Q&A: U.S. Public-Health Official Protests Federal Medical-Response Cuts

A scientist works at a medical laboratory in New York City in 2011. A senior official at the Centers for Disease Control and Prevention sharply criticized a Health and Human Services Department proposal to reduce federal grants to state and local public-health agencies in fiscal 2015.
National Journal
April 28, 2014, 10:49 a.m.

A seni­or U.S. pub­lic-health of­fi­cial has taken a stand against his de­part­ment’s latest push to cut fed­er­al funds to an ar­ray of med­ic­al-read­i­ness ini­ti­at­ives.

More than half a dec­ade of re­duc­tions to spend­ing on state and loc­al pub­lic-health agen­cies has already been “ex­tremely dam­aging” to cap­ab­il­it­ies across the coun­try for re­spond­ing to un­con­ven­tion­al at­tacks and oth­er dis­asters, Dr. Ali Khan, dir­ect­or of the Pub­lic Health Pre­pared­ness and Re­sponse Of­fice at the Cen­ters for Dis­ease Con­trol and Pre­ven­tion, told Glob­al Se­cur­ity News­wire in an in­ter­view.

The Health and Hu­man Ser­vices De­part­ment’s latest push would fur­ther un­der­mine ini­ti­at­ives that are now “stag­nant,” Khan ar­gued.

“We used to have a $1 bil­lion pub­lic health pre­pared­ness pro­gram, [and] that is al­most two-thirds to one-half that size at this point,” said Khan, re­fer­ring to a range of pro­grams that re­ceived an in­fu­sion of fed­er­al dol­lars after the Sept. 11 ter­ror­ist at­tacks. “With every new cut, that’s few­er people at the state and loc­al health de­part­ments, and few­er sup­ports for pub­lic health sys­tems that are keep­ing people safe from daily threats.”

Re­duc­tions sought in the health agency’s fisc­al 2015 budget pro­pos­al in­clude a $28 mil­lion cut to spend­ing on the Pub­lic Health Emer­gency Pre­pared­ness grant ini­ti­at­ive. Khan de­scribed that as a crit­ic­al fund­ing source for labor­at­or­ies and spe­cial­ists needed to con­tain dis­ease out­breaks, in­clud­ing any caused in­ten­tion­ally.

Health and Hu­man Ser­vices wants to max­im­ize agency re­sources “in the cur­rent fisc­al en­vir­on­ment,” and plans to shift the grant pro­gram’s fo­cus to “cap­ab­il­ity sus­tain­ment” after spend­ing more than $9 bil­lion since 2002 to up­grade med­ic­al re­sponse ca­pa­cit­ies across the coun­try, the de­part­ment said in its fisc­al 2015 budget jus­ti­fic­a­tion for the Cen­ters for Dis­ease Con­trol.

Khan, though, said many of those up­graded cap­ab­il­it­ies have already withered after pri­or rounds of cuts.

“This money is really sliced and diced very thinly already” among thou­sands of loc­al health agen­cies, said the vet­er­an Cen­ter ad­viser on bio­lo­gic­al ter­ror­ism threats. The grant pro­gram would re­ceive $617 mil­lion in the com­ing budget cycle un­der the Health and Hu­man Ser­vices pro­pos­al.

Oth­er tar­gets of the de­part­ment’s spend­ing re­duc­tions in­clude the Stra­tegic Na­tion­al Stock­pile, which main­tains med­ic­al treat­ments across the United States for re­spond­ing to po­ten­tial strikes in­volving weapons of mass de­struc­tion. Khan’s of­fice man­ages the pro­gram, which would see its fund­ing drop by $8 mil­lion un­der the health agency’s pro­pos­al for fisc­al 2015.

Khan as­sumed his cur­rent po­s­i­tion in Au­gust 2010, after hold­ing a range of posts that in­cluded as­sist­ant sur­geon gen­er­al and deputy dir­ect­or of the Na­tion­al Cen­ter for Emer­ging and Zo­onot­ic In­fec­tious Dis­eases. He joined the Cen­ters for Dis­ease Con­trol in 1991, after ob­tain­ing a med­ic­al de­gree from Down­state Med­ic­al Cen­ter in Brook­lyn, NY.

Khan spoke to GSN by tele­phone from the Cen­ters for Dis­ease Con­trol headquar­ters in At­lanta. Ed­ited ex­cerpts of the March 24 in­ter­view fol­low:

GSN: What chal­lenges has your of­fice faced in com­mu­nic­at­ing with the pub­lic about pre­par­ing for bio­lo­gic­al and oth­er un­con­ven­tion­al at­tacks?

Khan: “¦ Chem­ic­al and bio­lo­gic­al ter­ror­ism [is] an ex­tant threat “¦ but we try not to be that fo­cused on single threats for pre­pared­ness ef­forts. We really need to think about an all-haz­ards, all-com­munity ap­proach.

We need to make sure our com­munit­ies are pre­pared for pan­dem­ics, nat­ur­al dis­asters and ter­ror­ism, wheth­er it’s chem­ic­al, bio­lo­gic­al, [ra­di­olo­gic­al and nuc­le­ar] ter­ror­ism or oth­er forms of ter­ror­ism. And all of that [should be] laid on a found­a­tion of strong pub­lic-health and com­munity-re­si­li­ence sys­tems that can be scaled up for these dis­asters.

Our chal­lenge is to help our com­munit­ies un­der­stand “¦ that [pre­pared­ness] isn’t just the role of the feds. That’s the role of the state and loc­al health de­part­ments, that’s the role of the private in­dustry, that’s the role of the non­profits, and it in­cludes the role of an in­di­vidu­al in their pre­pared­ness. “¦

If some­body “¦ is in­di­vidu­ally pre­pared and their fam­ily [is] pre­pared, it al­lows the re­sponse com­munity to fo­cus on those people who un­for­tu­nately may not be pre­pared. “¦

GSN: Has the lack of a high-pro­file un­con­ven­tion­al at­tack in re­cent years factored in­to CDC’s com­mu­nic­a­tions strategy?

Khan: No, only if you think that our pre­pared­ness and read­i­ness pro­grams are just wait­ing around for something to hap­pen — for an im­pro­vised nuc­le­ar device or something — but we just had a pan­dem­ic in 2009 with H1N1, we just had a num­ber of na­tion­al storms, we just had a num­ber of ex­treme weath­er events.

There are nu­mer­ous routine pub­lic-health threats [such as] measles and mumps out­breaks in New York City [and] hep­at­it­is out­breaks. “¦ So it’s im­port­ant for us to re­mind our com­munity of those and use those as the ful­crum to get people to be pre­pared.

GSN: What emer­ging pub­lic health threats should the U.S. pub­lic be more aware of?

Khan: From an in­fec­tious-dis­ease stand­point “¦ a new flu strain al­ways re­mains a threat. So [do] oth­er eas­ily spread res­pir­at­ory vir­al dis­eases, such as coronavir­uses. There’s a new one cur­rently in the Middle East. And just knock­ing on our door is chikun­gun­ya vir­us out of the Carib­bean right now that po­ten­tially could be spread through the United States.

From a [de­lib­er­ate-use] stand­point, there’s a couple of patho­gens that worry us. “¦ At the top of that list [are] an­thrax and small­pox, but it also in­cludes oth­er agents such as plague and tu­lar­emia and botulism. [And] some of the vir­al hem­or­rhagic fevers are usu­ally in the top list of agents that we worry about and have taken sig­ni­fic­ant pre­pared­ness steps [against]. “¦

GSN: Is the CDC con­sid­er­ing any new op­tions for use of stock­piled an­thrax vac­cine near­ing ex­pir­a­tion, giv­en the slow pro­gress of an ini­ti­at­ive to dis­trib­ute such vac­cine to first re­spon­ders?

Khan: “¦We are work­ing with our col­leagues in [the Home­land Se­cur­ity De­part­ment] who are put­ting to­geth­er a pro­gram to think about how do they po­ten­tially vac­cin­ate an in­ter­ested first re­spon­der, but that’s in­de­pend­ent of the con­cern about ex­pired vac­cine.

They’re try­ing to do the right thing, and we’re try­ing to help them “¦ to provide vac­cine for those who may be in­ter­ested. “¦

GSN: How do you ex­pect pub­lic health pre­pared­ness to be af­fected by cuts sought in the fisc­al 2015 budget to the Pub­lic Health Emer­gency Pre­pared­ness Grant Pro­gram?

Khan: There are sig­ni­fic­ant cuts to pub­lic health pre­pared­ness mov­ing for­ward. This is not new; there have been on­go­ing cuts for the last six or sev­en years. We used to have a $1 bil­lion pub­lic health pre­pared­ness pro­gram, [and] that is al­most two-thirds to one-half that size at this point. And the data is pretty clear already, even without new cuts.

People are al­ways wor­ried what are the next set of cuts go­ing to do to you, and I would rather talk about what the cur­rent set of cuts have already done to us as a na­tion. If you look at ob­ject­ive, quant­it­at­ive meas­ures of pre­pared­ness, we can say un­equi­voc­ally that pre­pared­ness ef­forts in the United States are stag­nant, [or] are on the de­cline. “¦

The [Na­tion­al Health Se­cur­ity Pre­pared­ness In­dex] is the first nov­el meas­ure­ment scheme in the United States to give you a com­pos­ite meas­ure of what pre­pared­ness looks like at a state level. “¦

You can go look at those rat­ings between 6.9 and 8.2 [on a scale of 10] of where our vari­ous states “¦ are with­in five do­mains [health sur­veil­lance; com­munity plan­ning and en­gage­ment; in­cid­ent and in­form­a­tion man­age­ment; surge man­age­ment; and coun­ter­meas­ure man­age­ment] to make the point that we don’t think we’re fully pre­pared in the United States. “¦

The state and loc­al read­i­ness pro­gram “¦ is about mak­ing sure that states and loc­al pub­lic health de­part­ments have the tools, the people, the sys­tems, the boots on the ground that they need “¦ to re­spond to their daily pub­lic health threats and to be able to scale up for un­pre­dict­able or large threats. “¦

We have very good data on [15 pre­pared­ness cap­ab­il­it­ies] to show you that those are stag­nant also.

This is with cur­rent cuts, so don’t even be­gin to ask me [about] the im­pact [of] ad­di­tion­al cuts on our state and loc­al health de­part­ments, where we take this small amount of money, we divvy it out between the states, the cit­ies and ter­rit­or­ies, and they in turn divvy it out between any­where between 2,000 to 3,000 loc­al health de­part­ments or county health de­part­ments. This money is really sliced and diced very thinly already. “¦

At its height, we had unique things hap­pen in pub­lic health that we had nev­er seen, and I have the ad­vant­age of help­ing to put this pro­gram to­geth­er back in 1999 to see how far we’d come. You know, loc­al health de­part­ments didn’t even have com­puters, and we had this won­der­ful thing 10 years ago called the fax ma­chine that we were try­ing to pur­chase for many loc­al health de­part­ments. “¦

But county health de­part­ments all of a sud­den had epi­demi­olo­gists to in­vest­ig­ate out­breaks that they oth­er­wise wouldn’t have had. We have state health de­part­ments that built “¦ labor­at­ory sys­tems and their dis­ease-de­tec­tion sys­tems on these dol­lars.

And these dol­lars are used “¦ every day in our pub­lic health com­munit­ies to keep Amer­ic­ans safe from pub­lic health threats, so these are the routine set of re­sources they’re us­ing for their dis­ease de­tec­tion and re­sponse ef­forts and even some of our spe­cial­ized re­sources. “¦

[This in­cludes] the work we do with the Stra­tegic Na­tion­al Stock­pile to make sure that we have points of dis­pens­ing for something like an an­thrax at­tack, and they use these points of dis­pens­ing for vac­cine cam­paigns across the United States. “¦

Botulism oc­curs all the time in the United States, and when they need an­ti­tox­in it comes from the Stra­tegic Na­tion­al Stock­pile. That’s an­oth­er little ex­ample.

We’ve [also] provided fed­er­al med­ic­al sta­tions from the Stra­tegic Na­tion­al Stock­pile to vari­ous “¦ nat­ur­al dis­aster re­sponses over the years. “¦

[The cuts] have been ex­tremely dam­aging to date. “¦ With every new cut, that’s few­er people at the state and loc­al health de­part­ments, and few­er sup­ports for pub­lic health sys­tems that are keep­ing people safe from daily threats. “¦

In ad­di­tion to cuts to the state and loc­al pro­grams “¦ we’re cut­ting [fisc­al 2015 funds] to aca­dem­ic cen­ters, so we’re cut­ting a lot of the work that looks at [how] to use the lim­ited dol­lars we have to get the most out of our com­munit­ies from a pre­pared­ness stand­point and from a re­sponse-and-re­cov­ery stand­point.

GSN: Last year’s fed­er­al gov­ern­ment shut­down res­ul­ted in a sus­pen­sion of CDC in­spec­tions at Biosafety Level 3 and 4 fa­cil­it­ies. What level of risk did you see in that sus­pen­sion?  Have there been oth­er con­cern­ing im­pacts from fluc­tu­ations in fund­ing avail­ab­il­ity?

Khan: Our pro­gram was ex­tremely re­spons­ible dur­ing the fur­lough [be­cause] this was a na­tion­al-se­cur­ity is­sue. “¦ They did sus­pend a large num­ber of in­spec­tions they’ll have to make up at this point, but they were still avail­able for any act­ive con­sulta­tion that labs needed around biosafety and bi­o­se­c­ur­ity is­sues. “¦

This is the crit­ic­al pro­gram of the United States that makes sure that any­body that has, uses or trans­fers some of the most deadly patho­gens in the world is un­der reg­u­lat­ory over­sight “¦ [and it] con­tin­ues to evolve all the time. “¦

GSN: A re­cent New­s­week art­icle made the case that the pro­lif­er­a­tion of bio­lo­gic­al-de­fense labs over the last dec­ade poses a great­er pub­lic health threat than the danger of de­lib­er­ate and nat­ur­al out­breaks that such fa­cil­it­ies are in­ten­ded to counter. Speak­ing broadly, what is your ar­gu­ment against the idea that the cure is more po­ten­tially de­struct­ive than the prob­lem it was de­signed to ad­dress?

Khan: There’s prob­ably noth­ing more safe — or few things safer in the United States — than re­search on these patho­gens, thanks to the joint [U.S. Ag­ri­cul­ture De­part­ment-Cen­ters for Dis­ease Con­trol] Se­lect Agent Pro­gram that mon­it­ors these labor­at­or­ies. “¦

If you have the patho­gen — if you use it, or if you trans­fer it — that’s all cur­rently reg­u­lated by the USDA and [CDC]. These are fa­cil­it­ies that are mon­itored, in­di­vidu­als who work on these patho­gens are mon­itored, the nature of the work that they do is very closely mon­itored. Every year “¦ they have con­crete meas­ures of how well they’ve done. “¦

So there’s really great data on “¦ how ef­fect­ive these pro­grams have been in mak­ing sure that all of this re­search is done very, very re­spons­ibly. [The] New­s­week art­icle didn’t pick up … how re­spons­ible this work cur­rently is.

Cor­rec­tion: This art­icle was up­dated at the re­quest of Khan’s of­fice to cla­ri­fy his de­scrip­tion of agen­cies ad­min­is­ter­ing the U.S. Se­lect Agent Pro­gram.

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