Ready or Not? Protecting the Public's Health from Disease, Disasters, and Bioterrorism, 2006

QUICK SUMMARY

Ready or Not? 2006 finds that five years after September 11, public health emergency preparedness is still not at an acceptable level Limited progress continues to be but the big-picture goals of adequate preparedness remain unmet As a result, Americans continue to face unnecessary and unacceptably high levels of riskTrust for America's Health (TFAH) has issued an annual Ready or Not? report, beginning in 2003 Each report assesses the level of preparedness in the states, evaluates the federal government's role and performance, and offers recommendations for improving emergency preparedness Ready or Not? 2006 is the fourth in the series

In 2002, Congress passed the Public Health Security and Bioterrorism Act, allocating nearly $1 billion annually to states to bolster public health emergency preparedness. Even after this investment of almost $4 billion, the government health agencies have yet to release state-by-state information to Americans or policymakers about how prepared their communities are to respond to health threats.

TFAH issues this report to:

• Inform the public and policymakers about where the nation's public health system is making progress and where vulnerabilities remain;
• Foster greater transparency for public health preparedness programs;
• Encourage greater accountability for the spending of preparedness funds; and
• Help the nation move toward a strategic, “all-hazards” system capable of responding effectively to health threats posed by diseases, disasters, and bioterrorism.

State-by-state materials are available on TFAH's Web site at www.healthyamericans.org.

TFAH's report was supported by grants from the Robert Wood Johnson Foundation and the Bauman Foundation.

2006 marks the fifth anniversary of the September 11, 2001 and anthrax tragedies. Since 2001, the nation has experienced many additional threats to the public's health, ranging from Hurricane Katrina to a life-threatening E. coli outbreak to rising concerns about a potential flu pandemic.¹ 

America's public health system and the healthcare delivery system are among the most important components of the nation's preparedness against terrorism and natural disasters.  They are charged with the unique responsibility of protecting the health of all citizens. Public health and healthcare professionals act as first responders, investigators, strategists, medical care providers, and advisors to public officials and decision makers. They must diagnose and contain the spread of disease, and treat individuals who are injured or may have been exposed to infectious or harmful materials.

Intentional acts of terror and naturally occurring crises have the potential to cause serious harm to large portions of the American public. Decisions and actions taken by the public health system can greatly mitigate the negative impact of these threats and help protect the health and lives of the American people. Many health emergencies can also have serious global consequences, particularly infectious threats. Germs know no boundaries, so the U.S. must also remain vigilant and support the prevention and control of health threats around the world.

ASSESSING AMERICA'S READINESS

In order to evaluate public health emergency preparedness in the states, Trust for America's Health (TFAH) has issued an annual Ready or Not? report, beginning in 2003.  Each report assesses the level of preparedness in the states, evaluates the federal government's role and performance, and offers recommendations for improving emergency preparedness. Ready or Not? 2006 is the fourth in the series. 

In 2002, Congress passed the Public Health Security and Bioterrorism Act, allocating nearly $1 billion annually to states to bolster public health emergency preparedness.  Even after this investment of almost $4 billion, the government health agencies have yet to release state-by-state information to Americans or policymakers about how prepared their communities are to respond to health threats.

TFAH issues this report to:

• Inform the public and policymakers about where the nation's public health system is making progress and where vulnerabilities remain;
• Foster greater transparency for public health preparedness programs;
• Encourage greater accountability for the spending of preparedness funds; and
• Help the nation move toward a strategic, “all-hazards” system capable of responding effectively to health threats posed by diseases, disasters, and bioterrorism.

Read Full Section: Introduction (PDF)

To help assess health emergency preparedness capabilities, each state received a score based on 10 key indicators. States received one point for achieving an indicator or zero points if they did not achieve the indicator. Zero was the lowest possible overall score and 10 the highest. Taken collectively, these indicators offer a composite snapshot of preparedness, including strengths and vulnerabilities.

Very limited data are available to measure public health preparedness. Many key components of preparedness are not sufficiently measured or the data are not made available. TFAH compiles these indicators based on the best available data. The indicators focus on key areas of preparedness using the limited data currently available for all 50 states and D.C. TFAH has called for the government to develop national performance standards and to publicly release information on a routine basis about the states' performance in meeting these standards.  The indicators were selected based on:

• If they reflect a fundamental, systemic public health need;
• Consultation with key experts about areas important to serving basic public health emergency needs; and
• The availability of state level data, which were verifiable through independent means or consultation with states.

Scorew are not based on an absolutel scale of success, but indicate relative achievements in areas of preparedness, and highlight areas where increased prioritization and investment must be made to address problems. Additional measures have been proposed or may be used for other purposes. However, the data for the outcomes of these measure are not made available on a state-by-state basis. Many states have taken action in other areas of preparedness or may be in the process of increasing certain capabilities that are not reflected in this report.

More than half of states scored six or less. Twelve states and D.C. scored five or less. Oklahoma scored the hightest, with a score of ten. California, Iowa, Maryland and New Jersey scored the lowest, achieving a score of four. No state scored below a four. States with stronger surge capacity capabilities and immunization programs scored higher this year, with four measures focused on those capabilities.

Read Full Section: State-by-State Health Preparedness Indicators and Scores (PDF)

"When public health works best, it is invisible -- it's the disease you didn't get, the accident you didn't have, the disaster that didn't happen" is an adage within the public health community.⁸⁴ After September 11 and the anthrax attacks, it became clear that the nation's public health system was antiquated, unprepared, and underfunded to respond to modern health threats.⁸⁵ Public health practitioners have not always been considered “front line” responders, but with increased threats of bioterrorism and pandemic flu, they have been recognized as a central component in emergency threat response.

There are few existing structures or historical examples to build upon. Much of bioterrorism and public health preparedness has necessitated creating systems, technologies, and measures from scratch. To help meet this need, in 2002, Congress passed the Public Health Security and Bioterrorism Act, appropriating approximately $1 billion per year to help bolster federal and state preparedness.

1. Strengthening Preparedness Funds 

After the initial rounds of funds to support public health preparedness, the programs have already experienced cuts, even before many basic preparedness goals could be met. These cuts threaten to halt or even reverse progress that has been achieved.

Since FY 2004, over $90 million has been cut from CDC preparedness funds allocated to states, and over $23 million has been cut from HRSA funds allocated to states for hospital preparedness. Additionally, some funds originally designated for state preparedness have been “reprogrammed” to other bioterrorism activities, including $27 million in FY 2004 and $52 million in FY 2005 shifted to the Cities Readiness Initiative (CRI).

All of these reprogrammed funds are important for preparedness, but funding for new programs should not come at the expense of vital ongoing preparedness activities. Taking funds away from existing state and local preparedness efforts jeopardizes the progress that has been made.

2. Strengthening Accountability 

Another public health adage is that “preparedness is a process.” While that is clearly true, and it is impossible to be 100 percent prepared for every possibility, there are basic protections that should be in place in every state and community across the country.  Americans rely on their government to protect them from threats that are bigger than any individual or single community can respond to on their own. Other sectors involved in emergency response on a day-to-day basis, including law enforcement, public safety, firefighters, Emergency Medical Services (EMS), hospitals, and the military, have determined “optimally achievable” measures for preparedness.⁸⁶ The public health preparedness system does not currently have a comparable set of baseline objectives.

Five years after September 11, there is still little information publicly available to evaluate how states' preparedness capabilities have improved and what vulnerabilities remain. The lack of concrete data has raised concerns among Members of Congress, the GAO, and HHS, as well as independent analysts and watchdog groups. This means Americans do not have information about how well their communities and states are prepared, and do not know whether their tax dollars are being spent efficiently.  It also makes it difficult for Congress to know where it should strategically invest limited federal funds to address vulnerabilities and to hold states accountable for their use of these funds.

The CDC and HRSA have gone through a number of iterations toward establishing clear, objective “performance measures” for states. Each year, they have been updated to reflect more of an emphasis on demonstrating capabilities versus developing plans. However, the most recent measures are still viewed as inadequate and have received criticism for focusing on:

• Self-reported information from states that cannot be verified objectively or by external evaluators; 
• Releasing data only in aggregate form, rather than on a state-by-state basis, which denies the public and policymakers information about how prepared their communities are and how well the funds are being used;
• Process versus outcomes, such as evaluating time frames for activities rather than the quality and impact of the information; and
• Basic capabilities instead of how a state would be able to cope with a mass emergency when the regular functions would be quickly overwhelmed.

Useful performance standards must include:

• Baseline, "optimally achievable" standards that every jurisdiction shoudl be required to meet;
• Externally or objectively verifiable achievements;
• An emphasis on meeting mass emergency surge needs; and
• Public reporting of the information to citizens and policymakers in every state.

Read Full Section: Strengthening Funding and Accountability (PDF)

Five years after 9/11, public health preparedness falls far short of what is required to protect the American people. The nation has made slow progress toward improving basic capabilities, but is nowhere near reaching adequate, let alone “optimally achievable,” levels of preparedness across the 50 states and D.C.

TFAH calls for accelerating public health preparedness efforts, and urges an “all-hazards” approach to help protect against a range of possible threats, including bioterrorism, natural disasters, and a major outbreak of a new, lethal strain of the flu.

To strengthen emergency preparedness, we must focus on five key areas:

1. Accountability.
2. Leadership.
3. Surge capacity and the workforce.
4. Modernizing technology and equipment.
5. Partnering more with the public.

ACCOUNTABILITY

Little concrete information is available to the public or policymakers about public health preparedness and remaining vulnerabilities. While the CDC and HRSA have been working toward more clearly defining “performance measures,” there is still not clear enough consensus about how to define and objectively determine standards for public health preparedness. The current measures focus too narrowly on process instead of outcomes or the ability to respond to wide-scale emergencies.  Also, the information collected is largely based on self-reports and is only released in aggregate form, not on a state-by-state (or grantee-by-grantee) basis. Americans are not receiving the information they deserve to know about the safety of their own communities — or what standards they should hold the government accountable for.   

HHS and its agencies should give the high¬est priority to defining measurable, “optimally achievable” basic preparedness standards. These need to be baseline requirements that all states should be held accountable for reaching. The measures should include objective assessments and be able to gauge improvements on an ongoing basis.

†The federal government has chosen to take a “partnership” approach with states and localities for setting measures and goals. While collaboration and different perspectives are important, the “leadership by consensus” approach has resulted in neither leadership nor consensus. At this point, most opinions and differences have been voiced, and it is up to the federal government to break the deadlock and establish standards for the use of federal funds. The federal government should either determine standards or empower a committee of experts to determine the standards, but provide a clear, firm deadline by when they must be completed.

LEADERSHIP 

TFAH calls for increased leadership and oversight of U.S. bioterror and public health preparedness. HHS needs to integrate top-level management of multiple bioterror and public health preparedness programs.

SURGE CAPACITY AND WORKFORCE

Major health emergencies overtax the health systems of affected communities. Local, state, and federal emergency medical and public health planning must integrate academic health centers, large private healthcare systems, and private community hospitals, and consider how to stockpile equipment and other resources. Additionally, there is a massive impending public health workforce shortage that must be immediately addressed.

MODERNIZE TECHNOLOGY AND EQUIPMENT

Basic technology and tools of public health must be modernized to adequately protect the American people.

PARTNERING MORE WITH THE PUBLIC

Planning efforts must do a better job of recognizing that the media, general public, business community, and other audiences will not always conform to procedures or expectations. Plans must be revised to address these challenges and contingencies.

Read Full Section: Recommendations (PDF)