One: We have a fragmented and under-funded public health system -- at the local, state, and federal level -- that does not allow us to effectively detect and track disease outbreaks in real time.

Two: Since the disease has not been seen in the United States since 1949, very few health care professionals recognize the smallpox virus, so initial cases could be sent back home infectious, even after appearing at doctor's offices and emergency rooms.

Three: lab facilities needed to diagnose the disease are inadequate and out of date.

Four: there is insufficient partnership of communication across federal agencies and among local, state, and federal governments.

Five: the only way to deal with smallpox is with isolation and vaccination, but we don't have enough vaccines, and we don't have enough room, resources, or information for effective isolation.

Six: A biological weapons attack will be a local event with national implications, and that guarantees tension between local, state and national interest. In our exercise, the Governor of Oklahoma asked for vaccine for every one of his citizens -- as he had to in the interests of his state. The President said no, as he had to in the interests of the nation. Naturally, this will demand a high degree of coordination, because of the diverging interests, and because key players and partners are answerable to different leaders.

Seven: hospitals run at capacity all the time: a surge in patients from smallpox, combined with the inevitable infections of hospital personnel, and the flight of some fearful health care professionals, would create a catastrophic overload.

Eight: there will be a dearth of information on this kind of event. My staff and cabinet could not tell me ten percent of what I wanted to know: "How many cases are there right now? How many more are coming? When and where did the first infections take place? Who released it? What's the worst case scenario?"

And there are many tradeoffs. One of the biggest: We have 12 million vaccines; that's enough for one out of every 23 Americans. Who do we decide to vaccinate?

Other tradeoffs are: Do you take power from the Governors and federalize the National Guard? Do you seize hotels to convert them to hospitals? Do you close borders and block all travel? What level of force do you use to keep someone sick with smallpox in isolation? Do you keep people known or thought to be exposed quarantined in their homes? Do you guarantee 2.5 million doses of vaccine to the military; or do you first cover all health care providers? Do you take strong measures that may protect health, but could undermine public support or destroy the economy?

And finally: How do you talk to the public in a way that is candid, yet prevents panic -- knowing that panic itself can be a weapon of mass destruction?

My staff had two responses: "We don't know," and "You're late for your press conference." I told people in the exercise: "I would never go before the press with this little information," and Governor Keating -- who knows about dealing with disaster, said: "You have no choice." And I went, even though I did not have answers for the questions I knew I would face: "How bad is it?" "What’s the plan?" And "Why, after all this time, isn't there enough smallpox vaccine?"

One: We need to focus more attention, concern and resources on the specific threat of bioterrorism – understanding that it is different in kind from other threats we face. We have to recognize that we have reached a new realm in the dialectic of new weapons and new defenses. In the evolution of warfare, arrows were countered by shields; swords with armor; guns with tanks; and now biological weapons must be countered with medicines, vaccines and surveillance systems.

Two: This means that we need to recognize the central role of public health and medicine in this effort, and engage them as true partners. We must act on the understanding that public health is an important pillar in our national security framework. In the event of a biological weapons attack -- millions of lives will depend on how quickly doctors diagnose the illness, report their findings, and bring forth a fast and effective response at the local and federal level. This means, clearly, that public health and medical professionals must be part of the national security team. This is now no longer a matter just for DoD, NSC, CIA and DoE; it must include FDA, HHS, NIH, and CDC.

This may seem obvious enough. But several years ago, when Administration officials were meeting to discuss supplemental funding legislation for defense against biological weapons -- the presiding official from the Office of Management and Budget greeted the officials from the NSC, and FBI and CIA and DoD, then saw the Assistant Secretary from Health and Human Services at the table, did a double-take and said: "What are you doing here?" Health officials should not need to be given directions to the White House Situation Room.

Three: We need to engage all levels of government and a broad set of agencies in our efforts to understand and prepare for the threat of bioterrorism. It is critical that we understand our differing roles, responsibilities, capabilities, and authorities, and plan on how we will work together before a crisis. As our NTI bio-defense expert Margaret Hamburg has said: "People should not be exchanging business cards on the first day of a crisis."

Four: We will manage this crisis successfully only with a clear strategy for working with the media -- not as antagonists, but as key partners for communicating life-saving information and managing public apprehension and panic.

Five: The national pharmaceutical stockpile should be built to capacity as soon as possible -- and then dispersed to different sites. We don't want to fall victim to a twin attack that releases a bio-agent and simultaneously blows up all our drugs and vaccines.

Six: We need to develop plans for a surge of patients in the nation’s hospitals. We've already seen the degree to which hospitals are strained during routine outbreaks of the flu. Most hospitals are operating at, or above, capacity right now.

Seven: Officials at the highest level of the federal government -- and at state and local levels -- need to participate in exercises like Dark Winter. It is the best possible way to prepare. Theatre professionals on Broadway rehearse for months before the real thing. This is one case where life had better imitate art -- for the sake of life itself.

Eight: We need to increase the core capacities of our public health system to detect, track and contain epidemics, by providing resources for effective surveillance systems, diagnostic laboratory facilities, and communication links to other elements of the response effort.

Nine: We need to increase funding for biomedical research to develop new vaccines, new therapeutic drugs, and new rapid diagnostic tests for the most threatening bioweapon agents.

Ten: We need to increase our efforts to prevent the proliferation of biological weapons, in part by providing peaceful research options to scientists in the former Soviet Union, who represent the single greatest concentration of expertise in biological warfare in world.

Eleven: We need to encourage the scientific community to confront the sinister potential of modern biological research, and help them devise systems to prevent dangerous materials and information from falling into the wrong hands.

Twelve: We need to reexamine and modernize the legal framework for epidemic control measures and civil liberties -- the laws that would apply if we were to find ourselves managing the crisis that would come with a biological weapons attack. These laws vary from state to state and many are antiquated. We need to make sure that they are up-to-date, consistent with our current social values and priorities, and we need to reacquaint high-level officials in all areas of response with the specific authorities these laws provide and how to implement them.

We know how difficult it is to find funding for new initiatives, and public health is often left behind. We need to think about supporting public health activities in the same way we think about our national defense. Congress and the public should understand that funds for disease surveillance, building the pharmaceutical stockpile, and improving the capacity of our health care system will benefit the United States not only in responding to a biological weapons attack, but also by improving our responses to other disease outbreaks. It is rare indeed to have a chance to defend the nation against its adversaries and improve the public health system with the same steps; it is a chance we should take. ...