The public health lessons of 9/11, anthrax letters
while routine essential services were floundering due to a lack of resources. Local experiences across the country were uneven, with some states managing the influx of resources well while others did not. The 9/11-induced (or, at least, accelerated) economic recession decreased state revenues — decreases which were passed on to the state agencies. In some cases, this furthered the disparity between federally funded bioterrorism programs and traditional public health services. An example: The failed smallpox vaccination program initiated in December 2002 was driven by federal priorities yet had to be implemented at the state and local levels. To state officials, the true nature of the threat was not obvious. As a result, many of them did not fully engage in a program that was funded at less than its true implementation cost. What did not help were the activity of the already-existing, organized anti-immunization community, which fought all vaccination programs, and the legal climate in which malpractice litigation posed a threat to caregivers and healthcare administrators. The authors cite Gene Matthews of Georgia State University who said that “there were three concerns: liability, compensation, and risk assessment … these issues got mixed up with each other.” This smallpox vaccination program allows Rosner and Markowitz an example of how federal dictates to the states were ill-fated, mismanaged, and detrimental to long-term infrastructure goals. Rosner and Markowitz provide glimpses of the conflict within the government between those devoted to bioterrorism preparedness and those skeptics unconvinced that this focus was appropriate. Indeed, conflicting interviews will allow readers to assess for themselves the CDC’s actual preparedness for bioterrorism. Optimistically, the CDC’s post-9/11 response to the outbreak of severe acute respiratory syndrome (SARS) was universally seen in a positive light. Whatever the CDC was before 9/11, it is clearly a very different organization today and much better prepared for public health crises.
Rosner and Markowitz conclude with some basic lessons learned:
* First, in a crisis the available public health infrastructure makes all the difference in the quality of the local and federal response. Timely leadership was important, but it was effective only within the constraints of what the previous years’ efforts had provided. Because of the unpredictability of the next crisis, public health infrastructure is the single most important way of preparing the nation.
* Second, the authors argue for a redefinition of public health to be more comprehensive and to include the mental health of the population. In addition to the traditional concern with the physical well-being of the population, social and economic health need to be included in the response to crises.
* Third, they observed that the failure to communicate honestly to the public, even if officials have good intentions to calm a chaotic situation, will lead to the subsequent mistrust of all communication.
* Fourth, the authors recommend that clear lines of authority need to be established in a crisis. Local authority need not be usurped, but decisive leadership, perhaps from the federal level, is critical.
“So, the question remains,” Klime writes: “Are we ready? Although the authors advocate one path forward, we should never expect that the struggle to improve public health will be complete or finalized. Preparedness is an ongoing and consuming endeavor.”
-read more in Paul S. Kleim, “A Crisis Is a Terrible Thing to Waste,” Science 318, no. 584919 (19 October 2007) (DOI: 10.1126/science.1142469): 396-97 (sub. req.)
