Antibioterrorism efforts may bolster public health system - Homeland Security

In 2001, anthrax-laced letters killed five people. In 2003, the SARS epidemic revealed that Mother Nature can be a nasty bioterrorist herself. Future biological attacks are unlikely to announce themselves with letters saying, "This is anthrax--take Cipro." Instead, they may erupt a lot like severe acute respiratory syndrome, with patients quickly overwhelming an uncoordinated and deteriorating public health care system, according to physician Margaret Hamburg, vice president for biological programs at the Nuclear Threat Initiative (NTI), which aims to strengthen global security by preventing the spread of nuclear, biological, and chemical weapons.

"The best defense against any outbreak is robust public health--both science and practice," she says. "While it will never be possible to fully prepare for every potential, imaginable threat, it is possible for our nation to shore up its general biodefense and public health preparedness to a level which can minimize, if not prevent, the potentially catastrophic consequences of the many and varied microbial threats we may have to face."

Hamburg has served as assistant secretary for planning and evaluation at the Department of Health and Human Services. Working as commissioner of health for New York City from 1991 to 1997, she created the nation's first public health bioterrorism preparedness program. She maintains there are critical issues that remain to be addressed as America and the world prepare to deal with a threat once thought to be "the stuff of science fiction or Tom Clancy adventure novels." Today's "A-list" of threats includes anthrax, smallpox, plague, tularemia, viral hemorrhagic fevers, and botulism.

"We need to act on the understanding that public health is an important pillar in our national security framework, and public health professionals must be seen as full partners on international and national security issues." She advocates putting a public health expert on the president's National Security Council and having this new position rank among the leadership of the Department of Homeland Security.

Hamburg stresses that it is critical to remember that the front line of response--even in a national crisis--is always local. She recommends strengthening state and local public health departments, which "represent the backbone of our ability to respond effectively to a major outbreak of disease, including a bioterrorist attack. Yet, we have never adequately supported or equipped these public health agencies to do their job." She indicates that many hesitate to call the array of health structures at the state, county, and local level a public health "system" because years of relative neglect have left them undercapitalized, fragmented, and uncoordinated.

Strengthening disease safeguards, improving medical consequence management, and supporting fundamental and applied research will be essential in responding to a biological weapons attack. "But these investments will also enhance our efforts to protect the health and safety of the public from naturally occurring disease," Hamburg contends. "We have a chance to defend the nation against its adversaries and to improve global public health with the same steps."

Better disease surveillance will require training health care providers, improving laboratory tests, and modernizing computer connectivity for quick collection, analysis, and sharing of information.

Developing emergency plans for treating a surge of patients will prove challenging since the nation's hospitals are operating near capacity now. Moreover, private health care providers may be limited in what they can do alone. "We need to undertake a systemic examination of local capabilities and how they can be rapidly augmented by state and Federal assets," Hamburg insists.

Given the low probability of an attack at any one place, it wouldn't make sense to stockpile drugs at the local level. However, Hamburg believes America should continue to reinforce its national pharmaceutical supply, which consists of strategically located drugs that can be delivered to any place in the nation within 12 hours. Responsibility for this has been transferred from the Federal Centers for Disease Control to the Department of Homeland Security. More work needs to be done among national, state, and local partners to develop contingency plans for distribution, Hamburg cautions.

In addition, legal concerns need addressing. Which authority can declare an emergency? In what situations can people be quarantined or detained? Can the government compel production of certain medicines and vaccines? Unresolved issues of liability and indemnification have been especially troubling in vaccine development and delivery for both routine and biodefense needs.

"This will require greater partnership and trust between the intelligence community, law enforcement, and public health and biomedical science--not necessarily an easy or comfortable marriage. These disciplines do not routinely work together, and their professional cultures and practices are not easily merged."