8Advocacy and Resource AllocationThe Capitol Building in Was.docx

8
Advocacy and Resource Allocation
The Capitol Building in Washington, DC.
xxcheng/iStock/Thinkstock
Learning Outcomes
After reading this chapter, you should be able to
Differentiate between advocacy and lobbying.
Explain the use of data and media for public health
initiatives.
Examine the importance of resources in public health
advocacy.
This chapter highlights the importance of public health
advocacy and resource allocation. In fact, public health
professionals use advocacy far more often than lobbying. It is
rare for public health professionals, particularly those working
for health departments, to lobby at all. While lobbying and
advocacy are closely related, lobbyists are paid professionals
and advocates are not. This chapter will discuss the key
differences between lobbying and advocacy and examine the
purpose behind public health’s use of one versus the other.
Public health data is used for both advocacy and media
attention. While this chapter focuses more on advocacy work, it
is important to recognize that advocates can receive evidence
from data that supports their side of an argument or their point
to enact a policy. This chapter will explain some of those uses,
in addition to examining resource allocation and its importance
to the public health realm.
8.1 Effecting Change in Public Health

The terms advocacy and lobbying are often used
interchangeably, but they are distinctly different. Advocacy
seeks to affect society—to change a belief or behavior, or
convince individuals to act or not act on an issue. Lobbying is
typically an act by special interest groups or industries to
attempt to convince Congress to enact legislation on a particular
topic. In public health, it is rare to find a lobbyist. While
individuals in the role are important to effecting change in
legislation, public health finds itself more aligned with
initiatives to create change in population behaviors, regardless
of whether the initiative is a law or a recommendation. In this
regard, advocacy work is the key, and one of the most important
elements, for successful public health endeavors that reach large
populations.
The Role of Research
Research into health issues can often translate into advocating
for improvements in the public’s health, from developing
healthy eating habits to eliminating behaviors that can lead to
poor health. For example, it wasn’t until piles of research
finally uncovered the link between smoking and cancer that
public health professionals advocated for tobacco control (see A
Closer Look). When the law was proposed, lobbyists would
have likely come from tobacco companies to oppose it because
it would affect sales. In this case, advocacy was focused on
simply changing the public’s behavior through regulation of any
sort, while lobbying focused on specifically stopping the
passage of the particular act.
A Closer Look: The Family Smoking Prevention and Tobacco
Control Act
The Family Smoking Prevention and Tobacco Control Act is
considered the most comprehensive federal initiative against
smoking since 1971, when radio and TV advertising for tobacco
products was banned (Manz, 2009). What drove the act into
existence was research that showed the following staggering

statistics in 2009:
21% of American adults smoke cigarettes
23% of high school students smoke cigarettes
438,000 deaths each year can be attributed to smoking
A stack of cigarette packs with visible surgeon general’s
warnings.
Stock Connection/SuperStock
One of the requirements of the Family Smoking Prevention and
Tobacco Control Act is that manufacturers provide information
about the ingredients in tobacco products.
Where did those statistics come from? Public health research!
As research continued to show smoking caused poor health
issues, including death, so did advocacy efforts to make a rapid
and positive change. Advocates from numerous agencies,
including the American Public Health Association, American
Cancer Association, and American Lung Association,
campaigned for stronger controls on tobacco. In a collective
effort, these advocates wrote letters and attended meetings and
official briefings in front of legislators across the nation. While
that may appear similar to lobbying, the advocacy methods used
did not necessarily support any legislation. Lobbying efforts, on
the other hand, would have specifically asked Congress to pass
that particular law. And it is likely that some lobbying efforts
were done in that regard. The advocacy efforts were simply for
stronger policies on tobacco control. The end result was this
act.
Another driving force behind the law was the “endless series of
multimillion-dollar lawsuits filed by individuals against major
tobacco companies” (Manz, 2009, p. 2). Furthermore, Medicaid,
health insurance for low-income individuals in the United

States, was footing the bill of more than $360 billion for more
than 25 years of treating illnesses from tobacco use (Manz,
2009). Considering that Medicaid is paid by the tax dollars of
all Americans, it was a significant chunk of money for U.S.
residents to pay—whether they smoked or not.
Thanks to the advocacy work of public health professionals as
well as nonprofit organizations vested in smoking cessation
(such as the American Lung Association), there is now
regulation on the manufacturing, distribution, and marketing of
tobacco products. The act does the following:
Restricts tobacco marketing and sales to youth
Bans sales to minors
Bans vending machine sales
Bans free giveaways of sample cigarettes for promotional
purposes
Bans tobacco-brand sponsorships of sporting,
entertainment, or cultural events
Requires smokeless tobacco product labels that contain four
key warnings:
Can cause mouth cancer
Can cause gum disease and tooth loss
Is not a safe alternative to cigarettes
Is addictive
Ensures “modified risk” claims are supported by scientific
evidence (companies cannot state their product is “light,”
“mild,” or “low” without filing a modified risk tobacco product
application)
Requires disclosures of ingredients in tobacco products
Preserves state, local, and tribal authority, meaning that these
entities are the authorities over their specific jurisdictions
Sources: Manz, W. H. (2009). Congress and the tobacco
industry: A legislative history of the Family Smoking
Prevention and Tobacco Control Act of 2009. Retrieved from

https://www.wshein.com/media/brochures/69124.pdf?d=201710
21
U.S. Food and Drug Administration. (2018). Family Smoking
Prevention and Tobacco Control Act – An overview. Retrieved
from
https://www.fda.gov/TobaccoProducts/Labeling/RulesRegulatio
nsGuidance/ucm246129.htm
Who Advocates?
Who advocates for public health? That question could be
answered by two simple words: nearly everyone. However, there
are specific individuals and groups that advocate for specific
elements of public health. At the individual level, the most
common acts of advocacy come in the form of protests and
letters. One example is pride parades, which celebrate the
community of the LGBTQ population and are a statement of
equal rights for this group—especially health. Pride parades are
annual events across the globe that bring awareness to the
inequalities and disadvantages experienced by LGBTQ persons.
According to Guinness World Records, the 2006 Gay Pride
Parade in São Paulo, Brazil, was the largest pride parade ever
held, with an estimated 2.5 million participants (Ukrop News
24, 2016). Whether intentional or not, the efforts of these
individuals coming together comprise an advocacy effort. See
Spotlight on Public Health Figures for an example of an
advocate who sought to improve the quality of life for African-
American communities.
Spotlight on Public Health Figures:
W. E. B. Du Bois (1868–1963)
W. E. B. Du Bois in 1918.
Underwood Photo Archives/SuperStock
W. E. B. Du Bois was an advocate for basic civil and human
rights for Black communities in the United States.

Click each of the questions provided to learn more about W. E.
B. Du Bois.
Who is W. E. B. Du Bois?
William Edward Burghardt Du Bois was born in 1868. He was
the first African American to earn a doctorate degree from
Harvard University. Although his skin color was considered
“black,” he was mixed race and was able to attend schools with
Whites during a time when most schools were segregated. It
wasn’t until long after his education that he discovered most
Blacks across the nation were treated quite differently. This
unfair difference compelled him to study the issue of equality
and advocate for equal rights. He died at age 95 in 1963.
What was the political climate at the time?
The Jim Crow laws, a racial caste system that separated people
by color, pervaded the southern states during Du Bois’s time.
Although Lincoln had long ago freed the slaves, Black people
had very few rights, including basic human rights. They were
considered second-class citizens. The Jim Crow laws
legitimized racism against Blacks, under a very rigid series of
anti-Black laws primarily found in the southern and southern
border states. The political realm supported them through pro-
segregation speeches. Blacks who violated the Jim Crow laws
were subject to personal violence, typically in the form of
lynching. Lynchings were often public, the murders of Black
people were not considered vicious crimes, and the criminal
justice system favored Whites regardless of the situation.
What was his contribution to public health?
Once he learned about the Jim Crow laws and the poor
treatment of Blacks, Du Bois began to serve as an advocate for
civil rights. He founded the Niagara Movement, which was an
African-American protest group of scholars who focused on
advancing the rights of Blacks. He was also one of the founders

of the National Association for the Advancement of Colored
People (NAACP) and served as its director for several decades.
Furthermore, he wrote a significant number of works detailing
the inequities of Blacks in a world where slavery was illegal.
Among his most influential works on Black health was The
Philadelphia Negro: A Social Study, published in 1899. Du Bois
devoted all of his efforts to gaining equal rights for Black
people—which improved the overall health of the population
(especially in the South, where large populations of Blacks
resided).
What motivated him?
Brought up in a predominantly White neighborhood, he had
never encountered racism until he moved to Nashville,
Tennessee, in 1885 to attend Fisk University. It was there that
he first learned about the Jim Crow laws. Once he learned of
this discrimination, he felt motivated to do something about it.
This prompted his activism for equal rights for Black people.
Sources: Biography.com. (n.d.-c). W. E. B. Du Bois biography.
Retrieved from https://www.biography.com/people/web-du-
bois-9279924
Ferris State University. (n.d.). What was Jim Crow. Retrieved
from https://ferris.edu/jimcrow/what.htm
National Association for the Advancement of Colored People.
(2018). NAACP history: W. E. B. Du Bois. Retrieved from
https://www.naacp.org/oldest-and-boldest/naacp-history-w-e-b-
dubois/
At the group or organizational level, there are specific groups of
people who advocate under a single name for a cause. In public
health, a good example is the American Public Health
Association, which actually writes letters, visits politicians, and
focuses on activities that lead toward improved health

outcomes. The APHA has advocated for cities to become
smoke-free through its speaker network as well as formal letter-
writing campaigns. Most organizations that advocate for public
health are nonprofit organizations with a charitable purpose.
Charitable groups are not supposed to engage in paid lobbying;
therefore, they focus on advocacy.
At the committee level, there are groups that focus only on
advocacy and, in some cases, lobbying efforts for a cause. For
public health, these are often political action committees
(PACs) that work toward defeating candidates with opposing
views. For instance, a PAC was developed to represent gun and
firearms issues through the National Rifle Association. PACs
often lobby rather than advocate, as they are focused on the
passage or elimination of legislation.
Governmental agencies are typically barred from advocacy or
lobbying work. These are the organizations that enact the
policies and legislation that others lobby/advocate for or
against. However, in terms of taking a stance, governmental
public health organizations can use media outlets for
educational purposes. Consider the CDC’s focus on prevention.
Through its National Prevention Information Network, the CDC
can “advocate” for healthier behaviors to improve population
well-being. Activities include education on immunization,
smoking, and HIV/AIDS awareness (CDC, n.d.-d).
Policy Advocacy
Policy advocacy promotes or defends a position, person,
interest, or opinion. The act of policy advocacy is very closely
aligned to lobbying, and it is under this definition that lobbying
and advocacy efforts are interchangeable.
The International Centre for Policy Advocacy (2014) has
outlined several strategies that policy advocates use to preserve,
remove, replace, or revise a policy:

Pressuring decision makers for a policy. This may be the
local, state, or federal legislators who have influence over a
particular law or policy. The idea is to focus on the decision
makers in all advocacy efforts.
Pressuring those affected by the policy to take action. This
area involves using the public as a means of communicating to
lawmakers about their concerns. This type of effort typically
involves a multitude of mass communication efforts to garner
support for a particular project.
Building a coalition of community members to carry out the
direction of the advocate. In this strategy, a small group of
community members collectively focuses on influencing the
outcome of a policy.
Typically, an organization will take multiple approaches to
effect policy. This would include a little bit of all of the
aforementioned strategies, and more. One of the most critical
pieces for advocates to maintain is an understanding of the
decision-making process. It’s not a simple job to just write a
letter or have a face-to-face meeting; it is about understanding
how decisions are made and how to effect those decisions at the
right time.
Public health professionals have been trying for years to reduce
the smoking incidence and death rates through advocacy. While
it may seem obvious to some that removing cigarettes and other
tobacco products from the market would eliminate the problem,
it is not that simple. In fact, even asking for more governmental
regulation wasn’t that simple. It took until 2009 to pass the law
(as highlighted in A Closer Look: The Family Smoking
Prevention and Tobacco Control Act). Why then? The timing
was right.
There are a number of ways to predict when an advocacy effort
will be influential or fall on deaf ears (International Centre for

Policy Advocacy, 2014). The first is when new evidence comes
forth to set the agenda for meetings. This does not mean regular
evidence of issues, but rather new research. Two key pieces of
information that helped drive the passage of the smoking
regulations in 2009 were new and astounding: 438,000 deaths
each year could be attributed to smoking, and $360 billion in
Medicaid dollars had been spent for smoking-related treatments
over 25 years. (Education plays a role in identifying new
findings and creating public interest in public health. See
Spotlight on Public Health Figures for more about one
individual who helped make such topics more accessible to
citizens.) Second, new technologies and trends can help address
a policy issue. While this element was not in play for the 2009
smoking act, it could be relevant in other health areas. Third,
changes in leadership in the government can predict a
successful advocacy effort. When a Republican takes over for a
Democrat in the president’s seat—or vice versa—the time is
ripe to push advocacy efforts, especially if these efforts align
with the new political party in office. Finally, emergency events
can drive change. For instance, Hurricane Katrina led to a
significant change in the National Incident Management System
(see Chapter 7). Advocates for stronger protocols during
emergency times would have played a role in the NIMS
changes.
Charles-Edward Amory Winslow (1877–1957)
The American Museum of Natural History in New York circa
1902.
Quint & Lox Limited/SuperStock
The American Museum of National History in New York in
1902, where Charles-Edward Amory Winslow served as the
curator of public health. Winslow started his career as a
physician but later shifted his focus to public health.

Click each of the questions provided to learn more about
Charles-Edward Amory Winslow.
Who is Charles-Edward Amory Winslow?
Charles-Edward Amory Winslow was an only child born in 1877
to wealthy parents in Boston. His father was a Harvard graduate
and a successful businessman, and his mother was an actress
known for playing many Shakespearean heroines. He had
intended to enter the Massachusetts Institution of Technology
(MIT) and become a physician until he met a biology professor,
William Sedgwick. Sedgwick was a bacteriologist researching
in the public health field, a new field at the time. He studied the
link between unsanitary conditions, such as sewage and water
systems, and health issues and diseases. Winslow was so
intrigued by the idea of reaching an entire population rather
than treating one patient at a time as a physician that he moved
into the newly emerging field of public health.
Life in the United States during Winslow’s time was fairly
good. The country had established itself as a world power, and
industrial growth continued to bloom across the nation.
Vaccinations were just becoming commonly available, though
infectious diseases were still a public health problem. The solid
economy and growing interest in public health opened the doors
for Winslow to pursue his passion.
Winslow is considered the first public health educator in
modern times. The field of public health was just emerging
when Winslow stepped onto the scene. During his public health
education career, he became curator of public health at the
American Museum of Natural History in New York. He focused
his attention on preventing infectious diseases through
educating people on proper sanitation. He was a proponent of
germ theory and taught others how to keep themselves healthier

through cleanliness and health education. He developed the
first-ever exhibition in America on the etiology of vector-borne
diseases.
What motivated him?
Winslow’s largest influence was his biology professor, Dr.
Sedgwick. Sedgwick showed Winslow the possibilities in a
newly emerging and intriguing field. He was fascinated by the
prospect of helping thousands of people as public health
educator. Furthermore, he focused his attention on preventing
those diseases by understanding the link between sanitation and
disease.
Sources: Kemper, S. (2015, June 2). C-E.A. Winslow, who
launched public health at Yale a century ago, still influential
today. YaleNews. Retrieved from
https://news.yale.edu/2015/06/02/public-health-giant-c-ea-
winslow-who-launched-public-health-yale-century-ago-still-
influe
Library of Congress. (n.d.). America at the turn of the century:
A look at the historical context. Retrieved from
https://www.loc.gov/collections/early-films-of-new-york-1898-
to-1906/articles-and-essays/america-at-the-turn-of-the-century-
a-look-at-the-historical-context/
8.2 Public Health Advocacy in Action
Every nongovernmental public health organization and group
performs advocacy work at some level, but the largest
contingent of public health advocates hails from the
professional organization known as the American Public Health
Association (APHA). This is a membership-based organization
whose mission is to “improve the health of the public and
achieve equity in health status” (APHA, 2018a, para. 1). It
comprises multiple sections and interest groups that focus on
specialized areas in public health, including international

health, law, mental health, epidemiology, health information
technology, and food and nutrition (to name just a few) (APHA,
2018a).
APHA has an entire department devoted to advocacy for public
health. It acts in “coordination with its members and state and
regional affiliates to work with decision-makers to shape public
policy to address today’s ongoing public health concerns”
(APHA, 2018b, para. 1). It has representatives from the
headquarters offices in Washington, DC, focused on a variety of
topics. Currently, there is a petition circulating from APHA to
include maintaining the public health gains made from
Affordable Care Act, and a briefing that was sent to the
president about investing in an environmental health system to
combat climate change (APHA, 2018b).
An auto collision involving two vehicles.
RobertCrum/iStock/Thinkstock
Research has shown that the reduction of speed limits and use
of traffic lights led to fewer accidents. These results were
enough to promote the benefits of such public health safety
measures.
Public health researchers all aspire to have their work
recognized in the form of some resulting policy. While research
is the foundation behind public health advocacy work, not all
public health research leads to policy action, nor does it have
to. Very little research actually results in advocacy efforts. In
some cases, research simply needs a little publicity—not formal
advocacy work—to obtain results. For example, the risk
reduction from the use of speed limits did not require much
advocacy. Publicizing the results of fewer accidents and
highway safety was enough to promote speed limits, traffic
lights, and other safety aspects of highway driving.

But, when the issues are ambiguous, it is up to public health
advocacy groups to provide clarity. Advocacy seeks to change
attitudes, beliefs, behaviors, and even policy and law. Often,
just keeping the issue within public awareness can effect
change, promote new beliefs, and push policymakers to develop
a new law to address the issue. Some advocacy groups can butt
heads with the opposition, as was the case with the featured
smoking law. What about when advocacy efforts to change or
create policy affect individual liberties or even the free
enterprise system itself? The smoking issue certainly did bring
opposition from the tobacco manufacturers, who, thanks to the
new law, are now subject to far more regulatory processes.
During the public comment period when the law was proposed,
advocates and opposition alike were heard through an
administrative process. Obviously, the advocates won in this
case; however, it took significant work to point out the societal
benefits of enacting the law.
For policy advocacy to work effectively, there must be a
significant amount of support behind the effort followed by
solid evidence from professional and valid research. Without
both, the advocacy efforts may simply fail as the opposition will
bring forward a stronger case.
Data-Centered Advocacy
Data, facts, and statistics collected for reference, or analysis,
are the crux of all advocacy uses. Without carefully researched
evidence, public health officials are just offering an opinion on
an issue. While someone’s opinion may be a good one to
consider for policy change, it must be supported by evidence
before any formal action will take place.
A teenager consuming an energy drink.
Universal Images/SuperStock
Reports about highly caffeinated and sugary beverages, such as

Red Bull, provided a look at consumption patterns among youth
and possible health risks associated with such behaviors.
Campaigns such as Kick the Can are attempting to reduce
adolescent consumption of such beverages.
One of the most common public health advocacy groups in the
nation is known as Public Health Advocates. Based in
California, this nonprofit organization supports various
strategic public health initiatives across the nation by using
research to support its view (Public Health Advocates, 2018).
That research is the solid evidence for effecting change at the
community and policy levels.
A recent publication from Public Health Advocates provided
evidence against the consumption of sugary beverages by the
general public, but more specifically children and youth
(Pirotin, Becker, & Crawford, 2014). The group has tracked
various research projects from the early 2000s to today to
provide evidence for reducing the overall consumption of
sugared beverages. One of the most comprehensive was a 74-
page report showing nutritional data from 22 sugar-laden drinks
including Red Bull, Gatorade, Kool-Aid, Vitaminwater, and
Snapple (Pirotin et al., 2014). The study further outlined the
energy drink consumption patterns of youth and pulled
information from outside research as well as the 2010 National
Youth Physical Activity and Nutrition Survey (NYPANS). The
NYPANS was conducted in 2010 with three main purposes: 1)
to provide nationally representative data on behaviors and
behavioral determinants related to nutrition and physical
activity among high school students, 2) to provide data to help
improve the clarity and strengthen the validity of questions on
the Youth Risk Behavior Survey, and 3) to understand the
associations among behaviors and behavioral determinants
related to physical activity and nutrition and their association
with body mass index (CDC, 2017t). The Youth Risk Behavior
Survey is an annual survey that monitors health-risk behaviors

in youth (CDC, 2016m).
Once the information was presented, the research focused on the
health issues connected to each ingredient in those drinks,
including caffeine, various sugars (glucose, dextrose, sucralose,
and aspartame), ginseng, and ginkgo biloba (Pirotin et al.,
2014). The latter two elements are of concern because of their
purported energy assistance for the consumer. Health concerns
included blood pressure and heart issues, neurological
problems, sleep disruptions, and obesity (Pirotin et al., 2014).
The research showed that such drinks have had adverse health
effects on children and youth. Since then, advocacy efforts have
pushed for healthier options for this population. One such
movement is known as “Kick the Can,” an advocacy campaign
that focuses on pushing the beverage industry to quit marketing
such drinks to children and youth (Kick the Can, 2018;
“National Movement Against,” 2012).
As a direct result of the advocacy campaign, six states now have
proposed soda taxes. Table 8.1 shows a list of those states and
the proposed tax rate.
Table 8.1: Proposed legislation resulting from Kick the Can
advocacy efforts
State/jurisdiction
Legislation
Date introduced
Tax rate
Santa Fe, NM

Sections 18–20, SFCC 1987
10/13/2016
2 cents per fluid ounce of sugar-sweetened beverages
Illinois
House Bill 2914
2/9/2017
1 cent per fluid ounce of bottled or canned sugar-sweetened
beverages containing more than 5 grams of caloric sweeteners
per 12 fluid ounces
Illinois
Sections 1–97, Senate Bill 0009
1/11/2017
1 cent per fluid ounce of bottled or canned sugar-sweetened
beverages containing more than 5 grams of caloric sweeteners
per 12 fluid ounces

Massachusetts
Senate Docket, No. 1722
1/20/2017
Tiered tax system: 1 cent per ounce for beverages with 5–20
grams of sugar per 12 fluid ounces; 2 cents per ounce for
beverages with 20 grams or more of sugar per 12 fluid ounces;
requires warning labels on sugary drinks, prohibits marketing of
sugary drinks in schools, and sets standards for beverages sold
with children’s meals
Seattle, WA
Not publicly available
2/21/2017
2 cents per fluid ounce of sugar-sweetened beverages
Washington State
New chapter to Title 82, House Bill 1975
2/6/2017

2 cents per fluid ounce of sugar-sweetened and diet beverages
Source: Adapted from “Proposed Soda Taxes 2017 Overview,”
by Center for Science in the Public Interest, 2017
(http://www.kickthecan.info/sites/default/files/documents/propo
sedSodaTaxes2017Overview.pdf#overlay-context=cspi-
proposed-soda-taxes-2017-overview).
The Role of Media Advocacy
While it may seem like the media is often focused on
advocating for or against a cause, that has not often been the
case. According to the Public Health Institute (1987), as an
institution, the media has traditionally focused on documenting
personal health habits such as eating, sleeping, or exercising.
Mass media also tends to report on new medical breakthroughs
or medical miracles. Today’s advocacy efforts using mass media
are focused on social change and are known as media advocacy.
Rather than providing health information to the general public,
these mass media advocacy efforts promote health-related
policies that give the population a voice on public health issues.
As mentioned earlier, the Kick the Can campaign utilizes the
media to effect change. This particular campaign has used
social media outlets such as Facebook and Twitter in addition to
public service announcements on television. As noted with the
proposed legislation, the campaign has seen some successful
movement on identifying health problems associated with
sugary drinks.
Another successful media campaign example took place in
Australia through the Queensland AIDS Council, a community-
based health promotion nongovernmental agency (Butteriss,
2017). The council was formed in 1984 by a group of gay men
to provide education and services for people with HIV. The
media campaign started with billboard advertisements to reach
the gay community, but these were eventually removed due to a

significant number of complaints against such information
(Butteriss, 2017). The backlash was a sign that media certainly
did work to grab people’s attention. The council moved its
message to a social media platform with its “rip & roll”
campaign (Butteriss, 2017). Using YouTube, the council
developed a series of videos targeting men who have sex with
other men. The campaign was an instant hit, advocating for men
to use condoms and other safe sex methods to avoid HIV and
other sexually transmitted diseases. Thanks to the campaign’s
overall success in reaching a vulnerable population, a policy
changed to allow for outdoor advertising again across the nation
(Butteriss, 2017).
In many cases, advocacy efforts using the media are often free
for the organization. From the media’s point of view, these are
public service announcements. Many media outlets allow a
certain percentage of free public service announcements for
nonprofit organizations; however, if the advocacy content is too
political (e.g., pushing for a specific piece of legislation), the
public health organization must purchase the advertising space.
Social media sites such as Facebook and Twitter are free, so
organizations need only set up a page and hope people will click
on the “like” or “follow” buttons to receive continued advocacy
efforts. In some cases where more media advocacy is desired,
groups, businesses, or community members will underwrite the
costs of the advocacy campaign.
8.3 Public Health Resources
One of the key ingredients of successful public health changes
is money. Public health is financed through a mixture of
funding sources including federal, state, city, county, and local
dollars. States are provided with a certain dollar amount to
disseminate for public health issues in their jurisdiction. Figure
8.1 shows a typical distribution of public health funding for one
state.
Figure 8.1: State health agency funding source

Health agencies at the state level are primarily funded through
the federal government—funds that come mostly from tax
dollars. The distribution of public health services does include a
mix of other sources, including fees, fines, state funds, and
Medicare and Medicaid income.
Pie chart providing an overview of health agency funding for
one state. Funds from six different sources are identified. The
largest portion (45%) is from federal funds and second largest
(23%) is from state general funds. The smallest portion (4%) is
from Medicare and Medicaid.
Note: As of September 2011. Based on funding reports provided
by 48 agencies.
Source: Adapted from “Public Health Financing,” by Centers
for Disease Control and Prevention, 2013
(https://www.cdc.gov/stltpublichealth/docs/finance/public_healt
h_financing-6-17-13.pdf).
The federal government provides the largest chunk of money for
public health across the nation. That number exceeds $6 billion
annually, divided across all 50 states and the District of
Columbia (CDC, 2013c). Several factors influence how much is
allocated to each state, including congressional authorizations
or directives and eligibility to apply for funding, as in cases of
Medicaid and Medicare. Medicaid provides health insurance
needs to low-income families; Medicare provides the same for
senior citizens.
Most of the general fund dollars (non-Medicaid/Medicare) are
awarded directly to health departments by competitive grants or
merit-based awards. The latter is highly dependent upon the
success of a public health program in a state with a proven track
record. A good example would be a smoking cessation program
that has shown progress. If the results show a steady decline in

smoking reduction rates, or even a decrease in health-related
issues from smoking or tobacco use, then the federal
government would be more likely to grant awards to continue
that program.
Funding received by the state is then distributed to the counties
at multiple levels, such as nonprofits, academia, businesses,
community groups, and other organizations focused on public
health initiatives. In addition, awards made to the states are also
transferred to national associations to carry out programs such
as the American Red Cross’s disaster relief efforts.
The CDC (2013c) has noted that Congress largely determines
how funds are allocated:
Only Congress can raise revenue, borrow funds, and provide
funding to federal agencies for public health concerns.
Congress decides what agencies are authorized to do.
Congress decides the purpose and amount of all funds.
Congress decides the time period in which the funds can be
spent.
Congress can highlight what agencies cannot do with federal
public health dollars.
It is important to recognize the role of Congress in the
allocation of resources for public health and the connection to
advocacy. The stronger the case for a cause, the more likely it
will be known to Congress. That strong case is built through
data, research, and evidence used to formulate an advocacy
campaign to effect change.
The Prevention and Public Health Fund
The Prevention and Public Health Fund was a major milestone
in public health resource allocation. It drove additional money
toward prevention and public health efforts and was the nation’s
first-ever mandatory funding stream dedicated to improving the

population’s health (APHA, 2018c). The act was created by
Section 4002 of the Affordable Care Act, passed in 2010.
According to the text of the law, the Prevention and Public
Health Fund must be used “to provide for expanded and
sustained national investment in prevention and public health
programs to improve health and help restrain the rate of growth
in private and public health care costs” (42 U.S.C. § 300u-
11[a]).
Research supported by advocacy efforts has shown that if the
nation doubled the amount of federal funding for public health
prevention, bringing the amount to $12 billion, it could
adequately control the costs of medical care from illnesses and
diseases (APHA, 2018c). So far, the fund has provided only
$2.25 billion in prevention funding to support public health
activities.
After President Donald Trump took office in 2016, Congress
asked that the Department of Health and Human Services
provide information on the activities and programs that have
been funded through the Prevention and Public Health Fund.
Table 8.2 shows the most recent distribution of funds.
Table 8.2: Prevention and Public Health Fund distribution, 2017
Agency
Activity or program
Allocation ($)
Planned uses of funds
Administration for Community Living (ACL)

Alzheimer’s Disease Prevention Education and Outreach
14,700,000
To fund new grants to states that expand specialized services
and support targeting certain categories of individuals living
with Alzheimer’s disease or related disorders; to initiate a new
public awareness campaign to encourage consumers
experiencing memory loss to seek medical advice and to address
the stigma associated with dementia
ACL
Chronic Disease Self-Management
8,000,000
To fund a national resource center and award new competitive
grants to help older adults and adults with disabilities from
underserved areas and populations (including tribal
communities) better manage their chronic conditions by
providing access to evidence-based chronic disease self-
management programs; to assist grantees with developing and
implementing strategies for sustainable program funding beyond
the scope of the grant period
ACL

Falls Prevention
5,000,000
To fund a national resource center and award new competitive
grants to implement evidence-based community programs that
have been proven to reduce the incidence of falls for older
adults and adults with disabilities (including tribal elders), as
well as identify sustainable funding mechanisms for these
programs; via the resource center, to promote the importance of
falls prevention strategies and provide public education about
the risks of falls and ways to prevent them
CDC
Hospitals Promoting Breastfeeding
8,000,000
To fund community initiatives to support breastfeeding mothers
and support hospitals in promoting breastfeeding
CDC
Diabetes Prevention
72,000,000

To implement improved and enhanced diabetes prevention and
control strategies within state and local organizations that
address primary prevention and support the National Diabetes
Prevention Program lifestyle change intervention
CDC
Epidemiology and Laboratory Capacity Program
40,000,000
To enhance the ability of state, local, and territorial grantee
capacity for detecting and responding to infectious diseases and
other public health threats
CDC
Healthcare Associated Infections
12,000,000
To strengthen public health infrastructure for HAI activities
related to monitoring, response, and prevention across all health
care settings and to accelerate electronic reporting to detect
HAIs at the state level
CDC
Heart Disease and Stroke Prevention Program

73,000,000
To implement improved and enhanced heart disease and stroke
prevention efforts
CDC
Million Hearts Program
4,000,000
To improve cardiovascular disease and stroke prevention by
promoting medication management and adherence strategies and
improving the ability to track blood pressure and cholesterol
controls
CDC
Office of Smoking and Health
126,000,000
To raise awareness about the harms of tobacco use and exposure
to secondhand smoke in areas of the country with high rates of
tobacco use
CDC

Preventive Health and Health Services Block Grants
160,000,000
To support programs that focus on the leading causes of death
and disability and the ability to respond rapidly to emerging
health issues, including outbreaks of foodborne infections and
waterborne diseases
CDC
Racial and Ethnic Approaches to Community Health (REACH)
50,950,000
To improve linkages between the health care system and
minority communities with unique social, economic, and
cultural circumstances and change the chronic disease
conditions and risk factors in local communities
CDC
Immunization
324,350,000

To improve the public health immunization infrastructure in
order to maintain and increase vaccine coverage among
children, adolescents, and adults
CDC
Lead Poisoning Prevention
17,000,000
To support and enhance surveillance capacity at the state and
city level to prevent and ultimately eliminate childhood lead
poisoning
CDC
National Early Child Care Collaboratives
4,000,000
To support efforts to improve physical activity and nutrition
environments in early childhood education (ECE) settings
Substance Abuse and Mental Health Services Administration
(SAMHSA)
Garrett Lee Smith Youth Suicide Prevention

12,000,000
To fund continuation grants for Youth Suicide Prevention–
States grantees
Total
931,000,000
Source: From “Prevention and Public Health Fund,” by U.S.
Department of Health and Human Services, 2017
(https://www.hhs.gov/open/prevention/index.html).
More funding is available, but to obtain the funds, states must
apply through a grant process. If an agency believes it has a
program that fits within the parameters of public health, it is
recommended that it advocate for the grant through its state. A
good example of the use of Prevention and Public Health Fund
monies can be found in Case Study: Community Transformation
Grant Program.
Case Study: Community Transformation Grant Program
The Iowa Department of Public Health received a grant funded
through the Prevention and Public Health Fund to expand access
to blood pressure and tobacco use screens at dental practices
across the state. The strategic vision was to increase the number
of referrals to the state’s tobacco “Quitline” service and target
interventions across the state where stroke mortality rates are
high. Twenty-five intervention counties were identified through
local boards of health and their community coalitions. The main
targets were rural males ages 45 to 50 and people with
disabilities.

One particular success story that came out of the initiative
involved the Iowa Primary Care Association, which had trained
and provided technical assistance to three community health
center dental clinics to 1) refer dental patients who screened for
high blood pressure and tobacco use and 2) document blood
pressure, tobacco use, and Quitline referrals in the electronic
medical record.
Of the 2,535 dental exams completed, 741 adults (30%)
received blood pressure screening, with 8% being referred for
high blood pressure. Furthermore, 68% reportedly completed
the referral. One man was so thankful for being immediately
referred to his medical provider for a very high blood pressure
reading that he sent roses to the dental hygienist who made the
referral.
Source: Community Transformation Grant. (2011). Retrieved
from
https://www.legis.iowa.gov/docs/publications/IH/17177.pdf
Current lobbying activities at the congressional level are
pushing for the removal of the Prevention and Public Health
Fund, which would mean less money for prevention and a
continued increase in medical spending on disease treatment.
Currently, there are numerous battles of advocacy and lobbying
both in favor of and against keeping the fund.
Health Care Expenditures in the United States
Public health advocacy efforts promote healthy behaviors and
push key legislation through Congress. As the previous section
explained, the funding for this comes mostly from the
government, and the money goes toward population-based
initiatives, not individual health concerns. Currently, the nation
has an uneven funding distribution between health care, which
focuses on the health of the individual, and public health, with
most funding heading toward the health care sector.

The United States’ health care system is often touted as being
the best in the world; however, according to a study performed
by the Commonwealth Fund (Schneider, Sarnak, Squires, Shah,
& Doty, 2017), it ranks last in terms of positive health outcomes
among 11 high-income countries. The Commonwealth Fund is a
private foundation that focuses on evaluating health care system
access, quality, and efficiency. The organization performs a
significant amount of advocacy for improved health care in the
United States. The study found that the United States leads the
world in spending, yet the population is sicker than ever—and
more likely to die of preventable diseases. Figure 8.2 shows the
different countries’ expenditures on health care as a percentage
of their gross domestic product (GDP) from 1980 to 2014.
Figure 8.2: Health care spending as a percentage of GDP, 1980–
2014
The expenditures in health care have grown in nearly every
country since 1980. However, the health care spending in the
United States has increased significantly more than spending in
other industrialized nations.
Line graph identifies the trends in health care spending as a
percentage of GDP for 11 countries between 1980 and 2014.
Ten of the countries have similar trends, with the percentage
rising from between 5% and 8% to between 9% and 11%. The
United States, however, shows a more drastic increase, starting
at 8% and ending at just over 16%.
Note: GDP refers to gross domestic product.
Source: Adapted from “Mirror, Mirror 2017: International
Comparison Reflects Flaws and Opportunities for Better U.S.
Health Care,” by E. C. Schneider, D. O. Sarnak, D. Squires, A.
Shah, & M. M. Doty, The Commonwealth Fund, 2017
(http://www.commonwealthfund.org/interactives/2017/july/mirr
or-mirror/assets/Schneider_mirror_mirror_2017.pdf).

In 1980, the United States was aligned with most of the nations
in terms of health care expenditures. It was spending just over
8% of GDP on health care, while the United Kingdom was just
over 5% (Schneider et al., 2017). Since then, the gap has
increased, with the United States spending 16.6% on health care
in 2014 versus the U.K. spending 9.9% (Schneider et al., 2017).
In 2014, the country spending the lowest percentage of GDP
was Australia (Schneider et al., 2017). According to Figure 8.2,
most of the countries sustained a slight spending increase in
health care while the United States appears to be off the charts
in terms of health care expenditures.
Researchers looked at five key areas and found that the United
States was significantly lacking in each. The top ranked
country, the United Kingdom, showed excellence in all of these
areas, especially prevention. The five key areas are care
process, access, administrative efficiency, equity, and
outcomes.
Subdomains of the care process were safe care, coordination,
and patient engagement. In the United States, care is typically
measured by the doctor–patient relationship; however, the flow
of information among all care providers, specialists, and service
providers is far more important. This is why the care process
was ranked poorly in this study.
Under access, the United States performed worst in health
care affordability. One reason for this is because it was the only
nation of those examined that did not offer universal health care
coverage. While the Affordable Care Act has helped, there are
still many Americans facing high insurance deductibles and
higher out-of-pocket expenses, both of which lead to poorer
outcomes. When faced with such costs, Americans will
generally avoid seeking care until the health issue is chronic.
The third key area, administrative efficiency, refers to ease
of obtaining medical records and working with insurance

companies and the number of patients seeking treatment at the
right location. The study reported that doctors in the United
States spend far more time on issues related to claims or
insurance battles than on quality of patient care. Furthermore,
U.S. residents often seek treatment in an emergency room even
when a primary care physician could offer better treatment. All
of these deficiencies lead to poor and cumbersome
administration processes.
The fourth key area is equity. While human health is an
important factor for any individual, the United States ranks very
low in serving low-income individuals. There is a huge health
disparity between lower- and higher-income adults. Low-income
adults typically do not have a primary care physician and do not
seek treatment. Furthermore, sometimes doctors will spend
more time with a patient who has money than one who does not.
This creates a true inequity in health care for low-income
individuals.
Lastly, the United States ranked poorly in health care
outcomes despite having the largest expenditure among the 11
countries studied. According to the report, the United States has
the highest rate of mortality directly related to health care
access/cost/issues (Schneider et al., 2017). In addition, more
adults in the United States have multiple chronic conditions.
For example, 21% of the nation’s population suffers from at
least two chronic diseases (such as cardiovascular disease and
diabetes), compared with only 10% in the United Kingdom.
Figure 8.3 shows the distribution of multiple chronic diseases
among the 11 countries in the Commonwealth Fund study. The
country with the next closest percentage is Canada with 16%,
which is 5 percentage points lower than the United States.
Figure 8.3: Percentage of adults ages 18 to 64 living with at
least two chronic diseases
Although the United States spends far more dollars on health
care than other industrialized nations, it has significantly poorer

health outcomes. Twenty-one percent of the U.S. population is
living with at least two chronic diseases.
Bar graph showing the percentage of the population living with
at least two chronic diseases for 11 countries. For 10 countries,
between 8% and 16% of the population has at least two chronic
diseases. In the United States, however, 21% of the population
has at least two chronic diseases.
Source: Data from “Mirror, Mirror 2017: International
Comparison Reflects Flaws and Opportunities for Better U.S.
Health Care,” by E. C. Schneider, D. O. Sarnak, D. Squires, A.
Shah, & M. M. Doty, The Commonwealth Fund, 2017
(http://www.commonwealthfund.org/interactives/2017/july/mirr
or-mirror/assets/Schneider_mirror_mirror_2017.pdf).
Aside from the Commonwealth Fund’s country comparison, the
Centers for Medicare and Medicaid Services (CMS) provided
similar details in terms of actual dollars. U.S. health care
spending increased to $3.3 trillion in 2016, or $10,348 per
person (CMS, 2016). Table 8.3 shows a breakdown of where
those expenditures were made.
Table 8.3: Distribution of health care expenditures in the United
States, 2016
Type of care
Amount
Approximate % of total expenditures
Private health insurance
$1.1 trillion

34%
Hospital care
$1.1 trillion
32%
Medicare expenditures
$672.1 billion
20%
Physician/clinic services
$664.9 billion
20%
Medicaid expenditures
$565.5 billion
17%

Out-of-pocket expenses
$352.5 billion
11%
Prescription drugs
$328.6 billion
10%
Other professional service (physical therapists, optometry,
podiatry, chiropractic; excludes dentists and physicians)
$92 billion
3%
Dental services
$124.4 billion
4%
Health, residential, personal care services (home care including
ambulance needs and residential substance abuse facilities)

$173.5 billion
5%
Home health care (free-standing home health care agencies)
$92.4 billion
3%
Nursing care facilities and retirement communities
$162.7 billion
5%
Durable medical equipment (retail spending such as contact
lenses, eyeglasses, hearing aids)
$51 billion
2%
Other medical products (over-the-counter medicines, medical
instruments, surgical dressing)
$62.2 billion

2%
Source: Data from “National Health Expenditures 2016
Highlights,” by Centers for Medicare and Medicaid Services,
2016 (https://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/downloads/highlights.pdf).
Public Health Versus Health Care Expenditures
The United States spends $6 billion annually in public health
needs. The implementation of the Prevention and Public Health
Fund added another $2.25 billion to that figure, bringing the
total to $8.25 billion (APHA, 2018c; CDC, 2013c). Meanwhile,
the United States spent $3.3 trillion in 2016 on health care
(CMS, 2016). With a ratio of 0.0025 to 1, the United States
spends trillions more on treatment than it does on prevention.
For every $1 spent on health care, only one quarter of a cent is
spent on prevention. Public health professionals point out that
this is why it is difficult to obtain positive health outcomes.
A customer purchasing products from a pharmacist.
Thinkstock Images/Stockbyte/Thinkstock
The United States spends more on health care treatment than on
preventive care.
Why is so little spent on prevention and so much on health care
treatments? This question does not have a definitive answer.
The media has taken several stabs at why this may be the case.
For example, CheatSheet, an online media outlet, has suggested
that insurance companies, health care providers, pharmaceutical
companies, and other health care businesses are not nonprofit.
They need to make money to pay their employees, conduct
research for new products, and basically “keep the lights on”

(Becker, 2017, para. 3). An article in the New York Times has
suggested that it is the market price point. If people need it,
they will buy it, or demand will drive up price (Frakt & Carroll,
2018). Fortune magazine has speculated that it is due to the
social, economic, and environmental conditions that people live
in and have learned to accept (Galea, 2017).
Perhaps all of those opinions are correct. How can the nation
reduce the costs of health care and improve health outcomes?
This is the key question for health professionals, whether they
work in public health or medical care. From the public health
angle, sinking more dollars into prevention to reduce the
prevalence of preventable diseases is the answer. If the threat is
removed, then so is the need for treatment. On the other hand,
medical practitioners want more research into cures and better
treatments that enable healthier living. Which should take
priority?
Summary & Resources
Chapter Summary
Advocacy seeks to change a behavior or belief, sometimes by
convincing individuals or legislators to act or not act on an
issue. Lobbying is used to convince Congress to enact a specific
piece of legislation. Both are persuasive in nature, but advocacy
is used in public health more often. Lobbying is not the only
way to effect legislation. Several advocacy strategies work to
preserve, remove, replace, or revise laws and policies. These
include pressuring those who can actually make changes to
policies, such as members of Congress; garnering support from
people who would be affected by the legislation and influencing
them to participate in advocacy work; and building a coalition
within a community or several communities to perform
advocacy work. These have all been successful methods over
time, as demonstrated by the Family Smoking Prevention and
Tobacco Control Act.

The use of evidence and research data to support advocacy
efforts is a key principle in public health. Without evidence, or
data, that shows a change is needed, then public health officials
are just providing opinions. But public health cannot rely on
viewpoints for policy action; it needs supportive evidence.
Advocacy groups such as Public Health Advocates continually
provide up-to-date research on health issues to support
advocacy efforts across the nation.
Thanks to the 2010 Affordable Care Act, the United States has
additional money for prevention through the Prevention and
Public Health Fund. Still, that money pales in comparison with
what is spent on medical care. The nation spends one quarter of
a cent ($0.0025) on public health prevention efforts for every
dollar spent on health care. It seems that a paradigm shift is
needed to change the priorities to prevention. Currently, the
focus is on treating the problem after it arises. Public health
professionals seek to eliminate the problem so that it never
needs to be treated in the first place. That idea takes
resources—including money.
Critical Thinking and Review Questions
Explain the difference between advocacy and lobbying.
Explain why policy advocacy is used in the public health
realm.
Why is data-driven advocacy work important for public
health initiatives?
Consider the use of media for advocacy efforts. Describe one
current campaign that is successfully using the media to change
behavior.
Review Table 8.2, which contains the 2017 distributions from
the Prevention and Public Health Fund. What programs or
projects in your community could be added to this list and why?
Consider the program or project you thought of for question
4 and describe how you would advocate for more money to fund
it.

Why do you think the United States spends significantly
more money on treatment rather than prevention?
Should professionals in the field continue to advocate for
behavior changes, policies, and funding? Why or why not?
The United States spends significantly more on health care
than any other nation. Name two or three reasons why you
believe that is the case.
If you had control of the United States’ money, how would
you divide your funding between prevention and treatment?
Explain your reasons.
Additional Resources
The Trust for America’s Health
https://www.tfah.org/
This site provides real-time updates on activities related to
prevention policies.
The National Prevention Information Network
https://npin.cdc.gov/
This website connects public health professionals with work in
the field on health advocacy and education efforts.
The American Public Health Association
https://www.apha.org/policies-and-advocacy/advocacy-for-
public-health
https://youtu.be/KynoKd-Y0a8
Visit the American Public Health Association’s advocacy page
to learn more about this member-based organization with an
advocacy role in public health. Watch the video to learn about
what you can do as a citizen.
The Public Health Advocates’ Kick the Can campaign

http://www.kickthecan.info/
Visit this site to learn more about Public Health Advocates’
campaign to reduce and eliminate the consumption of sugar-
loaded beverages.
Key Terms
advocacy
An act to change a behavior or belief or convince individuals
to act or not act on an issue.
American Public Health Association (APHA)
A membership-based organization whose mission is to
improve the health of the public and achieve equity in health
status.
lobbying
An act by a special interest group or industry to attempt to
convince Congress to enact legislation on a particular topic.
media advocacy
The use of mass media to effect social change.
policy advocacy
An act to promote or defend a position, person, interest, or
opinion.
Prevention and Public Health Fund
A national fund that is the United States’ first-ever
mandatory funding stream dedicated to improving the
population’s health.
Public Health Advocates
A nonprofit organization that focuses on strategic public
health initiatives across the United States using research to

support its view.
7
Public Health Disasters and Preparedness
Flood barriers and sandbags on a flooded street where
emergency responders in orange apparel are patrolling.
Marc Bruxelle/iStock/Thinkstock
Learning Outcomes
After reading this chapter, you should be able to
Identify federal, state, and local agencies involved with
terrorism, emergency preparedness, and emergency response.
Outline the types of disasters and the public health responses
for each.
Explain the core functions of public health as they are
applied to emergency situations.
Analyze the effectiveness of emergency response and
preparedness, including the associated ethical issues.
Smoke rising from the World Trade Center during the
September 11, 2001, attack in New York City.
Greg Martin/SuperStock
The September 11, 2001, attacks on the World Trade Center
changed the way Americans viewed terrorism. Even though
terrorist attacks were not new to the United States, September
11 provided a vivid example of how vulnerable the country
could be in times of crisis.
For many people in the United States and around the world,

September 11, 2001, marked the beginning of an era of
terrorism. After the destruction of New York City’s World
Trade Center towers, the attack on the Pentagon, and the plight
of Flight 93, Americans seemed no longer exempt from the
terrorism occurring in other parts of the world (Yeboah,
Chowdhury, Ilias, Singh, & Sparks, 2007). In reality, terrorism
has occurred on American soil since the early 1800s. Some
would argue that terrorism began when Christopher Columbus
arrived in America and the struggle between white Europeans
and the Native Americans began. Regardless of when it began,
it is not a new concept. What is relatively new is bioterrorism,
which entered the global scene only in the mid-1980s (Resnick,
2013).
An examination of the history of terrorism and bioterrorism
over the last 50 years explains the past and current responses of
the United States to these incidents and to other disasters, both
manmade and natural. This also allows an exploration of the
role of public health in these emergencies, with a focus on the
principles of emergency response and preparedness and the
agencies charged with coordinating efforts to keep the nation
safe. The chapter also analyzes emergency response and
preparedness for all types of disasters. While this chapter
describes terrorist attacks and disasters, it concentrates on the
role of public health in coordinating responses, actions, relief,
and clean-up efforts to maintain the health of the nation as well
as the environment.
7.1 Governmental Agencies and Emergency Response
Although terrorism has occurred in the United States at least
since the 1800s, U.S. vulnerabilities were tested to the limit in
2001 with the events of 9/11 and subsequent anthrax attacks.
Since that time, the nation’s protocols for preparing and
handling all emergencies have evolved significantly. In the
event of a national emergency—terrorist attack, bioterrorism
threat, or disaster—certain procedures are followed, and

numerous governmental agencies take immediate action.
The Department of Homeland Security (DHS)
The Department of Homeland Security (DHS) was created in
response to the terrorist attacks that occurred on September 11,
2001. It provides protections from domestic and international
terrorism, and its primary mission is to protect the American
homeland (Koenig, 2003). From a public health perspective, its
creation means improved emergency preparedness and
cooperation with all levels of government. In fact, the American
Public Health Association helped develop the roles and
responsibilities for this new department, which was created and
passed under the Bush administration in 2002 (Late, 2002).
In the event of an emergency, the Department of Homeland
Security takes the national lead and guides upwards of 23
federal agencies that are also involved with coordinating efforts
during a national emergency. These 23 federal agencies all play
an important role in the health and safety of the nation’s
population. There are three key systems that operate to assist in
a national emergency. Functioning separately yet coordinated
under a partnership of federal agencies, these systems are the
National Disaster Medical System (NDMS), the National
Pharmaceutical Stockpile, and the Metropolitan Medical
Response System:
NDMS is a federally orchestrated partnership between the
U.S. Department of Health and Human Services, Homeland
Security, the Department of Defense, and Veterans Affairs.
NDMS fills in the gaps in medical needs and response in the
event of a national disaster (U.S. Department of Health and
Human Services, 2018b).
The National Pharmaceutical Stockpile, which handles drugs
and medical supplies for use during disasters, falls under the
U.S. Department of Health and Human Services and the CDC. In
late 2018, the stockpile is expected to relocate under the Health

and Human Services’ Office of the Assistant Secretary for
Preparedness and Response. That office ensures that the nation
can recover from a disaster by collaborating with hospitals,
health care coalitions, firms, community members, and
governments to improve readiness and response to emergencies
(U.S. Department of Health and Human Services, 2018a).
The Metropolitan Medical Response System, which develops
or enhances emergency preparedness in dealing with “weapons
of mass destruction” (e.g., bioterrorism) (Late, 2002, p. 5), is an
operational system at the local level. It operates within program
cities in contract agreements with the U.S. Department of
Health and Human Services’ Office of Emergency Preparedness
(Institute of Medicine, 2002).
The largest entity included under the DHS is the Federal
Emergency Management Agency (FEMA), which responds
under the Robert T. Stafford Disaster Relief and Emergency
Assistance Act (P.L. 93-288). This act, which went into effect
in the fall of 1988, contains significant responsibilities for
preparedness and response in the event of any emergency. Refer
to A Closer Look for more details on this act.
A Closer Look: The Robert T. Stafford Disaster Relief and
Emergency Assistance Act
The Disaster Relief Act of 1970 was the first federal law to
establish a permanent emergency relief program in the United
States. Signed into law by President Richard Nixon, the Disaster
Relief Act of 1970 was intended to provide funding to those
affected by natural disasters. The 1974 Disaster Relief Act
would amend the Disaster Relief Act of 1970 to further extend
assistance from the federal government to states, local
communities, and individuals in the event of a disaster such as a
tornado (Wolley & Peters, 2018).
President Richard Nixon found that the increasing number of
major disasters, mostly natural disasters, were financially

hurting businesses, organizations, individuals, and communities
across the nation. The original act (of 1970) provided financial
relief to help rebuild. It included four key items: 1) a property
tax revenue maintenance plan for those whose tax bases were
destroyed through the disaster, 2) the authority to repair or
replace damages to public buildings, 3) improvements to the
loan programs that assist people in the event of loss from the
disaster, and 4) authority for the federal government to assist
with lessening the effects of the disaster.
The most recently amended act, now known as the Robert T.
Stafford Disaster Relief and Emergency Assistance Act,
encompasses far more than natural disasters. The law states:
It is the intent of Congress, by the Act, to provide an orderly
and continuing means of assistance by the Federal Government
to State and local governments in carrying out their
responsibilities to alleviate the suffering and damage which
result from such disasters by:
Revising and broadening the scope of existing disaster relief
programs;
Encouraging the development of comprehensive disaster
preparedness and assistance plans, programs, capabilities, and
organizations by the States and by local governments;
Achieving greater coordination and responsiveness of
disaster preparedness and relief programs;
Encouraging individuals, States, and local governments to
protect themselves by obtaining insurance coverage to
supplement or replace governmental assistance;
Encouraging hazard mitigation measures to reduce losses
from disasters, including development of land use and
construction regulations; and
Provide Federal assistance programs for both public and
private losses sustained in disasters. (FEMA, 2016, p. 1)

Source: Federal Emergency Management Agency. (2016). The
Stafford Act, as amended and emergency management-related
provisions of the Homeland Security Act, as amended.
Retrieved from https://www.fema.gov/media-library-
data/1490360363533-
a531e65a3e1e63b8b2cfb7d3da7a785c/Stafford_ActselectHSA20
16.pdf
Numerous amendments were made to the Stafford Act as a
result of the 2004 Hurricane Katrina disaster. This affected
several sections of the act, including firearms policies, detailed
administrative functions, and community disaster loans. As a
result of these amendments, two additional acts were passed:
the Pet Evacuation and Transportation Standards Act of 2006
and the Security and Accountability for Every Port Act of 2006
(FEMA, 2016). The former addresses the needs of pet owners
and those with service animals (GovTrack, 2006), and the latter
addresses safety and security needs at all United States
maritime facilities (U.S. Government Printing Office, 2006).
Federal Emergency Management Agency (FEMA)
The mission of the Federal Emergency Management Agency
(FEMA) is “to support our citizens and first responders to
ensure that as a nation we work together to build, sustain, and
improve our capacity to prepare for, protect against, respond to,
recover from, and mitigate all hazards” (FEMA, 2017a, footer).
FEMA has a long history. It began, under no particular
organizational name, through the Congressional Act of 1803,
which is often considered the nation’s first piece of disaster
legislation. The act was passed so that funds could be released
to assist a New Hampshire community recovering from a
devastating fire. Unfortunately, disaster relief remained very
fragmented as the nation endured various earthquakes, floods,
and hurricanes. It was clear that there was a growing need for
disaster relief across the nation. In fact, according to FEMA

(2017b), more than 100 federal agencies were historically
involved when disasters and emergencies hit the nation, making
consistent relief efforts difficult to manage.
The Three Mile Island nuclear power generating station in
Pennsylvania.
Dobresum/iStock/Thinkstock
In March 1979, the Three Mile Island nuclear power plant
leaked radioactive gas from one of the plant’s reactors, inciting
President Carter to bring together the varied disaster relief
agencies under FEMA.
In an attempt to consolidate efforts, two groups were created to
provide larger relief: 1) the Reconstruction Finance Corporation
in the 1930s (FEMA, 2017b) to provide disaster loans to cities
to repair or rebuild public buildings following disasters, mainly
of the natural kind, and 2) the Federal Disaster Assistance
Administration, to help with housing and urban redevelopment
after a disaster. But it wasn’t until the 1970 Disaster Relief Act,
mentioned earlier, and its amendment in 1974 that the United
States had consistent and permanent federal relief during times
of emergency. In 1979, following the Three Mile Island nuclear
meltdown disaster, President Jimmy Carter ordered disaster
relief agencies to work under one central command: the Federal
Emergency Management Agency. Since then, many of the
disasters FEMA has responded to have been manmade
emergencies, such as the Exxon Valdez oil spill, the 9/11
terrorist attacks, the 2013 Boston Marathon bombing, and the
massive 2017 shooting at the Route 91 Harvest festival in Las
Vegas.
FEMA’s main role is to coordinate efforts of preparedness,
response, and recovery. The components of FEMA include the
Office of Response and Recovery, the Federal Insurance and
Mitigation Administration, the Mission Support Bureau,

Protection and National Preparedness, and the United States
Fire Administration. Depending upon the nature of the disaster,
FEMA dispatches the protocol designed to handle the
emergency. More on FEMA’s actual responsibilities is covered
later in this chapter.
Centers for Disease Control and Prevention (CDC)
The Centers for Disease Control and Prevention (CDC) works
with FEMA to assist with various disasters such as
natural/weather disasters, bioterrorism, chemical emergencies,
outbreaks/incidents, mass casualties (explosions), and radiation
emergencies. While its website is the primary public source for
emergency information, in terms of both personal response and
preparedness, the organization also plays a key role in disaster
situations. The CDC has two primary functions in the event of
an emergency: public health preparedness and medical
preparedness. The former helps the United States, including
individuals and communities, protect against health
emergencies. The latter works with the health care system to
ensure it is prepared to handle and recover from a health
emergency.
A romaine lettuce field.
Comstock Images/Stockbyte/Thinkstock
In 2018, epidemiologists from the Office of Public Health
Preparedness and Response (OPHPR) pinpointed the source of
an E. coli outbreak—romaine lettuce from a grower in Arizona.
As the response arm of the CDC, the Office of Public Health
Preparedness and Response (OPHPR) provides strategic
direction and coordination of efforts to prepare and respond to a
crisis. The OPHPR helps coordinate all protocols such as
deployments, travel, and providing support staff. One example
is its response to a foodborne outbreak, such as the 2018 E. coli
outbreak in romaine lettuce (Belluz, 2018; CDC, 2018b). In this

case, the OPHPR initiated the protocols to stop the spread of the
virus, including deploying epidemiologists to investigate the
source(s) and eventually recalling all infected lettuce. These
actions led investigators to the source: a romaine lettuce grower
in Yuma, Arizona. Before the source was finally discovered and
stopped, 98 people from 22 states were sickened (Belluz, 2018;
CDC, 2018b).
Response to the anthrax scares of 2001 prompted the CDC and
OPHPR to develop a training course on the communications
efforts needed during a bioterrorism attack. The CDC focused
on enhancing cooperation with all emergency response teams
and minimizing widespread panic (Courtney, Cole, & Reynolds,
2003). During the actual crisis, the CDC provided field
investigators to determine the spread of the disease and the
potential for stopping its progress in those already infected. The
goal was to lessen the impact by confining the infected as much
as possible. A central command center provided the link
between the field agents and other emergency responders, as
well as to the community at large. In addition, the CDC
provided the potentially exposed with a 60-day course of
antibiotics to combat further spread of the deadly weapon both
domestically and abroad (Malecki et al., 2001). According to
Polyak et al. (2002), the CDC’s epidemiologists, laboratory
scientists, and clinicians were asked to assist with anthrax
inquiries around the world, eventually responding to 130
requests from 70 countries and two territories. The results
helped alleviate worldwide panic, prevent unnecessary
antibiotic treatment, and enhance international surveillance of
bioterrorism events.
Health Resources and Services Administration (HRSA)
The main function of the Health Resources and Services
Administration (HRSA) in the event of a disaster is to distribute
grants to presidentially declared disaster areas. Only through
FEMA can HRSA provide financial assistance (HRSA, 2012).

According to the HRSA guidelines set by FEMA, the disaster
funds can be used only after local emergency management
assistance cannot handle the expenditure alone (HRSA, 2012).
Six steps must be followed in order to acquire disaster funding
from HRSA:
Local government responds first. If overwhelmed, the local
government must initially seek state funds.
The state responds with resources such as the National Guard
or other financial resources.
Damage assessment is performed through local, state,
federal, and volunteer agencies to determine losses and recovery
needs.
The state’s governor requests a Major Disaster Declaration,
with state funds allocated to recovery.
FEMA evaluates the request and recommends action from the
White House.
The president approves or denies the request, a process that
could take a few hours or weeks, depending on the scope of the
disaster.
Food and Drug Administration (FDA)
The United States Food and Drug Administration (FDA)
oversees the development of human and veterinary products and
monitors the food and blood supplies for the United States (U.S.
FDA, 2017). Operating under the FDA, the Office of
Counterterrorism and Emerging Threats (OCET) facilitates the
development of safe and effective medical countermeasures in
the event of a terrorist or bioterrorist attack (U.S. FDA, 2017).
As part of its duties, the OCET is charged with coordinating
emergency use activities as well as communication efforts
within and outside the agency. Among the OCET’s many
counterterrorism programs are the following (U.S. FDA, 2017):
Animal and Veterinary Products and Counterterrorism—

Monitors animal foods and veterinary drugs for safety and
handles various other food and drug concerns. In the event of an
emergency, this agency has numerous responsibilities to ensure
safe food and drugs for the United States. Two of these
responsibilities include the prevention of further distribution of
contaminated feed and timely approval of animal drugs in the
event primary facilities are overtaken or lost.
Biologic Product Security—Focuses on the safekeeping of
stockpiles of biological products such as medical supplies,
bacterial and viral vaccines, and blood. It also works to
expedite the development and licensing of products that will
diagnose, treat, or prevent diseases following exposure to
bioterrorism agents.
Drug Preparedness and Bioterrorism—Ensures there are
adequate supplies of medicines and vaccines to protect the
American public in the event of a bioterrorism attack.
Food Defense—Works with many agencies across the nation
to protect the food supply by reducing the risk of food and
cosmetic supplies tampering in the United States.
Medical Devices (Emergency Situations)—Distributes
appropriate medical devices in the event of an emergency, such
as diagnostic equipment and tests, surgical tools, and personal
protective equipment. While this is applicable to all
emergencies, it was intended to focus on natural phenomena
such as extreme weather (floods, hurricanes, tornadoes, and
earthquakes).
National Institutes of Health (NIH)
The National Institutes of Health (NIH) comprises 27 institutes
and centers, each focused on a different aspect of health
research (National Institutes of Health, 2017b). All of these
agencies have their own focal points in the event of a disaster,
but a description of each is beyond the scope of this textbook.
However, there is one program that has been especially helpful
during acts of terrorism. The NIH’s Institute of Neurological

Disorders and Stroke (NINDS) operates NIH CounterACT
(NINDS, 2018). This program focuses on developing new and
improved medical countermeasures that will prevent, diagnose,
and treat conditions caused by chemical threats (NINDS, 2018).
For example, substances that could be used as biological
weapons include arsenic trioxide, hydrogen sulfide, cyanide,
tetramine, bromine, and ammonia (NINDS, 2018). The NIH
supports efforts to find treatments and vaccinations to
counteract the effects of exposure to such substances.
Federal Bureau of Investigation (FBI)
The Federal Bureau of Investigation (FBI) is the federal agency
on the front line in all terror acts. Its employees investigate acts
and potential acts of terror. The Bureau comprises multiple
operations, including Joint Terrorism Task Forces, the Terrorist
Screening Center, the International Human Rights Unit, and the
Weapons of Mass Destruction Directorate (FBI, n.d.). It also
operates training programs for their employees and for others in
law enforcement. Programs include but not limited to bomb
detection, vehicle operations, and firearms skills.
While working with these agencies, among many others, the FBI
provides protection for the nation’s borders and seaports,
colleges and universities, food supply, and human rights and
freedoms (FBI, n.d.). Located in field offices scattered
throughout the country, the FBI’s main function is to protect,
investigate, and help dismantle extremist networks worldwide
(FBI, n.d.).
State and Local Agencies
Homeland security and emergency services are available in
every state and in the District of Columbia. Most of them are set
up to work closely with state governments, state health
departments, law enforcement, and other public health and
safety organizations. Each state has its own set of emergencies.
For example, the plains states deal with drought, states on the

East Coast often suffer from hurricanes, the mountain states
experience snowstorms and avalanches, and earthquakes occur
regularly on the West Coast.
Regardless of the type of emergency or the state in which it
occurs, local government entities typically trigger the
emergency response. Local law enforcement and fire
departments are often the first dispatched groups. If the event is
too difficult or overwhelming for local entities to contain, these
groups connect with their state officials. At each level of
response, the mission of homeland security and emergency
response is to lead, coordinate, and support public health and
safety.
7.2 Types of Emergencies
An emergency for one person may be a simple problem for
another. FEMA distinguishes between the terms hazards,
disasters, emergencies, and other similar words (FEMA, 2008).
A hazard is something that is potentially dangerous and is likely
the main cause for a disaster or emergency. A threat is an
indication of possible harm or danger. Threats can be naturally
occurring (a tornado or hurricane), manmade (chemical
explosions or industrial accidents), or intentionally human
caused (terrorist acts). While FEMA’s training manual lists 18
individual definitions of “emergency” (FEMA, 2008), the state
of Rhode Island Department of Emergency Management (n.d.)
has defined the word in the simplest of terms: An emergency is
an incident that threatens public health, safety, and welfare.
A person with an umbrella standing outside during a snowstorm.
kudou/iStock/Thinkstock
A state of emergency might be declared if one or more states in
a geographic region experience conditions that create a threat to
public health, safety, or welfare, such as the dangers associated
with extreme weather or forest fires.

States of emergency are categorized as occurring locally,
statewide, or nationally (FEMA, 2008). Local emergencies are
confined to a geographical region of a state such as a city,
county, or municipality. A state of emergency is confined to one
or more states within the nation. A state of war emergency is
declared when any part of the nation is threatened or attacked
by an enemy.
All emergencies require emergency preparedness, which
encompasses all activities that are planned and implemented to
manage an emergency. These include not only the individuals
and responsibilities of emergency response teams, but also the
community’s readiness to fulfill an emergency action plan. An
emergency response is the tactical planning and subsequent
activities used to protect the public’s health (environment and
life). Included within this definition are evacuation plans,
escalation protocols, damage reporting and assessment, medical
team dispatch, salvage, search and rescue, and hazardous
materials response and control. Escalation protocols, which are
necessary in an emergency, ensure that all emergency response
personnel carry out their roles and responsibilities effectively
and appropriately to protect the nation and promote the health
and well-being of the American people. They are intended to
prevent harm and reduce the risks of further danger and
damages from the declared emergency.
Technological, Manmade, and Chemical/Radiation Emergencies
FEMA (2008) has identified nuclear waste disposal spills, toxic
substances, hazardous materials accidents, utility failures,
pollution, epidemics, explosions, and fires under this category.
On its lengthy list of chemical/radiation hazards, the CDC
(2018a) has included poisons from plants or animals, blood
agents, lung/pulmonary agents, poisonous metals, nerve gases,
toxic alcohols, solvents, and radiation exposure. An example is
the Three Mile Island nuclear meltdown, which occurred on

March 28, 1979 (Smithsonian National Museum of American
History, n.d.). This was considered the United States’ worst
nuclear power plant accident, where radioactivity leaked from
one of the reactors into the surrounding community near
Harrisburg, Pennsylvania. Table 7.1 shows a chronological list
of some of the major manmade disasters that have occurred
within the United States.
Table 7.1: Major manmade disasters in the United States
The static table has been replaced by an interactive timeline.
The first federal declaration of a disaster from a manmade cause
came out of New York State in the neighborhood of Love Canal
in Niagara Falls (Binns, 2004). It took nearly 26 years to fully
clean up after toxic waste infiltrated the area starting in the
1920s. See Case Study: Love Canal: The First Federal Disaster
Area from Manmade Causes for more details.
Case Study: Love Canal: The First Federal Disaster Area From
Manmade Causes
The Love Canal disaster, which occurred over the course of 50
years, was one of the most significant industrial waste dumping
incidents in the nation. In the 1920s, William T. Love attempted
to build a canal in a neighborhood in Niagara Falls, New York.
The neighborhood was eventually renamed Love Canal. When
the plans failed, the large canal area became a dumping ground
for garbage, including some toxic waste. In the 1940s, Hooker
Chemical Company started emptying its industrial waste
products into the canal and covering it with dirt. It was
estimated that more than 80 different toxins were dumped into
the canal.
In 1953, Hooker Chemical eventually sold that land to the local
school district (with a price tag of only $1) for the construction
of a new school. Two years later, a 25-foot area surrounding the
school disintegrated, exposing the various toxic chemical drums

left by Hooker Chemical. These drums had apparently filled
with rainwater, in which the children played. Furthermore, when
the city began constructing new sewer lines for low-income
housing, sections of the abandoned canal broke, releasing more
toxic waste into the system.
According to one report, “Love Canal residents reported
exploding rocks, strange odors, and blue goo that bubbled up
into basements” (Mother Nature Network, 2018, para. 3).
However, the most immediate concern was the increase in
asthma, miscarriages, mental disabilities, and numerous other
health problems that plagued the residents of Love Canal; 56%
of children born between 1974 and 1978 suffered from birth
defects that were directly connected to the toxins from Love
Canal. This was the first time in the nation’s history that an
area was declared a federal disaster area from manmade causes.
In 2004, cleanup efforts were complete, and the neighborhood
was taken off the National Priorities List by the Environmental
Protection Agency.
Sources: Binns, J. (2004). Remediation: Cleanup complete at
Love Canal. Civil Engineering, 74(12), 22–23.
Mother Nature Network. (2018). America’s 10 worst man-made
environmental disasters. Retrieved from
http://www.mnn.com/earth-matters/wilderness-
resources/photos/americas-10-worst-man-made-environmental-
disasters/the-pla
Popkin, R. (1986). A new urgency: Hazardous waste cleanup
and disaster management. Environment, 28(3), 2–6.
Natural Disasters and Severe Weather
Both the CDC (2018a) and FEMA (2008) have identified
earthquakes, floods, hurricanes, tornadoes, tsunamis, blizzards,
drought, volcanoes, mudslides, and extreme heat under the

category of a natural disaster. The worst earthquake in the
history of the United States took place on March 27, 1964, in
Prince William Sound, Alaska (United States Geological Survey
[USGS], n.d.). According to the USGS, the earthquake, with a
magnitude of 9.2, and its associated tsunami, took 128 lives and
caused more than $311 million in damage. Communities
affected by the earthquake included Anchorage, Portage, Kenai,
Kodiak, and Wasilla (USGS, n.d.). The quake was felt
throughout most of Alaska, as well as parts of Canada. Table
7.2 lists some of the major natural disasters in the United
States.
Natural disasters occur across the country, but some states
sustain more severe weather incidents than others. See Case
Study: Iowa: A Magnet for Natural Disasters for details.
Table 7.2: Major natural disasters in the United States
The static table has been replaced by an interactive timeline.
Case Study: Iowa: A Magnet for Natural Disasters
Since 1990, Iowa has experienced 41 presidentially declared
disasters, most of which involved severe weather (Iowa
Homeland Security, n.d.-a). From 1951 to 1970, Iowa
experienced 10 flooding emergency declarations. In the 1970s
and 1980s, another 10 declarations were made for flooding and
severe storms. The 1990s brought 11 severe weather emergency
declarations. From 2000 to 2017, the state had 28 presidential
declarations of severe weather emergencies (Iowa Homeland
Security, n.d.-a).
Iowa’s emergency management practices began in 1965 as the
State Civil Defense Agency (Iowa Homeland Security, n.d.-b).
This organization coordinated emergency response and recovery
efforts for disasters such as floods and storms. The 2009 Code
of Iowa, Chapter 29C, outlines the responsibilities for Iowa’s
emergency management team, now known as the Iowa

Homeland Security and Emergency Management Division
(HSEMD) under the Iowa Department of Public Defense (Iowa
Homeland Security, n.d.-a). Iowa’s HSEMD operates like
FEMA at the federal level, but only within the boundaries of
Iowa. It supports local entities as they plan for and respond to
emergencies. The division also provides training, technical
assistance, communications, and other emergency preparedness
and response for municipalities within Iowa’s 99 counties.
HSEMD is the coordinating body for all emergencies within
Iowa. See Figure 7.1 for an illustration of its organizational
structure and support.
Figure 7.1: Emergency management structure in Iowa
How does the organizational structure of Iowa’s HSEMD help it
to plan for and respond to emergencies within the state?
An interconnecting figure demonstrating the flow of
information and management from the governor of Iowa to the
Homeland Security advisor and HSEMD administrator, to
HSEMD, and from there to the local, state, and executive state
policy and advisory bodies.
Source: Adapted from “Emergency Management Structure in
Iowa,” by Iowa Homeland Security, n.d.
(http://www.iowahomelandsecurity.org/about_HSEMD/EM_stru
cture.html).
While relatively new, Iowa’s emergency management system is
well designed. It operates 13 separate programs focused on
protecting the health and well-being of its residents. Some of
these programs include a Citizen Corps, Critical Infrastructure
team, E-911 system, School Safety Program, and Threat
Information and Infrastructure Protection Program.
Today, Iowa is still forward thinking in its protection efforts, as
it has added terrorism to its responsibilities. The Threat
Information and Infrastructure Protection Program works with

the federal government to ensure the safety of public and
private infrastructure in order to protect against the threat of
terrorism or bioterrorism. Its Intelligence Fusion Center was
developed post–9/11 to enhance efforts of information exchange
to maintain public safety (Iowa Homeland Security, n.d.-b).
There are 72 fusion centers in the United States, one in each
state and 22 in major urban areas. The Fusion Center in Iowa is
at the capital, Des Moines.
Source: Iowa Homeland Security & Emergency Management.
(n.d.-b). Iowa disaster history. Retrieved from
https://www.homelandsecurity.iowa.gov/disasters/iowa_disaster
_history.html
Internal Disturbances and Mass Casualties
FEMA (2008) has described internal disturbances and mass
casualty emergencies as riots, large-scale prison breaks,
demonstrations or strikes that lead to violence, and acts of
terrorism. The CDC (2018a) has added bombings to this list.
Probably the most vivid example of an emergency in this
category is that of the April 15, 2013, Boston Marathon
bombing. Three people died and nearly 200 people were injured
when two pressure cooker bombs exploded near the finish line
of the Boston Marathon (CNN Library, 2017). While the number
of people affected by this incident was far less in comparison
with the terrorist attacks of 9/11, it is still considered a mass
casualty event because of the multitude of people affected,
along with the potential for producing multiple deaths. It was
not only an emergency-type “act of terrorism” as defined by
FEMA, but it also involved mass casualties (which includes
both injuries and deaths) as identified by the CDC.
National Security Risks
A national security risk is outlined by four specific actions: 1)
The agent used must be easily disseminated or transmitted by
humans; 2) the result involves significant death rates, pointing

toward a major public health impact; 3) the act causes public
panic; and 4) the resulting incident requires public health
preparedness and response in a specified manner. Both terrorism
and bioterrorism constitute a national security risk. See
Spotlight on Public Health Figures to learn more about one vice
president’s role following the September 11, 2001, terrorist
attacks.
Dick Cheney (b. 1941)
Former Vice President Dick Cheney speaking at a conference in
Washington on February 10, 2011.
Alex Brandon/Associated Press
While serving as vice president, Dick Cheney played a pivotal
role in national security after the September 11, 2001, terrorist
attacks in New York City.
Click each of the questions provided to learn more about Dick
Cheney.
Who is Dick Cheney?
Dick Cheney was born in 1941 in Nebraska to agricultural
parents. Cheney attended Yale University on a full scholarship
but dropped out due to poor grades. He eventually graduated
with bachelor’s and master’s degrees in political science from
the University of Wyoming. He began his political career in the
Wyoming Senate. His family’s political positioning was aligned
with the Democratic Party, yet he eventually transitioned to a
conservative viewpoint and later declared his affiliation with
the Republican Party.
Cheney was 4 years old when World War II ended. He was alive
during the Korean and Vietnam wars and many other
international conflicts in the mid- to late 20th century. During

his tenure in politics, the nation was plagued by heightened
tension between Middle East regimes and the United States.
This was the era of Saddam Hussein and Operation Desert
Storm against Iraq. There were numerous terrorist attacks on
United States soil: the 1993 World Trade Center bombings in
New York; the 1993 Central Intelligence Agency bombing in
Langley, Virginia; the 1995 Oklahoma City bombing; and the
1996 Olympic bombing in Atlanta. Furthermore, the House of
Representatives impeached President Bill Clinton in 1998, and
the 1999 trial before the Senate forced Americans to question
the political ethics of the government. At the turn of the new
century, the nation suffered the deadliest terrorist attack on
American soil: the suicide flights that crashed into the World
Trade Center towers, reducing them to a pile of debris on the
ground of central New York City. It was an extremely turbulent
time in politics and international affairs, punctuated by the
resulting crumbling economy that followed these events.
Cheney served as vice president during the first George W.
Bush administration, which was in leadership during the attacks
of September 11, 2001. While Cheney was a high-ranking
political figure, it was his role in national security that
separated him from other vice presidents in history. In an effort
to restore international relationships and repair damage
allegedly done by past administrations, he built a national
security team that was larger than that of any other
administration. After the development of a national security
team, the vice president was managing one of the largest staffs
in the government. Cheney’s leadership raised national security
standards, and following the attacks of 9/11, the nation was well
positioned to tackle the ever-increasing terrorism and
bioterrorism issues that ensued.
What motivated him?
Political analysts and historians speculate that Cheney’s

dissatisfaction with the “ivory tower,” or academic, way of
thinking motivated him. During his college years, he witnessed
many protests and believed that many of those people did not
even understand the issues they were protesting. It was his
belief that people joined protests just to get involved, not
because they knew the full purpose of the protest. He felt he
could advocate for the people for the right reasons. Cheney
believed that advocacy should be used for a distinct purpose—a
key point. For that reason, he was successful in effecting
change. Some have noted that Cheney was willing to use his
position and power to get things done, and that he was not
worried about the political consequences of his actions. He was
driven, never apologizing for his actions nor removing himself
from the controversy.
Sources: Biography.com. (n.d.-a). Dick Cheney biography.
Retrieved from https://www.biography.com/people/dick-cheney-
9246063
Council on Foreign Relations. (2008). Presidents and the
National Security Council. Retrieved from
https://www.cfr.org/interview/presidents-and-national-security-
council
Dreyfuss, R. (2006). Vice squad. Retrieved from
http://prospect.org/article/vice-squad-0
Gale Group. (2003). The 1990s government, politics, and law:
Overview. Retrieved from
https://www.encyclopedia.com/social-sciences/culture-
magazines/1990s-government-politics-and-law-overview
Terrorism
Terrorism is an act of violence against innocent civilians or
unarmed groups/individuals by national, secretive, or
undercover groups (United States Code, 2005). International

terrorism involves the citizens of more than one country, and a
terrorist group is any group that practices international
terrorism. While the present decade is experiencing terrorism
through radical Muslim, Islamist, ISIS, and al-Qaeda terrorist
groups, the United States has seen other groups come and go
over the past two centuries. These groups include the Ku Klux
Klan, pro-slavery groups, Jewish extremists, leftist militants,
Black militants, Puerto Rican nationalists, Palestinian militants,
and many others.
Figure 7.2 shows that acts of terrorism have increased steadily
over the years, with a sharp incline from the 1950s to the 1980s.
This in part reflects improved surveillance. It is possible that
more terrorism occurred prior to the 1950s but is not reflected
here because of lack of quality surveillance. The United States
has seen 70 confirmed acts of terrorism from 2010 to 2018, and
that number is likely to increase further.
Figure 7.2: Confirmed acts of terror in the United States,
1800s–2010s
The number of terrorism acts within the United States has
dramatically increased since the 1800s. This increase in action
is what has prompted stronger emergency preparedness and
response protocols for both terrorism and bioterrorism acts.
Line graph depicting the number of confirmed acts of terror
between 1800 and 1899 and then for each decade from 1900 to
2010. After the 1950s, the numbers jump from single- to
double-digit numbers. While there were only four confirmed
acts for the 1800s (a span of 99 years), there were a total of 70
confirmed acts during the 2010s (a span of 10 years).
Source: Data from “Terrorist Attacks and Related Incidents in
the United States,” by Johnston Archives, 2017
(http://www.johnstonsarchive.net/terrorism/wrjp255a.html).
Terrorism, both domestic and international, has occurred in the

8Advocacy and Resource AllocationThe Capitol Building in Was.docx

8Advocacy and Resource AllocationThe Capitol Building in Was.docx

Recommended

Recommended

More Related Content

More from sleeperharwell

More from sleeperharwell (20)

Recently uploaded

Recently uploaded (20)

8Advocacy and Resource AllocationThe Capitol Building in Was.docx