Prior to September 11--People involved in environmental health worried that they were unprepared to respond to a catastrophe in their community involving terrorism and weapons of mass destruction.
September 11 and the ensuing anthrax threat--Suddenly, an alarmed public together with policy makers from all levels of government woke up. Many discovered that there was such a thing as public health. Others began to realize (for the first time, I might add) that without a functional public/environmental health infrastructure, our communities were terrifyingly vulnerable to acts of terrorism.
Immediately following September 11--As fears began to take hold that further attacks could result in unprecedented numbers of casualties, policy makers mobilized and quickly authorized funding for major improvements in our terrorism response capabilities.
Winter 2002--A conceptual framework for moving forward with 50 state terrorism response plans was developed and funded. Work to build capacities for terrorism response in all 50 states began.
Today--People involved in environmental health continue to worry that they are unprepared to respond to a catastrophe in their community involving terrorism and weapons of mass destruction.
Huh? How could this be?
Let's look more closely at what has happened in environmental health since bioterrorism first became an issue in this country and how our profession has fared in the story.
As many NEHA members know, bioterrorism became a reality for our country and for our profession with the food-poisoning incident in Oregon in 1984. One supermarket and between four and 10 restaurants were contaminated. Seven hundred and fifty-one people were made ill. What makes this incident particularly chilling is that when the authorities (including us) assessed this event, they concluded that the foodborne-illness outbreak was the result of improper food handling. It was not until a year later, when a member of the sect responsible for the attack squealed, that the full extent of the germ warfare program was uncovered.
In the aftermath of this incident, funding support for environmental and public health continued to erode.
Following the sarin gas subway attack in 1995 in Japan, which killed a dozen people and sickened thousands, it was learned that the Aum cult had some 50,000 members worldwide, a New York office, holdings of over a billion dollars, a history of training within the former Soviet military complex, and a fervent belief that cult members would be safe when the world came to an end.
In the aftermath of this incident, funding support for environmental and public health continued to erode.
Now we have September 11 to contemplate. The problem of getting the attention of the public and our policy makers seems finally--some 18 years after the Oregon incident--to be solved. Upward of a billion dollars have now been committed to terrorism response. States are busily moving forward with both terrorism response and hospital preparedness plans. Critical capacities have been identified and mandated for local health agencies. In addition, local health agencies are being encouraged to enhance capacities that further extend their reach in an incident requiring terrorism response. Coordination across a broad spectrum of agencies and organizations is now being worked out to ensure that our resources will be effectively deployed in the event of a terrorist incident. In every state, the effort to fashion an effective response plan is being led by the applicable state health agency.
These encouraging developments would suggest that at long last, we are coming to terms with this awful but real modern-day threat to the public's health.
Whoa ... not so fast.
As unbelievable as it may sound, evidence is mounting that, if anything, environmental health seems to be an afterthought in the frantic efforts now under way to build a system capable of responding to these horrible threats.
In preparing this column, I have studied page after page of the guidance documents that define what each state's response plan shall include. I have also spoken with a number of NEHA members from around the country to get a read on how local environmental health is becoming involved in terrorism response. What I've read and what I've heard is disturbing.
In close to 100 pages of guidance materials that define the content for each state plan, I could not find one reference to environmental health or environmental health professionals! (Once I saw the term "environmental agencies.") In fairness, I did find references to public-health personnel--which presumably includes us. Nonetheless, I was concerned that we weren't singled out for more direct attention.
What people have told me tends to confirm my concerns. From the front lines of our profession, I'm told that terrorism response tends to be viewed as "putting out fires and pulling people out." Firefighters and hazmat teams continue to constitute the core of what we commonly call "first responders." (Hospital facilities and emergency room response protocols are also starting to show up more frequently in discussions involving community response.)
In sum, on the practical side of things, I'm picking up that terrorist response is generally considered to be an activity that rests primarily on the shoulders of our local firefighters, hazmat teams, and hospitals.
On the conceptual side, one can't help but be impressed with the amount of thought that has gone into the guidance documents that the feds have created to help states both prepare their plans and secure the funding that they need. Still, all that good thinking notwithstanding, the guidance documents struck me as more a maze of considerations than an overall strategy and approach. In reading through these materials, I felt I was looking at the pieces of a jigsaw puzzle instead of the complete picture that, together, those pieces portray.
The documents do an impressive job of defining the critical capacities that local health agencies, in particular, are going to have to develop. The guidance documents also offer specific and helpful direction for the many considerations (or puzzle pieces) that are to be a part of these state plans. Virtually everything under the moon is addressed, from computers to laboratories to hospitals to "epi" teams to communication to databases to training and so forth.
Despite the impressive effort that has been made to identify the scores of issues that these plans must address, I found the guidance significantly lacking in two respects. First, no overview is offered of what, exactly, this is all about. I could not find a context, a theme, a message, or a statement of overall policy. That lack reminded me of instances when I have studied organizations with no mission statement. It is as if the states are being told, "Here are the pieces, now go to it and put them together in any way you wish." Other than what my own intuition and common sense told me, I could find nothing in what I looked at that assured me our communities would be materially better off with respect to minimizing the impacts of a terrorist strike once the plans are developed and in place.
The second glaring omission in the material was the complete absence of any reference to environmental health.
As many NEHA members know by now, in the immediate aftermath of the attack on the World Trade Center, the U.S. Environmental Protection Agency (U.S. EPA) sampled for air quality and basically declared that the air at ground zero was safe. Now we are finding out that large percentages of rescue workers are suffering from respiratory problems. Many will have asthma for the rest of their lives. The concentrations of fine particulates at ground zero exceeded the worst air days in Beijing and were higher than what one would find downwind from a coal-fired power plant or in the midst of the Kuwait oil fires.
Where is environmental health in this? Is U.S. EPA now environmental health? Is U.S. EPA now local environmental health?
If ever there were a role for this profession, terrorism response or response to large outbreaks of infectious disease would be it. The basic practice of our profession features many critical competencies. We assess and we analyze. We devise interventions to abate a problem. We advise if people should be relocated so as to take them out of harm's way. We work with law enforcement to compile evidence for prosecution. We collect, organize, study, and maintain data. We assess health risk. We communicate with the media and the public. And so forth.
We are trained--whether we work in food protection, air pollution, or body art--to recognize environmental threats to health and to do something about them. The puzzle piece that is us fits into the terrorism response puzzle picture as well as any other piece. And I say that with full respect for the many others who also play an important role in disaster response.
As I try to decipher what is happening as we begin the process of preparing for possible repeats of September 11, I am troubled by a number of developments. The absence of environment health on the response plan marquis is certainly foremost among my thoughts. But I also have other concerns.
After years--excuse me, decades--of neglect, money is finally starting to flow into public health. While that development is something to applaud, I'm also picking up that many hands are now stretching out to grab some of that money. After they have been without for so long, that is hardly surprising. Imagine someone who has starved for months and suddenly sees a big fat hamburger sitting right at hand.
What concerns me is that a host of long-starved public-health programs are now cleverly devising ways to link what they do to terrorism response. If that connection can be made, needed funds can be obtained, or so goes the theory. In the end, therefore, the amount of money that truly ends up going to terrorism response will likely be but a fraction of what was intended.
(On the other hand, I will acknowledge that any improvement in the public-health system will probably in some way enhance capacity. A better and more functional public-health system will surely contribute to a more effective terrorism response capability.
So perhaps I can moderate some of my concern. Nonetheless, the public-health community needs to continue, in my opinion, to press the case that we need to rebuild infrastructure--in regard to both terrorism response and overall public health--including, of course, environmental health.)
Yet another concern I have is the emphasis on money Again, I suspect that being without for so long has caused the public-health community to respond to this funding opportunity with all the vigor it can muster. Yet in the limited exchanges I have seen having to do with getting funds for terrorism response, I read far more often about the need to get the money as opposed to what we need to do with it. That is a crucial distinction in my mind. The commitment needs to be to the ultimate goal of response capability as opposed to getting one's fair share of the dollars.
But back to environmental health.
When my children were younger, I spent many years trying to help them find Waldo in those frustrating and incredibly detailed pictures. Funny how that memory comes back to me as I reflect on where we are today in the unfolding story of environmental health and terrorism response. If you look at a Waldo picture, you see far more detail than you do a complete picture. So too with the story of how we are going about building our terrorism response plans. There is a lot of detail to be found in all of this. There are many puzzle pieces. We are one of those pieces. Can anyone find Waldo ... can anyone find us? Where are we? We're not easy to find.
What are we to do?
I have been advised that the focal point for the development of state plans resides with the state health agencies. Unfortunately, NEHA is not well suited to interact with every state on behalf of environmental health. Many of you, however, are.
Our profession's mission and method puts us at ground zero. How we could possibly be an afterthought (as one of our members put it to me) is virtually beyond my comprehension. We need to make our case and impress upon our state leaders that we, too, have a role to play and a place to occupy at ground zero. Becoming a part of the team is in many respects a responsibility to our professional ethic.
So I close with a word of encouragement. I know that many of you are already involved or at least trying to get involved. From our board of directors to our mission statement, we urge you to stay the course. If you are not yet involved in your state's planning efforts, we encourage you to start pressing. Any response plan that excludes local environmental health will surely not be the plan and the response that our communities deserve. Nor will it be what we deserve of ourselves.