Order Code RL31719
Report for Congress
Received through the CRS Web
An Overview of the U.S. Public Health System
in the Context of Bioterrorism
January 17, 2003
Holly Harvey
Specialist in Social Legislation
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress

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An Overview of the U.S. Public Health System
in the Context of Bioterrorism
Summary
The anthrax attacks in 2001, along with the events of September 11, have
heightened concern about the nation’s ability to respond to bioterrorist attacks. The
role of public health in bioterrorism preparedness and response is to plan and
coordinate emergency medical and public health response capabilities, to detect,
investigate and identify disease outbreaks using surveillance systems, epidemiology
and laboratory services, to maintain healthy conditions by regulating environmental
conditions, food and water safety to minimize disease threats, and to communicate
rapidly and clearly with response partners, health practitioners, the media and the
public. The capacity to fulfill these responsibilities depends on the strength of the
infrastructure that supports the provision of public health services.
The public health infrastructure is the organizations, people and data systems
needed to assure the provision of essential public health services. Public health
organizations exist at the federal, state and local level and interact with each other,
the health care delivery system, public safety providers, private enterprises and
volunteer organizations to provide public health services. Even before September 11
and last fall’s anthrax attacks, a consensus had emerged among public health experts
that the public health system had deteriorated. Recent studies and reports have cited
outmoded technology and information systems, insufficient resources to combat
emerging and drug-resistant diseases, a public health workforce with inadequate
training to address new threats or to adapt to new ways of doing things, poor
communication among responsible parties, and inadequate capacity in hospitals and
laboratories to respond to a mass casualty event as several of the major challenges
facing public health organizations.
Recent congressional action has provided funding and guidance to improve
public health capacity at the federal, state and local level. Challenges remain in a
variety of areas, including: coordination and communication between public health
officials and other participants in public health preparedness and response, upgrading
data and information systems capabilities, improving laboratory capacity, increasing
emergency medical response capacity, improving the skills and education of the
public health workforce, and conducting research to improve bioterrorism prevention,
detection and treatment options. Finally, many worry about how to be sure that the
increased funding devoted to increasing public health capacity yields results in
improved preparedness and response capability. This report will be updated as the
public health system evolves and responds to congressional action.

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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Public Health Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Legal Framework for Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Federal Public Health Role and Organizations . . . . . . . . . . . . . . . . . . . . . . . 4
Department of Health and Human Services . . . . . . . . . . . . . . . . . . . . . . 5
Centers for Disease Control and Prevention . . . . . . . . . . . . . . . . . 5
Health Services and Resources Administration . . . . . . . . . . . . . . . 5
Food and Drug Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Substance Abuse and Mental Health Administration . . . . . . . . . . 6
National Institutes of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Agency for Health Care Research and Quality . . . . . . . . . . . . . . . 6
Department of Homeland Security (DHS) . . . . . . . . . . . . . . . . . . . . . . . 6
Office of Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . 7
Strategic National Stockpile (SNS) . . . . . . . . . . . . . . . . . . . . . . . . 7
State Public Health Role and Organizations . . . . . . . . . . . . . . . . . . . . . . . . . 7
Local Public Health Role and Organizations . . . . . . . . . . . . . . . . . . . . . . . . . 9
Public Health Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Public Health Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Data and Information Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Health Alert Network (HAN) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
National Electronic Disease Surveillance System (NEDSS) . . . . . . . . 13
Epidemic Information Exchange (Epi-X) . . . . . . . . . . . . . . . . . . . . . . 13
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Public Health Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Recent Congressional Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Strengthening Public Health Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
State and Local Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Hospital Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
National Pharmaceutical Stockpile (NPS) . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Challenges to Improving Public Health Infrastructure . . . . . . . . . . . . . . . . . . . . 21
Defining Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Coordination and Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Emergency Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Medical Care vs. Public Health Providers . . . . . . . . . . . . . . . . . . . . . . 22
Food Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Public Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Information systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Laboratory capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Emergency medical preparedness and response . . . . . . . . . . . . . . . . . . . . . 23
Public health workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

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List of Figures
Figure 1. LPHAs by Type of Jurisdiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 2. LPHAs by Population Served . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
List of Tables
Table 1. Distribution of States by Delegation of Public Health
Authority to Localities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Table 2. Full-time Equivalent (FTE) Staff at LPHAs . . . . . . . . . . . . . . . . . . . . . 10
Table 3. HHS Bioterrorism Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Table 4. State and Local Capacity Grants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

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An Overview of the U.S. Public Health
System in the Context of Bioterrorism
Introduction
Bioterrorism poses a unique challenge to the medical care and public health
systems. Unlike an explosion or chemical attack, which results in immediate and
visible casualties, the public health impact of a biological attack can unfold gradually
over time. Until a sufficient number of people arrive at emergency rooms and
doctors’ offices complaining of similar symptoms, there may be no sign that an attack
has taken place. The speed and accuracy with which doctors and laboratories reach
the correct diagnoses and report their findings to public health authorities has a direct
impact on the number of people who become ill and the number that die. The
Nation’s ability to respond to a bioterrorist attack, therefore, depends crucially on the
state of preparedness of its medical care systems and public health infrastructure.
The public health system plays a central role in orchestrating and coordinating
the response to a bioterrorist attack. The anthrax incidents in 2001 focused
lawmakers’ attention on the U.S. public health system. Lawmakers, along with the
rest of the public, turned to public health officials for information about the
symptoms of anthrax, the population at risk of exposure, the availability of
preventive measures, and appropriate medical treatment. In addition, public health
laboratories all over the country tested an unprecedented number of samples of
suspected anthrax.
In general, reviews of the response of public health during the anthrax crisis
have been mixed. However, it was actually a rather small scale incident and experts
worry that had more people or more localities been affected, the public health system
would have been overwhelmed. In addition, the anthrax incidents served to highlight
potential problems that public health officials have worried about in recent years.1
Several reports and evaluations described problems with the public health
system prior to the anthrax attacks. Among the problems cited were health
department closures, outmoded technology and information systems, a public health
workforce with inadequate training to address new threats or to adapt to new ways
of doing things, poor communication among responsible parties, and inadequate
1 Institute of Medicine (IOM). The Future of Public Health in the 21st Century. The
National Academy of Science, forthcoming, 2003. (Hereafter cited as IOM Report)
Currently available at http://www.nap.edu/books/0309086221/html/.

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capacity in hospitals and laboratories to respond to a mass casualty event.2 The
anthrax attacks demonstrated the seriousness of these problems.
Among the explanations given for the deficiencies of the public health system
are diffusion of responsibility for public health services across multiple government
agencies and declining funding for their activities, the reduction in risk of infectious
disease through imposition of sound sanitation practices and the development of
vaccines in the early twentieth century, the rising importance of effective biomedical
interventions to combat disease, and a shift in funding priorities to programs
providing medical care to those with no other source of care.3
Improving public health preparedness and response capacity is expected to offer
protection not only from bioterrorist attacks, but also from naturally occurring public
health emergencies. Public health officials are increasingly concerned about our
exposure and susceptibility to infectious disease and food-borne illness because of
global travel, increased volume of food imports, and the evolution of antibiotic-
resistant pathogens. Public health experts argue that a strong infrastructure provides
the capacity to prepare for and respond to both acute and chronic threats to the
Nation’s health, whether they are bioterrorism attacks, emerging infections,
disparities in health status, or increases in chronic disease and injury rates.
Primary responsibility for public health rests with the states. However, the
federal government plays an active role in public health by providing funding to
states and localities, establishing national priorities, providing technical assistance,
and coordinating knowledge dissemination.4 Some have suggested that the threat of
bioterrorism has made public health a national security issue and that the federal
government should therefore play a stronger role. Others worry that a stronger
federal role will reduce flexibility. They emphasize that events happen in localities,
that localities have differing needs, and that they must have a strong role in resource
allocation decisions.
While many in the public health community have welcomed the renewed
interest in building a strong public health infrastructure, others worry that the
emphasis placed on bioterrorism preparedness provides too narrow a focus to achieve
a truly effective public health system that is responsive to all potential health hazards.
2 See for example General Accounting Office, Emerging Infectious Diseases: Consensus
on Needed Laboratory Capacity Could Strengthen Surveillance, GAO/HEHS-99-26, Feb.
1999; Amy E. Smithson, and Leslie-Anne Levy, Ataxia: The Chemical and Biological
Terrorism Threat and the U.S. Response, Henry L. Stimson Center, Report no. 35, Oct.
2000; and Local Public Health Agency Infrastructure: A Chartbook, National Association
of County and City Health Officials, Oct. 2001. (Hereafter cited as NACCHO Chartbook)
3 Eileen Salinsky, Public Health Emergency Preparedness: Fundamentals of the “System,”
National Health Policy Forum Background Paper, Apr. 3, 2002. (Hereafter cited as
Salinsky NHPF Paper)
4 Bernard J. Turnock, and Christopher Atchison, Governmental Public Health in the United
States: The Implications of Federalism, Health Affairs, v. 21, no. 6, Nov./Dec. 2002, pp. 68-
78.

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In addition, the ability to sustain a newly improved infrastructure over time is of
concern to many.
As Congress continues to deliberate on how best to prepare for a bioterrorist
attack, information about the role of public health and the public health infrastructure
becomes increasingly relevant. This report continues with two sections. The first
provides an overview of the public health infrastructure. The second discusses the
changes and improvement that are underway, and the issues and challenges inherent
in improving public health preparedness.
Public Health Infrastructure
The mission of public health, as defined by the Public Health Functions Steering
Committee, is to promote physical and mental health and prevent disease, injury and
disability.5 The public health system includes a wide array of governmental and non-
governmental entities including:
! over 3000 county and city health departments and local boards of
health,
! 59 State and territorial health departments,
! tribal health departments,
! more than 160,000 public and private laboratories,6
! parts of multiple Federal departments and agencies,
! hospitals and other health care providers, and
! volunteer organizations such as the Red Cross.
Definitions vary but, in practical terms, the public health infrastructure is
federal, state and local public health organizations and the resources they need to
operate effectively.7 These governmental organizations form “the nerve center of
the public health system”and interact with a wide array of other partners to assure
public health.8 The public health workforce and data and information systems are
key resources. Of course, funding is also necessary to provide resources.
In the context of bioterrorism, some key functions of the public health
infrastructure include using disease surveillance systems to detect outbreaks,
conducting specialized laboratory tests to identify bioagents, using epidemiological
5 U.S. Department of Health and Human Services (HHS), From Public Health in America,
Public Health Functions Steering Committee, July 1995.
6 HHS, Centers for Disease Control and Prevention, Public Health’s Infrastructure: A
Status Report, Prepared for the U.S. Senate Appropriations Committee, Mar. 2001.
(Hereafter cited as CDC Infrastructure Status Report)
7 See Edward L. Baker, and Jeffrey Koplan, Strengthening the Nation’s Public Health
Infrastructure: Historic Challenge, Unprecedented Opportunity, Health Affairs, v. 21, no.
6, Nov./Dec. 2002.
8 B.J. Turnock, Public Health – What It Is and How It Works, 2d.ed. (Gaithersburg, MD:
Aspen Publishers, 2001).

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methods to identify persons at risk, and using knowledge of disease processes in
populations to determine appropriate responses (e.g. need for quarantine or
decontamination, dissemination of medical treatment recommendations), and
coordinating with other emergency response partners to establish effective response
plans.
Legal Framework for Public Health
The federal government exerts a strong influence on public health practice
through its ability to tax and spend and its responsibility for regulating interstate
commerce. Through its power to regulate interstate commerce, the federal
government can act to protect the environment, ensure food and drug safety, and
promote occupational health and safety. The power to tax allows the federal
government to encourage certain behaviors (e.g. deductibility of employee health
insurance costs encourages employers to provide insurance) and to discourage others
(e.g. raising the price of smoking through cigarette taxes). The federal government
can also set conditions on the expenditure of federal funds. For example, states must
set 21 as the minimum age for the legal consumption of alcohol in order to qualify
for federal highway funds.
Federal public health statutes are largely contained in the Public Health Service
Act, the Federal Food, Drug and Cosmetic Act, the National Environmental Policy
Act, the Clean Air Act and other related statutes. In general, the Public Health
Service Act authorizes the activities of the public health service agencies and creates
important vehicles for federal funding of public health activities in states and
communities. The Federal Food, Drug and Cosmetic Act authorizes the Food and
Drug Administration (FDA) to directly regulate the safety of food and cosmetics and
the safety and effectiveness of pharmaceuticals, biologics, and medical devices. The
National Environmental Policy Act and related environmental statutes authorize the
Environmental Protection Agency (EPA) to regulate the safety of the air, water, and
the ecological system. 9
Other provisions of the federal code apply under emergency circumstances when
federal assistance to states and localities is needed. The Stafford Act establishes
provisions for federal assistance to states in the event of a disaster. The act requires
the governor of the affected state to request a declaration of a disaster and vests the
president with the authority to make such a declaration and charge federal agencies
to provide support to state and local efforts.

Federal Public Health Role and Organizations
A recently released report from the Institute of Medicine, The Future of Public
Health in the 21st Century, identifies six main areas where the federal government
plays a role in population health. The six areas are policy making, financing, public
health protection, collecting and disseminating information about U.S. health and
9 Salinsky NHPF Paper.

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health care delivery systems, capacity building for population health, and direct
management of services.10
The Department of Health and Human Services (HHS) bears primary
responsibility for most public health activities at the federal level. Some key
activities are located in other departments such as the Environmental Protection
Agency (EPA), the Department of Agriculture (USDA), the Department of Defense
(DoD), and the Department of Veterans Affairs (VA). However, this paper will
focus on federal activities in HHS because it is the locus of funding to improve
public health capacity.

Department of Health and Human Services. The newly formed Office
of the Assistant Secretary for Public Health Emergency Preparedness within the
Office of the Secretary (OS) directs and coordinates the implementation of HHS’s
bioterrorism programs and activities. Other public health agencies within HHS with
responsibilities for bioterrorism preparedness and response include the Centers for
Disease Control and Prevention (CDC), the Food and Drug Administration (FDA),
the Health Resources and Services Administration (HRSA), the Substance Abuse and
Mental Health Administration (SAMSHA), the National Institutes of Health (NIH),
and the Agency for Healthcare Research and Quality (AHRQ).
Centers for Disease Control and Prevention. The CDC is the center of
federal public health activities. The CDC works with states, localities, and other
nations to detect, investigate, and prevent the spread of disease, to develop and
implement prevention strategies, and to monitor the effect of environmental
conditions on health. State and local public health agencies receive support from the
CDC in a variety of ways, including financial assistance, training programs, technical
assistance and expert consultation, sophisticated laboratory services, research
activities, and standards development.11 One of the key vehicles for support of state
and local public health agencies is the state and local preparedness grant program
established in 1999 and greatly expanded by the FY2002 supplemental.12 This
program provides funding and guidance to states to assist them in upgrading state and
local public health jurisdictions’ capacity to prepare for and respond to bioterrorism,
other outbreaks of infectious disease, and other public health threats and
emergencies.
Health Services and Resources Administration. HRSA administers the
state grant program to facilitate regional hospital preparedness planning and to
upgrade the capacity of hospitals and other health care facilities to respond to public
health emergencies–including the development of multi-tiered systems which enable
local health care entities to triage, treat, stabilize and refer multiple casualties to
identified centers for treatment. HRSA is also generally responsible for healthcare
10 IOM Report.
11 Salinsky, NHPF Paper.
12 An amendment to the FY2002 Defense Department appropriations bill (P.L. 107-117)
provided HHS with a total of $2.8 billion for bioterrorism-related activities from emergency
supplemental funds.

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workforce development –including funding for training in emergency medical and
trauma services, as well as funding to improve medical school curricula in the area
of bioterrorism recognition.
Food and Drug Administration. The FDA has responsibilities for ensuring
the availability of safe and effective drugs, vaccines, blood products, medical
devices, radiological products, and animal health products. The FDA also has
responsibility for assuring the safety of the food supply and does so in partnership
with the Department of Agriculture which is responsible for the safety of meat,
poultry and processed egg products. FDA establishes guidance and regulatory
requirements for assuring that food is not adulterated and ensures the safety and
efficacy of all drugs used in food animals and feeds. The FDA is supported by 3000
state and local offices responsible for monitoring retail food establishments and their
employees.
Substance Abuse and Mental Health Administration. SAMSHA is
responsible for improving the Nation’s health care capacity to provide prevention,
diagnosis, and treatment services for substance abuse and mental illnesses.
SAMSHA’s role in bioterrorism preparedness is to plan for the mental health
consequences of terrorist attacks and other major disasters.
National Institutes of Health. The NIH conducts and supports biomedical
research, including research targeted at the development of rapid diagnostics and new
and more effective vaccines and antimicrobial therapies. Within NIH, the National
Institute of Allergy and Infectious Diseases (NIAID) bears primary responsibility for
bioterrorism-related research. The anthrax attacks of Fall 2001 uncovered unmet
needs for tests to rapidly diagnose, vaccines and immunotherapies to prevent, and
drugs and biologics to cure disease caused by agents of bioterrorism. In February
2002, NIAID announced its strategic research plan which is directed at supporting
research needed to understand the pathogenesis of the agents of bioterrorism and the
host response to them and to translate that knowledge into useful interventions and
effective diagnostic tools for an effective response.13
Agency for Health Care Research and Quality. AHRQ sponsors and
conducts research designed to improve the quality of health care. In the area of
bioterrorism, AHRQ’s research focuses particularly on improving the clinical
preparedness of health care providers. For example, the agency has studied how best
to communicate with physicians and other private health care providers in the event
of a public health emergency and has assessed the most effective methods for training
physicians about bioterrorist threats.
Department of Homeland Security (DHS). The Homeland Security Act
(P.L. 107-296) leaves most public health activities in HHS. The exceptions are the
Office of Emergency Preparedness (OEP) and the National Pharmaceutical Stockpile
(renamed the Strategic National Stockpile) which are moved to the Emergency
13 NIAID, NIAID Strategic Plan for Biodefense Research, NIH, Feb. 2002.

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Preparedness and Response Directorate (EPR) of DHS.14 The EPR’s mission is to
improve the Nation’s capability to reduce losses from all disasters, including terrorist
attacks.15 In addition, P.L. 107-296 directs the Secretary of HHS to collaborate with
the Secretary of DHS in setting priorities for human-health related countermeasures
research and development and for all public-health related activities to improve state,
local and hospital preparedness and response.
Office of Emergency Preparedness. OEP manages the National Disaster
Medical System (NDMS) and the Metropolitan Medical Response System (MMRS).
The NDMS was established to provide medical care and hospitalization in the event
a disaster overwhelms local emergency services. It is a partnership of four federal
agencies (HHS, DoD, VA, and the Federal Emergency Management Agency
(FEMA)), state and local governments and the private sector.16 The primary focus
of the MMRS is to develop or enhance existing emergency preparedness systems in
metropolitan areas to manage effectively a large-scale public health emergency. The
goal is to coordinate the efforts of local law enforcement, firefighters, hazardous
materials cleanup (HAZMAT) teams, EMS, hospital, public health and other
personnel to improve response capabilities such as early identification of specific
hazards, protection of the public from dangerous exposures, mass patient care and
fatality management, and environmental safety. Enhanced metropolitan response
systems typically cost about $2.5 million and are jointly funded by HHS and local
governments, with funding primarily coming from local governments. As of July,
2002, 122 cities were part of the MMRS.17

Strategic National Stockpile (SNS). The SNS includes pharmaceuticals,
vaccines, and other medical supplies that can be deployed in the event of a
bioterrorist attack or any other public health emergency. The stockpile has two
components: (1) Push Packages, each consisting of 50 tons of preassembled medical
supplies, which can be delivered to any location in the country within 12 hours; and
(2) Vendor Managed Inventory packages, which are tailored to provide medical
supplies specific to a suspected or confirmed biological or chemical agent.18
State Public Health Role and Organizations
States have primary responsibility for protecting the health and welfare of their
citizenry. In general, all states have public health statutes that provide public health
authorities with the power to collect data, license businesses, health care delivery
facilities, physicians and other providers, conduct inspections, and engage in
14 According to the DHS Reorganization Plan released by the Administration on Nov. 25,
2002, OEP and the Strategic National Stockpile will be transferred to DHS on Mar. 1, 2003.
15 For a summary of EPR’s mission and components, see CRS Report RS21367, Emergency
Preparedness and Response Directorate in the Department of Homeland Security by Keith
Bea, William Krouse, Daniel Morgan, Wayne Morrissey, and C. Stephen Redhead.
16 For more information on the NDMS, go to [http://ndms.dhhs.gov].
17 HHS, Press Release, July 2002. For more information, go to [http://mmrs.hhs.gov].
18 For more information, go to [http://www.cdc.gov.nceh/nps].

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enforcement activities (including control of persons and property). However, states
differ a great deal in size, population, risks, needs and capabilities and in how they
organize the provision of public health services.
Many states deliver public health services through multiple state agencies.
Thirty-five states have free-standing state health agencies, while in other states public
health is part of a larger agency that is responsible for a wide range of activities (for
example, human services).19 Important aspects of public health, such as
environmental health and emergency medical services (EMS), may be housed outside
the state’s primary public health agency. In 36 states, the environmental health
agency is separate from the state health agency. Emergency medical services are
commonly found in the public safety department or governed by a separate EMS
authority or board when they are not housed in the state public health agency.

States differ in the amount of authority they delegate to local governments.
Some states provide local governments with very little authority, while others offer
local jurisdictions “home rule” over public health matters. Delegation of public
health authority can be classified into three categories: 1) a centralized approach in
which states have extensive legal and operational control over local authorities, 2)
a decentralized approach in which local governments are delegated significant
control, and 3) a hybrid approach in which some public health responsibilities are
provided directly by the state, while others are assumed by the localities. Table 1
shows the distribution of states by category.
Table 1. Distribution of States by Delegation of
Public Health Authority to Localities
Centralized
AR, DE*,FL, HI*, LA, MS, NM, RI*, SC, VA, VT*
Decentralized
AZ, CO, CT, ID, IN, IA, ME, MO, MT, NE, NV, NJ,
ND, OR, UT. WA, WI
Hybrid
AL, AK, CA, GA, IL, KA, KY, MD, MA, MI, MN, NH,
NC, NY, OH, OK, PA, SD, TN, TX, WV, WY
Source: Salinsky NHPF Paper.
* State-run systems that do not classify their field offices as local health departments.
Both the location of public health activities within state government and the
extent of delegation to localities may be important factors in determining the speed
with which state and local public health are able to adapt to new priorities. These
factors can have a large effect on the speed with which new guidance from the federal
government is incorporated into agency budgets and passed through to localities. For
example, if a general state hiring freeze is in effect, the proximity of the state public
health officer to the state’s governor can make a big difference in how soon an
exemption for hiring specialized staff for bioterrorism preparedness gets considered.
19 Salinsky NHPF Paper.

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States also differ in how long they have focused on bioterrorism. A number of
states received funding under CDC’s Bioterrorism Initiative beginning in 1999 for
a variety of different capacity building activities. While state governments vary in
both the breadth and depth of services they cover and the degree to which they
delegate to local governments, they, nevertheless, tend to play certain key roles in
public health emergency preparedness and response. Except in the largest
metropolitan local public health departments, local public health officials will
generally turn to state personnel and capacity for providing advanced laboratory
capacity and epidemiological expertise and serving as a conduit for federal
assistance.
Local Public Health Role and Organizations
The role and organization of local public health varies tremendously across the
United States. However, in general local public health departments are in the front
line in responding to public health emergencies. The diversity in local public health
organizations (LPHAs) can be illustrated with a few statistics from a recent survey
of local public health infrastructure conducted by the National Association of City
and County Health Officers (NACCHO).20 This variation may have important
implications for considering how best to improve public health preparedness.
Figure 1 shows the distribution of local public health agencies (LPHAs) by type
of jurisdiction. The most common arrangement is a LPHA serving a single county,
but 40% of LPHAs serve other
Figure 1. LPHAs by Type of Jurisdiction types of jurisdictions. County
LPHAS range in size from small
r u r a l c o u n t i e s t o l a r g e
metropolitan ones such as Los
Angeles County. County LPHAs
may or may not serve all
geographic areas within the
county–for example, a city within
a county may be served by its own
municipal LPHA. City public
health agencies may serve small
cities or large urban areas such as
Kansas City, MO, or New York
City. In some cases, a city and its
surrounding county join together
to form one city-county LPHA.
Township health departments are
usually located in states with
strong “home-rule” or “town-meeting” political systems such as Connecticut,
Massachusetts, and New Jersey. Finally, multi-county health departments serve more
than one county and often span large geographic areas in the western United States.
Multi-county LPHAs also include regional or district LPHAs whose health directors
may report to multiple county boards of health.
20 NACCHO Chartbook.

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CRS-10
Figure 2 shows the distribution of LPHAs by population served. Over two-
thirds of LPHAs serve jurisdictions with fewer than 50,000 people. In contrast, 4%
of LPHAs serve jurisdictions with populations of 500,000 or more. Not surprisingly,
the number of workers employed by LHPAs also varies tremendously.
Figure 2. LPHAs by Population Served
Table 2 shows both the
average and median number of
full-time equivalent (FTE)staff
f o r m e t r o p o l i t a n a n d
nonmetropolitan LPHAs. The
average staff of a metropolitan
LPHA is 108 FTEs. However,
half of metropolitan LPHAs have
28 or fewer FTEs. In
nonmetropolitan areas, the
average number of FTEs is 31,
but half of the LPHAs have 13 or
fewer FTEs. Administrative and
clerical staff, environmental
health specialists and public
health nurses are the occupational
categories most commonly used by LPHAs to describe the staff they employ. The
training and education of workers in these positions varies tremendously and
occupational titles do not always reflect professional public health training or degrees
in a particular discipline.
Table 2. Full-time Equivalent (FTE) Staff at LPHAs
Metro LPHAs
Non-metro LPHAs
Mean FTEs
108
31
Median FTEs
28
13
Source: NACCHO Chartbook.
The scope of services that LPHAs are responsible for also varies. In some areas,
LPHAs run county hospitals, while in others, the LPHA is only responsible for septic
systems and restaurant inspections. The most common bioterrorism-related programs
and services provided by LPHAs include epidemiology and surveillance,
communicable disease control measures, food safety, and restaurant inspections. The
NACCHO survey shows that over 70% of LPHAs provide: adult and child
immunizations, tuberculosis testing, community assessment, community outreach
and education, environmental health services, and health education.

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Public Health Laboratories
Public health laboratories are a special sub component of federal, state, and local
public health organizations. Laboratories are a critical component of early detection.
Identification of a specific pathogen often requires specific testing protocols using
specific reagents and sometimes specialized equipment. In addition, special safety
procedures (such as working under an exhaust hood) must be used with certain
pathogens–particularly those in aerosol form. Most clinical laboratories are not set
up to identify the pathogens likely to be used in a bioterrorist attack.
CDC, in cooperation with the Association of Public Health Laboratories and the
FBI, has established a multi-level Laboratory Response Network (LRN) which
includes local, state and federal laboratories and facilitates sample collection,
transport, testing, planning for the capacity to handle a sudden large increase in
samples, and training for laboratory readiness to identify CDC-designated critical
biological agents.21 Currently, all 50 state public health laboratories are registered
members of the LRN. Membership in the LRN gives laboratories access to standard
protocols for testing and for sample preparation and care that preserves the chain of
custody and maintains a sample’s viability for later testing.
Clinical and public health laboratories in the LRN are identified by increasing
levels of sophistication labeled from Level A through Level D. A lab’s designation
depends on the biosafety level of its physical facilities and its ability to perform
certain types of tests.22 The minimum requirements for Level A are having a certified
biological safety cabinet and the ability to rule out specific agents and to forward
samples to higher level laboratories for further testing. Most hospital and local public
health labs are Level A . Most state public health labs are Level B or C. Level B
labs maintain Biosafety Level 2 facilities and have the proficiency to adequately
process environmental samples, to identify specific agents and perform confirmatory
and antibiotic susceptibility testing. Level C labs are another step up in Biosafety
Level and in the sophistication of the tests they are capable of performing (e.g.
nucleic acid amplification, molecular typing and toxicity testing). Level D Labs are
the most secure and sophisticated. CDC maintains a Level D lab and is the
designated lab for bioterrorism events affecting civilian populations.
21 HHS, Centers for Disease Control and Prevention, The Public Health Response to
Biological and Chemical Terrorism: Interim Planning Guidance for State Public Health
Officials, July 2001.
22 Biosafety levels describe the combinations of standard and special laboratory practices,
safety equipment, and facilities recommended for work with a variety of infectious agents
in various laboratory settings. There are four biosafety levels described by CDC in the May
1999 ed. of Biosafety in Microbiological and Biomedical Laboratories, 4th ed.,GPO,
Washington, 1999.

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CRS-12
Public Health Workforce
Recent attempts to enumerate the public health workforce yield estimates of
roughly 450,000 employed workers deployed approximately evenly at the local, state,
and national levels.23 The public health workforce encompasses a wide range of
professional disciplines and occupations. Some of the most common are physicians,
nurses, environmental specialists, laboratorians, health educators, disease
investigators, outreach workers and managers. Professional public health training
includes studies in biologic sciences, epidemiology, biostatistics, environmental
health science, and health services administration. Estimates from a 1989 HRSA
study show that only 44% of public health workers had formal, academic training in
public health.24 As of 1997, 78% of local health department executives did not have
graduate degrees in public health.25
Data and Information Systems
Data and information systems are important components of the public health
infrastructure because of the need to manage and analyze large amounts of
information and the need to communicate quickly and accurately with a wide range
of other entities. Data and information systems encompass disease surveillance
systems, epidemiological analysis and communication systems. These systems are
currently a hodgepodge of paper, telephone and computer-based systems. For
example, only half of state, local and territorial health departments had full internet
connectivity on October 4, 2001, when the first anthrax case was reported. Another
20% lacked e-mail capacity and so were unable to receive electronic updates
regarding the anthrax events.26
CDC, along with partners from the state and local public health community,
have initiated several programs to implement recommendations from the National
Committee on Vital and Health Statistics and others to move toward a National
Health Information Infrastructure.27 These programs are described briefly below.
Health Alert Network (HAN). The Health Alert Network (HAN) is a
nationwide, integrated information and communications system serving as a platform
for distribution of health alerts, dissemination of prevention guidelines and other
information, distance learning, national disease surveillance, and electronic
laboratory reporting. The HAN program is managed by CDC and is also designed
to provide resources for building information technology capacity within local public
health departments. Currently, all 50 states, the District of Columbia, eight
23 HHS, Health Resources and Services Administration, Bureau of Health Professions, The
Public Health Workforce: Enumeration 2000, Dec. 2000. Available at
[http://bhpr.hrsa.gov/healthworkforce/reports/default.htm].
24 CDC Infrastructure Status Report.
25 Ibid.
26 IOM Report, p. 136.
27 IOM Report.

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CRS-13
territories, two-thirds of U.S. counties and major hospital networks and health
organizations are connected to HAN. The information technology capacity
improvements generated through the HAN program allow states and localities to
improve communication with CDC and each other for a range of activities.
National Electronic Disease Surveillance System (NEDSS). The goal
of NEDSS is to have integrated surveillance systems that can transfer appropriate
public health, laboratory, and clinical data efficiently and securely over the internet.28
To accomplish this goal, NEDSS promotes the use of data and information standards
which are necessary for the development of efficient, integrated and interoperable
surveillance systems at federal, state and local levels.29
Epidemic Information Exchange (Epi-X). The Epi-X system allows
secure, Web-based communications among federal, state and local epidemiologists,
laboratories and other members of the public health community. It also provides the
capacity for instant notification about urgent public health events and a searchable
database with information on outbreaks and unusual health events.30
Funding
Funding for public health comes from a variety of sources including local, state
and federal government programs, grants from foundations, reimbursements from
insurance companies, and patient and regulatory fees. As noted above, huge
differences exist in the scope of activities, size of population served and organization
of the governmental public health infrastructure at the state and local levels.
Differences in defining public health activities and in accounting practices make it
difficult to gather systematic and comparable national information on public health
expenditures from all sources. One specific difficulty involves counting all
expenditures related to a common set of public health activities (for example,
environmental health) regardless of where they are in the governmental structure.
Another particularly difficult problem is separating expenditures and receipts for
direct medical care services to individuals from those for general population-based
services.
Given the difficulty of measuring public health expenditures, it is not surprising
that estimates from different sources yield different results. Recently published
estimates based on National Health Account (NHA) data show total federal, state and
local public health expenditures of $17.1 billion for 2000.31 Federal spending
accounted for 28% of the total with state and local spending making up the remaining
72%. In these estimates, NHA data were adjusted in an attempt to include only
28 John R. Lumpkin and Margaret S. Richards, Transforming the Public Health Information
Infrastructure, Health Affairs, v. 21, no. 6, Nov./Dec. 2002. (Hereafter cited as Lumpkin
Health Affairs article)
29 For more information on NEDSS, go to: [http//:www.cdc.gov/nedss/index.htm ].
30 IOM Report.
31 Senator Bill Frist. Public Health and National Security: The Critical Role of Increased
Federal Support, Health Affairs, v. 21, no. 6, Nov./Dec. 2002.

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CRS-14
funding for population-based services. In contrast, estimates from a state-sponsored
survey of nine states done in the early 1990's showed that 50% of spending for
population-based public health activities came from states, while 32% came from
federal sources and 18% came from local sources.32
A separate analysis of local health agency funding sources shows that, on
average, 44% of LPHA funding came from local sources while 30% came from state
sources including pass-throughs of federal funding. An additional 3% of funding
came directly from the federal government to LPHAs and 19% came from fees or
service reimbursement.33 Metropolitan LPHAs tend to receive a larger share of
funding from local sources than non-metropolitan LPHAs.
HHS has provided support to a collaborative effort among state and local public
health associations to explore methods to measure actual public health expenditures
at the state and local level. Initial feasibility studies show some promise, but no
systematic accounting is currently conducted on a regular basis.34
Public Health Partners
Many entities beyond the governmental public health infrastructure play
important roles in protecting the public’s health. Physicians and other clinical care
practitioners and hospitals are two key partners. During routine times, private-sector
physicians and other providers can support the public health system by reporting
occurrences of certain diseases, by implementing public health recommendations for
preventive treatment and patient education and by participating in emergency
planning exercises. In a public health emergency, much of any needed medical
treatment will be provided by private-sector physicians and other providers subject
to the overall coordination of public health officials. Hospitals have disease
reporting and public education responsibilities and also provide emergency medical
treatment capacity in the event of a public health emergency involving mass
casualties.
32 Public Health Foundation. Measuring Expenditures for Essential Public Health Services.
Nov. 1996. Accessed at http://www.phf.org/Reports/Expend1/exec_summ.htm
33 NACCHO Chartbook.
34 IOM Report.

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Recent Congressional Action
Recent Congressional action has provided a framework for strengthening the
public health infrastructure at the federal, state and local level and has provided
funding for those activities. Table 3 shows federal bioterrorism funding for FY2002
and proposed levels for FY2003.
Table 3. HHS Bioterrorism Funding
($ millions)
Agency and program
FY2001
FY2002
FY2003
actual
enacted
request
Centers for Disease Control and Prevention
(CDC)
State and local public health preparedness
67
940
940
CDC capacity
22
116
144
National Pharmaceutical Stockpile
51
645
300
Smallpox vaccine procurement
0
512
100
Physical security and facilities
3
46
120
Other a
39
39
33
Subtotal, CDC
$181
$2,298
$1,637
Health Resources and Services Admin.
(HRSA)
Hospital preparedness and infrastructure
0
135
518
Other b
0
0
100
Subtotal, HRSA
$0
$135
$618
Food and Drug Administration (FDA)
Food safety
1
98
98
Vaccine and drug approval
6
47
54
Physical security
2
13
7
Subtotal, FDA
$8
$158
$159
National Institutes of Health
Research
53
183
977
Physical security and facilities
0
92
521
Anthrax vaccine procurement
0
0
250

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CRS-16
Agency and program
FY2001
FY2002
FY2003
actual
enacted
request
Subtotal, NIH
$53
$274
$1,748
Office of the Secretary (OS)
Office of Emergency Preparedness c
33
76
117
Office of Public Health Preparedness
30
41
33
Subtotal, OS
$63
$117
$150
Substance Abuse and mental Health
0
0
10
Services Administration
Total, HHS Bioterrorism
$305
$2,982
$4,322
Source: Dept. of HHS FY2003 Budget Request, Feb. 2002.
Note: Columns may not add due to rounding.
a Includes funding for anthrax vaccine evaluation and research, and national planning.
b Includes funding for poison control centers, medical curricula, and addressing children’s needs.
c Includes funding for the National Disaster Medical System (NDMS), the Metropolitan Medical
Response Systems (MMRS) program, and HHS cybersecurity.
HHS launched its bioterrorism initiative in FY1999. The initiative has six
strategic goals: prevention of bioterrorism, infectious disease surveillance, medical
and public health readiness for mass casualty events, the National Pharmaceutical
Stockpile (NPS), research and development of new drugs and vaccines, and
information technology infrastructure. Funding for these activities in the first 3 years
(FY1999-FY2001) totaled $730 million. CDC used most of those funds to begin the
process of improving the bioterrorism preparedness and response capacity of state
and local health departments.
HHS bioterrorism funding was increased from its original FY2002 enacted
level of $243 million by the emergency supplemental appropriations bill (P.L.107-38)
passed within days of the September 11 attacks. Twenty billion dollars of the
emergency supplemental were included in an amendment to the FY2002 Defense
Department appropriations bill (P.L. 107-117). P.L. 107-117 provides HHS a total
of $2.8 billion for bioterrorism-related activities. The appropriations act allocates
that funding under several broad categories, including $593 million for the National
Pharmaceutical Stockpile (NPS), $512 million to purchase smallpox vaccine, $865
million for state and local health departments, $135 million to upgrade hospital
capacity, $100 million to upgrade CDC’s facilities and capacity, $155 for NIH
research and lab construction, and $151 for FDA lab security, vaccine approval, and
food safety.
P.L. 107-188, the Public Health Security and Bioterrorism Preparedness and
Response Act, passed in June, 2002 and provides a 5-year authorization for activities
designed to bolster the nation’s ability to respond effectively to bioterrorist threats
and other public health emergencies. The Act authorizes a total of $2.4 billion in
FY2002, $2.0 billion for FY2003 and such sums as may be necessary for the

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remaining years. The Act establishes specific statutory authorities for many of the
bioterrorism-related activities already underway under the broader authorities granted
in P.L. 106-505, the Public Health Improvement Act. In addition, P.L. 107-188
requires the Secretary of HHS to register facilities and individuals in possession of
biological agents and toxins that pose a severe threat to public health and safety, and
to promulgate new safety and security requirements for such facilities and
individuals.
P.L. 107-188 also contains several provisions to protect the nation’s food and
drug supply and enhance agricultural security. It authorizes funds for USDA and
FDA to hire new border inspectors, develop new methods of detecting contaminated
foods, work with state food safety regulators, and protect crops and livestock. It also
enhances FDA’s ability to inspect and detain suspicious imported food. Finally, it
authorizes the provision of financial assistance to community water systems to
conduct vulnerability assessments and prepare response plans.35
The President’s FY2003 budget requests a total of $4.3 billion for HHS’s
bioterrorism preparedness programs and activities. The budget request includes
funds for strengthening the federal medical and public health response capacity,
upgrading CDC’s facilities, improving state and local public health preparedness,
developing vaccines and maintaining the National Pharmaceutical Stockpile,
preparing the nation’s hospitals, expanding FDA’s regulatory oversight of drugs and
biologics, and securing facilities to conduct critical scientific work. Most of the
increase is concentrated in NIH and HRSA while other HHS bioterrorism funding is
approximately maintained at FY2002 post-supplemental levels. Congress has not yet
completed deliberations on FY2003 appropriations and programs have been funded
at FY2002 levels under several continuing resolutions.
Strengthening Public Health Infrastructure
This section will discuss key aspects of the Nation’s public health infrastructure
targeted for funding by the Congress, the capacity improvements they are intended
to produce, and the challenges to making needed improvements.
State and Local Preparedness
The largest single increase in funding for bioterrorism-related activities in
FY2002 is the state and local capacity building grant program managed by CDC.
Funding for capacity improvements was allocated to states, territories and several
major metropolitan areas on the basis of population for FY2002. The funding is
directed at improving capacity in six focus areas: preparedness planning and
readiness assessment, surveillance and epidemiology, laboratory capacity for biologic
agents, Health Alert Network/communications and information technology, risk
communication and health information dissemination, and education and training.
35 For a complete summary of P.L. 107-188, see CRS report RL31263.

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Guidance from CDC established critical capacities within each focus area. The
capacities are the core expertise and infrastructure needed to enable a public health
system to prepare for and respond to bioterrorism, other infectious disease outbreaks,
and other public health threats. States were required in their grant applications to
provide (for each critical capacity) a brief description of the existing capacity in their
jurisdiction, an assessment of whether this capacity is adequate, and proposals for
improving inadequate capacity during the 2002 budget cycle. States were also given
the option of requesting support for enhanced capacities in areas where they have
already achieved critical capacity. State grant applications were due April 15, 2002
and most of the applications were approved in June, 2002. Table 4 shows the initial
distribution of funding across focus areas and the critical capacities for each focus
area.36
Table 4. State and Local Capacity Grants
Focus area
FY2002 a
% of
funding
funds
(in millions)
A. Preparedness planning and readiness assessment
$280
31%
Critical capacity:
– to establish a process for strategic leadership, direction,
coordination, and assessment of activities to ensure state and local
readiness, interagency collaboration, and preparedness;
– to conduct integrated assessments of public health system capacities
related to bioterrorism;
– to develop and exercise a comprehensive public health emergency
preparedness and response plan;
– to ensure that state, local, and regional preparedness and response
are effectively coordinated with federal response assets;
– to effectively manage the CDC National Pharmaceutical Stockpile,
should it be deployed.
B. Surveillance and epidemiology
$201
22%
Critical capacity:
– to rapidly detect a terrorist event through a highly functioning,
mandatory reportable disease surveillance system, as evidenced by
ongoing, timely and complete reporting by providers and laboratories
in a jurisdiction;
– to rapidly and effectively investigate and respond to a potential
terrorist event as evidenced by a comprehensive and exercised
epidemiologic response plan that addresses surge capacity, delivery of
mass prophylaxis and immunizations and as evidenced by ongoing
effective state and local response to naturally occurring individual
cases of urgent public health importance, outbreaks of disease and
emergency public health interventions.
C. Laboratory capacity –biologic agents
$147
16%
36 For complete text of the grant application guidance, see
[http://www.bt.cdc.gov/planning/coopagreementaward/index.asp].

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Focus area
FY2002 a
% of
funding
funds
(in millions)
Critical capacity:
– to develop and implement a jurisdiction-wide program to provide
rapid and effective laboratory services to support response;
– to ensure adequate and secure laboratory facilities, reagents, and
equipment to rapidly detect and correctly identify biological agents
likely to be used in a bioterrorist incident.
E. Health alert network/communications and information technology
$149
16%
Critical capacity:
– to ensure effective communications connectivity among public health
departments, healthcare organizations, law enforcement organizations,
public officials, and others;
– to ensure a method of emergency communication for participants in
public health emergency response that is fully redundant with e-mail in
case the Internet is disabled by a catastrophic event;
– to ensure ongoing protection of critical data and information
systems;
– to ensure secure electronic exchange of clinical, laboratory,
environmental, and other public health information in standard formats
between the computer systems of public health partners.
F. Risk communication and health information dissemination
$41
4%
Critical capacity:
– establish critical baseline information about the current
communication needs and barriers within individual communities and
identify effective channels of communication for reaching the general
public and special populations during public health threats and
emergencies in order to provide needed health/risk information to the
public and key partners during a terrorism event.
G. Education and training
$97
11%
Critical capacity:
– to ensure the delivery of appropriate education and training to key
public health professionals, infectious disease specialists, emergency
department personnel, and other healthcare providers in preparedness
for and response to bioterrorism, other infectious disease outbreaks,
and other public health threats and emergencies.
Source: CDC Planning Guidance.
a Projected amounts based on initial state plan submissions, Aug. 2, 2002.
Hospital Preparedness
In addition to the CDC grants for state and local preparedness, additional funds
have been directed to states, territories and three major metropolitan areas through
HRSA to improve hospital preparedness. For FY2002, $125 million was
appropriated and the President’s budget requests $518 million for FY2003. The
grants are for the development and implementation of regional plans to improve the
capacity of hospitals, their emergency departments, outpatient centers, EMS systems,

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CRS-20
and other collaborating entities for responding to incidents requiring mass
immunization, treatment, isolation and quarantine in the aftermath of bioterrorism
or other outbreaks of infectious disease.37 (HRSA grant guidance)
States have had to achieve three critical benchmarks in order to receive their full
allotments for hospital preparedness: (1) designate a coordinator for bioterrorism
hospital preparedness planning, (2) establish a hospital preparedness planning
committee including representation from a broad range of medical and emergency
management partners, and (3) devise a plan for responding to a potential epidemic
in each state or region. States also must develop a needs assessment for hospitals and
EMS systems and an implementation plan that addresses those needs.
The HRSA guidance identified four priority issues for states to consider in
developing their plans. These priority areas include: (1) developing contingency
plans for antibiotic and vaccine treatment of biological exposures; (2) planning for
personal protective equipment to protect health care workers and patients, portable
or fixed decontamination systems, or capital improvements designed to increase
capacity for quarantine and treatment of biological casualties; (3) assessing existing
local and state communications capabilities available to hospitals and collaborating
entities, and the ability to respond to overloading of standard telephone, cellular
phone and radio communications during a bioterrorist incident resulting in mass
casualties; and (4) planning community-wide biological disaster drills of sufficient
intensity to impact the community’s normal operations during the exercise and to test
bioterrorism disaster plans.
National Pharmaceutical Stockpile (NPS)
The National Pharmaceutical Stockpile (renamed the Strategic National
Stockpile by the Homeland Security Act) was created to ensure the availability of the
life-saving pharmaceuticals, antidotes and other medical supplies and equipment
necessary to counter the effects of nerve agents, biological pathogens and chemical
agents. The NPS is meant to augment state and local resources during an attack or
other emergency. Funds allocated to the NPS are used to purchase, store and rotate
supplies, to assist states and localities in developing plans for deployment and for
providing training and simulation exercises for state and local officials in the use and
distribution of deployed resources.38
Research
Research to develop new drugs and vaccines, increase understanding of how
organisms cause disease, how the immune system responds to disease, improve
diagnostics for human samples, and to improve environmental detection capability
is also an important component of preparing for a bioterrorist attack. Research
activities related to bioterrorism are spread throughout the federal government and
37 For the complete text of the HRSA hospital preparedness grant guidance, go to:
[http://www.hrsa.gov/bioterrorism.htm].
38 For more information on the NPS, go to: [http//:www.cdc.gov/nceh/nps/synopses.htm].

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occur at the state and local level as well. Within HHS, the main entities conducting
bioterrorism-related research are NIH, CDC, and FDA. Within NIH, much of the
bioterrorism-related research is housed in the National Institute of Allergy and
Infectious Diseases (NIAID). The NIAID has recently published a strategic plan that
sets priorities for counter-terrorism research. The strategic plan lists six areas of
research emphasis including the biology of the microbe, host response, vaccines,
therapeutics, diagnostics and research infrastructure improvements. At the CDC,
research efforts are directed toward supporting public health infrastructure capacity
improvements. FDA bears responsibility for food safety and for regulating the safety
and efficacy of new vaccines, antibiotics, other countermeasures and diagnostic
devices. FDA’s research activities provide the scientific basis for their regulatory
decisions and the tools needed to identify and assess risks.
Challenges to Improving
Public Health Infrastructure
While recent Congressional action has provided significant funding increases
for bioterrorism preparedness and response, challenges to achieving improvements
remain in several areas. As Congress assesses the effectiveness of initial funding
increases and considers future funding levels, information about how these
challenges are being addressed by different components of the public health system
may be of interest. These are discussed below.
Defining Preparedness
Bioterrorism is not one threat, but a broad range of threats encompassing
multiple different pathogens, multiple paths for transmission in many potential
locations. The broad nature of these threats require breadth and depth of
preparedness across many jurisdictions. One challenge in increasing preparedness
is establishing what minimum level of capacity must exist in every locality and what
capacity can be created on a more consolidated basis at a state, regional or federal
level.
While a number of assessment tools have been developed to assist states and
localities in defining their needs, there are no systemwide standards for public health
preparedness at the local, state or federal level. This makes measuring progress and
defining base funding needs difficult.
Coordination and Communication
The many parties involved in preparing for and responding to a bioterrorist
attack generate an almost overwhelming coordination and communication challenge.
In addition to sheer numbers, the need to coordinate activities and plans among
groups who previously had limited, if any interaction with each other poses a
significant challenge. At the most basic level, all parties involved in responding to
a public health emergency must be able to communicate easily with each other.
Development of compatible or interoperable communications for use by all

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responders has been proposed by many, but developing standards for
communications equipment across users with differing needs may be problematic.
Emergency Management. Standards for emergency response call for clear
lines of authority and clarity with regard to all participants’ roles and responsibilities.
However, a recent study by the GAO documents the fragmentation of responsibilities
across federal agencies.39 In addition, some have expressed concern over
coordination of federal and state authorities and responsibilities, particularly as they
relate to quarantine decisions and restrictions on travel and transportation across state
borders. Similar issues can arise between states, especially where major metropolitan
areas cross state boundaries. Coordination between states and localities can also be
problematic, especially in major metropolitan areas with strong local public health
infrastructure.40 Coordination and communication between public health officials
and private-sector health care providers is also a major concern. The recent anthrax
attack established that public health officials’ ability to communicate quickly and
effectively with private-sector physicians is severely limited.
Medical Care vs. Public Health Providers. One of the challenges in this
area is the need to bridge the gap between public health practice and medical practice
that developed during the 20th century. As biomedical advances greatly increased
physicians’ ability to treat disease, medicine and public health developed as distinct
professional fields with very different cultures and limited understanding and
acceptance of each other’s approach to protecting public health. This gap creates
challenges in improving public health preparedness because of physicians’
uneasiness about depending on public health professionals for medical treatment
protocols.
Communication between public health officials and hospitals is problematic for
similar reasons. In addition, the competitive nature of the hospital component of the
health care delivery system makes cooperation among hospitals to pool resources and
develop emergency response plans problematic. For example, one task hospitals
undertake to plan for surge capacity in a public health emergency is to develop lists
of where they can get additional supplies such as linens. If hospitals do not share this
information with each other, then it would be possible for multiple hospitals to be
depending on the same supplier for excess supply in an emergency. On the other
hand, hospitals prefer not to share information about suppliers with their competitors
because it can put them at a competitive disadvantage.
Food Safety. Concerns also remain about the effectiveness of the current
fragmented food safety system in preventing introduction of food-borne pathogens.
Specific concerns include the division of responsibility between FDA and USDA,
inadequate inspection and enforcement resources (especially in FDA), and the
39 GAO, Bioterrorism: Public Health and Medical Preparedness, GAO-02-141T, Oct.
2001.
40 Eileen Salinsky, Will the Nation Be Ready for the Next Bioterrorism Attack? Mending
the Gaps in the Public Health Infrastructure. National Health Policy Forum Issue Brief No.
776, National Health Policy Forum, June 12, 2002.

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inability to order food recalls (the current system depends on manufacturers to do so
on a voluntary basis).
Public Information. Clear and credible communication with the public is
believed to be essential for minimizing panic and providing necessary substantive
information. Experts have noted that public health agencies does not have adequate
plans, resources, or trained personnel to properly communicate risks and
recommendations to the public during health emergencies.
Information systems
Inadequate information and telecommunications capacities have been cited as
major weaknesses in the current public health infrastructure. Improvements in this
area could help meet many of the communication challenges cited above. As
described previously, CDC has established the Health Alert Network (HAN) to
enhance state and local computer and information technology capacity. The ultimate
goal of this program includes an Internet backbone, hardware, secure Web sites,
curriculum, distance learning, and media programs. However, some worry that the
basic needs in some states and localities are so great that much of the initial
investment will be needed just to purchase the necessary computer equipment.
Experts have also called for development of widely accepted data standards and
expanded use of electronic, Web-based disease reporting from physicians and
laboratories to improve reporting compliance and timeliness.41
Laboratory capacity
The anthrax attacks highlighted the need to improve public health laboratory
capacity and technological capabilities. Experts have called for accelerated
development and dissemination of rapid diagnostic and detection tests. Concerns
have also been raised about physical security at laboratory facilities that store and
process hazardous microbes and chemicals.
Research
While government funding for research on countermeasures to bioagents has
increased, concerns exist about the likelihood of significant investment by the
pharmaceutical industry in the development of antibiotics and vaccines. The
commercial market for these products and other countermeasures has been viewed
as modest and concerns over liability have further reduced industry interest.
Emergency medical preparedness and response
In addition to the coordination and communication challenges cited above,
concern has been raised over the significant resource needs of health care facilities
to respond to bioterrorism relative to the amount of funding committed for these
41 Lumpkin Health Affairs article.

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purposes thus far. Some have suggested that it may be possible to reduce the
resources required by pooling resources across regions and making strategic
investment decisions.
Public health workforce
In order to provide the public health services necessary for responding to the
bioterrorist threat, the public health system must have an adequate supply of people
with the skills and training needed to perform certain key functions. Among these
functions are: forming effective partnerships with other parts of the response
community to develop and implement public health preparedness plans, detecting
disease outbreaks through surveillance, epidemiology and laboratory testing, and
communicating health risks and preventive measures to the public, health care
providers, and key decision makers.
Even before last fall’s anthrax attacks, the gap between the skills and education
needed to provide public health services and those that exist in the current public
health workforce were of concern to many in the public health community. Salaries
are generally low for people working in public health which has made it hard to
attract and retain an adequate workforce. The average tenure of a state health
department chief executive is 2 years.42
Workforce development issues encompass both concerns about the availability
of enough skilled workers to fill the current needs of public health departments, the
adequacy of the supply in the educational pipeline, the adequacy of public health and
medical curricula and the ability to train current workers to provide needed skills.43
In addition, state and local health departments have expressed concern over hiring
additional personnel without assurance of stable funding. Specific concerns include
worries about ensuring adequate surge capacity for medical response, the ability to
attain adequate epidemiological staff to investigate disease outbreaks, and assuring
an adequate supply of trained laboratory personnel.
Inadequate supply of a skilled laboratory workforce is of particular concern in
the context of bioterrorism. A recent survey44 of state public health laboratory
capacity showed that states may have only one person trained appropriately to
perform bioterrorism testing. Among the states and territories participating in the
survey, a total of 76 more PhD- level molecular scientists were needed than were
available. Because other opportunities attract the limited number of experts, it is
doubtful that these positions can be filled readily. About half of respondents stated
that they had no full-time information technology staff dedicated to developing and
maintaining laboratory information systems. In addition, two-thirds of survey
42 CDC Infrastructure Status Report.
43 Kristine Gebbie, Jaqueline Merrill, and Hugh H. Tilson, The Public Health Workforce,
Health Affairs, v. 21, no. 6, Nov./Dec. 2002.
44 Association of Public Health Laboratories, State Public Health Laboratory Bioterrorism
Capacity, Public Health Laboratory Issues in Brief, Oct. 2002. Found at
[http://www.aphl.org ].

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respondents noted the need to hire additional staff to handle managerial, clerical,
information, communications, training and worker safety activities.
In addition to problems with hiring and retaining adequately trained workers,
public health agencies have had trouble training workers as new challenges arise.
Barriers to training include rural isolation for many local public health workers,
travel limitations, inadequately coordinated training efforts, overworked staff unable
to leave work for professional development, and lack of funding for training.
Finally, many worry about how to be sure that the increased funding devoted to
increasing public health capacity yields results in improved preparedness and
response capability.
Conclusion
The events of fall, 2001 have heightened concern about the nation’s ability to
respond to bioterrorist attacks. The strength of the public health infrastructure at the
federal, state, and local level is an important determinant of the speed and
effectiveness with which a response occurs and, therefore, of the severity of the
consequences in terms of number of people affected. Recent Congressional action
has provided funding and guidance to improve public health capacity at the federal,
state, and local level. As Congress grapples with future funding decisions, continued
interest in how public health agencies are using increased funding to improve
capacity is expected.

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