The events of Sept. 11, 2001 and the ensuing anthrax scare, along with fears of smallpox and other bioterrorism attacks, are focusing national attention on the country's public health system.

During 2002, more than $1 billion flowed from the federal government to the states and from there to some of the more than 3,000 local public health systems, money aimed at strengthening and preparing those systems to cope with a growing threat of bioterrorism.

We spoke with Patrick M. Libbey, Executive Director of the National Association of County and City Health Officials (NACCHO), about how the system has changed since Sept. 11 and what still needs to be done.

Q: Is the public health system better prepared today than it was a year ago to deal with a bioterrorist attack?

A: Absolutely. That's not to say we're fully prepared, but we are ready to respond, and we're much further along than we were a year ago. Still, we're not where we need to be.

Q: When you say we're "further along," what do you mean?

A: Plans are in place, and those plans have been exercised. There are improvements in surveillance and in inner system connections, that is, public health to clinical medicine to other emergency response systems. There's better integration of public health and bioterrorism issues within community and local emergency management plans, and improvement of public health connections within the emergency management structure at county and city levels.

There is also increased staff and staff trained in response. The clearest documentation of improvement is the degree to which emergency response plans have been developed and exercised. It's not enough just to have the plan.

Q: Do you have any numbers to put preparedness into context?

A: The difficulty is that most of our information is anecdotal. One area we're working on is getting that kind of baseline in place.

Q: Until 9/11 and the anthrax attacks, public health departments had been losing the funding and attention battle. Why did that happen, and why does it take something like the terrorist attacks to bring our attention back to something so important to communities?

A: When we do our job right, nothing happens. And if nothing is happening, it slides out of mind. You don't see a headline, "Nobody Got Sick Today." You just make pretty basic assumptions that when you eat in a restaurant the food is safe to eat, or that when you turn your tap on, the water's safe to drink. You don't think about who insures all that. So at times we're known more by the exceptions.

Q: What kind of improvements in surveillance have come about?

A: Most surveillance had been a relatively passive system. It was often a paper process that required full clinical confirmation of a fairly narrow set of specific diseases. In many locations we're seeing a more active surveillance, one using real-time, ongoing communication. In some areas, that's meant going to what we'd call a syndromic surveillance model. That is, rather than waiting for clinical confirmation of a specific disease, you look at real time information of different symptoms that might be associated with any number of agents, including a bioterrorism agent. You also look for other kinds of community indicators that would show something untoward or unusual going on, such as increased physician or hospital visits, increased absenteeism in school or work.

Some communities are working with neighborhood pharmacies to track a sudden spike in the sale of certain over-the-counter medications.

Q: How are the various public health systems using the federal money?

A: They're trying different approaches because it would not make sense to even attempt to bring all 3,000 public health departments up to the same state of readiness, both on the basis of resource availability and a wise use of the resources. Whatever resources are available in a community need to be maximized, but that's different from saying that every community health department needs to be at the same apex levels. So we're also seeing different forms of regionalization and shared services.

For instance, not every health department needs an epidemiologist on their staff; but every health department needs to have access to an epidemiologist.

Q: How well are public health systems communicating these days?

A: Communication within the governmental health system has come a long way. That goes back two-plus years with development of the Health Alert Network, which insures electronic communication linkage, including high speed Internet, linking federal to state to local health departments, not just in a linear manner, but through instant communication between them. Today, over 95 percent of the country's population is served by a health department with that interconnectivity. And it worked in anthrax and after 9-11. The next phase is making it work laterally at a community level, so that the emergency room to the health department to the emergency management center are all similarly linked.

We also need more work on issues of redundancy, insuring backup systems. So some departments are looking at satellite communications and even going back to radio communications. The other area where there has been significant progress is in standardizing the data reporting language. This is important because if information is to be shared across jurisdictions, there needs to be some common definition and common formatting of that information.

Q: How are public health departments doing in terms of communicating with other entities within their communities?

A:Public health needs to better understand, communicate with and work within the broader context of emergency management. My hypothesis is that those communities outside the areas that had actual anthrax cases that were best able to respond were those in which a relationship had already been established between the public health and emergency management systems.

Q: How is bioterrorism different from what most community emergency management systems are used to coping with?

A: Nearly all response scenarios, even those dealing with mass weapons of destruction, are based on time and place-specific events: earthquake, flood, a bomb going off. Bioterrorism may well unfold slowly, without a specific event or location. How quickly it is detected and responded to from the outset is key. Being ready means exercising and practice.

But training and exercising has to be done in the context of community and the partners you're going to have to work with. In doing that, you build your relationships and strengthen respondents. As one of the board members here says: You can't be exchanging your business card in the emergency operation center by way of introduction and expect to have this work out well.

Q: How do you envision getting information about a bioterrorism attack down to the individual physicians, and how can they be trained now to handle such an attack?

A: The answer to that question has to have started before an attack. And that goes back to the question of relationships. Are public health and medical clinical communities working together now to develop their response plans in concert? If the answer to that is yes, then the question of how it happens during the event is a mechanical question.

Q: Is there any sense that this emphasis on public health preparedness for bioterrorism has detracted from other important services public health performs?

A: Yes. When I talk with local health department directors from around country, they tell me that 35 to 50 percent of their time has been spent on bioterrorism over the last several months.

Q: What does that mean for the other issues they're supposed to be dealing with?

A: My assumption is that those things that probably have a little more long-term nature, that are proactive and preventive in nature, get set aside. For instance, in the community I was working in during the anthrax scare (in Washington state), we also had an active tuberculosis case in the area's largest high school, and a meningococcal death. We dealt with the TB, but we did set aside beginning some community processes to look at long-term health issues. The effects will catch up at some point.

Q: Public support is strong for increasing federal funding for public health. What sort of things could increased funding support?

A: Additional staff with specific skills, like epidemiology. We also have an increased need for people trained in communicating with the public, not just with the media, so we can create a better understanding and, from that understanding, perhaps a reduction in the sense of fear. Yet communication is one of the first areas to break down during exercises.

Q: At the same time public health needs are rising, state budgets are shrinking. How does this play into preparedness?

A: That's one of the things that's very worrisome right now. State and local governments are in an extraordinarily tough situation right now. As their general fund revenue capacities are diminished, they're having to cut. We're hearing from virtually all our members in almost every state that concurrent with the influx of federal money there's been a withdrawing of state funds. To the extent that we had talked about the federal bioterrorism money being built on a foundation of what was in place, and we're starting to withdraw elements of what's in place, it raises a question of what happens when that foundation becomes weaker.

Q: Americans are concerned about a bioterrorist attack—especially smallpox. What can you say to reassure people that public health is working to protect them?

A: It's not going to play out like it did on (the television show) ER. We are not unprepared. We are ready to respond. We can always do better, but that's a different answer than saying we're not ready. I think in the next few weeks, we'll have an opportunity to see public health in action with the likely advent of smallpox vaccination.