Covers | December 10, 2013 at 11:56 am

National Health, National Security


National Health National Security
October’s government shutdown revealed some troubling truths about the federal government’s ability to maintain operating capacity in essential public health functions. Particularly important to public health are the programs provided by the Department of Health and Human Services (HHS), which oversees everything from the Women, Infants, and Children program (WIC) to preventing and mitigating public health emergencies through the Centers for Disease Control (CDC). For 16 days, 48 percent of HHS employees were furloughed, critically impacting the national health infrastructure, and leaving America’s public health open to threats.

Impacts of the Shutdown

The detrimental impact of the shutdown on public health was predictable—and even predicted by the contingency plan developed by HHS. Some programs were discontinued entirely, including the CDC’s annual seasonal flu shot program, its technical assistance programs to state and local governments, and the FDA’s import inspections and notification programs. Others were granted only “minimal support,” which meant they experienced a “significantly reduced capacity” to respond to outbreaks and public health emergencies.

In a recent interview with Wired magazine during the shutdown, CDC director Thomas Frieden described the effect of the furloughs, saying, “We’re used to juggling things at CDC, but this is like juggling chain saws.” It was only a matter of time before problems surfaced: a multi-state, multi-drug-resistant salmonella outbreak occurred, requiring the recall of numerous employees from furlough to handle a threat that became serious enough to override the original contingency plan.

The effects of the shutdown extended to the state and local level, where health officials often rely on support from federal experts for their work in surveillance of public health threats, and funding for local health programs. Among these included health department screenings for infectious disease among individuals entering the country, and the protection of day-to-day food security for over 9 million low-income women, infants, and children through the WIC program. As Laura Hanen, the director of government relations for the National Association of City and County Health Officials, told the HPR, “WIC was running out of money … the recipients of that program had to go to smaller grocery stores and had their WIC card rejected.”

The discontinuation of these programs reveals an uncomfortable truth about the priorities of the federal government when
it comes to government programming: too often, risks to public health are underestimated until they come to a head and cannot be ignored. Opportunities to take a stand on preserving public health funding during government budget cuts have come before, particularly during sequestration when the CDC lost $580 million. But the deleterious impacts of just 16 days of reduced public health capacity suggest that it might be time to prioritize national health in budget debates. After all, public health is not just a matter of consumer protection, but indeed one of national security.

Public Health as Civil Defense

The idea of framing public health as a matter of national security is not new. In 2002, Senator Bill Frist (R-Tenn.), a practicing physician, published a 14-page analysis of the role of federal support in strengthening public health, acknowledging that
in the age of bioterrorism, “a strong public health infrastructure is important not only for the public’s health but also for
the nation’s security.” As he argued, the extent to which public health can be seen as contributing to national security is directly related to the degree of funding support for its programs at both the federal and state levels.

Frist’s argument frames public health as national security primarily through applications of civil defense, such as emergency preparedness and the potential of bioterrorism. This argument has led to the fragmentation of federal public health programs across various agencies—especially those involved with civil defense—each with their own priorities and goals. For instance, the Department of Homeland Security maintains its own public health programs separate from HHS, focused largely on emergency preparedness. While fragmentation can allow for a diversity of approaches to solve problems, lack of inter-agency collaboration can lead to inefficiency and replication, as well as unfair prioritization of certain projects depending on branch funding.

Confining public health to terms of civil defense, however, comes with its own set of dangers, including sending a message that improving public health is of limited value without an ulterior motive of preventing terror. But this is founded on a narrow and misguided interpretation of national security as protection only of the state. Instead, it should be recognized that national security extends to protection of citizens and the body politic, and that security is not only a matter of civil defense, but also
of stability. In this sense, it should be understood that what is needed is not the securitization of public health, but a commitment to investment in public health as it is broadly construed.

Public Health as National Security

More than civil defense alone, public health promotes the economic productivity and stability of our country. A salmonella outbreak or an aggressive flu season may at first seem less threatening than the prospects of a terrorist attack. But as the panic over the outbreak during the shutdown suggested, the greater probability of an outbreak’s occurrence, its greater geographical reach, and its unpredictable spread all make the relative risk and impact of such infectious disease threats worthy of the government’s attention. While the estimates of the costs of the salmonella outbreak have not yet been calculated, recent studies suggest that the aggregated costs of foodborne illness in the United States come to $77.7 billion per year. Other seasonal illnesses, such as influenza, cost a similar $71 to 167 billion per year in the form of healthcare costs and lost economic productivity.

Predictably, the system is at a substantial disadvantage to respond to such large crises when clinics are understaffed, drugs are in short supply, and hospital beds are unavailable—as happens when investments in public health are diminished. In response, Andrew Price-Smith, a professor at Colorado College, suggested in an interview with the HPR, “what you actually have to do is invest not in a militarized public health system, but in things like resilience within our medical infrastructure.” Such investments in health infrastructure would allow for greater capacity to respond to generalized public health threats, whether they come in the form of natural disaster, bioterror, or contagion. An additional place federal investments in public health can occur is in structures of governance, such as the NIH, the CDC, and the FDA, which function simultaneously as scientific research and consumer protection agencies. In the absence of strong leadership from a deeply divided House and Senate, these regulatory agencies are likely to play a growing role in driving initiatives in public health—assuming they receive adequate funding and support to enforce their rulings.

Indeed, the lack of enforcement on one particular front at the FDA may have contributed to the multi-drug-resistant salmonella outbreak during the shutdown. Rep. Louise Slaughter (D-NY), the only microbiologist in Congress, lamented that scientists have known for years that the quantity of antibiotics fed to livestock was driving up rates of antibiotic resistant infections in humans. Yet the FDA has lacked the teeth to control industry use of antibiotics, even as the outbreak demonstrated its potential harms. “I’ve been carrying a bill called PAMTA [Preservation of Antibiotics for Medical Treatment Act] since 1999,” Rep. Slaughter told the HPR in an interview, “and the situation’s much more acute now. We don’t have a chance in the world of getting any bill of ours on the floor of the House that would in any way aggravate any of the agribusiness. So our federal regulatory agencies have to step up to the plate.”

In the wake of such negative consequences that have ensued the government shutdown, one valuable lesson should be learned, at least in the sphere of public health: a reexamination of the role of federal agencies in protecting public health, and a broader definition of what constitutes public “security,” is urgently needed.

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