In an era when
bioterrorism attacks are a possibility, it has become critical for those working
in many fields to understand the public health system and our national defense
in responding to a bioterrorism attack and to assess related weaknesses that
endanger national security.
Fundamental to these weaknesses is the lack of a coherent vision and mission
for public healtha vision capable of influencing public policy and strengthening
national security. Years of underfunding have resulted in a public health system
lacking in basic infrastructure and trained personnel. Although there are many
exceptions, such as the Centers for Disease Control and Prevention (CDC), overall
a pervasive rift exists between practitioners of medicine and of public health.
Medicine and public health would each be stronger if they functioned together,
and this collaboration should begin at the academic level for each discipline.
A closer relationship among those working in medicine, public health, and public
policy would set the stage for developing and articulating a clear mission for
public health, thus protecting national security.
How Does Public Health Differ From Health Care?
To effectively plan for bioterrorism, one must understand the distinction
between private medicine and public health. In private medicine, doctors and
nurses see individual patients in hospitals and clinics operating independently
from public health. Private medicine is sometimes referred to as a system, though
it consists mostly of teaching hospitals and businesses with little formal interaction
and no central control. Although limited patient care is also provided by some
public health agencies, this is not the central mission of public health. In
public health, people analyze trends, find health risks, and implement protective
measures in the population as a whole, even if those measures are targeted to
However, effective communication between the fields of private medicine and
public health is essential to both. Persons taking care of patients are sometimes
in a position to see what measures are needed in the population to control disease.
They need to have a mechanism for input into the public health system. When
trends are suspected, confirmation and, if necessary, implementation of remedies
proposed by those working in public health often depend on the assistance of
those in private medicine. Therefore, those working in public health need to
understand how the private medical system works. Mutual understanding between
these fields will be essential for an effective and complementary process.
What Is the Role of Public Health?
The role of public health encompasses the full range of the medical field:
any kind of illness that affects individuals can be studied by persons in public
health to detect trends and take measures to decrease illness in populations.
Its mission of prevention rather than cure is universally compelling,
saving money and reducing human suffering. This mission now includes the need
for early detection of a bioterrorism release and rapid mobilization for investigation
Hepatitis A is
an example of a disease that public health can take measures to prevent. Persons
eating in a restaurant where a worker with early hepatitis A has not followed
proper handwashing procedures are at risk for hepatitis A. One
enthusiastic public health department worked to get a law passed in their county
requiring all restaurant workers to be vaccinated against hepatitis A. 
The surrounding counties
soon followed suit. Wouldnt you rather live in an area with a good public
Prevention becomes even more important for serious diseases, those released
as an act of war, or ones for which there is no cure. Considering the enormous
amount of money we spend on taking care of illness in this country, it would
make sense to spend more on preventing it.
The Current System for Public Health in America
Public Health: The Federal Level
event in the United States would almost certainly require national coordination:
for resources, for expertise, and to keep the rest of the country informed.
The CDC is the federal agency for public health. The CDC originated in the 1940s
as a military program to control malaria and has gradually grown to encompass
a broad range of public health programs. 
The CDC operates
under the direction of the Department of Health and Human Services, which also
oversees the National Institutes of Health, the Food and Drug Administration,
and many other large federal organizations.
The Bioterrorism Preparedness and Response Program was created within the
CDC two years ago. Since that time it has facilitated discussions, assisted
state health departments in beginning bioterrorism programs, participated in
planning exercises, and responded to potential threats. It coordinates between
the many units at the CDC that contribute to bioterrorism planning but does
not house disease programs. In the event of a bioterrorism attack, the Bioterrorism
Preparedness and Response Program would assist with coordination, but disease
programs would assist with outbreak investigation and control measures.
The CDC is organized by disease programs, which preside over every aspect
of prevention and control related to their disease(s). These disease programs
are one of the CDCs strengths. They monitor national rates of disease,
perform laboratory testing, conduct research, promote measures for control,
maintain hotlines for physicians and the public, assist state and local health
departments with corresponding programs, and sometimes administer funding. They
also provide the public health community, practicing physicians, and the general
public with access to medical scientists who have depth of expertise on a single
disease. This arrangement ensures that someone in the nation is focusing on
each disease and that unique control measures necessary for a rare disease are
not swept away by large bureaucratic processes.
Medical staff in the CDCs disease programs are highly trained, often
physicians with experience in research and publication. They are called upon
to respond to outbreaks both here and abroad, and their research programs are
international in scope. The CDC convenes panels and committees to prepare statements
on clinical recommendations (how to treat patients) and formulates policy for
public health programs, sometimes in conjunction with advisory boards. These
programs have the best expertise in the world for the control of outbreaks.
Because measures for diagnosis, treatment, and control are specific to each
disease, planning for bioterrorism response needs to occur in programs for each
bioterrorism disease known to be a potential weapon. But funding for disease
programs can vary according to the political strength of their constituencies.
Programs for the bioterrorism diseases need to be established and be ready to
advise decision makers in the event of a bioterrorism attack.
As the bioterrorism diseases are rare in actual practice, the programs for
these at CDC are small or exist within programs that also handle other diseases.
Communicable-disease programs tend to be organized by biologic classification:
viruses, bacteria, etc. Some of the bioterrorism diseases are viruses, and others
are bacteria, so their programs are scattered throughout different administrative
sections: the program for plague is within the Vector-Borne Infectious Diseases
program in Colorado, and the program for anthrax is in the Meningitis and Special
Pathogens program in Atlanta.
Because the CDC has provided sound and current clinical recommendations helpful
for practicing physicians, most physicians have heard of the CDC and respect
its leadership. If physicians need assistance with particular diseases, they
are likely to contact the CDC. During the anthrax events of 2001, the CDCs
website was overwhelmed with visits. This credibility will be important following
a bioterrorism attack. Because physicians less often contact their local or
state health agencies, they increase the workload on a massively overburdened
federal agency and decrease the link that should exist between private and public
medicine at the state and local levels.
Public Health: The State Level
If there were multiple bioterrorism releases in several states, the federal
government could be spread thin in responding to all of them. States must also
be able to respond to the full range of bioterrorism diseases. Because federal
funding and technical assistance from the CDC flow to state and local health
departments through the CDCs programs, the CDCs structure is reflected
in the organization of state and local health departments nationwide.
State health departments receive direction and funding for communicable diseases
almost exclusively from the CDC. Being smaller, state health departments frequently
combine activities from several federal disease programs into smaller and more
diverse programs. Most states have communicable-disease programs corresponding
to four CDC programs, based on the flow of funding: tuberculosis, diseases preventable
by vaccine, HIV/AIDS, and sexually transmitted diseases.
Generally, states have another program that handles any diseases that dont
fall into programs funded by the CDC. These communicable diseases without federally
funded programs have included foodborne illnesses, respiratory diseases, influenza,
and zoonotic diseases (in which animals play an important role in transmission),
such as rabies. By default, most states have included the bioterrorism diseases
in these programs. In recent years, the CDC has offered competitive funding
for some of these diseases, and new funding for bioterrorism will address this
situation. Programs for this collection of diseases exist in every state, handle
most of the outbreaks, and have been the most pertinent to bioterrorism prevention.
Programs at the state level tend to have less highly trained staff than at
the CDC and may have no physicians. State health departments lacking in medical
capabilities may have difficulty gaining the respect of the physician community
if they are unable to provide timely, accurate advice when physicians call or
if they fail to show leadership in promoting measures that physicians see as
important to the health of their patients.
Public Health: The Local Level
In some states, local health departments are field offices of the state health
department, but in most states local health departments are separate agencies.
The New York City health department is a local agency (now famous for its superb
handling of West Nile virus) that is larger than the state health department.
Large urban health departments are in many ways similar to state health departments.
Communicable-disease staff in urban areas are well situated to engage the
physicians in their community through attending meetings of infectious-disease
physicians. Teaching hospitals, often located in urban areas, usually have periodic
meetings at which specialists in infectious diseases discuss recent interesting
cases in their practice. The participation of persons with a public health perspective
in these meetings could foster the exchange of information beneficial to both
disciplines. This relationship would be particularly useful in a bioterrorism
event, as most physicians follow the lead of infectious disease specialists
in treating their patients. However, if nonfederally funded programs for
communicable disease have no physicians on their staff, or no persons capable
of following and contributing to such discussions, this important link is not
At the other end of the spectrum are numerous rural departments with only
a handful of staff. In many rural health departments, nonfederally funded
programs for communicable diseases are handled by one person, who may also have
responsibility for other programs. There can be a high turnover rate for staff
in rural nonfederally funded programs for communicable disease, which
have little funding and cover the largest number of diseases. As staff in smaller
rural health departments tend to be minimally trained in communicable diseases
that do not have federally funded programs, including the management of outbreaks,
they may depend on state health department staff expertise when they detect
outbreaks. One small foodborne outbreak can take two staff members several days
to investigatea large proportion of staff for some nonfederally
funded state programs for communicable diseases.
Public Health and Private Medicine: Surveillance for Diseases
Surveillance for diseases is necessary to detect the presence of outbreaks
and may provide the first indication that a bioterrorism attack has occurred.
Under the current system, public health agencies receive reports of diseases
from doctors and other health professionals who see patients. Although doctors
are legally responsible for sending reports of specific infectious diseases
to their local health agency, penalties for failing to do so are not enforced.
Doctors must remember which diseases need to be reported and keep track of a
myriad number of forms, which can vary among the reportable diseases. Not surprisingly,
only a small percentage of diseases reported come from physicians. The largest
percentage comes from infection-control nurses in hospitals and laboratories
that have been able to make reporting a part of their routine.
The current disease surveillance system demonstrates the need for closer collaboration
between the fields of medicine and public health. A system that depends on mailing
paper forms after a diagnosis has been made is not capable of detecting an outbreak
in time to intervene effectively. Given that confidentiality could be preserved,
an ideal system would collect specific data from computerized medical records
flowing electronically to databases at local, state, and federal levels of government
and setting off alarms if rates exceeded preset thresholds. However, since most
medical records are neither standardized nor electronic, and many health departments
did not have computers until recently, such a system is a ways in the future.
Each level of government is responsible for identifying unusual trends and
outbreaks within its jurisdiction. When a local health agency identifies an
outbreak beyond the capability of its staff or expertise, it may request help
from the state, which may in turn call upon the CDC. At both the state level
and the CDC, requests for assistance with outbreaks are handled by the appropriate
disease program, which may respond with medical information and epidemiological
advice, laboratory assistance, or personnel. Outbreak investigations have several
Many outbreaks result in the publication of new findings related to the transmission
or control of disease.
|Finding the cause of the outbreak and stopping it, such as by taking a food
product off the market or decontaminating a building from anthrax (finding
the cause may involve many interviews and some statistical analysis)|
|If it is not possible to contain the cause, preventing transmission may
still be possible with measures specific to each disease, such as vaccination,
spraying for mosquitoes, or recommending handwashing|
|Protecting people who may have been exposed, such as by providing antibiotics
to people in a building where anthrax has been found|
|Taking care of the ill by notifying doctors (and sometimes the public) to
facilitate proper diagnosis and treatment|
How Could the Public Health System Be Improved?
Areas for Improvement: The Federal Level
CDC lacks the authority necessary for its charge.
In this country we are fortunate to have an agency with the expertise and
capabilities of the CDC. State and local health officials normally receive assistance
and advice from the CDC on all aspects of communicable disease control, including
outbreaks. Practicing physicians see excerpts from the CDCs magazine (the
Morbidity and Mortality Weekly Report) each week in the Journal of
the American Medical Association and may contact experts at the CDC for
advice on patient care. The CDC also has an international reputation, as a consequence
of providing assistance to other countries experiencing outbreaks (such as Hong
Kong during the influenza crisis and India during the pneumonic plague outbreak).
But the CDC lacks authority and scope to address many of the charges that
fall under its mission, because other agencies often oversee parts of issues
that affect the health of the public. To adequately prepare for a biological
attack, a mechanism needs to be provided for adjudicating between federal agencies
when matters pertaining to human health affect issues regulated by other federal
The problem of
improving disease surveillance for bioterrorism demonstrates the need for collaboration
with other federal agencies. Biological weapon agents can be used to attack
animals, plants, and inanimate objects in addition to humans. It follows that
surveillance for biological attacks should occur for all these entities and
should ultimately integrate this information. But public health agencies do
not currently integrate their data with that of agencies tracking rates of disease
in plants or animals. If the authority to coordinate information applicable
to medical surveillance were designated within a single agency, data systems
to house this information and mechanisms to monitor it would still need to be
established. Much needs to be learned about the interaction of disease among
humans, animals, plants, the environment, climate, and other factors. 
Another example of this lack of authority is the relatively small CDC program
dedicated to diarrheal diseases, which are mostly food- or waterborne. Whether
animal or vegetable, sources of food go through many steps to reach the table,
not all of them overseen by the CDC. Improving food safety must include participation
from the Department of Agriculture, the Environmental Protection Agency, the
Food and Drug Administration, private industries, and other entities that play
a role in overseeing parts of the food industry. However, each entity brings
different priorities and perspectives, and the measures to protect food have
a cost. Lacking an easy way to resolve differences, issues tend to remain unresolved.
Much interagency work will be required to close gaps in keeping our food supply
The CDCs internal structure could benefit from integration.
Because the CDCs programs focus on a single disease or several disease,
they have a tendency to work more closely with their counterparts at state and
local levels of government than with other staff at the CDC. As a result, there
is an effective vertical integration of disease expertise across all levels
of government but a less effective horizontal integration across disease programs.
This structure (sometimes informally termed stovepiping) promotes
academic excellence and effective intervention strategies and benefits physicians
and the public when they call for information. However, it is also important
that mechanisms be in place to integrate functions between programs. This is
where the CDCs internal structure could be improved.
The weaknesses of the stovepiping structure could be mitigated by creating
an additional administrative structure of units designed to address disease
transmission. This would follow the CDCs approach of an organizational
structure that reflects scientific principles, because it would recognize disease
transmission as process that could benefit from both scientific study and practical
application. These units would allow participation from all programs with diseases
that share the same method of transmission. Some diseases being transmitted
through more than one route could maintain their research focus under viruses
or bacteria yet benefit from work done to prevent transmission through various
means. Current disease programs would maintain the strengths of their present
focus but also pool resources to address complex national problems (such as
diseases transmitted by food).
The CDC has combined some disease programs in organizational units based on
transmission. There is a Vector-Borne Infectious Diseases division for diseases
transmitted by vectors (such as insects and rodents). Recently the Sexually
Transmitted Diseases program added HIV/AIDS to its list of diseases. The Bioterrorism
Preparedness and Response Program is an example of a program formed specifically
to address a method of transmission, the intentional spread of weaponized biological
agents. The intent of a bioterrorism attack and its political implications require
preparation for many other issues. A more comprehensive approach for the CDC
would add organizational structures specifically addressing all the important
methods of disease transmission.
Similar units addressing intervention methods could also be established as
needed. The National Immunization Program is an example of a unit housing the
programs for diseases preventable by vaccine. Another potential health intervention
that needs study and public discussion is quarantine. If we faced a large outbreak
of a contagious disease, such as smallpox, how helpful would it be to close
airports or quarantine cities to prevent the transmission of disease, and what
effects would the quarantine have on the economy? Understanding the complex
issues around quarantine will require the participation of many parties external
to the CDC to bring together necessary expertise in economics, government, law,
Units organized around disease transmission or interventions may require broad
powers in order to undertake major prevention efforts. If this approach were
adopted, care would have to be taken so that the scientific and medical emphasis
that makes individual disease programs so successful is not lost in achieving
the broad authority to effect interagency cooperation.
Areas for Improvement: The State and Local Levels
There is a widespread lack of trained professionals with health care experience
at the state and local levels.
There is a need
for many more physicians, nurses, and trained epidemiologists at all levels
of public health. 
For nearly two decades, funding shortages and hiring freezes for communicable-disease
programs have left local and state public health departments with skeletal crews
and haphazard ability to detect outbreaks. 
Finding persons with the necessary skills can be difficult. Schools of medicine
and nursing teach little about public health. More students of public health
specialize in law or management (which offer the possibility of lucrative jobs
in the private sector) than specialize in epidemiology (which requires science
and statistics). Even students specializing in epidemiology may graduate without
training in infectious disease epidemiology or outbreak investigation.
The CDC has a two-year training program called the Epidemic Intelligence Service,
which trains doctors and veterinarians in the techniques of investigating outbreaks.
State health departments may request these trainees to assist them with specific
outbreak investigations under the guidance of disease program staff at the CDC.
The Epidemic Intelligence Service program was established 50 years
ago in anticipation of biowarfare attacks and has been helping ever since with
routine outbreak control. The program has about 150 officers, although
some of them may be involved with projects overseas.
But few state
and local health departments have been able to hire these persons at the salaries
that graduates of these training programs would expect. 
Hiring a majority
of employees with minimal training can work in a static system, but works less
well when a field is changing rapidly. Agencies in which a majority of persons
have minimal training tend to continue doing business the way they were taught,
neither seeing the need to change internally as the external world develops nor
resisting external pressures when they should to preserve the public health. In
these agencies, poorly paid administrative staff may end up advising nurses and
doctors on critical public health issues, resulting in low public health credibility.
A trained public health staff nationwide would greatly improve public health response
capabilities for the detection of all health problems as well as bioterrorism
What sort of training is appropriate for those working in public health
at the state and local levels?
The backgrounds of public health staff with undergraduate or graduate training
reveal the kaleidoscope of skills needed in this field. Nurses, veterinarians,
statisticians, pharmacists, microbiologists, doctors, and those trained in public
policy or public health all work side by side. Those in the field of public
health should possess
Whatever sort of training the applicants bring to jobs in public health at the
state and local levels, depending on the previous level of funding of individual
agencies and the expertise of existing staff, employees with training may encounter
some resistance from those with less training. Those now working in some state
and local public health programs have been filling roles for years without the
benefit of formal training, and they do not necessarily look with enthusiasm on
the arrival of new trained staff. They sometimes tend to avoid hiring such new
staff or to marginalize their roles after they are hired. Unfortunately, degrees
do not necessarily confer common sense. There are many trained persons who seem
unable to apply their training successfully and many persons without training
who through intelligence and application have acquired skills to function effectively
in their positions.
|Medical knowledge of how diseases are transmitted, diagnosed, treated, and
|An understanding of how the private medical system functions|
|An understanding of how to create and interpret databases (using epidemiology
and statistics) to identify abnormal trends, either in the population as a
whole or among subgroups of the population|
|Expertise and authority to investigate causes of an outbreak and to intervene
(such as identifying the West Nile virus and spraying for mosquitoes)|
|Effective channels for disease alerts to the public|
|Effective notification channels to those seeing patients in private medicine|
|An understanding of how the political system functions|
|Continual engagement in refining programs, public policy, laws, regulations,
and infrastructure (such as public drinking water)|
|Ongoing monitoring and application of research findings in both medicine
and public health|
|Ability to integrate bioterrorism response with other disciplines, such
as the incident command system with public safety and collaborative outbreak
investigations with law enforcement|
Nevertheless, everyone could benefit from training. Resistance could be countered
by providing mechanisms for existing staff to become certified, offering opportunities
to augment their experience with continuing education. Perhaps a way could be
found to channel lessons learned from their experience into public health curricula.
Clarifying the proficiencies needed for various positions may help to restructure
both public health agencies and public health training.
Existing capabilities at schools of medicine, nursing, and public health could
be a part of the solution. Funding opportunities could be written for academic
institutions and state and local public health agencies to encourage cooperation
on projects. Public health training would become more practical and government
agencies would have educational expertise available to them. An ongoing relationship
with academic communities could also help public health staff become informed
on new skills necessary to address the threat of bioterrorism.
The Gap Between Private and Public Medicine
Physicians are a familiar sight in CDC disease programs, but not in state
and local health departments, where the director or state epidemiologist may
be the only physician. Unfortunately, what openings there are have sometimes
attracted doctors who find the 40-hour work week better than their
long hours and call schedule in clinical medicine or who have failed to function
well in a clinical setting. These physicians have sometimes enjoyed high-level
positions but have been unable or unmotivated to work toward bringing public
health up to date with developments in the medical field. They have added to
the negative impression many public health staff have of physicians.
However, even if doctors bring excellent clinical skills and motivation, they
need many other talents to function effectively at the state and local levels.
Unlike doctors at the CDC, doctors at the state and local levels do not have
the luxury of focusing chiefly on the medical and epidemiological aspects of
a single disease or group of diseases. To function in more diverse programs,
they also need skills in administration, an understanding of the agencies and
levels of government that make up the public health system, and an appreciation
of how these interact with the political system. These training objectives should
be addressed at the academic level specifically for physicians entering public
health, because they are often asked to fill high-level positions in the field.
But at the academic level, there has been a divergence between the fields
of private and public medicine. Schools of public health have few physicians
on their faculties, and medical school curricula have tended to include little
about public health. Few physicians are trained as epidemiologists. Coordination
needs to begin between the academic communities of medicine and public health.
The same is true for the field of nursing. Health departments often hire nurses
at a lower salary than they would have to pay physicians, then ask them to autonomously
perform physician-like functions, such as providing medical advice to their
programs and to physicians who call. Some nurses have been able to fill these
roles well with only occasional assistance from physicians. Their level of contribution
should be fairly acknowledged and compensated. Other nurses are less able to
fill these functions, but they may report to administrators who are unable to
assess their competence. Standardized skills or certification might help with
Physicians and nurses working in clinical medicine contribute little to public
health in the current system, but their broader participation could be a major
part of making public health more innovative and relevant. Few people can be
as passionate about public health as physicians and nurses who encounter the
suffering of individual patients every day in their clinical practices.
Physicians are accustomed to following the medical literature and incorporating
developments into the care of their patients; these skills are needed to bring
the same advances into state and local public health programs. Yet there are
few openings for physicians in public health outside the CDC. Physicians who
choose to work in public health and want to keep up their clinical skills must
pay high malpractice insurance fees normally paid by employers of full-time
physicians. Complex problems in the medical care system are another reason physicians
are not more involved in public health, but those are beyond the scope of this
They do raise an interesting question, though: Why has the voice of public
health not been heard over the past several decades, defending the causes of
nurses, doctors, hospitals, and others struggling in the current medical system?
The chasm between the two disciplines has become so great that neither one sees
in the other the seeds of potential solutions to problems within their own discipline.
The mission of
public health is broad, including politically charged issues such as tobacco,
needle-sharing, HIV/AIDS, and sex education. This broad scope increases the
opportunities for political opposition. The average tenure of a state health
director is two years. 
Public health must
choose its agenda carefully during each political season, and the medical voice
often goes unheeded among those planning agendas for public health. Yet a medically
motivated mission visibly filling an important role would make public health more
attractive and politically viable at all levels of government. In an era when
public health must forge new relationships to defend against the threat of bioterrorism,
strong and visionary leadership is becoming increasingly essential.
Public health is a field increasingly being appreciated as having a critical
role in national security. Problems at the federal level include weakness in
authority and internal organization. These weaknesses differ from those at the
state and local levels, where a lack of trained staff and local political constraints
predominate. Throughout, an enormous gap between private and public medicine
has prevented these disciplines from mutual assistance.
Public health needs to articulate a clear and compelling vision to its partners:
the public, the legislature, academia, and private medicine. A dynamic public
health system, with the vision to identify problems, see solutions, and convince
national leaders to implement them, would be respected and would attract funding
and talented people at all levels.