LOCAL RESPONDERS TO MEET THE NEW THREAT OF TERRORISTS

The threat of terrorists using Weapons of Mass Destruction (WMD) has received increased attention in recent years.⁽¹⁾ And by all intents and purposes, from presenters at the First Harvard Symposium on Medical Consequences of Terrorism discusses the worst disasters the human mind can devise and how to counter them with the best efforts of which human nature is capable. They talked of the World Trade Center and Oklahoma City bombings, and the Aum cult nerve gas subway attack in Tokyo, Japan, and discovered that we are not ready. It is the general "we," and the audience made up of the medical first responder community as a whole. Though with Congressional hearings, investigations, and enactment of legislation, funds and programs are being made available to enable the local regional first responder public health agencies to get ready.⁽²⁾ An amendment to the 1997 Defense Authorization Act addresses some of these issues by calling for better training, equipment, and coordination among the emergency response personnel in the United States to deal with a terrorist incident involving a weapon of mass destruction.⁽³⁾

Detecting an attack is just the first problem, civil defense is not ready to handle this form of terrorist attack. America is stepping up preparations to cope with the new form of urban warfare. During May, 1997, in Denver, medical and weapons experts began to assess the city's ability to contend with terrorists using biological, radiological, or chemical weapons of mass destruction. Denver is the first of 120 cities where federal authorities will evaluate emergency capabilities under a $42.3 million Domestic Preparedness Program that is the largest civil defense initiative since the Cold War.⁽⁴⁾ This facilitation and enhancement of civil-military cooperation, was due to the enactment of the Defense Against Weapons of Mass Destruction Act of 1996, which seeks to increase our domestic preparedness in several fundamental ways to prevent and respond to terrorist incidents involving weapons of mass destruction, including the following: by enabling the Department of Defense and other federal supports to state and local prevention and response efforts; and by improving the capabilities of state and local emergency responders themselves. The 120 cities in the United States that have already been designated under the provisions of this legislation; their fire, police, rescue, and hospital emergency department personnel will receive training and equipment in this Department of Defense conducted program. This enhanced cooperation between military and civilian institutions is likely to pay big dividends if the challenge of altering our perspective and strategic thinking to allow the U.S. military a role in protecting the civilian population, and not just one of defending the United States against threats on foreign soil is achievable. The current case in point of an event that showcased the multi-agency partnerships that spanned federal, state, and local jurisdictions, and would serve as model for future response, was the Atlanta Olympics.⁽⁵⁾

REGIONAL MEDICAL PUBLIC HEALTH AS COUNTERTERRORIST

The FBI definition of terrorism is, the use of violence or the threat of violence in furtherance of a political or social agenda.⁽⁶⁾ Using US Federal Court terminology, a definition of counterterroism is counteracting groups making political statements through violent crimes designed to terrify the general civilian population. (The Mafia makes a statement sticking a horse's head in the bed of a capo but this doesn't scare the average person the way the World Trade Center bombing did.) The various agencies involved in counterterrorism are the Federal Bureau of Investigation, the Central Intelligence Agency, the National Security Agency, the Secret Service, the Justice Department, the State Department, military intelligence, and the intelligence divisions of big-city police departments. The FBI is the lead agency in counter-terrorism. This term is not interchangeable with counterintelligence - counteracting foreign governments trying to acquire sophisticated technology from the United States.⁽⁷⁾ Local medical personnel also contribute to the counterterrorism role in their functions of caring for and treating the injured, by being trained in recognizing the site of a chemical or biological terrorist incident is both a disaster area and a crime scene. Once the conflicts between the delivery of emergency medical assistance and the collection of forensic evidence are addressed, the efforts after saving human lives can be directed at preserving the chain of custody of evidence needed for successful criminal prosecution of the terrorist.⁽⁸⁾ Successful, competent, and appropriate swift treatment of causalities to a terrorist WMD attack does much to mitigate the stressors of fear and uncertainty inherent in such a horrendous event. This is itself diminishes the terrorists' ability to achiever their overall goal - the induction of terror.⁽⁹⁾

SURVEILLANCE AND REPORTING

The California Administrative Code, Title 17, Health. Section 2500, Reporting to the Local Health Authority, mandates that: It shall be the duty of every physician, practitioner, dentist, coroner, every superintendent or manger of a dispensary, hospital, clinic, or any other person knowing of or in attendance on a case or suspected case of any of the following diseases or conditions, to notify the local health authority.⁽¹⁰⁾ Reporting is the intake of any good infectious disease surveillance system. Having such a surveillance system would provide the benefits of establishing a more efficient system for detection and diagnosis of the possible terrorist strike vector, ensure a coordinated and effective public health response to future or multiple outbreaks/attacks, provide a mechanism for distribution of antitoxin in the event of an intentional poisoning, and provide data regarding the epidemiology of the biologic agent that could prevent future cases.⁽¹¹⁾ Unfortunately, the best detectors of biologic agents are human beings, and because of the dangers of working with such agents, the person who shows up in a public health ER may be the terrorist or future terrorist himself. Physicans should keep a high index of suspicion for any unusual diseases that show up. They could be intentionally caused, and an indicator of terrorist activity.⁽¹²⁾

FORECASTING THE COST OF TERROR AND COUNTER TERRORISM

Using an insurance risk analogy, a model was tested to provide economic justification for preparedness measures. Rapid implementation of a postattack prophylaxis program was the single most important means of reducing losses. The three classic biologic warfare agents the model compared were Bacillus antracis, Brucella melitensis, and Francisella tularensis released as aerosols in the suburb of a major city. The model was designed to show economic impact.⁽¹³⁾ Delay in starting a prophyslaxis program was the single most important factor for increased losses. This observation was supported by computing a actuarially fair premium for preparedness analysis. Reductions in preventable loss due to early intervention had significantly greater impact on the amount of an actuarially fair premium than reductions in probability of an attack through intelligence gathering and related activities. Counter terrorism is measures taken to mitigate the event after the attack. Prophylasix programs prevent disease after infection has occurred. Attack prevention measures seek to prevent infection, although implemented at different times in a threat-attack continuum, both attack prevention measures and prophylaxis programs are forms of preventive medicine, and in these situation are in the broad sense counter terrorist measures used by regional public health facilities to mitigate WMD terrorism.
 
 
 
 

References

Callen, D. 1997. Information Exchange. Transit Security Newsletter, July:1.

Chin, J., and P. Rank. 1983. Control of Communicable Diseases in California. Berkeley, CA: California State Department of Health Services.

Ember, L. R. 1996. FBI tales lead in developing counterterrorism effort. Chemical & Engineering News, 4 November:10-16.

------. 1996. Marines offer rapid response to chemical/biological terrorism. Chemical & Engineering News, 1 July:22-23.

Goldsmith, M. F. 1996. Preparing for Medical Consequences of Terrorism. JAMA 275(22, 12 June):1713-1714.

Harris, E. F. 1995. Guarding the secrets: Palestinian terrorism and a father's murder of his too-American daughter. New York: Scribner.

Holloway, H. C., A. E. Norwood, C. S. Fullerton, C. C. Engel, Jr., and R. J. Ursano. 1997. The threat of biological weapons, prophylaxis and mitigation of psychological and social consequences. JAMA 278(5, 6 August):425-427.

Horrock, N. 1997. The new terror fear: biological weapons. U.S. News & World Report, 12 May:36.

Kaufman, A. F., M. I. Meltzer, and G. P. Schmid. 1997. The economic impact of a bioterrorist attack: are prevention and postattack intervention programs justifiable? Emerging Infectious Diseases 3(2, April-June):http://www.cdc.gov/ncidod/EID/vol3/no2/kaufman.htm.

Shapiro, R. L., C. Hatheway, J. Becher, and D. L. Swerdlow. 1997. Botulism surveillance and emergency response, a public health strategy for a global challenge. JAMA 278(5, 6 August):433-435.

Sopko, J. F. 1996-97. The Changing Proliferation Threat. Foreign Policy 105 (Winter):3-20.

Tucker, J. B. 1997. National Health and Medical Services responses to incidents of chemical and biological terrorism. JAMA 278(5, 6 August):362-368.

MEMBER of the POD

MEMBER of the POD

1. ¹ Goldsmith, M. F. 1996. Preparing for Medical Consequences of Terrorism. JAMA 275(22, 12 June):1713-1714.

2. ² Callen, D. 1997. Information Exchange. Transit Security Newsletter, July:1.

3. ³ Sopko, J. F. 1996-97. The Changing Proliferation Threat. Foreign Policy 105 (Winter):3-20.

4. ⁴ Horrock, N. 1997. The new terror fear: biological weapons. U.S. News & World Report, 12 May:36.

5. ⁵ Tucker, J. B. 1997. National Health and Medical Services responses to incidents of chemical and biological terrorism. JAMA 278(5, 6 August):362-368; Ember, L. R. 1996. FBI tales lead in developing counterterrorism effort. Chemical & Engineering News, 4 November:10-16; Ember, L. R. 1996. Marines offer rapid response to chemical/biological terrorism. Chemical & Engineering News, 1 July:22-23.

6. ⁶ Goldsmith, M. F. 1996. Preparing for Medical Consequences of Terrorism. JAMA 275(22, 12 June):1713-1714.

7. ⁷ Harris, E. F. 1995. Guarding the secrets: Palestinian terrorism and a father's murder of his too-American daughter. New York: Scribner.

8. ⁸ Tucker, J. B. 1997. National Health and Medical Services responses to incidents of chemical and biological terrorism. JAMA 278(5, 6 August):362-368.

9. ⁹ Holloway, H. C., A. E. Norwood, C. S. Fullerton, C. C. Engel, Jr., and R. J. Ursano. 1997. The threat of biological weapons, prophylaxis and mitigation of psychological and social consequences. JAMA 278(5, 6 August):425-427.

10. ¹⁰ Chin, J., and P. Rank. 1983. Control of Communicable Diseases in California. Berkeley, CA: California State Department of Health Services.

11. ¹¹ Shapiro, R. L., C. Hatheway, J. Becher, and D. L. Swerdlow. 1997. Botulism surveillance and emergency response, a public health strategy for a global challenge. JAMA 278(5, 6 August):433-435.

12. ¹² Goldsmith, M. F. 1996. Preparing for Medical Consequences of Terrorism. JAMA 275(22, 12 June):1713-1714.

13. ¹³ Kaufman, A. F., M. I. Meltzer, and G. P. Schmid. 1997. The economic impact of a bioterrorist attack: are prevention and postattack intervention programs justifiable? Emerging Infectious Diseases 3(2, April-June):http://www.cdc.gov/ncidod/EID/vol3/no2/kaufman.htm.