structure, 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 epidemiologic 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). 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).

Vaccination: Only One Component of Smallpox Preparedness

In the early months of the smallpox preparedness program, preparations to respond to a potential smallpox attack have consisted largely of vaccination-related activities. These have been resource-intensive, giving rise to concerns about the opportunity costs (i.e., to essential public health services) of the smallpox vaccination program and about the optimal balance of investment of public health funds (e.g., are smallpox-related activities funded at the expense of a more wide-ranging kind of preparedness?) (APHA, 2002; Libbey, 2003; Madlock, 2003; NACCHO, 2003b; Nikolai, 2003). Surely, being prepared for a potential attack requires much more than just vaccination. It includes planning for a range of possible scenarios, including contingencies for crowd control, quarantine, and isolation; training, retraining, and management of response teams; education and training of health care providers, emergency responders, and many others to facilitate rapid surveillance, reporting, and notification; planning and coordination with many partners, including some at the state and federal level; and testing and continuous improvement of plans.

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