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The doctor's role in bioterrorism

2004; Elsevier BV; Volume: 364; Linguagem: Inglês

10.1016/s0140-6736(04)17629-0

1474-547X

Bruce W. Clements, Robert G. Evans,

Disaster Response and Management

At the beginning of this new millennium, the promise of the future is tainted by the emergence of terrorist threats, including bioterrorism. Terrorist doctrine and fanaticism have continued to evolve since the end of the Cold War. Historically, the goals of terrorism were to attract media attention and political concessions. These aims were pursued through high-visibility attacks that resulted in few casualties. However, the shifting goals of terrorism over the past decade indicate an increasing desire to inflict mass casualties. This fundamental change has spanned the extremes of terror organisations from the ideological right to the ideological left while cutting across ethnic, religious, state-sponsored, and single-issue terror groups. As this shift toward a higher order of violence occurs, terrorism arsenals are likely to expand beyond improvised explosive devices and aircraft hijackings. In the future, the greatest terrorism challenge modern medicine may face will probably be bioterrorism. Doctors stand at the forefront in preparing for this threat. In the past, doctors have also contributed to the creation and proliferation of these weapons. The emergence of new terrorist threats has created new responsibilities for the medical community. Unlike other forms of terrorism, in which an acute exposure or traumatic injury is rapidly inflicted and quickly recognised, bioterrorism may involve an incubation period of days or even weeks. During these events, patients will turn to their most trusted adviser on health issues, their doctor, who will be expected to recognise and take action against the rare diseases that top most threat lists. In an effort to narrow the focus of US preparedness initiatives, the Centers for Disease Control and Prevention convened a group of experts in 1999 to review biological agent resources and prioritise threats based on the potential effect of each agent on public health. The resulting category A list includes the pathogens that cause anthrax, smallpox, plague, tularaemia, botulism, and viral haemorrhagic fevers. Different lists have been developed by other agencies and nations. Although lists of threat agents are helpful in directing the fiscal decisions of preparedness programmes, they are of less use to doctors, who must consistently hone their intuition and skill in order to recognise unusual cases early on and take appropriate actions. This practice requires doctors to maintain a high index of suspicion. Most illnesses resulting from an act of bioterrorism will have an incubation period, which allows a window of opportunity for prophylactic treatment, even for some of the most deadly agents. But the delayed onset of illness can be used to the patient's benefit only if the doctor has a sufficient level of suspicion to be able to recognise uncommon trends early. The clues that should raise suspicion range from subtle, unusual trends in disease patterns to conspicuous evidence that may be provided through declarations made by aggressors or evidence discovered by law-enforcement authorities. No single clue may exist that identifies a bioterrorism event. Maintaining a high index of suspicion increases the likelihood of recognising an event sooner, which may ultimately translate into more lives saved. Given the publicity surrounding the anthrax letters in 2001 in the USA, and revelations of ricin production by terrorist cells in Europe, the bioterrorism threshold has been breached. These acts raise public expectations for doctors to be aware of, and prepared for, future threats, to sustain vigilance, and to stay informed of specific threats at all times. As intuitive as these may seem, there are embedded obstacles to maintaining an index of suspicion. When a doctor receives training in infectious diseases, the mantras heard may include: "common things occur commonly", or, "when you hear hoofbeats, look for horses, not zebras". Some may forego suspicion in favour of what seems most probable. Maintaining an index of suspicion requires taking an extra moment to consider the "zebras". For the sake of personal prudence, a balance must be found between suspicion and hysteria. Bioterrorism is unlike other forms of catastrophic terrorism in that there is no "ground zero". If a covert release is carried out, the first sign of the attack may be human illness. Cases could be spread out across a large region or even around the world before an incident is identified days or weeks later. Therefore, doctors and their colleagues throughout health care and public health become the first responders to an act of bioterrorism. This transfer of first-responder responsibility puts greater responsibility on doctors. Effective bioterrorism preparedness at the community level necessitates involvement and leadership by knowledgeable, motivated doctors. Perhaps the greatest challenge facing a doctor who engages in activities of bioterrorism preparedness is a lack of explicit standards. What makes a prepared doctor? What is a prepared hospital? What is a prepared community? Few answers are grounded in scientific rigour because contemporary terrorist threats are far too diverse. It is easy to assess and define vulnerabilities across a community but difficult to define preparedness because of the growing variety of options for terrorist attacks. What constitutes preparation is not sufficiently defined. Most nations have instituted a programme or initiative addressing bioterrorism. Many professional organisations have issued consensus standards and statements to address the role of their membership in preparedness. However, there are few established benchmarks by which preparedness can be assessed. It is important for doctors who engage in community bioterrorism preparedness initiatives to understand existing plans, standards, and guidance, as well as the innate limitations of each. The contribution of doctors to community preparedness must be rooted in fundamental education and training. All doctors must not only maintain an index of suspicion but must also know the procedures for notifying the appropriate authorities when they suspect something unusual. They must have a clear vision of proper management procedures in the event of patient surge, mass casualties, and mass fatalities. Herein is the paradox of doctor preparedness. Although much of the knowledge needed is new or emerging, such as diagnostic tests and empirical therapy, managing the consequences of a bioterrorism assault in the community may require the resurrection of outdated principles and practices. If the scope of an attack necessitates delivery of care in alternative settings, doctors must be prepared to offer advice to the community either on how to care for infectious people at home or on how to manage patients outside the hospital setting. Many of these principles of outbreak management have not been used in developed countries for decades. Doctors will need to bridge old and new knowledge required to manage successfully an outbreak resulting from bioterrorism. Above all, bioterrorism attacks are medical emergencies. Administrators and government officials are simply not equipped to lead all parts of a response to bioterrorism. Most doctors begin the pursuit of their training and education with a sincere desire to contribute to a higher purpose of the art and science of medicine. Unfortunately, history is replete with examples of those who have dedicated their time and abilities toward heinous purposes, betraying the quintessence of medicine. Others may have unwittingly engaged in research or practices that have contributed directly or indirectly toward the growing threat of biocrimes or toward the erosion of protection for research participants. History provides stark examples of doctors committed to unethical practices or research. Most notable are the Nazi doctors tried in 1946 at the Nuremberg Medical Trial. During that same era, Ishii Shiro led the Japanese biological warfare research initiative, known as Unit 731, in Manchuria. Under his leadership, human beings were infected with various diseases, from anthrax to yellow fever, and sometimes dissected alive to study the effects. Beginning in 1999, the 4-year trial of Wouter Basson, a South African cardiologist and the former South African Surgeon General, detailed his nation's biological weapons programme. It was alleged that under his direction, chemical and biological weapons research was done through companies he established. Research described during the trial included attempts to genetically engineer pathogens so they would affect only non-white people, the deaths of political prisoners used in research, and the use of toxins for assassination of political adversaries. Throughout the 1990s, the USA, during the Clinton administration, began to release many details of human research done in that country since World War II. These experiments involved biological, chemical, and radiological exposures, often without the knowledge or consent of the people exposed. This kind of research, which has not been unique to the USA, certainly involves the oversight and involvement of doctors. From those doctors who are truly barbaric to those who simply compromise their ethics for reasons they feel are justifiable, there are decisive moments when a firm grounding in the noble essence of their profession might avert poor ethical decisions. As we enter a new era when disease becomes a weapon of terror and those who understand disease become contributors to either its proliferation or protection, careful consideration should be given to the growing importance of ethical standards and training in the subject of bioterrorism.