Emerging from the events of 9/11 and the subsequent Ameri-thrax attacks, the discrete discipline of public health preparedness has emerged, matured, and, some would say, even come into its own. Before the 9/11 terror attacks in the United States, there was not as much focus on public health preparedness as a distinct discipline. Although there had been instances where public health was at the forefront of emergencies both domestically and internationally, the planning and infrastructure for public health emergency response were not funded and not in place.
In the post-9/11 era, federal, state, and local health have invested heavily in public health preparedness programs. These investments and planning efforts have focused on:
Interactions with other emergency response entities,
Compliance with the Incident Command System (ICS) and National Incident Management System (NIMS) in state and local health structures,
Exercising and demonstrating emergency plans to test staff and systems capabilities, and
Recruitment of subject matter experts in public health preparedness to fill health agency roles.
Public Health Emergency Response
The years since then have seen various public health emergencies that have been handled with mixed results. Emergencies such as SARS, H1N1, and even Ebola brought various response measures specific to public health into focus. These emergencies also stressed the need for communication with other disciplines (e.g., emergency management and emergency medical services) and a distinct need for response funding.
The public health field is reexamining its path forward after recent large-scale public health emergencies. Answering some key questions is a good start.
These emergencies also revealed some cracks in the foundation of public health preparedness. One of these gaps was in the federal funding specific to preparedness activities such as plan development, emergency exercises, and laboratory and epidemiological equipment rather than for actual emergency response – for example, Public Health Emergency Preparedness (PHEP) and Cities Readiness Initiative (CRI). This gap has led to a disease du jour approach to public health emergency response funding separate from the preparedness funding streams (PHEP and CRI) and brought with it specific limitations and definitive deadlines for utilization. This approach was seen during H1N1, Ebola, and Zika. Additionally, these response funds help augment short-term capacity but are so time-limited as to prohibit building public health infrastructure and future capacity – or even maintaining the capacity achieved during the response phase.
Another crack in this preparedness foundation is that many public health emergencies evolve before the state and local health departments have the time to enact various contracts, formal agreements, and even memoranda of understanding necessary to respond adequately. As such, these entities have, in the past, been unprepared to move forward with various administrative preparedness activities. The all-hands-on-deck approach to large-scale emergencies was a final area where public health had to learn its lesson. Health departments typically only train specific personnel in critical areas such as the ICS and event-specific contingency plans. This training gap has resulted in health departments limiting their emergency response personnel and capacity to only a specific portion of their agency staff.
The emergence of COVID-19 pushed agencies to reexamine various foundational elements of their public health preparedness efforts to date, including but not limited to:
Contingency plans and whether they took into account what could happen;
Relationships with other disciplines (e.g., emergency management) and whether each stakeholder understood the others’ capabilities and capacity;
The appropriateness of all the assumptions made to date regarding public health preparedness; and
Further understanding of the nature of healthcare coalitions in a prolonged public health emergency response.
Although each of the specific facets mentioned above is significant, one area that has seen both successes and challenges is the blurring of the lines between emergency management and public health preparedness during the COVID-19 response. Typically, pandemics are the purview of public health authorities, with emergency management playing a supporting role. However, the overwhelming nature of COVID-19 combined with many atypical areas made this incident unique. Some local, regional, and state jurisdictions saw relationships begin with a lack of understanding about distinct roles and responsibilities in supply-chain management and overall incident management responsibilities.
In addition, the COVID-19 response has already seen a bolus of multiple funding streams that concentrate on critical response areas such as workforce development, necessary laboratory and epidemiological enhancements, and even data modernization. State and local health departments should take the opportunity to examine these funds and determine how to utilize them best to strengthen core public health efforts. As a result, public health agencies would be better prepared to deal with large and small emergencies and enhance their capacity for “day-to-day public health.”
People queueing to receive the COVID vaccine (Source: Baltimore County Government, December 23, 2020).
Key Questions Decision-Makers Should Ask Themselves
The events of the last two-plus years have raised multiple questions, including:
Will new and existing funding from the Centers for Disease Control and Prevention (CDC)/ASPR to state and local health departments include the lessons learned from COVID and other emergencies?
Will the CDC funding have a built-in response funding mechanism?
Will COVID spur the CDC to revise/modernize its preparedness capabilities?
What does the future look like for the relationship between emergency management and public health preparedness?
Like many public health emergencies, COVID-19 significantly affected persons of color, under-resourced communities, and persons with disabilities. How can we ensure that future emergency preparedness planning efforts begin to focus on these areas holistically?
Will communities look to the lessons learned from COVID and move toward a greater state of resilience as opposed to focusing on response?
Decision-makers in the public health preparedness space must now analyze what went right and what did not. They need to determine which investments met their stated deliverable of making state and local health departments more prepared and which did not. They also need to determine if the existing relationships between the public health preparedness discipline and emergency management are sufficient and what to do about them if they are not. These and so many other areas require critical examination with an open mind. Now is the time for such introspection.
Raphael M. Barishansky, MPH, is the chief of Public Health Emergency Preparedness for the Prince George’s County (Maryland) Department of Health. Prior to establishing himself in this position, he served as executive director of the Hudson Valley Regional EMS (Emergency Medical Services) Council, based in Newburgh, New York. A frequent contributor to the DomPrep Journal and other publications, he can be reached at firstname.lastname@example.org.