Table of Contents Foreword Acknowledgments Executive Summary Introduction The Challenge of Bioterrorism Public Health: A Brief Historical Overview Bioterrorism: "Where Bad Bugs and Bad Guys         Come Together" Lack of Preparedness Dual Use for Bioterrorism Funding Mixed Reactions to Bioterrorism Funding Texas: A Case Study of the Mixed Blessings of         Bioterrorism Money Distortions Caused by Federal Bioterrorism Funding Effects of Budget Crises on Public Health and Emergency         Preparedness Economic Problems Affect Population Health Services Smallpox Campaign and Population Health Programs "Why Are We Doing This?": The Growing Uneasiness with         the Smallpox Vaccination Campaign Wisconsin: One Administrator's View The Draft Model Act and the States Reforming State Law Quarantine Surveillance Regional Coordination Conclusion Notes References The Authors

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Foreword

This report is the second of three by Gerald Markowitz and David Rosner on how the terrible events of September 11, 2001, and the subsequent cases of anthrax, SARS, and monkeypox are affecting policy for the health of populations in the United States. The first report in this series was titled September 11 and the Shifting Priorities of Public and Population Health in New York. In this report Markowitz and Rosner examine the experience of officials of the legislative and executive branches of state government who are making and implementing policy to respond to health emergencies. Their final report will examine the response of the federal government to recent health emergencies.

This series of reports is contemporary history, which the authors describe as the "first attempt to place the story that people experienced in a longer and broader historical context." Markowitz and Rosner are distinguished historians who have written extensively about recent events. They base their history on interviews, accounts by journalists, and available public documents. As professional historians they avoid evaluating what state officials have done or recommending what they should do.

Markowitz and Rosner introduce the major themes and findings of this report in an executive summary and elaborate them in the body of the report. Their most important finding is that Americans have reason to worry about the adequacy of our public health infrastructure despite recent attention to its shortcomings. They conclude, "The financial crises of the various states, combined with the shifting focus of the federal government from bioterrorism and terrorism in general to smallpox and the war in Iraq . . . lessened the early potential to enhance the system of services that are essential for the improvement of the nation's efforts to address [both] bioterrorism preparedness and the overall health needs of the American people."

The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan analysis, study, research, and communication on significant issues in health policy. Since 1905 the Fund has worked to improve and maintain health by encouraging and assisting persons who make and implement health policy to use the best available evidence. The Fund convenes meetings of leaders in the public and private sectors and publishes reports, articles, and books.

Each of the persons interviewed for this report reviewed it in draft. Other reviewers made many helpful comments. These generous individuals are listed in the Acknowledgments.

Daniel M. Fox
President

Samuel L. Milbank
Chairman

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Acknowledgments

The following persons were interviewed for this report and/or reviewed it in draft. They are listed in the positions they held at the time of their participation.

John O. Agwunobi, Secretary of Health, Florida Department of Health; Brian W. Amy, State Health Officer, Mississippi State Department of Health; J. Nick Baird, Director, Ohio Department of Health; Georges C. Benjamin, Executive Director, American Public Health Association, Washington, D.C.; Michael Caldwell, President-Elect, National Association of County and City Health Officials, and Commissioner, Dutchess County Department of Health, Poughkeepsie, N.Y.; Jan K. Carney, Associate Dean for Public Health and Research Professor, University of Vermont College of Medicine, Burlington; Ronald Cates, Chief Operating Officer, Missouri Department of Health; Harriette Chandler, Member, Health Care Committee, Massachusetts Senate; John D. Chapin, Director, Division of Health Care Financing, Wisconsin Department of Health and Family Services; J. Jarrett Clinton, Regional Health Administrator, Region IV, U.S. Department of Health and Human Services, Atlanta; Jack Colley, State Coordinator for Emergency Response, Texas Department of Public Safety; Angela Coron, Associate Director, California Department of Health Services; Tim Daly, Executive Assistant to Harriette Chandler, Massachusetts Senate; George DiFerdinando, Jr., Director, Medical Quality Improvement, Peer Review Organization of New Jersey, East Brunswick; Robert B. Eadie, Deputy Director, Metropolitan Health Department, Nashville, Tenn.; Catherine Eden, Director, Arizona Department of Health Services; David Engelthaler, Chief, Office of Bioterrorism and Epidemic Preparedness and Response, Arizona Department of Health Services; Thomas E. Gecewicz, City Forum Chair, National Association of County and City Health Officials, and Director, Bridgeport Health Department, Conn.; Lee Greenfield, Senior Policy Advisor, Hennepin County Health and Community Integration, Minneapolis; Norma Gyle, Deputy Commissioner, Connecticut Department of Public Health; Anne R. Harnish, Assistant Director, Ohio Department of Health; John Howard, Director, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Washington, D.C.; Joseph Hunt, Assistant Commissioner, Information Services and Policy, Indiana State Department of Health; C. Earl Hunter, Commissioner, South Carolina Department of Health and Environmental Control; Joseph P. Iser, Investigator, San Francisco District, U.S. Food and Drug Administration; Lisa Kaplowitz, Deputy Commissioner for Emergency Preparedness and Response, Virginia Department of Health; Mary E. Kramer, President, Iowa Senate; Rice C. Leach, Commissioner, Kentucky Department for Public Health; Captain Alvin Lee, Regional Emergency Coordinator, Region X, Office of Emergency Response, Public Health Service, U.S. Department of Health and Human Services, Seattle; Sabrina Jaar Marzouka, Director of Health Planning and Education, Dutchess County Department of Health, Poughkeepsie, N.Y.; Patrick Meehan, Associate Director, Management, National Center for Environmental Health, Centers for Disease Control and Prevention, Chamblee, Ga.; Richard Melton, Deputy Director, Utah Department of Health; Dora Anne Mills, Director, Health Bureau, Maine Department of Human Services; Carol M. Moehrle, County Forum Chair, National Association of County and City Health Officials, and District Director, North Central District Health Department, Lewiston, Idaho; Patricia T. Montoya, Secretary, New Mexico Department of Health; Anthony D. Moulton, Director, Public Health Law Program, Centers for Disease Control and Prevention, Atlanta; Melvin Neufeld, Member, Joint Legislative Budget Committee, Kansas House of Representatives; Patricia A. Nolan, Director, Rhode Island Department of Health; Dennis M. Perrotta, State Epidemiologist, Texas Department of Health; Sheila Peterson, Director, Fiscal Management Division, North Dakota Office of Management and Budget; Richard A. Raymond, Chief Medical Officer, Nebraska Health and Human Services System; Charlene Rydell, Health Policy Advisor, Office of U.S. Representative Tom Allen of Maine, Portland; J. Thomas Schedler, Chair, Health and Welfare Committee, Louisiana Senate; Richard H. Schultz, Administrator, Division of Health, Idaho Department of Health and Welfare; Mary C. Selecky, Secretary, Washington State Department of Health; Arvy Smith, Deputy State Health Officer, North Dakota Department of Health; Robert B. Stroube, Commissioner, Virginia Department of Health; Brenda Vossler, Bioterrorism Hospital Coordinator, North Dakota Department of Health; Janice L. Weinstein, Clinical Physician, Dutchess County Department of Health, Poughkeepsie, N.Y.; Robert S. Zimmerman, Jr., Regional Director, U.S. Department of Health and Human Services, Philadelphia.

This work was supported in part by an Investigator Award in Health Policy Research from the Robert Wood Johnson Foundation. The views expressed are those of the authors and do not imply endorsement by the Robert Wood Johnson Foundation. The authors would like to thank graduate students Sarah Vogel and Megan Wolff for their very valuable assistance.

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Executive Summary

Since the attacks of September 11, 2001, fear of terrorism and bioterrorism—and specifically the anthrax outbreak a month later, the threat of smallpox, and more recent outbreaks of SARS and monkeypox—has impelled government to pay more sustained attention and award more resources to health and health-related activities than it has done in years. Public health agencies are now in the national spotlight to a degree not experienced since the great epidemics of influenza, polio, whooping cough, diphtheria, and other illnesses during the first 50 years of the last century. Almost overnight, population health issues—the breadth of social and health services and activities that determine a population's health and well-being, including what is usually called public health—have been pulled into a semimilitary campaign as part of the nation's defenses, thrusting state health agencies into the forefront in the broader arena of emergency preparedness and national security.

This report, the second of three, is an account of important initiatives and responses that have affected the various states' public health systems in the two years following September 11. Here the focus is on the wide variety of adaptations, successes, stresses, and fears that state health and general government officials underwent. The final report will provide a look at the response of federal officials to September 11. General government officials, that is, elected legislators and their staffs, at the state and local levels focused on a broader array of social service, public health, and health care needs that all demanded scarce state and federal resources. Public health officials focused on the possibility of improving traditional public health infrastructural services such as lab capacity, surveillance systems, intra- and interagency communication, protecting the borders, and other specific needs of their agencies. Certainly, the mobilization around public health needs resulted in the allocation of significant resources and what many of our respondents called "progress."

This report is a contemporary history of this critical period of time. The purpose of contemporary history is to tell the story as people experienced it, using a wide variety of primary sources including published and unpublished reports, oral interviews with key participants, and government documents and popular media. Contemporary history is generally the first attempt to place the story that people experienced in a longer and broader historical context. This report is not proscriptive and does not offer specific recommendations to address the issues raised herein. Rather, as all history tries to do, it seeks to provide perspective on contemporary issues that may be incorporated, or not, into policy decisions. As historians, the authors hope to provide the reader with the lessons learned and insights gleaned by the participants themselves. Certain themes have emerged from the interviews and the primary and secondary sources that were examined.

• In the immediate weeks after September 11, there was widespread hope that the new focus on public health would result in a revitalization of the field and dramatic improvements in the public health infrastructure.
• Among the concrete accomplishments were stronger relationships between law enforcement and health providers, enhanced epidemiological capacity, better training for possible bioterrorist events, improved and more secure communication systems, enhanced laboratory capacity, and a group of inoculated health professionals capable of responding to a smallpox outbreak.
• Even in the early weeks following September 11, some public health agency administrators began to fear that the new focus on bioterrorism would distort public health priorities.
• Many in general government feared that a narrow focus on health as an adjunct to national defense could undermine their broader mission to provide a variety of services not necessarily tied to bioterrorism and emergency preparedness.
• The economic recessions that in some states had begun before September 11 strained state budgets and forced reduced spending in numerous sectors of the states' bureaucracies, including health.
• As legislators moved further and further away from the events of late 2001, population health preparedness became just one of a number of different budget priorities that needed to be considered in tough fiscal times.
• The budgetary problems were amplified by the federal mandate in late 2002 for a major smallpox inoculation campaign.
• The attempt to codify and reformulate state public health laws with the draft Emergency Health Powers Model Act and what some criticized as the poor federal handling of the anthrax episode and smallpox inoculation campaign served to stimulate a broad discussion of the obligations and responsibilities of health authorities in light of the new geopolitical situation.
• In the aftermath of September 11, conflicting values over the rights of individuals and the perceived need for greater bioterrorism preparedness served to heighten the sense of disorder for officials whose jobs had been radically transformed in a very short time.

September 11 presented the public health community and those involved with population health more generally a great opportunity to revitalize and rethink the health agenda for the nation. Politicians, administrators, and the general public came to appreciate the vital role that public health agencies could play in a national emergency and in the fight against terrorism, and public health administrators and advocates hoped that they could capture and perhaps recapture the potential that they believed public health had had in a bygone era. Some observers called for a revamping of the nation's health insurance system so that more of the population was covered as a means of improving the surveillance of disease; some called for an expansion of the scope of traditional public health activities so that the growing barriers between prevention and care would be reduced; some called for the extension of the social services system and the integration of the health care and public health systems; others called for the upgrading of the public health infrastructure as a necessary tool in the fight against terrorism. Yet others cautioned that simply increasing budgets and financial resources might do little to address the long-term problems affecting public and population health programs in the various states. While those in general government and public health agencies agreed on many points, those in general government were not looking for increased funding for public health department activities per se to solve decades of problems.

In the two years since September 11, much has been accomplished in terms of providing resources, legal reform, improved surveillance, and communication. Yet, much of the opportunity presented in the first few months has been hurt by a lack of continued focus on the part of various parties and the financial crises of various states, combined with a narrowing of federal attention from bioterrorism and terrorism in general to smallpox and the war in Iraq more specifically. Because of the centrality of the federal government in these issues, it will be the subject of the third and final report. In general, these interviews and the authors' reading of published and unpublished reports and media coverage suggest that the early potential to reform the system of services essential for the improvement of the nation's efforts to address bioterrorism preparedness and the overall health needs of the population is endangered.

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Introduction

The newspaper headlines were stark and eerie: "Efforts to Calm the Nation's Fears Spin Out of Control," "Local Public Health Officials Seek Help," "This Is Not a Test," "Some States Can't Handle Bioterrorism," "Scared into Action." And the pictures that accompanied them were worse: space-suited investigators, smallpox-ridden children, cold, stark laboratories staffed by masked personnel. State and local health departments were now supposed to be on a "war footing," as one headline noted. Health officials, knowing that their historical role was as the first line of defense against infectious disease, were, at the same time, energized and terrified by the prospect that their actions could be responsible for protecting or damaging the health of an entire state, even nation. How should they react? What were their goals? Their limitations?1

Public health is a methodical discipline, historically rooted in the collection of data, the tracking of disease outbreaks, and laboratory and epidemiological investigation, often working in the background, out of the public eye. But the events of September 11 and the October anthrax incidents placed public health and public health agencies in the spotlight to a degree not experienced since the great epidemics of influenza, polio, whooping cough, and similar illnesses during the first half of the 20th century. Many officials felt overwhelmed. The limitations of the public health surveillance system, laboratories, and treatment and social services became all too apparent. Almost overnight, public health services were pulled into a cooperative campaign as part of the nation's defenses. Beleaguered staff and limited laboratory space and supplies, along with the general inexperience with bioterrorism, led to a profound reevaluation—sometimes naïve, sometimes quite sophisticated—of the place of population health services in the country's antiterrorism and emergency preparedness systems.

September 11 and anthrax, the threat of smallpox, the continuing AIDS epidemic, as well as the more recent outbreaks of SARS and monkeypox, compelled general government—elected officials and their staffs—to pay more sustained attention and award resources to public health agencies and population health more broadly than it had done in decades. (Here we distinguish between public health and population health services. By "public health" we mean those services aimed at preventing epidemics and the spread of disease; promotion of chronic disease control and the encouragement of healthy behavior; disaster prevention; disaster response; public health department administration; and licensure and maintenance of facilities, vital records, and laboratories. By "population health" we include those services normally rendered by public health departments as well as access to personal health services of high quality; financial security for parents of young children and retirees; protection against harm as a result of poor water quality, air pollution, toxins in the soil, and contaminated food; control of risks from tobacco and other addictive substances; reduction of injuries and risk of illness in workplaces, homes, and public spaces; and protecting the independence of persons who are frail or have disabilities.)² Fear of terrorism—and bioterrorism specifically—thrust state agencies onto center stage in the broader arena of emergency preparedness and national security. Academics and public commentators alike argued that a new conception of traditional emergency responders was now upon us. "Firefighters, police officers, and other first responders will be on the front lines of a terrorist attack. . . . But in a bioterrorist attack, the people on the front lines will be the practicing physicians who will diagnose and treat diseases, and public health epidemiologists and laboratory personnel who will determine who has been exposed" to a host of biological and chemical agents.³ From established academics and public health professionals to conservative think tanks and state officials, everyone agreed that "nowadays protection from disease is nothing short of national defense."⁴ State government agencies were called upon to play a new and crucial role in emergency preparedness.

In his opening address to the American Public Health Association (APHA) annual meeting just a few weeks after the initial anthrax attacks, Secretary of the U.S. Department of Health and Human Services Tommy Thompson pledged that "we must take this opportunity to do everything we can to strengthen the public health system."⁵ The promise of federal bioterrorism money was seized upon by public health spokespeople and even commentators across the political spectrum as a possible salve for the system's inadequacies. Further, it was used to buttress ideological and political goals. One Fellow at the conservative American Enterprise Institute criticized public health leadership for having a "social justice agenda" that crowded out its true calling: "The upheaval of September 11 poses a momentous opportunity for public health to reclaim its proper focus: to protect the population from disease." Citing the 1988 Institute of Medicine study that described the public health infrastructure as being in "disarray," she argued that "that function has suffered for many years."⁶ Mohammed Akhtar, executive director of the APHA, disagreed with the overall argument that public health should be narrowly construed but agreed that severe weaknesses existed in the public health system that were the "result of neglect of many decades. . . . Since we conquered many infectious diseases, there have been no major outbreaks, so we continued to cut down on the system. It is at a point that it needs to be rebuilt and modernized."⁷

Those within and outside public health departments and general government had differing views on what constituted preparedness in general and bioterrorism preparedness in particular. Local health officials, worried about the weaknesses in their agency programs, sometimes came into conflict with some state elected government officials and their staffs, whose focus was on a broader array of population health needs. Those concerned with public health at the state level hoped that new federal money would allow state and local agencies to rebuild, even expand, their infrastructures. They hoped that the money could be used both to prepare the nation as well as to bolster general public health programs. But even in the immediate weeks after September 11, some public health agency administrators feared that the new focus on bioterrorism would distort public health priorities. A narrow focus on health as an adjunct to national defense could undermine their broader mission to provide a variety of services not necessarily tied to bioterrorism and emergency preparedness.

Unlike public health officials whose perspectives were framed by their agencies' pressing needs, many government legislators focused on the glaring weaknesses in the social services system, on hospital care facilities, and on the broader threat of terrorism and bioterrorism alike. In addition, they were dismayed that more had not been done to strengthen intrastate and interstate coordination for emergency response.

These early hopes and fears were framed by national crisis and broad social, economic, and political events. The economic recession that in some states had begun before September 11 was greatly exacerbated by the near cessation of travel and consumer spending that followed the terrorist attacks. Strained state budgets led to the need to reduce spending in numerous sectors of the states' bureaucracies, including health. As legislators moved further and further away from the events of late 2001, population health preparedness became just one of a number of different budget priorities that needed to be considered in tough fiscal times. In early 2002, federal grants through the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA), provided a substantial infusion of funds for specific health-related activities and programs aimed at improving the public health infrastructure as a part of general bioterrorism preparedness. Even though these funds could not be used to supplant existing programs, the federal mandate in late 2002 for a major smallpox inoculation campaign dramatically affected debates within state governments about where resources should be spent and how personnel should be allocated. In the end, the rapidly developed smallpox program planning and inoculation campaign provided an additional challenge to those in general government concerned with bioterrorism preparedness and to state public health officials who saw the new infusions of federal funds as enabling them to buttress the general public health infrastructure.

Fiscal crisis and political agendas were not the only forces reshaping thinking about population health over the course of the past two years. The attempt to stimulate new and revised law through the draft Emergency Health Powers Model Act (hereafter referred to as the draft Model Act) and, according to many of our respondents, the poor federal handling of the anthrax episode (as embodied in the confusing messages sent out by Secretary of Health and Human Services Tommy Thompson) and smallpox inoculation campaign served to highlight the difficult interface between the public health community and law enforcement. These factors also helped encourage a discussion regarding regional and even national public health response to the threat of biological or chemical attacks.

More than two years after the attacks, many public health officials believe that there is still tremendous ambiguity about what bioterrorism and emergency preparedness really mean. Some see it as synonymous with strengthening the existing public health infrastructure. Some see it as building population health services more broadly. Others see it as narrowly focused on smallpox, anthrax, emergency care, border protection, and the like. While all these formulations are obviously complementary, they often create competing demands for scarce resources.

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The Challenge of Bioterrorism

In this section we explore the waxing and waning of the initial expectations of public health officials in the immediate months following the attacks of September 11, 2001. At first, many officials believed that the federal emphasis on bioterrorism would allow for the revitalization of their field. Indeed, important improvements addressed serious weaknesses in the public health infrastructure. But many public health agency and government officials at the state level were wary that the emphasis on national defense could undermine other key programs necessary for improving the population's health.

Public Health: A Brief Historical Overview

September 11 helped galvanize the nation against terrorism, and the anthrax episodes in October 2001 and the mobilization against smallpox a few months later thrust public health and public health agencies into the national spotlight. But while public health authorities have been critical in vaccination and treatment programs aimed at preventing polio, flu, and smallpox, September 11 and the October anthrax outbreak stimulated those inside and outside government to see prevention, surveillance, and disease reporting—traditionally responsibilities of public health departments—as integral to the country's national defense system. Public health has historically played a role in national defense efforts. Malaria and yellow fever control have been part of American military campaigns from early-20th-century interventions in Latin America to World War II and Vietnam. As Robert Stroube, commissioner of the Virginia Department of Health, points out, the Epidemic Intelligence Service at the CDC had its origins in the Cold War.8

The events of the past two years—specifically the threats of anthrax, smallpox, SARS, monkeypox, and ricin—underscore the historical transformations in the field of public health. Throughout the 19th and early 20th centuries, traditional preventive public health activities were essential to the growth and stability of cities and states. Rampant epidemic diseases, such as cholera, smallpox, diphtheria, and influenza, undermined not only the health of young and old alike but also the economic well-being of the growing industrial and commercial centers throughout the country. While never competing with tuberculosis and other longer-term illnesses as the primary cause of death and disability, ferocious epidemics were a potential threat to the prosperity of such cities as New York, Chicago, Philadelphia, and New Orleans. Quarantine, isolation, surveillance, and the provision of pure water, sewerage systems, and street cleaning made public health departments central agencies in the municipal and state reform efforts. But in the 20th century, the very success of public health campaigns to improve and reform housing, sanitation, nutrition, water quality, and, in addition, the development of sewerage systems (as well as inoculation campaigns against infectious diseases and health programs targeted at women and children, among others) led to a slow decline in the perceived importance of public health departments themselves.⁹

By the second decade of the 20th century, public health officials were noting in their annual reports that the very diseases that had spurred the development of public health departments in the first place were on the wane as mortality statistics showed that longer-term illnesses were growing in importance. By the 1920s and 1930s, chronic diseases were the major causes of mortality in the United States, and many public health departments had begun programs aimed at addressing heart disease, cancer, and stroke, among other issues. As the century progressed, despite such periodic outbreaks as the influenza epidemics of 1918 and 1919, the polio epidemics into the 1950s, or AIDS and resistant tuberculosis since the 1980s, infectious diseases waned as the focus of public health activities.

Despite the shifting epidemiological picture, throughout the first half of the 20th century public health activities remained prominent and possessed tremendous political and cultural authority. But the growing importance of new medical technologies and treatments for infectious disease began to overshadow traditional public health techniques. The development of antibiotic therapies for individual patients with scarlet fever or rheumatic heart disease, for example, supplanted the authority of population-based approaches to prevention. The development of vaccines for polio, diphtheria, measles, and mumps, among others, were public health triumphs that, ironically, further undercut the rationale for extensive public health interventions in the second half of the 20th century. The mirage of a society freed from infections by antibiotics and vaccines and individuals treated or cured of many diseases by individual physicians—rather than by public health activities—dominated the popular imagination. Moreover, revenues for the care of the poor supported population health services provided by public health departments in many areas. "As new insurance programs were developed for the indigent population (e.g., SCHIP [State Children's Health Insurance Plan], Medicaid expansions)," Robert Stroube observes, "many state and federal leaders thought the funding for public health could be cut as there would be less need for indigent care." As a result, "revenues dried up."¹⁰

The diminishing stature of the field and the growing power of health care institutions as the bulwark against disease led to a conundrum for those concerned with the maintenance of the public health infrastructure. Public health departments were perceived as less central to preserving the population's health, and requests by state and city health officials for more funding and resources to address fissures in the existing public health system were now seen as self-interested appeals. As critical components of public health's original mandate were moved into departments of sanitation, waterworks, housing, and hospitals, and as the profession of public health became more isolated and specialized, the public and the political leadership no longer understood or sympathized with professional public health officials' goals or activities. For some, the result was chronic underfunding of both public health and population health activities. For others, public health officials were responsible for their own predicament: They had professionalized, defined their mandate too narrowly, and isolated themselves from broader concerns of population health more generally.¹¹

Bioterrorism: "Where Bad Bugs and Bad Guys Come Together"

The federal promises of money in late 2001 and early 2002 raised expectations that what many considered to be the long neglect of state and local public health agencies had, at long last, come to an end. For those in state public health agencies, the events of late 2001 were seen as potentially empowering, reversing what they perceived to be a century-long decline in status and authority. "Before, they left public health out [at the state level]," said Anne Harnish, assistant director of the Ohio Department of Health. "But bioterrorism brought us to the table and showed that we do have expertise."12 Similarly, Ronald Cates, former director of the Missouri Department of Health, reflects the ideology of many public health officials: "A lot of people who couldn't spell 'public health' now saw public health as the equivalent of the Department of Defense."¹³ Even in Massachusetts, a state with well-established public health traditions and the oldest department of health in the country, administrators and politicians believe that "public health was never really an equal partner at the table . . . in the past," that is, in the past half-century, but "became an equal partner as it was called upon to safeguard our water supply," protect the airports, and protect against the importation of biological agents into the state.¹⁴

State officials had a somewhat different perception of public health's place in history and in emergency preparedness. For Massachusetts state senator Harriette Chandler, the discussion of anthrax fundamentally transformed state officials' perception of public health. "The anthrax scare that we had was more than a public safety scare," Chandler recalls. "It required public health, it required testing, and it required knowledgeable people. But it also required the two groups [public safety and public health] to work together and to understand where the FBI comes in, local and state police, and if there's a role for municipal authorities. In that paradigm public health was basically the quarterback. We've never had that before." For Chandler, the need for a public health response was part of a broader problem. "It also showed all of the weaknesses that we have in terms of a national disaster or emergency."¹⁵

Even in states whose government agencies were vigilant in regard to planning for and coping with natural disaster, administrators in departments of health saw the anthrax episode as a watershed. In California, a state where earthquakes, fires, floods, and drought were a central concern of state emergency planning agencies, Angela Coron, associate director of the California Department of Health Services, remembers that "we took advantage of bioterrorism funds for California and Los Angeles to expand our capacity to respond statewide." California, like many states, has a decentralized system with 61 jurisdictions for public health. Moreover, public health came to be "included in emergency preparedness more and more," because anthrax and smallpox are "where bad bugs and bad guys come together."¹⁶

Across the country, administrators saw bioterrorism as an enormous opportunity to effect a sea change in public attitudes. They hoped that the money could be used both to prepare the nation as well as to bolster general public health programs. Dennis Perrotta, state epidemiologist for the Texas Department of Health, reflects the perception of the public health community that in most disasters public health was "always in the back helping. In bioterrorism, we moved to the driver's seat of the bus. . . . We have been brought to the front table. Sometimes in the past we have been well received, and sometimes not well received, but now the other players are our best friends."¹⁷ In Arizona, Catherine Eden, once a state legislator but now director of the state's Department of Health Services, and David Engelthaler, chief of the State Office of Bioterrorism and Epidemic Preparedness and Response, thought it was "interesting [that] the military, police, and fire . . . now know they very much need us." But that is "very new for public health to be so far out in the forefront," and it did not occur without a major effort by public health officials. "We had to insert ourselves into the emergency management/response community, and there has been a major culture shift in emergency management, perhaps across the country but definitely in Arizona. . . . We were able to get an understanding of the emergency management/response community and give them an understanding of us."¹⁸

Catherine Eden, perhaps because her background was in politics, not public health, is able to see the profound change in the culture of the department as public health personnel gained "respect with the legislature and the press."¹⁹ State legislators paid closer attention to the role that departments of health could play in antiterrorist planning. Similarly, Mary Kramer, president of the Iowa State Senate, recalls that anthrax led to "including public health people for the first time in our emergency planning efforts."²⁰ In Missouri, Ronald Cates, chief operating officer of the state's Department of Health, believes that "public health is the lead agency."²¹ Throughout the nation, the events of 2001 led those in public health to reevaluate the accuracy of their half-century-old ideology as an underfunded and unappreciated stepchild of government.

For the first time in many years, the departments of health were engaging in the kind of long-term planning that could result in the provision of services that would protect against bioterrorist emergencies and also protect population health in their states. Emergency preparedness could result in fundamental reform of public health practice. Rice Leach, commissioner of the Kentucky Department for Public Health, believed that public health was recovering its old, lost focus: "This [was] the first time since polio in the 1940s and 1950s that public health has had the opportunity to shine. It's a hell of a situation, but it gives us an opportunity to strut our stuff."22 Public health has "dealt with these things in the past, . . . but since polio and tuberculosis have declined, we have not had to handle things that affected the entire system."²³

Whatever loss of prestige the field suffered was immaterial in light of its now very relevant special skills and methodologies. The "decline" of state and local standing in the second half of the 20th century was paralleled by the growing importance of new federal initiatives to address disease in general and infectious diseases more specifically. Most important was the creation in 1946 of the Communicable Disease Center (renamed the Center for Disease Control in 1970, the Centers for Disease Control in 1980, and the Centers for Disease Control and Prevention in 1992) in the United States Public Health Service. This federal agency honed epidemiology, laboratory science, health surveys, and disease surveillance and reporting. Anthony Moulton, co-director of the CDC's Public Health Law Program, points out that the CDC built on state and local department strengths. Public health agencies routinely are engaged in "monitoring health of communities, including the surveillance for infectious disease . . . and monitoring unusual cases and patterns of disease and injury." Also central is close coordination with medical and public health professionals, such as private doctors, and emergency room nurses and physicians, who are often the first to notice unusual diseases or disease patterns. "One or more observant people see something amiss and may initiate quarantine [or isolation] and notify state/local public health agencies, which in turn would notify the CDC." Some very traditional public health activities that have been used during natural disasters in the various states "applied equally to biological, chemical, and radiological threats."²⁴

Once possible disease outbreaks are identified, public health authorities use public health laboratories and a panoply of tools such as inspection, isolation (the segregation of those with symptoms), and quarantine (the segregation of those possibly exposed but not symptomatic) to limit the impact of the disease on the population. Finally, public health authorities ideally do a "postmortem of the whole operation—seeing what went right and wrong—and planning for training courses" and infrastructural improvements.²⁵ Rice Leach of Kentucky summarized these traditional mechanisms: "In any emergency preparedness you have to detect, identify, intercept, neutralize, and recover. In public health we do surveillance for detection, we use labs and epidemiology for identification, we use vaccines, antibiotics, and quarantine to neutralize, and we are the only ones who can certify that we have recovered from a problem, whether it be bioterrorism or meningitis."²⁶

It is not as if the public health and emergency response communities had been caught completely unaware by the September 11 attacks and the anthrax episodes. Before September 11, the federal government had engaged in a number of exercises aimed at assessing the nation's preparedness for bioterrorist and chemical attacks. Two efforts were especially relevant for public health officials. In May 2000 the federal government organized a mock attack on three cities, "simulat[ing] a chemical weapons event in Portsmouth, New Hampshire, a radiological event in the greater Washington, D.C., area, and a bioweapons event in Denver, Colorado." Called "TOPOFF" for its involvement of top officials of the U.S. government, the exercise "illuminated problematic areas of leadership and decision making; the difficulties of prioritization and distribution of scarce resources; the crisis that contagious epidemics would cause in health care facilities; and the critical need to formulate sound principles of disease containment."27 Also, in 1999 the federal government had "made grants available in five focus areas for bioterrorism preparedness."²⁸

In June 2001 the nonprofit Center for Strategic and International Studies, the Johns Hopkins Center for Civilian Biodefense Studies, the ANSER Institute for Homeland Security, and the Oklahoma National Memorial Institute for the Prevention of Terrorism "hosted a senior-level war game examining the national security, intergovernmental, and information challenges of a [smallpox] attack on the American homeland," called "Dark Winter." The exercise spanned 13 days and came to some troubling conclusions about the readiness of the nation to confront a bioterrorist attack, including the lack of planning and coordination at the state and federal levels.²⁹ Not insignificantly, national concerns about the possibility of a computer system meltdown at the turn of the new century, commonly referred to as "Y2K," had also forced some state agencies to address emergency preparedness planning. Y2K revealed a great deal about the absence of coordination within government and between government and health care organizations.

As a result of these and other efforts, some states had been in the process of planning for the possibility of massive disruptions before September 11. For example, Norma Gyle, a former legislator and now deputy commissioner of the Connecticut Department of Public Health, notes that her state was "very fortunate," for it had been preparing studies during the previous two years. Because of the concerns surrounding Y2K, when in 1999 massive computer failures and disruptions were seen as a real possibility, the state had "organized a command center that stood [Connecticut] in good stead." Because there was at least "one general convinced that there would be no milk left on the shelves," officials were "well organized."30 Also, California was in relatively good shape, despite low morale due to the state's ongoing budget crises. A well-developed emergency response program had been sharpened in the face of recurrent natural disasters from earthquakes and mudslides to brush fires and chemical spills. Philip Lee, previously assistant secretary in the Department of Health and Human Services and now at the University of California at San Francisco's Institute for Health Policy Studies, said that "overall, California is better off than most states in bioterrorism preparedness. Historically, it has had a strong system of public health laboratories. . . . Chemical spills have honed the skills of hazardous materials containment teams—skills that translate well in the handling of both biological and chemical warfare attacks." Colorado's and Nebraska's labs, among others, were also identified as in relatively good shape in comparison with those of most other states.³¹ In addition, the Colorado "Department of Public Health and Environment has discovered ways to more rapidly test for such things as anthrax and plague."³²

Such planning did not cease when the predicted disasters did not occur. Before September 11, the Connecticut Department of Public Health, like those in 43 other states, had received a Health Alert Network grant from the CDC to improve its electronic communications systems.³³ The department had "made communications a major early priority . . . [and launched] a Web site that linked health care professionals and public safety officials with the health department." This would, in the words of Warren Wollschlager, chief of staff for the Department of Public Health, "provide nearly instant information on critical resources, such as available medicines and empty hospital beds," so that the "state is much better prepared to deal with a germ attack today than it was a year ago."³⁴

Lack of Preparedness

By and large, most state departments of health were grossly unprepared for September 11 and its aftermath. Georges Benjamin, then director of the Maryland Department of Health and also president of the Association of State and Territorial Health Officials, noted in October 2001, just weeks after the attacks on the World Trade Center and the Pentagon, that "in a field where communication can save a life, some state health departments" did not have an effective e-mail communication system with their local and county departments.35 The Atlanta Journal and Constitution, citing Benjamin, reported that "public health officials have been warning for years that the [public health] system is antiquated."³⁶ The lack of planning was one problem, but equally important was insufficient financial support. "Public Health funding has been woefully inadequate and it needs a boost," Benjamin decried. The basic infrastructure of public health needed to be "enhanced . . . at local levels to fund disease-surveillance systems, to do basic medical detective work, to coordinate with local officials, hospitals, and labs."³⁷ The National Association of County and City Health Officials (NACCHO), in its study "Local Public Health Agency Infrastructure: A Chartbook," and others pointed out that "most public health departments are not accessible 24 hours a day; 10 percent of the 3,000 local health departments don't have e-mail, let alone a computer network that links to hospitals and other health departments that would allow information about suspicious events to be distributed quickly."³⁸

Benjamin, now the executive director of the American Public Health Association (APHA), recalls that "September 11 brought home the fact that we had to do something about public health preparedness. Before, there was a small cadre of people concerned about bioterrorism and a small amount of money from the CDC on bioterrorism that was a specialty program and not well funded." And those people were not listened to but "were seen as doomsayers. The West Nile virus episode put people into a response mode, at least on the East Coast. They became tuned in to interagency cooperation to respond to an environmental event. Anthrax rolled out very slowly, insidiously. We knew it was about to come but hoped that it wouldn't . . . and then [were] shocked that it happened, but still there was an avoidance of its implications." After some days of confusion, there was "a quick response and great concern about the impact."³⁹

Benjamin's views reflected the growing worries about the public health infrastructure, which preceded the attacks. A CDC report published only months before September 11 detailed the terrible state of most public health departments across the country. Of the 3,000 county and city health departments, approximately 78 percent were directed by people with no graduate training. The CDC found that "only one-third of the U.S. population [were] effectively served by public health agencies." Even the most mundane technologies were lacking in many health departments around the country. "In a test of e-mail capacity, only 35 percent of messages to local health departments were delivered successfully."⁴⁰ The CDC lamented that "the U.S. public health infrastructure, which protects the nation against the spread of disease and environmental and occupational hazards, is still structurally weak in nearly every area."⁴¹ In summary, the CDC found that "our local public health agencies lack basic equipment. . . . Our public health laboratories are old and unsafe. . . . Our public health physicians and nurses are untrained in new threats like West Nile virus and weaponized microorganisms."⁴²

In the two years following the attack, state departments of health throughout the country sought to determine their own state of preparedness and to define exactly what "preparedness" actually meant. According to Southern California's North County Times, one nationwide survey found, "90 percent of county governments were . . . unprepared for biological or chemical attacks." Tom Milne, former executive director of NACCHO, reported that "a significant number of local health departments have no high-speed access to the Internet, no way of sharing data." In fact, Illinois doctors reporting outbreaks have to phone in or mail a form to the state, "basically 1920s technology for monitoring disease," said John Lumpkin, formerly the state's public health chief.⁴³ In Illinois the state's three labs—in Chicago, Springfield, and Carbondale—were not linked electronically. "The Springfield and Carbondale labs also need to be upgraded so they can perform more sophisticated tests on site . . . and new equipment that can deliver results of biological tests in one hour, as opposed to 48 hours, under conventional testing methods is needed." Iowa was in a similar position. "'Our personnel are very limited,' said [Mary] Gilchrist, who runs the University hygienic laboratory in Iowa City" and who was president of the Association of Public Health Laboratories.⁴⁴

To help remedy the flaws in the public health infrastructure that the anthrax attack had highlighted, President George W. Bush signed into law on January 10, 2002, a bill to send $1.1 billion to the states, territories, and three cities—Chicago, Los Angeles, and New York—to "develop comprehensive bioterrorism preparedness plans, upgrade infectious-disease surveillance and investigation, enhance the readiness of hospital systems to deal with large numbers of casualties, expand public health laboratory and communications capacities, and improve connectivity between hospitals, and city, local, and state health departments to enhance disease reporting."45

The moneys were distributed to the states in three components. All the states were initially given 20 percent of their per capita allotment upfront, in most cases several million dollars, to develop plans for how they would use the money and, after review, were provided with the remaining allocation. The moneys were divided into two parts. The first and significantly larger part consisted of grants from the CDC specifically "targeted to supporting bioterrorism, infectious diseases, and public health emergency preparedness activities." The second, provided through the Health Resources and Services Administration (HRSA) provided funding to "be used by states to create regional hospital plans to respond in the event of a bioterrorism attack."⁴⁶ To get the money, the governor's office, often relying on its department of health, submitted bioterror preparedness plans to the U.S. Department of Health and Human Services and was required, among other things, "to provide for at least one epidemiologist . . . for each metropolitan area with a population greater than 500,000, [and to] develop a communications system that provides a 24/7 flow of health information among hospital, state, and local health officials and law enforcement."⁴⁷ In addition, the CDC targeted "preparedness planning and readiness assessment, surveillance and epidemiology capacity, laboratory capacity, Health Alert Network/communications, risk communication and health information dissemination, and education and training."⁴⁸

In some measure, a disjuncture of expectations developed between federal officials and those at the state level. For state officials, the billions of dollars pledged to the states seemed like a huge bonanza that promised a possibility of saving the public health infrastructure that they saw as having been eviscerated by years, if not decades, of neglect. But to federal officials, responsible for literally hundreds of billions of dollars devoted to the maintenance of the nation's public health and health care infrastructure, the money made available through the CDC and HRSA augured only modest promise for improving the infrastructure.

In some states such as Virginia, the renewed attention to public health and the relationships developed through the governor's office were "beneficial to the public health system," said Robert Stroube. Because they had the "opportunity to actually interface with the governor's office," public health had "unprecedented visibility: The governor provided additional state funds for public health preparedness because he thought preparedness was as much a state responsibility as a federal one. Additionally, the governor authorized the state health department to hire an additional 140-150 people in full-time positions to carry out these new responsibilities."49

The hiring of trained personnel was a fundamental problem. Georges Benjamin said that in Maryland they were "trying to invest to get an adequate workforce. The good news is states have the money to do it, but the bad news is there [are] not a lot of people with those qualifications," and "there may not be enough qualified people to fill the jobs." Benjamin stated that Maryland was "hiring in all areas—epidemiology, laboratories, public relations, and information technology," and the state was "hopeful with two (local) public health schools that we'll find the staff we need." Texas epidemiologist Dennis Perrotta announced that Texas will hire 50 more public health workers at the state level alone. "New hires will help out at four new public health laboratories, work in public information departments and fill roles as regional bioterrorism prevention planners."⁵⁰

Unlike Maryland and Texas, the situation in Washington State was quite different. Washington is a geographically large and politically and socially diverse state with only one school of public health. Secretary of Health Mary Selecky believed that finding qualified personnel would not be easy: "You don't create epidemiologists overnight."⁵¹ In Kansas the problem of new hires was not merely financial, because in the western counties in particular depopulation had begun to seriously undermine local institutions, including health departments and hospitals. Melvin Neufeld, a member of the Joint Legislative Budget Committee of the Kansas House of Representatives, sees the issue more broadly. Some counties resist consolidation and even coordination of services because of the threat to their independence and integrity. In recent years, there have been battles over the attempts to consolidate school districts and other county governmental programs. Further, there were no trained health professionals willing to move to Kansas, a state whose major industries—agriculture and aerospace—were in decline.⁵² Other states, such as Nebraska and Illinois, used the grants to coordinate health services across county lines.

Dual Use for Bioterrorism Funding

Mary Selecky, among many others, raised the fundamental issue that this flood of bioterrorism money suggested: Was this money going to be there for the long term? And would it support the public health infrastructure generally and not just the short-term fashion of bioterrorism? "We have had numerous communicable diseases many times before we had anthrax last fall, and we're using the same systems." But would there "be a sustained, long-term investment, so . . . if headlines subside, we don't drop our attention?"53 Others asked a similar question. Officials in Chicago, for example, hoped that federal funds would go "beyond hazardous-materials suits and stockpiles of penicillin to computer networks, personnel training, modern laboratories, and updated equipment that is critical in times of crisis and in routine work." Patrick Lenihan, the deputy commissioner of the Chicago Department of Public Health, was quoted as saying, "The day-to-day stuff that is taken for granted is just what is called upon in a threat of bioterrorism." Epidemiology and surveillance were essential to the tracking of syphilis and tuberculosis as well as anthrax and smallpox.⁵⁴

Some state administrators see the efforts around bioterrorism as having had lasting positive effects on the public health infrastructure in their states. The Connecticut Department of Public Health's strategy "was the establishment of two hospital-based Centers of Excellence for Bioterrorism Preparedness and Response," at Hartford Hospital and Yale-New Haven Health System. They are "taking a leadership role in regional coordination, education, clinical care, and research to improve Connecticut's ability to respond to a large-scale bioterrorism event."⁵⁵

California had a CDC grant before September 11 for emergency planning, but in the words of Angela Coron, "September 11 focused our attention in a different way. It became very real. You look at things differently when they come home."⁵⁶

In Ohio the federal government provided nearly $35 million to fund bioterrorism-related activities, $30 million of which the CDC provided and HRSA the remainder.⁵⁷ Eleven million dollars went to local health departments as a result of these grants.⁵⁸ Anne Harnish, assistant director of the Ohio Department of Health, recalls that September 11 forced the department to "revamp the way we looked at everything. . . . In our strategic plan we added the goal of preparedness." The department improved the relationship between "local hospitals and local health departments" and "established 24/7 communication with local health groups so all public health has benefited." She notes that bioterrorism money was critical to the Department of Health "because when people were laid off, it was sometimes possible to rehire them under the bioterrorism rubric."⁵⁹

It was not just the money. The federal and state focus on bioterrorism aided the state in reorganizing its training program for local health agency leaders and Department of Health staff. The department trained 250 local health agency leaders and 413 Ohio Department of Health staff in the principles of their new Incident Command System that would become important for managing the state's smallpox vaccination program. Hospital personnel were trained to recognize "an unusual infectious disease outbreak due to the release of a BT [bioterrorism] agent."60 This sensitized hospital staff to the importance of reporting infectious diseases to state health authorities, a legal requirement that was often ignored in practice until then.

Virginia, home of the Pentagon and therefore a direct victim of the September 11 attacks, received over $27 million in federal funding, with over $24 million coming from the CDC. It used the money to hire epidemiologists and provide health planning for the 35 local health districts and five regions and to "implement plans for the [Strategic] National Pharmaceutical Stockpile and the smallpox vaccination program." The state also developed "biosafety level 3+ labs and a network of 90 local labs as well as 18 scientific staff to enhance biologic and chemical agent identification." Regional planning for the hospital infrastructure and disaster planning and surveillance activities were all improved as well.⁶¹

Lisa Kaplowitz, former director of the HIV/AIDS Center of Virginia Commonwealth University, was hired with this new federal funding as deputy commissioner for bioterrorism preparedness in the Virginia Department of Health (VDH) but soon found that her role had expanded to "emergency preparedness—an all-hazards approach." According to one report, the "health department [was now] involved in many types of disasters, natural and manmade."⁶² Kaplowitz believes that the department was making good use of the funding. "We are making good progress on the hiring of our public health response staff. About one-third of the 138 new positions have been filled, and most are expected to be filled by early next year. A key component of our preparedness efforts," Kaplowitz notes, "is to build public health infrastructure. People must be in place, trained, and equipped with a well-planned and tested system to effectively detect and respond to any public health emergency." Within a short time the VDH had hired "all key central office Emergency Preparedness and Response Staff, . . . [including] 20 of 35 district epidemiologists . . . [and] 11 of the 35 district emergency coordinators. . . . VDH's Health Alert Network has been established to ensure effective communication connectivity among public health departments, health care organizations, and other public health partners."⁶³ Kaplowitz recalls that the "Health Department was very pleased with the rapid funding" but that there was "a lot of anger and frustration" among police and fire officials "that they were not getting the money [$3.5 billion] that was promised. . . . People were counting on it, and the legislation was never passed" until mid-2003, and even then it was greatly reduced.⁶⁴

Some of the least populated and most rural states such as North Dakota, which had experienced massive flooding and other environmental disasters in the 1990s, found that the money earmarked for bioterrorism was a benefit to the state's public health infrastructure. Sheila Peterson, director of the North Dakota Office of Management and Budget, noted that the money helped the state to hire epidemiologists and to acquire more equipment for their labs. She does not believe that the new emphasis on bioterrorism created "a drain in resources." In fact, "federal moneys have enhanced our abilities so much."65

Arvy Smith, deputy state health officer, and Brenda Vossler, bioterrorism hospital coordinator for the North Dakota Department of Health, explain that the $6.9 million that the state received from the federal government has helped them develop new capabilities in bioterrorist response. The department expected that there would be 13 new hires. Whereas "previously [the department] had only one epidemiologist in each of six regional offices, [it] now [has] added two more. . . . Our labs needed updating and federal funding was important. . . . Our communications with partners improved dramatically. We are working on our Health Alert Network to connect emergency responders and health care providers electronically as well as improving training and coordination of public health programs throughout the state." The infusion of federal funds was of critical importance. "State budgets are very tight now. Without federal money, improvements to public health infrastructure are not possible."⁶⁶

In the days following the anthrax episode, bioterrorism became the "top priority" for the Arizona Department of Health as well as for the entire state, according to Catherine Eden. The department had organized an emergency response system six months prior, a plan that relied "heavily on our county health department partners." But following September 11 and the anthrax episode, the state health department took on greater responsibility for the laboratory testing of suspected anthrax cases, hoaxes, and other potential bioterrorist emergencies. Despite these added burdens, Catherine Eden and David Engelthaler recalled that "we were able to cover all of our needs. . . . I don't know of any specific issue that suffered."⁶⁷

Kentucky received $16 million, of which $14 million came from the CDC for bioterrorism but which also aided the state's public health infrastructural development. The state used this money to improve its public health laboratories, upgrade coordination among various institutions, and strengthen its epidemiological and surveillance systems. Kentucky had been the site of the first test of the Strategic National Pharmaceutical Stockpile even before September 11.68 Rice Leach, commissioner of the Department for Public Health, recalls how "October 8 was the exact date that everything changed. In the middle of a meeting a person came in and said that they had a possible anthrax [attack] in three of our clinics." Within half a day, "environmental protection, police, national guard, and other agencies came together to come up with a way to handle all the specimens." Although the state and the department "were caught somewhat flatfooted" by the anthrax scare, the "department, especially the laboratory side, worked almost around the clock to test samples," and the state had to absorb the enormous costs. "We definitely changed priorities. We had to stop doing some things. We got no new money until the CDC grant [$15 million]. We had to absorb the new planning with hospitals, med[ical] societies, etc. It was a public health emergency, and we responded."⁶⁹

Leach acknowledges that "the focus on bioterrorism has taken energy away from the routine monitoring that we engage in," but at the same time it has spurred improvement of the state's communication system so as to provide 24/7 communication with every health department in the state. He believes that "increasingly, people are working together better. People used to talk about each other and are now talking with each other." Leach believes that the states were immeasurably helped by how flexible the CDC was under Jeff Koplan, who told them that they could "use your other grant money to take care of anthrax. You didn't have to dot every i in the grants to prove you were using it for the purpose you stated. . . . The [secretary] of health and human services is trying to make it right. I give him an A for effort." Leach even believed that the essential issue was not the lack of resources provided by the CDC. "If you had given us more than $15 million, we might not have been able to spend it effectively."70

As part of Kentucky's grant from HRSA, the state was able to upgrade two animal laboratories. "Why animal labs? 'The critters could be a source of terrorism,' Leach said. 'Someone can infect our milk, eggs, chickens, and maybe, or maybe not,'" infect humans.71 Bioterrorism provided the rationale to improve a service essential to this rural state. In Missouri as well, state officials saw the federal government as a "great partner" in the months immediately after September 11. As Ronald Cates, interim director of the Department of Health and Senior Services, put it, the money was "tremendous for Missouri and helped to build a great system for the state."⁷² In Colorado federal bioterrorism money was used to improve the public health system. "'We discovered our infrastructure was very, very fragile,' said Chuck Stout, director of the Boulder County Health Department." The money was used "to hire 14 epidemiologists to help improve disease tracking" and "to improve communication among local health departments," as well as to "beef up laboratories at state facilities in Colorado Springs, Denver, Durango, Grand Junction, Greeley, and Pueblo."⁷³

Mixed Reactions to Bioterrorism Funding

While many state administrators and legislators were enthusiastic supporters of Washington's efforts to combat bioterrorism, other states, such as Kansas, Louisiana, New Jersey, and Texas, had mixed reactions to the impact of federal funding on their state health departments. Perhaps J. Thomas Schedler, chair of the Health and Welfare Committee of the Louisiana State Senate, put it most succinctly: "I guess there's always a good news/bad news scenario in everything you do. I think the good news from a public health standpoint is that the area of public health in Louisiana probably needed some drastic overhauls and new influx of money for years and years, and sometimes it takes a crisis to make that happen."74

Specifically, Louisiana "for a long time needed to upgrade [its] lab facilities. . . . That is occurring in several sections of the state [where it] would probably not have occurred without this crisis. . . . Communication lines between hospitals and the Department of Health and Hospitals have been improved. [We stockpiled] certain types of drugs that were not there before, and even though we had limited supplies, it certainly put a focus on those types of things." The other areas that benefited were "looking at things on a regional basis . . . and the structure of command in the event of a biological attack or some other crisis. . . . So that's the good side of it."⁷⁵

But, Schedler points out, "there's a down side as well." The new emphasis on emergency preparedness "has put an untold strain on our budget. . . . The states are having severe trouble right now with Medicaid and budgets and downturns of sales tax, corporate taxes, and the like. So the timing of this couldn't have come at a worse time, but nonetheless, we have seen a tremendous shift into that arena."⁷⁶

In New Jersey, George DiFerdinando, Jr., deputy commissioner of the state's Department of Health and Senior Services, recalled that since the state was the site of some of the first reported anthrax cases at the Camden Post Office and also directly across the river from the World Trade Center disaster, it was especially hard hit by anxiety in the weeks following September 11. "At that time," DiFerdinando recalls, "I was functioning in an operational role [as acting commissioner], and on 9/11, though we were not the lead agency in New Jersey, we could sign executive orders to let people get the medical records of missing relatives and to allow for the release of names of missing people." He remembers that they received "an agreement from Tommy Thompson from Health and Human Services that state agencies could use funds from other programs, for example, tuberculosis, for emergency purposes." While the state could therefore "reallocate people as needed," the strains on the system were enormous. "If there had been another explosion in Philly, then it would have been very difficult to decide where to put resources."⁷⁷

Federal money was especially important for "improving public health and health care infrastructure."78 In "Lessons from the Anthrax Attacks of 2001: The New Jersey Experience," Eddy Bresnitz, the state epidemiologist, and George DiFerdinando summarized the crisis that faced the state in the months of September and October 2001: "New Jersey became the focal point of the bioterrorism-related anthrax outbreak in the United States. At least four letters containing weapons-grade anthrax spores passed through the Trenton Postal Processing and Distribution Center [PDC] in Hamilton Township, New Jersey, in September and October 2001. The spore-filled letters caused widespread contamination." In all, 1,100 workers were exposed, and five of them contracted anthrax; one New Jerseyan who did not work in the post office also became ill with anthrax. The state immediately established a surveillance system that included 61 area hospitals from 15 counties. This created tremendous strains on the hospital staff and taught the state that "in the absence of a credible exposure or apparent outbreak, the most critical function is to have a sound surveillance infrastructure for routinely notifiable conditions, such as the more common infectious diseases that must be reported by law. This infrastructure establishes the relationships, lines of communication, and awareness of reporting procedures that are critical to identifying index cases and monitoring for other cases in the event of an intentional exposure. Most outbreaks are not detected by surveillance systems but by clinicians who suspect an unusual event and notify public health officials."⁷⁹

Bresnitz and DiFerdinando learned that in many ways "the response to the contamination of the Trenton PDC was fundamentally the response to a typical airborne contamination of a workplace." But the one major difference was that "the Trenton PDC exposure . . . occurred within a regional and national context of a national state of emergency, and the situation gained resonance beyond any typical workplace safety issue. As a crime scene and as part of an emerging national war on terrorism, the contamination of the Trenton PDC and the public health response involved all levels of the U.S. government and all forms of media."80 Federal money coming into the state following September 11, therefore, "went for public health and health care infrastructure."⁸¹

While New Jersey's experience with federally allocated bioterrorism money was generally good, and even though it was given leeway in the allocation of resources, the state still experienced difficulties. The first major problem was in planning for services when the federal budget itself was in crisis and decisions about funding occurred "only five months before the start of the fiscal year." The state did not know what cuts might occur in existing programs, whether it would be able to balance those cuts with new money, or whether federal mandates would dictate how the money should be spent. The second problem was that emphasis on emergency preparedness distorted some priorities. "Before September 11, New Jersey had a substance abuse task force" that estimated that "there might be a million people in need of treatment under the concept of treatment," of which 80,000 at any time might voluntarily ask for treatment. "In August of 2001 we had high hopes for extra dollars" to treat 40,000 people. "But no one heard that after 9/11. How could it be any other way after money started flowing for bioterrorism?" DiFerdinando and the state had expected increased revenues from the tobacco tax that had recently been raised to $1.50 per pack. "This would have allowed the $30 million commitment for tobacco control to rise to $45 million. But with the budget constraints, the governor is now proposing $10 million." The state budget crisis had undone the increase in revenues that the health department had expected from the tobacco tax. In the end, DiFerdinando believes the problems facing New Jersey were due to "a confluence of the state budget crisis, bioterrorism, and smallpox."⁸²

Texas: A Case Study of the Mixed Blessings of Bioterrorism Money

Texas, a huge state with 254 counties and a highly decentralized county-based public health system, was nearly overwhelmed by the anthrax episode. Jack Colley, state coordinator for emergency response, recalls that "with anthrax we quit trying to keep track of the number of undetermined white powders. What did we learn? Before we had eight labs working from 8:00 to 5:00, and now we have ten labs with 24/7 capacity." The state quickly became skilled at "how to process, detect, and give feedback, that is, confirm or deny, quicker." It "treated every single reported white powder as potential anthrax" and mobilized to swiftly "detect biological, chemical, and radiological agents."83

The problems facing a state the size and complexity of Texas, with many far-flung rural counties, were daunting. Emergency Medical Services and fire department personnel wanted new equipment, county officials wanted to ensure that localities have "plans in place to handle a biological outbreak and have the capabilities to detect, treat, and contain a biological incident. Local hospitals and health departments in the county need to be able to recognize signs of illness, report the suspect diseases, treat mass casualties, and provide necessary antibiotics or vaccines." One evaluation by the Texas Association of Counties of the state's emergency response system concluded that "since Sept. 11, the Texas Department of Health has been gearing up preparation and response activities, but the state system relies on local public health entities to identify attacks, and little is known about levels of readiness at the local level, especially in rural areas." The problems identified included poor infectious disease surveillance programs at the local level and "many health care professionals [who] lack[ed] the capability to handle bioterrorism."⁸⁴

Localities, like the state, were strapped by the increased demands placed on them at the very time when budgets were contracting and taxes were being reduced. "Harris County Sheriff Tommy Thomas, who serves on the governor's homeland security task force, said many agencies, both governmental and private, voiced concerns about the cost of security during a hearing about terrorism preparedness issues in Houston." As a result, many counties turned to the state and the federal government for additional funding.⁸⁵

Governor Rick Perry "authorized the use of more than $6 million from the health department's budget for improving bioterrorism preparedness, including adding staff, upgrading laboratory equipment, and improving training." In addition, the state received $2.1 million from the Department of Mental Health and Mental Retardation to address posttraumatic stress. The health department, according to state epidemiologist Dennis Perrotta, also began "working with other agencies to improve communication systems, prepare health facilities, and create a plan for getting medicines and improving detection of outbreaks." Perhaps what came through most forcefully was that "a strong and flexible public health system is the best defense."86

Perrotta, who had served as a consultant to the Asthma Surveillance Case Definition Work Group of the Association of State and Territorial Health Officials, had a broad view of the crisis affecting state health departments across the nation. He became acutely aware of both the tremendous support federal bioterrorism money provided for the states as well as the problems. The CDC grants were welcomed, but the "big surprise was the amount of work that the CDC and HHS [Department of Health and Human Services] wanted us to do in planning. Now it makes sense." While Perrotta believed that "there can be a distortion of priorities" as a result of the federal grants, overall "this money is really helping us build an infrastructure in epidemiology that I only dreamed about when I came here years ago. The dual nature of this money is being put to good use. Planning is crucial and we're able to do it, and we are building new relationships with the emergency preparedness people in other departments."⁸⁷

Perrotta points out that Texas was using the "money to build the infrastructure in local and regional health departments" where epidemiologic response teams were established for bioterrorism, but the state also "used them for other public health problems. Thirty-two people have been hired in the eight regional offices, which is key, and local health departments have hired two to three times that number of people." Perrotta believes that the state has been "dramatically improving its capacity and ability to respond" to bioterrorist threats, as well as to other infectious disease threats, such as the West Nile virus and SARS. "It is a nice time to be in my position."⁸⁸

Although there was a "great interest in the legislature in the activities of government to protect public health," Perrotta's "priorities have been overwhelmed by bioterrorism, with 90 percent of my time spent on the two bioterrorism grants and smallpox." Perrotta worried that since many counties had no local health department, "the state department would be required to do disease surveillance and other public health activities in these areas." The basic infrastructure needed to be reinforced before more complex systems were put in place. Perrotta believed that having a system of syndromic surveillance, for example, would be useful, "but with the resources I have, I need to worry about much more basic stuff."⁸⁹

Perrotta's experience as the state epidemiologist is very different from that of Jack Colley, the state coordinator of emergency response, illustrating the varying perspectives of those inside and outside health departments themselves. In short, Colley believes that his "budget is not adequate" for the effort the state put into planning and preparedness operations: "You will never be able to determine the cost of the effort that we have put into it. We cannot put a dollar amount on the pure effort. September 11 changed our whole operation." Right after September 11, "we were told that Congress was going to appropriate $3.5 billion for emergency preparedness that would go to the locals and the states. They promised $335 million in a supplemental budget to plan for how to use the $3.5 billion." Colley recalls that state employees "worked hard in the spring and developed many, many programs. We spent endless hours doing our homework. It was a tremendous effort to come together for a common cause, and there was no infighting, we were all in this together. . . . But the $3.5 billion has yet to appear, and the $335 million was reduced to $100 million. 'The check is in the mail' but has not been delivered," Colley laments.90 In an article in Washington Technology, William Welsh noted that President Bush's "2003 budget promised $3.5 billion for new first-responder grants to be overseen by the Federal Emergency Management Agency. But in the bill approved by Congress, only a fraction of the money is actually new funding, according to an analysis by the National Governors Association of Washington. Most of the funds come from older programs that either have been eliminated or consolidated, or whose scope has been broadened to include homeland security, the association said."⁹¹

The problem with the failure of the federal government to deliver on its promises was that "when we prepare for terrorism, we prepare for everything," Colley observes. Unlike public health officials, whose perspective was historically more limited to infectious disease outbreaks, Colley was involved in planning for a wide range of threats to population health. Since the summer of 2002, Texas has "gone through four presidentially declared disasters," including one flood that affected 41 counties, an area larger than that of South Carolina. In addition, major resources went into the effort to gather materials and evidence across a wide swath of the state following the Columbia shuttle disaster in February 2003. From the perspective of the emergency response team, "We are in constant response mode. . . . I'm disappointed that the federal government has not given more resources to state and local governments. Partnership should be about not just sharing information but sharing resources. The intention is there, but show me the money." Colley asserts that the establishment of the Department of Homeland Security in June 2002 further drained "resources that would have or could have gone to the states." Interestingly, in contrast to Dennis Perrotta, who believed bioterrorism money strengthened public health in Texas, Colley questioned whether emergency preparedness money was strengthening emergency preparedness in Texas. Colley asked whether emergency response to hurricanes, floods, and other natural disasters has been shortchanged. "FEMA [Federal Emergency Management Agency] was a very efficient organization, but they have been brought into the Department of Homeland Security. We need to make sure that these programs stay viable in 2004."92

As with public health, the relative poverty of rural county governments was of real concern in emergency preparedness. "For many counties low on funding, [antiterrorism and emergency preparedness] could be a large order to fill. The state's Division of Emergency Management [DEM] reported local governments need $195 million to better equip first responders such as police, public health, fire departments and hazardous materials teams with protective suits, decontamination equipment, and monitoring and detecting equipment. The DEM also reported there is a training shortfall among emergency responders with more than 290,000 personnel across the state in need of terrorism response training. It's safe to say that this shortfall lies largely within rural counties. Large, urban counties likely have a terrorism task force or a hazmat response team, while in a rural county the closest hazmat team might be 100 miles away and the county depends on neighboring counties for assistance and equipment."⁹³ Although metropolitan areas that participated in bioterrorist preparedness activities had received federal subsidies for several years, Texas and other states considered the subsidies inadequate. The states' experiences with the federal grant programs, which we will explore in the next report, varied in part because of regional and state distinctions.

Distortions Caused by Federal Bioterrorism Funding

While many state officials saw the federal involvement in bioterrorism and emergency preparedness as generally beneficial or at least a mixed blessing, American Public Health Association executive director Georges Benjamin (then president of the Association of State and Territorial Health Officials) and others developed a fundamental critique of the effect of federal funding for bioterrorism on population health. Within a few months of the World Trade Center disaster, Benjamin was cited in a February 5, 2002, New York Times article as cautioning that "while public health officials view bioterrorism preparedness as important . . . it should not come at the expense of other programs. They note that just five Americans have been killed by bioterrorism over the last year, while thousands die each year of chronic illnesses and infectious diseases. 'We will be very concerned if we are funding one thing at the expense of another,' said Georges C. Benjamin. . . . 'If you really want to push people towards better health, you have got to keep these programs in place.'"⁹⁴

The concern at the time was prompted by the fact that a new federal "budget proposal calls for a $57 million cut in the CDC's program for chronic disease prevention and health promotion. Infectious disease control, meanwhile, would be cut by $10 million, at a time when public health officials are particularly concerned about the threat of new and emerging infections." The budget for other programs, including "childhood immunization, environmental health, preventing birth defects, and sexually transmitted diseases, including AIDS," would remain flat. Advocates worried that their own public health priorities would be shortchanged. The New York Times quoted Marsha Martin, executive director of AIDS Action, who said that President Bush was sending "a clear message that our nation's public health has fallen off the administration's radar screen." Martin also asked for a broader definition of emergency preparedness: "homeland security also means investing in prevention and care services for people at risk and living with H.I.V."95

Benjamin was also concerned about the panicked and erratic reaction of federal officials who were sending out mixed messages about future funding and priorities. "'Yo-yo funding has been the history of public health,' said Dr. Georges C. Benjamin. Dr. Leslie M. Beitsch, the former health commissioner in Oklahoma, said, 'I think it's a very significant commitment, but the question then becomes, is it a long-term commitment?'" State health officials echoed these fears, saying "they were eager for the money [for bioterrorism preparedness] but were concerned that it would not last."96

In Connecticut there were worries among hospital and health care professionals that despite the promises of adequate supplies, the Strategic National Pharmaceutical Stockpile would not be there when it was needed. Norma Gyle, deputy commissioner of the Department of Public Health, has misgivings that the "42 local clinics that are being organized and have been extremely active in recruiting and staffing" might not have funding in future years.97 In Minnesota Lee Greenfield, former legislative leader and now an adviser to the Hennepin County (Minneapolis) Board of Commissioners, believes that the mixed messages about the funding for emergency preparedness would lead the "sheriff's people" to demand "space suits" for bioterrorism activities, while public health departments would go without. "Priorities were kind of mixed up."⁹⁸ In Iowa there were concerns that existing programs were already suffering because of the new priorities. As of April 2003, they had not received crucial funding so they "are taking money out of other programs. . . . We are shifting maternal and child health to the Medicaid side of the equation. We are borrowing people from the University of Iowa because it has a lot of talent that we can draw on to create a response team and do training." State officials worried that "we have top-down communication but no process by which to activate it.⁹⁹

When Angela Coron, associate director of the California Department of Health Services, was asked if the state was paying enough attention to the everyday issues of public health, she answered, "No. We are dealing with bioterrorism where the threat is unknown versus other issues where we know they are killing people. We always question where we put our limited resources." She acknowledges that "without the new bioterrorism grants from the federal government, we would not have been able to do what we have done. To do more, we need more money. We do not have enough funds to do all the things we know we need to do."100

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Effects of Budget Crises on Public Health and Emergency Preparedness

Whatever the conflicting views of state officials about federal bioterrorism money in general, there was a broad consensus that the budget problems that most states began to suffer in 2002 have had a deleterious impact on states' abilities to respond to both bioterrorism and population health needs. The positive effects of the federal bioterrorism funding in various states were undermined by the economic downturn that devastated most state budgets, and the distortions in services and attention created by that infusion of money were amplified as state legislatures attempted to cope with huge deficits and falling tax revenues. Except in a handful of states, officials complain that essential public health services had to be cut back in part because federal mandates required an increase in spending for targeted programs and was, in the case of smallpox, a generally ill-conceived effort. A few have questioned, however, whether the redirection of attention and resources had any major impact, asking whether "greater resources build sustained, integrated systems that will solve problems."101 In this section we will describe the experiences of the various states and the influence of growing deficits on public and population health programs. As legislators moved further away from the events of fall 2001, population health preparedness became one of a number of competing budget priorities that needed to be considered in tough fiscal times.

In midwestern states such as Minnesota and Iowa, downturns in the economy were exacerbated by September 11 and the broad economic recession that continued into 2003. "In Iowa we have done much difficult cutting in the past three years because our revenues have been down," Mary Kramer, president of the Iowa State Senate, observed. "Our economy is just stagnant."¹⁰²

In Minnesota, Lee Greenfield notes, "the immediate effect of 9/11 was most seen in the airport and air travel" industries. The state is the home of Northwest Airlines, and mass "layoffs occurred here, as generally in the country. A lot of people are choosing not to fly. That had a serious economic effect on everything at once." Minnesota had a $27 billion biennial budget and faced a $4.2 billion shortfall for which there was no hope of increased revenues, since the newly elected governor gained office "on a platform of no new taxes." Further, the state "house Republicans were also elected on that basis, and they are the majority in the house. . . . Obviously, without any new taxes the proposal from the governor's office is to essentially cut $4.2 billion in spending." Since the governor had vowed not to cut public education from kindergarten through twelfth grade, "that throws it all to the rest,"¹⁰³ and population health programs were a major portion of the rest. In fact, virtually all state agencies, including education, suffered serious cuts.¹⁰⁴ Cuts in budgets, new federal money, and changing goals of departments created a situation in which there was limited workforce availability in most states. Mary Selecky, secretary of the Washington State Department of Health, suggested that Washington State has "the same people doing many things—no matter the funding."¹⁰⁵

Arizona's state budget deficit in 2003 was $500 million, or 8 percent of the budget, and in 2004 the deficit is expected to top $1 billion, or 15.8 percent.106 In California Angela Coron notes the chasm the state is facing: "Our budget deficit is $34 billion, which is larger than the actual budgets of any state except New York."¹⁰⁷ By June 2003, the projected deficit was $38.2 billion, fueling a successful effort to recall the state's governor.¹⁰⁸

At the other end of the country, New England states also face crises of immense dimensions. In Maine, a fairly large state geographically with a small but highly dispersed rural population, $1 billion has been cut from the $6 billion two-year budget. "We've been losing federal money," notes Charlene Rydell, the health policy adviser to U.S. Representative Tom Allen and a former state legislative leader.¹⁰⁹

The situation in Massachusetts was equally grim. State Senator Harriette Chandler, a member of the health care committee, said the state was "between a rock and a hard place. . . . If we're talking last year and this year—last [fiscal] year being the [calendar] year we are currently in—I'd bet the budget has been cut 20 to 25 percent easily. On top of that there will be more cuts coming. We're $3 billion in deficit for 2004."110

Only Wyoming and North Dakota reported that their state economies and budgets were in good shape. Florida and Arkansas had no budget deficits in fiscal year (FY) 2003 but are projecting substantial deficits in FY2004. Sheila Peterson of the North Dakota Office of Management and Budget described the state's budget as "tight but balanced. North Dakota's economy does not tend to experience the wide fluctuations, the major ups and downs, like other states' economies. In fact, as an energy-exporting and commodity-exporting state, we tend to run countercyclical to the national economy."¹¹¹

Economic Problems Affect Population Health Services

The effects of these budget cuts on public health departments and programs were severe, especially in those states that had invested a significant amount of state money in building up population health programs. Ironically, states that had relied entirely on federal grant funding without investing state funds were affected less severely when state budget deficits forced a contraction of state health programs.

In Minnesota some of the health department's signature programs were threatened. The tobacco suits that were first initiated by Minnesota's attorney general had resulted in the creation of what was to be a permanent endowment "to pay for antismoking campaigns for young people and for some medical education and the like." About $1.3 billion, Lee Greenfield estimates, was to be put aside. But because of the budget deficits and the state's unwillingness to raise taxes, "the governor is undoing those endowments or at least suggesting they be undone" to provide a quarter of the money needed to close the budget deficit. The rest is being accomplished through programmatic cuts, "including some severe cuts in the various programs we have for providing health care for people."112

Minnesota, Greenfield points out, with its long tradition of populist politics, had developed in the mid-1970s the "only statewide general assistance medical care program for adults without children who would otherwise not be eligible for Medicaid." Then in 1992, "Minnesota Care was enacted to subsidize health insurance for working families (with and without children) whose incomes were above Medicaid eligibility and who paid premiums on a sliding fee scale. . . . The part that's for families and singles without children is being drastically cut, in fact eliminated." Greenfield estimates that "there are about 68,000 people who would lose their current coverage in state or federal programs." Traditional public health activities are also being affected, despite the influx of federal money for emergency preparedness and bioterrorism. "There is nothing being eliminated," Greenfield notes, but inspections of restaurants, nursing homes, and other establishments are being reduced.¹¹³

In Connecticut the state has ordered 5 to 10 percent across-the-board budget cuts, notes Norma Gyle. "Lots of lab people are taking early retirement—not because of 9/11 but because of the budget crisis. We have had to cut back and there is only one manager left at the lab, and eight have retired."¹¹⁴

In Ohio the Public Health Department budget was cut 21 to 25 percent, with cuts occurring in every area. As in Minnesota, education could not be touched, in this case because "Ohio is under court order to provide education for every child in Ohio." As a result, Anne Harnish recounts, "We've had staff reductions of 60 of 300 people approximately. Maternal child health clinics have been reduced, hemophilia treatments for adults have been eliminated, immunizations and laboratories have been cut, and local environmental health efforts have been reduced." There have been only two areas in which the department has seen increases in funding: vector-borne diseases, as a result of worries about West Nile outbreaks, and vital statistics, which is a result of charging increased fees.115

Virginia's "very large deficit" has resulted in the "yo-yo funding" that Georges Benjamin feared. Lisa Kaplowitz, the state's deputy commissioner for emergency preparedness and response, notes, "Last year more money was put in to fund epidemiological positions and emergency medical services, but this year much money was cut because of a $2 billion deficit." Public health was able to "support its core missions," and "care for women and children, HIV, immunization, etc., have been preserved." What suffered were funds that in more prosperous periods would have been sent on to nonprofit agencies.¹¹⁶

In Kentucky the budget had an 8 percent shortfall, and when the General Assembly did not pass a budget, the governor put together "a spending plan" that cut all departments by 10 percent. As a result, according to Rice Leach, commissioner of public health, the department was left "with no wiggle room at all. We used to have money to implement good new ideas, but no more." Even worse, the department "lost 40 positions out of 400, and there is a hiring freeze." Leach argues that public health should be doing various forms of environmental monitoring, such as septic tank and restaurant inspections and monitoring outbreaks of disease related to food, "but now we are working only on urgent problems, not routine monitoring, and things will happen if we don't keep an eye on routine monitoring."117

Leach relates that he had "been in public health since 1966, but this is the first time I can't maneuver to head off perceived problems like a meningitis outbreak or other acute issues." Kentucky is unable to do things in the same way it did before. For example, prenatal clinics may open for only three days, not five. "Maternal and child health doctors were reassigned to bioterrorism so that there was not a net loss of personnel to the department, but there was one person gone from maternal and child health."¹¹⁸

Kansas faced a particularly difficult period. As a result of the severe economic downturn, as well as the loss of tens of thousands of jobs in the aircraft industry that provided good health benefits, "charity clinics are being overrun," notes Melvin Neufeld. "There are also substantial cuts in Medicaid reimbursement and a lot of resistance from the provider community and threats to reduce provision of services." Residency programs for physicians are being cut, which is threatening services to 137,000 individual patients. If they lose the indirect costs of medical education under Medicare, "medical education in Kansas is threatened with collapse." Neufeld believes that ultimately this will result in fewer physicians in private practice and in local hospitals and, as a result, "charity clinics will be even more overrun." As in other states, "the governor vowed not to cut education, so the rest of government appropriations are collapsing." Neufeld notes that the State Children's Health Insurance Program (SCHIP) "may not have enough money to meet their matching costs, and therefore the state might have to give up all [its] federal money."¹¹⁹ Neufeld, as a state representative, sees the broad implications for population health of subtle demographic and economic changes on the funding of medicine and its institutions.

In Maine as well, Charlene Rydell, an adviser to Representative Tom Allen, is sensitive to the broader impact on population health of the "hundreds of millions of dollars" that need to be pared from the state budget. "They are cutting funding to providers; they're cutting the number of state workers; they're cutting the university; they're changing the way state purchases are done. They're cutting incentive payments to doctors for children's health visits." As Rydell explains, the state had expected more help from the federal government to do "more preparation" for emergency preparedness, "especially in hard fiscal times." Maine is "suffering from both hard economic times and heightened needs for homeland security."120

Local communities and the state do not have the resources to cover the added expenses. For example, airports are now a federal responsibility, but "local police have to be at the airports more, and they are a local responsibility." Rydell explains the ripple effects of such a seemingly small increased responsibility. "So we're taking police off the streets to be at the airports. This will cost more money either in overtime or in more police. And where are we going to get the money? The federal presence at the airport is very visible, but people are less aware of the uniformed and plainclothes police who are also there." She points out that there was supposed to be more money for first responders, but grants from the Department of Homeland Security have not come through, which has added strains "to already stretched budgets. We have had to spend more money to make sewers, water, etc., more secure."¹²¹

Similarly, in Massachusetts, State Senator Harriette Chandler is mindful of the substantial impact of budget deficits on social programs, hospital care, and other population health programs throughout her state. With the antitax platform espoused by the governor and much of the state legislature, public health programs will likely be devastated by the budget deficits. "The Department of Health, according to our governor's budget, is going to be totally reorganized with major cuts," Harriette Chandler and Tim Daly report. The governor has the constitutional power "to cut unilaterally in certain areas, and health and human services is one of those areas that he can cut. That is exactly what has happened here. So we have seen over and over again hits to public health." Among the services that have been affected are nursing and school-based clinics, which "in many cases are gone." In addition, research has been severely restricted, and "some of our AIDS programs have been tremendously cut—35, maybe even 40 percent. The cuts are enormous."¹²²

Daly laments the horrible consequences for health-related and often proven programs: "Tobacco control has basically been eliminated. We had a model program nationally and that's gone. Absolutely gone. Hepatitis research, cancer research, any funding that was disease specific, is gone. We have a new commissioner of public health, and I would assume that she will see her budget dramatically, dramatically cut." In short, according to Chandler, "It is a nightmare." This is her ninth year in the legislature, but for "the first time people come up to me and say, 'I'm so glad I'm not you. There are terrible, terrible things you have to deal with this year.' And they are terrible. We've cut Medicaid so that we have turned loose on the street without health care 50,000 Medicaid patients. We suspect more will be coming. I don't know what's going to happen to these folks without preventive health care. They are going to jam our hospital ERs, and those hospitals are already teetering on financial disaster."¹²³

Chandler worries that the original commitment to public health and emergency management is waning as we move further away from the September 11 tragedy. "As the days and the weeks passed since 9/11, I think the terror and the horrific impact that we had on that day and for such a long time after is receding in our minds," she worries, "and so we go about our lives, and of course we've been overtaken now with this incredible budget crisis that we have. That has become, unfortunately, our first priority. So everything becomes secondary to that." Even public safety is being cut. "We have an emergency medical system that we passed into the law in 2000 called EMS 2000 . . . and everybody hails it as a wonderful thing." Yet even this program, which appears so critical to the national agenda, has been stripped of funds. "In the governor's budget this year, he cut every penny from that line. . . . We have no way of rerouting ambulances to another hospital if a hospital is closed or [an] ER is filled. We have people in the rural areas who don't have hospitals nearby—I don't know what they are going to do without a communication system. In the case of a terrorist attack, I don't know what will happen if we depend on ambulances that have no interactive communication. And that is exactly where we are because of the budget."124

The profound budget crisis is having an equally devastating effect in California. Angela Coron describes the extensive cuts to the general immunization program: "The [then] governor [Gray Davis] has proposed a $4.5 billion cut in the health department, and Republicans are looking at between $700 million and $1 billion more."¹²⁵ Even in Texas, where state epidemiologist Dennis Perrotta notes that it was "a nice time to be in my position," critical services have suffered, including chronic-disease surveillance detection of birth defects, cancer care, and others. Because of the "proposed budget cut of 12 percent by the Texas legislature, there is a profound threat to the 'invisible' but 'real' public health planning, assessment, and protection services." While bioterrorism is "federally funded and not being cut," the "hepatitis and cancer registry are on the chopping block."¹²⁶

Health departments were also facing budget cuts in Tennessee. In Nashville, Robert Eadie, deputy director of the city's Metropolitan Health Department, notes that while the department has not yet felt the brunt of what he called the state's "huge budget crisis," the staff in the department was worried about the possibilities of grants that might not be renewed, staff cuts in the future, and further cutbacks.¹²⁷ Similarly, Arizona projects a 10 percent difference between revenues and projected income, which has led public health officials to fear for their various programs. Since "there is never any discretion in taking federal money and [using these funds] for other services" that are in danger of being cut, there is a great deal of anxiety about the upcoming budget. Catherine Eden "thinks we'll be okay—but every time you pick up a pa