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Research Brief

Key Findings

  • Since 9/11, substantial investments in public health have expanded and improved key response systems (e.g., disease surveillance, laboratories, communications) and supported planning and performance measurement.
  • Many challenges remain, including poor integration of the public health system; the need to improve the ability of the health-care system to absorb a large-scale "surge" of ill or injured persons resulting from a public health emergency; and variability in communities' ability to detect, respond to, and recover from health emergencies. Recent budget cuts to public health—the result of fiscal pressure on all levels of government—threaten to undo much of the progress that has been made.
  • To address these challenges, all sectors of society, not only public health and emergency management, must recognize their roles in a public health emergency, including preparedness, response, and recovery.

The 9/11 attacks and the anthrax attacks that soon followed were an important wake-up call for America's leaders, including the leadership of the nation's public health system—and they provided a chilling reminder that a robust public health system is vital for national security. In response to the attacks, the federal government invested billions of dollars to strengthen state and local public health systems and enhance hospital preparedness to respond to large-scale emergencies. With the infusion of these funds into public health preparedness—the term used to refer to these activities—public health officials, particularly at the state and local levels, began broadening their roles beyond the traditional practice of public health.

Now, a decade after 9/11, RAND Health researchers Jeanne Ringel and Jeffrey Wasserman have contributed a chapter to a collection of essays on the military, political, fiscal, social, cultural, psychological, and moral implications of U.S. policymaking since 9/11. In their essay, they consider how the public health system has fared in the wake of the government's investments and the system's new responsibilities. They note that although progress has been made in many areas of public health policy, significant challenges remain. Most notably, they call for a cultural shift that engages not only public health, but all sectors of society, in public health emergency preparedness, response, and recovery.

Progress Has Been Made in Many Areas of Public Health Policy

Substantial progress has been made since 9/11 in the way the public health system is organized and managed. Major investments have expanded and improved key response systems, including disease surveillance, public health laboratories, and communications. Extensive planning (e.g., to support mass delivery of medications to communities when needed) has been undertaken at federal, state, and local levels to promote public health disaster response and recovery. Progress has also been made in developing valid and reliable performance measures.

The nation's response to the H1N1 pandemic in 2009 provides the most substantial evidence that public health preparedness and response capabilities have improved. Successful aspects of that response included the swift identification and characterization of a novel pandemic virus, the record-breaking pace with which a new flu vaccine was developed and produced, the rapid distribution of antiviral drugs from the Centers for Disease Control and Prevention's Strategic National Stockpile, and effective communications with the general public regarding methods to prevent transmission of the virus.

Important Challenges Remain

However, important challenges remain, and their effect is compounded by growing financial constraints and recent reductions in federal funding to support state and local public health preparedness.

Many components of the public health system are still poorly integrated. The organization of services provided by public health departments differs across states and even within states, as do the services themselves. Hurricane Katrina revealed a pressing need to more clearly delineate roles and responsibilities among government agencies at all levels and to coordinate government actions with those of nongovernmental organizations, private-sector firms, and other stakeholders.

One of the most notable unmet challenges today is the need to improve the ability of the health-care system to absorb a large-scale "surge" of ill or injured persons resulting from a public health emergency. Many hospitals and other health-care facilities are currently operating at or near capacity. They need to work more closely with their local and state health departments and other response partners in their communities to develop and exercise plans to ensure that people receive the right levels of care in the right settings at the right time during and after a large-scale public health emergency.

There is troubling variability in communities' ability to detect, respond to, and recover from a potentially devastating health event. When put to the test, some communities demonstrate an impressive level of readiness. Unfortunately, others have been slow to grasp the potential magnitude of an event, much less initiate a robust response. Poorer-performing communities are frequently unable to provide their residents, including vulnerable populations, with adequate information on how to care for themselves and others in an emergency. Greater emphasis should be placed on recovery planning to foster collaboration, build connections among neighbors, and meet the health needs of local populations.

A Cultural Shift Is Needed

To address these challenges and continue to make progress, a significant cultural shift is needed, not only within public health and emergency management, but in all sectors of society. Everyone has a role to play in public health emergency preparedness, response, and recovery. The National Health Security Strategy, recently released by the U.S. Department of Health and Human Services, highlights the need for such a paradigm shift. The two overarching goals of the strategy are to build community resilience and to strengthen public health, medical, and emergency response systems.

RAND's researchers emphasize two steps that can support this new direction: (1) cultivating a sense of shared responsibility and (2) making efficient and effective use of existing resources to support preparedness.

Cultivating a sense of shared responsibility. The public and policymakers need to understand the vital role of public health and their roles in safeguarding it. Engaging all relevant stakeholders in discussions about national health security can increase their sense of ownership and thus their willingness to assume responsibility for specific activities and to follow through on their commitments. Public education is key to ensuring that everyone—from government officials and professional first responders to directors of nongovernmental community organizations, private-sector executives, volunteers, and individual citizens—understands how he or she can strengthen the nation's ability to prepare for, respond to, and recover from a public health emergency.

Making efficient and effective use of existing resources to support preparedness. In the current fiscal environment, it is crucial to use existing funding streams as efficiently and effectively as possible. Ideally, strategies should be crafted to encourage and leverage private-sector investments in preparedness and community resilience. An important first step would be to inventory existing federal grant programs to identify gaps, overlaps, and opportunities to better coordinate applications, reporting, and performance.

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.

This research in the public interest was supported by RAND, using discretionary funds made possible by the generosity of RAND's donors, the fees earned on client-funded research, and independent research and development (IR&D) funds provided by the Department of Defense.

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