12/08/2008 - 07:18

Unifying the U.S. government response to bioterrorism

Laura H. Kahn

Laura H. Kahn

A general internist who began her career in health care as a registered nurse, Kahn works on the research staff of Princeton University's ...

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Of the many ways in which the United States is unprepared to deal with an infectious disease outbreak or bioterrorist attack, here's one of the most problematic: The responsibility for public health is a state concern. In other words, at a time of crisis--i.e., an epidemic or bioterrorist attack--state public health agencies are in charge, which will more than likely result in an inefficient piecemeal response during any kind of multi-state event.

While the Justice Department is tasked with leading the federal investigation of a terrorist attack and the FBI is in charge of the operational response, the Centers for Disease Control and Prevention (CDC) must be invited by a state to investigate an outbreak. This is troublesome because state public health departments and their epidemiologic investigative capabilities are often variable and underfunded--even when taking federal bioterrorism funding into account. Plus, outbreaks are typically well underway by the time the CDC is asked to help. For instance, the 1993 Milwaukee cryptosporidium outbreak was almost over by the time state and local officials identified the crisis and called the CDC. In the meantime, it became the largest waterborne outbreak in U.S. history: More than 400,000 people became sick, and 100 people died.

If we are serious about improving disease surveillance, the CDC would function more like the FBI and EPA, stationing highly trained epidemiologists in CDC field offices around the country."

Although the CDC is headquartered in Atlanta, it has a number of personnel posted at state and local health departments. Many of them are trainees such as Epidemic Intelligence Service officers (EIS) and Preventive Medicine Residency Fellows. EIS officers spend two years in the field, and Preventive Medicine Residency Fellows spend another year in training after completing the EIS program. In response to a directive by the secretary of the Health and Human Services Department to increase the number of EIS-trained epidemiologists at the state and local level, the CDC developed the Career Epidemiology Officer Program in 2003.

Unfortunately, though, it's hard to train and recruit qualified epidemiologists. In 2006, the Council of State and Territorial Epidemiologists (CSTE) found that most health departments cited low salaries and poor promotion opportunities as major reasons for their retention difficulties. In total, the CSTE estimates that the country needs about 1,200 more epidemiologists. To pay them, states are increasingly relying on federal funding; in 2006, for example, 75 percent of epidemiology funding was from federal support.

If we are serious about improving disease surveillance, the CDC would function more like the FBI and EPA, stationing highly trained epidemiologists in CDC field offices around the country. In addition to its headquarters in Washington, the FBI has 56 field offices in major U.S. cities and more than 400 resident agencies in smaller cities and towns. Internationally, there are 60 "legal attaches" in U.S. embassies that have established diplomatic liaisons and information sharing with law enforcement in other countries.

Both law enforcement and environmental protection became federal responsibilities once policy makers recognized that criminal activity and air and water pollution cross state boundaries. Microbes, of course, don't recognize borders either.

The genesis of the EPA is a particularly salient model for a unified federal response to a bioterror attack or epidemic. Public concerns about the environment in the 1970s led President Richard Nixon to create the agency through an Executive Order that transferred 15 programs from three departments, two councils, and one commission--including the Department of the Interior, Agriculture Department, Health, Education, and Welfare Department, Atomic Energy Commission, Council of Environmental Quality, and Federal Radiation Council--into a single entity. From there, William Ruckelshaus, the first EPA administrator, worked to create a unified agency. In subsequent years, Congress passed environmental laws such as the Clean Air Act and Federal Environmental Pesticides Control Act that the EPA implemented.

More generally, the EPA develops and enforces national environmental standards that states and tribal territories implement. The agency has 10 regional offices, laboratories, and research centers located across the country that measure environmental radioactivity, evaluate emission control technology, and assess pesticide detection technologies in air and water, among other things.

It's important to note that the EPA isn't perfect. It has violated its own standards, engaged in corruption, and acted incompetently at times. But I would argue that at least in some of these cases, those in charge were as much at fault as the institution itself. And also in the EPA's defense, it has remained innovative despite budget cuts.

It goes without saying that the EPA wouldn't have achieved any success whatsoever if it was dependent on state support. Therefore, innovative public health surveillance, enforcement, and research would best be accomplished at a federal level with federal mandates and support--something the Obama administration should work with Congress to establish. Under such an approach, federal experts based in CDC field offices around the country would handle multi-state food-borne outbreaks, multi-drug resistant bacterial outbreaks, arthropod-borne disease outbreaks, and bioterrorist attacks. This would allow the CDC to work with state and local epidemiology partners to conduct proactive disease surveillance.

It would also create a situation where the FBI and CDC could work in tandem as leaders when investigating the criminal and public health aspects of a bioterrorist attack. And as with the FBI, public health experts should be based in U.S. embassies throughout the world to enhance diplomatic relations in global health. By removing these artificial political barriers, we will be able to offer a flexible and cohesive response to the twenty-first century public health challenges that we face.