In 2008, seven years after 9/11 and the subsequent anthrax bioterrorism attack, I wrote an opinion piece advocating that the government needed to restore, and even expand, its support of the public health infrastructure necessary to detect and respond to the next bioterrorism attack or the next infectious disease pandemic. This was in the face of declining federal funding for preparedness that followed 9/11 and the attacks.

I was moved to write the piece because I was haunted by a blueprint hanging in my office of the Trenton postal processing and distribution center in Hamilton, the site where anthrax-laden letters were processed in the fall of 2001, resulting in 22 cases of anthrax in the United States, five of whom died. Six of those cases overall were New Jersey residents. The blueprint was covered by hundreds of red dots representing positive anthrax samples taken from the Hamilton facility in advance of fumigation to return the facility to operation.

The op-ed was never accepted for publication. Hard to know why, but maybe the failing economy at the time made advocacy for infectious disease preparedness seem less important. Emergency preparedness planning has a hard time capturing the public’s and elected officials’ attention and funding, the more so as time passes since the previous crisis.

Funding roller-coaster

Prior to the COVID-19 pandemic, funding for public health at all levels had roller-coasted in response to the waxing and waning of various public health crises as successive governments focused their priorities on more immediate issues. This is despite the various infectious disease crises that have arisen since the 2001 anthrax attacks, such as the 2009–2010 flu pandemic and the Ebola and Zika outbreaks.

For many, these emerging diseases obscured any memories of the anthrax attacks, if they were ever formed (approximately one-half of the current U.S. population were either under the age of 20 or unborn in 2001). Certainly, the threat of biological warfare is far down the list of new infectious diseases to worry about, even now with the current conflict raging in Eastern Europe and the attendant escalating threats by Russia to use all weapons available to them.

The COVID-19 pandemic clearly changed the public health funding calculus for preparedness and response. Or has it?

Congress recently approved a stopgap budget measure to avert a government shutdown in the new federal fiscal year, but this continuing resolution did not include a long-standing request from the administration for significant supplemental funding for the COVID-19 and monkeypox responses and to prepare for future global infectious disease threats.

Our current economic situation may be leading to a repeat downward cycle of funding to prepare for future infectious disease crises. The opposition to new funding for the full fiscal year is largely along party lines, which is no surprise. This opposition is informed by two developments.

Understanding underfunding

First, there is the general acceptance that the COVID-19 pandemic has entered the endemic phase in the U.S., with most stakeholders returning to their pre-pandemic activities, without public health restrictions.

And second, over the past almost three years, the Trump and Biden administrations and successive congresses have provided significant funding through several appropriations targeted at federal/state/local/tribal and territorial public health and health care agencies to respond to the COVID-19 pandemic and enhance public health infrastructure.

These funds have been and will be instrumental in enhancing the initially slow public health response that was largely the result of the sudden emergence of a novel virus in an underfunded and underprepared public health care system.

In addition to addressing the urgent immediate needs to combat the pandemic, this supplemental funding has done much to improve overall preparedness and response at all levels of public health care infrastructure. This year’s Trust for America’s Health (TFAH) report on Protecting the Public’s Health from Diseases, Disasters and Bioterrorism categorizes New Jersey and Pennsylvania in the top tier, with New York in the middle tier, of states on level of preparedness, based on an aggregate assessment of 10 indicators.

Although the scoring system and indicators were different at the time of the first Ready or Not Report in 2003 and annual reports since, New Jersey and Pennsylvania clearly have improved in their ability to respond to a public health crisis over the years.

There is a caveat to some of the supplemental funding: It must be expended by Sept. 30, 2024. Based on history, there likely will be no new funding for emergency preparedness prior to that time unless some other novel infection emerges with a potential significant impact on illness and death. Given the large sums of money appropriated to date, it’s quite possible there will be unexpended funds at the end of spend-by dates but there is no guarantee that Congress would extend the spending time frame.

This is somewhat worrisome, but less so than what may happen after the 2024 elections if a new, and possibly divided, Congress and administration continue to remain at odds.

In many states, most of their preparedness funding comes from year-to-year discretionary federal appropriations, hence the challenge to the sustainability of preparedness when a crisis has passed and Congress cannot agree on new appropriations.

The uncertainty of funding has the biggest impact on attracting, enhancing and retaining skilled and experienced public health staff who are often overworked, underappreciated and underpaid, and in great demand by the private sector in a period of low unemployment.

The TFAH report concludes, as it has every year, that there is clearly room for improvement across the board at all levels of government. One consistent recommendation is increasing the amount of predictable and sustained federal funding that is appropriated for overall public health activities, especially the control of communicable diseases, including vaccinations.

What is not in the recommendations, but equally important, is the need to allow for more flexibility in how the funds are spent. The appropriations language is often specific for the crisis du jour, and when another crisis emerges (monkeypox, for example), the federal agency responsible for managing the new crisis does not allow, or makes it difficult, to use the funds to address the new crisis.

We can only hope that our policymakers will consider the many recommendations outlined in the TFAH and other federal and state-specific after-action reports, and act accordingly to continue to build and sustain our defenses before our inevitable next infectious disease or other public health crisis.