“All response is local” is a commonly heard phrase among public health practitioners who serve on the front lines of disease outbreaks, emergencies and disasters.
Whether it’s a measles outbreak, a terrorist attack or a hurricane, public health agencies are at the ready to deploy an emergency response infrastructure designed for one overriding purpose: to protect their communities against preventable disease and injury. That kind of preparedness takes an enormous amount of planning, training, practice and collaboration. It also requires sustained funding support — something that’s all too often hard to come by in the world of public health.
Since the terrorist attacks of Sept. 11, 2001, the nation has invested billions into public health and hospital preparedness, and by all accounts, the nation is much better prepared to respond to natural and manmade disasters. However, those gains won’t sustain themselves without adequate public health preparedness funding, which dropped by 35 percent between fiscal years 2007 and 2013.
That was the key message during an April Capitol Hill briefing organized by the Big Cities Health Coalition (BCHC), which is calling on federal policymakers to restore public health and hospital emergency preparedness funding to fiscal year 2010 levels and to increase transparency in how such funding is distributed. Briefing organizers noted that federal preparedness funds first go to the states, which then distribute the monies to local agencies. But with little transparency in how states allocate the preparedness funding, local public health agencies are often left at a disadvantage. To give you an idea of how quickly emergency response costs can mount, BCHC reported that in Maricopa County, Arizona, which had just two confirmed cases of measles during the most recent outbreak, early containment activities quickly reached $50,000.
So, what exactly does public health preparedness look like? It means being ready to coordinate the evacuation of more than 6,000 patients from nearly 50 health care facilities in New York City during Superstorm Sandy. It means having the ability to send out alerts to every hospital within a 30-mile radius of the Boston Marathon finish line within mere minutes of the 2013 bombing. It means having a nationwide public health laboratory network ready to respond to biological and chemical threats 24 hours a day. It means being able to immediately harness the human resources needed to trace, interview and monitor hundreds of people to stop an outbreak of highly contagious measles. It means building a Strategic National Stockpile that can deploy life-saving medical supplies and vaccines at a cost of less than $2 per person, per year. These examples are truly just the tip of the iceberg. And like we mentioned earlier, the planning, training and coordination required to make all this work effectively is an enormous undertaking.
The April BCHC briefing featured remarks from health officials in Los Angeles County, Chicago, Dallas County and Fulton County, Georgia, who spoke about their experiences responding to and preparing for emergencies. Below is a Pump Handle (PH) Q&A with two public health officials — Stella Fogleman, director of the Emergency Preparedness and Response Program at the Los Angeles County Department of Public Health, and Patrice Harris, chair of BCHC and director of health services in Fulton County, Georgia — on the importance of public health preparedness funding and the need for enhanced transparency.
PH: It’s frequently noted that public health preparedness funding comes in bursts, often in response to the most recent outbreak or disaster. And for years, public health advocates have explained why this funding pattern is bad for planning, preparedness and people’s health in the long term. Yet, we’re still struggling with less-than-ideal public health/hospital preparedness funding. Do you believe preparedness funding will be a perpetual struggle for public health? And do you have any insight into how we can effectively build support for this funding among constituents?
Fogleman: We hope that less-than-ideal public health and hospital preparedness funding will not be a perpetual struggle for public health. However, until funding for public health and health care system preparedness is increased to appropriate, necessary levels and consistently maintained at those levels, it will remain a struggle. During the last decade, we have had more frequent and severe naturally occurring weather events and emerging and re-emerging disease events. There is no indication that this will let up. Intentional terrorism threats continue to rise as well. The most crucial need for public health and health care preparedness is to support a dedicated interdisciplinary team of public health professionals with the ability and resources to anticipate, plan, train and exercise for a prioritized set of hazards. Public health, health care, and sectors of government, nongovernment agencies and community organizations and groups must establish the systems to accomplish and maintain this. It should be approached as a permanent and consistent part of what public health does, not a quick fix.
To build support for this funding, constituents must have a clear understanding of what efforts are happening and the reality of what the gaps are. Because this area is under-resourced to begin with, it is challenging to find innovative and improved means to communicate this need. Currently, there is a move in public health to improve the way we tell our story. That’s a step in the right direction.
Harris: I think it is important that we seize on the current climate post-Ebola to amplify the importance of preparedness funding. We also need to engage and educate nontraditional, non-health care partners on the importance of sustainable preparedness funding.
PH: Why is transparency in local public health emergency preparedness funding important? How could better transparency lead to better preparedness and strengthened capacity at the local level?
Fogleman: Transparency is very important to maintaining funding support. However, it is a challenge to get to a place of full transparency while not over exposing or focusing on vulnerabilities. We need to find a way to really show people the hard work happening on a daily basis to keep them safe and also demonstrate how much more we could do if we had more resources. That would improve our resources and strengthen our capacities. Again, finding better ways to reach people with compelling stories about the importance of public health and health care preparedness and about public health in general is the challenge we must undertake.
Harris: You can’t fix what you can’t see. With a clear picture of the funding, we can get to the point of analysis to ensure maximal impact and efficiency in the use of the funds we have and clearly identify the funding gaps.
PH: How important has the influx of preparedness funding since Sept. 11 been to forging and strengthening partnerships between public health agencies and hospital/health care systems? And how have the benefits of these partnerships spilled over into other areas of community health work?
Fogleman: The influx of funding since 9/11 has been extremely important to strengthening partnerships between local public health and the hospital and health care systems in Los Angeles. Prior to this, hospitals had limited emergency supply caches, response plans, access to federal stockpiles of medications, vaccines or experimental drugs, volunteer staffing resources and communication with local public health departments. These funds have allowed for systems to be built and refined so that when health threats such as H1N1 or Ebola have hit our borders, public health and the health care community have been able to respond collectively to save lives. This work has also lead to stronger relationships between the medical and public health community that allow us to work together better on other community health initiatives.
Harris: Partners in the broader health care delivery system are critical in any response to a public health emergency. Funding has allowed for and supported engaging these partners.
PH: How is the Section 317 Immunization Grant Program related to public health emergency preparedness? And how important does this program remain even as more and more Americans gain access to health insurance via the Affordable Care Act? (In his fiscal year 2016 budget proposal, President Obama recommended cutting the 317 program by $50 million.)
Fogleman: The recent outbreaks of pertussis and measles in California serve as good examples of how the Section 317 Immunization Grant and public health emergency preparedness are related. The resurgence of these vaccine-preventable diseases triggered a public health response that required public information/community education, emergency management, epidemiological investigation, laboratory testing and vaccination activities.
The Section 317 Immunization Grant allows public health departments to maintain critical staffing and resources to prevent outbreaks by providing routine vaccination for the uninsured or underinsured, and to respond by providing vaccines for outbreaks, post-exposure prophylaxis, disaster relief as well as mass vaccination campaigns or exercises for public health preparedness.
The Section 317 Immunization Program remains important in keeping our communities healthy. Although we anticipate more Americans will have insurance coverage for immunization services via ACA, other important public health activities are necessary to assure that the right vaccines get to the right people at the right time to protect their health, the health of our communities, and to prevent outbreaks or resurgences of vaccine-preventable disease.
Harris: There are many citizens who remain uninsured or underinsured. Vaccines are one of the greatest public health interventions with known efficacy, impact and reach in their ability to prevent major disease outbreaks, which are public health emergencies.
PH: What are some of the biggest lessons you’ve learned over the years when it comes to communicating with the public in an emergency/outbreak? And how has federal/state preparedness funding contributed to a more robust communications capacity?
Fogleman: Good communication with the public remains a top priority in public health. With each emergency or outbreak we face, we learn new ways to improve how to reach out to communities. Public health communication in a jurisdiction such as L.A. County requires a robust, well-resourced team of professionals who have access to as many layers and pockets of situational awareness as possible. We must have the ability to understand the communication needs and networks of our diverse communities and to reach out with relevant and timely information through means that are understandable and accessible for people. The recent response efforts to Ebola and measles in our jurisdiction highlighted the fact that with each event, the audience and the information needs are dynamic and will be different with each incident. With emergent diseases, especially, we are not going to have all the information we want up front and the picture will change as time elapses. We must still communicate early and often, be clear about what we do know at the time and what is currently being done, and what we want people to do to protect their health.
Preparedness funding has provided us the opportunity to enhance our communications capabilities by building upon our existing systems. We currently have automated notification systems to contact staff and reach out to our response partners in health care and other sectors as well as health care providers with vital information in the event of an emergency. Funding for the Los Angeles County Community Disaster Resilience pilot project also opened new channels of communication with the community and allowed us to work with community partners directly to get their perspectives on the best ways to reach out to diverse communities.
Harris: Getting accurate evidence and science-based information to the public in the midst of a public health emergency is a challenge, but it is one of the most important aspects of responding to an emergency. Assuring the public that health professionals are on the job and communicating accurate information to reduce anxiety and fear are top priorities.
PH: Notwithstanding wavering funding levels, preparedness funding since Sept. 11 has certainly made an enormous impact. Can you put in context for our readers just how far public health preparedness has come in the last decade or so?
Fogleman: Funding that came in shortly after 9/11 enabled the L.A. County Department of Public Health to establish needed systems and structures that were lacking prior to Public Health Emergency Preparedness (then called Bioterrorism Preparedness) funding. One of the significant systems that were established was a formal Incident Command System response structure for the department that was subsequently supported by a primary departmental operations center to manage emergency response efforts during an incident. Automated surveillance and situational awareness systems, as well as terrorism threat assessment and early warning systems were also developed. The department constructed a tiered training structure to continue to add to our current pool of trained disaster service workers who range from line staff to command structure leadership. As these systems and structures were established, we developed formal emergency response plans that have extensive reach across L.A. County by means of whole community planning.
Lastly — perhaps most importantly — an emergency preparedness and response program comprised of a skilled team of staff dedicated to continued situational awareness, whole community planning, emergency operations, community engagement, administrative preparedness and departmental training…is critical to maintaining a strong infrastructure to support overall public health and health care emergency preparedness and response efforts.
Harris: There has been great improvement in funding levels since September 11. We have to continue to assess current needs and risks and ensure sustained, adequate funding.
To learn more about the Big Cities Health Coalition and its efforts to address emergency preparedness as well as to access video from the April congressional briefing, click here. To learn more about public health emergency preparedness, visit the Centers for Disease Control and Prevention.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.
Excellent reporting as always, Kim. If you wonder how many people are reading this, here's another one:-)
I trust the public health authorities, because they have degrees and/or experience in the relevant sciences, and can be counted on to do their jobs conscientiously and in a nonpartisan manner.
One way to accomplish the goals of transparency while limiting the risk of disclosing information that could be of use to terrorists, is to have elected oversight boards that report to the public. These should be nonpartisan positions, and should require degrees from recognized institutions in relevant fields (in part to have necessary expertise, and in part to keep quacks away).
To present necessary information to the public, especially in emergencies: do not assume everyone has a "smart"phone and/or a broadband connection. Work with local print and broadcast media, and put signage on municipal vehicles, e.g. "Flu Emergency: get informed: (URLs, names of newspapers and broadcast stations)," and consider using postal mail for mass mailing of postcards with relevant information.