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Dr Laura Kahn has produced a useful book that provides a brief historical background on public health and terrorism, followed by interesting examples of leadership during outbreaks and events that escalated to public health crises. The roles of astute clinicians, public health professionals, appointed public health leaders, and elected officials are described by the players themselves. These insights provide important perspectives and are fascinating reading, but each event includes the voices of only a few of many participants. This omission may leave the reader hungry for a wider variety of viewpoints. Kahn takes the reader through a thought-provoking overview of the complexity of leadership and some early milestones in public health. Kahn makes it clear that politics, economics, communications, and interpersonal relations are as central to today’s public health crises as they were in the past. Persuasive examples support Kahn’s main thesis that political leadership is critical during a public health crisis, whether the crisis results from natural causes or from bioterrorism. Kahn says, “Questions about leaders and leadership have intrigued scholars in both Western and Eastern civilizations for centuries. Plato, Confucius, and Machiavelli all speculated about leaders… and the qualities of leadership.” Kahn concludes that 1) informed, engaged, and prepared elected officials are essential to effective response; 2) because crisis response decisions inevitably will be made in the absence of perfect information, leaders require judgment and common sense; 3) elected and appointed leaders must be effective; and 4) dual leadership during a crisis can cause confusion. The author provides a convincing case for her conclusions with lively examples and first-hand accounts and offers several concrete suggestions to prepare elected officials for leadership roles. The same compelling case is not made for Kahn’s assertion of a “legal conundrum when dealing with the bioterrorism attack.” She suggests that the Centers for Disease Control and Prevention (CDC) should lead the public health response to such episodes but alleges that legal and organizational impediments hinder CDC from fulfilling that lead role. Unquestionably, CDC must and does play a lead role during large-scale, multistate public health events. The legal and organizational impediments to fulfilling that role are not obvious to this reviewer, especially given CDC’s success in addressing many such crises. Kahn may be referring to impediments within the federal structure and chain of command. However, current law specifies the roles of CDC and the departments of Health and Human Services, and Homeland Security. CDC has ample legal authority to supplement its technical and scientific leadership during an emergency, especially when state and local capacities are outstripped. Kahn suggests federalizing and centralizing the national response system through changes in the legal framework and organizational structures of the public health system, arguing that if CDC were organized for response as the Environmental Protection Agency or the Federal Bureau of Investigation is, delays, leadership confusion, and communication issues would be resolved. She identifies some leadership problems but fails to acknowledge the strong collegial relationship between state public health authorities and CDC that has produced innumerable successful responses to crises. Restructuring the traditional relationship between states and the federal government seems unnecessary. This problem does not overshadow an otherwise informative and engrossing book. In an era of emerging infectious diseases, bioterrorism, and large-scale natural disasters, we will continue to have to address the types of events Dr. Kahn describes. Those involved in responding to such events would benefit from studying the lessons of the past to better manage future emergencies.

Brower and Chalk, authors of The Global Threat of New and Reemerging Infectious Diseases: Reconciling U.S. National Security and Public Health Policy, describe their book’s purpose as examining “the changing nature of security” and focusing on “the threat of infectious diseases.” There are many examples in today’s world where the intersection of threats to public health and national security should direct the attention of policymakers, security and public health strategists, and the systems that support each toward an organized response. The authors use two case studies: HIV/AIDS in South Africa and the U.S. public health response system. The first case, in South Africa, illustrates how a single microbial agent can undermine the economic, social, and medical underpinnings of a developed country. The second study shows the negative effect of newly emerging diseases such as HIV/AIDS, Hantavirus infection, West Nile virus infection, Creutzfeldt-Jakob disease, and intentionally released agents (Bacillus anthracis). This study demonstrates how events can overload the public health response system and weaken public confidence in its government. The reader can easily conclude that the intersection of disease and national security can be dangerously destabilizing and seriously undermine a nation’s social, economic, and political order. The current outbreak of severe acute respiratory syndrome reinterates the global nature and warp speed of emerging infections. In their summary and conclusions, the authors provide recommendations for policymakers addressing both public health and security issues. The thrust of the authors’ conclusions is to push policymakers and strategists to actions that strengthen the infrastructure of a public health response system and broaden the traditional definition of national security to include the impact of naturally occurring and intentionally released microbial agents. The authors present a compelling case study for HIV/AIDS in South Africa, where an emerging disease has gone unchecked and is having a devastating effect on a developed country. The case study of the U.S. public health response system is interesting and thoughtfully presented but lacks sufficient and carefully documented detail to aid the reader in drawing conclusions and formulating solutions. Unsubstantiated or incorrect examples also detract from the overall presentation of this case study. For instance, the contention that lack of good communications with area physicians and hospitals resulted in the deaths of postal workers in the fall 2001 anthrax crisis is not supported by the author’s reference or by any other authoritative materials known to this reviewer. In the public health response case study, the authors provide broad recommendations aimed at strengthening the public health infrastructure. Also included is an excellent summary of the current status of efforts begun in the mid-1990s in the United States to address the infrastructure of public health. The recommendations are presented in such a way that the shortcomings of the system can be addressed in critical areas, including a well-trained public health workforce; interagency coordination; private sector, hospital, and emergency response integration in public health; technical and educational interventions; and domestic and global investment in public health. Brower and Chalk’s book is a powerful and useful argument for the urgent need to integrate and streamline public health and national security strategies.