GEARING FOR BIOTERROR
19 Dec 2002
Source: Newsday, September 8, 2002.
Gearing for Bioterror
A Public Health Gamble Agencies big and small struggle to gauge if they're taking right steps
By Laurie Garrett, STAFF WRITER
When Dr. David Ackman started his new job in January 2001, he expected that serving as health commissioner for Nassau County would be a fairly low-key task.
That was, of course, before the affluent Long Island county's bond rating fell to near-junk status. Before two jets slammed into the World Trade Center. And, most significant to Ackman and his public health colleagues nationwide, it was before Robert Stevens (case 5) died on Oct. 5 of inhalational anthrax.
"I don't think we consider ourselves a major terrorism target," Ackman said. "But it does skew what we do here . . . I'm called upon to spend a lot of time thinking about bioterrorism."
It's hard to imagine what might constitute a target for germ warfare in Nassau County, but it does lie in the shadow of the biggest target of all: New York City. And that leads to several nightmarish suburban scenarios.
"There could be a letter \[contaminated by anthrax\] passing through the postal system on Long Island," Ackman ticked off. "Second, there could be exposures in New York City, and some people who work there live here in Nassau. Or there could be an aerosol release in New York City, and the prevailing winds carry it into Nassau County."
So Ackman has to take the threat of bioterrorism seriously. Responding to Sept. 11 and anthrax fears last fall cost his department more than $100,000, Ackman said, about $85,000 of which was eventually covered by federal emergency funds. During the summer the county received $1.3 million more from the federal Centers for Disease Control and Prevention for bioterrorism preparedness, and it will be Ackman's task to determine how best to spend the funds.
"But emergency preparedness planning is something we have no preparation for. Nobody in Nassau County even knew what 'incident command' meant six months ago," Ackman said. "Nobody's really decided what we have to prepare for. How big? How many cases?"
Somewhat arbitrarily, he conceded, Ackman set preparedness targets. By the end of 2003 he wants the department ready, within 36 hours of realization that a germ attack has been unleashed upon New York City or within Nassau, to "be able to treat up to 10,000 people with prophylactic medicines over a 48-hour period."
Having said that, Ackman asked, "Is that sufficient? Or too much? I don't know. Nobody's really told us what a place like Nassau County should be prepared for. We're making the best guess, and we'll go ahead, practice our bioterrorism drills, and in all probability never have to use it."
All over the country, health commissioners are trying to reckon what threats, realistically, loom over their communities and how best to juggle their typically shrinking non-bioterrorism budgets and staffs to protect the people whose health is their responsibility.
Ackman's counterpart in nearby Westchester County thinks everybody is overreacting, and he has no plans for such contingencies as large-scale quarantines. But his colleague in upstate Onondaga County is preparing for worst-case scenarios - a level of commitment that requires five full-time staffers and a budget for the cash-starved county of more than a million dollars.
Boston is spending about 10 percent of its public health resources on bioterrorism preparedness. And Los Angeles County, which for the second time in 10 years faces possible bankruptcy, is trying to find a cheap way to protect the nation's most expansive metropolis.
Who has it right?
It doesn't help, of course, that no one can really define the challenge. At a time when Congress is scrutinizing alleged failures to protect Americans on the parts of the FBI, CIA and National Security Agency, public health leaders are acutely aware of the political dangers. Dr. Alfred Sommer, dean of the Bloomberg School of Public Health at Johns Hopkins University, said in an interview, "You can't expect complete safety, no matter how many billions are poured into public health. The question is, how much safety is enough safety, from a legal, political or moral point of view?"
It's a public health gamble, a game of terrorism roulette.
Over seven months Newsday has interviewed local public health leaders across the nation to see how they plan to protect the American people from biological terrorism. Newsday found them deeply troubled by their charge. All expressed pleasure at the nearly $2.5 billion the federal government is expected to dole out in the coming months for local public health preparedness. But, without exception, they worry that beleaguered public health systems, most facing cutbacks in non-bioterrorism budgets due to severe deficits in at least 40 states, will not be able to meet the challenge.
One top-level federal health official who spoke on condition of anonymity said that Health and Human Services Secretary Tommy Thompson has become enraged when challenged by staffers to offer detailed guidance to local authorities. He has repeatedly told his inner staff that the key mission is to get the federal dollars out to the states - let local officials decide what their threats may be and how best to spend the money.
"Potentially any \[germ\] agent could be a bioterrorist threat that is used in a deliberate manner to cause illness or social disruption," Dr. Ernest Takafuji said. Takafuji recently retired as a colonel in the U.S. Army, focused on bioterrorism. Now he guides National Institutes of Health bioterrorism research agendas.
"Influenza is probably one of the best biological warfare agents we could be facing," Takafuji said. Influenza is far more contagious than smallpox, the current focus of HHS preparedness. And rare, super-virulent strains of flu, such as the one that killed 25 million people worldwide in 1918, would pose a challenge far exceeding anything the health system is currently equipped to handle.
Should the goalposts for bioterrorism preparedness be set far enough for health commissioners to handle a 1918-style superkiller influenza? Maybe, officials say, but first public health needs to achieve far less ambitious goals.
Dr. Frederick Burkle of the Defense Threat Reduction Agency at Johns Hopkins University said America's public health lacks "a real-time modern disease surveillance system" that can spot either naturally arising or terrorist disease threats. Though all local health departments and the CDC have surveillance systems, Burkle said, "there's so much noise we can hardly pick up the signal."
"We have no baseline epidemiology of infectious diseases," Burkle said. "We just don't know what the normal or background rates of infectious diseases are." Without knowing what "noise" is normal, disease trackers are hard-pressed to spot new threats.
In the absence of such information, the CDC is encouraging local public health leaders to develop systems of syndromic surveillance, which could allow them at least to notice increases in emergency room cases of illnesses that seem to involve symptoms similar to those produced by biological weapons.
Syndromic surveillance was first used extensively by New York City health officials to track the 1999 West Nile virus outbreak and is now being used nationwide to spot cases of that disease. It is swiftly becoming a mainstay of bioterrorism preparedness nationwide.
That has prompted a rash of false alarms, as doctors, trained to spot such syndromes, leap to conclusions they would never have considered before Sept. 11. On Aug. 4, for example, an emergency room physician at the Kings Highway Division of Beth Israel Hospital in Brooklyn decided that a young man with fever and a skin rash fit the description for smallpox. New York City's emergency response system was activated over what turned out to be a mild case of contact dermititis.
Dr. Julie Gerberding, director of the CDC, said her agency "loves those false alerts because it tells us clinicians are alert and are paying attention."
Not everybody is thrilled.
"Syndromic diagnosis - that's nothing but a big charade," said Dr. C.J. Peters of the University of Texas Medical Branch in Galveston, who formerly headed the CDC's top security lab and, decades ago, was part of the Army's bioweapons defense research program.
"By the time you start getting blips in emergency rooms, it's too late," Peters insisted. Surveillance systems have to focus on spotting the microbes, themselves, before people have incubated germs in their bodies for several days and started an epidemic, he said. But regardless of how surveillance is focused, the current system is inadequate, all experts agree.
Last fall's anthrax-spiked letters sparked a wave of public anxiety worldwide that overwhelmed public health laboratories in nearly every nation. In the United States local health departments and state and federal labs processed an astounding 125,000 human specimens that were suspected of containing anthrax, and more than 1 million environmental samples, according to Dr. James Hughes, director of the CDC's National Center for Infectious Diseases. If a genuinely contagious event occurred, the local burden would be exponentially greater.
So the mandate to prepare for such an event hits every community, large and remarkably small. "We are absolutely passionate about committing resources to remote areas," secretary Thompson said in a June 6 speech in New York City.
Health director Linda Lazzari's rural Essex County, N.Y., with a population of fewer than 40,000 spread over 1,800 square miles, is best known for its pastoral scenery and access to Lake Champlain. Its tiny health department, run by registered nurse Lazzari, is expected to devote time and resources to bioterrorism preparedness.
"Our budget has not been too affected, but our public health activities definitely have," Lazzari complained. "Our supervising nurse for preventive services spends almost all her time these days on bioterrorism. The same is true for myself. Between all these meetings I have been to and trainings I have attended on bioterrorism, I have had little time to spend on other programs and activities."
The question Lazzari faces is, if her prevention nurse hasn't got time to deal with school cafeteria inspections or child vaccine programs because she's swamped with bioterrorism meetings, is that in the best interests of the residents of rural Essex County?
In addition, all health departments worry that the federal bioterrorism funds will dry up in a year or two, which would force officials to lay off the very scientists and technicians they are now trying to hire. Many health administrators are trying to borrow personnel from other programs, rather than hire new ones.
At the other end of the scale is New York City, home to 8.5 million people and a clear target of terrorists. Due to plummeting tax revenues since Sept. 11, the state public health budget has been reduced, and the city, with its own budget deficit of about $5 billion, is in no position to offset those cuts. Mayor Michael Bloomberg has ordered a 12 percent slash in the city's health budget for this year and warns that further cuts will be necessary in the future. The biggest hits will be in such core programs as immigrant health, infant mortality prevention, tobacco control, HIV education, lead elimination and cancer programs.
The city has received more than $21 million for bioterrorism preparedness and expects that much again for next year. That makes bioterrorism the largest non-entitlement portion of the city's health department budget. City health officials insist they will try to build bioterrorism programs that offer protection against both natural and man-made epidemics. But they acknowledge that personnel from the full gamut of health programs have been involved in bioterrorism training and activities.
That basic dilemma - juggling finite, usually insufficient, resources against tremendous uncertainty - appears to be universal.
"If public health dollars are finite, we are very worried that funding for bioterrorism will come at the expense of other health programs," said Dr. Millie Svatek of the Suffolk County Department of Health Services. "It is essential that all bioterrorism money be viewed as additional money that will in the long run enhance all of public health."