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Public Health and Homeland Security

Are We Ready?

by Joseph M. DiMino, D.O.

Not too long ago, a terrorist attack with nuclear, biological or chemical agents was considered a remote possibility. Today, that possibility is considered far more real. While no one can say whether or where terrorists will strike on American soil, we must all be better prepared to deal with it or, better yet, prevent it.

While the American medical community is better prepared today to address potential terrorist attacks than we were two years ago, we need to do more. Creating standards for coordinating the massive medical services that would be needed in case of nuclear, biological, or chemical attack would be a major first step in giving direction to medical personnel and public health agencies.

Problems Faced

Public health and medical professionals not only plan for, but are critical to managing the aftermath of, major disasters. On a daily basis they work to ensure and maintain the safety of the food supply and water sources. They are, obviously, first responders in disasters. They are critical in situations such as the one currently plaguing parts of New York City, where many residents are suffering from respiratory problems after the destruction of the World Trade Center. And, whenever there are a large number of casualties, they work to assure prompt and safe handling of human remains.

As a doctor, I like to think I can take care of my patients and meet their medical needs. However, I was recently looking over a list of biological threats provided by the Centers for Disease Control and Prevention (CDC) and found I would be hard-pressed to diagnose many, let alone treat them. Biological threats such as anthrax, botulism, cholera, plague and tularemia can be difficult to diagnose if one is not familiar with their signs and symptoms, but what’s worse is that all of these organisms can be weaponized.

From this basic problem, the complications are many. Most public health and medical professionals do not have the capacity to diagnose some of these threats. Sending test results and samples to the CDC in Atlanta, Ga., may not always be an option if transportation is disrupted. While there are special resources, such as trucks loaded with equipment and supplies located around the country, even that support could be hampered by the many thousands of people who may be fleeing a major attack.

Local public health departments rely on the diagnoses and reporting of physicians to prevent and/or control the spread of potential diseases. Educating physicians on the many possible health threats posed by terrorism and their signs and symptoms is crucial to maintaining an effective public health system in today’s environment.

Establishing Standards

The absence of a functioning methodology to determine national requirements for emergency preparedness constitutes a public policy crisis. Establishing standards that define levels of preparedness is a critical first step toward determining the nature and extent of additional requirements and the human and financial resources needed to fulfill them.

Some of the many areas that require investigation or standardization include:

• Defining the requirements of, standards for, and compatibility of personal protective gear, creating strategies for securing ventilation systems or making air-handling, and decontamination procedures safer.
• Determining the minimum number of people that cities of a certain size should be able to decontaminate, inoculate, quarantine and treat after a chemical, nuclear, biological or radiological attack. Local jurisdictions would then be allowed flexibility in reaching those levels over a fixed period of time. Standards would make it possible to use funding efficiently to meet identified needs and measure preparedness levels on a national scale.
• Applied public health research is needed that examines the effectiveness of various interventions, from evaluation strategies for syndromic surveillance to modeling the use of quarantine in controlling communicable disease. Research into the behavioral issues and psychosocial consequences of a catastrophic event of large proportions is currently very limited, but should be made a high priority.

Clearly defined standards and guidelines for local first-responders need to be defined at all levels, including but not limited to:

• Emergency call centers;
• Urban search and rescue teams;
• Communications for emergency responders (800 megahertz systems);
• Enhancing public health preparedness;
• Strengthening state public health labs;
• Strengthening the Emergency Operations Centers for Public Safety;
• Standardizing protective gear and remediation equipment;
• Enhancing emergency agricultural and veterinary capabilities; and
• Developing surge capacity (overflow) hospitals.

The American response to the public health concerns posed by terrorist threats has to be based on the fundamental pillars of:

• Prevention – Reduce the likelihood that dangerous pathogens will be acquired by those who will do harm. Establish standards that will help prevent the development and spread of biologic agents as weapons.
• Detection – Rapid detection and response will depend on a well-trained cadre of public health professionals to enhance disease surveillance and outbreak investigation, educate and alert health care providers, upgrade labs to support diagnoses, and improve communication
• Containment – Enhance medical response by training health professionals to diagnose, report and treat disease. Develop strategies to improve the ability of the health care system to increase emergency capacity rapidly.
• Treatment – Improve detectors and diagnostics; improve vaccines and new medications. A comprehensive research agenda will serve as the foundation of future preparedness.

Some of these activities are already under way, but need to be strengthened and extended. Other programs and policies still need to be developed and implemented. These activities are all essential for homeland security. Activities of the new Committee E54 on Homeland Security will go a long way toward moving us forward in these areas.

It is my firm belief that the best defense against any outbreak is a robust public health system. While it will never be possible to prepare fully for every potential, imaginable threat, it is possible for our nation to shore up its general biodefense/public health preparedness to a level that can minimize, if not prevent, the potentially catastrophic consequences of the many and varied microbial threats we may have to face. //


“Public Health and Bioterrorism: Ready or Not?” Margaret A. Hamburg, M.D., Sellers-McCroan Lecture, April 18, 2003
“Emergency Responders: Drastically Underfunded, Dangerously Unprepared,” Report of an Independent Task Force sponsored by the Council on Foreign Relations, 2003
“Trust for America’s Health,” Excerpts, June 2003

Copyright 2004, ASTM International

Dr. Joseph M. DiMino, a member of ASTM Committee E54, is currently director of health and medical director of Montgomery County (Pa.) Health Department. He was the corporate medical director for Correctional Physicians Services, providing medical care in 45 prisons and jails in the United States from 1995 to 2001 and was also the corporate medical director for Correctional Health Education Services in New York, providing health education to the pharmaceutical industry and corrections.