**Public Health and Medicine in Emergency Management**

**Richard A. Bissell, PhD**

**UMBC Department of Emergency Health Services**

**Abstract**

Public health and medicine have many parallels with emergency management
in terms of overall goals, basic conceptual models, and many operational
modalities. The health sector and emergency management (EM) both strive
to protect the public from maladies using organizational and
science-based tools. Both health and EM are multi-disciplinary in their
scientific underpinnings, although health has gone much further than EM
in developing its own scientific disciplines. Despite many common values
and foci, as well as having many similar operational characteristics,
health and emergency management have mostly failed to share their tools
and personnel and have not collaborated smoothly in preparing for, and
responding to mass emergencies. This chapter addresses the
medical/public health approach to addressing threats to human
well-being, and outlines specific tools that health and emergency
management need to share in order to enhance their future collaboration
toward better population outcome in emergencies and disasters.

**Introduction**

If we ever thought it was "acceptable" that emergency managers did not
know much about the health sector and how it responds to threats and
real events, that time abruptly and permanently disappeared with the
recognition of bioterrorism as a serious hazard. This chapter provides
an overview of the basic concepts upon which medicine and public health
practitioners base their work, and their use of science to establish
appropriate interventions when health is threatened. We establish
similarities between EM and health, and describe some of the differences
in operational modalities, hierarchical structure, and approaches to
thinking about emergencies. We conclude the chapter with an overview of
specific lessons EM may take from the health sector, and ways in which
EM can help the health sector become more efficient at emergency
preparedness and response. The goal of the chapter is to help the
emergency manager understand how to productively interact with the
health sector as a full and meaningful partner.

**Overview of Public Health and Medicine**

**Problem Orientation**

Medicine and public health are complementary disciplines of science and
application within the larger field of health care. In the Western
world, allopathic medicine typifies what we think of as representing the
discipline of medicine: the application of science-based techniques and
technologies to the art of healing individuals who have become ill or
injured, and use of similar technologies to help keep individuals from
becoming ill. The science disciplines incorporated include many aspects
of biology, chemistry, physics and psychology. Public health differs
from medicine in that it has as its focus a population of people, not
individuals. It is also science-based and multidisciplinary, including
applications of medicine, epidemiology, biostatistics, sociology,
anthropology and psychology. The field of public health bases much of
its work on strategies of prevention, and when prevention cannot be
achieved, mitigation of illness and injury is pursued through the
efficient and effective application of medical and other societal
resources to limit or reverse pathological processes. The boundaries
between medicine and public health are often blurred, even to those who
work in health care. Good medical practice can contribute significantly
to the public's health, and good public health practice can contribute
significantly to the effectiveness of medical resources. Though the
stereotype is limited in many specific applications, the general concept
is that public health is prevention- and population-oriented while
medicine concentrates on the process of curing individuals.

Both medicine and public health are problem-oriented. Medicine, at least
in some primitive form, has been around ever since Homo Sapiens
recognized that they could intervene with ill or injured individuals to
comfort them or help them heal. Public health, as a specific endeavor,
first came about as a result of large numbers of people becoming
seriously ill at the same time during the great plagues of renaissance
and early industrial Europe. Early tools included quarantine and
isolation. The development of biostatistical methods (John Snow) and
germ theory[^1] led to major increases in the power of public health to
make a significant impact on disease mitigation. While the tools and
techniques of public health have widespread application in acute,
chronic, and slow-onset conditions, the very basis for developing public
health came from the need to respond to health disasters.

**Conceptual Models**

The practitioners of all disciplines conduct their work based on
conceptual models that define the discipline's understanding of causal
relationships between the phenomena that are of concern to the
discipline. These conceptual models help determine where it is that
participants in the discipline believe they can make interventions that
may help improve life, or productivity, or income. For example, one of
the core elements of modern medicine is the role that microbes ("germs")
play in initiating and sustaining what we call infectious
diseases...that is, that certain microbes are capable of invading the
body and causing reactions that can make us quite ill, or even kill us.
This germ theory component of the conceptual model of medicine and
public health allows us to develop interventions against the microbes as
a way of both preventing and curing certain illnesses. "Germ theory" is
but one of several conceptual models that help form the thinking of
health care practitioners. Others worth mentioning here are:

\- Human-Environment Relationships: From the times of Socrates, and
perhaps even earlier, health care practitioners believed that the
relationship between humans and their environment affected human health
status. Although we do not today focus primarily on the elements of
earth, air, fire and water as determining the health of populations,
they are among the many variables that contribute to our health. Since
we derive our most basic life-supporting substances from the physical
environment, such as air, food, and water, it is clear that the quality
of the environment has a primary effect on human health. Environments
that do not provide sufficient quantity or quality of these
life-supporting substances will result in poor human health, or even the
inability to support human life. On a more subtle level, deviations from
normal balances in the environment can lead to deviations in human
health.[^2] [^3]

-   

The relationship between humans and their environment is two-way. Humans
can, and do, change and affect the physical environment we live in. One
way we do this is to create artificial environments (the human-built
environment of structures). Another way is by physically changing
topography, vegetation patterns, water flow, or by depositing in the
soil, air or water chemicals and other substances that would not
naturally exist there. Whether in the natural or human-built
environments, the way we treat the environment affects its ability to
support our health.

\- Multiple Causality: Good health (or bad health) is not the result of
a single cause (or independent variable, to use the research
terminology). In order to remain healthy, we need an adequate quantity
of a broad variety of nutrients, clean air and water, physical exercise,
social connectedness, and good choices (our own behavior).[^4] Any one
variable can bring a person's health rapidly down, such as a bullet to
the brain or ingestion of a quantity of cyanide, but these single
variables are most often related to other variables, often behavioral in
character. For example, dealing illegal drugs increases the probability
that one will end up with a bullet in the brain. Good health is clearly
the result of multiple things going right; bad health is also usually
the result of multiple things going wrong.

\- Exposure and Vulnerability: In order to contract an infectious
disease, you need to be exposed to the microbe that causes the disease.
However, some people are exposed and never become ill, while others may
die from the same exposure. If we call the person who is exposed a
"host", the host may have certain vulnerabilities or strengths that
alter the outcome of the exposure. The host may have inherited genetic
traits that limit his or her vulnerability to a certain class of
microbes, or may have previous experience with the specific microbe, and
thus have an immune-response system that is poised and ready to fight
off the microbial invader.

Exposure to a given substance may have completely different effects on
health, depending on the quantity of the exposure. For example, we
cannot live without water, but we also know that ingestion or retention
of too much water can make us seriously, even fatally, ill. Many of the
medications we use have a dose at which they are effective, and a level
at which they are toxic. Exactly what levels are effective differs
according to host-intrinsic factors such as metabolic rates or the
health of the individual's liver and kidneys.[^5] Thus, throughout
medicine and public health, we recognize that both external and internal
factors affect how healthy we are, even in apparently identical
environments. Our behavior affects both our exposures (e.g. smoking,
alcohol, overeating) and our internal capacities (e.g. exercise, sleep
and nutritional patterns affect the effectiveness of the immune-response
system).[^6] [^7]

\- Primary, Secondary, and Tertiary Prevention: Much like emergency
management, public health conceptualizes various levels of activity
designed to prevent or decrease potential harm to humans. In public
health terms, *primary prevention* is the act of making sure something
will not happen. It is equivalent of *prevention* in emergency
management. Vaccination is a public health example of primary
prevention...it prevents disease from occurring even if exposure
happens. *Secondary prevention* means minimizing the harm that occurs
once a disease or injury affects an individual or population. In
medicine this is usually seen as curative care; in public health it may
mean using epidemiologic and disease control tools to minimize the
spread of an epidemic. Note that this concept includes components of the
emergency management concepts of *mitigation* and *response.* The public
health concept of *tertiary prevention* refers to actions taken to help
individuals who have been injured or ill to regain full capacity to live
normal lives. This is similar to components of the emergency management
concepts of both *recovery* and *rehabilitation.* As is the case with
emergency management, many health care practitioners will incorporate
into their recovery and rehabilitation programs aspects of primary
prevention, such as the program at Maryland's Shock Trauma Center
designed to prevent trauma victims from becoming repeat patients, by
teaching them life skills that will enable them to support themselves
without having to deal drugs on the street.

Medicine and public health both incorporate the concepts just described,
and, like emergency management, both strongly subscribe to the concept
that things happen for a reason...that is, that there are causal
relationships that lead to maintenance of, or deviation from good
health. Health care personnel, like emergency managers, believe that
well-placed interventions into a known causal relationship can change
the course of events and prevent or minimize human harm. Research is
needed to clarify the causal relationships and test the effectiveness of
proposed interventions.

**Operational Modalities**

Whereas emergency management may be seen as being primarily organized
and operated by government entities, with some action taken by private
commercial organizations and individuals at the neighborhood and family
level, medicine and public health in the United States are much more
fractured and complicated in their structure and organization.

In the United States, medicine is usually a private service provided by
physicians, nurses and other health care personnel within a
privately-owned and operated entity. It may be as small as a
solo-practice family physician's office, or as large as the
Kaiser-Permanente health maintenance organization. Because government
funds a substantial portion of medical care through programs such as
Medicare and Medicaid, it has an important regulatory role in
structuring and supervising medical services, but only directly supplies
a small proportion of the medical care Americans receive.[^8] Within the
private organization of medicine, there is an extreme variation of
management styles and hierarchical structure. Hospitals tend to be
structured with clear authority lines, while clinics and private
practices may be much more horizontal in their structure. In terms of
one-on-one patient care, the physician leads the decision-making;
however, government is increasingly limiting the options from which the
physician can choose through control of reimbursement and approved
treatment regimens. Nevertheless, at its core, medical care decision
making tends to be autocratic, although subject to review and
suggestions from others.

Organizationally, public health more closely resembles emergency
management. Most public health leadership and major decisions take place
within a government agency, although individual actions may take place
in private agencies, schools, neighborhoods and families. While medicine
and public health are both science-based, the breadth of public health
is generally thought to be too great for unilateral autocratic decision
making, resulting in a decision making model that is much more based on
research and scientific consensus. Scientific consensus is often based
on research that is statistically reported as significant at the 95%
confidence interval. This lengthy decision-making process clearly has
implications for EM interactions with the public health establishment
during emergencies.

Public health authorities have ultimate responsibility for virtually the
entire health sector, and are the primary policy makers and regulators
in health care. Hospitals and outpatient care practitioners fall under
public health regulations. Health departments are responsible for a
great variety of health activities, often organized into groupings
centered around maternal and child health, disease control and disease
prevention, food and water safety, epidemiologic services and
investigations, environmental health services, occupational safety,
licensure of health care practitioners, laboratory services, vital
records, and health education. Additionally, the federal Centers for
Disease Control and Prevention, and the U.S. Public Health Service now
require health departments to construct and operate a jurisdictional
health sector disaster plan, to help improve the interaction within the
various parts of the health sector during emergencies, as well as
interaction between the health sector and emergency management.

**History of the Health Sector and Disasters**

The relationship between the health sector and disasters is both central
to the development of key components of the health sector, and is a core
component to organized human response to disasters. Long before there
was organized emergency management there were attempts to organize the
health sector to both respond to disaster events, and prevent epidemics.

Many of the most deadly disasters in human history have not been
sudden-onset cataclysmic events like earthquakes or tsunamis, but rather
epidemics. The Black Plagues of the Middle Ages and Renaissance
variously took between a third and half of all Europeans living at that
time to an early death.[^9] [^10] [^11] Millions died, including entire
populations in some areas of Europe. Even within the last century, a
pandemic (widespread epidemic) of influenza took more than 20 million
lives.[^12] As Europeans in the late Middle Ages and Renaissance came to
discard notions that all their tragedies came as a result of displeasing
God, they looked for understanding of the causal relationships that
might exist on the physical plane, relationships in which they could
intervene. Long before "germ theory" became accepted in the 1800s,
health practitioners recognized that diseases could be transmitted from
one individual to others. This recognition lead to some of the earliest
public health tools, isolation and quarantine, which still remain
powerful tools that we may have to employ in future mass outbreaks.

During the extended time of the great plagues, government came to change
its ethic regarding its responsibility to citizens.[^13] It was no
longer sufficient to just protect citizens from foreign invasion or
domestic crime. Governments now recognized a responsibility to do what
they could to organize response to epidemics that took more lives than
war and crime combined.[^14] Early attempts at data collection and
analysis had the aim of keeping track of where deaths were occurring and
at what volume, often based on parish-level statistics. Tracking these
data helped demonstrate the transmissibility of contagion, and
frequently showed densely populated cities to be at higher risk than
sparsely populated rural areas. Based on this information, governments
were in a better position to suggest steps citizens might take to
protect themselves. Moving on into the 1800s, northern German states
created "Sanitätspolizei" (sanitation police), whose responsibility it
was to ensure that rules regarding cleanliness and the handling of food
and waste were followed, to ensure the public's health.[^15] In the
1850s, British physician John Snow used data collected on victims of a
serious cholera outbreak in London to detect the location of cholera
transmission (two contaminated water taps) and, thus, create an
intervention that worked (closed the water taps).[^16] The number of new
cases in that area of London virtually disappeared after the taps were
closed, thus demonstrating the strength of combining statistical
analysis and medical knowledge to control epidemics. With his book
published in 1855,[^17] Dr. Snow created the new field of epidemiology,
and greatly strengthened our ability to intervene against major threats
to population health, even when we sometimes do not know the exact
causal relationships.

War and Public Health

It was not only in the realm of contagion that the health sector made
major contributions to disaster response. Warfare tops the list of
human-caused disasters and has, since the dawn of civilization, provided
ample opportunity for humans to devise ways of responding in an
effective and organized fashion to large numbers of injured victims
requiring care at the same time. While Napolean's chief army surgeon
Dominique Larrey is often credited with the development of "triage" and
other tools for bringing order to the previously chaotic activity
surrounding the response to the injured on a battlefield in the early
1800s,[^18][^19] there are historical reports of Roman field physicians
developing and practicing similar techniques almost 2,000 years earlier.
Larrey's principles and techniques were utilized in the American Civil
War[^20][^21] for the benefit of wounded combatants, and by numerous
militaries during the First and Second World Wars. It was not until the
end of World War II that military and civilian health care providers
began applying what had been learned on the battlefield to civilian
casualties of the war, and later to victims of natural disasters.

By the end of the Korean War, some of the improved practices of wartime
medicine filtered back to U.S. civilian application in both routine
emergencies and disasters. These new techniques included both
organization of response forces, as well as numerous new techniques for
medically managing hemorrhaging, airway insufficiency and shock. It is
important to note that warfare has also driven significant developments
in public health, including the development of vector control methods
(e.g. mosquito control), mass food distribution, and emergency water
supply management.

During the post-War period, particularly beginning in the 1970s,
civilian response to medical needs of disaster victims began to take a
two-stage approach, based on the timeliness of the victims' needs. The
first stage is characterized by mass application of trauma care
personnel and resources, followed typically within a day or two by the
introduction of public health personnel who begin addressing the needs
for potable water, sanitation, shelter, reliable food, disease control,
and mental health care. Furthermore, in the 1970s researchers began to
use the tools of epidemiology to describe and evaluate the true health
consequences of various types of disasters,[^22] [^23] [^24] and later
used this same information to predict what kinds of health care
resources would be needed for response to particular disasters, as well
as evaluate the adequacy of completed responses.[^25] This process is
still underway, as the health sector tries to remain true to its
scientific foundations while striving to improve its preparedness for,
and response to disasters of many kinds.

The terrorist attacks of 9/11/2001 and the subsequent anthrax episodes
brought a new level of awareness to government as a whole, and
specifically to the health sector, regarding the primary roles of public
health and medicine in our nation's preparedness and response to
disasters. The federal government became aware of the lack of
coordination between the health sector and emergency management, and
recognized the paucity of funds available to public health sector
emergency preparedness. Progress is being made in this regard, but it
will take years of funded effort before we have the levels of
proficiency and equipment needed to be truly "ready."

One of the barriers to readiness is the traditional lack of
communication, common vocabulary, or even trust between the public
health and emergency management communities. Public health personnel
typically have no training in the vocabulary and concepts of emergency
management, and tend to make their decisions in a time-consuming
consensus process. Recent research demonstrated that emergency
management personnel feel distanced from health sector personnel who
typically have higher social and academic ranking.[^26] Emergency
management personnel also lack understanding of the concepts and
operations of the health sector (hence the need for this chapter you are
now reading!). While there is increasing cooperation between the health
and emergency management sectors in terms of preparedness and response
to rapid onset disasters, there has be no input from emergency
management to date in some of the world's major slow-onset disasters,
such as the HIV/AIDS epidemic in some parts of Africa.

**Health and EM Convergences and Departures**

While the organized health sector is much older than organized emergency
management, EM and health have developed along similar lines. Both hold
as their core value the protection of humans and promotion of their
well-being in the face of hazardous events. Both fields of work base
their core conceptual model on an understanding that human well-being is
a function of a multi-disciplinary causal string of events. That is to
say, our well-being is the result of access to a healthy combination of
food, water, clean air, and shelter, as well as social support,
education, etc. Both fields recognize that access to those resources is
affected by the application of politics, economics, the physical
sciences, engineering, and the social and behavioral sciences. Both
fields also recognize that departure from well-being, whether in an
individual or a population, is also the result of a causal string of
events, and that understanding the causal relationships can lead to
strategies for targeted interventions that can protect people, or help
them recover.

Both EM and public health see their work as taking place in stages that
overlap and reinforce each other. While the basic concepts of the stages
are virtually identical, the vocabulary is different...with the public
health vocabulary of primary through tertiary prevention being a bit
difficult to crack open for outsiders. Both sectors recognize that human
vulnerability is a combination of external factors, the hazards to which
we are exposed, and internal factors, such as the status of our immune
response systems or, at a community level, the design of our structures
or status of our public safety services.

Emergency management and the health sector both base their planning and
preparedness activities on accruing and using information regarding
natural and human-caused phenomena that can harm people...with
increasing attempts to share this information with others outside of EM
or health. While emergency management and health both use science to
acquire and analyze the information needed to plan and execute effective
interventions, EM could learn a lot from the health sector's use of
science to study the effectiveness of it's own actions. In medicine,
so-called "evidence-based" practice has started to make significant
inroads in the effort to abolish treatment modalities that are
ineffective[^27].

While both fields use scientific findings to inform their planning and
preparedness activities, public health has recently moved toward full
utilization of scientific research on the exact effects of different
kinds of disasters on human beings in order to tailor the response as
precisely as possible.[^28] Emergency management has lagged behind in
incorporating these findings that come from health-based researchers,
although it has at least a 30-year history of incorporating findings
from geography, geology, meteorology, architecture, hydrology, and
sociology. The annual Natural Hazards meeting at the University of
Colorado perhaps best typifies the ongoing effort to make emergency
management a field that is multidisciplinary and science-based. If EM
were to include in its understanding of the human consequences of
disaster more of the findings coming from public health researchers, it
would enhance collaboration between the public health and emergency
management sectors when dealing with events as broad in scope as
hurricanes and bioterrorism. Emergency managers would be better able to
gear up for public health requests, and would better understand why
health officials set certain priorities.

A key task for response managers is to know how much of what kinds of
human and materiel resources are needed, and to where they should be
sent. Emergency managers typically request a damage assessment and then
calculate needs from that information. Health response managers have
moved to incorporating the tools of epidemiology to conduct a *needs
assessment* rather than just a damage assessment, based on a combination
of information sources, including data purposely collected using rapid
survey techniques, and data from on-scene clinicians and public safety
personnel. These data are calculated, based on epidemiologic data
reported from other disasters of the same type, to predict the kinds of
health care that will be needed and in what volume. Recent rapid needs
assessment data collection tools also include mechanisms for assessing
gaps in available resources, and allows for estimates of the validity of
the information upon which the assessments are made.[^29] [^30] EM can
benefit from adopting some of the techniques used by public health in
conducting rapid needs assessments, and the overall response will
benefit if EM and public health do a better job of real-time sharing of
their event-specific information.

In emergency field operations, it is typical that emergency managers and
health sector personnel will each assume capabilities and willingness on
the part of the other, often without confirming either. Joint planning
is intended to help erase this difficulty, but the effort to overcome
this problem will be greatly enhanced if personnel from each sector take
the opportunity to come to understand the different authority
structures, organizational cultures, and operational modalities and
capabilities of the other sector. Neither public health nor EM has
allocated adequate research money or course preparation time to
effectively analyze differences and impediments to smooth collaboration
between the sectors.

Two barriers have been identified by this author and are currently under
investigation with some minor funding from the Centers for Disease
Control and Prevention and the Maryland Department of Health and Mental
Hygiene.[^31] The first barrier is a social distance that was reported
by emergency managers in a multi-regional survey, in which respondents
indicated that they had a difficult time working with health sector
personnel who come to the table with advanced degrees and an air of
superiority. The second barrier was identified during the 2001 anthrax
scares, in which it became obvious that public health personnel and
emergency managers have *very* different decision-making styles. Public
health's slow, deliberate consensus-building approach to making
decisions is the antithesis of what is often needed in a rapidly
developing emergency. Barbera, Macintyre, Bissell and others are
currently researching and developing courses to help train public health
personnel in the art and science of emergency decision-making, using
some of the concepts developed and taught at the Emergency Management
Institute for emergency managers.

**Specific Public Health Tools Potentially Helpful to EM**

In this section we look at some of the tools that have been developed in
the health sector that may prove helpful for emergency management.
Because this chapter is designed for EM personnel, we are not including
here the many EM tools that would benefit the health sector.

RNA. We have already been mentioned above the need for the development
and utilization of mechanisms for conducting rapid *needs* assessments,
instead of relying on the much less illustrative damage assessment
currently commonly in use by emergency management personnel. While
pioneered by public health personnel, the move from damage assessment to
a widely useful needs assessment tool for emergency managers would
require input from several sciences in order to enhance predictive
power.

Horizontal Information Sharing. Public health has always required a
certain amount of information sharing between health agencies,
particularly related to the so-called "reportable diseases." However,
this process has tended to be vertical, with only the top-level agencies
receiving all the information. As it became clear that bioterrorism is a
challenge not served well by vertical communications, numerous federal
and state public health agencies have joined together to form real-time
horizontal information exchange networks so that agencies can gain an
overview of what is going on in other units and jurisdictions. This
allows agencies to be better able to spot trends, and to prepare for
health problems that may be coming their way. CDC's network is open only
to health department personnel who have a high level of clearance.
However, Maryland's FRED system incorporates all of the state's health
departments, EMS agencies, hospitals and emergency managers, to allow
cross-agency and cross-discipline horizontal communication. This kind of
real-time horizontal networking could prove extremely valuable to EM
practitioners at all levels.

Commitment to Research. While commitment to research may not seem, at
face level, to be a tool...the information produced by research clearly
is. Research in medicine and public health has enabled us to understand
causal relationships ranging from the subatomic level to the population
level, and although there is still much to be learned, we successfully
use this understanding to effectively intervene to decrease harm and
promote health in the most trying of circumstances. Practice is driven
by research, although the process of integrating research findings into
the way things are done in the field is usually accompanied by lag time
and some trial and error. Practice in emergency management is usually
informed by previous experience and information provided by various
disciplines that have their own research base, i.e. geology,
meteorology, sociology. Emergency management lacks commitment to a
strong research base of its own...which may be both the cause of and
result of a lack of funding to both train emergency management
researchers and fund their work. Our allied scientific disciplines
(geology, sociology, meteorology, etc.) provide us with significant
information upon which to plan and act, but do little to help us sort
out what is effective in field application, and what is not, and under
what conditions.

**Recommendations**

Emergency management and the health sector are natural allies that have,
seemingly, only recently begun to recognize each other. They share the
same basic goal of protecting the public, and share many of the same
basic concepts. They are often both called upon to intervene on behalf
of the public during the same emergencies. EM has developed a system for
emergency decision-making and response management that public health is
only beginning to learn. The health sector has developed science-based
understandings that greatly increase the precision with which we
intervene at the biological level, and is increasingly using research
methods to assess and improve the strategies we employ for emergency
responses. In order to enhance the power of health-EM collaboration in
the future, we offer the following recommendations:

a\. The two fields need stronger integration at various levels:
planning, mitigation, preparedness and field operations. In order to be
successful, this must take place within jurisdictions. The two fields
must also improve integration by sharing research methods and findings.
One of the first coordinated research topics should be to describe
commonalities and then to identify barriers to collaboration and
evaluate methods of developing real time synergies between the two
disciplines.

b\. Integration will be substantially improved if students of EM and
medicine/public health learn about the concepts and operations of the
other. EM students need to learn about the health effects of disasters
of various types, as well as learning about how the health care system
responds to disasters and other threats.

c\. Short courses, perhaps online, should be developed, targeted at
current practitioners of EM and health, to accomplish the aims of item
b. above for those who are already mid-career.

d\. EM students and practitioners should take health's example and
dedicate more energy to studying the causal relationships that lead to
human harm, and identifying efficient intervention points and
strategies. We know much of the physics and mechanics of how people get
hurt, but still lack information on why people will put themselves in
harm's way, or fail to take protective action when faced with danger. We
also lack information on the effectiveness of certain strategies when
applied to a public who must implement them. For example, DHS Secretary
Ridge's attempt to describe to the American public strategies for
sheltering in place was met with disbelief and derision. We apparently
did not have the research available that would allow us to predict the
public's reaction. What aspects of Ridge's message were ineffective and
why? Where would be the appropriate point to intervene again with a
similar message, and how must it be presented in order to be effective?
When public health faced similar issues related to obtaining the
public's cooperation on public health issues (ranging from boiling water
after disasters to using birth control correctly), the field took
direction from research conducted by Everett Rogers and others on the
diffusion of innovations and other interventions.[^32]

e\. Specific EM interventions need to be researched for their
effectiveness, both in a general sense, and in terms of what specific
conditions may make a particular intervention effective or not. For
example, we draw up plans to evacuate nursing home patients and other
"special needs" populations prior to the arrival of hurricanes. Such
action can carry considerable risk for individuals who are already
compromised. In terms of actually saving or risking lives, under what
circumstances is an evacuation called for? How powerful must the storm
be and what characteristics must it have? How do the intrinsic
characteristics of the nursing homes affect the decision? How must
evacuation transportation be designed so that compromised patients can
be adequately supported while in transit? What characteristics of the
targeted temporary shelter enhance the probability of good outcome for
the special needs visitors? Under what circumstances is it safer for the
special needs patients to stay in place? What is the impact on the rest
of the surrounding population if resources are utilized evacuating
nursing home and other special needs patients? These are not idle
questions of no meaning to emergency managers and without consequence
for the affected populations. These questions are researchable and such
research may provide significant assistance to EM personnel who are
required to work with the health sector in devising and implementing a
workable policy.

f\. EM and public health personnel need to collaborate on researching
and assessing the true risks and vulnerabilities of local populations to
identified hazards. One of the big stumbling blocks to truly good
integrated local EOP development is that EM personnel do not have the
tools to accurately assess the health impacts (and hence response needs)
of specific local hazards. Local and regional epidemiologists and
emergency medical personnel can assist with this process. The resultant
information can be integrated into both preparedness and mitigation
activities.

g\. Good rapid *needs* assessment requires information from both the EM
and health sectors. Work needs be done to develop efficient means for
both sectors to collect and share the information needed, to avoid
duplication and enhance the quality of information available to
emergency decision makers in both sectors.

h\. Public health needs to work on developing and teaching good
emergency decision-making skills. EM models of decision-making could
form a solid base for public health personnel; effective collaboration
between experienced EM specialists on decision-making could
significantly enhance the process of bringing important decision-making
tools and strategies to public health personnel and students.

i\. The currently perceived social stature distance between EM and
health sector personnel will be decreased if the field of EM makes a
concerted effort to encourage its personnel to acquire baccalaureate, or
even graduate degrees.

j\. Both fields will benefit from taking a longer-run view of hazards
and vulnerability, given our rapidly changing world. If we are able to
lengthen the time frame of our planning to, say, the next 50 years, the
need for cross-sector collaborative work will become immediately
obvious. For example, it is clear that there will be far less petroleum
available 50 years from now.[^33] [^34]With a larger population
demanding energy and petroleum-based chemical products from a smaller
base resource, what will be the effects on the public's health? Food
production and distribution? Ability to respond to emergencies?
Appropriate research now may be key to developing workable mitigation
and response strategies for significant challenges that we will face, if
we are able to now take a longer-term view.

**Summary**

EM and the health sector have similar goals and conceptual models. The
health sector has a long history of basing its tools, techniques, and
strategies on solid research, and is now bringing that history to issues
related to emergency public health. Neither EM nor health personnel have
sufficient understanding of the methods and techniques of the other, and
each has tools that would contribute to the other's success in
emergencies. More importantly, given the compatible skills and
overlapping foci of EM and health care, it is imperative that the two
sectors actively collaborate with each other throughout the full
emergency management cycle.

**Acknowledgement**

I would like to thank Drew Bumbak, MS, Brian Maguire, DrPH, Stephen
Dean, PhD, and Sarah Edebe, MS for their invaluable content and editing
assistance in the development of this chapter.

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