scale biological attack. The NDMS might also serve a useful role in a large-scale chemical attack, though the rapid onset of effects from these agents puts a premium on actions within the first few hours following exposure. For that reason, the Metropolitan Medical Strike Teams being organized and equipped by the Public Health Service may be the most useful federal help in managing the medical consequences of a chemical attack. Similar help from deployable military teams will be optimal only if intelligence allows for predeployment or the attack occurs near the team's home base.
Rapid detection and identification of agents, either in the environment or in victims' bodies, is currently a piecemeal operation that, in the absence of other information, is as much art as science. In both chemical and biological agent incidents, initial treatment is likely to remain symptom-based for some time. In part this is due to diagnosis problems (knowing what detector to deploy in the environment or what medical test to request), limited detection capability at low but potentially harmful concentrations, and lack of specific treatments for some agents.
Finally, it is apparent that the IND status of some very specific treatments, present and future, will hamper their use in mass-casualty situations. Furthermore, in the case of many treatments, collection of the data on efficacy necessary for full FDA approval will not be possible for ethical reasons or economically attractive to a potential manufacturer because of limited market potential.
As expected, the committee's review of current capabilities pointed to a number of areas in which innovative R&D is clearly needed. The committee realizes that there is considerable R&D underway in both the public and private sectors that may meet some of these needs, and the following list of needs should not be construed as commentary on the quality of that research or the utility of its intended products. Rather, it should be seen as an empirically grounded starting place for the committee's subsequent assessment of potentially useful technology and R&D. The order within the list is not by priority, but follows the roughly chronological sections of this report.
There needs to be a system in every state and major metropolitan area to ensure that medical facilities, including the state epidemiology office, receive information on actual, suspected, and potential terrorist activity. Research may be necessary to determine what should be communicated, to whom it should be communicated, and even whether the system should vary by state and city, but it must include links to the law enforcement community.
The civilian medical community must find ways to adapt the many new and emerging detection technologies to the spectrum of chemical and biological warfare agents. First responders, emergency medical personnel, and public safety officials all need improved instrumentation for detecting and identifying chemical and biological agents in both the environment and in clinical samples from patients. Areas for improvement are simplicity, speed, cost, sensitivity, and specificity, but the key to widespread purchase and use lies with identifying a wide spectrum of toxic substances, including but not limited to military agents.