More than half of the country is ill equipped to handle public health emergencies, according to a new report from the Trust for America’s Health.

The report, Ready or Not: Protecting the Public’s Health from Diseases, Disasters and Bioterrorism, released December 20 and supported by the Robert Woods Johnson Foundation, found that 26 states and the District of Columbia scored six or lower out of 10 indicators in health emergency preparedness, such as funding for public health, flu vaccination rates, climate change readiness and food safety.

Only Massachusetts scored a perfect 10. North Carolina and Washington State scored 9 out of 10. Alaska and Idaho each only scored 3 out of 10.

A large part of the problem, according to the report, is that the current public health system is not built for readiness, so when an emergency occurs it diverts time, attention and resources away from other needs. For instance, instead of having a standing health emergency fund that can immediately be tapped to respond to a crisis, the country relies on a series of emergency supplemental funds which requires new debate and analyses. It took up to 10 months for Congress to respond to the Zika virus. Once an emergency subsides, complacency sets in, resulting in budget cuts. Health emergency preparedness funding for states has been cut from $940 million in fiscal year 2002 to $660 million in 2016.

There were bright spots. The report found improved communication and coordination, a “major” upgrade in public health labs and illness detection capabilities and improvements in legal protections during emergencies.

However, continued problems included lack of an interoperable, near real-time biosurveillance system, insufficient support for research to keep up with modern threats, and gaps in the ability of the health care system to deal with a large number of afflicted patients.

The threats range from viruses to superbugs, food borne illness, hospital acquired infections and bioterrorism.

Recommended priorities included:

  • Maintaining a set of “foundational capabilities” to respond to health emergencies
  • Creating stable, sufficient health emergency preparedness funding
  • Supporting global health security, since “germs know no borders”
  • Improving federal leadership before, during and after disasters
  • Pushing for innovation and the  modernization of infrastructure
  • Better recruitment and training of a public health workforce

TFAH interim President and CEO Rich Hamburg warned that in the years since 9/11 there’s been backsliding, and that “we’re not adequately maintaining a strong and steady defense” against these threats, in a teleconference with the media.

Dr. Eric Toner, Senior Associate, UPMC Center for Health Security, also warned against relying only on hospitals to handle public health emergencies. For instance, hospitals are ill equipped to treat individuals with chronic conditions who have been displaced during a natural disaster.

“The stress on hospitals could be reduced if other sectors were more resilient. New partners must be recruited to help health care coalitions,” he said.