Dr. Tara O’Toole
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SUSAN DENTZER: An area that you’ve isolated as very important in terms of response is the capabilities of labs to quickly perform the adequate tests and cultures, and so on. How has that worked in this situation?
DR. TARA O’TOOLE: I think the labs have really tried to rise to the occasion. Again, in Florida, the state lab correctly and quite rapidly diagnosed anthrax. I think that’s fairly amazing, and commendable. What’s happening now, though, at the–is that the labs are getting overwhelmed, not so much by anthrax cases but by–for demands to distinguish between one suspicious powder versus another. I mean, there’ve been thousands of cases of suspicious powders called in across the country, and that is taking its tool. There are about 83 state public health labs that are on CDC’s training list, and I think, as I said, they’ve been doing a good job. That’s not enough lab capacity.
Remember, we’ve only had 15 cases of anthrax thus far, and we’re close to maxing out our diagnostic capacity in this country. I mean, that’s not acceptable. I think we need to think through how we could engage hospital labs, how we could get them in the game, how we could improve the capacity of the state labs.
In our state, for example, in Maryland, there’s now a hiring freeze on, so you can’t hire anybody into the state lab, and I suspect that will happen in many other states, what with the economic downturn and the, the pressure on state budgets.
I think we need to think through who are critical personnel in these times and where we’re gonna get the lab capacity, looking forward.
SUSAN DENTZER: Hospital response has been a particular concern.
DR. TARA O’TOOLE: Uh-huh.
SUSAN DENTZER: What have we seen so far in this case?
DR. TARA O’TOOLE: Well, again, I think hospitals, over the past decade, have been under enormous financial pressure and there’ve been a lot of consequences for that. One is that they see a lotta patients were rapidly. So, for example, it’s probably hard for emergency room docs to take a complete “soup to nuts” case history, including, for example, occupational history, which is something you’re taught to do as a medical student but a busy ER doc, in the middle of the night might not think to ask, “Where do you work?” thereby tumbling the notion that this could be a person at particular risk for anthrax, if they were a postal worker, for instance.
Also, what has happened as a consequence of the financial pressures on hospitals is that they have virtually no surge capacity. It would be very difficult for any hospital in the country to deal with a sudden increase in demand for patient care, let alone an enormous increase. There’s no combination of hospitals in the country who could cope with a thousand people suddenly needing sophisticated medical care, you know, in a city like Baltimore or Washington, for example. That would be beyond our ken and we need to think through how we would deal with a mass casualty situation, if we needed to.
You know, the New York hospitals rose to the occasion, I think magnif–magnificently, after September 11th, but there were very few survivors, tragically, who needed health care, and most of those were folks with trauma, or a few burn cases.
What would we do if we had, you know, a thousand, or several thousand people all over the country needing sophisticated care? It would be very–very difficult.
SUSAN DENTZER: Okay. So we’re continuing to speak about hospital response.
DR. TARA O’TOOLE: Hospitals. Right; yeah.
SUSAN DENTZER: So the kind of dreadful scenario that is now being painted, where smallpox is introduced into the equation and thousands of people become sick with it on a very–very short time frame. We’re not equipped.
DR. TARA O’TOOLE: We’re not ready. Hospitals have been taught to be competitors, not collaborators, and to deal with something like a serious smallpox outbreak, we would have to create, I think, a coalition of hospitals in a city, working together to share resources. You might wanna dedicate one hospital to smallpox victims, for example. We’d probably have to do a lot of home health care in order to take care of folks.
But you need a plan before the epidemic happened, and that’s what we lack right now.
SUSAN DENTZER: Another point that you all have emphasized in the past is the, the need for a system to distribute therapies. We’ve essentially concocted one very rapidly in terms of distribution of Cipro and other antibiotics. Has–is–has this worked?
DR. TARA O’TOOLE: It’s worked in some places and not so well in others. It seems to be working fairly well in cities where you have robust public health agencies, or relatively robust agencies who can distribute from central points. I read in the paper that one New Jersey township was told on Friday afternoon, put several hundred of your mail handlers on antibiotics but over the weekend have them get them from their own physicians, which wasn’t really a practical alternative, late on a Friday afternoon.
So the mayor of this township kind of “rode to the rescue,” took the reins in hand, went off and got antibiotics using the state police, and, you know, set up a distribution center, and from what I can tell, calling around the country, the suburbs, in general, are less able to deal with the distribution problems than are the more centralized cities who are used to dealing with health emergencies on a more regular basis.
And the cities typically have more people, more capacity in their public health system than to the suburbs, and the counties, and the rural areas. Half of our local health departments in this country serve people of less than fifty–less than 50,000 population. That might not be a big enough entity to be efficient in the full range, you know, of public health disciplines, at this point.
SUSAN DENTZER: This gets to a very important point which is that the primacy of response in these attacks appears to be at the local level. If the local–
DR. TARA O’TOOLE: Absolutely; absolutely.
SUSAN DENTZER: Let’s talk about that.
DR. TARA O’TOOLE: [inaudible].
SUSAN DENTZER: First of all, if, if you could–I don’t want to put words in your mouth, but if you would talk about the, why the local level response is so important, and then we’ll talk about, a little bit more about what’s been the case in this instance.
DR. TARA O’TOOLE: Well, the local response is important for many reasons. First of all, the Feds aren’t going to get there instantly, and depending upon what salvation it is you want the Feds to bring–it may be 12, 24, 96 hours before they arrive. Also, the notion that the Federal Government can come in and take over public health or medical care in this country is simply crazy.
The CDC has, I think, in total, about 5000 people. You know, they can’t take over the health care of a city, let alone multiple cities, and they need to maintain a strategic posture. They can’t get down to ground level and go operational, very efficiently.
Also, the locals know the terrain best. I mean, they are the ones who know how to get to people, who know where people can get to if they’re going to distribute antibiotics, who actually have personal connections with the hospitals or the ambulance drivers, and so forth.
I mean, the locals know their municipality or their county best, and are probably best placed to put together a complicated, sustained response. Look at New York. Look what happened to New York. I mean, certainly, a lot of aid was rendered by the Federal Government and by New Jersey and by New York State over the days following 9-11.
But the initial response, that critical initial response was New York City.
SUSAN DENTZER: In this case, and let’s take this area as an example, the response to anthrax–has the local response been adequate overall?
DR. TARA O’TOOLE: Well, I think it has had positive and negative aspects. I mean, clearly, not all docs were aware of the possibility of anthrax being within their patient population. Clearly, not everyone knew to call the health department or call the right place in the health department. I have heard that some docs who were treating anthrax patients haven’t heard from the health departments, even after deaths occurred.
There has certainly been confusion about what to do when the notice came down from CDC, for example, following the discovery of the Brentwood cases, and new worries about who else might be at risk. When the announcement went out that all federal mailrooms should be checked for anthrax and people in them placed on antibiotics, many of the cities and counties who were told to go get this done, had no idea what those federal mailrooms were. They had to generate their own lists.
Some were able to do that very quickly. In some cases it was much more problematic. We’re still having problems contacting the people who worked in these mailrooms. We know everybody hasn’t shown up for antibiotics. From what I hear, in some localities we’ve got good records of who’s received antibiotics. They’re less perfect in other localities.
So I think, you know, everyone’s working their heart out trying to put this together, but there’s no system for doing this with maximum or even moderate efficiency, and of course we’re learning as we go, and not all of the lessons learned are being transmitted to everybody who needs to know ’em.
SUSAN DENTZER: Much has been made of the CDC’s slowness, in terms of recognizing the degree of the difficult at Brentwood. What, in your view, happened there?
DR. TARA O’TOOLE: I think the first problem is that there is a paucity of information about what’s going on. There’s a lot we don’t know and that can’t be known, but I think those uncertainties should be called out and identified, right up-front.
So if we don’t know how aerosolizeable the anthrax, that’s understandable, but let’s say so. I think this confusion about it being weaponized, not weaponized, is troubling, because it suggests, for example, that someone knew or suspected that the powder was very sophisticated, that it could remain airborne for long periods. That set of characteristics would suggest a greater risk for people working in a postal facility where such a letter had gone through, than would be the case if it was, you know, clunky powder that’s just gonna fall to the ground once you open the envelope.
I think also there were probably–it just wasn’t recognized that anthrax could actually leak through a well-sealed envelope. Okay; that’s fair enough. We didn’t know that then. But I think a clear explanation of what we did know and what we didn’t know, and how those kinds of whatever they are–if it’s a miscommunication or a failure to communicate amongst the parties who were analyzing the powder, and the people in CDC–whatever–ought to be acknowledged, along with what we’re gonna do to remedy the situation.
I also think this is a very complicated situation and people need to understand that. Who knows how anthrax comes out of a well-sealed envelope and contaminates a mail facility.
Now, clearly, we’re gonna learn a lot about thinking that through in the next few weeks and information about, for example, what the environmental sampling protocols are, what their reliability is, what our best guess is about who’s at risk, I think could be very helpful to the public and also to professionals, to public health practitioners as well as to physicians in the coming days.
I think CDC is, you know, pedaling as fast as they can to put this information together and we need to be patient as they do so. But at the same time, I think it’s fair to expect that as soon as they have that information, they will let the media and the public and the professionals know what they know and what they don’t know, and so far, you know, I think the grade on information flow has been poor.
SUSAN DENTZER: And primarily in–information flow coming forth from the CDC back to other key players in the system?
DR. TARA O’TOOLE: To key players in the system and to the public. I mean, there’s a lot of different notes to connect. You know, now there’s a lotta mailrooms. There’s a lotta different patients in hospitals. There’s patients in Tr–in New Jersey, there’s patients in Maryland and D.C., and Virginia and Florida. So there’s a lot of different participants who have to kind of “phone in” and that CDC has to get in contact to and tie together. There’s an awful lot of datastreams involved here. It’s a very complicated picture.
Nonetheless, I think one of the main responsibilities of CDC, and of HHS, is to inform the public, very clearly, what’s going on. They need to do better on that score.
SUSAN DENTZER: And it’s been poor to date.
DR. TARA O’TOOLE: It’s been poor to date. I think so far, that’s forgivable, given how chaotic it’s been and the need to attend to the situation.
But I think we need to take this seriously, and this isn’t, this isn’t a “slam” at the people who are working so hard at CDC. We don’t have a public health system in this country, if you use as a definition of a system, Kevin Kelly [?] system is something that talks to itself. We aren’t well-connected between the federal CDC centers and the state health agencies, and the local and the city health departments. All right. We need to build that and we need to understand, now, that that isn’t a matter of improving public health, which would be good for national security.
Creating that connectivity is now essential for national security and it will also be good for public health, but we have to do it for bio-defense, and it’s gonna require a significant investment.
SUSAN DENTZER: The administration has a billion and a half dollars in increased funding for the public health system, much of which would be aimed at increasing the pharmaceutical stockpile. How adequate is that?
DR. TARA O’TOOLE: Well, I think the administration is to be commended for increasing the stockpile. I was particularly glad to see that they plan to acquire a sufficient amount of smallpox vaccine. I think that’s very responsible. They’re also increasing the antibiotics that would be available in an emergency.
I do not think the amount of money that they have in their bill for improving public health infrastructure at the state and local level, and even at CDC, is anywhere near effi–sufficient.
Public health is now a national security issue, and if we can’t spend one or two billion dollars on public health right now, then I think that signals that people in Washington don’t “get it.”
SUSAN DENTZER: And you’re saying one or two billion dollars, in addition to what the administration has already re–
DR. TARA O’TOOLE: One–
SUSAN DENTZER: –quested?
DR. TARA O’TOOLE: –or two billion dollars, now, to start. I think at least a billion dollars, in addition to what the administration has suggested, most of which, as you point out, goes for drugs and vaccines, which are important, but do nothing to improve awareness or training or exercises, or the connectivity of the infrastructure you were talking about earlier.
This is going–and in that one billion that I am suggesting we need to spend now is only a beginning down payment on the investment we’re going to have to do, to make, to actually make the nation capable of responding to a bioterrorism attack.
As Ken Alibek said, I mean, anthrax is the beginning. This isn’t the end. We need to look to the future and look to the threats that are coming at us, and biological weapons are one of them. We can meet this threat. We’re the United States of America, and we have a phenomenal capacity in biomedical research, in pharmaceutical production capacity, in biotechnology.
We need to use it. Those sectors are not now engaged, deeply, in bio-defense, or in national security. We need to bring them into the game and we need to knit our health care system and our public health systems together so that we can respond, collaboratively and effectively, to big threats, not 15 anthrax cases, but even to more dire threats, and if we do that, I think we can eliminate the threat of biological weapons, at least as weapons of mass destruction. But we need to make that investment.
SUSAN DENTZER: So you’re saying, in effect, along with federalizing airport security and bailing out the airlines, and bailing out the insurers, the property and casual[ty] insurers, this is at least as important as doing all of those things that we’ve done in the week of–
DR. TARA O’TOOLE: Absolutely.
SUSAN DENTZER: –September 11th?
DR. TARA O’TOOLE: Absolutely.