Att B 2008 National Action Agenda

Assessing Competencies for
Public Health Emergency
Legal Preparedness
James G. Hodge, Jr., Kristine M. Gebbie, Chris Hoke,
Martin Fenstersheib, Sharona Hoffman, and Myles Lynk

Introduction
Among the many components of legal preparedness
for public health emergencies is the assurance that the
public health workforce and its private sector partners
are competent to use the law to facilitate the performance of essential public health services and functions.1 This is a significant challenge. Multiple categories of emergencies, stemming from natural disasters
to emerging infectious diseases, confront public health
practitioners.2 Interpreting, assessing, and applying
legal principles during emergencies are complicated
by the changing legal environment and differences
in governmental organization of emergency management functions.3 While law and legal competencies are
essential to routine public health practices, once government declares a state of public health emergency
or disaster, the legal landscape changes.4 Typical legal
responses to protect the public’s health may no longer
be the norm. Public health practitioners, legal counsel, health care partners, and others need to be able to
assess changing laws and policies and apply them in
real-time. To do so, they must be competent in their
understanding and use of the law during public health
emergencies.
In the context of public health systems, competencies may be defined as a complex combination of
knowledge, skills, and abilities demonstrated by members of an organization that are critical to the effective

and efficient function of the organization.5 Competency statements describe specific activities that individuals are able to do or perform depending on their
respective roles, responsibilities, and qualifications.6
Competency resources have been developed for a full
range of public health services,7 including emergency
response8 and legal preparedness.9
In this article we describe the modern development of competencies in public health law, ethics, and
policy, providing numerous examples of types of competency tools and materials. We further discuss existing and emerging actors within the public and private
sectors for whom legal competencies in public health
emergency preparedness are essential. Through these
examinations, we analyze the current status of legal
competencies for public health emergency preparedness and identify various gaps to be addressed in
improving competencies.

Modern Development of Competencies in
Public Health Law
Competencies for the public health workforce have
developed through extensive dialogues sponsored
largely by the Centers for Disease Control and Prevention (CDC) beginning in the late 1990’s.10 Yet, competencies have conceptual origins in industry practices
that assess the ability of the workforce to perform jobrelated activities. They have also been used extensively

James G. Hodge, Jr, J.D., LL.M., is an Associate Professor at Johns Hopkins Bloomberg School of Public Health; he is also the
Executive Director of the Center for Law and the Public’s Health. Kristine M. Gebbie, Dr.PH., R.N., is the Elizabeth Standish
Gill Associate Professor of Nursing and Director of the Doctor of Nursing Science at Columbia University School of Nursing;
she is also the Director of the Center for Health Policy. Chris Hoke, J.D., is the Chief, Legal and Regulatory Affairs, of the North
Carolina Division of Public Health. Martin Fenstersheib, M.D., M.P.H., is the Health Officer of the Public Health Department
in Santa Clara County, CA. Sharona Hoffman, J.D., is a Professor of Law and Bioethics, Co-Director of the Law-Medicine Center,
and Senior Associate Dean for Academic Affairs at Case Western Reserve School of Law. Myles Lynk, J.D., is the Peter Kiewit
Foundation Professor of Law and the Legal Profession at Arizona State University College of Law.

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Hodge, Jr., Gebbie, Hoke, Fenstersheib, Hoffman, and Lynk

in health education, particularly related to technical
and “just in time” training. Through this training,
persons with specific skills are evaluated based on
their ability to perform needed tasks and fill gaps. For
example, the training and certification of emergency
medical technicians have traditionally been competency-based, and included evaluation components.11
Required competency sets also guide curricula in
nursing,12 dentistry,13 preventive medicine,14 and other
disciplines.
Whether utilized in practice or academic settings,
competencies are comprised of facts, knowledge,
skills, attitudes, and values, as illustrated in Figure 1,
below.
Figure 1
Competency Creation
Building Blocks
Facts/Knowledge
Skills

Ability to Perform

COMPETENCIES

Attitudes/Values

Competency statements are typically based on a standard formula, including: (1) an action verb indicating
a level of performance (e.g., describe, apply, identify,
recognize); (2) a subject or content area (e.g., chain of
command); and occasionally (3) contextual references.
The following example of a competency in emergency
preparedness for public health workers includes these
elements:
A public health worker must be competent to…:
 escribe the public health role in emergency
D
response in a range of emergencies that might
arise (e.g., “This department provides surveillance, investigation, and public information in
disease outbreaks, and collaborates with other
agencies…).15
As requirements for employment, competency statements may describe complex performance expectations within the workplace similar to the knowledge/
skills/abilities (KSAs) statements of many job classifications. They can include a series of embedded tasks
that are either sequential or parallel and are demonstrated over long periods of time. Correspondingly, they
require contextual measurement based on a range of
contingent indicators. In contrast, educational competency statements form the building blocks of learning

experiences by describing structured learning objectives. Measurement indicators, such as examinations,
are usually used in the short term (e.g., specific class
or a course of study) to assess achievement of specific
competencies.
Competencies in a field of work or education should
not be confused with specific job requirements. A
single position may use only some of a worker’s preexisting competence, and may require the addition of
job-specific abilities. For example, public health legal
competencies may add to general competence in the
practice of law for attorneys working in public health.
An understanding of public health law may also be an
important addition to public health competencies for
many professional, technical, and support staff working in public health, and are thus referenced in other
public health competency sets.
In 2001, the Center for Law and the Public’s Health
at Georgetown and Johns Hopkins Universities led a
collaborative effort to describe necessary public health
law competencies for public health professionals.16
With support from CDC, the Center produced a set of
statements on law-specific skills and legal knowledge
desirable for the practice of public health. As featured
in Table 1, these statements were drafted to serve as
guides for public health leaders with specialized roles
related to public health law, as well as for front-line
professional staff who need a basic understanding of
the role of law to protect the public’s health. Though
not tailored to emergency legal preparedness, they
help provide a base for competencies in emergency
response.
Since the development of the Center’s competency
statements in public health law, there have been initial
efforts to (1) specify competencies (e.g., in the context
of specific achievements) or desired level of competencies (e.g., related to what an individual has achieved)
for public health legal preparedness and response and
(2) expand the number of persons receiving competency-based training. CDC authors and others have
suggested that legal competencies for public health
preparedness should include:
• Interpreting public health laws before, during,
and after public health emergencies;
• Applying emergency laws and provisions in
response to a declared emergency;
• Identifying legal issues requiring potential reform
or modification;
• Assessing the consequences of legal action or
inaction; and
• Integrating legal decisions within the larger
public health response.17

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Table 1
Public Health Law Competencies (Select)
I. Public Health Powers—Generally

Level

Describes the basic legal framework for public health; roles of federal, state, and local governments; and the relationship between
legislatures, executive agencies, and the courts.

F

Describes the meaning, source, and scope of states’ powers to protect the public’s health, safety, and general welfare (i.e., police
powers) and to protect the individual from identifiable harm (i.e., parens patriae powers).

M, O

Identifies and applies basic provisions of the governmental unit’s health code and regulations within the particular area of practice
(e.g., communicable disease control, environmental health, public health nursing).

M, O

Describes the scope of statutory and regulatory provisions for emergency powers.

O

Distinguishes public health agency powers and responsibilities from those of other governmental agencies, executive offices, police,
legislature, and courts.

O

II. Regulatory Authority/Administrative Law

Level

Describes basic legal processes, such as how legislatures create and amend laws, how executive officials enforce laws, and how
courts make and interpret laws.

O

Determines procedures for promulgating administrative regulations.

O

Determines procedures for obtaining mandatory or prohibitory injunctions from a court.

O

Follows administrative procedure laws for conducting investigations, holding hearings, and promulgating regulations and provisions
concerning open public records.

M, O

Weighs options and applies, when necessary, processes to address public health problems through criminal charges for specific
behaviors and civil suits for damages.

O

III. Ascertaining Authority/Obtaining Legal Advice

Level

Identifies legal issues for which legal advice should be sought and knows what action to take where legal issues arise, including
contacting legal advisors.

M, O

Provides factual assistance and states basic legal issues to legal advisors.

M, O

Reads and comprehends basic statutory and administrative laws.

M, O

Recognizes that legal rules do not always specify a course of conduct.

M, O

Develops enforcement strategies consistent with the law and in the interest of protecting the public’s health.

M, O

IV. Laws and Public Health Services and Functions

Level

Describes how law and legal practices contribute to current health status of the population.

O

Determines how the law can be used as a tool in promoting and protecting the public’s health.

M, O

Identifies the mechanisms through which law can deter, encourage, or compel health-related behaviors.

M, O

Identifies and exercises legal authorities, responsibilities, and restrictions to assure or provide health care services to populations.

M, O

Identifies and exercises legal authority over the quality, delivery, and evaluation of health care services within the agency’s jurisdictions.

M, O

Applies ethical principles to the development, interpretation, and enforcement of laws.

F, M, O

V. Legal Actions

Level

Describes how and under what circumstances legal searches of private premises can be performed.

S, M, O

Knows how and under what circumstances legal seizures of private property for public health purposes can take place.

S, M, O

Describes the limits of authority for legally closing private premises.

S, M, O

Identifies legal authority for compelling medical treatment or instituting mandatory screening programs.

S, M, O

Knows legal authority for imposing quarantine, isolation, or other restrictions.

S, M, O

VI. Legal Limitations

Level

Recognizes prominent constitutional rights implicated through the practice of public health (e.g., freedom of speech, right to privacy,
due process, equal protection).

S, M, O

Acknowledges the sources of potential civil and criminal liability of public health workers.

S, M, O

Legend: F = Front-line Professional Staff; M = Supervisory and Management Staff; O = Health Officials and Governance Boards; and S = Senior Level Professional Staff.
Center for Law and the Public’s Health, Core Legal Competencies for Public Health Professionals, Baltimore, MD 2001, available at .

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Hodge, Jr., Gebbie, Hoke, Fenstersheib, Hoffman, and Lynk

A growing array of new competency-related products has emerged to guide workforce development.
Table 2 provides examples of these products relevant
to public health legal competencies for emergency
preparedness.

Targeting Sectors for Competencies in Public
Health Legal Preparedness
One of the key factors in broadening the application
of competencies in public health legal preparedness is
identifying the individuals who should be capable of
demonstrating specific or general knowledge before,
during, and after emergencies. While many existing
public health legal competency models target the governmental public health workforce, public health legal
preparedness requires the efforts and competence of
a wider array of persons in public and private sectors.18 These individuals must work together to use
the law as a tool for public health responses during
emergencies.
Pivotal to these responses are legal counsel to public health agencies or departments.19 These individuals encompass attorneys in a variety of organizational
settings, including (1) general counsels and their staff
employed by public health agencies; (2) attorneys general and their staff representing public health agencies; (3) tribal, county, and city attorneys representing
public health agencies; and (4) academic attorneys
who guide and train public health lawyers and consult
others during emergency situations.20 Collectively,
these counsels must be able to:
• Analyze legal issues in emerging areas of concern in public health preparedness by interacting with public health practitioners, identifying
legal issues related to appropriate public health
responses, and resolving legal barriers;
•D
 raft legislation, regulations, model orders,
motions, and other legal documents in accordance with constitutional, national, state, and
local laws; ethical norms; and best practices in
public health;
•T
 rain practitioners in the effective use of public
health law;
•P
 articipate in preparedness planning and
exercises;
•A
 ssist in analyzing gaps and weaknesses; and
•P
 rovide real-time representation during
emergencies.
Public health legal counsel must accomplish these and
other functions in partnership with other members
of the public health workforce, a diversely trained,
multi-disciplinary group that includes physicians,

nurses, epidemiologists, health educators, laboratorians, community outreach workers, and others. These
persons have important roles that may require legal
competency during emergencies based on their training and education.21
In 2003, the Institute of Medicine identified law
as one of the essential areas of competence for public
health practice that should be included in the curriculum of schools of public health.22 Public health practitioners are increasingly cognizant of the importance
of law in day-to-day functions and emergency situations.23 Quarantining persons with communicable
diseases, closing unsafe buildings or unsanitary restaurants, initiating vaccination programs, reporting
diseases, and restricting children with infectious diseases from school are longstanding responsibilities of
public health practitioners that require competence in
public health law.24
However, the modern, multi-sectoral approach to
emergency preparedness and response presents new
challenges. Routine responses to complex, unpredictable emergency situations are inadequate. Accessing
information efficiently and accurately is critical. Decisions must be made in real-time with a firm understanding of their legal and ethical implications.25 Gaps
or impediments in the laws must be anticipated, identified, and rectified in collaboration with public health
legal counsel.
Accordingly, public health legal preparedness also
requires differing types of competency among (1) legislators and judges at the federal, tribal, state, and
local levels; (2) general legal counsel in the attorney’s
general and corporation counsel’s offices, departments of emergency management, public health,
environment, labor, housing, and other government
services; (3) private sector counsel representing hospitals, insurers, medical practitioners, and volunteers;
and (4) some members of the public participating in
community efforts. Functional knowledge of public
health law can help these persons use the law effectively during emergencies to collaborate and coordinate responses.26

Identifying Gaps to Improving Competencies
in Public Health Legal Preparedness
The public health workforce and many of its private
sector partners recognize the value of using a competency-based approach to increasing public health
legal preparedness, training, and response.27 Extensive
work to refine and broaden the scope of legal competencies has led to new products (see Table 2) and
better understanding of the role of law during public
health emergencies. Raising the level of competencies
through training in legal preparedness is increasingly

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Table 2
Select Examples of Competency (and related) Materials
That Facilitate Public Health Legal Preparedness and Response
Title & Source

Application Site/
Target Audience

Subject Areas

Identifying Individual Competency in Emerging Areas of
Practice: An Applied Approach (2002), Gebbie et al.,
Qual. Health Res

Education and Research

Competency Development

Competency-to-Curriculum Toolkit: Developing Curricula
for Public Health Workers (2004), Center for Health
Policy, Columbia University School of Nursing

Education and Research

Competency Application Through Training

General Resources

Public Health Competency Sets

(including legal competencies)

Core Competencies for Public Health (2005), Council
on Linkages Between Academia and Public Health
Practice

Workplace/Education – Foster
workforce development by helping academic institutions and
training providers to develop
curricula and course content and
to evaluate public health education
and training programs

Analytic/Assessment Skills
Policy Development/Program Planning Skills
Communication Skills
Cultural Competency Skills
Community Dimensions of Practice Skills
Basic Public Health Sciences Skills
Financial Planning and Management Skills
Leadership and Systems Thinking Skills

Public Health Nursing Competencies (2004), Quad
Council of Public Health Nursing Organizations

Workplace/Education – Guide for
agencies that employ public health
nurses and academic settings that
facilitate education and training

Application of Core Competencies in Public Health
Nursing

Core Competencies for Local Environmental Health
Practitioners (2001), American Public Health
Association

Workplace

Assessment
Management
Communication

Applied Epidemiology Competencies (2005), Centers
for Disease Control and Prevention/Council of
State and Territorial Epidemiologists

Workplace – Frontline, Mid-level,
and Senior Level Epidemiologists

Assessment and Analysis Skills
Basic Public Health Sciences Skills
Communication Skills
Community Dimensions of Practice Skills
Cultural Competency Skills
Financial and Operational Planning and Management Skills
Leadership and Systems Thinking Skills
Policy Development Skills

Core Legal Competencies for Public Health Professionals (2001), Center for Law and the Public’s Health
at Georgetown and Johns Hopkins Universities

Workplace/Education

Public health powers – generally Regulatory authority

Core Competency Development Project (2006),
Association of Schools of Public Health

MPH Education

32

Ascertaining authority
Public health services and functions
Legal actions
Limitations
Personnel/contracts Public health powers

Communication
Diversity
Cultural Proficiency
Leadership
Professionalism and Ethics
Program Planning and Assessment
Systems Thinking

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Hodge, Jr., Gebbie, Hoke, Fenstersheib, Hoffman, and Lynk

Bioterrorism & Emergency Readiness: Competencies For All Public Health Workers (2002), Center
for Health Policy, Columbia University School of
Nursing

Workplace – Public Health Leaders/Administrators, Health Professionals, and Technical and Clerical
Support

Emergency Response (all public health workers, in
addition to official-specific areas)

Introduction to Public Health Law for Bioterrorism
Preparedness and Response (2002), Center for Law
and the Public’s Health

Workplace/ Education – Public
health leaders/professionals, legal
counsel, students in law and public
health

Public Health Emergency Legal Responses

Public Health Emergency Law (PHEL) (2004), CDC
Public Health Law Program, CDC Coordinating
Office for Terrorism Preparedness and Emergency
Response

Workplace/Education – Public
health officials/professionals

Public Health Emergency Legal Issues and Responses

Workplace – Judicial Bench Book

Emergency Response Jurisprudence Resources

Resources for Applying Legal Competencies
Pennsylvania Public Health Law Bench Book (2006),
University of Pittsburgh Center for Public Health
Preparedness
Public Health Emergency Bench Book (2006) Washington
State
Jurisprudence Resources

Public Health Law Bench Book for Indiana Courts
(2005), Center for Public Health Law Partnerships,
University of Louisville
Health Officer Practice Guide for Communicable Diseases in California (2007), California Department
of Health Services, Division of Communicable
Disease Control

Workplace – Health officers

Legal Review of General authority of health officers;
Constitutional limits; Enforcement authority; Interjurisdictional coordination; Confidentiality; Media
resources;Various public health powers

Pandemic Influenza and Public Health Law:What Public Health Departments Need To Know (2007) (DVD),
CA Dept of Health Services, Immunization Branch

Workplace – Health officers

Review of specific public health law powers in response
to pandemic flu

seen as an essential part of comprehensive public
health emergency planning.28
Awareness of legal issues during public health emergencies is advantageous for preparedness, but practitioners must also be able to work together to construct a
favorable legal environment for emergency response.29
This implies a higher level of competency for some persons to not just understand the law, but also to wield
it effectively to further legitimate public health goals.
Despite significant advances in legal competency-building, several gaps or limitations must be considered:
Development of specific legal competencies for public
health emergency preparedness. Existing approaches
to public health legal competencies are beneficial, but
incomplete. Some existing competency products were
developed when the public health community had a
limited understanding of specifying and applying
competencies. These products may fail to identify key
sub-topics related to emergency preparedness; do not
always reflect changing legal and ethical norms dur-

ing emergencies; do not fully address the multitude
of individuals who are key to legal preparedness; and
may lack application in real-time. Competence in legal
preparedness should be developed within an organizational structure that allows for regular dissemination,
extensive training, and routine updating. As an initial
goal, core elements of public health legal preparedness
should be produced through processes similar to those
used to create existing competency statements,30 with
input from the relevant actors identified above.
Clarification. Coupled with the prior gap is the need
to clarify competencies for persons practicing public
health and public health law. Competencies must be
stratified to delineate knowledge, skills, and abilities
for each of the following groups:
• Public health leaders at each level of government;
• Legal counsels representing public health departments, institutions, and organizations involved in
protecting the public’s health;

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SPECIAL SUP P L EME N T

•P
 ublic health policymakers, including members
of city and county boards of health or councils,
federal or state agencies, and the judiciary;
•P
 ublic health professionals (in public health
departments generally or in specific public programs such as environmental regulation or professional/institutional licensing);
•P
 ublic health technicians and support staff (in
public health departments generally or in specific
positions such as persons handling laboratory
specimens, accessing vital records, or receiving
public inquiries);
•S
 taff of other organizations contributing to the
public’s health; and
•A
 cademics teaching public health law and ethics
(or related subjects).
Uniformity. Existing competency resources in public health legal preparedness have been developed in
response to specific needs within some portion of the
public health and legal communities (see Table 2).
Many of these excellent resources may be described
as core public health law materials that are meant
largely for a legal audience. Other competency tools
may feature or reflect legal or ethical principles for a
non-legal audience. However, because these legal and
non-legal resources have been developed over many
years, through multiple entities, and for differing purposes, they lack cohesion. Users may question which
competency tools are the most authoritative or helpful. Inconsistencies among approaches lead to incongruous legal responses. Uniformity of competency
resources across sectors of the public health workforce
could improve emergency preparedness.
Assignment of levels of competency. Competencies
for public health legal preparedness are not static.
Rather, they must be consistently examined and used
to assess whether certain individuals have obtained a
specific level of competence (e.g., novice, knowledgeable, proficient). Achieving levels of competency may
be based on several factors, including the individual’s
title or position, existing education, years of experience, and anticipated role(s) during emergencies. The
competency in legal preparedness of a counsel who
serves as the lead for emergency management issues
may differ from that of her counterpart in a public
health department whose responsibilities are unrelated to emergency management. Still, both counsels
need some level of competency in public health legal
preparedness because each may be called to act during
emergencies.
Implementation and evaluation. Beyond production or refinement of competency resources is the
need to ensure implementation of competence build34

ing at the workforce level. Legal public health preparedness is deemed optional for many members of
the public health workforce. Required training exercises or curricular objectives that coordinate individuals and institutions in the public and private sectors
may help disseminate legal knowledge. For example,
the New York City Department of Health and Mental
Hygiene requires workforce training on core public
health functions (including some legal topics) to better prepare for public health emergencies. In addition, competencies among various individuals should
be routinely measured and evaluated with an understanding that achieving competencies is continual.
These suggestions may require increased funds, new
methods to deliver competency resources, and changes
to public health curricula – each of which underlies an
improved national commitment to public health legal
preparedness.

Conclusion
Assessing public health legal preparedness among the
public and private sectors is challenging. Public health
emergencies raise unique legal issues, necessitate
rapid responses, and require consistent approaches.
Existing efforts to improve competencies in legal
preparedness have contributed to an awareness of
the role of law during emergencies. Yet, there is no
coherent, national strategy to improve competencies
in legal emergency preparedness that invites participation among partners in public and private sectors.
As a result, response to future emergencies may be
hampered, as has occurred in the past, by varying legal
responses among persons who lack the ability to use
the law effectively in real-time to improve the public’s
health. A uniform set of legal competencies that are
routinely implemented and evaluated would prove
invaluable to emergency preparedness and response.
Acknowledgements

The authors gratefully acknowledge the contributions of Benjamin Mason Meier, J.D., LL.M., M.Phil., Center for Health Policy,
Columbia University, for his extraordinary contributions to various parts of this manuscript, including tables and figures, as well
as Aleah Yung, J.D./M.P.H. Candidate, Georgetown and Johns
Hopkins Universities, and Katie Heley, B.A., for their editing and
research assistance.

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special supplement • the national action agenda for public health legal preparedness

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