States, cities still not ready for many emergencies, despite gains.

Regardless of increased attention to public health preparedness, many states and cities remain unprepared to face widespread emergencies, new analyses show.

In response to concerns such as terrorism, pandemic influenza and natural disasters, states and municipalities have experienced an influx of preparedness funding, training and planning in recent years. But only one state, Oklahoma, is adequately prepared, according to a December report from the Trust for America's Health. The report ranked each state, giving half of them a score of six or less on a scale of 10. The majority of states had large gaps in areas such as immunization programs and the ability to drastically increase the availability of medical care in the event of an emergency.

"Each year there is improvement, but we still have a long way to go," APHA member Jeff Levi, PhD, executive director of the Trust for America's Health, told The Nation's Health.

The nation's cities aren't faring much better. In scorecards released in January by the Department of Homeland Security, only four large metropolitan areas--San Diego, Minneapolis-St. Paul, Columbus, Ohio, and Washington, D.C.--had the emergency communications systems necessary to allow all emergency responders to communicate effectively.

The federal report found that policies allowing first responder agencies to communicate with each other during an emergency or disaster were in place in all 75 urban metropolitan areas across the country. Yet regular testing and exercises are needed to effectively link disparate systems and facilitate communication between responders across jurisdictions. The report found that while cooperation among first responders is strong, formalized leadership and strategic planning across regions needs work.

"For the reasons that were made abundantly clear in the Sept. 11 commission report ... there's nothing that's more important than getting this job of communications done, so we can do response as effectively and as safely as possible," said U.S. Homeland Security Secretary Michael Chertoff at a January news conference.

A few days after issuing its annual report on state-level preparedness, the Trust for America's Health commended the federal government's progress in executing the majority of the six-month benchmarks in its national pandemic preparedness plan, which was released in 2005 and is geared at preparing the nation to protect itself against a possible flu pandemic.

"We're at the beginning of the process," said Levi, who raised concerns about the plan not addressing such "critical, practical issues" as investing in surge capacity, or the ability to quickly respond to a widespread need for more medical care and other services during an emergency. However, the recently passed federal Pandemic and All-Hazards Preparedness Act, which was signed into law in December and addresses public health preparedness in particular, offers an encouraging example of a federal commitment to improve public health preparedness.

While health officials in Oklahoma said they were "pleased" with their distinction of being the only state in the Trust for America's Health report to earn a perfect score for preparedness, they viewed the result as a snapshot of their continuing process toward public health preparedness.

"I was elated," Shawna McWaters-Khalousi, MS, chief of the state's Terrorism Preparedness and Response Service, told The Nation's Health. "Let me admit, I am a bit surprised. Preparedness is not a destination, it's a journey. I don't consider us a 10."

McWaters-Khalousi said she believes that Oklahoma scored well because of a long-standing commitment among the public and the public health community to work together. Emergency responders also contend with regular concerns such as wildfires, floods and tornadoes, which keeps them prepared in the largely rural state, she noted.

As with many public health concerns, when it comes to helping states with preparedness, funding is an issue, Levi said.

"We have so far to go yet," he said. "To be cutting (Health Resources and Services Administration) dollars when we don't have near the surge capacity we need, means our funding levels are not matching the rhetoric of needing to be fully prepared."

While federal funding has recently increased in response to concerns about pandemic influenza, more than $90 million has been cut since 2004 from preparedness funds allocated to states through the Centers for Disease Control and Prevention, and more than $23 million has been cut from HRSA funds earmarked for hospital preparedness, Levi said.

APHA is working to improve preparedness of Americans through National Public Health Week this April. This year's theme is "Take the First Step! Preparedness and Public Health Threats: Addressing the Unique Needs of the Nation's Vulnerable Populations." Planning materials for the event can be downloaded now at <www.nphw.org>.

"Despite the danger of a health emergency, Americans remain largely unprepared for health disasters, including our most vulnerable populations such as young children and people with chronic illnesses," said APHA Executive Director Georges Benjamin, MD, FACP.

The Trust for America's Health's report, "Ready or Not? Protecting the Public's Health from Disease, Disasters and Bioterrorism," and state-by-state preparedness information are available at <www. healthyamericans.org>.

For a copy of the Department of Homeland Security scorecards and report, "Tactical Interoperable Communications Scorecards Summary Report and Findings," visit <www.dhs.gov/index. shtm>.