Bioterrorism

The public health system did not respond much better:

• Physicians, hospitals, and health departments were besieged by inquiries about what individuals and organizations should do about the events—but were poorly prepared to answer. For almost two weeks, the public received conflicting and sometimes incorrect information.

• Web sites were also contacted extensively. Some of the best sites were so overwhelmed that they could not respond; other sites contained incorrect information or promoted the sale of a variety of nostrums and devices to protect against infection.

• Public health laboratories were overloaded and often lacked the capacity to respond in a timely way to specimens obtained from suspected patients or other sources. This was true in many states and at the Centers for Disease Control and Prevention (CDC) in Atlanta.

• A renewed concern about smallpox exploded into public attention. Shortages of vaccines against smallpox, anthrax, and even childhood diseases became increasingly visible. The government contracted to purchase enough smallpox vaccine to immunize the entire U.S. population, but vigorous debates developed over who should be vaccinated and when. RAND investigators have modeled several of the strategies. These models should be considered in the debate.

• Jurisdictional issues arose as the FBI, local public health departments, and the CDC differed on which agencies should take charge of specimens and the scenes of attacks.

These experiences have taught us many lessons with major relevance to the research and public policy agenda. The lessons have to do with surveillance, detection, and diagnosis; biomedical research; communications strategies; international cooperation; and coordination of resources.

AP/WIDE WORLD PHOTOS/ALEX DORGAN-ROSS Emergency personnel in chemical and biological protective suits respond to the mock injuries of a victim during a July 13 exercise held by the University of Maryland Medical Center and the U.S. Air Force to simulate a terrorist attack on the Baltimore Ravens Stadium.

To counteract both natural and man-made biological agents, we need improved surveillance measures and information systems for monitoring them, expanded laboratories to diagnose illnesses more quickly, and rapid communication systems among the medical, public health, emergency medicine, and public safety communities. We also need to overcome a national shortage of public health epidemiologists and to resolve quarantine issues.

Fundamental biomedical research is needed to understand the natural history of the various biological agents that can be used in terrorism and to develop vaccines against them. The nation badly needs a new public-private strategy for the development, testing, and production of vaccines. Vaccines are costly to produce but have limited market returns and may result in considerable liability. The stockpiling and emergency distribution of vaccines and drugs for use in a bioterrorist event pose significant financial and logistical challenges. Similar barriers impede the research, development, and distribution of new antiviral agents and new antibiotics to fight drug-resistant organisms. Decontamination of buildings also poses a major research challenge.

Communications to the public and the professions during a biological event must be dramatically improved. RAND has already undertaken seminal research on the mental health aspects of terrorism. Further efforts to help the public (and professionals) better understand and communicate the nature of risks are essential if rational choices are to be made in response.

International cooperation is also required. Infectious agents can produce illness anywhere in the world and spread rapidly from one part of the world to another. Improved surveillance, vaccine availability, and antibiotic resistance are thus global challenges. Cooperation on these challenges among developed countries could not only protect people in those countries but also improve the health and economic capacity of people in developing countries.

Among the challenges and opportunities in addressing bioterrorism is the need for the dual use of resources. The need for better surveillance systems and vaccines for both natural and man-made infections underscores the importance of conducting research and programs that are integrated rather than separated. Likewise, the complex group of agencies and programs with roles to play should also coordinate their efforts. Continuing professional education, accreditation, and disaster exercises should emphasize that it is essential to prepare for all new and emerging infections—whether natural or man-made.

The creation of a Department of Homeland Security will bring together a number of agencies and programs crucial to health security. It is important that the new department not lead to separations of research and programs—separations that could undermine dual-use requirements. In addition, the need for coordination suggests a continued role for an effective Office of Homeland Security in the White House under the conditions recommended by the RAND-supported Gilmore Commission. Under those conditions, the U.S. Senate would confirm a director who has budget authority over bioterrorism-related activities in all the relevant agencies.

In the recently created RAND Center for Domestic and International Health Security, we are developing an agenda to address many of these questions, taking advantage of RAND's range of capacities in health, security, intelligence, computer modeling, and economics. We aim to make health a key component of U.S. foreign policy and also to protect the health of the American homeland by preparing it for possible future terrorist attacks.