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The threat of chemical
and biological terrorism, coupled with current world events, has caused
the many disciplines responsible for the health and welfare of the
public to evaluate their ability to respond adequately to an intentional
use of a weapon of mass destruction. The national medical
community--including public health agencies, emergency medical services,
hospitals, and health care providers--would bear the brunt of the
results of a chemical or biological attack. An attack of a chemical or
biological agent could result in civilian mortality and morbidity that
have not been seen in natural disasters or infectious outbreaks in the
United States since the influenza epidemic of 1918—1919.
As noted in the
preceding chapter, the medical community must prepare for three general
types of incidents. The first is an overt release resulting in a
chemical or biological exposure to a population with its subsequent
morbidity or mortality. In most cases illness exposure or risk is known
from the moment the exposure is identified, and efforts to mitigate its
effects as well as treat victims can begin immediately. The second type
of terrorist incident is a covert release involving an agent with a
delayed onset of illness and delayed identification that a population is
at risk. In this situation, exposure, illness, or injury may be
widespread before mitigation or treatment can begin. Finally, there is
the threat of a release by a terrorist group that has identified itself
or is discovered through normal intelligence operations. In this case,
medical authorities can serve as a surveillance system for law
enforcement by looking for medical indicators suggestive of terrorist
activity. Such indicators might include unusual illness or injury in a
community. Although medical organizations have historically not been
recipients of pre-incident intelligence, this practice needs to change
in light of recent concerns about chemical and biological terrorism.
The CDC now maintains a
database of individuals and organizations possessing any of 36
biological agents (listed in Appendix D) with
potential to cause a severe threat to public safety and health. The
legislation does not require CDC to share this information with state or
local health departments, however, and sharing has not been done in any
systematic way. Although facilities willing to report to CDC that they
are working with these agents are unlikely to be terrorist threats
themselves, they may be targets of terrorists, victims of theft by rogue
employees, or the source of an unintended release. All of these events
will be handled better if the local medical community is aware of the
possibility.
Of far more importance
is the need for an institutionalized linkage between the law enforcement
and medical communities. The response of even the most well prepared
medical facilities will be markedly improved by advance notice from the
law enforcement community. The latter understandably fear compromising
ongoing investigations, but may not fully appreciate the substantial
impact even very general information about possible incidents can have
in facilitating a rapid and effective response by the medical community.
Receipt of information concerning a possible mass-casualty event need
not involve more than a few key individuals who can review the
organization's seldom-used plan and begin to think about treatment
options, where and how to obtain needed antidotes and drugs, make
hospital beds and resources available on short notice, and ensure
adequate staffing levels. Inclusion of these key medical personnel in
anti-terrorist intelligence activity would no doubt be facilitated by
their willingness to undergo training on the needs of the law
enforcement community, especially procedures for proper preservation of
evidence.
After-action reports on
the Tokyo subway incident (Obu, 1996; Olson, 1996; Yanagisawa, 1996)
provide an example of the value of communication between the law
enforcement and medical communities as well as an example of a missed
opportunity for communication within the medical community that might
have made the medical response even more effective than it was. Japanese
police had apparently been planning a raid on Aum Shinrikyo facilities
throughout Japan, and for that reason the government had ordered medical
supplies, including nerve agent antidotes, not normally stocked in
quantity by hospitals (anonymous comments in Obu, 1996). One of the
reasons for the raids was the suspected involvement of the Aum Shinrikyo
in a previous toxic gas incident in the city of Matsumoto almost a year
before the Tokyo attack (Morita et al., 1995). The release in that city
in 1994 of what was subsequently identified as sarin resulted in seven
deaths and the treatment of an additional 250 people. A group of
Matsumoto physicians, recognizing that data from humans exposed to sarin
were very rare, collected a great deal of information on these patients,
which they sent to Tokyo hospitals and the Ministry of Health and
Welfare as soon as they heard of the subway attack. Although the
information reportedly was helpful, it seems obvious that a more formal
mechanism by which the Matsumoto group could have more rapidly and
systematically alerted other cities and hospitals to such an unusual
event might have been even more valuable.
In this country, the
District of Columbia's Emergency Management Office and Public Health
Agency were provided an extensive, although generic, briefing on the
terrorism threat just before the start of the Gulf War. Similar
briefings have no doubt taken place on occasions such as the 1996
Atlanta Olympic Games, and personal relationships may provide good
communication between the law enforcement and medical communities in
some cities. However, few have the sort of structural links that the
MMSTs are attempting to build into their operations--a law enforcement
section, headed by a local law enforcement officer, one of whose major
duties is to establish relationships with the local FBI office and other
law enforcement agencies sufficient to ensure that the team has the
maximum prior warning of potential nuclear, chemical, or biological
incidents.
It is necessary to have
an accurate ongoing assessment and prioritization of the chemical and
biological agents that pose the greatest threat as well as
identification of the agents that pose the most credible threat (using
some of the 36 agents on the CDC list of restricted agents). In order
for the medical community to efficiently prepare and respond to chemical
and biological terrorism, it must be equipped with the latest and most
accurate information on current risks. This is essential to ensure
adequate preparatory measures, such as stocking and maintaining
appropriate and sufficient amounts of vaccines, antibiotics, and other
pharmaceutical agents and to ensure maximum effort in providing for the
safety of health care providers, paraprofessionals, and support
personnel. These events often involve the use of medications or vaccines
that are often not available in large enough supply locally and, even if
maintained in regional stockpiles, still require time to obtain or
produce adequate stores to effect meaningful treatment or prophylaxis.
Emergency medical
workers would benefit from preincident warnings by entertaining a
broader range of hypotheses when entering an illness or injury site
where the risks are unclear. These added considerations could be the
difference between the loss or incapacitation of the rescue team or the
secondary spread of potentially contaminated/infected patients to other
health care sites.
Identification of the
agents used in chemical and biological terrorism may involve
sophisticated tests that take several hours to days for results. Initial
signs and symptoms in victims of biological terrorist events may present
as common disease processes. Not thinking about the possibility of these
more lethal or infectious diseases runs the risk of secondary spread and
additional cases of epidemic proportions. Early warning of potential
threats will stimulate an earlier screen of potentially exposed
individuals for intoxication or infection and a more rapid public health
response. This is even more important if multiple infectious agents or a
combination of chemical and infectious agents are suspected. Traditional
medical teaching is to try to explain a clinical condition by a single
disease process. Containing the disease outbreak or the chemical
contamination is the most important public health responsibility of
consequence management of a biological or chemical terrorist event.
Timely and accurate pre-incident intelligence is essential to achieve
this goal.
Health officials are
often the first medical personnel to be contacted by the press whenever
an epidemic or other public health threat occurs. Early knowledge of the
threat of a chemical or biological event would allow public health
officials to develop plans for effective risk communication and ensure
appropriate coordination with law enforcement authorities. Accurate and
timely information from public health officials is essential to prevent
public panic. Benefits of effective communication include: reducing the
inappropriate use of scarce health care resources by low-risk
individuals and ensuring that individuals at highest risk present for
treatment.
Although further
research is needed into the best ways to improve communication, the many
advantages of providing the medical community information obtained by
agencies monitoring and gathering intelligence on terrorist activity and
threats is vital.
In summary, the medical
community has the diversity to respond to a wide array of biological and
chemical health emergencies, including those which are intentional.
Although the intelligence community has a legitimate need to protect its
sources and the law enforcement community its operations, current and
accurate information must be made available to the medical community in
the pre-incident phase as well as the response phase of an event. This
includes any information regarding credible threats to a community and
potential agents that might be used. Information on successful
interdictions, including agents and plans for their dissemination, would
even be valuable after the fact for planning and training. The bilateral
sharing of information, intelligence, and clinical data will ensure that
victims receive the most efficient care possible, based on fact and
experience rather than on assumptions and conjecture.
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