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May 2001, Vol. 91, No. 5718 American Journal of Public Health

References

1. Wetter DC, Daniell WE, Treser CD. Hospital

preparedness for victims of chemical or bio-

logical terrorism.Am J Public Health. 2001;

91:710716.

2. Cohen HW, Gould RM, Sidel VW. Bioterrorism

initiatives: public health in reverse?Am J Pub-

lic Health. 1999;89:16291631.

3. Torok TJ, Tauxe RV, Wise RP, et al . A large

community outbreak of salmonellosis caused

by intentional contamination of restaurant saladbars.JAMA. 1997;278:389395.

4. LockwoodAH. The public health effects of the

use of chemical weapons. In: Levy BS, Sidel

VW, eds. War and Public Health.New York,

NY: Oxford University Press; 1997:8497.

5. Tucker JB. Bioterrorism is the least of our wor-

ries.New York Times. October 16, 1999:A19.

6. Broad WJ. Antimissile testing is rigged to hide

a flaw, critics say. New York Times. June 9,

2000. Available at: http://archives.nytimes.com/

archives/. Accessed March 26, 2001.

7. Myers SL. Drug may be cause of veterans ill-

nesses.New York Times. October 19, 1999:A18.

8. Anthrax immunization. Policy statement

adopted by the Governing Counci l of the

American Public Health Association, Novem-

ber 10, 1999. Available at: http://www.apha.

org/legislative/policy/policypdf1/pdf.Accessed

June 12, 2000.

9. Myers SL. Committee calls for suspension of

militarys anthrax shots.NewYork Times. Feb-

ruary 18, 2000. Available at: http://archives.

nytimes.com/archives/. Accessed March 26,2001.

10. Subcommittee on National Security, Veterans

Affairs and International Relations, House

Committee on Government Reform. The De-

partment of Defense Anthrax Vaccine Immu-

nization Program: unproven force protection.

Subcommittee report. Washington, DC, Feb-

ruary 17, 2000.Available at: http://www.house.

gov/reform/ns/reports/anthrax1.pdf. Accessed

May 9, 2000.

11. Wise D. Cassidys Run: The Secret Spy War

Over Nerve Gas. New York, NY: Random

House; 2000.

12. Garthoff RL. Polyakovs run.Bull Atomic Sci-

entists. 2000;56(5):3740.

13. Mead PS, Slutsker L, Dietz V, et al. Food-re-

lated illness and death in the United States.Emerg Infect Dis. 1999;5:607625.

14. Environmental Protection Agency and De-

partment of Justice. Accidental release pre-

vention requirements; risk management pro-

grams under the Clean Air Section 112(8\7);

distribution of off-site consequence analysisinformation; proposed rule.Federal Register.

April 27, 2000;65(82). Available at: http://

www.epa.gov/ swercepp/pubs/OCArule.pdf.

Accessed June 12, 2000.

15. Dugger CW. India wins battle in war on TB,

but it has a long way to go.New York Times.

March 25, 2000. Available at: http://archives.

nytimes.com/archives/. Accessed March 26,

2001.

16. Loeb V. US is urged to preempt terrorists.

Washington Post. June 4, 2000:A1.

The author is with the Division of Emergency Med-

icine, Childrens Hospital of Philadelphia, and the

Departments of Pediatrics and Emergency Medicine,

University of Pennsylvania School of Medicine, Phil-

adelphia.

Requests for reprints should be sent to Fred

Henretig, MD, Division of Emergency Medicine,

Childrens Hospital of Philadelphia, 34th St and Civic

Center Blvd, Philadelphia, PA 19104-4399.

Since 1996, the United States has em-barked on an ambitious counterterrorism pro-

gram, fueled by bombings in the 1990s atNew Yorks World Trade Center and the fed-eral building in Oklahoma City and by theAum Shinrikyo sarin attack in Tokyo. En-hanced emergency medical services and thestrengthening of hospital disaster-responsecapability for victims of unconventionalweapons are featured components of the do-mestic preparedness plan,1 although they rep-resent a very small fraction of its overall

budget.2 In this issue of the Journal, Wetteret al. have provided us with the results of theirsurvey of the preparedness of hospital emer-gency departments for terrorist incidents in-

volving chemical or biological weapons.

3

They found that, in general, the survey re-spondents were far less prepared than might

be optimal if such an incident were actually tooccur. This study replicates the findings ofseveral others that addressed emergency de-

partment preparedness for hazardous materi-als incidents,4,5 and it adds new data to sup-

port the widely held opinion that a biologicalweapons incident would overwhelm emer-gency departments (and the rest of our healthcare system) without specific educational ef-

Biological and Chemical Terrorism Defense: A View From theFront Lines of Public Health

Fred Henretig, MD

new or reemerging natural infectious diseaseoutbreaks, even if, as we all devoutly hope, no

such terrorist incident ever occurs. In my view,partnering with the federal mandate to com-bat terrorism offers enormous potential for ad-vances in the public health infrastructure at atime when funding for public health is other-wise diminishing.

Mitigating Risk

The actual risk of an attack is hard toquantify and is probably very low. There isevidence of recent biological weapons stock-

piling, particularly in Iraq12 and the former

Soviet Union.

13

A bioterrorism incident in-volving the widespread dissemination of ahighly lethal agent such as anthrax over a large

forts, management plans, and therapeutic in-ventories targeted to this threat.68

Recent commentaries on bioterrorism andpublic health have challenged the wisdom of arobust government-funded bioterrorism de-fense strategy and, in particular, the partneringof civilian and military medical experts in co-ordinating domestic preparedness.911 The low

probability of a bioterrorist attack, and the highcost of establishing and maintaining readiness,are among the cited concerns, along with theobservation, by analogy with the nuclear holo-caust scenario, that there really may not be aneffective response anyway. In contrast, I be-lieve that terrorism with chemical or biologi-cal weapons does indeed pose a serious public

health and security threat to our nation, andthat with foresight and preparation it will bepossible to mitigate the ensuing disaster if suchan attack occurs. Further, it strikes me that co-operation among a broad array of governmentagencies, both military and civilian, as well aswith concerned academic and professional or-ganizations, is precisely the correct approachfor addressing this potential national catastro-

phe. Perhaps most important, this strategy willalso enhance our public health capabilities toaddress unintentional toxicologic disasters and

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May 2001, Vol. 91, No. 5 American Journal of Public Health 719

metropolitan area might require the sophisti-cation and resources of state sponsorship andthus be considered a low-probability, highconsequence event.1 However, many publichealth, national security, and military author-ities consider that even such a low-probabilityevent, given the difficulty in quantifying justhow low the probability and its attendant po-tential for catastrophic consequences, is wor-thy of preparation.1,14 Of perhaps greater con-cern, a smaller-scale attack that might onlysicken thousands and kill hundreds is far morelikely and well within the capacity of ama-teur terrorists or those with access to the ex-

pertise of former bioweapons scientists. Forexample, in 1984 in The Dalles, Ore, 751 peo-

ple developed salmonellosis, with 44 requir-ing hospitalization, after the intentional spreadof bacteria on salad bars in order to disrupt alocal election.15An incident with a more lethalagent might have resulted in far greater mor-

bidity, and consequent mortality, as illustratedby the accidental release of airborne anthraxin 1979 in Sverdlovsk, Russia, resulting in atleast 66 deaths.16

Are we ready to accept even such alesser disaster without attempting to formu-late strategies to lessen the potential morbidityand mortality? I believe we can mitigate con-siderably the severity of such a catastrophe,and certainly its spread in the context of con-tagious agents, by careful, cost-effective train-ing and consciousness-raising in the emergencymedical services and medical communities,

both of which have been initiated in hospitalsnationwide.68 Early recognition of a terroristattack, local community-based response plans,

and attainable stockpiles of drugs and vaccinescan ameliorate some of the impact of an at-tack. Further advances in early detection andidentification of bioagents, and in immuniza-tion and therapeutic modalities, will enhanceour response capability and have obvious dual-use applications in our approach to ordinary,natural infectious diseases. From this per-spective, failure to take these steps would con-stitute a massive malpractice error of omis-sion on the part of public health and medicalauthorities.

Allocating Funds

It is true that counterterrorism funding tothe Department of Health and Human Servicesand the Department of Defense has increasedsignificantly in the past few years, but thesestill represent small fractions of the depart-ments overall budgets. Public health shouldnot be a zero-sum game. When health crisesarise (as was the case with the AIDS epidemic),overall funding must be increased within oursocietys limits. In my view, the potential threat

of biological and chemical terrorism to nationalhealth interests mandates considerable fund-ing. This in no way suggests a desire to de-crease funding for other worthy public healthinitiatives, such as fighting the reemergenceof tuberculosis in our inner cities, expandedchildhood vaccination programs, efforts tocounteract increasing antibiotic resistance, andenhanced infectious disease surveillance atlocal and national levels. Indeed, much of thecurrent research for combating bioterrorismwould have a positive impact, on the latter ini-tiative particularly.14 Further refinement of ourdomestic preparedness planning and budgetallocation, including shifting resources fromcompeting federal bureaucracies to favor localemergency medical services and hospital emer-gency departments on our front lines of pub-lic health, may also be warranted. According toSmithson, reporting in a recent comprehensivenational survey, in the past year $315 millionwent to emergency medical services person-nelonly 22% of the unconventional terrorism

program and 3.7% of the overall federal coun-terterrorism budget.2

Other Concerns

Biodefense critics have raised the con-cern that expanded bioterrorism defensive ef-forts may contain an inherent potential forcovert offensive biological weapons use or re-search. It is reported that numerous biomed-ical researchers, including many members ofthe National Academy of Sciences, recentlysigned a pledge not to engage in research or

teaching that might further the developmentof chemical or biological weapons.9 I believethat the broad coalition of medical and publichealth biodefense proponents would certainlyagree with this position, which has been offi-cial US policy for over 30 years. Of note, the

National Academy of Sciences is now partic-ipating vigorously in counterterrorism domestic

preparedness efforts. The academys Institute ofMedicine recently released a 279-page com-mittee report that stresses the importance ofintegrating domestic preparedness for chemi-cal or biological terrorism within existing emer-gency medical services and public health agen-

cies; it delineated numerous recommendationsfor high-priority research and developmentneeds to prepare optimally for this threat.14TheInstitute of Medicine committee consisted of 17national experts drawn primarily from civilianacademic and public health institutions, andthe report was further reviewed by 8 distin-guished independent reviewers. Currently, asecond Institute of Medicine committee ismeeting to devise evaluation strategies for onecomponent of the domestic preparedness pro-gram, involving the development of enhanced

local emergency medical services responsesystems in 72 of our largest cities.17

Additional concerns in the biodefense cri-tique reflect in one capacity or another a distrustof militarism in the national agenda on bio-terrorism. I would offer some differing viewson these concerns. Since 1969, the UnitedStates has conducted only defensive efforts inthe arena of biological weapons.18 Research atinstitutions such as the US Army MedicalResearch Institute of Infectious Diseases(USAMRIID) is conducted under a policy ofinformed consent and in accordance with theFreedom of Information Act. With the poten-tial threat of terrorist use of biological weaponson civilian populations, it is natural for emer-gency medical services and public health agen-cies like the Office of Emergency Prepared-ness and the Centers for Disease Control andPrevention (CDC) to partner with military med-ical sources of expertise in planning for po-tential civilian mass casualty incidents result-ing from bioterrorism.

There are ample precedents for the ad-vancement of civilian public health and gen-eral medical practice as a consequence ofgovernment-funded research and training

promptedbynational securityor defense con-cerns. The highly regarded Epidemic Intelli-gence Service of the CDC was organized inthe 1950s precisely as a response toour coun-trys thenperceived vulnerability to biologicalwarfareattack from ColdWarantagonists.16,19

Many modern emergency medical practices,traumaandburncare, andvaccinesarederivedfrommilitarymedicine-basedresearch,as wellas battlefield treatment and evacuation expe-

rience. Numerous current initiatives enhanc-ing medical and public health practice at thelocal and regional levels ultimately will addconsiderably to our ability to respond effec-tively to natural infectious disease emergen-ciesandunintentional hazardous materials in-cidents, thanks to training undertaken in thecontext of biological6 and chemical20 terror-ism preparedness.

Acenturyago, armysurgeonWalterReedpresentedhisseminalworkonyellowfever totheannual meeting of theAmericanPublicHealthAssociation.21Today, too, thelinkageof nationalsecurity and public health initiatives can have

criticaldual-usebenefits inprotectingournationfrombioterrorismas well asfromemergingandreemergingnatural infectiousoutbreaks,andintheprocessprovideabroadbaseofsocialandpo-liticalsupport fora strengthened national pub-lichealthinfrastructure.

AcknowledgmentsI gratefully acknowledge the considerable education

I received in biodefense matters from the staff of the

Operational Medicine Division at USAMRIID. Sev-

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May 2001, Vol. 91, No. 5720 American Journal of Public Health

eral members of the division contributed valuable crit-

icism to earlier drafts of this manuscript, as did a di-

verse group of other experts in the field, but the opin-

ions expressed herein are wholly my own.

References

1. Tucker JB. National health and medical serv-

ices response to incidents of chemical and bio-

logical terrorism.JAMA. 1997;278:362368.

2. Smithson A. Ataxia: the chemical and biological

terrorism threat and the US response. The Henry

L. Stimson Center; 2000;71103. Available at:

www.stimson.org/cwc/atxtoc.htm. Accessed

January 29, 2001.

3. Wetter DC, Daniell WE, Treser CD. Hospital

preparedness for victims of chemical or bio-

logical terrorism.Am J Public Health. 2001;

91:710716.

4. Burgess JL, Blackmon GM, Brodkin CA, Ro-

bertson WO. Hospital preparedness for haz-

ardous materials incidents and treatment of con-

taminated patients. West Med J. 1997;167:

387391.

5. Cone DC, Davidson SJ. Hazardous materials

preparedness in the emergency department.Pre-

hosp Emerg Care. 1997;1:8590.6. Eitzen EM Jr. Education is the key to defense

against bioterrorism.Ann Emerg Med. 1999;34:

221223.

7. Keim M, Kaufmann A. Principles for emergency

response to bioterrorism.Ann Emerg Med.1999;

34:177182.

8. Richards CF, Burstein JL, Waeckerle JL, Hut-

son HR. Emergency physicians and biologi-

cal terrorism. Ann Emerg Med. 1999;34:

183190.

9. Cohen HW, Gould RM, Sidel VW. Bioterrorism

initiatives: public health in reverse?Am J Pub-

lic Health. 1999;89:16291631.

10. Cohen HW, Sidel VW, Gould RM. Prescriptions

on bioterrorism have it backwards [letter].BMJ.

2000;320:1211.

11. Vergano D. Bioterrorism defense under fire.USA Today. June 21, 2000. Available at: http://

www.usatoday.com/life/health/general/lhgen

244.htm. Accessed March 2, 2001.

12. Zilinskas RA. Iraqs biological weapons: the past

as future?JAMA. 1997;278:418424.

13. Alibek K.Biohazard.New York, NY: Random

House; 1999.

14. Institute of Medicine-National Research Coun-

cil. Chemical and Biological Terrorism: Re-

search and Development to Improve Civilian

Medical Response. Washington, DC: National

Academy Press; 1999.15. Torok TJ, Tauxe RV, Wise RP, et al. A large com-

munity outbreak of salmonellosis caused by in-

tentional contamination of restaurant salad bars.

JAMA. 1997;278:389395.

16. Franz DR, Jahrling PB, Friedlander AM, et al.

Clinical recognition and management of patients

exposed to biological warfare agents.JAMA.

1997;278:399411.

17. Evaluation of the Metropolitan Medical Re-

sponse System Program to enhance local capa-

bility to respond to terrorism with weapons of

mass destruction. Institute of Medicine, National

Academy of Sciences; 2000. Available at: http://www.iom.edu/mmrs. Accessed January 29,

2001.

18. Christopher GW, Cieslak TJ, Pavlin JA, Eitzen

EM. Biological warfare: a historical perspec-

tive.JAMA. 1997;278:412417.

19. Langmuir AD, Andrews JM. The Epidemic In-

telligence Service of the Communicable Dis-

ease Center. Am J Public Health. 1952;42:

235238.

20. Brennan RJ, Waeckerle JF, Sharp T, Lillibridge

SR. Chemical warfare agents: emergency med-

ical and emergency public health issues.Ann

Emerg Med. 1999;34:191204.

21. Reed W, Carroll J, Agramonte A. The etiology of

yellow fever: an additional note.JAMA. 1901;36:431440.