The Real Biohazards

We do face bioterrorism -- but the three threats we face aren't anthrax, smallpox, and pneumonic plague.

As we confront bioterrorism, wouldn't it be great to have a few experts in the country who really know what's involved? Imagine listening to an emergency-room doctor who had faced a major outbreak of germ warfare. Such an authority would know what to do when thousands of people fall sick, when lifesaving medicines must be rushed to the right people, and when effective quarantining is crucial.

The trouble is, we've never confronted such a crisis before, and so such experts don't exist. Or do they?

Dr. Peter Pons, a senior emergency physician at Denver Health Medical Center, comes remarkably close to the ideal. For nearly a decade, he has been guiding one of the busiest trauma departments in the United States. Even on his routine days, he deals with dozens of life-and-death situations. But in the spring of 2000, Pons ventured into a much scarier world.

He joined Project Topoff, an elaborate four-day simulation of what would happen if terrorists conducted a large-scale release of pneumonic plague. There wasn't any way to "win" this government-run exercise; it was meant to test existing systems to the breaking point. But by the project's end, Pons and other participants knew a lot more about which parts of our emergency-response system work -- and which don't.

First the good news. "Just about everything that we would need to do is familiar to us in some fashion," Pons says. "Most major hospitals have had mass-casualty plans for years. We have thought about how to deal with enormous numbers of people coming in because of plane crashes or chlorine spills from train wrecks. We know how to contact federal authorities for help. Even when it comes to isolating people with contagious diseases, there are some parallels with our day-to-day practices."

Take a few moments to digest his message, and you won't feel quite so powerless. We know more than we think we do about how to deal with biological or chemical terrorism. There is vast expertise in America about rescue operations in general. That basic discipline of planning, command, and logistics will be valuable no matter what the threat.

But don't smile for too long. The Topoff experience and other analyses point to three worrisome shortcomings in our efforts to prepare for bioterrorism. Each is fixable, but there's no telling how little or how much time we have left.

First, we haven't rehearsed the whole spectrum of response plans nearly enough -- especially when they involve big, interlocking groups of people. We know how to start a disaster-response effort at the local-hospital level, and if things get really horrible, we know how to deploy federal stockpiles of vital supplies, such as ventilators, which can be flown or driven to afflicted regions. But when decisions about a worsening medical problem must make their way up the chain of command, we aren't nearly as practiced as we should be.

Take something as simple as telephone communications. "We all think that we know how to run a conference call," says Pons. "But during Topoff, we discovered that if you get 30 or 40 people on a call, and there's a lot of bad news coming in, that call can become chaotic. You need to set a very clear agenda ahead of time, with a very clear goal -- and a way to make sure that the most-important problems get addressed fast, before people bring up all sorts of other issues."

Something similar emerged in Dark Winter, a simulation that Johns Hopkins University ran last summer to see how the United States would respond to a hypothetical smallpox outbreak in Oklahoma. The exercise attracted amazingly savvy role players, with Oklahoma governor Frank Keating playing himself and former senator Sam Nunn acting as the president. But even with those veteran political leaders in command, a paralyzing argument still broke out about whether states or the federal government should have the ultimate say in setting quarantines and distributing scarce medicines and vaccines.

Sadly -- and frighteningly -- the challenges of mounting a fast, well-coordinated response to bioterrorism became all too clear this autumn. In October, investigators reconstructed the path of an anthrax-laden letter sent to Senate majority leader Tom Daschle. But they did not immediately test all postal employees at a Washington, DC mail-sorting facility -- missing their chance to spot what proved to be fatal exposure to the disease.

Federal authorities should have seen it coming. Last July, one of the Dark Winter participants, former New York State health commissioner Margaret Hamburg, urged Congress to increase disaster-response planning dramatically. In her testimony, she said that thinking ahead of time "can greatly mitigate the death and suffering that would result from a bioweapons attack."

There is a second big issue. All throughout the 1990s, hospitals were urged to cut down their inventories and adopt a just-in-time model. That businesslike approach does help cash flow, and, in a calm world with a reliable supply chain, it needn't impinge on care. But now we know that terrorist disruptions can happen on a scale that once seemed unimaginable. In that environment, limited, just-in-time inventories of critical medical supplies are the exact opposite of what we would need.

Fortunately, the just-in-time era of health-care planning seems to be yielding quickly to a margin-of-safety approach. On the federal level, Health and Human Services secretary Tommy Thompson has taken steps to begin stockpiling more than 300 million doses of smallpox vaccine. On a regional level, Colorado and other states are now requiring hospitals to have enough antibiotics on hand to provide every employee with a five-day dose. That way, at least the doctors, nurses, and aides would be well enough to treat a terrorist-induced epidemic.

Finally, one of the most jarring findings of the Topoff and Dark Winter projects was the realization that widespread panic could be as much of a health crisis as anything directly caused by bioterrorism. It's one thing to build the capacity to handle many thousands of attack victims. It's far tougher to cope with millions of the "worried well": Frightened citizens can swamp the health-care system, draining resources by demanding extensive treatment to ward off imagined risks.

The only antidote to panic is clear information presented at a pace that people can absorb calmly. The Internet works well here. The Centers for Disease Control and Prevention (www.bt.cdc.gov) is providing in-depth material to the public. For doctors, the UCLA Center for Public Health and Disasters (www.ph.ucla.edu/cphdr/bioterrorism) is sharing the essentials of diagnosing diseases that are associated with bioterrorism.

Will such crash courses take hold fast enough? That's what has Pons on the edge of his seat. In both the Topoff and Dark Winter exercises, everything happened over the course of a few days -- and before long, the scripted events far outpaced the ability of medical and political leaders to get useful information to the public. Now that he is playing for keeps, Pons hopes that a little extra time -- and well-thought-out messages to the public -- can bring a better outcome.

So far, doctors, hospitals, and the media have been mobilizing astonishingly quickly, trying to educate one another -- and a whole nation -- about bioterrorism. In Dallas, hundreds of doctors are pouring into seminars on how to spot the early signs of anthrax, smallpox, and other potential hazards. In Denver, Pons is taking every chance he gets to brief the public about diagnoses, treatment choices, and the ways that diseases will or will not spread. His belief: We can do a lot to fight bio-terrorism in our emergency rooms, but our biggest victories will be won through smart preparation and good, clear communication that reaches millions of healthy people -- and helps them stay that way.

George Anders (ganders@fast company.com) is Fast Company's Silicon Valley bureau chief. To find a catalog of his columns, click here.