Environmental Health Archives - Page 4 of 14

New TFAH Report: Persistent Underfunding of America’s Public Health System Makes the Nation Vulnerable and Puts Lives at Risk

Funding for public health programs via the CDC budget decreased by 10 percent over the last decade while public health risks grew

(Washington DC – April 24, 2019) – Chronic underfunding of the nation’s public health infrastructure has left the nation vulnerable to serious health and safety risks, according to a new report released today by Trust for America’s Health.

The report, The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2019, examines federal, state, and local public health funding trends and recommends needed investments and policy actions to prioritize prevention and effectively address 21st century health threats.

The federal government, primarily through the U.S. Centers for Disease Control and Prevention (CDC), provides critical support for the nation’s public health infrastructure including by funding a substantial portion of state and local public health programs. But, between Fiscal Year (FY) 2010 – Fiscal Year 2019, the CDC’s budget fell by 10 percent when adjusted for inflation. Cuts to the CDC budget have direct impacts on state and local public health departments’ budgets. In 2018, 17 states and the District of Columbia cut their public health spending.

“Our country is grappling with unprecedented public health problems including the opioid crisis, the increasing number of Americans with chronic diseases, virulent infectious diseases and a growing number of weather-related emergencies,” said John Auerbach, President and CEO of Trust for America’s Health. “The CDC budget is simply not sufficient to address these demands.”

“At a time when the country’s health security threats are increasing, reducing spending to prevent and respond to these risks is dangerous and makes Americans less safe,” Auerbach said.

“CDC funding represents the majority of public health funding nationally and locally. When CDC funding is cut, state and local governments are often forced to reduce funding for critical programs including those to prevent chronic and infectious diseases, to protect environmental health and to provide vaccinations for children, among many others. These are programs Americans need and support. They shouldn’t be constantly on the chopping-block,” Auerbach said.

Among the Report’s Key Findings Are:

Over the past decade, the Centers for Disease Control and Prevention’s program funding—more than half of which goes to states, localities, and other nonfederal partners—decreased by 10 percent, after adjusting for inflation. At the same time, substance misuse has skyrocketed, the incidence of obesity and related health problems continue to climb, and the threat of weather-related emergencies is on the rise.
Federal funding cuts negatively affect state health departments as these funds are a primary source of state public health budgets. On average, federal funding comprises 48 percent of state public health budgets. Similarly, these spending cuts have serious consequences for local health departments given that federal and state allocations constitute a substantial portion of local health departments’ budgets.
Seventeen states and the District of Columbia cut their public health funding in FY 2018.
One-fifth of local health departments reported decreases in their FY 2017 budgets.
Multiple years of funding cuts contributed to more than 55,000 lost jobs at local health departments from 2008-17. These cuts undermine efforts to hire, train, and retain a strong public health workforce, which in turn limits governments’ ability to effectively protect and promote the health of their residents.
Cuts to public health funding often result in higher health care costs as preventable illnesses and injuries are major causes of hospitalization and other medical interventions.

The Report’s Topline Recommendations Include:

Increase federal investments in public health. To protect the health and safety of all the country’s residents we need more funding for public health programs, not less.
Provide sufficient, full-year funding for federal agencies to avoid interruptions in funding for critical health security programs.
Increase state and local investment in public health, prioritizing prevention and the social determinants of health.
Work across sectors to improve the effectiveness and efficiency of public health investments.
Ease coordination of funding from multiple sources.

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Trust for America’s Health is a nonprofit, nonpartisan organization that promotes optimal health for every person and community and makes the prevention of illness and injury a national priority.

The Impact of Chronic Underfunding of America’s Public Health System: Trends, Risks, and Recommendations, 2019

TFAH Applauds Passage of Senate Farm Bill

(Washington, D.C., June 29, 2018) – John Auerbach, president and CEO, of Trust for America’s Health (TFAH) today made the following statement regarding Senate passage of “Farm Bill” legislation (the Agriculture Improvement Act – Senate amendment to H.R. 2) to reauthorize key federal agricultural and nutrition programs.

“The Trust for America’s Health is pleased the U.S. Senate has completed work on Farm Bill legislation that will support and promote good nutrition and improved health outcomes. By rejecting the approach taken by the House, the Senate bill largely protects and strengthens the Supplemental Nutrition Assistance Program (SNAP), which serves as a critical lifeline to millions of American children and families that otherwise lack the means to access adequate nourishment and make healthy food choices.

In addition to increases in funding to the Food Insecurity Nutrition Incentive Pilot, the Senate bill includes a Harvesting Health pilot that would help to further promote linkages between health care providers and anti-hunger and nutrition improvement activities.

According to TFAH’s State of Obesity report, roughly two out of every three adults or one out of every three children is either obese or overweight. Obesity remains both a significant public health crisis and a national security issue-being overweight or obese is the leading cause of medical disqualifications for military service, with nearly one-quarter of applicants being rejected for exceeding the weight or body fat standards. Additionally, obesity translates to higher health care costs and poor quality of life.

Many efforts are underway that encourage SNAP recipients to make healthy food choices; for example, incentive programs to use SNAP benefits at farmers’ markets. Such efforts, combined with other prevention programs and policies, have been shown to be effective. We must now continue to invest in and scale such approaches to help Americans eat healthier. SNAP and other Farm Bill programs will be critical to turning the tide against this longstanding health problem.

TFAH looks forward to continuing to work with Congress through the conference process as it develops a final Farm Bill that will lead us in the right direction, towards improving the health and prosperity of all Americans.”

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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

New Report: Funding for Public Health Has Declined Significantly since the Great Recession

Core Federal Emergency Preparedness Funding has been cut by More than One-Third Since FY 2002

Washington, D.C., March 1, 2018 – A new Trust for America’s Health (TFAH) analysis—A Funding Crisis for Public Health and Safety: State-by-State and Federal Public Health Funding Facts and Recommendations—finds spending on public health is insufficient.

“A healthy United States is a strong United States. A prepared nation is a safe nation. But persistent underfunding of the country’s public health system has left the nation vulnerable,” said John Auerbach, president and CEO, of TFAH. “The country needs a long-term commitment to rebuild the nation’s public health capabilities – not just to plug some of the more dangerous gaps but to make sure each community will be prepared, responsive and resilient when the unexpected occurs.”

Flat Federal Funding

In Fiscal Year (FY) 2017, the U.S. Centers for Disease Control and Prevention’s (CDC) budget was $7.1504 billion ($21.95 per person). Adjusting for inflation, CDC’s core budget—not including the Prevention and Public Health Fund—has been essentially flat for the last decade.

Because much of CDC’s budget is distributed to states and localities, the impact of budget cuts is experienced directly at the state and local level. Of the roughly 75 percent of CDC funds that go to states and local communities, support ranges from a low of $5.74 per person in Missouri to a high of $114.38 per person in Alaska.

In addition, 12 percent of CDC’s budget consists of the Prevention and Public Health Fund, with about $625 million a year of that directed to state and local efforts. From FY 2013 through FY 2027, the Prevention Fund will receive nearly $12 billion less than the law intended.

Within CDC, the Public Health Emergency Preparedness (PHEP) Cooperative Agreement Program is the only federal program that supports the work of state and local health departments to prepare for and respond to emergencies. Except for one- time, short-term funding to contain the Ebola and Zika viruses, core emergency preparedness funding has been cut by more than one-third (from $940 million in FY 2002 to $667 million in FY 2017) since the program was established.

State Public Health Funding Declining

Spending for public health by states has been declining. Based on a TFAH analysis (adjusted for inflation), 31 states made cuts to their public health budgets from FY 2015-2016 to FY 2016-2017. Only 19 states and Washington, D.C. maintained or increased their budgets, making it hard for states to compensate for reduced federal funding.

According to the report, state public health spending is actually lower in 2016-2017 than it was in 2008-2009, as some of the funding cuts that occurred during the Great Recession have not been fully restored—and federal funding has been essentially flat (almost half of state public health spending comes from federal funds).

Local Public Health Funding Decreasing

Since 2008, local health departments (LHDs) have lost 55,590 staff due to layoffs or attrition. In addition, about 25 percent of LHDs reported a lower FY 2016 budget than the previous year, with fewer LHDs reporting an increase in their budget for the current year as compared to the previous.

Recommendations

“Each year, we issue this report to examine the amount of public health funding each state receives and provide an independent analysis of how communities protect the public’s health. With life expectancy declining in the U.S. for the second year in a row—something unheard of in recent memory—policymakers must take the public’s health seriously and allocate the funds needed to improve well-being and prevent illness and injury,” said Auerbach.

The report includes eight key recommendations:

Increase Funding for Public Health – at the Federal, State and Local Levels
Preserve the Prevention and Public Health Fund
Prepare for Public Health Emergencies and Pandemics
Establish a Standing Public Health Emergency Response Fund
Build a National Resilience Strategy to Combat Deaths of Despair
Prevent and Reduce Chronic Disease
Support Better Health and Top Local Priorities in Every Community
Expand the Use of Evidence-Based, High-Impact Strategies to Improve Health in Every Community

The brief was supported by a grant from the Robert Wood Johnson Foundation (RWJF).

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Environmental Health

Supporting health is more than treating people when they get sick. Optimal health is determined by many factors, including where we live, go to school, work and play. Creating built environments that foster health and well-being includes working with community partners to ensure access to such things as well-stocked grocery stores, public transportation and recreation facilities.

In addition, the changing climate poses risks to people’s health including a greater number of extreme weather events. Mitigating and adapting to the impacts of climate warming and doing so in ways that increases community resilience and advances health equity, by focusing resources on those communities most risk, requires investment and multisector approaches.

Building a Community Roadmap to Health and Equity in Jackson, Mississippi

By Beneta D. Burt, Executive Director, Mississippi Roadmap to Health Equity

The Mississippi Roadmap to Health Equity, a community-run organization that seeks to generate and mobilize resources, utilizes our expertise to improve how community institutions operate and, at the same time, protect and promote the health of community members.

By working with everyday institutions that touch everyone’s life, we can advocate for changes that are good for the bottom line and promote better health equity in Jackson. By building important relationships, we can ensure community institutions support the community’s efforts to be healthy—and are true partners in making the healthy choice the easy choice.

How we started

With primary support from the W.K. Kellogg Foundation, Mississippi Roadmap’s work began in 2003 with a series of sessions aimed at addressing why African-Americans are sicker and die sooner than their peers.

Through concept mapping, we identified the many factors that contribute to poor health. And, just one year later, nearly 200 community residents, members of the Mississippi Roadmap Community Steering Committee (CSC) and National Advisory Board members created ideas to improve community health outcomes. Participants laid out a “roadmap” for a healthy present and an even healthier future, especially for the economically-disadvantaged citizens of Jackson. While the state of affairs regarding the health of African-Americans was central to the purpose of the conference, the overall goal was to develop a community-driven health movement that fostered equity, justice and respect for all people.

Initially we set out to improve access to fresh and affordable produce and safe and affordable places for people to exercise – there were simply no grocery stores or farmers’ markets in the area and no price-conscious fitness centers.

To solve these problems, we re-purposed a shuttered grocery store to include:

A state-of-the-art adult fitness center;
An indoor farmers’ market;
A children’ fitness area that accommodates pre-school through teens;
Space for healthy cooking classes, in partnership with dietitians from The University of Mississippi Medical Center;
A venue for senior citizens to congregate;
An affordable rental facility for community events and a venue to convene community conversations; and
A Technology Learning Lab that serves 4^th and 5^th grade students who participate in our afterschool program.

Additionally—in an effort to promote healthy eating habits, to demonstrate to city kids where good food comes from, and to encourage them to eat more fruits and vegetables—we developed 15 garden-based projects in elementary/middle schools in the Mississippi Delta, in Jackson, and on the Gulf Coast.

How we do it

A Community Steering Committee guides our work. An executive director, together with a staff of six, provides day-to-day management. CSC members each have their own “community constituents” who they work with and/or advocate for. These community constituents range from neighborhood associations to church groups to social justice and advocacy organizations—they run the full gamut of the community.

The diversity of ages, backgrounds, interests, professions, and community connections of the CSC members provide access to the pulse of each segment of Jackson and provides a voice for their issues, ideas, needs and concerns.

Going Forward

We are scaling up our work to focus even more on promoting the health and well-being of children by creating job training programs targeted to non-college bound high school graduates and other out of- school youth.

To do so, we began the process of becoming an affiliate of the National Urban League—this vital partnership, which was fully formed in February 2018, will promote employment equity.

Unemployment among teenagers and young adults are major issues in Jackson, especially during the summer, while unemployment among out-of-school youth is equally concerning. In 2016, approximately 600 Jackson high school graduates did not attend college and most had no plans or employment prospects.

In an effort to close this gap, Roadmap entered into a Memorandum of Understanding (MOU) with the City of Jackson in to acquire a city-owned, soon-to-be-shuttered golf course and club house that we will now use to develop a job training program in golf course management designed to develop landscaping-related employment opportunities.

Out-of-school youth will be recruited during the course of the year and enrolled in a GED program provided by Hinds Community College prior to enrolling in the job training program. We will incentivize participant training to encourage consistent attendance and attainment of GEDs prior to transitioning to the program. Additionally, a job developer will work with non-college bound high school seniors in March of each year to prepare them for entering the training program.

Upon completion of classroom and on-the-job training activities, and with Roadmap’s oversight, some participants will bid on landscaping management contracts with local public school districts. Successful bids will result in permanent, unsubsidized employment for participants.

To leverage these relationships and also improve physical fitness, golf pros will develop a program for integration into the curriculum of the local elementary school, which is located next to the golf course. And, a concurrent physical fitness program will be incorporated into the program. Eventually, we hope these plans and resources can benefit the health of the entire community.

Partnerships are Vital

Any measure of success that we have achieved can be attributed to the long-term support from the W. K. Kellogg Foundation, and to the large group of public and private sector members whose actions demonstrate that community partnerships play an integral part in achieving improved health outcomes. We have the good fortune to have local chefs, hospitals and health professionals, church ministries, and community-academic partners involved.

Just one partnership example: we are the grant recipient in partnership with the Mississippi State Department of Health and the University of Mississippi Medical Center (UMMC). For this grant, the Department of Health provides staff resources and UMMC provides the required match for the project, which allows us to create a culture of breastfeeding among young women in Jackson.

Local Public Health Preparedness and Response to Hurricanes and Other Emergencies: High Tech and High Touch

By Umair Shah, MD, MPH, Executive Director and Local Health Authority for Harris County Public Health

This story was published in Ready or Not? 2017.

Harris County, Texas, is a large and rapidly growing community. We are the third largest county in the United States with 4.5 million residents spread over 1,700 square miles.

We are diverse in every sense of the word, making it vital to communicate in culturally competent ways. Additionally, since we are growing and people come from all over, they might not have experience with mosquito or hurricane seasons. We cannot assume our constituents, year after year, are the same. So we must continue to reach out to our community and educate.

That means we need adequate capacity within the department and a diverse team with a broad array of skills and experiences who continual drill and train.

To ensure we reach all our constituents, we are mobile—we take public health to the public. We’ve built health villages with large RV units—that focus on all aspects of health from mosquito abatement to dental services to immunizations.

We didn’t stop there – we knew to be a trusted source during an emergency we must foster a real intimate sense of community.

I mention this because, day-to-day, we rely both on high tech and high touch. We must remember the importance of both. As much as we talk about technology, social media and sophisticated surveillance systems, we cannot lose the high touch of knocking on a door or stopping to share a story, laugh or cry. At the end of the day, the high tech gets the visibility, but it’s the high touch that allows the high tech to succeed.

This is the backdrop that all our preparedness activities take.

Being Prepared

Even preceding Hurricane Katrina, we made sure that every single Harris County Public Health employee had up-to-date Incident Command Systems (ICS) training—and new staffers get this training as part of initiation.

And, every year, we practice—drills, exercises, call down lists, etc.—making sure we can perform all the tasks we’ll need to do during a response.

So, in reality, our response to Hurricane Harvey started more than a decade before the hurricane ever made landfall.

Hurricane Harvey

Before Harvey even hit, our preparedness director alerted staff and the executive team that a major response would be necessary. With this advanced warning, we put all assets in place before landfall.

We set up communications pathways and communicated to all staff, ensuring they were aware of what was coming and their roles and responsibilities.

Once we were in place, we turned to the community. Our communications team sent out messages before the storm about how to be prepared: get your kits ready; what will you do without power; what if you’re displaced; how will you care for the elderly, children and pets; and many more.

Aside from those messages, we needed to make sure people avoided flood water—there could be any number of dangers from power lines to insects to animals to sewage to toxins.

I highlight talking to the public because we’re all in this together. We can respond great from a systems perspective, but if, for instance, people lose access to medications or begin to eat unsafe foods, we could see infectious disease outbreaks or worsened chronic conditions.

In addition to communicating, building and leveraging partnerships is key to a good response.

For example, we worked with state public health and federal partners (the U.S. Air Force) to continue ground and aerial spraying for mosquitos to ensure there wouldn’t be increased levels of Zika or dengue or chikungunya. All levels of government coordinated to ensure we maintained adequate control over mosquitos and other infectious diseases.

Harris County also sheltered a number of people. Our epidemiologists relied on outside experts and volunteers to help them go cot-to-cot to make sure there wasn’t an infectious disease outbreak and that people maintained access to medicines—a high touch strategy.

This is just a small sample of all the activities we did to keep people safe. At the end of the day, a good response involves working across systems to ensure strong partnerships are in place.

Going Forward

I’m always struck by the fact that everyone talks about the importance of health during an emergency, but, when the emergency goes away, we often forget that we need to adequately resource public health agencies so they have the tools and resources to take on the next emergency.

It’s about capacity.

I worry, one day, there will be an emergency that we haven’t trained for enough and don’t have adequate resources in place. Public health can’t all of a sudden be ready to respond to a major emergency – we need to drill and train and have access to infrastructure and technology.

To better prepare for and respond to emergencies, we also must improve technology solutions, electronic surveillance activities, and infrastructure support. We need more epidemiologists and environmental toxicology experts. And, we need more social workers and community health workers to fan into the community and link folks with vital social services.

The best response features a combination of high tech and high touch. This is where our department shines day in and day out. We’ve never let one overtake the other.

Nationally, though, we can’t rest on our laurels—the next storm could be different and we need to be ready and prepared.

Hurricane Katrina: What we learned, Then and Now

By Karen DeSalvo, Former Acting Assistant Secretary for Health, U.S. Department of Health and Human Services

This story was published in Ready or Not? 2017.

There are a significant amount of vital lessons that need to and have been learned from the preparation for, response to, and recovery from Hurricane Katrina. One long-term lesson that I think is worth highlighting and has shown its importance during recent weather-related emergencies is the need for public health to take a significant leadership and coordinator role before, during and after an emergency.

In the immediate aftermath of Hurricane Katrina, it was evident that connections were missing—whether it be local public health to state officials, public health to first responders, or public health to the community.

Public health leaders simply weren’t the chief health strategists for their communities. The field was focused on an important set of discrete responsibilities or program but not on the need to build connections with community leaders, first responders and other critical infrastructure that could ensure people had safe places to go and access to medications and other critical supports.

With this realization, it was apparent public health had to connect more with the full gamut of organizations and people involved with an emergency response. And, since then, we have done so not only in New Orleans, but in communities across the country.

For example, during subsequent hurricanes in New Orleans, public health was able to work directly and quickly with hospitals and other care facilities to know if power was on and what beds and medications were available.

And, if you look at the response in Houston, you’ll note that public health was everywhere. They were in communities meeting people and alerting them to potential dangers and infectious diseases, what food and water was safe, etc. And, they were all over social media in a culturally competent way, reaching more and more people.

If you compare the Houston Harvey response to Katrina, it should be apparent that one of the benefits in Houston was the high level of connectedness between public health and the community they serve.

How we can better Prepare for the Next Emergency

In addition to public health continuing to be the coordinator for health for our communities in disaster and every day, to better respond to the next public health emergency, the nation needs to:

Expand funding;
Improve the foundational capabilities of public health;
Better leverage technology;
Increase training; and
Focus on the underlying health and resiliency of our communities—particularly those who are most vulnerable.

We need more funding for public health—we need public health departments at the local and state levels to have the foundational capabilities required to respond to public health emergencies but also to help build resilience between events. These funds can’t be categorical, they have to provide core funding that can be nimble for a community to address their biggest health needs. For instance, parts of California might be more prone to wildfires while the Gulf Coast needs to focus on hurricanes. If we don’t have these capabilities in place, we’re forcing our public health workers to just react, rather than prepare to respond.

We also need more funding to go directly to local health departments. States have a huge responsibility during an emergency and often can’t funnel as many resources as you’d think to the local level. During Katrina, we saw this front and center.

While more funding is important, it must be paired with concrete expectations and accountability. Every single health department in the country should be accredited which will help ensure that they can stand up emergency operations when necessary.

When Katrina hit, we were using flip phones, Blackberries and an early version of Google maps. We’ve come a long way with technology in little over a decade, but our preparedness hasn’t quite kept up. We must do better with technology.

We have a great start with this by better leveraging the Department of Health and Human Services’ emPOWER, an online tool that houses and provides Medicare claims data to hospitals, first responders, and health officials to help map the electricity needs during an emergency. emPOWER enables responders to prioritize evacuations and can identify vulnerable populations who will need follow-up services. But it’s limited to the Medicare population. This type of tool must be expanded to or created for Medicaid and, where appropriate, private payers. First responders and public health must have real-time population level data.

An additional reason more resources are needed is to increase drills and training that specifically focuses on local leadership and the U.S. Public Health Service Commissioned Corps. Annually, public health workers should drill in a vulnerable area alongside the Commissioned Corps—an invaluable resource. Currently, when the Commissioned Corps deploys to an emergency the connections with local responders aren’t there and often the Commissioned Corps can be underutilized.

Lastly, we simply must do more to improve the resiliency of our communities. The healthier a group of people are, the better they respond to an emergency.

In-between emergencies, public health must use data and find opportunities to engage more with vulnerable populations. For example, this could include creating pilot programs with Medicare providers, home health organizations and others involved with the care of older adults. We must improve the health of our older population and, at the same time, have the processes in place that can maintain their connection to care during an emergency that might result in evacuations and/or loss of power.

The nation’s preparedness has improved immensely since Hurricane Katrina—we must keep improving.

Local Public Health Responsibilities During Wildfire Emergencies

By Dr. Karen Relucio, Chief Public Health Officer, County of Napa

This story was published in Ready or Not? 2017.

Responding to two wildfire events has taught me that public health has a significant role in wildfire emergency response. The role of public health includes shelter assessment, coordinating medical and mental health support in the shelter, ensuring environmental health and safety, and public health messaging.

During our first response in September 2015, there was a 75,000 acre fire that destroyed 1,300 structures, resulting in the evacuation of more than 1,000 people, which required us to open and support an evacuation center. The fire was predominantly in Lake County, which is adjacent to Napa County.

When something like this occurs, local public health works with our emergency management agency, fire and law, other County agencies and community partners to respond. Immediately, Napa County opened a shelter at the fairgrounds in Calistoga and stood up the emergency operations center.

Napa County Public Health took on the responsibility of assessing the health needs of most of the evacuees by using a modified community assessment for public health emergency response (CASPER). While Red Cross was on site, they only handled doing health assessments of the people that chose to stay inside the shelter. Surprisingly, we had many people show up in cars or RVs or with their own tents and with pets. Because animals were not allowed inside the building, they stayed outside on the fairgrounds property. It became our job to conduct health needs assessments of the majority of the 1,000 evacuees.

Additionally, our other role was providing medical support within the evacuation center. We worked with our local Federally Qualified Health Center, healthcare providers from our local medical centers and Medical Reserve Corps from Napa and neighboring counties to see patients. Most of the medical visits involved refilling medications and treating people who had respiratory issues from smoke inhalation or exacerbation of underlying health issues (diabetes, allergies and asthma). Thankfully, there were only a few people with slight injuries from the evacuation itself. We also provided flu and Tdap vaccinations.

It was also apparent that mental health needed to be addressed for the evacuees in a comprehensive way. We leaned on other local jurisdictions and nonprofits and were able to enlist a number of mental health professionals to come onsite. We quickly found that it was best to do more ad hoc checks and have the mental health professionals serve as support staff. They found it was easier to talk to folks—and avoid the stigma that might come with needing mental health services.

Another important aspect of our response was environmental health. These professionals ensured the shelter was safe and clean and that food was prepared and served safely. They went into the shelter and found donated food served potluck style, not at the appropriate temperature. In addition, there weren’t enough hand washing stations or bathroom facilities and the pets of evacuees were relieving themselves in areas where people were walking. We felt this was a prime setup for a gastrointestinal virus outbreak, which would make the situation worse. Our folks figured out how to maintain the integrity of food, installed more portable toilets and hand sanitizing stations, and provided bags for pet waste.

Throughout the response, public health information included a smoke advisory, heat advisory, and repopulation safety for evacuees once they went back to their homes. We also had to ensure people knew they shouldn’t sort through the debris without personal protective equipment.

This was great preparation for our recent fire in October 2017—which started at the same time our region was experiencing hurricane level winds of 50 to 90 miles per hour, resulting in rapid spread of the fire to our county and Sonoma County. The first 72 hours was focused on evacuations and safety.

We opened three different evacuation centers on that first evening and immediately began the plans for the type of medical coordination that we did in 2015. We also coordinated ambulance strike teams all over the region to help evacuate residential care and skilled nursing facilities.

In many ways our response was similar to 2015, except the scope of this emergency was much bigger and the recovery is much more complex. We had to declare a local emergency and a local health emergency to receive assistance for toxic ash and debris cleanup which is still in progress. Residential wildfire debris can include toxic materials such as asbestos, heavy metals, dioxins and polycyclic aromatic hydrocarbons that can be harmful to human health, and cleanup needs to be done carefully by experts. At this point, debris cleanup is still underway.

Additionally, we opened a local assistance center to help those who have lost properties, homes, and jobs. And, there are many crews working on erosion control in burn areas around water reservoirs, as we are now having heavy rains and anticipate debris flow and possible water contamination.

While we have begun to create an almost turnkey response plan to wild fires, we could always be better prepared, especially for the recovery phase. And, we really need to know a lot more about the long-term health impact of wildfires. For instance, will we see cancer rates go up? Will health inequities be worsened due to loss of homes and income? If so, is that something public health can work to prevent during the response or in the aftermath?

We also need more information and research on the impact of toxic debris and additional long-term health consequences as a result of repopulating an area that has suffered wildfire damage. The only studies that come close to looking at long-term health impacts of fire debris are the 2001 World Trade Center attacks. We can speculate on health impacts based on knowing what is contained in ash but, to my knowledge, there hasn’t been a long-term health impact study about residential wildfires. It is hard to make decisions and align future resources when we are uncertain about the long-term effects.

Q/A with Celeste Philip, MD, MPH Surgeon General and Secretary of the Florida Department of Health

This was published in Ready or Not? 2017.

TFAH: What are state public health responsibilities before a storm?

Dr. Philip: The Florida Department of Health (DOH) is designated as the lead agency for State Emergency Support Function 8 (EFS8), health and medical services. DOH coordinates the availability and staffing of special needs shelters; supports patient evacuation; ensures the safety of food and drugs; provide critical incident stress debriefing; and provides surveillance and control of radiological, chemical, biological and other environmental hazards.

DOH administers two statewide preparedness grants to build local capacity within the public health and health care community. The federal Public Health Emergency Preparedness (PHEP) grant supports all 67 county health departments (CHD) and public health laboratories in developing community preparedness, epidemiological surveillance and investigation, and medical countermeasure delivery. The Hospital Preparedness Program (HPP) funds 10 health care coalitions to build capabilities for medical surge, continuity of health care delivery, and preparedness partnerships among local health care partners.

TFAH: What are state public health responsibilities after a storm?

Dr. Philip: ESF8 assesses and stabilizes the public health and medical system; supports the ongoing sheltering of persons with special medical needs; coordinates patient movement and evacuations of health care facilities; conducts public health messaging; monitors, investigates and controls any threats to human health; and coordinates disaster behavioral health services with a sister agency.

During Hurricane Irma, ESF8 assisted with 76 patient movement missions that supported the transport of hospital, skilled nursing facility and assisted living facility clients. We conducted more than 1,000 post-impact facility inspections and more than 2,600 tests of public and private water systems and operated 113 special needs shelters.

TFAH: How do state health departments coordinate the public health response to a major storm?

Dr. Philip: Preparedness and response are driven by local leadership, personnel and assets. In Florida, each CHD coordinates and works directly with their local Emergency Management to meet the preparedness and response needs of their community. If the county Emergency Operations Center (EOC) cannot meet the local need, they request assistance through the state EOC via a web-based system that allows us to track and ensure completion of mission requests.

Based on these mission requests, the state ESF8 assesses regional and state assets. If the requested resources are not available in-state, ESF8 next looks to resources available from other states through the Emergency Management Assistance Compact (EMAC), or, in the case of a declared state of emergency, potential federal assets such as Disaster Medical Assistant Teams.

TFAH: Why are federal investments in public health critical on an ongoing basis?

Dr. Philip: During a major event, we are often shoulder-to-shoulder with our federal partners in the state EOC. This includes representatives from HHS, ASPR, and also FEMA who help to coordinate any requests we make for federal assistance.

Federal investment is critical for building a public health infrastructure that has the capacity to prepare for and recover from weather and other hazardous situations. If states are better prepared to respond, requests for federal assistance may be lessened. With the close succession of Hurricanes Harvey, Irma, and Maria, and wildfires in California, federal response agencies had to sustain their efforts across time and location which may not be feasible in the future.

TFAH: What federal programs and supports are critical for preparedness and response?

Dr. Philip: Both the PHEP and HPP statewide preparedness grants are important for public health preparedness and response. Preparedness programs in various HHS agencies hold meetings that provide training and networking opportunities for states.

TFAH: What is needed from the federal government to improve preparedness and response?

Dr. Philip: Knowing and having a relationship with our federal counterparts that will be deployed to the state EOC improves communication and manages expectations more effectively. A federal system that allows for tracking of deployed assets would improve situational awareness and real-time decision-making.

Better coordination of credentialing health care professionals between states would be helpful for patients who evacuate with their provider and for providers coming into disaster areas.

Streamlined and flexible funding to allow for nimble response as needed would greatly enhance public health’s ability to be effective.

TFAH: What lessons did you learn from the most recent storm? Was there anything different or new that happened?

Dr. Philip: Hurricane Irma posed a unique challenge because the track was very unpredictable, meaning that more hospitals decided to evacuate and more residents decided to shelter. This storm at some points was 500 miles wide – which exceeded the width of our state. And, personnel could not be moved around in advance of the storm as the track changed to support other counties in the new path. EMAC, federal and contracted assets were mobilized to support sheltering operations but some counties had to wait until the storm passed to receive additional staffing.

Because of the surge in last minute registrations to special need shelters, comprehensive planning and placement for each registrant could not be conducted resulting in the shelter having to accept clients with medical needs that exceeded the shelters’ level of care capacity.

Moving forward, we recognize a need to anticipate future storms that may impact much, or all of the state, a scenario not contemplated prior to Hurricane Irma. For DOH, statewide emergency response efforts could be bolstered by improving planning for our special needs residents, including better training and increased collaboration with other state agencies and the private sector to support Floridians with special needs.