As they rush to answer President Bush's call to vaccinate millions of emergency workers against smallpox, state and local health officials say they have stopped virtually all other counterterrorism efforts and in many cases have begun trimming services such as prenatal care, AIDS prevention, water testing and tuberculosis tracking.
In communities such as suburban Philadelphia and downtown Memphis, public health nurses have put childhood immunizations, new mother visits and diabetes screening on hold while they prepare smallpox vaccination clinics.
In the Oklahoma health department, all of the approximately 20 bioterrorism experts are assigned to the smallpox program, a requirement that has halted preparations for handling anthrax, plague and other deadly germs.
In the Seattle area, the health department is belatedly scrambling to control an alarming surge in sexually transmitted diseases. "We would have been on this faster and more effectively if I could have put a critical mass of infectious-disease people on this rather than on smallpox," said Alonzo Plough, director of the Seattle and King County public health department. "We are stretched as thin as I have ever seen."
On Dec. 13, Bush summoned the nation's public health community for a program of unprecedented proportions: inoculating as many as 10.5 million medical workers and emergency responders in a matter of a few months. The call has injected fresh energy into the world of public health, a field that had been neglected for decades, say public health veterans. But even at this early stage in the project, which began Jan. 24, they point to steep costs -- in dollars, staffing and fundamental public health protection.
"It's been disruptive," said Patrick Lenihan, deputy commissioner of the Chicago Public Health Department and president of the National Association of County and City Health Officials. "People who were doing routine health activities six months ago like taking blood pressures and assessing diabetes are now spending time preparing for smallpox vaccination and treatment."
In a survey of 539 health departments released by the association last month, 79 percent indicated the smallpox inoculation campaign was siphoning staff time and money from a long list of other initiatives designed to protect citizens from chemical, radiological and other biological agents such as botulism, Ebola virus and anthrax. About half the departments also "deferred, delayed or canceled" more traditional projects such as flu vaccinations for the elderly, STD clinics and checkups for low-income children, according to the report.
"Almost 90 percent of my time is devoted to homeland security," said Kathleen Toomey, head of the public health division at the Georgia Department of Human Resources. "It's difficult for other programs to not have the leadership of the commissioner."
Susan Allan, public health director in Virginia's Arlington County, said the smallpox program has left little time for anything else. She worries that the emphasis on smallpox, a disease eradicated 30 years ago, will leave communities unprepared for other types of assault. "The plan that rolled down to us is very narrow and specific, and it's like the tail wagging the dog," she said.
Maryland has vaccinated 18 health workers, Virginia 162, and the District of Columbia has not yet begun its program, according to the most recent data from the federal Centers for Disease Control and Prevention.
Michael Osterholm, director of the University of Minnesota's Center for Infectious Disease Research and Policy, said it is common for public health departments to shift staff and priorities during times of crisis.
"That's true whether we're dealing with outbreaks of meningitis or the anthrax attacks," he said. "The issue here is that it not last for months and months. Then it becomes more of a problem."
Officials at the CDC, who have been overseeing the smallpox campaign, sympathize with their local partners. Almost all of the 350 people in the CDC's immunization division are assigned to the smallpox program, said director Walter Orenstein.
"There has been a tremendous diversion in order to accomplish this," he said.
State officials acknowledge that the $1 billion in federal bioterrorism assistance they received last year for additional staff and infrastructure improvements will also benefit non-terror programs. An epidemiologist hired with a bioterrorism grant or computers purchased with the federal money also can be used to investigate a West Nile virus outbreak or plot cancer clusters, they said. The problem, many argue, is the heavy emphasis on a single program.
"It would be a mistake to think the overall public health agenda has been strengthened," said Robert Gage, president of the Pennsylvania Public Health Association. "As important as it is to be prepared for some horrific terrorist attack such as bioterrorism, we don't have a single case of smallpox, but people are still dying of cancer and cardiovascular disease."
Health commissioners say the long list of anti-terrorism duties they were given a year ago -- upgrading laboratories, building secure communications systems, training staff, crafting plans for chemical and radiological terror and developing post-attack smallpox response plans -- has been superseded by the immediate need to carry out the smallpox inoculations.
"The entire group of people we've employed to work on bioterrorism has been diverted to work exclusively on smallpox," said Leslie Beitsch, Oklahoma's health chief. "If we started getting anthrax letters through the mail again, we would probably not be well-positioned to respond to those."
Joseph Henderson, associate director of terrorism preparedness and response at the CDC, said states should be able to manage the first phase of the smallpox program -- inoculating as many as 500,000 medical workers nationwide -- by tapping into the $1 billion distributed last year. "Anything beyond that will be too much of a burden," he said, promising to lobby for more money for states.
Partly because of logistical and legal hurdles, the program has gotten off to a slow start. Nationwide, 7,354 health care workers were vaccinated as of Feb. 21, the CDC said. Many health professionals and hospitals have expressed reluctance, arguing that the known risks of the vaccine appear to outweigh the unknown, but slender, chances of a smallpox attack.
Most state and local health officers have been reluctant to publicly criticize the Bush smallpox plan or point to shortcomings in their own departments. But in private conversations and anonymous surveys, they paint a more alarming portrait.
One health department canceled a hepatitis vaccination clinic at the county jail, while a few Indian tribes said work on chronic problems such as alcoholism and diabetes has been hampered by new counterterrorism responsibilities.
In the Memphis and Shelby County department, Yvonne Madlock's community health planning team is too busy mapping out smallpox vaccinations for 800 to 1,600 medical workers to develop much-needed programs for childhood obesity or infant mortality.
Several factors have made the smallpox program unusually challenging. Because the vaccine has not been given in 30 years, few of today's doctors and nurses have been trained in the inoculation technique, which requires 15 pricks of the skin with a two-pronged needle. Because the live virus vaccine can cause severe complications, each inoculation requires elaborate pre-screening and follow-up.
Before a single vaccine is administered, health officials and hospital managers must hold a long series of meetings to cull lists of eligible volunteers, debate liability issues and develop a computer system for monitoring adverse effects.
In New Jersey, the infection control chief at one large hospital described in a memo how labor-intensive the process was. This person, whose name was withheld by state epidemiologist Eddy Bresnitz, spent five full days holding informational sessions. "The time involved in manpower was HUGE" and resistance was high, according to the memo. "We sent out about 1,700 educational packets. We received 175 YES replies." After screening out people with high-risk conditions, the hospital had fewer than 24 people to immunize.
"It is time-consuming, especially at the local and hospital level," Bresnitz said. So far, the preparations have cost about $10,000 for each hospital. Three educational meetings for a total of 900 workers across the state cost $45,000 in staff salaries, educational materials and travel time.
What worries health experts most is that the ambitious smallpox program is still in its infancy. Jumping from the first stage of inoculating 500,000 health workers to the second stage, when 10 million police, fire and medical personnel will be offered vaccine, seems overwhelming to many.
In Georgia, "Phase 2" could involve immunizing 100,000 people, said Toomey, and "we would be having to shut down other public health activities."