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11 Jun 2003

Source: New York Times, November 5, 2001.


Struggling to Reach a Consensus on Getting Ready for Bioterrorism


WASHINGTON, Nov. 4 In his five years as president of Johns Hopkins Hospital in Baltimore, Ronald R. Peterson has spent much of his time trying to make ends meet. But now that the anthrax scare has made bioterrorism a reality, Mr. Peterson is planning to spend money, not save it.

This year, Johns Hopkins will buy extra medicines, masks, ventilators and radios for its security force. It will retrofit a building with new air filters, to keep infectious germs from spreading. The price: $7 million. The question is, who will pay for it?

"The federal government is going to have to give us some assistance," Mr. Peterson said. Last week, the American Hospital Association estimated that the nation would have to spend $11.3 billion to get hospitals ready to handle a serious bioweapon attack. But the leading bioterrorism legislation in Congress proposes $3 billion for all aspects of preparedness, with $400 million earmarked for hospitals.

The gulf between these two estimates shows how far the nation is from a consensus on what must be done to prepare for bioterrorism. The current anthrax attacks, which have killed 4 people and sickened 14 others, have done more than years of reports and warnings to convince Americans that the nation must get ready for a large- scale germ attack.

But the anthrax-tainted letters, while terrifying, have not been much of a test of the country's hospital network.

The system they have tested -- the public health system -- has been strained to its breaking point.

"We have spent, in the last three years, one dollar per year per American on bioterrorism preparedness," said Dr. Tara O'Toole, director of the Center for Civilian Biodefense Studies at Johns Hopkins University. "We are basically getting what we paid for."

Senator Bill Frist, Republican of Tennessee, and Senator Edward M. Kennedy, Democrat of Massachusetts, are proposing legislation that would increase that amount tenfold, to $3.1 billion a year, Mr. Frist said.

Dr. O'Toole says that amount is merely a "down payment on what is going to have to be a long-term investment." There is little agreement among lawmakers and policy experts about how much is needed.

Mr. Kennedy, for instance, initially wanted to spend $10 billion on bioterrorism, including $5 billion to improve the public health system. The current Frist-Kennedy package, which could be taken up by the Senate this week, includes about $1 billion for public health.

In the House of Representatives, Democrats have proposed $7 billion for bioterrorism, including $3.5 billion for public health improvements; House Republicans are drafting an alternative.

The Bush administration has asked Congress for $1.5 billion to fight germ attacks, most of it to stockpile antibiotics and vaccines.

"We can achieve much better preparedness very quickly," Mr. Kennedy said, "but it will require a major national effort and a major commitment of new resources."

"The question is not whether we have the ability to protect the American people," he said, "but whether we have the will."

Having the will does not just mean having the money. It means training doctors and nurses and public health professionals. It will also mean a sea change in the way hospitals do business.

For more than a decade, managed care companies and the Medicare system have pressed hospitals to squeeze the extras out of their budgets. Hospitals have cut beds from emergency rooms. They have eliminated laboratory technician positions and pharmacy jobs. They no longer stockpile medicines, and instead buy drugs each day as needed. These steps have eliminated what is known as surge capacity, the ability of hospitals to handle a sharp increase in patients.

To prepare for bioterrorism, hospitals must build surge capacity back in. Yet because they are reimbursed by health insurers only for patient care, hospital executives say they have no way to pay for bioterrorism preparedness. And because hospitals compete for patients, most have not engaged in regional planning for a bioterrorist attack -- designating one city hospital as the burn unit, for instance, and another the infectious disease ward.

"Back in civil defense days, there were regional hospital planning committees that had some type of a game plan," said Amy Smithson, a bioterrorism expert at the Henry L. Stimson Center, a research organization in Washington. "Privatization of the hospital industry has meant that if physicians, nurses and hospital administrators could not charge their time to a health insurer or Uncle Sam, then it was difficult for them to do this type of thing."

The American Hospital Association estimates that, in a large-scale bioterrorist attack, each urban hospital will need to be able to care for 1,000 patients; the preparations will cost about $3 million per hospital, and more than $8 billion all told. Each rural hospital, the association has said, will need to be able to care for 200 patients, at a cost of $1.4 million per hospital, a total of more than $3 billion.

Some bioterrorism experts, among them Dr. Frank E. Young, the former director of the Office of Emergency Preparedness at the Department of Health and Human Services, have suggested that military field hospitals could be used to help cope with an attack. Others say that is not practical.

"I think it's nave to say we don't need to upgrade our hospital capabilities," said Joseph Waeckerle, an expert on bioterrorism who edits the Annals of Emergency Medicine. "People are going to go to emergency departments of hospitals, and they are going to go in waves." Of the current anthrax attacks, he said: "This is one small incident. What happens if we have a big one?"

Senator Frist said he was reluctant to commit the government to spending a lot of money on hospital preparedness until the hospitals developed bioterrorism plans. "Only one out of five hospitals even has a bioterrorism plan," Mr. Frist said. "If you gave them a billion dollars, they don't have a plan to spend it on."

There is general agreement, however, that the federal government needs to stockpile vaccines and antibiotics. The Bush administration has proposed spending $509 million to acquire 300 million doses of smallpox vaccine, one for every American, and $630 million to expand the National Pharmaceutical Stockpile, a cache of medicine and equipment that could be used in the event of a national emergency. Antibiotics from the stockpile are being distributed to people exposed to anthrax.

Kevin Keane, a spokesman for Tommy G. Thompson, the secretary of health and human services, called the administration's $1.5 billion plan "a strong investment and a good start." Mr. Keane said the health secretary is "continuing to work very closely with Senators Kennedy and Frist as well as other members of Congress on a final package."

But Representative Robert Menendez, a New Jersey Democrat who is chairman of the House Democratic caucus's task force on homeland security, said Mr. Bush's plan did not go far enough. The Democrats' $7 billion package, for instance, includes $1.1 billion to improve intelligence capabilities to detect bioterrorism, $870 million for law enforcement and $720 million for the military.

"The administration is way behind the curve," Mr. Menendez said. "They may be very aggressive in their war on Afghanistan. But in my view, and in the view of many people, they are not as aggressive on the homeland part of this issue."

As the debate continues, the nation's public health laboratories are struggling to analyze tests generated by the anthrax scare. Dr. O'Toole, of Johns Hopkins, said laboratory workers at the Centers for Disease Control and Prevention were "literally sleeping in the lab," while public health departments in affected states were working around the clock to analyze suspicious powders.

"We've been doing this for a few weeks now and people are tired," Dr. O'Toole said. "It is not sustainable over the long term. Public health has been so frayed and reduced in recent years that it is very hard to rise to the occasion."

There is a shortage of epidemiologists who are trained to recognize and investigate outbreaks of infectious disease, said Dr. Michael T. Osterholm, a professor of public health at the University of Minnesota who advises Mr. Thompson, the health secretary, on bioterrorism. "Many health departments couldn't hire one," Dr. Osterholm said, "even if they had the money."

So no matter how much money Congress appropriates, Dr. Osterholm said, the United States cannot prepare for bioterrorism overnight.

"It's going to be a multiyear building project," Dr. Osterholm said. "That's what people have to understand. It's like a skyscraper. Even if you want to build it tomorrow, it's going to take time."