This report depicts the scenario that will ensue if a terrorist attack were launched against an urban population center in the US today. Such an attack may employ suicide commandos as in 9/11 or use bio-chemical weapons, whose development and possible deployment have become as real as the anthrax crisis also in 2001 when suspected terrorists mailed anthrax-tainted letters to selected American officials and media men. That orchestrated attack left 5 persons dead and 12 cases of infection. Presidential Directive 39 came as a response to these events, which ordered the improvement of mitigation and response activities during terrorist attacks. Discussion for this paper then centers on how the political decision-makers, health/medical personnel, and emergency groups run an emergency response and mitigation management of a terrorist attack in the same or bigger magnitude than 9/11 and the 2001 anthrax scare. The scenario assumes that the attack, which may be delivered in a single blow or a series of strikes, kills millions of people so as to cause large-scale panic among the populace.
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An effective response is only one of four capabilities in disaster management that the Department of Homeland Security tries to develop, the other three phases being preparedness, recovery, and mitigation (Carafano, 2005). On preparedness, the evidence suggests that the US has yet to satisfactorily address the behavioral and organizational challenges posed by bioterrorism. According to Fischer III (2000), this contention is supported by official admissions that there are neither sufficient safeguards nor adequate preparations for bioterrorist attacks. In fact, the government in the National Strategy to Combat Weapons of Mass Destruction conceded that its defense is based only against chemical threats not against bioweapons. Setting this question of preparedness aside, the paper proceeds to catalog on a step-by-step basis the possible behavioral and organizational response to an emergency caused by a terrorist attack.
Assuming a biochemical weapon is released into a metropolitan area, the initial reaction would be fear of a flu outbreak since diagnoses of patients that will crowd medical centers and hospital emergency rooms show the general flu-like symptoms. Remedies for flu are duly prescribed but within 24 to 36 hours, at least half of these patients are dead. More serious testing begins to determine the precise medical culprit. Local political leaders and the media soon become aware of what the medical practitioners are encountering. It is determined that perhaps tens of thousands have developed these symptoms in this city alone, as a result of which the local healthcare delivery system will be completely overwhelmed.
Rumors rapidly spread throughout the city then the nation and the world, as television networks pick up the story. Reporters speculate that there is either a problem in the food distribution system, or there has been an accident at a laboratory that has been covered up, or we may be under attack from a foreign or domestic enemy. Political leaders at various levels indicate that an investigation has begun, the Centers for Disease Control and Prevention have been mobilized, and all appropriate steps are being taken to control the problem, cautioning against panic. They admit, however, all they really know at this point is what they themselves are getting from the media. Emergency response organizations begin to take steps to determine what they should do. Political leaders, law enforcement, and others discuss what steps they should take to prevent further exposure to whatever is causing the illness (Glass & Schoch-Spana, 2002).
As the number of victims grows, the idea for quarantine comes up with political leaders and organizations divided on which group should be quarantined and how large is the area to be quarantined. There will be suggestions of evacuating the healthy to safer areas to prevent further exposure and other officials will object. The reason for this divergence of views is that biochemical agents are invisible and odorless such that no one knows a terrorist attack is underway unless there was an earlier warning which is unlikely. Meanwhile, emergency response agencies work on the premise that an outbreak of a deadly flu virus has hit the aforesaid city. Family medical practitioners are inundated with patient phone calls for appointments and medical centers and hospital emergency rooms are suddenly besieged with those experiencing severe symptoms.
Subsequent diagnoses eventually reveal that the city has been exposed to a biochemical agent instead of flu, leading to conclusions of a terrorist attack. At this point, all federal agencies are mobilized into action as fear sweeps the nation. The CDC and its affiliated agencies such as the National Center for Injury Prevention and Control, National Center for Immunization and Respiratory Diseases, National Center for Environmental Health, and National Center for Zoonotic, Vector-Borne and Enteric Diseases assisted by the military and police spearhead a crash program to stock up on protective masks and decontamination equipment and to train personnel on decontamination procedures. A mass vaccination program has also started together with emergency antibiotics treatment (Glass & Schoch-Spana, 2002). These activities are complemented by public education programs to instruct citizens on what to do in case of a renewed attack.
If quarantine is determined as the appropriate response, public reaction to this measure will be divided. Most will cooperate and comply with the quarantine announcement but many will avoid being kept within the quarantine areas. The police and military will have their hand’s full handling looters and similar deviant behaviors, which become more pronounced as the emergency deepens.
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The reason is that as the crisis continues, it becomes increasingly difficult for victims, survivors, and caregivers to meet basic human needs (Fischer, 2000). So people in need of food and medicines will decide to grab these from available sources, which may lie rotting in stores anyway. Police authorities watch helplessly as shoppers converge on stores and engage in panic buying, thereby depleting the supplies in these stores. A breakdown in communications systems is likely since telephone calls will surpass their capacity.
On evacuation, this emergency response will create another set of problems for authorities. Families will want to leave together not as individuals and many will refuse to evacuate for fear that this may actually expose them to the bacterial agent. Many will also refuse to leave for fear that their property may be looted. It will take great effort on the part of authorities to convince these people that their property will be safe or that their lives are more important than any property. Thus, a large percentage of the population targeted for evacuation will not move when told to do so such that many will remain in the metropolitan area. As for the people who agree to evacuate, they will create traffic gridlocks as their vehicles converge along the exit routes. An extraordinary number of policemen are needed to make this movement orderly.
Announcement of the evacuation itself is a delicate process and must be done without fanning panic. Evacuation as a responsible decision is poor if decision-makers exaggerate the fear or if the measure is not warranted by initial findings of the disaster research. If the extent of the damage does not require evacuation, it victimizes more people rather than mitigates further exposure (Fischer, 2000). As the events unfold, political decision-makers and emergency organizations have to be careful of the information they feed to the media, which is considered an important factor in emergency response. The press needs a steady diet of timely and accurate information, otherwise, rumors will be purveyed as fact to muddle the situation and create unnecessary panic. The print and broadcast media are regularly updated on evacuation or quarantine plans as well as medical developments. For this reason, media command posts manned by highly trained professionals are established to distribute information and instructions.
The crisis will place great demands on all organizations concerned with health care, law enforcement, and political decision-making that far exceed their ability to effectively respond. Federal support in the form of military transport and dissemination of medical and subsistence supplies will be needed in unprecedented amounts. The stockpiling of necessary supplies within the disaster area is of utmost importance as is public education. Citizens need to be provided with accurate and helpful information to enhance their chance of effectively responding at the individual and family level, thereby enhancing the process of mitigation.
During an emergency, people are usually slow to respond to information and instructions, hence instructions for an evacuation or quarantine and information on where to obtain medical supplies should be articulated clearly, specifically, and repeatedly to be effective (Fischer, 2000). It is wrong for emergency personnel to assume that once such information has been disseminated, all the intended recipients will understand and respond. There is no guarantee that they receive the information the first, second, or third time it was passed and many will have a clear understanding. Even when the information is clearly understood, the recipient may still not follow the instructions for any number of reasons, among them disbelief, distrust, and refusal to leave home while separated from other family members.
For this reason, Carafana (2005) argues that the best time to educate citizens on how to respond to a biological or chemical terrorist attack is during normal times. This way, they will be in a much better position to respond effectively if they have prior training. Decision-makers may hesitate to engage the public in such a dialogue prior to an actual terrorist event, for fear of upsetting the public or contributing to a panic. There is consistent support to the argument that the public can be trusted far more than decision-makers think it can.
Recovery in emergency management refers to the cleanup stage when the affected population needs expert assistance to recover from the trauma, while mitigation ensures that the disaster will not be repeated (Carafana, 2005). These capabilities are built into the existing healthcare system through federal health agencies, public hospitals, and the office of the US Surgeon General.
However, the inadequacy of this system to respond to any statewide emergencies such as a biochemical attack showed during the 2001 crisis on anthrax-tainted letters. When the problem became a full-blown crisis, it exposed the shortcomings of the city’s health and crisis response systems. New York’s anthrax vigil began as soon as the first cases were positively diagnosed in Florida. The New York police and the estimated 65,000 physicians in the city were instructed to report and turn in suspicious cases and specimens. When the specimens came, however, the city’s handful of laboratory workers trained in bioterrorism had a hard time telling the real thing from the hoaxes (Glass & Schoch-Spana, 2002). Thus, a problem arose when a biopsy sample of the woman who handled the mail of NBC news anchor Tom Brokaw needed to be examined for anthrax spores. The case had to be brought all the way to Atlanta, the site of the Rapid Response and Advanced Technology (RRAT) laboratory of the CDC, which is the only facility in the world with such a capability. Even so, it took several hours before traces of anthrax were found in the biopsy sample, and only because of a new method developed by Sherif Zaki, top CDC medical examiner, who isolated a magenta-colored spot against blue cells.
For two weeks early in the anthrax scare, the Department of Health and Human Services insisted that one needed to inhale all of 10,000 spores for the agent to be fatal.
Later it was agreed that inhalation of fewer than 10 spores could be lethal, which makes the cleanup operations complex. A year and billions of dollars later, the US once more upgraded its public health systems involving laboratories, computers, scientific research, and hospital personnel training. Most of these upgrading efforts were based on lessons learned from the anthrax scare. But is America ready for another mass mailing of anthrax letters or, worse, a contagious disease attack? The CDC, through its director in 2002, Julie Gerberding, admitted that although some big steps forward had been taken, too much work still remains to be done.
The government acquitted itself well in controlling the anthrax spores but was adjudged to have done a terrible job of dispensing medical advice. Among the decisions said to be ill-advised were: allowing postal workers to continue breathing air in the sorting facility filled with anthrax spores; stocking up on Cipro, which many scientists believed to be unnecessary, even dangerous; hand-wringing on whether to order 300 million doses of smallpox vaccine; and allowing open speculations to spread about quarantines. Another example of inefficiency was the way the CDC people spent more time working on communication, which is important for both public relations and practical reasons. It was observed that the CDC’s Epidemic Intelligence Service, which functions as a sort of disease SWAT team, could not even afford such basic field equipment as two-way pagers. So when field personnel came upon unfamiliar diseases, there was difficulty in informing the doctors about the exact symptoms, the epidemiology, and the best steps to take when patients turn up in their waiting rooms.
In this scenario report, the inter-agency focus of the cleanup operations is on both relieving the affected populace of the trauma and eliminating all remaining traces of biohazards and carbon monoxide. Local health authorities and the CDC and its attached agencies also attend to the safe handling of human remains, the ministration of surviving victims, and the general decontamination process. The Department of Health and Human Services and the National Center for Environmental Health provide the medical needs of those injured and ensure the safety of water and food supply.
Other concerned agencies restore electrical power and similar public facilities.
The anthrax crisis proved to be difficult as to sap the capacities of the public health systems in New York City, which is supposed to be the most modern and complete in the US. As a result, the city government has intensified its focus on bioterrorism preparedness and mitigation. First, the local health department was asked to develop plans and protocols to respond better to threats and emergencies anticipated from bio-terrorism, and then the city set up its own Health Alert Network on bioterrorism and emergency preparedness communications. The State Department of Health now boasts of 4,300 people at the central office, 4 regional offices, 3 field offices, and 9 district offices across the state (NY Public Health Council, 2003).
On the part of the federal government, the CDC has established a $90-million computer link that connects the federal center with every state and local health department in the US. Another project in the pipeline is the establishment of a National Laboratory Research Network, a coast-to-coast diagnostic facilities system that would receive and analyze specimens from across the US. This would respond to such problems as those encountered during the anthrax crisis when incoming specimens overwhelmed most of the laboratories in the network. It was estimated that another $10 billion is needed to bolster the country’s public health system to respond more efficiently to a similar anthrax attack. It can be said that whoever first posted the anthrax letter through the US mail did the country a favor because at long last Americans are taking seriously a threat that has existed for years (NY Public Health Council, 2003).
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As an offshoot of 9/11, New York City has also started to address the threat of future terrorist acts on a permanent basis. Under an anti-terrorist program called Omega, as many as 1,400 officers are assigned daily to security patrols, posts at bridges and tunnels, the city hall, landmarks, and traffic checkpoints. The NYPD has also created the position of Deputy Commissioner for Terrorism, formed a Counter-terrorism Task Force, and assigned doctors at police headquarters who are trained in biological, chemical, and radiological weapons. In addition, police regularly undergo specialized training in anti-terrorism for future responses to attacks. The new police equipment includes protective suits, gas masks, and more sophisticated sensors to detect chemical, biological, and radiological weapons (Fischer III, 2000).
As for CDC, it now disseminates educational materials on the following dos and don’ts: 1) do not shake or empty the contents of any suspicious package or envelope; 2) do not carry the package or envelope, show it to others, or allow others to examine it; 3) put the package or envelope down on a stable surface; 4) do not sniff, touch, taste, or look closely at it or at any contents that may have spilled; 5) alert others in the area about the suspicious package or envelope; 6) leave the area, close any doors and take actions to prevent others from entering the area; 7) wash hands with soap and water to prevent spreading potentially infectious material to face or skin; 8) seek additional instructions for exposed or potentially exposed persons, which may come from a supervisor, a security officer, or a law enforcement official; and 9) make a list of people in the room or area when this suspicious letter or package was recognized and a list of persons who also may have handled this package or letter, which should then be given to both local public health authorities and law enforcement officials (NY Public Health Council, 2003).
Some nine years after 9/11 and the anthrax attack, a vaccine has been licensed to reverse the effects of biochemical agents but this requires multiple doses over a long period and so needs improved preparation. To make a new and better vaccine and make it available quickly for a variety of bioterror agents like anthrax is precisely the goal of the Bush government’s Project Bioshield. Because of the lessons learned from 9/11, the federal health system tasked to respond to emergencies also places equal attention now on prevention from vaccinating children to preventing exposures to lead and from curbing teenage drinking and drug use to evaluating family violence programs. The previous situation in which less than 2 percent of public health resources were allotted for disease prevention has been ameliorated (NY Public health Council, 2003).
In February 2003, then-President Bush announced the establishment of Project Bioshield for the research and production of “needed drugs and vaccines” to combat the threat of bioterrorism. The project’s aim is to make quickly available “safer and more effective vaccines and treatments” against such biowarfare agents as smallpox, anthrax, botulinum toxin, ebola, and plague. Under Project Bioshield, the government will have the spending authority to purchase these vaccines in huge amounts, sufficient to meet any emergency that may occur. This means that emergency personnel will not run short of medical supplies in case disaster strikes. They should also settle the question of when, where, and from whom victims should seek medical assistance.
The quality of the initial organizational response is important since lack of good information will create more chaos and medical and emergency organizations are likely to be swamped by the gravity of the disaster. Moreover, the public must be educated beforehand about the scope of the likely medical outcome and response problems, as well as how to prepare themselves for such an event. Citizens should receive appropriate inoculations if they so desire and appropriate equipment and medical supplies should be stockpiled in a manner that will lead to their effective use during the pre-impact and immediate post-impact time periods. Decision-makers and emergency personnel should also receive training on the actual rather than mythical behavioral and organizational response.
Scientists and medical specialists agree that an emergency on the order of 9/11 calls for the rapid conversion of hospitals, fire departments, public health offices, and diagnostic laboratories into crisis facilities that can process high volumes of material for a sustained amount of time. The US doctrine of preemptive strikes against terrorists and hostile states with suspected biochemical weapons is regarded as a step in the right direction. The focus on bioterrorism preparedness has intensified after 9/11, transforming the way public health is practiced. In New York, for example, the local health department is working overtime to develop plans and protocols to respond to threats and emergencies anticipated from bioterrorism, which is a problem that will not be confined to the attack site but will affect the whole world.
Carafana, J.J. Homeland Security. McGraw-Hill, 2005.
Fischer III, H.W. Mitigation and Response Planning in a Bio-terrorist Attack. Disaster Prevention and Management, Vol. 9, No. 5, 2000.
Glass, T. & Schoch-Spana, M. Bio-terrorism and the People: How to Vaccinate a City Against Panic. Clinical Infectious Diseases, No. 34, 2002.
NY Public Health Council. New York’s Public Health System for the 21st Century Strengthening. State Public Health Council Report to the Commissioner of Health, New York, 2003.