Georgia has repeatedly cut spending on public health emergencies this decade, despite heightened anxieties over bioterrorism and, more recently, the swine flu virus.
The cuts cast doubt on the state's ability to detect and contain virulent outbreaks such as pandemic influenza, experts inside and outside state government say. A severe pandemic, a 2008 study found, could kill 57,000 Georgians, or about one-half of 1 percent of the state's population.
State officials say the public health system is adequately handling the current, relatively mild outbreak in part because of extra work by lab technicians and other employees. But they acknowledge that the budget cuts of recent years could hamper the system's effectiveness.
"The public health work force has been diminished," said Dr. Patrick O'Neal, the preparedness director for the Georgia Division of Public Health, a unit of the Department of Human Resources. "If this were a really bad one and we were dealing with an eight- to 12-week wave with massive numbers of deaths and stress on the system, our people would not be able to keep up."
Overall public health spending —- on children's immunization programs, for instance, and other routine health care services paid for by federal grants —- has increased to reflect the state's population growth.
But programs dealing with public health emergencies have been hit especially hard by budget cuts, state officials said.
New spending on the division's epidemiology section, which investigates outbreaks of infectious diseases, will decrease by almost one-fourth during the next fiscal year, to a level slightly lower than in 2006. At the state public health laboratory, which tests cultures for viruses and bacterial agents, jobs have gone unfilled and vacant positions have been eliminated.
State officials said last week that they were too busy with swine flu cases to quantify the lab's turnover rate.
The state budget cuts followed suggestions from agencies, many of which looked first at eliminating vacant positions, said Bert Brantley, a spokesman for Gov. Sonny Perdue. High-priority programs got the smallest cuts, he said.
"The state has prepared for pandemic outbreaks for years," Brantley said, "and I think the successful response so far indicates that we were ready and appropriately prepared."
But even before the current outbreak, the main lab, in Decatur, was so stressed by cuts that it hadn't had time to study whether it could handle a surge in tests during an emergency, a state audit found in 2006.
The lab "does not keep up-to-date records of its surge capacity," the audit said, "though delays attributable to an inability to meet increased testing volume could slow emergency response and result in increased illness or fatalities."
For Georgia and other states, preparation for a public health emergency became imperative after the terrorist attacks of Sept. 11, 2001, and the anthrax scare that occurred the same fall. Public health spending across the nation spiked. But as fears shifted to avian flu and other potential pandemics, governments began shifting resources to other priorities.
As a result, thousands of public health jobs have been eliminated, said Jeffrey Levi, executive director of the nonprofit Trust for America's Health.
"The system is not overburdened yet," Levi said. "The big question is what happens when more and more cases are suspected, and more and more lab tests are necessary, and more and more work needs to be done in the community to educate people on how to protect themselves."
Georgia ranks 39th among the states in spending per resident on public health programs: $18.33, compared with the national median of $33.71, according to a report that Levi's organization released in 2008.
Legislators appropriated $175 million, including federal grants, for public health in the fiscal year that ended June 30, 2008. The figure for the current fiscal year is $191 million. Neighboring Alabama, for one, spends almost $100 million a year more.
In Georgia, no one has publicly advocated cutting the budget for public health emergencies. In fact, state legislators say they have tried to protect health programs from a budget crisis that has forced reductions throughout state government.
"The discussion has been: What is the most businesslike way to handle it?" said Senate Appropriations Chairman Jack Hill (R-Reidsville).
In 2006, for instance, the Senate rejected a proposal by Perdue to spend $15.7 million on antiviral medications to treat pandemic flu. The cost was too high, Hill said, especially since many of the drugs probably would have sat in refrigerated warehouses until they were too old to administer. But he said lawmakers have never intentionally "shorted" public health.
This year, Hill said, the Senate rejected Perdue's proposal to cut $3.5 million from county health departments. Consistently, he said, the Department of Human Resources has recommended extensive cuts to many of the public health division's programs. On July 1, the division will become a part of the Department of Community Health. Hill said public health should be a better fit with the new department.
"My opinion is public health has always suffered a higher degree of cuts than other areas of DHR," Hill said. In rejecting the proposed cuts to county health units, he said, "we started out with the idea they're underfunded and we believe the cuts were disproportionate."
Nevertheless, nearly every state budget measure since 2006 has cut into emergency preparedness spending.
This year, for instance, lawmakers eliminated three vacant positions in the epidemiology section for a savings of $139,954. The budget bill also cut $125,854 to wipe out three vacant positions in the preparedness section, along with $100,000 for storing antiviral medications.
A year earlier, lawmakers took $300,000 from the epidemiology section's budget to buy a bus for another public health program that promotes testing for sickle cell anemia.
For the fiscal 2010 budget, which takes effect July 1, lawmakers voted to reduce all public health spending by $1.4 million, or 6 percent.
The budget cuts leave the public health division with lab staffing issues and other problems that were identified in a state audit in 2006 —- as well as in another review 13 years earlier.
The 2006 audit said lab workers complained they "were experiencing difficulty attracting and retaining qualified personnel," partly because salaries were too low in comparison with those at the Atlanta-based Centers for Disease Control and Prevention.
Susan Lance, head of the epidemiology section, said last week that "a fair number of vacancies" exist now. Salaries remain uncompetitive, she said, and state personnel officials have been slow to authorize new hiring.
O'Neal, the preparedness director, said the agency has enhanced its disaster planning, enabling it to react quickly to the swine flu outbreak.
Despite the staff turnover, he said, "the people who have remained are among the most committed you'd see anywhere."
State Sen. Renee Unterman, the chairwoman of a subcommittee that oversees the public health budget, said the flu scare could lead to increased spending to prepare for future outbreaks.
"This is a fundamental part of what state government is supposed to be about," said Unterman (R-Buford). "At some point, the budget has to increase."
Hill, the Senate Appropriations chairman, isn't sure that point resonates among many lawmakers. While public health can attract attention when threats are obvious, he said, itmight not once the swine flu outbreak abates. "But the needs in public health," he said, "will still be there."
Staff writer Margaret Newkirk contributed to this article.
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