Limitations On And Of Governmental Public Health

In the words of historian Lord Aston, "Power corrupts, and absolute power corrupts absolutely'' (Powell, 2001). Therefore, the founding fathers of the United States divided power among three branches of government to create a system of checks and balances. However, these checks, balances, and other institutional mechanisms may slow or distort the development, implementation, and use of biosurveillance systems.

Funding decisions perhaps have the greatest effect. Biosurveillance funding competes for taxpayer financed funding with myriad other real and perceived needs. When the economy is poor, tax receipts go down and human service expenses,

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This is an official CDC HEALTH ADVISORY

Distributed via H&alth Alert Network

Saturday, November IE, 3003, 19:28 EST (7:29 PH EST) CDCHAN-00164- 03-11 -15- ADV- N

Consumers Advised That Recent Hepatitis A Outbreaks Have Been Associated With Green Onions

Message Retransmitted from PDA

Rtfl Food and Drug Administration(FDAJ is advising the public that sévirai recent hepatitis A outbreaks hava been associated with eating raw or undercooked green onions (stallions) Hepatitis A is a trver disease that develops within 5 weeks of an exposure. Hepatitis A Is usually mild and characterized by jaundice (yellow discoloration of the skin), fatrgue. abdominal pain, toss of appetite, nausea, diarrhea, and fever. It can occasionally be severe, especially in people with trvei disease

Hepatitis A outbreaks associated with raw or undercooked gieen onions semsd in isstauiants occurred in Tennessee, North Carolina and Georgia in September. Another outbreak dI hepatitis A among patrtrns of a single restaurant occurred in Pennsylvania during Jate October and early November, although Ihe source of the outbreak has not yet been determined CDC and the State of Pennsylvania have an investigation underway Jo determine if a specific foud is associated with Ihe Pennsylvania outbreak, and if so, the eiact source The source of the green onions in the Tennessee outtiieak is Mexico. FDA Is continuing to investigate and ts working with Mexican authorities to assess appropnate measures FDA offers Ihe following advice to consumais concerned about the possibility of getting hepatitis A from green onions'

» Cook green onions thoroughly This minimizes the risk of illness by reducing or eliminating Ihe virus. Cook in a casserole or sauté in a sklllel.

* Check food purchased at restaurants and delicatessens and ask

FIGURE 5.7 Cont'd b, Screenshot of an official CDC Health Advisory related to the hepatitis A outbreak described in Chapter 2. This was distributed to clinicians nationwide via individual states (CDC, 2005g).

such as Medicaid and Temporary Assistance for Needy Families, increase. Even if a legislature appropriates money, there will sometimes be a freeze placed on spending mid-year because of revenue shortfalls and a prohibition many states have against deficit spending.

Lobbying by special interests, including businesses, universities, and nonprofit groups, also influences the allocation of funding. Members of legislatures are cognizant that they will face re-election, which depends on political contributions and votes. As a result, programs that attract both votes and contributions get funded; programs that don't may not. If the public does not perceive a need, it is difficult for elected officials to justify the allocation of public funds when other real and perceived needs are not met. Sometimes an elected official who was a champion of a program will not get re-elected.

The newly elected official will have other priorities, and the program's funding will be in danger.

Sometimes legislatures allocate funding for activities that the executive branch did not ask for, or money is allocated but specified for a specific disease only. Developing systems to satisfy legislative requirements may take staff away from tasks that they consider more important. In addition, dedicated funding can not be used for anything else. Such earmarking of funds encourages the development of disease-specific surveillance systems at the expense of broader multipurpose systems.

Once funds are allocated, there is still the challenge of spending the money wisely within the stipulated time frame. Unspent money often reverts back to the general fund. This time frame is usually one year but can be less if a budget was passed late. One year is usually too short to plan, let alone develop a system. There are some mechanisms available to extend money or to guarantee continuing funds; however, administrators must be knowledgeable and careful.

Strict purchasing rules exist to eliminate political favoritism. They require administrators to develop specifications, submit them for review, and, finally, open them to bid. All decisions must be reviewed by other administrators (political appointees and civil service). Writing specifications is very difficult if you need to purchase something that does not yet exist or if the administrator is not knowledgeable about the specifications. Moreover, flexibility is limited, making it difficult to change specifications in response to newly identified needs.

These same problems exist when it comes to hiring. There are basically two types of positions: serve at will (or political appointees) and civil service. Serve-at-will positions are higher-level positions and easier to fill. However, the employees are likely to be released if the executive leader (president, governor, mayor) is not re-elected. Also, there is a temptation to appoint individuals who are politically connected even if they are not qualified.

Civil service developed to divorce hiring from politics and ensure that individuals are hired and promoted based on competency (Columbia Encyclopedia, 2005). Biosurveillance requires new skills that may not exist in current civil service classifications. Administrators must write new job descriptions, and the criteria for assessment must be developed. A time-consuming search for a qualified person adds to further hiring delays. Finally a uniquely qualified individual may need accommodations that are routine in the private sector (flexible hours, telecommuting) but are difficult for governments to offer.

Federalism is the term that defines the pattern of relationships between national, state, and local governments in the United States. The Constitution of the United States reserves certain powers for the federal government and delegates the remainder to the states. Although the Constitution is silent on the issue of the role of local governments, it has created a situation in the United States in which the federal government has the money, state government has the legal authority, and local government has the problem. This concept can be traced all the way back to Thomas Jefferson and the Federalist Papers (Nitzkin, 2001). What this essentially means is that money appropriated by the federal government may have to pass through three different bureaucracies, each with slightly different rules, until the money makes it to the local area where it is needed or must be spent.

If all of this sounds daunting, it can be. The best administrators usually find legal ways to make the system work including private-public collaborations and outsourcing to nonprofit organizations. At times they must make a choice between returning money (and not accomplishing the mission) or spending it less than optimally. However, for all of the difficulties that these checks and balances bring, most agree that it is worth the effort to preserve our democracy. Winston Churchill said it best: "Many forms of Government have been tried, and will be tried in this world of sin and woe. No one pretends that democracy is perfect or all-wise. Indeed, it has been said that democracy is the worst form of Government except all those others that have been tried from time to time'' (The Quote Garden, 2005). Nevertheless, the slow rate of progress in advancing surveillance capabilities in the four years since the October 2001 anthrax attacks suggests that it may be worth rethinking the role of government in biosurveillance or finding a way to create a governmental organization, much like early National Aeronautics and Space Administration (NASA), with fewer constraints and a mission focused solely on improving technical biosurveillance capabilities.

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