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Hospitals Prepare for First Line of Defense Role

As anthrax cases continue to spread and the public grows ever more anxious, hospitals and health departments across the country are scrambling to bring their facilities up to the daunting task of addressing the possibility of the "next big" terrorist attack. But public health experts and hospital industry officials say that years of cost cutting have left our public healthcare system woefully unprepared to handle an outbreak of anything more severe than the flu--and that our nation's hospitals simply do not have the monitoring systems, supplies, or facilities to handle a major bioterror attack.

The Early Show talks to Dr. Mohammad Akhter, MD, MPH, who is the executive director of the American Public Health Association, the oldest and largest organization of public health professionals in the world. Dr. Akhter is the former commissioner of public health for the District of Columbia. He was also health director for the state of Missouri from 1980 to 1984. He is board certified in preventive medicine.

How prepared is our nation's healthcare system to handle a bioterrorism attack?

The major metropolitan areas like DC and New York are fully prepared to handle the current level of anthrax attacks--a handful of cases--but if there is a massive attack we are not prepared to deal with handling thousands of casualties. We don't have the hospital capacity. And rural areas are even worse off. They are not prepared at all to handle even a small number of casualties because they don't have any kind of monitoring system in place. The National Association of City and County Health Officials did a poll recently and found that 20% of local health departments are prepared, 56% are developing their plans, and 24% are not prepared at all. We have been preparing our external defense for 50 years but we never prepared for a domestic attack. We have only seriously begun put a plan into action since September 11th. But we are learning fast that we need to develop a plan. State and local governments have been working nonstop to become prepared but they can't build capacity overnight: It takes time.

Why are we so unprepared? What are we lacking?

We are lacking a monitoring system where the health department is connected to the hospitals, the ambulance services, the clinics, and the physicians. So like in New York when a case takes place it gets immediately reported to the health department, but that system is not in place in most parts of our country.

How can we put such a system in place?

It's simple. You just have to electronically connect everyone. You put an email system in where all parties are connected to the health department so they can get involved right away and initiate the treatment and the investigation. The isolation and treatment of the patient and the investigation of the source of the infection need to be the primary concerns. In these bioterrorism cases, time is of the essenceWhen we are talking about a bioterrorism agent, it is imperative that we figure out as soon as possible where the disease is coming from so we can stop its spread.

How soon could we get our public health system up to speed?

If the money is available it would take between 18 months to 2 years to get us up to the level where we can deal with any possibility and any eventuality. We have asked for $1 billion to go to state and local health departments so they can build and strengthen their early warning system. But $1 billion is only the down payment that we need to get up to speed. It would cost about $10 billion over 5 years to really strengthen things. No community should be without an early monitoring system. If you don't have an early monitoring system in place then you are a sitting duck. This is not a local problem--this is a war against terrorism--it is a domestic, homeland defense issue and the money needs to come from the federal government to build and stregthen the reporting systems, to increase our hospitals' capacities.

Do we have enough medical staff to handle an outbreak or is just the system that is lacking?

We don't need more doctors, but we need to educate our doctors about these "new" specific diseases. Today's doctors have never seen a case of smallpox, or anthrax, or plague. There hasn't been any smallpox since the 1940s so they wouldn't really know how to recognize it. They need to be taught what to look for and how to recognize the symptoms and to report any suspicious cases. They also need to be able to plug the information into a quick and easy system that enables the health department to react to the cases. Look what just happened in DC: A postal worker came to the hospital sick and was sent home. When he came back the next day he died of anthrax. We can't have things like that happening. The doctors must be trained what to look for and know what to do with that information.

Where is our reporting system currently the best and where is it the worst?

Any major metropolitan area has a good system in place. New York City is currently the best because they started early on with the West Nile Virus outbreak 2 years ago. The West Nile outbreak gave them a head start and they have been building up their system ever since. That is why Giuliani can announce a case of anthrax at midnight--that would not be able to be achieved so quickly in any other jurisdiction. The systems are the weakest in towns with a population of 50,000 people or less. And the problem with terrorists is that they will always attack the weakest part of the system so we need to be vigilant.

So far we've only had to deal with anthrax. What would the situation be like if we were looking at an outbreak of smallpox?

I think we'd have a very different situation. From a public health perspective, we would need to identify one hospital to handle all smallpox cases. You can't just take ech potential patient to a different hospital because they'll infect the staff and patients at all the various hospitals. That is one of our glaring problems: We don't have a facility identified as such. Also, the incubation period between when you are exposed to smallpox and when you get sick is between 1 and 2 weeks. We travel a lot, so you could be walking around feeling fine and spreading the disease. It then becomes extremely difficult to track where each infected person traveled and to vaccinate everyone the infected person came into contact with. Smallpox would pose a much bigger challenge for our system than anthrax. It would require an unprecedented level of cooperation. Local, state, and federal authorities need to isolate the infected patients and to stem the outbreak.

Are we ready to handle something like that?

Not quite. That is why we need to get our act together. We can certainly handle a small outbreak of smallpox--100 people or less. But if there are thousands of people involved then it becomes a domestic and international challenge--the biggest challenge that we have ever had to face. That is why preparedness if so very important. Local preparedness is the key. No national plan will work without local preparedness because spotting and tracking these cases has to take place at the local level.

What about our hospitals' capacity? Can we handle the patient influx?

As you probably know from personal experience, hospitals always have a line at the emergency rooms. We don't have the large staff that we had in the 60s and 70s and we don't have enough beds. People wait for hours to be admitted. We can hardly handle a flu epidemic. We need to expand hospital capacity. We need to have all the regional hospitals get together and decide how they will handle the excess patients in the event of an outbreak. And the federal government must then give the hospital designated to absorb those additional patients the funds to asorb that extra capacity. That would be the easiest way to deal with it and that could be done very quickly. For example, in DC, the health commissioner, Ivan Walks, just reopened a previously closed hospital with 300 beds to absorb potential casualties and he is also setting up a MASH unit that he bought from the US Army that can be set up anywhere and can hold 300 additional patients. Communities need to start looking at their local resources and then decide what they need to do to increase their preparedness--whether they need to expand their current hospitals or buy themselves a MASH unit. We can get enough doctors to staff an outbreak, but we need to have the facilities to hold these people, especially if they are infectious cases.

Why has your organization taken such a strong position on this issue?

Our organization has a professional membership of 55,000 federal, state, and local level health department employees. They make sure that your children are immunize, that the water is clean, and that the food is safe. They are the people that work at the federal, state, and local health departments. They recognize that this is a national issue that must be handled cooperatively at the state and local levels and that there is a great deal of work to be done for the system to operate effectively--to ensure the health of our citizens.

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