Homeland Security Presidential Directive (HSPD) 21, which focuses on Public Health and Medical Preparedness, was issued in October 2007. It articulated the current administration policy on the strategic direction and focus of public health preparedness in coming years. HSPD 21 also focuses on four key components of public health and medical preparedness in particular: bio-surveillance; countermeasures distribution; mass-casualty care; and community resilience. The first three have been hallmarks of public health preparedness since the initial surge of funding and public interest in the nearly ten years that have passed since the 2001 terrorist attacks.
The key components of preparedness programs are therefore well understood – even though some associated definitions and measures of certain preparedness components continue to be debated. However, among the four components described by HSPD-21, community resilience seems to be the least understood and most poorly defined.
The two key documents issued since HSPD-21 to clarify, elaborate, and explain the operational implementation of this policy are the National Health Security Strategy (NHSS, issued in December 2009) and the Biennial Implementation Plan (BIP, issued in July 2010). The NHSS focuses on the general activities and outcomes needed to move the nation toward the strategy, and the BIP provides a roadmap for the next two years to move the nation toward health security – which, as spelled out these documents, define health security as follows:
National health security is achieved when the Nation and its people are prepared for, protected from, respond effectively to, and are able to recover from incidents with potentially negative health consequences.
In order to create this complex health security framework, two goals are established: (a) building community resilience; and (b) strengthening and sustaining health and medical emergency response systems. Those involved in managing these programs have done an outstanding job in developing the federal, state, and local health and medical preparedness and response infrastructures. Over the past decade, the Centers for Disease Control and Prevention (CDC) provided over $7 billion for the Public Health Emergency Preparedness Program (PHEP).
In addition, over $3 billion has been allocated by the Department of Health and Human Services (HHS) for the Hospital Preparedness Program (HPP). The infrastructure and capacities established through these programs form the foundation of the proposed health security framework. Today, the new challenge is orchestrating these systems and capabilities into the resilient, coherent, and functional framework suggested in HSPD 21 and the follow-on documents mentioned above.
Public Health Preparedness and Community Resilience
The methods used to measure public health preparedness have evolved in recent years and continue to be the focus of considerable debate. In addition, the term “community resilience” has become even more challenging to define and measure. The NHSS suggests that community resilience is predicated upon healthy individuals who have an informed understanding of preparedness – and of the resources needed to care for themselves in times of emergency. The resulting resilience also requires a fundamental inter-connectedness of individual citizens, both in their neighborhoods and in their extended community, to facilitate the sharing and balancing of available resources. This community connectivity is sometimes referred to as social capital. However, measurement of this preparedness prerequisite is complicated by the vagueness of the social capital concept itself.
It seems ironic that, in this new age of social networking tools such as Facebook and Twitter that individual citizens are often less connected to others living in the same general geographic area than ever before. Use of the new Internet tools is an excellent way to keep in touch with others across the country and around the world. However, these connections are often based more on common interests than they are on zip codes. One result is that, although on-line “communities” continue to rapidly expand, people living in closer geographic proximity to one another often have less interaction. However, direct connections with one’s neighbors can still make a major and even life-saving difference during emergencies.
This is especially true for the most vulnerable populations – e.g., elderly residents living alone who lack a personal support structure, including nearby friends and family members. This deficiency in social capital represents a cultural shift in recent decades that poses ongoing challenges to the assurance and sustainment of community resilience when the community is facing major public health emergencies.
Public Health Preparedness and Systems Resilience
The concept of resilience is not limited to the sum total resilience of individual citizens, their families, and their communities. It also includes the robustness and interconnectedness of public health and healthcare systems. While these systems have achieved tremendous progress in preparedness over the past decade, efforts are still hampered by unstable funding “silos.” When these systems operate in such silos it creates a lack of connectivity that precludes resilience. If anything goes wrong with a single system, therefore, failure may well have a domino effect that causes needed systems to collapse like a house of cards amidst critical operations.
Truly resilient preparedness systems are robust, interconnected, and redundant. They also must be able to leverage public/private partnerships. No single government program or system can achieve resilience on its own. Nor can any private system, including those run by non-governmental organizations (NGOs), operate autonomously with true resilience. A sound public health emergency response system must include private organizations, as well as public agencies at the local, state, and federal levels of government. They must work in harmony to optimize resilience.
A resilient public health preparedness infrastructure may be cultivated only by focusing on the three core public health functions: Assessment; Policy Development; and Assurance. These public health systems are guided by rigorous epidemiological Assessments to focus resources on health threats. They are implemented through effective Policy Development that is built upon rigorous science translated into practice. Finally, they are Assured by continuous evaluation that ensures improvements are identified through after-action reviews from actual emergencies, as well as exercises and drills. Improvements are incorporated into future plans and training and the process is repeated. The nurturing of public health preparedness system resilience requires that these core functions be orchestrated across multiple layers of governmental and non-governmental stakeholder agencies.
Unfortunately, the systems described are often lacking throughout the United States. There are still no interoperable electronic health and medical intelligence systems available to provide real-time situational awareness. Moreover, research, although necessary in the development of sound preparedness policy, is not funded under the primary public health and medical preparedness funding streams (PHEP and HPP). There is also a tendency across all of these systems to focus on preparedness and response – but with little effort toward community recovery. Obviously, resilient systems must expand their focus to include long-term recovery efforts that are often left for the NGOs mentioned earlier.
A Few Remaining Questions Related to Emergency Resilience
A resilient community and public health system limits the impact and/or stress of an emergency and facilitates a rapid recovery. Individuals, families, and communities with an established level of preparedness are better able to respond effectively and to withstand the health impact of a disaster. They are also able to return more quickly to normal. Moreover, communities with greater social capital are able to leverage their interconnectedness to help compensate for those less able to prepare, respond, and recover. However, the role of government in expanding community resilience is still not well understood.
That lack of understanding raises several public policy questions, including the following: (a) Should local, state, and federal agencies play a role in enhancing person-to-person and community-to-community relationships? (b) If so, how much control should be exercised? (c) Should government play a facilitating role? (d) After these roles have been defined, what programs or processes may be instituted to develop community resilience?
There has been very little published to date, it seems, that would adequately answer these and other critical questions. Fortunately, though, a synergistic environment of public health emergency resilience usually does result when a resilient community is supported by a similarly resilient health and medical infrastructure. Health and medical systems of the future must be prepared to meet anticipated as well as unanticipated challenges. The goals and strategies described in the key foundational documents mentioned earlier are a major step in a new direction. The only way to meet these challenges is by intentionally building and strengthening public health and healthcare partnerships based on clear definitions, quality measures, and systematic evaluations. To achieve all this will require not only more succinct guidance from the funding agencies involved but also additional resources. These resource needs are unlikely to be met in the near future given current budget shortfalls. Today, most federal agencies and the programs they fund are being asked – as are the American people – to do more with less. Given the challenging vision for the future of public health preparedness, one can only hope that the value of this infrastructure and the need for this resilience is established as a necessary and continuing priority.
Bruce Clements
Bruce Clements is the Public Health Preparedness Director for the Texas Department of State Health Services in Austin, Texas, and in that post is responsible for health and medical preparedness and response programs ranging from pandemic influenza to the health impact of hurricanes. A well-known speaker and writer, he also serves as adjunct faculty at the Saint Louis University Institute for BioSecurity. His most recent book, Disasters and Public Health: Planning and Response, was released in 2009.
