Bioterrorism preparedness has been making its entry into public health over the past few years. Prior to September 11th, 2001 I was asked to consider the position of bioterrorism coordinator for the Washington State Department of Health (WSDOH). I declined, the position was filled, and as I reflect back over the past few years working at WSDOH in community health assessment, I am increasingly aware of how receiving large sums of money for very specific things (e.g. bioterrorism preparedness) shifts public health in a way that, in my opinion, is opportunistic and does not protect and improve the health of people in Washington in a reliable way. General emergency preparedness would probably help the public health system respond to an event like the bombing of the twin towers. And, bioterrorism preparedness would likely help us respond to the release of anthrax by U.S. citizens. While the last case of smallpox in the world was in the 1970s, putting energy into smallpox planning should help us in the event of a smallpox case or outbreak. We must remind ourselves, however, that responding to bioterrorism is only a part of public health. In my opinion, as we shift more energy and resources into this narrow reactionary focus, general public health suffers, and our prevention efforts are undermined.

I received an email from Mary Selecky, the Secretary of the WSDOH, on February 4th, 2003 stating that we had ordered 4,000 doses of smallpox vaccine from the Centers for Disease Control (CDC) in order to move ahead with Stage 1 of our Smallpox Vaccination Plan (Phase I). On February 21st I received another email from Mary stating that WSDOH had held our first Smallpox Vaccination Clinic at Camp Murray the day before. At this pilot clinic, with our Department of Defense "partners", 70 state and local volunteer public health workers were vaccinated. It is estimated that smallpox related activities involved about 500 WSDOH staff hours in February alone. While the cost of a smallpox vaccination has been estimated as low as $13 per person, Pat Libbey, director of the National Association of City and County Health Officials, estimates that the actual cost of the smallpox vaccination is between $200 and $400 per person.

This Thursday, after the U.S. started attacking Iraq, I received another email from Mary Selecky stating, "Public health is an important part of the homeland security of our State and we are on alert, ready to respond." These "readiness" resources range from an after hours emergency hotline for drinking water to a mobile radiological monitoring assessment center. Again, I question the role of public health and the balance between a reactionary versus a preventative system. Some of the questions I have were recently addressed in a couple articles by David Solet, an epidemiologist in the Puget Sound area with over 15 years of experience in public health. (Smallpox pre-vaccinations misdirect resources,http://seattlepi.nwsource.com /opinion/109138_smallpox19.shtml and Pre-vaccination Poses Too Many Risks, http://www.wspha.org/wspha_winter_2003_newsletter.pdf

The following Q&A is drawn from an interview with Solet and excerpts from the two columns mentioned above.

Q: How does the plan to pre-vaccinate public health staff with smallpox misdirect public dollars?

Many public health priorities could use support because of state budget cuts and are not receiving adequate funding. For example, in King County, despite increases in tuberculosis and sexually transmitted diseases, there are no funds to support programs to address these increases. Resources allocated to bioterrorism preparedness are unavailable to help offset deep cuts in basic human services. To fill a $2.4 billion shortfall, Gov. Gary Locke's budget proposes elimination of dental, vision and hearing coverage for about 300,000 poor adults covered by Medicaid; cutting enrollment in the Basic Health Plan by 42 percent, and cutting support that helps cover the cost of hospital charity care. In the face of these cuts to basic health and the fact that we can vaccinate up to three days after exposure, spending resources to pre-vaccinate health care workers and, potentially, others (if Phase II and III are carried out) is questionable.

Q: What is it like working as a public health professional in the current environment of preparing for bioterrorism?

Like many other public health staff across the state, I was recruited to join a core of "first responders" to be pre-vaccinated against the smallpox virus. The recruiters were ethical, answered questions and provided much information. But, for me, it brought home the real issue of what public health as an institution should be doing. It's my opinion that requiring pre-vaccination isn't a good approach. It sets up the expectation for others to ask for pre-vaccination when it is not recommended. The health risks associated with the vaccine are greater than any known threat of the disease. Many people would like to help in a team of first responders, but do not want to be vaccinated. Requiring pre-vaccination makes it more difficult to recruit a full team of first responders.

Q: What have been some of the reactions to your articles?

I have only heard positive comments - both in person and through email. People have told me that the columns reflect their views and they are glad they were published. They felt like there was a vacuum where no one was articulating these important issues. I have also heard from people in other states such as Oklahoma and New York. Of course, this doesn't mean that some people don't disagree with the columnI just haven't heard about it.

Q: Are there contradictions public health faces in planning for bioterrorism?

In my opinion, public health isn't being given the freedom to utilize resources in the most rational way for emergency preparedness. Instead, public health is being channeled into relying mostly on secondary treatment - our emergency preparedness plans prepare us to pick up the pieces after an attack rather than help us prevent the attack from occurring. Public health needs to be opposing war, a truly preventive approach, in order to protect the health of citizens. The Centers for Disease Control and Prevention says there is "no reason to believe that smallpox presents an imminent threat." The CIA reports that attacking Iraq will markedly increase the likelihood of terrorist attacks against the United States. The possibility of terrorism is considered remote by the CIA in the absence of war. Yet, the Bush administration is trying to convince citizens that starting a war with Iraq will protect us from terrorism.

Q: Is smallpox pre-vaccination necessary?

I think we are relying on pre-vaccination too much. Vaccination is effective up to three days after exposure and available in the event of a smallpox crisis. We could recruit teams of first responders and not require pre-vaccination. Some leading experts, including Dr. William Foege, former CDC chief and a leading authority on smallpox control, question pre-vaccination, citing the lack of current information about its safety. Dr. Linda Rosenstock, dean of the UCLA School of Public Health, said in December that no evidence has so far been provided to warrant the vaccination of any American. Data from the era when everyone received a smallpox vaccination show that one in a thousand suffered serious health problems, and one in a million died from complications of the vaccine. So, no, I do not think the reliance on pre-vaccination is necessary.

Q: Do you have any advice to offer the general public?

Bioterrorism is a potential hazard and of course worries about bioterrorism are legitimate, increasingly so as the U.S. engages in attacking Iraq. But the public health community in Washington is strongly recommending against vaccination for the general public. I am certainly not going to be prevaccinated unless it is documented that the threat level becomes high. I would encourage each individual to ask whether it is worth the risk of side effects that range from the merely uncomfortable to potential death. Ask what the chances are that a smallpox attack will occur, and whether there is vaccine available in case there is an attack. What are the potential political motives for the vaccination program, occurring as it did with the ramp-up of war with Iraq.

Fear is a powerful persuader.

Q: Any final thoughts you would like to share?

I think the administration wants us to limit our discussions to whether pre-vaccination is safe or not.

However, they don't want us to question their role in actually increasing the risk of a bioterrorist attack through their foreign policy. Military aggression strengthens extremist political movements and puts all of us at an increased risk. Public health needs to take a broader approach to prevent war and prevent bioterrorism.

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