BMJ  2005;331:E378-E379 (17 September), doi:10.1136/bmj.331.7517.E378

BMJ USA: Education and debate

Funding the public health response to terrorism

¹ Department of Family and Preventive Medicine Emory University School of Medicine Atlanta, GA, efrank{at}emory.edu

Thoughts on the fourth anniversary of 9/11

On September 11, 2001, 3400 people died because of four horrific, intentional plane crashes. These individuals' only unifying characteristic was that they were in the wrong place in America at the wrong time. Their deaths, and those of Londoners killed on July 7, 2005, were a tragic alarm about our vulnerability, and they understandably launched an avalanche of responses.

Among the consequences of these deaths, several subsequent deaths from anthrax, and other current and potential terrorist threats, were a major redefinition and redirection of the United States government's role in and funding for public health. Since governments must protect their citizens, addressing these possible future threats is appropriate and could prove essential to Americans' health. However, there is an immediate, real threat that these government actions will allow enormous numbers of Americans to die unnecessarily. This threat is the redirection of funds away from basic, currently necessary public health services to the prevention of potential future bioterrorism (BT) threats.

In 2002, New York State designated $1.3 million to reduce heart disease, the leading killer of New Yorkers; contrast this with the $34 million awarded by HHS for bioterrorism preparedness.

What problems do basic public health services try to address, and why is diversion of resources away from them of concern? Using national estimates of mortality attributable to various risk factors (table 1) and actual death counts by disease (table 2), I have estimated the number of Americans who likely died on September 11, 2001, not from terrorism but from the major sources of mortality that many basic public health services work to address.

View this table: [in this window] [in a new window]   Table 1 Estimated number of US deaths attributable to leading risk factors,11 September 11, 2001

 

View this table: [in this window] [in a new window]   Table 2 Estimated number of US deaths from 10 leading causes, September 11, 200113

 

The importance of these numbers is not only their magnitude—between 3000 and 5000—but also their predictability. A similar number of deaths from these same causes happened not just on September 11, 2001, but on September 12, 2001, and every day since then.

Concerns about disproportionately funding BT versus other public health functions have been building for some time. As early as 2002, many thought that the Bush administration's smallpox vaccination plan was a misguided redirection of public health funds for BT, and it was thwarted. Initial smallpox vaccination cost estimates ranged from $600 million to $1 billion,¹ and plans for vaccination and treatment of smallpox, anthrax, and botulism were projected to exceed $6 billion over the following decade.² Even the CDC's own Morbidity and Mortality Weekly Report documented state health departments' "difficulty allocating the necessary time and resources for the pre-event smallpox vaccination program."³ Concerns about an inadequate science base for this initiative and about it being a distraction from more fundamental public health needs helped to redirect this effort.

But while mass smallpox immunization efforts are no longer a major focus for public health departments, BT preparedness still seems magnified well beyond the level of what current competing mortality threats might logically prescribe. For example, in September 2002, New York Governor Pataki proudly spoke of a "critical program" that awarded $1.3 million to reduce heart disease, the leading killer of New Yorkers (accounting for 37% of all deaths in New York State).⁴ Contrast this with the $34 million awarded to New York by the US Department of Health and Human Services for BT preparedness, part of over a billion dollars in BT preparedness funding announced nationally in 2002.⁵ Similarly, North Dakota's Governor Hoeven announced $300,000 in funding for heart disease and stroke prevention⁶; this can be compared with the $7 million designated for BT preparedness in the state.⁵ Due to BT funding, state health departments increased the number of epidemiology workers doing infectious disease and terrorism preparedness by 132% between 2001 and 2003.⁵ But concurrent with this increase in BT funding came additional BT mandates, with 66% of health departments having problems allocating time for general planning, and 55% having problems establishing even basic disease surveillance systems.³

More recently, in May 2005, the New York Times reported that Congressional auditors found that FBI funds designated for investigating health care fraud appeared to have been improperly shifted to other purposes, including fighting terrorism, over the past three years.⁷ In response, Joseph L Ford, the FBI's chief financial officer, said the attacks of September 11, 2001, "demanded an instant, 100 percent commitment toward counterterrorism."⁷

Also in May 2005, the Pentagon proposed being exempted from aspects of the Clean Air and RCR (hazardous waste recovery) Acts, including capping its "legal liability for cleaning up polluted sites once it sells land to a new owner, and allowing military areas that do not meet national air standards to remain that way for an additional three years."⁸ And the Associated Press reported that 34 military bases shut down since 1988 are on the Environmental Protection Agency's Superfund list of worst toxic waste sites (most of them for at least 15 years) and none are completely cleaned.⁹

But the clearest recent example of diversion of resources may be the transferring of senior CDC scientists away from their regular disease prevention duties to study creating a BT preparedness kit for each American household. Several involved CDC scientists have bemoaned the extraordinary waste of scientific and financial resources they believe this represents, the inappropriateness and danger of the potential national distribution of antibiotics, and the general wrongness of pursuing such an ill-conceived course for such an unlikely event at the expense of major, immediate national priorities.¹⁰

These observations are not intended to diminish the tragedies of September 11, 2001, or July 7, 2005, or other terrorist plots, or to negate the importance of developing effective and humane ways of making sure such tragedies are not repeated. It is certainly justifiable for governments to appropriate substantial funds to prevent potential future threats to our security. But public funding for other current threats should not be compromised. We must recognize that a highly predictable tragedy is happening daily. We already know many strategies to help reduce the numbers of deaths from these predictable causes. We know that millions of people will certainly die unless we protect the population against "routine" causes of death. Let's not make Americans wonder if they're in the right place at the right time if they want to stay healthy. Let's not have one more American die because of the horrors of September 11, 2001.

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Competing interests: None declared.

References

1. Connolly C. Smallpox plan may force other health cuts: states cite inability to fund vaccinations. Washington Post.December 24, 2002; A1.
2. Neergaard L. Administration wants to stockpile treatments for bioterror pathogens. Associated Press. January 29, 2003: 1.
3. Centers for Disease Control. Terrorism preparedness in state health departments—United States, 2001--2003. Morb Mortal Wkly Rep 2003;52: 1051-53.[Medline]
4. New York State Office of the Governor. Governor: $1.3 million in funds for heart disease prevention. Available at: www.state.ny.us/governor/press/year02/sept27_02.htm. Accessed July 8, 2005.
5. Department of Health and Human Services. Bioterrorism preparedness grants. Available at: www.hhs.gov/news/press/2002pres/20020606b.html. Accessed July 8, 2005.
6. North Dakota Office of the Governor. North Dakota receives funding for prevention of heart disease and strokes. Available at: www.health.state.nd.us/ndhd/press/n030709.htm. Accessed July 11, 2005.
7. Pear R. FBI is said to misuse money for health care fraud cases. New York Times. May 16, 2005; 18.
8. Eilperin J. Pentagon seeks waivers on environmental rules. Washington Post. May 11, 2005; 15.
9. Heilprin J. Dozens of closed military bases are on EPA's Superfund list of worst toxic waste sites. Associated Press. May 12, 2005: 1.
10. Frank E, and CDC personnel. Discussion of bioterrorism preparedness kit development. Atlanta, GA:July 4, 2005.
11. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270: 2207-12.[Abstract]
12. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291: 1238-45.[Abstract/Free Full Text]
13. Anderson RN, Smith BL. Deaths: leading causes for 2001. Vol 52, No. 9. Hyattsville, MD: National Center for Health Statistics, Division of Vital Statistics; 2003.

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