A Public Mess

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Nobody ever said that protecting the public's health was an easy job--whether it's being done quietly and invisibly in peaceful times, or hurriedly and worriedly in the glare of media attention. But experts agree that the weaknesses exposed in the wake of the anthrax attacks must be fixed--and in such a way that a newly nimble system can handle both the sudden emergency and the everyday job of fostering national wellness. "For the last 20 years we've neglected public health," says Tennessee Senator Bill Frist, the Senate's only physician. The terrorist attacks have "shocked Americans into realizing how dependent we are on the system."

The public-health system of 2002 is nothing like the public-health system as it was established in 1798. Known then as the Marine Hospital Service, it was charged with the crisply defined mission of caring for the health of merchant seamen, as well as ensuring that drinking water and food were sanitary and that disease outbreaks were quickly detected and diagnosed. Like all federal agencies, however, the service eventually fell victim to mission creep. And in 204 years, it has crept a lot.

The federal health system now comprises eight departments and agencies and more than 50,000 employees, concerning themselves with everything from vaccinating children to preventing lead exposure, from curbing teenage drinking and drug use to evaluating family-violence programs. Similarly complex--if smaller--bureaucracies are in place in all 50 states and most of the localities within them.

Such a vast medical network would seem like a good thing, ensuring that no health problem would be too small to be noticed. But the seemingly comprehensive system masks a lot of inefficiency, underfunding and chaos.

The biggest problem, as it so often is, is money. The dry rot at the CDC labs in Atlanta--where leaky walls are repaired with duct tape and a sputtering power system caused a blackout during the height of anthrax testing last fall--is only the most conspicuous part of the problem. Funding throughout the agency is so meager that members of the CDC's Epidemic Intelligence Service--a sort of disease SWAT team--cannot afford even such basic field equipment as two-way pagers.

At the local level, things are little better. Many city and county health departments lack up-to-date diagnostic equipment and even high-speed Internet access--a service that a third of the local agencies don't have. At all levels of government, there is a growing staffing crisis, with fewer schools offering degrees in public health and those people who are qualified to serve declining jobs with such notoriously low pay.

When funding is pumped into the leaky system, it's often spent unwisely. According to recent figures, less than 2% of health dollars are allocated to the economically smart business of preventing disease. The rest goes to research and the costly job of treating illness afterward. "There's no better place in the world to get sick," says Satcher. "Our weakness is in preventing disease in the first place."