The Pew Charitable Trusts

Hours after Attorney General John Ashcroft warned the American public of the "likelihood of additional terrorist activity" Sunday, Health and Human Services Secretary Tommy Thompson assured viewers of CBS' 60 Minutes that, should terrorists attack using biological or chemical weapons, "we're ready to perform." But Congress' research arm isn't so sure. A bioterrorism report released last week by the General Accounting Office cited numerous concerns with fragmentation and inadequate resources among federal, state and local governments. What do state officials think?

Maryland Health Secretary Georges C. Benjamin, a physician appointed by Gov. Parris N. Glendening two years ago to oversee the state's 10,000 public health employees, says the discussion is no longer theoretical: His department is already working to defend the public. Benjamin, the new president of the Association of State and Territorial Health Officials, says states are in a better position to respond to an act of bioterrorism than they were even three weeks ago but much more needs to be done.

Stateline.org :Despite concerns raised by the Centers for Disease Control (CDC) and the General Accounting Office (GAO) about the preparedness of the nation's public health infrastructure to address a biological or chemical terrorist attack, HHS Secretary Tommy Thompson told CBS' 60 Minutes last night that the United States is prepared to respond, contain the threat, and minimize any damage done. Do you agree with his assessment?

Benjamin : I agree that we expect a lot of work and time and effort in terms of putting in a national response to bioterrorism. It is true that the first efforts are going to need to be at the local level. And therefore we need to spend lots of effort, money and resources on building up that local effort. It is good that we have some support, which I think the Secretary showed last night, in terms of a national response.

A biological event is going to look like a big foodborne outbreak or a local infectious outbreak initially. The vast amount of [detecting] the early warning that is necessary is going to be done locally long before the federal response kicks in. Therefore we need the infrastructure in place at the local level to do that earlier identification and respond to it. We also need the resources to do some prevention.

You know, one of the things that local communities can do for themselves is know who has what and where it is in their community. We have lots of labs and lots of people who grow organisms and some of them work with some pretty risky stuff. And insuring the security of those materials is an initial first step. Linking that information stream with the public health department, with the intelligence community, et cetera, to the extent we need to, is very, very important.

Here in Maryland and [elsewhere], we had a terrible event two weeks ago. But guess what? Our systems are still turned on and we don?t see any opportunity to turn them off any time soon. So, we still need additional resources to keep those systems turned on. You can pool resources from existing services for only so long. And then those existing services fall through. So you can always respond to a disaster in the short term. It's the long-term [consequences] of a disaster that a public health system needs to be able to respond to. And that's very much a local response.

Stateline.org :When you say the system is "turned on," how does it look day-to-day now compared to the way it looked before September 11?

Benjamin :We are doing much more disease surveillance. We have a much lower sensitivity [threshold] to go in and look at a cluster of diseases than we did a few weeks ago. We double check ourselves a lot more. We're more likely to go in and actually look at those records and look at those patients, and talk to those patients' doctors and families than we were two weeks ago.

That's very intensive work. It requires phone calls. It requires visits. These are disease detectives and if you think about the work that goes into a single criminal case and multiply that by five, ten, fifteen, twenty, thirty people, once our index of suspicion is raised, that's very intensive work.

Stateline.org :What budget does Maryland have to do this sort of work and what kind of increase in resources are you talking about?

Benjamin :I don't know the numbers offhand, but I can tell you it wasn't enough. We're fortunate that we?re recipients of funding from the federal government, from the CDC, to help craft some new systems. But those systems are never enough. There isn't enough money to handle this kind of increasing workload.

Stateline.org :Do you think that those resources need to come from the federal government, or are the states going to have to contribute significantly more?

Benjamin :This needs to be a federal government response. This is a national security issue and therefore the money should come from the federal government. The states do step up and they always have.

Stateline.org :Generally, are state health departments the first line of defense against a chemical or biological attack? You've mentioned local response early on. How would you characterize the state health department's role?

Benjamin : The state health department is the intermediary between the feds and the locals. We have the overall coordinating role for the state. We have the global role for planning for the state. We have the linkage to the federal government. So we have a communications, education, and training role.

We are the backup for the local community. There are many communities where to try to duplicate that infrastructure in every single local community would be much more expensive and much more onerous. And to try to have the expertise for a broad variety of diseases, et cetera, you couldn't do it. So, the state serves as a training broker, to bring resources in, to develop those resources as a link.

Those of us who are fortunate to sit in big cities, a lot of those resources are integral to the big city. But many of us who are in smaller communities certainly don't have those resources. We need to be able to broker those federal resources to the local community.

Stateline.org :Secretary Thompson mentioned eight federal "push packs" - secretly located deposits of medication and equipment - that could be rushed to any city after an attack. Are state officials aware of the locations of these push packs?

Benjamin :I know how to get access to it. The CDC director has the authority to release that push pack, and I know how to get hold of Jeff [CDC Director Dr. Jeffrey P. Koplan].

These are huge movements. You've got to move all that material. You've got to have the ability to dispense all of that. It's wonderful that those are going to be there. They got it to New York in seven hours. That?s pretty good. Having said that, the initial response is still going to be local.

Remember that the first few people in an epidemic are going to be people that the local community is treating. So they're going to treat from existing stockpiles and existing medicines and pharmacies and that kind of thing. It's still a local response.

I do think we need to emphasize to the public that we shouldn?t go out and buy antibiotics and stockpile antibiotics for local use. There are lots of more common diseases I would like to see people get their vaccinations for, like their flu shot and their pneumococcal shot and to get their kids all their routine immunizations.

Stateline.org : So you think that the average American is more threatened this fall with the flu than it is from a possible terrorist attack.

Benjamin :Guaranteed that the flu will be here this fall. And I guarantee there will be people who will get pneumococcal pneumonia. I do not know whether there will be a bioterrorist attack. I hope not. But I guarantee those other two things will be here. So I think first things first. I want to make sure the public knows that they absolutely need to do those things.

There are a lot of diseases a terrorist could use. We want to make sure you get the right treatment, either prophylactically or if you get sick, for the right disease. We can target it better if we don't have people simply just dropping pills, which would not be very helpful for them.

Unfortunately, it's a fuzzy message. We do think that we need to get prepared. But in my view, part of that preparedness is telling people what the real risk is. The public is very smart. They'll figure it out. If we tell them what the real risk is and put it in perspective, they'll do the right thing.

Stateline.org :You feel confident about that in light of Attorney General Ashcroft?s remarks over the weekend that there is still a "likelihood of additional terrorist activity?"

Benjamin : Yes. But remember you don't know what, you don't know where and you don't know when. There is no magic bullet antibiotic and there is no magic bullet vaccine. You've got to know what you're treating. And it's true that, for those things for which we do have vaccines, the federal government has it available. They have it in the push packs. And we will have to decide at that point who to give it to, when to give it and that kind of thing.

Stateline.org :A lot of questions have been raised, most recently last week in a report on bioterrorism released by the GAO, over the preparedness of the federal and state governmenta. Are any states really ready in the strict sense for a bioterrorist attack?

Benjamin :I think the correct response, and I can't speak for all states, is that many of us are much more prepared now than we were four years ago. But we've got a ways to go. I?m more confident in my state that we will pick something up much sooner than four years ago and certainly much sooner than we would have two weeks ago.

Stateline.org :What do states need to do?

Benjamin :The first thing they need to do is assess what their resources are right now. What do I need and what do I have. They need to identify their experts. I think they need to look at what their surge capacity is, what the bed capacity is in their hospitals, to have some feeling for how many new patients they can handle. And then the second question is, if they get full, where would they call for help?

They need to bring their telephone trees up to speed and make sure they know who to talk to at the federal level. They need to make sure - you know, a lot of public health people don't know who their emergency managers are, the state equivalent of FEMA. They need to pick up the phone and identify them so they know who they are. They need to sit down with their hospital association and begin the discussion about hospital preparedness, so that there isn't confusion if something happens. They need to review their legal authorities in terms of treating people, quarantining, isolation, opening and closing facilities through whatever regulatory authority they might have. They need to ask themselves whether they have the authority to convert a school or a nursing home to an acute care facility if they needed to.

They need to ask themselves about their supply line. How would they get pharmaceuticals in the short term if they needed to get a whole bunch of medication. And they need to make sure that their emergency people and first responders are up-to-date on basic stuff. Make sure everybody has their tetanus shot and the immunizations they're required to have.

I'm just going down a huge laundry list, but all of these things are absolutely essential for the public health responders to do. It's not just important to know what your laboratory has the capacity to test for, but other people have to know that you have the capacity to do those tests and who to call. They need to know how you would ship an infectious specimen from one point to another. There's a proper way to do that. We had to go through all of that in Maryland as we began looking at our system.

Know your FBI contact. Know your state veterinarian. Make sure they have a plan for animals. The first sign for one of these events may very well be in the animal population before the human population.

Have a discussion with your regional poison control center director. People don't present with diseases, they present with syndromes and symptoms and signs. So the poison control center may very well be the first place where people present a variety of similar symptoms. When they see that, they should call the health department and report that to them. Lots of stuff.

Stateline.org :Are any states setting benchmarks of where every state should be right now?

Benjamin :I don't know if "benchmarks" is the right term. Most states have gone down some kind of checklist like than and are measuring themselves. One of the things the federal government has done is put together surveys to ask us whether or not we're prepared. And states have used those various checklists to identify things that need to get done. I do think they've been helpful in helping people think through what they need to do.

Let me say one other thing. The reason we call them "disasters" is they're unplanned events. They strap your existing resources. The reason we do this planning is to shorten the time between utter chaos and a more organized emergency response. And that's what this whole planning activity is about. The states are trying to do what they think, within their own systems, will help them shorten that response time.

Stateline.org :Aren?t there any preparedness standouts?

Benjamin :That'd be hard to say. We think we?ve done some wonderful work here in the Washington metropolitan region. But I think we have to let others decide whether we've been any good at it or not. Obviously, we're hoping that we?ll never have to answer that question.

Stateline.org :Has dealing with flooding and other natural disasters been useful in preparing health departments for manmade threats?

Benjamin :Yes, partially. It?s important to know that these disasters are different. What's most helpful are large foodborne outbreaks and large infectious outbreaks where we've had to vaccinate a lot of people or do surveillance work to track down people who?ve been exposed. Those have been the most helpful for a biological event.

Stateline.org :Would money spent on bioterrorism preparedness be wasted if we never sustain a biological attack?

Benjamin : Absolutely not. The reason is that it's one of the few investments that we'd use every day. Again, there isn't a day when somewhere in this country there isn?t some moderately sized foodborne outbreak. And so the same people who do that kind of disease surveillance do this surveillance.

There is a fire department analogy that you would never have a community without a fire truck. The difference is that we get to use this stuff every single day. The systems would not go wasted. There are some things you?d have to reserve. Obviously, you'd have a pharmaceutical stockpile and a vaccine stockpile and you have to increase the number of ventilators that we'd have.

Those expenditures aside, the vast majority of the dollars would be well used and would do so much to improve the health of the public in general, that this would absolutely not be a waste of money.

Stateline.org : When the Maryland General Assembly meets to discuss appropriations for things like bioterrorism preparedeness and someone asks you what kind of additional resources you?d need, what kind of number would you be looking for?

Benjamin :That?s also a hard number. I guess it depends on what ultimately happens. I think every state in the nation is going to need somewhere around $10 to $15 million to enhance their system. We're a small state, so I don?t know that you can measure that.

Maryland also has some very unique needs. We?re close to the nation's capital. We?re right up in the northeast corridor. We have multiple regional linkages. We have to link up north to the Pennsylvania area, we have to link out west to West Virginia. And many other states have that same problem. But I think probably the best answer to that is that the $1.6 billion they're talking about on the Hill for public health in general is a fair starting point.