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Research Brief

The recent emphasis on emergency preparedness has created heightened expectations and raised questions about the extent to which U.S. public health systems have evolved in recent years. The federal government has invested some $5 billion since 2001 to upgrade the public health system's ability to prevent and respond to large-scale public health emergencies. However, the public health system is still recovering from years of being underresourced and often ignored by federal policymakers.

During the past three years, RAND has examined the public health infrastructure through a series of interrelated projects, including an assessment of California's public health preparedness; a study of the impact of variation in state and local relationships on preparedness; a review of quality improvement efforts; and the development and conduct of tabletop exercises (simulated public health emergencies that require participants to work together to describe how they would respond to the evolving scenario at specific points in time). All told, RAND visited 44 communities in 17 states and conducted over 30 exercises. These studies led to several conclusions about how public health preparedness is transforming public health agencies:

  • Key signs of change include new partnerships, changes in the workforce, new technologies, and evolving organizational structures. Each of these elements has had some positive effect on public health; however, integration of preparedness with other public health functions remains challenging.
  • The preparedness mission has also raised challenges for leadership, governance, quality, and accountability. In tabletop exercises, the RAND team repeatedly observed that strong leadership trumped all other factors in determining how jurisdictions fared when presented with a wide range of scenarios related to infectious disease outbreaks. The research also identified barriers to effective emergency preparedness, including marked variability in the mission, scope, and performance of public health agencies; little consensus regarding who should be responsible for what; and a lack of evidence-based performance measures.
  • Although emergency preparedness has not been easily incorporated into public health, it is clearly stimulating the evolution of public health practice. By importing new frameworks, practices, partnerships, and concepts into public health, the emergency preparedness mission can help public health leaders transform the U.S. public health system. However, the pace of evolution is slow. Revolutionary thinking—and action—are necessary to move to a public health system prepared to meet and respond to the challenges of the 21st-century world.

This report is part of the RAND Corporation Research brief series. RAND research briefs present policy-oriented summaries of individual published, peer-reviewed documents or of a body of published work.

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