The lack of preparedness evident this year is not solely due to a failure in anti-terrorism planning. It also reflects many years of indifference and dis-investment in the public health system in the United States. The crisis certainly underscored many weaknesses in the public health system. 

There is a difference between medicine and public health, although they are sister disciplines and both are committed to good health. Public health agencies, which are devoted to prevention, control and tracking disease rather than individualized medical care, are mostly the responsibility of state and local governments in this country.  Investment in public health-oriented research and the budgets of public health agencies have been inadequate for many years. A good book documenting how public health has been neglected is Laurie Garret's Betrayal of Trust, which I strongly recommend.
 
Currently, the federal response appears to be to develop a purpose-built system for managing bioterrorism assaults. Such programs may spend much money while local capacity that would sit idly, especially when the threat recedes. It would be wiser to use that investment to rebuild the public health system. Investigating and managing conventional disease outbreaks, emerging infections, food-borne illness, air pollution and water contamination require the same technologies of prevention, disease surveillance and outbreak investigation as coping with bioterrorism. 

A huge advantage of a “dual use” strategy, in which the same system that protects public health is also the sentinel for bioterrorism, is that the public health system already exists would not be hard to upgrade. The system is staffed by very bright people who have all the required expertise, are already effective beyond their resources, and are desperately needed in place at the state and local level. It Another advantage is that it will recover much of the sunk cost of building a bioterrorism response system by enhancing the response to costly, frequent disease outbreaks and conventional hazards. Finally, a huge advantage is that a “dual use” will be continually tested. There will be no doubt whether it is prepared, even if future bioterrorism events are years apart, because disease outbreaks occur in every community, all the time.

A strengthened public health system would protect Americans all the time and would be there, tested and in readiness, when needed to respond to bioterrorism. This policy of “dual use” would benefit Americans whether or not another bioterrorism assault occurs. And because it would be frequently tested, Americans would know that the system works. 

Even the under funded, obsolete public health system we have today works most of the time but it is showing the strain. Many of these became apparent during anthrax assaults. There are many lessons from 9-11 and its aftermath for public health, as well as emergency management. 
The two fatal cases of anthrax in the DC area were not immediately recognized as high risk and would have fallen through the surveillance system except for the action of alert physicians. The medical care system, separate from the public health system, is the first level at which a problem is likely to be identified but this information needs to be verified and then communicated to public health agencies for patterns to be revealed. 

People got confused about individual rights and the public interest. In DC, many people jumped the line by getting anthrax testing done privately probably thought that they were being smart. The result was loss or delay of potentially valuable information denied to public health authorities trying to map the so-called "perimeter of exposure", essentially where the anthrax was and who was really at risk. People who jumped the queue may have been over treated in many cases because this important information was then not available to help everyone, and to determine their own risk level more accurately. 

Another example is the number of people who obtained and in many cases hoarded cipro although they were at low risk. Cipro is a nasty although important drug. People who obtained it without appropriate indication are likely to misuse it, causing themselves harm from serious side effects and leading to the emergence of strains of bacteria resistant to the drug. 

As the anthrax assault evolved, It became obvious that the subordination of the of the public health system to the medical care system and the increasing fragmentation of the medical system is working against effective surveillance of disease outbreaks. One of the great challenges facing public health agencies right now is that the conventional mechanisms for surveillance are not adequate to the task for bioterrorism. Some local public health departments in the United States do not have email; disease reporting is based largely on postcards and snail mail. 

Another major issue was the degree to which forensics trumped environmental health and principles of disease transmission in the investigation of postal handling facilities. In the race to track the contaminated mail to its source, the risk to workers along the way was initially overlooked. The people running the investigation were thinking, "How can I trace the letter back to its origin and catch the perpetrator?" Those of us with environmental health backgrounds were thinking, "What is the chance and degree of exposure at every point all along the trail and who else, like postal workers, is going to be at risk?" In New Jersey, the decision was made, locally, to treat postal workers prophylactically on the basis of a judgement regarding risk potential. In DC, the initial recommendation of the CDC was not to treat. You know what happened – and what did not happen in New Jersey. 

Pubic health authorities were effectively sidelined early in the anthrax assault. Where was the Surgeon General? On the sidelines. Why was he not in front, addressing an unprecedented disease and giving reassurance to Americans? Now, the biggest challenge facing public health is a loss of public confidence in the ability of authorities to deal with such crises and the need to make it clear what the role of public health is and should be.

In retrospect, what happened in Florida may represent the best possible scenario one could ever reasonably hope for. It was a given that the first case would be recognized too late to save the victim; although tragic, that is not unexpected. Fortunately, the assaults to date have been inept. The perpetrator(s), from that perspective, did us an incalculable favor. It is not impossible that future, new outbreaks could be managed as smoothly and quickly as the anthrax outbreak in Florida but it will take re-investment in a public health system that has become dangerously dilapidated. 

The federal government is working hard on these problems but the solution goes beyond federal responsibility. The deficiency lies with the inadequacies of the public health system after years of neglect and dis-investment by politicians and voters who assume that public health problems are solved or that medical care (diagnosis and treatment) will be enough.

We will be analyzing 9-11 for lessons for generations to come. Some lessons are obvious, e.g. “Do not build your command center in the bull’s eye of the target.” Others are not. I offer these as a summary of some of the not-so-obvious lessons we have learned about security and public health:  

· Do not assume that the next war, epidemic or confrontation will be like the last war, epidemic or confrontation. 

· Preparing against a single threat means vulnerability to the threat you did not think of. 

· Emergency responders may be trapped by a sequence of murderous assaults just as purposefully as if they were ambushed by a sniper. 

· The United States has been one lucky country. Its luck is still holding. Its takes away nothing from the tragedy to say that the events of 9-11 were far from the worst-case scenario that could have happened. 

· A criminal investigation and an outbreak investigation are similar in many ways but they do not necessarily mix well. 

· The time for law enforcement, security, intelligence and public health officials to get to know one another is before an incident occurs, not during one. 

· Public health preparedness works. The initial anthrax outbreak in Florida was recognized immediately and controlled. (Fortunately, it was also inept.) 

· Beware of your blind spots. Who in their right mind would have consciously thought that envelopes were hermetically sealed, such that fine powders could never escape? But it is all too easy to make such assumptions on the run. 

In public health, we can turn our attention as scientists and scholars to these problems in the same way that we address other issues in health and medicine. This means applying the very powerful tools of epidemiology, toxicology, environmental health research, behavioral research, health services research and biomedical research to crack the most difficult problems in the surveillance, biology of virulence, dissemination, prevention, treatment and countermeasures and above all, the behavioral context of how and why these things happen and what countermeasures work. 

Emergency management and public health are natural partners. We can apply the same tools mentioned above to problems of mitigation and preparedness, response planning, mobilization, recovery, extraction, prehospital care, surge capacity for treatment, prevention, rehabilitation and countermeasures. As Joe Barbera has often said, we need a "basic science" supporting emergency management, a scientific underpinning worthy of its importance and potential. Public health can provide this, in creative partnership. 

Dr. Guidotti is the Chair of the Dept. of Environmental and Occupational Health, School of Public Health and Health Services and Professor and Director, Division of Occupational Medicine and Toxicology, Department of Medicine, School of Medicine and Health Sciences, The George Washington University Medical Center.