Annotated bibliography

The Evolution of Public Health Emergency Management as a Field of Practice

The health impacts of recent

global infectious disease out-

breaks and other disasters have

demonstrated the importance

of strengthening public health

systems to better protect com-

munities from naturally occur-

ring and human-caused threats.

Public health emergency man-

agement (PHEM) is an emer-

gent field of practice that draws

on specific sets of knowledge,

techniques, and organizing prin-

ciplesnecessaryfortheeffective

management of complex health

events.

We highlight how the na-

scent field of PHEM has evolved

in recent years.

We explore this development

by first examining multiple

sites of intersection between

the fields of public health and

emergency management. We

then analyze 2 of the principal

pillars on which PHEM was built:

organizational and program-

matic (i.e., industry) standards

and the incident management

system. This is followed by

a sketch of the key domains,

or functional areas, of PHEM

and their application to the

emergency management cy-

cle. We conclude with some

observations about PHEM in

a global context and discuss

how the field might continue

to evolve. (Am J Public Health.

2017;107:S126–S133. doi:10.2105/

AJPH.2017.303947)

Dale A. Rose, PhD, MSc, Shivani Murthy, MPH, Jennifer Brooks, MPH, and Jeffrey Bryant, MS

In recent years, the health im-pacts of infectious disease outbreaks, natural disasters, in- dustrial and environmental ca- tastrophes, and conflict have captured the world’s attention and reinforced the importance of strengthening public health sys- tems to better protect commu- nities and populations from naturally occurring and human- caused threats. Various ap- proaches and programs have been developed to address these needs in domestic and global contexts, including initiatives to strengthen public health pre- paredness and global health se- curity. Although much has been written about these ap- proaches,1,2 there are few re- ports on the interface between public health and emergency management—and even less about what we call “public health emergency management” (PHEM).

PHEM is an emergent field of practice that draws on specific sets of knowledge, techniques, and organizing principles found in the fields of emergency man- agement and public health that are necessary for the effective management of complex health events and emergencies with serious health impacts. Although concepts such as public health preparedness and global health security include significant components of PHEM, the various terms should not be conflated.

We highlight some of the ways the nascent field of PHEM has evolved in recent years. We

explore this development by first examining multiple sites of in- tersection between the fields of public health and emergency management. We then analyze 2 of the principal pillars on which PHEM has been built: organi- zational and programmatic (i.e., industry) standards and the incident management system (IMS). This is followed by a sketch of the key domains, or functional areas, of PHEM and their application to the emer- gency management cycle. We conclude with some observa- tions about PHEM in a global context and discuss how the field might continue to evolve.

PUBLIC HEALTH AND EMERGENCY MANAGEMENT

Public health and, of course, emergency management have long histories of engagement in disasters and complex emer- gencies. Before public health practitioners worked from emergency operations centers (EOCs) or had even heard of an IMS, they were leading or supporting response efforts in numerous infectious disease emergencies, such as those caused

by yellow fever, smallpox, and HIV/AIDS, as well as environ- mental and technological catas- trophes, including hurricanes, floods, and industrial chemical releases. Similarly, the field of emergency management, de- fined here as “the managerial function charged with creating the framework within which communities reduce vulnerabil- ity to hazards and cope with disasters,”3 has long been ori- ented toward an array of emer- gencies, including but not limited to public health events.

Early forerunners to the field of emergency management were characterized by a mix of efforts such as volunteer disaster relief services, enhancing fire code safety, improving actuarial as- sessments of insurable risk, and civil defense.4–6 Although mod- ern emergency management is a younger field than is public health, it has become an in- creasingly professionalized field with its own disciplinary knowledge, professional asso- ciations, credentialing, and university-based programs of study.

For much of their respective histories, interactions between public health and emergency management were rare, and for

ABOUT THE AUTHORS Dale A. Rose, Shivani Murthy, Jennifer Brooks, and Jeffrey Bryant are with the Office of Public Health Preparedness and Response, Division of Emergency Operations, Centers for Disease Control and Prevention, Atlanta, GA.

Correspondence should be sent to Dale Rose, Division of Emergency Operations, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop D-75, Atlanta, GA 30329 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This article was accepted April 18, 2017. doi: 10.2105/AJPH.2017.303947

S126 Perspectives From the Social Sciences Peer Reviewed Rose et al. AJPH Supplement 2, 2017, Vol 107, No. S2

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decades little attempt was made to coordinate or align their mis- sions. Moves toward closer alignment can be traced at least as far back as the 1970s, when the field of emergency management began to shift away from its ori- entation to civil defense, which was focused on nuclear attacks, to a greater range of natural and human-caused hazards and threats (later to be termed “all hazards”).6 In the 1990s, public health similarly broadened its scope, with increased attention to atypical threats such as biological and chemical terrorism, pan- demic influenza, and other emergent threats—natural and intentional.

The relationship between public health and emergency management came into sharper focus after the events of Sep- tember 11, 2001, and efforts to strengthen ties have continued to evolve. Critical drivers to ac- complish this include the advent of homeland security as an ap- paratus of government, which eventually led to the wide-scale adoption of the National In- cident Management System by government agencies and state and local recipients of federal preparedness funds.7 The Na- tional Incident Management System helps guide the manage- ment of incidents and emergency operations and adheres to prin- ciples of incident management.

Congressional funding for preparedness programs such as the Public Health Emergency Preparedness program adminis- tered by the US Centers for Disease Control and Prevention (CDC) has also been a key driver in bringing public health and emergency management closer together by creating emergency response capacity in health de- partments at the state and local levels. These various efforts have been accompanied by the

establishment and refinement of national-level doctrine codifying the relationship between public health and emergency manage- ment in such documents as the National Response Framework8 and its corresponding Emergency Support Function and Biological Incident Annexes.9,10 Guidance has also been offered that de- scribes public health and health care preparedness capabilities that emergency response entities such as health departments and hos- pitals are expected to have or have access to.11,12

Public health and emergency management have also come together in the professional as- sociations of each field. For ex- ample, the International Association of Emergency Managers has organized several caucuses addressing the ramifi- cations of a range of health- related emergencies. Similarly, the National Emergency Man- agement Association has part- nered with the Association of State and Territorial Health Of- ficials to form a joint policy work group. This group coordinates federal grant program activities between emergency manage- ment agencies and public health departments and aligns exercise requirements across multiple programs, among other things. The National Association of City and County Health Officers, a leading policy and advocacy organization for local health departments in the United States, holds an annual conference fo- cused on issues of public health and health care preparedness, response, and recovery.

Finally, several repositories and producers of knowledge contain or generate content at the intersection of public health and emergency management, including specialized peer- reviewed journals such as Health Security (formerly Biosecurity and

Bioterrorism: Biodefense Strategy, Practice and Science) and Disaster Medicine and Public Health Pre- paredness, and programs housed at academic institutions such as the Preparedness and Emergency Response Research Centers and Learning Centers, which were previously funded by the CDC.

THE EMERGENCY MANAGEMENT CYCLE

A useful heuristic to un- derstand the relationship be- tween public health and emergency management is the emergency management cycle, which has been described in emergency management curric- ula, textbooks, and government sources using different models.8,13,14 We adopted a 4-stage model of this cycle that includes mitigation, pre- paredness, response, and recovery (Figure 1). These 4 phases are useful for describing the capac- ities and activities of an emer- gency management system and are closely related to but different from the 5 mission areas and corresponding core capabilities described in the most recent edition (June 2016) of the Fed- eral Emergency Management Agency’s National Response Framework.8

Mitigation focuses on re- ducing hazard losses or risk and controlling anticipated damage; activities in this phase can be carried out before, during, or after an event. “Mitigation” is an infrequently used term in public health or PHEM contexts. Examples of mitigation are targeted human and animal vac- cination efforts, animal culling, and other public health control measures, including food safety and sanitation practices to reduce the impact of an infectious disease

outbreak or environmental ex- posure risks in the context of a disaster (e.g., at a shelter or other congregate setting). Preparedness activities occur before an event and center on building or maintaining staff, systems, and infrastructure capacity as well as carrying out the planning, train- ing, and exercising necessary to identify gaps and improve emergency response capabilities. Examples are the development, testing, and evaluation of emer- gency response plans, notifica- tion and warning systems, and surge staffing procedures as well as training staff and enhancing physical and information tech- nology infrastructure such as EOCs and surveillance and reporting systems.

Response in the emergency management cycle occurs in recognition of a hazard that threatens to overwhelm day-to- day functions or capacities. In the public health context, emer- gency response activities can vary widely but generally include the following:

d coordinating select public health response functions across multiple entities or partners;

d collecting, integrating, and analyzing epidemiologic, lab- oratory testing, and other data;

d sharing information with partners;

d developing and disseminating guidance, emergency risk communication messages, and other recommendations to targeted audiences or at-risk populations; and

d coordinating the imple- mentation of control measures such as the distribution and dispensing of appropriate medical countermeasures.

Finally, the recovery phase occurs during and after the

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response and encompasses efforts to return or adapt to “new” normal conditions after an event. In the public health context, this may include efforts to implement an orderly transition of response-related activities to regular public health programs and functions, capacity-building efforts to reestablish or strengthen health systems, or monitoring long-term sequelae such as mental or behavioral health issues in affected populations following a significant public health emer- gency or disaster.

STANDARDS We define standards as codi-

fied expectations for practice, typically in the form of guidelines or requirements for functions, processes, resources, or perfor- mance in an organization or

system.15,16 Standards serve multiple purposes.17 For exam- ple, they can drive improvement in an organization or program by serving as the desired end state or outcome of a certain activity (e.g., be able to activate an EOC within 60 minutes of notifica- tion). Gaps in capacity or capa- bility can be assessed against the standards and strategies put into place for addressing those gaps. Standards also serve an important accountability function; meeting standards assures funding au- thorities and governance bodies that organizations and programs are directing their efforts and activities in preferred or even required ways or that their level of performance meets minimally acceptable requirements.

Related to this, standards can also act to enhance trust and credibility in an organization or program. In some disciplines and

industries, meeting standards can even convey excellence or elite status. Another key benefit of standards is that they can be recognized and accepted across entire communities of practice, irrespective of geography, type of organization, or individual background. Finally, adherence to standards is verifiable through empirical observation, often through second (i.e., purchaser or funder) or third (independent, outside) party review, which re- duces the need to rely exclusively on self-assessment.

The field of PHEM is cur- rently coalescing around several sets of standards and guidelines (Table 1). Public health and health care–related standards are relatively new: most, if not all, have been published within the past 10 years. Standards de- veloped in the field of emergency management have a longer

history, with early roots in fire safety and building codes and later developments in a theory of practice linked to the emergency management cycle with signifi- cant emphasis on planning, training, exercising, and evaluation.

Multiple sets of emergency management standards exist in US and global contexts. These standards tend to include some or all of the following functional areas:

d hazard and risk assessment, d planning, d prevention and mitigation, d incident management, d resource management, d communications, d operations, and d training, exercising, evalua-

tion, and corrective action and continuous quality improvement.

Long-term monitoring as part of

surveillance and control activities for

populations directly affected by an

event

Vaccination and related surveillance

and control activities to reduce

infectious disease outbreak effects

Interventions to improve food handling

and sanitation practices, and other

surveillance and control and

coordination and logistical support

activities, in disaster settings such as

shelters to reduce potential

environmental exposures

Development and execution of plans to

transition response-related activities to

regular public health programs

Emergency Management

Cycle

E

Staff preidentified for key roles in support of

incident management and response

Enhancing facilities, management, and

operations capacity, such as building and

equipping an Emergency Operations Center Developing policies, plans, and procedures

for response management and operational

tasks Enhancing surveillance and control systems

for timelier detection and reporting of threats

Testing internal communications and

information technology Training, exercising, and evaluation program

implemented based on public health

emergency management principles

Activating an incident management system in

support of incident management and

response

Implementing procedures for collecting,

integrating, and sharing public health data

and information with responders and

partners Plans and procedures enabling timely and

accurate communication of critical

information to target audiences Coordination and logistical support for

deployed field epidemiologists, health

communicators, and other responders

Disseminating timely, credible, actionable

information to target audiences in support of

emergency risk communication efforts

Building capacity to reestablish or

strengthen health systems (e.g., related

to facilities, management and

operations, or incident management

and response)

FIGURE 1—Examples of Public Health Emergency Management (PHEM) Activities Across Phases of the Emergency Management Cycle

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In the United States, the gold standard of emergency manage- ment standards is part of the Emergency Management Ac- creditation Program, a volun- tary standards, assessment, and accreditation process for disas- ter preparedness programs throughout the country.19 The Emergency Management Ac- creditation Program addresses a range of elements and functions expected to be in place for an emergency management pro- gram, from administration and finance to communication and warning systems. In 2013, the CDC became the first civilian agency of the US government to receive accreditation by the Emergency Management Ac- creditation Program in recogni- tion of meeting all necessary standards for its emergency management program.

Related standards include (1) the National Fire Protection Association 1561 and 1600 standards, long embraced by first responder organizations and professional associations as foundational emergency management standards in the United States, and (2) in- ternational standards such as the International Organization for Standardization 22300 series, which covers topics such as continuity of operations, incident response, organiza- tional resilience, emergency management capability assess- ment, and guidelines for exercises.20,22,23

Highlighting these standards is not meant to suggest that these have been adopted evenly, or in some cases at all, across the landscape of public health pre- paredness and response programs or the nascent field of PHEM. Although many public health preparedness capabilities have, for example, been comprehen- sively adopted by health

TABLE 1—Standards and Related Guidelines That Inform the Field of Public Health Emergency Management

Standard Description

Center for Medicare and Medicaid Services—emergency

preparedness rule18 Requires a wide range of health care organizations to develop an

emergency plan, an emergency communications plan, a training

plan, policiesand procedures,and implementation of exercisesto

receive Medicare or Medicaid reimbursement

Emergency Management Accreditation Program19 A voluntary standards, assessment, and accreditation process for

disaster preparedness programs throughout the country

Health care preparedness and response capabilities12 Four capabilities, composed of multiple objectives and activities,

describing what entities in the health care delivery system should

do to effectively prepare for and respond to emergencies

International Organization for Standardization

22300—societal security20 Establishes common understanding on the protection of society

from, and response to, incidents, emergencies, and disasters

caused by intentional and unintentional human acts, natural

hazards, and technical failures

National Association of City and County Health

Officials—Project Public Health Ready21 Criteria-based emergency preparedness program developed for

local health departments with an emphasis on documentation of

an all-hazards preparedness plan, workforce capacity

development, and a comprehensive exercise plan

National Fire Protection Association 1561: standard on

emergency services incident management system and

command safety22

Contains requirements for emergency services on the principles,

structure, and operations of an incident management system to

ensure the safety of emergency responders and others during an

incident

National Fire Protection Association 1600: Standard on

disaster, emergency management, and business continuity

and continuity of operations programs23

Contains requirements for the development, implementation,

assessment, and maintenance of programs for prevention,

mitigation, preparedness, response, continuity, and recovery

National public health performance standards24 Forty standards also linked to the 10 essential public health

services, whose purpose is to drive improvement at a public

health system level in a jurisdiction; emergency management

content similar to PHAB standards, with additional content

related to legal authority in emergencies

PHAB—multiple standards25 Thirty-two standards linked to the 10 essential public health

services for use by agencies seeking public health accreditation;

standards related to emergency management include

requirements for emergency plans, policies, and procedures;

training; exercises; 24/7 operations if needed; surge staffing;

emergency risk communications; incident management;

continuity of operations; and workforce development

Public health preparedness capabilities: national standards

for state and local planning11 Fifteen capabilities composed of functions and tasks that state and

local health departments are expected to be able to do on the

basis of resources they are expected to have or have access to

WHO—Framework for a public health emergency

operations center26 Recently published guidance by WHO for use by ministries of

health and other health authorities outlining “key concepts and

essential requirements for developing and managing a PHEOC”

for the purpose of enabling “a goal-oriented response to public

health emergencies”

Note. PHAB = public health accreditation board; PHEOC = public health emergency operation center; WHO = World Health Organization.

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departments funded to build or sustain the public health emer- gency preparedness programs (CDC, unpublished data), emergency management stan- dards such as the Emergency Management Accreditation Program and the National Fire Protection Association 1600 have not. PHEM as a field of practice has begun to take shape in areas where these standards intersect: hazard and risk identi- fication; planning, training, and exercising; use of the IMS; and emergency communication to the public.

INCIDENT MANAGEMENT SYSTEMS

Another fundamental com- ponent of PHEM is the IMS. The IMS is a scalable, flexible system for organizing emergency response functions and resources characterized by principles such as standardized roles, modular organization, and unity of command.7 Although it em- braces management by objective at the level of an overall response, IMS is in essence a modified command-and-control sys- tem.27 An effective IMS hinges on the integration and co- ordination of staff, systems, and infrastructure under a stan- dardized organizational struc- ture, which is typically managed from an EOC, joint field office, or similar entity. In the United States, recipients of prepared- ness funding are required to develop an incident manage- ment framework that complies with the National Incident Management System.

The National Response Frame- work describes key contributions of an IMS in a response context, including

(1) developing a single set of objectives, (2) using a collective, strategic approach, (3) improving information flow and coordination, (4) creating a common understanding of joint priorities and limitations, (5) ensuring that no agency’s legal authorities are compromised or neglected, and (6) optimizing the combined efforts of all participants under a single plan.8

Drawing from, and adapting, foundational scholarship in the field, we suggest that the main work of an IMS in a PHEM context includes coordination between functional units or groups of expertise within and across organizations; information collection, integration, and sharing internal to the IMS but also external to response partners and other stakeholders; de- veloping and disseminating public information and warning and crisis and emergency risk communication messages to tar- get audiences and the general public; and providing access to and deployment of resources such as staff and equipment to an EOC or the field (including the management and logistical sup- port of surge staff).28 A fifth purpose, more prominent in certain response contexts, relates to the IMS’s role in informing policy or engaging with elected and other political or senior officials (e.g., to address multi- faceted challenges such as man- datory evacuation orders, the quarantine of well individuals, closure of schools or businesses, and recommending travel re- strictions to avoid exposure to harmful pathogens).

IMSs are rooted in the concept of the incident command system, a typically on-scene command- and-control organizational struc- ture characterized by standardized functions and terminology ini- tially developed to facilitate in- teragency coordination and

integration of resources for com- bating wildfires.29 There is sig- nificantandongoing debate about the implementation and effec- tiveness of the incident command system and IMS. Whether these systems are being implemented appropriately or consistently and whether they are equally effective in managing emergency responses across different hazard and threat contexts are of concern.27,30,31

Despite this, documented examples of IMS use in public health contexts notably increased over the past several years. For example, health departments in the United States have high- lighted the successful use of in- cident command system or IMS principles in various response contexts, including pandemic influenza exercises,32 natural di- sasters such as floods,33 and vector-borne disease out- breaks.34 Similarly, the use of IMS principles has been noted globally,35–37 and the momen- tum it has gained internationally has led the World Health Or- ganization to advocate its use in the context of broader emer- gency management capacity– building efforts.26

In the United States, the CDC has activated its IMS 62 times between 2003 and 2016, in- cluding during recent responses to outbreaks of Ebola (2014– 2016) and Zika (2016 to the present). However, the CDC has not been immune to IMS implementation challenges. Early efforts to adopt the IMS within the agency were met with variable success. Public health scientists were not clear on how to work effectively in a rel- atively structured command- and-control model for response activity, and emergency man- agers were hard pressed to im- plement the IMS with a public health workforce that was used to handling major infectious disease

outbreaks without integration into an emergency management program.38 Related to this were warning signs of a broader clash of professional cultures.

Commentators have noted that a strict application of the IMS to public health may run counter to the “collaborative cultures and decision-making styles found in public health environments.”39(p416) Finally, despite relatively recent contri- butions to the literature de- scribing beneficial process outcomes of an IMS structure, especially in global contexts,36

the scarcity of evidence illus- trating the effectiveness and im- pact of an IMS prompts important questions about its advantages and why emergency responses should be organized around it.27

Drawing lessons from past experience, the CDC maintains a highly flexible IMS structure able to integrate subject matter expertise and operational capa- bility from traditional public health functions—such as epidemiology and laboratory testing—and from specialized functions—such as community mitigation (e.g., social distancing and school closures), medical countermeasures (e.g., vaccines, prophylactics, respirators, and personal protective equipment), vectorcontrol,andbirthdefects— which can be activated as needed. The CDC organizes these func- tions under a “scientific response section,”whichhasbeenpartofall major IMS activations since the agency’s response to H1N1.38

DOMAINS OF PUBLIC HEALTH EMERGENCY MANAGEMENT

Although no definitive list of PHEM domains exists, we have

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drawn from the literature to suggest some of its principal do- mains. The domains listed in Table 2 describe specific sets of discrete functional activities that draw on resources or capacities, such as staff with competencies or expertise in specified areas; systems that, using a broad defi- nition, include policies, plans, and procedures as well as pro- cesses, protocols, and partner- ships; and infrastructure entailing facilities, communication, and information technology and equipment, supplies, and other material goods.

EMERGENCY MANAGEMENT IN A GLOBAL CONTEXT

Internationally, PHEM is be- coming a more prominent fix- ture in global health initiatives. In 2005 the revised International Health Regulations provided a framework for member coun- tries to better protect their pop- ulations from public health threats and emphasized the need for emergency preparedness and response activities to meet their obligations. Despite the In- ternational Health Regulations being a binding legal instrument for all member states of the World Health Organization, enforcing obligations under them remains challenging. The Global Health Security Agenda launched in 2014 expanded on International Health Regulations (2005) by strengthening national public health EOCs among other elements of PHEM.2 Aligned with this initiative, the CDC hosts a Public Health Emergency Management Fellowship pro- gram to train leaders and practi- tioners in the global public health community in PHEM concepts and principles.40 Through 2016,

TABLE 2—Select Key Domains of Public Health Emergency Management

PHEM Domains Scope

Facilities, management, and operations Encompasses the EOC facility and related resources as well as the

personnel and processes necessary to ensure the effectiveness of

day-to-day operations and activation procedures. Examples

include the physical structure and supporting infrastructure for

an EOC facility and permanent or on-call staff able to activate an

IMS quickly.

Policies, plans, procedures, and partnerships Primary reference documents, examples of which include

emergency operations plans and continuity of operations plans,

as well as policies, standard operating procedures, and protocols

that provide guidance and indicate specific PHEM-related

management and operational tasks. Also includes personnel with

expertise in planning and policy development to develop and

update these documents.

Internal communications and information technology Staff, systems, and infrastructure to support internal

communications. Examples include teleconferencing equipment,

computers, servers, and trained staff who are able to operate

available resources and technology to facilitate communication

and information exchange between organizations, partners, and

other responders.

Crisis and emergency risk communication and public

information and warning

Staff, systems, and infrastructure for the synthesis and

dissemination of accurate and timely information, guidance,

warnings, or recommendations aimed at specific target audiences

or at-risk populations to enhance knowledge or promote health

protective behaviors or other actions. Examples of relevant

capacities include public information officers and health

communicators, communication plans that address triggers for

issuing warnings to the public, procedures to disseminate risk

communication messages to targeted or at-risk groups, Web and

social media platforms, and media contact information.

Surveillance and control Staff, systems, and infrastructure that facilitate timely, accurate

receipt, management, and dissemination of information related

to cases of infection, disease, or exposure, clinical management,

broader measures of burden of disease or health status, and

protocols and procedures to initiate appropriate and timely

control measures. Examples include existing and ad hoc

surveillance systems, trained epidemiologists and related staff,

informatics capacity, and processes to develop guidelines and

recommendations for control measures and health protective

behaviors.

Information collection, integration, and sharing Staff, systems, and infrastructure to support collection, analysis,

integration, visualization, and sharing of public health data and

other information generated as part of response operations.

Example capacities include data analysts and information

management specialists, data use and sharing agreements,

standardized data sets, and analytic, data visualization and

mapping software.

Continued

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this fellowship has graduated 39 health officials from 25 countries. Graduates are versed in the principles of emergency man- agement and trained to imple- ment an emergency management program in a public health context.

Challenges persist in de- termining how to best maximize limited available resources in public health infrastructure; in some cases, governments’ polit- ical will to invest in PHEM sys- tems and capacities is lacking, and money or expertise is instead diverted to other health or eco- nomic priorities. In some nations, civil conflict and instability dis- courage the implementation of national-level strategies to im- prove public health. The Ebola outbreak in West Africa and Zika virus outbreak in the Americas and elsewhere have underscored the importance of strengthening the PHEM

capacities required to prevent, respond to, and recover from public health events. The public health EOC framework de- veloped by the World Health Organization in 2015 attempts to present scalable aspects of PHEM capacities, so national govern- ments can make investments to achieve basic requirements addressing the country’s partic- ular health vulnerabilities and tailor strategies to do so in their specific geopolitical and socio- economic contexts.26

WHERE DO WE GO FROM HERE?

A spate of recent global disease outbreaks serves as a reminder of the importance of developing and maintaining capacities to effectively manage responses to public health emergencies. We

have attempted to sketch some features and pillars of a fluid yet gradually cohering field of PHEM. The future of PHEM as a field of practice is difficult to predict, but its maturation may hinge in part on at least 2 factors. The first factor re- lates to the need for evidence. Prominent public health pro- grams in areas such as infectious and chronic disease surveillance and prevention depend on high-quality data and evidence of effectiveness.

Similar scientific rigor to eval- uate effectiveness or identify best practices does not yet exist across the board for PHEM. Although techniques of evaluation in the form of hotwashes and after- action reviews are key compo- nents of emergency management, the field has been slow to adopt scientific evaluation of practice, leaving open questions regarding the effectiveness and impact of

PHEM-related activities acrossthe emergency management cycle. Fortunately, public health practi- tioners and researchers trained in the sciences and evaluation are well positioned to remedy this deficit and yield extensive insights about what—at present—we take to be self-evident.

The second factor relates to instruction and pedagogy. Whether and to what extent PHEM will further cohere as a field of practice will depend on how its core precepts and practices are imparted to entering practi- tioner cohorts. Will the next generation of public health emergency management practi- tioners learn from professionals, scholars, and instructors who have extensive experience in PHEM practice, research, or both? Will curricula draw on rigorously evaluated and identified best practices? Will PHEM be taught widely across schools of public health and elsewhere? Will future cohorts of public health pro- fessionals embrace precepts of emergency management as tools to help respond to complex public health emergencies? The answers are not yet clear, but the viability of PHEM as a sus- tainable field of practice in years to comemightdependontheresults. The CDC has made strides in this area with its Public Health Emergency Management Fel- lowship program and other efforts to train public health emergency responders and leaders, yet the field has immense room to grow both domestically and in- ternationally. Where will PHEM go from here?

CONTRIBUTORS D. A. Rose developed the analytical framework. D. A. Rose and S. Murthy conceptualized the article and wrote substantial portions of the article. J. Brooks reviewed the article. J. Brooks and J. Bryant provided subject matter expertise on the content and cowrote portions of the article.

TABLE 2—Continued

PHEM Domains Scope

Incident management and response Staff, systems, and infrastructure that facilitate effective incident

management of a public health emergency response using

accepted emergency management principles. Example capacities

include preidentified staff to fill IMS roles, preestablished

decision-making processes, and processes to track and account for

the use of resources.

Coordination and logistical support of field operations Staff, systems, and infrastructure that support emergency

response field operations, including coordination and logistical

support for deployed responders and dispensing of

countermeasures. Examples include trained logisticians;

infrastructure to support storage, shipping, and dispensing of

medical countermeasures; and processes and procedures to

prepare and safely deploy responders for field operations.

Training, exercising, and evaluation Staff, systems, and infrastructure that support a training,

exercising, and evaluation program on the basis of accepted

emergency management and quality improvement principles.

Example capacities include a process or program to ensure that

responders receive required training, an exercise design and

implementation program, and a system of performance

monitoring and evaluation to assess capability and performance.

Note. EOC = emergency operations center; IMS = incident management system; PHEM = public health emergency management.

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ACKNOWLEDGMENTS The authors would like to gratefully ac- knowledgethemembersoftheDivisionof Emergency Operations, Centers for Dis- ease Control and Prevention (CDC) for their specific contributions to public health emergency management at the CDC.

Note. The findings and conclusions in this article are those of the authors and do not necessarily represent the official po- sition of the CDC.

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