Where Do We Go From Here? Voices From the Field on the Future of Preparedness

A well-resourced and supported public health preparedness and response infrastructure is essential for our society's safety and security. As part of that infrastructure, state and territorial health agencies are critical to our nation's ability to prepare for, respond to, and recover from public health emergencies and threats. This is apparent in their response to public health threats including: 1) helping to prevent the spread of highly pathogenic avian influenza in farm and processing workers, 2) working together to identify Lassa fever,1 3) identifying botulism in infant powdered formula and developing/providing the only source of infant botulism treatment worldwide,2 4) responding to long-term care and skilled nursing facility closures that require skilled continuity of care, and much more. Without ongoing investments in public health, these prevention and response activities would be diminished or non-existent. Yet recent years have revealed a dangerous gap in understanding and valuing public health, resulting in inadequate national investment. The Directors of Public Health Preparedness—an ASTHO-hosted network of jurisdictional (state and territorial) preparedness and response leaders—have identified the following priorities for a forward-adapting, well-equipped, and effective public health preparedness system that is understood and supported at a national level. Core Function Identification Due to lessons learned from previous large-scale responses, current global outbreaks, increases in severe weather, and the reduction in federal investment, there is a need to redefine the core functions of jurisdictional preparedness. The identification of core functions allows preparedness planners to focus their efforts and streamline activities to the most impactful and foundational skills/capabilities required for any response, no matter the size or cause. During this time of reduced funding and support, it is imperative that jurisdictions have clarity on the core functions — not just those they will perform but those the federal government will provide. Much of the current preparedness planning and priorities reflect the funding requirements associated with vital federal cooperative agreements such as the Public Health Emergency Preparedness program3 and Hospital Preparedness Program.4 Federal agreements have and will continue to provide a solid foundation and benchmarks, but emerging threats demand a more comprehensive approach. Because of that, it may be beneficial to broaden the perspective and examine functions based on other factors (ie, increased influence of jurisdictional risk assessments, Emergency Support Function 8,5 inherent and implied jurisdictional legal authority, known and emerging threats). However, it must be noted that “rethinking emergency preparedness programs demands a renewed commitment to public health broadly, recognizing that programs focused on emergency response depend on the foundation of core public health capacity to be successful.”6 These foundational capacities include disease surveillance and epidemiology, laboratory testing, community partnerships, communications, evaluation, quality improvement, and more. Therefore, continued investments and commitment to public health's core functions of assessment, assurance, policy development, and the aforementioned capacities will aid in the growth and reimagining of public health preparedness. Strategic Vision For jurisdictions and communities to accurately plan and effectively utilize changing resources, an updated analysis of strategy is needed. In his book The First 90 Days, author Michael Watkins suggests that strategic direction is identified by focusing on the four Cs: Customers, Capital, Capabilities, and Commitments.Customers: Asks us to identify which existing internal or external customers we will continue to serve? Capital: Of the business that we [are], what will we continue to invest in? What sources do we have for existing [and new] funding/capital? Capabilities: What are we good at? What existing capabilities can we leverage? What do we need to create or acquire? Commitments: What critical decisions should be made about resource commitments? What commitments should be kept? Which should be released? By applying this framework and honestly answering its questions, the public health preparedness enterprise will be better equipped to identify what it will and will not do. These conversations must, secondarily, include assessment of jurisdictional and national coherence, adequacy, potential implementation, core processes, structure, and skill bases. Robust state, local, territorial, and tribal stakeholder engagement is necessary to identify and understand how the changing of one component may impact others. In the end, we need a jurisdictionally influenced national vision that reinforces adaptation, innovation, and our value in advancing our nation's health and security. Once identified, implementation will be key to “[enabling public health] to transform information, materials and knowledge into value in the form of […] viable products or services, new knowledge or ideas, productive relationships or anything else the larger [community] considers essential.”7 As implementers, state, local, tribal, and territorial public health agencies and leaders play a key role in assuring any new strategic vision aligns with essential community needs that position public health preparedness and response for long-term clarity and success. Communication and a Collective Voice As trust in public health continues to rebuild, proactive and unified communication with the public, partners, and among all levels of government is imperative. Sound bi-directional communication between federal, state, and local response partners is a key foundation that highlights the importance of public health. The needs and benefits of jurisdictional public health must be communicated early and often using common language, trusted and non-traditional messengers, and various methods based on an audiences' specific needs and/or circumstances (eg, parents, caregivers, community leaders, and those with disabilities) to inspire emotion, empowerment and behavior change—not fear. A revised strategic vision and core functions will help set the stage in defining our collective voice and refining an “elevator pitch” for legislators, funders, and other response partners. Public health has struggled to develop an easy-to-understand, long-lasting overview of our importance. Other disciplines such as Fire, EMS, Police, and Emergency Management have tangible symbols aiding in public understanding of their roles, duties, and impact if not supported. Meanwhile, for public health, we often work in the background. We must step into the spotlight and make our impact visible because without support, the consequences are profound. Resiliency Successful application of these priorities requires continued resiliency. Merriam-Webster defines resiliency as 1) “the ability of something to return to its original size and shape after being compressed or deformed, or 2) an ability to recover from or adjust easily to adversity or change.”8 For decades, public health preparedness and response has been forced to strengthen its resiliency. In a cyclical pattern, the enterprise is continuously required to adapt to changes that compress staffing, authorities, resources, and infrastructure based on the “boom and bust” cycle of financial and systemic support. For example, the onset of large-scale public health emergencies, such as Ebola, Zika, and COVID-19, led to significant emergency supplemental increases of national and jurisdictional public health funding. These supplemental funds allowed for the expansion and surge of necessary capabilities. However, these funding boluses are not always long-lived or, more importantly, do not often translate into long term-funding increases. For example, “the June 2023 Fiscal Responsibility Act rescinded unobligated [COVID-19] pandemic response appropriations and funding from the American Rescue Plan Act that had been allocated to CDC, the Administration for Strategic Preparedness and Response, [and other agencies]. In total, the Act rescinded approximately $13.2 billion in emergency response funding, according to estimates from the Congressional Budget Office.”9 More recently, the early 2025 abrupt cancellation of grants totaling more than $11 billion was alarming and detrimental to state and territorial health agencies.10 Each time supplemental funds are rescinded without sustained and consistently rising funding, a fiscal cliff emerges — hindering public health's ability to sustain tools, resources, and a workforce that could be leveraged for long-term systemic growth and resilience. Now, after decades of this cycle, there is a desire to lean into or even create a new mindset of public health resiliency. One that requires a continued, deliberate shift from a reactionary posture (characterized by these short-term surges and crisis-driven decisions) toward a resiliency mindset that prioritizes 1) stable funding, 2) sustainable staffing, 3) adequate policies and authorities, and 4) adaptable systems capable of withstanding prolonged and overlapping public health threats in known and unknown economic, social, and political ecosystems. Conclusion As a national network of public health leaders, the Directors of Public Health Preparedness and ASTHO will continue to hold conversations that allow state, local, territorial, and tribal health agencies to assess their distinct local and regional vulnerabilities, prepare for, respond to, and recover from public health emergencies—via a sustained infrastructure that enables pre-disaster posturing and all-hazards planning/readiness. The group's ongoing discussions, internal and with partners, will aim to highlight and support implementation of actionable steps that catapult public health preparedness and response into a well-understood, resourced, supported, and recognized component of our national infrastructure.