We are all in this together: Terrorism and the physician executive. (Bioterrorism).

WHEN I ARRIVED AT the Pennsylvania Amtrak Station at 8:55 AM on September 11 to walk to my mid-town Manhattan office, my life was forever changed by what I saw and heard on that crisp Autumn day.

Nearly all levels of American society were caught off guard and surprised by the events of September 11 and the subsequent letters containing anthrax spores. Before it all began, terrorism experts were divided into two camps:

1. One side emphasized the conditions and complaints that resulted in suicide bombers. Or, as Brian Michael Jenkins put it, "Terrorists want a lot of people watching and a lot of people listening, and not a lot of people dead." (1)

2. The other group concentrated on the terrorists' destructive nature, a viewpoint conveyed by James Woolsey who says, "Terrorists don't want a seat at the table; they want to destroy the table and everyone sitting at it." (1)

Westerners did not fully comprehend the change in the mind-set of the religious terrorists that Bruce Hoffman describes.

"For the religious terrorist, violence is first and foremost a sacramental act or divine duty executed in direct response to some theological demand or imperative. Terrorism thus assumes a transcendental dimension, and its perpetrators are consequently unconstrained by the political, moral, or practical constraints that may affect other terrorists." (2)

And yet, we should have been more aware of the potential danger of terrorism both abroad and at home.

It's estimated that between 10 and 17 nations control biological warfare agents.

The largest national effort in the former Soviet Union employed 65,000 scientists in 70 facilities and weaponized at least 50 different diseases. This program used genetic engineering to produce organisms that could foil conventional treatment and vaccines.

The U.S. government estimates that 10,500 former scientists of this massive program are critical proliferation risks, and there are anecdotal reports of these experts working for both national and terrorist groups in the Middle East. (3)

Previous attacks

Several years ago, the Japanese Aum Shinrikyo religious group raised between $300 million and $1 billion, and they invested at least $30 million in a sophisticated effort to develop both chemical and biological warfare agents.

Although their attempts to spread biological agents were largely unsuccessful, they did kill seven in Matsumoto on June 27, 1994, and 12 in the Tokyo subway attack on March 20, 1995, with sarin. (3)

This group punctured the conventional wisdom that only nation-states had the resources to mount a highly sophisticated chemical and biological weapons program.

Homegrown terrorism included the two Chicago teenagers, Charles Schwander and Stephen K. Pera, who planned to kill all humans except those vaccinated members of their ecoterrorism group.

They were able to obtain seed cultures of typhoid fever and N. meningitis and made elaborate but ultimately unsuccessful plans to poison the water and air supply of several Midwestern cities.

The Bhagwan Shri Rajneesh and his followers in Oregon attempted to affect voter turn-out in Wasco County where they were attempting to take over the local government of the small town of Antelope. Their bioterrorism campaign using Salmonella typhimurium caused illness in 751 people but no deaths.

Agents of injury and death

Terrorist agents are usually classified into two broad categories: chemical weapons and biological agents.

Chemical weapons can be divided into four kinds:

1. Skin blister agents such as mustard gas

2. Oxygen transport blockers that affect the red blood cells such as hydrogen cyanide and cyanogen chloride

3. Choking agents like phosgene and chlorine

4. Nerve agents such as tabun, sarin, soman, and VX.

Biological agents are usually described as:

* Category A - plague, tularemia, smallpox, viral hemorrhagic fevers, botulism, anthrax

* Category B - Brucellosis, Q fever, ricin toxin from castor beans, Glanders, epsilon toxin of Clostridium perfringens, and enterotoxin B of Staphylococcus)

* Category C - Nipah virus, hantavirus, tickborne hemorrhagic fever, tickborne encephalitis viruses, yellow fever, and multidrug-resistant tuberculosis

While emergency authorities recognize attacks with chemical agents such as sarin on the Tokyo subways immediately, bioterrorism attacks can be difficult to identify.

Some of the letters with anthrax represented an overt bioterrorism attack where the perpetrators announced their intentions and the first responders are often fire, police and emergency medical departments.

In covert bioterrorism attacks, recognition, response and treatment can all be delayed because the first responders are physicians and other health care professionals who have to stumble onto an unannounced attack.

The food poisoning attack in Oregon is a good example of a covert bioterrorism event. It went unrecognized for months until those involved confessed to authorities.

Epidemiologic clues to a bioterrorism attack must become more widely appreciated by health care professionals. Bioterrorism should be considered when diseases are encountered in geographic locations that rarely experience the above diseases and when cases cluster at unusual times of the year.

Disease outbreaks that affect both humans and animals should be closely investigated and clinical cases that are more severe than usual for that pathogen may indicate genetic alteration of the organism.

Atypical antibiotic resistance patterns for a given pathogen may be a clue to a bioterrorism attack and clusters of cases from one building raise obvious suspicions. (3)

Response readiness

The Henry L. Stimson Center in Washington, D.C., conducted extensive research into the readiness of American cities to respond to both chemical and biological terrorist attacks.

Although the study found the federal emergency training enacted following the Tokyo subway attacks helped, there is still much room for improvement.

Using a scale from 1 to 10 with 10 being totally prepared, the report found a readiness rating of 3.1 before chemical terrorism training and a readiness rating of 5.9 after training.

For bioterrorism, the ratings came in at 1.7 before training and 4,1 after training. (3)

Numerous studies, including the Dark Winter computer simulation exercise in June 2000, which modeled a hypothetical smallpox attack in shopping centers in Oklahoma, Georgia, and Pennsylvania, identified several areas that need improvement:

Lack of basic understanding and medical expertise

Although every year in the U.S. there are 60,500 accidents with hazardous materials resulting in 2,550 casualties, many physicians are not adequately trained to deal with such emergencies.

There are only 250 medical toxicologists in the United States and most infectious disease experts have never treated a case of pulmonary anthrax or smallpox. The spread of the anthrax spores from the letter sent to Sen. Tom Daschle, D-S.D., taught us that our basic understanding of the spread of altered spores was initially flawed.

As a participant in the Dark Winter exercise put it: "There is something out there that can cause havoc in my state that I know nothing about, and for that matter the federal government doesn't know a whole lot either." (4)

Early responses not always optimal

Covert bioterrorism attacks present significant problems for the health care system because we have not maintained a strong disease surveillance system. Non-specific first signs and symptoms, time lags in reporting cases and lack of public health funding all contribute to weaknesses in detecting covert bioterrorism attacks.

New York City's best practice of monitoring EMS codes and over-the counter medicine sales to identify suspicious clusters of diseases should be emulated in other parts of the country.

Health Hero Network, a Silicon Valley biotech startup company, is testing BASIICS (Biothreat Active Surveillance Integrated Information and Communication System) in the Stanford University emergency room. The simple desktop unit allows triage nurses to monitor symptoms and feed the data to local and state health departments. (5)

In chemical attacks, the most glaring weakness is decontamination. Although all the protocols specify that patients should undergo this process before being taken to the hospital, 80 percent arrive at the hospital in need of decontamination.

Most hospitals do not have adequate plans to decontaminate large numbers of victims. George Washington University Hospital in Washington, D.C., and Parkland Hospital in Dallas are exceptions with well-developed plans.

Conflicts between different levels of government

Local officials single out the National's Guard's Weapons of Mass Destruction Civil Support Teams as the most disruptive attempt to help local governments.

One city manager in the Stimson study said he planned to station police at the city limits, guns pointed outward, to keep all the helpers from overrunning the city.

In the Tokyo subway attack, 85 percent of the 5,510 patients who went to the hospital were suffering from anxiety, not sarin gas exposure.

In a 1993 Richmond, Calif., chemical accident that harmed 22 people, 22,000 patients presented to area hospitals in the next 10 days thinking they had been exposed.

How to deal with the walking worried well presents a major planning and emergency challenge.

Conflicts between goals of law enforcement and medical providers

Good communication between law enforcement and health officials is needed to support two worthy goals that can come into conflict with each other:

1. Preserving a chain of custody of medical specimens that become part of a criminal investigation

2. Studying the specimens for clues about how best to treat patients

"People worry about anthrax and smallpox, but there are many other agents and threats out there," warns Dr. Ken Alibek, former deputy chief of the Soviet biological weapons program who is now an American citizen aiding the defense of America against terrorism. "What's important for people to understand is that anthrax is not the end of the story; it's just the beginning of it." (6)

Physician executives can play a leadership role during these difficult times. By ensuring that their organizations are ready for such attacks, they can help us face our biggest risk.

"The current crop of terrorists...has no chance of conquering us or (realistically) killing a large fraction of our population. They cannot destroy us; our biggest risk is our own panic.

"What we face is terrorism in the most elementary sense: actions whose hoped for impact is paralysis of the target rather than direct damage from the action itself." (7)

Kent Bottles, MD, is managing member of Proteomed Capital, LP, 645 Madison Avenue, 12th Floor, New York, NY 10022-1010.

References:

(1.) Lemann, Nicholas. "Letter from Washington: What Terrorists Want." The New Yorker. October 29, 2001, 36-41.

(2.) Hoffman, Bruce. Inside Terrorism. Columbia University Press, New York 1999.

(3.) www.stimson.org/cwc/ataxia.htm.

(4.) "Avoiding a Dark Winter." The Economist. October 27, 2001, PP. '29-30.

(5.) Feder, Barbara. The San Jose Mercury News. November 1, 2001.

(6.) The New York Times. October 28, 2001, B3.

(7.) Diamond, Jared. The New York Times. October 21, 2001, Op-ed page.

RELATED ARTICLE: IN THIS ARTICLE...

The threat of bioterrorism striking America is no longer a threat. It's real. Take a look at how the anthrax-laced letters and future acts of terrorism impact physician executives. Also consider some ways to prepare your physicians for a bioterrorism emergency.

Prepare your organization for bioterror:

* Educate yourself and your employees about the biological and chemical agents.

* Participate in planning at the local level so that patients can be shifted during crisis.

* Make sure protocols are in place and understood by all on day and night shifts.

* Make contingency plans to deal with the worried well.

* Make plans to decontaminate patients of a chemical attack.

* Implement APIC/CDC Bioterrorism Readiness Plan: A Template for Health Facilities

* Assess pharmaceutical, antibiotic and poison antidote supplies.

* Establish internal and external communication so that ER and ID physicians and staff report unusual findings to health department monitors.

Web Resources on Terrorism

Best government medical site: www.bt.cdc.gov/

Best general medical portal for bioterrorism: www.slu.edu/colleges/sph/bioterrorism/

Best public policy portal: www.stimson.org/cwc/ataxia.htm

Best source of hospital readiness plan: www.apic.org/bioterror/

Best city health department site: www.ci.nyc.ny.us/html/doh/