2

Public Health Emergency Planning: Lessons from the Past and Present for the Future

Despite the growing field of public health emergency preparedness since the turn of the twenty-first century and the preparedness plans and exercises developed, speakers described a suboptimal national response to the emergence of COVID-19 in early 2020. This chapter highlights speaker experiences in public health emergency preparedness both prior to and during COVID-19, with their suggestions for an improved response. Speakers also discussed various indices and metrics available to measure levels of preparedness, and how those measures could be improved.

EXPERIENCES BEFORE AND DURING COVID-19

While COVID-19 has been one of the most significant public health emergencies in terms of impact across all facets of society, there have been other smaller outbreaks and epidemics that occurred in the years leading up to the present pandemic. This section summarizes speaker comments on what was done during prior outbreaks and responses, what action was taken in response to COVID-19 initially, and what could be changed moving forward.

The Nation’s Approach to Preparedness and Response Prior to the Pandemic

Ali S. Khan, dean of the College of Public Health at University of Nebraska Medical Center, said “We have witnessed the greatest political and public health failure in our nation’s history.” This is not a partisan

statement, he continued, as there have been more than 20 years of preparedness to try to be ready for this pandemic. Even as far back as 1951, when the Centers for Disease Control and Prevention (CDC) stood up their Epidemic Intelligence Service, preparedness and response were “in the DNA of the agency.” Lots of amazing things happened in preparedness at the turn of the twenty-first century, said Khan, and key components of preparedness were established, thanks to CDC funding for states, plans for coordination with the Strategic National Stockpile, and exercises done together with emergency management and public health and health care. There were also numerous plans and playbooks developed throughout this time. However, Khan explained, what did not exist was more imagination, better leadership, and centralized authority across this broad enterprise—while the trust that did exist in public health prior to the pandemic was lost.

To give a sense of preparedness spending, Khan presented the state and federal sources of funding on all-hazards preparedness and response activities expenditures, showing declines over the last 2 decades. Similarly, workforces have also shrunk at the state and local public health level.

In addition to response and continuity of operations plans, the United States had plans around preparedness, he noted, and understood the gaps, especially for something like pandemic influenza. There was also a Presidential Memorandum on the Support for National Biodefense, demonstrating the level of involvement from U.S. leadership. But preparedness plans were not fully implemented and were never taken seriously, Khan explained. Even in 2018, the exercise Clade X found that the country was unprepared and made various recommendations Watson et al., 2019). Again in 2019, Crimson Contagion, a joint exercise to test federal and state ability to respond to pandemic influenza originating in China, showed all the gaps in those original plans and exercises (HHS, 2020). The Crimson Contagion exercise, Khan noted, found critical issues, such as a lack of statutory authority by the U.S. Department of Health and Human Services (HHS), insufficient federal funding, the lack of a common national picture of operations attributable to data-sharing issues, and inadequate personal protective equipment (PPE) manufacturing and supply chain resources. He shared the preparedness level status of the United States as of January 2020, according to the National Health Security Preparedness Index (NHSPI), objectively highlighted that the United States was unprepared for a pandemic; incidentally, the community planning and engagement and health care delivery sections received the lowest scores (see Figure 2-1).

Discussion

Suzet McKinney, principal and director of Life Sciences at Sterling Bay, asked Khan how hopeful he was when COVID-19 began circulating

in other parts of the world in December 2019, considering all of the planning done over the decades. He replied that he was actually initially quite confident that the United States would have a strong response. If a different playbook had been used, the United States could have done really well, he noted. For example, South Korea made different choices initially and decided to treat the virus like severe acute respiratory syndrome (SARS), ramping up testing immediately. We could have taken a similar approach, Khan explained, but instead the United States’ approach was more from an influenza perspective, detecting outbreaks but not trying to count and prevent every case.

McKinney referenced Khan’s 2016 book, The Next Pandemic, and asked how similar the response to COVID-19 was to other outbreaks in the past. It was actually quite similar, said Khan, with many of the same themes experienced, such as a lack of vaccine confidence and the need to work closer with faith-based organizations. Things such as political partisanship were likely to occur, Khan said. McKinney also quoted a line from Khan’s book saying, “No country can afford to isolate its public health system,” and asked how that played out in 2020. There are multiple versions of that concept, said Khan, but essentially, you cannot protect national security

without addressing global security. “We need to rethink various instruments such as the International Health Regulations (IHR) to better incentivize countries to share information and report what is going on so we can do better in responding locally,” he noted. As long as there is air transport, the risk of outbreaks will always be present.

Many agencies lost credibility during the pandemic, said McKinney, and she asked if they can bounce back. “Absolutely,” responded Khan, saying, “There are so many dedicated experts working at agencies like CDC, and I believe they will rebuild their credibility over time.”

Assessment of Successes and Failures of the Nation’s Response to COVID-19

Data-Centered Response

Deborah Birx, former coronavirus response coordinator at the Office of the Vice President, started off her presentation by noting that historically, the United States is good at collecting data but not great at using the data to find solutions to the problems identified. She shared things that went well, and what has not gone well in the last few years of the pandemic (see Box 2-1). The objective of community engagement measured on the NHSPI was the number one priority, said Birx, but the time was never taken to do the behavioral research or implementation science on why people were not getting their flu shot, she added. To move forward, Birx added, it is important to look back and see what had been done with past preparedness funding and how it was used. She highlighted Chicago as an example, having used the preparedness money for supplies such as PPE, and also having formed a coalition of public and private partners in public health and health care. At any one point, the City of Chicago had a dashboard showing where every piece of extracorporeal membrane oxygenation (ECMO) equipment and ventilator was, and patients were transferred based on need, not profit, Birx said.

For all of the plans and planning, she lamented that they resulted in a historical syndromic disease approach to surveillance, and not a twenty-first-century technology approach. That in itself is not sufficient to halt a pandemic, she argued, as you cannot guess whether an illness acts like influenza. Birx drew comparisons between her experiences addressing human immunodeficiency virus (HIV) in sub-Saharan Africa with that of the COVID-19 response in the United States. She said she had more capacity and real-time data in sub-Saharan African countries than existed in the United States.

Finally, Birx emphasized the need to address the structural issues with data, using clinical data that already exist with hospitals and health care today. Until we look at every hospitalization and death as a failure of

our programming and hold ourselves accountable, Birx argued, we will not be ready for the next pandemic. Engagement of behavioral scientists and implementation scientists is needed, Birx argued, and to follow up with institutions to ensure that they are implementing solid actions with evidence, not just putting up guidance without data. Everyone knows epidemics can be political, she stated, but in sub-Saharan African countries where she worked on the President’s Emergency Plan for AIDS Relief program (PEPFAR), they combatted it every day in the community using people on the ground and trusted relationships.

Preparing for the Next Pandemic

COVID-19 will not be our last pandemic, said Jennifer Nuzzo, director of the Pandemic Center at the Brown University School of Public Health. This has to be a constant reminder, she continued, because all of the data are screaming that the frequency of new and emerging diseases is increasing. It is imperative to learn what went wrong and make improvements in order to address the next threat. Most new diseases have not gone on to result in pandemics, Nuzzo noted, but the probability of another pandemic not occurring is decreasing given the number of emerging viruses and pathogens. She reflected on some of the successes over the last few years to highlight the hard-fought gains that were won.

First, she noted that there are now multiple tools to combat this virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is a remarkable success. While some may seem like miracles, such as the messenger ribonucleic acid (mRNA) vaccines, that ignores the decades of work that led up to their development, including research on coronaviruses and vaccine platforms, work to develop robust at-home testing, and so on. She shared that the U.S. Food and Drug Administration (FDA) just approved a multiplex home test that can simultaneously test for COVID-19, influenza, or respiratory syncytial virus, better known as RSV (FDA, 2022). An important milestone is the fact that more than 250 million Americans have gotten at least one dose of the COVID-19 vaccine, she said. Nuzzo pointed out that while this number is not enough, it is a huge success. Before this achievement, the country did not even have the infrastructure to accomplish something of this scale. The third area of progress she highlighted is that mainstream conversations about inequity are finally being held. Not having these conversations up until now is not just a moral failing, she said, but a strategic failing, with a lack of understanding of how our social vulnerabilities are critical pandemic vulnerabilities.

Going forward those inequities not only need to be addressed, Nuzzo added, but any future plans need to ensure that remaining inequities are taken into account. The glaring disparities in hospitalization and death data

early on by race and ethnicity also reflected similar disparities in testing. Part of the system that failed consisted of the inability to bring diagnoses to people so they could take the right precautions and protect others in their family and household, she noted, especially when certain parts of the population were faced with more exposure because of work or structural inequities.

In addition to these successes, there are also gaps that Nuzzo shared, summarizing them in three main categories:

1. Lack of resources—Going into this pandemic, the base of state and local response had been seriously eroded from decades of disinvestment in funding. Prior to COVID-19, she said, studies found that health departments did not have enough resources to do contact tracing even during small measles outbreaks. At the same time, prior to COVID-19, hospitals were being pushed to the brink during influenza seasons. When health departments were asked about their ability to distribute vaccines, Nuzzo explained, they reported that there were plans somewhere, but the person overseeing them had left, and the institutional knowledge had left with them.
2. Lack of a national COVID-19 strategy—The pandemic was never treated like the emergency it was when it emerged, and for too long, she said, states were left to themselves, and there was no national strategy to respond. States were expected to procure PPE and testing supplies even from other countries or international companies, competing on their own. Even now, she noted, it is not even clear what the end goals are for the pandemic for the United States.
3. Failure of engagement—“I am deeply worried about rollback in state and local laws on public health response,” stated Nuzzo. Many laws were modernized after 2001, but seeing a rollback in public health powers is deeply troubling. She also worried about the level of support for public health going forward, given the backlash that has occurred over the last few years, with many leaving the profession entirely. There is a need going forward for a public health playbook that relies less on mandates and restrictions and more on resources and people making informed choices. The most frequent thing I hear from people about vaccines, she explained, is that they do not know whom to trust. But many in the rural South do not even have a primary care provider, demonstrating the opportunity for better health engagement in many places.

Lastly, Nuzzo said she was concerned that too many decision makers will come out of this global pandemic and think they are done dealing with something similar for the next 100 years. She sees a Congress that

is unwilling to authorize new funding for testing, treatments, or vaccines, while more than 1 million Americans have died in this crisis. She argued for an end to funding single-use responses, and instead called for funding systems and strategies that will be used in many future crises.

Discussion

McKinney opened the discussion by reflecting on her own experiences as a deputy commissioner with the Chicago Department of Public Health, noting that as her team was starting to build the stockpile, the amount of criticism she faced in preparing for an event that was yet to happen was almost unbearable at times. Andrew Pavia, from the Infectious Disease Society of America, then asked, “How do we make some progress on having a sustainable public health care system, sustainable responses, and sustainable public health emergency preparedness?” Birx replied that it starts with the data and needs to be transparent. Information cannot go into a black box and come out months later, Birx noted, which is what happened when a recent surge in deaths occurred in people who had been vaccinated. Data available to people can help inform them and allow for more advocacy to hold leaders accountable, but the data need to be publicly available so it is clear who is at risk and what structural issues might be preventing solutions and progress, Birx stated.

Nuzzo added that if you spend a lot of time talking to people, there is more hope than many realize, demonstrating that while the level of distrust might be present nationally, it is often a different story locally. She called for more of a bottom-up approach in engaging other partners in work. This continues beyond COVID-19, Nuzzo said, as there are many other challenges in communities, where people would benefit from having their routine health concerns addressed, in addition to figuring out ways to provide the right resources to the right people, which would be key to success. For example, public health works best when it is seen from a social worker perspective compared to a law enforcement perspective, Nuzzo said. This will take more funding and resources, she admitted, which is a responsibility of the federal government and states who have not invested enough in their state health programs.

Tom Kirsch of the National Center for Disaster Medicine and Public Health said that these are all great platitudes, but the big question from his perspective is, “How do we engage our society when there is active disinformation and opposition to scientifically based practices in both traditional media and social media, as well as leadership?” Birx suggested chipping away at it community by community, state by state, addressing the issues that are important to those residents and community members. There are community groups that exist, but public health needs to bring people in

and have conversations that are important to those community representatives. We have neglected these rural communities for decades, Birx stated. As a comparison, she highlighted the 22 Level I Trauma Centers in New York City, while there is just one Level I Trauma Center in the whole state of Mississippi. Poor community hospitals have not had access to research dollars for decades. The fundamental investment strategy needs to change, said Birx, and it needs to focus on meeting communities where they are.

ASSESSING PUBLIC HEALTH EMERGENCY PREPAREDNESS CAPABILITIES, AUTHORITIES, AND FUNDING

The fundamental problem of the COVID-19 response is rooted in many resources that never came, measures that were not taken, and actions that were delayed or not accomplished, said Lisa Koonin, founder and principal of Health Preparedness Partners. Koonin moderated a discussion with speakers on assessing public health emergency preparedness. This section summarizes speakers’ reflections on existing metrics of preparedness for organizations, what else should be in place, and how plans can be improved.

Global Health Security Index

Jessica Bell, senior director of Global Biological Policy and Program for the Nuclear Threat Initiative, explained that their work looks at biological, catastrophic threats, and how it folds into the work with Johns Hopkins to develop the Global Health Security (GHS) Index. The goal of the GHS Index was to broaden the aperture and look at more contextual factors of GHS. The GHS Index framework looked at not only prevention, detection, and response, she explained, but it also looked at the foundational health of health systems, and longer-term financing, as well as various types of risk (see Figure 2-2). The Nuclear Threat Initiative published the first report in 2019, a few months prior to the emergence of COVID-19, and then published a second iteration of the GHS Index in 2021. The GHS Index assessed 60,000 data points, including quantitative and qualitative data, and incorporated work with partners across languages and countries. The overall finding was a severe lack of preparedness, she stated.

She highlighted that it is important to emphasize the type of data used. Pandemic preparedness can be thought of in a similar fashion to fire preparedness, said Bell, focusing on surveillance and detection, and whether policies are in place. The GHS Index looks at existing capacities, such as if a country has surveillance, detection, and testing at the national level. It does not measure behavior for a response, and it is also not a model, nor is it predictive, she explained, but simply an assessment of current capacity.

Moving forward, for the 2021 iteration, the developers wanted to make sure the second version captured the advancements that countries made in responding to COVID-19 and those who were making progress at national-level capacities. However, no country scored in the top tier.¹ Somewhat surprisingly, approximately 118 of the 195 countries assessed fell in the bottom two tiers. Out of the six categories measured—prevent, detect, respond, health, norms, and risk—prevention of the emergence or release of pathogens, which encompasses elements such as antimicrobial resistance, zoonotic plans, immunization, and biosecurity, was the lowest-scoring category measured across the board (Bell and Nuzzo, 2021). Findings of the 2021 report also had financing as an underlying issue, Bell reported. Most countries have not made dedicated financial investments in strengthening pandemic preparedness, and political and security risks have increased in nearly all countries. Moving forward for future versions, the Nuclear Threat Initiative hopes to promote transparency and create a community to share information where data can help drive decision making across countries.

___________________

¹ The GHS Index groups scores according to five tiers of 0–20; 20.1–40; 40.1–60; 60.1–80, and 80.1–100 (Bell and Nuzzo, 2021).

Ready or Not

Dara Lieberman, director of Government Relations at Trust for America’s Health (TFAH), covered a range of indicators as she reviewed TFAH’s annual report measuring levels of preparedness across states and the District of Columbia. Based on the findings and recommendations from this report, Lieberman explained that the organization tries to synthesize them to advocate for policy action. TFAH pulls 10 key indicators of preparedness, drawn largely from the National Health Security Preparedness Index, across a range of sectors, including in the context of both outbreaks and natural disasters. TFAH provides a checklist of actionable steps that states can take to improve their preparedness and tell a story across a range of issues to make the findings relevant to each state.

She reviewed some of the key findings from recent years, saying that almost all states had plans in place for laboratory surge, most states and the District of Columbia are accredited in public health and emergency management, and the seasonal influenza vaccination rate has risen significantly, though it is still far below the 70 percent target of Healthy People 2030. Some of the challenges TFAH has uncovered include the weakened public health infrastructure and depleted workforce caused by chronic underfunding. Only half of the U.S. population is served by a comprehensive public health system, she added, and only 28 percent of hospitals, on average, earned a top-quality patient safety grade in states, a number that decreased from 31 percent in 2020. The erosion of funds over recent years has laid the groundwork for where we are today, Lieberman noted (see Figure 2-3). Demonstrating the boom-and-bust cycle of funding, she stated that the Public Health Emergency Preparedness (PHEP) Cooperative Agreement to states and locals has been cut by about half since fiscal year 2003 when accounting for inflation, and the hospital preparedness program has been reduced by nearly two-thirds since fiscal year 2003 when accounting for inflation.

A key takeaway is that we need to be investing in crosscutting public health infrastructure, said Lieberman, and include public health data modernization. Many health departments were still using fax machines and spreadsheets that were not centralized, making rapid surveillance and real-time decision making more difficult. Other key federal recommendations from TFAH’s report include the following:

• Prioritize investments in health equity and social determinants of health.
• Provide job-protected paid leave.
• Accelerate the development and distribution of medical countermeasures.

• Strengthen the health care system’s ability to respond and recover from health emergencies.
• Invest in public health communications, including earning and building trust.
• Create a COVID-19 commission.

Measuring Preparedness at The Joint Commission

Marisa Voelkel, physical environment specialist at The Joint Commission, reviewed the organization’s history, noting its founding in 1951 and that it is now the oldest and largest standards setting and accrediting body in health care. To answer the question about how preparedness is measured, she explained that The Joint Commission has an emergency management chapter, whereby the accreditation requirements and survey processes assess an organization’s overall preparedness level. The Joint Commission reviews documents, interviews staff, discusses real events and simulation exercises, and discusses levels of education and training. If there are areas of noncompliance, the organization receives a request for improvement, and it has 60 days to provide evidence of compliance or show proof of action moving forward. Once those are accepted, she explained, it can renew its accreditation.

In terms of how prepared organizations were, Voelkel noted that some organizations were better prepared than others and had plans, but they were not able to adapt the plans. There are 124 elements of performance in The Joint Commission’s emergency management chapter, which were designed to guide organizations to be better prepared from an all-hazards approach. Improvements to this emergency management chapter were already in progress owing to the pandemic, but the pandemic gave those involved in the improvements an opportunity to contribute more. She listed some of the top issues that continually emerged from April 2020 to April 2022:

• The emergency operations plan did not identify capabilities and establish response procedures to sustain the organization for 96 hours.
• There was no succession plan or delegation of authority plan.
• There were no procedures to request an 1135 waiver for care/treatment at alternative care sites;² many did not even know what an 1135 waiver was.
• Medical staff bylaws did not identify individuals responsible for granting disaster privileges to licensed independent practitioners.
• Exercises were not conducted or documented.

Voelkel added that all of the elements of performance are established through work with the Joint Commission’s federal agency partners at the Administration for Strategic Preparedness and Response, CDC, U.S. Department of Homeland Security; improved understandings stemming from the Centers for Medicaid & Medicare’s 2016 Final Rule for emergency preparedness; and recommendations from the Federal Emergency Management Agency. The Joint Commission tries to examine a large range of input from organizations to find ways to assist health care institutions to be better prepared.

Measuring Preparedness

James Lawler, executive director of International Programs and Innovation at the Global Center for Health Security at the University of Nebraska Medical Center, discussed the issues in measuring health system prepared-

___________________

² During a declared disaster or emergency, the secretary of Health and Human Services (HHS) can temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program requirements to ensure that sufficient health care services are available to meet the needs of individuals in Social Security Act programs, and providers who give such services can be reimbursed and exempt from sanctions. For more see https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/1135-Waivers-At-A-Glance.pdf (accessed June 15, 2022).

ness. “Most institutions across the United States, including mine, do not measure preparedness very well,” said Lawler. But taking a step back, it is important to recognize what the problems are and understand what needs to be addressed at a fundamental level. Framing this in any context that is political misses the mark though, he noted, as people are continuing to make the same fundamental mistakes now in May 2022 as in March 2020. There is still limited visibility of transmission in communities, commented Lawler, identifying where problems are arising is slow, and the public health guidance is incomprehensible to most Americans. The obvious conclusion has to be that the system for preparedness and response is fundamentally broken, and Americans should not keep funneling money into a system that does not work, Lawler stated.

The second lesson he shared is that the solution is not in the public health community. Making decisions rapidly in emergency situations is not a fundamental attribute of public health. Additionally, breakdowns have occurred in the health care system. These systems are not connected, but both are contributing because of weaknesses in diagnoses, communication of information, and procurement of supplies. Additionally, the health care system is a widely diverse $4 trillion section of the economy that exists mainly in the private sector, he stated, and it cannot be significantly influenced with $230 million of a hospital preparedness program. He argued that it is not amenable to top-down fixes, and most executive leaders within hospitals do not often think about preparedness because it does not typically affect their bottom line. Lawler called for a change to this status quo within the health system and communities, using an example of the Leadership in Energy and Environmental Design (LEED) designation in buildings. This designation and trend were generated by the industry itself as a self-sustaining intervention and enforcement, he said, and did not require any government initiatives to start. Elements of LEED do not necessarily have any economic incentives, Lawler explained, but are driven by expectations across the community, such as bike storage and air-quality interventions. Customers also have expectations and want new buildings to be socially and environmentally conscious. Echoing Bell’s comments about fire prevention, Lawler also mentioned the evolution of how fire prevention is approached in society. In 2021, there are smoke detectors, sprinklers, building codes, and standards, all woven into municipal codes, taxes, and other expenses in communities. “Why can’t we take that same approach to health emergency preparedness in our communities?” he asked. If your community has an AAA rating for health emergency preparedness, why should that not translate into better health insurance or bond ratings for your community? He argued that it is possible to make health preparedness financially sustainable and economically beneficial to businesses and health care.

Discussion

Koonin asked what entity should be responsible for preparedness and relevant metrics in the United States. Bell responded that she has thought about this question a lot from the global perspective and what accountability looks like. The World Health Organization (WHO) plays a critical role, but it is a very small organization, so elevating things higher up to the level of the United Nations may be an option. Bell noted that while these measurements should span globally, speakers repeated the importance of local accountability and measurement. Lawler added that there are a number of ways to address overseeing metrics, but there needs to be buy-in from the local level, and the health system needs to be engaged as well as the community at large and the private sector. All of these groups need to be involved in creating the standards, measuring them, and validating them, he concluded. Koonin also asked if just the fact of measuring at all makes a difference. Lieberman said they have definitely seen progress in capabilities over time. She explained, “I think the smartest states are the ones that take the TFAH report to their government leaders and show where the gaps and weaknesses are. I think an independent voice has some value.”

Voelkel added that one of the more apparent things she noticed while revising their emergency management chapter and working with organizations dealing with the pandemic was the lack of leadership involvement and support. To try and assist with that, she said, The Joint Commission’s new standards for hospitals includes elements of performance for leadership engagement. Another area of weakness was supply chain issues. There are supply chain resources that can be augmented by local pharmacies and schools, but without the relationships, those connections are really difficult to make. She commented on the work at The Joint Commission to structure and streamline the new chapter from 124 elements down to 60. “We do not want to overwhelm health care organizations, but we want to help them build an organization that coordinates communication at the local level to build a more robust program and draw attention to the need for funding and leadership buy–in,” Voelkel said.

Considering the most important metric moving forward, Voelkel said hands down it is communication. “There are still areas functioning in silos, whether departmental, or health care systems within cities, that do not want to talk to other health care systems,” she said. Bell added that these communication pathways need to happen daily and be embedded into practice instead of only communicating during emergencies to truly be sustainable. Lieberman appreciated that the Global Health Security Index highlighted trust in government as a proxy for things, such as political will, that are difficult to measure. Lawler emphasized that the most important aspect of metrics is that they need to be reproducibly quantifiable. He shared

some of his work looking at how to build economic incentives into health emergency preparedness. The most important development in the earthquake industry is the Richter scale, he noted. Risk can be rated against a quantifiable known factor that can help predict damage and loss, Lawler stated. Truly quantifiable metrics in health systems and community health emergency preparedness are needed to build a sustainable system, he added.

Another participant voiced concerns about system interaction and integration, saying that what frustrates many Americans is that there are a lot of resources and systems, but preparedness and response sectors require numerous stakeholders to work together that do not normally work together on a regular basis. While there are strong individual systems, they lack the coordination to bring them all together. He asked for thoughts on a regional medical operations center, or regional operating coordinating cells that could be networked at various levels. This would not solve the problems, he acknowledged, but if we were able to share information across that network, it would go a long way. Certainly, better mechanisms for coordinating are important, and we have made some progress in this area, said Lawler; however, there need to be true underlying incentives for health systems and others to participate in these systems in the long term and between emergencies. We have buy-in now, he said, but once a pandemic is over, hospitals go back to competing versus working together.

John Armstrong, division director of the University of South Florida Morsani College of Medicine and member of the American College of Surgeons Committee on Trauma, asked how population health measures could be used as an assessment of readiness. In our health systems, we all measure conditions such as obesity, hypertension, diabetes, or opioid addiction, he said. “If these metrics were improved, would that help to address some of the structural and process issues that have been raised?” he asked.

Lieberman replied that in addition to the Ready or Not report, TFAH also puts out an annual report on obesity, and one of its frustrations with Congress is that public health is often seen as only focusing on infectious disease, even though these different issues are inextricably linked. It is important for responding entities to understand who is at higher risk in their communities and how to reach them, Lieberman added. Providing resources to community organizations is also very important, and she noted the progress made in recent years, but this cannot be a one-off thing. For public health to engage with communities at higher risk for a certain disease, they will not be successful by swooping in during an emergency for the first time to try and collect information. Lawler added that part of engaging with communities needs to include making the issues of addressing health inequities relevant to the bottom line of businesses and health preparedness.

It is important to recognize that we have some of the best health care in the world for some, and for others some of the worst, he said. Providing incentives for communities to address some of their underlying issues could help pave the way to progress.

This page intentionally left blank.