The Rising Priority of
Local Public Health
| By Lois M. Davis and Janice C. Blanchard |
Lois Davis is a health policy researcher at RAND whose work focuses on public health and emergency preparedness issues. Janice Blanchard is a doctoral fellow at the RAND Graduate School and an assistant professor of emergency medicine at George Washington University Medical Center.
Hospitals and public health agencies represent the front lines for defending the public against biological and chemical terrorism. The terrorist attacks and anthrax exposures of 2001, however, have called into question the ability of our hospitals and public health systems to respond effectively to such incidents.
A key concern is whether the public health and medical communities are sufficiently integrated with the preparedness activities of other local emergency responders—such as police and fire departments—to address bioterrorism or other acts of terrorism inside our borders. Some officials have characterized the lack of integration of health responders with other first responders as a serious flaw of U.S. national strategy.
Just prior to the Sept. 11 attacks, RAND completed a nationwide survey of more than 1,000 state and local response organizations to assess their preparedness for domestic terrorism involving biological, chemical, or other weapons of mass destruction (WMD). The organizations included fire departments, law enforcement agencies, emergency medical services, hospitals, public health departments, and emergency management offices. Here, we focus specifically on the results for city and county ("local") public health departments and for general acute-care hospitals (both public and private).
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Mostly Unprepared
Figure 1 shows that only about a third of the local health organizations reported having plans in place to respond to a moderate-sized biological attack, such as the intentional release of brucella bacteria at a regional airport. Hospitals and public health departments in large metropolitan counties were only slightly more likely than were the health organizations in other counties to have such response plans.For moderate-sized incidents involving chemical weapons (such as the release of a toxic chemical agent by an explosion inside a building occupied by 200 people), the preparedness of public health agencies was similar to their preparedness for biological incidents. In contrast, hospitals were somewhat better prepared for chemical incidents, since more than half had response plans in place. Once again, large metropolitan counties were relatively better prepared than other counties.
Response plans are of limited value if they are infrequently exercised. Only about one-sixth of the health organizations with a plan for a biological incident had also exercised the plan within the previous year. Just one-third of the health organizations with a plan for a chemical incident had exercised that plan within the previous year (see Figure 2).
Survey respondents also reported that the bioterrorism planning of public health departments was usually not well integrated with the preparedness activities of other local emergency response agencies. General acute-care hospitals, however, were somewhat better integrated with other response agencies, at least according to the respondents from hospitals.
There is great room for improvement in planning for biological and chemical terrorist attacks at the local level. Public health has traditionally been peripheral to emergency planning. As a result, many hospitals and public health departments are unfamiliar with the command systems used by law enforcement groups and other emergency responders at disaster scenes. Confusion continues to exist between health responders and other emergency responders over who has what authority and who is in charge of the response.
In our view, insufficient attention has been paid to improving planning at the local level and to integrating hospital and public health planning activities with those of other emergency response agencies. Many hospitals and local public health agencies are unaware of what type of capabilities or surge capacity may be required to respond to chemical or biological attacks. Many health responders do not fully understand the role that other responders may play. Many health responders are not sufficiently prepared to communicate with other responders or with the public.
Better planning is needed at the local level to have an effective public health and medical response to a terrorist attack. To date, most of the emphasis of U.S. preparedness for biological and chemical terrorism has been on improving the capacity of national and state public health systems. We need to go beyond these efforts, to shift the focus toward the front lines, and to make sure that local plans and systems are in place to make the best use of local assets. Only through integrated planning and exercises and improved communications among health responders and other emergency responders will local communities be able to respond effectively to future biological or chemical threats.
Are Local Health Responders Ready for Biological and Chemical Terrorism? Lois M. Davis, Janice C. Blanchard, RAND/IP-221-OSD, 2002, 8 pp., no charge.
Measuring and Evaluating Local Preparedness for a Chemical or Biological Terrorist Attack, Ronald D. Fricker, Jr., Jerry O. Jacobson, Lois M. Davis, RAND/IP-217-OSD, 2002, 7 pp., no charge.
The mailing of anthrax-laced letters in 2001 underscored the critical importance of timely and effective communication by public health authorities to the media, the public, and other health providers and emergency responders about dealing with such incidents. We found that the vast majority of local public health departments that have an emergency response plan also have plans to communicate with the media. However, only 13 percent of the departments with emergency response plans also had written materials or information that could be distributed rapidly to inform other emergency responders about how to handle a biological incident.
Once Peripheral, Now Central
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