AJPH EDITORIALS Public Health Disasters: Be Prepared In 1907, three years before the founding of the Boy Scouts of America, Robert Baden-Powell famously created the Scout motto “Be Prepared,”1 which subsequently became the Girl Scouts motto as well. Today’s scouts can earn a merit badge (Figure 1) by demonstrating knowledge in five aspects of emergency preparedness: prepare, respond, recover, prevent, and mitigate losses in emergency situations.2 In public health we, too, seek to be prepared—albeit against a wide-ranging spectrum of potential public health disasters— using specific and all hazards approaches. These may result from causes both natural (e.g., earthquakes, floods, and pandemic influenza) and humanmade (e.g., bioterrorism attack, exposures from sources of ionizing radiation, and explosions).
PUBLIC HEALTH PREPAREDNESS SUPPLEMENT This special public health preparedness supplement of AJPH, developed in collaboration with the Centers for Disease Control and Prevention, provides insights into the challenges and successes of the evolution of the full spectrum of public health emergency management from preparedness to response and recovery. The original epidemiological, social, and clinical research and
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evaluation articles and the perspectives and critical reviews “showcase the emergence of public health emergency management as a discipline in the United States since September 11, 2001, by highlighting innovative and effective evidence, strategies, solutions, and policies to achieve functional public health emergency management programs with demonstrated preparedness capabilities” across the 15 public health preparedness capabilities defined by the Centers for Disease Control and Prevention.3
THE PRICE OF PREPAREDNESS Appropriately, the issue of funding—particularly the importance of sustainable funding —for public health preparedness is addressed in the supplement. Ultimately, however, public health preparedness, as well as other public health programs, is a “purchasable commodity”: societies must consciously decide how much preparedness to buy. Every day, on an individual level, persons make decisions about how much to pay for insurance policies for their homes to prepare against financial loss (owing to such causes as tornados, hurricanes, and lightning strikes) or for additional structural features to prevent loss (such as reinforced foundations, fire resistant roofs, and grading with drainage). However, as individuals, we
often face the quandary of how much we can afford to pay with our finite resources versus what we would like to do to prevent financial and structural loss—or even loss of our loved ones. We all eventually must determine our own tolerance for risk and decide on the balance between paying for prevention versus paying for the necessities of living (including shelter, food, transportation, and clothing) and other wants in our lives (e.g., convenience appliances, travel, and entertainment). Societies must make similar decisions, albeit on a much larger scale, with respect to how much the society can pay for preparedness and prevention of loss through such mechanisms as taxation. For example, it is possible to conceive of full preparedness for a major pandemic of influenza that would encompass increasing surge capacity in the hospital system (including setting up field hospitals) through a massive program of construction of facilities (and stockpiling of portable field hospitals). This would also require training and recruiting large numbers of physicians, nurses, and other health care workers and ancillary staff to fully care for the
anticipated hundreds of thousands or even millions of severely ill patients. If such preparedness was done, the societal cost would be heavy, especially because there is already great public debate regarding the cost burden of the current health care system. It would also result in inefficiencies because of facilities and personnel operating at low capacity utilization, potentially for decades, awaiting a very infrequent event.
WHERE TO PLACE THE INVESTMENTS Individuals, after considering their discretionary resources and what they can afford or are willing to pay, must decide where to place those dollars for preparedness. For example, most insurance policies will not cover sinkholes, and, except in Florida, a homeowner who is concerned about coverage for that contingency would have to take out special policies or riders to their existing policies to insure against such a hazard. Individuals would need to weigh their perception of risk (ideally, their actual risk) and their ability to pay (the insurance premium or the repair or replacement expense) to decide if taking out such a policy was desirable and feasible.
ABOUT THE AUTHOR Robert James Kim-Farley is with the Departments of Epidemiology and Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles and is an associate editor of AJPH. Correspondence should be sent to Robert James Kim-Farley, MD, MPH, UCLA Fielding School of Public Health, Room 71-235E CHS, Box 951772, Los Angeles, CA 90095 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted June 20, 2017. doi: 10.2105/AJPH.2017.304039
AJPH
Supplement 2, 2017, Vol 107, No. S2
AJPH EDITORIALS
FIGURE 1—Preparedness Merit Badge
Societies must also make similar conscious decisions. Preparedness comes in many different forms, including the following: 1. preparing for financial loss by maintaining a cash reserve, or rainy day, fund; 2. preparing for earthquakes by strengthening foundations and other structural elements in buildings (both for existing structures through requirements for retrofitting and for future structures through building codes); 3. preparing for the care of persons during an influenza pandemic or bioterrorist attack by purchasing and maintaining caches of medicines and medical equipment for urgent deployment; 4. helping to provide early warning and detection of select agents of a bioterrorist attack by buying and monitoring a system of highly specialized sensors (e.g., the US Department of Homeland Security BioWatch system)4; and 5. strengthening disease surveillance systems (e.g., syndromic surveillance and notifiable disease surveillance systems) by using electronic syndromic
Supplement 2, 2017, Vol 107, No. S2
and electronic case reporting systems on the basis of electronic health records. Preparedness measures that are dual use, that is, that can also be used in day-to-day public health work (e.g., strengthening routine disease surveillance systems), are especially attractive preparedness investments. As with individuals, societies must weigh their perception of risk (again, ideally, the actual risk) and the availability of funds to pay (either through reprioritizing current income streams or by raising income through measures such as increased taxation) to decide if a particular preparedness effort is financially and socially feasible and acceptable.
preparedness investment. Additionally, the public has a better understanding of these events and the wisdom of preparing for them because they have witnessed them personally or vicariously on the television news. Lower likelihood events that may have a relatively higher price tag to prepare for (e.g., the BioWatch program for detecting bioterrorist events) are more challenging for the public to understand. The exact likelihoods of risk are difficult to estimate and the extent of damages (both in terms of human lives and financial loss) are difficult to quantify because there are so many variables involved. In the bioterrorism example, this may include the extent to which a bioterrorist agent has been weaponized, the quantity of agent released, the density of the population attacked, the geographic area of dispersal, and even the weather conditions at the time of attack. As Bill Gates warned during a panel at the Munich Security Conference this year, “A genetically engineered virus is easier to make and could kill more people than nuclear weapons—and yet no country on Earth is ready for the threat.”5
Robert James Kim-Farley, MD, MPH REFERENCES 1. Wendell B. Be prepared: the origin story behind the scout motto. Available at: https://blog.scoutingmagazine.org/ 2017/05/08/be-prepared-scout-mottoorigin. Accessed July 19, 2017. 2. Meritbadge.org. Emergency preparedness. Available at: https:// meritbadge.org/wiki/index.php/ Emergency_Preparedness. Accessed July 19, 2017. 3. Centers for Disease Control and Prevention. Public health preparedness capabilities: national standards for state and local planning. Available at: https://www. cdc.gov/phpr/readiness/00_docs/ DSLR_capabilities_July.pdf. Accessed July 19, 2017. 4. US Department of Homeland Security. The BioWatch Program. Available at: https://www.dhs.gov/biowatchprogram. Accessed July 19, 2017. 5. Selk A. Bill Gates: bioterrorism could kill more than nuclear war—but no one is ready to deal with it. Available at: https:// www.washingtonpost.com/news/ worldviews/wp/2017/02/18/bill-gatesbioterrorism-could-kill-more-thannuclear-war-but-no-one-is-ready-todeal-with-it/?utm_term=.0378960dcd0e. Accessed July 19, 2017.
CONCLUSIONS DECISION TIME Ultimately, societies and their elected and appointed officials, like individuals, weigh the decisions of how much and what types of preparedness to pay for. Without investments, we cannot be prepared. Higher likelihood events that have relatively lower costs to prepare for (e.g., hurricanes and tornados in high-risk areas of the country) have more near term payoffs for the
AJPH
This supplement on public health preparedness provides an opportunity for us to reflect on these societal issues, provides information on the progress and the investments that have been made in preparedness, presents the approaches and frameworks to be considered when considering preparedness investments, and conveys the importance of not letting our individual or collective guard down—in other words, to “Be Prepared.”
Kim-Farley
Editorial
S121
PUBLIC HEALTH PREPAREDNESS SUPPLEMENT This special public health preparedness supplement of AJPH, developed in collaboration with the Centers for Disease Control and Prevention, provides insights into the challenges and successes of the evolution of the full spectrum of public health emergency management from preparedness to response and recovery. The original epidemiological, social, and clinical research and
S120
Editorial
Kim-Farley
evaluation articles and the perspectives and critical reviews “showcase the emergence of public health emergency management as a discipline in the United States since September 11, 2001, by highlighting innovative and effective evidence, strategies, solutions, and policies to achieve functional public health emergency management programs with demonstrated preparedness capabilities” across the 15 public health preparedness capabilities defined by the Centers for Disease Control and Prevention.3
THE PRICE OF PREPAREDNESS Appropriately, the issue of funding—particularly the importance of sustainable funding —for public health preparedness is addressed in the supplement. Ultimately, however, public health preparedness, as well as other public health programs, is a “purchasable commodity”: societies must consciously decide how much preparedness to buy. Every day, on an individual level, persons make decisions about how much to pay for insurance policies for their homes to prepare against financial loss (owing to such causes as tornados, hurricanes, and lightning strikes) or for additional structural features to prevent loss (such as reinforced foundations, fire resistant roofs, and grading with drainage). However, as individuals, we
often face the quandary of how much we can afford to pay with our finite resources versus what we would like to do to prevent financial and structural loss—or even loss of our loved ones. We all eventually must determine our own tolerance for risk and decide on the balance between paying for prevention versus paying for the necessities of living (including shelter, food, transportation, and clothing) and other wants in our lives (e.g., convenience appliances, travel, and entertainment). Societies must make similar decisions, albeit on a much larger scale, with respect to how much the society can pay for preparedness and prevention of loss through such mechanisms as taxation. For example, it is possible to conceive of full preparedness for a major pandemic of influenza that would encompass increasing surge capacity in the hospital system (including setting up field hospitals) through a massive program of construction of facilities (and stockpiling of portable field hospitals). This would also require training and recruiting large numbers of physicians, nurses, and other health care workers and ancillary staff to fully care for the
anticipated hundreds of thousands or even millions of severely ill patients. If such preparedness was done, the societal cost would be heavy, especially because there is already great public debate regarding the cost burden of the current health care system. It would also result in inefficiencies because of facilities and personnel operating at low capacity utilization, potentially for decades, awaiting a very infrequent event.
WHERE TO PLACE THE INVESTMENTS Individuals, after considering their discretionary resources and what they can afford or are willing to pay, must decide where to place those dollars for preparedness. For example, most insurance policies will not cover sinkholes, and, except in Florida, a homeowner who is concerned about coverage for that contingency would have to take out special policies or riders to their existing policies to insure against such a hazard. Individuals would need to weigh their perception of risk (ideally, their actual risk) and their ability to pay (the insurance premium or the repair or replacement expense) to decide if taking out such a policy was desirable and feasible.
ABOUT THE AUTHOR Robert James Kim-Farley is with the Departments of Epidemiology and Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles and is an associate editor of AJPH. Correspondence should be sent to Robert James Kim-Farley, MD, MPH, UCLA Fielding School of Public Health, Room 71-235E CHS, Box 951772, Los Angeles, CA 90095 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted June 20, 2017. doi: 10.2105/AJPH.2017.304039
AJPH
Supplement 2, 2017, Vol 107, No. S2
AJPH EDITORIALS
FIGURE 1—Preparedness Merit Badge
Societies must also make similar conscious decisions. Preparedness comes in many different forms, including the following: 1. preparing for financial loss by maintaining a cash reserve, or rainy day, fund; 2. preparing for earthquakes by strengthening foundations and other structural elements in buildings (both for existing structures through requirements for retrofitting and for future structures through building codes); 3. preparing for the care of persons during an influenza pandemic or bioterrorist attack by purchasing and maintaining caches of medicines and medical equipment for urgent deployment; 4. helping to provide early warning and detection of select agents of a bioterrorist attack by buying and monitoring a system of highly specialized sensors (e.g., the US Department of Homeland Security BioWatch system)4; and 5. strengthening disease surveillance systems (e.g., syndromic surveillance and notifiable disease surveillance systems) by using electronic syndromic
Supplement 2, 2017, Vol 107, No. S2
and electronic case reporting systems on the basis of electronic health records. Preparedness measures that are dual use, that is, that can also be used in day-to-day public health work (e.g., strengthening routine disease surveillance systems), are especially attractive preparedness investments. As with individuals, societies must weigh their perception of risk (again, ideally, the actual risk) and the availability of funds to pay (either through reprioritizing current income streams or by raising income through measures such as increased taxation) to decide if a particular preparedness effort is financially and socially feasible and acceptable.
preparedness investment. Additionally, the public has a better understanding of these events and the wisdom of preparing for them because they have witnessed them personally or vicariously on the television news. Lower likelihood events that may have a relatively higher price tag to prepare for (e.g., the BioWatch program for detecting bioterrorist events) are more challenging for the public to understand. The exact likelihoods of risk are difficult to estimate and the extent of damages (both in terms of human lives and financial loss) are difficult to quantify because there are so many variables involved. In the bioterrorism example, this may include the extent to which a bioterrorist agent has been weaponized, the quantity of agent released, the density of the population attacked, the geographic area of dispersal, and even the weather conditions at the time of attack. As Bill Gates warned during a panel at the Munich Security Conference this year, “A genetically engineered virus is easier to make and could kill more people than nuclear weapons—and yet no country on Earth is ready for the threat.”5
Robert James Kim-Farley, MD, MPH REFERENCES 1. Wendell B. Be prepared: the origin story behind the scout motto. Available at: https://blog.scoutingmagazine.org/ 2017/05/08/be-prepared-scout-mottoorigin. Accessed July 19, 2017. 2. Meritbadge.org. Emergency preparedness. Available at: https:// meritbadge.org/wiki/index.php/ Emergency_Preparedness. Accessed July 19, 2017. 3. Centers for Disease Control and Prevention. Public health preparedness capabilities: national standards for state and local planning. Available at: https://www. cdc.gov/phpr/readiness/00_docs/ DSLR_capabilities_July.pdf. Accessed July 19, 2017. 4. US Department of Homeland Security. The BioWatch Program. Available at: https://www.dhs.gov/biowatchprogram. Accessed July 19, 2017. 5. Selk A. Bill Gates: bioterrorism could kill more than nuclear war—but no one is ready to deal with it. Available at: https:// www.washingtonpost.com/news/ worldviews/wp/2017/02/18/bill-gatesbioterrorism-could-kill-more-thannuclear-war-but-no-one-is-ready-todeal-with-it/?utm_term=.0378960dcd0e. Accessed July 19, 2017.
CONCLUSIONS DECISION TIME Ultimately, societies and their elected and appointed officials, like individuals, weigh the decisions of how much and what types of preparedness to pay for. Without investments, we cannot be prepared. Higher likelihood events that have relatively lower costs to prepare for (e.g., hurricanes and tornados in high-risk areas of the country) have more near term payoffs for the
AJPH
This supplement on public health preparedness provides an opportunity for us to reflect on these societal issues, provides information on the progress and the investments that have been made in preparedness, presents the approaches and frameworks to be considered when considering preparedness investments, and conveys the importance of not letting our individual or collective guard down—in other words, to “Be Prepared.”
Kim-Farley
Editorial
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