and priorities and multiple sources of evidence and data are involved (Gostin, 1995). The process that led to the smallpox vaccination policy may have been similar to the development of other public health policies, except for its unusual marriage of public health and national security. Although many principles that guide other public health programs appeared to apply, the nature of the problem to be addressed by the policy made it likely that most decisions would, in time, be scrutinized and criticized. The decision to take preventive action in circumstances in which preparation itself poses a risk or cost (as in the case of smallpox vaccine) would be criticized if the threatened event did not occur. Without a doubt, a decision to do nothing would be criticized if the threat did materialize. The smallpox vaccination program occurred in an environment of great uncertainty, so it required a clear explanation of its scientific and public health rationale and required every reasonable effort to ensure transparency and effective, regular communication among public health agencies at the federal, state, and local levels.

The presentations of multiple public health and health care leaders at the committee’s meetings, substantial coverage by the mass media, surveys and briefs from ASTHO and NACCHO, findings of the 2003 GAO report, a summary of interviews with public health workers (Markowitz and Rosner, 2004), and ultimately the slow and halting progress of the vaccination program itself provided the committee with ample evidence that many in the public health and health care communities were skeptical or confused about the rationale for the program. The committee asserts that the reaction of the public health community in particular to the program (for example, deferring or refusing participation) indicates that the trust of public health agencies, officials, and workers in CDC as the nation’s public health leader was compromised. As National Institute of Allergy and Infectious Diseases Director Anthony Fauci stated (2002),

because people of good intentions disagree on government policy regarding smallpox vaccination in the context of a bioterrorist threat, the general public must understand the decision-making process as well as the rationale behind decisions that may affect their health and their lives. The need to be forthcoming is of particular importance, given the terrible trauma caused by the unforeseen events of September 11, 2001, as well as the anxiety associated with the continued threat of bioterrorist attacks. Because the population feels powerless, it must rely heavily on the deliberations and decisions of government leaders.

Explaining the decision-making process behind the smallpox vaccination policy to the public was important for both ethical and practical reasons (to inform and to reassure). Yet the federal government provided little public communication during program implementation. For the people expected to implement and participate in the program, explaining



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