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Public Health Strategies to Address Terrorist Threats

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Posted On: April 03, 2002          Updated On: April 03, 2002
© Terence T. Gorski, 2001

Public Health Strategies to Address Terrorist Threats
Institute of Medicine (IOM)
<Read It On The IOM Website>

The IOM proposes to initiate new activities, and capitalize on work currently in progress, to develop and communicate anti-terrorism strategies based on public health principles. The goal is to provide guidance on specific issues of national, local and individual concern, within the framework of a comprehensive strategy to assure the health of the public in the 21st century. The Institute's selection of activities will be guided by the following criteria: 1) The issues are significant to the nation and the world. 2) The activity takes advantage of the particular strengths and comparative advantages of the Institute and the Academies. 3) The project can be accomplished within the time frame necessary for decision and action.

In this time of national emergency, policy decisions, infrastructure investments and program re-alignments will be made with a focus on terrorism. The country will be better served if these decisions are also considered within the framework of what is needed to protect and assure the health of the public when the immediate threats diminish. Thus, an over-arching goal will be to advance the acceptance of "dual purpose" public health responses to terrorist threats. This will not only enhance the value of investments, but will create the enduring advantage of ongoing, dual capacities to deter and detect future episodes of bioterrorism and to promote health more generally.

We envision a multi-year series of studies and other activities conducted in collaboration with national, state and local public health organizations, federal agencies and health care professionals. Products will be diverse, and directed to multiple audiences including the general public. Some will be traditional committee studies, but others will be quick turn-around activities. The projects described below are examples of the types of work intended. Already nearing conclusion is a broad-based study to create a vision for assuring the health of the public in the 21st century, scheduled for release in March 2002. The framework described in that report will provide the context for other projects.

Studies and other activities will address priorities for prevention, detection and mitigation/recovery. Although each activity or product will be complete in itself, all will be referenced to the over-arching framework necessary to assure the health of the public. Our goal is to contribute in important ways to the Academies overall response to the national emergency, while at the same time using the crisis-generated teaching moment to build a long-lasting appreciation for the importance of investing in public health.

Specific projects under consideration, in development or in progress include:

Comprehensive bioterrorism threat assessment. The Forum on Emerging Infections conducted a two-day workshop on Biological Threats and Terrorism: How Prepared Are We? The workshop (November 27-28) assessed the science and our response capabilities. Following that discussion, the Institute will consider follow-up activities. They may include analysis of organisms that are candidates for bioterrorist activity and of modes of prevention, detection and containment. Such analyses would be a foundation for judging the preparedness of the public health system to detect and respond, as well as to the legal community's readiness to identify and deter hostile capacity.
Communications. Risk communication - particularly for novel and unexpected threats -- is difficult under optimal circumstances. Problems include confusing and inaccurate information, the absence of an authoritative source of information and speculative saturation news coverage that creates unwarranted fears and panic behavior. The increasing diversity of the American people also complicates effective communication posing barriers of language, differences in trust of public institutions and widely varying levels of comprehension of scientific information. Existing studies (NRC and IOM) provide a framework for guiding effective risk communication. They should be re-examined, updated if appropriate, and focused on the challenge of communicating terrorist threats/risks, particularly to culturally diverse audiences. Such a report would be directed to public officials and others who are in charge of communicating general and specific risks related to terrorist threats.

In addition, it may be useful to create a specialized document to be used or adapted by public officials to communicate the purpose and nature of radical public health measures that might be required in the face of a smallpox or other contagious disease outbreak. Few Americans have ever faced quarantine, and the probability of non-compliance and evasion are extremely high. Further, the logic of any rationing system that may be needed to distribute limited supplies of a vaccine, antibiotic or antimicrobial must be extremely well communicated. The civil conflict that would ensue if life-saving medicines were perceived to be unfairly distributed, could be reminiscent of the 1960s. Developing and testing explanatory messages in advance of need is extremely important.

Legal authority. Legal authorities at the state and federal level are inadequate to address public health emergencies that may arise as a result of a threatened or completed act of terrorism. Legal authorities at the intersection of federal and state public health functions are particularly problematic. For example, CDC must be invited by a state to conduct disease outbreak investigations - often resulting in a critical loss of time and evidence. Very sensitive issues in information sharing, transfer of personnel, control of materials and persons (mandatory medical examinations, individual testing, mandatory reporting, isolation and quarantine, mandatory treatment) are examples of areas where the legal basis for actions that may be necessary for an emergency response are absent in most states, and at the national level. Nor is there clarity about when the federal government can override state laws, nor what legal authorities will apply in multi-state regions (e.g. Washington and New York). A committee workshop study could identify the critical functions that require new statutory authority and produce (or critique) the basic elements of model federal and state emergency health powers act.
Vaccine policy. Before September 11th, vaccine policy in the United States could be fairly described as 'in disarray', but not a subject of interest outside the public health community. The importance of vaccines as prevention against biological threats has brought that disarray to broader attention. However, the complexity of the problem and the many inter-related pieces that must be addressed are poorly understood. The country is wholly dependent on the private sector for development and production, and only two American manufacturers continue to produce vaccines. Inexplicable shortages occur in well-established, widely used vaccines (currently tetanus is very scarce, and influenza vaccines have been delayed and in short supply for several years). Limited use or neglected vaccines are an even greater problem. The country's only manufacturer of anthrax vaccine has been shut down for two years. Issues include: high risk of failure, high capital investment, lengthy time from discovery to license (12 years), liability concerns, absence of long term government funding commitment, insufficient production capacity, small net present value for vaccines v. drugs, and regulatory obstacles. In addition, federal and state budgets for vaccine purchase are inadequate for even routine childhood immunizations. Recent events raise important questions about the adequacy of finance mechanisms necessary to purchase, stockpile and provide access to vaccines for the general public in response to emergency conditions. Three activities are contemplated:
Vaccine Policy Committee. A small committee of individuals experienced in vaccine issues who could raise questions about what we are doing, and highlight the major areas of policy concern that should be addressed as the Administration and Congress grapple with emergency concerns. The purpose would be to create a public dialogue about a complex area of science and public policy that is poorly understood today and where narrowly focused decisions could have serious unanticipated effects. The committee could hold public symposia, develop synthesis reports drawn from earlier work and identify issues for new studies. Examples of issues include the need for immunization registries to track results of mass immunizations, intellectual property concerns (if a manufacturer stops producing a critical vaccine such as tetanus, should the patent be forfeit?), do current assumptions regarding federal and state roles in vaccine finance make sense?
Vaccine Finance Committee (existing study). Modification of a study that has already been funded (on vaccine finance), to add three additional questions to the original charge:
  1. What finance strategies are available to federal and state governments and private providers in purchasing vaccines to respond to national emergencies or regional outbreaks?
  2. What is the relationship between finance strategies used by public agencies to purchase vaccines for routine use and those that are used to respond to national emergencies?
  3. Are existing vaccine purchase plans adequate to maintain a state of readiness in response to national emergencies and regional outbreaks while also meeting the traditional needs of immunization programs throughout the United States?
Comprehensive Biological Preventive Policy Study to examine all of the pieces, and recommend a national policy responsive to the immediate and near-term needs for vaccines and other biological agents to prevent or mitigate diseases introduced by terrorists, and the complex, longer-term problems that must be resolved to assure the development and availability (affordability) of all vaccines, anti-viral, and antibacterial agents.
Surveillance systems. What types of surveillance systems are necessary to provide national and local detection of disease outbreaks and to track the course of an epidemic - over time and place, in sub-populations and by risk factors? Robust surveillance systems will be necessary to evaluate the effectiveness of prevention measures, to allocate resources for prevention, treatment and care services. Current disease surveillance systems are wholly inadequate for these purposes. As comprehensive and more aggressive systems are developed a range of highly sensitive issues must be addressed including reporting requirements, and the fears of certain groups (particularly African Americans) that authorities will inappropriately use the systems for law-enforcement or harassment purposes unrelated to public health needs. If such concerns are not addressed, they will further compromise the willingness of minority populations to engage with the public health system. A fast-track report on surveillance systems, identifying critical issues and making recommendations about how to address them, could be one of the first priorities of IOM's efforts.
Laboratory Capacity. Without adequate laboratory capacity, surveillance systems are blind. State and regional laboratory capacity has been severely degraded over the last decade, with a loss of not only physical plant but also trained professionals. Rebuilding capacity will require a regional/national planning effort, new approaches to funding public laboratories and reimbursing private labs that guarantee capacity for public health testing. A fast track study focused on laboratory capacity and funding approaches could flesh out options for federal and state officials.
Interventions to address the psychological consequences of terrorism. This could be accomplished through an analysis of the existing literature on disasters (domestic and international), as well as related literature on stress, depression and anxiety. Interventions at all levels (individual, community, and society) should be addressed. The analysis should include acute events and the continued threat of future terrorist events with special attention to public health campaigns and to high-risk populations (related to communication node). Products would be addressed to health care professionals, federal and state agencies, and households.
The long-term mental health consequences of asymmetric warfare. The unpredictability, probability, malicious intent and fear of contagion exacerbate the psychological and physiological impact of chronic stresses. Ethnic diversity and cultural experiences of the U.S. population will influence perceptions and reactions. Chronic stress imposed by the unsettling circumstances can have far-reaching implications for society that should be better understood. These will range from individual decisions about where to live, the value of saving and investing, education and occupational choices to broad attitudinal changes regarding privacy, trust and tolerance of diversity. The reactions of children and adolescents whose security has been disrupted can have long-lasting implications for our society. A study on this topic would assess the likely psychological consequences of asymmetric warfare and consider prevention and treatment interventions to mitigate its negative impact.
What are the immediate issues for communities, organizations, employers, and schools? How should they deal with the acute problems - non-functional employees, terrified children? The research literature on the effects of different types of post-trauma interventions (in schools, workplaces, and communities) is not large. However, a number of European scholars have studied the issue, and their findings challenge conventional wisdom regarding group counseling and other responses that were widely employed in the U.S. following September 11th and other events such as the Columbine killings. A committee workshop exploring the available research and summarizing it could be valuable to multiple audiences.
Education and training needs for personnel to carry out these Functions. A study of the Future of Schools of Public Health held its first meeting in November. The committee was asked to pay special attention to training needs related to terrorism. In addition, the study underway on Microbial Threats to Health in the 21st Century will contain a section on bioterrorism, and may include recommendations regarding training. The final report of the Committee to Assess the Metropolitan Medical Response System Program will address training issues. Other activities may also be considered.
The ideas above will be discussed by the Board on Neurosciences and Behavioral Health, the Health Sciences Policy Board, and the Board on Health Promotion and Disease Prevention at their meetings in November and December. We expect additional suggestions from these Boards, as well as a critique of the ideas contained in this memo.

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