An Exercise in Utility: The Role of Public Health

Effective emergency preparedness requires, among many other things, drills and exercises of various types to test the preparedness, response, and recovery capabilities of the numerous agencies and individual responders involved. Regardless of the professional discipline – law enforcement/public safety, emergency management, homeland security, and/or public works – it is particularly important: (a) to have a well-established emergency plan in place that is based on realistic pre-identified hazards; and (b) to exercise that plan on a regular but not necessarily “routine” basis. In public health, there is still a need to fully develop applicable emergency plans – and, subsequently, to drill and exercise those plans.

The drills and exercises for public health agencies and organizations are not really much different than those for other response agencies; for one thing, they usually use similar terminology, and also rely heavily on the participation of, and input provided by, a number of partners. Most emergency preparedness exercises fall into two principal categories, as follows:

  1. Discussion-based exercises – workshops, seminars, and tabletops that bring together the partners involved to stimulate discussions focused on a hypothetical situation; and
  2. Operations-based exercises – drills, which test a single, specific operation or function in a single agency; functional exercises, which are conducted by one or more agencies to evaluate capabilities and functions through use of a simulated response; and full-scale exercises, which involve two or more agencies and jurisdictions and test many interrelated facets of emergency response and recovery operations.

A helpful rule of thumb to follow is to begin an exercise cycle with a discussion-based exercise so that all agencies and organizations that are assigned roles and responsibilities in a response can fully understand them before proceeding further and testing their own operational capabilities.

Essential Reading: HSEEP Guidelines; CDC/ASPR Preparedness Capabilities Guidance In that context, a helpful resource to develop a better understanding of various exercises, and how to conduct them to your best advantage, is the federally developed and capabilities-based DHS Homeland Security Exercise and Evaluation Program (HSEEP) that provides the standardized guidance and terminology used for exercise design. It is imperative that there are personnel in the health department, at every level of government, who have actively participated in HSEEP training and understand the various elements involved in developing, conducting, and evaluating an effective exercise.

Such training is appropriate for all types of exercises – including, for example: (a) a local health department scheduling a “call down” drill with the incident command staff; (b) a county or regional health authority planning a functional exercise to test the movement of POD (point of dispensing) materials to a predesignated POD site; and (c) a state health department carrying out a full-scale exercise with external partners to test the preparedness and response capabilities – of all of the agencies participating – required to cope with the outbreak of a deadly disease such as a pandemic influenza.

Not coincidentally, there have been several reports and/or policy papers issued over the past 13 months that underscore the overall importance of the readiness capabilities – again, at all levels of government – needed to respond to large-scale events. Two of those documents – the Public Health Preparedness Capabilities, released in March 2011 by the U.S. Centers for Disease Control and Prevention (CDC); and the Department of Health and Human Services (HHS) Healthcare Preparedness Capabilities, released in January 2012 by the Department’s Assistant Secretary for Preparedness and Response (ASPR) – focus special attention on the realities facing the agencies and organizations involved in the public health response. Those realities include, but are not necessarily limited to: (a) the type of events the participating agencies may encounter; (b) the capabilities required to respond to such events; and (c) the assessment of the potential gaps that might exist between what is needed and what is available. One of the most important elements in understanding and eventually filling the gapsentified is the development of, and participation in, various emergency exercises.

Public Health Preparedness Exercises: A Clear Focus on ESF #8 State health authorities frequently take the opportunity to exercise with their local jurisdictions and partners on a regular basis. One example of this is that many state level public health authorities tested their pandemic preparedness and response capabilities through various exercises in the wake of the H1N1 pandemic.  The scenario of these functional or full-scale exercises with local counterparts was the time period in the middle of a pandemic in what the World Health Organization (WHO) refers to as the Pandemic Alert Period – during which there is limited human-to-human transmission and the virus might evolve into a strain increasingly adapted to humans.  These exercises dealt primarily with the various elements of Emergency Support Function (ESF) #8 (Public Health and Medical) responsibilities, and typically included: (a) the opening of both state and local emergency operations centers (EOCs); (b) fulfilling of Strategic National Stockpile (SNS) requests – from the states involved, to the federal government; and (c) communications with hospitals, emergency medical services (EMS) agencies, and other health partners likely to be involved.

Federal health agencies – usually HHS and/or DHS – also exercise their preparedness and response roles, emergency plans, and collaboration with state, territorial, regional, and local partners on a regular basis. National Level Exercises (NLEs) are a series of congressionally mandated preparedness exercises designed to prepare federal, state, local, private-sector, and international partners, departments, and agencies to respond, collectively as well as individually, to a broad spectrum of potentially catastrophic events and incidents.

The June 2011 NLE – “Operation Dark Winter” –was designed as a bioterrorist attack simulation. The tabletop exercise started with a scenario that postulated a localized smallpox attack on Oklahoma City that quickly spread to several other states and required that federal resources be requested. The overarching goal of the exercise was to establish preventive measures and response strategies by increasing governmental and public awareness of the magnitude and destructive potential of such a threat, particularly one posed by a terrorist group using biological weapons.

Other NLEs have included similar public health elements. More specifically:

  1. The 2003 NLE (previously referred to as TOPOFF) was a full-scale exercise designed toentify vulnerabilities in the nation’s incident management capabilities. The scenario postulated that a terrorist organization had: (a) detonated a simulated radiological dispersal device in Seattle, Washington; and (b) released the pneumonic plague bacteria into several metropolitan areas in and around Chicago.
  2. The 2010 NLE scenario used a simulated terrorist act involving an improvised nuclear device and tested the readiness of federal, state, and local partners to demonstrate and assess their individual and joint emergency preparedness capabilities.

The Short- and Long-Range Goals: Continuous Quality Improvement Establishing and following a continuous quality improvement cycle – i.e., plan, train, exercise, implement corrective actions to the plans, then repeat the cycle – continues to be a common and, in some jurisdictions, a mandated practice by public health authorities. The principal components of this cycle include: (a) exercising plans; (b) ensuring that staff are fully and effectively trained; and (c) building and maintaining the capabilities needed to respond to a major emergency.

Unfortunately, the fiscal resources that many public health and healthcare organizations rely on – funds provided through the Cities Readiness Initiative (CRI), Hospital Preparedness Program (HPP), and Public Health Emergency Preparedness (PHEP) programs – have been cut back significantly over the past few years. Nonetheless, even as budgets and staff continue to decline in the foreseeable future, it remains critical that public health departments continue to plan and conduct effective, realistic exercises. Doing so can be a daunting task, but there are a few common-sense recommendations – including the following – that will help compensate for the reduced funding and are already in effect in various jurisdictions throughout the country:

  1. Maximize the benefits available from state-level exercises – When a state agency plans an exercise, use that exercise to simultaneously test various other aspects of an agency’s preparedness plans.
  2. Regionalize – Combine resources with neighboring jurisdictions to exercise as a region.
  3. Collaborate – Combine resources with other response agencies and/or healthcare facilities within the same or neighboring jurisdiction to exercise jointly.

Regardless of the specific type of event being exercised, it is essential that members of the public health sector understand not only the plan and goal(s) of any exercise, but also the specific roles and responsibilities of each agency participating. It is also important to ensure that public health agencies are represented in the after-action discussion and evaluation processes to: (a) document the lessons learned; (b) comment constructively about the exercise; (c) address the gaps and issues involving current plans and/or processes that have beenentified; and (d) most important of all, develop and implement an improvement plan. Involvement in such discussions will in itself facilitate a continuous quality improvement process.


For additional information on: The tools, resources, and templates related to the design, development, conduct, evaluation, and improvement of the exercise planning process, visit

Raphael Barishansky

Raphael M. Barishansky, DrPH, is a public health and emergency medical services (EMS) leader with more than 30 years of experience in a variety of systems and agencies in positions of increasing responsibility. Currently, he is a consultant providing his unique perspective and multi-faceted public health and EMS expertise to various organizations. His most recent position prior to this was as the Deputy Secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health, a role he recently left after several years. Mr. Barishansky recently completed a Doctorate in Public Health (DrPH) at the Fairbanks School of Public Health at Indiana University. He holds a Bachelor of Arts degree from Touro College, a Master of Public Health degree from New York Medical College, and a Master of Science in Homeland Security Studies from Long Island University. His publications have appeared in various trade and academic journals, and he is a frequent presenter at various state, national, and international conferences.

Audrey Mazurek

Audrey Mazurek, MS, has worked at all levels of government for nearly 20 years in public health and healthcare preparedness, emergency management, and homeland security. She was a program manager with the National Association of County and City Health Officials (NACCHO) Project Public Health Ready program. She supported the U.S. Department of Homeland Security in the development of an accreditation and certification program for private sector preparedness. She also served as a public health emergency preparedness planner for two local public health departments in Maryland, where she developed over 30 preparedness and response plans, trainings, and exercises. She is currently a director of public health preparedness with ICF, primarily supporting the U.S. Department of Health and Human Services, Assistant Secretary for Preparedness and Response’s (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) program as the ICF program director.



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