counterterrorism application as well; it could provide knowledge about the use of filters for reducing the current epidemic of asthma in U.S. cities, particularly among children.

Recommendation 3.10: Improve environmental and personal protective equipment. Agencies such as EPA, NIOSH, CDC, DOD, and DOE should perform and support research on new technologies that increase the protection factors of such equipment, and ensure uniform testing oversight to certify efficacy.

Approaches to Preparing the Health Care System for Response and Recovery: The Need for Surge Capacity

The U.S. health care system has focused on efficiency in the past decade. Redundancies have been eliminated through hospital closures, decreases in the numbers of physicians in many specialty practices, and consolidation of traditional public health activities within health care delivery organizations. Furthermore, the budgets of many agencies that could deal with significant epidemics have been curtailed because no such incidents have occurred in the United States in recent years.

Efficient systems use resources to deal with predictable health problems, but almost by definition they lack the resilience (in the form of excess capacity) to deal with unusual episodes of disease, particularly large-scale outbreaks or those that may result from an act of bioterrorism. The challenge is to devise a system that would create capacity on demand to cope with sporadic and potentially very large demands on the health care infrastructure without destroying the efficient use of resources that characterizes the current situation.

It is probable that the given medical capacity in any community can respond immediately to a terrorist attack, providing the following two conditions are met:

  • The attack does not destroy the hospitals and emergency departments in that community. A chemical attack might destroy multiple hospital emergency departments or contaminate them so completely that they could no longer be used; a biological attack could quickly spread to medical personnel, thereby effectively destroying their capacity to respond.

  • The attack is short-lived and can be handled within a short time frame (less than 24 hours). For example, during the attack with sarin on the Tokyo subway in 1995, there were few fatalities and a small number of serious cases. Yet the total number of patients (of all types) created an overwhelming workload for the emergency departments of Tokyo hospitals, though only for a short period of time. Had the attacks continued on a daily basis (as in the case of a biological agent that would spread over time, such as the plague bacterium or smallpox virus), there would have been a need to divert some capacity to care for the usual

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