For many citizens, the term “biodefense” conjures up images of suited-up response personnel looking into cracks and crevasses for potential threats, long lines of civilians awaiting medication, and worried public health officials addressing the nation as events unfold. The reality of planning for a biological attack is quite different. Nonetheless, a wealth of information must be analyzed not only for the past and present state of readiness to cope with such an attack but also for the future level of biological preparedness needed.
In the aftermath of the “anthrax letters” mailed shortly after the 9/11 attacks, U.S. public health and emergency management officials worked quickly to better understand the realities of the chemical, biological, radiological, and nuclear (CBRN) threats against the U.S. homeland. Special emphasis has been placed since then on planning for, and responding to, biological attacks. However, many biological agents – e.g., anthrax, plague, smallpox, and ricin – are extremely difficult to detect and may not cause discernible illness for periods ranging from several hours to several days. For that reason, as well as the potential of those and other agents to cause mass panic and disruption of the infrastructure throughout an entire city or state, biological agents also would be a particularly attractive weapon of choice for would-be terrorists.
Recent Developments & Presidential Mandates In 2006, the Strategic National Stockpile (SNS), a division of the U.S. Centers for Disease Control and Prevention (CDC), began developing more robust detection tools and other resources to help state and local health departments increase their capacity to receive, distribute, and dispense SNS assets in the event of another major emergency or national disaster. In 2007, the CDC’s Technical Assistance Review (TAR) also started: (a) to collect and report data, as viewed from the federal level, of state and local readiness to receive SNS materiel; and (b) to analyze the plans, in accordance with the Cities Readiness Initiative (CRI), of numerous “Metro Statistical Areas” and use that data to upgrade the ability of such areas to ensure the prompt delivery of prophylaxis to their populations within 48 hours after the start of a significant public health emergency – an anthrax attack, for example.
The TAR also provides reviews of other critical criteria – including, but not limited to, the following: (a) the availability of the personnel needed to staff SNS point of distribution (POD) sites; (b) the percentages of the population covered by open PODs as opposed to closed PODs; (c) site security requirements; (d) POD site management; and (e) existing memoranda of understanding. The TAR scores are updated annually and made public.
Clearly, the use of biological agents by terrorists is still a major concern for the nation’s public health and emergency management personnel. Some additional recent analyses and reports have addressed other aspects of the ever-expanding world of biological agents and the need to defend against them. The WMD Prevention and Preparedness Act of 2011, for example, requires, among other things, that:
- The President assign a member of the National Security Council to serve specifically as Special Assistant to the President for Biodefense;
- A national biodefense plan be developed;
- The Administrator of the Federal Emergency Management Agency (FEMA) assist state, local, and tribal authorities in improving and promoting their individual and community preparedness against – and their collective responses to – terrorist attacks involving CBRN materials; and
- Guidance and modeling to enhance the ability of emergency response providers to respond to an attack, including guidance for the dispensing of medical countermeasures, be developed.
Fundamental Goals: An Interdisciplinary Approach Is Required On 31 July 2012, President Obama, in his introduction to the National Strategy for Biosurveillance, focused on several important issues that must be addressed in the near future.
Two significant foundational themes, among others, were stressed in that document. First, the fundamental goal of the national biosurveillance enterprise should be to save lives by ensuring that leaders have the information they need to make timely decisions during a public health emergency. However, biosurveillance products are virtually useless if they are not also distributed and shared in a timely fashion, particularly at the local level.
Second, an interdisciplinary approach must be used to build a successful biosurveillance program – one that incorporates information and knowledge from sectors beyond health, such as law enforcement, intelligence, agriculture, the private sector, and others. Although there have been previous calls to better integrate existing federal biosurveillance efforts, there also have been several daunting challenges. This specific articulation by the White House of the importance of sharing and integrating information across all sectors is intended to help improve coordination and cooperation between and among the many private- and public-sector agencies and organizations. Future advances in technology, the advent and use of social media, and new scientific breakthroughs all provide additional opportunities to strengthen national biosurveillance capabilities.
The Highest & Most Difficult Hurdle: Funding Cutbacks Although it is clear that biodefense is a critical area of concern for the nation’s leaders, there also are other issues related not only to implementation and operationalization but also to cooperation and communication that must be addressed. First, there is a continuing need for sustained funding of the programs at the local, state, and federal levels of government that support biodefense activities. More than two years ago, in fact, the Trust for America’s Health – a non-government private-sector organization headquartered in Washington, D.C. – reported that there have already been numerous funding cutbacks adversely affecting this vital element of the public health infrastructure. More specifically, the Trust said, such cuts had been made on three levels, and included the following:
- State cuts: Of the 33 states and Washington, D.C., that cut funding for public health from FY 2009 to FY 2010, more than half were cutting public health preparedness funding for a second year in a row.
- Local cuts: In January 2010, 53 percent of the nation’s local health departments reported that their core funding had been cut from the previous year, and 47 percent anticipated additional cuts in FY 2011. These and other reductions have resulted in a weakening of the “boots on the ground” capabilities of the public health infrastructure and led to the loss of approximately 23,000 jobs – an estimated 15 percent of the local public health workforce – in the two years since January 2008.
- Federal cuts: Since FY 2005, federal support for public health preparedness had been cut by approximately 27 percent.
Past & Current Difficulties, But Future Strengths Clearly, in the years that have passed since the 9/11 attacks, there has been significant forward progress in building and improving the nation’s biodefense capabilities. There was significant stakeholder cooperation, for example, specific to the National Strategy for Biosurveillance that helped outline some excellent points related to that doctrine’s guiding principles and core functions. At the same time, the actual biosurveillance efforts taken at the local, state, and federal levels have been effectively “combat-tested” by such events as the 2009-2010 H1N1 flu pandemic.
Another consistent issue not yet adequately addressed is the true integration of public health emergency preparedness and response efforts into the homeland security framework. The role of public health at the federal, state, and local levels has become an important component of the nation’s overall emergency preparedness efforts. As has been evident during other disasters in the post-9/11 era – the response to Hurricane Sandy, for example – no single agency of government seems to be fully prepared and/or equipped to independently mount an effective response to a major disaster or other mass-casualty emergency. It seems clear, therefore, that any response to a biological event will require close and continuing cooperation between public health and emergency management agencies at all levels of government.
As the newest agency – in at least some respects – on the scene, the public health sector is still working hard on integrating more effectively with other first responder agencies such as police and fire departments and emergency medical services agencies. A continuing challenge impeding such integration is that the public health landscape differs in several respects at the federal, state, and local levels. Failure to take into account limitations at each level almost ensures that there will be a continuing cascade of problems as responses become more complex. A true and more detailed national strategy in this area, therefore, must be developed based on the weakest link in the chain, not the strongest.
For additional information on: Bill Summary & Status, 112th Congress (2011-2012) H.R.2356, visit http://thomas.loc.gov/cgi-bin/bdquery/D?d112:46:./temp/~bssb9ZB
The National Strategy for Biosurveillance, visit http://www.whitehouse.gov/sites/default/files/National_Strategy_for_Biosurveillance_July_2012.pdf?goback=%2Egde_2060384_member_141908766
The 2011 TAR scores, visit http://www.cdc.gov/phpr/pubs-links/2011/documents/SEPT_UPDATE_REPORT_9-13-2011-Final-appendix2.pdf
Trust for America’s Health December 2010 report, visit http://healthyamericans.org/assets/files/TFAH2010ReadyorNot%20FINAL.pdf
________________________ Raphael M. Barishansky, MPH, is the Director of the Office of Emergency Medical Services (EMS) for the Connecticut Department of Public Health. Prior to establishing himself in this position, he served as Chief of Public Health Emergency Preparedness for the Prince George’s County (Maryland) Department of Health and as the Executive Director of the Hudson Valley Regional EMS Council, based in Newburgh, New York. He is a frequent contributor to the DomPrep Journal and other publications and can be reached at email@example.com.