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Shoe-Leather Epidemiology Needs More, Not Less Funding

Infections from contaminated steroid injections, influenza outbreaks, destruction from Sandy, West Nile Virus, measles and pertussis outbreaks. These are just a few of the public health crises we faced down in 2012, thanks to the tireless efforts of local and state health departments. Each outbreak takes tremendous resources on top of day to day surveillance activities, but public health is now facing its own crisis of funding: The sequestration will cripple local and state public health departments. Analysts calculate an effective funding reduction of 9%, with the Centers for Disease Control and Prevention losing $350 million. While every federal agency will have to tighten its belt, for public health there are no more belt holes.

“Sequestration would impact every CDC program and could increase the risk of disease outbreaks,” Centers for Disease Control and Prevention Director Thomas R. Frieden recently told CQ HealthBeat. “More than two-thirds of our budget goes out to boots-on-the-ground work at the state and local level to find and stop outbreaks and other health threats.”

Maybe those making fiscal policy don’t appreciate what those boots actually do. Here’s an example: Last September, my friend and colleague Dr. Tim Jones, state epidemiologist in Tennessee, was on his way to Ethiopia to assist with influenza surveillance when he received an email message from a Vanderbilt University physician with the subject heading, “Unusual Case.” This doesn’t always herald an epidemic, but every unusual case needs to be investigated. Tim had to pull colleagues from other projects like flu vaccination. This “unusual case” happened to be a person with fungal meningitis, and in the following days, similar cases were discovered and the cases were no longer unusual. Tennessee health department staff were plucked from their routine activities. In order to prevent a massive outbreak, they had to determine the source of the infections.

In public health, we use the term “shoe-leather epidemiology” for the investigations that epidemiologists must conduct in such cases. Tim’s staff had to engage in detailed, one on one conversations with each new patient and their loved ones and acquaintances the way that detectives hunt down a criminal. Shoe-leather epidemiology is how health departments around the country collectively discovered the source of this outbreak: contaminated steroid injections. Once identified, the Tennessee Department of Health and many others around the country were in full crisis mode as they raced to prevent additional infections.

Outbreak response is what local and state health departments do 24/7. Once an outbreak is identified, an emergency operations center is formed. In Tennessee, six task-specific working teams met in the morning in a tiny converted break room to prioritize surveillance, interview, and communication activities. Employees’ 9-5 schedules were scrapped and they spent long hours searching for new cases, interviewing ill patients and their loved ones, and answering questions from the public and the media. As the list of infected grew, Tim ate breakfast, lunch, and dinner with his co-workers. It was not unusual to see health department staff arriving or leaving with deflated air mattresses and sleeping bags tucked under their arms. Every outlet was occupied by a charging Blackberry.

In November, after a recall of the tainted products, there was a lull in new cases. The emergency operations center was scheduled for break down. Just when it seemed that Tim and his co-workers could sleep in their own beds and eat with their own families, a new cluster of infections was discovered. The air mattresses and sleeping bags returned and stale coffee was being reheated in the microwave. Everybody in the health department had to refocus and figure out this new wave of infections and how to contain it. One of Tim’s challenges was how to pay for all of it after depleting his department’s budget so early in the fiscal year.

Tim’s experiences and those of the Tennessee Health Department were duplicated in Minnesota, Indiana, and Virginia, each of which had outbreaks involving more than 40 people. To date, more than 700 individuals around the country have experienced infections related to the tainted injections, and 47 have died. Without the rapid response of public health workers at local, state, and national levels, those numbers would have been exponentially higher.

Budget cuts not only affect how effectively public health departments respond to crises, but our health intelligence at the national level. Federal funds from CDC support local and state efforts, a mutually beneficial arrangement that facilitates sharing of data and resources. Frieden reported that during the meningitis outbreak, the agency helped 23 health departments notify 14,000 people at risk of exposure in a matter of days, and it disseminated information on treatment to doctors around the country. If the CDC has to slash its state resources, local and state health departments will have no choice but to discontinue their surveillance activities, which means our nation’s ability to detect and respond to disease outbreaks will be compromised.

The Affordable Care Act earmarked $18.75 billion for a Prevention and Public Health Fund to be disbursed through fiscal year 2022, but it has been slashed to $4.5 billion since the sequestration has gone into effect. These reductions will all but eliminate our country’s capacity to control the next outbreak. Forget boots-on-the-ground shoe-leather epidemiology. Without funding, the boots will have to remain in the closet, desperately in need of repair.

Andi L. Shane, MD, MPH, MSc is an Assistant Professor of Pediatric Infectious Diseases and Global Health at Emory University and a Public Voices Fellow with The Op-Ed Project.

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Rachel Heckscher
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Rachel Heckscher

Nice article.

Ian Mordant
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Dear Andi, Excellent article. Deserves to be republished widely. maybe you should have mentioned laurie Garrett’s ‘The Coming Plague’ book? or is it too well known to need a mention?

Ian