COVID-19 Highlights Urgent Need for Increased Public Health Funding

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: asking Congress for more funding to hold off the coronavirus; state and territorial health officials travel to Washington, D.C. to lobby the White House and Capitol Hill.

JIM BLUMENSTOCK:
And the public health community is not only providing the proper scientific approaches to the issues, but they're also doing their very best to educate and inform the community they serve, to put it in proper perspective, and sort of to create that community-wide response to manage and control the issue.

DR. NIRAV SHAH:
My hope is to pull back the curtain and share stories and data around what state-level public health is really doing. I think that's the first necessary step toward a better conversation about what kind of funding is needed.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: in search of the money needed to gear up ahead of the coronavirus as concern mounts over an infection that could soon lead to a global pandemic.

ASTHO's Washington Week agenda takes an urgent turn with state and territorial health officials holding meetings with members of Congress and the Trump administration, looking for money to boost efforts aimed at curbing coronavirus back home.

We have two conversations.

Jim Blumenstock is ASTHO'S chief of health security. He's along to discuss the strategy public health professionals use to stem an outbreak. We'll examine the several layers of response intended slow and, eventually, stop the infection spread.

But first, we hear from Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention, one of those making the coronavirus case to lawmakers this week.

In Washington this week, the big topic is coronavirus and you're here to make the case for more funding to help fight it.

SHAH:
That's right.

What we see in every single large outbreak response is that—although there's a lot of work being done at the international level and the national level—the real response happens on the ground at the state level. And what we want to do is make sure that members of Congress, as well as the administration, are aware that states have to have funding in order to do this work.

As I like to tell folks, you cannot pour from an empty cup; and, in this situation right now, what we're looking at with coronavirus is a long-term, intense activation at the state level, working across the healthcare system.

We want to make sure that we have adequate resources and funding to pull that off.

JOHNSON:
You don't always know if you're going to have enough money to do that because, with any outbreak like this, you are just not sure how long it will last, how many will be affected—too many variables to predict.

SHAH:
One of the challenges of public health is that we often operate with less than all of the information that we would want to have in the ideal world. That is, unfortunately, the nature of public health.

What we know is that in these situations, though, even though we don't necessarily have a sense for where we may end up, we know that, in order to get there—wherever that "there" is—additional funds are going to be needed. That's just the nature of planning for big situations.

What we want to do right now is make sure that, as we start moving down that path, as states start ramping up their activation to get ready for—for example, a surge in the number of ill people going to the healthcare system—that we've got the resources that we need to start that process.

Where we end up, we're not quite sure yet, but we know that we need to start.

JOHNSON:
Some states have had to start moving money around already.

You have not been faced with that challenge just yet, but it's not an easy game to play.

SHAH:
It's not. In state funding, every single dollar that is spent by a governmental agency, like health departments, has to be separately and specifically authorized by the legislature in that state, and this is a pattern in almost every state.

What that means is if the state legislature tells us, "you can spend $10,000 on lab equipment," but if we need to actually spend $12,000 in order to test for more people with coronavirus, we need to go back to the state legislature to get permission to spend that additional $2,000. That process is very, very labor-intensive, and we're starting to think now about how to do that.

The reason why this is important is that, in public health, we talk a lot about preparedness. And a lot of times what we think about when people talk about preparedness, what they're thinking about is the hospital system, the EMS system, making sure that those things are ready to go. But folks often neglect administrative and political preparedness, and that's what these things like shifting money around in the budget are about.

We have to be just as prepared to go meet with our legislators to talk about shifting funds. We have to be just as prepared to do that as we are to work with the hospital that sees a surge in patients.

JOHNSON:
Why do you think that neglect happens?

SHAH:
I think it happens for a lot of reasons.

The principal one is that it's easy to get lulled into the status quo; and what we know in big situations—situations that are low likelihood but high magnitude—is that everything we knew before about the status quo doesn't apply.

And so, we have to avoid the risk of getting lulled into the notion that the way things worked before is the way that they'll work in the future.

JOHNSON:
There is fear of a global pandemic with coronavirus. Does that make getting the money easier?

SHAH:
You know, certainly when you have a situation that is new or a situation that folks have not faced before, there is a natural fear response. We never want to play on that. The best principles of public health are those that are rooted in science and not any type of concept of fear or scare.

What we know about coronavirus is that it's concerning. Although the risk in the United States right now remains low, we certainly know that just this week, there are increasing numbers of the virus happening in countries outside of China—South Korea, Italy, most notably.

And so, those concerns suggest that the virus is popping up in significant places around us, and we've got to be ready for that here in the United States.

JOHNSON:
So, now is the time to get the funding you need to make sure that you don't drop the balls anywhere.

SHAH:
That's exactly right.

What we know about congressional funding is that it's not a light switch on the wall that can be flipped whenever we want it to. These processes, these conversations, take time.

And given that lead up time—in order for the funding to be appropriated by Congress, for the administration to sign off on it, and then for the funding to actually arrive at the states—it could be a significant number of weeks.

That's why we feel it's important right now, this week, here in Washington, to start having those conversations.

JOHNSON:
What does the money go toward? What do you spend it on?

SHAH:
Really for us, it's two big categories at the state level.

The first is human resources to keep this level of activation up. The frenetic pace that we've been operating on is going to require additional people. Right now, in my own agency, I've got several staff who are doing double duty—they're doing their full-time job during the day as the influenza coordinator; they're also doing a second job as our lead epidemiologist for coronavirus. That pace cannot be sustained for long. As leaders, we have to take care of our staff. So, one thing we'll need it for is HR.

Another thing that we will need it for supplies and materials. If we are thinking about looking to test the additional numbers of people for the virus at the state level, those materials, those reagents, those test tubes that we use—the funding for that will be essential.

JOHNSON:
And then there's the situation with the programs that are giving up resources and money so that this can be handled—can't let those go unattended for very long either.

SHAH:
That's right. We will not have served the public's health if we add to coronavirus simply by taking away from something else.

So, our goal is to ensure a continuity of operations across the agency, and that involves probably adding staff, depending on how this activation goes. Right now, we don't know, but one of the mantras of public health is, "hope for the best but prepare for the worst."

JOHNSON:
What is your hope for this week?

SHAH:
Our hope is to be able to pull back the curtain for members of Congress on what local and state public health is about.

There's a lot of sense out there that public health is important, and we know we need to fund it better than we have historically. My hope is to pull back the curtain and share stories and data around what state level public health is really doing. I think that's the first necessary step toward a better conversation about what kind of funding is needed.

JOHNSON:
And get consensus on the fact that you need more money.

SHAH:
That's exactly right. The first step is getting buy-in on the fact that states do need additional funding for long-term activations. The second step is how much funding.

JOHNSON:
Since the 1970s, Jim Blumenstock has taken on some of the nation's biggest public health crises—first in New Jersey State Health Department, and now at ASTHO.

Here's his take on the public health approach to the coronavirus outbreak.

BLUMENSTOCK:
The nation's public health system has a lot of experience in dealing with small and large outbreaks.

Again, you know, since September 11th and even before that, they had been building their capabilities and capacity to handle all hazards; and by all hazards, I mean, things that could range from an act of terrorism to natural disasters—such as floods, fires, or earthquakes—and also what Mother Nature will throw at us as far as the infectious diseases that emerge somewhere in the world and could cause a threat or pose a threat to any country, any continent, any community around the world.

JOHNSON:
Everyone in the public health space, whether they're at the federal level or the local level, is working on this.

What does that approach look like?

You've written about that as well—you call that an aggressive layered approach.

BLUMENSTOCK:
Sure.

I think everyone would sort of characterized this as an all-hands-on-deck, meaning that no matter where you are in the government—federal, state, local—you are identifying and putting towards this response every available asset and resources you have to have this layered approach. So, when you look at what the term means, it requires multiple features at different points that, collectively, will provide you that barrier or that level of protection.

So, the layered effect does include such things as what's going on in China—basically, to tamp down and control the outbreak and ensure that sick individuals do not leave the area of concern in China. So, that could arguably be layer one.

Layer two would be what we are doing to protect our homeland through the screening of individuals traveling back into the United States from China to ensure that we know if they're healthys; and following them during the 14 day incubation period to make sure that, if they do show symptoms, they could be readily identified and cared for. That's another layer.

And the third layer is, obviously, if we do see community spread from person to person, to ensure that we have the appropriate disease surveillance, laboratory testing, and clinical capabilities to care for individuals who may be infected by the coronavirus.

So, those are sort of three elements that add up to sort of this layered effect. So, not one of those actions in itself will solve the problem; but collectively, they all contribute to a risk-based strategy to basically protect the public.

JOHNSON:
Do you feel like it's a good approach?

BLUMENSTOCK:
Absolutely.

To me, it reflects a commitment and a recognition that we need to take prudent steps, but it's not a panic.

So, you know, many people who look at this may feel that it's too aggressive, it's too draconian, as far as the steps that the U.S. government is taking or other parts or other governments around the world. And the issue with a novel virus is we really don't know what its potential is to cause harm to individuals, to communities, or to societies.

So, taking these aggressive, prudent approaches that are all temporary—you know, they'll be adjusted as time goes on and we learn more about the virus and we see how our control measures are making impacts. I mean, they are continuously evaluated and modified accordingly to, basically, provide the appropriate and necessary level of protection but also trying to reduce the inconvenience or the hardship on individuals whose livelihoods may be restricted temporarily just until we get control the situation and learn more about the virus.

The other issue with a novel virus, like this coronavirus, is—unlike a seasonal flu, as an example; every year we have a vaccine, we have known medical countermeasure drugs that are effective in treating people who become sick with the flu. That doesn't exist with a coronavirus. There is no vaccine against it, and there's really no known or proven medical treatment for the disease.

So, if you become ill, you know, you're providing the highest quality supportive therapy to treat your symptoms and support your body to fight the infection, and that's another reason why this aggressive layered approach to the issue is necessary because we don't have the arsenal of medical countermeasures for this coronavirus that we would have for other diseases—like the seasonal flu, as an example.

JOHNSON:
Your layers, essentially, are trying to contain and control what's already in the community.

BLUMENSTOCK:
Containment is the operative term. That is the number one strategy that's being followed.

JOHNSON:
And then ride it out.

BLUMENSTOCK:
Exactly. Riding it out, constantly monitoring it, making those adjustments.

We also try to look and see what other steps we need to put in place to, basically, mitigate its effects as well. And that would be sort of more upstream activities, such as when a vaccine becomes available, obviously to have a campaign to make that available to members of the public who may be at risk.

And, certainly, the other elements of containment are public education and awareness. I mean, there are things that people can do to protect themselves: you know, knowing to how to avoid certain risks as far as personal hygiene; cough etiquette; you know, sanitation; being familiar with your environment; seeking medical care if you feel that you are at risk either because of your travel history—which is key to certain areas—or if you've been with somebody who is known to have coronavirus.

So again, all of these elements add up to that level of protection and that level of containment that's designed to protect public health.

JOHNSON:
Other than a vaccine, which we've heard is about a year away, what other tools are still available to deploy into the community if necessary?

BLUMENSTOCK:
So, actually, we are using, I believe, all the tools that we have available to us and we are using them appropriately.

A couple of examples that immediately come to mind: you know, number one, we are building laboratory capacity so individuals who are at risk—that are showing symptoms of possible coronavirus illness—can be rapidly and accurately diagnosed to determine whether or not they are and infected with coronavirus.

The other strategy that's being applied is basically separating individuals who either have been exposed or are not yet ill. So, we put them sort of in that quarantine category, which basically means they've been exposed to the virus but they're still healthy, and we just want to monitor them to ensure that, for the 14-day incubation period, they remain in that proper state of health.

And then, of course, those individuals who have been confirmed to be infected with the coronavirus have to be given the proper medical treatment that they need and they deserve. We need to put them in a clinical setting—in an isolation area where they're not causing harm or threat or risk to other individuals—where they could be properly cared for throughout the course of their illness by being provided with supportive therapy to ensure that secondary infections don't take place; and if they do, like pneumonia, that they can be cared for.

Other community-based interventions—if you will—would be in a hospital, a healthcare setting: you know, ensuring that medical professionals—I mean, they deal with people with infectious diseases every day, but obviously this issue is no different as far as ensuring that their infection control practices are spot on, as far as technique and understanding that our healthcare facilities, our medical community, has a full appreciation of what are some of the risk factors of coronavirus, including travel histories—in theory, an individual could present in any hospital or any doctor's office around the country.

So, you know, everyone really, whether you are a public health professional, a healthcare professional, or just an interested member of the community—you know, being aware, being astute, but not being afraid, you know, is really what I would strongly stress as sort of being our best approach.

Fear in itself is an epidemic, and following fear is the issue of stigma. So, you know, we do have an issue and a societal responsibility to be sensitive, compassionate, and not overreact, or go into sort of that stigmatization because of somebody's travel histories or ethnicity, and to attribute them to sort this global concern that we're dealing with right now. So, you know, with coronavirus, this is not a new issue. We've seen stigma and community fear back when we were dealing with Ebola in 2014, 2015.

So, again, the public health community is not only providing the proper scientific approaches to the issues, but they are also doing their very best to educate and inform the community that they serve, to put it in a proper perspective, and sort of create that community-wide response to manage and control the issue.

JOHNSON:
Your members, the state health departments, are responding. This must be doing a number on their budgets.

BLUMENSTOCK:
It is in a couple of ways because this type of response in itself carries with it additional expenditures: you know, the purchase of equipment and supplies; salaries for staff that are being, you know, dedicated to this response 24/7. So, you know, they are using the resources they have allocated to infectious disease or emergency response activities. They are moving resources away from other important programs to this project.

So, there's that second order, or that collateral impact of other programs and projects sort of being slowed down, or maybe, you know, half-speed type of an operation because they just need to move the resources to this critically important project.

So, besides the true financial impact of having a large-scale response of this type, it's also having, you know, service reductions in many of the other programs that they would normally be responsible for and on a day-to-day basis.

And then, if you have a jurisdiction that has another emergency hit us—you know, whether it be a blizzard, a forest fire, a typhoon in the Pacific—I mean, the list could go on and on of plausible events that could happen tonight tomorrow, next week, heaven forbid—those jurisdictions have to manage those types of acute incidents or emergencies as well.

And, as we said before, we're, what, week seven and week eight into this response? You watch the news on an hour-to-hour, day-to-day basis. There's no end in sight. I mean, there's no sense that this is winding down. So, the concern now is that the long-haul capability of, you know, how do we sustain this effort, probably have to do more and do it longer; but at the same time, not allow it deterioration or erosion of all of those other critically important public health programs.

So, it's difficult. It is very, very difficult for governmental public health to manage these sets of circumstances.

JOHNSON:
Is there anything that can be done on the funding side of this issue to help alleviate some of that stress?

BLUMENSTOCK:
Well, the federal government clearly has provided outstanding leadership and technical assistance and support to the state and territorial health officials. They've also showed a great deal of latitude in allowing states to use existing grant dollars that they have, whether it be for preparedness programs or other programs, to put towards this. But that's a finite amount of resources.

So, right now, the conversation is where will additional funds come from, you know, from the U.S. government, to basically supplement the current response and allow to build back the programs that have sort of contributed to this effort but in the process of also, you know, suffered by not having their routine services conducted.

So, you know, our association and our members continue to engage with the administration and congress to really find the most appropriate funding mechanism to allow this large-scale response to maintain at the appropriate level, but also not to allow the other programs to language simply because they are contributing to the overall response.

JOHNSON:
Is this going as planned?

BLUMENSTOCK:
I believe it is, I believe it is.

Following the lead of the CDC, the administration's taskforce, and other federal leaders, the playbook, my opinion, it's sort of a best-of from other types of successful responses we put in place over the years to basically contain this disease. And the whole principle around a containment is to delay its entry and tamp down its impact when it gets here.

So, I would say if that is the measure of success, I think clearly delaying entry and really tamping it down has been quite impactful, considering today we only have 14 or 15 cases. That could change tonight; but I mean, those are manageable and expected numbers.

So, I think we are successful in our strategic efforts in these particular areas.

JOHNSON:
Let's hope that continues.

You can find links to the resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

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This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.