The treat of terrorism marks daily life in Washington, D.C., as it does in no other place. The low, hollow whoosh of jet fighters on routine patrol continues to echo through the skies day and night. The Supreme Court sat in session outside of its chambers for the first time in history, and congressional office buildings have been closed because of the threats of anthrax. Life has changed, perhaps too much so.
"I believe that we will see many, many more civilian casualties" from terrorism, said Michael Osterholm, who for 15 years was chief epidemiologist of Minnesota and built that public health service into one of the best in the nation.
Sen. Bill Frist, R-Tenn., the only physician in the Senate, agreed with that assessment. They were among the speakers at a Nov. 1 forum on bioterrorism and biodefense that originally had been scheduled for the Hart Senate Office Building, now closed due to exposure to anthrax.
Closing that building was "unfortunate and unnecessary" said Osterholm. "It sends a very bad message to the public that we have a bigger problem than we do." He explained that the larger particles had settled and unless disturbed would not cause a problem, while the smaller ones had long since dissipated to concentrations that would not cause infection.
Frist called public health "a system that is not unprepared but it clearly is under prepared" for bioterrorism. "We have underinvested as a nation" in public health and preparation for bioterrorism.
"The assumptions that we would have made a month ago, throw them out the window." He said that scientists, physicians and the American public are all on "a steep learning curve" when it comes to anthrax and similar issues.
Laurie Garrett, reporter for Newsday and author of the best selling book The Coming Plague, praised Frist as "a remarkable communicator as a physician/Senator" during the last few weeks. She feared that the $1.4 billion appropriated for public health preparedness "will get sucked up" purchasing pharmaceuticals to store in warehouses.
Only $10 million is going to filter down to bolster the public health laboratories necessary to identify such disease threats in individuals. Garrett said that the city of Omaha, Neb., is offering $55,000-a-year for the public health director it is seeking to hire. The applicant must have a MD and MPH. It is no wonder that the public health infrastructure is frayed.
Osterholm accused Congress of sending "a horrible, horrible message" by quickly bailing out the nation's airlines so that some of them actually reported a profit, while at the same time lagging on efforts to bolster the nation's public health infrastructure.
Margaret Hamburg, former Assistant Secretary at the Department of Health and Human Services, said that we need to think about bioterrorism in the context of infectious disease. That includes adopting a global perspective because modern transportation can quickly spread infection across national borders.
The healthcare system, like much of American business, has developed a "just in time" approach that minimizes inventories, capacity, and the ability to respond in emergencies. Those capacities have to be built up in order to handle a crisis. The key roadblock is not medicines or even hospital beds but skilled personnel to make the diagnosis of unusual diseases and sufficient labs and technicians to run the tests that make such diagnosis possible.
Garrett used the example of Hawaii where health officials identified an outbreak of dengue fever on Sept. 10. Only one person in the entire state was trained to run the lab tests to identify that disease and anthrax. And they were not able to get the necessary reagents from the Centers for Disease Control to run the dengue lab tests because CDC was overworked. Some medical supplies in the state ran low when airplanes were grounded for several days.
"Infectious agents do push all of our ancestral buttons of fear," said Osterholm. "The psychology of this situation is as important as the physiology. The fear and panic and the effect on society cannot be underestimated with terrorism. We have to address that as a society."
"We have a choice," he said, "We can live in fear or we can live with fear." Osterholm believes there is a window of opportunity in which to prepare the public health system. Unfortunately that will mean adopting "the military concept of anticipated losses," and working to minimize them.