Is your town ready for a possible pandemic of bird flu or any other large-scale health emergency?
Dr. Karen Smith, public health director for Napa County, Calif., wanted to find out. The answer was a real eye-opener, she said, and has kept her awake at night.
“We examined five nursing homes in our area and asked them what plans they had if they had to evacuate," said Smith. "Each of the nursing homes told us they had a contract with a local van service. What they didn’t know is that they were all counting on the same service."
The lesson is that “if there is a crisis, no one is affected individually, so one cannot plan alone. That is why we need a community plan," Smith added.
As countries around the world report the presence of the H5N1 avian influenza virus in poultry and wild birds, health officials are preparing for the arrival of the deadly germ on U.S. shores. The biggest fear is that the virus will eventually mutate and become easily transmitted from person to person, sparking a massive outbreak.
But if a deadly virus becomes widespread in the United States, will local public health departments — the “Marines” on the front lines of the outbreak — be prepared?
‘All public health is local’
“The lesson we learned from Katrina is that ultimately, all public health is local,” said Dr. Paul Etkind, an epidemiologist and deputy director for public health in Nashua, N.H.
In the event of a disaster or deadly pandemic, "local public health departments have to be ready to shoulder the load and do it without any external help, at least for the first couple of days,” said Etkind. “The federal government has been quite clear. They've said, 'We don’t have any personnel to come to your rescue,' and the states are saying the same thing."
Last fall, President Bush proposed approximately $7 billion in emergency funding to help states prepare for a possible outbreak of bird flu. But only about $600 million was earmarked for local public health departments. Congress has approved roughly $3 billion of Bush's proposed funds, setting aside around $350 million for local preparedness.
The bulk of the funds are slated for the development and stockpiling of vaccines and anti-viral drugs, but what about funding for personnel to distribute these medications?
Preparation pitfalls
Etkind has been working on various pandemic scenarios, and one of his biggest concerns is the shortage of local health workers and other vital staff. Nashua’s Department of Public Health has only six nurses, at most.
“If we have a pandemic flu, we’ve estimated we would immediately need 230 people to run mass clinics of two shifts a day,” Etkind explained. And in order to handle approximately 200,000 anxious people, nurses would be just part of a larger emergency scenario. There would also be a need for administrative staff, parking and traffic control personnel, janitorial services, as well as vendors to provide food and water.
Smith, of Napa County, wishes she had a full-time staffer in her local public health department whose sole job was to work with the community to coordinate disaster plans. But public health agencies have lean budgets, and the necessary funding is not available.
Cutting through red tape
In a major emergency, there is no time to waste, and the more doctors and nurses who show up to help, the better. But finding medical workers who can legally perform duties in a particular area is not as easy as it sounds.
“Nashua, N.H., is right near the border with Massachusetts. If doctors or nurses from there volunteer, right now I couldn’t use them since licensing is done at the state level. Am I going to turn them away?” asked Etkind, adding that he’s constantly calling for changes to these antiquated laws.
And what about the friendly retired school nurse who offers to help out?
“If there is one thing I would be doing instead of stockpiling Tamiflu, it is changing the liability laws,” said Smith. “Everyone is worried about getting sued. So, for example, our local hospitals could not 'lend' a nurse to us if we needed one.”
More hospital beds needed
Besides the availability of doctors and nurses, Smith posed another vexing issue: the lack of hospital beds.
“That’s the biggest weak link,” said Smith. "Here in Napa, there are two community hospitals every year that are packed to the gills in a normal flu season ... not even a pandemic. It would really strain the system."
But the problem is not just the shortage of beds or medical personnel. What about making sure health workers are kept up to speed on the skills needed to handle a pandemic?
“Currently, 80 percent of my staff is out in the field as revenue generators," said Smith. In other words, local public health nurses perform home care and other services in the community, and the money the state gives local departments for the nurses' work covers their salaries.
This situation means few nurses can take time off for extra training in areas such as epidemiology, case investigation and quarantine procedures — all vitally important issues in the event of an outbreak.
What would they do differently?
If Etkind and Smith had their way, they would disburse the $350 million in federal funds earmarked for local preparedness much differently from the way it is currently being allocated.
Etkind would prefer that the federal money not be funneled and limited to such specific purposes because many crucial areas of disaster preparedness are being overlooked.
“Supporting local public health is the best bang for the buck,” said Etkind. “We can have all the vaccines we need, but who is going to administer them? Who is going to work in the labs? Remember the anthrax scare?”
Despite such criticism, Bill Hall, spokesman for the Department of Health and Human Services, defended the need to keep tight control on how local public health agencies use federal funds.
“It is the public’s tax dollars. For us just to hand out money is not good financial stewardship. A state could use the money for something that is unrelated."
According to Hall, it is unfair to say that the money allocated for building the national drug stockpile is not for “local” use. If a pandemic were to occur, Hall explained, the money the federal government might spend to prepare 50 million courses of anti-viral drugs for use would all be distributed to the different states and localities. And if the government develops and stockpiles an effective vaccine, all Americans benefit, he added.
A one-woman ‘infrastructure’
Smith sees the federal government’s acknowledgement of the possible dangers of bird flu and the stockpiling of vaccines as a step in the right direction but said gaps in preparedness clearly remain.
"Finally there’s federal recognition that they can’t do this alone, because it’s not like the CDC (Centers for Disease Control and Prevention) is a huge force of saviors that will swoop in.… It’s not going to happen. They’re finally getting that.
“On the other hand,” Smith said, “the federal plan calls for the development of a local ‘infrastructure’ for medical convening and planning. I'm it around here in terms of infrastructure.”
And as local public health officials struggle to deal with everything from diabetes programs to breast cancer screenings, preparing for a possible pandemic is just one of a long list of tasks.