Carnegie Reporter, Vol. 1, No. 4 | Preventing “Dark Winter”— The Public Health System’s Role in Strengthening National Security, page 7 (low bandwidth)

Beyond the issue of treatment looms the dilemma of containment after a terrorist-created disease outbreak, which might mean that some population group or locality would have to be quarantined. But who would make the difficult decisions involved?

Quarantine is a state issue, says Dr. Julie Gerberding, Acting Deputy Director of CDC. Unfortunately, many localities and states don't have clear rules. Some laws have not been revised since Typhoid Mary infected about two dozen people in the early 1900s. A minefield of legal issues stands in the way of swiftly quarantining a geographic area, for example, even if it were determined that such a response might contain a potentially massive outbreak of disease. Under those circumstances, if a governor tried to close state borders, who would enforce the order? Would there be enough police officers to stop people driving down back roads or walking across a field to the next town?

When she was health commissioner of New York City, Dr. Hamburg helped draft a sensitive system for quarantining tuberculosis patients who refused to take medication but could spread the disease. It used persuasion, made treatment easy, provided legal counsel and hearings for patients and used quarantine only as a last resort. Nevertheless it took time-time probably not available in a fast-spreading epidemic.

In an emergency, could authorities force preventive treatment such as vaccination on people who didn't want it? They did in a smallpox epidemic in Boston in 1903, when police officers held down people who didn't want to be vaccinated so that doctors could immunize them. While it seems difficult to imagine authorities going to those lengths today, government officials, medical staff and law enforcement personnel now find themselves in the uncomfortable position of thinking about all kinds of situations that until recently seemed highly unlikely but that have suddenly inched closer to the realm of possibility.

If It Happens: Surge Capacity

After the September 11th attack on the World Trade Center, hospitals in the New York area canceled elective surgery and sent home patients who could be discharged while they waited for a wave of injured victims. Unfortunately, there were few.

It would be different with a biological attack. Hospitals and laboratories would soon be overwhelmed. "Essentially there is no surge capacity in the healthcare system," says Dr. O'Toole. Managed care has meant that hospitals don't have empty beds and staff and supplies such as antibiotics and intravenous sets are provided on a "just-in-time" basis. Hospitals compete with each other and don't participate in community plans.

How can the system build in excess capacity? Do we "mothball" some hospitals? Designate large facilities, such as gymnasiums, armories, or piers as emergency centers to care for patients? And even with these measures in place, how would we deal with the need for special treatments and equipment? Bioterror infections such as smallpox and plague spread through the air and patients must be cared for in negative-pressure rooms, which have air pressure lower than the outside corridor and high-efficiency particulate air filters that capture the dangerous organisms. Such rooms would be desperately needed, but there are few of them available.

After September 11th, the American Hospital Association (AHA) looked at what it would cost the nation's 4,900 acute care hospitals to increase their ability to respond to a nuclear, biological or chemical attack. The AHA distinguished between about 2,700 metropolitan hospitals and 2,200 rural or community hospitals. Among the considerations taken into account were that hospitals would need the ability to communicate with each other and with emergency medical services, the public health department, police and fire departments, the FBI, and others. Existing systems have problems with interference and often rely on outdated equipment-mobile radio systems are, on average, ten years old. (In a related, tragic illustration of how critical radio communication can be in an emergency, the firemen who rushed into the World Trade Center towers after they were attacked had such unreliable radio contact with each other that many probably never heard orders to evacuate.) Backup systems are needed if the existing system fails, even bullhorns for crowd control. Translators and translated information leaflets and multi-lingual signs for directing patients would be needed in hospitals.

Hospitals would also need to improve their surveillance of unusual infections, get better at disease reporting and disseminating real-time information and buy instruments, monitors and testing solutions for radiation and for chemical and biological agents. They would have to invest in personal protective equipment-gowns, gloves, goggles, respirators and protective suits-for everyone on staff, simply because they would not know what they were dealing with. A receptionist would be at just as much risk as an emergency medical technician. Hospitals would have to stock antibiotics, antitoxins, antidotes, ventilators, respirators and other supplies to treat huge numbers of victims until medicines and equipment from the National Pharmaceutical Stockpile reached them. They would have to plan for counseling and psychological help for victims of the attack and for police, fire, rescue workers, health care workers and people in the community.

What would all this cost? The AHA estimated that for a metropolitan hospital the cost would be just over $3 million; about half that for a non-metropolitan hospital. Nationally, that would mean over $8 billion to bring all metropolitan hospitals up to the needed standards, and another $3 billion for non-metropolitan hospitals.

Who would pay this staggering bill? Hospitals have no source of funds to upgrade for disaster planning or to recompense them for the revenue they would lose if they took care of people injured in a bioterror attack. Managed care plans pay for treatment of individual, insured patients-not for building surge capacity or for the care of uninsured patients. When New York hospitals emptied beds and prepared to care for victims of September 11th, they lost millions in expected revenue.

Next page: Telling the Public the Bad News

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