An expert in meeting public health challenges talks about readiness
Today, on the sixteenth anniversary of the 9/11 attack and the infamous anthrax letters, the nation naturally turns its attention to emergency preparedness. Despite having worked as a infectious disease specialist for seventeen years, I like many of my colleagues, had no real knowledge of emergency preparedness or bioterrorism before that awful day in 2001.
That morning is impossible to forget. As I came out of a meeting at Elmhurst Hospital, there was a small crowd gathered around the television in the Department of Medicine watching smoke billowing out of the side of the North Tower of the World Trade Center. By 10:30 am, both towers had collapsed, the Pentagon had been struck and we had prepared for mass casualties. By the evening shift, several doctors set up a temporary blood bank to accommodate the hundreds of volunteer donors. But the casualties never came. Thousands had died, but few needed emergency care and stretchers stood in empty rows outside of Manhattan hospitals. Beginning one week later, letters containing anthrax spores began arriving at several news organizations and congressional offices, eventually infecting 22 people and killing five — once again putting us on alert.
For years after these events, preparations for mass-casualty attacks, especially bioterrorism, received great attention, especially in the medical world. Publications on terrorism, rare in medical literature before 9/11, surged 20-fold. Taskforces and workgroups were formed in New York’s public and private hospital system to examine preparedness measures, develop strategies and apply for funding. We were determined to be ready if it happened again.
Yet now, 16 years later, we are facing a different world. Hospitals and hospital beds are disappearing in the United States under government pressure to drive down costs. Beds per 1000 population have fallen from 4.6 in 1992 to 3 in 2014, as a host of services have been moved to the outpatient setting. As a result, our ability to treat mass casualties may be shrinking to less than it was on 9/11/01.
Yet, while working on my new book Ebola: Clinical Patterns, Public Health Concerns, (CRC Press, 2017). I became increasingly aware that now, sudden occurrences of rare infections, along with increased terrorist threats and disasters sparked by climate change, will most likely test the readiness of our nation’s health care and emergency systems. But our hospitals — especially those in dense urban areas — may not be ready for the challenge.
Newly-recognized infectious agents, including the viruses causing SARS, MERS, West Nile disease, Ebola and Zika, require a swift response. Novel influenza strains such as H7N9 pose the greatest risk of a global pandemic, according to the Center for Disease Control and Prevention, but each new agent calls for different diagnostic strategies and methods of prevention. Identifying these rare diseases is complex because they mimic much more common conditions. Because of this, they often defy established medical knowledge. The first case of any of them in a hospital emergency room or clinic is not likely to be recognized.
Hospitals cooperate with public health authorities in conducting drills to test our ability to diagnose and appropriately isolate, manage or transfer patients with highly contagious infections to isolation facilities. Ten centers have been designated in the United States to receive certain patients requiring unique diagnostic and treatment facilities. But the public and many public health professionals may not realize that these steps are simply not enough.
To improve our capacity to address these significant public health challenges, we can:
• Use electronic medical records to put information about unusual infections, based on travel history and symptoms, at the fingertips of emergency department staff, often the first people to see patients.
• Standardize the all-hazards approach to the care of patients and mitigation of risk to staff, endorsed by the Joint Commission on Accreditation of Health Organizations.
• Develop standardized plans for expansion of hospital bed capacity to accommodate unexpected crises.
As a physician who works in a busy city hospital, I know we have made progress since 9/11, but let’s not forget the valuable lessons we learned on the tragic day. This September 11th, which also falls in National Emergency Preparedness Month, let’s work to make our health care system more nimble, and ready for the new and uncertain challenges we face today and in the future.
Joseph R. Masci, MD, is the director of the Department of Medicine at Elmhurst Hospital Center, a public hospital in New York City, and professor of medicine, infectious diseases and of environmental medicine and public health at Icahn School of Medicine at Mount Sinai and a Fellow Ambassador of The New York Academy of Medicine.