As I look back on the public health response to the 9/11 and anthrax tragedies, my perception hasn’t changed. If anything, I am even more impressed with how the public health community, many different jurisdictions and the nation as a whole dealt with two historic acts of terrorism.

At the time, I was the senior assistant commissioner of health for New Jersey and the health department’s weapons of mass destruction coordinator. Ultimately, I became the incident commander for both terrorist events. It was absolutely amazing, but not really surprising, how the jurisdictions (Washington, D.C., Florida, Maryland, Virginia, etc.), against all odds, effectively responded to meet the immediate and long term needs of the public. I saw people do things for the public’s good and push themselves beyond the limits of what they ever thought they could. They never took a break, never buckled and never faltered.

When the towers went down, people evacuated into New Jersey, and those who had minor injuries were coming to our hospitals. In addition, many New Jerseyans worked in New York City. The response and recovery was a huge activity; we sent a lot of our urban search and rescue and ground and air medical transports to the scene and nearby mustering points. We also used some of the properties across the river in New Jersey as staging areas for equipment and recovery planning, including Liberty State Park. As it continued over time, a large portion of our response shifted to mental health counseling and grief support. Many people who lost their lives were residents of the great Garden State.

When anthrax was confirmed, the public health community had just spent four weeks managing the daunting response to the 9/11 attacks. Many states were still running significant response/recovery activities. Then, someone in Florida contracted anthrax, yet you find out that ground zero for that attack was actually in New Jersey. All of a sudden, you are dealing with a crime scene and law enforcement investigation across several jurisdictions. There was potentially a fatal biological agent being distributed by a terrorist using the postal system that could do harm to innocent people all across the country. You had public fear on an unprecedented scale, all the while health agencies were dealing with a biological agent they weren’t accustomed to — sure some dealt with naturally occurring anthrax and had trained for such an event, but this was the first “real deal.”Then the lab samples start flooding in and they need to be tested in labs that were not originally designed and built for this kind of event.

Prior to the 2001 anthrax attack, New Jersey did about 10-15 specimen tests a year, principally for Federal Bureau of Investigation (FBI) powder investigations. In the fall of 2001 alone, our public health lab tested over 3,000 specimens. The demand for surge capacity was huge because we had samples coming in from local post offices and FBI as part of the investigation and other “white powder” scares. We also knew we would get positives, so we had people under incredible stress testing specimens they knew to be hot. Yet, all 3,000weredone and there was not one incident of cross contamination at our laboratory nor did any worker get infected. This is just one of a hundred stories that can be shared that show the true grit of the public health workforce. When you get down to it, they were working in outdated labs that didn’t have the state of the art containment features that we have today. They maximized the use of what they had, innovated when necessary, and relied on their formal training to get the job done as safely, effectively and reliably as possible.

This was a great example of American spirit, pride in public service, talent and teamwork.

As I see it, there are three milestones when it comes to public health and emergency preparedness and response:

• 1999: The country began to invest in public health preparedness, giving many states a couple of years to start developing capacity to handle those types of events. There is no doubt in my mind that this foundational work made all the difference in the world in better preparing us for the events that were soon to follow!
• 2001: Every aspect of the country’s public health system felt the impact of 9/11 and anthrax and learned what it took to respond to a massive terrorism and bioterrorism emergency.
• The decade since: Through the passage of key federal laws and establishment of critical federal cooperative agreement programs with the states, there has been exponential growth in the capacity and capability of local, county, state, territorial and national public health professionals to be more at the ready to respond to and recover from all hazards and threats, not just acts of terrorism.

As a result of the attacks, the public health, law enforcement and full family of emergency services communities were thrust together. It was a clear turning point, sending the signal that we were all in this together and that incredibly different sectors had to work together. Over the last10 years there has been success after success that shows this. When you look at other events the emergency/disaster/terrorism community has responded to — such as the H1N1 Pandemic and many natural disasters such as hurricanes and other flooding events — clearly public health, law enforcement and emergency management are much more in step and familiar with each other’s disciplines and specializations.

It truly is impressive how far we have come in the past 10 years. When I think back to the fall of 2001, the biggest limiting factor was human resources. As an example, there really weren’t protocols fully developed and implemented at that time for having workers cross-trained as a means to provide sufficient surge capacity. Most of the work that was being done fell to primary responders (planning, hazmat, and bio hazardous lab folks) because there wasn’t yet a mature means to stand up a robust incident command system, which would have created tiers of state workers and possibly even use private sector assets and volunteers able to stand in and take shifts across disciplines.

So, we had to overwork the folks responding to9/11 and anthrax because we couldn’t cross-train others in time. Today, we know you have to build depth on the bench to enable a public health system to have the capacity to scale up as necessary to deal with long-term and multiple events at the same time. No question about it, we pulled it off but it also was a huge wake up call for America that we cannot expect to fully protect the public “next time” without a better developed, trained and equipped public health system. Ten years later, we are much smarter and better prepared as far as having a competent, resilient and flexible workforce.

Following the 2001 tragedies, Congress and President Bush authorized a significant increase in funding for public health systems to build up capacity, capabilities, tools and knowledge. This was a huge turning point. Preparedness is a process, not an endpoint. The main take-away from 2001:the United States responded well, not only to the specific attacks, but recognizing it as a reality check that we needed a better and more resilient public health system and that decades of neglect should be reversed.

To our credit, our public health system has been improved dramatically over the last decade. State of the art biosafety laboratories and Emergency Operations Centers have been built and equipped, real time information collection and sharing systems are in place, plans and procedures have been refined, stockpiles of lifesaving medical countermeasures have been purchased and strategically stored, and many drills and exercises have taken place to prepare for real world events. There is no doubt that we would be able to handle a response better and for a longer period of time in 2011.

We need to keep our eyes and minds open to any and all threats — an all-hazards approach —because anything is possible in this world. We also must overcome complacency. The longer we go without an incident, the public and policymakers think that it’s something that we don’t have to continue to worry about. That’s flawed thinking and the public/policymakers must view and treat this as a matter of national priority.

To that end, even during times of economic difficulty, we must continue to invest in public health as a prevention strategy and maintain what we have built and continue to identify and fill remaining gaps. To be truly prepared, every aspect of the public health system must be developed and refined, we can’t let the system that we built crumble or fall apart from a lack of continued investment. Public health emergency preparedness is a matter of national security.

I dedicate my reflection of the events of September2001 to the many men and women of the New Jersey State Department of Health and Senior Services who gave everything they had to help protect the health of the public whom they proudly and tirelessly serve.

James Blumenstock, Chief Program Officer, Public Health Practice, Association of State and Territorial Health Officials and former Deputy Commissioner of Health, New Jersey

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