Edward Davies: How health is being hit by the US shutdown

Edward DaviesThe closure of Panda Cam at the Smithsonian National Zoo may be the highest profile casualty of the government shutdown in the US, but with a third week edging ever closer, some of the emerging consequences are a cause for considerably more concern.

The nature of a shutdown means a comprehensive national picture is difficult to patch together: some workers are furloughed, others are deemed essential and continue (although often unpaid), some are deemed non-essential, but find themselves needing to work anyway, while some deemed non-essential have since been discovered to be at least rather useful and have returned to work.

Government bodies and research
The Department of Health and Human Services has furloughed roughly half of its 80,000 staff, but activities that do not rely on annual appropriations, and activities that involve the safety of human life and protection of property have continued.

At the National Institutes of Health (NIH) a message on its website confirms it will continue to care for patients currently admitted to the NIH Clinical Center, but only provide “minimal support” for ongoing protocols, and maintain “minimal staff” to safeguard NIH facilities and infrastructure.

What the NIH furlough means in practice is hazy, but some details are emerging. Many investigators running trials have been furloughed, but The New York Times reports that the agency has continued to admit critically ill patients to existing trials: “About 12 patients were enrolled between 1 October, when the government shutdown began, and 8 October Most were cancer patients, said Renate Myles, an NIH spokeswoman. That is substantially fewer than would have been enrolled had there been no shutdown. In a typical week, the agency enrolls roughly 200 new patients. About 30 of those are children, a third of whom have cancer.”

There are also significant problems emerging for researchers trying to continue their work. Databases and websites such as the National Library of Medicine are down, and some federally funded research projects can not be immediately resumed at the same point, including basic lab science where live experimental samples evolved over long periods of time may be lost and will need to be recreated.

There is also the issue that researchers can’t register their studies in clinicaltrials.gov, so they may face a situation where an RCT is ready to start enrolling patients, and may in fact start enrolling patients, yet they are unable to prospectively register the trial.

At the US Centers for Disease Control and Prevention (CDC) there is “minimal support” for many of its programs and it is having a significant impact on many of its functions. Notably for the time of year it cannot sustain its annual seasonal influenza programme.

Human stories are also beginning to leak out about how individual patient treatment is suffering during the shutdown.

This week, the Washington Post published an interview with Michelle Langbehn, who was recently diagnosed with sarcoma. After nine months of chemotherapy, she and her doctor began looking into other potential treatment options, including a trial at the NIH. Langbehn began filling out the paperwork to apply last month. Things were going well until late September, when she got a call from the NIH: if the government shut down, the trial would not accept new patients. She is now one of the hundreds of patients being turned away from trials.

Many news outlets have also focussed on children not being enrolled into similar cancer treatment trials.

Public health
On a population scale there are increasing concerns that the shutdown could cause large scale problems. As well as the CDCs withdrawal from parts of its influenza programme, the FDA has also stopped some of its safety activities such as routine establishment inspections, some compliance and enforcement activities, monitoring of imports, and the majority of its laboratory research. But it is the decision to stop “the majority of its food safety, nutrition, and cosmetics activities” that is causing greatest alarm.

There are various reports (though largely assertion at present) that furloughing FDA employees will result in poorer quality food inspections, and therefore disease outbreaks, and the subject was raised in the House of Representatives earlier this week. The FDA has stressed this is not the case, and that a reduced staff of 344 FDA employees are still working to inspect food imports. But this hasn’t stopped an unusual glut of general food safety stories hitting the press such as a salmonella outbreak in Califormia and in shrimp imported from Asia.

This morning the New York Times joined the fray quoting the concerns of various politicians and food campaigners: “This is a self-inflicted wound that is putting people’s health at risk,” said Representative Rosa L. DeLauro, Democrat of Connecticut, a longtime food safety advocate. Because the shutdown comes on top of earlier budget cuts to the agencies, she said, “you’re creating the potential for a real public health crisis.”

The knock on effects
And finally, it’s easy to forget the impact of the wider job uncertainty this causes. It was estimated that around 800,000 workers were furloughed on 1 October, which is a lot of people to simultaneously worry about their next pay check. And beyond this is the service industry that supported those people.

One simple tweet from a Washington DC correspondent this week makes that wider impact clear when he wrote: “Message to Obama from my DC cab driver who had two fares all day and has only covered his gas money since shutdown began: ‘bring them back!’”

Edward Davies is US news and features editor, BMJ.