• Promotion of public health—Strive for the most favorable balance of public health benefits and harms based on the best available research and data.

• Stewardship—Demonstrate stewardship of public health resources.

• Distributive justice—Distribute benefits and harms fairly, without unduly imposing burdens on any one population group.

• Reciprocal obligations—Recognize the professional’s duty to serve and the reciprocal obligation to protect those who serve.

• Transparency and accountability—Maintain public accountability and transparency so that community members grasp relevant policies and know from whom they may request explanation, information, or revision.

• Proportionality—Use burdensome measures, such as those that restrict liberty, only when they offer a commensurate gain in public health and when no less onerous alternatives are both available and feasible.

• Community engagement—Engage the public in the development of ethically sound dispensing plans for medical countermeasures, including plans to preposition antibiotics, so as to ensure the incorporation of community values.

Recommendation 5-3: Consider the risk of attack, assess detection and dispensing capability, and evaluate the use of prepositioning strategies to complement points of dispensing. State, local, and tribal governments should, in partnership with each other and with the federal government, the private sector, and community organizations:

• Consider their risk of a potential anthrax attack.

• Assess their current detection and surveillance capability.

• Assess the current capability of and gaps in their medical countermeasures dispensing system.

• Based on their risk and capability assessment, evaluate whether specific prepositioning strategies will fill identified gaps and/or improve effectiveness and efficiency. The decision-making framework should include, for a range of anthrax attack scenarios:

— evaluation of the potential health benefits and health risks of alternative prepositioning strategies;

— evaluation of the relative economic costs of alternative prepositioning strategies;

— comparison of the strategies with respect to health benefits, health risks, and costs, taking into account available resources; and

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