Examining Challenges and Possible Strategies to Strengthen U.S. Health Security Proceedings of a Workshop (2018) / Chapter Skim
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3 Proposed Priorities and Persistent Challenges Related to Health Security
3 Proposed Priorities and Persistent Challenges Related to Health Security
Pages 11-48
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From page 11... ...
In this chapter, experts representing a variety of sectors discuss their perspectives on the priorities and persistent challenges related to health security, focusing specifically on health care and public health critical infrastructure protection, data collection and use, funding for health security programs, preparedness for global health emergencies, and vulnerable populations and community resilience. Ensuring a robust health care and public health sector will greatly advance the nation's ability to respond and recover when faced with a health security threat.
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From page 12... ...
. The HHS/ASPR CIP Program works with government and privatesector partners to enhance the security and resilience of the health care and public health sector by mitigating risks to critical infrastructure.3 2 For example, Wolf noted, going to a medical office for treatment in a facility that has power and water; where staff take health insurance information and access electronic health records; where a doctor uses lab tests to make a diagnosis; and if treatment is needed, where prescriptions are easily transmitted to a pharmacy that has the needed supplies in stock.
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, plans and payers, mass fatality management, state and local public health departments and related associations, and federal response and program offices. Oscar Alleyne, NACCHO, noted that from a local health department lens, the "staff" element of critical infrastructure means ensuring there are enough trained staff on the ground to respond during an emergency while maintaining continuity of operations with regular programs and services.
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He commended the University of Nebraska's National Ebola Training and Education Center for inviting environmental health and industrial hygienists to the table early on to address issues related to the transmission of Ebola in those environments. Wolf illustrated the evolving threat to the supply chain of health care and public health critical infrastructure.
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. Hick explained that the level of event in this model would have a dramatic impact on health care and public health critical infrastructure.
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. Presenters and participants identified persistent difficulties related to assessing, protecting, and strengthening the existing health care and public health critical infrastructure, as well as strengthening stakeholder engagement in national-level discussions about health security.
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Roy Alson, Wake Forest School of Medicine, pointed out that communities with health care systems that are able to provide effective care on a routine basis are better prepared to respond to disasters. However, he explained that many components of health care and public health critical infrastructure are situated in systems that are stressed and often inadequate on a daily basis.
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For example, no one contracted and died of Ebola virus in the United States during the worldwide pandemic, but this successful solution was not recognized or celebrated as it would be in other professions. DATA COLLECTION AND USE Margolis explained that data collected from a disaster comes in different forms that include EHRs, but also draw from "operational data, administrative data, scheduling data, workforce data, inventory management data." Public health departments are effective when it comes to technical components of data interoperability platforms, noted Lee Stevens, director, Office of State Policy, Office of the National Coordinator for Health IT, HHS.
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Runnels observed that public health does not always have the type of data it needs; for example, most local health departments do not have access to EHRs. Furthermore, 10 Margolis explained that this gap in situational awareness is evident during an emergency, when state, local, and emergency management need real-time, detailed information about hospitals: "What hospitals are open/closed?
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20 CHALLENGES AND STRATEGIES TO STRENGTHEN U.S. HEALTH SECURITY she suggested that lack of data may lead other entities to perceive public health as vulnerable, and this perception may undercut public health's authority and involvement in a community.
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These are the choices that data lead us to." Without a clearly established mission, data can effectively paralyze the response. He explained that having a data point about a person does not show one survivor, it shows all the potential survivors who could express that data point: "An oxygen-dependent woman, who might be fine, might not be fine, might have family, might not have family, might have support, or might not have support." Several participants also emphasized weaknesses in the system's current ability to collect, validate, and disseminate data on risk and threat information during emergencies, to integrate advances in research and technology, and to use and collect electronic health data before, during, and after an emergency response.
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Protecting the Public's Health from Diseases, Disasters, and Bioterrorism,13 discusses an established pattern within public health financing. Overall baseline public health funding is cut, and then a new crisis arises for which Congress may provide supplemental funding; once the crisis passes from national attention, the system reverts to budget cuts.
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From page 23... ...
For example, she quoted Chairman Kohl of the Labor–HHS Appropriations Subcommittee in the House of Representatives as opposing President Delays in Funding for Public Trump's approach of a commensurate cut in nondefense spending with a commensurate increase in defense spending, and stating that CDC is as Health Emergencies 1 Day: Hurricane Katrina (2005) 42 Days 51 Days 53 Days 235 Days Ebola Virus H1N1 Hurricane Zika Virus (2014-2015)
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She explained that most health departments receive money through their state health departments, with 55 percent of local health departments relying solely on federal funding. There has been a 34 percent reduction in PHEP funding over the last decade, and she noted that this lack of sustained and robust funding presents problems when issues arise and Congress must be asked for resources (see Figure 3-6)
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. Two-thirds of the MRC units, another piece of the Preparedness Enterprise, are based in local health departments.
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She highlighted the bipartisan Public Health Emergency Response and Accountability Act (Senators Bill Cassidy and Brian Schatz) , which includes a funding formula that looks at the past 14 years of public health emergency spending (approximately $1.5 billion to start)
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SOURCES: Hanen presentation, March 9, 2017; NACCHO based on funding awards. FIGURE 3-9 Strategic National Stockpile funding history (FY 2003–FY 2016)
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NACCHO and other organizations carried out a survey of their members to better understand 15 Other proposals Lieberman and Hanen discussed included the FY 2017 House Labor– HHS CDC Infectious Disease Rapid Response Reserve Fund, which puts $300 million into CDC infectious disease rapid response (overall public health funding would also be cut, including for infectious disease) ; the Public Health Emergency Preparedness Act (Representative DeLauro)
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A further concern is that the noyear fund might be viewed as an attractive funding source for Congress or HHS even with limitations incorporated into the statute to prevent another outbreak. For example, the unspent Ebola outbreak supplemental funding should have been spent on continued efforts in West Africa, but was instead 17 See the impact of the redirection of public health emergency preparedness (PHEP)
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The uncertainty causes delays for federal agencies in their planning and spending that trickles down to both state and local health departments and ultimately creates further uncertainty for MCM developers (see Figure 3-11)
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STATE HEALTH DEPARTMENTS Pass funds from Federal Investment and State General Funds through to local health departments. FIGURE 3-11 Appropriations process.
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Shah emphasized the need to adequately fund local public health capacity first, noting that public health departments across the country are suffering because we have not invested in the systems and that local public health capacity is a critical component of on-the-ground emergency response that must be adequately funded. Onora Lien, Northwest Healthcare Response Network, noted that at the community level, the annual funding cycle and different approaches taken by various funding streams make it difficult to create alignment to mobilize all efforts toward consistent and sustained common outcomes.
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In the past year, his department spent $1.5 million on multidisciplinary approaches to Zika virus response. As a result of a 7-month funding delay, they were forced to repurpose physicians and other staff in order to respond to the Zika virus outbreak appropriately.
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role in Global Health, Kaiser Family Foundation Health Tracking Polls.
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This preparation is already under way: a global push led to the development of WHO's Health Emergencies Programme, an ASPR-like structure that brings together humanitarian system programs and the IHR community under one line of command to respond to all kinds of public health emergencies. She explained that priority areas include a unified WHO emergency program, a global health emergency workforce, IHR core capacities and resilient national health systems, improvements to IHR, accelerated research and development, and an international financing and contingency fund.
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The joint external evaluation tool is now being used in conjunction with the IHR; 29 have been completed so far, 31 more 21 Katz further explained that GHSA action packages include antimicrobial resistance, zoonotic disease, biosafety and biosecurity, immunization, national laboratory systems, realtime surveillance, reporting, workforce development, emergency operations centers, linking public health with law and multisectoral rapid response, MCMs, and personnel deployment.
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The number of outbreaks per year has tripled since 1980, with the majority being zoonotic in origin.22 Katz explained that if a disease emerges in one part of the world, it can be anywhere else within 24 to 48 hours due to globalization and the movement of people, animals, and goods. Recent examples of emerging infectious diseases over the past decade include the severe acute respiratory syndrome outbreak in South China; MERS-CoV in Saudi Arabia and South Korea; the Ebola outbreak in West Africa; Zika virus in the Americas; the resurgence of polio, particularly in fragile states; the more recent outbreaks of yellow fever; and the ever-present threat of new variants of influenza.
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38 GHSA Success: External Evaluations Sample frame
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FIGURE 3-15 GHSA joint external evaluations. NOTE: CO = Country Office; FAO = Food and Agriculture Organization; GHSA = Global Health Security Agenda; HO = home office; IHR = International Health Regulations; JEE = Joint External Evaluation; MoH = Ministry of Health; OIE = World Organisation for Animal Health; RO = Regional Office; TWG = Technical Working Group; WHO = World Health Organization.
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efforts in international public health disaster emergency response, as well as sustaining the commitment to GHSA. Hanfling, a practicing emergency physician with 20 years of urban search and rescue response experience with the U.S.
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Kurilla noted that broad processes are in place internationally that are not specific to a particular emerging infectious disease or public health outbreak response. Review processes, cycle times, funding decisions, and so forth are not aligned across different countries, which is an issue that cannot be effectively addressed in the midst of a crisis, when consensus is impossible to reach.
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Another question going forward is whether public health departments can, or will, use a scalable model of community resilience programs that is embedded in the ongoing work in chronic disease, violence prevention, and other areas of day-to-day focus. Communities directly affected by disasters are not the only ones that benefit from resilience.
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population has some sort of disability. Dan Dodgen, director, Division for At-Risk Individuals, Behavioral Health, and Community Resilience, ASPR, HHS, suggested that to improve individual- and community-level preparedness, the focus should be placed on the people most at risk (although that group can be difficult to define)
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This research also revealed a willingness by undocumented immigrants to engage with certain trusted public officials, particularly around health issues (U.S. physicians and public health officials were particularly trusted)
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Inglesby raised the issue of carrying out preparedness and community resilience work in the environment created around immigrants and refugees in the United States in early 2017, given the reactions to proposed or enacted immigration and security policies. Hanfling called these policies a retrograde step that may force the immigrant community back underground, where they will not seek help in anything other than life-or-death situations.
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He related an example, from the local health department perspective, of communicating the risks associated with cancer in a community where people were convinced there was a cluster (despite no evidential link) and perceived the government as trying to hide the existence of cancer clusters across the country.
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From page 47... ...
ASPR uses the phrase at-risk individuals; CDC tends to prefer vulnerable populations because it thinks in terms of disease risk; and FEMA has two competing favorite terminologies: whole community and access and functional needs.
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