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Statement
of
Michael C. Caldwell, MD, MPH
Commissioner of Health
Dutchess County Department of Health
New York
on
behalf of the
NATIONAL ASSOCIATION OF COUNTY AND CITY HEALTH OFFICIALS
before the
Committee on Governmental Affairs
United States Senate
Hearing on “The Local Role in Homeland Security”
December 11, 2001
Good morning, Mr. Chairman and Members of the
Committee. I
am Michael C. Caldwell, MD, MPH.
I am Commissioner of the Dutchess County Department of
Health in New York. I am honored to appear before you representing the National
Association of County and City Health Officials (NACCHO) on
whose Board I serve. NACCHO
is the organization representing the almost 3,000 local public
health departments in the country.
I have been intimately involved in bioterrorism and
emergency preparedness planning in Dutchess County and I am
very familiar with national work to develop guidance and
performance standards in bioterrorism preparedness for local
public health systems. I am here today to share with you some
of the lessons we have learned in our work and how much
farther we need to go.
Are we prepared for
bioterrorism as a nation? Not nearly enough.
Local public health departments have long experience in
responding to infectious disease outbreaks and other local
emergencies with public health implications.
We have made progress and learned important lessons
about the challenges of bioterrorism preparedness in the last
few years. But we
have a long way to go to achieve nationally the capacities
necessary to detect and respond to an act of bioterrorism
quickly and efficiently in order to contain it, prevent the
spread of disease and save as many lives as possible.
The challenge, and
potentially the great strength, of bioterrorism preparedness
is that it requires a combination of the resources and skills
of public health with those of other public safety and
emergency preparedness disciplines.
Each of these disciplines must have a robust system in
place. As our recent experience with anthrax has demonstrated,
public health leadership, expertise and resources are
essential when an act of bioterrorism is suspected or
threatened.
Our nation’s bioterrorism preparedness activities
prior to September 11th were limited, but we are not starting
from scratch. We
have some experience and some results from funding that
Congress has appropriated thus far that I will share with you.
In addition, we have a legislative framework in place
for expanding our general public health preparedness.
The “Public Health Threats and Emergencies Act of
2000,” which has not yet been funded, establishes a process
for systematically defining what our federal, state and local
public health systems need to do, for assessing what they
already can do, and for filling in the gaps by building
capacities.
Every component of the public health system plays a
vital role. Federal agencies rely on the public health
infrastructure at the local and state level to support the
system. State and
local public health agencies must collaborate closely together
and with their federal partners, sharing information and
resources. Properly equipped laboratories and data management
and communication systems are essential, as is leadership and
technical support from the Centers for Disease Control and
Prevention (CDC) and other agencies of the Department of
Health and Human Services (HHS).
Federal Guidance to Local and State Public Health Agencies
NACCHO has been working with CDC and other public health
partners on a national level to define just what state and
local public health agencies need to prepare for and respond
to a bioterrorist act and to provide them solid guidance.
We have developed a set of core capacities and some
measurement tools to gauge the extent to which an agency has
achieved them. Defining measurable objectives is an essential
part of achieving preparedness.
Establishing standards will enable us not only to
assess where we stand, but also to assure that funds are spent
prudently and that the ultimate outcome will be an effective
system serving the country’s overall needs.
These core capacities consist of four major areas, within
which are many more specific elements.
The four major areas are:
Surveillance and epidemiologic investigation, which
requires monitoring community health status to detect
the presence of bioterrorism agents and to characterize the
public health threat or emergency;
Laboratory capacity to identify, rule out, confirm and
characterize biological threat agents;
Communication, which includes collection, analysis and
communication of information among the response community,
decision-makers and the general public during a public health
emergency. This
capacity also includes the local public health agency’s core
responsibilities of education and assurance as well as the
development of local Health Alert Networks nationwide; and
Public health
intervention, which includes advance planning,
coordination of emergency response and implementation of
emergency measures to control and contain an outbreak.
This involves the integration of public health
expertise and activities with that of other emergency response
agencies.
For any locality to achieve fully these core capacities, it
must have a fundamental infrastructure of trained people,
equipment, facilities and systems.
Building this infrastructure is absolutely essential;
without it, we will not obtain the necessary capacities for
bioterrorism preparedness.
However, as we invest in public health infrastructure,
we are not just preparing for bioterrorism but also
strengthening our ability to respond to other health
emergencies. The
systems for disease surveillance, for communication, for data
management, for interagency planning, for mobilizing the
community to respond, are the same for bioterrorism as they
are for any other disease outbreaks or emerging infections
such as West Nile Virus, E. coli, Hepatitis C, Lyme Disease
and Ehrlichiosis. These
systems have multiple uses, extending even to improving our
abilities to address other public health problems more
effectively. Every
dollar we spend on bioterrorism preparedness will pay off in
countless other ways.
The next step is to enable states, counties, cities and
towns to transform this framework of core capacities into
their own practical action plans for bioterrorism preparedness
and response. One
of our highest priorities now must be to give states and
localities the resources to take this next step and to develop
more tools to help them.
All Public Health Preparedness is Local
The federal government can and must provide
technical assistance, funds and specialized expertise.
In the end, though, all public health preparedness is
local. Bioterrorism
preparedness planning, just as all local emergency planning,
is not adequately addressed by taking a plan or set of
guidelines off the shelf.
The act of planning itself brings together people from
public health, emergency response, law enforcement, local
hospitals and physicians, to develop a plan that suits their
own community’s circumstances and needs.
The act of planning itself establishes the lines of
communication that we have seen are so critical following
September 11th and it identifies what capacities and resources
remain to be developed and put into place.
Across the nation, local public health departments and their
communities are learning that partnerships between public
health agencies, health care providers and the traditional
first responder entities, such as fire, police and emergency
services, can be built and are essential for further progress.
In order for the diverse public and private agencies in
a city or county to work effectively together to respond to an
emergency, they must know each other and have planned together
well in advance. They
should not be exchanging business cards of introduction during
a real crisis! Local
surveillance and response systems will not work unless we have
thoroughly trained people to use them and the people who use
them knowing exactly what to do and have sufficient practice
doing it in advance.
Planning preparedness for a smallpox event affords an
excellent, if frightening, example.
The federal government can and should be responsible
for the development and stockpiling of smallpox vaccine.
However, an adequate vaccine supply is useless unless
deployment plans to distribute it efficiently are established
and understood at all levels.
There may be a role for states in planning for regional
vaccine distribution. Ultimately, however, it will be local
public health authorities that will take the lead in arranging
to get vaccine into people’s arms.
Planning for stockpile distribution therefore requires
that the federal government plan with the states, that states
plan with localities, and that local governments plan with
their emergency response personnel, hospitals and health care
providers and law enforcement how to vaccinate people safely
and maintain public order.
NACCHO was pleased that the President’s budget
request for bioterrorism preparedness included vaccine
purchase, but dismayed that it almost wholly ignored the
complex and critical issue of distribution at the local level.
We have also learned some unexpected, but important, lessons.
For instance, Internet-based information and
communication systems became widely unavailable on
September 11th and many health departments could not access
email for hours to receive health alerts from CDC or their
states. The
lesson is that wireless, handheld communication capacity is
one important emergency tool that public health agencies
should not be without. Another
lesson learned during the current anthrax outbreak is that an
important first step for many jurisdictions involves setting
up a 24-hour hotline to receive reports and dispense accurate
information. Unlike
fire and police agencies, few local health departments have
staff available 24/7, nor do they have pre-arranged means to
access a new telephone line to create an immediate emergency
hotline. Responding to a new and unexpected public health
threat consumes all available resources and places severe
stress on the existing infrastructure of any agency. A third
lesson, therefore, is that unless emergency capacities and
cross-training of staff are integrated into the staffing
structure of a department, the more routine, non-emergent work
of public health quickly becomes neglected when an emergent
threat occurs. It
is undeniable that meeting these newly recognized challenges
requires additional funding from the federal government to
provide more resources at the state and local level.
Public Health Emergency Planning in Dutchess County, NY – a
case example
Dutchess County,
with a population of 280,000, is located about
seventy-five miles north of New York City and seventy miles
south of Albany. About
4,600 people commute each weekday between Poughkeepsie and New
York City by MetroNorth railroad service. Should any commuter
become infected with smallpox, it would be days before the
disease manifests itself and by that time many people in
Dutchess County could have been exposed to and infected with
the virus. We
know that we need a strong reporting mechanism from hospitals,
private physicians and laboratories so that we will learn
quickly of any suspicious disease outbreak. We also know that
crisis and consequence management locally will involve many
local authorities. From
detection, to surveillance and response, several county
agencies will share responsibilities at a variety of levels,
including the Departments of Health, Emergency Response,
Mental Hygiene, Planning, the County Sheriff and the County
Executive’s Office.
West Nile Virus: Lessons
Learned
The outbreak of West Nile Virus encephalitis in the New
York City metropolitan area in the summer of 1999 was an
unprecedented event. By the end of the fall of 2000, all but
one county in New York State had documented West Nile Virus
activity. The New
York State Department of Health relied heavily on
municipalities and county health departments to provide needed
field surveillance and scientific data on which to base cost
effective actions. But few counties had an active mosquito
surveillance/control program in place and, when faced with the
outbreak, were forced to take costly emergency measures.
I distinctly remember, early on, receiving a message from a
concerned citizen in the southern part of our County concerned
about a dead crow that she found in her backyard.
As a local Commissioner of Health, we receive a number
of unusual calls, but while this one seemed strange, there was
nothing that I could do but tell her it was probably an old
crow and thank her for calling. One week later, the CDC made the link between the crow deaths
and the human cases of encephalitis.
This points out how important it is for local, state
and federal public health authorities to develop routine and
comprehensive communications with our veterinary colleagues.
Four years ago, I remember that a local veterinarian
had informed me of his concern about seeing three cases of
tick paralysis in dogs one summer.
Shortly thereafter, a two-year-old girl in the County
came down with the disease and nearly died.
The Dutchess County Department of Health initiated a vector
control and surveillance system that would better prepare the
County to deal with outbreaks of vector borne diseases, such
as Eastern Equine Encephalitis (EEE) and West Nile Virus (WNV.)
The program consists of a permanent ongoing arthropod
surveillance as well as the enhancement of public health
education initiatives to raise the level of awareness and
knowledge of personal protection individuals can take to
reduce the potential exposure to mosquitoes and ticks. This
approach required that we work with every single municipality
within the County. The program allowed Dutchess County to
enhance its infrastructure, enabling cost effective control
measures that lessen and often prevent outbreaks of vector
borne diseases.
Dutchess County Executive William R. Steinhaus
committed over $1 million in funding, in the first year, to
deal with this newly emerging public health threat.
While the majority of the funding was used to contract
for a comprehensive mosquito surveillance and control program
and a research scientist, we were able to create a
biostatistician position and a Geographic Information System
(GIS) coordinator. We received about 40% funding from New York State and
also received $80,000 in reimbursement from FEMA.
Lessons learned:
Lack of preparedness in the local public health infrastructure
and lack of scientific data on which to base cost effective
actions resulted in some local municipalities taking costly
emergency actions against a perceived wide scale public health
threat.
A local early warning system against the spread of arthropod
borne diseases to humans is critical to the planning of any
cost effective activities locally and regionally.
Lab support is critical for supporting the surveillance
system.
Leadership and rapid communication of developing
information from the CDC to the local and state health
departments was critical to providing a standard and cohesive
surveillance and response plan across multiple jurisdictions.
Sept.
11th – more lessons learned
On Tuesday, September 11, 2001, the Centers for
Disease Control and Prevention requested monitoring for
unusual disease patterns that could indicate bioterrorism. The
same day, the New York State Department of Health transmitted
a CDC health alert to hospitals and local health departments
throughout the state advising them to enhance surveillance for
unusual disease events.
In Dutchess County, working with our local 911 center and
hospitals, we were able to quickly establish a heightened
sense of awareness for likely bioterrorism symptoms in
addition to creating a daily monitoring system of hospital
emergency room visits. We
also worked with our local Medical Society to enhance
communication with the area physicians and provided for
regular information and communication on the latest
recommendations from the Centers for Disease Control and
Prevention concerning the recognition and treatment of
diseases related to exposure to biological agents.
We responded to requests of assistance to the September 11th
attack with the deployment of nine of our public health
sanitarians to ground zero, to provide additional support and
resources to the New York City Health Department.
We are expecting some financial assistance from FEMA as
well as our usual 36% reimbursement from New York State.
Lessons Learned:
To prepare for and
respond to any terrorist incidents will involve the
collaboration and coordination of services among local, state
and federal authorities.
Federal agencies rely on the public health
infrastructure at the local and state level to support the
system.
Bioterrorism preparedness planning: Developing the necessary resources
County health departments in New York State responded to a
survey conducted in early November 2001 on their workforce and
training needs related to emergency preparedness. Preliminary
survey results indicate that there is an urgent need to assist
counties in developing adequate coordinated plans and
training.
Key Findings
Local Health
Departments lack arrangements with a wide range of health
professionals and organizations essential for emergency
preparedness.
There is an urgent need for training in biological, chemical
and radiological emergency preparedness for a wide range of
health professionals.
There are a
number of public health personnel shortages related to
emergency preparedness that may impact on counties’ ability
to effectively respond to these situations.
Under the leadership of County Executive Steinhaus, Dutchess
County will be creating our first epidemiologist position on
January 1, 2002, as well as continuing our work to develop
enhancements to the County’s Comprehensive Emergency
Management Plan. We
were fortunate that the biostatistician hired for our West
Nile Virus program could be temporarily reassigned to this new
position immediately and be designated as the County’s
full-time bioterrorism preparedness coordinator.
Additionally, our Medical Examiner program is currently
being studied and we expect to upgrade it in 2002 to include a
full-time forensic pathologist who will be able to provide
greater scrutiny of the causes of death of Dutchess County
residents.
While Dutchess County needs to continue to develop its
program, we are much more fortunate than most local health
departments and even some state health departments.
Many are not “full service” departments and do not
maintain or operate environmental health programs.
Many do not have professional public health information
resources. Some
are still not linked to the federal Health Alert Network.
Since the first case of human anthrax, we have been quite busy
fielding calls from physicians and other healthcare
professionals, businesses, elected officials, law enforcement,
emergency response and the general public.
Whether it was a worker who was at NBC studios or the
Eagle Scout who received a congratulatory letter from Senator
Daschle with a postmark of Monday, October 15, 2001, it was
the local Dutchess County Health Department that was called
and expected to provide the right advice.
We are the first responders in a case of suspected
bioterrorism. The
local public health department is on the front lines and
should have the professionally dedicated staff, equipment,
tools and resources necessary to fulfill our mission as an
integral member of America’s homeland defense.
The local public health system has finally emerged as a
necessary component of our national security.
We’re not too late to improve our readiness for a
large-scale attack, but we must act swiftly and without delay.
Lesson learned:
Local public health agencies need full-time professional and
dedicated staff who are able to coordinate bioterrorism and
other emergency preparedness efforts within the local
political framework.
Conclusion
Franklin Delano Roosevelt, a Dutchess County native said,
“Never before have we had so little time to do so much.”
His words ring true for us now as we strive to improve
our readiness for a large-scale bioterrorist assault.
It is important to note that even if we were never to
have another bioterrorist event, any resources provided will
be put to good use and will improve each community’s
readiness for any naturally occurring health emergency.
Enhancing bioterrorism preparedness and emergency response
capacity creates a dual use response infrastructure that will
enable us to respond to other public health emergencies and
threats as well.
Finally, we need to recognize that everyone can’t do
everything. Each
agency must develop its own set of responsibilities and
expertise; however, we must leave no community behind.
Every local public health department should be
professionally assessed and brought up to its potential as
soon as possible.
Regionalization will be a necessary part of improving
our local public health infrastructure in New York.
While Dutchess County is just one of fifty-eight local
health districts in the state, we are one of ten within the
designated Metropolitan Area Region of the state health
department and one of seven in a loosely organized Hudson
Valley Regional Health Officials Network (HVRHON) that has
been meeting for the last five years.
Each one of us has different political boundaries and
strengths and weaknesses, but we all know that we must work
together on many issues in order to make progress.
That is why we are working with the state to form a
regional Health Data Institute (HDI), which will provide us
with health data from the Hudson Valley region that will be
more insightful and comprehensive than any other existing
database. This is just one example of many cooperative efforts that are
ongoing throughout the country that will complement all of our
bioterrorism preparedness efforts.
Local public health agencies need flexible federal support
now, and we need direct federal resources to the local
level guaranteed in the language of any assistance bill under
consideration. Coordination
with state and federal partners should be required but there
is no question that little to no money has reached down to the
local level for bioterrorism preparedness.
We cannot wait to create the necessary positions in our
public health workforce; to enhance our laboratory capacity;
to improve our rapid epidemiologic surveillance; to develop
the necessary local health information and communication
systems; to provide assurance and a comprehensive and
immediate response to any public health crisis.
Our local public health system requires the same
dramatic overhaul as the airport security industry.
I used to take care of patients who needed a dose of
epinephrine right in their heart to save their lives.
The 3,000 local health departments look to you to take
the necessary steps to provide that shot of adrenalin and to
ensure that your constituents have the best chance to survive
the next biological attack. |