Since September 11, 2001, the country's focus on preventing terrorism has overshadowed the public health preparedness necessary to respond to the weekly events that happen across the United States. In 2002 alone, there were 49 major disaster declarations in 37 states and territories,1 including earthquakes, severe flooding, hurricanes, ice storms, outbreaks of infectious disease, tornadoes, and the worst wildfires in California history.2 Although there may not be a universally understood construct of what "being prepared" actually represents, we hear repeatedly, such as in the after action reports from TopOff2 (the Top Officials training exercise conducted in Seattle and Chicago in May 2003) that the country is not prepared. Any attempt to improve readiness is undermined by the naysayers who lump all mitigation together and advocate that preparedness activities unnecessarily divert resources from "important" public health activities. Whereas those in the disaster field believe that mitigation improves health and mental health outcomes, little documented evidence exists to support the allocation of resources to preparedness. This is the quintessential public health problem-the effectiveness of our actions is only evident when bad events do not happen.

If we look for practical evidence that preparedness makes a difference, examine the World Health Organization's (WHO) efforts to combat influenza. WHO has monitored the transmission of infectious disease, developed rapid response teams, adjusted vaccines based on southern hemisphere changes, and designated labs. This solid scientific cooperation among the international community paid off in the winter of 2002-2003, when the world experienced and controlled the first global Severe Acute

Respiratory Syndrome (SARS) outbreak. In the maturation of their preparedness activities, WHO is establishing an international Epidemiological Intelligence Service, expanding their ability to strike fast when the next worldwide outbreak occurs. These actions are a powerful affirmation that the allocation of resources for preparedness is merited.

Evaluations of efforts undertaken to reduce disasters' negative outcomes have often been one-shot with a focus on outputs (eg, numbers trained in disaster planning), rather than outcomes (eg, lives saved, illness avoided). Many have surmised that in 2003, the United States avoided a SARS epidemic when Canada did not, in part, because public health systems had significantly enhanced their preparedness activities for two years through surveillance and provider health education. Although awareness about the need has increased and public health has consistently been included in community preparations, we don't know if these efforts make a difference. Until it can be demonstrated that preparedness is a cost-effective use of resources, there will continue to be a tension between those who advocate for preparedness and those who feel the risks don't merit the investment. This issue of Family & Community Health helps bridge that gap.

This issue covers a range of preparedness topics: earthquake-producing injuries, psycho-social effects from one of the most common natural disasters-floods, the disastrous consequences of global climate change on community health, communication following terrorist attacks, the effects of training public health nurses who delivered services following the World Trade Center (WTC) attack, the views of teachers responsible for students schooled near the WTC towers on September 11, and preparations for those working in child care.

Some articles provide evidence that preparedness makes a difference, some identify activities of preparedness that have yet to be taken, and some suggest actions in settings or with groups that have been previously overlooked.

In an invited commentary, Tadmor shares the insight that he gained as the head of the medical department of the Home Front Command in Israel. While laying out a framework for understanding health sector preparedness, Bissell et al present a landmark paper demonstrating that preparedness has saved lives. They conceptualize a model that explains how preparedness operates and provide evidence that highlights the value of these activities. Moore et al provide first-hand accounts of the human impact of floods. Their work identifies community activities that may be effective in preventing the negative psychosocial impacts that often follow disasters. Diaz describes precursors to natural disasters and emerging infections that can be mitigated by the policies developed by our society and by the actions of mankind. In response to Diaz's article, Westphal's commentary reminds us that preparedness must be looked at broadly because of the global village in which we live. The next big disaster, brought about by changes in our environment, may be prevented by breaking both known and unknown chains reactions. Utilizing what is known about communication theory, Wray et al recommend practical actions that communities can take to enhance their success in communicating during emergencies. Quereshi et al demonstrate that training helped public health nurses function better during an emergency. Since children are often in school or day care when disasters occur, two articles address issues inherent in these settings. Pfefferbaum et al assessed teacher preparation for emergency response with their students, and Gaines and Leary provide guidance for preschool settings. Finally, Glick et al describe the collaboration between the public health department, local hospitals, and the school of nursing in one community as they address disaster preparedness.

This issue would not have been possible without the help of the reviewers who generously gave their time to make it a success. Their comments were insightful, constructive, and led to the improved preparation of all of the articles. Heartfelt thanks go to Gail Cairns, Linda Degutis, Ehren Ngo, Darcy Vetro Ravndal, and Robert Westphal. Bob was particularly helpful, at times acting as an assistant issue editor. Their efforts were instrumental in making this issue a success.

It is my hope that these articles open a window for those who wonder why our country is investing so much into public health preparedness. Since the success of public health is often witnessed in the avoidance of negative outcomes, may we build on our current preparedness activities so that we only surmise about the deaths avoided when the next disaster hits.

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