What EMS leaders need to know about public health

By Sean Caffrey, NEMSMA

It has been said that EMS is at the intersection of public safety, health care and public health.

The public safety component of EMS is the most clear. EMS systems are prepared to respond to medical emergencies and traumatic injuries in their communities 24/7 with staff, vehicles and equipment. Much like police departments, fire departments and emergency management, this availability to the community constitutes an essential safety net that can respond immediately. It is this availability to respond that often justifies the public funding of EMS through tax collections or other assessments on the community as a whole.

The health care role for EMS is also pretty clear and begins as soon as we encounter a patient in the field. From that point forward, we are providing individual health care services much like any other part of the health care system. This aspect of EMS requires medical knowledge, care protocols, physician oversight and a level of integration with other health care components. It is the provision of these individual health care services that is the justification for EMS to bill patients directly, a practice uncommon to other public safety functions.

What is the public health connection to EMS"
Public health is an amazingly broad discipline which includes injury prevention, disease surveillance, meeting the needs of underserved populations, and much more. The American Public Health Association has no less than 31 interest areas and or sections for its members, spanning from HIV/AIDs to school-based health to health information systems to behavioral health. There is even an emergency health services section concerned with EMS and emergency care systems.

As a general rule, public health is a catch-all discipline that is concerned with the health of communities in general. As a result, it is essentially anything health-related that is not an individual health care service. Despite its broad mission, public health is only a fraction of the health care system, especially in the U.S. where we have a substantial focus on acute care services.

The history of public health is extensive, and includes many great successes regarding environmental health, the control of infectious diseases, occupational health and reductions in smoking amongst the general public. Public health is often a governmental responsibility and is accomplished to varying degrees at all levels of local, state and federal government. At the federal level, multiple agencies, including the U.S. Public Health Service and the Centers for Disease Control and Prevention, have public health responsibilities. Every state has a health department, as do almost all counties and many larger municipalities.

Many public health professionals are very concerned with vulnerable populations and health equity issues. Individuals at the lower end of the socio-economic spectrum are more likely to suffer from many diseases, particularly those linked to the environment like asthma or lead paint exposure. Many of these populations also suffer from a lack of access to medical care. The poor and vulnerable, however, often benefit the most from public health accomplishments over time including advances key areas such as clean air and clean water.

Why does public health matter to EMS"
Perhaps the most visible area where public health crosses over into EMS are regarding access to care and regulatory oversight issues, a key role of state health departments. Odds are good that your state EMS office is part of the state health department.

State EMS offices are concerned with ensuring that ambulance and EMS systems meet minimum standards and are accessible to all citizens. Many of these offices also investigate complaints to ensure the public is protected from substandard care.

You may also note that there is somewhat of an inherent contradiction in that state EMS offices are often charged with both regulating and building EMS capacity simultaneously in their enabling state legislation. This relates to the public health aspects of EMS where both access to care and effective regulation are essential.

What are the types of public health prevention"
Public health practitioners view their work through three types of prevention.

• Primary prevention that involves eliminating disease before it occurs.
• Secondary prevention that involves identifying disease early through screening and other methods and limiting its progression.
• Tertiary prevention that occurs in concert with acute treatment and involves minimizing the impact of disease on individuals and populations.

What are the types of diseases"
Public health views disease as infectious or non-infectious. Infectious diseases are exactly as they sound and are the historic bread and butter of public health work. Diseases such as cholera, malaria, measles, Ebola and Zika virus qualify in this category.

Non-infectious diseases, however, represent what EMS is most involved with including such diseases as asthma, diabetes, heart disease and trauma. Due to the success of previous efforts to eradicate infectious diseases, non-infectious diseases have become the population health challenge of our time, and EMS is on the front lines of combating them. Health departments also spend a large amount of time developing and deploying programs to prevent and mitigate these non-infectious diseases.

How is public health engaged in emergency preparedness and response"
Another important aspect of public health activities is emergency preparedness and response to public health emergencies. This begins with surveillance activity for a variety of reportable diseases and also involves epidemiology, the investigative aspect of health.

As emerging diseases are identified, public health officials are charged with monitoring outbreaks and mitigating the consequences. This also involves multi-disciplinary planning activities, such as those to address SARS, pandemic influenza and Ebola that likely involved your EMS service at some level in the past. If you are in an area prone to large scale natural disasters, such as hurricanes or floods, you have also likely participated in public health emergency planning activities.

What is a public health assessment"
A final aspect, particularly of local public health agencies, is community health assessments. These assessments are usually taken on as part of the routine planning activities of local health agencies and are updated on a regular basis. These assessments identify the key health risks in the community and programs in place to address them. In many cases, they have become the basis for community paramedicine and similar programs in the community. If you haven't seen one for your community, you can probably find it on your local agency's website. You may be surprised at how much it could inform the activities of your EMS system.

What is the future of EMS and public health collaboration"
EMS will continue to be regulated and influenced by public health at multiple levels. We are fortunate, however, that public health professionals will also remain very interested in the availability and viability of our EMS systems. State rural health offices, the National EMS Information System and the federal EMS for Children program are examples of this type of involvement.

EMS systems should also be willing to partner with their local public health agencies as they often face many of the same population health concerns as EMS. They receive funding from a variety of sources that may help your service provide injury prevention and other programs. At the very least, knowing your local health officials can come in very handy if you find yourself in the middle of a disease outbreak or similar emergency.

Make sure to befriend and connect with public health practitioners in your state and community. Many of them hold a Masters in Public Health or a similar advanced degree. As EMS leaders, we can both benefit from, and provide benefits to, the overall health of our community through public health partnerships.

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