Public health practice parallels the whole community approach advocated by 21st century emergency management practitioners. Therefore, public health’s emergency preparedness actions integrate nicely with contemporary emergency management practice. Several methodologies of public health practice lend themselves to collaboration with other planning and response disciplines. By examining these methods, public health can extend and maximize its role in community-based emergency planning, response, and recovery.
The public health sector examines an entire community, demographic, cultural, health, and/or environmental status before proceeding with a strategy to affect shortcomings. Through community analysis, it identifies weaknesses or disparities in the population and then brings stakeholders together to plan strategies that will improve community health status and thus build community health resilience. Health status is one factor addressed from within the framework of the whole community approach.
One example is mass vaccination, which was very effective in historically eliminating childhood diseases. In recent years, communities have experienced resurgence, but the premise is what epidemiologists (disease investigators) call “herd immunity” – vaccinate an estimated 80 percent of the population, protect an entire community, and avert a public health crisis. Resurgence results from several factors, one of which is the cessation of vaccination among age groups that are most vulnerable to childhood disease.
Building a Resilience Toolbox
The Community & Regional Resilience Institute (CARRI) was established in 2010 to promote community resilience to the vulnerabilities communities confront. CARRI describes a community’s resilience as being “measured by its sustained ability to prepare for, respond to, and fully bounce back from a variety of crises.” Mass vaccination, such as the annual flu vaccination campaign is just one strategy that public health officials advocate to support community health resilience, which is the premise and goal of the whole community approach. However, emergency preparedness adds an entire layer of community complexity and “resets” the basis for study and planning when an all-hazards threat analysis is the basis for a community-wide comprehensive emergency planning effort.
The whole community approach is similar to traditional public health methods that remain in the toolbox today as communities confront ever-emerging infectious diseases as well as bioterrorist threats. The Federal Emergency Management Agency (FEMA) recognized the tendency for various sectors to rely on the government for planning, response, and recovery for threats that communities confront throughout the nation. FEMA learned from communities confronted with disaster that what works best is when all community stakeholders share the responsibility for preparedness and recovery. This is achieved through unique community structures – whether the business sector, nonprofit organizations, or faith-based or citizen groups. What emerged is FEMA’s whole community approach, with strength coming from the integration of government and other sectors, including residents. In November 2011, FEMA shared the following definition in A Whole Community Approach to Emergency Management: Principles, Themes, and Pathways to Action:
“As a concept, Whole Community is a means by which residents, emergency management practitioners, organizational and community leaders, and government officials can collectively understand and assess the needs of their respective communities and determine the best ways to organize and strengthen their assets, capacities, and interests. By doing so, a more effective path to societal security and resilience is built. In a sense, Whole Community is a philosophical approach on how to think about conducting emergency management.”
A few examples illustrate the application of public health methods and include multidisciplinary, multijurisdictional approaches, coalition building, situational awareness, and resilience building. As a result, the practice of public health emergency management integrates emergency preparedness efforts with first responders, healthcare sector, and emergency operation centers (EOC) – both public and private EOCs.
Examples of Collaborative Efforts
A critical function that public health provides to members of the traditional emergency planning community is that of situational awareness, used during recent emerging infectious disease threats and described in the February 2016 issue of the DomPrep Journal by Raphael Barishansky and Seth Komansky. This role played out during the Ebola dust-up in 2014, when public health biostatisticians produced graphics that targeted outbreaks while also providing extensive but detailed guidance on actions to take. Much of this built on pandemic preparedness plans that were developed, exercised, and executed during the 2009 H1N1 pandemic. This plays out once again with the Zika virus.
Communities witnessed another example of public health’s ability to leverage a range of associations during the 2009 H1N1 pandemic, when it collaborated with the private sector to extend manpower for a mass vaccination campaign. Private sector medical practices joined numerous public sector clinics, but pharmacies – both independently owned and franchise operations – were recruited to join the campaign. These associations were pre-existing through the regulatory function assigned to public health in most states. As a result, established relationships were leveraged to tap private sector entities whose corporate missions include the responsibility of ensuring community health.
Public health also represents a composite of several but distinct health and safety disciplines whose natural orientation is regulation, safety, and preparedness. These disciplines stand ready to fulfill staffing functions for the emergency support function structure when emergency operation centers are activated. The reach of these disciplines extends well into the everyday lives of citizens for issues such as food safety, clean drinking water, fresh air, waste treatment, nuclear power, dam safety, and regulation and certification of healthcare workers and healthcare facilities. The integration of these public health disciplines into an emergency operation center structure adds technical assistance with subject matter experts to solve complex health, safety, and environmental infrastructure breakdowns during emergency operations.
Another example, the driving force behind the Hospital Preparedness Program is the healthcare coalition, a stakeholder group that would be affected when an emergency escalates to a community-wide mass casualty or mass fatality incident. The coalition makeup consists of regional hospitals as well as emergency medical services, emergency management, public health, and other partners that could be involved in any number of high-priority planning efforts.
A healthcare coalition serves as a vehicle to identify both threats and weaknesses in regional capabilities and to improve response by ensuring that all stakeholders are present. For example, initial preparedness activities for terrorism, chemical, and biological events, used a multidisciplinary approach for planning, training, and exercise scenarios. A gap was identified that medical examiners/coroners (ME/Cs) had a critical role in the planning and resolution of such events and that multidisciplinary teams should include ME/Cs. It was also recognized that these planning teams be trained in postmortem operations and essential services needed in a mass fatality incident. Public health has a responsibility through Emergency Support Function 8: Health and Medical, which places it in a lead role to form and nurture multidisciplinary, multijurisdictional preparedness initiatives. In a scenario such as this, the coalition must expand to not only include ME/Cs, but other agencies and organizations that may be involved in a mass fatality – such as family assistance services, which requires not only spiritual and emotional support services, but also support services such as housing, insurance, and legal assistance.
A mass fatality incident is dependent on these community services and, in many communities, agencies coordinate through Volunteer Organizations Active in Disasters (VOAD), which includes local chapters of the American Red Cross and member agencies such as the Salvation Army and the Southern Baptist Disaster Relief. Although VOAD members provide a full range of support services, another critical sector to incorporate into region-wide planning are federal technical agencies such as the Disaster Mortuary Operation Response Team (DMORT), the DMORT Family Assistance Team, or the National Transportation Safety Board’s Victim Assistance team. In the planning for emergency scenarios, the role of public health is to work closely with ME/Cs and integrate – both vertically and horizontally – the local, state, and federal partners that may be on the ground in the event of an emergency turned disaster. In many state and local jurisdictions, ME/Cs take lead roles in mass fatality incidents. In others, law enforcement may take the lead role.
Unity Through Complexity
Complexity exists in emergency planning when high-risk threats – such as hurricanes, tornadoes, terrorism, snow and ice storms, or historic rainfalls – are studied and solutions to preparedness, response, and recovery sought. Planning cannot be limited to public health, emergency management, or other government-related structures, but must incorporate all sectors of the community including state and federal agencies, which also have a stake in response and recovery. Another example underscores the importance of community health resilience and illustrates an understanding of this complexity at the federal level.
The Centers for Disease Control and Prevention (CDC) has joined with FEMA in promoting the whole community approach. Through its foundation, CDC funds community-based projects that encompass the whole community approach through its Building a Learning Community & Body of Knowledge: Implementing a Whole Community Approach to Emergency Management project report. In collaboration with community partners, public health emergency management practitioners should study CDC whole community projects for not only their community resilience lessons learned but equally as models to strengthen health security. CDC’s Office of Public Health Preparedness and Response Learning Office works to identify promising examples of existing community efforts that reflect the whole community approach. This mix of training, knowledge, and resources place practitioners in a unique position to synchronize these complex vertical and horizontal relationships, recognizing that the outcome is improved community resilience.
An outcome of these collaborations is social connectivity among stakeholder groups before a crisis. Community resilience is realized when established community connections are tested and the result is a spirit of cooperation to overcome challenges. However, this cooperation is also seen at the federal level. Through a collaborative partnership, FEMA and CDC have positioned themselves to encourage, support, and build community resilience via social connectivity while encouraging collective action after an adverse event. Public health’s role at the local level, with its tradition of whole community, is a vital partner in this process with the skill set, technical expertise, and mission to improve health status, which maintains resilience while fulfilling the goal of the whole community approach.