WASHINGTON, Nov. 16 (UPI) -- The terrorist attacks on Washington and New York City raised questions about the U.S. public health system's ability to deal with a widespread assault using biological or chemical weapons. And the series of anthrax-tainted letters revealed deficiencies in the system of public health care, both on the federal and state levels.
Dr. Georges C. Benjamin, president of the Association of State and Territorial Health Organizations, told United Press International that the U.S. public health system will need at least a $1 billion to jumpstart its bioterrorism and disaster preparedness efforts. Benjamin also said public health workers with the experience and expertise to recognize and treat for pathogens used in biological warfare are being lost to retirement.
Benjamin serves as secretary of the Maryland Department of Health and Mental Hygiene in Baltimore, Md. He was chairman of the ambulatory care unit at the District of Columbia General Hospital in Washington and practiced emergency medicine at Walter Reed Army Medical Center during the 1980s.
Benjamin said the public health system needs more medical personnel trained to identify and treat people affected by ailments such as anthrax, private hospitals equipped to handle mass casualties, and better funding of the public health system.
U.S. Health and Human Services Secretary Tommy Thompson has requested $1.5 billion -- out of the $20 billion that has been set aside for fighting terrorism -- to strengthen the nation's ability to respond to and treat potential bioterrorism. The total request of $1.9 billion represents more than a six-fold increase above the $297 million Congress appropriated in fiscal year 2001 for HHS' bioterrorism preparedness efforts.
Q. What is ASTHO and what is its role in the nation's public health system?
A. ASTHO is the organization that represents state health departments. It is represented by the person who is either considered the state health official -- or in some of these agencies where you have umbrella agencies that are human services agencies, public health is the major component. ASTHO certainly represents in many ways the states' perspective, although we have very, very strong linkages to the other associations, such as the National Association of County and City Health Officials. We work very closely in coordination with them.
After Sept. 11, most ASTHO members talked more seriously about the risk of a biological threat attack, and (in) many states that had put in play some early plans for disease surveillance, those plans were enhanced or activated. So in the Washington metropolitan community, where we had experience already with the presidential inauguration and preparations for the International Monetary Fund meetings, we basically increased turning those systems on. In fact, the IMF system had already been put in place, but it hadn't been activated. We activated it on Sept. 11.
Since that time, ASTHO put together an advisory committee on biological terrorism. The purpose of that advisory committee was to begin looking at some policy issues around biological terrorism, to try and vet some of the policies that come out of the federal government, to actually try to give our governors advice as chief health officials on where they want to go.
We are also strongly linked to some of the other public health communities like (the National Governors Association). Each of the public health specialties have a national organizations, like state epidemiologists. State lab directors have an organization Those are affiliate components of ASTHO. Again we coordinate a lot of what we do with those organizations.
Q. Has your membership identified any key areas needing improvement within the public health system to address biological threats?
A. To that end, ASTHO has identified some areas we think are critical areas of public health capacity that need to be enhanced. They include preparing a response capacity. What I mean by that is that you clearly need a good plan. We have encouraged people to identify their existing assets and their needs. That includes things like stockpiling drugs, equipment, supplies, medical training and an appropriate communication plan. Another critical capacity was epidemiology and surveillance, that being defined as having the competencies and people to do basically the grassroots detective work as necessary to detect both when an outbreak has occurred -- particularly when it's a rare event, a new organism or something that doesn't occur very often -- and then trying to track where that disease came from and identifying who is at further risk.
Another competency is laboratory capacity. Pretty much every state has a public health lab capacity. Some are pretty robust. Some are not so robust. Those lab capacities historically represent the role of that state health department in a particular community. So if you have a public health laboratory where there are a lot of clinics, take care of a lot of underserved or indigent populations, they have more of a clinical lab that does blood counts, electrolyte levels and some blood testing levels. Some labs may be more of an environmental lab. Some may be more of a disease surveillance lab, and some may be a combination of all of those, of course. So we felt certainly that is another component that needed to be beefed up.
Really, it means having the right people, enough of them and well-trained, but obviously trained in identifying some threat diseases -- smallpox, plague -- and being able to culture those organisms in the laboratory, making sure the laboratories are safe to do that kind of work in, of course, and then being able to rapidly communicate that information when you find diseases up and down the chain.
By that I mean back to the federal government, to the (U.S. Centers for Disease Control and Prevention in Atlanta), to other parts of the health community that needs to have that information.
Q. How important is technology to preparing for a biological threat? How well did your state do on Sept. 11 in that area?
A. We talked a great deal about having secure and accessible information systems. It was very clear after Sept. 11 that communications, rapid and secure and accurate, was one of our biggest challenges. The capacity to do that both requires the use of technology (and) the funding.
To give you an example, my department spent the money -- it was unbudgeted -- but we literally had to set up a morning conference call with my senior staff.
That (conference call was) pretty much every other morning or every morning, depending on what was going on. Those are fairly expensive conference calls to have. In addition to that, (what) we invested early on a couple of years ago in making sure our departments were networked -- that technology has gotten pretty old. So the capacity to send an e-mail to someone is good, but we've learned you have to have e-mail in more than one place. We may hook each health department up, but that box may be in one person's office but not the right person's office. Some of the technology was old. We still have people with 286 computers so if we're sending WordPerfect Version 6, they can't open it.
We had to set up an emergency blast-fax capacity. We had to fax information out to multiple people at one time. We did utilize people that we had. We utilized the medical society for example. They have a blast-fax capacity to 1,500 doctors. We went through our emergency management agency, and we went through the EMS system. But simply being able to get out information out to the press rapidly was frankly a chore early on because of our lack of capacity to do that. We worked through all those things and we put new systems in place. Those are the examples of those kinds of things that health departments throughout the country need to have.
In Maryland, we had a pretty decent plan. We have been working on it for three or four years. It is fascinating how we had to readjust that plan based on this experience, in the D.C. area, a multi-jurisdictional experience. We had always talked about talking to our colleagues in other regions, but (we need) more linkages to not only the hospital association in Maryland but clearly the hospital association in D.C., and linkages across the three regions.
Q. Can you talk about the challenges that the public health system is facing on the state level?
A. We also talked a great deal about the public health work force. Public health is an amorphous work force. We have lots of different people with lots of different competencies, lots of different training. One of the things that was very clear was that you're going to have to go out and train a lot of different workers beyond what a lot of them already have, because if this (anthrax) outbreak had been larger you would have had to have a lot more people with really basic epidemiology training, surveillance training. Had this been smallpox, you would have had to have given a lot of shots awfully quick.
Public health has not been really invested in. A lot of people have gone out and gotten MPH's -- master's in public health. That has certainly happened. But there are a lot of core parts of the system that have not been well invested in. Just like in the federal government work force which is aging, you have an aging public health workforce in a lot of very critical areas in the laboratories. A lot of my lab workers are coming near their retirement periods. While we can hire laboratorians, the skills necessary to work in a public health lab are quite different. They are not necessarily trained to measure lead levels. They didn't practice that. They certainly have not seen these threat agents. My lab guy, for example, was actually involved overseeing the taking-apart of an offensive-warfare program at Fort Detrick. We're hoping he never retires because when he leaves, that whole experience is lost. We don't have anybody like that. I'd have to go out and try and find somebody like that with that expertise.
While there is some expertise out there, we have in some ways become a victim of our own success. In other areas the fiscal investments just haven't been made.
Q. So we've gotten very good at vaccinating against these threat diseases but at the same time we don't have the workforce to actually look under a microscope and identify them?
A. That's right. And we are going to have to teach them that giving a flu shot isn't the same as giving a smallpox shot. It's done differently. We have to teach people. We have lots of nurses. That's skill, that's a competency. That takes resources and time.
Q. Is there a dollar figure on that yet?
A. There is an initial investment dollar figure that people have kind of pulled out of the air, and what I mean by that is that they sat down and said, "OK, what do we really need for public health?" It's about $2 billion. The initial investment for sure is $1 billion. Several people sat down three or four weeks ago at the Nuclear Threat Initiative and we went through a brainstorming process about what the public health system needed initially and it was easily $1 billion. That does not include hospitals. That does not include first responders. That does not include enhancing stockpiles.
Q. Let's talk about the public hospitals. Over the last decade, we have seen a lot of them close down. What effect is that going to have? For example, District of Columbia General Hospital, which was one of Washington's centers for bioterrorism response, ceased operations.
A. We no longer have a lot of public hospitals in this country, which basically means we have to rely on existing private hospital systems in many places. I am not sure that's the issue. I think the issue is that hospitals have to have a competency to manage large numbers of individuals in any kind of disaster scenario as much as you can, and in an orderly and comprehensive a manner. That means they need to have certain infrastructures.
They have to have the capacity to identify in their facility that there is someone sick there, that has an unusual disease there. That means in the emergency department, in the (intensive care unit), in the medical ward, they have to make that diagnosis.
Secondly they need to -- in the event someone needs to be decontaminated for chemicals or biologicals -- they need to have the capacity to do that. That may be anywhere from one patient to a broader number of patients, and it depends on the community and how they plan to do that. Then it may not necessarily be in the facility. It may be outside the facility.
If you have a warm weather community, it's not such a big deal. If you have a community with four seasons, that's a big deal. In Chicago, decontamination on the outside is not much of an option, particularly if you're talking about taking off clothes and showering. They have to have an organized system to do that.
We have not brought the hospital planners into that debate yet. Washington Hospital Center is looking at such a design. That is an important issue. We're building lots of ERs in this country and that clearly needs to be a major component of those ER designs. How are you going to decontaminate a lot of people as part of your process? How are you going to handle the air flow in case the air is contaminated, make sure it vents into a proper place so no one else gets sick? We need to clearly be able to look at how you pay for that standby capacity for hospitals as part of the reimbursement strategy. How do you reimburse a hospital for a disaster?
Q. What part do hospital credentialing agencies play in preparing for disasters and making sure hospitals are ready?
A. It wasn't a basic part of the review. We now need to pay a lot more attention to that as part of the credentialing process for hospitals. People do what people say. I think that disaster management needs to be a more important part of the review for hospitals.
Q. How coordinated has the effort been between the public health officials on the state level and those in the federal government?
A. For ASTHO, we have always had a very strong working relationship with the federal government. CDC basically talks to states. We receive our money from the CDC for lots of grants. The relationship between states and the federal government has always been very strong. I don't know if that's been an issue at all on the medical side of things and on the public health side of things. The issue from our perspective has been resources. We've always felt that public health has always been under-resourced. Not just the states, we always felt the federal government was under-resourced for their own capacity. The CDC just underwent a major lab rebuilding process. Prior to that, frankly, the labs were embarrassing. Great work in old facilities. They've gone on a rebuilding process to rebuild their infrastructure.
Q. Are you content with how the federal government handled the anthrax situation?
A. We have all been playing catch-up on this. Have we made some mistakes? Sure. In retrospect, would we have done some things differently? Absolutely.
Q. What mistakes? And what would you have done differently?
A. I think we should have probably have sat down with the media and said "This is what we think. This is what we know. This is what we think we are going to do and this is how we think our plan is going to be modified as we go along." And frankly, "This is what we know and this is what we don't know" because there was an impression early on that people didn't quite know what they were doing, or where we were going, or we were playing catch-up.
Let me put it in a different perspective. Did we have any of those questions when the Twin Towers came down? No. You know why? Because we could see two planes going into a building and everyone understood immediately what that meant, what a catastrophe that was. People could picture it and understand it.
You had a disease catastrophe and you also had a potential catastrophe that was averted -- that somehow has gotten missed in this whole thing. Think about the fact of all the people in the Hart building that had nasal swabs positive. Those were potential inhalation anthrax cases that were averted. Think about the people who were treated with prophylaxis. We will never know truly how many lives were saved in this. Public health does its best work when nothing happens. I think that whole angle has been missed.
Yes, we have been playing catch up. Yes, we've not been able to communicate accurately because we've been chasing the letters, chasing the evidence. It's an event that's never happened before. We've had earthquakes before. We've had that terrible bombing in Oklahoma City. People understood when a bomb goes off or a terrible crash occurs. People can conceptualize that. But this is the first massive outbreak that was followed by national and international television, print media. The rumors were unbelievable. The amount of talking heads was unbelievable.
The amount of misinformation was unbelievable. I think when you look back at this I think that people will be amazed at how an under-resourced public health system responded to this potential disaster.
