Our first line of defense

An expert on public health talks about what America needs to fight a bioterrorist attack, why we don't have it and how stocking up on cipro is a danger to everyone.

Published October 17, 2001 9:28PM (EDT)

Fears over the (still very small) number of anthrax cases apparently caused by exposure to contaminated mail have many Americans rushing to their doctors in search of prescriptions. Pulitzer Prize-winner Laurie Garrett, author of the acclaimed "Betrayal of Trust: The Collapse of Global Public Health" and a reporter for Newsday, finds the mad dash for ciprofloxacin as troubling as the threat of bioterrorism itself. Our public health system, we're told, is our most important line of defense against germ warfare, but in her book (published last year) Garrett observed that the system, in its current state, is "a wreck." Will the government's plan for fighting an anthrax outbreak work? Salon telephoned Garrett at her New York office to get her perspective on the crisis.

In the many articles I've read about the possible remedies for a biological weapons attack, the mantra has been that people can't respond or protect themselves effectively on an individual basis -- it has to be done on the level of the public health system. What exactly does that mean?

Let's back up a second and ask, what are we doing? Our government is buying ciprofloxacin, and we're buying tons of it. We're buying so much cipro that Bayer in Germany has to reopen a long-shutdown factory to accommodate the American demand. That seems to be the primary thrust of this administration's commitment at this point.

In my book, purchasing massive quantities of ciprofloxacin is a medical response, not a public health response. The appropriate public health response, it seems to me, would be to look for the most frontline primary antibiotic that appears to be effective. As far as we can tell, the stuff that's floating around right now in people's envelopes is completely penicillin-susceptible. It would make a whole lot more sense and it would save hundreds of millions of dollars -- not to mention you wouldn't be breeding broad-spectrum, drug-resistant bacterial disease in millions of Americans -- if you use penicillin. Why in the world are we going for the world's most expensive, broad-spectrum, highly resistance-prone antibiotics?

Why do you think that is?

Because the response of a physician to the situation is: When in doubt, go for your bazooka even if a BB gun will work. That's appropriate when you're thinking about the individual, but when you're thinking about the population as a whole, what's appropriate to the individual is probably not appropriate on a population-wide basis. Using cipro is first of all highly expensive and second of all highly likely to breed resistance. What worries me is that if we wind up spending something on the order of $1.5 billion on ciprofloxacin alone -- and that's just direct federal-level expenditure not including state-, individual- and insurance plan-level expenditure -- we could well go over the $4 billion mark on ciprofloxacin in the next two weeks. Is that the appropriate way to spend $4 billion that the public health structure has been starving for for more than a decade?

If the public health structure has been starving for funds for so long, is it in any kind of shape to respond to a serious biological attack or catastrophe?

We've been preparing, but only on the level of a handful of highly committed and already convinced individuals who have staged various war game scenarios, tried to enhance the state of readiness, tried to increase the level of concern. The best-prepared city in the nation was New York, and we can see even with this very tiny number of cases -- a handful, literally -- there have been a lot of mistakes made. The fact that police officers went in and sniffed it is ... that's out there.

What exactly does the public health system consist of?

Public health first of all is not medicine. There are some medicines that can be used for public health. You know, many Americans say when surveyed that they're against public health -- in fact, most Americans do -- but then in the same surveys they misdefine what they say they're against. Most Americans think that public health is services for poor people and since most Americans hate poor people and want all poor people's services destroyed, they hate public health.

They also see public health as intrusive. For example, many state legislatures have dropped regulations that gave public health officials the authority to keep track of whose children were vaccinated and whose were not and to send gentle reminders to parents that their child needed a booster for measles. This was considered an intrusion in people's lives and most legislatures either failed to pass laws that would've allowed public health to track vaccinations or removed laws that had been on the book. We've had a real backlash against public health regulation in the last decade, even longer in some states.

What public health really is is a trust. That's why I used the term "Betrayal of Trust" as the title of my book. It's a trust between the government and the people. The private sector is only on the sidelines in this trust, because public health is almost by definition a government function. It's a trust in which government says, "You pay your taxes, put your faith in us and we in return agree to do the best we can to provide you, on a population basis, with safe drinking water, proper sewage, safe air, safe food, vaccination, disease control, epidemic control." The city of New York's campaign against West Nile virus is a classic public health initiative.

No wonder that public health projects are languishing. It's so much the American inclination to want to respond on an individual level, rather than on the level of the polity these days. Is being prepared something that we need to do on a national level as well as a local one?

A key question is, what's the difference? Public health is a local function. Over the years, on a national level, it's come to be about cost and budget. It's come to be about controlling federal expenditures, monitoring appropriate costs for medical care, cost-effectiveness interventions, research and a long-languishing Centers for Disease Control. What really is the basis for public health is what goes on at the local community level. And the problem is, will all those federal dollars filter down to the local level and what's the preparedness at that local level?

Here we have a real problem. If you get down to pretty much any municipal county level, whether it's rural or urban, you're going to find tremendous holes in the public health safety net, holes so big you could drive a truck through them. We're talking about things like: Do you even have computers in place that are capable of communicating with the federal computers? Do you even have laboratory equipment in place to make a diagnosis of anthrax? Do you even have water inspectors who are on the full-time payroll and routinely inspect the drinking water for your state? Do you have people on your payroll who routinely spot-check the food supply for your state? If you start calling around, you'll find that most states are grossly deficient.

Why is that?

There are several reasons, but one is that public health is a negative. That means that when it's working and everything's going great, there's no evidence of a need for it. There are no epidemics, no catastrophes. Right now, everybody's running around talking about public health because they're scared silly. But will they be talking about public health a year from now if our fear of terrorism peters out? We always start demanding "Where was our public health infrastructure?" when there's an epidemic, but a year after the epidemic is gone and everything has calmed down, the budget cutters are quick to slice the public health budget.

If you compare public health to other public goods such as police and fire departments, it's quite a different scenario. You rarely see state or local politicians advocating reducing the fire budget because everybody has seen fires or heard the sirens at night and knows that, dammit, if their house catches on fire, they want those guys there real fast. Everybody wants the cops there if somebody is beating them up. And now we're back in a situation where cutting back the military budget will not be politically feasible. Public health has to prove its mettle and prove its worth over and over again. Even now, in the midst of concern over bioterrorism, there are many in Washington who are asking, "What do you mean, give it to the public health infrastructure? Why don't we just give it to the military or the FBI? What is this public health infrastructure, anyway? How does it work and what does it do?"

What's behind the ignorance and devaluation of public health on the part of government officials?

Some are historical and go back a hundred or more years. Some are quite immediate in our political history. Who's the lowest-paid powerful physician in town? Probably the commissioner of health. Who's the lowest-paid laboratory director in town? Probably the director of the local public health/infectious disease lab. Who's the lowest paid administrative nurse in town? Probably the chief of the public health nursing corps. You can go on down the list.

These people are looked down upon by the rest of the medical profession. They're considered substandard scientists. They're treated in a really pejorative manner, and frankly, the best and the brightest coming out of med and nursing schools and microbiology departments these days don't choose public health unless they're altruists. And, in fact, when you get down to the local level, you do see a mix of fairly mediocre personnel and then those exceptional, stellar light bulbs who've made a choice to sacrifice themselves -- to take lower pay, work longer hours in cramped, dingy offices with second-rate equipment and with the sneering loathing of their medical colleagues -- because they believe in the mission of public health. Many of them have quit over the last 10 or 20 years because it was just so demeaning and frustrating. We're fortunate here in New York City that one stellar example of that altruistic pool, Dr. Marcelle Layton, who runs all infectious disease programs for the city of New York, has chosen to hang in there with the crummy pay. A few other cities have a Marcie Layton, but my God, if you go around the country, it's palpable, the level of depression among public health people.

Why does the medical establishment look down on public health professionals?

There was a long-standing fight between organized medicine and public health. The American Medical Association and organized medicine have systematically gone to war against public health regulation. The position of the AMA was always -- and they're finally coming around about a 100 years later -- that organized public health was a threat to their dollars. They saw public health authorities as meddling with their profits and in their individual rights to relate one-on-one with their patients. In the early days, physicians were reluctant, for example, to turn over the names of their tuberculosis carriers because they didn't want rival physicians to know who their patients were.

Even now, as we talk about ciprofloxacin and fears of overuse, the truth is that all over New York City there are doctors writing out prescriptions for their patients, saying "Sure, go right ahead. Here's a stockpile of cipro, you can have it in your home." That's deliberately making a choice to give a prescription for a very profound drug and there's no direct medical indication. It's impossible to regulate individual physician prescription practices. Once a drug is approved, doctors can write prescriptions for it for any indication -- even for indications for which it wasn't approved.

There's no ability by public health to intervene. Public health can't go into the hospitals without being invited. Most of the time, hospitals refuse to allow public health inspectors inside, so we don't even really know what most hospitals' capacities are. We have to just accept the word of the hospital administrators: "Yes, we have excellent labs." Good enough labs that your people can look at an anthrax sample without getting infected in the process? Probably not.

We basically have a marketplace approach to medicine and that's overwhelmed the approach that is by necessity the key to public health, which is not marketplace. The public health approach is that everyone, regardless of their ability to pay, has to receive an equal level of attention in order to protect the community as a whole.

You mentioned that New York is the best-prepared city in the nation to deal with a bioterrorist threat, and yet several mistakes were made in handling the recent anthrax cases. What was the problem?

Part of it is that some mistakes were actually in compliance with somebody's rule book. The old rule books have long since needed to be upgraded. One of the problems we've had all along with bioterrorism is that, until very recently, in power struggles over who was going to get the dollars to deal with and call the shots on bioterrorism, everything was going toward police, the FBI and the military. Public health was perceived as a small-time player that would make the diagnosis and then step aside and let the big boys in.

Well, an epidemic is an epidemic, whether it's a deliberate epidemic or a natural one. As one person I talked to very succinctly put it, "We don't usually let the military solve our flu epidemics." The skill set involved in making a diagnosis, in creating rational systems of control and in determining how to protect the population against further spread of disease are the tools of public health. The investigation to determine who caused the problem requires a combination of skills: a classic disease surveillance -- in our country a CDC function -- and the FBI. There, the FBI and public health should be working hand in hand. They should be sharing information. But on the actual ground of controlling the epidemic, every other kind of agency should be taking their orders from public health, not the other way around.

You could argue that one of the reasons we had a lot of trouble trying to bring West Nile around and never did bring it around and now have endemic West Nile in 17 states is because we were a little late to recognize that it was there, and we responded with a mix of the mayor's office -- a political response -- and public health measures. Perhaps we put too much weight on the political response.

In your opinion, what would be a rational, effective response to the threat posed by anthrax, these contaminated envelopes or a more serious threat ?

That's very real. I have to face that here. Someone has been using the mail -- and has been for some time, and has sufficient quantities that they're able to put a little powder in an envelope and mail maybe hundreds of these. We have no idea how many have been sent out. I think we're going to keep hearing about this here and there, and postal workers who may come down with symptoms. This could really strap us. Nobody role-played a scenario like this. I've seen many scenarios involving, say, a crop-duster spreading anthrax, or an aerosolized release in a subway tunnel, something like that.

That's what you'd expect serious terrorists like al-Qaida to do, or at least to contemplate, not something sneaky like sending anonymous letters, which also doesn't really seem lethal enough for them.

Right, this idea of sowing panic by targeting media organizations with individual letters, this is not something that anybody anticipated. The interesting thing is that in the classic role-playing exercise, the response strategy to a single big assault is to identify where the boundaries of the community that was exposed are, and then just to go in and give all those people cipro or some other antibiotic, and then you had controlled your problem. This is different because how many people in the ABC building should get antibiotics? I've talked to people from the Times who are upset that they drew the line out to some kind of perimeter from [targeted Times reporter] Judith Miller's cubicle and no further, and so all these people at the Times wanted cipro but they only gave it to this confined group. Frankly, I said be glad, because overdosing on cipro is a bad thing and cipro has its side effects. I think we're going to end up having to use much more antibiotics in this kind of approach.

Furthermore, with a single event, all the notions of panic control are oriented toward a single site where you go in immediately with intense education, with counselors and appropriately trained cops and all that. But now we're talking about a whole nation in a state of panic because nobody knows where the shoe is going to drop. Nobody knows who the next target will be. It's outside the box of what anybody role-played or planned.

What should be we doing?

Well, I do think that there's reason for the government to keep saying things to try to calm people down. But they have to be very careful because it sounds disingenuous. What you say and how you say it is absolutely critical right now. Every word that comes out of the mouth of Tommy Thompson, or the surgeon general, or the White House has to have been parsed ad nauseam. They've got to think very carefully about mixed and confusing messages, messages that cause panic or messages that sound cocky. When Tommy Thompson went to the Hill, the appropriations committee in the Senate last week, they ripped him apart and said, "We don't believe you," when he said, "Don't worry, I'm totally prepared." Nobody believes that. The public health system is a mess. You can't claim to be totally prepared. Where do you create the ground between trying to set the public panic level down and trying to be honest about your needs and frailties? It's very hard. I don't envy these guys.

The other thing that I'd be doing right now is to, on an emergency basis, create squads of EIS officers -- Emergency Intelligence Service, that's the CDC -- to send on a rapid basis to every major hospital center in the nation. They'd run briefings for worried physicians and health providers, telling them immediately not just what anthrax is, because they can look that up in a book, but "Here's your procedure: You call this number. You do this with your sample. You call the cops, but they only do these things." You tell them who touches the sample, who processes it, how it gets to what lab, how you tell if it's a hoax or the real thing, what's your immediate chain of containment, how you maintain a criminal control site and how you maintain a disease control site. What are the things that should involve the cops and what are the things that should involve the local public health responders? People don't know this, and we don't know this anywhere in the country.

The rule book is getting written as the epidemics are unfolding. We need to have somebody sit down, on an emergency basis, right now, and decide what the game plan is and get out to the hinterlands, all over America, immediately. This isn't about faxing a bulletin. It's about being in a Q&A situation where doctors and health providers can ask their worried questions and get their answers, and go away from the meeting feeling like they learned something concrete and that they know precisely, if they see a suspect case, who they're supposed to call and in what chain of command. They don't know that right now.

When the Sept. 11 attacks hit, a lot of organizations of all kinds found themselves scrambling to respond without a plan.

What this reminds me of is when, for many years, I worked for National Public Radio. I was based in San Francisco and Los Angeles. I sent one memo after another to headquarters in Washington saying, "We will be having a major earthquake in one of these two cities or both, and we need a game plan because the phones won't work, our own offices may be shattered and so on." It always came back with "Nice idea, but we haven't got time." So when the earthquake struck in Los Angeles, the NPR bureau collapsed. Everyone was scrambling to figure out how to cover it and how to get personnel in. People forget that airports tend to get shut down, that you can't fly in a staff from 3,000 miles away.

The scenario here in New York always involved flying in CDC, but guess what? They couldn't fly in. The airports were shut for several days. We haven't, any of us, regardless of our professions, adequately role-played the scenarios and prepared for various options and eventualities. None of us anticipated, now that we've become reliant on cellphones, that the cellphones would be so clogged that none of us would be able to call our editors, and that the land-based phones wouldn't work.

Right now, we're acting like the people I've seen when covering a number of earthquakes. The aftershocks keep coming, so the trauma never goes away. The sleepless nights continue and continue. At what point are there cool heads making decisions? We'd like to think that our leaders are getting sleep while we're all up pacing at night, and we'd like to think our leaders are rational while we know in subtle ways that we ourselves are not anymore. Every one of us feels all this and we imagine that our leaders are not the same, and we're wrong. If anything, our leaders are more sleep-deprived than we are, more stressed and more likely to be overreacting. We have to somehow make decisions right now with cooler heads and with a longer term perspective. That's very difficult to do.

Having the procedures set up in advance is exactly the kind of thing that helps people function effectively when they're in a stressed state.

What we can do is step back, take a deep breath and consider all the ramifications of the actions we take. For those who say we have to act more rapidly, I'd say we don't have that luxury. The long-term impact of throwing all this cipro into the human ecology may be something very serious. Have we thought it through? Similarly, to skew our public health resources to such a degree -- we have hundreds and hundreds of local public health people working on bioterrorism, and so now will our basic disease control programs fall apart, and our HIV programs, our STD tracking programs? If so, then what will we be dealing with six months from now?

What are some of the risks of cipro use?

The biggest problem is breeding drug-resistant bacteria. And it's a broad-spectrum antibiotic, so that's a lot of bacteria -- anything that's in your body, not just anthrax. Drug-resistant streptococcus pneumonia, drug-resistant staph. We already have huge problems with drug resistance. We're losing the efficacy of our antibiotics as it is. A word of caution is warranted, and for physicians to be writing prescriptions based on "I like this patient, they're nice people and they're worried. Let me set their mind at ease and give them a cipro prescription": Please, doctors, make it penicillin.

By Laura Miller

Laura Miller is the author of "The Magician's Book: A Skeptic's Adventures in Narnia."

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