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Officials: Bioterror would challenge health facilities

By Mike Fish
CNN.com

ATLANTA, Georgia (CNN) -- Ask how public health care in the United States would perform in a bioterrorist attack and Dr. Tara O'Toole flails away at the system.

"The hospitals do not have the capacity to deal with a sudden surge in patient demand," said O'Toole, deputy director of the Johns Hopkins Center for Civilian Biodefense Studies. "And the big problem is not beds as everyone seems to suppose -- it is staff. And there is no way to fix that in the short term."

O'Toole, an assistant energy secretary in the Clinton administration, testified in October before the House Intelligence Committee that the U.S. health system is unprepared to respond to a mass casualty situation. Even the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, which killed 168 people, resulted in the admission of less than 100 patients to local hospitals, she said.

In addition to staffing shortfalls, O'Toole cites other problems: the challenge of handling large numbers of patients; medical staffs inadequately trained to deal with infectious diseases and other illnesses related to bioterror attacks; the difficulty of transferring information between government agencies and clinics.

O'Toole isn't alone. Dr. Mohammad N. Akhter, executive director of the Washington, D.C.-based American Public Health Association, also warned a Senate committee that a bioterrorist attack would overwhelm an already stressed public health system, emphasizing the need for better intelligence in detecting bioterrorism threats.

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"I think the cities are under prepared, and I could just start here in Washington, D.C.," Akhter told CNN.com. "There were 80 or so people who had to come from the CDC to help the city cope with half-a-teaspoon of anthrax -- two grams. That contaminated all of these buildings, resulting in two deaths and 7,000 people taking (the antibiotic) Cipro. And it was quite a difficult situation for the nation's capital to deal with. If it was a smaller city I don't know what they could have done."

Bioterror attack won't be obvious

A bioterror attack won't be obvious, officials warn. It could take days, or even weeks, for the symptoms of biological agents to begin to manifest. And the first responder isn't likely to be a police officer or a firefighter -- but a primary care physician, health care provider, epidemiologist or perhaps a veterinarian. It would fall upon the public health and medical communities to detect the attack, contain it, and treat the victims.

It is the ability of germs to spread before telltale symptoms appear that makes bioterror agents fundamentally different from other weapons of mass destruction.

Six days before the September 11 attack, former Sen. Sam Nunn (D-Georgia) testified before the Senate Foreign Relations Committee on the "Dark Winter" exercise, in which he was a leading figure in a simulation of a smallpox attack that demonstrated America "was vulnerable to biological terrorism."

Nunn, co-author of the Nunn-Lugar-Domenici measure, which nearly six years ago established the country's first defenses against bioterrorism, warned of the need for significantly more training of medical personnel -- not just doctors and nurses, but pharmacists and veterinarians, too. He expressed concern about the vulnerability of the animal-plant food chain, calling for a sophisticated communications system linked to the Centers for Disease Control and Prevention (CDC).

Officials say it is imperative that the public health infrastructure be strengthened so that local doctors and medical personnel are in place to recognize and identify the deadly agents in the early stages when they are treatable. It's equally important that the federal, state and local health departments address the issue of reliable and timely reporting of dangerous diseases. In a biological incident, experts say that time is of the essence.

Under the current staffing profile of most health departments, Akhter told Congress that if a bioterrorist attack occurred on a Friday afternoon, there would be no report of it until Monday morning.

Surge capabilities critical

The threat of bioterrorism has reached new levels of concern since September 11, and officials acknowledge the system is playing catch-up.

If a contagious agent such as smallpox were to be used, for example, officials say it is unlikely there would be enough isolation facilities to quarantine people.

As of January 2002, a CNN.com survey found 22 states did not have a CDC-sponsored epidemic intelligence service officer ("disease detective") assigned. Another nine states did not employ a designated public health veterinarian, which is a concern, experts say, because 17 of the 20 designated bioterrorism agents are either transmitted from animals to man, fairly common diseases of animals, or are food-borne illnesses.

"You wouldn't have a police department without a police detective to really do the groundwork on the street and identify who the criminal is and bring him to justice," said Akhter, head of the nation's largest public health association. "Similarly, to detect a disease you need to have these trained, qualified people work with the community."

Sen. Bill Frist (R-Tennessee), the only senator who is a medical doctor, has expressed concern that only one in five hospitals have developed plans for dealing with the calamity resulting from a potential bioterrorism attack. The hospitals' ability to deal with the dramatic surge of patients on short notice - not only the medical staff available to treat the ill and stricken, but also the number of ventilators and intensive care unit beds that would be in demand -- is of particular concern.

Surge capabilities are critical, officials say, whether it's medical laboratories, hospitals or the Emergency Medical Service (EMS) system. And yet, most of the time taxpayers are questioning whether they should pay for simply day-to-day public health activities.

"It's real important that a municipality have a city-wide hospital or health care disaster plan," said Dr. Lew Stringer, medical director of the Special Operations Response Team, which serves as a national medical response team for the U.S. Public Health Service.

Crucial to such a plan, Stringer said, is that hospitals not only have adequate medical supplies, but are able to work together and share resources.

Bleak finances confront many health systems

Asked to identify some of the better prepared medical communities, health officials mention New York, Philadelphia, San Diego, the San Francisco-San Jose corridor and Chicago -- in large part, because of the collaborative effort of the local government and the hospital community. But in general, they paint a bleak fiscal picture of public health care.

"Half of the academic medical centers and one-third of all hospitals in the country are losing money, which people don't understand," said O'Toole, the former Clinton administration official.

According to the American Hospital Association, 64 hospitals closed last year. The reasons most often cited are financial problems, reorganization and mergers.

Many county and city public hospitals have been taken over and slimmed down or closed by for-profit chains. Of the country's 4,915 hospitals, less than a quarter are government-owned facilities.

The problem with for-profit hospitals, officials say, is they're bottom-line driven and until recently, haven't participated with much vigor in preparedness for mass casualty terrorism incidents. And because they're not part of the city or county medical system, local officials have less immediate control over them.

Stringer recalled a government-sponsored training exercise for a chemical attack before September 11, in which none of the hospitals in a city he refused to identify participated in the drill. The exercise concluded with the patients treated on the sidewalk, but not transferred to a hospital.

Since then, Stringer said, hospital officials have been more eager to learn how to participate.

"Now, since 9/11, you bet everybody is talking. You bet everybody is interested in me teaching them and everybody else teaching them," Stringer said.

"That is good, but it is going to take time to fix the problem."