Margaret Hamburg
Margaret Hamburg, Challenges Confronting Public Health
Agencies, 116(2) Public Health Reports S59(5) (March-April, 2001)
As public health agencies prepare to counter the threats posed by biological
weapons, what are their competing demands and responsibilities? What
resources are available? How does this new mission fit with the
profession's traditional objectives and capacities? What do we need to
do? Many individuals have important perspectives on these questions.
Mine is that of someone who served first as a local health officer and
then as a federal public health official. In addition, as New York
City's health commissioner when the World Trade Center was bombed, the
threat of terrorism has a grim reality for me. However, having witnessed
the disruption, devastation, and death caused by that event, I can only
imagine how much worse that devastation--and the associated morbidity
and mortality--would have been had it involved the covert release of a
biological weapon. Fortunately, it did not. Nonetheless, as health
commissioner, I did have the opportunity to grapple with a wide range of
infectious disease outbreaks and epidemics, from the small and routine
to the much more large and exotic; the threat of imported disease in an
international hub like New York City; the impact of newly emergent
diseases ranging from problems like Cyclospora to HIV/AIDS; and
resurgent diseases such as tuberculosis (TB), often in a new
drug-resistant form.
Certainly, experiences as a local health officer have been critically
important to me as I've taken on a broader role in the federal efforts
to address emerging infections and bioterrorism and shape the
bioterrorism program that the
Department of Health and Human Services is trying to develop. I have
little doubt that the issues being addressed by this conference are
among the most central for the future in terms of protecting and
promoting the health of individuals and communities and protecting our
nation's security and that of the world.
My bias is to consider these issues along a continuum of infectious
disease threats, both naturally occurring and intentionally caused.
Bioterrorism clearly represents the extreme end of that continuum in
terms of its potentially catastrophic consequences for health and the
disruption and panic it will cause.
My discussion focuses on some of the important challenges that are
placed squarely before us when addressing the problem of bioterrorism.
In particular, I emphasize certain key areas of unfinished
business--critical issues today and into the future--and do so in a
balanced way that recognizes the perspectives of local, state, and
federal public health agencies. Addressing these challenges will be
crucial for local, state, and federal efforts in trying to counter the
threat of bioterrorism. However, addressing these challenges will also
strengthen the ability of public health agencies to meet their
responsibilities to respond to naturally occurring infectious disease
threats, both routine and extraordinary.
I believe that the first challenge remains communicating the importance
of the threat and the unique and essential roles of public health
agencies in concert with the medical and scientific community. The
statement was made earlier that we could now put the era of
consciousness-raising behind us and get on with the business of actually
doing things. I am afraid that view is unduly optimistic. Although I
could not agree more that we must get on with the business of doing and
not just talking, we continue to need to get policymakers, legislators,
and program planners to understand the threat of bioterrorism: that it
is both real and different. Meaningful progress against this threat
depends on understanding it in the context of epidemic disease. The
paradigm is different than that for conventional terrorism or a chemical
or nuclear attack. It requires different investments and different
partners. Until the concept of what the true nature and scope of a
bioterrorist event would be is fully recognized, our nation's
preparedness programs will continue to be inadequately designed:
* The wrong first-responders will be trained and equipped.
* We will fail to fully build the critical infrastructure needed to
detect and respond to a real bioterrorist event.
* The wrong research agendas will be developed.
* We will never effectively grapple with the long-term
consequence-management needs that such an event would entail.
Frankly, if we look at what has
been developed in the context of bioterrorism preparedness, urgent
public health and medical care issues have been underdeveloped and
underfunded. Of the roughly $10 billion invested in counterterrorism
efforts today, only a very small percentage is truly going into the
support of activities that should be considered core elements of a
coherent program to address needs posed by a bioterrorist threat.
The framework is there, but we need to strengthen and extend programs
such as a robust public health infrastructure, including surveillance
and lab capacity; innovative approaches to expanding the capacity and
flexibility of the health care system in a catastrophic crisis; the
pharmaceutical stockpile for civilian use; and an appropriate research
and development agenda at the basic level of genomics, disease
pathogenesis, and the human immune response as well as for new drugs,
vaccines, and detection methodologies. In addition, we must focus more
on prevention. As Amy Smithson pointed out, we are currently missing
critical opportunities to support collaborative research efforts with
former Soviet bioweaponeers and redirect their talents into prosocial
biomedical research activities.
Richard Butler's presentation also underscored the need for fuller
engagement of the public health and the biomedical communities in
designing constructive, positive strategies for nonproliferation of
bioweapons.
In reflecting on an array of
experiences and current activities, I am heartened that there is a
greater understanding and awareness of what public health is and why it
is important. With this comes a real opportunity to make a difference.
Certainly, in New York City, the resurgence of TB (including its more
frightening form of multiple-drug-resistant TB) helped to change the
debate. We saw the mobilization of political will to address public
health concerns that we had not witnessed before, because, for the first
time, the potential economic and social impact of epidemic disease was
strongly felt by critical leaders.
For example, during the height of our epidemic in New York City, the
correctional officers threatened to go on strike because they
believed--not inappropriately--that there were risks of TB communication
to them working in New York City's vast system of prisons and jails. Had
they gone on strike, there would have been a major disruption and a
political crisis for City Hall. Such events helped mobilize attention
and concern to the public health problems involved. Similarly, the
headlines 'Killer TB on Subways' in the New York Post helped them feel
that they might have some public support for putting more money into TB
prevention and control. That experience told us that once the issue was
framed in a way meaningful to key political leaders and policymakers, it
was possible to mobilize the commitment
and ultimately the financial support to put critical programs into
place. Fortunately, in the case of TB, it was not a complex program.
Working within the framework of a clearly defined plan, we were able
to swiftly implement effective measures, such as directly observed
therapy, that in just a few years' time enabled us to dramatically turn
the tide on TB.
This was an important demonstration of the effectiveness of public
health. The unexpected appearance of West Nile virus in this country
represents another example of the broad ramifications, including
political and economic, of a significant infectious disease outbreak as
well as the requirements for an effective public health response. Today,
the growing concerns about the bioterrorist threat give public health a
new importance and offer us another chance to make significant strides
forward.
It is critical now, more than ever, that we continue raising
awareness about the importance of public health and then translating
that awareness into real programs. In doing so, we must emphasize the
basics at the state, local, and federal levels in terms of trained
epidemiologists and infectious disease specialists; surveillance
capacity, including appropriate lab capacity; enhanced information
technology expertise and capabilities; and improved working
relationships between the medical community and health departments that,
as Marci Layton showed, were so essential
in identifying the West Nile virus outbreak and triggering the rapid
response. This, of course, is a two-way street. Physicians and the
health care providers need to know what to report and to whom. When they
report, they need to find a responsive health department that gives them
critical feedback that affects their ability to care for patients.
We also need to recognize that at every level of government there
must be accountability in terms of programs and funding. At different
levels of government, core functions and responsibilities of a public
health agency vary, but they are all critically important. Those various
functions must be integrated and must reflect a robust, sustainable
system of funding. There is often an unfortunate tendency to point
fingers and suggest that someone else is responsible and someone else
should pay.
However, leadership at every level of government must understand the
importance of these activities, be committed to funding them, and
understand that if they do not, they are not serving the people who
elected them and put their administrations into place. That is a
continuing challenge.
As assistant secretary for planning and evaluation, I must also
stress the importance of comprehensive planning. This too is an
important challenge and must be done at the local, state, and federal
levels.
Planning is key to effective crisis management and response.
Unfortunately, there is no
one-size-fits-all plan that can be produced at the federal level and put
on the shelves. It needs to be a dynamic process directly undertaken by
localities and states in collaboration with the federal government.
The difficulties involved in managing an event will be defined by the
nature of organizational systems unique to specific states and
localities and also, of course, by the characteristics of the pathogen
involved and the circumstances of the exposure. The challenge of
planning is enhanced by the fact that bioterrorism, in particular, is a
low-probability but high-consequence event. It is often hard to engage
attention, and it is also going to be very hard to sustain efforts into
the future.
However, effective strategies must build on existing systems when
possible but build in flexibility. We do not want to develop an entire
ancillary system for responding to the bioterrorist threat. Rather, we
should strive to integrate our thinking and planning into the continuum
of infectious disease threats and potential disasters to which public
health agencies are already charged to respond. The last thing we want
is to find ourselves in the situation of trying out a plan for the very
first time in the midst of a crisis. Instead, we want to find the
systems that work in routine activities and then identify what we need
to do to amplify or modify them to be appropriately responsive for these
more acute and catastrophic
situations. For example, for many reasons, we do not want to rely solely
on the traditional systems of surveillance. We need to be innovative and
creative in our thinking about much more real-time surveillance systems
that will enable the kind of rapid detection that can lead to
appropriate and effective interventions and response. Of course, we need
to constantly integrate new technologies as they emerge into our
strategies for response.
Throughout our work, partnerships are key, but bioterrorism raises
additional challenges. These have been discussed already to some degree.
Sadly, when responding to an infectious disease outbreak, it is
difficult enough to get the medicine and public health communities to
work fully together in the ways that are so critically important. In the
context of enforcement and the intelligence community as well. These are
partners that we have not historically worked closely with and that in
some ways make us quite uncomfortable. Yet it will clearly be critical
to our success. Many communities have demonstrated effective ways of
partnering, and there is a great deal to learn from them as we continue
to work at the state, local, and federal levels. Importantly, we must
make sure that these partnerships are real, enduring, and
institutionalized so that they are not just dependent on relationships
that develop between individuals.
An additional challenge to the
development of full partnership among the critical communities required
for effective bioterrorism preparedness and response concerns the issue
of security itself. Our department's inexperience dealing with
classified documents, clearances, and other aspects of the world of
security concerns made it that much harder for us to be fully engaged in
national security discussions. The department is currently in the
process of developing secure video conferencing capability, which will
allow real-time communications in a crisis or on a routine basis with
key partners in the security community talking about sensitive issues.
However, for the longest time, an enormous number of activities went on
and we were not part of those discussions. Even obtaining a secure fax
was a challenge. For many reasons, it has been difficult for the
department to be accepted as a full and legitimate partner as
counterterrorism planning and discussions have gone forward.
Certainly, further marginalization has occurred because of our
inability to function easily in the world of security concerns. I can
only imagine that at the state and local levels this is going to be even
more critical over time.
When I was health commissioner in New York City in the 1990s, the
issue of having a security clearance and dealing with secure documents
was simply something that never came up. However, in terms of the kinds
of issues that now need to be
addressed, we will need to examine this in a much more focused way.
Returning to a more traditional, yet equally challenging partnership,
controlling disease and caring for the sick will require a very deep
engagement of the public health and medical community. There are many
pressures on health care providers and the hospital community that limit
their ability to prepare in some of the critical ways necessary to
effectively handle a bioterrorist threat. The enormous downsizing that
has occurred, the competitive pressures to cut costs, the 'just-in-time'
pharmaceutical supply and staffing approaches, and the limited capacity
for certain specialty services (e.g., respiratory isolation beds and
burn units) that may become critical in a biological or chemical
terrorist attack all need to be recognized and addressed.
We must be realistic about the potential costs to these institutions
and individuals as well as the enormous up-front investments if they are
truly to prepare. In many ways, making those preparatory investments is
a high-risk undertaking for a health care institution today. By
preparing, you are also almost setting yourself up to incur a series of
costs that may not be reimbursed after the crisis is over.
We know that we must find better ways to strategically support our
health care institutions, because of the implications of a bioterrorist attack
and the existing demands on the system, as evidenced by the fact that in
the past year a routine flu season threatened to overwhelm our system's
capacity to respond. There is an urgent need to develop programs that
target dollars for health care disaster planning and relief, including
training, templates for preparedness, and efforts to develop strategies
in collaboration with other critical partners for providing ancillary
hospital support in the event of a crisis, whether it is through the
army field hospital model or going back to what was done in the 1918
pandemic flu, when armories, school gymnasiums, and the like were taken
over to provide medical care. In doing this, we need to support local
and state planning efforts to assess community assets and capabilities,
and we need to determine what federal supports can be brought to bear in
a crisis.
In planning for an effective response, an array of legal concerns
exist that remain unresolved. Issues range from such basic matters as
declaration of emergency--Who are the existing authorities? Are they
public health, or do they rest in other domains that will be relevant?
What are the authorities that still need to be established?--to the
ability to isolate, quarantine, or detain groups or individuals, the
ability to mandate treatment or work, restrictions on travel and trade,
the authority to seize community or private property (e.g., hospitals,
utilities, medicines, or vehicles), and the ability to compel production
of certain goods. Also, there is
the issue regarding the use of pharmaceuticals or diagnostics that are
not yet approved or labeled for certain uses in a crisis.
All of these questions involve many different levels of government
and many different laws and authorities and raise many complex and
intertwined ethical issues. In a systematic and coherent way, we must
address this array of pressing issues and concerns, and not just what
laws are in place or could be put in place but also what policies and
procedures would be necessary to actually implement them.
Another major gap in current preparedness and planning efforts
involves engaging the public and, importantly, working effectively with
the public in the event of a crisis. We must begin now, with investments
in research, to better understand how the public will react in the event
of a bioterrorist attack. As a nation, we have little experience with
this kind of disaster. By examining the response to natural disasters,
such as fires and floods, as well as to terrorist bombings or attacks,
we can glean some important insights. Yet we must also recognize that
the fear of a silent, invisible killer such as an infectious agent will
likely evoke a level of fear and panic substantially greater than what
has occurred in response to those more 'conventional' disaster
scenarios. Certainly, the response to previous major disease
epidemics--such as the outbreak of pneumonic plague in
Seurat, India, in 1994--suggests a level of panic and civil disruption
on a far greater scale.
Anyone who has ever dealt with disaster response knows that the
manner in which the needs of the public are handled from the very
beginning is critical to the overall response. In the context of a
biological event, this will no doubt be even more crucial. Managing the
'worried well' may interfere with the ability to manage those truly sick
or exposed. In fact, implementation of disease control measures may well
depend on the constructive recruitment of the public to behave in
certain ways, such as avoiding congregate settings. In the final
analysis, clear communication and appropriate engagement of the public
are key to preventing mass chaos and enabling disease control as well as
critical infrastructure operations to move forward.
Correspondingly, the needs and concerns of response personnel,
including health care workers, must also be addressed. Again, prior
experience with serious infectious disease outbreaks tells us that when
this does not occur, essential front-line responders and key workers are
just as likely as the public to panic if not flee. The mass exodus of
health care workers after onset of the Ebola virus epidemic in Kikwit,
Zaire, in the mid-1990s serves witness to this point.
This discussion brings me to the role of the media. The media represent
a critical partner, key to our efforts in a crisis to communicate
important information and reduce the potential for panic. Working with
them in a crisis means working with them now in a process of ongoing and
continuing mutual communication and education. We must strive for the
development of a set of working relationships grounded in trust--trust
that we will provide them with information in a timely and appropriate
manner and in turn they will use that information in a responsible,
professional way. No doubt there will always be tensions between the
desire to get out a good story and an appreciation of the complexities,
sensitivities, and uncertainties inherent in such a crisis. However,
stonewalling the press or viewing them as the enemy is virtually
guaranteed to worsen the situation.
Moreover, we will need the press as an absolutely essential partner
in disseminating information to protect health and control disease.
My final concern is the issue of limited resources. Our nation has
never been comfortable with issues of health care rationing or triage.
Some of it goes on already, and we all know it. However, it may be very
stark in the kind of crisis that we are talking about at this meeting.
There may be delays in getting drugs and vaccines on site, or we may
simply not have them. We are going to have to make hard decisions about
who gets access to drugs or other pharmaceuticals. Unlike in many other
circumstances, decisions will not be made simply on the basis of
maximizing the preservation of
life, but on maintaining critical infrastructure and supporting key
workers, including health care workers. Thus, we must begin to think
about whether we have a set of priority groups for the use of scarce
resources and what that is going to be. Clearly, this represents an
essential, yet enormously charged and complex undertaking.
We have been considering this in the context of pandemic flu, where
we know there will be vaccine shortages. We need to think about it in
the context of bioterrorism as well. We need to bring together a broad
set of stakeholders, need to involve every level of government, and
need, as a nation, to become comfortable with this situation in which we
will almost certainly find ourselves.
I have only touched on some of the critical challenges that lie
before us. They are complex and difficult, and we will probably never
find completely acceptable or effective solutions. However, we are on a
critical path. All of us are partners in this effort.
