Lessons Have Been Learned

The lessons learned from managing two recent infectious outbreaks, West Nile and anthrax (one apparently naturally occurring and one intentional), have helped the public health community address SARS. These lessons demonstrated the need for a strong public health system as one component of an integrated homeland security program. We also learned what capacities we need to ensure preparedness and where some of the gaps remain that must be filled. Ensuring an effective public health infrastructure is a top priority for the APHA. An adequate public health infrastructure to manage the infectious disease threat is one where there is an adequate work force that is well trained, with the proper tools and resources to effectively respond to current and emerging infections. SARS is an excellent example of the need for a strong public health system and the infrastructure required for it to be effective. This infrastructure includes the capacity to:

• Prevent disease outbreaks;

• Know when a new disease has entered the community;

• Provide definitive diagnosis and laboratory verification;

• Track the spread of the disease;

• Contain the disease;

• Ensure effective treatment;

• Demonstrate an adequate legal framework for this work;

• Effectively communicate with the public, medical and public health providers and other stakeholders; and

• Partner on a local, regional, national and global level.

The effective use of many of these capacities have been demonstrated at the federal, state, and local level in the initial response to SARS, and represents a significant improvement over our response to the anthrax attacks of 2001 and some improvement over the early response to West Nile virus.

In the fall of 2001, I was Secretary of health for the state of Maryland. During the anthrax outbreak, as with West Nile virus two years before, we learned a lot that helped the public health community to better prepare to respond to SARS. We learned that any disease outbreak is a community event that can quickly grow in scope and size. These events require a high degree of coordinated communication and cross-jurisdictional cooperation. It is critical that in times of crisis, the public trust their public health officials and receive a clear, consistent message. In order to accomplish this, we have learned that rapid, early communication by credible spokespersons is essential.

During the current SARS event, the U.S. Department of Health and Human Services communicated early and frequently to a broad range of both medical and public health providers. What is important is that this communication occurred before the disease entered the borders of our country and gave us a head start on preparedness. These briefings were held by experts who were able to adequately tell us what they knew and what they did not know. Today there are frequent SARS briefings from either the high-tech, secure, command center at the Department of Health and Human Services or the Centers for Disease Control and Prevention (CDC) new Emergency Operations Center.

The Health Alert Network, which received its first real workout after September 11th, has become a mainstay of communication to the medical and public health community. CDC has set up and is using a free registry to provide clinicians with real-time information to help prepare for and respond to terrorism and other emergency events. Participants receive regular e-mail updates on terrorism and other emergency issues and on training opportunities relevant to clinicians. This highly focused, centrally coordinated effort has made a difference in the ability of local public health authorities to control the outbreak and also to educate clinicians and the public in their communities. This rapid and consistent message has allowed for those clinicians and medical facilities to properly manage suspect and probable SARS cases in the United States with minimal risk to others.

Anthrax also taught us that it was important to aggressively coordinate our external communications efforts, not just our response efforts, very early in order to ensure that we had control of the message and that we spoke with a single, consistent voice. This approach is imperative to avoid confusion, misinformation and panic. This is extremely important in an event like SARS when our understanding of the science shifts rapidly. Both the World Health Organization (WHO) and the CDC have done a much better job at being clear about telling us what they know and what they do not know, and quickly sharing new knowledge when it becomes available.

We need to be proactive in monitoring the global situation. SARS is a good example of a proactive approach and how with good public health practice and some luck, we have had only a few cases and no deaths in the United States. More than 20 years ago HIV -- the virus that causes AIDS -- emerged from Africa and since then has killed millions of people and devastated entire communities and countries. When West Nile first hit our shores it also was not new. West Nile virus was first isolated in Uganda in 1937 and was later recognized in Egypt in the 1950s and in Israel in 1957. In the 1990s, outbreaks occurred in Algeria, Romania, the Czech Republic, the Democratic Republic of the Congo and Russia. When it finally reached our shores in 1999 we were perplexed and surprised. It has now spread throughout North America and will probably enter the few remaining communities during the coming summer. The response to SARS has been much more proactive with every community on alert and vigilant.

Similarly, when the anthrax outbreak occurred in our region, much of the management focus initially was narrowly directed at the District of Columbia with less attention to Maryland and Virginia. This made it very difficult to have an effective regional strategy. SARS not only required managing a regional strategy around individual cases but a global one as well. This is a substantial improvement over our response to the anthrax attacks. I do want to caution, however, that our limited experience with suspect and probable SARS cases is limited and we should not get overconfident in our capacity to manage and coordinate a large biological event.

The CDC and the WHO have been doing yeoman's work on SARS and there has been unprecedented global communication. The WHO has been effective in helping to contain SARS and coordinating research at major institutes around the world once the disease became known. As cases popped up from China to Canada, WHO officials linked a network of 11 laboratories in nine countries to identify the agent causing the illness and devise treatments. In the past, international laboratories have competed to solve an epidemiological challenge. But in this case, labs have been exchanging data on a daily basis. Lines of communication between research facilities, physicians treating cases, and the public have been strengthened. Recently, scientists in Canada and the United States have broken the genetic code of the coronavirus that apparently causes SARS.

There are also global lessons to be learned. The WHO's Global Outbreak Alert System, set up after its experience with Ebola, and unfortunately proved inadequate because China failed to alert the WHO immediately. Currently, notifications are voluntary and limited to yellow fever, plague and cholera. The SARS experience should be used to identify gaps in the global response system. SARS also serves as a reminder that there is no alternative to effective multilateral institutions and global cooperation. While SARS is a human tragedy, what is remarkable is how quickly -- leaving aside earlier Chinese secrecy -- the world has joined together in responding to it. In June, WHO will host an international scientific gathering to plan the next steps in dealing with the disease.

Needs for the Future

SARS has reminded us once again that in this age where we not only have a global economy but a globalization of disease, the 20th century's model of protecting ourselves from disease is no longer sufficient. We need to look at new, more strategic models of doing business.

The SARS outbreak and others, including anthrax and West Nile, have also exposed gaps in our own public health system in the United States. We are at a critical juncture in public health. For many years, experts have been warning us that our nation's public health infrastructure is in disarray. Recent preparedness funding has provided for improvements in the public health preparedness infrastructure, however gaps remain. There still is a lack of adequate personnel and training, laboratory surge capacity and there are still holes in our communications networks. There remain serious gaps in our disease surveillance systems. These and other shortcomings have been known for sometime, but have also been more recently documented by the Institute of Medicine, the General Accounting Office and others as current pressures on the public health system make these failings more visible. One big problem today is the erosion of the foundation upon which we are building the new preparedness system due to funding cuts at the federal, state and local level in core public health programs. Today these programs allow for a surge capacity in public health to address emerging issues. This foundation needs to be strengthened.

Perhaps never before has it been so important to shore up our public health system. This system is being asked to support our response to some of the most threatening emerging diseases of our time and to prepare for diseases yet unknown. In this age when biological and chemical terrorism is added to the portfolio of public health threats, we need to be assured that the system works and works well.

I want to thank you for your support for the emergency supplemental funding this year for both the smallpox preparedness and the SARS response effort. These funds are critically important. However, it is time for Congress to take the next step and support the public health system in a more holistic way - to support public health as a system - not crisis by crisis. The public health system serves as the front line for our nation's public health defense system against emerging and reemerging infectious diseases. From anthrax to West Nile to smallpox to SARS, the CDC is our nation's and the world's expert resource and response hub, coordinating communications and action and serving as the nation's laboratory reference center. It continues to need strong support from Congress.

Public health is being asked to do more with less. Unless we start supporting our public health base in a more holistic way, we are going to continue to need to come to Congress for special emergency requests for funds as each new threat emerges. Funding public health outbreak by outbreak is not an effective way to ensure either preparedness or accountability.

In the absence of a robust public health system with built-in surge capacity, every crisis "du jour" also forces trade offs-attention to one infectious disease at the expense of another, infectious disease prevention at the expense of chronic disease prevention and other public health responsibilities. This is true especially given the current budget pressures facing states and the federal government.

It is time to think more strategically about the future of our nation's public health system, to develop a blueprint for where we want to be 10 years from now and how best to fund it. Because of their impact on society, a coordinated strategy is necessary to understand, detect, control and ultimately prevent infectious diseases. We believe that far more significant investments in public health will need to occur if we are to prepare the nation's public health system to protect us from the leading causes of death, prepare us for bioterrorism and chemical terrorism, and respond to the public health crises of the day.

I hope we all recognize that this SARS event is not over and that we still have a ways to go to ensure containment. In the future we will always be one plane ride away, one infected person away, and one epidemic away from a global tragedy. We cannot lower our guard, not today, not tomorrow.

Mr. Chairman and members of the subcommittee, I thank you for this opportunity to testify before you today about one of the most important public health issues of our time. On behalf of the American Public Health Association, I look forward to working with you to strengthen our nation's public health system.