Commentary

Domestic Disease Detection: The Other Surveillance

in Program

Dying crows fall broken to New York City streets; flamingos succumb at the Bronx Zoo; dozens of feverish patients with severe neurological symptoms stagger into hospitals in Queens. What connected all of these events? In 1999, only the hunches of one astute clinician and a determined zoo veterinarian sounded the alarm that a new disease had appeared in the US The National Biosurveillance Integration System, launched five years later, was supposed to ensure that timely detection of unexpected outbreaks would no longer have to rely on serendipity.

If the anthrax assaults of fall 2001 highlighted the need to build U.S. disease surveillance capabilities,[1] the 1999 emergence of West Nile Virus in New York supplied the blueprint. In addition to lessons learned about clinician training, laboratory capacity, and real-time disease reporting, the case underscored the consequences of poor information-sharing among agencies that monitor disease threats, especially across the gulf dividing animal and human health.

A noticeable die-off of New York City’s crows and captive exotic birds preceded recognition of the human epidemic by weeks, but cost and administrative barriers denied zoo and wildlife officials critical laboratory diagnostic tools until the human-animal nexus finally became clear. If a single doctor had not reported an unusual disease cluster at her hospital, the outbreak might have been detected much later, if at all. West Nile Virus is far from the only emerging disease to infect domestic, captive, and wild animals as well as people – other notable culprits include avian influenza, as well as several “select agents” deemed likely materials for bioterrorism. Multiple reports on U.S. biodefenses issued after the West Nile and anthrax outbreaks argued that informational silos between and within public health, animal health, food, water and environmental threat monitoring systems could prevent decision makers from recognizing a deliberate biological attack or natural epidemic in time to intervene.

Since 2001, Congress has committed an estimated $32 billion dollars to biodefense at the local, state, and Federal levels. Laws and executive orders expanded biological threat surveillance missions at a slew of Federal agencies, including Heath and Human Services (encompassing CDC and FDA), USDA, EPA, VA, Energy, and Defense. In 2004, President Bush directed the Department of Homeland Security to coordinate this new government-wide “biological threat awareness capacity,” and to create a single comprehensive disease early warning system. In response, DHS launched the National Biosurveillance Integration System, or NBIS, to integrate and analyze bio-surveillance information from all available Federal sources.

This year, in Washington’s quiet August, the DHS Inspector General released a bleak report on progress under NBIS. In his assessment, an initially promising technical effort faltered as ownership of NBIS transferred among four directorates in three years. The program received little support until a November 2005 speech on bio-surveillance by President Bush startled senior DHS officials into a sense of urgency. The renewed effort foundered in logistical problems and false starts, compounded by high staff turnover and a lack of leadership continuity. Due to inadequate technical guidance from DHS, progress under a $14.3 million contract to develop an NBIS database remains limited. In the absence of coordination, the Federal agencies charged with biosurveillance essentially shrugged and resumed developing their own systems independently.

The DHS response cited improvements, and stated that many of the concerns in the report have been addressed already. Its Chief Medical Officer, the program’s current director, acknowledged the criticisms but expressed optimism that the NBIS program office has finally been elevated to an appropriate level, with a proposed increase in its annual budget to $118 million over the current $5 million.

The inspector general’s criticisms – inadequate funding, constant reorganizations that undermine programming, and poor partnering with stakeholders – precisely reflect those leveled by the Government Accountability Office in a general evaluation of progress at DHS since its creation.[2] It would be easy to dismiss the findings on the national biosurveillance program as just an example of bureaucratic paralysis, symptomatic of the problems of the larger organization in which it resides. While partially true, to leave the problem at that overlooks the complexity of the underlying challenge. A database is only as good as the data that goes into it, which means that the various entities that collect data on health threats (from clinics to zoos) require resources appropriate to the challenge of making information available to NBIS in real time. Creating “total disease situational awareness” demands more than just a well-administered program and new information technologies: it requires a sea change in the cultures of agencies and professionals accustomed to looking at health threats only in one specific context. In turn, that change demands serious commitment at the highest level of government, an overarching strategy under which to set priorities and monitor real progress.

Six years after the anthrax assaults spurred a tremendous investment in public health, the American people have a right – and policymakers an obligation – to ask exactly how much preparedness that investment has purchased. With the Pandemic and All-Hazards Preparedness Act of 2006, Congress took a step towards demanding accountability by requiring the Secretary of Health and Human Services to develop a National Health Security Strategy for building U.S. defenses against deliberate or naturally occurring outbreaks, with realistic benchmarks for progress. This national strategy would presumably help stakeholder agencies identify shared goals and priorities for disease surveillance and response efforts. However, the first installment is not scheduled until 2009. In the meantime, Federal decision makers must support, with resources and attention proportionate to the task, real interagency coordination to use existing disease detection and response resources as efficiently as possible.

Disease outbreaks, whether deliberate or natural, can undermine economic growth, stall movement and trade, and take dozens, hundreds, or thousands of human lives within nations. No act of war or terrorism has ever managed to unleash havoc equivalent to Mother Nature’s work; the 1918 “Spanish Flu” pandemic alone is estimated to have caused 50-100 million deaths worldwide after apparently leaping from animals into humans. The risk that a pandemic influenza strain will emerge in coming years has disappeared from the headlines, but not from the real world; modern clinical medicine offers no guarantee against an equally large number of deaths. The difference between 1918 and now is that tools exist to help avert health catastrophes, if decision makers receive the right information in a timely fashion. NBIS offers one potential technological tool to transcend the limits of human intuition (and endurance) in poring through existing human, animal, food, and environmental data, possibly gaining valuable hours to ameliorate emerging health threats. Implemented poorly, in the absence of meaningful dialogue with experts and stakeholders, it will be remarkable only as another symbol of a struggling agency.

Rather than allowing the NBIS debacle to fade into general lamentation about reorganization woes at DHS, this summer’s report offers an opportunity to spur a real national debate on how much the U.S. should expect from its public health system, where disease threats stand in the context of national and homeland security, and how to make the most out of the billions spent already on biodefense. After all, the lessons of the West Nile outbreak have not changed; it would be a shame if the critical gaps in U.S. disease surveillance capacities revealed in a murder of crows also remained the same.

 

[1] Disease surveillance refers to the systematic collection and analysis of health data that can be used to identify outbreaks or clusters of disease, recognize associated risk factors, and take steps to protect the public.

 

[2] Government Accountability Office, Report GAO-07-1081T: Progress Report on Implementation of Mission and Management Functions (2007). http://www.gao.gov/new.items/d071081t.pdf

 


Julie Fischer is a Senior Associate with the Global Health Security Project at the Stimson Center.

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