New Focus on Public Health

The tragic events of September 11, 2001 have resulted in a new focus on public health. Now public health surveillance and capacity are linked to the imperative of preparedness against unexpected terror attacks involving biological, chemical, or nuclear threats. National leaders, editorial writers, and various commentators are using the term "public health infrastructure," apparently recognizing that first response exists at the local level and that a major infusion of resources is needed. This boosting and apparent commitment to our field is unprecedented in recent times.

Commentators have remarked that public health has been ignored for the past 15 years. Actually, the period of neglect stretched through almost all of the twentieth century. The great advances in public health began at the end of the nineteenth century, sharply reducing the infectious diseases that were the leading causes of death. Stemming tuberculosis, sanitizing the community water and food supply, and mass immunization were major advances spurred by collective or community action. This definition of public health based on communal activities goes back to ancient times and was formalized in the Middle Ages by authorities responding to the threats of infectious disease. More recently, the citizenry and their elected representatives have taken these gains for granted, expecting safe water and the absence of vaccine-preventable disease.

Efforts to improve the health of our society were diverted by policy makers to preoccupation with health services and their attendant costs and away from the basic determinants of community health status.

But the new focus on public health, at least that concerned with preparedness, is not likely to disappear because its stimulus is the need to protect the community. The arsenal of public health, which includes surveillance or early recognition of natural or purposeful agents of illness, is indispensable and no other capacity can provide a substitute. Ironically, many of the public health measures now being discussed will be renewals of previous strategies, some more than five centuries old. Some may need to be redeployed to combat threats once conquered. Tragically, smallpox, declared eradicated by the World Health Organization (WHO) in 1980, now is feared as a weapon of bioterrorists. Responding to this threat requires planning by public health agencies with components of surveillance, isolation (quarantine), vaccination, and public information.

Cieslak and Eitzen, 1 in a special bioterrorism issue of this journal (June 2000), point out that, "A single case of smallpox occurring anywhere in the world today would represent the gravest of public health emergencies, and suspicion should prompt immediate consultation with health authorities. Strict quarantine (airborne and contact precautions in current terminology) should be instituted immediately for victims (until all scabs separate) as well as their contacts (for 17 days from last exposure.)."

Quarantine is not within the repertory of contemporary health officials. Its purpose is protection of the community from the spread of infectious disease. Quarantine is derived from quarantenaria, or 40 days believed in the thirteenth century to mark the separation between acute and chronic disease and also having biblical significance (the flood lasted 40 days). 2 Quarantine was employed first in Venice (1348) in response to plague by a council of three men empowered to supervise the public health of the community and to take whatever measures were necessary to safeguard it. This is the progenitor of our local health departments and boards of health.

Local public health agencies throughout the nation are responding to this challenge with planning and by building infrastructure. The capabilities, including the authority of public health for quarantine and mass vaccination, must be examined. For example, New York state at the time of this editorial had a disease-specific quarantine statute that did not include smallpox or other important bioterrorist agents. There appears to be a consensus that resources are needed, but in the recent past, bioterrorism funding stopped at federal and state health agencies and was not distributed to local health departments where it is most needed. The new focus on public health is an opportunity; resources and hard work to develop local infrastructure will not be wasted even in the fortunate event that threats never become an eventuality.

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