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31 Oct 2002

Source: Washington Post, April 7, 2002.

U.S. Health Care System Grapples With New Role

Md. Typifies Challenges of Bioterror Response

By Susan Okie,  Washington Post Staff Writer


Peter Beilenson is a doctor whose patient is a city. And since last fall's terrorist attacks, Beilenson, Baltimore's health commissioner, has been checking his patient's vital signs first thing every morning.

He looks at how many ambulance runs were made on the previous day, and why. He checks how many children were absent from elementary schools. He watches sales of over-the-counter flu remedies at the city's biggest pharmacies. He tracks how many dead cats and dogs were picked up on city streets: A spike in the number could be the first evidence of the release of a chemical or biological weapon.

"This is ... an early-warning system," Beilenson said. "You find one of these things askew, you call and check."

Beilenson's stepped-up monitoring of his city's well-being reflects a new, unprecedented level of vigilance on the part of public health officials nationwide. In the wake of Sept. 11 and the ensuing anthrax outbreak, state and local health departments -- downsized and starved of funds for decades -- have been catapulted into a critical new role as protectors of national security. And the nation's already overtaxed emergency rooms are trying to plan for a possible flood of casualties.

"Prior to 9-11 we were focused on the HIV-AIDS problem, focused on teenage pregnancy, focused on immunizing kids," said Mohammed Akhter, executive director of the American Public Health Association. "Those things are now on the back burner."

To defend against future bioterrorist attacks, the nation's vast and decentralized health system has begun creating better methods to recognize an attack at once and responding rapidly and decisively. Like Beilenson's city Health Department but on a grander scale, the nation's public health system now resembles an organism trying to grow a nervous system.

But ensuring prompt action is only half the battle: Health officials fear that the possible toll of such an attack could overwhelm an emergency medical care system already operating dangerously near capacity. And so officials around the country have begun searching for ways they might handle the inrush that could follow a terrorist attack.

"Just think about 100 sick people showing up at an emergency room and not having the beds," Akhter said. "In a big emergency, ... there'd be lines of people outside the hospitals."

Watching for Symptoms

The health of Americans is entrusted to an array of guardians that traditionally have operated independently of one another. They include hospitals and clinics, doctors and managed-care organizations, local and state health departments, agencies in charge of emergency services and disaster planning, and the Centers for Disease Control and Prevention, which provides federal funding and support to health departments as well as coordinating the response to major disease outbreaks.

After last fall's events, many public health experts believe this immense network needs to develop keener senses for perceiving threats, nerves to relay information rapidly and a brain to guide the response.

The changes underway in Baltimore -- at the city Health Department and at Maryland state agencies -- reflect changes taking place around the nation. Maryland is in a better position than many states: It has a centralized public health system in which county health departments are staffed by state employees, as well as a nationally recognized statewide network for coordinating emergency responses and treating trauma victims.

In Maryland and elsewhere, statewide planning for mass casualties involving chemical or biological weapons began in the mid-1990s. But to many participants, the drills and scenarios involving such weapons seemed far-fetched -- until Sept. 11.

Now, Jerry Huffman, a systems analyst with the Baltimore Health Department, logs onto his home computer by 5 a.m. most days to begin checking e-mail reports on the previous day's ambulance runs. Shortly after 9, Huffman delivers a sheaf of colored graphs to the health commissioner's office. At a glance, Beilenson can tell whether anything unusual is going on.

The daily statistics are a form of "syndromic surveillance," a means of seeking early clues to disease outbreaks. First used extensively in New York, the approach has been employed by the CDC and by other state and local health departments, especially during crowd-drawing events where health officials worry about terrorist incidents or outbreaks of infectious disease.

Critics of syndromic surveillance argue that it has never picked up a true disease outbreak, raising questions about whether its benefits justify the potential cost of large-scale use. Such systems would not have detected last fall's anthrax outbreak, for example -- it involved too few cases and was identified by reports from individual doctors.

The CDC, however, would like to see it used more widely. "I think it's a creative and very important and useful way to better prepare us for bioterrorist events or even new naturally occurring diseases," said Jeffrey P. Koplan, who was CDC director during the anthrax episode.

But alerting officials that something is amiss is only half the equation. If a terrorist attack occurs, containing it will also depend on how hospitals and health departments react.

The anthrax episode tested those reflexes at health departments around the nation. At the Maryland Department of Health and Mental Hygiene, it transformed the job of Julie Casani, who heads the department's new bioterrorism division, from planning for the unthinkable to coping with a real crisis.

For several weeks during the outbreak -- in which Maryland had three confirmed cases of inhalational anthrax and the department investigated 85 other possible cases -- Casani's Baltimore office became the nerve center relaying information among Maryland's hospitals and doctors, its local health departments and CDC experts.

The staff monitored frequent e-mail advisories from the Health Alert Network, a national communications system linking state and local health departments with the CDC. In turn, they transmitted bulletins to a list of health officials and doctors groups that mushroomed by the day. Casani said the staff waited until evening to send out each day's bulletin because the facts and recommendations changed so fast.

"If we put something out at 3 in the afternoon, by 4 it would have been obsolete," she said.

State and local health officials in Maryland and elsewhere praised the CDC's epidemiologists and researchers for providing superb medical and laboratory expertise. But some echoed the widely voiced skepticism of the agency's ability to provide rapid, decisive guidance during a bioterrorist attack or similar emergency.

Casani noted that the CDC was hampered because scientific understanding of how finely milled anthrax spores would behave was sketchy and changed during the outbreak. And, she added, various federal officials sometimes offered contradictory advice that confused doctors and patients.

"There was no doctor who stood up and said, 'This is what we have, and this is what we're going to do,' " she said. "We needed a Dr. Giuliani."

Red Alert, Yellow Alert

In the communications center on the fifth floor of the Maryland Institute for Emergency Medical Services (MIEMS), operator Norm Gifford fielded calls from Baltimore's ambulances. On Gifford's computer console, a screen listed the 24 hospital emergency rooms in Region 3, the Baltimore area. It was not yet 2 p.m., but already yellow or red boxes had popped up next to more than half the hospitals on the list.

A yellow alert means a hospital's emergency room is so busy that ambulances are instructed to take patients elsewhere unless they are too unstable to travel. A red alert means, "Don't bring anyone who would require intensive care or cardiac monitoring: Our beds in those units are filled."

MIEMS is the state agency that coordinates emergency communications among ambulances and hospitals throughout Maryland. On an average day, Region 3 operators field about 240 calls from ambulance crews ferrying patients to Baltimore area hospitals. It's up to Gifford and other operators to advise crews where to take them.

"At this time of year, flu season, hospitals become overloaded," Andrew J. Pilarski, director of the institute's Emergency Medical Resource Center, said recently. "It's not unusual to look up there and see only a handful of hospitals not on alert."

Health officials said the same pattern is occurring all over the country. In recent years, in response to economic pressures, hospitals have eliminated empty beds, cut staff and trimmed inventories of drugs and supplies. Even at normal times, hospitals in many regions are short of beds, and emergency departments are frequently so full that even critically ill patients must be diverted elsewhere.

Now, health and hospital officials are struggling to draw up detailed plans for dealing with the possible consequences of terrorist attacks. But because the nation's hospital system is operating so close to capacity, experts said, preparing for mass casualties can seem like an exercise in futility.

In Maryland, which has more than 15,000 hospital beds, officials have figured out strategies to free 800 beds at most, said Richard L. Alcorta, state medical director for emergency services at MIEMS. "That is something that we found a little alarming," he said.

Hospitals might be able to reopen unused wards or set up extra beds in medical office buildings, said Frank Monius, assistant vice president for administration at the Maryland Hospital Association. But they would still have to provide doctors, nurses and other workers to care for the additional patients. And in a chemical or biological attack, those workers would need protective gear and the training to use it properly.

Experts said planning for mass casualties is a problem that the federal government and the health system have barely begun to address. Although federal agencies -- the National Institutes of Health and the CDC -- are responsible for supporting medical research and public health, there is no comparable government agency in charge of ensuring the availability of immediate medical care in a disaster, they said.

"Mass casualty medical care must be recognized as a public safety function, and therefore as a government responsibility," said Joseph Barbera, an emergency physician and co-director of the Institute for Crisis, Disaster and Risk Management at George Washington University.

Officials are also worrying about how to gear up laboratory and health department resources to handle disease outbreaks that could be much bigger than the recent anthrax episode. They said it might take years to replace the trained staff, expertise and resources that have been lost to the public health system during the last two decades. Part of the dilemma is deciding how big a disaster to plan for -- and how to get ready without neglecting other important public health duties, such as immunizing children and preventing the spread of AIDS, tuberculosis and other infectious diseases.

"When it comes to national preparedness, I think there's a minimum level of preparation that should be everywhere," Akhter said. "Because the terrorist picks the agent, picks the time and picks the place. If it happens to be an infectious agent, it's a matter of hours before it spreads to all parts of the country."