“Oh, all roads lead to the hospital. We're born here, we get sick here, we get well here. All these big dramatic moments and the hospital just gobbles 'em up.” --Niles Crane of “Frazier”
Medical systems are a vitally important but oft-neglected component of the nation’s homeland-defense strategy. The Incident Command System (ICS), which provides the guidelines used to respond to catastrophic events, blends the capabilities of different local services and numerous local jurisdictions into an integrated team. The ICS scales upward toward the National Incident Management System (NIMS), which integrates multiple state and federal agencies to coordinate the overall national response to major disasters and other incidents of national significance.
Public health has received large federal grants to rebuild needed infrastructure, but what has been largely left undone is a serious analysis of the role of medical systems. No matter what the disaster, all roads eventually lead to a hospital or other medical facility for the victims. In the case of the clandestine release of an illness-producing chemical, radiological, or biological weapon, the nation will depend upon medical systems not only to treat victims, but also both to detect and characterize the threat.
There are a number of reasons why medical systems are not included as full and equal partners in the national-preparedness architecture. First, most U.S. medical systems are not government agencies, but are independent private businesses. These businesses compete with one another in the health care market and are not always predisposed to cooperate with one another. In addition, each medical system represents a unique organization ranging from single-proprietor clinics to major university medical centers.
Moreover, there is no overarching national organization of medical systems that is specifically responsible for homeland preparedness. In addition – and unlike police or fire departments, many if not all of which are designed to have extra capacity available if needed – medical systems are designed for maximum efficiency. Finally, because most cash inflows to medical systems consist of reimbursement for medical care – and very little if any for preparedness planning – any training drills or exercises, equipment, or personnel costs related to disaster training must be paid for from the medical system’s own capital or operating funds.
Speed Is of the Essence
The net result of these market forces is that the U.S. medical system is both fractured and underfunded, and not focused on medical detection, consequence management, and the broad spectrum of other issues involved in dealing quickly and effectively with acts of terrorism and/or natural disasters.
The need for a greater investment in health care is particularly urgent in the detection of a covert or unannounced terrorist event. Detection of the covert release of an illness-producing substance may be clinically determined either by discerning a unique illness (e.g., one caused by anthrax) from normal illness or by discerning an unexpected pattern of illness in the targeted population.
The anthrax events of 2001 provide an instructive example on the costs of diagnostic delays: Those who received the anthrax threat letters, and presumably inhaled the most spores, suffered no mortality, thanks in large part, it seems evident, because of the quick and effective ICS-mandated response. In contrast, those who became the most severely ill from the anthrax letters – and, in fact all of those who died – were among those who had been exposed covertly to contaminated mail and/or mail-handling systems.
America’s next experience with bioterrorism may not come with a warning letter. Recognizing the need for early detection of covert events, the U.S. Congress has funded both a BioWatch system for environmental monitoring and a BioSense program for data-mining. While the efficacy of environmental monitoring and data-mining for early detection in civilian society has yet to be proven, it already has been demonstrated that bioterrorism and emerging diseases can be, and have been, reliably diagnosed by clinical medical providers (e.g., anthrax in Boca Raton, West Nile Disease, Hantavirus, and Monkeypox).
The Same Thing, Only Different
While requesting funds for a variety of civic services, the National Institutes of Health, and the National Strategic Stockpile, President Bush’s 2006 homeland-security budget proposal does not include language that would improve the actual organization of medical systems for disaster response.
A common misconception is that investing in public health is more or less the same as investing in medical systems per se. That is not the case, though. Although public-health agencies do work hand in hand with hospitals and other medical systems, they are distinctly different organizations. Most public-health agencies are branches of state or local governments, but they usually do not provide medical care to the citizens of the states and communities they represent. Public health functions, rather, as a referral service to evaluate laboratory specimens and disease patterns suspected by clinicians and/or by the general public. For practical purposes, therefore, this means that most public-health officials can deal only with what is reported to them.
Moreover, although every state in the union has enacted mandatory disease-reporting laws, it is estimated that only about 50 percent of the diseases that should be reported actually are reported. The disease-reporting rate seems to depend, in fact, primarily on the prevalent local patterns, with media awareness of the disease also playing a significant role. For example, the reporting rates for AIDS and tuberculosis run between 80 percent and 99 percent, but the rate for meningitis is less than 50 percent.
Disease reporting for less than “newsworthy” diseases is further complicated by individual behaviors and medical practice habits. For example: For every 100 persons infected with Shigella, 76 became symptomatic, 28 consulted a physician, nine physicians ordered stool cultures – seven of which were reported positive (but only six were reported to the local health department) – and only five were reported to the Centers for Disease Control and Prevention (CDC, the national repository for such information).
The First and Primary Victims
It seems clear that, although additional investments in public-health agencies are needed, programs to strengthen the role of medical systems in the homeland-defense architecture might be even more important. Developing a medical system’s role in national defense is a vital need because medical systems will be damaged by communicable disease and contaminations. Biological terrorism may involve highly lethal and/or communicable pathogens that are rare, and in some cases, perhaps, totally unknown to the American medical community.
In addition, some delays and preventable infections of health care workers (HCWs) can be expected to occur. As the experience with the SARS (Severe Acute Respiratory Syndrome) outbreaks of several years ago suggest, the rate of infection for HCWs can be well above the national norm. In fact, of the 8,096 probable SARS cases diagnosed throughout the world – according to statistics based on the onset of symptoms between 1 November 2002 and 31 July 2003 – roughly 21 percent (1,706 workers) were identified as HCWs.
More specifically: In Canada, 109 of the 251 cases reported (43 percent) involved health-care workers. In Singapore, the rate was 47 percent (97 of the 238 cases reported). In Toronto, the rate was 51 percent (73 of 144 cases), and in Hong Kong the rate was 62 percent (85 of the 38 secondary and tertiary cases reported).
It should be noted that a SARS infection is not nearly as lethal as a viral hemorrhagic fever or smallpox would be. Should a covert bioterrorist event occur in the United States and recognition delayed, not only would a high mortality rate be likely, but the ability to care for others would quickly diminish if and when, as seems probable, health care workers themselves became victims. The health care system and its personnel are not only the detectors and responders, but they also would be among the first victims of a covert biological attack.
Needed: A Forensic Epidemiology System
As dire as this situation may seem, it is fixable. A helpful first step to improve detection would be to focus on the development of “medical self-awareness.” While the majority of clinicians may not have a sustaining interest in terrorism-related material, many do. These clinicians should be recruited, trained, and supported to create a forensic epidemiology system. Forensic epidemiology has been defined as: (a) the use of epidemiologic methods as a part of an ongoing investigation of a health problem for which there is suspicion or evidence regarding possible intentional acts or criminal behavior as factors contributing to the health problem; and/or (b) the use of epidemiologic and other public health methods in conjunction with or as an adjunct to an ongoing criminal investigation.
By sharing with clinical providers known terrorist threats against the nation’s health, better initial reporting and analysis could be supported. A forensic epidemiology system may better detect emerging infections, as well as bioterrorist threats, because physician experts would be in the best position to monitor various disease findings and patterns, and to consult with other physicians on their findings. Such a network of clinical experts could also serve as local organizers of response between competing medical systems.
The second important step would be to diminish medical inertia by providing much clearer guidelines for medical-system responses to threat conditions. As terrorist threats to the nation’s health wax and wane, medical systems should be advised about those threats, and funded to add extra capacity in terms of staff and equipment. The National Strategic Stockpile addresses equipment support, but without additional medical staff trained and ready to go, the ability to use that asset will be degraded. Like the DEFCON system that guides the U.S. military to adopt different staffing and deployment postures in response to threats, the nation’s medical systems should be supported to respond to homeland-security threats without having to divert their own operating revenue.
Finally, it should be recognized that, although most medical care is funded as a commodity, many types of medical care have been legislated as a right. Hospitals must be allowed by crisis guidelines to deviate from their “normal-day” regulations. These guidelines would establish common key strategic and ethical strategies under which health care systems would render care.
In addition, compensation for the care rendered would be paid at rates based on the resources expended, rather than on the documentation of individual patient bills. Reimbursement to medical systems must include assurances that the medical system would be fully compensated for crisis care and, as a corollary, be granted relief from various malpractice and regulatory penalties that might otherwise be imposed.