Background. Terrorism, disease outbreaks, and other natural disasters and mass casualty events have pushed health care and public health systems to identify and refine emergency preparedness protocols for disaster response. Ethical guidance, alongside legal and medical frameworks, are increasingly common components of disaster response plans.Objectives. To systematically review the prevalence and content of ethical guidance offered for disaster response, specifically around crisis standards of care (CSCs).Search methods. We systematically indexed academic literature from PubMed, Google Scholar, and ISI Web of Science from 2012 to 2016.Selection criteria. We searched for peer-reviewed articles that substantively engaged in discussion of ethical guidance for CSCs.Data collection and analysis. Researchers screened potential articles for identification and discussion of ethical issues in CSC planning. We categorized and cataloged ethical concepts and principles.Main results. Of 580 peer-reviewed articles mentioning ethics and CSCs or disaster planning, 38 (6%) met selection criteria. The systematic review of the CSC ethics literature since 2012 showed that authors were primarily focused on the ethical justifications for CSC (n = 20) as well as a need for ethics guidelines for implementing CSCs; the ethical justifications for triage (n = 19), both as to which criteria to use and the appropriate processes by which to employ triage; and international issues (n = 17). In addition to these areas of focus, the scholarly literature included discussion of a number of other ethical issues, including duty to care (n = 11), concepts of a duty to plan (n = 8), utilitarianism (n = 5), moral distress (n = 4), professional norms (n = 3), reciprocity (n = 2), allocation criteria (n = 4), equity (n = 4), research ethics (n = 2), duty to steward resources (n = 2), social utility and social worth (n = 2), and a number of others (n = 20).Although public health preparedness efforts have paid increasing attention to CSCs in recent years, CSC plans have rarely been implemented within the United States to date, although some components are common (e.g., triage is used in US emergency departments regularly). Conversely, countries outside the United States more commonly implement CSCs within a natural disaster or humanitarian crisis response, and may offer significant insight into ethics and disaster response for US-based practitioners.Conclusions. This systematic review identifies the most oft-used and -discussed ethical concepts and principles used in disaster planning around CSCs. Although discussion of more nuanced issues (e.g., health equity) are present, the majority of items substantively engaging in ethical discussion around disaster planning do so regarding triage and why ethics is needed in disaster response generally.Public health implications. A significant evolution in disaster planning has occurred within the past decade; ethical theories and frameworks have been put to work. For ethical guidance to be useful, it must be practical and implementable. Although high-level, abstract frameworks were once prevalent in disaster planning—especially in the early days of pandemic planning—concerns about the ethically difficult concept of CSCs pervade scholarly articles. Ethical norms must be clearly stated and justified and practical guidelines ought to follow from them. Ethical frameworks should guide clinical protocols, but this requires that ethical analysis clarifies what strategies to use to honor ethical commitments and achieve ethical objectives. Such implementation issues must be considered well ahead of a disaster. As governments and health care systems plan for mass casualty events, ethical guidance that is theoretically sound and practically useful can—and should—form an important foundation from which to build practical guidance for responding to disasters with morally appropriate means.

Public health in the rural United States is a complex and underfunded enterprise. While urban–rural disparities have been a focus for researchers and policymakers alike for decades, inequalities continue to grow. Life expectancy at birth is now 1 to 2 years greater between wealthier urban and rural counties, and is as much as 5 years, on average, between wealthy and poor counties. This article explores the growth in these disparities over the past 40 years, with roots in structural, economic, and social spending differentials that have emerged or persisted over the same time period. Importantly, a focus on place-based disparities recognizes that the rural United States is not a monolith, with important geographic and cultural differences present regionally. We also focus on the challenges the rural governmental public health enterprise faces, the so-called “double disparity” of worse health outcomes and behaviors alongside modest investment in health departments compared with their nonrural peers. Finally, we offer 5 population-based “prescriptions” for supporting rural public health in the United States. These relate to greater investment and supporting rural advocacy to better address the needs of the rural United States in this new decade.

Residents of rural jurisdictions face significant health challenges, including some of the highest rates of risky health behaviors and worst health outcomes of any group in the country. Rural communities are served by smaller local health departments (LHDs) that are more understaffed and underfunded than their suburban and urban peers. As a result of history and current need, rural LHDs are more likely than their urban peers to be providers of direct health services, leading to relatively lower levels of population-focused activities. This review examines the double disparity faced by rural LHDs and their constituents: pervasively poorer health behaviors and outcomes and a historical lack of investment by local, state, and federal public health entities.

Context: Public health practitioners, policy makers, and researchers alike have called for more data on individual worker's perceptions about workplace environment, job satisfaction, and training needs for a quarter of a century. The Public Health Workforce Interests and Needs Survey (PH WINS) was created to answer that call. Objective: Characterize key components of the public health workforce, including demographics, workplace environment, perceptions about national trends, and perceived training needs. Design: A nationally representative survey of central office employees at state health agencies (SHAs) was conducted in 2014. Approximately 25 000 e-mail invitations to a Web-based survey were sent out to public health staff in 37 states, based on a stratified sampling approach. Balanced repeated replication weights were used to account for the complex sampling design. Setting and Participants: A total of 10 246 permanently employed SHA central office employees participated in PH WINS (46% response rate). Main Outcome Measures: Perceptions about training needs; workplace environment and job satisfaction; national initiatives and trends; and demographics. Results: Although the majority of staff said they were somewhat or very satisfied with their job (79%; 95% confidence interval [CI], 78-80), as well as their organization (65%; 95% CI, 64-66), more than 42% (95% CI, 41-43) were considering leaving their organization in the next year or retiring before 2020; 4% of those were considering leaving for another job elsewhere in governmental public health. The majority of public health staff at SHA central offices are female (72%; 95% CI, 71-73), non-Hispanic white (70%; 95% CI, 69-71), and older than 40 years (73%; 95% CI, 72-74). The greatest training needs include influencing policy development, preparing a budget, and training related to the social determinants of health. Conclusions: PH WINS represents the first nationally representative survey of SHA employees. It holds significant potential to help answer previously unaddressed questions in public health workforce research and provides actionable findings for SHA leaders.

Between the 2009 Great Recession and the onset of the COVID-19 pandemic, the US state and local governmental public health workforce lost 40,000 jobs. Tens of thousands of workers also left during the pandemic and continue to leave. As governmental health departments are now receiving multimillion-dollar, temporary federal investments to replenish their workforce, this review synthesizes the evidence regarding major challenges that preceded the pandemic and remain now. These include the lack of the field's ability to readily enumerate and define the governmental public health workforce as well as challenges with the recruitment and retention of public health workers. This review finds that many workforce-related challenges identified more than 20 years ago persist in the field today. Thus, it is critical that we look back to be able to then move forward to successfully rebuild the workforce and assure adequate capacity to protect the public's health and respond to public health emergencies.

Age-based COVID-19 vaccination prioritizes white people above higher-risk others; geographic prioritization improves equity.