Funding the public health response to terrorism
http://www.100md.com
《英国医生杂志》
Has cut funds for common chronic diseases—and for disaster relief in New Orleans
On 11 September 2001, 3400 people died because of four horrific, intentional plane crashes. These individuals' only unifying characteristic was that they were in the wrong place in America at the wrong time. Their deaths, and those of Londoners killed on 7 July 2005, highlighted our vulnerability to terrorism and launched an avalanche of repercussions.
As a response to these deaths, several subsequent deaths from anthrax, and other current and potential terrorist threats, the US government redefined and redirected its role in funding for public health. Governments must protect their citizens, and anticipating these possible future threats is appropriate and could prove essential to Americans' health. However, there is also an immediate and real threat that because of the US government's policy, enormous numbers of Americans will die unnecessarily. This threat is the redirection of funds away from basic, currently necessary public health services towards preventing potential bioterrorism in future.
To estimate how many Americans died on 11 September 2001 from the major sources of mortality that many public health services aim to prevent and treat, I used national estimates of mortality attributable to various risk factors (over 3100 a day; see table 1 on bmj.com) and mortality data for specific diseases (over 5200 a day; table 2). A similar number of deaths from these same causes has happened every day since then.
The most recent effects of these diversions of funding have been seen in the unfolding tragedy of Hurricane Katrina in New Orleans and the surrounding area.1 In June 2004, the emergency management chief for Jefferson Parish, Louisiana, told the New Orleans Times Picayune: "Nobody locally is happy that the levees can't be finished... It appears the money has been moved into the President's budget to handle homeland security and the war in Iraq, and I suppose that's the price we pay."2 Further, the response to the disaster was hampered by the mobilisation of 7000 members of the Louisiana and Mississippi National Guard to Iraq.3 As citizens in New Orleans died or became refugees, the city became a chaotic Petri dish of pathogens, pollutants, and eroded infrastructure in ways which will affect the health of its population for years. And, as with every public health crisis, the poor and people of colour have been especially affected.
Concerns about disproportionately funding the prevention of bioterrorism in the US rather than funding other public health functions have been building for some time. As early as 2002, many people working in public health thought that the Bush administration's plan for smallpox vaccination was a misguided redirection of public health funds for bioterrorism preparedness, and it was thwarted. Estimates of the initial costs of smallpox vaccination ranged from $600m to $1bn (￡330m to 550m, 480m to 800m),4 and costs for vaccination and treatment of smallpox, anthrax, and botulism were projected to exceed $6bn over the following decade.5 And the Centers for Disease Control and Prevention (CDC) publication Morbidity and Mortality Weekly Report documented state health departments' "difficulty allocating the necessary time and resources for the pre-event smallpox vaccination program."6
Although pressure to provide mass immunisation against smallpox has subsided, preparedness for bioterrorism still seems magnified well beyond its proportional risk. For example, in September 2002 New York Governor Pataki proudly spoke of a "critical program" that awarded $1.3m to reduce heart disease, the leading killer of New Yorkers (accounting for 37% of all deaths in New York state).7 Contrast this with the $34m awarded to New York by the US Department of Health and Human Services for bioterrorism preparedness, part of over $1bn in nationwide funding announced in 2002.8 Similarly, North Dakota's Governor Hoeven announced $300 000 in funding for preventing heart disease and stroke9; this can be compared with the $7m designated for bioterrorism preparedness in the state. Owing to funding for prevention of bioterrorism, state health departments increased by 132% the number of staff in epidemiology to work on preparedness for infectious disease and terrorism between 2001 and 2003.8 But with this increase in funding came additional mandates related to bioterrorism, with 66% of health departments struggling to allocate time for general planning and 55% having problems establishing even basic systems for disease surveillance.6
More recently (in March 2005), the New York Times said surveillance for anthrax "rattled the stock market set the White House on alert."10A subsequent article reported that congressional auditors had found that FBI funds designated for investigating fraud in health care seemed to have been improperly shifted to other purposes, including fighting terrorism, over the past three years.11 In defence, Joseph L Ford, the FBI's chief financial officer, said the attacks of 11 September 2001 "demanded an instant, 100 percent commitment toward counterterrorism."11
The responses to the perceived importance of the threat go even further. For example, the Pentagon has proposed that it should be exempted from aspects of the clean air and hazardous waste recovery acts, including capping its "legal liability for cleaning up polluted sites once it sells land to a new owner, and allowing military areas that do not meet national air standards to remain that way for an additional three years."12And Associated Press reported that 34 of the military bases that have been shut down since 1988 are on the Environmental Protection Agency's superfund list of worst toxic waste sites (most of them have been on the list for at least 15 years) and none are completely cleaned.13
These observations are not intended to diminish the tragedies of 11 September 2001 or 7 July 2005 or other terrorist actions or catastrophes, nor to negate the importance of developing effective and humane ways of making sure such tragedies are not repeated. Nor do I intend to suggest that all the blame for catastrophic or everyday events should be attributed to any government, or that any quantity of redirected funds could completely erase these events. It is certainly justifiable for governments to appropriate substantial funds to prevent potential future threats to our security. But public funding for current threats should not be compromised. Predictable tragedies happen every day. We know strategies to reduce deaths from tobacco, alcohol, poor diet, unintentional injuries, and other predictable causes. And we know that millions of people will die unless we protect the population against these routine causes of death.
Erica Frank, professor
Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA 30303-3219, USA (efrank@emory.edu)
Tables showing estimated deaths attributable to risk factors and specific diseases are on bmj.com
Competing interests: None declared.
References
Attywood WB. Why the levee broke. Alternet. 1 Sep 2005. www.alternet.org/module/printversion/24871 (accessed 2 Sep 2005).
Grissett S. Shifting federal budget erodes protection from levees; because of cuts, hurricane risk grows. Times-Picayune 8 Jun 2004: 1.
Gonzales J. Iraq mess adds to the problem. New York Daily News 1 Sep 2005.
Connolly C. Smallpox plan may force other health cuts; states cite inability to fund vaccinations. Washington Post 2002 Dec 24: A1.
Neergaard L. Administration wants to stockpile treatments for bioterror pathogens. Associated Press 2003 Jan 29: 1.
Centers for Disease Control. Terrorism preparedness in state health departments—United States, 2001-2003. MMWR 2003;52: 1051-3.
New York State Office of the Governor. Governor: $1.3 million in funds for heart disease prevention. 27 Sep 2002. www.state.ny.us/governor/press/year02/sept27_02.htm (accessed 8 Jul 2005).
Department of Health and Human Services. Bioterrorism preparedness grants. 6 Jun 2002. www.hhs.gov/news/press/2002pres/20020606b.html (accessed 8 Jul 2005).
North Dakota Office of the Governor. North Dakota receives funding for prevention of heart disease and strokes. 9 Jul 2003. www.health.state.nd.us/ndhd/press/n030709.htm (accessed 11 Jul 2005).
Shane S. Anthrax scare is attributed to a testing error. New York Times 2005 Mar 16: A16.
Pear R. FBI is said to misuse money for health care fraud cases. New York Times 2005 May 16: A18.
Heilperin J. Pentagon seeks waivers on environmental rules. Washington Post 2005 May 11: A15.
Eilprin J. Dozens of closed military bases are on EPA's superfund list of worst toxic waste sites. Associated Press 2005 May 12: 1.
On 11 September 2001, 3400 people died because of four horrific, intentional plane crashes. These individuals' only unifying characteristic was that they were in the wrong place in America at the wrong time. Their deaths, and those of Londoners killed on 7 July 2005, highlighted our vulnerability to terrorism and launched an avalanche of repercussions.
As a response to these deaths, several subsequent deaths from anthrax, and other current and potential terrorist threats, the US government redefined and redirected its role in funding for public health. Governments must protect their citizens, and anticipating these possible future threats is appropriate and could prove essential to Americans' health. However, there is also an immediate and real threat that because of the US government's policy, enormous numbers of Americans will die unnecessarily. This threat is the redirection of funds away from basic, currently necessary public health services towards preventing potential bioterrorism in future.
To estimate how many Americans died on 11 September 2001 from the major sources of mortality that many public health services aim to prevent and treat, I used national estimates of mortality attributable to various risk factors (over 3100 a day; see table 1 on bmj.com) and mortality data for specific diseases (over 5200 a day; table 2). A similar number of deaths from these same causes has happened every day since then.
The most recent effects of these diversions of funding have been seen in the unfolding tragedy of Hurricane Katrina in New Orleans and the surrounding area.1 In June 2004, the emergency management chief for Jefferson Parish, Louisiana, told the New Orleans Times Picayune: "Nobody locally is happy that the levees can't be finished... It appears the money has been moved into the President's budget to handle homeland security and the war in Iraq, and I suppose that's the price we pay."2 Further, the response to the disaster was hampered by the mobilisation of 7000 members of the Louisiana and Mississippi National Guard to Iraq.3 As citizens in New Orleans died or became refugees, the city became a chaotic Petri dish of pathogens, pollutants, and eroded infrastructure in ways which will affect the health of its population for years. And, as with every public health crisis, the poor and people of colour have been especially affected.
Concerns about disproportionately funding the prevention of bioterrorism in the US rather than funding other public health functions have been building for some time. As early as 2002, many people working in public health thought that the Bush administration's plan for smallpox vaccination was a misguided redirection of public health funds for bioterrorism preparedness, and it was thwarted. Estimates of the initial costs of smallpox vaccination ranged from $600m to $1bn (￡330m to 550m, 480m to 800m),4 and costs for vaccination and treatment of smallpox, anthrax, and botulism were projected to exceed $6bn over the following decade.5 And the Centers for Disease Control and Prevention (CDC) publication Morbidity and Mortality Weekly Report documented state health departments' "difficulty allocating the necessary time and resources for the pre-event smallpox vaccination program."6
Although pressure to provide mass immunisation against smallpox has subsided, preparedness for bioterrorism still seems magnified well beyond its proportional risk. For example, in September 2002 New York Governor Pataki proudly spoke of a "critical program" that awarded $1.3m to reduce heart disease, the leading killer of New Yorkers (accounting for 37% of all deaths in New York state).7 Contrast this with the $34m awarded to New York by the US Department of Health and Human Services for bioterrorism preparedness, part of over $1bn in nationwide funding announced in 2002.8 Similarly, North Dakota's Governor Hoeven announced $300 000 in funding for preventing heart disease and stroke9; this can be compared with the $7m designated for bioterrorism preparedness in the state. Owing to funding for prevention of bioterrorism, state health departments increased by 132% the number of staff in epidemiology to work on preparedness for infectious disease and terrorism between 2001 and 2003.8 But with this increase in funding came additional mandates related to bioterrorism, with 66% of health departments struggling to allocate time for general planning and 55% having problems establishing even basic systems for disease surveillance.6
More recently (in March 2005), the New York Times said surveillance for anthrax "rattled the stock market set the White House on alert."10A subsequent article reported that congressional auditors had found that FBI funds designated for investigating fraud in health care seemed to have been improperly shifted to other purposes, including fighting terrorism, over the past three years.11 In defence, Joseph L Ford, the FBI's chief financial officer, said the attacks of 11 September 2001 "demanded an instant, 100 percent commitment toward counterterrorism."11
The responses to the perceived importance of the threat go even further. For example, the Pentagon has proposed that it should be exempted from aspects of the clean air and hazardous waste recovery acts, including capping its "legal liability for cleaning up polluted sites once it sells land to a new owner, and allowing military areas that do not meet national air standards to remain that way for an additional three years."12And Associated Press reported that 34 of the military bases that have been shut down since 1988 are on the Environmental Protection Agency's superfund list of worst toxic waste sites (most of them have been on the list for at least 15 years) and none are completely cleaned.13
These observations are not intended to diminish the tragedies of 11 September 2001 or 7 July 2005 or other terrorist actions or catastrophes, nor to negate the importance of developing effective and humane ways of making sure such tragedies are not repeated. Nor do I intend to suggest that all the blame for catastrophic or everyday events should be attributed to any government, or that any quantity of redirected funds could completely erase these events. It is certainly justifiable for governments to appropriate substantial funds to prevent potential future threats to our security. But public funding for current threats should not be compromised. Predictable tragedies happen every day. We know strategies to reduce deaths from tobacco, alcohol, poor diet, unintentional injuries, and other predictable causes. And we know that millions of people will die unless we protect the population against these routine causes of death.
Erica Frank, professor
Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA 30303-3219, USA (efrank@emory.edu)
Tables showing estimated deaths attributable to risk factors and specific diseases are on bmj.com
Competing interests: None declared.
References
Attywood WB. Why the levee broke. Alternet. 1 Sep 2005. www.alternet.org/module/printversion/24871 (accessed 2 Sep 2005).
Grissett S. Shifting federal budget erodes protection from levees; because of cuts, hurricane risk grows. Times-Picayune 8 Jun 2004: 1.
Gonzales J. Iraq mess adds to the problem. New York Daily News 1 Sep 2005.
Connolly C. Smallpox plan may force other health cuts; states cite inability to fund vaccinations. Washington Post 2002 Dec 24: A1.
Neergaard L. Administration wants to stockpile treatments for bioterror pathogens. Associated Press 2003 Jan 29: 1.
Centers for Disease Control. Terrorism preparedness in state health departments—United States, 2001-2003. MMWR 2003;52: 1051-3.
New York State Office of the Governor. Governor: $1.3 million in funds for heart disease prevention. 27 Sep 2002. www.state.ny.us/governor/press/year02/sept27_02.htm (accessed 8 Jul 2005).
Department of Health and Human Services. Bioterrorism preparedness grants. 6 Jun 2002. www.hhs.gov/news/press/2002pres/20020606b.html (accessed 8 Jul 2005).
North Dakota Office of the Governor. North Dakota receives funding for prevention of heart disease and strokes. 9 Jul 2003. www.health.state.nd.us/ndhd/press/n030709.htm (accessed 11 Jul 2005).
Shane S. Anthrax scare is attributed to a testing error. New York Times 2005 Mar 16: A16.
Pear R. FBI is said to misuse money for health care fraud cases. New York Times 2005 May 16: A18.
Heilperin J. Pentagon seeks waivers on environmental rules. Washington Post 2005 May 11: A15.
Eilprin J. Dozens of closed military bases are on EPA's superfund list of worst toxic waste sites. Associated Press 2005 May 12: 1.