In The Line Of Fire

ne evening last October, when anxiety over anthrax attacks in the eastern United States was at its height, Dr. Ivan Walks was having dinner at the Henley Park Hotel in Washington. He was taking a much-needed break from his work at the city's Department of Health, where he then served as chief health officer. The tension in Walks' office was high: Two local postal workers had died of inhalation anthrax, and others were hospitalized. Buildings where anthrax had been discovered were closed and under guard, including a postal facility and a Senate office building.The Centers for Disease Control and Prevention had taken over a portion of Walks' offices to establish a command center for investigating the outbreak. It seemed like half the city was taking antibiotics to prevent infection and the round-the-clock television news coverage was taking a toll on public confidence.

Walks' break for dinner was hardly relaxing. His cell phone rang throughout the meal. Walks took every call, but one in particular sticks in his mind months later. It was from a local television station, where a reporter had information that the Washington Hospital Center was treating another anthrax victim and unnamed sources said the hospital was covering it up to avoid panicking the public. Hospital and federal health officials weren't talking, but a relative of the alleged victim had substantiated the story. The station was ready to go with it, but wanted a comment from Walks. Before he took another bite, Walks called the medical director at the hospital to find out what was happening. Within minutes, he called the reporter back-the story was wrong, the man in question did not have anthrax, no matter what his relative believed. Walks put the reporter directly in touch with the hospital medical director, who explained the situation. The story never ran.

Walks has a pretty good idea of what would have happened if he hadn't taken that call: The story would have run, other stations would have picked it up and reported it as well, with the angry relative center stage. The public, already questioning the veracity of conflicting information they had been hearing from various public officials, would have been further shaken and confused, and health officials would have been inundated with media calls, distracting them from important work. Because of Walks' action, the public was spared another piece of misinformation that might have caused a panic in an already jittery community. Walks and hundreds of other men and women thrust onto the front lines of America's battle with anthrax last fall made countless critical decisions that had tremendous impact on how the crisis unfolded. They weren't following any federal or national plan to perform a particular way or abide by certain rules. They used their best judgment, based on long experience and common sense.

Combating terrorism is unquestionably a federal responsibility, but the overwhelming burden of responding to a terrorist attack will fall to state and local officials like Walks. The efficient flow of information and expertise among all levels of government, the private sector and the public is critical to effectively managing any crisis. It's also extraordinarily difficult to achieve. The men and women most likely to be called upon first to respond to and manage the fallout from a terrorist attack are not part of some well-oiled organization, nor are they generally part of the federal bureaucracy. They are quite literally our friends and neighbors, the millions of Americans performing key public and private services-health care workers, fire fighters, transit officials and police officers. They are the people Americans looked to first on Sept. 11 and during the anthrax attacks last fall. While the federal government struggles to anticipate and prevent future terrorist attacks, it also needs to do a better job of helping these local responders when prevention fails. They especially need better training and equipment, and help planning their responses to future attacks.

FIRST TO FIGHT

A key challenge is knowing what sort of situations they should be prepared for. Attacks with chemicals? Disease-causing agents? Conventional bombs? Bombs packed with radiological material? Suicidal pilots flying fuel-laden airplanes into crowded buildings? All of the above, and probably a number of other things no one has yet imagined. Each of the scenarios requires a different response. The people who respond are different, the planning is different and the equipment, expertise and information they require are different. For several years now, the Justice, Defense and Health and Human Services departments have provided equipment and training for front-line personnel through a number of grant and training programs. But the efforts have been widely criticized as duplicative, confusing and, in some cases, irrelevant, says Amy Smithson, an expert on terrorism preparedness at the Henry L. Stimson Center, a Washington think tank. "There's a lot of turf out there," Smithson says. "The turf has descended from executive branch departments as well as from Capitol Hill." The federal programs, most of which sprang from legislation passed following the 1995 nerve gas attack in the Tokyo subway system, were not administered in any coordinated manner and failed to provide a uniform approach for training and equipping personnel.

Smithson found that grant programs to fund the purchase of equipment had varying time lines and requirements, different goals and conflicting views on priorities for responding to particular events. Federal agencies offer dozens of terrorism preparedness courses, she says. For local personnel, figuring out how to get the most beneficial training or equipment from this maze of programs is nearly impossible. Only a small fraction of federal funds disbursed under such programs ever make it to local responders-most funds are consumed by the federal agencies or by consultants the agencies have hired to administer the programs. Smithson's overall assessment of existing federal programs: "a fractured mess."

"I don't think the federal government should be in the training business at all. If this were done well, the feds wouldn't be out there as trainers. The training would be institutionalized in local police and fire academies. The training would be given to physicians in medical school, nurses in nursing school. That's how one gets training across the country instead of in spots," Smithson says. "Washington doesn't seem to be able to get itself out of the way. If they were doing training in a cost-effective manner, it would not be an approach where trainers hopscotch across the country. It would be an approach wherein professional standards are established and institutionalized."

The Bush administration wants to boost spending for local responders and move the bulk of federal programs aimed at helping them from the Justice Department, where they are administered under the Domestic Preparedness Program, to the Federal Emergency Management Agency. The intent is to create a streamlined plan to distribute funds as soon as possible to local officials. (The Justice Department would retain jurisdiction over law enforcement relationships with state and local forces, but FEMA would handle all programs pertaining to training and purchasing equipment for responding to terrorist attacks.) Local fire departments and law enforcement units would apply for funding through their state homeland security directors-all 50 states now have such directors. It would be up to the states to develop FEMA-approved statewide or regional security plans that ensure common standards and compatible communications technology.

While that sounds like an improvement, it doesn't solve a fundamental problem: Federal agency grant requirements are so cumbersome only a fraction of the available funding makes it to local jurisdictions, and local governments have trouble spending the money wisely once they get it. Glenn Fine, the Justice Department's inspector general, reported that as of mid-January, more than half of the funds appropriated for the grant program from 1998 through 2001-$141million out of $243 million-had not been awarded; and half of the money that was awarded remained unspent. "Also, we found that nearly $1 million in equipment purchased with grants was unavailable for use because grantees did not properly distribute the equipment, could not locate it, or had been inadequately trained on how to operate it," according to the report. Without measurable performance standards for grant programs, it will be impossible to gauge their effectiveness, Fine concluded.

WANTED: FORKLIFTS

The most effective support from FEMA came in the form of the national Urban Search and Rescue (USAR) team that quickly showed up at the scene. FEMA supports 28 such teams, which are funded and equipped to deploy nationwide within six hours. Each team includes search dogs and has 62 members ranging in expertise from medical care to structural engineering. Most team members are professional firefighters or rescue specialists.

At the Pentagon, the Urban Search and Rescue team's use of dogs facilitated a quick search for survivors that otherwise would have been impossible. In addition, "the inclusion of structural engineers provided the expert supervision that we needed to conduct the safest possible operation," Plaugher says. "Where else, in a crisis, do you find people with expertise like that?"

Despite the fact that local fire and law enforcement personnel have long practiced emergency response operations at the Pentagon and have close working relationships with their federal counterparts, Plaugher says his education about the Urban Search and Rescue teams began only after they arrived at the burning building. "It would be helpful if fire chiefs nationwide had a good understanding of USAR's role, capabilities and limits in advance of a catastrophe," he says. He recommends that such information be included in FEMA's training program at the National Fire Academy in Emmitsburg, Md.

Plaugher also said the teams need better gear. "I learned that there is an equipment shortage that allows for only one appropriately equipped team to be deployed at a given time from any one of USAR's 28 bases. If the airplane that crashed in Pennsylvania the morning of Sept. 11 had instead reached Washington, D.C., how would we have chosen where to send the existing cache of USAR equipment?" Just getting the teams to the scene demonstrated some critical needs. Jeffrey Metzinger, a fire captain with the Sacramento Metropolitan Fire District in California, was on his way to work on Sept. 11 when he heard news of the attacks in New York and Virginia on the radio. As an Urban Search and Rescue member based in Sacramento, he realized his team would likely be deployed and immediately headed across town to the team's mobilization site. There, he learned that the forklift needed to load the team's large rescue pallets with equipment was in use several miles away. "We quickly hired a transport truck and escorted our forklift across town in rush-hour traffic," he told the Senate Committee on Environment and Public Works last October. "A second forklift would have been highly useful."

UNCHARTED TERRITORY

The still-unsolved anthrax attacks of last fall, painful as they were, do not even begin to demonstrate how devastating an attack with biological weapons could be, says Dr. Tara O'Toole, director of the Johns Hopkins University Center for Civilian Biodefense Studies. Consider the widespread confusion and even panic generated by just 18 confirmed cases of anthrax (11 inhalational and seven cutaneous) occurring in four states and the District of Columbia, in which five people died. The stress on the medical system was extraordinary-laboratory personnel were literally living in their labs in an effort to keep up with the demand for testing. Untold health care resources were diverted to cope with the outbreak.

"The economic and social disruption resulting from a large bioweapons attack could conceivably generate sufficient fear and urgency to threaten fundamental democratic principles, and could undermine confidence in government," O'Toole says. In a paper presented at a symposium at Syracuse University in January, O'Toole wrote: "There is no hospital or geographically contiguous collection of hospitals in the country that could cope with 1,000 patients suddenly needing advanced medical care. Moreover, the bioterrorism response planning carried out in some cities during the past few years under the [Justice Department's] Domestic Preparedness Training Programs, has, for the most part, not included hospitals. The hospitals claim that their busy personnel cannot be spared to participate in these training programs and exercises. The result is that few municipalities have any community-wide plans for dealing with the medical care aspects of large-scale disasters."

During the tension-filled days of last fall when new reports of anthrax seemed to be appearing every other day, one of the most glaring problems was a lack of reliable information. Health officials from several state and local jurisdictions, from Connecticut to Florida, as well as hundreds of federal disease experts, were managing and investigating the anthrax outbreak. There was no central source of reliable information. In fact, it was seldom clear who was in charge of any particular facet of the investigation or in any particular jurisdiction.

The fact that Walks had a long-established relationship with many local health reporters and made himself available 24 hours a day proved an invaluable resource for the community, but such skills are far from universal. "You have to be able to provide information quickly," says Walks. "You can't say 'I'll get back to you tomorrow.' You've got to stop whatever you're doing and make the calls. That sort of real-time connection with the media is a critical lesson that a lot of folks aren't comfortable with. They think, 'We can't talk to the media until we have all of our story together. We will give you a press release next Wednesday.' The media, in today's society, can't be fed that way. That was a tremendous lesson for us."

There were other important lessons from the anthrax outbreak as well: For one thing, federal officials don't always know as much as they think they know, and that can be a dangerous thing. Just days before the two postal workers died, experts at the CDC said anthrax spores found in a letter to Senate Majority Leader Tom Daschle, D-S.D., posed so little threat to postal workers that they didn't need to be tested. Federal officials were unaware of a Canadian study that showed just how dangerous anthrax contained in an envelope could be. If disseminating accurate, timely information to the public is difficult, it is apparently just as difficult for professionals to communicate among themselves. Health officials in Fairfax County, Va., where two postal workers were hospitalized, sometimes learned important medical information from television news stations long before they got it from federal health officials, resulting in inconsistent care for patients being treated for anthrax.

Dr. Carol Sharrett, director of the Fairfax County Health Department, said problems with both the county and state e-mail systems made communication difficult. "We had to rely on an already overtaxed fax system to collect information updates from the Virginia Department of Health and the CDC and disseminate them to the local medical community and laboratories," she says. "This resulted in delays and omissions in receiving vital information and providing appropriate direction."

And those problems were occurring in one of the best-prepared regions in the country. According to a study by the National Association of City and County Officials, only one-quarter of public health departments are trained and equipped to cope with incidents of bioterrorism. Many health departments lack even the most basic resources, such as full-time staff and Internet access, says Mohammad Akhter, executive director of the American Public Health Association. "These are serious problems. It will take years of sustained funding and attention to deal with them. And frankly, I'm not sure there is the will to tackle that."

-- Kellie Lunney contributed to this report.