National policy discussions in 2002 about emergency preparedness displaced discussions regarding broader issues of public health workforce size and preparedness at all levels of government. Subsequent procedural oversight for emergency preparedness appropriations at the state and federal levels produced a dilemma: Could the connection between preparedness for emergencies and the core functions of governmental public health agencies be supported with these funds, or must they be used to support emergency preparedness exclusively? The former approach can accomplish the preparedness objectives while yielding other important returns.

Who is the Governmental Public Health Workforce and What do They Do?

The governmental public health agency workforce may be employed by the local, state, or federal government. The workforce is composed of a multidisciplinary staff of administrative and management personnel, professionals, technicians, protective service specialists, paraprofessionals, administrative support personnel, skilled craft workers, service and maintenance staff, and others.1 Many of these credentialed and noncredentialed people have little or no formal training in the values, principles, and sciences of public health.2,3 This is not surprising since most found their way serendipitously into the governmental public health workforce. This is, however, unfortunate since a background in public health would enrich their work.

Despite being chronically understaffed and underfunded, the workforce nonetheless delivers "a broad array"of services annually, including effective response to disease outbreaks and disasters on an ad hoc basis.4,5 The workforce exhibits great variation in methods used to respond to emergencies and to other day-to-day threats to public health.6,7 The workforce is also the current and intended audience for many different preparedness initiatives.

Terrorism preparedness and emergency response fit naturally into the mission and portfolio of the governmental public health workforce, that is, assuring the conditions in which people can be healthy. As evidence of this, the public health workforce regularly responds to events that exercise in real time some of the same skills, competencies, and technologies needed for emergency response, albeit in a less intensive, extensive, and population-limited manner. Many of the skills and competencies required by the workforce for emergency response preparedness are the ones needed for best performance in its other day-to-day work. For each, rapid and informed response require trained and practiced staff. This involves skills and competencies first elaborated under the general categories of assessment, policy development, and assurance,8 now further differentiated in public health jargon as essential services5 and in emergency preparedness jargon as mitigation, preparedness, response, and recovery.9

Preparing the Workforce

The increase in emergency preparedness funding and the renewed attention to the importance of the governmental public health workforce brings unprecedented opportunity to sharpen and strengthen competency, knowledge, and skills needed not just for less frequent large-scale disaster but for more frequent smaller-scale day-to-day response as well. The nation's health regularly depends on these smaller-scale responses, even though they are invisible to most policy makers and the public. They provide experience needed to perform well during emergencies.

Responsible stewardship for these funds would encourage training for the broadest possible use given the uncertainties associated with the type of events which may be encountered in the future. Efforts to prepare the workforce for emergencies should avoid the trap of creating yet another categorical program and, instead, be integrated within a more substantive competency-building framework that considers and appreciates the daily activities of this workforce and the challenges faced by those who manage it.

The need to ensure adequate surge capacity during emergencies also argues for this more comprehensive approach. No single governmental public health agency has all the resources needed for effective large-scale response and must frequently rely, therefore, on resources from neighboring jurisdictions. More uniform content in training programs nationwide can help ensure that when staff assists in other jurisdictions they will possess the skills and competencies needed in the receiving jurisdictions. Rapid response need not be delayed for orienting staff to their work or the reasons for it.

Training and Education for Preparedness

Thoughtful efforts to prepare governmental public health workers for the range of tasks policy makers and the public expect them to perform during emergencies should consider the context and content of their current work. Understanding these tasks as part of their usual work makes the transition during an emergency smoother. Preparation efforts should make frequent use of the range of new educational technologies and strategies now available in addition to the more traditional face-to-face settings, which have been the educational method of choice for thousands of years.

Learning systems should meet the needs of those presently in the workforce and the people of the communities they serve. Effective response requires staff who know what to do and a community knowledgeable about and comfortable with their responsibilities. These same systems can be adapted to train the next generation for the workforce, that is, those who are presently in primary, secondary, and college settings. The current and future workforce could be training together and learning from one another. Regular evaluation of these systems can ensure that content remains relevant to the actual challenges encountered and that those teaching are competent as educators.

Recent assessments of the knowledge, skills, and abilities of the workforce have identified critical needs and deficiencies.10,11 Learning management systems and preparedness curricula are being developed and marketed rapidly by various centers, associations, and schools. These same systems can improve the capacity of the public health workforce to detect, respond to, and decrease threats to the environment, rates of communicable disease, chronic disease, and injury, if designed with these ends in mind. Successful response to each requires many of the same personal and organizational relationships, skills, technologies, and communication channels.

Strategic and directed use of current funding streams can ensure that practice-oriented content becomes part of the curriculum at graduate schools of public health and the many undergraduate programs which now train the helping professions for the workforce. Coursework which includes planned, structured learning experiences such as mentoring, experiential learning, and exercises of various forms outside the "classroom" can keep the present workforce competent and engaged with the future workforce and keep faculty expertise relevant to community practice.

Courses offered in formats, locations, costs, and times convenient for the present adult workforce are an incentive toward competency and can help ensure that a workforce already busy delivering services full time is able to participate in and concentrate on this coursework. Course designers should consider that adults learn best when (a) they are rewarded for achievement; (b) content is repeated, understood in the contexts of current work and a clear need "to know"; and (c) the connection between learning and better results is apparent (J. Cioffi, personal communication, July 2004).

Course content must help the governmental public health workforce learn something about the roles and competencies of their emergency response partners, including, for example, medicine, law enforcement, other first responders, and the military, and about organizational forms and practice such as incident management, which make it easy for those from different fields of practice to work together smoothly during an emergency. Training programs and exercises designed for partners from other sectors should clearly define the roles and responsibilities of the governmental public health workforce during response and the legal basis for it. Involving each of these partners in learning system design and delivery can help ensure that the content reflects the real life of local communities and of those who work and reside in them.

Assuring a Current and Future Governmental Public Health Workforces

It is prudent to seize on the current heightened awareness about the importance of the governmental workforce as one means to attract its next generation. Education and training for terrorism preparedness and emergency response can help address an emerging public health workforce crisis. Managers and administrators responsible for the maintenance and continuity of the governmental public health workforce identify recruitment of new workers and retention of current workers as among the highest personnel priorities.12 The workforce is aging and a majority of the workforce will soon begin to retire. Competition heightens among levels of government and among governments, the private sector, and academia for staff. Strategies to address these challenges include recruitment of the next generation of the workforce and retention of current workers.* Promoting the intellectual and practical challenges confronting the governmental public health workforce and having available an exciting and stimulating curriculum may help to attract and retain the workforce needed.

Conclusion

Education and training for emergency response preparedness fit within the larger context of preparedness for day-to-day disease prevention, health promotion, and health protection. Education and training programs designed with this in mind can mitigate a wide range of threats, including those now considered in an all-hazards approach, while at the same time attracting the governmental public health workforce of the future.

There will be a time when the perceived threat from weapons of mass destruction is displaced in the minds of the public and policymakers by other emergencies. International travel, lifeform gene mutation, an aging population, and random events will see to that. Education and training for full use will ensure the preparedness the nation expects.

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