warrants the trade-offs necessary to address it. According to Raub, three key disagreements exist among officials, (1) the likelihood of a terrorist attack that will result in such mass casualties, (2) the balance of investment between the general enhancement of public health infrastructure and the special emergency response capabilities needed to respond to an event of such magnitude, and (3) the necessary balance of investment among local, state, and federal government assets. To best protect the public’s health, Raub noted the need for better communications concerning the nature of the risks and the vulnerabilities and trade-offs in addressing them, as well as vertical and horizontal integration of assets to strengthen the ability of the United States to respond to large-scale events.

To determine the local, state and federal resources that are necessary to respond to disasters, Jonathan L. Burstein has suggested a model defining the preparedness and response problem in terms of systems, supplies, staff, and space (Burstein, 2004). The systems component of the model seeks to address the communications and logistics needed to prepare for and respond to crises. The supply variable addresses the drugs, vaccines, and basic necessities—housing, food, and water—that victims need, and how to best distribute those resources among affected communities. Staff considerations include training and credentialing adequate numbers of volunteers and ensuring their safety throughout the response effort. The final component of the model, space, takes into account the physical space needed for patient care, isolation, if necessary, and the distribution of community prophylaxis. Upgrading the public health and health care systems by strengthening systems, supplies, staff, and space, will allow local, state, and federal governments to better respond to disasters.


During recent disasters in the United States, responders have encountered numerous problems, including confusion over the jurisdiction responsible for coordinating the response effort; an inability to communicate the vulnerabilities and risks before, during, and after the crisis; difficulties in getting responders to the disaster site while moving victims away from it; and problems distributing essential resources among those who need it most. To alleviate those problems during future responses, the U.S. Department of Health and Human Services has made improvements in state and local preparedness by providing funding and guidelines for all 50 states, the District of Columbia, the territories, and three major urban areas—New York City, Chicago, and Los Angeles County. According to Raub, the Department hopes to improve the response capabilities for bioterrorism and other disasters, while overcoming decades of neglect in the public health infrastructure with respect to containing infectious disease outbreaks.

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