OAKLAND, Calif. (AP) — The swine flu outbreak fell short of a full-blown international crisis, but revealed the precarious state of local health departments, the community bulwarks against disease and health emergencies in the United States.
A sustained, widespread pandemic would overwhelm many departments that are struggling with cutbacks as well as increased demand from people who have lost jobs and medical insurance.
Stung by the lean economy, 13 states and U.S. territories had smaller health budgets in 2008 than in 2007, and eight more made midyear cuts, according to a survey by an advocacy group, the Association of State and Territorial Health Officials. With local budgets also in trouble, many health officials fear a serious outbreak.
"We would be in a lot of trouble," said Alameda County's director of public health, Anthony Iton in Oakland. "We weren't tested to push the system to see how it responds when you have to make hard decisions. I worry about that because the resources have been cut."
A review by the U.S. Health and Human Services Department in January noted great strides in preparedness but said many shortfalls remain. They include the ability to maintain public health functions such as food safety and daily needs during a pandemic, and the capacity to meet surges in health care demand and to strategically close schools.
State capabilities vary. But some local departments, strapped by layoffs and working overtime on swine flu, say they could not maintain the pace in a major outbreak. An Associated Press review found troubling signs:
—Twenty-nine public health workers in Sacramento County, Calif., learned just before being called to work on swine flu that they probably will lose their jobs this summer. Senior nurse Carol Tucker, contacting potential flu victims, thought about future epidemics.
"Who will be around to do these things?" she said.
—Nationwide, officials have reported more than more than 6,700 swine flu cases, and 12 deaths.
"We have good plans and we're exercising them," said Matthew A. Stefanak, health commissioner of Mahoning County, Ohio, whose work force dropped 20 percent in two years. "But for the nuts and bolts of an outbreak — contact investigations, probable cases of H1N1 flu — we don't have the manpower, the trained disease investigators the public health nurses who would do it. That's where we're weakest right now."
—Federal investment in local emergency planning since attacks of Sept. 11, 2001, has paid off in a smooth response to the limited swine flu outbreak. But the money has dwindled.
Last year at least 10,000 local and state health department jobs were lost to attrition and layoffs, including at laboratories that identify disease strains, according to surveys by the state and territorial group and the National Association of County and City Health Officials.
An annual flu-shot clinic no longer comes to town hall in Berlin Center, Ohio. "The real danger is how many just won't get shots," said Ivan Hoyle, 78.
Public health nurses such as Erica Horner won't deliver in-home newborn help in Mahoning County. With the program closed, Horner's duties will change.
—People calling for routine immunizations now reach a recording saying the Worcester, Mass., clinic is closed. With just two of its six public health nurses surviving layoffs, the city is re-evaluating its responsibilities and says it can meet emergencies by working with the University of Massachusetts and local hospitals.
Ann Cappabianca, one of the remaining nurses, scrambles to track communicable disease and tuberculosis cases. "We just can't get it all done. You try to focus on the most important thing at the moment," she said.
Worst is having to make cuts without "enough ability to assess the needs of my community," said Bob England, the health director of Arizona's sprawling Maricopa County, which closed its family planning clinic.
Public health departments will get some help from this year's stimulus spending of $1 billion for prevention and wellness efforts.
But it will take years to bring local health agencies to the point where they can fight a sustained, widespread pandemic, said Richard Hamburg, a lobbyist at the nonprofit Trust for America's Health, an advocacy group supported by private and government grants.
A report from the group in December found emergency planning gaps in areas such as rapid disease detection, food safety and "surge capacity" to quickly scale up equipment, staff and supplies to meet a major outbreak.
Dan Sosin, head of emergency response at the Centers for Disease Control and Preparedness, praised the federal swine flu response, but acknowledged that public health officials face "capacity issues in terms of ongoing resources and funding."
"We could spend more money," he said. "We could use more than we have."
The CDC's acting director, Richard Besser, told Congress last month the government is concerned about states being too short-staffed to conduct required emergency exercises.
The main fund for local health emergency planning after the Sept. 11 attacks, the federal Public Health Emergency Preparedness program, has dropped nearly one-third since a 2006 peak of almost $1 billion, according to CDC figures. The money had included a special three-year congressional allocation for pandemic flu preparation that ran out last year.
President Barack Obama now is asking Congress for $1.5 billion to fight swine flu.
A second fund to help local agencies plan for public health emergencies, the Hospital Preparedness Program, has fallen nearly a quarter from $457 million in the 2006 budget year.
Decreases in the Public Health Emergency Preparedness program were most significant in Iowa, Mississippi, Colorado, Missouri, Michigan, Ohio, Pennsylvania and Louisiana. After a pair of killer hurricanes hit Louisiana in 2005, Washington sent nearly $15 million in 2006 health emergency help. This year, it's down to $9.8 million.
Louisiana's dollars from the hospital program slid from $7.1 million in 2006 to $5.2 million this year.
Even New York City, site of one of the Sept. 11 attacks, saw its Public Health Emergency Preparedness program funds fall to $20.6 million this year from $28.7 million during the 2006 budget year.
In Orange County, Fla., people were diverted from other duties for swine flu needs in a health department increasingly burdened with a range of demands as people lose jobs, said health director Kevin Sherin.
Sherin, president of the advocacy group American Association of Public Health Physicians, questioned longer-term capabilities for lab and field work in his state and elsewhere.
"In the event of a real emergency, these systems have capacity problems," he said.
Georges Benjamin, executive director of the American Public Health Association, a nonprofit lobbying group, said that after the federal emergency buildup, "We didn't complete the job and we didn't make the system sustainable. Our ability to manage more than one thing, or scale up fast is really worrisome."