Playing for keeps: a bioterrorism war game teaches professionals from the insurance, health-care, pharmaceutical and government sectors what they each must do to be ready for an attack. (Life/Health: Terrorism).

An aerosole pneumonic plague bacteria is released simultaneously in two major U.S. cities in a coordinated terrorist attack. Although the initial symptoms resemble the flu, plague is almost always fatal if not treated early with powerful antibiotics. Worse, still, unlike anthrax or West Nile Virus, it is highly contagious. Can officials from public and private sectors work together to prevent the plague from spreading? Can they coordinate efforts to avoid a national disaster?

This was the scenario posed to 75 insurance, health-care-provider, pharmaceutical and government professionals in a bioterrorism war game conducted recently in Washington, D.C. During the exercise, which was sponsored by the Council for Excellence in Government and Booz Allen Hamilton, participants discovered just how quickly health-care systems, law enforcement, local governments and social services can be stressed to the breaking point. The war game highlighted the need for a new kind of public/private partnership in the pursuit of homeland security, and it clarified the insurance industry's role in the creation of such a partnership. The game also pointed to a need for businesses to pay increased strategic attention to security, because the things that went wrong in this bioterrorism scenario--and many things did go wrong--are all too easily extrapolated to other types of terrorism.

After two days of effort, participants concluded that the levels of preparation and response in place in the United States today are inadequate and must be improved. They also recognized that authorities and responsibilities they had assumed were in place, were not.

Traditionally, neither private industry nor many government agencies have played an active role in homeland security, which has been assumed to be almost exclusively the domain of the Department of Defense. But a potential bioterrorist attack blurs the lines of authority and would require government agencies--in particular, the Department of Health and Human Services--pharmaceutical companies and health-care businesses to play a new national security role. The nation can cope with such an attack, but only if it is ready with a response that is quick, coordinated across business and government sectors well prepared.

One difficult reality that the game uncovered is that government alone cannot protect the American people from the effects of bioterrorism. It is essential to mobilize business resources. Coordination and cooperation across businesses, many of which are competitors, must be implemented to address the scale of the problem.

Participants also learned that communicable bioterrorism is not like natural disasters or epidemics, because it spreads much more rapidly and it can be launched simultaneously in multiple locations. In addition, there is the challenge of managing the human response. Those who are not yet infected, known as the "worried well," quickly overload the health-care system, and widespread panic stresses law enforcement and other social services. And while the immediate responders are all local, the issues quickly become national as officials struggle with decisions such as where and how many drugs to distribute, how to educate the public and when to close borders or airports.

The War-Game Process

War gaming is a powerful process for thinking about the future that challenges conventional wisdom and allows participants to break with "known truths" and past assumptions. The goal of this war game was to mobilize government and health-care businesses to explore innovative ideas and practical solutions to improve the nation's preparedness to respond to bioterrorism. Health-care executives had discussed the possibility of a bioterrorist attack with government agencies, even before Sept. 11. The war game, however, was unprecedented, in that it brought together chief executive officers and other senior executives from insurance, pharmaceutical and biotechnology companies; senior policymakers in the Department of Health and Human Services, the Federal Emergency Management Agency, the Department of Defense, the Department of Veterans Affairs and state and local government; and representatives of leading hospitals, health maintenance organizations, physicians and health industry associations.

Participants were organized into teams representing key business and government sectors, with a mix of government and business people assigned to each team and a trained facilitator to help keep the group on point. The mixed groups gave individuals a rapid education in how other organizations think and act, as well as providing a first check on ideas and suggestions. After the game was over, industry-specific groups met to clarify their observations, develop a list of internal industry priorities and lay Out key requests to other entities to improve the national response to potential bioterrorism.

The teams discovered that massive, immediate action was required, but they also found that the lack of a common language between government and industry and the lack of a single point of contact between these groups stymied the rapid movement needed. Clearly, the extreme contagiousness of plague and the lack of a vaccine called for both quarantine and the rapid and extensive prophylactic treatment of uninfected individuals with antibiotics. But quarantining massive portions of the population raised civil-liberties and law-enforcement issues that had no easy answers, while widespread prophylaxis would strain drug supplies, leaving the country vulnerable to new attacks or naturally occurring epidemics. Simple logistics issues, such as how to deliver drugs to millions of people, raised seemingly insurmountable obstacles.

It became clear that the difference between a controlled outbreak and a massive epidemic ultimately hinged on three key factors. The first was leadership. Confusion about who was in charge in the first few days of the attack had major consequences during the following weeks. Second was easy and timely dissemination of knowledge. Participants agreed that thousands of lives depended on ready information about pharmaceutical and medical equipment stockpiles throughout the nation. Finally, there has to be some method of coordination. Individual companies and local governments responded well, but what ultimately mattered was immediate and quick coordination between companies, across agencies and among states.

Participants agreed that new ideas were needed, but many groups at first fell back on established practices and processes that slowed everyone's response. Government and business teams initially followed a conservative, measured approach, as they struggled to define their roles, understand the scope of the disaster and recognize where to go for information, direction and resources. No mechanisms were in place to enable an accurate assessment of the situation and quick coordination across agencies and businesses to mobilize the resources available. Lacking prearranged mechanisms hindered the groups abilities to cope with these issues.

Building and sharing knowledge means assessing potential actions and their impact. To do that, the nation needs to develop epidemiological models that look at the effect of actions, such as quarantine and prophylaxis, on various potential contagious biohazards. It is critical to measure public-health readiness and to establish a national inventory of medical supplies and other essential materials. Above all, the information must be shared across government and industry.

Insurers' Role

Insurers that participated in the war game observed several critical industry-specific issues. They found that the insurers' primary role in such a crisis would be to facilitate consistent communication and ensure that the delivery system is viable. In fact, they noted that insurers could play an important role by working with the government now to modify their existing Internet-communication capabilities into a national emergency communications infrastructure. By starting now to work with government and industry to develop such a communications infrastructure, the insurance industry could play a central role in assuring homeland security far into the future.

The main threat to the insurance industry from a successful bioterrorist attack, participants concluded, would be breakdown of operations over the long term. Under the war-game scenario, economic issues did not prevent service from being delivered to members, but a long-term crisis, lasting 60 days or more, might produce serious industry challenges. In the event of a real bioterrorist attack, insurers, health-care providers and government agencies must be prepared to care for hundreds of thousands to millions of people who are ill or dying. As one insurer said, "We need to make sure that we'll be able to keep paying bills to keep the system afloat." This applies to any type of terrorist attack, of course, as a primary goal of terrorism is to cause as much damage as possible to both infrastructures and people.

Any major terrorist scenario will result in tremendous losses. Insurers need to start talking now about how to deal with such losses and stay afloat. They need to create task forces to determine internal industry priorities as well as to find ways for state, local and federal government to work with insurers. The team determined that it is critical to assess the stress thresholds now and establish mechanisms that might be activated during a crisis to assure providers' liquidity.

The insurance team members suggested several internal and external priorities:

* establish a system to provide uniform and coordinated communications with members, providers, employers and consultant/brokers during a crisis;

* review existing mechanisms to assure liquidity for providers to determine whether they are adequate for such a crisis;

* reassurance of coverage under existing benefits plans is critical, so insurers should consider leveraging a study under way by the American Academy of Actuaries on bioterrorism financial exposure to understand economic implications for the industry;

* create stronger focal points within the local, state and federal government for information and decision making;

* to ensure stability and the ability to cover commitments in existing plans, establish a government-based mechanism for liquidity;

* strengthen and update the Federal Response Plan;

* facilitate support for the Office of Homeland Security;

* pursue appropriate emergency waivers and relief regarding issues such as privacy, fee schedules, prompt pay, health and safety rules; and

* support and help to facilitate enhanced federal investment in the industry's--and, perhaps, the nation's--information-technology and communications infrastructures.

Getting Prepared

The bioterrorism war game pointed to gaps in national preparedness that go beyond the threat of bioterrorism. Security traditionally has been viewed as a series of independent measures designed to protect people or infrastructures, such as real-estate and manufacturing facilities, or information-technology, transportation and power networks. Today, security also includes assuring the continuity of the agencies and enterprises that keep the country functioning. That means developing and supporting policies for government/business partnerships, when the businesses are critical to the continuity. It also means incorporating protocols for inter- and intra-industry communications into business strategies and planning.

Further, businesses need to start working now to understand the operational and economic risks that terrorism can impose on an organization and its extended enterprises. And, it is critical to develop coordinated and integrated risk-mitigation strategies that create greater business resilience in the face of potential disaster.

Clearly, government and business organizations need new capabilities to execute their new roles. Individual companies and agencies could create response plans linked to the overall national plan. Health and Human Services' ability to perform its new national security mission could be enhanced--and the insurance industry could play a key role--by establishing a crisis-action communications system that would link key government and industry players. The government should develop and disseminate a public-health threat and response program, in effect, reinventing the old Civil Defense System. Finally, the public-health infrastructure must be strengthened at all levels.

Public/private partnerships can improve the nation's terrorism preparedness and ability to respond through several key actions:

* identifying and involving relevant participants;

* establishing agreed-upon roles and responsibilities;

* sharing information on stockpiles and surge capacities;

* predefining economic, legal and liability parameters and limits; and

* coordinating public awareness and education efforts.

Since Sept. 11, security has become a strategic imperative for businesses and organizations of all kinds. Bioterrorism presents unique challenges in terms of early detection, containment, escalation, response and recovery. But the basic lessons learned from the war game apply to all types of terrorist threats, Participants in the game walked away with the knowledge that they all must continue the dialogue and work together to strengthen the security of the United States.

Gary Ahiquist is a senior vice president in the Chicago office of Booz Allen Hamilton Gil Irwin and David Knott are vice p residents in Booz Allen Hamilton's New York office.