The final vaccination policy differed considerably from the recommendations of public health leaders and other important constituencies, and those groups were left with questions about the rationale for the vaccination program. That contrasts with the implementation of more typical public health programs and with the principles of public health practice. First, the ethos of public health attaches great importance to the empower-ment and participation of a broad constituency in decision-making; a high degree of openness and collaboration also is consistent with the democratic principle of public accountability (Gostin, 1995). Second, effective policy-making requires identifying potential obstacles, and those are likely to be known or anticipated by key constituencies. The implementation of the vaccination program reveals missed opportunities at the level of policy-making to identify or adequately address potential obstacles to implementation (discussed in Chapter 3). For example, in addition to unease about compensation and liability issues, state and local public health agencies expressed concern that implementing a vaccination program of massive proportions, beyond the initial 500,000 vaccinees, would have safety implications and enormous resource requirements (Connolly, 2002; Hardy 2002; Libbey, 2003a, 2003b; Rosado, 2003).

That the policy was not consistent with the recommendations of key constituencies and its rationale was not clearly and adequately explained to them may also have led to difficulties in balancing competing priorities. For example, the vaccination program’s single-agent focus and great resource requirements burdened the public health system to the detriment of other public health activities, including the routine activities of public health and preparedness for other kinds of emergencies. Smallpox efforts were all-consuming for many local public health agencies, especially smaller health departments. Despite the bioterrorism grants that had been made available to states, state and local public health officials expressed frustration at the program’s vast underestimation of its direct and opportunity costs and argued that the vaccination program necessitated a diversion from bioterrorism plans that they had already developed in anticipation of funding (ASTHO, 2003; Cook, 2003; GAO, 2003; Kuhles and Ackman, 2003; Markowitz and Rosner, 2004; NACCHO, 2003a, 2003b; Staiti et al., 2003; U.S. House of Representatives, 2004). Of local public health agencies surveyed by the National Association of County and City Health Officials (NACCHO) in March 2003, 79 percent reported that smallpox activities adversely affected their other bioterrorism preparedness efforts (NACCHO, 2003a). County health officials also reported on opportunity costs of diverting staff to smallpox activities and on delaying or deferring other public health programs (Kuhles and Ackman, 2003; Madlock, 2003; Nikolai, 2003; NACCHO, 2003b; Markowitz and Rosner, 2004; U.S. House of Representatives, 2004). As one county public health agency struggled with

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