Research Brief
C O R P O R AT I O N
The Public Health System a Decade After 9/11
Key Successes and Continuing Challenges
RAND Research areas
Children and Families
Education and the Arts
Energy and Environment
Health and Health Care
Infrastructure and
Transportation
International Affairs
Law and Business
National Security
Population and Aging
Public Safety
Science and Technology
Terrorism and
Homeland Security
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T
he 9/11 attacks and the anthrax attacks that
soon followed were an important wake-up
call for America’s leaders, including the
leadership of the nation’s public health
system—and they provided a chilling reminder
that a robust public health system is vital for
national security. In response to the attacks, the
federal government invested billions of dollars to
strengthen state and local public health systems
and enhance hospital preparedness to respond
to large-scale emergencies. With the infusion of
these funds into public health preparedness—the
term used to refer to these activities—public
health officials, particularly at the state and local
levels, began broadening their roles beyond the
traditional practice of public health.
Now, a decade after 9/11, RAND Health
researchers Jeanne Ringel and Jeffrey Wasserman
have contributed a chapter to a collection of essays
on the military, political, fiscal, social, cultural,
psychological, and moral implications of U.S.
policymaking since 9/11. In their essay, they consider how the public health system has fared in
the wake of the government’s investments and
the system’s new responsibilities. They note that
although progress has been made in many areas
of public health policy, significant challenges
remain. Most notably, they call for a cultural
shift that engages not only public health, but all
sectors of society, in public health emergency
preparedness, response, and recovery.
Progress Has Been Made in Many
Areas of Public Health Policy
Substantial progress has been made since 9/11
in the way the public health system is organized
and managed. Major investments have expanded
and improved key response systems, including
disease surveillance, public health laboratories,
and communications. Extensive planning (e.g.,
to support mass delivery of medications to com-
Key findings:
•Since 9/11, substantial investments in public
health have expanded and improved key
response systems (e.g., disease surveillance,
laboratories, communications) and supported
planning and performance measurement.
• Many challenges remain, including poor integration of the public health system; the need
to improve the ability of the health-care system to absorb a large-scale “surge” of ill or
injured persons resulting from a public health
emergency; and variability in communities’
ability to detect, respond to, and recover
from health emergencies. Recent budget cuts
to public health—the result of fiscal pressure
on all levels of government—threaten to undo
much of the progress that has been made.
• To address these challenges, all sectors of
society, not only public health and emergency management, must recognize their
roles in a public health emergency, including
preparedness, response, and recovery.
munities when needed) has been undertaken at
federal, state, and local levels to promote public
health disaster response and recovery. Progress
has also been made in developing valid and reliable performance measures.
The nation’s response to the H1N1 pandemic
in 2009 provides the most substantial evidence
that public health preparedness and response
capabilities have improved. Successful aspects of
that response included the swift identification
and characterization of a novel pandemic virus,
the record-breaking pace with which a new flu
vaccine was developed and produced, the rapid
distribution of antiviral drugs from the Centers
for Disease Control and Prevention’s Strategic National Stockpile, and effective communications with the general public
regarding methods to prevent transmission of the virus.
Important Challenges Remain
However, important challenges remain, and their effect is
compounded by growing financial constraints and recent
reductions in federal funding to support state and local public health preparedness.
Many components of the public health system are still poorly
integrated. The organization of services provided by public
health departments differs across states and even within states,
as do the services themselves. Hurricane Katrina revealed a
pressing need to more clearly delineate roles and responsibilities among government agencies at all levels and to coordinate
government actions with those of nongovernmental organizations, private-sector firms, and other stakeholders.
One of the most notable unmet challenges today is the need
to improve the ability of the health-care system to absorb a largescale “surge” of ill or injured persons resulting from a public
health emergency. Many hospitals and other health-care facilities are currently operating at or near capacity. They need to
work more closely with their local and state health departments and other response partners in their communities to
develop and exercise plans to ensure that people receive the
right levels of care in the right settings at the right time during and after a large-scale public health emergency.
There is troubling variability in communities’ ability to
detect, respond to, and recover from a potentially devastating
health event. When put to the test, some communities
demonstrate an impressive level of readiness. Unfortunately,
others have been slow to grasp the potential magnitude of an
event, much less initiate a robust response. Poorer-performing
communities are frequently unable to provide their residents,
including vulnerable populations, with adequate information
on how to care for themselves and others in an emergency.
Greater emphasis should be placed on recovery planning to
foster collaboration, build connections among neighbors, and
meet the health needs of local populations.
A Cultural Shift Is Needed
To address these challenges and continue to make progress,
a significant cultural shift is needed, not only within public
health and emergency management, but in all sectors of society. Everyone has a role to play in public health emergency
preparedness, response, and recovery. The National Health
Security Strategy, recently released by the U.S. Department
of Health and Human Services, highlights the need for such
a paradigm shift. The two overarching goals of the strategy
are to build community resilience and to strengthen public
health, medical, and emergency response systems.
RAND’s researchers emphasize two steps that can
support this new direction: (1) cultivating a sense of shared
responsibility and (2) making efficient and effective use of
existing resources to support preparedness.
Cultivating a sense of shared responsibility. The public
and policymakers need to understand the vital role of public health and their roles in safeguarding it. Engaging all
relevant stakeholders in discussions about national health
security can increase their sense of ownership and thus their
willingness to assume responsibility for specific activities and
to follow through on their commitments. Public education
is key to ensuring that everyone—from government officials
and professional first responders to directors of nongovernmental community organizations, private-sector executives,
volunteers, and individual citizens—understands how he or
she can strengthen the nation’s ability to prepare for, respond
to, and recover from a public health emergency.
Making efficient and effective use of existing resources to
support preparedness. In the current fiscal environment, it
is crucial to use existing funding streams as efficiently and
effectively as possible. Ideally, strategies should be crafted to
encourage and leverage private-sector investments in preparedness and community resilience. An important first step
would be to inventory existing federal grant programs to
identify gaps, overlaps, and opportunities to better coordinate applications, reporting, and performance. ■
Funding for this study was provided by RAND’s Investment in People and Ideas program, which combines philanthropic contributions
from individuals, foundations, and private-sector firms with earnings from RAND’s endowment and operations to support innovative
research on issues crucial to the policy debate but that reach beyond the boundaries of traditional client sponsorship. The
study is documented in “The Public Health System in the Wake of 9/11: Progress Made and Challenges Remaining,” by Jeanne S. Ringel
and Jeffrey Wasserman, Chapter 14 of The Long Shadow of 9/11: America’s Response to Terrorism, edited by Brian Michael Jenkins
and John Paul Godges, MG-1107-RC, 2011, 222 pp., $19.95, ISBN: 978-0-8330-5833-1 (available at http://www.rand.org/pubs/
monographs/MG1107.html). This research brief was written by Kristin Leuschner. The RAND Corporation is a nonprofit institution that
helps improve policy and decisionmaking through research and analysis. RAND’s publications do not necessarily reflect the opinions
of its research clients and sponsors. R® is a registered trademark.
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CHILDREN AND FAMILIES
EDUCATION AND THE ARTS
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