Anthrax 2001: observations on the medical and public health response.

Abstract

THIS ARTICLE DESCRIBES ASPECTS of the medical and public health response to the 2001 anthrax attacks based on interviews with individuals who were directly involved in the response. It has been more than 18 months since B. anthracis spores were discovered in letters sent through the U.S. postal system. The specific purpose and perpetrator(s) of these attacks remain unknown. A total of 22 people developed anthrax as a result of the mailings, 11 suffered from the inhalational form of the disease, and 5 of these people died. Thousands of workers—including health care, public health, environmental, and law enforcement professionals—participated in the response to the attacks. Thousands more were directly affected, including individuals working in facilities contaminated by the attacks and their families. The immediate and continuing medical and public health response to the anthrax attacks of 2001 represents a singular episode in the history of public health. After-action assessments of the response to the anthrax attacks could offer invaluable opportunities to better understand and remedy the systemic vulnerabilities revealed by America’s only experience with an anthrax attack. Yet there still has been no comprehensive published analysis of the response to these events. In December 2001, the Center for Strategic International Studies convened a meeting, which included high-level government officials directly involved in managing the crisis, to discuss the response and review lessons learned. The report describing this meeting has been withheld from public distribution by the Department of Defense, which supported the meeting, on the grounds that the document contains sensitive information.1 The “response” to the anthrax attacks was extremely complex, and any analysis that purports to assess the response must account for this complexity. The unprecedented nature of the attacks and the context in which the response occurred are also crucial to understanding what happened and why. The long-standing neglect of federal, state, and local public health agencies, and the highly stressed condition of U.S. medical facilities, which routinely work at the limits of their capacity, are acknowledged by virtually all informed observers. That the medical and public health institutions involved in the response functioned as well as they did is a tribute to the extraordinary efforts of the individuals involved. Despite the commitment and hard work of the individuals in these professional communities, what was revealed by the anthrax attacks was an unacceptable level of fragility in systems now properly recognized as vital to national defense. Too many citizens, elected leaders, and national security officials still have limited understanding of the degree to which 22 cases of anthrax rocked the public health agencies and hospitals involved in the response to this small bioterrorist attack. Most of the vulnerabilities in the medical and public health systems revealed by the response remain unaddressed. It is not the purpose of this article to praise or criticize individuals who responded to the 2001 anthrax attack. The emphasis here is on how to improve response systems. The article seeks to identify the strategic and organizational successes and shortcomings of the health response to the anthrax attacks so that medical and public health communities as well as elected officials can learn from this crisis. The recent international spread of Severe Acute Respiratory Syndrome (SARS) is illustrating once more the importance of effective public health response systems. Initial impressions of the Centers for Disease Control and Prevention’s response to SARS indicate that the agency has improved several aspects of epidemic response that were problematic in the aftermath of the 2001 anthrax at-