One Year After the Terrorist Attacks: Is Public Health Prepared?

A Report Card from the American Public Health Association
The American Public Health Association developed its Guiding Principles for a Public Health Response to Terrorism soon after the attacks of Sept. 11, 2001.1 This report card assesses whether U.S. policy since the attacks has been consistent with these principles. We can and should strive to always improve and evaluate our preparedness for a terrorist attack. For decades, public health has been grossly underfunded. Since Sept. 11, new investments in our nation's public health system have begun to reverse this trend and better prepare the public health system in the event of an attack. It is critical that such investments are sustained. It is also important that funding for bioterrorism preparedness does not supplant resources needed for other important public health activities. This "report card" analysis examines the progress we have made in the past year to improve our public health readiness and highlights areas in need of additional attention.

 1. Address poverty, social injustice and health disparities that may contribute to the development of terrorism. D

 - In 2002, the U.S. Budget for foreign development, humanitarian and economic aid, as a proportion of the overall budget, is at its lowest level since the end of World War II.2
- At the end of 2001, 40 million adults and children were infected with HIV/AIDS. The United States is the richest country in the world, but of the G8 countries, it has contributed one of the lowest amounts to the new Global Fund For AIDS, TB and Malaria as a proportion of its overall wealth. A CIA report concluded that the "persistent infectious disease burden is likely to aggravate and, in some cases, may even provoke economic decay, social fragmentation and political destabilization in the hardest hit countries in the developing and former communist worlds." 3
+ On July 18, 2002, the full Senate Appropriations Committee approved their version of the Fiscal Year (FY) 2003 Foreign Operations bill. Overall, the bill includes $16.4 billion, which is a $953 million increase above last year's levels for foreign assistance programs. The bill includes small funding increases for HIV/AIDS, child and maternal health, family planning programs and infectious disease control.

 2. Provide humanitarian assistance to, and protect the human rights of, the civilian populations of all nations that are directly or indirectly affected by terrorism. C

 + Human rights violations such as discrimination or violence against women and children and harmful traditional practices can have serious health consequences. This year, for the first time, the Commission on Human Rights, the main U.N. policy-making body on human rights, adopted a resolution on the right to health to appoint a special rapporteur (an independent expert) to report annually to the Commission on the extent to which governments are fulfilling the right to health.
+ U.N. member states voted to explore the creation of a new mechanism within the International Covenant on Economic, Social and Cultural Rights whereby individuals can petition their governments at the international level for failure to respect, protect or fulfill the right to health and other economic and social rights.
- The Administration proposes a minimal increase in spending for International Development and Humanitarian Assistance and for the Economic Support fund from a total of $11.5 billion in FY2002 to $11.6 billion in 2003. These initiatives were level funded in 2002. The President's proposal for a Millennium Challenge account does not call for any increases in foreign economic aid until 2004.
- The United States identified the restoration of Afghan women's basic rights as one of the principal goals of ousting the Taliban. After the Sept. 11 attacks, the U.S. government threw its full energies into combating terrorism emerging from militants in the Islamic world. But it has done little to expose and condemn the ways some states are using radical interpretations of Islamic law, or Shariah, to subordinate and exclude women. 4

3. Advocate the speedy end of the armed conflict in Afghanistan and promote non-violent means of conflict resolution. B+

 + Afghanistan has been mired in conflict for over 20 years. The U.S. military campaign began on Oct. 7, 2001 against the Taliban movement that ruled the country and hosted the Al Qaeda terrorist organization. The Taliban collapsed at the hands of the U.S. and Afghan opposition military in November-December 2001. Although the military campaign is largely over, U.S. forces remain in Afghanistan, serving as peacekeepers and searching for Taliban and Al Queda fighters and leaders that remain at large.
+ In June 2002 Hamid Karzai was confirmed by an Emergency Loya Jirga ('grand council') as head of a Transitional Administration.
+ The United States is working to further stabilize an interim government, arrange humanitarian and reconstruction assistance and expand the Afghan national army in order to maintain stability.
+ The United Nations and the United States are in the process of lifting U.N. and international sanctions imposed on Afghanistan since the Soviet occupation.

 4. Strengthen the public health infrastructure (which includes workforce, laboratory and information systems) and other components of the public health system (including education, research and the faith community) to increase the ability to identify, respond to, and prevent the problems of public health importance, including the health aspects of terrorist attacks. B

 + Comprehensive state plans to strengthen public health systems and prepare for terrorist attacks were approved by the U.S. Department of Health and Human Services (HHS) in June. State and local governments will receive $1.1 billion to create bioterrorism surveillance programs, improve infectious disease surveillance and enable hospitals to deal with large numbers of casualties. The funds are being used to renovate laboratories and increase their capacity, improve the detection of bioterrorism and other infectious disease outbreaks, train health workers, improve bioterrorism response facilities and equipment and develop surge capacity, and ensure to ensure that at least 500 hospital beds are available in each community to handle a sudden influx of bioterrorism victims.
+ On May 12, 2002, The Bioterrorism Preparedness Act was signed into law. The law aims to address gaps in biodefense, surveillance systems and public health infrastructure through federal investment in research, planning and preparedness.
+ The Centers for Disease Control and Prevention (CDC) has created diagnostic and epidemiological guidelines for state and local health departments and will be assisting states in holding drills to assess bioterrorism preparedness.
+ Since Sept. 11, the CDC has funded the development of new laboratories throughout the country that can test for microbes and chemicals that might be involved in a bioterrorist attack. There is at least one such laboratory in each state.
+ As of July 23, 2002, 17 states have introduced legislation based, in whole or in part, on a model State Emergency Health Powers law. This model was developed by the Center for Law and Public Health at Georgetown and Johns Hopkins Universities. The model law recognizes that governors and public health authorities may need additional temporary authority to respond rapidly and effectively in the case of an emergency in order to protect the publics' health. CDC believes that almost all states have used the draft model law as an assessment tool in reviewing their public health statutes.
- There currently does not exist a baseline set of performance goals and measures upon which to assess and improve preparedness. Without such national outcome measures in place to ensure that the states and localities use federal money for the purpose for which they are intended, we risk a divergence of priorities between the federal, state and local governments. This may result in state and local governments supplanting their own previous levels of commitment in these areas with new federal resources.5
- Coordination at a regional level is still lacking. Preparation in rural areas falls behind the level of preparedness in major metropolitan areas.
5. Ensure availability of, and accessibility to, health care, including medications and vaccines, for individuals exposed, infected, made ill, or injured in terrorist attacks. B+

 + Since Sept. 11, 2001, the National Pharmaceutical Stockpile Program managed by the CDC has stockpiled enough smallpox vaccines to vaccinate the entire U.S. population. In addition, HHS will have enough of the anthrax antibiotic cipro stockpiled by the end of the year to treat 20 million people.
+ Within the past year, HHS has also increased from eight to 12 the number of "push packs" that are stockpiled. Each Push Pack has at least 84 different types of supplies, such as antibiotics, needles and nerve-gas antidotes. These 12 stockpiles, located throughout the United States, can be available anywhere in the country within 12 hours.
+ The National Health Service Corps plans to recruit 40 new U.S. Public Health Service officers to work in medically underserved communities. In addition to providing primary health care services, the officers will be available to respond to local or national emergencies.
+ In July, HHS made $2 million in grants available to develop volunteer Medical Reserve Corps units on the local level. The grants will be used to train volunteers to assist medical professionals during large-scale emergencies to be transported to the site of a bioterrorist event within 12 hours.
+ The National Disaster Medical System now has over 10,000 volunteer healthcare workers that can deploy within hours to the scene of an attack.
- There currently exists a severe shortage of epidemiologists, microbiologists and public health nurses. Although $20 million has been funneled to training programs in public health schools, it is going to take time to educate and train these important public health professionals.
- Despite new funding approved for hospital preparedness, most of the money has yet to reach institutions in need. In April, 78 percent of hospitals indicated that a shortage of funds is keeping them from creating systems to track and identify outbreaks, train personnel and improve communications capabilities.6 Hospitals have voiced major concerns about the current lack of "surge capacity," the ability of hospitals to accommodate a sudden increase of patients. 7

6. Educate and inform health professionals and the public to better identify, respond to, and prevent the health consequences of terrorism, and promote the visibility and availability of health professionals in the communities they serve. B

 + Many medical schools and teaching hospitals held special programs on emergency
preparedness and anthrax exposure following Sept. 11. Many schools have revised the contents of courses on infectious diseases and path physiology to include information related to bioterrorism.
- There is no general consensus as to how medical schools should address bioterrorism preparedness in their curricula.8
+ The Web site of the CDC provides detailed information for health professionals and the public on biological and chemical agents and gives instructions on what to do in case of a biological or chemical attack.
- According to the Association of Public Health Laboratories, a shortage of qualified laboratory professionals remains.

 7. Address the mental health needs of populations directly or indirectly affected by terrorism. B

 + The National Institute of Mental Health (NIMH) responded to Sept. 11 terrorist attacks by awarding new grants for research on mental health needs. The grants were funded through its Rapid Assessment Post Impact of Disaster (RAPID) grants program, and are aimed at helping to design large-scale studies on prevention and treatment of mental illnesses resulting form exposure to mass violence.
+ The Public Health Security and Bioterrorism Preparedness and Response Act was signed into law June 12. It allocates $1.6 billion in grants to help states improve bioterrorism and mental health disaster response. A portion of that money would fund more counseling and training in disaster response.
- Teams of counselors and therapists are still needed and being trained to help the public cope with possible future catastrophe. Efforts are being made but according to Dr. Ann Norwood, chairwoman of the American Psychiatric Association's committee on disasters, they are not quite there.
+ The military recently announced that U.S. soldiers will be screened for psychological problems before they leave Afghanistan and commanders will watch out for symptoms of depression and anxiety among their troops. 9

8. Ensure the protection of the environment, the food and water supply, and the health and safety of rescue and recovery workers. B

 + All U.S. water authorities have begun vulnerability assessments since Sept. 11. The
largest plants will finish their assessments by December 2002, and the smaller plants should be finished by December 2003. In addition, most plants have significantly tightened security by ending tours, installing new security systems and screening drivers.
- Thousands of facilities, including chemical plants and water treatment plants, use and store hazardous chemicals in quantities that put millions of Americans at risk in the event of a release.
+ The U.S. Environmental Protection Agency (EPA) received a supplemental appropriation from Congress of $89 million to improve safety and security of the nation's water supply. The EPA's Water Protection Task Force and Regional Offices, working with many partners, are taking actions to improve the security of the nation's drinking water by providing direct grant assistance to drinking water facilities, supporting the development of tools and technical assistance to small and medium drinking and wastewater utilities, and promoting information sharing and research to improve treatment and detection methods.
+ Last year the number of food inspectors was 125. This year Congress provided the funds to hire up to 750 new inspectors.
+ New technology is allowing for quicker checks of food.
- HHS Secretary Thompson recently singled out food inspections as an area of particular concern and vulnerability.10 Experts are concerned that gaps in biological and intelligence data on foreign-plant and foreign-animal pest and pathogens and inadequate inspections at the nation's boarders increase the threat to the nation's food supply.

 9. Assure clarification of the roles, relationships and responsibilities among public health agencies, law enforcement and first responders. C

 + The proposed Department of Homeland Security, if enacted will have a central role in coordinating and consolidating preparedness efforts.
+ At present, the Federal Response Plan gives the Federal Bureau of Investigation the authority to coordinate law enforcement efforts following an act of terrorism, while the Federal Emergency Management Agency (FEMA) is responsible for coordinating measures to protect the public health and safety. In the event of an act of chemical/biological terrorism, HHS will work with FEMA to perform hazard detection, threat assessment, decontamination and medical support tasks.
- The General Accounting Office concluded that a highly integrated approach to the homeland security effort has not yet been achieved.11
- The roles of state and local agencies and first responders are not clearly defined. According to the Federal Response Plan, in the event of a terrorist attack "Local, State and Federal Responders will define working perimeters that may overlap. …Control of these perimeters may be enforced by different authorities, which will impede the overall response if adequate coordination is not established."
- A significant barrier to services exists due to inflexible physician licensure requirements during the case of an emergency. Physicians currently are not permitted to practice outside the state in which they are licensed. This limits coordination on a regional or intrastate level in the case of a public health emergency. Legislation is needed to establish an advance registration system for physician volunteers, which verifies their credentials, licenses, and hospital privileges.

10. Prevent hate crimes, ethnic, racial and religious discrimination, including profiling; promote cultural competence, diversity training, and dialogue among peoples; and protect human rights and civil liberties. F

 - Operation TIPS (Terrorism Information and Prevention System) was introduced as a Department of Justice program in development in January 2002. While few details are available about the program, it seems to propose that the government recruit informants among letter carriers and utility workers -- people who enter the homes of Americans for reasons unrelated to law enforcement--to help conduct surveillance efforts. This could be a direct violation of civil rights and deserves closer scrutiny.
 - In October, 2001, Congress passed the Patriot Act, whose provisions included new government powers to detain foreign nationals suspected of involvement in terrorism or 'any other activity that endangers the national security of the United States' for up to seven days without charge. The act authorizes the attorney general to continue to detain indefinitely on national security grounds foreign nationals charged with immigration violations, whose removal was ''unlikely in the reasonably foreseeable future."12
- The detentions of U.S. citizens Yaser Hamdi and Jose Padilla as "enemy combatants" may violate a 1971 law that bars citizens from being imprisoned or detained except pursuant to an act of Congress.
- In November President Bush signed a military order allowing for non-U.S.citizens suspected of involvement in ''international terrorism'' to be tried by special military commissions' which would expressly bypass the normal rules of evidence and safeguards prevailing in the U.S. criminal justice system. Under the order, the commissions could operate in secret and pass death sentences, and their decisions could not be appealed to a higher court. Trials before such courts would violate the principle of non-discrimination and international fair trial standards.
- Secret deportation proceedings against aliens detained in terrorism investigations threaten basic civil rights. A total of 74 detainees remain in custody out of an estimated 1,200 that were rounded up after Sept. 11. Some were initially denied the right to an attorney and not told why they were being held.
- According to the National Conference for Community and Justice 2000 Survey of Intergroup Relations in the United States (TAP II), there is cause for optimism when it comes to interracial/interethnic contact. Unfortunately self-reports by respondents indicate discrimination as a common part of many Americans everyday lives and 79 percent feel that "racial, religious or ethnic tension" is a very serious or somewhat serious problem.
- The Civil Rights Department of Justice has been involved in the investigation of alleged incidents involving violence or threats against Arab American, Muslim American, Sikh American, and South-Asian Americans. The Civil Rights Division, the Federal Bureau of Investigation, and the U.S. Attorneys' offices have investigated approximately 380 such incidents since Sept. 11-three times as many investigations than before Sept. 11.

 11. Advocate the immediate control and ultimate elimination of biologic, chemical and nuclear weapons. D

 - In November 2001, the United States rejected a protocol aimed at strengthening the 1975 Biological Weapons Convention (BWC). This protocol was developed by an Ad Hoc Group to address concerns about noncompliance. On the last day of the conference, the U.S. attempted to force through a decision to disband the Ad Hoc Group and terminate its mandate. To avoid a collapse of this meeting aimed at bolstering the BWC, parties agreed to suspend work until November 2002. The conference will reconvene Nov.11, 2002.
- Effective June 13, 2002 the United States terminated its participation in the Anti-Ballistic Missile (ABM) Treaty

+ The Chemical Weapons Convention (CWC) currently has 145 state-party signatories including the United States. The CWC requires not only the elimination of all stocks of chemical weapons but also international monitoring of both government and commercial facilities to verify that Parties were complying with their obligations.
- Although all four declared possessors of chemical weapons are moving forward with their destruction efforts, both Russia and the United States have informed the CWC treaty organization - the Organization for the Prohibition of Chemical Weapons (OPCW) - that they will be unable to meet the April 2007 deadline for destroying their chemical weapons stockpiles. Also, the OPCW is in the second year of a financial crisis, resulting in serious cutbacks in verification activities. During 2001, only 67 percent of the planned inspections were carried out; further cuts in inspections are expected in 2002.

12. Build and sustain the public health capacity to develop systems to collect data about the health and mental health consequences of terrorism and other disasters on victims. B

+ Since last fall, CDC has conducted research to learn more about anthrax, how to treat it and how to best mobilize the public health system in the event of an anthrax attack. In addition, follow-up is being conducted to ascertain the current health status of anthrax survivors as well as the nearly 10,000 people who were exposed to anthrax during last fall's attacks and were advised to take a 60-day course of antibiotic prophylaxis.
+ Expanded communications systems - such as the Health Alert Network (HAN) and Epidemic Information Exchange (Epi-X) - are now getting vital information to public health workers quickly.
+ CDC is evaluating the speed of the health systems response to an outbreak by analyzing the time between the ordering of a blood test by a doctor who suspects a patient is infected with West Nile and the confirmation of the diagnosis by a state or local health department.

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References:

1. These principles were adopted by the APHA Governing Council in November, 2001
2. Shapiro, I. And Birdsall, N. "How does the proposed level of foreign economic aid under the Bush budget compare with historical levels" Center on Budget and Policy Priorities. March 20, 2002.
3. The Global Infectious Disease Threat and Its Implications for the United States, NIE 99-17D, January 2000, www.odci.gov/cia/publications/nie/report/nie99-17d.html
4. Human Rights Watch
5. General Accounting Office, Testimony by Patricia Dalton. Effective Intergovernmental Coordination is Key to Success, GAO-02-1011T, August 20, 2002
6. American Hospital Association
7. New York Times, Threats and Responses to Bioterrorism. Section A, Page 16, Column 1, Sept. 9, 2002.
8. Voelker, R. Medical educators weigh curriculum changes to address threats of terrorism. JAMA 287(9):1099-1100, March 6, 2002.
9. Soldiers Mental Health Monitored, AP, 8/30/02.
10. Thompson: Food Supply Attack a Concern, AP Online, 09/03/02.
11. General Accounting Office, Testimony by Patricia Dalton. Effective Intergovernmental Coordination is Key to Success, GAO-02-1011T, Tuesday August 20, 2002.
12. Amnesty International
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