|
UNITED STATES SENATE
Committee on Governmental Affairs
Testimony of Thomas V. Inglesby, MD
Deputy Director, Johns Hopkins Center for
Civilian Biodefense Strategies
April 18, 2002
Mr. Chairman and distinguished
members of the Committee, thank you for the opportunity to
testify on the subject of Public Health Preparedness for
Bioterrorism. I am the Deputy Director of the Johns Hopkins
Center for Civilian Biodefense Strategies. The mission of our
center is to influence policies and practice in ways that lower
the likelihood of mass casualty bioterrorist attacks on
civilians, and in ways that would diminish the dire consequences
of such attacks should prevention strategies fail. I am also a
physician with a specialty in infectious diseases on the faculty
of Johns Hopkins Hospital where I have worked for the past 10
years. This Committee has asked me address issues of
coordination and communication among federal, state and local
public health agencies and to offer comments on overall
bioterrorism preparedness.
Communication and Coordination during the
Anthrax attacks
The anthrax attacks of 2001
produced an extremely complicated set of management problems for
public health agencies, with communication and coordination
being particularly difficult. CDC had never before responded to
a bioterrorist attack, let alone attacks in multiple states.
The attacks necessitated rapid interactions between local, state
and federal public health agencies on technical issues that
evolved quickly. Pre-existing scientific knowledge was limited
regarding a number of the complex issues (such as how best to
prevent anthrax infection after exposure to the spores or how to
assess the risk of an environment contaminated with anthrax
spores), also seriously slowing down communication. The attacks
required federal, state and local public health agencies to
communicate fast changing information and guidelines to doctors,
nurses and hospitals – something without precedent on this
scale. No one had anticipated such a widespread need for rapid
communication amongst public health agencies or between public
health agencies and the medical care delivery system. This was a
dynamic and changing context; the events changed as the anthrax
cases and information unfolded, and public health agencies had
to work very hard to keep up with changing conditions. At times,
the need to change public health recommendations multiple times
in a single day was unavoidable. There were dedicated public
health professionals at the federal, state and local level who
were working day and night to make the best interventions. This
all being said, it is important to try to understand clearly
where communication did not work well and why. There are a
number of examples from the anthrax attacks that are useful. I
would group communication difficulties of public health agencies
during the crisis into three main categories: problems of
incoming communication, problems of scientific analysis and
decision-making, and problems with outgoing communication.
There were a number of problems
with communication of incoming information. There were few
efficient mechanisms to get information from where anthrax
illnesses were occurring (e.g., the Capitol, Brentwood, NYC
media organizations, NJ postal offices, hospitals, etc) to those
at CDC, state or local health departments who needed to make
real-time decisions and recommendations. In most places,
doctors do not often seek guidance from local or state public
health agencies, and therefore are not accustomed to sharing or
reporting information to public health agencies. They are quite
distinct professional communities that have far less routine
interaction than is imagined. As a separate issue, tracking and
managing the sheer volume of patient laboratory data,
environmental testing data of various types and quality was an
extremely difficult task for public health agencies. There were
scores of environmental tests performed on buildings suspected
of being contaminated with anthrax spores. Simply getting the
tests performed, processed and the test results forwarded to
persons with decision-making responsibility in public health
agencies was difficult. The anthrax attacks revealed how
challenging it is for public health agencies to acquire and
manage the type of incoming health and environmental data needed
to make decisions and recommendations in a real-time crisis.
The second set of communication
problems were related to the many complicated scientific
problems that required new collaborations of experts to
address. Most health care professionals, state and local public
health agencies and the general public looked to CDC for the
answers to technical scientific questions during the crisis.
One key example of such a technical question was the role of the
anthrax vaccine following the attacks. A recommendation
regarding who should receive the anthrax vaccine was necessarily
dependent on the answer to many scientific questions, including:
how likely is it that anthrax spores could cause disease after
being dormant in a body for weeks; would it be a safe
alternative approach to wait for signs of anthrax infection and
then begin immediate medical treatment; how much anthrax
vaccine was actually available and how quickly would new vaccine
be produced; and, how quickly would the anthrax vaccine produce
immunity; how safe were existing vaccine stocks; and more. For
CDC to answer these questions, or even to know what the range of
questions should be, required input from experts from a variety
of scientific backgrounds: experts in experimental biology,
epidemiology, infectious disease medicine, anthrax vaccine
science, and immunology. There were many other similarly
complicated scientific questions (eg, what is the most effective
antibiotic treatment regimen for anthrax; what risks should
begin antibiotic prophylactic treatment to prevent disease; who
should get the anthrax vaccine; what should be done about
contaminated buildings; how likely is it that anthrax spores
will leak out of envelopes, etc). For much of the crisis, there
were not efficient processes for bringing together these
disparate scientific communities to help provide information to
CDC or for decision-makers, though processes for doing this did
evolve as the crisis progressed. When answers to scientific
problems could not be resolved with speed and authority,
decisions could not be made, and necessary technical information
or recommendations could not be communicated.
A third set of communication
challenges were related to problems of outgoing information.
Again, it is important to understand that these are complex,
systems problems that will take strategy and resources to fix,
but it is critical to know what did not go well in order to
improve. First, there were not rapid or reliable ways for
public health agencies to communicate to doctors and nurses what
was happening or what public health was recommending. Doctors
and nurses looked to public health agencies for recommendations
on who to treat, vaccinate, and test. Doctors and nurses have
told us that the during the crisis the information forthcoming
from public health agencies was often too slow for what they
needed; in other cases, public health agencies were making
treatment recommendations quickly, but there were no easy
mechanisms for delivering the information to their intended
clinical audience. The chief of infectious diseases at one of
America’s best hospitals said in the midst of the crisis that he
was getting had to get his medical information from CNN.
What is happening now to
address these problems
Guidance and Grants for
Public Health Agencies
The Appropriations Bill of 2002
appropriated DHHS 10 times the pre-existing funding for
bioterrrorism preparedness programs, with much of that going to
state public health agencies. These grants are being
distributed rapidly by DHHS, with benchmarks set that are
coherent and comprehensive. Some of those benchmarks are wisely
aimed at improving communication capacity. The Office of Public
Health Preparedness in HHS is moving with speed and efficiency
to get this grant money to public health agencies. The focus on
state and local public health agencies is on target; state and
local health systems will bear much of the burden for preparing
and responding to bioterrorist attacks.
But our expectations for the
short term must be realistic. At baseline, public health
agencies around the US have a limited capacity to drop
everything and immediately begin an outbreak investigation; many
cannot even find the human resources to answer an emergency
hotline 24 hrs day. We hear that state public health agencies
have had literally to put their other work on hold just to
respond to the new HHS grants. This looks like a great deal of
money to be spending on public health, but in terms of true
preparedness for bioterrorism, we need to understand that we are
asking public health agencies to now provide a serious component
of our national security. And with respect to bioterrorism, we
are essentially beginning from a standing start. For years,
public health has often been among the first things cut in state
budgets. In many locations, it has a broad mission without
clear edges, diluting its power and capacity. In the end, this
funding is only a down payment on the ultimate cost of the
public health system needed to confront the bioweapons threats
of the future.
Changes at CDC
CDC is and should remain the
federal agency with responsibility for providing technical
expertise and resources to state and local public health
agencies for biopreparedness. It should be supported in this
effort. It is an organization with many dedicated professionals
and a home to many great scientists. But we must acknowledge
that bioterrorism response is different in key ways from other
CDC missions. And it is a tremendous new responsibility. In
order for CDC to bring the nation substantial and sustained
improvements in bioterrorism preparedness, CDC will require the
development of new systems and strategies, and it will need
resources commensurate with this responsibility.
Path forward on improving
communication and bioterrorism preparedness
At the most fundamental level,
countering the complex threat of bioterrorism will require
strategic planning, funding, human capital and time. Without
these, our best intentions will not make us more secure. There
are also a number of additional specific initiatives that in my
judgment would improve communication among federal, state and
local public health agencies prior to and during a bioterrorist
attack:
1)
Connections
between public health agencies and medicine need to be greatly
strengthened – an issue that can also be called improved
connectivity. Doctors and nurses need more efficient ways
to communicate information to public health officials and vice
versa. I think this is more important than sophisticated
electronic surveillance systems. It will take will, people and
time, because in most places these are very distinct
communities. But I cannot conceive of an electronic
surveillance system that would have detected the anthrax case in
Florida faster than Dr. Larry Bush recognizing a case of anthrax
and quickly relaying his concern by phone to Dr. Malecki of his
local health dept. Unfortunately, the ability for medicine and
pubic health to connect in that Florida county is the exception
not the rule. But we need to work to change that.
2)
The clinical
medical care community should develop systems to more quickly
communicate key information within its own organizations and
professional societies. Other than television or radio
broadcast, no existing information systems that I am aware of
could immediately reach a majority of physicians or nurses
practicing in a city or state, though some localities are
further ahead on this issue than others. An example of a system
that developed in response to this type of information need is
the daily conference call started by physicians in the DC area
to share information on the evolving anthrax crisis. This proved
to be extremely valuable to them and eventually was a conduit to
send information from their community to public health agencies
and vice versa.
3)
CDC and other
public health agencies should design more robust processes for
incorporating the various needed scientific competences into
decision-making during a crisis. There is no easy fix for this
– a new bioweapons attack with different pathogen or via
different dissemination technology would require a new
combination of competencies at the table. But we think it is
important to assume broad outside scientific collaboration will
be needed and to plan for it.
4)
A priority should
be placed on improving strategies for communicating with the
American public. The importance of communicating comprehensive,
current information to the public in the aftermath of such an
attack cannot be overemphasized, even if it is disturbing
information. It is important to have our medical and scientific
leaders who will lead such efforts be exceptionally trained in
the difficult skill of media communication. The potential for
positive or negative impact is so great that this must be a
priority.
5)
I have been
greatly impressed by the value of drills and exercises in
preparing for the anthrax attacks. Individuals or organizations
that had begun to do bioterrorism preparedness training or
exercises prior to the attacks of 2001 consistently reported how
useful they have been. New relationships and lines of
communication were developed. There was a new understanding of
the roles other groups in a bioterrorism response effort would
play. While there are certainly examples of poorly designed or
inefficient exercises, many more exercises have been of clear
value. Exercises should continue to be an important component of
bioterrorism preparedness efforts at all levels of public
health.
6)
Moving beyond
communication issues, there are an array of other strategic
initiatives that will be needed to counter the bioweapons
threat. The nation needs regional health care plans designed to
cope with mass casualty attacks. The nation needs a sustained
biomedical research and development program aimed at preventing,
diagnosing and treating the range of infectious diseases that
exist now and those that will be engineered in the future. The
nation needs the deep engagement of its biological scientists in
and out of government to seek new ways to manage the growing
power of this science. And each of these complex and long-term
pursuits will require more talent and human resources in
government. We cannot accomplish all we need without more human
capital.
The bioweapons threat ahead
It is essential to analyze what happened in the
fall, what went well and what did not, because the threat of
bioweapons will only grow with time. Senators Hart and Rudman
and the Commission on National Security in the 21st
Century, in their prescient report on national security, singled
out bioweapons as one of the most serious threats to US national
survival. Admiral Stansfield Turner has said that bioweapons
are one of the only two categories of weapons that have the
theoretical capacity to “push the nation to the point of
non-recovery.” Bioweapons ultimately represent a survival
threat to the nation. The anthrax attacks of the fall were just
the prologue to the bigger story of bioweapons.
In the years ahead, the biotechnology used to
create bioweapons will become far more powerful, more available
and less expensive. Engineering, computing, and the capital
markets will push biology forward on a rapid trajectory. What
used to take a highly skilled team of scientists to accomplish
can now be done in rapid fashion with automated kits in an
afternoon. Industrial techniques allow the cheap manufacture of
pathogens or toxins to tonnage quantities in places around the
world.
Already present on the planet
are examples of biological knowledge that are disturbing: the
methods for making new influenza strains never before seen on
earth; the directions for making Ebola virus from non-living
fragments of genetic material; the techniques to make anthrax or
plague resistant to many or even all available antibiotics;
attempts to combine a set of genes from viruses that cannot
spread to viruses that can; biological aerosols that might once
have harmlessly floated away can be stabilized in the
environment and altered to become more easily inhaled. The
long-term threat is certainly grave. It is therefore critical to
take a dispassionate look at how we have prepared for
bioterrorism and what now should be done. In the end, the
measure of success is whether our public health and other key
government institutions are preparing to address not only more
anthrax attacks, but the future of bioweapons as well. |