Over the past decade, U.S. public health agencies (local, state, and federal) have seen an increase of responsibility in preparing for, responding to, recovering from, and mitigating emergencies. In addition to planning for responses to naturally occurring disease outbreaks, these agencies are often key partners in responding to weather emergencies, manmade threats, and chemical, biological, radiological, nuclear, and explosive (CBRNE) incidents.
Today, although public health plays mostly a supporting role during such incidents, there is an increasing demand by the federal agencies that fund various Public Health Emergency Preparedness (PHEP) programs – for example, the U.S. Centers for Disease Control and Prevention (CDC), the U.S. Department of Health and Human Services, and the U.S. Department of Homeland Security – for building the additional capability and capacity needed to respond to such events.
More specifically, public health’s role during a radiological emergency has been gaining attention primarily because: (a) large metropolitan areas must plan for possible terrorist attacks using such new and/or improved weapons as Radiological Dispersal Devices (RDDs); and (b) political jurisdictions near nuclear power plants, or research centers using nuclear technology, must update or develop their own comprehensive response plans. Both of these requirements have received greater attention since the radiological emergency caused by the meltdown of Japan’s Fukushima Daiichi Nuclear Power Plant in 2011.
However, many local jurisdictions are faced with a disconnect between: (a) a more realistic expectation of the capabilities and capacities needed to respond to radiological incidents; and (b) the current and growing realities of reduced funding, stressed workforces, a lack of subject matter experts possessing the technological background needed in these fields, a long history of limited or no training in the same fields, and numerous competing priorities.
Current Public Health Roles & Responsibilities
According to the CDC, the principal public health responsibilities during a radiological emergency include (but are not necessarily limited to) the following:
- Making recommendations to either shelter in place or evacuate;
- Identifying persons contaminated with or exposed to radioactive materials (population monitoring);
- Conducting or assisting with decontamination; and
- Developing the criteria required for entry to and/or operations within the incident site.
These responsibilities are in addition to traditional public health responsibilities – which also must continue, and often are growing in both size and scope. Included on that already long list are: surveillance, monitoring, and assessment of public health/medical needs; ensuring the availability and provision of behavioral health services, public messaging, and disease control; dispensing of medical countermeasures; and monitoring the safety of food. Many health departments also may be requested to assist in such other tasks as triage, volunteer management, and the operation of Community Reception Centers. (After a mass-casualty radiation emergency, as the CDC has noted on its website, public health professionals play a crucial role at Community Reception Centers in assessing and monitoring people potentially exposed to radiation or contaminated with radioactive material.)
In addition, the activities that already fall under the responsibility of “population monitoring” are immense – and continuing to grow. The CDC defined population monitoring, in an August 2007 report, as “a process that begins soon after a radiation incident is reported and continues until all potentially affected people have been monitored and evaluated” for:
- The medical treatment needed;
- The presence of radioactive contamination on the body or clothing;
- The intake of radioactive materials into the body;
- The removal of external or internal contamination – decontamination, in other words;
- The radiation dose received and the resulting health risk from the exposure; and
- Long-term health effects.
A Heavy Overload of Roles & Responsibilities
Under the Federal Emergency Management Agency’s June 2008 Nuclear/Radiological Incident Annex of the National Response Framework (NRF), the CDC has been designated by the Department of Health and Human Services as its lead agency for population monitoring. For that reason, the CDC has the responsibility for, among other things: assisting state, local, and tribal governments in monitoring those affected; decontaminating those who have been exposed; and creating a registry of the persons who were exposed, or potentially exposed, to radiation from the incident. The CDC also must assist state and local health departments in: (a) determining the level of radiation exposure; and (b) monitoring long after the incident for any health effects caused by radiation exposure and/or from the stress of being involved in the incident.
The bottom line is that, according to the NRF, state and local health departments – with some assistance from the CDC – may well be responsible for all of these monitoring activities both during and after a radiological incident. These major and potentially long-lasting responsibilities have understandably raised serious concerns among many public health and public safety professionals.
However, the already stressed public health infrastructures of many communities throughout the nation are struggling each day not only to maintain adequate staff, funding, and the material resources they need, but also to stay updated on new skills and information. Unfortunately, today’s public health environment is already not conducive for fulfilling some of the roles and responsibilities that will be asked of the hard-working professionals assigned all of these important duties and responsibilities.
Current Realities: Gaps & Challenges
According to the National Association of County and City Health Officials website, there are approximately 2,700 local public health departments of various types and sizes in the United States. Only a very small number of them, though, are directly affected by nuclear power plants. Moreover, most public health professionals within a 50-mile emergency planning zone of nuclear power plants already have plans in place for responding to an incident involving any of those plants.
Typically, these jurisdictions already: (a) participate in a broad spectrum of planning, training, and exercises – usually funded through federal grants and/or by the power plants themselves; (b) have established the working relationships needed with key response partners; and (c) have on hand the hospital plans required for receiving and treating patients admitted as a result of a radiation incident.
Some of these same health departments, however, do not have available the special plans needed for responding to a radiological or nuclear “terrorism incident.” Such incidents usually differ from a nuclear power plant operational incident in several ways: (a) There is less warning time; (b) The scale of the incident is typically much larger; (c) There is a larger number of potential victims; and (d) Various unknown materials were probably used by the terrorists. For the health departments that do not have any radiological or nuclear terrorist incident response plans immediately available, and/or have not developed the close working relationships with other jurisdictions responding, the harmful effects could be even more devastating.
Additional Duties, More Training & Less Funding
In addition to the significant planning – unrelated to radiological emergencies – already occurring within PHEP programs specific to biological attacks and region-specific hazards (e.g., hurricanes, wildfires, and earthquakes), health departments are now being asked to meet the requirements set forth in CDC’s March 2011 Public Health Preparedness Capabilities. For many jurisdictions, complying with the 15 PHEP Capabilities requires adding multiple hazard-specific annexes – including one for radiological emergencies – to their current All Hazards Emergency Response Plans.
These plans also must be maintained and updated, and may require additional training and exercises as well. However, because of limited resources, competing priorities, and the requirement to deal with other potentially large-scale hazards, health departments throughout the nation have necessarily become much more selective in developing and carrying out their various training and exercise plans.
Jurisdictions that are not within the 10-mile emergency planning zone of a nuclear power plant or not one of the four major U.S. metropolitan jurisdictions – Chicago, Illinois; Los Angeles County, California; New York City; and Washington, D.C. – that receive specific PHEP funding from the CDC, are probably not, for the reasons cited above, participating in any training or exercises specific to radiological responses. Nonetheless, they would still be required to respond to any radiological incident that does occur.
Limited Understanding But Fewer Training Opportunities
Responding to sudden emergencies and planning for such a wide range of hazards are still relatively new responsibilities for many public health professionals. In addition, the PHEP staff members of most health departments already attend various trainings, participate in exercises with a broad spectrum of external partners, and respond to all actual emergencies. Other health department staff, who are focused primarily on carrying out the tasks of traditional public health service agencies and organizations, also have a very heavy workload.
According to a 2010 survey by the National Association of County and City Health Officials, only about 65 percent of the nation’s health departments have emergency preparedness staff – and the average number of PHEP staff is 0.5 full-time employees. Moreover, there usually are no full-time CBRNE professionals, health physicists, or subject matter experts in most local health departments. State health departments may employ health physicists who could be called upon during a radiological event; however, those same physicists may not be available during a major incident or event.
There also may be some health department staff available who have had training in responding to a radiological event – environmental health as well as medical staff, for example. However, the numbers vary depending on both the public health infrastructure in the jurisdiction and the role assigned to public health professionals during a radiological event. The bottom line is that, because of the exponential increase in the different types of training required coupled with the limited time available, the training required to deal with CBRNE incidents is often not a high priority.
Trained Professionals, Good Equipment & Advance Planning
Fortunately, public health professionals have started to become truly active partners and increasingly important players in the first responder communities. But they still do not receive the same level of training, funding, and other resources usually available in more traditional first responder agencies. This gap becomes more apparent when one considers the types of equipment – dosimeters, Geiger-counters, portal monitors, and thyroid uptake scanners – needed for population monitoring. At present, many public health professionals do not possess and/or know how to use much of that equipment. The lack of training and resources, as well as limited participation in exercises focused on CBRNE events, will make some public health staff uncomfortable and possibly unwilling to respond to a radiological incident.
The next logical step for most health departments, therefore, might be to take a more honest look at their own capacities and capabilities specific to the types of incidents that might reasonably be anticipated. One reality that must be kept in mind is the delicate balance between (a) fully understanding the difficulties involved in resolving current problems; and (b) not overstressing PHEP programs and the people who work in them. There are various tactics that a health department can use to avoid such situations, for example:
- Requesting that existing exercises funded and planned by other agencies take into account the radiological response aspects of those exercises;
- Participating in free online training and webinars offered by federal agencies, professional associations, and universities – including CDC’s own “Public Health Planning for Radiological and Nuclear Terrorism” and “Radiological Terrorism: A Tool Kit for Public Health Officials”;
- Using existing capabilities and other resources – for example, mutual aid agreements and regional resources – to help leverage responses during a radiological event;
- Working with county, regional, and state partners to more clearly define a smaller role for public health during a radiological emergency, and incorporating that information into a countywide plan – for example, because many health departments do not possess their own decontamination capabilities, it should be specifically noted in the plan that only hazmat teams or firefighters may be assigned to decontamination duties.
Clearly, the roles of public health agencies in emergency planning and response have expanded exponentially in the past decade. Therefore, to help ensure an effective response to any hazard, public health leaders should: (a) know the types of emergencies that a department may face; (b) fully understand their department’s own capacity and capabilities; (c) be able to effectively prioritize the material resources and the time required for planning, training, and exercises; (d) leverage existing resources to ensure that, if possible, they can be used for responses to many types of emergencies; and (e) work closely with both traditional (e.g., fire, police, hospitals) and nontraditional (faith-based and volunteer organizations, the private sector, and academia) partners.
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.
Raphael M. Barishansky, DrPH(c), is a consultant providing his unique perspective and multi-faceted public health and emergency medical services (EMS) expertise to various organizations. His most recent position 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. He is also currently a doctoral candidate at the Fairbanks School of Public Health at Indiana University.