A situation playing out right now among top health officials in the United States is giving us a bit of déjà vu.
Let's call it the looming-health-disaster money scramble.
Whenever there's a threat of an infectious disease landing here and spiraling out of control, officials and researchers from around the country head to Washington, DC, to plead for emergency funds before Congress — and the media. They remind lawmakers and the American people that we really, really need money to prepare for this epidemic. If we don't act fast, more people will suffer and die and the outbreak will be harder to stop. This pleading gets mired in inevitable political squabbles and delays.
The scramble plays out with disturbing regularity — with Ebola, H1N1 (also known as swine flu), and now Zika.
Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, is a regular on this circuit. He was on his way to Congress last Thursday for his sixth hearing on Zika this year when we caught up with him.
Asking for funding to prepare for and manage a potential Zika outbreak (President Obama put the price tag at $1.8 billion, which senators are voting on today) has become a full-time job, he told us.
"Ebola was the same thing, the same sort total consuming of one's efforts," he said. "You have to do it because it's for the health of not only a country but the world."
The stakes are indeed high. Zika can cause severe birth defects and death in fetuses, as well as neurological problems in adults. Fauci, for one, needs more funding to support federal scientists who are trying to develop a Zika vaccine. Money is also needed to better understand the disease's natural history and develop diagnostics and screening tools.
If we know that globalization, climate change, and other factors are only heightening the risk of potentially devastating pandemics, why do we subject health officials to what has become an annual scramble? Why do we imperil our own health and global health every time a potential outbreak is on the horizon?
I put those questions to leading health thinkers and asked them how we might do better. Here's what they told me.
Why we're so bad at preparing for disease threats
First, there's the simple answer: There's no emergency money stockpile for them. Hence the perennial looming-health-disaster money scramble.
"Up until recently, we have not really considered infectious diseases a critical component of public health preparedness and emergency response at the federal level," explained Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine.
While that's changed somewhat since the White House implemented the Global Health Security Agenda — a commitment to working with other countries for better detection and control of disease outbreaks — that mandate hasn’t translated into permanant allocations of funding from Congress to actually do the work.
It also doesn't help that there's a massive national deficit and cost cutting across the board, Hotez added. "I think it could be something done at the level of the Office of Management and Budget, but that generally means taking funds away from something else." And doing that isn't easy when there's not a lot of money to go around.
What makes allocating money to looming health disasters even more difficult, said Fauci, is how we typically perceive risk. "There's always a reluctance to put resources into something that isn't happening yet. There are constrained resources; everyone is vying for things that are justifiable and needed."
Outbreaks that are still only just a possibility "go low on the priority list," Fauci added.
Duane Gubler, a researcher in mosquito-borne diseases at Duke-NUS Medical School in Singapore who worked for the Centers for Disease Control and Prevention for nearly 30 years, also attributed the lack of preparedness to our "crisis-oriented society."
"We [delay in responding to outbreaks] because at a time when there are competing priorities for limited resources, it is politically not safe to react too soon or to prevent an epidemic," he said. "Public health officials are accused of wasting money on a disease that wasn’t a problem."
As New York Times columnist Nicholas Kristof wrote in a column yesterday, Obama urgently requested Zika funding back in February, "and Congress since then has done nothing but talk. Republicans have protested that the administration doesn’t need the money, that they have questions that haven’t been answered or that the request is vague."
According to Suerie Moon, of the Harvard Global Health Institute and Harvard School of Public Health, deadly diseases that could sicken and kill thousands aren't above this sort of political wrestling.
"It was the same thing in 2014 with Ebola — but that was the midterms. The $1.8 billion being requested [for Zika] is not a lot of money — it's a fraction of what Congress had to allocate for Ebola because we did wait too long."
How we might do it better
It's not just the US that's terrible at preparing for these epidemics we know will come. As I've written before, it's the entire global health system.
"Ebola is still fresh in everybody’s minds and we’re still struggling at mobilizing the money," Moon pointed out.
But there is a better way, said Lawrence Gostin, a Georgetown University global health expert, and we desperately need to improve our epidemic responses, as the scale and rapidity of outbreaks seems to be getting worse. It's not just Zika, but SARS, MERS, new flu viruses, Ebola, and yellow fever.
"Politicians see many emerging diseases come and go without great incident, so they tend to ignore pending threats," Gostin said. "But sooner or latter major epidemics strike, and they can be deadly."
Ron Klain, the "Ebola czar" who coordinated the US response to Ebola, has also thought long and hard about how to prepare for outbreaks. The Federal Emergency Management Agency (FEMA) was established to respond to natural disasters, he pointed out, but there's still no equivalent for health. So he's been advocating for a new federal response agency to help us organize for and rapidly deploy in the event of a major epidemic.
"We should have an agency doing for epidemics what FEMA does for hurricanes — and then, yes, we would have some common response items prepositioned and some immediate funds for action and contracting in the response," he said. But, like FEMA, even if a health fund existed it might need to be supplemented with emergency funding if a particularly bad epidemic were to hit.
Hotez also favors the creation of a new funding agency to manage infectious disease emergencies. While each epidemic looks a little different, having some sort of mechanism in place that could trigger an immediate release of money would be extremely useful and probably lifesaving.
"You could even make those funds time-sensitive — use them for the first 30 days, then go back to Congress to continue funding," said Hotez. "But at least the first tranche of money is there to begin [responding to the outbreak]."
For now, health officials are left waiting for Congress to come around. On the ground in Harris County, Texas — one of the states expected to be hardest hit by Zika — public health and environmental services director Umair Shah said the money needs to trickle down in the next few weeks as mosquito season starts up.
Harris County has had a robust mosquito control program in place for the Culex mosquito for 50 years. But the Aedes species that carries Zika is another kind of mosquito and needs to be managed differently, at additional cost.
"Mosquito season is … around the corner," Shah said. "We don't want to have funding happen in October or November, after the fact. We need to have the dollars now."