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Last Updated

25 Mar 2003

Source: New York Times, March 25, 2003

Experts See Gains and Gaps in Planning for Terror Attack


With war under way and the government warning that America is at high risk of terrorist attacks with chemicals, germs or radiation, experts say the nation's response capacity is greater than it was in the past, but still has significant gaps.

"We're better off than we were, but we're not there yet," Dr. William Schaffner said last week. He is chairman of the preventive medicine department at Vanderbilt University and one of the infectious disease experts who have advised the government about smallpox vaccination.

Dr. Tara O'Toole, director of the Johns Hopkins Center for Civilian Biodefense Strategies, said: "We have done some useful things, as a nation and in states and some cities, to prepare for a bioterror attack. But I think people don't appreciate the kind of scale of effort that is needed and has not been achieved. I think there is also an understandable reluctance to talk truthfully about how vulnerable we are, lest we encourage would-be terrorists and undermine our own defense. I don't think we're a lot less vulnerable now than we were in 2001."

But Dr. Julie L. Gerberding, director of the Centers for Disease Control and Prevention, said her agency had markedly increased its preparedness level since Sept. 11.

"We are ready to go if we have to step forward for a terrorism event," Dr. Gerberding said.

As evidence, she cited the disease centers' ability to respond rapidly to severe acute respiratory syndrome, the mysterious illness that has affected hundreds of people in Asia and elsewhere. She said dealing with the SARS outbreak required skills much like those needed to respond to a terrorist attack.

"Within the first 24 hours we had calls to the state health officers and clinician community," Dr. Gerberding said, adding that the C.D.C. had also tapped a team of medical experts to advise about treatment. Within 36 hours the agency had issued guidelines on isolating patients to prevent the spread of the disease, she said.

In 2001, the agency was severely criticized for not providing crucial information about anthrax to the public promptly. Dr. Gerberding said that since then the disease centers had "taken giant steps in streamlining our capacity to communicate information to the public."

She added, "If you watched the response to anthrax, then West Nile and now SARS, any observer could not help but notice that there has been a dramatic improvement in the efficiency and effectiveness in what we are doing on the communications and scientific front."

Since Sept. 11 the agency has also offered doctors training materials to sharpen their ability to recognize anthrax and other unusual infections. Health experts cited other advances as well, including the computer systems now used in many communities to flag odd patterns of illness or medicine use. In addition, hospitals have retooled their disaster plans. The United States now has enough smallpox vaccine to inoculate the entire population, and, Dr. O'Toole said, vaccinating military personnel and health workers has helped doctors learn how to conduct immunization programs.

The government has also stockpiled antibiotics, treatments for burn and blast victims, and antidotes to chemical weapons and nerve gases. A federal program called the Strategic National Stockpile, part of the Department of Homeland Security, says it has enough medicine to treat 12 million people exposed to anthrax, 100 million exposed to plague and 50 million exposed to tularemia, a bacterial infection. The program says it can deliver the drugs anywhere in the country in 12 hours or less.

But there is still a way to go. For instance, it is not clear whether states are equipped to get the emergency medicine to people who need it.

"It may be so near and yet so far," Dr. Schaffner of Vanderbilt said. "I'm sure every state health department is wrestling with how you can dispense this medication quickly."

Dr. Gerberding said there was "a lot of work to do to bring every jurisdiction to the same level of preparedness." Some states and cities have been working on responses to bioterrorism for a long time, while others started only recently, using federal money given for that purpose.

The government has asked health care workers to volunteer to be vaccinated against smallpox, to create a pool of professionals to vaccinate others and treat cases in an attack, but far fewer workers than expected have volunteered. Many expressed concerns about health risks from the vaccine and about the lack of compensation for people who missed work or were harmed by side effects. The Senate Committee on Health, Education, Labor and Pensions is considering legislation to compensate injured workers, but Democrats and Republicans have not agreed on the details.

By March 14, only 21,698 health workers had been inoculated.

"It is not ideal, and we have a ways to go before I feel we have achieved the full preparedness we need," Dr. Gerberding said.

She said progress had been made in improving the country's preparedness for a chemical attack. But, she added, "there is no antidote to so many of the chemical terrorism threats." Scientists must develop antidotes, she said, "because it is likely that those chemicals could be the weapons of choice for domestic terrorism."

"C.D.C. is putting out a lot of information about chemical attacks, because we know that clinicians have extremely limited experience dealing with those types of situations," Dr. Gerberding said.

The agency provides information on bioterrorism on its Web site,

Another weak point is the lack of treatments for some potential germ weapons. In addition, disaster plans that look good on paper need to be tested, but drills are hard to conduct when so many hospitals have no staff members to spare and are filled, often with a high proportion of severely ill patients.

And the drills that have been conducted may not have been realistic enough. James D. Bentley, senior vice president of the American Hospital Association, said: "The problem is, we tend to organize these drills in a way I'll call non-disruptive drills, on Saturday morning, with off-shift nurses and firemen. We haven't done many in this country where at 2 o'clock in the afternoon Mayor Bloomberg goes out there and stages something that will really disrupt the Bronx or Brooklyn. If there is a real terrorist incident, we'll have to do that. It's those kind of drills that I think the preparedness community wishes we could do more of."

More scientists are also needed. In a letter this month to Health and Human Services Secretary Tommy G. Thompson, Dr. D. A. Henderson, who led the vaccination campaign that rid the world of smallpox and has been advising the government on preparedness, said, "We have recruited an outstanding team, but we all recognize that it is still substantially below the numbers needed."

In an interview, Dr. Henderson said that the recently created Office of Public Health Emergency Preparedness, which has about 45 employees, needed to double its staff. He also said the office, in the Department of Health and Human Services, needed mature researchers and public health workers with experience in investigating outbreaks and conducting vaccination programs.

"It is very difficult to find those people, and it is very cumbersome to bring in people on short order," he said. "You need people with stature and with a tough shell. They include people who know vaccines, drugs, epidemiology and diagnostics."

Dr. O'Toole of Johns Hopkins also said it was hard to find people with the right training, and hard for states in particular to pay them.

"In September 2001, Maryland had one full-time bioterror person," she said, and when the attacks created a need for more, it was hard to find qualified people.

"For a generation, we have failed to move the best and brightest of medical and graduate students into government positions," Dr. O'Toole said. "And now we have something like 48 states in recession, and hiring freezes in many as a consequence, and health departments in dire straits."

Washington has provided more than $900 million to states for bioterror preparedness, but experts say more will be needed.

"The longer things go on, the more resources will be necessary," Dr. Schaffner said. "I know health departments, local and state, are already looking ahead, and they do not see sustained support, and they're already worried about that."

Public health experts say society simply cannot allow itself to imagine that the anthrax attack of 2001 was a one-time event.

"I think a bioterror attack is a real possibility," Dr. O'Toole said. "It's not a far-fetched, imaginary scenario. It's already been done. Someone made high-grade anthrax and disseminated it. Someone can make more."