A Public Mess

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Such stitch-in-time wisdom should be obvious to cash-strapped governments trying to do more with less, but at the moment there's no single national figure teaching the preparedness lesson. In the 1980s, Surgeon General C. Everett Koop helped calm the early hysteria over AIDS, telling the well how to stay that way and reminding them that in the meantime there was no reason to fear the sick. Thompson and Ridge, national doctors without a medical degree between them, have been no match for that kind of performance. Even Satcher has not achieved the same iconic status. During the anthrax attacks, says Dr. Jeffrey Koplan, chief of the CDC, "we found ourselves deploying more and more people just to work on communication issues."

That work is important for more than p.r. reasons. When an unfamiliar disease hits, even doctors may not know what the signs of the illness are and what to do when patients turn up in their waiting rooms. If HHS, the CDC and other government agencies are jostling one another on the podium, the message is often mixed. And when you toss in the local police and the FBI--as was the case with anthrax--that mixed message turns to gibberish. During the hantavirus outbreak of 1993, the government handled the problem well, with Dr. C.J. Peters, then chief of special pathogens at the CDC, taking the lead in answering questions, even though the HHS Secretary was technically the senior health authority working on the problem. "We decided that I would speak for HHS," Peters says, "because I was the one with the technical expertise."

The most important step toward improving things--apart from simply finding a Koop-like figure and seeing to it that that person is the only one who takes the mike during emergencies--is upgrading the public-health system's surveillance powers. The ability to spot new disease outbreaks, diagnose them properly and get word out on the medical wires is central to managing crises like anthrax as well as more routine problems like Lyme disease, tuberculosis and the flu. Emergency rooms often perform this function in an ad hoc way; the emergence of West Nile virus in New York City was first detected by a hospital physician who was suspicious of two cases of encephalitis among her patients and prodded the city health department to launch an investigation. The CDC relies on a national network of sentinel doctors to do this kind of monitoring during flu season and uses a similar system of local labs and DNA fingerprinting to track food-borne illnesses. Cities and states have physician-alert programs that do the same job.