In Seattle, the morning when the towers came down, there was a sense of trauma. I went to my office and walked the floors and there was this sense of shock amongst everyone.

As director and health officer for the Seattle and King County Department of Public Health, I had to spearhead the response to ensure the public was safe. The public heath implications of the 9/11 attacks were instantly clear. We had to identify what might be next. At the time, any city that had a significant landmark could be at risk and there were all kinds of rumors that iconic architecture symbols were on the list.

Once it became clear the 9/11 attacks were isolated to the east coast, our role shifted to focusing on the mental health needs of the public.

The events were highly transformational —something had fundamentally changed in the public health field after 9/11. It was, in a way, almost similar to AIDs and HIV in the 1980s in that public health was being taken in a completely new direction and would have to serve new functions.

This was nailed home when the anthrax attacks occurred. Quite simply, never in the history of public heath had diseases we thought were in the past been reintroduced as a weapon.

Even though we had been thinking about bioterrorism in Seattle since we hosted the World Trade Organization (WTO) conference in 2000 and had a syndromic surveillance system, these public health attacks were unprecedented. We had thought that our senses were heightened to bioterrorism, but, in reality, our focus wasn’t that high. September 11, 2001pumped it up high and anthrax took it to new heights. It was a frenetic period.

Because of the WTO conference, we were able to, somewhat, reassure the public that the city was prepared. We had a syndromic system that would give us pattern recognition if there was anything going on in our vicinity.

So our response to anthrax was mainly one of surveillance and risk communication. We had to keep public concerns at a level commensurate to the actual level of risk. We were able to do this, but not without a lot of effort. I mean we were getting press calls about whether people should steam iron their mail.

While the public was our main concern, we quickly discovered that we had no relationship with the intelligence community. We were saying things that the intelligence community knew not to be the case. At one point the public health department was on record saying anthrax hadn’t been weaponized, when law enforcement knew that it had been.

We also had to build relationships with the first responder network. One day, I looked out the window (we were across the street from the regional Federal Bureau of Investigation (FBI) building) and saw fire trucks and tape all around it. I spoke with the fire chief who said there had been a white powder scare, yet they hadn’t thought to contact anyone in public health. Clearly, we had a major and immediate need to work better together, especially during the flurry of white powder scares.

As the crisis went on, we worked with law enforcement and first responders to allay public fears and educate. As director, my main role became to interface with the public and government and take on the risk communication function.

When I look back on that frenzied time, the biggest gap was the lack of a relationship between public health and intelligence. Now, through Homeland Security, we jointly perform combined threat assessments. I have a security clearance. If anthrax happened now, we would be doing two-way surveillance, intelligence assessments and have real-time knowledge of the threat. This was entirely missing in 2001. In addition, we are able to pass correct information to the public — during the initial response to anthrax, the information we had was wrong.

As a nation, we took a lot away from this. In the aftermath, we were one of the first groups to work with the Centers for Disease Control and Prevention to form what would become the Public Health Emergency Preparedness (PHEP) cooperative agreements, which now support preparedness nationwide in state, local, tribal, and territorial public health departments.

With the agreements and lessons learned, we’ve come a very long way. I think about H1N1 and how quickly and successfully we were able to respond— that response was totally based on the funding and knowledge that had been built coming out of the PHEP agreements. Bioterrorism programs had evolved to include pandemic and all-hazards programs. I think that, appropriately, the field has moved from just a single concern of bioterrorism to focus on a variety of low-probability, high consequence events.

Currently, as the director of emergency preparedness and response for the Los Angeles County department of Public Health, I know my job is a lot easier now. We have biowatch monitors, which can identify the top five bio agents that could be used in an attack. We have fusion centers with FBI, Homeland Security and first responders. In addition, there are specific protocols in place that determine when intelligence becomes actionable during a particular scenario. We can also do pattern recognition and early detection for bioagents. In LA County, we fund hospital preparedness programs — 102 hospitals are trained to respond to terrorist events. None of this existed during 9/11 and the anthrax attacks.

It’s clear, we’re much more prepared now than at any time before. Yet it requires a lot of juggling to remain this prepared. There are oscillating funding streams that peak up when there is a problem and are cut when things appear to be quiet. But we need to view preparedness the way we view the fire department. There will be something in the future — it’s true. As we get 10 years away, there is just complacency that bioterrorism attacks might not be probable — that’s not true. Every major study says that this isn’t true.

As a country, we need to think about the incredible times in 2001 and ensure we are better capable to respond in 2011, 2021 and on.

By Alonzo Plough, M.A., M.P.H., Ph.D., Director of Emergency Preparedness and Response, Los Angeles CountyDepartment of Public Health Board of Director, Trust for America’s Health

You can download the PDF version of the story here.