Domestic preparedness for events involving weapons of mass destruction.

UNTIL RECENTLY, CHEMICAL AND BIOLOGICAL WEAPons have not been the focus of domestic planning, unlike our long-standing preparedness for a nuclear attack. Today, however, these weapons of mass destruction (WMDs) are readily available to many countries, including so-called rogue states. Even more alarming, WMDs are a viable alternative to conventional weapons for terrorist groups and disgruntled individuals. This availability, coupled with terrorists’ willingness to use these deadly agents, has created a credible and serious threat to the nation’s security. The probability of a WMD incident is greater than ever and threatens the United States and other countries with potentially devastating consequences, including widespread death and disease and destruction of societal infrastructure and possibly society itself. Recent US federal government initiatives have addressed this threat by establishing preparedness programs for local and state personnel. The intent is to enhance domestic preparedness in an attempt to mitigate the consequences of a WMD incident and to deter potential use of these weapons. In this issue of THE JOURNAL, Macintyre et al discuss some of the major challenges confronting health care professionals responsible for planning an effective health care facility response to a WMD event. While the authors focus on “events that require decontamination of exposed persons,” these recognized experts certainly put into perspective many of the problems currently encountered in planning and implementing preparedness programs in the United States. To date, there has been minimal involvement of health care facilities and health care professionals in WMD preparedness programs. The lack of integration of health care facilities in the overall community response is a serious flaw in US national strategy. Why have health care facilities not been integrated into the program? A main factor is that federal funds have so far been directed to traditional first responders: firefighters and law enforcement. This is an appropriate initial direction because these responders are the first line of defense. However, now is the time to incorporate the entire medical response system. Because of a lack of funds, hospital administrators have been reluctant to involve their institutions. Administrators are continually confronted with unfunded mandates in a time of fiscal constraints. This particular program is potentially very expensive because it requires specialized equipment and supplies and a large number of personnel being trained to rather sophisticated levels. In addition, the possibility of contaminating the health care facility and suspending or limiting hospital access to community patients because of participation in response to an actual or alleged WMD event is a valid concern for hospital administrators. Federal support and consideration of protection from inappropriate litigation are needed. The lack of involvement of physicians, nurses, and other health care professionals in current preparedness programs is also an obvious concern. Health care professionals will be essential in any response to a WMD incident, so involving them is mandatory. These professionals, in turn, must understand the need to become active participants in the preparedness arena. Macintyre and colleagues correctly point out that another major issue is health care professionals’ lack of working knowledge of the incident command system. This is a major flaw that must be addressed quickly, as traditional first responders base their command and control on the incident command system. Fortunately, an incident command system is available for hospitals and should be incorporated rapidly in disaster preparedness plans for health care facilities. Four other critical challenges to an effective response include a concern that preparedness programs are not comprehensive, the lack of effective surveillance systems to detect the release of WMD agents, the need for training of health care professionals, and the need for central federal coordination of these efforts. First, current preparedness programs are not comprehensive in their design because the contemporary model that serves as a planning framework for a community response against WMDs is the hazardous materials (HAZMAT) model.