Preparedness Guiding Principles

September 01, 2017

State and territorial health agencies are critical to our nation's ability to prepare for, respond to, and recover from public health emergencies and threats. Principally, they ensure the public health of their jurisdictions through their inherent and often legal authority to protect and promote the health, safety, and general welfare of their populations. Over the last 15 years, virtually all state and territorial health agencies have developed the infrastructure needed for a 24/7 readiness posture in partnership with responsible individuals, communities, other government and non-governmental organizations and the private sector. There is broad agreement that a resilient public health response infrastructure is essential for our society’s safety and security, as well as the health and economic well-being of our nation. At the core of this public health infrastructure, however, is a relatively fragile and carefully built network of highly-skilled people and relationships, rather than durable and consumable materials.1  The challenge of sustaining federal, state, and local funding has impacted all jurisdictions, including the training, exercises, and the responses this network relies on to maintain its capacity and resiliency. There is no public or commercial market for providing these essential services, therefore it falls on governmental agencies to assure this capacity, maintain the requisite capabilities, and fund the resources needed. However, the benefits that result from such a capacity make this a good investment for all.

A collaborative national preparedness effort is critical and requires a clear understanding of roles and responsibilities among federal, state, local, territorial, and tribal agencies. As the national nonprofit organization representing the state and territorial public health agencies of the United States, the U.S. territories and freely associated states, and the District of Columbia, the Association of State and Territorial Health Officials (ASTHO) recognizes the need for strong federal support for state and territorial public health preparedness to maintain and advance this hard-won public health emergency response capacity. State, territorial, and local public health departments have repeatedly demonstrated their robust capabilities to protect the health and safety of their populations from the effects of natural and man-made disasters. Yet these capacities can degrade rapidly without the support of federal grant policies and community and business practices that foster coordinated planning and response activities.

Prevention, Mitigation, Resilience, and Recovery

A community’s ability to recover from a disaster begins with “its efforts in pre-disaster preparedness, mitigation, and recovery capacity building.”2  State, territorial, and local public health leaders must work to provide the education, tools, ongoing training, policies, and programs to equip their jurisdictions with critical capabilities to prevent and mitigate threats to the public's health and respond to and recover from potential disasters.

Creating a resilient community first requires identifying the community’s vulnerabilities. To do so, public health leaders should assess a community’s general health, access to mental health and other health services, socioeconomic statuses of various sub-communities and overall social interconnectedness. This knowledge can assist communities in making sure they “recover in a way that moves the community to a state of self-sufficiency and at least the same level of health and social functioning following adversity as before it, if not better.”3   A structure and mindset dedicated to recovery should influence activities at all levels of the preparedness cycle.i   ASTHO strongly supports the continued development and adoption of federal guidance, collaboration, training, support, and resources to assist state and territorial jurisdictions in becoming more resilient communities. 

Sustained Funding for All-Hazards Preparedness

Public health preparedness requires the long-term development and continuous improvement of public health systems that can respond to all hazards. These systems are built through flexible, sustained federal, state, and territorial support. Federal programs, such as CDC's Public Health Emergency Preparedness (PHEP) and ASPR's Hospital Preparedness Program (HPP) cooperative agreements, help develop emergency-ready public health departments and healthcare systems that are flexible, adaptable, and resilient. These grants should be maintained and reliably sustained for the long-term to provide the resources needed to conduct training and exercises; develop corrective action plans and implement improvements; train new members of the preparedness workforce; reinforce the skills of seasoned preparedness professionals; and support systems for communications, laboratory analytical services, biosurveillance, and information sharing. Funding for all-hazards work should be a shared responsibility among federal, state, and local governments. ASTHO urges the following:

  • State and territorial health officials should work with their governors, legislators, and appropriators to find dedicated funding sources to help support funding for all-hazards preparedness.
  • Congress and the Administration should support federal funding for all states and territories in order to build preparedness across all public health departments, communities, and healthcare delivery systems using a systematic approach. This strategy will ensure that the necessary resources to respond quickly and collaboratively to public health emergencies are in place across the country.

Optimal Health and Preparedness for All Populations

Optimal health for all is achieved when the public health and medical needs of all individuals are considered in the planning for, response to, and long-term recovery from public health emergencies.4  Emergency situations can compromise a range of nonclinical services that are essential to an individual’s daily survival and well-being (e.g., low-cost meals, language interpretation, or care for service animals). The inclusion and consideration of individuals who “may have disabilities, live in institutionalized settings, are from diverse cultures, have limited English proficiency or are non-English speaking, are transportation disadvantaged, have chronic medical disorders, or have pharmacological dependencies” is vital to the resiliency of a community.5  It is important for public health decision makers to recognize the assets and skills of vulnerable populations and the systems, organizations, and individuals that support them.

Preparedness Science, Technology, and Emerging Threats

As global threats increase in complexity, severity, and mobility, the preparedness community must create and embrace new tools and technologies for preparedness and response. Innovation must be incentivized to develop new technology that enhances existing surveillance tools, provides historical data to help predict trends in disaster and disease movement and frequency, and increases public education and resilience. There also must be recognition of the social and behavioral aspects contributing to violent extremism and terrorism prevention. The public health preparedness community can play a very important role in recognizing the social and behavioral aspects of terrorism prevention and in advancing and targeting community based interventions that could help prevent the potential radicalization of individuals for the purpose of committing acts of terrorism or other violent acts. This includes promoting and supporting investments in early childhood cognitive development, parent-child relationships, family counseling, after-school programs, adolescent and young adult mental health and drug abuse, community and police relations, anger management, bullying prevention, and other social and economic effects leading to feelings of isolation, withdrawal, or distress. The use and support of these programs and strategies align with the application of a multi-tiered6  public health model.ii  Public health departments have the opportunity to administer programs that offer tiered prevention strategies and can use existing data collection and surveillance tools to prove their value and significance of impact.iii

Lastly, we must support the continued acceptance and adoption of prevention techniques used by parallel disciplines. Intelligence-led tools, such as the Department of Homeland Security’s suspicious activity reporting and fusion centers, are valuable. As public-facing figures, public health officials and healthcare professionals can see suspicious behaviors and alert authorities for further investigation.


ASTHO recognizes the critical importance of collaboration with all sectors having mission-related roles and responsibilities in protecting the public during all phases of the disaster cycle. To fully prepare, mitigate, respond, and recover, public health agencies need to establish, maintain, and enhance collaborations with emergency management, homeland security, and other relevant public agencies.

The private sector also has an important role in ensuring the preparedness and resilience of its workforce, stakeholders, and the communities where they reside. ASTHO encourages the following:

  • State and territorial health departments involve private-sector representatives in all stages of preparedness planning. The private sector provides valuable resources, such as human capital, critical infrastructure, data, community trust, economic stability, and other national interests.
  • The private sector should increase its investments in prevention, security, threat resilience, and collaboration with state, local, tribal, and territorial health departments. These collective partnerships may act as a model to help stakeholder collaboration expand to other traditional and nontraditional partners.

Sustained Performance Metrics, Preparedness Evaluation, and Return on Investment

Federal funding to public health should include adequate resources to measure preparedness efforts through flexible, valid, and meaningful performance metrics that demonstrate progress and areas of greatest need for future development and to maintain accountability and drive improvement. CDC PHEP and ASPR HPP capabilities currently allow state and territorial health agencies to assess their level of preparedness and provide an aggregated snapshot of the nation's preparedness capabilities. Additionally, the National Health Security Preparedness Index is an important tool to measure health security in states and should continue to be developed with academic and practice communities so it best reflects the multi-sectoral nature of health security. The public health community and its stakeholders must continue to guide the collaborative development, implementation, and evaluation of appropriate and consistent performance measurement tools that use relevant, actionable information to achieve a higher level of health security preparedness, support quality improvement, inform resource and policy decision making, enhance collaboration and shared responsibility, and advance the science of measuring health security preparedness.

Approval History:

Preparedness Policy Committee Review and Approval: July 2017
Board of Directors' Review and Approval: August 2017
Ratified by ASTHO Assembly of Members: September 2017
Policy Expires: September 2020
Expiration Date Extension due to COVID-19: September 2022

ASTHO policies are broad statements of enduring principles related to particular policy areas that are used to guide ASTHO's actions and external communications.


  1. Annual Review of Public Health. “The Public Health Infrastructure and Our Nation’s Health.” Available at: Accessed 7-26-2017..
  2. Federal Emergency Management Agency. “National Disaster Recovery Framework.” Accessed 7-24-2017.
  3. HHS Office of Disease Prevention and Health Promotion. “Healthy People 2020: Preparedness.” Available at: Accessed 7-24-2017.
  4. National Academies. Committee on Post-Disaster Recovery of a Community’s Public Health, Medical, and Social Services. Board of Health Sciences Policy. “Healthy, Resilient, and Sustainable Communities After Disasters: Strategies, Opportunities, and Planning for Recovery.” Available at: Accessed 7-26-2017.
  5. HHS Office of the Assistant Secretary for Preparedness and Response. “At-Risk, Behavioral Health, and Community Resilience (ABC).” Available at: Accessed: 7-24-2017.
  6. National Academies. “Countering Violent Extremism Through Public Health Practice: Proceedings of a Workshop.” Available at: Accessed 7-26-2017.
  1. The National Incident Management System defines preparedness as "a continuous cycle of planning, organizing, training, equipping, exercising, evaluating, and taking corrective action in an effort to ensure effective coordination during incident response." This "preparedness cycle" is one element of a broader national preparedness system to prevent, respond to, recover from, and mitigate damage from natural disasters, acts of terrorism, and other man-made disasters. Components of the preparedness cycle include: Plan, Organize and Equip, Train, Exercise, and Evaluate and Improve. More information is available at:
  2. For example, primary prevention activities would use community level strategies such as preventing early childhood trauma, or finding ways to reduce social isolation and exclusion. A secondary prevention strategy would be through the engagement of gang affiliated youth with no history of violence. Positive prevention interactions at this point may help reduce their already elevated risk of violent behavior before adulthood.
  3. The Baltimore City Health Department oversees its Safe Streets Baltimore Program. The program aims to reduce youth gun violence and employs outreach professionals. In an evaluation by the John Hopkins School of Public Health, the program resulted in a 56% reduction in homicides in one neighborhood alone. Additionally, 88% of participants received assistance in finding a job, and 95% received assistance in getting into a high school or GED program.