A Public Mess

• Share

The plague unfolded like one of those pre-9/11 bioterrorism war games. It started with a simple case or two that quickly grew to dozens, then hundreds. Local health officials, who had tracked the epidemic's course through Asia and Europe, sprang into action. Hospitals were set up in schools, banks and offices. Incoming ships were stopped 300 yds. offshore; vehicles were blockaded a mile outside of town. Health officials swept through the city, cleaning up streets, distributing medicine and imposing strict guidelines on food preparation. Eventually, the disease went into retreat, but not before 3,000 people had died.

This was no contemporary war game, however. It was New York City in 1832, when the town was struck by a devastating cholera epidemic. That the city fought back as hard and effectively as it did was a tribute to a health system honed by floods of immigrants and the diseases they carried. New York's response to its great plagues, in fact, became a model for the rest of the country. In the decades to follow, the city's lessons were to be institutionalized in the creation of new federal health agencies, new public hospitals and, in 1870, the brand-new office of national Surgeon General.

But a public-health system that had become the envy of the world has fallen into disrepair. The drive to lower health care costs and the reforms of managed care have taken their toll. Government laboratories are running out of funding and equipment; emergency rooms are running out of staff and beds; emergency-preparedness plans have become moldy and outdated. Many of the labs at the Centers for Disease Control and Prevention are crumbling, a fact that outgoing Surgeon General David Satcher believes Americans should consider "a national disgrace."

The system still does many things well, but how serious its shortcomings have become was made abundantly clear last fall, the moment the first anthrax case surfaced. The government did a passable job of controlling the anthrax spores but a terrible job of dispensing medical advice. Frozen in the bright lights of the 24-hour news cycle, Health and Human Services Secretary Tommy Thompson and Homeland Security chief Tom Ridge often looked flummoxed and misinformed, learning medicine on the go and winging it when they didn't know. It was a sharp contrast to the celebrated performance of former New York City mayor Rudy Giuliani, who drew a bright line between facts (known and unknown) and his basic message of reassurance, and never seemed to confuse the two.

Under Thompson and Ridge, bad--and sometimes fatal--decisions were made. The U.S. government allowed postal workers to continue breathing the air of a sorting facility filled with anthrax spores; it went tearing off to stock up on Cipro when many scientists believed it unnecessary and even dangerous; it wrung its hands about whether to order 300 million doses of smallpox vaccine--sowing its own kind of terror with its very indecision; and it allowed open speculation about quarantines to spread unchecked, without a clear consensus on the extent of its legal powers to impose them in the first place.

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.