In the past few years, there has been renewed attention to the state of our nation’s public health preparedness. The terrorist attack of September 11th, the anthrax incidents, SARS and fears of an influenza pandemic, and the poor national and local response following Hurricane Katrina have all reaffirmed the importance of having a capable and prepared national and local public health infrastructure. While the issue of public health preparedness has been an important topic for decades, the recent events have sparked considerable activity in the policy arena in the past five years. The resources identified in this issue module focus on some of the key topics related to the current state of public health preparedness in the United States.

Public health preparedness refers to the field of work charged with preventing, preparing for, and responding to public health emergencies and threats. The range of possible emergencies is broad, such as a terrorist attack, the surfacing of a new infectious pathogen, or a natural disaster such as an earthquake or hurricane. Several national reports have identified major gaps in preparedness at all levels related to funding, infrastructure, planning, and communication. A 2002 Institute of Medicine report declared that the “governmental public health infrastructure has been neglected and an overhaul of its components is needed to ensure quality of services and optimal performance.” [1] A 2005 report from the Trust for America’s Health rated the federal government poorly on public health emergency preparedness activities and found that nearly 85% of states received relatively low scores on a number of indicators for emergency preparedness. [2] Both of these reports emphasize the importance of making public health preparedness a serious priority at a national, state, and local level.

At the federal level, the Department of Health and Human Services (HHS) encompasses a number of agencies that have historically taken the lead managing public health emergencies. Following September 11th, the federal Department of Homeland Security (DHS) was created and assigned responsibility for emergency planning, prevention, and response. Because of the overlap between public health and homeland security issues, each of these departments includes sub-agencies that conduct work on public health preparedness. Some of the key agencies within HHS that are responsible for public health preparedness include the Centers for Disease Control and Prevention (CDC), the Health Resources and Service Administration (HRSA), and the Office of Public Health Emergency Preparedness (OPHEP). DHS includes the Federal Emergency Management Agency (FEMA), which is responsible for preparing for and responding to a broad spectrum of national emergencies.

While federal agencies play a critical role in leading and funding preparedness efforts, state and local agencies organize and provide public health services on the ground level. State agencies are responsible for the development and implantation of emergency plans and services tailored to the needs of their states and local communities. Although there is considerable variation in structure and organization, each state has a department of health. While some of these departments include responsibilities for emergency management, some states have separately created homeland security departments following the model of the federal system. In addition to planning, states and local departments carry out several essential functions, such as staffing first responders, running basic laboratory services, and operating public hospitals and clinics.

The potential fallout from a large scale public health emergency also requires that the public health workforce and other first responders have a diverse and honed set of skills. Among other things, public health practitioners are relied upon to develop plans for responding to emergency situations and carry out essential tasks such as distributing medicines, disseminating critical information and instructions, providing emergency vaccinations, establishing and staffing surge hospitals, and identifying new threats through epidemiological research.

One of the major policy issues in the area of public health preparedness is the level of funding allocated to preparedness activities. Historically, limited funding has stressed public health agencies and restricted their ability to maintain an adequate infrastructure to address emergencies should they arise. Following the September 11th terrorist attack, funding for certain public health preparedness activities—in particular fighting bioterrorism—increased tremendously. However, funding for many other related public health preparedness activities has not increased at the same pace.

While years can pass without a major crisis, a public health emergency rapidly exposes the cracks and strains on a system that are not always evident during normal times. Designing, maintaining, and financing a public health infrastructure that can respond in a timely and effective manner when an emergency strikes is among the most difficult challenges in health policy today.

Discussion Questions

• Who are the major government players with responsibility for public health preparedness? What are their different roles and how are they coordinated?
• Identify the major challenges facing the public health system in the area of preparedness.
• How would responses need to differ for different types of public health emergencies? How would they need to be the same?
• Describe the major funding trends in the area of public health preparedness. How would you set funding priorities in programming for public health preparedness with limited resources? Are there certain programs and populations that should be prioritized?
• According to research, where are the major gaps in the nation's state of preparedness? What are the policy levers that can be used to address the shortfalls? What are the non-financial barriers to improvement?
• Does the high number of uninsured Americans affect our health care system’s ability to deal with a public health emergency?
• Give examples of how different regions, states, and communities have different needs. As a policymaker or planner, how would you make sure that these needs are addressed?

Acknowledgements: Prepared by Becca Miller, Amber Hsiao, Usha Ranji, and Alina Salganicoff of the Kaiser Family Foundation.
Updated: March 2008.

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