Public Health in the States
States have a unique role in public health emergency management. They develop policies and authorities that govern strategy and activities for public health emergency preparedness, response and recovery activities. Recent incidents, including the national significant Ebola, Zika and Hepatitis C outbreaks, as well as more localized emergencies such as water supply contamination and measles re-emergence, have highlighted the challenges that states face when responding to public health emergencies. NGA is partnering with the CDC to assist states in understanding and developing the legal, political and regulatory frameworks that enable effective management of public health emergencies.
This virtual resource center was developed as a repository for state-focused resources pertaining to public health emergency preparedness policy. The resources are targeted at state leaders in the fields of public health, emergency management and administration, although due to the cross-disciplinary nature of public health emergency preparedness, a broader audience may find these tools useful. Resources are grouped into four major sections:
- Lessons Learned: advice for states from other states, rooted in real-life experiences in policy development for public health emergency preparedness.
- Promising Practices: a collection of ideas and activities that have been implemented and evaluated to varying degrees that have the potential to positively impact states in their pursuit of effective policy on public health emergency preparedness.
- State Examples: an archive of past state projects, including policy approaches and strategic implementation plans that support effective preparedness for and response to public health emergencies. Projects ranged from ensuring that public health is represented within the state fusion center to developing a playbook for legal authorities during a public health emergency.
- External Links: Additional documents, webinars and useful information from vetted sources that address additional policy topics such as isolation and quarantine practices and risk communication.
The Request for Applications for the National Governors Association Public Health Preparedness and Response Workshop for State and Territorial Gubernatorial and Legislative Leadership will be released on March 10, 2020.
About the Workshop
The NGA workshop is an opportunity for governors, legislators, and key state staff to gain a greater awareness of policy solutions to mitigate the consequences of public health emergencies. During the workshop, state teams will have access to national experts through virtual meetings and regular conference calls and will receive ongoing technical assistance from NGA Center to implement their strategic action plan. The workshop will take place on June 8-9, 2020.
This project is funded by the U.S. Centers for Disease Control and Prevention.
Please contact Carl Amritt for more information.
Webinar Series on Legal Preparedness for Public Health Emergencies
The NGA Center, in collaboration with the U.S. Centers for Disease Control and Prevention and the American Bar Association, launched a webinar series on Legal Preparedness for Public Health Emergencies. This four-part series aimed to provide an in-depth look into the common legal challenges posed by public health emergencies. The webinars featured subject-matter experts and spotlighted states’ and localities’ responses to public health emergencies. The recordings and PowerPoint slides can be accessed below:
- Rough Waters: Disaster Preparedness, Response And Recovery For Hurricanes And Floods Webinar: Presents from Nebraska, University of Nevada, and CDC
- Emergency Management Assistance Compact: Legal Considerations In 90 Minutes Webinar: Presenters from Ohio, CDC, and NEMA
- Ebola And Beyond: Legal Preparedness For Outbreaks Webinar: Presenters from CDC and Illinois
- Information Sharing 101: Protecting Public Health Data Webinar: Presenters from Texas A&M, CDC
Public Health Preparedness and Response Workshop for State and Territorial Gubernatorial and Legislative Leadership
Governors and state legislators play a critical role in the success of any major public health response. Legislators make laws that can facilitate (or inhibit) a successful response. And governors make decisions that can result in lives saved or lives lost. With multiple threats (environmental, emerging infectious disease, terrorism, etc.) states may activate their state emergency operations centers with increasing frequency to address minor incidents and complex emergency crises that impact health. Therefore, it is imperative that public officials are become familiar with public health emergencies and confront policy challenges that may impede a successful response.
To better support state governments in ensuring readiness for public health emergencies, National Governors Association Solution: Center for Best Practices (NGA Center) has partnered with Centers for Disease Control and Prevention (CDC)’s Center for Preparedness and Response to support the design and implementation of promising practices, policies, and procedures to address policy challenges in public health preparedness and response.
The NGA Center and the CDC’s Center for Preparedness and Response hosts a public health preparedness workshop for governors’ senior staff, legislators, and other state officials. The purpose of the workshop is to develop policy approaches and strategic implementation plans that support effective preparedness for and response to public health emergencies. As part of this opportunity, states receive technical assistance from the NGA Center to strengthen their ability to handle a broad range of public health emergencies.
These projects are made possible through a grant from the Centers for Disease Control and Prevention.
Declaring a public health emergency can require significant legal review. Conducting that legal analysis in advance enables a state to more nimbly respond to an emergency.
Convening a multi-disciplinary team to discuss needs for public health preparedness is crucial to establishing a comprehensive plan for policy changes.
To enhance coordination during a response, ensure the state health official has significant insight into public health preparedness and a strong working relationship.
Strengthening understanding within the state legislature of public health preparedness and emergency response is an important step for enhancing the state policy framework around public health preparedness and addressing any legislative needs.
Assigning a public health analyst to the fusion center allows for the homeland security, emergency management and public health sectors to conduct their work using a common operating platform that can enhance public health preparedness.
Involving the governor’s office helps create momentum and obtain buy-in around strategic public health preparedness planning to create effective policy change.
In a public health emergency, be first, be right, be credible, express empathy, promote action and show respect.
Legal reviews of public health emergency authorities should be tested—through processes like exercises or tabletops—in order to ensure that the state is prepared when an emergency occurs.
Due to the wide spectrum of state, local, and regional personnel necessary for a response, a multi-disciplinary approach is necessary for public health preparedness and planning.
Implementing long-term improvements to public health preparedness policies can be challenging in the midst of an emergency response.
2019 States’ Plans To Enhance Public Health And Emergency Response
Commonwealth of the Northern Mariana Islands (CNMI)
CNMI expanded its capacity to provide mass care and health services to residents during a disaster by ensuring regulations and laws are responsive to the changing needs of the islands. In October 2018, Super Typhoon Yutu made landfall in CNMI, creating significant structural damage to islands Saipan and Tinian, leaving the majority of residents without electricity or running water and many without homes. One challenge of the Commonwealth Healthcare Corporation was the ability of health officials to mobilize personnel and resources. CNMI aimed to provide NIMS certification at all levels of their Healthcare Corporation to ensure proper coordination across partners and alignment with not only healthcare priorities but also with CNMI government expectations. To date, CNMI has:
- Passed legislation to adopt the Emergency Management Assistance Compact (EMAC), enabling the territory to share resources during natural and human-made disasters, including terrorism;
- Created a mandate for Incident Command Systems training across territorial agencies to improve emergency response coordination; and
- Completed the first draft of a playbook to strengthen the coordination between ESF 6 and ESF 8 so that residents receive the most comprehensive care in the wake of disaster.
Minnesota created a public health preparedness “playbook” for local elected officials to increase their understanding of authorities in public health emergencies to respond rapidly and effectively. When responding to global health threats such as Ebola and Zika, Minnesota highlighted the importance of strategic planning and timely public health emergency response operations, policies, and procedures. These events highlighted the need for a definition of clear lines of authority, coordinated communication, and coordinated decision-making at all levels of government. Minnesota’s “playbook” addressed these gaps thereby improving its readiness posture for large scale health emergencies. To date, Minnesota has:
- Completed the first draft of a playbook covering overarching priorities in every incident, essential responsibilities of agency personnel, what to expect in public health emergencies, and public messaging around the incident; and
- Scheduled to present and test the playbook during the state-wide Community Health Conference with County Health Commissioners.
Mississippi pursued legislative action to provide volunteer liability coverage when responding to acts of bioterrorism, infectious disease outbreaks, and other public health threats and medical emergencies. Under state law, non-employees of the state are not allowed to be reimbursed for death, disability or injury, or receive compensation to their heirs in the event of death. Nor in the case of the event of injury or disability while responding to an officially declared emergency or during emergency preparedness training. Mississippi developed a strategic plan to increase legislative leader’s awareness of the importance of in-state or out-of-state volunteers in readiness, response, and recovery efforts to move towards legislation providing liability coverage. To date, Mississippi has:
- Identified and met with key legislators and committees to assist in advancing potential legislation; and
- Developed draft concepts and language for legislators to consider to be introduced; and
- Expanded their state employee risk pool to provide volunteer liability coverage with minimal added cost.
Pennsylvania strengthened medical countermeasures and mitigation to reduce morbidity during a public health incident. In the case of a deliberate release of anthrax, the Pennsylvania Department of Health is required to distribute and dispense medication to affected populations within 48 hours of requesting the Strategic National Stockpile (SNS). Given the small window to mobilize a response, a clear understanding of the legal and policy considerations for medical dispensing is imperative to avoid delays. Pennsylvania aimed to create a roadmap to inform the Governor and their key advisors of their emergency authorities as well as outline liability protections for corporations, nonprofits, and other dispensing authorities when responding to an anthrax event. To date, Pennsylvania has:
- Reviewed Open and Closed POD policy examples provided by the State of Mississippi;
- Participated in the federal functional exercise, Crimson Contagion, to simulate the disaster declaration process for a pandemic flu response. Lessons learned from the exercise will be used to inform a state-wide anthrax exercise in October;
- Created standing orders that were tested during a full-scale distribution and dispensing exercise in October; and
- Reviewed state dispensing laws for medical countermeasures with the Department of State Chief Counsel.
Washington worked to create a regional agreement within FEMA Region X to enhance their abilities to share healthcare resources. In Washington, most of the healthcare resources are held by the private sector, and the state has limited means of requesting support to address these gaps. The limited availability of medical surge capacity within any given jurisdiction, coupled with increasing reliance on interstate mutual aid during disasters, underscores the need for a regional approach. Washington is leading the charge to develop the framework for establishing and sustaining regional surge teams, including both private and public medical resources, and will be testing these plans through multi-state training and exercises. To date, Washington has:
- Convened a legal working group of Attorneys General from Alaska, Idaho, and Oregon to create a regional agreement focusing on training, drilling, communications, registration, and coordination of multi-state teams;
- Partnered with the Association of State and Territorial Health Officers (ASTHO) to survey the availability and readiness of mission-ready packages including Medical, Pediatric, Nursing, and Behavioral health strike teams;
- Discussed legal barriers and the authority of the state in medical emergencies with the Governors’ Office; and
- Briefed the House of Representatives Wellness Committee on action plan objectives.
2018 States’ Plans To Enhance Public Health And Emergency Response
Arizona pursued an enhanced emergency readiness posture by creating a specific public health preparedness “playbook” for the governor’s office. The playbook was inspired by the state’s experience declaring a public health emergency for the opioid crisis from June 5, 2017 to May 29, 2018, which required a significant preliminary legal review. The purpose of the playbook is to streamline state authorities and provide examples demonstrating how public health emergency declarations enabled additional capabilities to guide executive decision-making during crises. The Arizona team also conducted a tabletop with senior staff to test the playbook using a pandemic influenza scenario and refined its contents for real-world implementation.
Hawaii pursued enhanced statewide integration of information on various aspects of public health preparedness and response planning. The state’s participation in the NGA/CDC workshop helped solidify crucial relationships during the Kilauea volcanic eruptions to enhance the capacity and integration of Emergency Support Functions #8 and #10 . During the response, the Hawaii Department of Health reorganized its emergency preparedness program to report directly to the state health official, a chief objective of the state’s strategic action plan formulated at the NGA/CDC workshop. Hawaii also conducted outreach to law enforcement across the state to engage them in updating and strengthening Strategic National Stockpile (SNS) security plans.
Illinois pursued enhanced public health preparedness coordination and created a series of dedicated working groups to enhance public health preparedness across the state, including working groups focusing on plan deconfliction, public information officer for risk communications, and crisis standards of care. The communications working group is developing templates and trigger points in order to enhance the state’s ability to communicate more quickly in an emergency. Plans are also being enhanced to integrate the Joint Information Center (JIC) concept into public health operational plans. Exercises will then be utilized to test those plans. Through this project, Illinois is creating its first legislative caucus around emergency management, which will regularly bring important public health preparedness challenges to key decision-makers in the state. Additionally, Illinois is collaborating with legislators to provide them additional knowledge on key preparedness issues with the assistance of a legislative champion who participated in the workshop.
New Jersey pursued enhanced information sharing through several strategies. The state created the Healthcare and Public Health subcommittee on its gubernatorial Domestic Security Preparedness Task Force, which mirrors the federal National Security Council at the state level. Through this body, state leaders are better able to integrate healthcare and public health preparedness planning with homeland security, emergency management and law enforcement throughout the state. New Jersey also selected a public health analyst to staff the state fusion center to provide a common operating procedure for both public health and intelligence professionals. This was achieved through a joint process to complete initial hiring and drafting a Memorandum of Understanding to formalize information-sharing components of the position. New Jersey continues to reinvigorate its regional medical coordination centers (RMCCs) in emergency management processes through sustained engagement from the state, at both the local and regional levels.
Oregon pursued an enhanced emergency readiness posture through stronger communication with the state legislature, judiciary and executives. A prolonged water contamination crisis in the state capital highlighted Oregon’s need for action around public health preparedness and external communication l soon after the workshop. The Oregon team conducted a legislative briefing and prepared an accompanying packet while refining its risk communications in light of the emergency. Despite the response, the team has completed a refresh of its judicial bench book on public health emergencies to ensure a broad understanding of public-health emergency authorities in the judiciary. The Oregon Governor’s Disaster Cabinet also conducted a large-scale exercise focusing on a public health emergency. Oregon absorbed its lessons learned on public risk messaging from the water contamination crisis into its implementation of the state’s action plan and is examining how this crisis might inform responses to other unregulated contaminants.
West Virginiais working to draft legislation that would create a specific public health emergency declaration authority for the governor. West Virginia continues to propagate this idea throughout state government with the ultimate aim of enhancing the governor’s powers to respond to public health emergencies and solidifying them in law.
- CDC Center for Preparedness and Response
- Drexel University Dornsife School of Public Health Social Media Message Library
- An Assessment of State Laws Providing Gubernatorial Authority to Remove Legal Barriers to Emergency Response
- Emergency Declarations and Tribes Mechanisms Under Tribal and Federal Law
- Evolution of Law in Biopreparedness
- Judicial Opinions Arising from Emergency Preparedness, Response, and Recovery Activities
- Reframing the Opioid Epidemic as a National Emergency
- The Case for Streamlining Emergency Declaration Authorities
- The Changing Nature and Scope of Public Health Emergencies in Response to Annual Flu
- The Opioid Epidemic and the Future of Public Health Emergencies
- NACCHO Administrative Preparedness Presentation
- Governor’s Guide to Public Health Preparedness