SESSION 1:  Public Health Systems (Section A)

Discussion leader:  Alfred Sommer (Johns Hopkins University)
Reporters:  Carolyn Fulco and Alina Baciu (IOM)

Questions:  What can IOM do (collectively as an institution, and individually through its membership) to increase preparedness?  What are the key ‘systems’ issues that need to be fixed?  How do we help mount a federal response when resources are at the local level?  If resources are limited and/or threats are imminent, can local resources be federalized?  Is there or should there be a federal equivalent for health that is similar to the National Guard for defense and unrest? How do we relate global threats to the preparedness of local and state departments of health and medical systems?

Public Health Education and Information

>There is a need for cross-training between public health and medicine.  Because we don’t know what the next public health crisis will be (nor can we ever know in advance), the IOM might develop a study that would look at the basic information that would need to be taught to health care professionals and other public health practitioners, including curriculum development of basic public health principles (e.g., epidemiology, infectious disease control/containment).  A committee could determine the basic knowledge and core skills required by all health care professionals; a core set of public health competencies should be defined for physicians, nurses, and other health care workers.  For instance, all physicians entering practice should know the fundamentals about health departments and what diseases are reportable, etc.

>Prepare educational materials or develop training that will allow public health practitioners to be receptive to information received “at the last minute” or “just-in-time” to manage a crisis or respond to emerging threats; to know how to get “just-in-time” information (IOM could identify resources for that information); and to encourage recognition of things that are out of the ordinary or different.

>On the side of reporting rather than reception, there is a need for a description of the breadth of the response required in sharing/getting information with/from local hospitals to local departments of public health and state departments of public health, etc.  SARS was a lesson in Public Health Epidemic Control 101, but many of the barriers to rapid response were due to the difficulties of providers in reaching local and state health departments (lack of clear contacts, 24/7 coverage); the rapidity of the administrative response is an issue.

>Training/Education for new members of Congress or their staff—IOM members could offer training in public health.  (A parallel was drawn with Harvard's Kennedy School training for new legislators.)

Global Health

>Global health partnerships – develop focused relationships with the international community.  Look at nearby countries like Canada and Mexico, for example, and also meet with members of other IOM-like organizations in more distant countries.  Where appropriate, conduct comparisons with other nations' public health and preparedness systems or assist in developing public health blueprints for governments.

>Focus on global solutions for general public health problems.  For example, the IOM could work on developing models for a global CDC-like system with a concentration on infectious disease (WHO not entirely filling that role currently).  it might be a model for a “virtual” CDC, or built from each country's local CDC-type organizations and could be assisted by meetings between IOM members and counterparts in other countries.  Evaluate what other countries have done and what might be done.

>IOM could also report (with CDC) on how other countries are dealing with issues of preparedness and the needs of their public health systems.

>Global solutions around SARS could be examined to see what were best practices of international (and intersectoral?) collaboration.

Synthesis of IOM Findings

>The IOM could convene a committee or roundtable to review and synthesize the recommendations in all of its recent reports relating to public health (The Future of the Public's Health, Who Will Keep the Public Healthy?, Microbial Threats to Health, etc.) The goal would be to determine common underlying systemic issues to develop into a strategic focus.  How would the recommendations in these reports be promoted and operationalized?

Public Health Infrastructure

>There is a disconnect between the recognition of the public health system's breakdown and the lack of action in response to the threat posed by its current condition.  The IOM could develop a study on rebuilding the public health infrastructure.

>Specifically, the gap between available and needed resources could be quantified.

>The IOM could help facilitate the inclusion of the Department of Health and Human Services in discussions between the Department of Homeland Security and the Department of Defense, or generally help bridge the links between public health and national security issues.

Terrorism, Emergency Medicine, and the Broader Public Health

>How can minimum standards be established for bioterrorism response systems and collaborations?  A broader dialogue is needed, to go beyond the traditional stakeholders.  For example, more should be done in partnerships with opinion leaders, such as AARP and others who would want to be part of the dialogue on strengthening the public health system.

>Terrorism is just one part of the broader issue of acute, largely infectious disease threats, and with the exception of anthrax, all microbial crises of the past few years have not been terrorism related.  SARS is a particularly good example of international collaboration that had nothing to do with terrorism or homeland security.  Perhaps there is a need to wean public health workers away from using the term “bioterrorism” because it is a law enforcement term and paradigm.  Public health should be able to respond to an infectious disease crisis whether it is intentional or not, and in many cases, the public health role comes after the emergency.

>However, emergency public health is more than just infectious disease, and there are substantial differences in the perspectives of police, fire, and EMS communities as compared to those of public health.  How does one prepare or train for an “all hazards approach”?  And could the IOM study or identify the community benefits from emergency medicine and ways to support or broaden its reach?  There are 5000 community hospitals that interact with local health departments.

>In the area of public health and health care collaboration, hospitals are constantly looking to provide community benefits in order to maintain non-profit status. Perhaps this should include collaboration with local public health agencies and community education?

Integration of Public Health

>There is a need for increased linkages between the worlds of public health and clinical medicine, as well as greater linkages with veterinary medicine.

>The IOM could develop a study that examines veterinary issues such as the transmission of veterinary diseases and their impact on the public’s health.  What are the threats and opportunities, and how can this knowledge be incorporated into action to secure the health of the public?

>Integration must span across many disciplines.  The IOM could develop a study to examine different mechanisms for ensuring public health across many disciplines, including infectious disease, mental health, children’s health, etc., rather than only the creation of separate infrastructures for potentially related things.

>Develop a study that will examine ways to organize a response to a threat (for an optimal response and minimal response, depending on the need).  Look at a schematic diagram of PH organizations:  CDC, FEMA, DHS, State health, local health, state EMS, etc, then determine who goes first; who calls whom; set-up lines of command.

>IOM could explore and suggest areas where basic research and public health collaboration might be promoted.