“State health departments have been actively involved in planning and preparing for the possibility of a bioterrorist event. We are now seeing that this level of preparation can also assist in unexpected natural outbreaks.”

Tommy Thompson, Secretary of the Department of Health and Human Services, in reference to the monkeypox outbreak (CDC, 2003a)

The discussion of integration of smallpox preparedness into overall public health preparedness is organized around four main topics: (1) Challenges in Defining and Assessing Public Health Preparedness; (2) Elements of Preparedness; (3) Testing Preparedness; and (4) Sustaining Smallpox and Overall Public Health Preparedness.

Challenges in Defining and Assessing Public Health Preparedness

There is significant agreement about the difficulties and flaws that characterize the public health infrastructure, and in the last two years there has been considerable discussion about the need for public health preparedness. Public health system leaders know the system is not sufficiently prepared based on the way it has responded to a number of threats and crises in recent years. However, the public health system is still in the early stages of developing consensus on defining preparedness and identifying evidence-based standards for planning for and evaluating preparedness. At a minimum, public health preparedness requires adequate and sustained funding based on priorities supported by evidence, and a strong public health infrastructure, including surveillance, workforce, and communication (IOM, 2002).

Assessments of the public health infrastructure’s capacity to respond to bioterrorism conducted after the events of September and October 2001 found a severe lack of financial resources, and a great deal of fragmentation within the public health system, from surveillance systems (which were multiple, overlapping and duplicative, and incompatible in various ways) to communication (which was limited, reliant on obsolete, inefficient channels, etc.) both internal and with other sectors (IOM and NRC, 1999; Heinrich, 2001; Peters et al., 2001; IOM, 2002; Salinsky, 2002). It is unclear at this time whether the recent influx of funding aimed at strengthening the public health infrastructure is being used to reinforce public health capacity in an integrated way, responsive to local needs and epidemiological evidence, or to simply create new funding and program categories, adding to existing fragmentation. The IOM Committee on Emerging Microbial Threats to Health in the 21st Century has described recent funding increases as opportunities for the nation to prepare to “protect against acts of bioterrorism and improve the U.S. public health response to all microbial threats” but expressed alarm that “some of these funds have been diverted from multipurpose infrastructure building to single-agent preparedness” (IOM, 2003a: 171). In fact, smallpox may have “received the lion’s share of attention and … drawn attention away from the wide range of other agents that could be used” in a bioterror attack (Powers and Ban, 2002).

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