“Basically, we’re out of money.”
Those are not encouraging words from the head of a federal health agency in the face of a novel and serious infectious disease threat. It is more than a little troubling that they’re from Dr. Tom Frieden, Director of the CDC.
America is facing not one, but two Zika-related crises. One is playing out in Florida and the Gulf Coast region, where sporadic local transmission of the Zika virus has begun, and in Puerto Rico, where more intense transmission is occurring. The other is unfolding in Washington D.C., where political gridlock has dangerously limited the size and scope of our response.
To review, the Zika virus was first described by microbiologists working in Uganda in 1947. For the next 70 years or so, Zika remained an obscure piece of medical trivia; it didn’t spread readily or have a recognized impact on human health. Then, without warning, Zika began to circumnavigate the globe like Magellan in reverse, arriving in South America sometime in 2014 by way of the South Pacific.
Zika is an arbovirus, which means that it requires a mosquito vector in order to be transmitted to humans. Unlike other arboviruses, like dengue and chikungunya, Zika infection results in relatively mild symptoms for most people. The main exception to this rule, however, is the growing number of unborn babies from infected pregnant women, as they’re at risk for severe congenital defects including microcephaly and other neurological complications. There are no vaccines or medications currently available, though several are in the early stages of development. This means that the most effective defense against Zika is to reduce the size of the mosquito population that spreads it—by spraying insecticides to kill adult mosquitos and their larvae, and encouraging local communities to reduce the available amount of standing water, which mosquitos need in order to breed, thus reducing exposure and infection rates.
On February 22nd 2016, President Obama requested an emergency appropriation of $1.9 billion from Congress. Over 200 days later, that request has yet to be translated into funding. To put that into historical context, a sitting President has had to request an emergency appropriation due to an infectious disease emergency three times since 2001. A crude calculation of previous intervals between presidential request to presidential signature is instructive. In 2005, President Bush’s request for general pandemic preparedness funding was fulfilled in 59 days. In 2009, in response to the H1N1 influenza pandemic, funds were made available by Congress in 57 days. And in 2014, the Ebola emergency appropriation was signed by the President in 41 days.
Unfortunately, to date, the response to Zika has been funded only through the diversion of funds from other important public health priorities, including programs dedicated to improving the world’s defenses against future Ebola epidemics. The delay in appropriations can be blamed on legislative gamesmanship on the part of Republican lawmakers, coupled with a missing sense of urgency regarding the health and economic consequences of the Zika virus pandemic.
I was hopeful that Congressional appropriators would reach an agreement on the Zika funds shortly after returning from recess. However, the most recent vote on the funding resolution failed in the Senate due to Democrat’s concerns over several of the legislation’s provisions, including one that would make Planned Parenthood ineligible to receive federal support for emergency contraception provision, as well as the persistence of unrelated riders. There are two paths forward. Either legislators return to negotiations and agree to pass a clean emergency appropriation for Zika, or the Zika funding gets added to a continuing resolution to fund federal operations, which must be passed by the end of September. Regardless, it means a further delay before it can honestly be said that the government is doing all it can to prevent further cases of Zika from occurring.
As we’ve seen, the practice of waiting for political battles to be waged and won before support for emergency response materializes puts lives at risk. So we must now ask ourselves: What do we need to do differently to ensure a more timely response to future infectious disease emergencies?
I propose three priorities for action.
1) Establish a Public Health Emergency Response Fund
Because of the need for a surge in resources and staff to respond to high impact epidemics or pandemics, the Administration has needed to request that Congress disburse emergency appropriations. These one-time cash infusions are necessary to deal with the crisis at hand, and will continue to be a part of the governmental response. However, they also create their own challenges, including the potential for political gridlock like what we’re witnessing right now.
One concept that has been gathering traction of late, and even seems to have a measure of bipartisan support, is the establishment of a dedicated fund for public health emergency response. Recently, Secretary Hillary Clinton endorsed the idea. While details of the Clinton proposal have yet to be released, there are several principles that would contribute to its successful implementation. First, the fund should consist of “new” money, not money transferred from other federal health accounts. Second, access to the fund should be tied to an emergency declaration, to ensure that the fund is not drawn down for non-emergency use. Third, without being overly prescriptive, the fund should be of sufficient magnitude to jumpstart an all-out federal response, somewhere in the neighborhood of one to two billion dollars. A fund of this size would mean that, in all likelihood, an emergency appropriation will still be needed, but that the response could move ahead in a timely manner and not suffer if Congress is slow to act.
2) Increase Federal Funding for State and Local Preparedness Programs
As a result of the post-9/11 anthrax attacks, public health agencies at all levels of government gained a new mission: preparedness. An influx of federal funding gave rise to programs intended to make the public health, life science, and health-care sectors more responsive to emergencies. A strong public health and medical response to infectious disease emergencies is based on existing local, state, and federal infrastructure that can’t be built up overnight. It takes a skilled workforce with access to the right facilities and equipment to do things like operate a laboratory, assess the extent of disease spread within a population, run a mass vaccination campaign, or provide clinical care for large numbers of people. As the struggles in Flint, Michigan have demonstrated, infrastructure—physical as well as operational—must be maintained in order to function properly.
In addition to having its own response capabilities, the Department of Health and Human Services also provides funds to state and local preparedness programs. The ability of local health departments to be responsive in a crisis is critical, as they can react faster and with more local knowledge than their federal counterparts. But despite being called upon in all manner of crises, federal support for those programs has been on a downward trajectory for years. For example, funding for the Public Health Emergency Preparedness grant program has decreased 30% from its 2002 high, and a similar program focused on hospital preparedness has been roughly halved from its 2003 high. Funding reductions of this magnitude will jeopardize the significant progress that state and local health departments have made over the last decade. The next administration should, therefore, work with Congress to shore up preparedness programs at all levels of government.
3) Continue to Support the Global Health Security Agenda
A final priority—and I’m echoing what “Ebola czar” Ron Klain wrote in these pages—would be to continue to improve the state of global, as well as national, health security. The Obama Administration’s Global Health Security Agenda (GHSA) was launched in 2014 as a means to improve disease surveillance and response capabilities in 53 nations around the world. Because of Congress’s inaction over Zika, the CDC has had to rely, in large part, on GHSA funds to enable initial response activities. However, programs supported under the GHSA are critically important for reducing the time to recognition of novel and emerging infectious diseases, as well as for improving public health systems to quench epidemics more effectively before they go global. Support for the GHSA should be a priority for Congress, and for the next administration, if they wish to prevent further lost lives and expensive emergency responses in the future.
If the past is any guide, epidemic and pandemic infectious diseases are going to continue to threaten our health and safety, and it is incumbent on all of us—policymakers, legislators, and public health professionals alike—to be ready.