If a family enters an emergency room with inflamed lesions covering their bodies, accompanied by fevers and debilitating weakness - symptoms of a chemical or biological attack - the admitting hospital should know who to call and how to treat each family member.
That wouldn't always happen, however. Almost six years after 9/11 - after spending billions of tax dollars on disaster preparedness - many cities remain unprepared to respond to a biological or chemical attack, according to several leaders in the public health community.
A lack of coherent national policy on biological and chemical weapons preparedness has produced a hodgepodge of ineffective initiatives at the local level, according to critics. Yet others say national standards frequently are ineffective at dictating local issues.
"When you talk about emergency preparedness and disaster response, the important thing to keep in mind is that most of that work is done at the state and local level," said David Quam, director of federal relations for the National Governors Association (NGA). "National solutions sound easy and important, but it is their implementation and their respect for the different roles at the different levels of government that really become the most important."
The lack of a clearly defined, long-term, national consensus on what a prepared America is cripples the nation's biological and chemical preparedness according to some public health experts.
Rhyme and Reason
The U.S. Department of Health and Human Services (HHS) handles most biological and chemical preparedness initiatives for the federal government, which in turn spends hundreds of millions on such initiatives for state and local government. The HHS currently funds activities the public health community typically advocates, like state and local pandemic influenza preparedness, hospital equipment upgrades and similar initiatives.
The problem, according to some public health officials, is that the type of preparedness funding Congress allows seems to shift with whatever preparedness priorities are politically chic at the time.
"There is no long-term plan. There's not even a five-year vision. Everything is just reacting to the political issue of the moment. After Katrina, it was, 'What happened to FEMA? Let's elevate FEMA in the hierarchy so it can report to the Homeland Security secretary during a crisis,'" said Tara O'Toole, who was assistant energy secretary for Environment, Safety and Health during the Clinton administration, and currently is the CEO of the Center for Biosecurity at the University of Pittsburgh Medical Center.
The federal government began ramping up disaster preparedness during the Clinton administration, said O'Toole.
"Congress first started putting money on the streets to train first responders," she said. "But they didn't really think through what we were responding to, or who the first responders were, so all police and fire got a piece of the pie."
That money, she said, was used to purchase a lot of equipment that is largely useless.
"There were constraints against spending it on people," O'Toole added. "You had to buy equipment. They bought a lot of test kits to diagnose whether a powder was anthrax, which didn't work very well. They bought suits to protect against chemical attacks, some of which were OK, some of which were just kind of sitting in lockers moldering away."
There was no rhyme or reason to what people bought, she said, and there weren't any standards to guide agencies on what type of equipment to purchase. "Some people bought good stuff," she said. "Other people bought low-quality or unreliable stuff. It was all over the place."
Lack of a cohesive plan for those involved in incident response may have cost the nation an opportunity, said Elin Gursky, principal deputy for biodefense in the National Strategies Support Directorate of ANSER, because future funding availability is difficult to forecast. "
We've wasted a lot of money that we may not see again because of competing fiscal priorities," she said.
What would help local governments receive federal medical equipment funding on a more systematic basis, Gursky said, is a clearly defined national vision for disaster preparedness.
"Do I expect every local community to have biological containment and negative pressure medical facilities?" she asked. "Probably not, but they don't need to."
They may not need a negative pressure facility, which uses a ventilation system to keep contaminated air from escaping to other parts of a medical facility, they need a systematic process for routing but patients to nearby hospitals that have those facilities.
"We have 5,000 acute care hospitals that are stretched to the limit. We need to recognize where we can stretch further, or what reasonable expectations are that we build greater capacity at a regional level, and not a community level," Gursky said, adding that a national vision would also ensure better use of preparedness equipment funding.
Immediately after 9/11, local governments received such funding on a somewhat equal basis, she said, adding that Congress began funding more strategically since then, but needs to make more progress.
"Two-thirds of our local public heath departments treat populations of 50,000 or less. That's not the best distribution of resources," Gursky said. "Let's look at vulnerabilities, population densities, and plan accordingly."
In addition, Congress funds parts of biodefense preparedness on a year-to-year basis, so the HHS is unable to develop sturdy, mature programs capable of growth, O'Toole said, and public health departments don't know if they can rely on future funding.
Congress should commit to multiyear funding all biodefense activity, she said, the way it funds Department of Defense (DoD) projects.
When the DoD decides it's ready to deal with a new threat, O'Toole said, it has a specific planning process that assesses what its budget will look like for the next few years, so it can commit to training more special forces troops, for example.
"Nothing like that is happening in the Department of Homeland Security (DHS), or in the HHS, for biodefense," she said. "And HHS is where most of the bio stuff lives."
Biological and chemical response is not intended as a primary issue for the department, according to Larry Orluskie, a spokesman for the DHS.
Marc Wolfson, HHS public affairs specialist, said the agency gets some multiyear funding for preparedness and response programs. Specifically Congress set up a special reserve fund for Project BioShield, the program to identify and acquire medical countermeasures against chemical and biological threats identified by the DHS. The special reserve fund for BioShield is available for 10 years - from 2003 to 2013.
Also, funding for the strategic national stockpile (SNS) can be carried over from one fiscal year to the next. The HHS uses the SNS to store and deliver medical supplies, equipment, vaccines and other drugs during a public health emergency.
The United States, O'Toole said, needs to rethink some of its national security funding priorities. "Why are we spending more than $10 billion per year - and have been doing so for decades - on missile defense, when a covert bioattack would be more devastating, and is thought by the National Intelligence Council to be more likely?"
Because Mother Nature strikes the United States more often than terrorists, some think preparedness for natural disasters should receive more funding than biological and chemical preparedness.
Though O'Toole said she agrees natural disaster preparedness needs attention, it shouldn't receive more consideration than chemical and biological weapons.
"Unless it's California falling into the Pacific, a natural disaster is not going to take down the country," she said. "A thinking enemy,
and in particular, our current adversary, al Qaeda, is determined to take down the country. I think a bioterrorist attack could do it. I also think a nuke going off in an American city could totally transform people's willingness to live in cities."
Though the NGA and U.S. Conference of Mayors are working to solve the lack of preparedness issue, Gursky said, state and local governments need to establish preparedness benchmarks to enable effective congressional oversight.
"Congress needs to know its investment is paying off," Gursky said. "We have to put some metrics in place, and figure out if people are meeting these - and, if not, why."
This lack of a national vision for preparedness makes any catastrophe - natural or manmade - more feasible, Gursky said, and groups like the U.S. Conference of Mayors and the NGA should initiate collaboration involving federal agencies to create standards.
There also needs to be strong leadership that articulates what a prepared America is, she said, adding that the executive branch and Congress must encourage state and local governments to develop that national vision.
The problem, Gursky said, ultimately stems from a foggy definition of homeland security - the DHS needs to shift more of its emphasis toward disaster response.
"There has been so much attention paid to borders, issues of watch lists, tracking terrorists and connecting the dots that the response issues have gotten much less attention," O'Toole said. "[The DHS is] mostly a giant police organization, focused on borders, the Coast Guard and that kind of thing, with a tiny little directorate of science and technology stuck on the side."
Establishing national standards would likely be difficult for the United States, Gursky noted, given that the Constitution lets states plan independently of their neighbors. But that doesn't mean national standards shouldn't be created.
"Diseases do not respect borders. Hurricanes do not respect borders," she said. "We have to develop a focused effort to harmonize our capabilities across geopolitical boundaries."
If an anthrax attack occurred in Sacramento, Calif., O'Toole said, the governor would have difficulty evaluating the number of attacks, their size and who was infected. Some of those who were in Sacramento when it happened might travel post-exposure to other places.
And the lack of good diagnostic techniques and data sharing makes it difficult for public health officials to react quickly and effectively to biological threats.
"We don't have good diagnostic techniques, so a guy who gets sick in San Francisco may not even be recognized as [having] anthrax for a while," O'Toole said. "Getting a count of how many people are ill, given the incubation period, could be a day, or many days. It's not going to happen right away. That's going to cause a lot of consternation."
A lack of that data would severely handicap the response planning.
"If it was the beginning of a campaign of attacks, you wouldn't want to take all of your best CDC [Centers for Disease Control and Prevention] people and park them in Sacramento," O'Toole said. "None of this has been thought through. This is why a conduct of operations plan - exactly what actions we are going to take if this happens - is important. The fact that it's missing, even for an anthrax attack, is another symptom of our lack of any kind of strategic thinking."
In addition, the 2005 National Intelligence Estimate identified a biological attack as one of the gravest threats the country faces, and a lack of a national vision for emergency preparedness has kept federal agencies from developing effective prevention and response programs for biological weapons, O'Toole said.
Though she credits the Bush administration
with taking biological threats seriously, O'Toole said the approach needs more specifics.
The conceptual categories - threat awareness, prevention and protection, surveillance and detection, and response and recovery - are a pretty good rendering of the necessary facets in the bioterrorism arena, O'Toole said.
"But it doesn't say, 'In five years, the country is going to have achieved this. And these are our top priorities. And this is how much we think it's going to cost.'"
She said the federal government could more easily produce those specifics if it had an official whose sole responsibility was to direct biodefense for the entire federal government.
"There are some people in DHS who have responsibility [over biological threats] - a number of people in HHS headquarters," she said, adding that some are in the National Institutes of Health, the CDC, the DoD and the State Department.
"There's no conductor of the orchestra. And it's not clear what sheet of music we're singing from," O'Toole said. "They try to coordinate from the White House, from the Homeland Security Council, but there really hasn't been any clear articulation of our overall strategy."
And that strategy, she said, needs to include state and local governments.
Many preparedness obstacles in local government stem from an absence of protocols - how officials should respond after discovering a biological or chemical weapon emergency, Gursky said, adding that officials need established information flows.
If a patient with smallpox - which also poses a great danger to the country due to its contagious nature - enters a doctor's office, for example, the doctor needs a pre-established line of communication to follow. A communication flow starting at the local level and leading up to state and federal agencies must exist in all local governments, Gursky said.
"If police don't know how to reach the public health official, and don't know how to get the mayor, and how to get Transportation or Sanitation, then there's a real fundamental problem of information flow."
To establish such a protocol, local, state and federal agencies need to formally gather to form a consensus as to what preparedness means, said William Yasnoff, managing partner of the National Health Information Infrastructure (NHII), an initiative aimed at improving health care in the United States through a network of interoperable information systems.
"You can agree on things such as, 'We want all emergency responders to be able to communicate with each other. We want local, state and federal officials to have real-time situational awareness.'"
Achieving agreement on broad matters like those, Yasnoff said, would be an easy first step.
However, not all agree on the necessity of national standards.
Many states are already developing those standards independently, according to the NGA's Quam, who cautioned against a national approach because it could be a wrong fit for some local governments.
"When you start talking about national solutions to what are really local issues, you have to be very careful, because almost always, one size will not fit all," Quam said. "At the NGA, we routinely get different groups together to talk about best practices."
The NGA actively encourages states to collaborate with the DHS when planning, for example, communication interoperability initiatives, he said, adding that many statewide interoperability plans are already in the works.
Virtually all decision-makers in state and local government already agree on the need for interoperable communications systems, he said, even if some didn't yet know how to establish them.
"The Department of Commerce has a billion dollars that it needs to issue for interoperable communications. NGA, working with the DHS, hosted an entire workshop developing state interoperable communication plans," Quam said. "That was all of the states coming together in one place, with the federal government, talking about what these plans needed to reach their objectives."
Though state and local decision-makers may agree on the need for interoperable communications systems, ANSER's Gusky said a consortium of local, state and federal decision-makers should officially establish that all governments need such systems, even if they don't all need extravagant ones."Let's define the basics," Gusky said. "The basics are a work force that is trained in a number of different all-hazards problems. The basics are communication systems that let you notify not only the work force, but also the people living in the communities - saying, 'Close your windows. Do not allow ventilation in because there is a plume of some chemical that was inadvertently released.'"
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