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Dr. D.A. Henderson

Several decades ago, Dr. Donald A. Henderson was instrumental in working towards the eradication of the deadly virus smallpox. On November 1st, Health and Human Services Secretary Tommy Thompson named Henderson director of the new Office of Public Health Preparedness. Excerpts from his conversation with Susan Dentzer follow.

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    Let's talk about what we've learned so far from this current episode of bioterrorism, the anthrax attacks. What do you–how do you think our system, if we can say we even have a system of public health, how has it responded, in your view?


    Well, one can look at it as we have a long way to go or we have come a long way. We are not able to respond as well as we would like. There's no question about that. But the history of the dealing with infectious diseases is one of, in the last 30 to 40 years of neglect. We've had vaccines. We've had antibiotics. We've had fewer infectious diseases. We've been protected by two oceans and from many of the tropical diseases. And with this we've let our capability in the public health sector wither. So that we come to this event with anthrax, and this is a very unusual and very extraordinary event which we've not had a lot of practice in dealing with.

    As I look to see what has been done, how quickly the response has been possible, the actions taken, I would say that we've written a very good history, if you will. I think the record is good. The thing that worries me is suppose we have many more cases. Would we be as adept as we are? And I think it would be very difficult.


    Some critics have already pointed to a number of difficulties in connection with the response to the anthrax attacks. One was that communication up and down the line was inadequate, whether from the CDC, whether to individual practitioners of medicine who were not sufficiently aware that anthrax–that they might see cases of anthrax.

    What do you think? Is that a fair assessment? Was communication just extremely poor in this situation?


    Well, I can say at our center, at Johns Hopkins, we had spent the last three, four years trying to anticipate what would be needed in case of an attack and what we should do and where are our problems.

    Now, we identified the problem of communications and of dealing with the media, of dealing with the public, as certainly one of the important areas. Despite that, I can say we were really dumbfounded by the tremendous amount of interest, concern that was generated both on the part of the media and on the part of the public, and really how difficult it was to get out a message as to how worried should you be, what can you do about it, what are the facts.

    And so even for ourselves, outside of government, trying to figure out how best to deal with this, we were surprised ourselves that it generated the type of response that it did.

    I think we could do better now. I think we've learned a lot more about how best to communicate. And in a sense, this was–has been a very small outbreak. We're dealing really with 22 cases in all. And, in a sense, what–if there's any good to have come from this, it is to illustrate to us what needs to be done and how better to respond. And I think we are learning those lessons, no question.


    How would public officials communicate differently in the next bioterrorist attack, having learned what they've learned from this one?


    Well, I think we do a couple of things. I think we would make a greater effort to put professional people who are knowledgeable of this more to the front to talk to the people, the public, as to what do we know, what don't we know, how concerned you should be.

    I think we would probably want to communicate more frequently than we did at first because I think there is almost–we're used to having virtually an hour-by-hour accounting of what is happening. I don't think we need to go that far, but I think we need to have several press conferences and briefings every day.

    I think we need to probably identify more people who can talk to the press, who can be before the public, than we did. I know from my own experience trying to respond at Johns Hopkins that we were just inundated, we were buried. Even when we brought in more people and more people, we just couldn't keep up. And yet we wanted to convey a message to the public and to explain what was happening as best we could explain it, to educate, to allay fears. But it was not easy doing this.


    A panel of the Institute of Medicine has already come forth with some specific criticisms of the response. It noted some of the deficiencies in the public health infrastructure that paved the way for that, specifically a shortage of laboratories at the CDC, as elsewhere. That, in fact, delayed the determination that anthrax spores had been found in other government buildings.


    A network of laboratories has been created only fairly recently. This is only over the last couple of years, which CDC has identified a number of laboratories and begun to train the people there in how to identify these different organisms, because most laboratories would not normally be processing specimens for plague or anthrax or smallpox or these other agents. So it's been started from scratch. One had to train them, get consistent protocols so everybody's acting in the same way, providing them the reagents, the testing materials, and actually they've done quite a good job, I think, in doing that in a fairly–fairly short period of time.

    They need more money. There's no question about that. And they do need themselves to get an experience of testing these different unknowns that come to them.

    I think there is also a need in this case–and we have not quite figured out how best to do this–to identify which specimens have–deserve priority and which ones we shouldn't process at all because they're not of value. And I think the laboratories, trying to respond to all requests from all sources, found themselves completely inundated and, therefore, not at this–not able to sort out what are the ones that we run first, which ones do we put aside, and which ones do we tell the people submitting them should not have been sent at all. That needs to be sorted out.

    But now we've had this experience. I think, again, we will be in a better position here on to deal with this problem.


    Another problem that's been commonly cited in terms of the infrastructure at the public health local and state level is a shortage of information technology and access to information technology. Specifically only about a half of local public health departments have continuous 24-hour access to the Internet. How big a problem is that? And what can be done at the federal level to begin to address that?


    Well, many of the, let's say, county or smaller-city health departments do not have access to the Internet, and that's true. And I think the Internet has become very important of recent years as a source of information and a means of communication. And certainly this would be the case here, that we can put up information very quickly and inform people. We can send out, let's say, information sheets which could be available for experts in infectious disease or for the lay public.

    So it is important we have that communication. It's very different than it used to be many years ago where you didn't have that type of access. So I think this is important.


    Responding to a smallpox outbreak would require steps that we haven't had to undertake in this country for many, many years — quarantining, perhaps, of massive numbers of individuals, hospitalizing patients in hospitals where they would have to be segregated from others. What plans are being drawn up now for those kinds of exigencies?


    There are a number of plans that are being developed now, and some of these in fact are published and available. But the problem of housing infectious patients in hospitals is a difficult one. Some of the hospitals now are able to do this with patients with the multiply drug-resistant tuberculosis cases, so that the room itself is under negative air pressure, and so that no organisms cannot flow out, and then there's a filter where the air comes out so as to trap any organisms that might in the air. There are very few hospital rooms that are so equipped.

    Now, certain of the hospitals are able to take an entire wing or segment of the hospital, which is on a single air conditioning/heating unit, and can assign that just for patients who would be infectious. And this I think can accommodate quite a number of patients, but we've got to plan ahead to be in a position to do that.

    So as far as isolating patients, the system that we have used in a trial run in the United States some time ago, was to identify those people who have been in contact, and then to assure that we got a temperature reading from them every night because they could wander around the city, and until they–remember, until they get a rash, they're not going to infect anybody. So suppose they–a person is infected. He can go for the whole 8, 10, 12 days feeling well. He's not going to spread the disease. Then he comes down with this very serious flu-like syndrome and will feel perfectly terrible, and then only after a couple of days he develops a rash. Then he begins to transmit the infection.

    So the people we would like to isolate or quarantine are those who have been in contact, who come down with a fever or have a rash which we're not sure what it is, and we put them into separate quarters for quarantine, not a whole population because I think you try to get involved in quarantining an entire city or an entire area, you run into a lot of difficulties. There are people who take this among themselves to–well, they're going to get away somehow or other, and we're just not in a position to quarantine or isolate huge numbers of people, to close down airports, to prevent the flow of food into a city, for example. It creates an enormous amount of chaos.

    I think we can do this more intelligently than this. It obviously requires the cooperation of the public. It requires the public health infrastructure to be able to do that. It requires people who can organize vaccination programs. And this is where we're weak. We do not have that structure in place yet in the local areas.


    Some critics have said that–notwithstanding the fact that smallpox represents a terrifying threat, if in fact, also a low-probability one, that we're mistaken to assume that we don't have equally great if not greater threats coming from other pathogens. Ebola virus is frequently cited as one that is easier to disperse and spread, that is in the hands of more people, more labs around the world. Is that at least as great a risk if not a far greater risk than smallpox? And if so, what do we do to get ready for that threat?


    About 3 years ago there was an expert group that was convened of 25 people to look at all of the potential organisms that might be used to–as a bioweapon and of course the list can be very very long indeed.

    And this group then contemplated what are the ones that we're most worried about? What are the ones that could, if you will, jeopardize the functioning of a civilian organization, of a city?

    And we actually came up with six that were looked upon as being the major ones. Smallpox and anthrax were right at the top of the list, and interestingly, at the top of the list by the Russians too, and they felt these were the two most likely agents to use for a whole lot of considerations.

    Ebola or the hemorrhagic fever virus, is one of the group. But as we've learned from working in the countries where ebola outbreaks have occurred, this disease does not spread that easily. In fact, it spreads with some reasonable difficulty, much less well than smallpox. So that fairly simple isolation measures will tend to confine it.

    We do not have a vaccine for ebola virus. Could we develop one? Yes, we probably could. But it's going to take a concerted research effort. Could we develop a drug that might be useful? Yes, I think we could, but it's going to take resources and a determination to do that.

    One looks at the other agents. People think of a plague as being something that would be a big problem. They think back to the middle ages and the Black Death and things like that. But as we look very carefully at outbreaks that have occurred over the last 50, 100 years, there have been a lot of plague in a lot of different cities and ff countries, which is usually caused by a flea, and that people get what are called bubonic plague, and then it goes into the lungs eventually in some and become pneumonic plague. This is the great fear, of pneumonic plague, that those individuals will spread it by coughing, won't require fleas and won't require rats.

    But what we find is very little pneumonic plague. And pneumonic plague outbreaks are very, very rare indeed and very small. So that was what we felt really caused the Black Death was the pneumonic form of this disease.

    What we see now is very cases, very few outbreaks of this sort and very small. So plague is to be worried about, but it is not going to be a catastrophic rapidly spreading epidemic as we see it. Moreover, we have antibiotics to deal with it, and those antibiotics are indeed being–being accumulated in stockpiles.


    We spoke a moment ago about hospitals preparing themselves to have isolation wards for infected patients. The American Hospital Association says that hospitals need $11 billion in federal assistance to get ready for bioterrorist threats. Is that accurate? Is that an accurate statement of the hospitals' need and are they going to get that kind of assistance from the federal government?


    Well I don't know that $11 billion is an appropriate figure. I just have not really had a chance to look at or analyze the figures. But I think we can say there's absolutely no question about it, is that we've become very cost conscious with our whole health care system. And so the hospitals have tried to run leaner and leaner, and trying to assure full occupancy of their–of their beds, to the extent that when a sudden surge of cases comes, even with an influenza outbreak, suddenly the hospitals are in very difficult straits. They cannot accommodate the patients.

    We do know that every when we have outbreaks of influenza, one part of the country or another, the hospitals in that area will often be for a couple, 3 weeks, on bypass, what they call emergency bypass. We cannot accept any more emergency patients. We are full up. And you have to take patients somewhere else. Certainly this has happened at our own hospital at Johns Hopkins, for 2 to 3 weeks in a row in the middle of an ordinary influenza epidemic, we're stuffed, we can't take any more patients.

    So that one has to ask the question: doesn't it make sense, as a social necessity, to have some reserve capacity in our hospitals to deal with epidemics of disease, or let's say, a large number of trauma cases or what-have-you, at least provide for that, and that is going to cost money of course.

    We have problems at this point in time with the nursing personnel, and auxiliary personnel. They're very short, and a number of the hospital directors say to me, "If we had the beds, I don't know how I would staff them, because so many of our nurses are now dealing in outpatient settings and nursing is not such an attractive profession now as it used to be. There are many other alternatives for women now in terms of careers, so we're very short of personnel there.

    So one looks at the problem, what we're revealing now with the–looking at this from the standpoint of the bioterrorism is that we have some, if you will, organic troubles with our whole health system. We have this problem with public health being as weak as it is. We have problems with hospitals. And it makes sense to strengthen these, not only because of bioterrorism, but we've got a number of organisms coming into this country, or originating, that we didn't have before.

    The new emerging infections as they're called, have grown rapidly in number, and one looks, for example, for 3 years ago in Hong Kong. There was a new strain of influenza called H5N1. It only infected 18 people, but it killed 6 of them. And the thought occurred to everybody, my goodness, if this begins to spread, we would have a catastrophe beyond anything we could believe.

    So what do we need? Well, we need to be able to make influenza vaccine for this new strain rapidly. We're not equipped to do that right now. We need–we would need hospital beds and a surge capacity and an ability for our public health structure to react. We are not really prepared to do that on something like an H5N1 flu. We have–we've had a new disease called AIDS, which we didn't have before. And one asks the question, "Suppose AIDS spread more like influenza, where would we be?"

    And things are things the world around us is changing. Organisms are continuing to mutate, continuing to change. We're moving much more quickly from place to place. We have huge urban cities in different parts of the world, which are obvious sites, if a new organism were to begin where the people are packed together and they're malnourished, poor sanitation, if an organism is to get started, where better could it get started now? and this is a huge change that's take place just in recent decades.

    So I think we're well advised to think very seriously about the deficiencies in our health system, not just because of bioterrorism, but because of a threat of microorganisms which are very potent.

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