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American military
forces have been struggling with the issue of chemical and biological
warfare for decades--a 1917 National Research Council Committee laid the
groundwork for the Army Chemical Warfare Service--but it was the attack
of the Tokyo subway with the nerve gas sarin in March 1995 that suddenly
put the spotlight on the danger to civilians from chemical and
biological attacks. The Federal Emergency Management Agency (FEMA) and
the Department of Health and Human Services' Office of Emergency
Preparedness (OEP), which is responsible for medical services, have an
admirable record of helping state and local governments cope with
floods, storms, and other disasters, including terrorism, but,
fortunately, no direct experience with the consequences of chemical or
biological terrorism. In May 1997, the Institute of Medicine was asked
to help OEP prepare for the possibility of chemical or biological
terrorism, and, with help from the National Research Council's Board on
Environmental Studies and Toxicology, formed this committee to provide
recommendations for priority research and development (R&D).
In the ensuing year and
a half, the committee met four times, heard presentations on existing
technology and ongoing R&D, attempted to absorb a virtual mountain
of information, and formulated their recommendations. In the process, a
number of things became clear to me. I suspect the rest of the committee
would agree, but I will exercise the chair's prerogative at this point,
and share the view from my perspective.
First, there is no way
to prepare in an optimal fashion for a terror incident. There is too low
an incidence to justify the enormous financial outlay it would take to
optimally prepare every community for every possible incident.
Furthermore, there are not enough incidents for any community to acquire
enough experience to make a significant impact on response to the next
episode.
Second, although there
is a sophisticated technology, described within the body of the report,
for in-line detection of an opposing forces chemical agent, it will not
be possible to select the sites to protect in a civilian setting with
such technology, even if the expense could be borne. At best, it might
be possible to selectively protect a public arena where the President
was to give an address.
Third, there is no
guarantee that the terrorist will announce the attack. Without such an
announcement, there will be no recognition that a biological attack is
occurring until enough cases, including a number of fatalities, are
observed and reported to allow recognition of an epidemic of an unusual
disease. Since exposed victims will almost certainly not seek medical
care in the same facility, the problem becomes compounded even more
greatly.*
Fourth, virtually all
the militarily important biologic agents present with early clinical
symptoms that resemble viral flu syndromes. Since these are the most
common form of acute illness, and since they are usually mild and
nonserious, it is probable that the early victims of the attack will be
unrecognized, and sent home from a physician's office or Emergency
Department as a mild viral syndrome. Therefore, in any response
planning, it has to be acknowledged that it will be impossible to
prevent ALL mortality, no matter how good a technology can be developed,
and no matter how much money we are willing to spend to enhance our
response.
Fifth, there is a huge
gap between detection technology and therapy. There are many biologic
agents, and certainly many chemical agents for which there are no known
treatments. We should not expect that terrorists will choose the agents
for which we are prepared, and for which we have effective treatment,
even if they are the easiest to create and disperse, such as anthrax or
sarin.
Sixth, the approach
that the committee found most useful to consider in making its
recommendations was considering how to superimpose a response to a
terror attack upon the systems that are already in place to deal with
nonterror events. For example, an earthquake, or a chemical spill, or a
flu epidemic will all stress and often overload existing medical
facilities. There must be systems in place to deal with these problems,
not only on a local basis, but when help must be brought in from outside
the afflicted area. These are the systems that will be most appropriate
to build on for an effective response to an incident of chemical or
biological terrorism.
Seventh, communication
between the medical community and agencies that gather and analyze
intelligence about potential terrorists and attacks is critical. As
alluded to above, it will not only shorten the identification issues and
lead to more effective responses, but will clearly lower mortality.
There are a number of
areas that will not be covered in this report. For example, it was not
possible for the committee to discuss every conceivable biological and
chemical weapon that might be used in an attack. It is probable that to
prepare only for the list of known weapons and most likely agents will
take a commitment and a financial expenditure that will exceed the
resources of virtually all communities.
The committee's charge
did not include making recommendations on organization and training of
individuals and groups faced with managing the consequences of a
chemical or biological incident, nor on how to equip such persons or
groups, nor on what therapeutic options they should choose.
Nevertheless, as noted in our interim report, the committee believes
that it would be irresponsible to focus solely on R&D while ignoring
potentially simpler, faster, or less expensive mechanisms, such as
organization, staff, training, and procurement. Examples from our
interim report include:
- Survey major metropolitan hospitals on supplies of antidotes,
drugs, ventilators, personal protective equipment, decontamination
capacity, mass-casualty planning and training, isolation rooms for
infectious disease, and familiarity of staff with the effects and
treatment of chemical and biological weapons.
- Encourage the CDC to share with the states its database on the
location and owners of dangerous biological materials. State health
departments in turn should be encouraged, perhaps by education or
training on the effects of the agents and medical responses required, to
add infections by these materials to their lists of reportable diseases.
- Convene discussions with FDA on the use of investigational
products in mass-casualty situations and on acceptable proof of efficacy
for products where clinical trials are not ethical or are otherwise
impossible.
- Develop incentives for hospitals to be ambulance-receiving
hospitals, to stockpile nerve-agent antidotes and selected antitoxins
and put them in the hands of first responders (this may require changes
to existing laws or regulations in some states), to purchase appropriate
personal protective equipment and expandable decontamination facilities
and train emergency department personnel in their use.
- Supplement existing state and federal training initiatives with
a program to incorporate existing information on possible chemical or
biological terror agents and their treatment into the manuals, SOPs, and
reference libraries of first responders, emergency departments, and
poison control centers. Professional societies and journal publishers
should be recruited to help in this effort.
- Intensify Public Health Service efforts to organize and equip
Metropolitan Medical Strike Teams in high-risk cities throughout the
country. Although MMSTs are designed to cope with terrorism, because
they use local personnel and resources, they also increase the
community's general ability to cope with industrial accidents and other
mass-casualty events.
Even though the tasks
of being prepared and responding adequately appear at times to contain
insurmountable obstacles, the committee does believe that by utilizing
the resources that are present, along with improvements in
communications, monitoring capabilities, detection, and therapeutics, it
will be possible to minimize the damage that a terror attack will cause.
It is not our intent to leave the readers of this report with feelings
of hopelessness. Even if preparation for certain attacks only forces the
attackers to choose a weapon that we have not prepared for, we will have
developed a system with which we can improvise. The goal, as always in
medicine, is to reduce morbidity and mortality and minimize suffering.
In closing I would like
to offer my sincere thanks to the staff of the Institute of Medicine,
who made our meetings as comfortable and efficient as possible and
pulled our sometimes splintered efforts into a coherent whole, and to
the members of the committee, busy professionals who volunteered
precious time and energy in a highly collegial manner. It was a
privilege to work with this outstanding group.
*For example, in
Wyoming this year (Summer 1998), there has been an epidemic of E.
coli diarrhea from a contaminated spring that fed the water supply
of the small town of Alpine. There were well over a hundred cases that
involved 12 states since the tourists who acquired the disease were from
many different locations. It took at least two months to find the source
of the contamination, and the only reason that the epidemic was
recognized as early as it was, is that there were only a small
number of medical facilities available to the victims.
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