Bioterrorism response, unintended consequences, and the role of environmental health. (Managing Editor's Desk).

When I read about change, the one point that always unnerves me is that the speed of change is increasing. To say that we live in a world moving at breakneck speed is to pretty much put the exclamation point at the end of the sentence of modern-day life.

We can't change this reality but we can learn to adapt. I would argue that adaptation means that we must vigilantly monitor, analyze feedback, and continually adjust.

We can't avoid change or slow down its pace. We can, however, influence it by making continuous adjustments so that as change pushes forward, it gets steered in positive directions.

Right now what is on my mind are the major changes occurring in public and environmental health and the speed with which those changes are taking place. I am more specifically concerned with what is happening (and, in many instances, not happening) to our profession as the outlines of our nation's approach to bioterrorism response planning take shape.

This is the third column I've written on bioterrorism response since September 11. (I wrote several before 9/11 as well.) Each time I comment on current events, more change takes place quickly thereafter. It is hard to keep up with everything, but keep up--and influence it--we must. If we (meaning our profession) don't engage this issue and make the effort to steer events in a way that is consistent with our mission, then we will be guilty of dereliction both of our professional heritage and of our professional credo.

I don't have to tell anyone reading this column that bioterrorism (BT) response is arguably the most significant public-health issue of our lifetime (including even the creation of the U.S. Environmental Protection Agency). As this issue has begun to unfold, it concerns me that local environmental health is too often relegated to a status of being outside looking in. To me, it is utterly inconceivable that any bioterrorism response planning would not include local environmental health. After the anthrax attacks of last year-not to mention the role that many in our profession played in both Washington, D.C., and New York-ask anyone anywhere who works in local environmental health if we are not involved, and involved at the front lines.

Following September 11, Congress acted with dispatch to set up a program to build a bioterrorism response capability in this country Almost a billion dollars were appropriated for this undertaking. The Centers for Disease Control and Prevention (CDC) acted with equally impressive speed to develop considered guidelines for the 50 states to follow in putting such plans into place. And the money quickly flowed.

Many of us in environmental health watched and smiled, for surely this infusion of dollars would mean more funding support for local environmental health. As I wrote several months ago, that initial optimism may have been misplaced. Many local environmental health people with whom I have spoken have shared that they have seen little if any of this money Similarly, many have not been consulted about allocation of the money.

Let me return to the concept of speed and change for a second. So much is happening so fast right now as we, as a nation, mobilize to defend our communities against a potential bioweapons terrorist strike--which, as our AEC keynote speaker in Minneapolis emphasized, is a sure bet. Many good people, with many equally good intentions, are designing systems, making funding decisions, setting priorities, and establishing response protocols. All of this is unarguably good and necessary

Still, as is always the case when things are done so quickly (that speed-of-change thing again), there has to be a monitoring and feedback loop to the system to ensure that the overall objective being pursued gets attained. When things happen so quickly, it is virtually a foregone conclusion that adjustments will have to be made as the final product begins to take shape. If such adjustments aren't made, the law of unintended consequences rears its ugly head, and all sorts of problems develop. These problems can wreak havoc on any project--well intended or not.

As the face and structure of BT response begin to become visible, we can also begin to see the outlines of those unforeseen and damaging "unintended consequences." We must hunt these down, understand them, and take the appropriate corrective actions, or the overall goal that we are chasing may end up being compromised if not missed. In our case, I would suggest that the objective of this furiously paced initiative is an effective BT response capability that includes a meaningful role for local environmental health.

Is that objective being realized? My impression is that we have made some progress but that we are a long way from where we want to be. I am also worried that we are seeing more and more unintended consequences materializing that are both hindering and compromising our objective.

Let me back up to make this as simple as I can. Congress allocated a billion dollars to enable our country to plan and build an effective BT response capability. Sounds easy, right? For a systems engineer like me, the input arrow into the box is money, and the output arrow out of the box is effective BT response systems all throughout the nation. As we go from the drawing board out to the real world, however, that simple picture I just drew is being clouded by unintended consequences like those listed below:

* Following decades of neglect, money is finally flowing into the public-health system. It can't therefore be surprising that we are seeing some of the BT money being picked off to make basic improvements in public health. As but one example of many, I know of an instance in which BT money was used to transform a half-time health officer position into a full-time one. While such improvements in the public-health system will undoubtedly contribute to a better BT response capability (the what-is-good-for-public-health-is-good-for-bioterrorism-response philosophy), the fact remains that money spent for such purposes becomes money that is not available for direct BT response--let alone environmental health.

* I hear comments that a number of states are viewing the availability of this money as a way to cover their budget shortfalls. Forty-six states are projected to have budgetary shortfalls this year. State tax revenues fell by a whopping 10 percent for the second quarter in 2002--and this was the fourth straight quarter for declining receipts. The new federal BT money represents a tempting source of income for money-strapped states. Yet, to divert this money into any other program--related or not--is to divert it from BT response and a role for environmental health.

* In the hallway chatter, it is also being speculated that some states are looking at this money as an opportunity to reduce their expenses (and thus save money) as they move to replace their funding of public-health programs with federal dollars. In a time of recession-strapped state budgets, this temptation could be hard to resist. Besides, such an approach is seen not as a diminishment of public health but rather as a net zero-sum game in which the source of funding gets changed but not the overall funding level. If the states can supplant their funding of public-health programs with federal dollars, they can save money Any increase in the BT response capability of the system becomes a fiction, as the status quo merely gets maintained.

* What complicates the above scenario is that states are already cutting back in anticipation of federal funding. The question must be asked: What if the expected money doesn't come through? Suddenly the zero-sum game becomes a deficit game for public and environmental health.

* We are also hearing that states (and even localities) are sometimes reluctant to make the financial commitment to sustain the positions that are today being created with the federal money. Thus, people being hired to work in BT are sometimes being hired as temporary help with no sense if their positions and work will be for the long term. This situation has implications that range from the quality of personnel that are being hired (how many seasoned professionals would accept a job that only has a duration of a year or so?) to the sustainability of any long-term system enhancements on behalf of BT response. Such transience in the work force also deprives us of building any deep knowledge base in this important topic area.

* The verdict has been expressed that the extent to which environmental health is being included in local and state plans depends on the extent to which the local health officer prioritizes environmental health. Thus, even though the logic for a substantive role for environmental health is there, if the health officer has other priorities, then environmental health is probably not going to get any meaningful funding. (The corollary to this is that environmental health will get prioritized to the extent that it is popular in local politics.)

* We are also hearing that if we go to war against Iraq, BT funding may very well be cut. For those states who are expecting this money and who are counting on it to replace their funding of public health, so much for overall systems improvements. In such a scenario, public-health capacity will actually decline, not increase, and this at a time (assuming that we are at war) when arguably we would need our public-health system the most.

* Some fear that the emphasis on BT is quietly but significantly transforming public health into bioterrorism response and that the public-health system is fast becoming a BT response system. I hear CDC now being called CBT. If public health is being transformed into a different kind of system, what does this mean for existing and traditional environmental health programs?

In addition to the unintended consequences that are manifesting themselves in the fast-paced and rapidly changing world of BT response, other factors, ranging from the impact of the recession to the emergence of the West Nile virus in the west, have further complicated the picture. For example,

* Today the West Nile virus is completing its spread across. our country. For whatever reason, the media has made a spectacle out of this. Accordingly, the public is alarmed, which translates into increased workloads for local environmental health. This diversion also drains state and local financial resources from what otherwise would or could be BT programs.

* As budgets tighten up, I am hearing more about gambling and shell games. For example, I know of one county that has dropped its food protection program because of local budget shortfalls. This program is mandated by the state. The county is gambling that the state will come in and fund the program because the program is state mandated. On the other hand, no one really knows how this gamble is going to work out.

In laying these observations out, it has not been my intention to offer a negative commentary on what is happening today in BT response. To the contrary I am arguing that things are changing fast. In such a scenario, we have to monitor, understand, and adjust. If unintended consequences are appearing that could jeopardize our objectives, then we must initiate corrective action so that we might guide these changes in a way that they lead us to our goal--and not away from it.

We have a message that needs to be heard. We are trained professionals who represent, in many respects, one of our community's best hopes for an effective BT response. If we are not being included, as the director for BT in California recently told the local environmental health directors of that state, then "Stand up and be heard!" We implore you to do just that.

That is what we have done at NEHA.

The entire BT response program has been built around the states. If locals are to be involved, they are being involved only because states are working with them, As far as any contact between the feds and the locals are concerned--except in a handful of large cities--there isn't any In the face of this situation, we are making the case that the feds need to be supporting the locals and particularly local environmental health.

We've shouted ... and we have been heard.

Going against the grain, NEHA has successfully advocated its position to CDC, to the effect that we have been awarded special grant funding to put on a series of workshops for people in local environmental health. More specifically beginning by perhaps the time you read this, NEHA will be sponsoring a series of all-expenses-paid workshops for local environmental health personnel on the topic of epidemiology as it relates to bioterrorism. These workshops will be held at CDC in Atlanta. You are urged to apply

This program is huge for several reasons. First, by raising our voices and getting involved, we have succeeded in targeting significant federal dollars to the local level and to environmental health. Second, this is the very training that many local environmental health people need in order to significantly enhance their BT response capability And finally, this program comes at no cost to the participant.

Our success demonstrates that we can be heard and that we can be involved--as we should be.

Speak up. Get involved. Push the environmental health agenda. By doing so, we can rail against some of the unintended consequences that are beginning to surface, and we can steer the change taking place in public and environmental health toward our prime objective--which is an effective bioterrorism response system that includes local environmental health. To quote a popular line, "It's time to rise and shine!"