By Jeff Rubin, PhD, CEM
Homeland1 Columnist
In January 2010, Health and Human Services (HHS) Secretary Kathleen Sebelius released the first National Health Security Strategy (NHSS), billed as an attempt to “refocus the patchwork of disparate public health and medical preparedness, response, and recovery strategies in order to ensure that the nation is prepared for, protected from, and resilient in the face of health threats or incidents with potentially negative health consequences.”
National strategies are never accompanied by guarantees of success, or even implementation, but the NHSS is intriguing in its potential. Not only does it state reality, i.e., that “healthcare system” is an oxymoron, but it incorporates disciplines and areas of focus that previously had little or no truly cross-cutting strategic unification: emergency preparedness, healthcare and homeland security.
This holistic character is displayed in the strategy’s 10 objectives:
1. Foster informed, empowered individuals and communities.
2. Develop and maintain the workforce needed for national health security.
3. Ensure situational awareness so that responders are aware of changes in an emergency situation.
4. Foster integrated, healthcare delivery systems that can respond to a disaster of any size.
5. Ensure timely and effective communications.
6. Promote an effective countermeasures enterprise, which is a process to develop, buy and distribute medical countermeasures.
7. Ensure prevention or mitigation of environmental and other emerging threats to health.
8. Incorporate post-incident health recovery into planning and response.
9. Work with cross-border and global partners to enhance national, continental and global health security.
10. Ensure that all systems that support national health security are based on the best available science, evaluation and quality improvement methods.
The recently released NHSS draft biennial implementation plan, for which the 30-day comment period has just closed, has fleshed out the objectives with a first cut at an action plan and means of assessment. That’s an important step, and with luck the somewhat clunky tool for providing comments will not have precluded the necessary input to better connect the NHSS and its implementation plan with achievable practice.
As the supporting documentation points out with admirable understatement, achieving health security is a “formidable task” that requires long-term commitment. Without implementation, the NHSS is clearly just another well-meaning document, but it’s nonetheless worth looking at the concepts.
A closer examination
The first objective recognizes that everyone has a piece of this, as well as the necessity of engaging and informing individuals and communities. That in itself, however, is not unique and seems more of an idealized desirable end-state than a particularly achievable objective (despite the official intention of “achievable and realistic” goals).
Likewise, the second and fourth objectives recognize critical pieces of the healthcare and healthcare preparedness puzzles (staffing, integration and resiliency) that will become steadily more acute in the coming years, though the NHSS isn’t the first policy document to recognize this need. Recent global health concerns such as H1N1 and H5N1 influenza, not to mention dengue fever and other emerging/expanding diseases, have brought home the link between health and national security.
Objectives three, five, seven, and eight are what set this strategy apart.
Situational awareness (#3) is one of the biggest buzzwords in emergency preparedness, but it’s only recently that we’ve seen guidelines, tools and practices that cut across disciplinary and jurisdictional boundaries (not to say that some regions haven’t carried this to impressive levels on their own).
Unfortunately, situational awareness seems to follow the late Justice Potter Stewart’s “I know it when I see it” characterization and tends to include healthcare only when the situation at hand generates casualties. True situational awareness on any level must include healthcare, healthcare situational awareness must include the community, and both must be on a daily basis.
Communications (#5), the top “issue” in every after-action report, is even more fragmented among healthcare components than within public safety, although combining communications systems with communication content under a single objective does not make for a coherent or manageable objective.
If public health has a dirty secret, it’s the status of environmental health (#7) within the profession. Major disasters and everyday incidents have demonstrated environment health’s value in community resiliency, but even within many health departments there is poor integration between it and other programs.
Seeing environmental health as a priority in the NHSS is a positive step.
Speaking of correcting oversights, how many strategies, national through local, have focused solely on preparedness and response? Recognizing recovery (#8) as a priority for healthcare could help reduce the post-incident morbidity and mortality that we see in most disasters, particularly among the segments of our population who have the slimmest daily margins and thus are most vulnerable to disruption of their minimal safety nets.
As for the 10th objective, while stating the desirability of using scientific methods and quality improvement processes for national health security might seem obvious, those concepts have been missing from most of this decade’s homeland security programs, including many recent and current compliance mandates.
Paying for it all
Last but not least, what of funding? The NHSS is not a funding instrument. Clearly the most important piece of the implementation process will be how and whether the NHSS leads to a (more) integrated system of federal preparedness grants.
Just coordinating between the two HHS programs that “own” much of health preparedness, the Assistant Secretary for Preparedness and Response (ASPR) and the Centers for Disease Control and Prevention, has been a challenge over the past several years.
Now add the numerous DHS programs: Will the major federal players bring their respective grant programs closer together? Will efforts to identify, prioritize and fund needed preparedness programs be better integrated and will the respective stakeholders them support such a move? For example, would public safety responders recognize healthcare as partners in funding as well as planning?
One could argue that linking health security to national security, or that moving toward consistency and congruency among the various federal preparedness grant programs, or that recognizing that concepts such as situational awareness really need to be interdisciplinary to be effective, shouldn’t be considered revolutionary, and certainly shouldn’t be showing up in a major national strategy after almost a decade of federal focus on terrorism and (occasionally) other aspects of emergency preparedness, but there you have it.
Kudos to Secretary Sebelius and ASPR’s Nicole Lurie and her organization, who have a big piece of health security implementation, for bringing this forward.
Now let’s see what happens. The ball isn’t just in their court; it’s in ours as well.
Jeff Rubin is the emergency manager for Tualatin Valley Fire & Rescue, Aloha, Ore., which hosts a comprehensive hospital preparedness website. His views do not necessarily represent those of his employer.