Still Not Ready in The ER

By Arthur Kellerman
Friday, August 5, 2005

One of the fundamental responsibilities of government is to coolly and dispassionately assess health threats against the populace and take decisive action to counter these threats.

Faced with the twin specters of mass casualties from international terrorism and emerging biological threats, our government has failed to take effective action on either front.

International terrorism's weapon of choice is explosives -- improvised and otherwise. The London attacks and the devastating Madrid bombings are only some of the more recent examples. Over the past decade terrorist bombings have caused many civilian deaths and injuries in Israel, Russia, Bali, Colombia, Iraq, Spain, Egypt, Yemen, Kenya, Tanzania, Argentina, Afghanistan, the Philippines and other places, including two U.S. embassies in Africa.

But unfortunately, rather than strengthen our nation's beleaguered emergency and trauma care system to meet this threat, the federal government has turned a blind eye to the problem. Across the United States, underfunded emergency rooms and trauma centers lack sufficient beds to meet their daily mission, much less absorb large numbers of victims from a terrorist attack. Few ambulance personnel know how to assess a blast scene or properly evaluate multiple casualties from a bombing. The tiny amount of federal funding ($3.5 million) devoted to trauma systems planning and development is being targeted for elimination by the House.

One reason we are so ill-prepared is that the bulk of federal preparedness funds have been poured into bioterrorism, a frightening but less likely threat. Over the past three years, billions in taxpayer dollars have been spent to purchase "sniffer stations," mount an ill-fated and ultimately unsuccessful vaccination campaign against smallpox, and stockpile antibiotics. There are 17 federally funded Centers for Public Health Preparedness in the United States that focus exclusively on biological and other exotic weapons of mass destruction. There is not one focused on civilian injuries from explosives.

But at least we are safer from biological agents, right? Well, no. Two years after SARS had a devastating impact in Southeast Asia and in Toronto -- arguably one of the most medically sophisticated cities in the world -- we are woefully unprepared to handle a recurrence of severe acute respiratory syndrome. We are even less capable of meeting a far more deadly threat: the emergence of a pandemic strain of influenza from Southeast Asia.

In 1918-19 the Spanish flu killed 20 million to 40 million people worldwide -- more than 500,000 in the United States alone. Many of the victims were young, healthy adults. Despite knowledge that pandemic strains occur every 10 to 50 years, and despite increasingly worrisome reports from Southeast Asia, we are woefully unprepared to protect the United States from an outbreak of pandemic flu. Federal officials are "meeting," but a national plan for countering pandemic flu has not progressed beyond the draft stage. State-level planning and preparedness efforts vary widely; no specific deadline exists for their completion. Despite overwhelming evidence that many hospitals are already diverting ambulances because of overcrowding, the Health Resources and Services Administration does not plan a meeting to discuss the lack of hospital "surge capacity" before next fall.

A year after the flu vaccine debacle, the United States still lacks sufficient production to meet its needs. Six to eight months of lead time are required to create a new vaccine. The virulence of the avian strain emerging in Southeast Asia is posing huge technical challenges to vaccine makers. Our approach to distributing vaccine and antiviral agents is woefully inadequate. Front-line paramedics, nurses and ER doctors lack adequate protective equipment for respiratory pathogens. Many cannot even get a shot of flu vaccine. America's most mission-critical hospital resources are struggling to meet daily demands, much less the additional burden of an epidemic.

It is ironic that our government's single-minded focus on "bioterrorism" has left us less well prepared to handle either an emerging biological threat (such as SARS or avian influenza) or a terrorist strike (which will most likely involve the use of explosives). Unless we quickly rethink our priorities and broadly allocate resources to meet the most plausible threats to the U.S. population, our only option will be a "faith-based initiative."

Pray that nothing happens.

The writer is professor and chair of emergency medicine at the Emory University School of Medicine in Atlanta.


© 2005 The Washington Post Company