Just before the July 4 holiday this past summer, as National Guardsmen with sniffer dogs monitored the nation's bridges and airports, Jerome Hauer, an assistant secretary at the Health and Human Services Department, dispatched a technician to Atlanta to set up a satellite phone for the new director of the Centers for Disease Control.
If smallpox broke out, if phones failed, if the federal government had to oversee mass vaccination of an urban center, Hauer would have a way to communicate with the CDC director, who since last fall has worked with him on health crises, particularly bioterror. It was one of many precautions that might make the difference between a manageable event and full-scale disaster.
But at the same time, an attempt at crisis management of a more immediate kind was unfolding 2,500 miles to the west. As the FBI chased reports of potential new threats, including a possible attack on Las Vegas, Dr. John Fildes, the medical director of Nevada's only top-level trauma center, watched helplessly as a real medical disaster developed, one that had nothing and everything to do with the problems that Hauer was working to solve.
Faced with a dramatic spike in the cost of their malpractice insurance, fifty-seven of the fifty-eight orthopedic surgeons at University Medical Center in Las Vegas resigned, forcing the state's only trauma center that could treat it all--from car crash, burn and gunshot victims to potential bioterror casualties--to close for ten days.
With Las Vegas a potential target, a quarter-million tourists at the gaming tables and the closest high-level trauma center 300 miles away, the crisis barely registered in the federal government. Nevada's Office of Emergency Management called to inquire about a backup plan, which, as Dr. Fildes later recounted, was to dissolve the county's trauma system, send patients to less prepared hospitals and take the critically injured to Los Angeles or Salt Lake City, both about eighty minutes by helicopter.
During that anxious week Hauer's satellite phone and Fildes's resignation letters formed two bookends of the nation's disaster planning. Hauer--whose Office of the Assistant Secretary for Public Health Emergency Preparedness (ASPHEP) was created by the department Secretary, Tommy Thompson, after the anthrax attacks--can get a last-minute satellite phone, a crack staff and even the ear of President Bush on public health concerns.
But Fildes, whose trauma center is the third-busiest in the nation and serves a 10,000-square-mile area, struggles to keep his staff intact and the doors of his center open. And this is in a state with no appointed health director, few mental health facilities, no extra room in its hospitals and the nation's only metropolitan area, Las Vegas, without a public health laboratory within 100 miles. In the event of a public health disaster, like a bioterror attack, Fildes says, "we're prepared to do our best. And I hope our best is good enough."
A Public Health 'Train Wreck'
On taking office, President Bush eliminated the health position from the National Security Council, arguing that health, while in the national interest, was not a national security concern. In the wake of the anthrax attacks last year, he changed his tune, declaring, "We have fought the causes and consequences of disease throughout history and must continue to do so with every available means." Next year's budget for biodefense is up 319 percent, to $5.9 billion. States, newly flush with $1.1 billion in biodefense funds, have gone on shopping sprees for emergency equipment like gas masks, hazmat suits and Geiger counters. Newly drafted to fight the war on bioterror, doctors and public health officials are now deemed vital to national security, and their hospitals are even under threat, according to an alert released in mid-November by the FBI.
And yet this flurry of interest and concern has not begun to address America's greatest public health vulnerability: the decrepit and deteriorating state of our healthcare system. In states from Nevada to Georgia, dozens of health officials and doctors told The Nation that anemic state funding, overcrowding and staff shortages may be greater problems in responding to bioterror than lack of equipment or specific training. "We don't have enough ER capacity in this country to get through tonight's 911 calls," said Dr. Arthur Kellerman, chairman of the emergency medicine department at the Emory University School of Medicine in Atlanta. Two decades of managed care and government cuts have left a depleted system with too few hospitals, overburdened staff, declining access for patients, rising emergency-room visits and an increasing number of uninsured. The resulting strain is practically Kafkaesque: How do you find enough nurses to staff enough hospital beds to move enough emergency-room patients upstairs so that ambulances with new patients can stop circling the block?
The infusion of cash for bioterror defense without consideration of these fundamental problems is like "building walls in a bog," where they are sure to sink, said Dr. Jeffrey Koplan, the recently departed head of the CDC.
Between 1980 and 2000, the number of hospitals declined by 900 because of declining payments and increased demands for efficiency, according to the American Hospital Association, leaving almost four-fifths of urban hospitals experiencing serious emergency-room overcrowding. Burnout and low pay have left 15 percent of the nation's nursing jobs unfilled, and the staffing shortage has led to a drop in the number of hospital beds by one-fifth; in Boston by one-third, according to the Center for Studying Health System Change in Washington.
Meanwhile, emergency room visits increased by 5 million last year, according to the American College of Emergency Physicians. One in eight urban hospitals diverts or turns away new emergency patients one-fifth of the time because of overcrowding, the American Hospital Association reports. And the costs of health insurance and medical malpractice premiums continue to soar.
In public health, chronic underfunding has closed training programs and depleted expertise. According to a recent CDC report, 78 percent of the nation's public health officials lack advanced training and more than half have no basic health training at all. During the anthrax crisis inexperienced technicians in the New York City public health laboratory failed to turn on an exhaust fan while testing anthrax samples and accidentally contaminated the laboratory.
A government study of rural preparedness this past April found that only 20 percent of the nation's 3,000 local public health departments have a plan in place to respond to bioterror. Thirteen states have had no epidemiologists on payroll, said Dr. Elin Gursky, senior fellow for biodefense and public health programs at the ANSER Institute for Homeland Security. Meanwhile, 18 percent of jobs in the nation's public health labs are open, and the salaries create little hope of filling them. One state posted the starting salary for the director of its public health laboratory program--a PhD position--at $38,500, said Scott Becker, executive director of the Association of Public Health Laboratories. Becker calls the combination of state cuts and work-force shortages a "train wreck."
Amid this crisis, clinicians have a new mandate: to be able to fight a war on two fronts simultaneously. They must care for the normal volume of patients and track the usual infectious diseases while being able to treat mass casualties of a terrorist event. They now have some money for the high-concept disaster, but with many states in dire financial straits, there is less money than ever for the slow-motion meltdown of the healthcare system, in which 41 million Americans lack health insurance. In the event of a smallpox attack, the tendency of the uninsured to delay seeking treatment could be catastrophic.
Hauer hopes that the "dual use" of federal resources could herald a golden age in public health, with tools for tracking anthrax or smallpox being used also to combat West Nile virus or outbreaks from contaminated food. But politicians of all stripes continue to propose beefing up biodefense in isolation from more systemic problems. In October, Al Gore argued in a speech that the problem of the uninsured should take "a back seat" temporarily to the more urgent matter of biodefense. And Bush has proposed shifting key public health and biodefense functions into his proposed Department of Homeland Security, a move likely to weaken daily public health work like disease surveillance and prevention, according to the General Accounting Office. A bipartisan report recently issued by the Council on Foreign Relations warned that America remains dangerously unprepared for a terrorist attack, with its emergency responders untrained and its public health systems depleted.
The solution, say doctors, is to tackle the systemic and not just the boutique problems. "If you have a health system that is chaotic and has no leadership and is not worried about tuberculosis and West Nile and just worried about these rare entities, you'll never be prepared," said Dr. Lewis Goldfrank, director of emergency medicine at Bellevue Hospital Center in New York City. "To be useful, money has to be earmarked for public health generally, so that it will prepare you for terrorism or naturally occurring events."
President Bush strongly resisted federalizing airport security until it became clear as day that private security companies and their minimum-wage workers would continue to let a flow of box cutters, knives and handguns through the metal detectors. Some clinicians now say that the specter of bioterror raises a similar question, which almost nobody in Washington has yet begun to address: Has healthcare become so vital to national security that it must be centralized, with the federal government guaranteeing basic healthcare for everyone?
"Forget about paying for the smallpox vaccine," said Dr. Carlos del Rio, chief of medicine at Atlanta's Grady Memorial Hospital. "Who's going to pay for the complications of the vaccine? With what money? We haven't even addressed that. As you look at bioterror issues, it's forcing us to look at our healthcare delivery."
Crisis Management in Crisis
Hauer spends much of his time in a windowless set of offices within the vast Health and Human Services Department, trouble-shooting the medical consequences of a hypothetical dirty bomb or intentional smallpox outbreak. He must also navigate the knotted bureaucracy of forty federal agencies that respond to terrorism, twenty of which play some role in bioterror response, and guide the states through infrastructure problems so severe they boggle the mind. His tactic at a meeting in Washington this August with state emergency managers was to put the fear of God into them. In the event of mass vaccinations for smallpox, the logistics are "very daunting," he told the small and sleepy group in a conference room at the Mayflower Hotel. "They will fall on emergency management, and the health departments will turn to you and say, 'You need to open 200 vaccination centers.'"
This seemed to focus the group. Before Hauer got up, these local and regional representatives had been talking about lessons learned from managing hurricanes and the best kinds of hand-held chemical-weapons detectors.
Tommy Thompson created Hauer's office after the CDC, then his lead agency on bioterror, appeared to bungle the anthrax response and the Administration found itself in a scientific and logistical quagmire. Some officials claimed the White House muzzled the CDC. Others accused the CDC of sloth and bad science for failing to realize quickly that anthrax spores can leak from taped envelopes. Hauer seemed like a good choice to find a way out of this mess: He had developed the nation's first bioterrorism response plan as director of New York City's Office of Emergency Management under Mayor Rudolph Giuliani.
Hauer told the group that his office had moved $1.1 billion to the states in ninety days and was now doing audits, offering technical assistance and helping to stage drills.
But it was the nitty-gritty of mass vaccination that really quieted the room. Training a vaccinator usually takes two hours, though it can be done in fifteen minutes; for every million people vaccinated, about two will die; the vaccinators need to be federally insured because of liability; and all those vaccinated must keep the vaccination site unexposed to others for up to twenty-one days. Who would pay the salaries of contract workers on their days off?
Few emergency managers seemed to have considered such problems. Most were still immersed in competing disaster plans and state budget battles, coping with teetering local health departments and vendors hawking "equipment that will detect the landing of Martians ten miles away in a windstorm," as James O'Brien, emergency manager for Clark County, Nevada, put it.
Hauer returned that afternoon to just such a morass: figuring out how to create a unified command for the national capital area, encompassing Maryland, Virginia and the District of Columbia, seventeen jurisdictions over 3,000 square miles, with embassies, consulates, the World Bank and the International Monetary Fund. He had assigned this problem to a team from the Office of Emergency Response (OER), the federal office under ASPHEP that coordinates medical resources during disasters, who arrived at his office to report their progress.
Each state, unsurprisingly, wanted to be the lead responder, and the team recommended that Hauer try to break the logjam and give direction. He pored over the list of those invited to a coordinating committee meeting--twenty-nine people from twenty-nine different agencies--and concluded, "We need to come away with plans, not some loosie-goosie love fest where everyone pats each other on the back and jerks each other off."
The OER team trooped out with its marching orders and the next meeting began. The CEO of the New York Blood Center, Dr. Robert Jones, with a DC consultant in tow, came to ask for money to expand the center's program of making umbilical cord (placental) blood, used for patients exposed to massive radiation. Jones said the center already had about 18,000 units of cord blood stored in "bioarchive freezers" on First Avenue in Manhattan.
"You might want to think about storing it away from Manhattan," said Hauer, suggesting the obvious, as he got out a little booklet and looked up a one-kiloton nuclear bomb. "You'd need 20,000 to 40,000 units" to begin treating a city of people, said Hauer. "What's the lead time for getting it into a patient?"
Jones, who had never met Hauer before, seemed surprised to be taken so seriously and to be crunching numbers about three minutes into the conversation. Hauer, wanting to stockpile cord blood, seemed surprised that Jones had not brought a written proposal with a dollar amount. This was no time to be coy about asking for money.
Suddenly Hauer's secure phone rang and the room fell silent. "This is Jerry Hauer," he said. "You have the wrong number."
Leaving Las Vegas--in the Lurch
In Las Vegas, a gaming town with an appetite for risk, little by way of a medical infrastructure ever developed. With the population exploding and 6,000 families a month moving into the Las Vegas area in Clark County, population 1.4 million, it is also dramatically short on hospitals. By a thumbnail calculation--for every 100,000 people you need 200 beds--the county, which has eleven hospitals, is 600 beds short, said Dr. John Ellerton, chief of staff at University Medical Center, where the trauma center closed.
Even if you build more hospitals, how would you staff them? The state ranks fiftieth in its nurse-to-patient ratio, and because of the malpractice crisis, ninety of the state's 2,000 doctors have closed their practices and another eighty-three said they have considered leaving, according to Lawrence Matheis, executive director of the Nevada State Medical Association. The overcrowded emergency rooms are closed to new patients 40 percent of the time. Paramedics often drive and drive, waiting for an open emergency room. In turn, patients can wait four hours for an X-ray, three for a lab test. "There is no surge capacity, minimal staffing, minimal equipment," said Dr. Donald Kwalick, chief health officer of Clark County. "Every hospital bed in this county is full every day."
At times, the populace and even the doctors have seemed strangely indifferent. One night this summer an ambulance crew from the private company American Medical Response got called to a casino, and as they wheeled a stretcher amid the gaming tables, not a single patron looked up. Their patient: a man with a possible heart attack slumped over a slot machine. "The purity of our devotion to individual liberties tends to diminish our security and humane concern," said Matheis.
The September 11 attacks did not entirely transform this mindset. Since 1998 the city had been included on a federal government list of 120 cities that should prepare for possible attack. Eleven of the world's thirteen largest hotels, one with more than 5,000 rooms, are here. But this August, even the president of the state's medical association, Dr. Robert Schreck, said he worried little about terrorism. Al Qaeda's intent is "to kill capitalism," he said, sipping wine in the lobby of the elaborate Venetian Hotel, home to a massive casino and dozens of stores. "Why would they hit us?"
But last year Nevadans began to lose their cool as the medical system disintegrated. As malpractice insurance premiums skyrocketed, about thirty of Clark County's ninety-three obstetricians closed down their practices. Insurers, trying to reduce risk by limiting the remaining obstetricians to 125 deliveries a year, left thousands of pregnant women to hunt for doctors, some by desperately rifling through the Yellow Pages under "D." This year, the last pediatric cardiac surgery practice packed up and left the state.
Not surprisingly, Nevada was also unprepared for the anthrax crisis. Last October, when Microsoft's Reno office got suspicious powder in the mail that initially tested positive, an "outbreak of hysteria" ensued, said Matheis. The Clark County health district got 1,200 phone calls reporting everything from sugar to chalk dust, and investigated 500 of them with its skeletal staff. The state had no stockpiled antibiotics, and without a lab in Clark County, samples were shipped 500 miles north to Reno for testing.
The new federal money for bioterror preparedness, $10.5 million for Nevada alone, will help enormously. Of that, more than $2 million will go to building a public health laboratory in Las Vegas. But the money will do nothing to solve the problems of staff shortages and soaring medical malpractice premiums that forced the trauma center to close in July.
By July 4, the city of Las Vegas awoke to maximum fear of terror and a minimal medical system, with the trauma center closed for a second day. Governor Kenny Guinn had called an emergency session of the legislature and vowed to make sure that doctors did not abandon the state. An official at the nearby Nellis Air Force Base called the chief of orthopedics, Dr. Anthony Serfustini, asking what to do in the event of injuries. The lanky surgeon said that he reminded the man, You're the Air Force. You can fly your pilots to San Bernardino.
The community's medical infrastructure had declined to a level not seen in twenty-five years, said Dr. Fildes. And on July 4, the inevitable happened. Jim Lawson, 59, a grandfather of nine, was extracted from his mangled car and rushed to a nearby hospital--one with a nervous staff and little up-to-date trauma training--and died about an hour later. His daughter, Mary Rasar, said that she believes the trauma center, had it been open, could have saved him.
Atlanta's Health Emergency
On September 11, 2001, Dr. Arthur Kellerman was in Washington waiting to testify before Congress about the consequences of uninsurance when a plane struck the Pentagon, across the street from his hotel room. He immediately called back to Grady Memorial Hospital in Atlanta, where he oversees the emergency room residents, and got a disturbing report.
While Atlanta appeared to be safe from terrorism, the emergency room had twenty-five admitted patients waiting for hospital beds, the intensive-care area was packed and the staff had shut the emergency room to new patients. Worse, every emergency room in central Atlanta had declared saturation at the same time. None were taking new patients, and loaded ambulances were circling the block. If attacks had occurred in Atlanta that morning, "there was no way on God's earth we could have absorbed more patients," said Kellerman. Since then, all the Atlanta-area hospitals have gone on simultaneous diversion numerous times, leaving "nowhere to put casualties."
Despite all the effort to gear up for biological terror, the problem of overcrowded and understaffed emergency rooms--where terror's victims would be treated--has received only spotty attention. U.S. News & World Report featured the problem as a cover story, "Code Blue: Crisis in the E.R.," but it ran on September 10, 2001. A month after the attacks, Representative Henry Waxman prepared a report on ambulance diversions and their effect on disaster preparedness, finding a problem in thirty-two states. In at least nine states, every hospital in a local area had diverted ambulances simultaneously on a number of occasions, causing harm or even death to some patients. In Atlanta, one diverted patient was admitted only after he slipped into respiratory arrest while in the idling ambulance. The report quoted an editorial from the St. Louis Post-Dispatch last year:
A word to the wise: Try not to get sick between 5 p.m. and midnight, when hospitals are most likely to go on diversion. Try not to get sick or injured at all in St. Louis or Kansas City, where diversions are most frequent. And if you're unlucky enough to end up in the back of an ambulance diverted from one E.R. to another, use the extra time to pray.
In Washington, Hauer has directed each region to identify 500 extra beds that can be "surged" or put into use quickly, which has led a number of states to identify armories, school auditoriums, stadiums and hotels that can be used as MASH hospitals. But no bubble tent can replace a hospital bed, with a full complement of services readily available within the "golden hour" so crucial to treating trauma patients, said Kellerman. And no proposal exists to address the problem as a systemic one, in which a shortage of nurses and cutbacks in reimbursement have made it impossible for hospitals to staff enough beds.
Without a solution in sight, Grady Memorial uses a makeshift system, parking admitted patients on stretchers in the hallways beneath handwritten numbers that run from 1 to 30. With the crisis deepening, more numbers--1a, 1b, 1c, for example, seventeen additional spaces in all--have been squeezed between the initial numbers up and down the hall. The other night Kellerman had fifty patients lined up waiting for rooms. "These are not disaster scenarios," he said. "This is Friday night. Wednesday afternoon."
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.
Preparing for the Worst
Past a strip mall outside Washington, and down a nondescript road, the federal OEP keeps a warehouse of equipment that can all but navigate the end of civilization. It has the world's most sophisticated portable morgue units, each one able to support numerous autopsies. Another pile of boxes unfolds to become a full operating theater that can support open-heart surgery, if need be.
All this equipment can function during "catastrophic infrastructure failure," said Gary Moore, deputy director of the agency. And all of it can be loaded onto a C-5 transport plane and flown anywhere in the world. The federal government has massive resources--twelve fifty-ton pallets of drugs called the National Pharmaceutical Stockpile, which can get anywhere in the country in seven to twelve hours. After the New York City laboratory became contaminated, the Defense Department flew in six tons of laboratory equipment and turned a two-person testing operation into ten laboratories with three evidence rooms, a command center and seventy-five lab technicians operating around the clock.
This monumental surge capacity is crucial to preparedness. So are supplies. Dr. Kohl at Long Island College Hospital, who describes himself as a "paranoid of very long standing," feels ready. He's got a padlocked room full of gas masks, Geiger counters and Tyvek suits of varying thicknesses, most purchased after the anthrax attacks. Pulling one off the shelf, he declared confidently, "You could put this on and hang out in a bucket of Sarin."
But none of this can replace the simple stuff: hospital beds, trained people, fax machines, an infrastructure adequate for everyday use. Indeed, as states slash their public health and medical budgets, the opposite may be happening: We are building high-tech defenses on an ever-weakening infrastructure. In Colorado, for example, Governor Bill Owens cut all state funding for local public health departments in part because the federal government was supplying new funds. Public health officials there suddenly have federal money to hire bioterror experts but not enough state money to keep their offices open. While the Larimer County health department got $100,000 in targeted federal money, it lost $700,000 in state funds and fifteen staff positions. A spokesman for Governor Owens did not return calls seeking comment. States across the country are making similar cuts, said Dr. Gursky of the ANSER Institute, their weakened staffs left to prepare for bioterror while everyday health threats continue unchecked.
From her office window, Dr. Ruth Berkelman, director of Emory's Center for Public Health Preparedness, can see the new, $193 million infectious-disease laboratory rising on the CDC's forty-six-acre campus. While the new laboratory and information systems are needed, she says, if we detect smallpox, it's going to be because some doctor in an emergency room gets worried and "picks up the telephone."