This post was originally published on June 6, 2017 in The Hill.
The public health community has been closely watching proposals for a badly needed public health emergency response fund. Such a fund would jump-start the response efforts in the event of a public health disaster and avoid the political wrangling and partisan gridlock that delayed the response to Zika virus.
While there is a decades-old response fund, it is virtually unfunded and was not written for the environment we live in now, facing the threat of infectious diseases and bioterrorism. Currently, we live without a funding mechanism to respond to these crises.
In order for a meaningful fund to be created it needs to address complex questions about its purpose, triggers for use, funding levels, and be the product of a deliberative process that includes the various stakeholders who will be affected by it.
First and foremost, an emergency fund needs to provide the fiscal resources to respond to a disaster that affects the public’s health, without drawing from preparedness resources and other live-saving public health activities.
The most recent examples of public health response requiring emergency supplemental funding have been for infectious diseases such as Ebola, Zika and Pandemic Influenza. Although other disasters, such as the contamination of the water in Flint, Michigan also constituted a public health emergency that could have benefitted from an emergency public health response fund. Intentional acts of bioterrorism, threats to our food supply, and animal diseases with the potential to infect humans are also in the realm of possibility and would require significant action in a short period of time.
In any of these situations, there is a need for people to respond and necessary supplies likes testing equipment and protective gear. There is a need for logistics to make it happen, and the rapid development of new countermeasures and treatments to protect those at risk of illness.
It requires fund to carry out all of these actions. In order to access these funds, however, some sort of emergency declaration would need to be made.
Under the current model, for FEMA and other emergency managers to access traditional disaster funds, states must request a disaster declaration from the president. This is made once it is established that local and state resources are not sufficient, or are anticipated to become overwhelmed with the response.
For public health threats emerging within a single state, this kind of a disaster declaration request process may be appropriate. But for broader infectious disease threats that are more likely to spread, state borders may be less meaningful and a similar declaration process may be incomplete.
As was the case with Zika and Ebola, the majority of the disease activity was overseas for months before affecting the United States. In these cases it would be more prudent to have an additional option for a national level declaration that could trigger use of the fund based on public health threat information. This could also be informed by the World Health Organization, although given their delays in responding to Ebola, a domestic declaration should not rely on their declaration.
Additionally, current authority for declaring a public health emergency resides with the Secretary of Health and Human Services. However, the creation of an Ebola “Czar” was an example of the need to coordinate across the Departments of Defense, State, Health and Human Services, Homeland Security and others from the White House. The work of the Blue Ribbon Study Panel on Biodefense has also highlighted the fragmented nature of our biodefense capabilities across agencies, and the need for White House level oversight and budget management.
Because of this fragmentation, a declaration to access this fund should reside with the president, and be made based on either advice or input from relevant cabinet agencies and the National Security Council or in response to a request made by state and local jurisdictions.
Of course, the greatest source of disagreement to date has been how much funding should be provided.
A letter from 21 lawmakers proposes $300 million, a bi-partisan Senate bill introduced by Sen. Bill Cassidy (R-La.) proposes a rolling average of public health emergency relief expenditures over the past 14 years, while the president’s budget proposes no additional funding, but rather a department-wide transfer authority for the Department of Health and Human Services for up to 1 percent of any account.
Past emergency funding for public health response has been inconsistent as well, and has covered a varied range of activities. Of past supplemental funds, the Zika emergency supplemental appropriation was passed at $1.1 billion, the Ebola emergency funding was $5.4 billion, and the pandemic influenza emergency appropriation was $6.7 billion in 2005 and another $7.7 billion for H1N1 in 2009.
Within these funds, a significant amount went to things like operations overseas, investments in US pharmaceutical infrastructure and additional strategic investments in preparedness. These are all-important initiatives, but may not necessarily belong in a standing public health response fund.
The National Center for Disaster Preparedness at Columbia University’s Earth Institute recently suggested a $2 billion fund should be created with an auto-replenishment schema. The Center for Health Security at John’s Hopkins University suggests a fund of $1-2 billion. While more work is needed to define the levels of funding for such a bill, these analyses provide a reasonable starting point.
The importance of creating such a fund cannot be overstated, but it should also not be oversimplified.
This legislation has the potential to change the way we prepare for, respond to and recover from public health disasters for generations to come. But it will ultimately be up to Congress and the Trump administration to invest the time and political capital to make it happen.