"In a time when catastrophic terrorism is increasingly considered to be a significant risk," write the authors of a recent paper issued by the Kennedy School of Government, "close examination of hospital preparedness capabilities reveals troubling issues." This paper, "Ambulances to Nowhere," details why the American public health-care system is grossly underprepared to deal with a significant biological or chemical terrorist attack. "It is presumed that even if a large number of patients were brought simultaneously to a hospital, they would receive the same high-quality care as the individual patient does under regular hospital conditions. This confidence in today's health care system, however, is unfounded."

After the formerly unimaginable acts of September 11, the recent anthrax cases obviously bring to mind the possibility of a large-scale biological or chemical terrorist attack. The chances of such an attack are extremely small. But though we all still have a much better chance of being killed in a car accident than being killed by a terrorist, what if something terrible DOES happen?

Since the budget-slashing of the Reagan years, the American public health system has fallen into a woeful state. The very concept of a public body actively monitoring and maintaining health in the community at large seems archaic; despite growing and genuinely alarming public health problems like drug-resistant microbes, most people under 40 have no memory of large-scale public health efforts, aside from privately initiated activist movements like those for AIDS research. In her 2000 book, Betrayal of Trust: The Collapse of Global Public Health, Laurie Garrett writes that during the Reagan era, "three critical public health themes developed in parallel: emergence of new contagious threats to health; skyrocketing numbers of uninsured Americans; and a heightened sense of individual rather than community responsibility for disease."

Managed care is another problem. "Ambulances to Nowhere" states that "managed-care payments... are often not adequate to cover the total cost of providing even regular medical care." This "directly affects preparedness for mass casualty incidents." Hospitals have restructured their staffing, resulting in a steep increase in individual workload. Anyone who's recently spent time in a city emergency room knows that walk-in waits of several hours are to be expected; if that walk-in patient was presenting flu-like symptoms--which guarantee you very low priority in the ER case order--but turned out to have smallpox, everyone there would be exposed.

The Seattle-King County Department of Public Health assures us on its website that a "bioterrorism surveillance and response system" is in place, including BERT (Biological Emergency Response Team) and a preliminary plan for the mass distribution of medications. Mark Oberle of the Northwest Center for Public Health Practice says, "Seattle is probably better off than many places because of extensive planning for WTO 1999 and ongoing earthquake preparedness.

"But," he says, "there is still a long way to go." BERT has been around for a while but is currently being reexamined; an electronic "syndromic surveillance" system for use in emergency rooms is being developed to detect unusual patterns of disease outbreaks, in order to contain them at an early phase. This system is currently being used by "a few" Seattle hospitals, but it still has bugs. An "active surveillance" system was developed during the WTO events, but as Oberle says, this isn't "something that you can continue very long"--a week or a month, maybe; it is not directly funded. Oberle says there is some communication between the military and public health officials; the military is "a lot more active in maintaining surveillance" than Public Health, and is "aggressively looking for problems."

The fact is, should there be a large-scale biological or chemical attack affecting thousands of civilians, Seattle is not prepared. No American city is. New York City lost more than 300 seasoned firefighters and police officers in the World Trade Center attacks. These men, sent in with training, experience, and equipment, ready to meet the worst sort of civilian disaster, were completely overwhelmed by the war-sized scale of the event.

Our emergency health systems might easily be equally overwhelmed. The biggest problem is the inability of health workers to recognize an attack as such and to act quickly enough to contain an infectious agent or neutralize a chemical. There are not likely to be four exploding jumbo jets announcing such an attack, and symptoms from bugs like anthrax can take weeks to appear. "The earlier you can get a handle on exposed or infected case distribution, the faster you can design targeted control," says Oberle. "Getting a handle on early cases before a definitive diagnosis is probably as important as static hospital surge capacity, especially if the bioterrorist agent can be transmitted person-to-person, like smallpox."

Ah, smallpox. Most health workers today are not trained to recognize symptoms of smallpox, which has been officially eradicated for years; routine vaccinations ended in 1971, and immunity is not expected to remain even in those vaccinated (it's the vaccine that leaves the circular scar on your arm). If smallpox were released into our current population, a catastrophe comparable to the decimation of the Native American population by blanket-bearing Europeans might be the result.

But where on Earth would a terrorist get smallpox? Garrett reports that in 1997, U.S. Secretary of Defense William S. Cohen said: "The United States remains concerned at the threat of proliferation, both of biological warfare expertise and related hardware, from Russia. Russian scientists, many of whom are unemployed or have not been paid for an extended period, may be vulnerable to recruitment." The Soviet Union's Biopreparat lab mass-produced tons of smallpox virus and came up with a way to "weaponize" the microbes in aerosols. Garrett reports that the whereabouts of thousands of former Biopreparat workers are unknown.

And anthrax? The Boston Globe recently reported that "scores of low-security labs store the deadly bacteria with little oversight." A 1999 National Research Council report states that "vaccines against the agents of concern are, with only a couple of exceptions, of questionable utility, given the need to vaccinate far in advance of exposure... large numbers of casualties will quickly exhaust the limited supplies of antidotes, antibiotics, antitoxins, supportive medical equipment, and trained personnel."

Are you freaking out yet? Please keep in mind that it's a lot easier to imagine horror scenarios like this than it is to actually carry them out. But think on this: If the "war on terrorism" continues for the next few years, it IS likely that George W. Bush will be "reelected" in 2004. Now that's scary.

For more information about bioterrorism, check out:

www.sciam.com (Scientific American)

www.metrokc.gov/health (Public Health-Seattle and King County)

www.healthlinks.washington.edu/nwcphp/index.html (Northwest Center for Public Health Practice)

www.harvard.edu (gateway to the Kennedy School of Government and other Harvard researchers)