Brick by Brick: The Strategic Re-Building of the Public Health Infrastructure

Supplement: CHDS Essay Contest (First Annual – 2008)

Meredith Allen

ABSTRACT: The public health infrastructure in the United States has eroded unnoticed; however, the tragic events of September 11, 2001 highlighted the need for a robust public health system. Homeland security funding and the Department of Homeland Security’s strategic goals have directly impacted the rebuilding of the public health system. While numerous improvements have been made which would directly affect the nation’s ability to respond to a public health emergency, such as the implementation of disease surveillance programs, the fostering of interagency cooperation, and the development of the Medical Reserve Corps, these improvements are also useful during routine incidents. The creation of a strong public health infrastructure will help protect the public from homeland security threats but will also protect them from everyday hazards. The ability to strengthen the nation’s response to everyday hazards, while having the ability to scale-up a response for a national emergency, is the most critical aspect of the success of homeland security programs and funding.


The events of September 11, 2001 and the ensuing anthrax attacks have highlighted the need for public health preparedness in the United States. The public health infrastructure of the United States has eroded during the last twenty years due to a “lack of funding, focus, and national attention.” 1 There has been a decrease in the number of laboratories and public health personnel which has, in turn, diminished the ability of professionals to collect and analyze data, conduct disease surveillance, and design interventions for the community. 2 The public health system had been “chronically under-funded for the past several decades and the ‘infrastructure had greatly deteriorated.’” 3 The anthrax attacks of 2001 served as a wake-up call for public health and medical professionals, the American public, legislators and those tasked with homeland security; the nation’s public health system was not equipped to rapidly and effectively respond to a bioterrorism attack whether small or large in scale. 4

To help the nation rebuild the public health infrastructure to respond adequately to any terrorist attack, Congress has passed the Public Health Threats and Emergencies Act of 2000 and the Public Health Security and Bioterrorism Act of 2002, which has led to the influx of approximately ninety-nine million dollars into the rebuilding the public health infrastructure. 5 In addition to the increase in funding directed at the strengthening of the public health infrastructure, public health has finally been included as a member of the homeland security “team.” On October 18, 2007, President George W. Bush issued Homeland Security Directive-21 regarding public health and medical preparedness. The directive sets forth a National Strategy for protecting the health of Americans during a disaster. Homeland security funding has provided for the reversal of the last twenty years of public health infrastructure erosion resulting in the emergence of a stronger, more prepared public health system. Although the strengthening of the public health infrastructure has been the most successful aspect of homeland security, its ability to sustain the newly strengthened infrastructure by ensuring that newly funded programs and staffs are able to protect the nation’s health during times of crisis while maintaining healthy communities during daily life is public health’s greatest challenge.

The Department of Homeland Security (DHS) was formed to serve as the unifying force to lead a national effort to protect and secure America and its people. While the public health community is not a centralized federal department, public health professionals aim to protect and secure the American people from poor health, illness, and disease. The strategic goals developed by DHS (awareness, prevention, protection, response, recovery, service, and organizational excellence) serve as important benchmarks by which to measure the success of the revitalization of the American public health infrastructure.

The public health community has increased its awareness of disease movement and illness occurring throughout the community by enhancing its surveillance systems and hiring epidemiologists trained in recognizing disease trends and outbreaks. One such example of a surveillance program, introduced by the Department of Homeland Security in conjunction with the Environmental Protection Agency (EPA), is BioWatch. BioWatch is a program which utilizes biological pathogen detectors in conjunction with EPA air quality monitors to collect particles from the air which are then analyzed by public health laboratory professionals. 6 In the event of a pathogen release, the goal of the BioWatch system is to provide early warning to public health professionals before the affected population begins to present at their doctor’s offices and local emergency rooms. 7

In addition to BioWatch, some local Departments of Health have been able to implement syndromic surveillance programs due to the increased funding provided by DHS. Syndromic surveillance programs allow public health professionals to collect and analyze data on health trends (i.e. visits to the emergency department and flu medication sales). Syndromic surveillance allows for the categorization of patients’ chief complaints of symptoms into coded syndromes (i.e. vomit, diarrhea, and rash). Syndromic surveillance allows public health professionals to have access to “real-time” data allowing for the detection of a sudden increase in any syndrome without waiting for final diagnoses or lab results. While syndromic surveillance can serve as an alerting system that there is an unusual health event in the community, it is also prone to false alarms from truly sporadic cases of illness; therefore it is imperative that trained public health professionals respond to the “alarms.” Homeland security funding has often provided the funding for the hiring of additional Epidemiologists for local health departments.

Not only will increased surveillance capacity aid public health professionals in detecting any suspicious pathogen releases, it can also be used routinely to detect naturally occurring or seasonal outbreaks in communities. The influx of homeland security funding which was in part used to bolster surveillance systems has helped to rebuild the public health infrastructure needed to maintain healthy communities throughout the country, not just to protect them in the event of a bioterrorist attack.

Each year in the United States approximately 36,000 people die from the seasonal flu. 8 While increased surveillance has aided public health professionals in monitoring the annual flu season, homeland security funds have also helped public health professionals prepare for the seasonal flu outbreaks. In the event of any large-scale bioterrorism attack, local health departments may need to provide preventive medication and/or vaccine to their citizens (mass prophylaxis). Homeland security funding has allowed local health departments to plan for and practice their mass prophylaxis plans. Many health departments have used their seasonal influenza vaccination program, giving free flu shots to members of their community immunizing them for the upcoming flu season, to test their mass prophylaxis plans. One local public health department (Bucks County, PA) was able to immunize 4,664 people on a Saturday at four locations which would be used in an emergency for mass prophylaxis. Homeland security funding allowed the health department to order additional supplies in order to give community members free flu shots, along with providing the funding for staff on a Saturday – a more convenient time for many working adults who would like to be vaccinated. While local health departments are preparing for and practicing the delivery of mass prophylaxis, which may be necessary in the event of a bioterrorism attack, they are able to help prevent seasonal influenza in their communities. Local health departments will be able to sustain a state of readiness by holding practice drills of their mass prophylaxis plan each year in addition to providing a needed immunization free of cost to their local community.

While public health professionals aim to protect the public from disease and illness, homeland security initiatives have allowed public health departments to begin to help protect the nation’s food supply. Public health professionals have long been involved in restaurant inspections; however public health is now involved in planning for and responding to agroterrorism, the deliberate introduction of a plant or animal disease. Homeland security initiatives have allowed public health professionals to be involved in food safety from “farm to table.” The increased involvement of public health has allowed for an increase in education about food-borne illness. Food-borne illnesses are not always caused by improper food handling, but sometimes are a result of actions that occur on the farm. Homeland security has allowed for formation of professional relationships among public health, agriculture, and distribution professionals along with retail companies. The formation of these relationships and the resulting understanding of the “farm-to-table” process allow public health professionals to know who to call during outbreaks, such as the 2007 spinach outbreak related to California spinach producers.

Homeland security initiatives have also allowed for a more coordinated response to not only bioterrorism emergencies but to any naturally occurring outbreak. Homeland security has provided for the formation and upgrading of many communication systems (Health Alert Network) which have assisted public health professionals in recognizing multi-jurisdictional outbreaks, thus breaking down the jurisdictional silos that often limit the flow of information between colleagues.

In addition to an increase in communication systems, DHS has also provided for the opportunity for cross-jurisdictional training. One such program, Forensic Epidemiology, provides for public health professionals and law enforcement professionals to train together resulting in a better joint understanding of job functions and specimen collection, developing joint patient interviewing, and establishing chain of custody of samples. In the event of a bioterrorism attack, law enforcement and public health will need to work together to identify the source of the attack and the pathogen. While the importance of the alliance of public health and law enforcement is easy to see in the event of an attack, the alliance also has important implications for routine operations. Law enforcement professionals are often involved in transporting criminals, who may claim to have (or do have) infectious diseases such as tuberculosis (TB). The formation of the linkage between public health and law enforcement has given each discipline a resource. Any officer who has questions about his or her possible exposure to TB after a transport will know who to call to obtain exposure information.

Not only have homeland security initiatives assisted public health professionals in successfully responding to events, they have also helped public health professionals to assist in the recovery after a major event such as bioterrorism. Homeland security has made public health professionals part of the first responder community and as part of that community public health professionals are responsible for the health and safety of other first responders. Public health professionals can provide vaccinations and prophylaxis to first responders and their families so that they are able to continue their response in an emergency.

The anthrax attacks of 2001 demonstrated the importance of effective public education and media relationships. Homeland security initiatives have allowed for public health professionals to have media training. It became clear that during a health emergency, such as the anthrax attacks of 2001, the public wanted to hear information from medical personnel, not public information spokespersons. Public health professionals have received media training and will be able to assist in the recovery efforts by providing accurate and appropriate health information and instructions.

The Department of Homeland Security is a unifying department in the federal government, which exists to serve the people of the United States. While serving the American population, homeland security initiatives have also provided opportunities for the American population to serve each other and volunteer. The Medical Reserve Corps (MRC) was founded in 2002 and is a federal program aimed at strengthening the resources of local communities. The MRC provides an opportunity for interested community members to volunteer to help their community prepare for and respond to local emergencies, along with promoting healthy living. 9 In a true health emergency, public health and emergency workers will not be able to provide the staffing resources needed to operate enough centers to accomplish mass prophylaxis in a community; MRC volunteers are a surge support that local public health agencies can call upon in an emergency.

Not only will MRC volunteers be an invaluable resource during an emergency, they can also increase community connectedness with local public health departments. When public health professionals do their jobs well, it often is not public knowledge. When an outbreak is prevented, there are no news stories or press releases, so much of the public is unaware of the great resource a local public health department can be. MRC volunteers provide public health professionals an important link to the community they serve. By becoming a more visible and trusted part of the local community, public health messages delivered may be heeded in times of calm as well as during an emergency.

The rebuilding of the public health infrastructure was also greatly influenced by the final strategic goal of homeland security: organizational excellence. The public health system in the United States is a segmented system consisting of independent local health departments, state health departments, and, at the federal level, the Centers for Disease Control and Prevention (CDC). The introduction of the National Incident Management System (NIMS) has provided all public health agencies with a standardized management system with which to respond to emergencies large and small. NIMS incorporates best practices from other management models and provides a consistency throughout all agencies. NIMS has not only enabled different public health agencies to speak the same language but has also enabled public health agencies to communicate effectively with other first responder agencies. The introduction of NIMS has eliminated the use of professional jargon in emergency response and has created a system where responders can plug into a response regardless of whether or not it is being led by their jurisdiction.

With the increase in opportunities for multi-jurisdictional and multi-disciplinary training, the introduction of NIMS has allowed for a seamless response to emergencies. The introduction of ICS (the Incident Command System, a sub-section of NIMS) has eliminated the need for specific profession-related job titles and has allowed first responders from different agencies and from across the country to effortlessly “plug-in” to an active response. NIMS has created a standard operating procedure for the many different first responder agencies that provides a form of unity across all jurisdictions.

The public health infrastructure in the United States had been slowly eroding throughout the past few decades. Homeland security funding has begun the re-building of the nation’s public health system. Each of the seven strategic goals of DHS (awareness, prevention, protection, response, recovery, service, and organizational excellence) has directly impacted the re-building of the public health infrastructure. The most critical aspect of the success of homeland security initiatives is the ability to use the improvements made possible by DHS in routine incidents as well as those which are emergencies. Creating a strong viable public health infrastructure will always ensure that there will be qualified professionals conducting surveillance for pathogens, practicing mass prophylaxis, safe-guarding the food supply, participating in cross-jurisdictional training and communication efforts, participating in media training, keeping first responders healthy, creating volunteer opportunities and community outreach, along with continuing the development of a consistent approach to incident management. Each one of those activities will help to protect the community from homeland security threats and will also protect the community from everyday hazards such as the presence of E.coli in spinach and seasonal influenza outbreaks. The improvements in the public health infrastructure will help during everyday occurrences but can also be scaled-up to handle large scale bioterrorism attacks. Homeland security must become a part of our everyday lives, not something which we concentrate on only when the security threats are raised. To be a part of our daily lives, homeland security programs must be sustainable and applicable to everyday life. The continued strengthening of the public health infrastructure allows for the use of homeland security improvements and initiatives while also preparing to identify and respond to any threat to our security.

Meredith Allen is currently the epidemiologist for the Bucks County Department of Health, where her daily responsibilities include disease surveillance, outbreak control, and bioterrorism preparedness. She is a dissertation candidate in the DrPH program at Drexel University’s School of Public Health. Her research focuses on community inclusion in governmental preparedness drills and its effect on participant’s level of confidence in government emergency preparedness planning. She holds a master’s degree in epidemiology with a concentration in infectious disease from Harvard University and a bachelor’s in biology from the University of Delaware. Ms. Allen may be contacted at mgallen@co.bucks.pa.us.


  1. B. Frist, “Public Health and National Security: The Critical Role of Increased Federal Support,” Health Affairs 21, no. 6 (2002):119.
  2. Ibid.
  3. S. Hearne, L. Segal, M. Earls, C. Juliano, and T. Stephens, “Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism,” 1, http://www.healthyamericans.org.
  4. Frist, “Public Health and National Security.”
  5. D. Santiago and A Richter, “Assessment of Public Health Infrastructure to Determine Public Health Preparedness,” Homeland Security Affairs 2, no. 3 (October 2006), https://www.hsaj.org.
  6. D. Shea and S. Lister, The Biowatch Program: Detection of Bioterrorism (2003), http://www.fas.org/sgp/crs/terror/RL32152.html.
  7. Ibid.
  8. Centers for Disease Control and Prevention, Key Facts About Seasonal Influenza (n.d.), Link has expired. See https://www.alarms.org/flu-statistics/ for more information.
  9. Medical Reserve Corps, Overview of the Medical Reserve Corps (n.d.), http://www.medicalreservecorps.gov/QuestionsAnswers/Overview.

This article was originally published at the URLs https://www.hsaj.org/?article=essays.1.2 and https://www.hsaj.org/?fullarticle=essays.1.2.

Copyright © 2008 by the author(s). Homeland Security Affairs is an academic journal available free of charge to individuals and institutions. Because the purpose of this publication is the widest possible dissemination of knowledge, copies of this journal and the articles contained herein may be printed or downloaded and redistributed for personal, research or educational purposes free of charge and without permission. Any commercial use of Homeland Security Affairs or the articles published herein is expressly prohibited without the written consent of the copyright holder. The copyright of all articles published in Homeland Security Affairs rests with the author(s) of the article. Homeland Security Affairs is the online journal of the Naval Postgraduate School Center for Homeland Defense and Security (CHDS). https://www.hsaj.org

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