Six months after the specter of bioterrorism became reality, the School's Center for Civilian Biodefense Strategies has staked out a more activist role in national preparedness.

By Brian W. Simpson

As the final speaker at the School's bioterrorism intersession course, Tara O'Toole faced a standing-room-only crowd of 150 researchers and officials from the Pentagon, the Environmental Protection Agency, state and local health departments, and a host of other government agencies. They had already been schooled for eight hours in bioterrorism's sinister challenges: genetically altered biological agents that promise greater lethality, "dirty" bombs that would disperse radioactive material, contaminated municipal water supplies, and other nightmares.

For the closing talk that day in mid-January, O'Toole, director of the School's Center for Civilian Biodefense Strategies, chose a suitably forbidding topic: the Byzantine complexities of the federal budget process.

The stakes couldn't be higher: the health and safety of the nation and a once-in-a-lifetime chance to rebuild the nation's crumbling public health infrastructure. As unprecedented amounts of federal funds surge into the nation's public health system, the key is how to ensure the money gets to the right people and is used in the most effective way.

The United States must work quickly to prepare for and hopefully prevent another round of terrorist attacks that could come in biological, chemical, or nuclear form. Cities must develop response plans, states may need to update quarantine laws, surveillance networks must be established to warn of disease outbreaks, hospitals must be readied for mass casualties and infectious patients, and physicians must be able to quickly get reliable information and warnings of new threats. The to-do list may be endless, but one thing is certain. Few items can be checked off without one indispensable resource: federal money.

"What I was trying to convey [at the intersession course] is the message that the government is not an opaque and inscrutable mystery," says O'Toole, MD, MPH '88. "One can figure it out. One can influence it. [But] you have to understand what the budget process is. You have to recognize the constraints on the administration and the Congress. You have to give them what they need, when they need it, in a package they can understand."

Six months after the fall anthrax attacks, the Center has gone operational. The willingness to advise government officials and to engage other public health experts in the federal budgetary process reflects a more "activist" role for the Center, which emerged last fall as the national resource on bioterrorism.

Its new name now the Center for Civilian Biodefense Strategies, not Studies underscores the new attitude. "I think what we wanted to convey was the notion that we are interested in making things happen, not simply studying what was going on," O'Toole says. "We are interested in how we can change the world so that we actually are better prepared for a bioterrorist attack should it occur and also help thwart it from ever happening.

"It's not enough to do the analysis and publish it. That's the starting point," O'Toole says.

So in addition to publishing research in top journals such as the Journal of the American Medical Association and Clinical Infectious Diseases, and bringing out a new book (a collection in April of their JAMA papers on biological agents), O'Toole, Tom Inglesby, MD, deputy director, and others at the Center are meeting with top administration and other government officials to ensure the best use of bioterrorism preparedness funds $2.9 billion in the current fiscal year, and $5.9 billion proposed for the next.

While it's widely accepted that the nation must "rebuild its public health infrastructure," the method for achieving this goal, or even how to define it, is not clear-cut. "We are going to have to figure out what that means and certainly the School of Public Health should be deeply engaged in that. Then we're going to have to make it happen," O'Toole says. This requires a clear articulation of state and local health department needs, and a sophisticated understanding of how money flows, what programs are possible at each level of government, who needs the money most, and how progress can be measured.

Against all odds, government can act quickly and effectively. Inglesby points to the decision to build a national reserve of 280 million doses of smallpox vaccine and the accelerated schedule for developing a new anthrax vaccine as important immediate steps. But planning for the long term must also be part of what's considered right now. "One of the short-term things is creating policy infrastructure and resources for work done one, three, five, ten years from now," Inglesby says. "Science takes a while. But it's literally the only way out. We need absolutely new technology, and new vaccines and diagnostics to manage these threats."

O'Toole envisions a national research priority on the scale of the nation's Apollo moon project that would stake out clear goals for the biomedical sciences. "In the long term, we ought to learn enough about the pathological mechanism of disease and the immune system that we can [quickly] identify, diagnose, and prevent and treat any kind of engineered bug that anybody wants to throw up at us," she says. Such research would spin off new knowledge and tools to deal with drug-resistant tuberculosis, malaria, HIV/AIDS, and other diseases that already cause half the premature mortality in the developing world, O'Toole says.

As a related priority, the Center will work with scientists to devise methods

of self-governance to prevent new science from being used for dark purposes and resulting in new bioweapons.

In the Center's long-term future, O'Toole sees its continued expansion to meet the numerous demands. The Center will need more faculty members and visiting scholars.

Ongoing projects at the Center include writing a history of the anthrax attacks and the response, developing a national strategic research and development plan for biodefense, and continuing briefings to everybody from the vice president to the U.S. Conference of Mayors, and high-level officials at the departments of Defense, State, and Health and Human Services (HHS). ("When I try to remember where I've been talking in the last two months, it all blurs," O'Toole says.)

As the Center moves forward with its agenda, O'Toole and her colleagues maintain a close link to the Center's former director, D.A. Henderson, MD, MPH '60, now leading the Office of Public Health Preparedness at HHS. When HHS staff wanted more information on preparing for nuclear or radiological attack, O'Toole, a former Department of Energy official, connected them to the right people in government. And when Henderson wanted to know what hospital preparedness needs were, the Center hosted a meeting of hospital and public health experts with HHS staff. "We knew who to invite," O'Toole says. "That's the kind of thing the Center can do."

For the Center and the nation, studying bioterrorism in the abstract is no longer possible. Fast yet methodical preparation across a range of public health fronts is demanded because tomorrow's bioterrorism may look very different from last fall's anthrax terrorism. Inglesby warns: "As we've said before, it was the preface to the story. It was not the whole story."

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