The high cost and heavy demands of being ready for a possible smallpox attack are squeezing basic public health services, state health officials say, forcing cutbacks in such areas as childhood vaccinations and tuberculosis prevention.
"It has forced trade-offs in everything we do," said Dr. Alonzo Plough, public health director for Seattle and King County, which is battling its worst tuberculosis outbreak in 30 years.
But federal health officials have some advice: Get used to it.
"We are never going to get back to the days when we did 'regular' public health," said Dr. Ed Thompson, of the Centers for Disease Control and Prevention. "For the rest of all our careers in public health, we're going to do the emergency crises and the daily work side by side."
Some state and local health agencies warn that the result could be more outbreaks of preventable diseases like TB and hepatitis. Seattle officials blame a shrinking budget and the emphasis on smallpox for contributing to the TB outbreak.
Federal officials say local health workers simply need to get better at juggling daily duties with emergency demands.
"That's the nature of public health — things come up," said Thompson, deputy director for public health services at the CDC. Public health workers need to adapt to emergency interruptions in their routines, he said.
He agrees, though, that more money is needed for all the demands. "Support of protection of the public health is going to have to become a priority," Thompson said.
While Seattle's TB outbreak may be the most dramatic example, many state and local health departments say they are cutting bread-and-butter services.
In Memphis, Tenn., some childhood immunizations and diabetes screenings have been put on hold. Health officials in Camden County, N.J., near Philadelphia, have canceled family planning clinics. In Wake County, N.C., home of Raleigh, workers have delayed some programs and canceled client visits to meet the demands of smallpox planning.
"This situation has led to questionable preparedness, poor response to community requests for service and an overextended staff — not a good combination," said Gibbie Harris, community health director for Wake County, N.C.
The smallpox campaign began last December, when President Bush ordered the voluntary vaccination of 450,000 civilian health workers.
Most of the burden for carrying out the plan fell to state and local health departments. County health officials in Washington state said they had to shelve preparations for other bioterrorism threats, such as anthrax, to meet federal expectations for smallpox.
But the attitude toward the smallpox plan seems to differ in East Coast urban areas that believe they are more likely targets of bioterrorism. Few complaints are heard in the Maryland Department of Health and Mental Hygiene.
"There really hasn't been a discernible impact on day-to-day operations," said J.B. Hanson, spokesman for the Maryland agency. He said health workers seem committed to the vaccination plan.
"The locale obviously has something to do with it," Hanson said. "We're very aware that we border the nation's capital."
But in Seattle, the more pressing need seems to be TB — a disease that is at an all-time low nationally.
Plough, Seattle's health chief, said the TB response could have been "faster and more focused," if they had more money, or fewer smallpox mandates.
When the outbreak began last year, Seattle health officials might have sent a team of nurses out to track down people like Hayward Brown, who was living on the streets when he got TB.
Instead, many of those public health nurses were going to smallpox planning meetings, Plough said. And Brown wasn't stopped from spreading the disease until February when he went to an emergency room.
"I had a lingering cough, but I thought it was just a cough, like everyone else," said the 53-year-old man. After a few tests, "they whisked me away to a room by myself."
Now he lives in an apartment paid for by the public health district. Health workers bring him his anti-TB pills every morning and watch him take them, something Brown agrees is a "pretty good idea."
To make up for the slow start the county health department is now doing X-ray screenings in homeless shelters, sleuthing out the identities of people who may have been exposed, and tracking the outbreak with DNA fingerprinting.
But the smallpox vaccinations will take attention, too.
"We should be the first responder for bioterrorism, no question," Plough said. "But we can't stretch ourselves that much. We're not that elastic. You can't do more with 50 percent less budget."
By REBECCA COOK