The People's Role in U.S. National Health Security: Past,Present,and Future

Abstract

Over the past decade, assumptions have been made and unmade about what officials can expect of average people confronting a bioterrorist attack or other major health incident. The reframing of the public in national discourse and doctrine from a panic-stricken mob to a band of hearty survivors is a positive development and more realistic in terms of the empirical record. So, too, is the realization that citizen contributions to national health security encompass not only individual preparedness and volunteerism but also mutual aid and collective deliberation of the tough choices posed by health disasters. In projecting what needs to occur over the next 10 years in biosecurity, 2 priority challenges emerge: retaining the lesson that a public prone to panic, social disorder, and civil unrest is a myth, and building an infrastructure to bolster the public's full contributions to health emergency management.

According to the National Health Security Strategy (2009) and its implementation plan (2010) released by the Department of Health and Human Services (HHS), “informed, empowered individuals and communities” underpin U.S. resilience to a catastrophic health event.^1,2 Echoing the sentiment, President Obama included this tenet in his 2010 National Security Strategy: “We will emphasize individual and community preparedness and resilience through frequent engagement that provides clear and reliable risk and emergency information to the public.”³ In a public address that same year, Department of Homeland Security (DHS) Secretary Napolitano entreated the country “to build resilience—the ability to get up and come back stronger if we get hit.” She went on to explain, “That doesn't come from a set of government programs; that comes from the heart of the American people.”⁴ When unveiling the nation's first ever preparedness goal in 2011, Federal Emergency Management Agency (FEMA) Administrator Fugate argued, “As we work to build a more prepared nation, we must work with the entire community—the public and private sectors, faith-based and non-profit organizations, and most importantly the public.”⁵

The notion that citizens have a positive and consequential role to play in managing public health and other disasters seems obvious today, but this was not always so. Neither was the idea that people could be resilient—that is, capable of coping with, rebounding from, and even experiencing positive growth as a result of a disaster. Chronicled here, then, are the diverse ways in which the public's role in a health emergency has been imagined, taking into account important historic events, policy milestones, and programmatic initiatives over the past 10 years. Neither a comprehensive nor strictly linear history, this broad brush picture documents the transformation in basic assumptions about the citizenry's ability to cope with a health disaster. Once considered a hindrance to the official response, the public is now seen as a critical ally. No small feat, this shift in collective thinking nonetheless represents only a partial victory for biosecurity and the country. If the past decade has been about defining a genuine role for citizens in public health emergency management, then the next decade must be about fully institutionalizing that role. That is, the same methodical and material effort to achieve other critical public health preparedness capabilities such as biosurveillance, medical surge, and medical countermeasure dispensing must be applied to community engagement.

Panicky Mob

“How will the public react to a biological attack?” was a question underpinning many conversations in the late 1990s among U.S. national security, public health, and medical authorities about the bioterrorist threat and the best ways for managing its consequences. Responsible for protecting the population's health and safety, these professionals focused principally on the potential for widespread psychological and social disturbances brought about by a terrorist attack with unconventional weapons.⁶ As a result, terrorism-related literature, professional discourse, and response exercises tended to cast the public as emotionally vulnerable as well as prone to panic, social disorder, and civil unrest. Rare was the viewpoint that the public could play a more productive role in the context of an attack involving weapons of mass destruction (WMD).⁷ Such thinking had direct parallels to early civil defense when programs were explicitly designed to control panic; in the minds of security planners, the terror that the public might experience with an atomic attack was seen to be as problematic as the destructive weapon itself.^8-10

Included with the 1997 articles in the Journal of the American Medical Association on the medical and public health aspects of the bioterrorist threat was a thoughtful article on the probable psychological impacts.¹¹ Here, as in other period literature, the central concern was maladaptive responses by the public.^11,12 Among the “common psychosocial responses” following an act of bioterrorism cited were horror, anger, panic, magical thinking about microbes and viruses, fear of contagion, anger at terrorists, scapegoating, paranoia, social isolation, demoralization, and loss of faith in social institutions.¹¹ The authors identified effective risk communication as one possible intervention to protect against some of these effects. Nonetheless, fully absent from their analysis was any discussion of possible constructive reactions such as humanitarianism, hopefulness, resilience, resourcefulness, and reasoned caution, as well as the frequency with which these positive reactions might occur.⁶

National meetings convened in the same time frame reflected a similar mindset. In a July 2000 HHS and Department of Defense (DOD) conference on the behavioral and mental health aspects of bioterrorism, attendees concurred that “[a] swift and effective response by public officials to a bioterrorist attack can prevent negative consequences (e.g., panic, stigma, scapegoating) and promote responsible behavior by citizens (e.g., staying away from contaminated areas).”^13(pxiii) They also recommended further research on mass behaviors, including “actions and settings which increase/decrease hysteria, evacuation, rioting, and panic.”^13(pxix) In December 2000, the DOD and the Federal Bureau of Investigation (FBI) convened a workshop on “human behavior and WMD crisis/risk communication,” focusing panels on the following questions: “How can public panic/fear be lessened?” “How can the public be persuaded to take appropriate action and to avoid inappropriate actions?” “Who among responders and the public are at higher risk of adverse psychological effects and how can such effects be prevented or mitigated?”^14(ppi-ii)

Commonly woven into the narratives or “scenarios” structuring early awareness-raising tabletop exercises were expectations of societal breakdown in the context of a bioterrorist attack. In Biowar, the first nationally televised tabletop featured on Nightline in October 1999, a panel of city authorities contemplated aloud the response challenges of an anthrax release in a crowded subway system and the resulting outbreak of 65,000 cases.¹⁵ The expressed priority concern for both the police commissioner and the mayor was “panic.” The mayor, in fact, pondered the need to bring in federal troops during the crisis, explaining:

I've got to stabilize the population because I think … no matter how much information—there's widespread panic. There are people that are storming hospitals. There are people that are breaking into doctors' offices. I think no matter what you say from the mayor's posture, you've still got to stabilize the population from a panic point of view.¹⁵

The Biowar broadcast featured riot scenes with looted drug stores and other sites that might store antibiotics. In May 2000, a $3 million drill known as TOPOFF was held to test the readiness of top government officials to respond to multiple unconventional terrorist attacks; mock civil unrest unfolded in one scenario as people, learning of a plague attack, scrambled to get scarce life-saving antibiotics.¹⁶ Rioting, self-serving, panic-stricken mobs, too, were featured in the June 2001 Dark Winter Exercise, in which 12 former senior officials simulated National Security Council deliberations in reaction to a covert smallpox attack and a vaccine shortage.¹⁷ Among the information “briefed” to tabletop participants was a mock news report on violence erupting at vaccination sites, with one riot in Philadelphia leaving 2 people dead.¹⁷

Arguably, by anticipating the adverse reactions of the public to bioterrorism, authorities could better consider ways to reduce their occurrence and severity.^11-14 Nonetheless, an exclusive focus on negative psychosocial impacts possibly fostered expectations that these constituted the population's prevailing response.⁶ Scenario typecasting of citizens in one-dimensional roles—as mass casualties or as panicked mobs fleeing stricken areas or obtaining scarce medical resources through violence—might have prepared policymakers and emergency professionals for the “worst,” encouraging them to think through every contingency.⁶ Yet, such plotlines did not likely inspire thoughtful planning for people's adaptive, pro-social reactions. Instead, they may have helped perpetuate an image of the public as consumed by antisocial behavior, something refuted by extensive sociological research into natural and technical disasters^18-20 and by detailed accounts of infectious disease outbreaks.^21-23

Able Volunteer

Whatever notions policymakers and emergency professionals may have held about public reactions to hypothetical biological and catastrophic terrorist attacks, they were confronted with very real events and behaviors in the fall of 2001.

Social cohesion rather than social disarray characterized public reactions even before the World Trade Center (WTC) twin towers collapsed. An estimated 17,400 people were in WTC Towers 1 and 2 at the time the attacks occurred, and more than 14,000 were estimated to have successfully evacuated the buildings.²⁴ The congressionally mandated study of the WTC evacuation indicated that fully 99% of the occupants below the floors of impact successfully evacuated²⁵—this despite inconsistent instructions.²⁶ Evacuees most frequently cited assistance from co-workers, emergency responders, and photo-luminescent markings in the stairwell as aiding their departure.²⁵ Indeed, individuals risked their own lives assisting mobility-impaired colleagues.²⁵ Gathering personal items (eg, keys, files), searching for a friend or co-worker, and making sure that others were able to leave were the first actions people most often took before deciding to leave the buildings.²⁶

Creative coping and mutual aid similarly marked collective behavior as lower Manhattan residents and commuters sought refuge from the destruction and the polluted and suffocating air. Immediately after the attack, members of the tenants' association for the Independence Plaza housing complex just north of the WTC towers self-organized to perform a critical public safety function when many police had been called away.⁶ These residents helped orient and direct the streams of people running away from the collapsed structures through the Independence Plaza area. By 11:00 am, every manner of watercraft (eg, ferries, tour and dinner boats, private pleasure craft, tugs, outboard runabouts, pilot boats, oil response vessels) had begun to converge on the shoreline of lower Manhattan—some of their own accord, some at the Coast Guard's request—ready to transport evacuees elsewhere.²⁷ This ad hoc fleet moved at least 300,000 persons, and perhaps as many as 500,000, without any casualties or accidents in a matter of 6 to 7 hours.²⁷ Photo and video documentation of the event showed thousands of civilians calmly waiting their turn and helping one another to climb into waiting craft.²⁷

The catastrophic destruction and loss of life, the broad exposure provided to the tragedy via televised reports, and the national security implications of a terrorist attack triggered immense levels of volunteerism and charitable giving.²⁸ In New York City, those who could converged on the scene of disaster to aid the search-and-rescue efforts and the longer-term recovery; others did what they could from afar.^6,28,29 On September 11, an estimated 500 potential blood donors arrived at St. Vincent's Hospital and Medical Center, the trauma facility nearest to Ground Zero, and organized themselves by blood type using makeshift cardboard signs.^6,30 In the following weeks, national blood collection rates were several times their normal levels, with first-time donors accounting for 50% of all contributions, in comparison to the usual 20%.^6,31 Two weeks after the attacks, 59% of Americans—and a higher percentage of New Yorkers—reported that they had donated or attempted to donate blood, made charitable donations, and/or performed extra volunteer work.³²

Volunteerism in New York City demonstrated people's resourcefulness in organizing humanitarian efforts. Unions, churches, tenant associations, professional societies, businesses, and many other non-disaster groups used their existing communication and organizational structures to channel a collective desire to help.^6,28,33 The American Red Cross (ARC) and the Salvation Army also activated their trained, highly structured disaster volunteer membership and coordinated with unaffiliated individuals who wanted to help.⁶ By 2½ weeks after the attacks, the Red Cross had approximately 22,000 offers of assistance and had processed 15,570 volunteers.²⁹ ARC and affiliate groups such as the Church of the Brethren supported the Disaster Assistance Service Center, which aided displaced families and workers; the Family Assistance Center, which offered resources to families of the missing and deceased; and the Respite Centers that provided food and resting places for rescue workers at Ground Zero.²⁹

As a result of this national burst of volunteer spirit, President George W. Bush announced in his 2002 State of the Union address the creation of the USA Freedom Corps—a vehicle “to connect Americans with more opportunities to serve their country and to foster a culture of citizenship, responsibility, and service.”³⁴ Part of this initiative, the Citizen Corps, was launched to facilitate individuals' contributions to the safety and security of their hometowns. Citizen Corps Councils—local coordinating bodies to bring together leaders from government, businesses, nonprofits, advocacy groups, and faith and community organizations—were a new platform to develop community emergency plans, encourage volunteerism via federal partner programs, conduct public outreach and education, and offer training and participation in exercises.³⁵ Citizen Corps volunteer programs today include the Fire Corps, Volunteers in Police Service (VIPS), USAonWatch-Neighborhood Watch, and the Community Emergency Response Team (CERT) and Medical Reserve Corps (MRC) programs.³⁵

The concept of an MRC program—which, as of December 2011, included a national network of 973 units and 203,673 volunteers³⁶—originally grew out of the experience of a cadre of medical volunteers responding to the NYC mayor's request for physicians to help at Ground Zero.³⁷ They arrived at the chaotic Stuyvesant Triage Center (normally a school), organized themselves, and began to triage and treat injured search and rescue workers. From this grew the idea that the city and perhaps the nation could use trained and prepared volunteers to supplement emergency medical and public health response efforts. This compelling notion, coupled with the realization during the soon-to-follow anthrax attacks that any large-scale mass dispensing/mass vaccination would require volunteers, was the impetus for the MRC's formation.³⁷ Since then, MRC volunteers—both medically and non-medically trained—have played important roles during disasters including Hurricanes Katrina, Rita, Gustav, and Ike,³⁸ and during more routine public health events like immunization drives, health fairs, and screenings for high blood pressure and kidney disease.³⁹

Attuned Audience

The pro-social, problem-solving stance of most people in reaction to the WTC and Pentagon attacks belied expectations of social mayhem and self-serving behavior in the context of catastrophic terrorism. Communication failures on the part of authorities during the response to the soon-to-follow anthrax letter attacks further called into question the prevailing notion of the public as a panicky mob. That is, the hard-earned lesson from the fall of 2001 that sharing timely, substantive information with the public is essential to outbreak containment helped shift thinking of the public from a problem to be managed to a constituency to be served: anxious people understandably in need of knowledge about what the danger is and what to do about it.

Shocked by evidence of vulnerability to attack, alerted to the possibility of future hostility, and confronted by the devastation and disruption of terrorism, many people wondered following the 9/11 attacks what to expect and what they and the government should do about a possible bioattack.⁶ Despite the public's strong appetite for authoritative and personally relevant knowledge, however, political and public health officials engaged in a restrained communications campaign at the outset of the anthrax crisis.^40,41 Predicated on the need to avoid panic, this approach unintentionally diminished the credibility of some officials. The iconic failure, and that which initiated a steady stream of criticism beginning in late September, was over-reassurance by the Secretary of HHS on government readiness to handle a biological attack, as well as underestimation of the significance of the first anthrax death.^40,41

Other communication missteps during the anthrax response, which have been detailed and debated elsewhere, included the absence early on in the crisis of highly visible spokespersons expert in the medical and public health implications of the unfolding bioterrorist incident; the initial void of information for civilians on how to cope with the threat of additional terrorist attacks; the shifting of public health protocols regarding patient screening and prophylaxis, with insufficient transparency in the reasons why; the lack of robust linkages between the public health sector and private physicians, the experts to whom many people turned for protective guidance; and insufficient sensitivity to the complex trust factors arising in public health interactions with minority members of the postal workforce.^41-45

As a result, a number of critical analyses and guidebooks for officials on successful communications with the media and the larger public began to emerge in the wake of the anthrax letter attacks. In 2002, the Substance Abuse and Mental Health Service Administration released Communicating in a Crisis: Risk Communication Guidelines for Public Officials.⁴⁶ That same year, the Centers for Disease Control and Prevention (CDC) released Crisis and Emergency Risk Communication, the core text of a training course—now much expanded—for state and local health public information officers, first responders, healthcare professionals, and others.⁴⁷ A robust academic literature evaluating the communication practices and challenges of the anthrax response, as well as proposing “lessons learned” and “best practices” for the future, was also established.^48,49

Also, in response to the events of 2001, the federal government took swift and strong measures to reinvigorate the U.S. public health infrastructure by way of the Public Health Security and Bioterrorism Preparedness and Response Act of 2002.⁵⁰ This act established the system of federal grants to state and local health departments to upgrade their readiness and response capabilities for bioterrorism and other public health emergencies. In the CDC guidance issued with this funding, “risk communication and health information dissemination” were singled out as 1 of 7 priorities for practitioners.⁵¹

Underscoring the health security role of an informed public was the nation's first biodefense strategy, Homeland Security Presidential Directive 10: Biodefense for the 21st Century (HSPD-10).⁵² Released in April 2004, HSPD-10 argued that “[t]imely communication with the public … can significantly influence the success of response efforts including health- and life-sustaining interventions.”⁵² The reauthorizing legislation for the federal preparedness grants (ie, the Pandemic and All Hazards Preparedness Act of 2006, or PAHPA) reaffirmed that same role by naming risk communication and public preparedness as “essential public health security capabilities.”⁵³

Practical investments in improved risk communication capability made their mark over the long term. The response to the 2009 H1N1 influenza pandemic suggested a significant break from the prevailing communication practices during the anthrax scare when guidance on citizen protective measures was judged late in coming and inscrutable when it did.^54,55 During the pandemic, the U.S. government relied on all manner of media to disseminate educational materials on preparedness and self-protection.^56,57 The GAO found that, according to public surveys and its poll among state officials and professional associations, CDC's pandemic public communication campaign was largely considered effective.⁵⁸

Agency officials attributed this in part to the decision to be transparent and open with the public about both known and unknown information.⁵⁸ Another study revealed that a majority of state and local health departments provided online information about the H1N1 pandemic within 24 hours of the declaration of a public health emergency, with smaller local health departments being the least successful in this effort.⁵⁹ Nonetheless, significant gaps remained in the ability of public health officials to reach minority segments of the population at risk for increased morbidity and mortality during the pandemic.^60,61

Self-Reliant Stockpiler

Another notional public emerging in the aftermath of fall 2001 was the self-reliant stockpiler: individuals prepared to take care of themselves and their families by putting together a plan and emergency “kit” and by becoming versed in unconventional threats and self-protective actions. Storing essential goods and being self-sufficient until the professionals arrive have long been tenets in the fields of emergency management and civil defense.^8-10 The extraordinary events of 2001, however, heightened the perceived urgency of this advice, both generally and in the context of WMD terrorism. In fact, in the aftermath of the 9/11 attacks, all levels of government, but especially the federal government, were highly criticized for the initial void of official guidance on civilian self-protection—a void that existed despite government warnings about the potential for additional terrorist attacks.^54,55,62

Inhibiting some officials from issuing clearer guidance on terrorism-related personal preparedness and response measures was worry that doing so would instigate public panic and undercut the political message that the government was doing everything it could to protect the country.^55,62 One Washington Post reporter, driven by her own search for authoritative guidance and by reader demand, queried contacts at HHS and FEMA about what “the average citizen should do to prepare.”⁵⁵ During her investigation, she asked Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, who had emerged as a medically authoritative voice during the anthrax scare, “Why doesn't the government tell us more?” In his reply, he explained, “There is a delicate balance between the government giving guidance and alarming people into a state of paralytic anxiety.”⁵⁵ Such a dilemma—no doubt seen as genuine by many authorities—nonetheless was based on unsubstantiated fear, given what is known about actual behavior and communication needs in a crisis.^18-20

In light of the U.S. government's perceived reticence to lead the development and delivery of authoritative guidance on citizen preparedness, others stepped in—many with Alfred P. Sloan Foundation support. In 2002, Senator Bill Frist released his own practical guidebook for the public, When Every Moment Counts: What You Need to Know about Bioterrorism from the Senate's Only Doctor.⁶³ Sponsored by Sloan, RAND carried out a study to develop guidance for average citizens to complement terrorism readiness efforts at local and federal levels.⁶⁴ The final text, released in 2003, Individual Preparedness and Response to Chemical, Radiological, Nuclear, and Biological Terrorist Attacks, was accompanied by a “quick guide” and portable reference card.⁶⁴ Another Sloan grantee, the Center for Strategic and International Studies, issued strategic recommendations in 2003 on “civil security”—that is, the “ability of Americans to recognize danger, limit damage, and recover from terrorist attacks,” along with a detailed catalogue of personal protective actions.⁶⁵

February 2003 marked the launch of “Ready,” a national public service advertising campaign and website (www.ready.gov), the result of a collaborative effort among DHS, the Advertising Council, and the Sloan Foundation to “educate and empower American citizens to prepare for and respond to potential future terrorist attacks.”⁶⁶ Ready.gov has since grown in mission, now addressing natural, technological, and terrorist hazards; advising on the full disaster cycle including recovery; reaching a broad audience across 12 different languages; readying businesses; and providing materials for children. Advance planning and self-reliance are now applied to the whole of civil society and commercial enterprise. In 2006, the National Strategy for Pandemic Influenza: Implementation Plan provided preparedness checklists for individuals, families, businesses, schools, and faith- and community-based organizations.⁶⁷ In 2008, as a result of 9/11 Commission findings, DHS moved to establish common criteria for private sector preparedness and a voluntary certification program now known as PS-Prep.⁶⁸

Since 2001, pollsters, researchers, and emergency professionals have steadily queried Americans as to whether they have taken basic steps to prepare for the unexpected; these professionals also have investigated motivators and barriers to citizen preparedness.⁶⁹ Even the dramatic consequences of Hurricanes Katrina and Rita, some surveys indicated, were not enough to raise the numbers of prepared citizens significantly.^70,71 In December 2006, to help reverse this trend, the Council for Excellence in Government released the Public Readiness Index and the online RQ (Readiness Quotient) Test, developed in collaboration with DHS, the American Red Cross, and the Sloan Foundation.⁷² With a simple measurement tool, the developers argued, citizens could independently assess their preparedness, recognize their accomplishments, and set goals where more effort was needed.⁷²

Exhortations on individual and family preparedness, nonetheless, have had uneven success. Behavioral experts note that many people believe that a disaster will not really happen, and if it does, it will happen to other people. People's perceptions of “being safe” are reinforced every day that a disaster does not occur, undercutting any incentive to prepare.⁷³ Historical evidence suggests, in fact, that experiencing a disaster may be the strongest motivator for people to prepare.⁷³ At the same time, federal calls for citizens to prepare have been met with some skepticism, as indicated by the comedic ridicule directed at DHS Secretary Tom Ridge in 2003 for encouraging people to stock up on duct tape and plastic sheeting to seal windows in case of a biological or chemical attack⁷⁴ and at HHS Secretary Mike Leavitt in 2006 for advising people to put cans of tuna and powdered milk under their beds to prepare for an influenza pandemic.⁷⁵

Despite some cause for derision, reasonable arguments still support the idea of a public equipped to make do on its own. Becoming more knowledgeable about unconventional threats may reduce the shock value of otherwise dread-inducing hazards such as chemical, biological, and radiological weapons.¹¹ Family emergency plans target a meaningful solution to the worry and uncertainty about the welfare of loved ones in disasters. Gathering flashlight, crank radio, nonperishable foods, routine medications, and other “basics” is a human-scaled task with real material value, depending on the circumstances.⁷⁶ Lastly, every self-sufficient individual and household eases the burden of emergency professionals who have to protect an entire population, allowing them to target resources to those most in need.⁷⁷

Policymaking Partner

The initial view of the public in the context of a biological attack as, at best, getting in the way of the professionals and, at worst, constituting a secondary disaster, was in keeping with much of the thinking in the history of North American civil defense as a quasimilitary activity. As such, the organizational emphasis had been on a chain of command among authorized personnel and on centralized decision making and communications.^78,79 Disaster planning, by and large, was seen as something done for, not with the community.^79-81

At the same time, the risk communication model promoted in the wake of the anthrax scare was reminiscent of a command-and-control approach. How state and local health agencies spent their preparedness grants suggested an understanding of the public as a passive receptor for directives issued by knowing officials and channeled by mass media. Surveys of health departments indicated that the preparedness grants early on had supported the hiring of public information officers to interface with journalists and the training of designated spokespersons in risk communication.^82-84 As one public health preparedness observer noted, however, much still remained to be done in terms of building direct, long-term relationships with the public, businesses, and faith-based organizations.⁸⁵

The concept of the public as policymaking partner grew alongside and in many respects in reaction to the idea of the public as merely the recipient of government directions. The Working Group on “Governance Dilemmas” in Bioterrorism Response, convened by the Johns Hopkins Center for Civilian Biodefense Studies in 2003 with Sloan and DHS support, encouraged authorities to support the public's own active role in remedying a health emergency and to situate public communications within a broader understanding of the societal dilemmas that could be anticipated with bioattacks, based on past epidemics.⁸⁶ Among the group's charge to governors, mayors, and health officers was “… approaching the public as a capable ally, not a problem that needs managing; keeping response transparent through open channels with the media and a community's other trusted sources; prioritizing voluntary compliance among the many over coercion of the few; advancing equity in access to emergency resources; [and] sharing difficult decisions when they arise. …”^86(p36)

Similarly, in 2004, the New York Academy of Medicine's Redefining Readiness study argued that emergency planners had been focusing a great deal on public education and risk communication but not sufficiently listening to the public about its own concerns, priorities, and potential barriers to acting on government instructions.⁸⁷ Study findings suggested that current planning assumptions about public reactions to a smallpox outbreak or dirty bomb explosion did not reflect people's experiences and perspectives and that greater inclusion of the American public in terrorism preparedness plans was necessary.⁸⁷ The initiative developed community demonstration projects as well as a suite of practical tools through which residents could contribute their essential knowledge to emergency preparedness efforts.⁸⁸

Public inclusion and community-based collaboration in emergency planning efforts, too, were the goals of the Ready, Willing, and Able Act (HR 3565), federal legislation introduced by mental health advocate Rep. Patrick J. Kennedy (D-RI) in July 2005 and then again as HR 1891 in April 2007.^89,90 Drafted and promoted with the support of staffer Michael Barnett, a psychiatrist, the act laid out the empirical evidence for public resilience in disasters as well as strategic plans for “the American public to have a direct and influential role in developing and reviewing community disaster preparedness, response, recovery, and mitigation plans. …”⁸⁹ Unfortunately, the bill did not advance far.

The devastating impacts of Hurricanes Katrina and Rita in 2005 underscored the importance of assuring the social acceptance and practical feasibility of emergency plans to protect the population, especially groups proven to be more vulnerable in disasters. For instance, the highway-based evacuation plan for New Orleans was, on the one hand, considered a major success in that more people were able to leave the city in a shorter time than was thought possible.⁹¹ On the other, many people in low-mobility groups were stranded—namely, the poor, the socially isolated, and the frail; those with no car, no money for gas to fuel a car, or no license or insurance to rent a car; those who were worried about losing a job if they left town; those who were not poised to receive and interpret warnings; and those who were elderly or frail or who had to care for an elderly or frail person.^91,92

Having witnessed the shocking and broad effects of Hurricane Katrina, public health professionals took actions they hoped would prevent the disproportionate impact of future disasters. Public Health Seattle and King County (WA), for example, established the Vulnerable Populations Action Team (VPAT) in 2006 to work collaboratively with community-based organizations that serve vulnerable populations to ensure the continuity of this safety net in emergencies, to exchange emergency information with hard-to-reach populations, and to advocate on behalf of vulnerable groups for greater consideration in emergency preparedness.⁹³

In 2006, at the federal level, health policy staff in Senator Lieberman's (I-CT) office prepared the draft bill, the Public Health Emergency Preparedness Community Engagement Act, “to improve public involvement in preparedness for and response to bioterrorism and other public health emergencies and disasters.” Among the bill's objectives was disbursing community engagement practices and training grants that would help strengthen state and local disaster planning for special needs populations. While the bill was never introduced, the analytic and advocacy efforts behind it led to a successful amendment to PAHPA creating the Office of At-Risk Individuals under the new HHS Assistant Secretary for Preparedness and Response. This office was charged with advising public health agencies on the needs of at-risk individuals in federal, state, and local preparedness and response strategies.⁹⁴

In the wake of Katrina, public health officials also stepped up efforts to address the enhanced risk of certain subgroups to the effects of a potential pandemic influenza, the national planning for which was already under way. In 2007, with support from CDC, the Association for State and Territorial Health Officials began developing model guidance on the protection of vulnerable populations in a pandemic, relying on input from public engagement meetings with members of at-risk populations and their service providers and with national organizations working with at-risk populations.⁹⁵ A top planning recommendation was “collaboration with and engagement of at-risk populations”—that is, ensuring that “at-risk individuals shape the pandemic influenza planning and policies that affect their lives.”^95(pp3-4)

Pandemic flu planning, in contrast to early bioterrorism response planning, was marked by strong arguments for providing members of the public with the opportunity to weigh in on key preparedness policy decisions—in particular, those with a strong ethical component.^96-98 Collaborative problem solving on federal health policy in the pandemic flu context was piloted in the form of public deliberations among citizens at-large and national stakeholders in 2005 about the best, early use of limited vaccine⁹⁹ and in 2006 about the economic and social tradeoffs associated with community mitigation measures.¹⁰⁰ Select state and local jurisdictions also conducted their own public engagement exercises,^101,102 some funded with federal preparedness funds explicitly set aside to implement promising practices for involving the public in the policymaking process.¹⁰³

Resilient Survivor

Though perhaps not yet conventional wisdom among all practitioners and policymakers, the idea that the U.S. public plays an essential role in disaster and epidemics and has a rightful claim on the direction of emergency plans has still managed to crowd out earlier assumptions of the public as panicky, selfish, disorderly, and potentially violent. In fact, key federal documents on emergency preparedness, response, and recovery policy increasingly have embraced the notion of community resilience, the capacity of people to adapt to and “bounce back” after a major disruptive or destructive event. A burgeoning literature on resilience^104-107 is making its way into policymaking circles, now eager to enlist individuals, civil society, and private industry in the larger societal effort to reduce disaster-related losses. (Nonetheless, some adherents to the panic myth may continue to hold out, especially when doing so serves institutional interests.^108,109)

Released in October of 2007, Homeland Security Presidential Directive 21: National Strategy for Public Health and Medical Preparedness (HSPD-21) identified community resilience as one of the “four most critical components of public health and medical preparedness,” alongside biosurveillance, countermeasure distribution, and mass casualty care.¹¹⁰ Community resilience was 1 of the 2 top goals in the 2009 National Health Security Strategy,¹ the implementation plan for which saw strength in:

• Community members, including at-risk groups, who are knowledgeable about health threats, what to do, and where to seek out help;

• Faith-based organizations, private businesses, and NGOs with community ties that are integrated into emergency planning; and

• Social networks that are adept at disseminating risk information and aiding community members in response and recovery.²

In March 2011, the CDC issued Public Health Preparedness Capabilities: National Standards for State and Local Planning to aid state and local health departments when forming strategic plans, setting priorities, and measuring progress.¹¹¹ At least 4 of the 15 capabilities related to citizen and civil society contributions, with “community preparedness” (a named “community resilience” capability) presenting the most robust agenda. Among the steps to strengthen this capability, state and local planners were advised to: (1) convene coalitions that include business as well as community- and faith-based partners; (2) incorporate community input into emergency operations plans and into problem-solving sessions; (3) provide occasions for volunteers to participate in safety efforts year round and to help maintain health services during an incident; and (4) identify community leaders who can serve as trusted spokespersons to deliver public health messages.

Conclusion: What's Next?

Though present doctrine supports the idea of community resilience to a health emergency, the potential still exists for the strong return of thinking about people as an unstable menace to suppress. In spite of accumulated evidence to the contrary, belief in mass panic and social breakdown in disasters and epidemics lingers in the U.S., fueled in part by Hollywood blockbusters and distorted news reports on disaster behaviors.^112,113 The latest incarnation of such imagery exists in Contagion, a heavily viewed 2011 film that has been lauded by some health authorities as having a strong scientific base.¹¹⁴ While the depictions of viral mutation and epidemiology may ring true, the societal response does not. Such exaggerations of mayhem and violence are problematic not simply because they are erroneous, but because belief in them has the potential to influence individual, organizational, and government responses.¹¹² Coercive forms of epidemic management become defensible when people are defined as a problem to control, rather than an ally in caring for the sick and preventing the spread of disease.^115,116

If, as the National Health Security Strategy sets forth, community resilience is 1 of the country's 2 top health security goals, then we need to recommit to strengthening the public health infrastructure, this time with an emphasis on hiring, training, and assigning sufficient staff to partner with the public in emergency preparedness, response, and recovery. No other public health preparedness capability—whether biosurveillance, medical countermeasure dispensing, or medical surge—is treated as if it were an organic process that will somehow happen on its own.¹¹⁷ The March 2011 Public Health Preparedness Capabilities guidance charts a good path forward. Yet, enough dedicated people—with leadership's support—are still needed to develop an engagement strategy, cultivate relationships with community- and faith-based groups, conduct broad public outreach and communication, mobilize volunteers, and involve the public in preparedness policymaking. Now that a consensus has seemingly emerged around what constitutes a genuine role for citizens in a public health emergency, the country must move forward in expanding the institutional base to realize this vision.

References

U.S. Department of Health and Human Services. National Health Security Strategy. December 2009. http://www.phe.gov/Preparedness/planning/authority/nhss/strategy/Documents/nhss-final.pdf. 2011 December 15.

U.S. Department of Health and Human Services. Biennial Implementation Plan for the National Health Security Strategy of the United States of America - Draft. July 2010. http://www.phe.gov/Preparedness/planning/authority/nhss/comments/Documents/nhssbip-draft-100719.pdf. 2011 December 15.

The White House. National Security Strategy. May 2010. http://www.whitehouse.gov/sites/default/files/rss_viewer/national_security_strategy.pdf. 2011 December 7.

Leggiere

. Napolitano: public resilience is key. HSToday, April 19, 2010. http://www.hstoday.us/focused-topics/cybersecurity/single-article-page/napolitano-public-resilience-is-key/3acb0da147709efc825af4401d2c23dd.html. 2011 December 7.

Leggiere

. Fugate outlines first national preparedness goal. HSToday, October 12, 2011. http://www.hstoday.us/channels/fema/single-article-page/fugate-outlines-first-national-preparedness-goal.html. 2011 December 7.

Schoch-Spana

. Educating, informing and mobilizing the public. Levy

, Sidel

. Terrorism and Public Health. New York: Oxford University Press, 2003; 118–135.

Taylor

. Are we prepared for terrorism using weapons of mass destruction: government's half measures. Policy Anal, 2000; 387:1–19.

Oakes

. The Imaginary War: Civil Defense and American Cold War Culture. New York: Oxford University Press, 1994.

Grossman

. Neither Dead nor Red: Civilian Defense and American Political Development during the Early Cold War. New York: Routledge Press, 2001.

10.

McEnaney

. Civil Defense Begins at Home: Militarization Meets Everyday Life in the Fifties. Princeton, NJ: Princeton University Press, 2000.

11.

Holloway

, Norwood

, Fullerton

et al. The threat of biological weapons: prophylaxis and mitigation of psychological and social consequences. JAMA, 1997; 278,5:425–427.

12.

DiGiovanni

. Domestic terrorism with chemical or biological agents: psychiatric aspects. Am J Psychiatry, 1999; 156,10:1500–1505.

13.

Ursano

. Planning for Bioterrorism: Behavioral and Mental Health Responses to Weapons of Mass Destruction and Mass Disruption. Bethesda, MD: Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, 2001. http://www.dtic.mil/cgi-bin/GetTRDoc?Location=U2&doc=GetTRDoc.pdf&AD=ADA392688. 2011 December 8.

14.

Defense Threat Reduction Agency, Federal Bureau of Investigation, and U.S. Joint Forces Command. Human behavior and WMD crisis/risk communication workshop. Final Report, March 2001. http://www.au.af.mil/au/awc/awcgate/dtra/human-behavior-wmd.pdf. 2011 December 8.

15.

ABC News. Biowar (transcript) Nightline, October 1 5-8. 1999.

16.

Inglesby

, Grossman

, O'Toole

. A plague on your city: observations from TOPOFF. Clin Infect Dis, 2001; 32,3:436–445.

17.

Dark Winter. Bioterrorism Exercise. Andrews Air Force Base June 22-23, 2001. Final script. Johns Hopkins Center for Civilian Biodefense, Center for Strategic and International Studies, ANSER, and Memorial Institute for the Prevention of Terrorism. http://www.homelandsecurity.org/darkwinter/docs/DARK_WINTER.pdf. 2011 December 8.

18.

Quarantelli

. The sociology of panic. Smelser

, Bates

. International Encyclopedia of the Social and Behavioral Sciences. New York: Pergamon, 2001; 11020–11030.

19.

Fischer

. Response to Disaster: Fact Versus Fiction and Its Perpetuation, 2nd. Lanham, MD: University Press of America, 1998.

20.

National Research Council. Facing Hazards and Disasters: Understanding Human Dimensions. Washington, DC: National Academies Press, 2006.

21.

Oshinski

. Polio: An American Story. New York: Oxford University Press, 2006.

22.

Crosby

. America's Forgotten Pandemic: The Influenza of 1918. Cambridge, UK: Cambridge University Press, 2003.

23.

Jonsen

, Stryker

. The Social Impact of AIDS in the United States. Washington, DC: National Academy Press, 1993.

24.

Gershon

RRM

, Qureshi

, Rubin

et al. Factors associated with high-rise evacuation: qualitative results from the World Trade Center evacuation study. Prehosp Disaster Med, 2007; 22,3:165–173.

25.

Averill

, Mileti

, Peacock

et al. Federal Building and Fire Safety Investigation of the World Trade Center Disaster: Occupant Behavior, Egress, and Emergency Communications. NIST NCSTAR, 1–7. Washington, DC: U.S. Department of Commerce, September 2005. http://fire.nist.gov/bfrlpubs/fire05/PDF/f05120.pdf. 2011 December 9.

26.

Zimmerman

, Sherman

. To leave an area after disaster: how evacuees from the WTC buildings left the WTC area following the attacks. Risk Anal, 2011; 31,5:787–804.

27.

Kendra

, Wachtendorf

, Quarantelli

. Who was in charge of the massive evacuation of lower Manhattan by water transport on September 11? No one was, yet it was an extremely successful operation. Implications? Securitas, Sep/Oct 2002; 1,5 http://www.semp.us/publications/securitas_reader.php?SecuritasID=5. 2011 December 9.

28.

Kendra

, Wachtendorf

. Rebel food…renegade supplies: convergence after the World Trade Center attack. Preliminary Paper #316. University of Delaware Disaster Research Center. 2001(revised December 13, 2004)http://dspace.udel.edu:8080/dspace/bitstream/handle/19716/708/PP%20316%20.pdf?sequence=5. 2011 December 9.

29.

Lowe

, Fothergill

. A need to help: emergency volunteer behavior after September 11th. Beyond September 11th: An Account of Post-Disaster Research. Special Publication No. 39. Natural Hazards Research and Applications Information Center, Public Entity Risk Institute, and Institute for Civil Infrastructure Systems. Boulder, CO: Natural Hazards Research and Applications Information Center, University of Colorado, 2003; 293–314.

30.

Becker

, Galloro

. An overwhelming response; within hours of disaster, medical supplies were on their way to NY, DC. Mod Healthc, September 17, 2001; 31,38:18–19.

31.

Villarosa

. A nation challenged: the volunteers; out to do good, some first-time blood donors get bad news. New York Times, December 20, 2001. http://www.nytimes.com/2001/12/20/us/nation-challenged-volunteers-good-some-first-time-blood-donors-get-bad.html. 2011 December 15.

32.

Smith

, Rasinski

, Toce

. America rebounds: a national study of public response to the September 11th terrorist attacks—preliminary findings. October 25, 2001. National Opinion Research Center, University of Chicago http://www3.norc.org/NR/rdonlyres/FFADA257-1D4C-4A69-B180-ED2FD614D3FA/0/SmithT_America_Rebounds_2001.pdf. 2011 December 10.

33.

Sutton

. A complex organizational adaptation to the World Trade Center disaster: an analysis of faith-based organizations. Beyond September 11th: An Account of Post-Disaster Research. Natural Hazards Research and Applications Information Center, Public Entity Risk Institute, and Institute for Civil Infrastructure Systems. Special Publication No. 39. Boulder, CO: Natural Hazards Research and Applications Information Center, University of Colorado, 2003; 405–428.

34.

The White House. The Bush Record—USA Freedom Corps: strengthening service to meet community needs. http://georgewbush-whitehouse.archives.gov/infocus/bushrecord/factsheets/needs.html. 2011 December 10.

35.

Federal Emergency Management Agency. Citizen Corps: A Guide for Local OfficialsRevised October 2011http://www.citizencorps.gov/downloads/pdf/councils/FEMAReport2011.pdf. 2011 December 15.

36.

Medical Reserve Corps. http://www.medicalreservecorps.gov/HomePage. 2011 December 10.

37.

A brief history of the Medical Reserve Corps—fact sheet. Washington, DC: NACCHO, August 2011. http://www.uwmidlands.org/pdf/mrchistory.pdf. 2011 December 10.

38.

Frasca

. The Medical Reserve Corps as part of the federal medical and public health response in disaster settings. Biosecur Bioterror, 2010; 8,3:265–271.

39.

Middleton

. Medical Reserve Corps: engaging volunteers in public health preparedness and response. Biosecur Bioterror, 2008; 6,4:359–360.

40.

Schwartz

. The truth hurts; efforts to calm the nation's fears spin out of control. New York Times, October 28, 2001. http://www.nytimes.com/2001/10/28/weekinreview/the-truth-hurts-efforts-to-calm-the-nation-s-fears-spin-out-of-control.html?pagewanted=all. 2011 December 11.

41.

Thomas

. The Century Foundation's Homeland Security Project Working Group on the Public's Need to Know. The Anthrax Attacks. New York: Century Foundation, 2003. http://911investigations.net/IMG/pdf/doc-1387.pdf. 2011 December 11.

42.

Chess

, Calia

, O'Neill

. Communication triage: an anthrax case study. Biosecur Bioterror, 2004; 2,2:106–111.

43.

Stein

, Tanielian

, Ryan

et al. A bitter pill to swallow: nonadherence with prophylactic antibiotics during the anthrax attacks and the role of private physicians. Biosecur Bioterror, 2004; 2,3:175–185.

44.

Quinn

, Thomas

, McAllister

. Postal workers' perspectives on communication during the anthrax attack. Biosecur Bioterror, 2005; 3,3:207–215.

45.

Blanchard

, Hayword

, Stein

et al. In their own words: lessons learned from those exposed to anthrax. Am J Public Health, 2005; 95,3:489–495.

46.

U.S. Department of Health and Human Services. Communicating in a Crisis: Risk Communication Guidelines for Public Officials. Washington, DC: Department of Health and Human Services, 2002. http://www.hhs.gov/od/documents/RiskCommunication.pdf. 2011 December 11.

47.

U.S. Centers for Disease Control and Prevention. Crisis and Emergency Risk Communication. Atlanta, GA: Centers for Disease Control and Prevention, September 2002. http://www.bt.cdc.gov/cerc/pdf/CERC-SEPT02.pdf. 2011 December 11.

48.

Kennedy

. Public health communication during the September 2001 bioterrorism-related anthrax outbreaks. J Health Commun, 2003; 8,Suppl 1.

49.

Glik

. Risk communication for public health emergencies. Annu Rev Public Health April, 2007; 28:33–54.

50.

Public Health Security and Bioterrorism Preparedness and Response Act of 2002Pub. L. No. 107-188, 107th Cong.June 12, 2002. http://www.gpo.gov/fdsys/pkg/PLAW-107publ188/pdf/PLAW-107publ188.pdf. 2011 December 11.

51.

U.S. Centers for Disease Control and Prevention. Continuation Guidance for Cooperative Agreement on Public Health Preparedness and Response for Bioterrorism - Budget Year Five Program (Announcement 99051) June 14, 2004. http://www.bt.cdc.gov/planning/continuationguidance/pdf/guidance_intro.pdf. 2012 February 29.

52.

U.S. Department of Homeland Security. Homeland Security Presidential Directive 10: Biodefense for the 21st Century. April 2004. http://www.dhs.gov/xabout/laws/gc_1217605824325.shtm#1. 2011 December 11.

53.

Pandemic and All Hazards Preparedness Act. Pub. L. 109-417, 120 Stat. 2831 December 19, 2006. http://www.phe.gov/Preparedness/legal/boards/nbsb/Documents/Public%20Law%20109-417.pdf. 2011 December 11.

54.

Quinn

. What we need to know. Washington Post, October 3, 2001; A-31.

55.

Quinn

. I asked, but I couldn't find one. Washington Post, December 9, 2001; B-1.

56.

U.S. Department of Health and Human Services. Flu.gov http://www.pandemicflu.gov/. 2011 December 13.

57.

U.S. Centers for Disease Control and Prevention. The 2009 H1N1 Pandemic: Summary Highlights, April 2009-April 2010. http://www.cdc.gov/h1n1flu/cdcresponse.htm. 2011 December 13.

58.

U.S. Government Accountability Office. Influenza Pandemic: Lessons from the H1N1 Pandemic Should Be Incorporated into Future Planning. Washington, DC: U.S. Government Accountability Office, June 27, 2011. http://www.gao.gov/new.items/d11632.pdf. 2011 December .

59.

Ringel

, Trentacost

, Lurie

. How well did health departments communicate about risk at the start of the swine flu epidemic in 2009? Health Aff, Jul-Aug 2009; 28,4:w743–750.

60.

Quinn

, Kumar

, Freimuth

et al. Racial disparities in exposure, susceptibility, and access to health care in the US H1N1 influenza pandemic. Am J Public Health, 2011; 101,2:285–293.

61.

Plough

, Bristow

, Fielding

et al. Pandemics and health equity: lessons learned from the H1N1 response in Los Angeles County. J Public Health Manag Pract, 2011; 17,1:20–27.

62.

Gellman

. Government is slow to offer safety plans; local, national offices have yet to disclose advice people could use in a terrorist attack. Washington Post, August 6, 2002; A-1.

63.

Frist

. When Every Moment Counts: What You Need to Know About Bioterrorism from the Senate's Only Doctor. Lanham, MD: Rowman & Littlefield Publishers, 2002.

64.

Davis

, LaTourette

, Mosher

et al. Individual Preparedness and Response to Chemical, Radiological, Nuclear, and Biological Terrorist Attacks. Santa Monica, CA: RAND Public Safety & Justice, 2003.

65.

Dory

. Civil Security: Americans and the Challenge of Homeland Security. Washington, DC: Center for Strategic and International Studies, 2003.

66.

U.S. Department of Homeland Security. Department of Homeland Security launches citizen preparedness campaign [press release] February 19, 2003. http://www.dhs.gov/xnews/releases/press_release_0089.shtm. 2011 December 12.

67.

Homeland Security Council. National Strategy for Pandemic Influenza: Implementation Plan. May 2006. http://hosted.ap.org/specials/interactives/wdc/documents/pandemicinfluenza.pdf. 2011 December 13.

68.

U.S. Department of Homeland Security. Secretary Napolitano announces new standards for private sector preparedness [press release] June 15, 2010. http://www.dhs.gov/ynews/releases/pr_1276616888003.shtm. 2011 December 13.

69.

Citizen Corps. Citizen preparedness surveys database. http://www.citizencorps.gov/downloads/pdf/ready/Citizen%20Corps%20Survey%20Database%20May%202010.pdf. 2011 December 14.

70.

Light

. The Katrina effect on American preparedness. New York University Center for Catastrophe Preparedness and Response. November 2005. http://www.nyu.edu/ccpr/katrina-effect.pdf. 2011 December 12.

71.

Peter

. Hart Research and Public Opinion Strategies for the Council for Excellence in Government and the American Red Cross. The Aftershock of Katrina and Rita: Public Not Moved to Prepare, December 2005. http://www.volunteerwv.org/cerv/news/aftershock.pdf. 2011 December 12.

72.

Council for Excellence in Government. Are We Ready? Introducing the Public Readiness Index: A Survey-Based Tool to Measure the Preparedness of Individuals, Families and Communities. December 14, 2006. http://www.citizencorps.gov/downloads/pdf/ready/pri_report.pdf. 2011 December 12.

73.

Wood

, Mileti

, Kano

et al. Communicating actionable risk for terrorism and other hazards. Risk Anal, 2011, 10.1111/j.1539-6924.2011.01645.x[Epub ahead of print].

74.

Lichtblau

, Drew

. Ridge's record: color alerts and mixed security reviews. New York Times, December 1, 2004. http://www.nytimes.com/2004/12/01/politics/01home.html?_r=1&ref=tomridge. 2011 December 13.

75.

Leavitt

. Remarks as delivered on Public Health Emergency Medical Countermeasures Enterprise Stakeholders Workshop 2008 and BARDA Industry Day. September 24, 2008. http://www.hhs.gov/news/speech/2008/sp20080924a.html. 2011 December 13.

76.

Federal Emergency Management Agency. Are you ready? An in-depth guide to citizen preparedness. August 2004. http://www.ready.gov/are-you-ready-guide. 2011 December 14.

77.

Craig Fugate, “Post‐Katrina: What it Takes to Cut the Bureaucracy and Assure a More Rapid Response After a Catastrophic Disaster,” testimony before the House Committee on Transportation and Infrastructure, Subcommittee of Economic Development, Public Buildings and Emergency Management. U.S. House of Representatives: Washington, DC, July 27, 2009. http://www.fema.gov/pdf/about/testimony/072709_fugate.pdf. 2011 December 14.

78.

Dynes

. Community emergency planning: false assumptions and inappropriate analogies. Int J Mass Emerg Disasters, 1994; 12,2:141–158.

79.

Waugh

, Sylves

. Organizing the war on terrorism. Public Adm Rev, 2002; Special Issue:146–153.

80.

Lindell

. Are local emergency planning committees effective in developing community disaster preparedness? Int J Mass Emerg Disasters, 1994; 12,2:159–182.

81.

Pearce

. Disaster management and community planning, and public participation: how to achieve sustainable hazard mitigation. Natural Hazards, 2003; 28:211–228.

82.

Association of State and Territorial Health Officials. Public Health Preparedness: A Progress Report—The First Six Months. Washington, DC: ASTHO, 2003.

83.

Bashir

, Brown

, Dunkle

, Kaba

, McCarthy

. The impact of federal funding on local bioterrorism preparedness. J Public Health Manag Pract, 2004; 10,5:475–478.

84.

Hyde

, Kim

, Martinez

, Clark

, Hacker

. Better prepared but spread too thin: the impact of emergency preparedness funding on local public health. Disaster Manag Response, 2006; 4,4:106–113.

85.

Fraser

. After 5 years of public health preparedness, are we ready yet? J Public Health Manag Pract, 2007; 13,1:3–6.

86.

Working Group on “Governance Dilemmas” in Bioterrorist Response. Leading during bioattacks with the public's trust and help. Biosecur Bioterror, 2004; 2,1:25–40.

87.

Lasker

. Redefining Readiness; Terrorism Planning Through the Eyes of the Public. New York: New York Academy of Medicine, 2004. http://www.redefiningreadiness.net/pdf/RedefiningReadinessStudy.pdf. 2011 December 15.

88.

Lasker

. With the Public's Knowledge: A User's Guide to the Redefining Readiness Small Group Discussion Process. New York: New York Academy of Medicine, 2009. http://www.redefiningreadiness.net/pdf/With_Public_Knowledge.pdf. 2011 December 15.

89.

Ready, Willing, and Able Act, HR 3565, 109th Congr. July 28, 2005. http://www.gpo.gov/fdsys/pkg/BILLS-109hr3565ih/pdf/BILLS-109hr3565ih.pdf. 2011 December 15.

90.

Ready, Willing, and Able Act, HR 1891, 110th Congr. April 17, 2007. http://www.gpo.gov/fdsys/pkg/BILLS-110hr1891ih/pdf/BILLS-110hr1891ih.pdf. 2011 December 15.

91.

Wolshon

. Evacuation planning and engineering for Katrina. The Bridge: Linking Engineering and Society, 2006; 36,1:27–34.

92.

Eisenman

, Cordasco

, Asch

et al. Disaster planning and risk communication with vulnerable communities: lessons from Hurricane Katrina. Am J Public Health, 2007; 97,Suppl 1:S109–S115.

93.

Public Health-Seattle and King County. About VPAT. http://www.kingcounty.gov/healthservices/health/preparedness/VPAT/about.aspx. 2011 December 15.

94.

Mair

, Maldin

, Smith

. Passage of S. 3678: The Pandemic and All-Hazards Preparedness Act. Baltimore, MD: Center for Biosecurity of UPMC, 2006. http://www.upmc-biosecurity.org/website/resources/publications/2006/2006_article_pdfs/2006-12-20-allhazardsprepact.pdf. 2011 December 15.

95.

Association for State and Territorial Health Officials. At-Risk Populations and Pandemic Influenza: Planning Guidance for State, Territorial, Tribal, and Local Health Departments. Executive Summary. http://www.astho.org/Display/AssetDisplay.aspx?id=401. 2011 December 15.

96.

Schoch-Spana

, Chamberlain

, Franco

et al. Disease, disaster, and democracy: the public's stake in health emergency planning. Biosecur Bioterror, 2006; 4,3:313–319.

97.

Reissman

, Watson

, Klomp

et al. Pandemic influenza preparedness: adaptive responses to an evolving challenge. Journal of Homeland Security and Emergency Management, 2006; 3,2 http://www.bepress.com/jhsem/vol3/iss2/13/. 2011 December 15.

98.

Schoch-Spana

, Franco

, Nuzzo

et al. Community engagement: leadership tool for catastrophic health events. Biosecur Bioterror, 2007; 5,1:8–25.

99.

Keystone Center. Citizen voices on pandemic flu choices: a report of the public engagement pilot project on pandemic influenza. December 2005. http://ppc.unl.edu/publications/documents/PEPPPI_FINALREPORT_DEC_2005.pdf. 2011 December 15.

100.

Keystone Center. The Public Engagement Project on Community Control Measures for Pandemic Influenza. May 2007. http://ppc.unl.edu/userfiles/file/Documents/projects/PEPPoPIE/FinalReportMay2007.pdf. 2011 December 15.

101.

Baum

, Jacobson

, Goold

. “Listen to the people”: public deliberation about social distancing measures in a pandemic. Am J Bioethics, 2009; 9,11:4–14.

102.

Li-Vollmer

. Health care decisions in disasters: engaging the public on medical service prioritization during a severe influenza pandemic. J Particip Med, 2010 Dec 14 2:e17. http://www.jopm.org/evidence/case-studies/2010/12/14/health-care-decisions-in-disasters-engaging-the-public-on-medical-service-prioritization-during-a-severe-influenza-pandemic/. 2011 December 15.

103.

U.S. Centers for Disease Control and Prevention. CDC awards $24 million for pandemic influenza preparedness projects [press release] September 24, 2008. http://www.cdc.gov/media/pressrel/2008/r080924.htm. 2011 December 15.

104.

Norris

, Stevens

, Pfefferbaum

et al. Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. Am J Community Psychol, 2008; 41,1-2:127–150.

105.

Pfefferbaum

, Reissman

, Pfefferbaum

et al. Building resilience to mass trauma events. Doll

, Bonzo

, Mercy

et al. Handbook on Injury and Violence Prevention Interventions. New York: Kluwer Academic Publishers, 2005; 347–358.

106.

Chandra

, Acosta

, Stern

et al. Building Community Resilience to Disasters: A Way Forward to Enhance National Health Security. Santa Monica, CA: RAND Corporation, 2011. http://www.rand.org/content/dam/rand/pubs/technical_reports/2011/RAND_TR915.pdf. 2011 December 15.

107.

National Research Council. Building Community Disaster Resilience Through Private-Public Collaboration. Washington, DC: National Academies Press, 2011.

108.

Tierney

. Disaster beliefs and institutional interests: recycling disaster myths in the aftermath of 9/11. Research in Social Problems and Public Policy, 2004; 11:33–51.

109.

Tierney

. From the margins to the mainstream? Disaster research at the crossroads. Annu Rev Sociol, 2007; 33:503–525.

110.

U.S. Department of Homeland Security. Homeland Security Presidential Directive 21: Public Health and Medical Preparedness. October 18, 2007. http://www.dhs.gov/xabout/laws/gc_1219263961449.shtm#1. 2011 December 15.

111.

U.S. Centers for Disease Control and Prevention. Office of Public Health Preparedness and Response. Public Health Preparedness Capabilities: National Standards for State and Local Planning. March 2011. http://www.cdc.gov/phpr/capabilities/. 2011 December 15.

112.

Tierney

, Bevc

, Kuligowski

. Metaphors matter: disaster myths, media frames, and their consequences in Hurricane Katrina. Ann Am Acad Pol Soc Sci, 2006; 604,1:57–81.

113.

Mitchell

, Thomas

DSK

, Hill

et al. Catastrophe in reel life versus real life: perpetuating disaster myth through Hollywood films. Int J Mass Emerg Disasters, 2000; 18:383–402.

114.

Toner

, Cicero

, Adalja

et al.

Contagion: public health's “Top Gun.”

Baltimore, MD: Center for Biosecurity of UPMC, 2011. http://www.upmc-biosecurity.org/website/resources/publications/2011/2011-09-09-Contagion-movie-commentary.html. 2011 December 16.

115.

Annas

, Mariner

, Parmet

. Pandemic Preparedness: The Need for a Public Health—Not a Law Enforcement/National Security—Approach. New York: American Civil Liberties Union, January 2008. http://www.aclu.org/pdfs/privacy/pemic_report.pdf. 2011 December 16.

116.

Berger

, Moreno

. Public trust, public health, and public safety: a progressive response to bioterrorism. Harvard Law and Policy Review, 2010; 4:297–317.

117.

Schoch-Spana

. Community resilience: beyond wishful thinking. Crossroads in Biosecurity: Steps to Strengthen US Preparedness. Baltimore, MD: Center for Biosecurity of UPMC, September 2011; 36–41. http://www.upmc-biosecurity.org/website/resources/publications/2011/pdf/2011-09-08-Crossroads-in-Biosecurity.pdf. 2011 December 16.