Convened December 9–10, 2024

Enhancing the Resilience of Health Care and Public Health Critical Infrastructure
Proceedings of a Workshop—in Brief

When disaster strikes, critical infrastructure¹ failures can follow—from loss of power and water to failures of information technology (IT) infrastructure and systems. Threats to the nation’s health care and public health (HPH) critical infrastructure are highly complex and rapidly evolving, creating potentially new or increased national health security risks and disruptions, challenging assumptions about the current and future resilience of HPH critical infrastructure design and operations, and altering the implications for interdependent sectors and workforce.

Considering the changing risk environment, the National Academies of Sciences, Engineering, and Medicine’s (the National Academies’) Forum on Medical and Public Health Preparedness for Disasters and Emergencies convened a workshop on December 9–10, 2024, to examine strategies, policies, and innovative actions to improve the resilience of HPH critical infrastructure concerning impacts from disasters and other emergencies.² The workshop convened speakers from different sectors, such as government, business, nonprofits, and academia, to (1) explore the evolution of the HPH critical infrastructure sector from infrastructure design, technology, and operational perspectives; (2) assess evolving threats, including emerging risks and vulnerabilities specific to HPH critical infrastructure with the built environment, water and wastewater, energy, IT and communications, supply chain, and workforce; (3) review opportunities to enhance resilience, including risk reduction and mitigation strategies needed to address the changing infrastructure and these evolving threats; and (4) describe the key characteristics of a resilient HPH critical infrastructure sector and outline proactive steps to achieve this resilience. While HPH critical infrastructure relies on many sectors, the workshop focused on built environment, water and wastewater, energy, IT systems, communication systems, supply chains, and the HPH workforce.

Paul Biddinger, Mass General Brigham Center for Disaster Medicine, opened the workshop and outlined the breadth of sectors—e.g., HPH, transportation, built environment, energy, commerce, communications—that compose the nation’s critical infrastructure. Acknowledging the scale and complexity of the HPH critical infrastructure sec-

___________________

tor, he remarked that HPH are critical infrastructure, but HPH are also highly interconnected with and dependent upon larger community infrastructure systems. Resource constraints exacerbate these crosscutting interdependencies and make substantive collaborations more difficult, he added. Biddinger also highlighted the uneven impacts of disaster-related infrastructure failures on society, particularly with respect to HPH service delivery.

W. Craig Vanderwagen, East West Protection, LLC, cautioned that the existing HPH infrastructure in the United States is not configured to tolerate an existential challenge, such as a sustained mass trauma surge or a nation-state cyberattack. The understanding of disaster preparedness, response, recovery, and mitigation is evolving to reflect new and changing dynamics. Understanding these dynamics in the context of the disaster cycle is foundational to empowering communities to enhance their social infrastructure resiliency. Emerging responses to these changing dynamics require enterprise thinking, which Vanderwagen defined as collective action across multiple stakeholders and sectors that are oriented to solve challenges and generate solutions that align with community-specific priorities.

This Proceedings of a Workshop—in Brief is not intended to provide a comprehensive summary of information shared during the workshop. It reflects the knowledge and opinions of individual workshop participants and should not be construed as representing any consensus among the workshop participants, the Forum on Medical and Public Health Preparedness for Disasters and Emergencies, or the National Academies.

DEVELOPING AN EVOLVED RESPONSE TO AN EVOLVING RISK LANDSCAPE

Strengthening Resilience Across HPH Critical Infrastructure

In the workshop’s opening fireside chat, panelists representing the built environment industry, health care, and public health discussed important considerations for adapting to change and building resilience into HPH critical infrastructure.

Julie Hiromoto, HKS, asked the HPH sector to think about the larger potential of the built environment and what can be achieved within, through, and beyond the built environment. She outlined five different forms of resilience—infrastructure, economic, social, health, and environmental—and emphasized how the built environment can be leveraged to build resilience through intentional design and capital infrastructure investment decisions that promote public health, safety, and welfare.³ Building strong community connections can be achieved through creative engagement strategies that identify local needs and priorities, followed by consistent communication about ongoing initiatives that are underway to address them, said Hiromoto. She continued that community resilience can be strengthened through redundancy, both formal and informal, to ensure that individuals receive care via connections to multiple organizations, institutions, and resources. A unique initiative she highlighted was work on optimizing the built environment to enhance cognitive function (i.e., brains in the built environment) and how to shift to a positive brain potential.⁴ Investments to strengthen resiliency may need a business case with quantifiable outcomes, but the business case for maintaining the organization’s reputation and long-term financial sustainability also can justify these investments, said Hiromoto.

Nathan Weed, Washington State Department of Health, underscored the challenge of strengthening resiliency in HPH infrastructure given the complexity of the rapidly evolving threat landscape, which is compounded by changes in climate, medicine, science, technology, information, community demographics, and other factors. Strengthening resiliency warrants a framework that is broader than an event-by-event definition, said Weed. The increasing risk of conventional and unconventional threats requires a dynamic threat matrix to highlight potential hidden and cascading second-order impacts. A further challenge is that communities vary widely in their levels of financial capacities and degrees of engagement in conversations about building resilience. Weed suggested that intentional collaboration with communities and stakeholders during noncrisis times can help to identify risks and vulnerabilities and enhance response effectiveness, noting that this can be facilitated through local and regional social, business, and institutional connection points.

___________________

Peggy Duggan, Tampa General Hospital, described how hospitals can serve as a safety net for their communities through high-reliability work and resiliency during crises. Duggan reported that Tampa General has invested substantially in hurricane preparedness to enable independent operation and maintain continuity of care during crises, including an AquaFence™ to protect the facility, an emergency power plant, wells, and other protective measures. Duggan suggested that to gain buy-in from executive-level leadership for investment, advocates for resiliency should emphasize the effect of disasters on business continuity and develop strong relationships with an organization’s chief financial officer. Stakeholders should be considered broadly to facilitate bringing more people into these conversations about strengthening resiliency and to make interconnectedness less opaque. Although these conversations may be difficult, they can help build relationships and trust among codependent and interdependent critical infrastructure sectors, noted Duggan. Citing the OneBlood cyberattack in 2024,⁵ which compromised the purveyor of blood for about 90 percent of Florida, Duggan commented that the growing scope and impact of cyber risks require hospitals not only to support their own cyber resiliency but also hold third parties accountable for resiliency.

Understanding Past and Current Performances of HPH Critical Infrastructure

To level-set the workshop, panelists from the federal government, health care, and public health examined current and past performances of the HPH infrastructure sector in response to emergencies and maintaining operations during crisis situations and highlighted how those responses can strengthen future activities. Andrew Pickett, Pennsylvania Department of Health, commented that the health care sector tends to focus first on building internal resiliency and capacity, while public health tends to focus on building resilience and capacity through broader community-based partnerships; he asked how those approaches might become more balanced.

TJ Christl, Office of Cybersecurity and Infrastructure Protection, Administration for Strategic Preparedness and Response (ASPR), described federal-level efforts to build resilience and manage risks to the nation’s HPH sector infrastructure. He remarked that resilience requires cooperative efforts to identify threats, understand risks, and manage consequences in the face of complex and dynamic hazards. Christl regards resilience as being built through investments of resources, thought, time, and engagement in the effort to identify risks and establish key partners. He explained that the National Defense Authorization Act (2021)⁶ established clear responsibilities for federal health sector risk management agencies. The 2024 release of National Security Memorandum 22⁷ heightened the focus on addressing threats to critical infrastructure through intersectoral coordination, collaboration, and partnerships. To that end, ASPR convenes joint working groups that span more than 500 private sector organizations to collaborate strategically on topics such as cybersecurity, supply chain, and risk management.

Melissa Harvey, HCA Healthcare, presented a case study on HCA’s response to Hurricane Helene in North Carolina. During any emergency event, HCA’s core emergency operation priorities are (1) life safety, (2) infrastructure, (3) operations, and (4) mission (i.e., delivering care and improvement to human lives). HCA responded to Helene in Asheville, North Carolina, while simultaneously responding in other markets throughout Florida and Georgia, with surge staffing, helicopter delivery of supplies, satellite-enabled telecommunication services, portable electricity generators, and a 28-truck fleet of water tankers to provide potable water to hospitals. Emergency operations benefit from developing facility-level metrics and competencies to aid in emergency operation goal setting, she added, noting that facilities should be prepared to operate with minimal to no support for 72 hours. Harvey suggested that hospitals can balance demands for internal and community resiliency through partnerships via participation in local emergency coalitions (e.g., hourly crisis calls) while also remaining committed to the hospital’s mission of serving patients.

Theresa Cullen, Pima County Health Department, offered a local-level perspective on emergency preparedness,

___________________

noting that it has not historically been a high priority for local health departments. She emphasized that state-level public health departments should build relationships with local partners primed for activation of Emergency Support Function (ESF) #8—Public Health and Medical Services⁸ in response to public health and medical emergencies. Cullen outlined other lessons learned from local-level response to public health emergencies, including (1) the value of trust and engagement; (2) the importance of communication and communication infrastructure; (3) the need for interoperable, robust, and agile data systems; (4) the critical role of county-level knowledge of supplies in solving supply chain issues; (5) the importance of workforce training and support; (6) the need to institutionalize effective components of preparedness and response efforts (e.g., establishing ethics and community engagement committees); (7) the importance of building trust with communities; and (8) the need to develop strong HPH expertise, partnerships, and organizational resiliency.

Panelists discussed the value of moving toward a collaborative ecosystem in which data on failures and near-misses are shared to inform predictions about requirements for future crises. Christl remarked that prediction is valuable when justifying costs and establishing returns on investments in preparedness; past experiences could be more effectively analyzed for the purposes of prediction, but barriers remain. For instance, Harvey suggested that health systems will need to overcome the competitor mindset to enact peer assessment systems with metrics. Cullen said that public health authorities and local hospitals need a forum for safely sharing metrics, assessments, and after-action reports to inform predictions. Christl commented that ASPR’s data modernization efforts are seeking to inform data-driven decision making; Cullen noted that a similar initiative is underway at the Centers for Disease Control and Prevention (CDC) along with efforts to develop better predictive tools through forecasting and analytics. To increase information system resilience, Harvey called for honest engagement with HPH leaders about priorities in emergencies to inform dashboards and an understanding of their underlying vulnerability regarding information systems.

Assessing Future Threats

Looking ahead, panelists from the federal government, health care, and emergency management explored what the future risk landscape for HPH infrastructure might look like in both the short and long term. Mahshid Abir, RAND, asked panelists to question the assumptions we are making, or should be making, about vulnerabilities to HPH infrastructure and to envision worst-case scenarios and how they might impact critical infrastructure elements at the interface of HPH, including the supply chain and the prehospital environment.

Trent Frazier, Cybersecurity and Infrastructure Security Agency (CISA), remarked that resilience in infrastructure sectors has historically focused on self-reliance, but the current and future threat of environments necessitate a shift toward the concept of interdependence. Building resilience requires acknowledging that plans may fail, then planning for failure to mitigate cascading effects, said Frazier. Worst-case scenarios are characterized by cascading failures, as seen in cyber events where systems are not secure by design. He described how modern infrastructure is characterized by overlapping layers of infrastructure, whereby every new layer creates new interdependent relationships but increases vulnerability to cascading effects when infrastructure functions are compromised. Moreover, the distinctions between the local, regional, and national-level tiers are becoming blurred, with national-level problems rapidly becoming local-level problems and vice versa; this warrants mechanisms for moving nimbly between those tiers to make efficient decisions during crises, said Frazier. He added that such decisions require access to critical information at the right time—before, during, and after an incident—that necessitate developing high-functioning systems for assimilating and quickly analyzing data; he emphasized that such systems do not form organically.

Jeff Butler, Medxcel, emphasized that health facilities should conceptualize resilience using an enterprise mentality with an emphasis on maintaining facility operations when facing disruptions. Butler noted that a new platform released in 2023—the Risk Identification Site

___________________

Criticality toolkit⁹—provides a comprehensive vulnerability assessment in addition to assessing hazard risk; it also allows data to be shared with other private and public sector organizations. He suggested that efforts to strengthen resilience in the health care delivery system would also benefit from continuing the trend of public–private partnerships that emerged during COVID-19, which engaged health care coalitions as well as nontraditional partners that constitute critical infrastructure upon which the HPH sector is reliant.

Threats exist on a continuum from existential (e.g., cybersecurity, nation-state threats) to community and micro-level disasters, said Chas Eby, Maryland Department of Emergency Management. Emergency management risk assessments offer perspectives on reducing risk using the model of “threat, vulnerability, and consequences.” Eby contended that, historically, there has been too much emphasis on threats and consequences without sufficient focus on identifying vulnerabilities. The latter approach is hazard-agnostic and better facilitates the identification of commonalities across hazards. Thus, rather than planning for individual hazards, the HPH sector can develop the baseline capability to be more agile, scalable, and flexible in dealing with a multiplicity of known (and unknown) future threats. Eby noted that emergency managers are assessing how they determine risk based on new metrics that may be released by the Federal Emergency Management Agency in 2026. Butler maintained that hazard assessment should be data driven and led by local facilities rather than a top-down approach.

BUILT ENVIRONMENT

Kirk Pawlowski, Educational Service District 112 Construction Services Group, opened the panel on the built environment by highlighting the power of individual leadership in advancing resilient infrastructure. Reflecting on decades of experience, he stressed that even the most forward-thinking institutions regret not prioritizing preparedness more. Therese McAllister, National Institute of Standards and Technology (NIST), explained that the built environment includes buildings and systems for energy, water, transportation, and communications. She described how successful infrastructure and community resilience plans are contingent on core interdependencies characterized by rapid recovery of critical functions after disruptions. Amber Wirth, HKS, highlighted that resilience involves highly-integrated social, economic, environmental, climate, health, and infrastructure components.

William Seed, Jackson Health Systems, described how aging infrastructure and extreme weather events pose challenges at many health facilities, and service provision is vulnerable to supply chain and labor force disruptions. He stated that facilities should identify critical risks and vulnerabilities and develop prioritized capital investment plans in facility improvements accordingly. Infrastructure investment and preparedness efforts include (1) hardening buildings; (2) augmenting generator capacity; (3) upgrading storm drainage; (4) planning for increased labor needs caused by weather events; and (5) creating multiple, redundant IT backup systems in various U.S. geographical regions. Built environment interventions require holistic thinking and place-based solutions to achieve both disaster resilience and improved carbon neutrality, said Wirth. She added that regenerative design strategies for building infrastructure systems is intended to reverse degeneration of local natural systems and coevolve with these systems to generate mutual benefits for building services, users, and local communities.

The NIST Materials and Structural Systems Division studies post-disaster damage to the built environment; this research informs the NIST Community Resilience Planning Guide,¹⁰ said McAllister. Noting that many community planning, preparation, and maintenance efforts are conducted by small groups, she emphasized the value of incorporating key stakeholders, including people likely to be affected by disruptions, in community resilience planning efforts. She added that plans based on historical events are insufficient for preparedness, given the possibility of future increases in hazardous events. National building codes serve as models of minimum requirements for life safety and hazard events but do not address resilience. These codes require adoption

___________________

and enforcement at the state or local level. Wirth highlighted that building codes are historically based and do not account for the increasing severity and frequency of weather events related to climate change. Seed noted that flexibility in national codes in accordance with local risk conditions could more effectively enable building owners more targeted risk management strategies.

Pawlowski noted that rational and forward-thinking capital funding strategies are crucial for disaster mitigation and resilience, strategies often complicated as they typically involve long-term debt and public–private investments. Emphasizing the capital and operational costs to owners associated with lack of preparedness, Wirth noted that resilient design mitigates damage and loss of revenue. The business case for resilience investments should evaluate the cost–benefit ratio on a holistic lifecycle basis rather than on first costs, she stated. Noting competition for capital, Seed remarked on the importance of prioritizing sustainability initiatives. He added that collaboration with insurance providers as input providers could offset the cost of risk management services and improve returns on investment. McAllister highlighted a long-term strategy in which an organization or system slowly incorporates resilience each time repairs or updates are made, thereby avoiding large initial outlays of capital.

WATER AND WASTEWATER

Pawlowski, inspired by the saying “we all live downstream,” described that water availability and quality are fundamental to life and essential for resilient HPH infrastructure. Panelists focused on the critical role of water infrastructure and its connection to broader environmental and community resilience; they discussed innovative storm and wastewater management, water resource development, and how communities can enhance economic opportunities through sustainable water strategies.

Gary Hartz, U.S. Public Health Service Commissioned Corps, stated that preparedness initiatives should consider and better understand cultural norms and that emergency interventions should be assessed for their sustainability and alignment with community expectations. He noted that rural locations often lack the redundancy that may be required during a crisis, thus establishing redundant water supply via water towers would bolster preparedness.

Jake Marshall, National Transportation Safety Board (NTSB), noted that health care disruptions ranging from water main breaks to severe weather events can cause immediate water loss that necessitates infection control measures and initiates expensive cascading failures related to heating and cooling, humidity control, computer systems, laboratory services, and other medical technology. Water contingency and emergency preparedness countermeasures generate returns on investment within five years and include water connectors, deep water wells, and bulk water tanks, said Marshall. He emphasized the importance of developing the capacity to quickly and efficiently receive aid from community partners and the federal government. Facility engineers can establish emergency water connections to supply minimum water requirements for hospital industrial operations. Advocacy for temporary relaxation of state transportation regulations—such as weight restrictions and driver distance and duration limits—could potentially expedite water delivery to a facility in crisis. Water regulatory bodies could adopt water restoration prioritization matrices based on the model employed by electricity providers. Marshall noted that the ramifications of Hurricanes Helene and Milton offer windows of opportunity in which to convince legislators of the importance of more resilient water infrastructure.

Pawlowski emphasized the importance of broad, community-based strategies in water resource management, which contribute to fostering resilience in HPH infrastructure. Hartz highlighted the value of managing community expectations when addressing water issues during crises. He added that community relationships developed via communications facilitates crisis water management. Marshall noted that strong relationships with community partners enable interventions, such as local fire departments providing water tanker trucks to hospitals. Chrissy Dangel, U.S. Environmental Protection Agency (EPA), noted that EPA’s Water Infrastructure and Cyber Resilience Division convenes workshops promoting emergency preparedness via increased planning, communication, and relationship building. Bringing together stakeholders from water, public health, and health care,

the workshops feature lessons learned from outbreaks of waterborne diseases and water disruptions caused by flooding, hurricanes, earthquakes, and wildfires. Dangel noted that water disruptions pose issues to health facilities ranging from outages to contamination to changes in water chemistry. Regional Healthcare Preparedness Coalitions provide forums for emergency preparedness collaboration between water and health care sectors, said Dangel.

ENERGY

Get W. Moy, AECOM, remarked on the evolving nature of critical infrastructure resiliency throughout the decades as new technologies and disciplines are introduced to the topic and how the energy sector has adapted to those changes. Scott Aaronson, Edison Electric Institute, highlighted the critical importance of the electric power sector and emphasized that building resilience in energy services requires identifying and prioritizing essential resources in targeted infrastructure improvements. Patrick Murphy, PSE Healthy Energy, remarked that energy infrastructure is highly interconnected with other critical infrastructure, thus failures can initiate a series of cascading events across multiple sectors.

Christopher Riccardi, Children’s Health of Orange County (CHOC), explained that aging energy infrastructure is prone to fire damage and requires power companies to temporarily interrupt electricity services. Health care facilities are vulnerable to electrical outages, which cause cascading effects on water, chillers, humidity control, and patient-care technology. Framing resilience in terms of distance to essentials, Murphy described how individuals’ energy resilience and vulnerability varies within and between communities.

An all-hazards approach to preparedness in the electric power sector considers potential threats, such as cyber and physical attacks, storms, fires, and pandemics, said Aaronson. Preparedness planning uses regulation, cross-sector partnerships, and resilience building. Planning exercises provide opportunities for identification of critical resources and relationship building between various parties involved in crisis response. Aaronson emphasized that response efforts should prioritize communicating with the public to mitigate the fear, uncertainty, and confusion common during crises. Highlighting the value of self-sufficiency during disruptions, Riccardi noted that CHOC is subject to mandates requiring maintenance of a 45-day supply of personal protective equipment and a water supply for 72–96 hours of operation. Hospital preparedness plans should detail generator capacity, fuel reserves, load shedding (i.e., usage reduction) priorities, and power requirements for lifesaving medical services, he outlined. Energy disruption mitigation strategies include diesel generators, independent power plant IT systems, and energy-efficient technology. Riccardi added that emerging technologies for renewable energy, battery storage, and artificial intelligence (AI) offer additional opportunities. Murphy noted that policy responses to address energy resilience include (1) increasing affordability; (2) achieving equitable reliability; (3) reducing environmental burdens; and (4) promoting participation in decision making.¹¹ Aaronson suggested that addressing existential power sector risks and an evolving electrical grid that incorporates renewable and decarbonized energy sources will involve electrical providers, state economic regulations, and North American Electric Reliability Corporation standards.

INFORMATION TECHNOLOGY SYSTEMS

William Yurcik, Centers for Medicare and Medicaid Services (CMS) Headquarters, commented on how pervasive IT systems are in the HPH sector and will be increasingly so moving forward. Natalie Sullivan, George Washington University, highlighted the extent to which health care providers and staff are increasingly dependent on IT systems. Given that electronic health records (EHR), orders for tests and imaging, and connected diagnostic equipment and medical devices all rely on IT, cyberattacks and ransomware threats extend beyond privacy and financial concerns to patient-care implications. Yurcik remarked that IT enables greater numbers of patients to be treated by a limited health care workforce, but this dynamic results in fewer employees being available to address gaps created by IT disruptions.

Joshua Corman, Institute for Security and Technology, cautioned that hospital and pharmaceutical supply chains

___________________

are overdependent on unreliable IT, creating vulnerabilities to accidents and adversaries that can result in delayed or degraded care. In terms of cyber risk, health care remains a target-rich environment with poor cyber defenses, he remarked. Ransomware attacks can increase the likelihood that a hospital will close. Moreover, nation-state actors such as Volt Typhoon, a Chinese state-sponsored hacker group, have targeted U.S. infrastructure that the health system depends on.¹² Initiatives to mitigate cyber risks include CyberMed Summit,¹³ I Am The Cavalry,¹⁴ and UnDisruptable27,¹⁵ said Corman.

Raj Ratwani, MedStar Health Research Institute, explained that EHR downtime interrupts medication provision, laboratory operations, documentation, access to patient history, and provider communication, and unplanned disruptions can therefore affect patient safety. Sullivan explained that disruptions to IT systems are particularly detrimental to the management of time-sensitive conditions, such as myocardial infarction, stroke, sepsis, and trauma. Moreover, cyberattacks have been associated with worse cardiac outcomes at hospitals adjacent to the target facility, possibly due to diversion time and increased patient loads. She emphasized that IT disruptions can cause cascading failures in water and electricity infrastructure. Sullivan remarked that health care systems should develop plans for analog care provision and access to mobile systems in the event of a cyberattack and conduct simulations with health care providers. Ratwani stated the need for incentives for health care facilities to develop more robust downtime plans and practice these procedures. Furthermore, plans should prioritize and streamline operations, given the limited health care workforce and the time-intensive nature of manually replicating electronic tasks. He added that AI and IT automation have resulted in deskilling in the health care workforce, creating additional vulnerabilities during IT downtime. Emphasizing that failures can compound quickly, he remarked that IT disruption concurrent with a natural disaster could result in a reduced labor force having to rely on analog methods of care. Sullivan remarked that a hospital she worked at experienced a ransomware attack that caused weeks of EHR downtime during the height of the COVID-19 pandemic. Ratwani noted that EHR developers could create backup systems and downtime operations guidance and include these in certification criteria.

Ratwani noted that data collection on the effects of unplanned EHR downtime is challenging, given the unpredictable nature of such disruptions, and hospitals may be reluctant to share data with researchers that reflect decreased quality in care. Gregory Pluta, University of Illinois at Urbana-Champaign, stated that measurement and data sharing can result in updated regulations, as was the case with earthquake research leading to improved building codes and black-box data informing aviation safety measures. Similarly, increased measurement of cybersecurity incidents and their effects could result in better cyber risk management. Pluta remarked on the need for a health care cybersecurity entity like the NTSB. Such an entity could enable health care organizations to share data about cyberattacks and cascading failures without fear of legal liability; these data would inform improved cybersecurity measures.

COMMUNICATION SYSTEMS

Pickett highlighted the dependence of the HPH sector on the communications critical infrastructure sector. Communications systems are a critical enabler of HPH services and operations, he noted. Cathy Lester-Junda, Stantec, described how communications systems function within an integrated ecosystem that links clinical teams, first responders, public health authorities, and supply chain partners to ensure seamless coordination during disasters.

Lester-Junda warned that the communication systems for the HPH sector are vulnerable to operational silos, natural disasters, interdependencies that lead to cascading failures, and man-made challenges, such as cyber threats. Kathryn Condello, Lumen Technologies, stated that HPH dependencies on the communications sector may be assessed in the following layers: (1) the services and applications and (2) the access networks (wireless, wireline, cable) being leveraged and finally (3) the core network underlying it all for national and global tran-

___________________

sit. Describing this dependency assessment as the cornerstone of resilience planning, she explained that this process identifies organizations’ service priorities, the communications required for those services, and allow the HPH provider the means to develop alternatives in the event of communications disruption. The effects of disruptions can be mitigated by creating resilient community enclaves that prioritize the most essential communications for the provision of care and distribute responsibilities and capacities across other HPH partners. Condello emphasized the importance of developing plans for addressing these dependencies and potential cascading failures in advance of and outside times of crisis, since widespread impact of cyberattacks could be instantaneous.

Recounting the 2016 Gatlinburg wildfires that destroyed all cell phone towers, landlines, and radio repeaters in the area, Sean Kice, Tennessee Department of Health, noted that public health departments may need to provide communications support to disrupted areas during crises. Examples include (1) equipping ambulances with radios and satellite phones; (2) providing satellite-enabled mobile operations centers; (3) distributing burner phones to public health departments; and (4) locating and deploying message boards. He described how layers of technological redundancy enhance resilience by providing alternative modes of communication when preferred technology is unavailable. Lester-Junda remarked that while interdependencies can cause cascading failures, they can also create cascading benefits. The ecosystem concept of resiliency emphasizes redundancy, interconnection, and adaptability. Resilience in communication systems can be strengthened via primary, secondary, and tertiary layered modes of communication, shared networks with hybrid command centers, integrated clinical responses, nontraditional partnerships, and cross-sector drills. Lester-Junda highlighted opportunities such as integrated layered redundancy featuring ground and satellite communication, mobile power and water sources, and tethered drone Wi-Fi bubbles. Aerial networks established with gliders provide Wi-Fi services for larger areas. Additionally, simulations and predictive modeling enable scenario testing across an ecosystem and provide projective insights. Condello noted that responding to cyberattacks might require disconnecting certain services, so she underscored that organizations should create plans to protect specific functions by assuring their access across a wide array of options, so that critical functions are not lost if disconnecting communications capabilities.

Emphasizing that accessibility features should not be disconnected during crises, Marcie Roth, World Institute on Disability, highlighted the importance of including disability leaders in preparedness and response planning. Roth spotlighted that the United Nations (UN) Early Warning for All Initiative¹⁶ prioritizes a people-centered approach to improving early warning systems and building capacity. Led by the UN Office for Disaster Risk Reduction, the World Meteorological Organization, the International Telecommunication Union, and the International Federation of Red Cross and Red Crescent Societies, the initiative supports countries in building and operating inclusive, multi-hazard early warning systems. She underscored that strategies for communication accessibility must address pre-disaster, disaster, and post-disaster communication and meet the needs of people with hearing, cognitive, and/or intellectual disabilities. Roth stated that registries are not an effective mechanism for targeting early warnings to people with disabilities, and increasing information accessibility is more likely to make such information actionable. Kice noted that collaboration with communities of people with hearing or vision impairments informs efforts to increase information accessibility.

SUPPLY CHAIN

Nicolette Louissaint, Healthcare Distribution Alliance, underscored the role of a resilient medical product supply chain in HPH sector—its resilience directly affects the continuity, effectiveness, and security of HPH services and operations in emergency and non-emergency times. To help describe the scope and complexity of ensuring resilient supply chains, Brooke Courtney, Food and Drug Administration (FDA) Office of Public Health Preparedness and Response, explained that FDA-regulated products are manufactured or handled at nearly 300,000

___________________

registered facilities, more than half of which are located outside of the United States. In recent years, factors such as the COVID-19 pandemic, natural disasters, worker strikes, increased demand of certain drugs, and lack of incentives to reward supply chain resilience have strained the medical product supply chain.

Courtney outlined that FDA addresses potential shortages via communication with companies, depending on the situation and the product, may use various regulatory tools to help prevent or mitigate a shortage. For example, FDA’s roles may include expediting review of regulatory submissions and inspections, working with firms to help them augment production if they are willing, or allowing for temporary importation of appropriate products during a shortage to help increase supply in the United States. She noted that FDA lacks authority to purchase, import, stockpile, or set pricing for products or to compel domestic manufacturing or allocation, and that underlying economic factors such as intense pharmaceutical price competition and uncertain revenue streams for generic drugs are outside of FDA’s purview to address alone. Some authorities to help provide FDA with increased visibility into supply chains include manufacturers reporting annually to FDA on the amount of each listed drug that was manufactured, prepared, compounded, or processed for commercial distribution and notifying FDA of a permanent discontinuance in the manufacture of drugs and biological products, or an interruption in their manufacture if it is likely to lead to a meaningful disruption in the supply of such products in the United States. Way-land Coker, ASPR Office of Industrial Base Management and Supply Chain (IBMSC), stated that ASPR collaborates closely with FDA in addressing public health emergencies. Working to establish end-to-end supply chain visibility, IBMSC conducts surveillance and vulnerability assessments. During public health emergencies, the office coordinates acquisition and regulatory issues.

Anita Patel, Walgreens, reported that most Americans visit their pharmacy more often than any other health care provider, creating opportunities for pharmacies to establish trusting relationships with customers. Supply chain interruptions can introduce friction into these relationships. Pharmacies are often among the first entities to become aware of issues with select supply chain materials—as was the case during the COVID-19 pandemic—and Patel suggested that supply chain surveillance efforts should leverage collaboration with pharmacies. She emphasized that supply chain disruptions to specialty drugs, such as cell, gene, and oncology products, can have potentially life-threatening consequences for patients.

Coker stated that a resilient medical product industrial-based supply chain anticipates and resists disruption and, when disrupted, recovers quickly. He noted the need to diversify global manufacturing sources and build redundancy to foster resilience across U.S. geographic regions. Patel stated that pharmaceutical shortage strategies include partial filling of prescription quantities for patients and use of central distribution sites that hold and rapidly distribute products to pharmacies as needed. She added that smaller, decentralized stockpiles—continuously refreshed to address expiration issues—could improve supply chain visibility. The establishment of dashboards for drug availability could inform stockpile release. Louissaint remarked that given the high expenses involved, the feasibility of maintaining and refreshing medication stockpiles is uncertain. Some states have models that provide health care systems and coalitions with funding to establish buffer stock (e.g., a reserve of several days of medication). A CMS policy enables small independent hospitals to voluntarily purchase and hold buffer stock of up to 86 medications designated as essential,¹⁷ although reimbursement issues related to buffer stock maintenance persist. Patel noted that in addition to expense, questions regarding the logistics of stockpiling medications remain, including how to determine which drugs and quantities to stockpile, distribution strategy, tracking, and interactions with the traditional supply chain.

Coker remarked that long-term structural solutions involve investments that may not produce immediate returns. Preparedness efforts could employ long-term

___________________

market analysis and strategic forecasting in formulating plans for supply chain resilience. Louissaint commented that investment and regulatory control could address products likely to face shortages. She noted the need for better understanding of meaningful incentives to encourage private sector investment in resilient supply chains. Highlighting knowledge-sharing initiatives, Courtney noted that the Department of Health and Human Services (HHS) shares mitigation and conservation strategies during certain shortages (e.g., via stakeholder calls and its website), and Coker noted that ASPR Ready receives and responds to shortage-related questions from localities across the United States.

Louissaint underscored the need for public–private collaboration in increasing supply chain resilience. Given that government has regulation, funding, and facilitation mechanisms, while industry is responsible for manufacturing, stronger public–private partnership is needed, said Coker. Moreover, joint planning with allied nations could increase preparedness. Patel said that Increasing Community Access to Testing, Treatment, and Response (ICATT)¹⁸—a public–private partnership established between HHS, CDC, and select pharmacies during the COVID-19 pandemic—could be leveraged to address future shortages.

EXPLORING SOCIAL COMPONENTS SUPPORTING CRITICAL INFRASTRUCTURE

Herminia Palacio, NexusBridge Strategies LLC, characterized the human workforce as the backbone of all essential services and industries that sustain HPH critical infrastructure and all other sectors. Palacio said that without a well-trained, healthy, and supported workforce, even the most advanced physical and digital infrastructure would be ineffective. It is essential for governments and businesses to prioritize workforce development, protection, and resilience to safeguard critical infrastructure.

However, HPH recruitment and retention has faced and will continue to face challenges in the next 5–10 years, said Palacio. J. P. Leider, University of Minnesota School of Public Health, shared that approximately 50 percent of U.S. public health workers left the workforce during COVID-19, and among those age 35 and under, approximately 75 percent left the health care division. Henry Garrido, NYC District Council 37, noted ongoing cuts could undermine recruitment and retention programs, he stated, emphasizing that health care workers require adequate compensation to work in highly stressful environments with mandatory overtime. Additionally, many younger professionals seek nontraditional benefits, such as childcare, remote work, and flexible or compressed schedules, said Garrido, and labor unions can play a role in maintaining a robust workforce by advocating for these nontraditional benefits. Garrido added that although workers in the home health care and health care industries share many challenges, home health care retention bonuses are rare.

Kelli Nations, HCA Healthcare, also remarked on the need for continued efforts to foster recruitment, and HPH organizations can promote recruitment and retention by focusing on the factors that drive departures in the first 12 months of employment. Noting the piecemeal nature of institutional recruitment and retention efforts, Nations observed the need for a holistic, systemic approach that engages academia in recruitment outreach. Leider added that policies that incentivize HPH fellowships and internships via mechanisms, such as student loan repayment and forgiveness, should be considered.

Recalling the public celebrations of workers in health care, public health, and other sectors recognized as essential during the COVID-19 pandemic, Palacio inquired about current HPH worker perspectives. Leider emphasized that “public health hero” accolades should be accompanied with the understanding that HPH workers are humans with needs, which include reasonable pay, safety, and benefits. Garrido stated that hundreds of health care workers in his public employee union died from COVID-19, and many workers decried the shortages of necessary personal protective equipment as increasing the risks of working in health care. He underscored that since the start of the COVID-19 pandemic, a substantial number of frontline workers have left health care for industries perceived as safer. Moreover, the percentage of public health care workers aged 35 years and younger who resigned during the pandemic was significantly higher than the resignation of older individuals. Nations remarked on the need to acknowledge that many health

___________________

care workers have lingering emotions about the hardships they faced during the pandemic and that providing opportunities for health care workers to openly discuss their experiences can be helpful.

RE-ENVISIONING A RESILIENT HPH CRITICAL INFRASTRUCTURE SECTOR

During the closing roundtable, panelists were asked to re-envision how the HPH critical infrastructure sector can be more resilient and prepared for 21st century threats. Monique Mansoura, The MITRE Corporation, highlighted the need to account for geopolitical risks and identify blind spots, particularly given the globalization of the supply chain and workforce. Biddinger noted that many vulnerabilities remain unidentified, unmeasured, or unaddressed. The discussion centered on metrics and measurement, financing, and approaches to foster collaboration and information sharing.

Efforts to strengthen resilience, including making investment cases, should begin by establishing measures and metrics, suggested Mansoura. O. Sami Saydjari, Dartmouth College, added that metrics should be carefully constructed against a well-established baseline and aligned to clearly defined goals. Mark Jarrett, Northwell Health, maintained that metrics should be meaningful and relatively easy to measure, given the volume of data that health systems and providers are already facing.

Efforts to strengthen resilience will require both short- and long-term financial support, and Cole Roberts, ARUP, suggested focusing on cost-effectiveness approaches to make the case for investment in strengthening resilience. As an example, he suggested making cost-effectiveness cases to build more intersectoral resilience hubs (e.g., decentralized energy resources), which have already been established in areas vulnerable to natural disasters. Saydjari remarked that establishing key principles and developing a unifying roadmap for success, including both incremental steps and a clear endpoint, would aid in navigating trade-offs (e.g., cost versus mission impact) and gaining buy-in from key institutional stakeholders.

The panelists explored a range of approaches that could contribute to building a culture that promotes information sharing and collaboration, facilitating efforts to strengthen resiliency more efficiently and effectively. For instance, Jarrett highlighted the value of a learning mindset, which enables organizations and individuals to learn from past experiences and adapt to new challenges. The NTSB serves as a model for promoting this culture, whereby lessons learned about failures and mistakes can be shared in a protected environment, added Sadyjari. Mansoura suggested that a coalition of the willing could serve as early adopters of a new system for near real-time learning. Roberts noted that in other sectors, resilience-building efforts are moving toward voluntary (and eventually mandatory) disclosure of information. Bettinger emphasized that data must be protected to encourage sharing of information about failures and vulnerabilities.

Jarrett and Roberts discussed how forums for sharing vulnerabilities and failures should be developed based on (1) a culture of trust and collaboration; (2) appropriate institutional representation; and (3) inclusion of all relevant stakeholders. Jarrett called for regionally based forums that include not just the major health systems but also the rural, tribal, and safety-net facilities. Sadyjari remarked that forums for sharing information about vulnerabilities should be both sector-specific as well as cross-sectoral in scope. Saydjari also suggested integrating cybersecurity and system failures into a single framework that brings principles from systems engineering and reliability engineering into the HPH sphere.

Roberts introduced the concept of “ecosystem” mindset, an integrated, holistic approach through which organizations and communities can more effectively adapt to rapidly changing environments by fostering new partnerships and connections, both within the HPH sector and between HPH and other critical infrastructure. He suggested that this could be coupled with an adaptation approach, which defines adaptation as the confluence of the ability to resist and the ability to recover (i.e., resilience).

WORKSHOP CLOSING REFLECTIONS

Biddinger underscored the importance of early action—“do it early”—to strengthen resilience in the HPH sector and across the breadth of other critical infrastructure sectors. This includes efforts to plan for threats, con-

sider essential dependencies and interdependencies, and build collaborative relationships that allow for influence on budgeting, planning, and project prioritization. Early actions can be embedded into existing external and internal organizational activities, suggested Biddinger. Externally, ongoing collaborations, partnerships, and coalitions can serve as forums for regularly considering infrastructure concerns and resilience-related issues (e.g., resource constraints, risk sharing, priority sharing). He noted that this will hinge upon creating structures for effective collaboration within and across sectors. Internally, routine operations, interactions, and meetings can provide opportunities to raise issues related to resilience planning. When advocating for resilience efforts with key institutional leadership, the case for investments in these efforts may be framed as a priority for business continuity and ensuring that operations can be maintained during crises.

Noting the tendency to focus on top-down strategies to strengthen resilience, Vanderwagen highlighted the opportunity to work from the bottom up to address large-scale existential challenges to HPH systems (e.g., cybersecurity issues). Breaking out of silos through robust intersectoral collaboration can yield a host of benefits. When stakeholders break out of silos and collaborate, they can develop a common language and leverage their differences to serve as a synergistic strength that enables enterprise thinking and promotes redundancy.

In closing, Vanderwagen emphasized the importance of building on the work and ideas presented throughout the workshop (see Box 1) and urged stakeholders within the HPH critical infrastructure sector and beyond to prepare with urgency, as existential challenges may potentially arise in the near term. “We should not wait for that existential challenge to be real before we decide that we are going to work collectively to address some of these issues and bring about a coherent systematic approach that addresses preparedness, response, recovery, and mitigation,” he said.

DISCLAIMER This Proceedings of a Workshop—in Brief has been prepared by Anna Nicholson, Evan Randall, Matthew Masiello, and Lisa Brown as a factual summary of what occurred at the meeting. The statements made are those of the rapporteurs or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution. The planning committee comprises Paul Biddinger (Chair), Mass General Brigham; Mahshid Abir, RAND; Nicolette Louissaint, Healthcare Distribution Alliance; Kevin Meeks, Chickasaw Nation; Get W. Moy, AECOM; Herminia Palacio, NexusBridge Strategies LLC; Kirk R. Pawlowski, Educational Service 112’s Pacific Northwest Regional Construction Services Group; Andrew Pickett, Pennsylvania Department of Health; Laura Wolf, Blue Shield of CA; William Yurcik, CMS Medicare Headquarters.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Peggy Duggan, Tampa General Hospital, and Kirk R. Pawlowski, Educational Service 112’s Pacific Northwest Regional Construction Services Group. Leslie Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS This workshop was partially supported by federal funds from the Administration for Strategic Preparedness and Response (75A50121P00089); Centers for Disease Control and Prevention (75D30121D11240/75D30123F00018); National Highway Traffic Safety Administration (693JJ924P000015); National Center for Disaster Medicine and Public Health of the Uniformed Services University of the Health Sciences; National Institutes of Health, Department of Health and Human Services (HSHQDC-17-A-B0001/70RWMD21F00000031), including the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Cancer Institute, National Institute on Aging, National Institute of Allergy and Infectious Diseases, National Institute of Environmental Health Sciences, National Institute on Minority Health and Health Disparities, National Institute of Neurological Disorders and Stroke, Office of Behavioral and Social Sciences Research, under Contract no. HHSN263201800029I, Task Order no. 75N98023F00030; U.S. Department of Defense (HT0011230060); and U.S. Department of Homeland Security. This workshop was also supported by the American Burn Association; American College of Emergency Physicians; American College of Surgeons—Committee on Trauma; American Hospital Association; Association of Public Health Laboratories; Association of State and Territorial Health Officials; Council of State and Territorial Epidemiologists; Emergency Nurses Association; Healthcare Distribution Alliance; Healthcare Ready; Infectious Diseases Society of America; Mass General Hospital; The MITRE Corporation; National Association of Chain Drug Stores; National Association of County and City Health Officials; National Association of Emergency Medical Technicians; National Fire Protection Association; Sandia National Laboratories; Society of Critical Care Medicine; Trauma Center Association of America; and University of Nebraska Medical Center. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

STAFF Lisa Brown, Senior Program Officer; Matthew Masiello, Associate Program Officer; Shalini Singaravelu, Program Officer; Michael Berrios, Research Associate; and Rayane Silva-Curran, Senior Program Assistant.

For additional information regarding the workshop, visit https://www.nationalacademies.org/event/43533_12-2024_enhancing-the-resilience-of-healthcare-and-public-health-critical-infrastructure-a-workshop.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2025. Enhancing the resilience of health care and public health critical infrastructure: Proceedings of a workshop—in brief. Washington, DC: National Academies Press. https://doi.org/10.17226/29081.

Health and Medicine Division Copyright 2025 by the National Academy of Sciences. All rights reserved.