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Lessons learned from last fall's anthrax attacks

From the April ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

In the wake of last fall's anthrax attacks, it became woefully clear that the U.S. health care system was not prepared to handle a sustained bioterrorist attack. Hospitals had no surge capacity, physicians weren't trained to recognize unusual agents and funding to get anyone up to speed was just a dream.

Since then, much has changed. The federal government has begun distributing the $1.1 billion approved for bioterrorism defense to the states. According to the CDC, it is the single largest funding allocation for public health in the nation's history.

That's good news for officials like Julie Casani, MD, MPH, bioterrorism coordinator for Maryland's Department of Health and Mental Hygiene. During last fall's anthrax crisis, Dr. Casani—an internist and emergency physician—rushed to coordinate the state's response, from local physicians to the CDC and across state agencies. Three people in the state presented with inhalational anthrax, and two of them died.

Dr. Casani, who conducts training seminars on bioterrorism for physicians and other providers, said the attacks put a spotlight on the cracks that have formed in this country's public health system. "We have 'skinnied down' public health to almost bare bones in some places," she explained.

Recruiting more public health experts, however, is only part of the solution. Because public health has taken on such a low profile in recent years, the relationship between physicians and public health officials has suffered. Instead of working together to fight common enemies like polio, most physicians talk to public health representatives only when they have to report problems like sexually transmitted diseases.

"The relationship has become an occasional reporting mechanism instead of a collaborative partnership," Dr. Casani explained. "Last fall, the credibility and familiarity between the two groups had to be re-established very quickly."

To recreate that partnership, she said, physicians must do more than put the local health department's phone number higher on their phone list. They must also build relationships that they can count on during a crisis like the anthrax attacks.

"One of the lessons we learned was that pre-established relationships are invaluable," she said. "The people we knew, the ones we'd talked to and had lunch with at meetings, those were the people we called."

Although problems came to light last fall, Dr. Casani said that some strengths also emerged. The local medical community, for example, showed a remarkable degree of solidarity during the crisis, as state and specialty medical societies gave public health officials access to their e-mail databases and fax networks to contact physicians.

And once the initial shock of the attacks wore off, she added, most physicians reacted calmly and professionally. "People thought we had to create a whole new wheel, but we didn't," she said. "Physicians are taught in medical school how to recognize unusual cases, so once we got over our initial panic, we realized we were dealing with an infectious disease and that we could pull this together."

In any future crisis, she hopes to make better use of the volunteerism demonstrated by individual physicians in the community. Several states, she said, are busy preparing groups of doctors who want to be mobilized in the event of another attack.

Because unprepared "volunteer" physicians can be a liability during an actual event, states and medical organizations are convening loose networks of physicians willing to undergo brief orientation on how to work together as a team.

"Everyone pays attention to the 'traditional' first responders—fire, rescue and EMS," said Dr. Casani. Those groups, however, will not be on the front lines in a bioterror attack. "Physicians, whether in their offices or hospitals, will be the first responders. But with that focus comes responsibility."

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