One year ago, in January 2005, the Centers for Disease Control and Prevention launched an effort to develop its first ever, agency-wide public health research agenda, reflecting its vision for 2006-2015. The CDC has reorganized itself, through the Futures Initiative, “to become a more effective public health response agency to meet the challenges of the 21st century,” and this was a major effort in updating the agency to meet those challenges.

In The Future of the Public’s Health in the 21st Century (2002), the Institute of Medicine recommended that the “Centers for Disease Control and Prevention should develop a research agenda and estimate funding needed to build the evidence base that will guide policymaking for public health practice.” The CDC’s initiative toward a new research agenda was also the CDC’s response to the need to better relate research to practice, a need addressed in 1999 by the Public Health Foundation:

“For many years, the public health practice community has been frustrated by the apparent disconnect between research studies and practice needs.  Where research exists which has application in community settings, it often is not adequately translated or disseminated in a manner to facilitate its application.  In addition, an insufficient amount of research in the fields of health and medicine focuses on human behavior, an area of critical importance to public health. There also is a strong perception that the current research agenda is driven by resources, rather than identified needs in communities.  Too often, potential users of research at the community level are not involved in identifying information gaps or in establishing research needs.” 

It set about developing the agenda through workgroups comprised of CDC staff and “external partners,” including stakeholders and the public at large. As a result of this engagement, it expected to have a draft of the research agenda available for public comment by May 2005. The agenda was to be finalized in August after the public comments were reviewed and integrated.

 CDC’s research priorities were to be set according to four criteria[i]:

·       Public health need/importance of problem

·       Relevance to reducing health disparities

·       Potential for broad impact (>1 subject area)

·       Relevance to CDC’s mission/goals

The six different areas of research interests that reflect CDC’s new organizational structure are:

• Infectious Diseases;

• Health Promotion;

• Environmental and Occupational Health and Injury Prevention;

• Health Information and Services;

• Global Health;

• Community Preparedness and Response.

My Workgroup

The process went public with a series of four meetings around the country to gather input for CDC’s research agenda from stakeholders, researchers, and representatives of partner organizations invited to attend along with the public-at-large. I was a member of the Community Preparedness and Response Research workgroup that met in Columbus, Ohio at the end of March. Its charge was to focus on developing research areas or themes associated with preparedness and response to both natural disasters and naturally occurring disease outbreaks such as influenza, and those events associated with human made disasters including terrorism.

There were six of us comprising this workgroup, and about a month prior to the meeting, we had been given a list of 18 Research Themes representing potential research priorities. Out of these overlapping areas, I identified two in which I thought that health planning could make a signal contribution:

1. Community Actions: Describe and explain how diverse communities detect, interpret, respond to, and communicate perceived and actual public health threats.

2. Public Health, Mental Health, and Medical Response Systems: Assess and identify strategies and model practices for integration of public health, mental health, and medical response systems to respond to terrorism, other disasters, and public health emergencies.

HIGXYZ29HIGZYXIt seemed obvious to me that the first theme should address the potential of community health planning processes in preparing communities to deal with emergencies. We agreed to recommend the following Research Activity: “Can public health planning approaches, e.g., MAPP (Mobilizing for Action through Planning and Partnerships), be effective for community engagement and public participation in emergency preparedness planning?” Related Research Themes addressed strategies for communicating information to communities so as to maintain trust, and here we recommended the use of social marketing to establish the efficacy of the strategies. I think that communities must be engaged by planners if they are to be protected, for they are best protected from within by the empowerment that comes from being informed. Four years ago, I wrote an article that addresses this, and it is accessible at: http://www.ahpanet.org/Health_policies.html#Protecting.

The difficulty of protecting communities is succinctly stated in the following passage from almost a decade ago:

“If the public understands the limitations within which crisis management must operate BEFORE a crisis occurs, then public trust can be maintained despite the constraints that a crisis inevitably imposes on government openness and accountability, and even in the face of emergency measures that suspend the rule of law in certain areas. On the other hand, in an era of deficit reduction and cost-cutting, publics who vote for governments who promise tax cuts, deregulation and privatization should be educated in the consequences these trends may hold for public safety and security. If those agencies and companies that take over government responsibilities are less publicly accountable or less subject to legal controls, and if profitability and the interests of stock-holders take precedence over the public interest, people should not be surprised when governments have little control over the prevention of future crises.” [ii]

HIGXYZ33HIGZYX The second theme addresses the heart of the system response to emergencies. What I thought it overlooked was the need to identify means to implement emergency preparedness and management strategies in rural areas without effective local health departments. In most such areas, it will be incumbent upon local community hospitals to play the role of a public health agency, and JCAHO has issued guidelines for what is expected of them. I recommended that CDC ensure that JCAHO’s standards for hospitals engaging in emergency preparedness planning in their communities reflect best practices in public health. Of course, this raises the perennial issues reflecting the age-old barrier between public health and personal health, but I don’t think there will be effective preparedness without the seamless integration of medicine and public health.

The draft research agenda we were given presented research questions about planning for emergency preparedness, but those questions look quite different when seen from the perspective of a practitioner who must implement the planning. We were well aware of the practical considerations surrounding the emergency measures, considerations unanticipated in how those research questions were framed for us. A further deficiency in CDC’s process was that we were not given sufficient information about CDC’s current research and planning activities, nor any information about what similar research was being undertaken and sponsored by other federal agencies, e.g., AHRQ and NIH.

Questions About CDC

Inexplicably, CDC did not release its public comment draft until November, fully six months behind schedule. The draft was available for public comment for 60 days from November 18, 2005 to January 15, 2006. Out of this, the new CDC Health Protection Research Guide, 2006-2015 is expected to be completed during Spring 2006. The Research Guide will serve as a resource for defining the prioritized CDC Health Protection Research Agenda, in support of its Health Protection Goals and Priorities. In addition, portions of the Research Guide will be used to inform research initiatives that address other critical public health needs and research priorities of other agencies.

Unfortunately, neither of my two themes found their way into the draft. In fact, planning WITH communities is totally missing here.