Bioterrorism defense priorities.

U.S. defense strategies to counter bioterrorism have largely centered on smallpox. That concentration of effort has diverted attention and resources away from more basic general public health considerations that are even more vital to bioterror defense. Without the capacity to implement response plans and to treat cases that were unan-ticipated before the event—capacities that depend on a strong public health infrastructure— our present preparations are little more than window-dressing. Perhaps most disturbing is the limited usefulness of programs directed at defense against smallpox. Given the wide diversity of potential biological agents that might be used in an attack, it would seem prudent first to strengthen the public health system overall, a strategy that serves defense aims whatever biological agent might be employed. The lessons learned in the United States should be helpful to other nations that are vulnerable to bioterrorism and even more helpful to the global effort to manage emerging infections of all kinds. Significant resources have been devoted in the United States to smallpox defense preparation, including stockpiling vaccine and the initial relatively unsuccessful effort to vaccinate response teams. U.S. funding to strengthen the public health system overall , by contrast, has been relatively modest. Federal block grants made available to cities and states, intended to build up the neglected public health system to prepare for possible bioterror, total only about $1 billion distributed among all 50 states. Consider: The American Hospital Association has indicated that hospitals alone need at least $11.3 billion to purchase the equipment necessary to respond to a bioterror attack; and a RAND study released in 2002 found that before September 11, 2001, few state and local public health agencies even had written plans or policies for bioterror response. The heavy needs of basic public health infrastructure contrast sharply with the relatively modest funding that any state or locality's share of the federal $1 billion represents. As a result, plans developed in accordance with requirements for the block grant program are certain to encounter an inability on the part of state and local public health agencies to implement those plans. A recent survey released by the National Association of Counties and the National Association of County and City Health Officials shows that few states or counties have the necessary resources to establish the capacity to respond to bioterrorism without significant federal assistance. Funding priorities, however, have focused on more " glamorous " projects. In …