Risks from infectious and non-infectious emergencies are increasing in communities globally, influenced by emerging infectious diseases, extreme weather and climate change, and the complexity of our communities. As a clinician working in a downtown Toronto emergency department (ED) in the early days of the 2009 influenza pandemic, there was still a lot of uncertainty around the virus and the risks. I saw a patient in the ED during that time with a travel history to the location of interest and signs of the flu. Even as a clinician interested in public health, it was hard to remember the key information such as what mask I should be wearing; what were the lab instructions for testing; and what other key information was important to protect myself and other patients. Integrated communication and information flow during an emergency is a universal challenge for health systems, and systems that support the front lines are essential.
The lessons from the health system perspective after the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak have been well-documented and system-level challenges featured prominently at that time. Dr. Naylor’s report pointed to a lack of surge capacity in the clinical and public health systems, difficulties with timely access to laboratory testing and results, and weak links between public health and the personal health services system. Even in recent years, the World Health Organization (WHO) recognizes the system-level challenges we face globally around public health emergencies. In the context of Ebola Virus Disease outbreaks, the WHO calls for countries “to create resilient integrated systems that can be responsive and proactive to any future threat”. It is crucial that lessons inform learning and improvement towards building resilience. Ultimately, health system resilience supports its capacity to protect and promote the health of our citizens.
The public health sector, distinct from clinical or hospital-based care, has a crucial role in emergency preparedness that occurs largely in the background until an event like SARS raises the profile. Public health plays a diverse role in protecting population health for both infectious and non-infectious emergencies. Activities include performing surveillance; epidemiologic investigation; implementing preventive measures; development of policy and guidance for the public, health system partners and health-care practitioners; and communicating risks with the public and other stakeholders. Despite the lessons learned from SARS, a persistent challenge for front line public health workers is defining what it means to be prepared and assessing system performance in public health emergency preparedness (PHEP). The literature indicates this is a knowledge gap globally and this was echoed when we met with stakeholders working in the field across Canada. The idea of “how do we know if we are prepared?” and “how do we measure it” were the top priorities for research for the field when we hosted a priority-setting meeting. Addressing these questions has practice and policy relevance and importantly supports learning and improvement to foster resilience in the system.
In Canada, we have made initial progress towards answering these questions for our context. With Canadian Institutes of Health Research funding, our team has developed a framework and set of indicators which aim to measure preparedness at the local/regional public health agency level. We found that ensuring system resilience for emergencies involves working as a complex system to address eleven essential elements including governance and leadership, collaboration, workforce capacity, learning, and engagement with our communities. The development of indicators represents an important step towards measuring preparedness which can inform learning, practice improvement and evidence-informed policy. The complex nature of the health system and the essential elements of PHEP requires considerate implementation through a collaborative, continuous improvement approach which has relevance across Canada. Future work is required to ensure that data gaps and reporting burden are assessed for local/regional public health agencies and relevant decision-makers. Progress on implementing preparedness indicators is increasingly important for practice and policy going forward given limited public sector resources, emphasis on accountability, and increasing risks of disasters and emergencies.