Commentary A Resilient Nation—Critical to National and Global Health Security Ali S. Khan, MD, MPH rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Emergencies and disasters often severely affect the health and well-being of citizens around the world. Natural disasters, disease outbreaks, chemical and radiological disasters, terrorism, and other events underscore the need for a robust public health system in the United States and around the globe. Health security, a critical component of national security, depends on our nation’s ability to prevent, protect against, mitigate, respond to, and recover from public health threats.1 A secure and resilient nation requires a comprehensive approach to build and sustain national preparedness. The Centers for Disease Control and Prevention, in collaboration with state and local partners, works to enhance our nation’s capability to prepare for and respond to public health threats and hazards that pose the greatest risk. The substantial investment in state and local preparedness and response infrastructure in support of public health preparedness since 2001 has made it one of the great public health accomplishments of the decade after September 11, 2001.2 Significant progress in recent years includes marked improvements in a capability-based approach to public health preparedness within state and local health departments.3 While there have been substantial improvements in federal, state, and local governmental public health preparedness systems,4 a shift in focus from governmental systems to improving national health security through community preparedness and resiliency can advance the future of public health preparedness.5 Practicing whole community preparedness, where collectively there is cooperation among government, businesses, and local communities, can contribute to the resilience of our population in the face of ongoing threats.6 To accomplish whole community preparedness, it may require more and sustained cross-sector collaboration moving forward.7 Not just at the federal, state, and local government levels but also J Public Health Management Practice, 2014, 20(5), S3–S6 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
at the community level among government, academia, nonprofits, other public entities, and all components of health care and emergency management.8,9 Moving forward, focusing on the following areas of opportunity will support improvements in building health security and resiliency and ensure robust community-wide responses to disasters.
● Building Community Resilience Recognition among academia, government, and public and private sectors of the need to build resilient communities is beneficial.10 This shifting norm will require broader thinking about public health and public health education than there has been in the past. Activities such as integrating preparedness into routine organization and community operations, buildings skills in the affected population for a response, and developing policies to support recovery, rebuilding, and long-term community development can strengthen the ability of all communities to respond. Building everyday partnerships and systems that can be scaled up to meet the Author Affiliation: Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia. The author acknowledges the Preparedness and Emergency Response Learning Centers for their contributions toward improving the public health workforce in support of national health security, as well as the Centers for Disease Control and Prevention’s Learning Office within the Office of Public Health Preparedness and Response for their assistance in preparation of this commentary. The findings and conclusions in this commentary are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention. The author is Director of the Office of Public Health Preparedness and Response at the Centers for Disease Control and Prevention and declares that he has no conflicts of interest in relation to this work. Correspondence: Ali S. Khan, MD, MPH, Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, Atlanta, GA 30333 ([email protected]). DOI: 10.1097/PHH.0000000000000109
S4 ❘ Journal of Public Health Management and Practice needs of an emergency response is the basis of a robust public health infrastructure and to ensuring resilience within a community. Of course, building resiliency includes not only scaling up essential public health functions at all levels of government but also making sure the general public has a strong sense of purpose in supporting their own health and safety. Ensuring our families and ourselves are prepared can free up limited assets to help those who are significantly impacted by the emergency or considered more vulnerable during emergencies.
● Planning for Vulnerable Populations Recent images of Hurricane Sandy’s aftermath were clear reminders that even in areas where good response systems are in place, vulnerable populations will still need extra attention. Vulnerable populations are much broader than the very young and old but also include those with mobility issues, those with language barriers, those who may be dependent upon electricity for their survival, and many others. Even those not routinely thought of as vulnerable may become vulnerable in an emergency situation. These individuals make up a large portion of our national population, and their needs should be considered going forward. Strategies for protecting these populations during emergencies should be integral to preparedness planning from the very beginning.
● Data, Analytics, and Measurement There are new tools and systems available to us in support of data collection and analytics such as electronic medical records and social media. However, finding out what is going on in communities through timely and reliable data can assist in making informed decisions on how to intervene sooner. With the availability of data from multiple sources growing, improvements in measurement and data analytics will be crucial to ensuring appropriate and timely responses to events. Collaboration among partners in both public health and academia can help identify the best science in these areas, develop the best evidence base to measure improvements, and use those findings to improve national and global health security. One recent improvement in the area of measurement is the National Health Security Preparedness Index.11 Through the use of this index, the public health community can engage emergency management and health care, for example, as well as many other sectors to better understand their unique contributions and improve areas within the index that require broad community engage-
ment. The index demonstrates that local and state public health organizations that think broadly on how the areas of emergency management, health care, and other sectors can work synergistically to improve community resilience. Academia can continue to inform these types of evidence-based approaches to measurement, intervention strategies, and policy.
● Global Health Security There may be a growing focus on improving global health security in the coming years.12 Globalization is increasing, and while many positive opportunities arise from it, there are also opportunities for the spread of novel infectious diseases, the rise of drug resistance, and greater chances of emerging natural or man-made threats to the world’s health. In light of this recognition that a disease threat anywhere is a threat everywhere, the Centers for Disease Control and Prevention and others are working globally to ensure national health security for all Americans through the prevention, detection, and response to global health security threats. Leveraging the science, technology, and innovation through domestic and international partnerships will be beneficial to improving global health security capacity.13
● Innovation Strategies to improve preparedness should also reflect the current changing and evolving threat environment. The development of new and novel tools, programs, and activities to reach goals and improve collaborative partnerships can lead to achieving better results. Social media, crowdsourcing of information, and real-time data for situational awareness are only a few areas where current opportunities for innovation exist. Future research is needed to identify opportunities and ways of thinking that build resiliency, strengthen global healthy security, and improve the operation of our public health systems. As resources decline, the state and local public health workforce is becoming smaller.14,15 Leveraging partnerships for preparedness, using new tools and media, and optimizing resources can improve national health security in new ways that are more effective and efficient. Opportunities to enable frontline staff to rapidly keep pace with skills and technology for response, mitigation, and recovery can be explored. Information sharing, multisector collaboration, continuous improvements through exercises/drills, and action-based learning are important.
A Resilient Nation—Critical to National and Global Health Security
● A Competent and Prepared Workforce Public health preparedness is dynamic and must continually adapt to a changing political and fiscal environment. There is a need for the workforce to adapt, maintain, and improve its level of preparedness in light of ongoing, new, and increasing requirements to build state and local preparedness capabilities. Effective preparedness and response, and ultimately national health security, cannot be achieved and improved upon without a backbone of highly skilled and trained frontline public health, health care, and emergency management workers. With competing priorities emerging within state and local health agencies,14,15 the national infrastructure of a public health workforce that is knowledgeable, skilled, and has the ability to appropriately respond has been under increased demands. Despite the significant challenges affecting public health today, local, state, and federal health agencies all have an important role to play in educating public health practitioners and finding ways to operate more efficiently and effectively. Academic institutions, specifically schools and programs of public health, are key partners in ensuring that the current and future public health workforce is prepared to respond to current and emerging threats to our nation’s health. It may be beneficial to examine how students and practitioners are being trained to synthesize the vast amount of data available from multiple sources and apply them to real-time situations. Skills in building partnerships and cross-sector collaboration will be valuable for improving whole community preparedness. Communication skills are important—practitioners at every level should be able to use new and innovative tools for communication and be versed in social media, health literacy, and culturally competent dialogue. Through acquiring, practicing, documenting, and evaluating the results of using these skills, public heath students and practitioners can better define the pathways to building community resilience. State and local health department leaders and professional associations are important in strengthening the link between academia and practice and benefit from practice-informed research and curriculum.16 Education and learning do not stop with the conferring of a degree. Ideally, learning should take place in the context of lifelong learning and skill development across the career spectrum.17 Preparedness and emergency response as a learning domain is constantly evolving (eg, a shifting focus toward community resilience, global health security). How can the public health practice and academic communities ensure there are systems in place at the local, academic, state, and federal levels to enhance access to the lifelong learning required
for a competent, sustainable, and prepared workforce? The Preparedness and Emergency Response Learning Centers are one example of efforts at linking academia to practice for preparedness education, training, and technical assistance. This network of centers provides a model to evaluate, distill lessons learned, and inform the field going forward. Schools of public health are often large organizations embedded within their local communities, but they are routinely involved and oftentimes at the forefront of larger local, national, and global public health activities that go well beyond a preparedness focus. As demonstrated throughout this supplement, there is vast expertise within these academic institutions, important to improving the science and practice of public health preparedness and response, as well as to inform efforts to build community resilience. It is clear that in the face of unending threats to the public’s health, a sustainable lifelong learning system for public health and other frontline health care professionals, both domestically and abroad, is important to national and global health security and resiliency. Much more can be accomplished to protect our communities, and progress will be the result of a shared vision and strong partnerships across public health, health care, emergency management, and other community sectors. REFERENCES 1. Department of Health and Human Services. National Health Security Strategy of the United States of America. Washington, DC: Office of the Assistant Secretary for Preparedness and Response. http://www.phe.gov/Preparedness/planning/ authority/nhss/strategy/Pages/default.aspx. Published December 2009. Accessed February 25, 2014. 2. Centers for Disease Control and Prevention. Ten great public health achievements—United States, 2001-2010. MMWR Morb Mortal Wky Rep. 2011;60(19):619-623. http://www .cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm. Accessed February 20, 2014. 3. Department of Health and Human Services. Centers for Disease Control and Prevention. Public health preparedness capabilities: national standards for state and local planning. http://www.cdc.gov/phpr/capabilities/ DSLR capabilities July.pdf. Published March 2011. Accessed February 20, 2014. 4. Department of Health and Human Services. Centers for Disease Control and Prevention. The 20132014 national snapshot of public health preparedness. http://www.cdc.gov/phpr/pubs-links/2013/documents/ 2013 Preparedness Report.pdf. Accessed March 7, 2014. 5. Chandra A, Acosta J, Stern S, et al. Building Community Resilience to Disasters: A Way Forward to Enhance National Health Security. Santa Monica, CA: RAND Corporation; 2011. http: //www.rand.org/pubs/technical reports/TR915. Accessed February 20, 2014.
S6 ❘ Journal of Public Health Management and Practice 6. Department of Homeland Security. Federal Emergency Management Agency. A whole community approach to emergency management: principles, themes, and pathways for action. http://www.fema.gov/whole-community. Published December 2011. Accessed March 20, 2014. 7. Marcus L, Dorn B, Henderson J. Meta-leadership and national emergency preparedness: a model to build government connectivity. Biosecur Bioterror. 2006;4(2): 128-134. 8. Buehler J, Whitney E, Berkelman R. Business and public health collaboration for emergency preparedness in Georgia: a case study. BMC Public Health 2006;6: 285-298. 9. Simo G, Bies A. The role of nonprofits in disaster response: an expanded model of cross-sector collaboration. Public Adm Rev. 2007;67(1):125-142. 10. Department of Health and Human Services. Community resilience. Office of the Assistant Secretary for Preparedness and Response Web site. http://www.phe.gov/ Preparedness/planning/abc/Pages/community-resilience .aspx. Accessed March 20, 2014. 11. National Health Security Preparedness Index. http://www .NHSPI.org. Accessed February 20, 2014. 12. Department of Health and Human Services. Nations commit to accelerating progress against infectious disease threats. Press release. http://www.hhs.gov/news/press/2014pres/
02/20140213a.html. Published February 13, 2014. Accessed April 21, 2014. Department of Health and Human Services. Global health security agenda: toward a world safe & secure from infectious disease threats. http://www.globalhealth .gov/global-health-topics/global-health-security/GHS%20 Agenda.pdf. Accessed April 21, 2014. National Association of City & County Health Officials. Local health department job losses and program cuts: findings from the 2013 Profile Study. National Association of City & County Health Officials Web site. http://naccho .org/topics/infrastructure/lhdbudget/upload/SurveyFindings-Brief-8-13-13-2.pdf. Published July 2013. Accessed March 31, 2014. Association of State and Territorial Health Officials. Budget cuts continue to affect the health of Americans: update October 2013. http://www.astho.org/budget-cuts-Nov-2013. Published 2013. Accessed March 31, 2014. Herrmann J, Blumenstock JS. Global Health Security: Training a Public Health Workforce to Combat International and Domestic Threats. J Public Health Manag Pract. 2014; 20(suppl 5):S118-S199. Olson D, Hoeppner M, Larson S, et al. Lifelong learning for public health practice education: a model curriculum for bioterrorism and emergency readiness. Public Health Rep. 2008;123(2):53-64.
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