Kenneth I. Shine, M.D.
Institute of Medicine
The National Academies
For a Hearing on
Risk Communication: National Security and Public Health
Subcommittee on National Security, Veterans Affairs, and International Relations
Committee on Government Reform
U.S. House of Representatives
November 29, 2001
I am Kenneth I. Shine, President of the Institute of Medicine of the National Academy of Sciences. For the last three years I have also served as a member of the congressionally mandated Commission on Weapons of Mass Destruction, chaired by Governor James Gilmore of Virginia, otherwise known as the Gilmore Commission. My comments reflect the opinions of the National Academies, as represented by Bruce Alberts, President of the National Academy of Sciences, and William Wulf, President of the National Academy of Engineering, whom I joined in signing a statement on October 3, 2001. In this statement, we advised the American public and health professionals to seek authoritative information on Anthrax from three websites, those at the Centers for Disease Control and Prevention, The National Library of Medicine, and the Johns Hopkins University. We made the statement because of our concern about the amount of misinformation being conveyed about the Anthrax incidents and the confusion that had resulted from multiple sources of analysis, commentary and advice.
Mr. Chairman, in 1988 The Institute of Medicine issued a report called The Future of Public Health. The report described the state of infrastructure for public health in America as in "disarray". The report recommended renewed national attention to the infrastructure, human resource needs, educational capacity, and programs in public health in America. In 1992, the Institute of Medicine issued a report on new Emerging Infections: Microbial Threats to Health in the United States, from a committee chaired by Nobel Laureate, Joshua Lederberg, and Dr. Robert Shope. In that report, additional recommendations were made for strengthening the capacity of public health and medicine to deal with new and emerging infections including those presented by terrorism. Although some additional resources were provided to the Centers for Disease Control and Prevention in response to these reports, these were limited. Over the past decade the overall condition of the public health system in America has continued to erode. Many of these weaknesses were graphically displayed during the anthrax episodes. Laboratory capabilities, adequate staff for investigations, the relationship and responsibilities of public health to law enforcement and especially for purposes of this hearing, the effectiveness of communications to the public and to health professionals about the anthrax terrorism were found wanting.
Key to the role of public health is education and information for the public and for health professionals. Whether an epidemic is a naturally occurring one such as that involving west nile virus, or whether produced by a terrorist, public health professionals and public health departments around the United States need timely, accurate, and reliable information.
Every epidemic results in new knowledge as it is studied and understood. In the case of anthrax, information about the inhalation form of the disease was limited to a very small number of cases over an extended period of time. Medical practitioners and public health officials in the United States never had direct experience with inhalation anthrax. Not only is it important to learn in an ongoing way as such an epidemic develops, but it is also important to rapidly translate that knowledge into reliable guidance to health professionals and to the community.
In this testimony I will focus on two critical methods of communication about these issues in the 21st Century: verbal communication -- particularly via Television -- and the Internet. I begin with remarks concerning verbal communication.
Within the Department of Health and Human Services, there must be a single credible medical/public health expert spokesperson that reports regularly, most likely daily, to the American people in regard to any outbreak with national significance. This is analogous to the situation in local communities where there is a need for such an individual to communicate on behalf of the local health department. Several months before the anthrax outbreak, uninformed statements on local television in a community with two cases of meningococcal meningitis resulted in thousands of individuals taking antibiotics or seeking immunizations that were not indicated. Local stores of antibiotics were depleted and many people were subjected to risk from unnecessary treatment. This episode emphasizes the need for credible medical/public health information during natural events, as well as during those that are produced by terrorism.
In the case of the anthrax episodes, the media responded by interviewing countless numbers of individuals. Among them was a self-professed pundit who announced he was an expert on the "anthrax virus." Anthrax is a bacterium, not a virus. In many cases, well intentioned infectious disease specialists who knew a good deal about the literature on anthrax could provide accurate retrospective information, but when pressed about the current events, they were not privy to the information about the cases that had occurred. They were then forced to either acknowledge their limitations, which the responsible experts did, or in the case of others less responsible, to speculate based on news reports, rumors and a variety of other kinds of incomplete or false information.
In a national emergency, such as that experienced with anthrax, the regular appearance on television of a credible medical/public health expert spokesperson who has up-to-date knowledge of the outbreak is important. Such a responsible individual can of course consult with law enforcement agencies with regard to information that might be important in an ongoing criminal investigation. However the goal of the terrorist is to produce terror. Terror arises from fear magnified by an exaggerated sense of risk, and perpetuated by misinformation and rumors. In these episodes, the balance should be biased in favor of providing good information to protect the public health.
In addition to the Department of Health and Human Services, the other major stakeholder that must provide public information in the case of terrorism is the Office of Homeland Security. The Gilmore Commission has urged that one of the associate directors of that office be an Associate Director for Health. We know far too little about the availability of hospital beds, burn units, decontamination capability and a variety of other parameters required by the health system to deal with terrorism. Moreover, the necessity for dramatically improved communications between the public health system, the medical care system, and law enforcement all require a high level of coordination and communication. If this individual is also to be a spokesperson on such episodes as the anthrax outbreak, it is critical that his or her statements should be carefully coordinated with the principal credible medical/public health spokesperson within the Department of Health and Human Services. These messages must be well thought out and consistent to avoid confusion and misdirection. And clearly both individuals must be kept completely up to date with the most recent information, including the complete results of scientific and forensic analyses.
It is understandable that political leaders and Administration officials wish to be the spokespersons for their departments or agencies in the face of a threat to the national security or to the nation’s health. It is important that they do so. But the impact of their communications are not diminished when they are joined by a credible medical/ public health expert spokesperson who is knowledgeable about the nature of the disease and is also privy to up-to-date information about the outbreak. Turning to such an individual when technical questions are raised does not diminish, but rather enhances, the authority of the non-medical leader in addressing the public’s concerns. For example, the presence of Dr. Anthony Fauci at hearings and press conferences came late in the sequence of events but his appearance was extremely valuable. Furthermore, his interviews by the media were paradigms of clarity, accuracy, and relevancy. It is noteworthy that, in one of his appearances with a number of so called experts, he was forced to correct inaccurate statements made by others during the program.
The other major issue that was identified by the October 3 statement from my colleagues and me is the importance of authoritative, well presented, up-to-date websites where health professionals, the public, and others can quickly obtain good information. The Internet has been flooded with multiple websites concerning anthrax. Many are reliable. But, as noted in our message, many are incorrect, inaccurate, misleading, and in some cases are downright scams. Identifying the most reliable during an emergency is important for those who seek such information.
The CDC maintains a website for this purpose. Ultimately, as we indicated in our statement, excellent information appeared at that website, though it was not as well organized as it might have been. The capacity of the CDC website to respond to inquiries was, for a period of time, limited. Access was limited by the large number of inquiries. In view of the importance of credible and accurate information, accurate resources should be made available so that the CDC can provide information using the most modern technologies, the most professional presentations, and have both the bandwidth and the human capacity to respond to a large number of inquiries. The spokesperson for the Department of Health and Human Services/and or the office of Homeland Security should regularly remind the public and health professionals that they can get such reliable information at the CDC website.
There is an important lesson in this experience for other government agencies. We do not know where other terrorist events may occur. Does the Department of Energy have the capacity to respond to inquiries from the public and professionals with high quality, rapidly updated information should there be an incident involving radiological materials or a nuclear event? Can the Department of Agriculture respond with the type of credible expert to whom I refer and have a website with the capacity required for all inquiries, should there be any problems in the areas of agriculture or animal husbandry? Where will the appropriate website be located for information about an episode involving terrorism using a chemical agent? There are many agencies involved in these issues, but if information for the public is crucial the principles that I have outlined for the Department of Health and Human Services and the office of Homeland Security should also apply in each of these other areas. A single preferred information source should be assigned now to a single government agency in each case, and resources must be dedicated by this agency to maintaining this capability on high alert.
Mr. Chairman, many individuals in both the public and private sector work very long hours, seven days a week in coping with the anthrax episodes. They deserve enormous credit for their efforts in this regard. As the Institute of Medicine reports have emphasized for 13 years, the public health infrastructure at the state, federal, and local levels requires substantial upgrading. Strengthening the size and configuration of the Epidemic Intelligence Service, the facilities at the CDC, and the surveillance capacity at the federal, state, and local public health and medical entities are crucial. The Gilmore Commission has recommended that the Associate Director for Health in the Office for Homeland Security have an advisory panel consisting of representatives from a wide variety of hospitals, medical organizations, and first responders who can develop methodologies to rapidly communicate throughout the country the information required about how to meet emergencies in a timely way. The Institute of Medicine has published a preliminary report (to be followed by a full report next year) on the methodologies by which we can assess the capacity of local communities to respond to an episode of terrorism. The American Medical Association has developed an excellent plan to create educational programs and disaster planning efforts through their State and local Societies. The Joint Commission on Accreditation of Healthcare Organizations has developed a plan for hospitals to improve their capabilities to cope with disasters. Resources will be necessary to make these happen, some of which will require federal help.
Additional research to deal with biological agents is essential. For example, the current anthrax vaccine requires six doses over 18 months. While studies are underway to determine the efficacy of fewer doses we desperately need a much better, purer, and effective vaccine against anthrax. The Council of the Institute of Medicine has called for the establishment of a national vaccine authority or its equivalent to assure supplies of vaccines which are not available through the market or which require public/private collaborations to assure adequate supplies, as exemplified by shortages of anthrax and smallpox vaccines. This should include vaccines for childhood diseases, adult infections, and in the case of preventing the spread of hoof and mouth disease, for animals. Improved diagnostic and therapeutic options are also required.
Central to all of these efforts is information and communication: information, which the American people can understand, and information about the concepts of risk and how to apply them. In the case of anthrax, less than 20 cases resulted in thousands of people taking antibiotics that were not indicated. Perhaps twenty percent of these individuals experienced some side affects from these drugs. These antibiotics changed the bacteriological environment and may have rendered some organisms resistant to the antibiotics employed. Several effective antibiotics were available and better early information might have prevented the exhaustion of stores of Ciprofloxacin. A clear recommendation that one not take Ciprofloxacin unless one is a member of a specifically defined high risk group, e.g. postal workers or those with potential exposures on Capitol Hill would also have been very helpful in this situation.
The debate about smallpox vaccination will be much more straightforward if the American public understands the concept of risk/benefit. Smallpox was controlled throughout the world by vaccination of the populations who had been potentially exposed to a case ---that is, by surrounding the cases as soon as they were observed with vaccinations. Even two or three days after exposure, vaccination will prevent the disease. The public needs to be informed that this represents an excellent alternative to mass vaccination--which is likely to kill hundreds of people and seriously damage many more. We also need additional research to determine how many Americans who were vaccinated years ago have persistent immunity. This would help further refine the risk/benefit analysis and the needs for vaccine.
In summary, I have emphasized the critical role of a credible medical/public health expert spokesperson, knowledgeable about the current events, who speaks for the Department of Health and Human Services and stands side by side with the Secretary in his communications. If a similarly qualified spokesperson on bioterrorism is to be designated in the Office of Homeland Security, the credible medical/public health expert spokesperson(s) must carefully coordinate their statements so that they are accurate, authoritative and understandable, and consistent. Much more serious attention should be paid to the role of well organized, well presented, and technologically sophisticated web-sites for providing information to the public, health professionals, the media, and others. Such sites should be developed and be on alert (and when needed be well advertised) for each of the areas relevant to a potential terrorist attack.
Thank you Mr. Chairman, for this opportunity and I would be happy to answer any questions.