After the airplane terrorism attacks of Sept. 11, 2001, and the anthrax mailings that followed, President George W. Bush visited the Centers for Disease Control and Prevention headquarters in Atlanta.

It was the first time a U.S. president had visited the agency, and it signified the CDC's important role in responding to these events and preparing for potential ones.

At the time of the president's visit, Case Western Reserve University undergraduate and medical alumna Julie Gerberding had not yet been named director of the agency—that would come in July 2002—but as acting deputy director of the CDC's National Center for Infectious Diseases and, later, as part of a four-person team running the agency after the resignation of the director, she was closely involved in the CDC's post-9/11 activities.

Gerberding relayed some lessons learned through and since the events of the fall of 2001 as well as the agency's current terrorism readiness status in a for-credit grand rounds talk, "Beyond Orange Alert: Public Health and Preparedness in the Healthcare Environment," earlier this month at the CWRU School of Medicine. After 9/11, the CDC operated from an emergency response center set up in an auditorium.

"It was not a pretty picture," Gerberding said.

The agency opened a new emergency operations center earlier this year.

"We'll be in much better shape," if terrorism strikes again, she added, saying that she believes it will strike again.

In anticipation of future events, clinicians, academic investigators and public health officials must learn to diagnose the health effects of biological, chemical and radiation terrorism and must integrate this information, much like they did information about HIV/AIDS, into their roles, according to Gerberding.

They also can learn from the CDC's experience, she said, telling attendees to beware of dogma; learn to make decisions as new information is available; be sure that laboratories, staffing levels and information systems are adequate; coordinate and collaborate with others; and remember that communication is critical.

Local-level public health departments and clinicians must be prepared, according to Gerberding, because they will be the ones first encountering illness. She noted, however, that "preparedness is a process, not an outcome."

The CDC 2003 budget calls for investing $1 billion in local and state health departments with similar funding planned for 2004. She said this investment is needed.

"We have a very fragile public health system in this country. It is broken," Gerberding added.

Gerberding said that any investments made to improve the public health system's ability to respond to health-related terrorist threats will improve its ability to respond to other, more general public health issues as well.

When a threat first materializes, "we can't tell upfront whether it's an epidemic [naturally occurring] or terrorism, so the public health system, which is on the front line for epidemics, must be on the front line for terrorism," she said.

Regarding terrorism preparedness at the CDC, Gerberding added, "From the outside looking in, it looks like we're concentrating on smallpox now."

But the agency also is examining potential threats related to anthrax, plague, tularemia, Ebola virus, Marburg virus and botulism, she said. Threats include not only biological weapons but also chemical terrorism through the use of choking, blood and blister agents; and radiation terrorism through dirty bombs, food and water supply contamination and power plant activity.

The CDC director had many kind words about her alma mater.

"This is a wonderful institution, and it is a huge honor to be back," she told faculty and students in attendance, adding that the "spirit of excellence" instilled in her as a medical student has remained with her throughout her career.

Gerberding's talk at the School of Medicine was organized by the CWRU/University Hospitals of Cleveland Center for AIDS Research, a 94-member organization originating with the National Institutes of Health and emphasizing interdisciplinary collaboration between basic and clinical investigators; translational, prevention and behavioral-change research; and the inclusion of minorities. Michael Lederman, professor of medicine, directs the center.

Gerberding is an expert on HIV/AIDS and other infectious diseases.

Her trip to Cleveland also included reunions with faculty who had taught her, visits with members of the local media and a talk to health law students and some additional guests in the CWRU School of Law classroom of Maxwell J. Mehlman, Arthur E. Petersilge Professor of Law, Law-Medicine Center director, and professor of bioethics at the School of Medicine. The Law-Medicine Center, based at the law school, currently is celebrating its 50th anniversary.