The events of 9/11 and the anthrax outbreaks in the fall of 2000 marked a shift in national consciousness. Individuals and organizations were profoundly affected. This remains true in public health whether one's perspective is federal, state, or local. Improving public health preparedness is now a national priority that has resulted in increased funding for capacity development. With this funding came high expectations and demands for accountability. "Business as usual" means integrating terrorism preparedness with day-today public health responsibilities. It requires a crosscutting-not a silo-approach and both an immediate and long-term vision.
A New Organizational Model
In August 2002, the Centers for Disease Control and Prevention (CDC) established the Office of Terrorism Preparedness and Emergency Response (OTPER) to achieve a model that integrates strategy, budget, and performance. The OTPER resides within the office of the director of CDC and includes staff with responsibilities ranging from oversight of agency-wide education and training efforts to development and implementation of research supporting terrorism preparedness and response efforts. Key operational components include the State and Local Preparedness Program (SLPP); the CDC Emergency Response Operations, and the Select Agent Program.
The SLPP is responsible for managing the $1 billion state and local cooperative agreement program. State and local projects receiving these funds include all 50 states, U.S. territories, and New York City, the City of Chicago, Los Angeles County, and Washington, D.C. Funding supports planning, stockpile management, surveillance and epidemiology, laboratory capacity, communications and information technology/Health Alert Network, risk communications/public information dissemination, and education and training.
The SLPP's primary objective is to ensure a high state of readiness for bioterrorism and other public health threats and emergencies. The Emergency Response Operations develops CDC's emergency response capacity through day-to-day management of the 24/7 Emergency Operations Center, the Strategic National Stockpile, and management of CDC Emergency Response Teams. The Select Agent Program regulates the possession of biological agents and toxins that have the potential to pose a severe threat to public health and safety.
The management structure of OTPER facilitates CDC's efforts internally and externally. The guiding vision and mission for CDC's national public health strategy for terrorism preparedness and response are as follows:
* Vision: People protected-Public health prepared
* Mission: Prevent death, disability, disease, and injury associated with urgent health threats by improving preparedness of the public health system, the health care delivery system and the public through excellence in science and services.
To chart the course to accomplish the mission and realize the vision, two equally important classes of strategic imperatives have been identified:
1. Programmatic
* Timely, effective, and integrated detection and investigation
* Sustained prevention and consequence management programs
* Coordinated public health emergency preparedness and response
* Qualified, equipped, and integrated laboratories
* Competent and sustainable workforce
* Protected workers and workplaces
* Innovative, relevant, and applied research and evaluation
* Timely, accurate, and coordinated communications
2. Enabling
* Achieving shared goals through partnerships
* Coordinated and secure information systems
* Creative and effective management services
Each of these strategic imperatives is supported by a number of critical objectives and key program actions needed to be undertaken to ensure success at all levels of the effort-federal, state, and local. OTPER's prime directive is to provide the strategic direction, resources, and system of accountability to ensure successful achievement of CDC's terrorism preparedness and response goals.
Building the foundation for preparedness
CDC's ability to adapt to and address such a wide variety of public health issues hinges on the application of fundamental public health competencies that will continue to provide the foundation of the agency's terrorism and response strategy. The front line of preparedness is people-people in public health, health care, and the first responder community. This "army" must function in a coordinated manner with independent yet integrated roles. This commentary will focus on key strategies for public health workforce preparedness, provide examples of programs in action, and set forth tenets for sustainability.
Preparing the workforce: What does it take?
A state health officer characterized educating and training the public health workforce as follows: in the best of circumstances there will be duplication of efforts; the worst scenario is one plagued by inconsistent and conflicting information.
Although much work remains, significant foundational efforts have been completed or are ongoing. Since 2000, CDC, along with 45 different partner organizations (representing professional associations; governmental agencies at the local, state, and federal levels; practice academia; and the private sector), has developed a national strategic plan for public health workforce development.1 The framework supporting the plan has been promulgated as a reasonable approach by the Institute of Medicine (IOM) in its recent report, "Who Will Keep the Public Healthy?"2 Recently, 200 representatives from these partner organizations developed an agenda for action to address key recommendations from the national strategic plan and the above-mentioned IOM report.
Core to the strategic framework for public health workforce development are six key questions representing the elements:
1. Workforce composition: Who is the public health workforce?
2. Competencies and curricula: What knowledge, skills, and abilities must they possess to perform effectively?
3. Distributed learning modalities: How can learning delivery match learners' needs and preferences?
4. Incentives: Why should public health professionals engage in lifelong learning, and how will enhanced competencies be documented, rewarded, and deployed?
5. Evaluation and research: What is the relationship between a competent workforce and a high performing public health entity in place to deliver the 10 essential health services,3 both of which are aimed at improving community health outcomes?
6. Financial support: How can we make workforce development a smart business investment?
The application of this framework to terrorism preparedness provides important insights.
The who, what, and how of front-line preparedness
CDC is bolstering action at the state and local levels to develop state-based needs assessments that should result in effective plans for training and surge capacity.4
Effective terrorism preparedness and response requires similar workforce-related information from partners in medicine, law enforcement, first response, primary care, and many others. The need for speed prescribes a simultaneous rather than sequential strategy for workforce development (i.e., immediate action to prepare individuals for their functional role in response) and a longer-term, more holistic effort guided by the strategic framework for public health workforce development previously cited. Early progress is evident in the partnerships between practice and academia described in this issue of the Journal of Public Health Management and Practice (S. Morse's article "Building Academic Partnerships: The Center for Public Health Preparedness at the Columbia University Mailman School of Public Health Before and After 9/11" and C. Atchison et al.'s article "Developing the Academic Institution's Role in Response to Bioterrorism: The Iowa Center for Public Health Preparedness"). Those efforts are building on outstanding previous work in several states and local agencies as well as long-standing partnerships in other areas of public health.
Core competencies for bioterrorism and emergency readiness were published in November 2002.5 They address the functional roles of public health staff in emergency response. They form the foundation on which technical, discipline-specific education and training can occur, and are easily translated to curricula and educational materials.
There is growing agreement that preparedness training should be competency driven; performance based; target audience specific; and accessible via diverse delivery modalities. Priority content areas include incident command systems; weapons of mass destruction (WMD); epidemiology/surveillance; risk communication; laboratory systems/practice; information technology; legal issues/authorities/forensic epidemiology; trauma/mass casualty management; Strategic National Stockpile; psychosocial/mental health; and worker safety. The list exemplifies the cross-fertilization among the partners in preparedness and response. By adopting terminology of the response community (e.g., ICS), the public health view can be understood. The breadth of the topics (e.g., mental health, risk communication) indicates the importance of the behavioral sciences and attention to new increasingly important areas (e.g., law). Of the many training materials available, too few are targeted to public health or accompanied by objective ways to document performance.
In the context of terrorism preparedness, "paper and pencil" evaluation strategies are insufficient. Performance-based training suggests evaluation of skill improvement through a range of exercises. In addition to feedback on individual performance, gaps in teamoriented execution of tasks form an effective basis for strengthening overall preparedness and response.
Key Programs in Action
In 2000, CDC established Centers for Public Health Preparedness program. This national network of 31 centers (academic, specialty, and advanced practice sites) focused on enhancing front line readiness for current and emerging health threats including bioterrorism. The cornerstone of the program is academic centers in accredited schools of public health (A-CPHP) that provide comprehensive services for state and local partners in areas such as: assessment, development/delivery of training, certification/credentialing, evaluation, and research. By the year 2001, the first seven centers had been established. The program grew exponentially after 9/11; there are now 19 A-CPHP centers in 2003. The articles already mentioned in this issue authored by S. Morse (Columbia) and Atchison et al. (Iowa) demonstrate why the program is of national and local importance. Other strong effective partnerships are evident in Illinois, Georgia, North Carolina, Oklahoma, and Washington State.
Another very promising effort in front line bioterrorism preparedness is "Project Public Health Ready,"6 a collaboration between the National Association of County and City Health Officials, the Center for Health Policy at the Columbia University School of Nursing, and the CDC. The goal is to prepare the staff of local governmental public health agencies to respond to terrorism and other public health threats and emergencies. It will result in voluntary agency certification based on performance criteria including assessment, competency-based training, and an approved emergency response plan tested/evaluated through exercises and drills. The program will be pilot tested in 10 to 12 local health departments in the spring and summer of 2003, with national implementation proposed for 2004. A NACCHO advisory committee guides the project with representation from other state, federal, and academic partners.
Sustaining the Investment
Integral to preparedness are planning, capacity building, and education and training. To ensure sustainability, public health should consider adopting a business model. The focus must be on performance with clear accountability for results. The demand for quantitative, qualitative, and time-sensitive information and data to assess readiness requires vigilance in monitoring performance. For education and training, this implies establishing mechanisms for individual certification and credentialing that prepare staff for everyday public health practice as well as emergency events, including terrorism.
Preparing people also means a focus on the front line workforce in public health and health care throughout their career pipeline. Formal professional education of the future needs to include preparedness for terrorism-biological, chemical, nuclear, radiological, and mass trauma. The "First Contact, First Response" project led by the Association of American Medical Colleges7 is an attempt to influence medical school curricula, residency preparation, and, potentially, board certification for physicians to ensure preparedness for diagnosis and treatment and consequence management of WMD. A similar project is underway in schools of public health through the Association of Schools of Public Health.8 Several other allied health educational institutions have also embarked on such efforts.
Sustainability requires strategic partnerships in both the public and private sector. Coordination to ensure capacity building is increasingly complex. Regardless of whether partners are old or new, all are clarifying and evolving their roles in this arena. Finally, delivering effective public health services depends on a strong science base. Whether the issue is vaccine development, competency assessment or evaluation, the science of public health must be advanced to protect our communities.
Public health leaders must be guided by a vision for the long haul: improving readiness means bolstering preparedness of our nation's public health system as a whole. By applying the best science and technology, employing dedicated professionals, and working closely with diverse partners, CDC will continue to leverage and build on these assets to serve and to protect the public from the negative health effects of terrorist acts.
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