Last autumn's anthrax attacks, as frightening as they felt to most Americans,
were not the end of the bioterrorism story. They were merely the prologue.
The biggest lesson they taught us was the importance of preparedness.
And they showed us that America faces a truly major public health crisis.
We have no homeland defense when it comes to bioterrorism.
How did we arrive at this point? Though we have known for years that
we were vulnerable to biological attack by those with malicious intent,
whether homegrown terrorists or overseas ones, we have never made the
commitment of funds, personnel, and energy necessary to bring our defenses
up to the task. But with sufficient political will, we can eliminate the
threat of biological attacks as weapons of mass destruction. We need to
make public health an integral part of our national security system, make
the necessary investment -- about $2 billion immediately and $2 billion
more in 12 to 18 months -- and sustain it for the coming years. Even at
$4 billion, this represents only an initial down payment on basic safety
for Americans over the long haul.
How bad is the problem? First, let's consider the magnitude of
the challenge. Our initial response to the anthrax attacks was telling:
misinformation, confusion, and widespread public alarm all flowed from
the lack of a coherent response plan -- and from the absence of a clear
public communications strategy. One lesson was immediately clear: tell
the people what you know and what you don't know. Make sure the tellers
know their material.
Our inability to provide the public with a solid response to bioterrorism
rests, in part, on the long-standing neglect of our public health system.
As infectious diseases were conquered and private medicine took over most
treatment, our public health infrastructure became undervalued, underfunded,
and decrepit. Public health departments are often staffed by people without
professional training in public health. Tight state budgets have frozen
hiring in many departments. Half of the 3,000 local public health departments
in America are not even connected to the Internet. Most are not staffed
at night or on weekends, when critical reports of epidemics might begin.
Our hospitals are not in much better shape. In the age of cost controls,
with staff cuts and just-in-time purchases of medications, hospitals have
lost their surge capacity. No city in America could handle, say, 1,000
new patients in an emergency, even with several major hospitals; they're
already working at capacity. Even New York City on Sept. 11 did not have
to handle an influx on that order; most victims were either dead or safe.
The hospitals have no antibiotic and vaccine stockpiles, only a several-day
supply. Furthermore, our hospitals have become competitors, rather than
collaborators. This hinders the development of local coordinated-response
plans.
We also sorely lack planning strategies and practice. The vast majority
of our public health departments have no plan in place for responding
to a bioterrorist attack. And almost none of them has done drilling and
war-gaming to prepare for the actual event. No one knows how to handle
a big contagious outbreak.
In the medical world, we also have a weak bench when it comes to public
health. We need more epidemiologists and, especially, more people with
deep expertise in epidemic response and containment.
Most of all, we face a connectivity and communications crisis. During
the first days of the anthrax letters, the Web site of the Centers for
Disease Control and Prevention (CDC) was not working for hours on end,
sometimes for a whole day; there was no backup system or redundancy to
fill the communications gap. Even when all systems are up, the parts of
our medical response system -- CDC, state public health departments, local
public health clinics, practicing physicians -- communicate poorly with
each other. They are not directly linked, and information often moves
slowly among them.
Doctors, in particular, are left out of the information loop. This may
have contributed to the failure to diagnose two postal workers when they
initially showed the symptoms of anthrax in Washington, D.C., area. The
CDC, which has been on the frontline in the new crisis, typically does
not direct its bulletins to the practicing doctors, but to public health
departments. With the exception of a state like New York, which did an
excellent job of communicating with its professional medical societies,
most state health departments are not structured to quickly notify a critical
mass of physicians. Doctors, who often must see a new patient every 15
minutes, do not have time to browse the Internet for bulletins. They are
frequently caught in a slow-motion information paradigm.
Serious threat? The threat of bioterrorism is real and serious.
When a letter addressed to Sen. Patrick Leahy (D-Vt.) was found in November
to contain anthrax, the senator announced that it was judged to be so
powerful that it could kill 200,000 people. "It's so powerful they
still haven't figured out how to open it," he added, more than a
week after the letter's discovery.
What do we need to do, and when do we need to do it? First, there are
certain things that can be done fast; they should have priority. Other
things, like a high-tech surveillance system and increased laboratory
capacity, will take time.
Our highest priority should be connectivity and communications. Communication
in the midst of public health crises must become a strategic priority,
just as it is in the military. The ability to link local, state, and federal
health officials, along with practicing physicians, in a robust, real-time
communications network is critical to bioterrorism response. The U.S.
Department of Health and Human Services should come up with a plan to
ensure that federal, state, and local health agencies can meet the information
needs of the public, the media, and professional communities. It should
include a clear map of how information would flow during a crisis and
the equipment necessary to rapidly move large amounts of data among many
disparate communities. Once we develop a strategy for accomplishing this,
we must realistically fund it.
The need for a new level of connectivity applies to communicating from
the field -- the physicians' offices -- to the central public health agencies,
and vice versa -- getting information back out to the doctors. It applies
to exchanging information among key medical players -- CDC, local and state
public health departments, and the appropriate professional societies,
like the American College of Physicians, the Infectious Disease Society
of America, and the American College of Emergency Physicians. Finally,
it applies to getting information and useful guidance to the public.
We need to establish the surge capacity of state and local health departments
to rapidly investigate and track disease outbreaks and to contain the
spread of contagious diseases. To get the experience of the practicing
doctors into the system faster and more reliably, we need to create 24/7
reporting systems. Every state public health department should immediately
hire 50 to 100 people. These should be well-trained professionals, including
epidemiologists and health communicators who are experts in providing
the public with information.
Each state health department should then set up a reporting hotline staffed
by a medical professional every day, all day and night. Any physician
who calls in should be able to get a human on the line and have a professional
consultation, whether on a Sunday afternoon or in the middle of the night.
He shouldn't be told, as one was last fall in California, that he was
450th in line to speak to someone. She shouldn't get a voice mail answer,
and she should never hear, "We are closed for the weekend; call back
on Monday."
At the Johns Hopkins Center for Civilian Biodefense Studies, we have
generated rough estimates for the immediate cost of starting to build
our bioterrorism defense system -- about $1.9 billion, plus another $2
billion for pharmaceutical stockpiles and a real-time electronic surveillance
infrastructure. These are initial costs that need to be added to the budget
right now to begin putting the system in place. Our estimate for the start-up
cost of building public health surge capacity, for instance, is $500 million.
We also need to build a communications infrastructure. Every public health
department should have Internet access and email. Cell phones, laptops,
and wireless handheld devices should become commonplace. But because phone
lines, cell phones, and cable systems are vulnerable to terrorism, we
should have redundant connectivity that is satellite-dependent, rather
than based on terrestrial support. We estimate the initial investment
to build public health connectivity at $150 million.
We also propose the creation of a Physicians' Biodefense Network based
on Internet Web sites and satellite-connected handheld devices. The network
would assemble listservs, hold appropriate teleconferences, and set up
real-time interactions among clinicians. It would cost $400,000.
Additionally, we recommend the creation of a Community Alerts and Risk
Communication network for delivering timely, accurate, and credible health
information, both within the medical communities and to the public. We
estimate its cost at $154 million.
The first weeks of the anthrax outbreak were a textbook model of what
not to do. Because the public communications portfolio was passed
around among various politicians and professionals, the message differed
from day to day, sowing confusion and fear. We've learned from the events
on and after Sept. 11 that people don't panic in a crisis; they tend toward
panic in the face of uncertainty. When the terrorists attacked New York
and the Pentagon, people stayed cool and responded rationally. Even the
general populace, which could see everything on television, showed no
signs of panic. Transparency creates calm. But when the anthrax scare
came along with all the miscommunication, contradictions, and uncertainty,
public fear rose sharply. That's why efforts to "spin" information
and shield the public from disturbing information should be avoided.
We should also provide rigorous and rapid training in epidemic response
and containment to the existing public health community. This will initially
cost about $390 million. Finally, we need to develop curricula to train
physicians, nurses, mental health, and other professionals to diagnose
and treat disease caused by the most likely bioweapons agents of the future.
Such a program would cost roughly $400 million at the outset.
For this initial downpayment to work, and to get the political support
it deserves, we need to understand that public health is now an essential
aspect of national security. Public health officials should be integrated
into the highest decision-making bodies on homeland defense and national
health policy. A public health specialist should be part of the National
Security Council. Public health officials should be in the Office of Homeland
Defense. By raising public health's importance and status in our national
life, we will also be able to attract more specialists in epidemiology
and bioterrorism to government service, and we will attract more of our
medical school graduates into this demanding and understaffed field.
By once again making our public health system one of the best in the
world, we will also reap all sorts of tangential benefits in terms of
better public health, better prevention of natural diseases, and a more
capable medical care system. But we have to make the investment.
