ABSTRACT
Local and state public health departments are the primary entities responsible for preparing for and responding to infectious diseases that threaten our society. For over 100 years, local public health departments (LHDs) have been preventing, mitigating, and eliminating infectious disease through the core public health functions of surveillance, epidemiologic investigation, and treatment. The emergence of globalization, which has brought populations closer together through travel and commerce, and diseases used as weapons against civilian populations have placed new responsibilities and expectations on health departments. The anthrax attacks of 2001, the SARS epidemic in 2002-2004, and the heightened awareness of the H5N1 avian flu epidemic have all increased the attention of the public and elected officials to the threats that the United States faces in this age of globalization and terrorism. Reliance on traditional health department core functions remains the principal way in which health threats are addressed. However, this new environment highlights the need to strengthen and modernize these core functions, and to forge closer collaborations with other governmental agencies to better respond to emerging threats. The development of robust and functional relationships between public health and other agencies is essential to yielding quicker and more effective responses to a wide range of health threats. This chapter will explicate the roles and responsibilities of local and state health departments in emergency response to infectious disease threats and how these departments relate to federal agencies. It uses the experience of the Los Angeles Department of Public Health, which is one of the largest local health departments in the United States and is larger than many state health departments, as representative of the responsibilities and challenges facing these departments throughout the nation. However, in considering the perspective informing this chapter, it is important to recognize that there exists significant variation in the capabilities and readiness of different agencies. A substantial section of the chapter treats the
legal authority under which federal, state, and local health departments can act to protect the public’s health. Other legal considerations are dealt with in a separate chapter. Today most large urban public health departments are well equipped and well positioned to both detect and respond to common infectious threats faster than state and federal health agencies. However, these capabilities do not automatically translate into adequate preparation to detect and respond to a lowprobability, high-impact bioterrorism threat. In some instances, LHDs may realize that they must rely upon the expertise of other agencies in order to more effectively respond to a particular threat. During the SARS epidemic of 2002-2004, for example, LHDs relied upon data from customs agencies to track down people who may have been exposed to SARS and to conduct their epidemiologic investigations. In addition, while those LHDs with the largest budgets and staff may be better able to prepare themselves for novel disease threats, improved public health preparedness is not entirely dependent on internal resources. In a high-impact event, local resources that are part of a response effort, such as the local public health lab that is suddenly forced to conduct tests on a large quantity of samples, can quickly become overwhelmed. Public health agencies need to strengthen partnerships with other response agencies and with similarly missioned agencies at the state and federal levels, and integrate preparedness activities into their day-to-day activities through planning, training, and exercising. Connecting the resources of agencies at multiple levels of government, as well as agencies operating in fields that are not traditionally aligned with public health (such as law enforcement and intelligence which is covered in another chapter), will increase the abilities of the larger public health system to effectively detect and respond to a growing list of emerging threats. For smaller public health agencies, it is essential to collaborate with other agencies in their region to amass sufficient capacity and technical expertise to attain an adequate level of preparedness for a bioterrorism threat. There are different levels of collaboration. They range from informal relationships to carefully constructed and formalized written agreements about the respective roles and responsibilities of multiple parties. For example, first responders from multiple agencies often meet to confer on new technologies for use in field response. This form of collaboration is needed to build camaraderie among field response personnel. At another level, formalized arrangements are often helpful to clarify roles and develop operational response plans. This can be very helpful for public health, law, and fire agencies, which have fewer day-today interactions. Formalized arrangements that do not rely on informal, personal relationships between a limited number of individuals are preferred. However, more important still is how often and extensively any collaborative arrangement is exercised through drills that simulate the most likely and most feared threats.
