In the 5 years since the attacks of September 11, 2001, local, state, and federal public health agencies have spent hundreds of thousands of hours and more than 5 billion dollars in preparedness-related activities.1 But have these investments in our nation's public health readiness "paid off?" Is our public health system any better than it was 5 years ago? Indeed surveying 5 years of public health preparedness efforts with an eye toward future disease threats, including potential pandemic influenza, has led many working in public health to ask "are we ready yet?" The answer to this question may be a surprise to some, especially those looking for a "quick fix" to our nation's public health infrastructure. While a number of important preparedness activities have been accomplished in the past 5 years, a great deal more remains to be done. In fact the best answer to the question "are we ready yet?" may be a resounding "it depends." Unfortunately, that is not an answer that generates a great deal of enthusiasm in Washington, District Columbia, nor Atlanta, nor in public meetings and other venues at which healthcare officials are presenting the fruits of 5 years of preparedness labor.

Certainly a number of excellent efforts have been undertaken to improve the nation's public health system in the past 5 years. Public health agencies are now significant partners in emergency management at the local, state, and national levels. While it may have been uncommon for public health agencies to attend emergency planning meetings in pre-"9/11," public health now has a "seat at the table" in most jurisdictions. Traveling across the country I hear health officials report that they are now seen as the lead agency for emergency planning efforts related to public health and medical responses to disasters in their communities. "Incident command," once a foreign language for public health workers, is now a second language for many. Agencies fluent in command and control concepts are engaged with partner public safety organizations such as fire services and law enforcement to coordinate readiness activities and drill together.

A number of new emergency response positions have been added to health departments in the past 5 years, although a steady stream of budget cuts and retirements has drained other parts of many agencies. Preparedness funds have hired or supported contracts with trainers, planners, epidemiologists, laboratory workers, public information officers, and other specialists. The efforts of these individuals have resulted in a more competent public health workforce, codified preparedness and response plans, and developed corrective action reports from exercises and drills that concretely illustrate systems are in place to respond to health threats at the local, state, and national levels. A national program to recognize local public health departments that have achieved a set of preparedness criteria, "Project Public Health Ready," continues to be oversubscribed demonstrating a desire for agencies to obtain excellence, and recognition for their efforts to prepare.2 Communities are involved in preparedness efforts; for example, the Medical Reserve Corps project has registered 489 units in communities nationwide and has a national network of almost 90,000 volunteers ready to assist in a health emergency.3

New disease detection and "syndromic surveillance" systems, though still early in their development, hold promise for rapid detection and identification of potential health threats using data from pharmacy sales, hospital admissions and discharges, EMS runs, and environmental samples in major metropolitan areas nationwide. Networks of public health laboratories have been funded to share information, develop new techniques, and bolster laboratory surge capacity in the event of emergencies. Anecdotally, experts whom I queried unanimously agreed that the September & October 2006 nationwide outbreak of E coli associated with consumption of raw spinach was detected earlier than it would have been 5 years ago, and the rapid response to that outbreak was successful because of time spent on local and state preparedness activities in the past 5 years.

So, are we ready yet? Does all of this activity really mean that the public health system could effectively respond to a health emergency such as pandemic influenza? In the words of a Trust for America's Health report on public health preparedness released last year, "[W]hile the experts clearly acknowledged that significant progress has been made in federal efforts since September 11, 2001, overall the experts give the federal public health and bioterrorism preparedness performance a grade of D+."4 Harking to similar media statements from 5 years ago, a front-page article in a July 2006 edition of USA Today headlined 'Cities' Disaster Plans Lacking: Survey paints grim picture of preparedness' and cited a US Conference of Mayors survey in which only 30 percent of respondents reported that their city could handle a pandemic influenza outbreak.5 Methodology and politics aside, a D+ average and negative headlines about preparedness efforts do not build confidence in any local, state, or national effort prepare. Success stories to counter these claims are woefully lacking, if they exist at all. Governmental responses to major disasters have been dubbed "failures": the 9/11 Commission's Report cited a "failure of imagination" in preparing for a terrorist attack using hijacked airplanes, and the 2005 Congressional report on the Hurricane Katrina response was bluntly titled "A Failure of Initiative" because of the time it took to marshal Federal resources necessary to assist the Gulf region.6,7 Five years after 9/11, would we characterize public health preparedness as a success or failure? Do we have systematically collected stories of effective preparedness efforts that are convincing in their messages and will be useful to people who need them to advocate and educate the public about what we have been doing for 5 years? Again, it depends.

Certainly there is evidence to suggest that public health agencies are not ready for a disaster response of the size and scope required in a global influenza pandemic. Seasonal influenza already taxes the capacity of the industry and government to provide immunizations to those who need them, let alone the "worried well." Shoppers routinely storm the local K-Mart to get the latest video game in time for Christmas; what can we predict will happen to a scarce resource such as oseltamivir phosphate (Tamiflu) at the first signs of pandemic flu? What risk education have we provided to mitigate this kind of behavior, and how have we engaged members of the community to avoid the panic and civil disorder that may accompany these health emergencies? Have we done all we can do with our stakeholders to prevent other deleterious outcomes or irrational behavior, or are we just accepting that "chaos happens" and proceeding with our Strategic National Stockpile Point of Dispensing plans as if nothing could change them? Have we investigated the resources and needs of potential partners including businesses, faith communities, or school systems as preparedness plans are developed, and is there meaningful involvement of these partners in public health preparedness activities at the local, state, and federal levels?

The public health preparedness "failure" in pandemic influenza may in fact be a "failure of intervention" by not taking the time now to build community resilience and think through crisis communications and public health education interventions that may support an effective response to a major public health emergency before the emergency itself. It is time to resurrect tried and true public health interventions that were successes in the past: meaningful health education about voluntary social distancing and other low-tech, highly successful public health interventions. While the US Department of Health and Human Services "Bioshield" program is investing billions of dollars in vaccine research and development, a similar project to develop standard public health education messages and basic public health interventions that could be tailored to fit every community in the country may yield even more promise than vaccines in the face of a contagious disease outbreak such as pandemic influenza.8 If we learned anything from the anthrax attacks of October 2001, it was that people want information about how to protect themselves and their loved ones. In the face of an outbreak, and in the absence of good public health information and interventions, people will order what they are told is Ciprofloxacin on-line, microwave their mail, and treat powdered donuts as a biohazard. Have we envisioned messages for future outbreaks that might help stave off this kind of a response to a future disease threat, such as influenza, or are we busy figuring out how much vaccine we will not have? Can we predict some of the things people will want to know in an emergency about their health, why vaccine may not be effective or available, and share those potential messages now so that we are not caught short, again, in the future?

Frustrating to many in the field is the time and political machinations spent on work to define public health preparedness and develop measures to evaluate preparedness programs to answer the question "are we ready yet?" While everyone wants data on preparedness, no one, short of Project Public Health Ready, has clearly defined it for local or state public health agencies. This has led to confusion: is preparedness the capacity of a state or local health department to meet its Centers for Disease Control and Prevention (CDC) Preparedness Cooperative Agreement objectives? Is preparedness being able to respond to 15 "national planning scenarios" laid out by the US Department of Homeland Security (DHS)? Is preparedness asking every member of every health department to take the DHS on-line test on the National Incident Management System and print out a certificate? Is preparedness participating in a community-wide drill that could simulate a real emergency, and evaluate what action is needed to respond better next time? In the absence of a clear definition of preparedness, health departments have defined preparedness as all this and more.

In a recent presentation, a colleague inventoried 23 state and local preparedness performance measures developed by the CDC's Coordinating Office for Terrorism Preparedness and Emergency Response, 6 additional CDC pandemic influenza performance measures, 21 measures for hospitals in the Health Resources and Services Administration Hospital Preparedness program, a set of measures for regional cross-border preparedness developed by US Department of Health and Human Services' regional health administrators, in addition to 36 "target capabilities" developed by the DHS.8 Had stakeholders agreed to a standard set of measures 4 years ago, perhaps the panoply of every agency developing its own measures could have been avoided and we could be charting our progress over the last few years. Instead, we are left with good anecdotes about being ready (or not), but no objective assessment to account for billions spent to improve public health preparedness. Did we get the E. coli faster? Not sure. Did we do a better job staving off seasonal influenza last year than the year before? Don't know. Did we detect an outbreak of pertussis earlier than we would have in the past, saving lives? It depends.

If public health is to truly answer the question "are we ready yet?" with a resounding yes, we have some work to do. First, we have to agree on a core set of preparedness measures and stick to them to longitudinally track our progress (or lack thereof) over time. Part of this project is to envision what a prepared public health system looks like, build a strategic plan to meet that vision, and fund programs to reach it. Without that vision, without a plan, and without performance data, weary appropriators will continue to chop public health preparedness budgets, citing "lack of data" demonstrating an acceptable return on investment. And frankly, I do not blame them one bit. If my retirement portfolio was managed like we treat our preparedness investments, I would fire my broker and invest with another firm too.

Second, we have to take seriously the potential "failure of intervention"-are we doing what we can now to anticipate future outbreaks and marshaling our communities to take public health preparedness seriously? At a recent local pandemic influenza summit, the moderator asked the audience of 500 people to indicate whether they thought that local, state, and federal governments were taking adequate steps to prepare for pandemic influenza. Eighty percent (80%) of the audience indicated that they did not think government was doing enough. But when asked whether they, personally, had done anything to prepare for pandemic influenza, 80 percent (80%) of the audience indicated that they had not.9 Are we waiting for them, or are they waiting for us? Regardless of how you interpret this finding, that summit was an eye-opening experience.

How can we answer the question "are we ready yet?" if preparedness becomes yet another public health "silo" along with the other programmatic categories and stovepipes that define governmental public health? To be truly "ready," the assets of entire agencies, not just the preparedness coordinators, need to be tapped. Are our public health departments instilling a "culture of preparedness" across their agencies or are we relying too heavily on the work of a few? In a major public health emergency all employees will be needed: do they know that? Will they report to work when called? What have we done to lay the groundwork for that to happen?

Finally, for public health to truly "be ready" we have to take our preparedness partnership activities to the next level. Enough time has been spent getting to know the players-the next step is action. Are all our meetings, planning groups, coordinating councils, and special committees moving beyond discussions of preparedness and into concrete activities to test preparedness, evaluate the experience, and improve for the future? Are public health activities inexorably tied to community-wide plans, or are public health assets in a binder on a shelf in a basement that no one will use for anything other than a doorstop. Effective collaboration means more than sitting around a table-meetings are a means to ends, and not an end in themselves. Collaboration defines the contributions of each partner, tests those relationship through exercises, and facilitates learning together how to make things better. There is no magic bullet that will get us prepared, but there are ways to build preparedness programs in which we can have confidence and from which we can discern measurable impact. Let us hope that in 5 years the answer to the question "are we ready yet?" is a resounding "yes!!"

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