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The transformation of public health. (Health & Medicine).

LEST WE FORGET, NOT ALL OF THE TERRORIST attacks launched against the United States last fall came on September 11. In the weeks following the airliner-turned-missile strikes on New York and Washington, a number of Americans became infected, some fatally, with anthrax that apparently was spread purposely by some malevolent agent. Whether that agent is associated with the terrorists of September 11 is unknown at the time of this writing. But what is known is that bioterrorism represents a new challenge for the U.S. public health system.

The U.S. public health system is unique in all the world. It is responsible for a number of remarkable accomplishments, including the elimination or near-elimination of several deadly diseases that ravaged the nineteenth century. But, as politicians and other public officials try to respond to the bioterrorism crisis, the system is in danger of undergoing a radical change in design and purpose that could make it ineffective in meeting its traditional obligations and new responsibilities.


The business of public health is the prevention of disease and injury, especially by "health protection" -- protection from environmental hazards such as impure water, contaminated foods, and infectious or "quarantinable" diseases. In many nations, responsibility for the promotion of public health is vested in the national government. But in the United States, the Constitution does not grant any such duties to the federal government; those duties instead belong to the states.

They, in turn have developed state and local health departments that hold responsibilites relating to public health. Each health department is directed by a "health officer" who holds broad authority and, at his or her discretion, can perform acts (such as the mandatory quarantining of persons with contagious diseases) that are possible for no other U.S. government agent. It is in the pursuit of health protection that the broad and sometimes coercive powers of state and local health officers have been brought to bear.

Federal role In the U.S. public health system, the traditional role of the federal government has been to assist the state and local health departments with guidance, laboratory support, people, and money from the U.S. Public Health System (USPHS) to assure that national priorities are considered. When a public health problem could affect more than one state, the federal government has used such constitutional authority as "protecting interstate commerce" to take a more direct, active role.

However, in recent decades, Congress has mandated a number of large programs that have created major perturbations for the loose federalism originally characteristic of public health. For example, the Environmental Protection Agency (EPA) and the Occupational Safety and Health Administration (OSHA) gave the federal government vast new authorities to operate directly in the states and perform functions formerly reserved for state and local health departments. Huge federal programs of medical care and nutrition -- Medicare for the elderly, Medicaid for the indigent, and W.I.C. for dependent women, infants, and children -- have implications for health departments and have further blurred the lines of authority for the public's health.

However, in the area of disease control, the federal Centers for Disease Control and Prevention (CDC) have continued to respect the primacy of states. As an operating philosophy to this day, the CDC engages in epidemic investigations in a state Only on request of the state health officer.

Acute care In emergencies, health officers often exercise their "convener" role in the community to stimulate and coordinate the provision of emergency medical services by hospitals, clinics, and medical societies. However, acute medical care -- especially acute emergency medicine -- is far afield from the preventive function for which public health has unique expertise. Most public health physicians are not equipped by their day-to-day professional experience to provide acute clinical care. Appropriately, that is the work of clinical physicians in the medical community.

Acute medical care is more dramatic, more apparently heroic, and more glamorous than public health. What is more, it is natural for conscientious human beings to want to help people who are suffering. However, those realities do not alter the vital importance of public health; it is still true that "an ounce of prevention is worth a pound of cure." Hence, the diversion of public health professionals from prevention to acute medical care is, at best, a less-than-profitable investment, and the longer such a diversion persists, the greater the compounded loss.


In its response to both September 11 and the anthrax bioterrorism that has followed, the federal government has altered the distribution of fundamental authorities and responsibilities in public health. Immediately after the airliner attacks, U.S. Department of Health and Human Services (HHs) Secretary Tommy Thompson ordered USPHS teams to Manhattan to provide acute care to the injured and support rescue workers. However, the USPHS, along with state and local public health officials, could not take the lead in handling the anthrax attacks -- a role that better fits the agencies' traditional public health duties -- because of Presidential Decision Directive 39. That directive, issued under the Clinton administration, designates the Federal Bureau of Investigations as the lead agency in the event of a biological or chemical attack on the United States, and charges the Federal Emergency Management Agency (FEMA) with ensuring adequate federal response to the consequences of terrorism.

In contrast to the 1976 outbreak of Legionnaires' disease that was managed by the local/state/CDC system, the FBI's handling of the anthrax attacks is not especially impressive. We are two months into the field investigations with no identification of an apparent source, and the federal agency has drawn sharp criticism from Congress over the lack of progress. But one should not expect the FBI to have the particular epidemiological skills required for the task. There is a profound difference between an epidemiological investigation aimed at identifying the source and preventing transmission of a disease, and a criminal investigation aimed at identifying, apprehending, and convicting a perpetrator. Is there a need for cooperation between the FBI and CDC? Of course. Is there a need for reassignment of lead responsibility for epidemiological investigations to the FBI? I think not.

More bureaucracy A further compromise of existing authorities is exemplified in Secretary Thompson's establishment of the new Office of Public Health Preparedness (OPHP). The office's stated purpose is to "coordinate national response to public health emergencies." One wonders what the OPHP can do that could not be done better by FEMA, which already exists and is well funded. Or, if there is need for better coordination between the agencies of the USPHS (CDC, National Institutes of Health, Food and Drug Administration, etc.), why could that not be done by the assistant secretary for health or the surgeon general? Each of those positions has the authority to convene the agency directors for any necessary clarification of roles and operational "ground rules." If there is "jawboning" to be done, why should it not be done within existing lines of authority? Why add a new "coordinating" bureaucracy to make more miserable the lives of agency directors already distracted by the challenges of dealing with bioterroris m and the accompanying media circus?

Congress is considering further compromising HHS authorities by establishing a new position: assistant secretary for emergency preparedness. In so doing, Congress would take that responsibility away from the Public Health Service. The new assistant secretary would leave the assistant secretary for health with a diminished portfolio and alter agency priorities to favor emergency preparedness instead of traditional public health efforts to prevent disease and promote health.

Compromised credibility The bioterrorism has provoked round-the-clock media coverage that has heightened public fears. Those fears have not been allayed by public health officials' seeming inability to answer, in timely fashion, such important questions as, "Is this bioterrorism or not?" "If this is bioterrorism, how did it happen?" and, "What do these environmental tests mean?" Citizens' expectations that public health experts could speak confidently on such issues are reasonable. But, because those experts lacked necessary preparedness, each new finding of an anthrax spore fed the media frenzy and increased public worries.

In truth, there has been much less to fear than what the public may believe. As weapons go, anthrax seems a bit under-whelming: The number of cases generated by the attacks is, at the time of this writing, less than one week's worth of deaths from occupational injuries. Compared to the effects of an influenza epidemic, the anthrax bioterrorism seems almost trivial. Unfortunately, public health officials failed to communicate that message effectively to the media and the public.


Recognition of the comparatively small number of anthrax cases generated by the bioterrorism attacks may ease public worry, but there still is great fear about future attacks using more potent weapons. Stirred by media reports about the federal government's "Dark Winter" hypothetical doomsday model, the public has given tremendous support to the creation of new offices and the spending of vast sums of tax dollars to counter such threats.

The gravest fears involve smallpox, and they are not without warrant: If terrorists were to use the variola major strain of the virus, which once racked the Indian subcontinent, 40 percent of the people who are infected would die. But if the federal government, through the CIA, military intelligence, and the State Department, has convincing evidence that terrorists possess weaponized smallpox, it has not been revealed to the public.

Stockpiling vaccine However, the federal government is acting as though that threat is real, and is spending the kind of money justified only if it were. The antiterrorism bill moving through Congress at the time of this writing includes some $2 billion in new spending to buttress public health programs, including hundreds of millions for the purchase of smallpox vaccine. (The new purchases would add to the 15 million doses the government already has stockpiled, and the 40 million doses ordered by the CDC in 2000.)

However, the plan calls for no availability of that vaccine to the public until there is a confirmed smallpox outbreak. That is, the federal government -- which is the sole owner of a highly effective preventive measure -- will sit on its stockpile until several Americans actually become victims of smallpox. The idea that the government would withhold the only effective means of protecting the population from a terrible disease until an epidemic is confirmed is new to public heath. Prevention, in this new context, obviously has no meaning for the "sentinel" Americans who will become ill and die of smallpox as trigger for the government's response. Truth is, this is not prevention and not public health as we have known it before.

The stated reason for withholding the vaccine is potential side effects, especially for persons with HIV/AIDS. According to Surgeon General Dr. David Satcher, "You're always hesitant to immunize people against the disease unless there is going to be a risk." That quote presents a significant contrast to the traditional "ounce of prevention" public health philosophy. To see that contrast more clearly, consider the statement made several years ago by former CDC director Dr. David J. Sencer, who headed the agency when it spearheaded the World Health Organization's global smallpox eradication program: "Stockpiling antibodies in the body is preferable to stockpiling vaccines on warehouse shelves."

Last year, when all bioterrorism was still hypothetical, the Public Health Policy Advisory Board examined the smallpox vaccine availability issue. The board suggested the option of making the vaccine available as it is produced, informing the public of the risks and benefits, and allowing individuals to decide whether or not to avail themselves of the protection. For those of us not infected with HIV, the risks of vaccination are known and negligible when compared to smallpox.

Cost Major financial resources are being committed to combat the anthrax bioterrorism and the threat of smallpox attack. Because resources for public health are always limited, there is no "fat" in public health budgets. One wonders, which ordinary public health functions are being sacrificed in order to pay for the bioterrorism measures? As yet, nobody's talking about such tradeoffs, but rest assured, loss is being incurred in public health as Congress fixates on bioterrorism, real or imagined. One can only hope that the phantoms we now chase are worth the losses suffered by public health, or, that the phantoms will soon disappear.


Potentially, the worst consequence of September 11 for U.S. public health would be reduced visibility of its national professional leadership. A lot of public health functions are non-regulatory and non-coercive, and depend on broad acceptance by the public of measures for which the value is not immediately obvious. Effective, persuasive professional leadership of the kind exhibited by President Reagan's surgeon general, C. Everett Koop, is critical to success.

The most prominent national governmental voice in the current crisis has been that of HHS Secretary Thompson, the former governor of Wisconsin. Secretary Thompson is well known for his expertise in reform of state welfare programs, but to my knowledge he does not possess extraordinary experience in public health, and these are extraordinary times for public health. In turn, the public has seen and heard less than it should have from the assistant secretary for health, the surgeon general, and the directors of the public health service agencies.

In addressing the felt need for "preparedness," Secretary Thompson had an opportunity to strengthen the leadership capacity of the talented professionals who work for his department. Existing units within HHS could have been organized to meet the challenges of the bioterrorism crisis, but he chose to create the Office of Public Health Preparedness and look outside of government for an appointee to run it. Rather than create new bureaucratic structures and bring in outside hires, I believe much would have been gained from leaning on and learning from professionals already in place inside HHS. Not to do so diminishes the stature of public health professionals and threatens the effectiveness of public health leadership in the future.


While "an ounce of prevention..." is an accurate truism, the work of public health under ordinary circumstance is largely prosaic. When prevention is at its best, calamities are not happening and the public and the media are not stimulated. Those of us who directed the smallpox eradication campaigns were puzzled by America's reaction (or lack thereof) to that enormous achievement. Smallpox eradication was without precedent in human history, yet the public remained blase and no leaders in that successful "war" became Nobel laureates. The same might be said of other major triumphs of prevention -- pure water supplies, reduced infant and maternal mortality, increased longevity, improved quality of life -- all of which are attributable almost entirely to prevention. Prevention is not glamorous, but it is powerful and important.

Our society benefits greatly from an effective public health system and should be interested in the events that affect public health for good or bad. September 11 and its aftermath were major events that have affected public health. Some of those effects already are visible, others will become manifest later. Some are transient; others will persist from here on. Some offer opportunities to better understand the importance of prevention. Others, ominously, threaten the ability of public health to achieve important goals in the future.

Public health is too valuable to this society to be abandoned to a fate dictated by media-driven fear and the idiosyncrasies of shallow thought. Much that has happened to public health in the last three months, and much that is being pushed in Congress today, is ill advised and unnecessary, and potentially hazardous to the future of public health. We have cause to fear that public health could become one of the victims of September 11.

J. Donald Millar is vice chair and a distinguished fellow of the Public Health Policy Advisory Board. He is also president of Don Millar & Associates, a consulting firm dealing with occupational and environmental health. Millar is a former director of the National Institute for Occupational Safety and Health and has headed the National Center for Environmental Health, the Bureau of State Services, and the Smallpox Eradication Program at the Centers for Disease Control and Prevention.
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Author:Millar, J. Donald
Geographic Code:1USA
Date:Dec 22, 2001
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