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Public Health Nursing Practice: Aftermath of September 11, 2001

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Bobbie Berkowitz, PhD, RN, CNAA, FAAN


America’s experience on September 11, 2001, forms the backdrop of this review of the public health nursing role in bioterrorism preparedness. The risks and challenges to the public health infrastructure are reviewed in order to place bioterrorism preparedness in a public health context. A review of the literature provides background material on the extent to which public health has evolved in planning for a bioterrorism event. The skills and competencies that will prepare public health nurses in their planning for and response to threats of bioterrorism are addressed. Anthrax is used as an example to illustrate how public health nursing can assist in a bioterrorism response.

Citation: Berkowitz, B. (September 30, 2002). "Public Health Nursing Practice: Aftermath of September 11, 2001". Online Journal of Issues in Nursing. Vol. 7 No. 3, Manuscript 4. Available:

Key words: public health infrastructure; bioterrorism; public health nursing; public health core functions; public health competencies; anthrax

Public Health Nursing Practice: Aftermath of September 11, 2001

Events that change lives are common and are the stuff of headlines. Events that change the progress of society are not uncommon in America; common enough that we have progressed at an unbelievable speed. New discoveries in the fields of manufacturing, information technology, health care, transportation, agriculture, and many others have changed the fabric of our society and the order of things. Events that change the foundation of a society, however, are not common. On September 11, 2001, our lives and the social order of America changed and have changed continuously for almost a year now. September 11, known as "911", brought to most Americans an understanding of what it is like to feel the threat of terrorism. For many of us it was the first time we bore witness to the effects of terrorism as the images of the New York World Trade Center Towers and the Pentagon played over and over on our television screens. The events of that one day have led to war, financial and economic crisis in many sectors, heightened security at airports and public events, threats to civil liberties, and acts of racial and ethnic discrimination and violence. The events of September 11 may have also heightened our sense of patriotism, family and community solidarity, and resiliency.

The response to the events of September 11, 2001, has been felt at the individual, family, organization, and system level. The public health system has been profoundly affected along with public health nursing. This article will explore how this event has affected not only the lives of individuals, but also the system that includes public health and the practice of public health nurses.

Impact of 911 on Individuals, Families and Organizations

Although the focus of public health is at the population level, the impact of 911 on individuals and families has helped frame the need for the types of service communities will need to plan for in a bioterrorism event. Individuals and families have responded to this new threat of terrorism in America with a variety of coping mechanisms. In some cases the response has been an overwhelming sense of fear, depression, and unrelenting stress. As an example of psychological responses, Beaton and Murphy (2002) reviewed the literature for what is known about the impact of disasters on psychological functions and the psychological impact of combat experience by soldiers in wartime. The impact of threat of terrorism is less well known. The authors draw from the literature the likely psychological and behavioral responses to bioterrorism. They state that the threat of an actual bioterrorism attack might lead to anxiety, acute stress disorder symptoms, and chronic post traumatic stress disorder symptoms. No doubt research on the actual impact of bioterrorism, such as that experienced from the anthrax attack in October 2001 on psychological response will soon be reported in the literature. The lesson for public health is that mental health services should be an important component of a bioterrorism plan.

Organizations have been stressed and health care is no exception.

Not only do public health nurses have a role in interventions related to bioterrorism; they have a role in protecting the public from future risks of bioterrorism.
The first responders to the events of September 11, along with firefighters and police, were health care providers. Public health, whose mission is the promotion of health, prevention of disease, and protection from threats to health, became actively engaged with the anthrax attack. Public health nurses, as members of the public health workforce, have had to face serious challenges in their response to threats of bioterrorism. Not only do public health nurses have a role in interventions related to bioterrorism; they have a role in protecting the public from future risks of bioterrorism. In addition to these interventions, planning for the future is happening in a context where public health is facing risks and challenges of its own.

The Public Health System

Core Functions

The public health system is a broad term used to describe all of the government and non-government organizations and agencies that contribute to the improvement of the health status of a population.
The public health system is a broad term used to describe all of the government and non-government organizations and agencies that contribute to the improvement of the health status of a population. Public health departments at the state and local level are the primary providers of public health services. The United States Department of Health and Human Services provides a large portion of the funding for governmental public health through its many grants and contracts with state public health agencies. Public health agencies deliver services to individuals, families and populations using a framework called the core functions. The core functions include assessment, policy development and assurance. Assessment, the epidemiological part of public health, includes the collection, analysis, and interpretation of data about health status and threats to health. Policy development is the decision-making process used by public health. By utilizing data from community and statewide assessments, decisions can be made about the best approaches to reducing risks and threats to health. Interventions that require health policy can be targeted to local, state, and federal policymakers. The assurance function is the service end of public health. These activities assure that individuals living in communities have access to the programs and services that will help to prevent disease, protect health, and promote healthy choices and environments. These core functions are at the heart of public health.

The public health system also includes organizations that participate in the core functions but may not have direct responsibility for delivering public health services. For example, hospitals may assist the public health department in a tobacco use reduction campaign by providing tobacco cessation materials to their clients. Medical care providers may detect the early signs of an outbreak of foodborne illness and refer the case to the local health department. Local churches may participate in health fairs, promoting physical activity and healthy nutrition. All of these organizations contribute to the health of the public and are part of the public health system. As important as these partners are to the public health system, the mainstay of public health, the state and local health departments, remain responsible for the infrastructure that supports the core functions. Public health infrastructure including information systems, organizational structures, and public health workforce have been challenged by the threat of bioterrorism.

Risks and Challenges to Public Health

Given the heightened focus within the government and public on bioterrorism, public health faces risks in several key areas.

Following the anthrax exposures, the media lacked a consistent public health message and consistent leadership.
One concern is that our public health opinion leaders need to be given legitimate authority and power to inform the public about these threats to health. Following the anthrax exposures, the media lacked a consistent public health message and consistent leadership. At times it seemed as if public health did not know how to communicate with the public. Our second risk is our strategic response to the Public Health Threats and Emergencies Act. Will state and local health departments take this opportunity to develop plans that integrate preparedness with the day-to-day infrastructure needs in public health, including the need for public health nursing? As new funding comes into states for preparedness, we must not lose our focus on our core public health mission of health promotion and protection and disease prevention.

Perhaps our greatest risk lies in the challenges of building a strong public health infrastructure. The public health infrastructure today faces multiple challenges. Information technology, stable funding, workforce capacity with particular emphasis on the nursing shortage, leadership at the local, state and national level, and gaps in applying public health interventions all characterize challenges within our infrastructure. For example, although great improvements have been made in health status since the Healthy People 2000 report, the new Healthy People 2010 (U.S. Department of Health and Human Services, 2001) reports on a number of objectives for which the data show a decline in health status rather than improvement. For example, obesity has increased since 1980. Pregnant women are less likely to quit smoking than previously. The use of firearms has increased by youth. Health care access has declined since 1989 and the rates of drug-related deaths and drug abuse related-emergency room visits have increased. Our public health workforce, especially in rural America, may not have the training or capacity to engage in new responsibilities related to bioterrorism preparedness. Richardson, Casey and Rosenblatt (2001) examined the public health workforce in local health districts in Wyoming and Idaho. They concluded that small local health departments may not have the capacity to work effectively in all areas of the ten public health essential services listed in Table 2. The ability for public health to prevent threats to health such as bioterrorism is questionable if we can’t manage public health’s basic prevention agenda.

Review of the Literature

Public health has been planning for the potential of bioterrorism for some time now. The Centers for Disease Control and Prevention has developed a vast set of materials and recommendations on bioterrorism preparedness ( Prior to 911 the literature had examined the biological agents most likely to be developed into weapons; and in many parts of the country we have set in motion planning activities related to an effective response. For example, Cieslak and Eitzen (2000) reported what is known as the "threat list." On that list are agents considered lethal (Bacillus anthracis, Botulinum toxin, Francisella tularensis), incapacitating (Venezuelan equine encephalitis, Staphylococcal enterotoxin B, Brucella suis, Coxiella burnetii) or anti-crop (wheat-stem rust, rye-stem rust, rice-blast spore). In other words, these agents are capable of causing mortality, morbidity or endangering our food supply. The authors recommended that in order to prepare for the potential of bioterrorism, it is important that a knowledge base of these agents and others in terms of their use as a weapon, and also clinical skills in the detection, diagnosis, management, and prevention of the effects of a biological attack be developed. In a later article Eitzen (2001) stated that it is important to consider risk in terms of the ability of a terrorist to access the agent, to have the scientific capacity to manufacture the agent, to weaponize the agent, along with the intent of the terrorist to use the agent.

Previous activities have helped us recognize our weaknesses. Based on an incident in 1998 in Wichita, Kansas where a suspicious white powder was found in an office building, Garrett, Magruder, and Molgard (2000) reported that weaknesses in their health department’s emergency response procedures were significant. They experienced inadequate communication between the health department and the investigation site and lacked access to effective information systems. The response they were able to mount to a possible anthrax threat did involve the health department’s nurse epidemiologist who collected contact information and gave instructions about how potentially exposed individuals could protect themselves.

Hamburg (2000) wrote that the initial response to bioterrorism will be the responsibility of local government, including public health, and that the Federal government will respond as a supplemental partner. The author cited a critical need to enhance the public health and medical care system in order to prepare for mass causalities or exposure to toxic agents. When the actual event occurred with anthrax, it was clear that local system capacity was severely stressed.

Rotz, Koo, O’Carroll, Kellogg, Sage, and Lillibridge (2000) reported what they determined to be the role of public health in a bioterrorism event.

The first lines of detection of a biological agent released into the population reside with a physician or nurse who diagnoses an individual with signs and symptoms of the biological agent.
The first lines of detection of a biological agent released into the population reside with a physician or nurse who diagnoses an individual with signs and symptoms of the biological agent. This means that physicians and nurses must be trained to recognize these presenting signs and symptoms. Physicians and nurses have the role of reporting the suspected diagnosis to public health officials who then have the responsibilities of detecting an outbreak, determining the cause of illness, identifying the risk factors for the population, implementing interventions to control the outbreak, and informing the public of the health risks and preventive measures.

Gallo and Campbell (2000) also reported on the public health approach to bioterrorism. The approach begins with the development of a response plan in collaboration with multiple partners at the local level, including emergency response and law enforcement, and an inventory of all resources that can be utilized in the event of bioterrorism. A series of informational materials should be prepared, such as fact sheets, response protocols, and educational materials. In addition, the authors noted that infrastructure such as surveillance and communication systems, laboratory capacity, and medical provider education and training are essential elements of a preparedness program.

Skills and Competencies: Implications for Public Health Nursing

Public health nursing has the skills and competencies to meet these challenges, but our practice must evolve in order to do so.

Public health nursing has the skills and competencies to meet these challenges, but our practice must evolve in order to do so.

The competencies most critical in responding to the aftermath of September 11 include analytic, communication, policy development, cultural competence, research, leadership, and management skills. These skills and competencies are not unique to public health nursing; however, the public health nurse brings a unique perspective. These competencies can be examined in detail by a review of work completed by The Council on Linkages ( This Council, a consortium of the major public health and health care organizations, developed a set of core competencies for providing the essential public health services. The "Competencies Project" ( developed eight domains of core competencies and skills (Table 1). The skills are cross-referenced with each of the ten essential services listed in Table 2. Additional information can be found at the Public Health Functions Projects website, The competencies are relevant for bioterrorism preparedness and for a public health nursing response to bioterrorism.

Table 1:

Domains of Core Competencies and Skills

  • Analytic assessment skill
  • Policy development/program planning
  • Communication
  • Cultural competency
  • Community dimensions of practice
  • Basic public health sciences
  • Financial planning and management
  • Leadership and systems thinking

Table 2:

Ten Essential Public Health Services

Essential Service # 1:

Monitor health status to identify community health problems

Essential Service # 2:

Diagnose and investigate health problems and health hazards in the community

Essential Service #3:

Inform, educate, and empower people about health issues

Essential Service #4:

Mobilize community partnerships to identify and solve health problems

Essential Service #5:

Develop policies and plans that support individual and community health efforts

Essential Service #6:

Enforce laws and regulations that protect health and ensure safety

Essential Service #7:

Link people to needed personal health service and assure the provision of health care when otherwise unavailable

Essential Service #8:

Assure a competent public health and personal health care work force

Essential Service #9:

Evaluate effectiveness, accessibility, and quality of personal and population-based health services

Essential Service #10:

Research for new insights and innovative solutions to health problems

A Nursing Response to An Anthrax Attack

How might we advise public health nursing leaders and their staff about gaining these competencies and taking part in roles related to bioterrorism? Let’s take the example of an anthrax attack. Anthrax (Bacillus anthracis) is able to survive for long periods of time and is well suited to aerosolization and therefore a prime agent of terrorism. Most anthrax cases are cutaneous, acquired by exposure to infected cattle, sheep, or goats. Anthrax that infects the skin is treatable with antibiotics. Inhalation anthrax is much more serious, causing a flu-like illness with a mortality rate as high as 95%. The primary treatment and prophylaxis options for anthrax are Ciprofloxacin or Doxycycline (Cieslak & Eitzen, 2001). Diagnosis of a potential case of anthrax is step number one, generally occurring in a health care facility or primary care practice. This would be followed by the notification of public health officials that a case of anthrax has been diagnosed or suspected. Notification and confirmation require laboratory capacity and a communication system between medical care providers, the lab, and local and/or state health officials. A case of anthrax would engage the local, state, and federal health agencies in surveillance and epidemiology activities. Surveillance is the on-going, systematic collection, analysis, and interpretation of outcome-specific data for use in planning, implementation, and evaluation of public health practice (Thacker & Berkelman, 1988). Linking the disease to its cause and route of transmission and understanding the prevalence and spread of the disease is epidemiology. Both of these activities help us understand the actual or potential threat and spread of the disease on an ongoing basis. Public health nurses should be involved in both of these activities, using the skills of data collection, analysis, interpretation, and communication. This is part of the assessment function of public health practice and is closely aligned with the assessment and diagnosis function of the nursing process. Nurse epidemiologists are visible in many local and state health departments

The next step is to begin treatment of the case or cases and establish the best method for post-exposure prophylaxis and other methods to reduce the spread of the disease. In the case of anthrax, potentially exposed persons would receive antibiotics as soon as possible. Reducing the spread of anthrax would require eliminating the source of the bacillus itself, such as the spores on letters sent through the mail, since anthrax has very little risk of transmission from person to person. This step is a part of the assurance function of public health and is aligned with the implementation function in the nursing process. Public health nurses may be engaged in the actual delivery of the treatment and prophylaxis to individuals. They may be involved in mobilizing nurses to perform this function or they may be involved in securing prophylaxis from a pharmaceutical stockpile.

Communicating with the public should be an ongoing process throughout a high risk and threatening situation such as an anthrax attack.
Communicating with the public should be an ongoing process throughout a high risk and threatening situation such as an anthrax attack. Communication for the purpose of informing individuals and groups of people about anthrax, their risk and needed response is a role for public health nurses.

Communication for the purpose of informing individuals and groups of people about anthrax, their risk and needed response is a role for public health nurses.
Public health nurses must fine tune their skills in risk communication. Risk communication is a form of communication used when the public is made aware of a situation for which there may be a risk. Lum and Tinker (1994) stated that the purpose of risk communication is to decrease the potential for alarm, provide information about options, mediate public disagreement about policy, clarify highly technical issues, and listen to community concerns.

Evaluating the results of a bioterrorism threat to a population is another critical role for public health nurses and their colleagues in schools of nursing. Research that will help us understand individual responses to threats such as the October 2001 anthrax incident and the most effective interventions needs to be conducted. Since public health nurses are in day- to-day contact with their communities, they are the logical partners in a research effort to understand more about the nature of the public’s response to terrorism. Schools of nursing should examine their curriculum to ensure that the skills and competencies related to public health practice and emergency response are an integral part of the required coursework.

Participating in the policy formulation process is critical for public health nurses. During this period of time when states and local communities are planning for emergency response and increasing their capacity to respond to bioterrorism, public health nurses should be involved to assure that all aspects of the human and community response to health threats are taken into consideration. This includes all aspects of health and health care including mental health. Public health nurses should be providing leadership to activities related to mobilizing communities around actions to prevent health threats. Communities are ultimately responsible for the health and welfare of their citizens, and public health nurses have the skills to create coalitions for problem solving and decision making around managing bioterrorism threats.


The more we come to understand the risks of bioterrorism, the more we realize that a prepared public health system is a system able to handle not only the threats of anthrax, but also the many other threats to health, such as tobacco use, that we have longed to resolve since the first public health nurse packed her bag and set out into the community.

Although public health has been seriously challenged by the threat of bioterrorism, the planning that occurred prior to September 11, 2001, and the opportunity to strengthen public health infrastructure through funds from the Public Health Threats and Emergencies Act will increase the preparedness of the system overall. As significant partners in preparedness, public health nurses will need to add additional competencies to their current set of skills. These competencies will include knowledge about potential agents of bioterrorism as well as political skills to enable them to influence policy decisions about public health practice.

Ultimately, the best response to bioterrorism is interdisciplinary in nature and carried out in a partnership with the communities at risk. The more we come to understand the risks of bioterrorism, the more we realize that a prepared public health system is a system able to handle not only the threats of anthrax, but also the many other threats to health, such as tobacco use, that we have longed to resolve since the first public health nurse packed her bag and set out into the community.


Bobbie Berkowitz, Ph.D., RN, CNAA, FAAN

Bobbie Berkowitz is currently Professor and Chair of the Department of Psychosocial and Community Health at the University of Washington School of Nursing and Director for the Robert Wood Johnson Foundation Turning Point National Program Office. She also holds an Adjunct Professor appointment with the Department of Health Services at the University of Washington School of Public Health and Community Medicine. She joined the faculty at the University of Washington in July 1996 after having served as Deputy Secretary for the Washington State Department of Health. During her tenure at the Department of Health, she chaired the Public Health Improvement Plan Steering Committee and was responsible for the development of The Washington State Public Health Improvement Plan (1994,1996). Prior to 1993, she was Chief of Nursing Services for the Seattle-King County Department of Public Health. Bobbie served on the Washington State Board of Health from 1988 to 1993 and was appointed by the Governor to the Washington Health Care Commission from 1990 through 1992. Bobbie is a member of the Board of Directors for the Hanford Environmental Health Foundation and serves on the Editorial Advisory Board of the journal, Public Health Nursing. She serves on the Board of Directors of Qualis Health and The Public Health Foundation. Bobbie is a Fellow in the American Academy of Nursing, a member of the Institute of Medicine and was the co-chair of The Institute of Medicine Committee on Public Health Performance Monitoring. She holds a Ph.D. in Nursing Science from Case Western Reserve University and Master of Nursing and Bachelor of Science in Nursing from the University of Washington.


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© 2002 Online Journal of Issues in Nursing
Article published September 30, 2002

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