Global Warming and the impact on the Public Health System in the United States and around the World

Jonathan B. Weisbuch, MD, MPH


The fact that the average annual temperature of our planet is rising is no longer in doubt. The average global temperature has increased by one degree Celsius since 1920; it is expected to rise by a similar rate for the foreseeable future.  The profound impact this situation will have on the health of the planet is discussed in detail in the other chapters in this report.  This chapter will describe systems and resources required by local and state public health organizations to meet the challenges a rising global temperature will place upon United States communities; and by inference, on public health systems around the globe.

Rising temperature will produce weather changes, a rise in the surface of oceans, shifts in agricultural yields in the U.S. and abroad, changes in the ecology of disease vectors (e.g. insects, reptiles, rodents, and other mammals), and it may increase human illnesses associated with heat and stress. This paper will focus on the acute manifestations of warming  that result in major meteorological events such as blizzards, ice storms, hurricanes, tornadoes, floods, droughts and short periods of excessively high temperatures. 

These events, which may or may not be caused by global warming, per se, appear to be increasing in frequency bringing destruction, disease, disability and death to the communities in which they occur.   The magnitude of the losses associated with these events, regardless of their cause, is often a function of the quality of the public health and public safety responders and the speed with which they engage. Local preparation prior to an event, and the rapid response of highly skilled, well prepared teams, working together under a unified command structure will define the overall loss of life and property.  

Today, however, even though resources have been increased since 9/11, the public health arm of the response team is deficient. The workforce, barely able to meet daily public health needs, is insufficient to meet the demands of a major occurrence. Local health agencies have limited experience with disasters and lack the information technology they need to monitor and manage the event or its aftermath when the rise of illness, the impact of inadequate food and water, the loss of housing and shelter, all begin to take their inexorable toll on the exposed population.  Inadequate surveillance of the health status in the effected community may lead to a second disaster following the first.

Disaster may strike at any time in any place.  Therefore, all local public health and public safety agencies must be staffed, trained, equipped and able to assume their mutual roles in whatever situation may arise.  Special equipment, test kits, satellite phones, special radios and caches of vaccines and antibiotics are all important items to have in advance of a calamity.  They pale in importance, however, when compared to the necessity of the first responder groups, public health, police, fire, doctors and hospitals, the Red Cross and others, working together in advance of any event to plan, prepare, organize, communicate and establish the rules for command and control.  

Disease surveillance is a core element for public health preparedness.  A surveillance system combines advanced information technology wit clinical, epidemiologic and technical skills to function optimally.  Surveillance provides the information supply chain that allows public health leaders to monitor community health during normal periods and in a disaster.  The system, functioning around the clock, is managed by epidemiologists, physicians, nurses and other public health professionals.  They plot the ebb and flow of births and deaths, infectious diseases, trauma and ambulance runs, hospital admissions, discharges and occupancy, the occurrence of unusual illnesses; and the shifting nature of the physical environment, its air and water status, temperature, wind flow, humidity, particulates and unusual pathogens that may be identified through air, water, and laboratory samples.  Pattern change is measured against historical data.  

Many states, and most local (city, county or regional) health departments, however, do not have the resources to buy the equipment and hire the skilled information technologists to make it work.  They cannot employ the skilled epidemiologists, PH nurses and physicians without whom the process will not function.  When surveillance is weak, evaluating changes in community health brought on by a natural or intentional events is slow.  Hours, days, weeks may be lost allowing problems to magnify before they are recognized.

A skilled workforce, able to respond to any threat, is essential; but many public health departments do not have enough employees to carry out the daily mandates of their office, much less respond to an emergency.  The number of public health workers, on a per-capita basis, is highly variable, ranging from 60 workers for every 100,000 residents up to nearly 100. (Ref: HRSA, 2005).  The quality of the professional staff is also variable; some departments have trained public health physicians in leadership position, while others have administrators without professional degrees and with limited experience.  In a disaster, the people on the ground are the ones who will respond.  If they are unskilled, inexperienced, and unfamiliar with the methods of other public safety professionals in their region (e.g., police and fire), time, energy and resources may be misused in the critical early period.

Hiring and maintaining a professional workforce, skilled in the daily activities of public health and able to respond to any emergency requires adequate salaries and benefits to attract health professionals from direct clinical care activities, sufficient leadership to attract quality professionals, and sufficient resources for the health agency to meet its legal mandates.  These resources derive from elected officials who are faced with short budgets and conflicting political priorities.

Training: A skilled workforce requires training for the entire staff to preserve their professional skills and learn new techniques to meet unusual challenges.  Continuing education should be tailored to meet the needs of each professional group, and allow sufficient the time (from 5% to 10%) to assure that competencies improve and new skills are acquired.  An agency with the resources and commitment to allow its workforce to spend 150 hours (7.5% of a 2000 hour year) in training will achieve two distinct goals.  

First, the skills of employees will be high, the quality of their daily functions will be optimal, and turnover will be diminished.   Second, an agency with 5% to 10% of its workforce in training on any given day is an organization that can expand its capacity to meet the extreme needs of an emergent situation, immediately.  In any emergency, all the training programs can be immediately suspended, providing a large number of professionals to meet the crisis.  Training programs provide a surge capacity of skilled professionals immediately available to respond when time is critical.

Part of the training curriculum is to teach the principles of the Incident Command System (ICS).  In any emergency the public health department will be part of a regional network working with other public safety providers that are essential participants in the event.  These agencies, including police and fire, local non-governmental response groups (Red Cross, religious charities, public and private service agencies, etc.) and the medical care organizations and hospitals within the community, will function within a unified command structure.  By planning together and conducting simulations, table-top exercises, and working on small events together, the members of the team will acquire experience in group cooperation, collaboration, and coordination.

A critical aspect of training for any emergency is giving public health, public safety and the political leadership the knowledge, experience and ability to know when to assume command and control, and when to relinquish that authority either to other local agency heads or to higher authority, whether state or federal depending on the magnitude of the event.  Planning, preparing, training and responding together provide every agency the skill to meet the demands of a crisis in the shortest possible time.  

From the perspective of public health, emergency preparation assures the community that actions by the department before, during and in the recovery phase will be of high quality.  Work will be conducted by skilled professionals.  Decisions will be based on information garnered from the surveillance system, from communication with other agencies involved in the process, and from the process of state and federal health agencies working in concert.

Communication within the agencies managing the event, with the media, and with the public, are important facets of the overall public preparation to meet a disaster.  In any event where disease, disability and death are significant elements, public health professionals must be part of the communication team.  How does information between agencies occur?  Who shall provide information to the press?  Who shall be the prime spokespersons when public announcements are necessary?  Which agencies are responsible for acquiring information?  These are questions that must be determined in advance, and assigned in accordance with the nature of the crisis at hand. When infectious disease and epidemics, excessive heat or cold, disability and death from unknown causes, food and water problems deserve to be handled by the public health authorities. 

These elements of response to disaster are well known by the public health authorities at the federal, state and local level; but little has been done in the past half-decade to augment available resources.  A PH Service Report in 1994, suggested that U.S. public health systems should receive about 3% of the national expenditure for all health services, or nearly $60 billion in 2005 dollars. The budget for state and local public health systems and services in 2005 was below $30 billion, however.  With less than 50% of the resources needed to carry out their legislative mandates, public health agencies are unable to respond to major crises.  We have seen the results of these deficiencies in a host of situations over the past decade, the most serious of which include the spotty response to the mailed anthrax in 2001, the Salmonella munchen epidemic from non-pasteurized orange juice in 1999, and the complete social breakdown prior to, during, and after Katrina. If the public health system is not strengthened, future events will see similar losses.

In conclusion:  Public Health is an essential factor in reducing the impact of any problem facing the nation resulting from global warming.  To be effective, however, state and local health surveillance systems must be improved.  The workforce must be strengthened.  Continuing education and training is essential.  To achieve these improvements, budgets for public health agencies at all levels must expand. 300,000,000 Americans spend nearly $6000 each for individual health care.  Is it not possible to spend $200 each for community preparedness and public health?    At about $100 per capita, we have a long way to go.  

A deficient public health system has a major impact on National Security.  When an event occurs and is not handled efficiently, effectively, and appropriately from the outset, national expenditures escalate and resources needed for other facets of national protection must be channeled to meet the needs of the single emergency.  Hurricane Katrina is a recent example; appropriate management from the time the eye was in the Gulf would have saved lives, reduced disease, and might have lowered property losses, saving the nation hundreds of billions of dollars.