September 11's Hard Lessons

New York City, with sixty-four hospitals, more than any other in the country, was probably the best prepared for a mass-casualty incident. Except that on September 11, most of the victims were dead. Within minutes, the Bellevue emergency room was crowded with hundreds of doctors, each bed with its own team of specialists, from surgeons and psychiatrists to gynecologists. "The entire physician and nursing force of the hospital just came down at once," said Dr. Brian Wexler, a third-year emergency medicine resident. At Long Island College Hospital in Brooklyn, Dr. Lewis Kohl, chairman of emergency medicine, said that by noon, he had a doctor and a nurse for each available bed and could have tripled that number. Doctors from all over the country at a defibrillation conference in downtown Brooklyn were begging to work. "I spent most of the day sending volunteers away," he recalled.

Tragically, so many people died that doctors had little to do. But the people who answered phones, counseled the distraught or drew blood from volunteers were overrun. A web-based patient locator system cobbled together by the Greater New York Hospital Association got 2 million hits within days from frantic relatives. Beth Israel Medical Center ran out of social workers, psychologists and psychiatrists to answer calls. "I answered the phone for half an hour and said, 'I'm not qualified to do this,'" said Lisa Hogarty, vice president of facility management for Continuum Health Partners, which runs Beth Israel.

If anything, New York learned that targeted improvements, such as the creation of regional bioterror treatment centers, will not work. Susan Waltman, senior vice president of the Greater New York Hospital Association, told a CDC advisory committee in June that on September 11, 7,200 people, many covered in debris, wound up at 100 different hospitals, jumping on trains, boats and subways, or walking, to get away from downtown Manhattan. Now imagine if the debris had been tainted with some infectious biological agent. "You can't put the concentration of knowledge or staffing or supplies in regional centers," she said, "because you can't control where patients go."

The anthrax attacks, when they came, were a wake-up call of the worst kind. Baffled government officials with minimal scientific knowledge attributed the outbreak initially to farm visits, then contaminated water and finally to a fine, weaponized anthrax that had been sent through the mail. With no clear chain of communication or command for testing the samples, reporting the results, advising the medical community or informing the public, samples vanished into dozens of laboratories. Conference calls between officials from different local, state and federal agencies were required to track them down, said those involved with the investigation. Testing methods were not standardized, with the Environmental Protection Agency, the postal service, the CDC, the FBI and the Defense Department all swabbing desktops and mailrooms using different methods and different kits, some of which had never been evaluated before. "A lot of those specimens that were said to be positive were not," said Dr. Philip Brachman, an anthrax expert and professor at the Rollins School of Public Health at Emory University.

For three weeks, from the initial outbreak on October 4, 2001, Americans seeking clear information from the CDC were out of luck. Until October 20, the agency's website still featured diabetes awareness month instead of the anthrax attacks. Dr. David Fleming, the CDC's deputy director for science and public health, said that while the CDC did respond quickly and accurately, "we were too focused on getting the public health job done, and we were not proactive in getting our message out."

But it wasn't just the CDC. Few officials nationwide knew what to do. In New York, police were marching into the city's public health laboratory carrying furniture and computers they suspected of being tainted, recalled Dr. David Perlin, scientific director of the Public Health Research Institute, an advanced microbiology center then located a few floors above the city lab. Since those terrible days, the CDC under new director Dr. Julie Gerberding has made a great effort to establish its leadership and develop emergency response systems. "We have the people, we have the plans and now we have the practice," Gerberding, a microbiologist and veteran of the anthrax investigation, declared this September 11. "We're building our knowledge and capacity every day to assure that CDC and our partners are ready to respond to any terrorist event."

After September 11, however, such confident talk rings a little hollow. This past September the CDC laid out a radical plan for vaccinating much of the country within a week in the event of a smallpox attack. Medical experts greeted the plan as unrealistic and almost impossible to execute, given that disasters inevitably depart from plans to address them. They are pressing for the prevaccination of critical healthcare workers, and a decision on this is soon to be announced.

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