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expensive or time-consuming actions in preparation for such events are extremely difficult for local governments to justify. Moreover, much of what could contribute to averting or mitigating casualties from terrorist chemical or biological attacks is urgently needed anyway to avert or mitigate severe hazards to health from toxic substances and prevailing or emerging infectious diseases of natural origin. As a result, the committee first gives special attention to developing recommendations for actions that will be valuable even if no attack ever occurs. A second type of recommendation focuses on specific actions that would be valuable in some of the more plausible scenarios. A third type of suggestion involves more generic, long-term research and development, although, even here, much of what needs to be done to deal with possible terrorist incidents will be of benefit to the nation's health irrespective of actual attack.

Organization of the Report

This report analyzes preparedness at four levels of medical intervention—local emergency response personnel, initial treatment facilities, state departments of emergency services and public health, and a variety of federal agencies. The specific capabilities assessed are pre-incident intelligence (Chapter 2); detection and identification of chemical and biological agents in the environment and in clinical samples from victims (Chapters 4 and 6); personal protective equipment (Chapter 3); recognizing covert exposures of a population (Chapter 5); mass-casualty decontamination and triage procedures (Chapter 7); availability, safety, and efficacy of drugs, vaccines, and other therapeutics (Chapter 8); prevention and treatment of psychological effects (Chapter 9); and computer related tools for training and operations (Chapter 10). A list of specific R&D needs is provided at the end of each chapter. These R&D needs, numbering 61 in all, are summarized in eight overarching recommendations.

Pre-Incident Communication and Intelligence

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 and where and how to obtain