One state's less-than-stellar experience tracking disease
By Katherine Eban

As spinach tainted with a deadly Escherichia coli made its way last year from a California farm through 26 states, sickening more than 200 people and killing three, a bill to advance symptom monitoring was making far slower progress through the California state bureaucracy. To some public-health experts, it was d￩j￠ vu all over again, on two counts: a tidal wave of symptoms that no one saw, until it was too late; and a possible solution encountering bureaucratic resistance.

Since 2003, two statewide commissions on emergency preparedness had advised that California urgently needed electronic systems for syndromic surveillance and disease reporting. A report by the Little Hoover Commission in 2003 noted that in California, only one-fifth of "reportable" diseases and conditions are actually reported to public health officials. "When a California food processor" - Odwalla - "was shipping contaminated juice that sickened scores of people, it took Washington State to detect the source and notify California authorities," the report pointed out.

In the two years that followed, almost none of the commission's recommendations were implemented. When the commission met again in 2005, its witnesses were blunt: "If there were to be another outbreak of a new disease like SARS or a terrorism attack using biological agents, California's medical and public health system is not prepared to detect the outbreak in a timely manner," Eric Koscove, chief of the Kaiser Permanente Medical Center's emergency department in Santa Clara, testified.

Without an electronic system to monitor emerging symptoms, critics argued, California's public health officials effectively remained blind. The US Centers for Disease Control and Prevention has not yet expanded Biosense to California. There seemed no shortage of bad news for California's bioterrorism responders. A number of reports and score cards found the state woefully unprepared for the worst.

The problem was not just surveillance. It was the erosion of the state's laboratory network, the lack of planning for a sudden surge in patients, and widely varying standards of preparedness at the numerous county health departments, and little centralized oversight.

From 2002 to 2004, Los Angeles County had only spent $69 million of the $83 million it had received from the CDC to prepare for a bioterror attack. Yet the county had inappropriately spent $2 million of its federal grant money on public-relations paraphernalia.

Unable to find enough volunteers, it paid actors to join in a smallpox vaccination drill and afterward rewarded them with gift bags, according to a report in the Los Angeles Times. It spent more than $128,000 on trinkets including letter openers and flashlights, more than $4,000 on stress balls and clipboards for an epidemiology conference and hundreds to replace a podium damaged by rodents, spending defended by county health officials as meeting Federal guidelines.

Among its recommendations, the 2005 Little Hoover Commission proposed creating a real-time surveillance system that could detect symptoms "in time to save thousands of lives." The populous far-flung counties of California, used to acting autonomously, had become an extremely dangerous model in a post 9/11 world. As one former California health official, who asked not to be named, explained, you wouldn't dream of having 65 different air traffic control systems that couldn't communicate with each other. That, however, had long been California's public health system. Given the necessity of a new model, some informatics experts grew hopeful that California might become a "miracle story" of a dramatic turnaround.

Last August, the state legislature passed Bill AB 1956, which required the state to test three competing syndromic surveillance systems with the goal of choosing one to implement. The SYRIS program, designed by Alan Zelicoff, would likely have been one of those chosen. In 2005, Zelicoff had briefed the state's secretaries of health and agriculture about his system. It had all seemed hopeful.

But ultimately, the plan was scotched. There was to be no controlled test, no study. Last September, Governor Arnold Schwarzenegger returned the bill unsigned, saying that he did not want to divert limited federal preparedness dollars for "new, costly, experimental systems."

Zelicoff argues that SYRIS is both effective and cheap. "Why can't we do a blinded controlled test? That's called science." At the end of the day, he believes that our lack of preparedness may have more to do with human limits than with technological ones. In public health, "The ?not-invented-here' syndrome is a metastatic disease," he says.