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RAND Review
Five Years After 9/11
Public Health Preparedness
An Opportunity and a Challenge
By Nicole Lurie
Nicole Lurie is a physician, public health researcher, and codirector of the RAND Center for Domestic and International Health Security. She is also the Paul O’Neill Alcoa Professor of Policy Analysis at RAND. Her comments here are based on work done at RAND over the past three years on public health preparedness, including tabletop exercises to help state and federal health agencies prepare for outbreaks of smallpox, anthrax, botulism, plague, and pandemic influenza. Portions of this article appeared in the July 2006 issue of Health Affairs.
The 9/11 terrorist attacks and subsequent anthrax attacks pushed public health emergency preparedness in the United States to the top of the national agenda. Concern has intensified with the feeble response to the 2005 Gulf Coast hurricanes and with the growing possibility of a pandemic caused by the H5N1 avian influenza virus.
The U.S. federal government has responded with an investment of some $5 billion during the past four years to upgrade the public health system’s capacity to prevent and respond to large-scale public health emergencies, whether terrorism related or due to natural agents. Yet the federal government’s call to arms on preparedness has fallen upon a system still in the process of recovering from years of neglect. Public health has traditionally been underfunded, and often ignored, by policymakers.
Most health departments are facing difficulties related to staff availability and budgets. |
Our team at RAND has examined America’s public health infrastructure through a series of related projects, including an assessment of California’s public health preparedness, the development and conduct of tabletop exercises in 32 communities in 12 states, and a review of quality improvement efforts in public health. All told, our team has visited 44 communities in 17 states. Taken together, these assessments suggest that public health is in the midst of a major transition, spurred in part by the addition of emergency preparedness to the responsibilities of state and local public health agencies.
Key changes include new partnerships, new workforce needs, new technologies, and the integration of emergency preparedness with other public health functions. While each of these factors has had some positive effects on public health, they have not been managed without problems. The preparedness mission has also posed major challenges for public health in the areas of leadership, quality, and accountability.
Nearly 4,000 turkeys are held in one of 219 buildings on the Jaindl Farm in Orefield, Penn., where about 750,000 turkeys are raised per year. Pennsylvania public health officials say they have been preparing intensively for an avian flu pandemic that could strike nearly 13 percent of the human population and cause some 9,000 deaths statewide. |
Key Changes
The process of preparing a community to meet the challenges of a potential public health emergency has required public health departments to build relationships with new kinds of partners — emergency management agencies, law enforcement agencies, and other first responders — in addition to the hospital and health care community. Preparedness planning has been instrumental in forging these new relationships. Communication and working relationships between many of these entities is better than in the pre-9/11 era, despite persistent differences among the communities in culture, work style, and mission.
Most health departments are facing difficulties related to staff availability and budgets. Many states currently have hiring freezes in place. There is no robust pipeline of trained personnel to work in public health, and salaries for public health nurses, epidemiologists, laboratory technicians, and physicians are often not competitive with those of their private-sector counterparts. An aging workforce has compounded workforce shortages in public health.
Many communities have invested in technology that enables public health officials, emergency medical services, fire departments, and police departments to communicate on the same radio frequencies even when power is not available. Federal funding has spurred other advances in the information technology infrastructure, from a national Health Alert Network and Laboratory Response Network (both for electronic reporting of diseases) to statewide systems for conducting surveillance and investigating outbreaks.
The integration of emergency preparedness with other public health functions has not been easy to implement. Public health agencies that have made strides to integrate preparedness with other functions seem to have better performance on preparedness exercises. In contrast, less well-integrated health departments have either tended to perform poorly on tabletop exercises or reported other challenges in responding to real events.
Major Challenges
One clear and consistent finding from our work concerns the role of strong leadership in public health preparedness. In our exercises with agencies, strong leadership repeatedly trumped all other factors in determining how jurisdictions fared when presented with a wide range of scenarios related to infectious disease outbreaks. The performance of health departments whose leaders were willing to take responsibility and make decisions in a hypothetical situation was far better than the performance of departments whose leaders said they would be willing to be coleaders with others.
There is a “quality chasm” in public health that is analogous to that in the personal health care delivery system. |
Leaders were important in facilitating organizational change, motivating staff, developing relationships with key community groups and other constituencies, training staff to assume backup roles in the event of an outbreak, conducting strategic planning, and understanding when and where to hand off functions to officials from other agencies. Although our work to date has not examined closely the best means of developing and promoting strong public health leadership, we noted that successful health jurisdictions often provided aggressive leadership training programs for staff.
Because so much of public health preparedness depends on other routine functions and responsibilities of public health departments, we have been able to gain insights into the state of governmental public health more broadly. From that perspective, we argue that there is a “quality chasm” in public health that is analogous to that in the personal health care delivery system. Evidence for this chasm includes the marked variability in mission, scope, and performance of public health agencies, related to preparedness and other core responsibilities; the duplication of efforts seen in many areas of preparedness, such as training; and the uneven protection of the public in the event of a public health emergency. Beyond preparedness, health departments differ, for example, in the amount of emphasis placed on chronic disease prevention, such as obesity and diabetes.
Members of New Jersey Gov. Jon Corzine’s cabinet meet with emergency management officials at state police headquarters on June 19, 2006, to discuss emergency evacuation plans in case a hurricane hits the New Jersey coast this year. |
Public health has made significant progress in the area of performance measurement in general but has lacked the kinds of methods that have been developed to compare outcomes in the personal health care sector, making it difficult to compare outcomes across different public health systems. In the area of preparedness, the lack of well-accepted, standardized measures and metrics makes it difficult to gauge the level of preparedness, let alone to satisfy the numerous and frequent demands for accountability.
An important precondition for the development of an effective accountability system is greater agreement among stakeholders at the federal, state, and local levels regarding who should do what. Ironically, the advent of needed public health preparedness grants from the federal Centers for Disease Control and Prevention soon after 9/11 posed significant challenges for the complex web of federal, state, and local government relationships that constitute the nation’s public health system. Unfortunately, the initial funds were distributed so rapidly that there was little time to determine which level of government should be responsible for what. In the ensuing years, there has been little clarification about the allocation of responsibilities between federal, state, and local public health agencies. Resolving this ambiguity is an important prerequisite for holding various governmental entities accountable for their performance and expenditures.
A key dilemma is that because massive public health emergencies are rare, we must rely on exercises and drills to measure the capacity to implement and to adapt an emergency response plan. Such exercises can be quite expensive. However, our team has been developing a model of relatively small-scale drills and exercises that focus on the most important preparedness components and that apply an accompanying small number of standardized metrics. At the same time, we urge similar efforts that take advantage of more routine activities, such as those surrounding annual flu vaccinations or back-to-school immunizations, to test other aspects of preparedness. Creative development of such drills, which is a core part of our team’s work, offers the potential not only to enhance emergency preparedness but also to strengthen other aspects of public health.
Measurement of performance, of course, must be supplemented by efforts to develop and to implement corrective actions, and repeatedly we have seen health departments struggle in this area. We are now pilot testing methods to spread the adoption of quality improvement in public health; but we recognize that, in the long run, external incentives will be necessary.
Vital Commitments
Part of the reason for the current state of public health is that it has been significantly underfunded for a long time. Preparedness has raised the stakes regarding the implications of relying on a chronically underfunded system. Sustained federal funding for public health preparedness, and for the infrastructure on which it depends, will remain important for years to come. As the public health workforce ages into retirement, the assurance of an attractive career path for “the best and the brightest” in public health will be crucial.
Preparedness has raised the stakes regarding the implications of relying on a chronically underfunded system. |
The country also needs a uniform definition of public health as well as standard expectations for public health agencies. Even though today no clear national understanding exists of what public health is and does, the demand for emergency health preparedness has at least helped to create an understanding among Americans that all citizens should be protected from the consequences of a public health emergency, whether due to bioterrorism or a new emerging infection such as pandemic influenza.
The National Association of County and City Health Officials has taken steps to develop a uniform definition of a local public health agency. If widely adopted, this definition could help reduce uncertainty about what the public can expect from such an agency and should also encourage the analogous clarification of expectations from state health departments. The federal Centers for Disease Control and Prevention could, in turn, clarify the aspects of preparedness for which it is accountable and develop a set of performance measures for itself. Taken together, such actions could go a long way toward creating a more uniform standard of health protection for the nation.
As is often the case when individuals or institutions are asked to assume new and difficult responsibilities, the circumstances present a series of opportunities and challenges. On the one hand, the emergency preparedness mission can help public health leaders transform the nation’s public health system so that it can respond effectively and economically to a broadening spectrum of health threats. On the other hand, sustained commitments will be necessary to move the public health system toward this goal. 
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