If you're someone who worries about how first responders and hospitals in your town would perform after a hurricane like Sandy, a Joplin tornado, an anthrax mailing, an outbreak of bird flu or other health threat, a new study has some pointers: stay away from Kansas and Montana.
But you might want to consider moving to Maryland, Mississippi, North Carolina, Vermont or Wisconsin.
On Wednesday, two nonprofit groups released "Ready or Not?", a 79-page analysis of public health preparedness - that is, the ability of hospitals, health departments and others to prevent and respond to emergencies ranging from bioterrorism to influenza outbreaks to catastrophic weather.
It's a grim reckoning. The assessment is based on how many of 10 key benchmarks a state met, such as whether it holds drills to make sure public health workers can respond quickly to, say, a catastrophic release of radiation, and whether its labs can work overtime to identify a mystery disease.
This year, thirty-five states met fewer than seven of the 10 benchmarks. Only five met eight of 10.
In 2010, in contrast, more states made the grade: 17 met at least nine benchmarks and 25 met seven or eight. No state met fewer than five.
In the new report, Maryland, Mississippi, North Carolina, Vermont and Wisconsin scored highest, meeting eight out of 10 preparedness benchmarks. Kansas and Montana brought up the rear, meeting three. Alabama, Arkansas, California, Delaware, Nebraska, New Hampshire, New Mexico, New York, North Dakota and Virginia met seven of the 10 criteria.
"We have not paid sufficient attention to the everyday threats" such as influenza and food poisoning and extreme weather, said Dr. Jeffrey Levi, president of the Trust for America's Health, which produced the report with the Robert Wood Johnson Foundation.
There's a reason for that, say experts on preparedness. After the September 11 attacks and the anthrax mailings of 2001, public health preparedness became synonymous with being ready for bioterrorism.
Starting in 2002, states began receiving upward of $1 billion a year from the federal government - $13.6 billion so far - to prevent and respond to public health emergencies.
"But it was all about anthrax and other bioterrorism instead of the other things that might come over the transom, such as bird flu," said health policy analyst Art Kellerman of RAND, a Santa Monica, California-based think tank, who was not involved in the report.
Because the federal money came with tight restrictions - a state health employee working on, say, early-detection systems for a bioterror attack was prohibited from working on anything else - "you had a shifting of attention and resources away from preparing for all hazards to biodefense only," Kellerman said. "It was like we built a biodefense skyscraper at the same time that we took the concrete out of the foundation."
To be sure, states are more prepared for public health disasters than they were a decade ago, says Levi. They've improved their ability to identify a rare disease, such as plague, in time to impose quarantines and trace its spread, for instance.
But budget cuts threaten even that progress, said James Blumenstock, who oversees public health programs at the Association of State and Territorial Health Officials.
Since 2008, 48 states have cut their health budgets as the recession slashed tax revenues. Federal money for state and local preparedness, mainly funneled through the Centers for Disease Control and Prevention, has fallen 38 percent since 2005 and at least 45,700 health-department workers lost their jobs.
The Trust cast a wide net to evaluate public-health preparedness. For instance, it counts vaccinations: only two states met the national goal of immunizing 90 percent of toddlers against whooping cough.
This year Wisconsin, Vermont and Washington are all in the midst of whooping cough outbreaks, with more than 10,000 cases among them. None of the three states vaccinate 90 percent of their toddlers against the disease.
The Trust also assessed readiness for events like Superstorm Sandy. Only 15 states have plans on adapting to climate change, and the more severe weather it could bring. New Jersey, where Sandy killed two dozen people, is not among them.
One critical job of public health agencies is figuring out why people are dying of flu-like illnesses in time to impose quarantines and other steps to prevent a disaster like the one depicted in the 2011 movie "Contagion." Yet 13 states do not have the staff to work five 12-hour days for six to eight weeks to identify and track an outbreak of, say, bird flu.
Outside experts said the report might paint an even grimmer picture if it counted other crucial public-health capabilities. For instance, the country cannot produce flu vaccine in time to handle an unexpected outbreak, such as swine flu (H1N1) in 2009. "It was produced in record time, but still not fast enough to affect the epidemic" before it petered out on its own, said Jeanne Ringel, a health analyst at RAND.