CDC has disgorged $225 million to state and local health departments for bird fluhttp://www.dhhs.gov/news/press/2006pres/20060711.html. That's some good news, made better by the fact that these phase II allocations seem usable for a wider range of public health needs than bioterrorism or bird flu, narrowly conceived.
The money goes to help states pay for activities above and beyond what they normally provide, said Joe Posid of the U.S. Centers for Disease Control and Prevention, which distributes the money."They'll use the CDC funds for more macro or public health purposes such as surveillance, epidemiology and mass communications," Posid said in a telephone interview. (Reuters)
As usual, though, there are some stipulations. How many we don't know:
"We are asking that all states go through a number of exercises or drills or simulations that we believe will be necessary if and when a pandemic comes our way."
For instance, states need to have plans in place to close schools and set up mass vaccination clinics, he said.
Tabletop exercises and planning if a pandemic comes are necessary and important, but it would be a shame if these requirements took the lion's share of the allocations. General strenghtening of our public health infrastructures is needed. An infrastructure is the invisible structure below the things everyone sees, the services and skills that allow the rest of the system to run. This means retaining skilled personnel, staffing essential elements like disease reporting, vital statistics, maternal child health services, substance abuse, injury control, occupational health and the rest of "normal" public health activities, not just those related to pandemics or even infectious diseases. Public health systems have horizontal synergies, not vertical ones. When one part of the system improves it improves the others along with it, provided the improvement hasn't been bought at the expense of another part of the system. Unfortunately that happens too often.
Even within pandemic preparedness there is a shortage of funds. When federal officials recommended states acquire enough antiviral agents (Tamiflu or Relenza) for a quarter of their population, most replied they couldn't afford it. So the feds announced a sizable subsidy. But even cutting the cost by 80% isn't sufficient for some states:
At least six states plan to buy smaller quantities of antiviral drugs than the federal government has offered them, a setback for part of the government's bird flu pandemic plan.
[snip]
"It would be irresponsible to put all our eggs into one basket, for a drug that we don't know will work, against a pandemic that we don't know we'll have," said Arizona state epidemiologist David Engelthaler, in an e-mail.
Less than two weeks before a federal deadline for states to announce their plans, at least 16 say they're undecided how much Tamiflu and Relenza they'll buy. Thirteen others -- including California, the biggest state -- say they plan to buy their full allotments.
[snip]
Arizona plans to spend $1 million for 70,000 courses. The state's full allotment of 585,780 courses would cost about $8 million, draining funds needed to prepare hospitals, Engelthaler says.
Colorado plans to buy 5,400 courses -- not the 477,470 allotted to it. Officials want more evidence the drugs work against bird flu before spending "precious state resources," says Chris Lindley, state emergency response chief.
Arizona and Nebraska are trying to get local entities to pay for more anti-virals. So is Oklahoma, which now plans to buy 9% of its allotment but may increase it. Montana and North Dakota also don't plan to buy full allotments. Other states didn't respond. (USA Today)
So while $225 million sounds like a lot of money, by the time it is applied to the many deteriorated parts of a sinking system it won't go far. The funds will get divied up among the fifty states, the District of Columbia, New York City, Chicago and Los Angeles County and five US Terrirotries and three Freely Associated States of the Pacific.
If you want to see how much each is going to get, you can find the allocation table here.
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Guess the CDC didn't pay attention to Michael Haber;s study at Emory Univ, which showed that closing schools does not stop the spread of pandemic avian flu.
In each state, which official has final say as to how these funds are spent?
HT: In most (all?) states the governor is the theoretical boss on this, but we don't know the federal strings/constraints on these funds. Maybe someone out there in a state health dept. knows what they are.
The link to the allocation table seems broken somehow. It takes me to a download page for Adobe's Acrobat Reader that includes an install of Yahoo's tracking toolbar, unless you turn it off before you do the download.
MoM and others: Fixed link to allocation table (.pdf!). Sorry about the broken link.
The stipulations will be important, as will some measure of oversight and the threat of audits. In the past, states have moved money from prevention grant mechanisms of other sorts to plug budget deficits in their general funds, essentially negating the purpose of the grants. In general, the applications that states submit for funding are usually weak, compared with a typcial research grant application. The strongest applications and plans tend to come from the more functional state health departments (i.e., small to medium sized states in New England, Midwest, and Pacific Northwest, with strong grants sometimes coming from the larger states, esp. outside of the sunbelt). It usually takes a period of several years of weak performance, or obvious malfeasance before CDC will step-in and then the quality of technal assistance and supervision is contingent on the technical & people skills of the project officers (which vary widely). Things would be better if CDC were still posting public health advisors and medical epis to the states to the degree that was common even 10 years ago.
I always get confused on this point. The stated reason for preparedness funding for the states is to strengthen the public health infrastructure. Yet the states are told how to spend the money, often by buying drugs, giving vaccines (smallpox), and otherwise shifting the flow of dollars to pharma?
Craig: The funds are for bioterrorism and pandemic preparedness. That's much narrower than infrastructure and also constrained even within those categories. What they need are some big, healthy block grants.
Block grants will just get sucked into state's general funds or spent on silly pork barrel projects. A "real" grant mechanism, as oppoes to theglorified pass through would get states to spend money wisely.
Been there...: I didn't mean block grants to the state, I meant block grants to the state health department, as we had many years ago. There were specific block grants for program areas (like MCH) but within those areas there was flexibility to use as required. This has its own pitfalls, but it's better than someone at HHS deciding in advance what each health dept. should use the money for. The transaction costs alone in those cases are substantial.
The strongest applications and plans tend to come from the more functional state health departments (i.e., small to medium sized states in New England, Midwest, and Pacific Northwest, with strong grants sometimes coming from the larger states, esp. outside of the sunbelt). It usually takes a period of several years of weak performance, or obvious malfeasance before CDC will step-in and then the quality of technal assistance
According to the summary, the ISG is making two recommendations. First, it's recommending that the U.S. actively engage Iraq's neighbors -- the only two it names are Syria and Iran -- without preconditions in order to induce them to help stabilize the situation in Iraq. The report states that the U.S. has "discentives and incentives" available with which to influence these countries. The only such incentive or disincentive mentioned in the summary is "dealing directly with the Arab-Israeli conflict."
The strongest applications and plans tend to come from the more functional state health departments (i.e., small to medium sized states in New England, Midwest, and Pacific Northwest, with strong grants sometimes coming from the larger states, esp. outside of the sunbelt).