Public Health Infrastructure: Creating a Solid Foundation.

The nation's public health system remains in disarray, despite the 1988 warning by the Institute of Medicine in its landmark report. "The Future of Public Health." Recent concerns about antibiotic resistance, inadequate disease surveillance capabilities, bioterrorism, and an increasing need far training the public health workforce have brought this problem into the forefront of congressional concern. Recent legislation aimed at addressing this problem was passed last Fall and signed into law. This program will take a significant step towards ensuring a solid public health system when it is fully implemented.

KEY CONCEPTS

* Public Health Improvement Act of 2000

* Public Health Threats and Emergencies Relief Act of 2000

* Addressing the Deficiencies in the Public Health System

* Public Health Concerns

* Creating an Adequate Public Health Infrastructure

The Public Health Threats and Emergencies Relief Act of 2000 or, as it is commonly known in the public health community, the Frist/Kennedy/Burr/Stupak Bill, was signed into law this Fall as a component of H.R. 2494, The Public Health Improvement Act of 2000. With its signing, the United States went one step further in addressing the deficiencies in the country's public health system identified in the 1988 Institute of Medicine Report, "The Future of Public Health."

This important study identified the poor state of the public health system and made recommendations concerning how to improve it. One fiscal recommendation noted that "federal support of state-level health programs should help balance disparities in revenue capacities and encourage state attention to national health objectives. Particular vehicles for such support should include core funding with appropriate accountability mechanisms, as well as funds targeted for specific uses." [1]

While some progress has been made since 1988, many think this has not been enough. In some areas, such as disease surveillance, the system has even fallen further behind. Dramatic action is needed to address this problem to move the public health system forward. The Public Health Threats and Emergencies Relief Act of 2000 fulfils this need.

Public Health Threats and Emergencies Relief Act

During the 106th Congress, Senators Kennedy (D-MA) and Frist (R-TN) and Congressmen Burr (R-NC) and Stupak (D-MI) introduced S.2731 and H.R.4964 respectively. These bills were later incorporated into an Omnibus bill called The Public Health Improvement Act of 2000, Title I of which represents the Public Health Threats and Emergencies Relief Act. The relief act, in part, amends Part B of Title III of the Public Health Services Act (42 U.S.C. 243 et seq.) section 319.

The relief act authorizes the Secretary of HHS, in consultation with appropriate officials, to determine that a disease or disorder is a public health emergency. It also creates a non-relapsing fund that can be used to address such emergencies.

The Secretary is required to determine the core capacities of national, state, and local public health systems over the next year. These capacities must be accessed at least every ten years and efforts made to enhance, improve, or expand them. Developing the capacity to respond to major outbreaks of infectious disease, identify and respond to pathogens with antibiotic resistance, and react to acts of bioterrorism are examples of threats identified in the law. The specific capacities that may be included to address these threats include: [2]

* Rapidly identify disease-causing organisms

* Recognize the clinical signs and epidemiological characteristics of significant outbreaks of infectious disease

* Develop plans to prevent disease in exposed populations and treat those infected

* Utilize communication systems to share information in a timely and effective way

The Secretary is authorized to provide grants and contracts to states or consortia of various political subdivisions to conduct this assessment and to award competitive grants to address deficits found. These grants made be used to:

* Develop plans to respond to public health emergencies

* Train public health workers

* Improve public health laboratory capacity and facilities

* Develop or improve electronic public health communication systems for disease detection

An effective public heath infrastructure requires a well-trained and adequate workforce, properly equipped to accomplish the job. This legislation authorizes $99 million to achieve this goal in the first year. The law also authorizes $180 million for renovations and new construction at the U.S. Centers for Disease Control and Prevention (CDC) for needed laboratory and office space to support the core capacities identified under the relief act. This is an important component because of the central support role that the CDC provides to the nation's disease surveillance system.

To address anti-microbial resistance, the Act requires the Secretary to establish a taskforce to give advice and coordinate federal programs on anti-microbial resistance. It authorizes the federal research agencies, such as the Centers for Disease Control and Prevention and the National Institutes of Health, to conduct studies on anti-microbial resistance. It authorizes $40 million in funds for training, demonstration programs to control the spread of anti-microbial resistance, and public health programs to detect and track resistant organisms.

Finally, the Act provides $215 million for a range of programs to improve the nation's capacity to respond to bioterrorism. Programs for education and research, as well as competitive grants to states to improve their infrastructure to respond to intentional infectious agents, are authorized.

Next steps

Once Congress appropriates the funds to initiate this law, the medical and public health community needs to work together to put programs in place. This will require carefully assessing community needs and new partnerships between the medical and public health community.

Conclusion

Repairing the public health infrastructure must be a goal of the entire medical community. Public health remains the centerpiece of our population-based health care system and is an important component of our national defense against bioterrorism. The Public Health Threats and Emergencies Relief Act of 2000 will go a long way toward ensuring a solid system.

Georges Benjamin, MD, FACP, is the Secretary of the Department of Health and Mental Hygiene in Baltimore, Maryland.

Note

The stated views are those of the author and do not represent those of the State of Maryland or the Department of Health and Mental Hygiene.

References

(1.) Institute of Medicine. "The Future of Public Health." Washington, D.C.: National Academy Press, 1988.

(2.) www.naccho.om/advocacy257.htm.