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Last Updated

11 Oct 2002

Source: USA Today, October 10, 2002.

1 year later, anthrax alert still echoes

Steve Sternberg, USA TODAY

A year has passed since one or more bioterrorists sifted anthrax spores into four ordinary envelopes and mailed them. Four envelopes with a terrifying toll: five dead, 22 people sick, thousands exposed and millions worldwide afraid to open their mail.

No one knows who carried out the anthrax attacks or why. Whoever is at fault -- and whatever the motive -- the envelope attacks accomplished something that had frustrated health experts for years. The scare prompted the government to launch an unprecedented $1.6 billion overhaul of the nation's neglected public health system.

The anthrax crisis caught the government off guard, experts say, with outdated guidelines for treating anthrax, short supplies of vaccine and no notion that an envelope could be turned into a bioweapon.

More than 2,000 federal, state and local health officials responded to outbreaks in Florida, New York, Washington, D.C., New Jersey and Connecticut. Scientists in a federally funded laboratory network tested more than 1 million specimens for anthrax. A national drug stockpile distributed nearly 4 million doses of Cipro and other antibiotics, according to the journal Emerging Infectious Diseases. Neither the lab network nor the drug stockpile existed three years earlier.

''You couldn't buy Cipro in Florida, because everybody was taking it,'' says Larry Bush, the physician at JFK Medical Center in Atlantis, Fla., who diagnosed the first case and alerted the nation to the attack. ''There was a black market for it.''

If President Bush was appalled by public reaction to the attacks, he was alarmed by the response of an expert at the state laboratory who resisted making a diagnosis even after the diagnosis was obvious. ''I don't want to call it anthrax because of the implications,'' the lab worker said.

Since then, such reservations have vanished. The Centers for Disease Control and Prevention (CDC) now uses an emergency-operations approach for all major epidemics, including the West Nile virus, using them as dress rehearsals for a bioterror attack. As part of this effort, the CDC has built a multimedia communications network to supply information to journalists, doctors and the public. CDC has also expanded its lab network to nearly 100 -- with labs in each state -- and funneled nearly $1 billion into state and local terrorism preparedness. Yet disturbing questions remain: Could the system deal with contagious germs? Could hospitals handle mass casualties?

Just 24 days after the Sept. 11 attacks -- with the World Trade Center destroyed, the Pentagon battered, war brewing and millions of Americans trying to recover from the shock -- the anthrax attacks reinforced a new sense of national vulnerability.

They also transformed the widely accepted view of public health. Once taken for granted by many as a piece of America's social safety net, public health is now viewed as a key to national defense.

''Now more than ever, public health plays a key role in homeland security,'' says Secretary Mary Selecky of the Washington State Department of Health.

But some experts express misgivings about how the bioterrorism money will be spent. They wonder whether it can correct fundamental weaknesses in the nation's ability to respond to bioterror attacks, including a desperate shortage of trained personnel, public health training programs that churn out experts who have never looked into a microscope, and a deep schism between public health experts, practicing physicians and hospitals.

''There's all this money going out, spread through so many agencies, with no plan to make sure it's being spent appropriately,'' says Van Blackwood, a bioterrorism expert for the Federation of American Scientists (FAS).

States have their hands full

Whether public health agencies are up to the challenge is an open question. Most state health departments, which have carried much of the burden of public health, have had their hands full with more ordinary challenges.

Unlike most doctors, who treat one person at a time, public health experts view whole populations as their patient. Their goal is prevention, not cure. They combat epidemics; fight vaccine-preventable childhood diseases; work to prevent injuries and occupational illnesses; oversee food safety; and educate people about the risks of obesity and heart disease, among other things.

Long treated as a taxpayer-financed stepchild of curative medicine, public health programs must somehow stretch scarce resources to provide this dizzying array of services.

''We can't divert resources to bioterrorism and stop dealing with tuberculosis, sexually transmitted diseases and chronic conditions that are killing us,'' says Pat Libbey, executive director of the National Association of County and City Health Officials.

CDC's power has limits

States rely on the CDC in Atlanta to oversee the public health piece of the security effort. The agency serves as the command center of a state-run nerve network that tracks infectious diseases and issues alerts nationwide.

But public health is a state responsibility. Without a state invitation, the CDC has no authority to investigate outbreaks. That limitation has long produced tension between a federal agency with ample resources and struggling state health departments.

Another factor is the CDC's Atlanta location, which has long insulated the agency from the hurly-burly of Washington politics.

Michael Osterholm, one of Health and Human Services secretary Tommy Thompson's key biodefense advisers, says the anthrax attacks and a host of emerging infectious diseases have yanked the agency from relative ''isolation,'' chasing smaller outbreaks, into a more complex and challenging role.

Problems in the nation's public health system are not new. In 1988, the National Academy of Sciences (news - web sites)' Institute of Medicine (IOM), a quasi-public think tank financed by Congress, issued a call for reform. Called ''The Future of Public Health,'' the report asserts, ''This nation has lost sight of its public health goals, and the health of the public is unnecessarily threatened as a result.''

Peter Hotez, chairman of microbiology at George Washington University, says: ''The irony is that all of the failures that occurred were predicted 14 years before. Things have not only not gotten better, they've gotten worse.''

A follow-up IOM study, called ''The Future of the Public's Health,'' supports this view. The report, delayed to assess the public health response to 9/11 and the anthrax attacks, isn't due until November. But one of the report's proposed working titles -- ''Coming Up Short: America's Health Readiness in the 21st Century'' -- suggests how much work must be done.

Some of the problems date to the roots of modern medicine, when patient care diverged from public health. The division still exists today.

''The problem we faced before the anthrax outbreaks is that when we tried to raise the issue of bioterrorism, the hospitals wouldn't talk to each other because they were competitors,'' says Harry Hull, Minnesota's state epidemiologist. ''If we have a jumbo jet that crashes here and most people survive, we don't have enough hospital beds. We can't handle 500 people. What are we going to do when we get one of these massive bioterrorism attacks?''

Another challenge is recognizing bioterrorism when it occurs. Most health department surveillance depends on calls from alert doctors.

Yet few practicing physicians or nurses have ever seen a case of smallpox or other A-list threats. ''You're talking about literally millions of people who need training,'' says Blackwood of FAS.

Hotez notes that few of the nation's public health schools even teach courses in infectious diseases. ''I was astonished at how poorly trained students are,'' he says. ''Public health students don't learn how to use a microscope.''

One potential remedy to the disease-detection problem is a computer-based early-warning system called syndromic surveillance.

The CDC announced last week that it had awarded $1.2 million to a vast consortium of researchers for a system that will constantly sweep 20 million outpatient records in all 50 states for clusters of symptoms linked to infectious diseases and bioterror agents.

Minnesota's Hull challenges the need for such a system and says the record sweeps take 24 hours to sound an alarm. By then, he says, ''our emergency rooms would be overwhelmed.''

Marcelle Layton, chief of infectious diseases for the New York City Department of Health, says her agency also uses a syndromic system that makes it possible to go through ''every admission at every hospital every day to make sure we're not missing something. We detect flu each year that way.''

Layton says New York, a target in both the 9/11 and anthrax attacks, takes the threat of bioterrorism seriously -- so seriously that the health department began canvassing hospitals for cases of anthrax as soon as she learned about the Florida case.

Layton's bigger concern is keeping the momentum going to face the public-health challenges of the future.

''If nothing happens, will the interest in sustaining this effort go away?''