On September 11, 2001, our country’s notion of national defense forever changed. With the subsequent anthrax attacks, it became apparent that public health is just as important to protecting our citizens as any missile defense shield.

In 2001, I was secretary of the Maryland Department of Health and Mental Hygiene and also serving as president of the Association of State and Territorial Health Officials (ASTHO),so I had my fingers on the pulse of many public health programs and priorities around the country.I always knew we protected people and improved their health, but we had never before seen ourselves as an integral part of the homeland security infrastructure.

We were fortunate in Maryland. A few years before the attacks, my state had begun to build a bioterrorism plan. While serving on the Institute of Medicine’s Bioterrorism and Chemical Preparedness Committee, my eyes opened to the potential threats out there. I worked to ensure that Maryland was one of the early grantees of the Centers for Disease Control and Prevention(CDC) Bioterrorism grants. By mid-2001, we had already made substantial investments in time,training, plans, and creating relationships with law enforcement. We had included the Federal Bureau of Investigation (FBI) and other law enforcement agencies in our plan, mostly, to forge relationships that would be needed if an attack took place. I didn’t want us first exchanging business cards in the middle of a disaster. We also identified a “go-to place” for an alternative command center should we not be able to use our building. This is where we convened on 9/11 because no one knew if there were other planes and there were rumors that any additional planes might be targeting Baltimore and Annapolis.

After 9/11, we knew we had to be prepared for another attack. In October, I learned through the beltway rumor mill about a confirmed case of anthrax in Washington, D.C. So, I picked up the phone and called District of Columbia health officer,Dr. Ivan Walks, and offered our help. I perceived it was his problem, but quickly learned otherwise.

The victim was a Maryland resident who was hospitalized in Virginia who worked in Washington, D.C. Clearly this case eclipsed borders and the entire metropolitan area needed a coordinated, consistent and coherent response.The victim was Thomas L. Morris Jr., a postal worker whose job was to carry mail from the Brentwood Facility in Washington, D.C. to Baltimore Washington International Airport (BWI). At the time, Brentwood hadn’t been clearly established as the site where he was exposed — which we refer to as the powder drop — so we had to quickly determine where he got infected. If he was exposed at the airport, people all over the country and possibly the world could have been exposed.

Working through the night, we began piecing it together. We determined that the victim primarily carried mail to an air cargo facility on the outskirts of BWI and consequently could not have contract anthrax in the airport. This was a great relief,but it also raised other concerns. If Brentwood was the most likely place of exposure,that would mean not only were other workers and residents at significant risk, but so were other members of the Washington metropolitan region.

In addition, many of Baltimore city’s (and other Maryland counties) mail came directly (one“mail stop” away) from the D.C. Brentwood Facility.Several banks and other businesses were impacted by this, some having mail rooms with high speed sorting machines similar to those used in the Brentwood postal facility. We received calls from bankers and others whose employee’s wouldn’t go near the mail even to process checks. They needed to know if the mail was safe. Unfortunately, we didn’t have a good answer for them, so we ended up conducting a state wide testing program for business mail rooms to define our risks and reassure the public.Like other public health agencies we tested all kinds of things, from personal mailboxes to powders that turned out to be from donuts.

It was incredibly difficult to allay public fears because there were few reliable rapid tests for anthrax in the environment. In some cases we were inventing new testing methods based on the best science we had. We simply didn’t have a lot of experience with environmental testing under these conditions and no experience with mass exposure to anthrax. We got through it, but with a lot of ingenuity and teamwork.

Ten years ago, public health workers answered our nation’s call to action. Before that, preparedness had not always been considered central to our jobs. Some feel that the added responsibilities undermine our other important work. But in the 21st century, it’s clear that preparedness is an integral and important part of public health. It is not an either or thing. At the end of the day, preparing for any threat makes us better prepared for all threats, whether it’s bioterrorism or a flu pandemic.

We learned a lot from these attacks. There is no question that the old Boy Scout motto “be prepared” is still very relevant today, and we are much better prepared for bioterrorism, pandemics and basically any public health emergency. However, I do worry that our short-sighted zeal for financial solvency is putting our health preparedness and safety at risk. Simply trading our long-term health future for short-term fiscal stability isn’t a reasonable trade off.

Georges C. Benjamin, M.D., FACP, FACEP (E), FNAPA, Hon FRSPH, Executive Director, American Public Health Association

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