nation was essential for preparedness (CDC, 2003a). Not until several weeks into the program did CDC state that “preparedness is not numbers,” echoing statements made by ASTHO and by the present IOM committee (Cook, 2003; IOM, 2003d; Kuhles and Ackman, 2003; NACCHO, 2003a; Selecky, 2003). Months into the program, when CDC attempted to reorient program focus toward the full scope of preparedness, the efforts were perceived as an attempt to divert attention from a troubled program (McGlinchey, 2003b). The pattern of confusing vaccination numbers with preparedness continued. In 2004, the DHHS secretary responded to a question about the status of smallpox vaccination, stating that “we would like to be able to keep increasing that vaccination number, so that every state is ready” and perhaps reinforcing the perception that numbers were a correlate of readiness (DHS, 2004).

Despite the late effort to differentiate preparedness and vaccination, the committee has determined that many people and institutions were able to distinguish between the two. For example, public health agencies worked on training staff, developing communication plans, and other preparedness activities while hospital administrators who decided not to receive or implement vaccination at the time continued to work on planning, training, education, and other elements of preparedness (Edmond, 2003; Selecky, 2003; Toomey, 2003).

There are other challenges to the claim that preparedness was the program goal from the beginning. If preparedness, not numbers, was the program’s focus, the frenetic pace of vaccination imposed at the beginning of the program was not needed. If the program had all along been about preparedness and not about numbers of vaccinees, CDC could have decided to delay the program because of concerns about compensation, the states could have been encouraged to proceed with their planning, training and education, and related preparedness efforts while deferring vaccination until compensation and other issues were resolved. The federal government’s single-minded and intense focus on vaccination and vaccination targets also imposed great burdens on public health agencies that may have affected not just the routine work of the agencies (the Ten Essential Public Health Services) but their ability to develop comprehensive smallpox preparedness in the context of bioterrorism preparedness.

It is unclear whether smallpox preparedness has been strengthened. Government officials have said that preparedness has been improved, but the committee is not aware of the evidence that such readiness has been reached. That type of evidence, properly communicated, is critical to reassure the public that local, state, and federal public health agencies have the