Plan needed to fight terrorism: Public health officials are urging state lawmakers to strengthen a public health system that has been in serious need of financial and political support for years.

Texas Representative Dianne White Delisi doesn't have psychic powers, but four years ago she did call for a study to see how prepared the Lone Star State was for a bioterrorism attack.

How did her colleagues react? "I was met with chuckles when I floated that idea around," she says. Delisi knew, from talks with her constituents (her district includes Fort Hood, which houses one-fifth of the Army's total population) and taking part in national public health meetings, that the issue was no laughing matter.

"Because of my relationship with the military, I became aware of the threat of bioterrorism and the lack of our coordination in the state. I saw we were very vulnerable to an attack in Texas," she explains. Undaunted by the lack of support at the state Capitol, Delisi continued work on bioterrorism, approaching it from the broader angle of public health.

Her dedication paid off, as Texas lawmakers and former Governor George W. Bush OK'd in 1999 a Delisi-crafted measure to beef up what's known as the "public health infrastructure" in her state. Among the provisions, the law defines public health services to include monitoring communities' health, diagnosing community health problems and developing policies and plans that support community efforts to improve health. In addition, the measure details the importance of a competent workforce and calls for a report on the public health system to be filed with the governor and legislative leaders every other year.

DEFINING THE TERMS

Words like "workforce" and "infrastructure" sound a little technical, complicated and detached, but what Delisi's measure aims to target--and what's being talked about more and more these days following the events of Sept. 11--is the general public health system. It includes clinics and other facilities where people go for treatment or check-ups. Infrastructure also encompasses personnel--public health workers from nurses to lab techs to doctors. Improving that system means employees will know what to do in case of an emergency, epidemic or terrorist attack with biological, chemical or radiological weapons. It also means making sure those workers can sometimes spot disease outbreaks before they become widespread.

In Delisi's words, it means creating a system "that will not only protect Texans from some madman with anthrax, but will also assure them protection from lyme disease, dengue fever and even obesity."

Since the events of Sept. 11, many people equate public health only with bioterrorism or anthrax scares, but it covers infectious diseases like HIV/AIDS and chicken pox, environmental health, chronic conditions like asthma, immunizations, injury prevention and occupational health and safety as well.

WHAT HAPPENS WHEN THOUSANDS ARE INFECTED?

Colorado public officials acquired a better grasp on the public health infrastructure after the state participated in a congressionally mandated test of emergency preparedness called Operation Topoff in May 2000. In the mock drill, thousands of people were infected and many hypothetically died when terrorists released pneumonic plague into the ventilation system of Denver's premier theater complex.

With an eight-week lead time heading into the exercise, Colorado's state and local government officials beefed up the emergency preparedness system by temporarily appointing people to the governor's emergency response panel and assigning workers to a state disaster response team. Officials also established a communications command center complete with telephone, computer and TV equipment, according to a November 2000 article in the journal Emerging Infectious Diseases.

Prior to the drill, Representative John Witwer had been working with former public health department Director Richard Hoffman to revamp Colorado's emergency preparedness procedures. The Topoff exercise and subsequent media attention gave credibility to the efforts, and lawmakers in the 2000 legislative session passed a measure that defines bioterrorism and creates a governor's panel to address state emergency needs in case of an epidemic. To demonstrate how all-encompassing an effective team is, members of the panel include the state's chief medical officer, an epidemiologist, the attorney general, the state veterinarian, an infectious disease specialist, an emergency medical physician, a post-traumatic stress management expert and a wildlife disease expert, among others.

"Were we really thinking about bioterrorism? Yes, but we were also thinking about epidemics," says Witwer, who is a physician schooled in treating malaria and smallpox.

BIOTERRORISM ON THE AGENDA

Policymakers across the country will no doubt be thinking about bioterrorism, epidemics and other public health emergencies during this year's legislative sessions. At least 29 legislatures hope to modify or expand laws on reporting of diseases to municipal and state health authorities, according to a January 2002 survey from NCSL's Health Policy Tracking Service. Twenty-seven states will expand their public health statutes, regarding quarantine and isolation of patients. Twenty-four states plan to address collecting, sharing and disclosing information.

Similar to Delisi's line of thinking, health officials are urging state lawmakers to look beyond terror and the immediate threat of agents like anthrax, smallpox or chemical weapons to strengthen a public health system that has been in serious need of both financial and political support for years.

Dr. Jeffrey Koplan, director of the U.S. Centers for Disease Control and Prevention (CDC), says that the centers and other federal, state and local agencies lack resources to respond to a major crisis. The Bush administration earmarked $1.1 billion for public health in the federal emergency relief budget, but Koplan and other state and local health officials say more is needed to bolster infrastructure in state and local health departments and forge relationships between clinical care and public health, so that doctors and other health workers are aware of what's going on in the larger community.

Ed Baker, who heads up the CDC Public Health Practice Program office, says the money and related efforts should be targeted in two places. "There are specific technical bioterrorism needs for things such as labs and investigations," he says. "But there's a whole other range of threats that we need to be equally prepared for, such as chemical or nuclear weapons and natural disasters and epidemics.

"That's going to be tough because we're preparing for things we don't know will happen," he adds.

HEALTH ALERT

One tool that Baker and state officials say has been helpful in emergency preparedness efforts is CDC's Health Alert Network. Up and running in all 50 states, the District of Columbia, Guam, three metropolitan health departments and three public health preparedness centers across the country, the $90 million system gives state and local health workers access to computers, trains workers and distributes laboratory findings. Baker says health officials have used the system extensively since Sept. ii. From mid-September to the beginning of November, CDC "sent about 50 messages to a network of centers for public health preparedness," he says.

Colorado's Witwer agrees communication is key in getting a state prepared to deal with bioterrorism or an epidemic. Lawmakers, he says, should also pay attention to other key provisions when drafting an across-the-board plan suitable for any emergency.

First, health care providers have to be "freed up" to take care of sick patients. "The paperwork burden may be excessive ... and the last thing doctors and nurses should be doing is filling out paperwork when they have hundreds of people to take care of," he says.

Medical liability must also be addressed, so that health care workers may "enthusiastically volunteer to take care of their fellow citizens," Witwer notes. "We don't want to put anything in their way, because in a serious disaster, very difficult decisions have to be made extremely quickly."

Policymakers will need to make some tough decisions that in many cases will be politically tricky or even unpopular, Witwer notes. Difficult decisions may include how to triage or move patients through the medical system, how to ration supplies and care, and how to quarantine and isolate individuals at risk of spreading disease.

FUNDING DECISIONS

As Washington state's health secretary, Mary Selecky is used to being among those who make the "tough decisions." She and other officials have been working on strengthening Washington's public health system for nearly 10 years.

Selecky, who is president-elect of the Association of State and Territorial Health Officials, says one of the most important lessons she has learned is the need for flexible spending.

In Washington, the Legislature doles out public health money in a format known as "local capacity development funds." Local communities tell state agency officials what they want to spend money on--which can be anything from communicable diseases to environmental health or access to care. Once a project has been up and running, those same local officials have to report back on how using that money has made a difference in the community. Accountability for such projects is key, Selecky says.

In addition to doling out money based on local needs, Selecky says it may be time for lawmakers to nix old programs that aren't working. "Twenty-five years ago, it may have been a good idea to put money into certain programs," she says, "but given the slowing economy and the fact there isn't enough money to go around, it's now time for us to look again at old decisions and make good decisions for 2002 and beyond." Investing in technology is not a sexy thing, she says, but it's a necessary part of improving the public health system.

Selecky agrees that a big picture response is needed for the current terrorism threats. "For public health protection, you have to be in it for the long haul. An infusion of one-time money that gets pulled away means you do very little," she says.

Mary Guiden is a former NCSL health writer who now covers health policy for Stateline.org. Some of the material in this story first appeared in Stateline.org.

RELATED ARTICLE: IT'S A MODEL-NOT A MANDATE

Protecting the greatest number of Americans in the face of a I bioterrorism epidemic. That was the scenario for public health experts Lawrence Gostin and James Hodges at Georgetown and Johns Hopkins universities, who developed the Model Emergency Health Powers Act.

"This model law provides a foundation upon which each state can develop emergency legislation that best protects it," notes Tommy Thompson, U.S. secretary of health and human services. "I was a governor for 14 years. If I learned anything during that time, it's that Wisconsin is not New Jersey and New Jersey is not North Carolina. Each state is different."

Thompson went on to say that the model legislation was designed as a springboard for states to craft emergency public health powers for their specific needs. "States may adopt any or all of the model legislation, as well as tailor it to meet their individual needs," he said.

Comments on the model act were provided by a group of legislators and legislative staff assembled by the National Conference of State Legislatures. The National Governors Association and the National Association of Attorneys General also participated in draft review.

NCSL has not endorsed this model law, but staff members have developed a checklist of the key issues raised in the model act for legislators to use in considering whether additional public health legislation is needed in their states. A copy of the checklist can be obtained from the NCSL Marketing Department, [phone].

Cheryl Runyon, NCSL

OLD THREAT BROUGHT BACK BY VISIONS OF TERRORISM

Smallpox was considered eradicated from the face of the planet. Vaccinations were no longer given, and only very small stockpiles of the lethal disease could be found in heavily secured laboratories.

But in the face of the looming threat of bioterrorism, the Centers for Disease Control and Prevention (CDC) has developed a draft plan for a potential response to a smallpox outbreak.

One of the key tools in the plan is a "ring vaccination," a technique that was successful in eradicating the disease in 1978. It involves quickly spotting the first victims, isolating them in their homes or hospitals and vaccinating people who might have come into contact with them. This creates a "protective ring" around the infected.

Although the CDC is advocating mass vaccinations only if an outbreak occurs (due to side effects of the vaccine), about 100 of its employees have been vaccinated so they can respond to an attack.

Maryland Health Secretary Dr. Georges Benjamin has been discussing a plan to place temporary bans on public events, isolate patients, require vaccinations and generally involve an appeal to the public to stay home until the danger passes.

"It is very, very unlikely that there will be a bioterrorism release of smallpox in the city of Baltimore and even in the region," says Dr. Peter L. Bielenson, city health commissioner. "But the consequences of this happening are so serious that we're irresponsible as public health officials if we don't prepare."

Benjamin also plans to vaccinate a core team of 10 to 12 staff members, but could vaccinate a larger group of "first responders" (local health officers, paramedics, firefighters and police officers) when additional vaccine is available.

The scenario that Maryland and Baltimore have developed is:

* Place smallpox patients in isolation rooms.

* Vaccinate patients and employees at the hospital admitting smallpox patients.

* Use nursing homes, hospital ships and military hospitals to accommodate overflow patients if hospital capacity is exceeded.

* Use schools as "triage, transport and treatment centers" where family members and others at risk could be vaccinated and acquire face masks.

Cheryl Run yon, NCSL