Public Health Emergencies - Looking Toward the Future

Many victories for public health emergency preparedness programs at the federal, state, and local levels have occurred over the past decade. Those victories include but are not limited to leading efforts in: medical countermeasures dispensing; all-hazards preparedness training; implementation of the National Incident Management System within public health; procurement of new or improved communication systems; collaborative drills and exercises compliant with the Homeland Security Exercise and Evaluation Program; and a shift toward planning based on all-hazards capabilities.

More changes loom large in the future of public health emergency preparedness based on current trends in funding, workforce, and performance measures. A 7 January 2014 white paper released by the Institute of Medicine (IOM) Forum on Medical and Public Health Preparedness for Catastrophic Events, titled “Value-Based Models for Sustaining Emergency Preparedness Capacity and Capability in the United States,” provides seven recommendations to help serve as a roadmap to enhance the sustainability of preparedness efforts in the United States. These recommendations are based on performance measures, funding, and threat evolution.

Measuring Public Health Performance

It is important, and will prove to be more so in the future, that public health emergency preparedness demonstrates the value of government and taxpayer investments by better preparing communities. Attempts at developing quantitative and qualitative measures to accurately capture the returns on investment of public health preparedness are ongoing.

Over the past few years, the Centers for Disease Control and Prevention (CDC) has used the Technical Assistance Review as its primary tool for annually evaluating medical countermeasure dispensing efforts through the Cities Readiness Initiative program for jurisdictions designated as metropolitan statistical areas (MSAs). There currently are 72 MSAs, with at least one Cities Readiness Initiative MSA in every state. However, some states require all jurisdictions to participate in the Technical Assistance Review, even if they do not receive additional Cities Readiness Initiative funding – with the state, rather than the CDC, conducting site visits and the evaluation.

Another tool to qualitatively measure public health emergency preparedness programs against a standard set of criteria was the Project Public Health Ready Program, administered by the National Association of County and City Health Officials (NACCHO) since 2003. This program evaluates a local health department’s capability in planning for a broad range of hazards and outcomes, workforce training, and exercises. It took into account capability beyond medical countermeasure planning and was the precursor to the CDC releasing its Public Health Preparedness Capabilities in 2011.

Since 2011, the public health emergency preparedness community has been waiting for an overhaul of the Technical Assistance Review to move from a medical countermeasure/strategic national stockpile focus to a more all-hazards, outcome-based approach. This shift has begun, with performance measures being a key focus in the most recent (Budget Period 3) CDC Public Health Emergency Preparedness cooperative agreement. Additionally, the Technical Assistance Review is evolving from the current version focused on medical countermeasures, to one that includes all public health preparedness capabilities.

Finally, in response to the lack of national standardized assessments of health emergency preparedness, the 2013 National Health Security Preparedness Index, according to the IOM white paper, “combines different preparedness criteria into one composite set of measures that can be used to determine relative health preparedness capabilities over time.” In addition, the Association of State and Territorial Health Officials claimed that the index “will provide benchmarks of health emergency preparedness and allow communities to track their preparedness levels over time.”

The IOM white paper included the following recommendations specific to development of measures:

• Recommendation 1: The federal government should develop measures of emergency preparedness both at the community level and nationally. A research agenda that would help guide this effort is proposed.
• Recommendation 2: Measures developed should be used to conduct a nationwide gap analysis of community preparedness.

Funding & Financial Support

Fortunately, there have not been any recent major public health emergencies in the United States. Unfortunately, for public health, that means funding is slowly diminishing or, in the case of the hospital preparedness program, quickly being slashed. Various funding streams benefit public health preparedness efforts – for example, the Cities Readiness Initiative, Hospital Preparedness Program, and the CDC Public Health Emergency Preparedness cooperative agreement. These have fluctuated over the years and sometimes have been supplemented by short-term funding to address a specific health threat, such as the Public Health Emergency Response grant in response to H1N1 in 2009.

Federal funding is a core source of financial support for both state and local public health preparedness programs. Since 2002, the CDC Public Health Emergency Preparedness cooperative agreement alone has provided nearly $9 billion to public health departments across the nation. In an August 2007 NACCHO report, 41 percent of state and local health departments that received the CDC’s Public Health Emergency Preparedness cooperative agreement funding reported that these funds comprised 100 percent of their budget for preparedness activities (this includes dedicated emergency preparedness staffing). An additional 40 percent of respondents reported that federal funding made up at least three-quarters of their preparedness budget. A 2010 survey conducted by NACCHO indicated that, 58 percent of local health departments rely exclusively on federal funding to carry out preparedness activities.

Additional funding that has benefited public health emergency preparedness has come from various other federal agencies – for example, U.S. Department of Homeland Security – or local funds. In the 2007 NACCHO report, 46 percent of the nation’s local health departments reported receiving at least some financial support from local, city, or county funds. However, that percentage dropped to 29 percent in 2009, according to NACCHO, and continues to decrease.

According to the authors of the IOM white paper, “The major issue facing emergency preparedness and other traditionally government-funded services is that the infrastructure that has been built to ensure national preparedness is threatened by budget cuts and de-prioritization.” Public health emergency preparedness will continue to have unexpected and unstructured funding cuts unless there is a large-scale public health emergency that prompts additional funding. However, it is possible that funding could eventually be tied to performance measures and how well jurisdictions meet those measures.

The IOM white paper had the following recommendations specific to funding:

• Recommendation 3: Alternative ways of distributing funding should be considered to ensure that all communities can build and sustain local coalitions that can support sufficient infrastructure.
• Recommendation 4: When monies are released for specific projects, there should be clear metrics of grant effectiveness.
• Recommendation 5: There should be better coordination at the federal level, including funding and grant guidance.
• Recommendation 6: Local communities should build coalitions or use existing coalitions to build public-private partnerships with local hospitals and other businesses with a stake in preparedness.
• Recommendation 7: Communities should be encouraged to engage in creative ways to finance local preparedness efforts.

Preparing for Evolving Threats

Much of the impetus for developing a more robust public health emergency preparedness system stemmed from the 2001 anthrax attacks (Amerithrax). Thirteen years later, there have been no similar large-scale manmade biological attacks, but there have been significant emerging infectious disease threats such as SARS, H1N1 virus, Middle East respiratory syndrome coronavirus, and Ebola. Many more have affected other countries, and experts anticipate a rise in newly emerging and re-emerging infectious diseases with the rise in economic development and land use, changing ecosystems, climate change, and lack of adequate public health in many parts of the world.

Much of public health emergency preparedness efforts and funding was directed toward responding to manmade biological attacks. The return on investment may seem minimal for low-risk/low-probability events versus the high cost and resources spent on preparedness efforts. However, the partnerships established, lessons learned, technology developed, and infrastructure built as a direct result of those efforts can be and are being used to prepare for, respond to, and recover from naturally occurring disasters. Despite much talk about all-hazards planning, there is still a large amount of effort and resources spent on manmade biological attacks, rather than a true focus on all-hazards preparedness and response.

The future of public health emergency preparedness must be able to balance preparedness and response efforts between manmade and natural disasters. This can be done, in part, by focusing on outcomes-based, infrastructure-building efforts. For instance, the benefit of ensuring that communication systems are robust, current, and used is recognizable regardless of the emergency or threat. Additionally, medical surge capacity, surveillance and epidemiological investigation, mass care, non-pharmaceutical interventions, and public information and warnings are other areas that are critical in almost every incident with public health significance.

Addressing Trends & Challenges

In addition to the aforementioned areas that will likely have a large effect on shaping what public health emergency preparedness looks like in the future, the following additional trends and challenges are important to note:

• Gradual shifting in efforts and resource considerations from preparedness to response and recovery;
• Decreasing workforce retention as the public health professionals that started with the preparedness programs in 2002-2003 retire, and new highly trained public health emergency preparedness personnel are difficult to recruit;
• Continuing effort to establish and carve out a niche/identity within public health and the traditional first responder community;
• Assessing and defining the value proposition for public health emergency preparedness;
• Finding sustainable approaches to fund preparedness efforts; and
• Conducting more cross-jurisdictional sharing of services (i.e., regionalization).

There are numerous areas – for example, mass fatality management, pandemic planning, and mass dispensing of antivirals secondary to a biological incident – where federal, state, and local public health emergency preparedness, response, recovery, and mitigation efforts have become much more robust since 2001. However, key questions remain about the outlook for public health emergency preparedness: Is there a future for public health emergency preparedness programs? Does the state of healthcare system readiness go away? Does the discipline of emergency management have the resources to take over, continue, and possibly even expand public health preparedness efforts and programs, or will public health preparedness remain a discrete discipline?