The National Health Security Strategy
Years ago, the Secretary of HHS was directed to begin publishing a quadrennial review of the state of national health security. This document was intended to be similar to the quadrennial National Homeland Security Report and National Defense Review and give the President an overall look at the status of security efforts and plan strategies for the next four-year cycle.
Last month, DHHS published the initial National Health Security Strategy, and an accompanying Interim Implementation Guide. I got the opportunity to review the Strategy this past weekend and wanted to comment on it. Read this post understanding that I know the devil is really in the details for such a satellite-level view of National Health Security, so it will be difficult to find fault with this “wish-list” document. The implementation guide, I imagine, will be a bit more of a helicopter-level view of National Health Security, in which we can make out some of the gory details. The real problems with this, though come on the ground, when these goals are actually (or not, as the case may be) implemented. To that end, let’s take a jaunt through the document.
Really, the first thing to talk about is, what is national health security. DHHS defines it as:
National health security is a state in which the Nation and its people are prepared for, protected from, and resilient in the face of health threats or incidents with potentially negative health consequences.
Talk about a squishy term. I’ve made note of my confusion around this idea of “resiliency” before, and to then accept it in a definition of what our overall strategy should be is kind of difficult. If we read that part as “prepared for, protected from, and [able to bounce back from] health threats or incidents with potentially negative health consequences,” it makes a bit more sense. But the definition worries me because of the focus on events. Is it not fair to say that 45,000 people dying yearly from automobile accidents is a “health threat with potentially negative health consequences?” Now, some of you will say, but auto accidents don’t really have anything to do with security. The document, though, makes specific note of chronic conditions (like HIV/AIDS) and long-term situations (like climate change) as threats to health security. Based on those situations, focusing on incidents as a part of the very definition upon which this planning takes place is potentially misleading.
The Strategy document notes there are two overarching goals of this effort:
- Build community resilience
- Strengthen and sustain health and emergency response systems
First of all, good on them for focusing on community first. Ultimately, this effort should not be about making a better system or ensuring that the health care infrastructure endures, but about keeping people healthy and safe. In fact, the very first strategic objective is to “foster empowered individuals and communities. I still worry about the squishiness of the whole resilience term, but feel that if it’s set up as integrating regular people into the framework of homeland security, I’m all for it. I’m encouraged by this passage on page 6:
After an incident, individuals and communities are able to mount an appropriate “bystander response” until emergency responders arrive, i.e., they are sufficiently healthy to sustain themselves and attend to heir own health needs (including the need for psychological support) until help arrives and can assist in addressing the needs of at-risk individuals.
And, I thought this passage would be interesting to my more public health-y colleagues:
Community resilience is supported by the promotion of healthy lifestyles; disease prevention; access to culturally informed, timely and high-quality health care; and a robust public health system.
The document then goes on to talk about shortcomings of the existing system, specifically things I’ve talked about this several times before related to workforce issues:
The Nation’s public health workforce is undersized and fast approaching retirement. Predicted shortages in nursing, epidemiology, and the laboratory sciences will affect critical core public health capacities. Differences in the scope and breadth of formal public health training and the absence of certification requirements limit the cohesiveness of the Nation’s public health workforce and its ability to serve in different settings (e.g., agencies,
communities, or states) during an incident.
Efforts to increase and improve the workforce for national health security should focus on both basic education and additional hiring of qualified staff. PAHPA calls for the creation of educational degrees and certification programs in public health emergency preparedness. A multidisciplinary approach to education in health security should be explored. At the same time, stable funding is a prerequisite to attract and retain high-quality staff for public health, health care delivery, and emergency management. Loan forgiveness programs and other incentives might be employed to attract those with highly critical skills.
But they also talk about the structure of the system, and how antiquated it is quickly becoming:
It is important to note that the Nation’s public health agencies were first developed almost 200 years ago to detect and mitigate local disease outbreaks, provide health care, and provide other health-related services. Over time, the roles of public health agencies have matured and expanded, and the Nation must ensure that these agencies can meet the evolving requirements of our time, including their contributions to national health security. The need for public health agencies to play a significant role in national health security has only recently become generally understood. (For the academics among us, check out this citation: R.G. Evans and G.L. Stoddart, “Producing Health, Consuming Health Care,” Social Science and Medicine, 31(12), 1990, 1347–1363.) Most public health agencies are ill-equipped to respond to severe pandemics and natural disasters that result in a large number of casualties or patients with highly infectious disease, let alone a catastrophic act of terrorism. Moreover, the Nation lacks a comprehensive, coordinated national health information system that can quickly provide health care data in the early stages of an incident.
I took special note of a passage that some of my more close friends at NACCHO will be proud of (especially those folks involved with the Preparedness Summit):
Critical to all these efforts will be a continuation of the work initiated by the U.S. Department of Health and Human Services (HHS) and DHS to develop and implement a rigorous performance measurement system to track the Nation’s progress toward achieving national health security, provide information for quality improvement efforts, and ensure transparency and accountability among all stakeholders. Information gained from these efforts can be used to build the evidence base for national health security. Achievement of national health security is a continually improving process that requires evaluation of the effectiveness of efforts to provide information that can be used to develop and improve technological, policy, operational, and clinical components. Lessons learned should be widely disseminated and incorporated into practice. The participation of the full range of stakeholders helps ensure progress toward national health security and provides an opportunity for stakeholders to identify specific ways in which national health security might be further improved.
The first appendix discusses the list of capabilities that are necessary to achieve national health security. Capabilities are something you should be able to do. Target capabilities exist existentially somewhere between overall goals and implementation actions.
Of the eight general areas discussed, seven of them heavily reference the DHS Target Capabilities list (TCL) (warning: HUGE, MASSIVE PDF), or an existing ESF-8 capability. One of them, though, has basically been built from the ground up, full of things never having been listed as a capability “necessary” to achieve national or homeland security.
It is the “Community Resilience and Recovery” section, which is comprised of the following capabilities:
- Public education to inform and prepare individuals and communities (new)
- Public engagement in local decision-making (new)
- Local social networks for preparedness and resilience (new)
- Integrated support from non-governmental organizations (new)
- Emergency public information and warning (taken from TCL)
- Post-incident social network re-engagement (new)
- Case management support or individual assistance (new)
- Reconstitution of the public health, medical, and behavioral health infrastructure (taken from TCL)
- Mitigated hazards to health and public health facilities and systems (new)
- Support services network for long-term recovery (new)
You can see how many of the above capabilities are brand new. No other section has nearly that many new capabilities to strive for. On the one hand, this is disheartening, because you can see how excluded from the process the community and individuals have been in the past. No special effort has been made to incorporate their input or needs into the planning, response or recovery aspects. The two existing capabilities include public information and warning (listen to what your government tells you you need to worried about) and reconstitution of the health care system (which really falls under the broad term of infrastructure recovery and isn’t specific to the health care community).
On the other hand, the fact that these capabilities are now included is something to be proud of. It is now a priority of the federal government to include regular people in emergency planning. Simple as that. Folks like Amanda Ripley and John Solomon will be very happy to hear that.
Finally, it’s apparently going to be a busy nine months for the folks at DHHS. They are planning on publishing a final version of the Implementation guide in September. They will use the intervening period to:
[W]ill allow for coordination with ongoing planning by DHS, including completion of the next round of revisions to the Target Capabilities List (TCL), revision of HSPD-8, and the development of health security workforce competencies for health care, public health, and emergency management.
The Interim Implementation Guide:
[S]eeks to set in motion a number of foundational activities that require immediate action:
- Identify and prioritize a list of investments to enhance the capabilities required to achieve national health security. HHS will generate an initial, nascent list of investments to improve performance on capabilities. The Guide thus suggests the need to undertake, during the next nine months, a process to develop and prioritize a list of investments to enhance specific capabilities.
- Conduct a workforce gap analysis and develop workforce competencies for all sectors involved in national health security. The Guide suggests steps for filling known shortages in occupational specialties that play a key role in health security, developing workforce competencies, providing continuing education and training to the existing workforce, synthesizing findings from existing workforce gap analyses, and planning a more comprehensive workforce gap analysis.
- Coordinate HHS’s efforts to improve national health security with those of DHS, the Department of Defense, and all federal agencies involved in national health security and national security. The Guide highlights the importance of ongoing coordination among HHS, DHS and other federal agencies to ensure interagency consistency of approaches to improving national health security, particularly in areas such as detection and response to outbreaks.
- Begin to identify and develop methods for risk analysis appropriate to the broad range of risks to the public’s health. The Guide lays out a set of principles for developing clear and consistent risk assessment methods, based on definitions and methods described by DHS.
- Develop an evaluation framework, including plans for performance monitoring and evaluating the impact of investments. So that efforts to improve national health security will be data-driven and evidence-based, measures of performance that support evaluation and accountability need to be developed. Thus, the Guide lays out a concrete plan of action and timeline for ensuring that all communities have a clear set of measures. The Guide also recommends a design for reporting, development of algorithms for combining the assessments of multiple measures, and data collection to allow for presentation of data in a format that is useful to decisionmakers and other end users.
- Promote and implement quality improvement (QI) methods for health security on a broader scale. The Guide provides an approach for developing and disseminating quality improvement methods, which involve systematic collection of data, evaluation of findings, and adaptation of interventions. These methods can help support community- and national-level improvement efforts.
- Propose an agenda for research to enhance national health security. The Guide highlights the importance of conducting research to help establish an evidence base for national health security. HHS will work with other federal agencies and stakeholders to propose a research agenda for national health security.
- Conduct an assessment of the countermeasures enterprise with the aim of identifying how to develop, manufacture, and ensure availability and delivery of countermeasures faster and more efficiently.
I’ll try to review the Implementation Guide this week and give a report soon.