In May 2012, one of the most comprehensive reports to date on the state of preparedness in the United States was released. As ordered by Presidential Policy Directive 8 (PPD-8), the Federal Emergency Management Agency (FEMA) created a National Preparedness Report (NPR) that focuses on the threats and hazards that pose the greatest risk to U.S. security and resilience – including, but not limited to, acts of terrorism, cyber attacks, pandemics, and catastrophic natural disasters.
The NPR identifies areas where the nation has made significant progress and reinforces important principles of national preparedness. This report – created in cooperation with other federal, state, local, and tribal agencies and governments, private businesses, nonprofit organizations, and the public – touches on a broad spectrum of preparedness topics.
In the May 2012 report, “Public Health and Medical Services” is described as being delivered by a broad range of partners who contribute to a highly responsive national Public Health and Medical capability. That definition encompasses public health, hospitals, and emergency medical services.
In general, the emergency preparedness elements associated with public health are noted to have improved significantly since the terrorist attacks of 11 September 2001. Four of the key findings address: (a) biosurveillance capabilities; (b) medical countermeasure efforts; (c) surge planning and capabilities; and (d) funding impacts. Following are some relevant notes about each as described in NPR 2012.
Chemical and biological agent detection, confirmation, and characterization capabilities have improved in key laboratories across the nation, contributing to improved biosurveillance capabilities. That statement translates directly into the improved U.S. ability to confirm chemical and/or biological incidents. The report points out that, although the overall number of laboratories has decreased since 2007, the performance of the remaining labs has improved. Those labs – comprising federal, state, local, tribal, territorial, and hospital partners – are essential components of a broader effort to develop biosurveillance capabilities nationwide and provide a “front line of defense for public health preparedness” by effectively detecting outbreaks and contributing significantly to other public health events.
One of the better known and robust of the biosurveillance programs is BioWatch, which provides biological agent monitoring and detection capabilities designed to detect and counter the intentional release of aerosolized biological agents in targeted high-risk urban areas across the country. BioWatch coordinators in the field work closely with local, state, and regional planning teams to advise public health, emergency management, and other local agencies and decision-makers on BioWatch operations.
Medical Countermeasure Efforts
Federal coordination of medical countermeasure efforts across agencies – from research and development through utilization – has greatly improved since 2001. According to the report, The Public Health and Medical Services component ranks highest for average core capability (78 percent). This success is attributed to several factors, including: (a) the creation and buildup of the Strategic National Stockpile of emergency medical countermeasures; (b) the planning efforts of the state and local jurisdictions responsible for dispensing these countermeasures; and (c) the allocation of more than $4 billion in grants that have been awarded since 2002 to improve the resiliency of U.S. healthcare systems. The U.S. Centers for Disease Control and Prevention (CDC) continue to evaluate the medical countermeasure mass-dispensing efforts annually through its Technical Assistance Reviews (TARs) for both state and local public health entities.
Surge Planning and Capabilities
A focus on hospital medical surge planning and capabilities has improved hospital preparedness nationwide. Greater emphasis is being placed on community approaches that involve healthcare coalitions, which include a variety of healthcare organizations, public health, mental and behavioral health, and emergency management to enhance medical surge. The report also highlights the Hospital Preparedness Program (HPP) of the U.S. Department of Health and Human Services (HHS), which has awarded approximately $4 billion to states throughout the nation since 2002, and also has strengthened the communications, medical evacuation, and fatality management capabilities of hospitals across the nation. The HPP is currently focused on developing community- and regionally-based coalitions of healthcare organizations and various public health and emergency management agencies with their plans to collaborate in strengthening preparedness efforts.
The nation has built a highly responsive public health capability for managing incidents, but recent reductions in public health funding and personnel have impacted these capabilities. Since 2001, U.S. public health authorities at all levels of government – federal, state, and local – have had to develop, define, and embrace their emergency preparedness and response roles. Data provided by the CDC in 2009 show that designated state public health personnel with lead incident management roles need only about 66 minutes, on average, to report for duty when responding to a public health emergency with no prior warning. Moreover, 47 states have reported that, in responding to an infectious disease outbreak, they have sufficient staffing capacity to cover five 12-hour days for a period of six to eight weeks.
Continuing Cutbacks & New Areas of Concern
The preceding metrics highlight the responsiveness of the nation’s public health capabilities, but it should be noted as well that the United States also has experienced a reduction in local public health jobs – primarily as a result of funding reductions. The lack of adequate funding for public health preparedness programs already has resulted, for example, in significant staff layoffs across the nation. In addition, many state and local health departments are now faced with unpredictable fluctuations in funding while managing their budgets, hiring and training staff, and conducting long-term strategic planning.
Moreover, from 2007 to 2009, according to the report, the percentage of states that created and promulgated fatality management plans increased from 64 percent to 96 percent. However, it is important to note that any objective assessment of these fatality management plans shows that some of them are not yet adequate or fully “actionable.” Another critical point cited in the report was the reliance on federal assets in a mass-fatality event or incident (e.g., the 2011 Joplin, Missouri, tornado) where the number of deaths overwhelms the typically limited state, local, tribal, and territorial capabilities immediately available.
During large-scale incidents – e.g., pandemics or attacks involving weapons of mass destruction (WMDs) – it is obvious that the larger the number of fatalities are, the greater the likelihood of contamination becomes. Although there have been major improvements, hospital preparedness and surge-capacity efforts are constantly being tested by a combination of: (a) structural problems; (b) increased nonemergency patient visits to hospital emergency departments; (c) the occasional (but sometimes frequent) diversion, for various reasons, of emergency medical services; (d) the increased regionalization of surgical care; and (e) overall healthcare workforce shortages.
Significant Improvements – But Major Problems Remain
To briefly summarize, public health agencies across the United States play a critical role in the nation’s overall emergency preparedness and response capabilities. Their role has become even more important since the 2001 anthrax attacks, during numerous natural disasters, food-borne outbreaks, and other major public health emergencies (e.g., SARS and H1N1) that have been in the headlines in recent years. In short, the latest report shows that local and state health departments are, in fact, now better prepared for emergencies than ever before in the nation’s history.
Since 2001, moreover, state and local preparedness capabilities have improved, both consistently and significantly, in such areas as mass vaccinations and prophylaxis planning, all-hazards preparedness training, implementation of the National Incident Management System and Incident Command System, and the installation and use of new or upgraded communication systems. Over the past 10 years, there have been exceptional increases in various areas of healthcare system readiness, including biosurveillance, hospital preparedness, and communication among FEMA’s Emergency Support Function (ESF) #8 – Public Health and Medical Services partners and others.
One of the still looming issues that was minimally highlighted in the report is the possible impact that recent-year (and probable future) funding cuts will have on state and local readiness. Interestingly, only weeks after the latest NPR report was promulgated, a New York Times headline on 13 May 2012 proclaimed that Cutbacks Hurt a State’s Response to Whooping Cough. The article that followed disclosed that, because of the current economic recession, Washington State’s Public Health Department was having significant difficulty in responding to an infectious disease outbreak. The bottom line, according to the article, is that, although “state and local health departments [are] on the front lines of defense,” they have been seriously “weakened by years of sustained budget cuts.”
For additional information on: The 30 March 2012 National Preparedness Report (NPR), visit https://www.govinfo.gov/content/pkg/CHRG-112hhrg79503/html/CHRG-112hhrg79503.htm
The 13 May 2012 New York Times article, visit http://www.nytimes.com/2012/05/13/health/policy/whooping-cough-epidemic-hits-washington-state.html
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.