. It was a sharp contrast to the celebrated performance of former New York City mayor Rudy Giuliani, who drew a bright line between facts (known and unknown) and his basic message of reassurance, and never seemed to confuse the two.

Under Thompson and Ridge, bad--and sometimes fatal--decisions were made. The U.S. government allowed postal workers to continue breathing the air of a sorting facility filled with anthrax spores; it went tearing off to stock up on Cipro when many scientists believed it unnecessary and even dangerous; it wrung its hands about whether to order 300 million doses of smallpox vaccine--sowing its own kind of terror with its very indecision; and it allowed open speculation about quarantines to spread unchecked, without a clear consensus on the extent of its legal powers to impose them in the first place.

Nobody ever said that protecting the public's health was an easy job--whether it's being done quietly and invisibly in peaceful times, or hurriedly and worriedly in the glare of media attention. But experts agree that the weaknesses exposed in the wake of the anthrax attacks must be fixed--and in such a way that a newly nimble system can handle both the sudden emergency and the everyday job of fostering national wellness. "For the last 20 years we've neglected public health," says Tennessee Senator Bill Frist, the Senate's only physician. The terrorist attacks have "shocked Americans into realizing how dependent we are on the system."

The public-health system of 2002 is nothing like the public-health system as it was established in 1798. Known then as the Marine Hospital Service, it was charged with the crisply defined mission of caring for the health of merchant seamen, as well as ensuring that drinking water and food were sanitary and that disease outbreaks were quickly detected and diagnosed. Like all federal agencies, however, the service eventually fell victim to mission creep. And in 204 years, it has crept a lot.

The federal health system now comprises eight departments and agencies and more than 50,000 employees, concerning themselves with everything from vaccinating children to preventing lead exposure, from curbing teenage drinking and drug use to evaluating family-violence programs. Similarly complex--if smaller--bureaucracies are in place in all 50 states and most of the localities within them.

Such a vast medical network would seem like a good thing, ensuring that no health problem would be too small to be noticed. But the seemingly comprehensive system masks a lot of inefficiency, underfunding and chaos.

The biggest problem, as it so often is, is money. The dry rot at the CDC labs in Atlanta--where leaky walls are repaired with duct tape and a sputtering power system caused a blackout during the height of anthrax testing last fall--is only the most conspicuous part of the problem. Funding throughout the agency is so meager that members of the CDC's Epidemic Intelligence Service--a sort of disease SWAT team--cannot afford even such basic field equipment as two-way pagers.

At the local level, things are little better. Many city and county health departments lack up-to-date diagnostic equipment and even high-speed Internet access--a service that a third of the local agencies don't have. At all levels of government, there is a growing staffing crisis, with fewer schools offering degrees in public health and those people who are qualified to serve declining jobs with such notoriously low pay.

When funding is pumped into the leaky system, it's often spent unwisely. According to recent figures, less than 2% of health dollars are allocated to the economically smart business of preventing disease. The rest goes to research and the costly job of treating illness afterward. "There's no better place in the world to get sick," says Satcher. "Our weakness is in preventing disease in the first place."

Such stitch-in-time wisdom should be obvious to cash-strapped governments trying to do more with less, but at the moment there's no single national figure teaching the preparedness lesson. In the 1980s, Surgeon General C. Everett Koop helped calm the early hysteria over AIDS, telling the well how to stay that way and reminding them that in the meantime there was no reason to fear the sick. Thompson and Ridge, national doctors without a medical degree between them, have been no match for that kind of performance. Even Satcher has not achieved the same iconic status. During the anthrax attacks, says Dr. Jeffrey Koplan, chief of the CDC, "we found ourselves deploying more and more people just to work on communication issues."

That work is important for more than p.r. reasons. When an unfamiliar disease hits, even doctors may not know what the signs of the illness are and what to do when patients turn up in their waiting rooms. If HHS, the CDC and other government agencies are jostling one another on the podium, the message is often mixed. And when you toss in the local police and the FBI--as was the case with anthrax--that mixed message turns to gibberish. During the hantavirus outbreak of 1993, the government handled the problem well, with Dr. C.J. Peters, then chief of special pathogens at the CDC, taking the lead in answering questions, even though the HHS Secretary was technically the senior health authority working on the problem. "We decided that I would speak for HHS," Peters says, "because I was the one with the technical expertise."

The most important step toward improving things--apart from simply finding a Koop-like figure and seeing to it that that person is the only one who takes the mike during emergencies--is upgrading the public-health system's surveillance powers. The ability to spot new disease outbreaks, diagnose them properly and get word out on the medical wires is central to managing crises like anthrax as well as more routine problems like Lyme disease, tuberculosis and the flu. Emergency rooms often perform this function in an ad hoc way; the emergence of West Nile virus in New York City was first detected by a hospital physician who was suspicious of two cases of encephalitis among her patients and prodded the city health department to launch an investigation. The CDC relies on a national network of sentinel doctors to do this kind of monitoring during flu season and uses a similar system of local labs and DNA fingerprinting to track food-borne illnesses. Cities and states have physician-alert programs that do the same job.

But there are plenty of holes in the surveillance net. How well a disease gets detected and reported can depend on anything from how good the monitoring is in a given state to how sleepy the emergency-room resident is at a given hospital. To tighten things up, the CDC is establishing a Health Alert Network, a $90 million, two-way computer link connecting the federal center with every state and local health department in the country. When it's completed, the Internet will be used to speedily send out advisories, lab findings, prevention guidelines and educational materials from Atlanta and to gather up information about possible disease outbreaks from everywhere else across the nation. The idea is a good one and the states are behind it, but with so many of them still not wired to the Internet, it could take years before the entire system is up and running.

In the meantime, the CDC is working to give aging labs a boost. The agency already funds and runs a National Laboratory Response network, a coast-to-coast system of diagnostic facilities that receive and analyze specimens from across the country. But at least some of the labs in the network can become overwhelmed, as they were by anthrax, and Koplan hopes for more money to widen the system. And in order to keep the network running, the CDC also wants to expand the public-health workforce, increasing its size and improving training.

None of this, however, will come cheap. The CDC's 2001 budget was only $5 billion, and 75% of that was distributed to states and localities. Wringing more cash out of Washington in wartime won't be easy. After the anthrax scares, Massachusetts Senator Ted Kennedy calculated that it would take $10 billion to bolster the public-health system sufficiently to respond to such threats. The Bush Administration countered with a bare $1.6 billion, a figure that even Thompson was reduced to gamely calling "a great start." Ultimately, Frist and Kennedy agreed to seek $3.2 billion. "That was enough to take us from an unprepared state to a more prepared state," grumbles Frist. "I won't even say 'adequate' yet." Last week the President signed a new appropriations bill that included a $2.1 billion down payment on whatever figure Frist, Kennedy and Congress ultimately send him, bringing the CDC's total budget for this year to $7.5 billion.

Until the money is made available, some states are taking matters into their own hands. Nebraska passed legislation last September to improve its public-health system, earmarking $6 million from its share of the national tobacco settlement to establish five new health departments that cover 19 of the state's 93 counties. Texas is relying on revenue from the state's telecommunications fund to wire itself for the Health Alert Network. Georgia, which had been given CDC grants to fight such problems as West Nile virus and emerging infections, decided that the best way to do that was to hire a new team of epidemiologists to keep an eye out for all these ills. Such self-sufficiency at the state level will not only make grass-roots disease tracking more efficient but also make local authorities better able to function as a first line of defense in emergencies. That, say health experts, is something they ought to be doing anyway, since it's the states that know the personnel and the resources on the ground better than federal agencies swooping in with a planeload of strangers. "In the final analysis, all response is local," says Dr. Margaret Hamburg, a former New York City health commissioner.

Just as response is local, responsibility--the burden of ensuring that individuals and their families stay healthy--is personal. Seeing to the public weal has always required appealing to the public will. The best bureaucracy in the world can't force wellness on the people it serves. The most it can do is make good health available--providing all the information and resources that people need to take care of themselves. Ultimately, the rest of the caretaking is up to us.

--Reported by David Bjerklie and Andrea Dorfman/New York and Andrew Goldstein/Washington

With reporting by David Bjerklie and Andrea Dorfman/New York and Andrew Goldstein/Washington