Rand Report Critique as Discussed

Rand Report Critique

As discussed in the RAND report, in major cities across the country, the federal government helped stage simulated biological, chemical, and radiological (dirty bomb) attacks to mobilize local officials for emergency response. Police, firefighters, and emergency medical teams rehearsed the rescue of afflicted civilians, played by com- munity volunteers. Domestic preparedness? was far from standard. Local government leadership determined the degree of participation, the plans for mobilization, and what resources would be requested from the federal government-whether new computers or police cars or ambulances or support for personnel and training. We shall look at further scenarios to bolster our reaction to the RAND report with regards to bio terrorist attacks and infectious diseases.

Our starting assumption was that an exemplary practice should be "technically sound, effective, replicable and sustainable." As we began to review practices, however, we realized that many of the practices had only recently been implemented, and that there was scant evidence of their effectiveness as an individual practice of preparedness, and in some cases, lack of evidence of effectiveness for a whole category or practices (e.g., syndromic surveillance) (RAND Report). In 2000, to test if domestic preparedness legislation was improving national readiness, Congress asked the Justice Department and FEMA, together with the National Security Council, to stage an exercise that would mobilize top government officials in a simulation of an attack response. The exercise, called TOPOFF (for ?top officials?), was directed by an established defense contractor, SAIC (Science Application International Corporation). Costing around $lo million, TOPOFF simulated a mustard gas attack in Portsmouth, New Hampshire, where the response went smoothly, and a scripted plague aerosol attack in Denver, Colorado. The Denver exercise produced chaos (locating mortuaries to store fictive cadavers was a major problem) and brought out the difference between a limited chemical attack and one with a contagious disease. This difference was important. An explosion or chemical attack would be immediately evident and localized (Neergaard, 2011).

A disease outbreak, though, could be undetected at first and then last over weeks. Patients could leave the attack locale without realizing they were infected, fail to understand the gravity of their illness, and, if the disease were contagious, perhaps spread and prolong the epidemic. In July 2001, another bioterrorist simulation, called ?Dark Winter, emphasized the contagious disease threat, even more strongly, on the scale of war. Held at Andrews Air Force Base, Dark Winter was a tabletop exercise, based on a fictional pandemic of smallpox; the scenario condensed the events of thirteen days into two. The invited participants or actors were Washing- ton political insiders.

For example, Senator Sam Nunn, a key sponsor of domestic preparedness legislation, played the part of the president. The script, written largely by staff at the Johns Hopkins Center for Civilian Biodefense Studies, illustrated a worst-case scenario in which smallpox spread across the nation, where insufficient vaccine was available to stop it. The U.S. military had to intervene to curtail violence and social breakdown. Then a worldwide pandemic was added. The Dark Winter scenario was later criticized by scientists at the Centers for Disease Control (CDC) and other infectious disease experts for its exaggerated contagion rates and its lack of emphasis on proven simple ways to curtail epidemics, such as home care, wearing face masks, hand washing, and, perhaps most important, avoiding hospitals where transmission rates would soar.57 In fact, the exercise served well as political rhetoric. Two weeks later, its organizers and participants testified before Congress in support of increased funding for stockpiling smallpox vaccine and for domestic response training.

The exercise showed that the scale of an imagined bioterrorist attack could vary greatly, according to the scriptwriters and their intents. During 2002, as polls indicated, the American public became more intimidated by the possibility of a nationwide smallpox outbreak.59 Among experts, concern about a future smallpox outbreak with perhaps a new strain had a direct impact on indefinitely delaying the WHO scheduled date (December 31, 2002) for destroying the U.S. And Russian reserves of the virus, the last known in the world. Following the WHO smallpox eradication campaign, no case of the disease had been recorded since 1979. Experts who saw basic science as the key to defense against bioterrorism envisioned the development of antiviral drugs to replace current vaccines, which, although valuable, were already contraindicated for people with compromised immune systems. Political justification for the delay was found in fears that Saddam Hussein might use smallpox in a last-stand attack or that North Korea's Kim Jong-il would do the same (Frist, 2002). "The needs assessment enabled the Department of Health to coordinate risk communication procedures locally, regionally, and statewide by creating a plan that integrates the protocols already in place with the anticipated communication needs for an emergency" (RAND Report).

By this reckoning of future threats, it could be argued that the smallpox stocks should be preserved for research purposes. Donald A. Henderson, a leader of the WHO smallpox eradication campaign and founder of the Johns Hopkins unit that organized Dark Winter, disagreed. His solution was for the government to destroy the virus and stockpile enough smallpox vaccine to counteract an American pandemic. The smallpox virus itself is not used in making the present vaccine; better vaccines, Henderson argued, could be developed without retaining the virus. A report from the Institute of Medicine disputed the wisdom of destroying the virus.63 In agreement, the WHO delayed the extinction of smallpox. Developing nations most vulnerable to smallpox reemergence protested. At the same time, the U.S. government moved forward with the production and stockpiling of the smallpox vaccine in the event of a bioterrorist attack on America.

Public Health And Bioterrorism

If bioterrorism posed a collective infectious disease threat, public health seemed the obvious response. The United States, though, had only inconsistently supported public health, which was often seen as a way in which government might curtail individual liberties and the operation of a free market. In the 1990S, the low-status and underfunded American public health system was charged with disease prevention and health care for the disadvantaged, such as AIDS and hepatitis testing, prenatal care, childhood vaccinations, drug abuse prevention, annual influenza shots for the elderly, and the laboratory monitoring of disease outbreaks. Its professional organizations and schools were also oriented to international infectious disease problems; national security was a limited and even unrealistic framework for risk reduction in a world with accelerated global travel, trade, and movement of populations (Frist, 2002).

In 1999, the Clinton administration heralded the integration of public health and national security to fight the threat of bioterrorism. But this integration was oriented not toward a reinforcement of, say, Medicaid, the nation's most comprehensive public health program, but toward techno- logical solutions such as electronic disease surveillance and reporting, better medical diagnostic tests, and improved surveillance of water supplies and food production. Public health physicians became concerned about the impact that civilian biodefense? And its emphasis on emergency response could have on their role in providing routine services and protecting patients' rights (Neergaard, 2011).

Victor Sidel, the public health leader who advocated the elimination of the U.S. biological weapons program, saw a conflict between what were fundamentally national security goals and professional responsibilities to patients. He made the point that military, intelligence, and law enforcement agencies and personnel have long histories of secrecy and deception that are contrary to the fundamental health principles of transparency and truthfulness. They may therefore be unsuitable partners for public health agencies that need to justify receiving the public's trust:' (Tanielian, et al. 2005) Troubling issues of military deception and secrecy had already tainted the Department of Defense's universal anthrax vaccination program, AVIP. Side effects were being underreported or suppressed by the Pentagon.

The private pharmaceutical company had failed to win FDA approval for vaccine production and was relying on old, faulty stocks inherited from the last manufacturer, the State of Michigan . Soldiers refusing the vaccination were being dishonorably discharged. Much of this information was released only because independent critics, such as Dr. Meryl Nass and Victor Sidel, and the families of soldiers had pressured Congress for investigation.

Sidel and others who emphasized trust and openness in disease management spoke from practical experience. In all outbreaks, accurate information-about the source of the disease, its nature and transmission, about who might have been exposed and why and where, and about how the victims can be quickly helped-is crucial to local public awareness and mobilization and, on clinical level, to early diagnosis and saving lives (Fauci, 2003). The 1979 Sverdlovsk outbreak provided a worst-case example on a small scale of how military and government secrecy can have deadly consequences for the public. A larger outbreak similarly fraught with misinformation and disinformation would be a true catastrophe. The millennium ended without the predicted bioterrorism event. The perceived threat of biological weapons, rather than diminishing after the end of the Cold War, continued to increase.

Technological Solutions: The Smallpox Vaccination Campaign

During the second Bush administration, advocates for domestic preparedness and civilian biodefense continued to talk about a revitalization of American public health.26 Yet public health continued to mean, even more than in the Clinton administration, a technological approach to national defense. In the Bush administration, pharmaceutical protection became the centerpiece of biodefense policy. On December 13, 2002, convinced of the Dark Winter-type threat of smallpox, President Bush announced his nationwide smallpox inoculation program. Publicity about Iraq's potential biological arsenal, especially in the lead-up to the 2003 invasion, and the threat of bioterrorism had convinced many in the public to participate. The states and the CDC were ready to handle the logistics. In addition, civilian participation was voluntary, which reduced legal liability for those who administered the vaccine and for the government.

As might have been predicted, this smallpox vaccination campaign found it difficult to circumvent the well-known fears of vaccination as a source of bodily pollution and the mistrust engendered when vaccines appear a worse health risk than the forecast epidemic. The swine flu vaccination program during President Gerald Ford's administration was a controversial miscalculation that killed two dozen and sickened hundreds and, because the flu never struck, it caused widespread distrust in government health initiatives (Tanielian, et al. 2005). Reliance on intelligence calculations can be a necessary but problematic basis for predicting epidemics, even for the military.

The Pentagon's universal anthrax vaccine program in the 1990S resulted in dishonorable discharge for more than four hundred soldiers who refused to be vaccinated and it caused dozens of National Guard pilots to resign, out of fear of serious, unpredicted side effects that appeared worse than any biological weapons threat. ' The first phase of the smallpox campaign was the mandatory vaccination of 500,000 military and government employees who might be deployed to the Middle East or other potentially high-risk areas.

Starting January 2003, Phase One also included the voluntary vaccination of 500,000 ?front-line? civilian health workers and first responders on specialized ?Smallpox Response Teams. In the second phase of the smallpox vaccination program, in March- April 2003, ten million additional healthcare workers and first responders could opt to be vaccinated. In the fall of 2003, in Stage Three the vaccine would become available to the American public at large. (Phases Four and Five were emergency strategies for containment in the event of a smallpox outbreak, which meant quarantine and mass vaccination.) Unlike the anthrax vaccine, the most available U.S. smallpox vaccine, called Dryvax, had a well-known history' (Neergaard, 2011). Administered with a bifurcated needle, it took six to eight days to be effective. If given within four days of exposure, the vaccine might significantly reduce the chances of sickness and death.

The typical reactions to the smallpox vaccine ranged from soreness at the vaccination site to headaches, swelling of the lymph nodes, and fatigue. Brain swelling (en- cephalitis) was a known but rare reaction. The death rate estimated for universal smallpox vaccination could theoretically be as high as one percent: if ten million people were vaccinated, some ten thousand might die, unless risk factors were recognized in advance. The vaccine was contraindicated for those with eczema or other skin diseases, for pregnant women, and for those whose immune systems were compromised or who were taking immune-suppressing medication.