Terrorist attack using a biological weapon against civilians will require

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terrorist attack using a biological

weapon against civilians will require

a response that is fundamentally dif-

ferent from the response demanded by

an attack that employs chemical

weapons or explosives--even nuclear explo-

sives. The medical and public health

response to a bioterrorist attack will also dif-

fer significantly from response to natural dis-

asters such as earthquakes or fires.

Construction of effective response programs

requires that these differences be clearly rec-


The outcome of a bioterrorist attack on

civilians would be an epidemic. A bioterror-

ist attack on civilians could have several out-

comes, ranging from low-grade symptoms

confined to a local area and not immediately

recognized as a consequence of biological

weapons use, to a widespread epidemic. The

“first responders” to such an event would be

physicians, nurses, and public health profes-

sionals in local health departments. A covert

bioterrorist attack would likely come to

attention gradually, as doctors became aware

of an accumulation of inexplicable deaths

among previously healthy people. The speed

and accuracy with which physicians and lab-

oratories reached correct diagnoses and

reported their findings to public health

authorities would directly affect the number

of deaths, and--if the attack employed a con-

tagious disease--the ability to contain the epi-

demic. Few, if any, practicing clinicians have

Medicine & Global Survival, June 2000; Vol. 6, No. 2

Bioterrorism 76

The Medical First Response to


Tara O'Toole, MD, MPH

At the time of publication TO'T was Senior

Fellow, Center for Civilian Biodefense Studies,

the Johns Hopkins University Schools of Public

Health and Medicine. She was US Assistant

Secretary of Energy for Environment Safety and

Health from 1993-1997. Address correspon-

dence to: Tara O'Toole, MD, 111 Market Place,

Baltimore, MD 21201.

Adapted from testimony before the

Subcommittee on National Security, Veterans

Affairs, and International Relations, Committee

on Government Reform, US House of

Representatives, on September 22, 1999.

© Copyright 1999 the Johns Hopkins University

Center for Civilian Biodefense Studies. Reused

with permission.

There is a need to raise awareness within the medical community of the threat of

bioterrorism. The first responders to an epidemic caused by such an event would be

physicians, nurses, and public health professionals in local health departments.

Effective response will require extensive coordination and cooperation. Unfortunately,

the public health infrastructure in the US has been neglected. There are pressing

needs to upgrade the capacity of local public health systems to respond to an inten-

tional epidemic; to engage the medical community, including hospitals, in bioterrorism

response planning and preparedness; and to ensure institutional connectedness to

mount an effective response. M&GS 2000;6:76-81.


ever seen a case of smallpox or anthrax or

plague. Only a handful of laboratories have

the ability to identify definitively the

pathogens of greatest concern.

No recent disasters on American soil

have resulted in large numbers of patients

needing immediate and sustained medical

care. It is hard to identify a modern event that

has truly tested the capacity of the US health

care system to respond to massive casualties.

Nothing in memory is comparable to the sit-

uation that would arise if a US city were tar-

geted with, say, an aerosolized anthrax


In the most fearsome bioterrorist scenar-

ios, hundreds, thousands, or perhaps even

tens of thousands of people would need

immediate care, and many would require

intensive therapy or ventilators. Hospitals,

which thus far are almost entirely absent

from any bioterrorism response planning

activities, are already overburdened. Few

cities have sufficient numbers of unoccupied

hospital beds, staff, or equipment to absorb a

large, sudden influx of severely ill patients.

In any situation involving the use of bio-

logical weapons, the number of people who

were ill and in need of hospital treatment

would likely be exceeded by individuals

seeking care because they were fearful of

being sick. The Scud missile attacks on Israeli

citizens during the Gulf War produced large

numbers of people going to physicians and

clinics for symptoms of acute anxiety--symp-

toms that closely mimic early nerve gas

effects. Similarly, in their initial stages many

of the diseases delivered by biological

weapons resemble common illnesses. Rapid

diagnostic tests for smallpox, anthrax, and

other diseases would be most helpful, but

even the availability of such tools will not

prevent the need to distinguish the truly sick

from the worried well. Accomplishing this,

and triaging affected individuals so as to best

deploy limited drugs and equipment, will

require significant resources.

In the event that a bioterrorist attack

employs a contagious pathogen, provisions

must be made to protect health professionals

from the diseases afflicting their patients and

to prevent patients from infecting others.

Most hospital infection plans are capable of

managing a handful of infectious patients.

We are unaware of any hospital that has the

capacity to effectively isolate as many as 50 to

100 such patients. Not even the largest acad-

mic medical centers have more than a dozen

isolation rooms. Most planning documents

address “infectious disease emergencies” in

terms of one or two contagious patients. The

need to handle dozens of potentially conta-

gious patients simultaneously seems not to

have come up.

No one knows how people would react

to an attack with a deadly pathogen. Some

health care workers might leave their jobs to

care for their families; others might leave

fearing for their own safety. Maintaining

security at hospitals, health care centers, and

pharmacies would pose great challenges

since many hospital security staff are off-

duty police officers who would presumably

be needed elsewhere during the crisis.

Media coverage of modern epidemics

will have a profound influence on the out-

come of response efforts should a biological

attack occur. It is easy to imagine the oppor-

tunities for misinformation, or contradictory

interpretations by various self-appointed or

media-anointed “experts” in the context of a

bioterrorist attack, fueling public mistrust.

Yet providing the public with accurate, time-

ly information that people not only believe,

but act on, could literally save lives.

The Role of Public Health in

Bioterrorism Response

Public health agencies at the municipal,

county, state and federal levels will be central

participants in efforts to recognize and

respond to bioterrorist attacks. Public health

response activities will be especially essential

to shaping the scope and outcome of a bioter-

rorist attack. Containment of transmissible

disease outbreaks in the modern world is a

formidable undertaking. The mobility of

urban populations, the global availability of

high-speed transportation networks, and

legal limits on the authority of public health

officials are factors that have an impact on

epidemic management.

Electronically-based syndromic surveil-

lance systems may possibly be helpful in

detecting an attack; it is certain that such sys-

tems will be essential tools in managing an

epidemic. Thus, the ability of local and state

health departments to analyze and monitor

the epidemiological situation is a key compo-

nent of any national response system.

Epidemiologic analysis of initial victims may

be critical in determining where the attack

occurred, who is at risk, and who requires

prophylactic treatment.

Efforts to limit the number who become

ill will include the identification of contacts

requiring vaccination, antibiotics, or quaran-

tine. Epidemiologic tracking of the epidemic

will be necessary to determine if response

efforts are succeeding, where resources

should be invested, and whether additional

attacks have occurred. History shows that

governments' ability to describe accurately

the course of disease outbreaks has a great

impact on public credibility and on citizens'

willingness to follow the recommendations

of public health authorities.

77 Bioterrorism


Unfortunately, the public health infra-

structure in the US has been neglected for

decades. In 1988, the Institute of Medicine

wrote that “public health in the United States

has been taken for granted” and that “our

current capabilities for effective public health

actions are inadequate” [1]. In the ensuing

likely decade, the situation has only gotten

worse. City and state health agencies remain

seriously underfunded and understaffed, a

situation that endangers the potential to

manage effectively an epidemic among the

civilian population. The state grants program

initiated this year by the US Centers for

Disease Control and Prevention (CDC)

Bioterrorism Preparedness and Response

Office is an important first step towards

strengthening state and local public health

capacities [see Lillibridge].

Collaboration between public health

departments and the medical community is

also critical to bioterrorism response. The

gulf between medicine and public health is

well documented and significant.

Communication between hospitals and state

health agencies is extremely limited. For

example, few state health agencies have the

ability to determine how many intensive care

unit beds in the state are occupied at any

given time, and few physicians know how to

contact government health agencies were

they to suspect a case of smallpox or anthrax.

Re-establishing the linkages among medical

practitioners, hospitals and public health

agencies will be extremely important (and is

likely to yield dividends beyond bioterrorism


The Role of Medicine

There is an enormous need to raise

awareness within the medical community of

the threat of bioterrorism. During a bioterror-

ist attack, health professionals will be the first

responders. Yet, this critical component of

the nation's response capability has thus far

received inadequate funding. Moreover, very

few medical or hospital industry leaders

seem aware that bioterrorism is a problem.

Physicians must be educated about the

potentially calamitous consequences of

bioterrorism and the critical role that astute

clinicians could play in recognizing such

attacks. It is essential that at least a core of

practitioners in selected medical specialties--

such as emergency medicine, infectious dis-

ease, internal medicine, and hospital epi-

demiology--are aware of the basic clinical

manifestations and management of diseases

caused by biological weapons.

Should a bioterrorist attack on civilians

occur, hospitals would be frontline institu-

tions for dealing with the response, regard-

less of the type or scale of the attack. The cur-

rent hospital system is not well prepared to

deal with a mass disaster. Economic pres-

sures have reduced staff and the number of

available hospital beds. Intensive care and

isolation beds are particularly scarce. Drugs

and equipment are purchased on an “as

needed” basis, which has resulted in reduced

stockpiles available for immediate use.

Hospitals have been largely missing

from bioterrorism response planning to date.

Efforts to include hospitals in exercises spon-

sored by the Domestic Preparedness pro-

grams have been slowed by the preoccupa-

tion of hospital leaders with the changing

and financially competitive terrain of modern

health care. A carefully thought out menu of

national incentives could encourage and

motivate many hospitals to develop and par-

ticipate in bioterrorism response programs,

which, in the absence of such incentives,

could face resistance as unfunded mandates.

Effective response to a bioterrorist

attack that results in hundreds or thousands

of patients will require extensive coordina-

tion and cooperation among dozens of hospi-

tals and health maintenance organizations in

a city or region. The protocols and infrastruc-

ture for implementing such collaboration

should be examined, especially in view of the

autonomous and financially competitive

nature of health care organizations.

It is critical that response roles and capa-

bilities of hospitals be carefully examined

and augmented as appropriate. The Hopkins

Center for Civilian Biodefense Studies has

begun a project to design a “template” that

would identify key elements in creating insti-

tutional capacities required for effective hos-

pital response [see sidebar]. Increasing

awareness among hospital leaders and staff

of the threat bioterrorism is a key component

of building such capacity.

Social Dimensions of Bioterrorism

Planning for a response to terrorist

attacks must not neglect the social conse-

quences of epidemics. A deliberate epidemic

may continue to produce victims over a peri-

od of weeks or months. Additional attacks

must be anticipated. If the biological weapon

used is a contagious disease, fellow citizens

may represent ongoing threats to public safe-

ty, or be perceived as such. Managing the

response to a bioterrorist attack will exact a

physical and emotional toll on the whole

population, but especially on health care

workers and family caretakers, many of

whom may fear for their own health. Normal

routines and commercial activity are likely to

be seriously disrupted, possibly on a city-

wide or regional basis and for an extended

Medicine & Global Survival, June 2000; Vol. 6, No. 2

Bioterrorism 78


time period. Proper attention to the psycho-

logical needs of people in crisis is essential.

Historically, some disease control mea-

sures taken in times of public health emer-

gencies have been at odds with, or perceived

as violating, certain democratic principles

and processes [2]. For example, mandatory

quarantine or enforced vaccination to limit

disease spread have been perceived as

threats to individual autonomy and the right

to privacy, or as discriminatory actions

against certain groups. During a crisis, com-

munication failures among different commu-

nities and between government officials and

citizens can create suspicions and resistance

that inhibit the accomplishment of public

health objectives. Moreover, differing ideas

of what constitutes proper response can also

have long term political consequences, con-

tributing to distrust of government institu-

tions and disengagement from the processes

of representative democracy.

A bioterrorist attack will undoubtedly

raise many important political and legal

questions, including issues of civil liberties,

the authority of state and federal health offi-

cials, liability in the event mass vaccination is

necessary, and others. Efforts to identify and

better understand such issues are important.

Federal Bioterrorism Response


All Federal response plans in place and

under development--including those of the

Department of Defense (DOD) and the

Department of Health and Human Services

(HHS)--are designed to support local

resources and capabilities. However, it is esti-

mated that 24-48 hours will elapse before fed-

eral resources arrive on the scene. During this

initial--and for bioterrorism, most crucial--

phase of response, local hospitals and health

agencies are on their own. Thus, it is extreme-

ly important that the federal efforts to aug-

ment state and local bioterrorism response

capacities be expanded to include as partners

the medical and public health communities.

In recent years, a number of laudable

federal efforts aimed at augmenting terror-

ism preparedness on the local level have got-

ten underway. Some of these programs have

been criticized for being poorly coordinated

on the federal level, an observation not with-

out foundation. Such criticism may reflect, in

part, the complexity of the technical issues

and the unusual panoply of actors that would

be engaged in terrorism response activities.

Both of these aspects--the technical difficulty

of the issues and the challenge of integrating

diverse organizations and cultures--are mag-

nified in the context of bioterrorism.

Three aspects of current federal pro-

grams deserve emphasis. The first is the

pressing need to upgrade the capacity of local

public health systems to respond to an inten-

tional epidemic [see Lillibridge]. The second

is the imperative to engage the medical com-

munity, including hospitals, in bioterrorism

response planning and preparedness. The

third aspect of federal efforts that requires

attention is the institutional “connectedness”

that will be essential to mount an effective

response to acts of bioterrorism.

Bioterrorism Response Planning

The Nunn-Lugar-Domenici Domestic

Preparedness Programs have thus far

focused primarily on responses to terrorist

attacks using conventional explosives or

chemical weapons. Training exercises

focused on chemical attacks or conventional

explosions have appropriately targeted tradi-

tional “first responders”--firefighters, emer-

gency response technicians, law enforcement

personnel, and the like. Few cities have con-

sidered or practiced responding to an attack

that employs biological weapons. Thus, the

medical community, hospitals, and even

state health departments have been missing

from training and exercises sponsored by the

Domestic Preparedness Programs. Further-

more, even when bioterrorism scenarios are

considered, clinicians, hospital leaders, and

public health experts are frequently not


The Office of Emergency Preparedness

(OEP) within HHS is in charge of a number of

programs that carry out important medical

missions during natural disasters. The

National Disaster Medical System (NDMS) is

designed as a partnership between the public

and private sectors during emergencies and

includes resources from the Departments of

Defense, Veterans Affairs, and the Federal

Emergency Management Agency as well as

HHS. OEP's role within the NDMS might

provide important support functions follow-

ing a bioterrorist attack, including logistical

support and coordination of hospital


The NDMS is specifically envisioned as

a supplement to state and local medical

resources. About 7,000 volunteers nation-

wide comprise Disaster Medical Assistance

Teams (DMATs), which are typically mobi-

lized during natural disasters or discrete

events such as the bombing of the federal

building in Oklahoma. DMATs usually

include about 30 people, only one or two of

whom are physicians and are trained to inter-

act with traditional emergency response per-

sonnel. Other OEP capabilities, including

mental health services and mortuary ser-

vices, might be extremely useful resources.

How such teams would interface with hospi-

tals or local health departments; how and

79 Bioterrorism


whether such volunteer teams could be mus-

tered during a large epidemic; and how any

public health or medical unit will interact

with federal program personnel are all areas

needing attention.

It is not easy to engage the medical com-

munity in bioterrorism response planning

and preparedness. The practical task of edu-

cating clinicians about the possibilities and

medical implications of biological weapons is

probably best addressed by professional soci-

eties. Hospitals and large HMOs are unlikely

to devote scarce resources to bioterrorism pre-

paredness without promises of financial sup-

port and the engagement of key authorities

within the hospital community. Whether all

hospitals should be prepared to respond to

bioterrorism or whether a limited number of

institutions should be selected to pursue more

advanced capabilities is an open question.

Institutional Coordination

Institutional coordination is an impor-

tant aspect of response planning. The lack of

a precise understanding of roles and respon-

sibilities among federal agencies involved in

terrorist response is well recognized. Local

institutions are not, in general, in better

shape, and have far fewer resources to devote

to planning activities.

Coherent statewide plans that embrace

all relevant parties--including hospitals,

emergency response systems, and govern-

ment health agencies--in functional consortia

would be extremely useful. CDC, OEP, and

state preparedness initiatives must address

issues of coordination and collaboration that

result in a constructive reexamination of

strategies and plans.

All 50 US states responded to the CDC's

1999 request for proposals to strengthen pub-

lic health response to bioterrorism; to date,

however, very few representatives of the

medical or hospital communities have partic-

ipated in planning projects or are even aware

of the threat posed by bioterrorism. The lead-

ership from both the medical and public

health communities must become engaged

soon, to ground the process in an accurate

understanding of technical and institutional

issues, and to incorporate a realistic and

thoughtful analysis of the social repercus-

sions of public health options.

Coordination between the health sector

and law enforcement authorities is especially

important, given that a bioterrorist attack

will necessarily involve a high-profile, high-

stakes criminal investigation and will raise

profound national security issues. Efforts to

ensure adequate communication and collabo-

ration among health authorities and law

enforcement deserve a high priority given

the lack of practical experience in such col-

laboration and the significant cultural differ-

ences among these sectors.


A number of steps must be taken to

develop the appropriate level of readiness at

the local, state, and federal levels to deal

effectively with the threat of bioterrorism:

1. Augment local public health capaci-

ty: Investment of talent and money in the

HHS bioterrorism response program in CDC

should continue and be significantly

increased. More attention should be directed

towards identifying and implementing the

essential elements of bioterrorism response,

and toward making sure that federal efforts

can effectively plug into local resources. All

agencies involved with the public health

response to bioterrorism should seek greater

cooperation and a more explicit understand-

ing of responsibilities and capabilities.

2. Improve clinicians' awareness of the

threat of bioterrorism and the diagnosis and

treatment of diseases caused by biological

weapons: The medical community must be

brought into the planning and preparations

for bioterrorism response. In the event of a

bioterrorist attack, local health resources--

physicians, nurses, and the technicians and

administrators who support them--will carry

the weight of the response. Yet none of the

preparedness programs now in place include

any appreciable engagement of physicians or

hospitals. Increasing health professionals'

awareness of the medical manifestations of

biological weapons and educating clinicians

about what to do should they suspect a bio-

logical attack must be a top priority. This can

be accomplished most efficiently if curricula

are designed and distributed through profes-

sional societies such as the American College

of Emergency Physicians, the American

College of Physicians, and the Infectious

Diseases Society of America, rather than by

for-profit contractors. (A professional effort

currently underway by the ACEP has not yet

produced any materials.)

3. Engage hospitals in bioterrorism pre-

paredness and response planning: With very

few exceptions, hospitals are not yet partici-

pants in any response planning efforts. Given

the competing priorities facing health care

institutions, initiatives to make hospitals

aware of the bioterrorist threat and of their

critical role in bioterrorism response must

engage leaders within at the appropriate lev-

els of authority and influence. As the path

towards constructive integration of hospitals

into response planning becomes better

defined, proper heed should be paid to the

resources hospitals will require to fulfill their

roles and missions.

4. Assess the impact of the media:

Medicine & Global Survival, June 2000; Vol. 6, No. 2

Bioterrorism 80


Careful anticipation and study of the influ-

ence of the media on the events following a

bioterrorist event is needed. The media's

impact on the epidemic and its concomitant

potential to generate or quell public panic has

great salience for any practical response plan-

ning. Consideration should be given to

advance preparation of educational videos

and briefings for reporters. Protocols for pro-

viding the public with rapid and accurate

medical information in the event of an attack

should be determined.


If a bioterrorist attack occurs, the ensu-

ing response will engage all levels of govern-

ment, most federal agencies, and multiple

professional communities, most particularly

health care providers and public health pro-

fessionals. It will take place in an atmosphere

of great tension, uncertainty, and fear.

Decisions will have to be made and coordi-

nated very rapidly. Planning and implemen-

tation of effective response strategies must

take into account the complexity of this chal-

lenge and the essential multidisciplinary,

inter-institutional nature of the problem.

There is an urgent need to develop a compre-

hensive picture of what such a response

should include and how it might be orga-

nized, recognizing the importance of crafting

strategies that are locally based and flexible

enough to accommodate specific contexts

and unexpected conditions.


1. Institute of Medicine. The future of public

health. Washington, DC: National Academy

Press. 1988.

2. Gostin L, Mann J. Towards the development

of a human rights impact assessment for the

formulation and evaluation of health policies.

Health and Human Rights 1994;1:58-80.

81 Bioterrorism


Johns Hopkins Center for Civilian Biodefense Studies

The Johns Hopkins Center for Civilian Biodefense Studies is dedicat-

ed to fostering the development of medical and public health policies

and structures to prevent the use of biological weapons and protect

the civilian population from bioterrorism. The Center's principal focus

is upon those bioweapons that have the potential to cause catastroph-

ic, potentially destabilizing epidemics.

Begun in September 1998, the Center is dedicated to a sustained

examination of the policy and operational issues associated with med-

ical and public health implications of bioterrorist threats, providing

opportunities for informed dialogue among a diverse array of policy

experts and health practitioners. The Center itself possesses expertise

in medicine, public health, and government.

The Center's approach includes three focus areas:


Raising national and international awareness of the medical

and public health threats posed by biological weapons, thereby aug-

menting the potential legal, political, and moral prohibitions against

their use.


Developing a broad appreciation of the threat posed by the

biological agents of greatest concern--and possible medical and public

health management options--through analysis of expected clinical

manifestations, available treatment strategies, epidemiology, and

potential methods of prophylaxis; and disseminating this knowledge

throughout the medical and public health communities.


Catalyzing development of effective, practical systems to

respond to epidemics; informing the planning and preparation for pos-

sible bioterrorist attacks, thereby lessening their potential effects and

attractiveness as instruments of terror; engaging the medical and pub-

lic health communities in comprehensive planning in critical areas

such as epidemiological characterization of intentional epidemics, the

care and treatment of casualties, communication of information to the

public, and the pursuit of unmet research and preparedness needs.

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