The tragic event of 9/11 and the subsequent anthrax attacks horrified the nation and the world and awakened us to the importance of health security as a shared public health homeland security priority. In the decade since these tragic events, public health preparedness has emerged not as a standalone discipline but rather as critical component of public health.

Almost immediately after these events there was an influx of funding to support preparedness for public health and medical infrastructure. Those funds have enhanced the preparedness of our nation to respond to public health and medical emergencies. Now, a decade later, it’s useful to think about how far we have come.

In 2001, we weren’t even sure what a prepared public health system looked like. But we knew there were big gaps. Many health departments did not even have the basics, like computers or access to the internet, and blast fax was considered a new technology. Similarly, numerous health departments lacked the ability to receive and respond to urgent case reports 24/7 or to use principles of risk communication to rapidly communicate with the public. The use of the Incident Command System was by and large a foreign, uncomfortable concept.

Looking back on the last decade, we have come a long way. Recent reports from both the Public Health Emergency Preparedness and the Hospital Preparedness programs document substantial progress, including enhanced surveillance and laboratory capacity, improved surveillance capability, and better hospital surge capacity. In fact, over 75% of hospitals participating in the Hospital Preparedness Program met 90% of pre-specified goals.

Moreover, the investments in preparedness have strengthened day-to-day public health systems. Numerous health departments now use the incident command system structure to investigate outbreaks, for example, and report that the investigations are faster and more complete. In recent tornados and floods, states have been able to handle medical needs, including hospital and nursing home evacuation, on their own, without federal assistance. Many state and local health departments report that planning and practicing for mass distribution of countermeasures made a major contribution to their ability to respond to the H1N1 pandemic, including through mass vaccination efforts.

Moreover, events since September 11 and the anthrax attacks have moved us from a focus on threat-specific preparedness efforts to the concept of all-hazards preparedness, and to the identification of, and focus on, a core set of capabilities needed for public health and healthcare system preparedness. The response and resilience at the community level demonstrated during recent natural disasters including the Mississippi floods in the Midwest and tornados in Alabama and Joplin, MO are testament to work that has been done at the federal, state, local and hospital level over the past decade. Yet, we still have a ways to go, including in the development of medical countermeasures for chemical, biological, radiological, and nuclear threats. The Secretary’s Public Health Emergency Medical Countermeasures Enterprise Review, published last year, made a number of recommendations for strengthening the medical countermeasure enterprise, and these are now being implemented, with a long term goal of developing rapid, flexible, nimble countermeasure manufacturing capacity to respond to a novel threat, whether natural or man-made.

With tightening federal, state and local budgets, it’s tempting to ask, ‘are we there yet?’ and to drastically cut or eliminate investments in preparedness. Maintaining and sustaining the capabilities of the people and systems involved in day-to-day public health and preparedness is a critical, continuing requirement for our nation’s health security. While public health departments and hospitals have ‘bought stuff’ that lasts for a long time, some of it will need replacement. Staffs need continued training and practice, and there are ongoing needs to train new people as the normal turnover of personnel occurs. For me as a primary care doctor, I liken our investments in preparedness to caring for a patient with chronic diseases. There is an initial, substantial investment that has been made in the initial assessment and testing, but my patient’s diabetes or hypertension is not cured after they take medicine for a month. It’s usually medicine they need to take forever, and it is for them a ‘new normal.’ The same is true for preparedness; the threats will always be with us, and our need to become and stay prepared is our ‘new normal.’

At the end of the day, preparedness will be built and maintained through strong, day-to-day systems in health care and public health. Conversely, the preparedness imperative has, and will continue to strengthen those systems.

My office, the Assistant Secretary for Preparedness and Response (ASPR) for the U.S. Department of Health and Human Services, is responsible for ensuring that the nation is prepared for, and can respond to and recover from public health emergencies. The National Health Security Strategy charts a course for doing just that. None of us wants to see another public health emergency happen. And while each event—a terrorist attack, a novel infectious disease outbreak, or a massive tornado—is thankfully rare, taken together, it’s extremely likely that another emergency will happen. And we as a country need to be ready for whatever it is.

Nicole Lurie M.D., M.S.P.H., Assistant Secretary for Preparedness and Response (ASPR), U.S. Department ofHealth and Human Services

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