1. Novick, Lloyd F. MD, MPH

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Health departments can trace their roots to collective efforts dating to ancient times to protect the health of a community. Local public health departments, such as the one I direct in Syracuse, NY, got their start from the necessity to control communicable disease early in the 19th century-cholera transmitted on canal boats traveling on the Erie Canal. The mechanisms of quarantine and isolation employed by health departments in the United States in the 18th and 19th century are similar to those first employed by Venice in 1423 when a pesthouse was erected to detain individuals suspected of plague.


Local health departments are again on the frontlines with respect to public safety. New techniques of surveillance, informatics, and communication are key. The importance of public health agencies to preparedness was widely recognized after September 11 and in the anthrax scare that followed. A public health infrastructure is needed to respond to bioterrorism and naturally occurring emerging diseases.


This issue of the Journal of Public Health Management and Practice illustrates the various roles of the public health agency in meeting this formidable challenge. Ensuring the safety of our communities from terrorism has become top priority of public health agencies nationwide. The approaches documented here are impressive in their depth, careful planning, and resource intensity. The breadth of the preparedness effort impacts on the entire practice of public health.


New capabilities in surveillance and information management have also been useful for outbreaks of nonterrorist related infectious disease, notably severe acute respiratory syndrome (SARS). The organization and management of the response effort has spurred regional collaboration. Involvement of teaching institutions in training creates valuable academic-practice links.


In the editorial, Lichtveld of the Centers of Disease Control and Prevention begins the issue by adding national perspective to workforce and training issues. In the following articles, collaborative efforts by local and state health agencies are described by Rauf et al. of the National Association of County and City Health Officials (NACCHO), McKenna et al. of the Boston Health Commission, Billitier in western New York State, and Bekemeir and Dahl of the Turning Point Project.


The public health response to anthrax is explored by Nolan et al. of the Rhode Island Department of Health. Cole reports on his investigation of the possibility of cross-contaminated mail as an explanation for some of the cases of anthrax that occurred in the fall of 2001. Local and state health departments were besieged with telephone calls about mysterious powders from concerned citizens, postal workers, police, hazardous material teams, emergency departments, and physicians. Although some of these situations seem unimportant in retrospect or even quasi-humorous-powder in tissue boxes or related to highway flares-the concern of the public was a reality and a public health response was required. When situations of this type occur in health departments, new staff is not added for this purpose.


The anthrax crisis was not unique. Responding to public concern and marshalling staff for West Nile virus and SARS calls for adjustment in work and reordered priorities. However, what has been notable in my county and affirmed in discussions with my colleagues, is even after the abatement of the anthrax scare, the new emphasis on bioterrorism preparedness is not a short-term endeavor or investment of effort.


The complexity and detailed nature of the preparation process is illustrated by articles by Carney et al. on Vermont's distribution program for potassium iodide and Beaton et al. on a pharmaceutical stockpile dispensing exercise in Washington State. Smallpox has received singular attention as a potential biologic terrorist agent. Billittier et al. describe an information and tracking system for a mass vaccination clinic. Millock provides a lucid and extremely well-documented analysis of the legal issues associated with smallpox vaccination. The issue concludes with articles demonstrating the valuable contributions of academic institutions to education and training in this area by Atchison of the University of Iowa, Morse of Columbia University, and Eastwood of SUNY Upstate Medical University.


Public health departments face an unprecedented challenge in meeting their responsibility of ample preparedness for terrorist events and while continuing to provide essential public health services to their communities. The issue is not simply bioterrorism versus essential public health services, because emerging diseases, most recently SARS and relatively recently West Nile virus, have also stretched overall public health resources to the limit. Difficulties in responding to the challenge can be attributed to two concurrent trends: First, bioterrorism preparedness has indeed become the #1 priority for local health departments. Although, federal funding for this activity was provided, the actual expenditures and staff assignments exceeded the resources provided. The second trend is the loss in funding support for public health agencies related to large state and local fiscal deficits.


Bioterrorism preparedness has come at a cost. Local health agencies confronting these two trends have had to make difficult choices in staff allocation to bioterrorism versus essential public health services in infectious disease control, sexually transmitted disease, maternal and child health, and prevention of chronic disease.


Smallpox vaccination of health care workers adds to this problem. Vaccination of health personnel and local health departments is a resource intensive endeavor. Workers must be advised of the risks of this vaccination calling for extensive education and screening activities. The number of volunteers has been significantly less than anticipated. Even so, this is another expense for which there is not adequate federal reimbursement.


This issue emphasizes the extent of public health activities for bioterrorism preparedness. It makes a case to expand the capacity of public health agencies and to build their infrastructure to address the concurrent issues of emerging diseases without compromising the improved delivery of essential public health services.