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Stanford Report, June 4, 2003

Physician details 'A-list' of scary bioterrorism threats; calls for 'robust' public health system to protect country

BY DAWN LEVY

In 2001, anthrax-laced letters killed five people. In 2003, the SARS epidemic revealed that Mother Nature can be a nasty bioterrorist herself. Future biological attacks are unlikely to announce themselves with letters saying, "This is anthrax -- take penicillin." Instead, they may erupt a lot like SARS, with people quickly overwhelming an uncoordinated and deteriorating public health care system, physician Margaret Hamburg told a Kresge Auditorium audience May 29 during the 2003 Drell Lecture. The Center for International Security and Cooperation sponsored her speech, which was titled "Bioterrorism: A Challenge to Science and Security."

"The best defense against any outbreak is robust public health -- both science and practice," said Hamburg, who is vice president for biological programs at the Nuclear Threat Initiative (NTI), which aims to strengthen global security by preventing the spread of nuclear, biological and chemical weapons. "While it will never be possible to fully prepare for every potential, imaginable threat, it is possible for our nation to shore up its general biodefense and public health preparedness to a level which can minimize, if not prevent, the potentially catastrophic consequences of the many and varied microbial threats we may have to face."

Hamburg has served as assistant secretary for planning and evaluation at the U.S. Department of Health and Human Services. Working as commissioner of health for New York City from 1991 to 1997, she created the nation's first public health bioterrorism preparedness program.

In her speech, Hamburg highlighted critical issues that remain to be addressed as America and the world prepare to deal with a threat once thought to be "the stuff of science fiction or Tom Clancy adventure novels." Today's "A-list" of threats includes anthrax, smallpox, plague, tularemia, viral hemorrhagic fevers and botulism.

"We need to act on the understanding that public health is an important pillar in our national security framework, and public health professionals must be seen as full partners on international and national security issues," Hamburg said. She advocated putting a public health expert on the president's National Security Council and having this new position rank among the leadership of the Department of Homeland Security.

Hamburg said it is critical to remember that the front line of response -- even in a national crisis -- is always local. She recommended strengthening state and local public health departments, which "represent the backbone of our ability to respond effectively to a major outbreak of disease, including a bioterrorist attack. Yet we have never adequately supported or equipped these public health agencies to do their job." She said many hesitate to call the array of health structures at the state, county and local level a public health "system" because years of relative neglect have left them undercapitalized, fragmented and uncoordinated.

Strengthening disease surveillance, improving medical consequence management and supporting fundamental and applied research will be essential in responding to a biological weapons attack. "But these investments will also enhance our efforts to protect the health and safety of the public from naturally occurring disease," Hamburg noted. "We have a chance to defend the nation against its adversaries and to improve global public health with the same steps."

Better disease surveillance will require training health care providers, improving laboratory tests and improving computer connectivity for quick collection, analysis and sharing of information.

Developing emergency plans for treating a surge of patients will prove challenging since the nation's hospitals are operating near capacity now. And private health care providers may be limited in what they can do alone. "We need to undertake a systemic examination of local capabilities and how they can be rapidly augmented by state and federal assets," Hamburg said.

Given the low probability of an attack at any one place, it wouldn't make sense to stockpile drugs at the local level. But Hamburg said America should continue to strengthen its national pharmaceutical stockpile, which consists of strategically located drugs that can be delivered to any place in the nation within 12 hours. Responsibility for this stockpile has been transferred from the federal Centers for Disease Control to the Department of Homeland Security. More work needs to be done among national, state and local partners to develop contingency plans for distribution, Hamburg said.

In addition, legal concerns need addressing. Which authority can declare an emergency? In what situations can people be quarantined or detained? Can the government compel production of certain goods? Unresolved issues of liability and indemnification have been especially troubling in vaccine development and delivery for both routine and biodefense needs.

Addressing the threat will require new partnerships and new approaches, Hamburg said. "This will require greater partnership and trust between the intelligence community, law enforcement and public health and biomedical science -- not necessarily an easy or comfortable marriage. These disciplines do not routinely work together, and their professional cultures and practices are not easily merged."

But today's investment in research and development will be the foundation of tomorrow's preparedness, Hamburg said.

That investment needs to extend beyond U.S. borders, she said. International, collaborative health programs can bridge a new trust among communities or nations formerly at odds, Hamburg said, noting that the United States has been an important participant in international initiatives to address HIV/AIDS, TB and malaria, and has finally paid its dues and arrears to the World Health Organization. "We can and should use health programs as a vehicle to improve the common good and to demonstrate -- building on our country's enormous strengths in science and medicine -- our goodwill and concern for others around the world."

The Drell Lecture was established by a grant to the Center for International Security and Cooperation from Albert and Cicely Wheelon in honor of physicist and arms control expert Sidney Drell, professor emeritus at the Stanford Linear Accelerator Center. The lectureship makes it possible for Stanford scholars and students to meet people who play important roles in international security.

 

At this year's Drell Lecture, Margaret Hamburg stressed the importance of the public health system. Photo: L.A. Cicero