Spurred by Bush administration warnings against biological and nuclear terrorism -- and by more than $1 billion in federal preparedness funding -- health agencies around the country are vaccinating staff against smallpox, upgrading labs to test for anthrax, stockpiling radiation antidotes and augmenting communication networks.
Some health agencies say the new funds -- provided by the 2003 Labor, Health and Human Services and Education appropriations bill -- can be put to "dual use," simultaneously fighting terrorism and shoring up a crumbling public health infrastructure.
But critics say the preparedness drive distracts from day-to-day public health concerns like diabetes, stroke, tuberculosis, HIV and sexually transmitted diseases.
Onondaga County, N.Y., received a grant for $458,000 for bioterrorism preparedness, but spent $485,635 more than it received. "We had to shortchange other public health programs," including tuberculosis, breast and cervical cancer programs, and home visits to women with high-risk pregnancies, said Dr. Lloyd F. Novick, the county health commissioner.
The McLean County, Ill., public health department also spent more on its terrorism preparedness than the $115,000 it was allocated. Funds went to computer upgrades, pharmaceutical stockpiles and smallpox vaccinations.
Bob Keller, director of the McLean County Health Department, measures some of the costs as staff time lost to more mundane health programs. He estimates that his staff spends about 40 hours per month -- valued at $25,000 to $30,000 per year -- on terrorism preparedness.
These health care workers otherwise would have spent their time on tuberculosis surveillance and sexually transmitted disease prevention, he said.
Nationally, Bush's ongoing smallpox vaccination program -- aimed at roughly 400,000 healthcare workers who would inoculate others in case of a terrorist attack -- has cut into local agency budgets and staff time.
The Washington, D.C.-based National Association of County and City Health Officials (NACCHO) found that -- when considering staff training, facilities expenses and crucial follow-up with patients -- each vaccination costs between $154 and $284.
According to Karen Nikolai, supervisor of immunization services in Hennepin County, Minn., the program was a burden to her department. "I and several of our staff had to drop much of our regular work to do this," she said, but noted that the immunization program was "partially worthwhile" because it improved overall preparedness in case of a real emergency.
A NACCHO survey of local health agencies across the country indicated that Nikolai's experience was not unique: 53 percent of responding agencies said implementing bioterrorism preparedness made it difficult for them to maintain routine public health services.
Thirty-seven percent said the new funding has simultaneously helped other public health programs and activities.
In California, Berkeley volunteer health commissioner Tom Kelly says he and other commissioners are concerned that staff time has been diverted from the city's low-income minority communities. Dr. Poki Namkung, director of Berkeley's health department, feels the preparations are worthwhile because the threat of terrorism is real. "It isn't a fantasy," she said. "We have the responsibility to be prepared."
According to Namkung, terrorism preparedness can only be a benefit to a public health system that has been underfunded for decades.
"These funds are not just for terrorism," she said. "Nature is by far a more fierce opponent than bioterrorism ... We live in an age of emerging infectious diseases, SARS being the most recent example, and West Nile virus just around the corner for California."
Namkung said she now spends about 80 percent of her time "rebuilding the public health infrastructure" using the new federal funding. "We haven't cut back on anything," she said. "[T]his is the first significant money we've received to rebuild public health."
Berkeley is using federal funds to upgrade communication systems with local hospitals and clinics, vital in case of a smallpox attack and in the ongoing battle against infectious diseases like SARS, food-borne illness and meningitis, she said.
Dr. Wendel Brunner, public health director for Contra Costa County, located near Berkeley by the San Francisco Bay, cites a recent case of tuberculosis at a local high school. A letter to parents was rapidly translated into Spanish and sent home with students; simultaneously, the information was put onto a Web site.
"Normal communication procedures were enhanced by bioterrorism expenditures," Brunner said.
In Texas, the San Antonio Metropolitan Health District has used federal terrorism funds to expand laboratory capacity and develop an "all hazards approach" that can respond to a biological attack, a flood or hurricane.
San Antonio also cross-trained its nurses, so that a nurse working in pre-natal care is able, for example, to respond to a "dirty" bomb. "If we can cross-train staff, we get a bigger bang for the buck," said Tom Fletcher, emergency management coordinator for the city.
San Antonio's health district director Dr. Fernando A. Guerra said his district has been reimbursed for about 80 percent of their costs, but that "some of our other efforts have been displaced for a while ... We can't let [terrorism preparedness] take us too far in that direction or we'll miss the childhood diseases, the diabetes, the early loss of life."
Dr. Hillel Cohen, assistant professor of epidemiology and population health at Albert Einstein College of Medicine in New York City, said that the smallpox vaccination program was used as a ploy to get U.S. opinion behind the invasion of Iraq.
According to Cohen, giving the vaccine at this time "is nonsensical and, in my opinion, criminal."
There hasn't been an outbreak of smallpox in 30 years, he said, and there is little threat of one, given that the disease is difficult to obtain and deploy. For Cohen, it's a question of priorities: Five people died from anthrax attacks, he said, but some 20,000 die each year from the flu, mostly the elderly and impoverished. "So-called dual use is really the least efficient use of resources," he said. "[B]ioterrorism preparedness measures divert resources from public health needs with much higher priorities."
Patrick Hays, mayor of North Little Rock, Ark., believes each community must make the choice for itself; some may be at greater risk for a terrorist incident than others. "I choose to allocate funds toward the more likely things that might happen," he said, and noted that there is a greater chance that his community would be hit with an ice storm, tornado or earthquake than a terrorist attack. "I'm trying to take a sensible approach," he said.
Dr. Alonzo Plough, director of public health for Seattle and King County, Wash., agreed that preparation is necessary, but said that his jurisdiction doesn't have the resources for both terrorism and the public's critical health needs. "The post-9/11 world is all new," he said. "It's new for public health and the government. We have to figure out what to do. It's time for collective learning."
Additional reporting was provided by Josh Wilson.
Independent journalist Judith Scherr can be contacted at firstname.lastname@example.org