Biodefense spending misses the mark, says FP expert

BY CINDY BORGMEYER

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Despite a full-court press by the Bush administration, U.S. spending on biodefense may not be producing the desired effect.

The numbers are staggering. Since Sept. 11, 2001, the administration has spent or allocated $12.9 billion for bioterrorism preparedness.

And that's not including the amounts set aside in the president's fiscal year 2005 budget proposal for readiness and response efforts, including a recently announced $274 million for biosurveillance.

But according to one FP in the know, the feds are missing the mark.

"We are no better off"

"From the health care provider standpoint and from the emergency response standpoint, we are no better off and are perhaps worse off than we used to be," says Jonathan Temte, M.D., Ph.D. Temte is associate professor of family medicine at the University of Wisconsin, Madison, and has a special interest in infectious disease. He serves on a CDC working group on pandemic influenza and has spoken about bioterrorism at the AAFP Scientific Assembly.

Invited last year to testify before a subcommittee of the House Select Committee on Homeland Security, Temte voiced concerns then that even the most high-tech biosurveillance system could find itself hamstrung if the information gathered didn't filter back to those on the front lines of biodefense.

Primary care physicians, he told the committee members, need to be wired into the public health system. To respond to emerging threats, community-based clinicians must be connected to sources of information that are "rapid, redundant, reliable and relevant," and the clinicians must have easy means through which to quickly report unusual cases to public health personnel. (Go to http://www.aafp.org/x24128.xml to read Temte's testimony.)

Now, Temte says, "There's been huge amounts of money going into surveillance, but is the information reaching the people who really need to know? I think that has been a tremendous failure."

In fairness, part of that failure may be attributed to the challenges inherent in implementing legislation that slices through multiple federal departments, offices and agencies.

Agencies reorganize

Public Law 107-188, known as the Public Health Security and Bioterrorism Preparedness and Response Act, was signed into law on June 12, 2002. HHS was the primary federal agency charged with implementing provisions of the act and was granted the funding to do so.

Since passage of the Homeland Security Act in February 2003, however, the Department of Homeland Security has shared biodefense resources and responsibilities with HHS -- in some cases, the respective roles and tasks of the two departments have overlapped or even flip-flopped.

The National Disaster Medical System offers a prime example.

NDMS was created by presidential directive in the 1980s to provide health and related services to victims of a public health emergency via a largely volunteer workforce. PL 107-188 officially authorized NDMS, placing it under HHS, says John Gaffney, special assistant to NDMS director Capt. Gary Sirmons.

It seemed a logical fit for an agency operating a system for advance registration of health professions volunteers to be deployed in the event of a public health crisis such as a bioterrorist attack. PL 107-188 also authorized grants for training NDMS volunteers, enhancing communications among public health agencies and coordinating preparedness activities. It also included liability coverage for medical professionals wishing to volunteer -- a key leverage point.

"PL 107-188 was actually written by medical professionals with an emergency background with the exact aim of filling some of these gaps," Gaffney says.

Then the Homeland Security Act shifted NDMS to the Homeland Security Department -- minus some of its attendant resources and funds.

"Before Homeland Security, by President Reagan's design, we were pretty much a self-contained entity supported by four federal agencies -- HHS, the Federal Emergency Management Agency, Veterans Affairs and Defense Department -- but managed by the Public Health Service," explains Gaffney. "We had our own logistics shop and so forth. When they moved us into FEMA (housed within Homeland Security), they carved it up and rearranged some things."

Open under new management

Now, Gaffney says, "There are things coming at us from a number of different laws and directions. With our office just having moved over to Homeland Security from HHS, we're still learning our way and organizing our resources. Interestingly enough, we've lost budget in the equation, and we've lost staff."

He acknowledges the system, as it exists today, is far from perfect.

"Anybody at this point would be foolish to deny that there are gaps," Gaffney says. Still, he notes, "The law is there, everything's been tackled. We're just at varying degrees of completion."

Even so, says Temte, "You're not going to have much of a response capacity in the community when you've degraded all your emergency response personnel due to budget cutbacks. And you're not going to have very good response if you're in an area that's terribly underserved and you have no primary care for patients."

The government has to get its priorities straight, says Temte, and that begins with asking the right questions of the right people.

"You start with a dialogue between several levels, and I just don't think that dialogue is taking place," he says. "I think it's more basic than looking at solutions right now; I think there first has to be a mutual understanding of what problems exist in terms of implementing things.

"We've put in a lot of effort in terms of 'How do we go about detecting something? How do we build a nifty system to go through the electronic medical records of all the insured patients in our HMO to look for an event?' We've put a lot of investment into building nifty little devices to sniff the air, but we haven't put much into what we do about it when we find something. We love the technology. But the solution isn't technology, the solution is adequate people."

To reach writer Cindy Borgmeyer, e-mail cborgmey@aafp.org.

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