Physicians consider usefulness of terror warnings

BY TONI LAPP

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It's early March. Do you know the color level of the Homeland Security Advisory System's terror alert right now? If you do know it, does it mean anything to you? Will your practice do anything differently? Will your local health department? How about your area emergency rooms?

The color-coded threat levels are helpful "to the extent that the color codes help public agencies have a sense of awareness," says Doug Campos-Outcalt, M.D., M.P.A., a member of the AAFP Commission on Clinical Policies and Research.

However, Campos-Outcalt, formerly medical director for his county health department in Phoenix, has concerns about the terrorism warning system. It debuted in March 2002 as an effort to keep the country on its toes.

"The potential is you have so many alarms that people begin to ignore them," he says. "I have a feeling that when we're finally hit with another terrorist attack, it will be independent of the color that's up."

Indeed, when ricin was discovered in February in the nation's capital, the threat level was a moderate Code Yellow.

Changes in the warning level should have little bearing on the daily practices of individual physicians, Campos-Outcalt says. FPs should already be on heightened alert to look for unusual presentations of disease in clusters and be ready to report such presentations regardless of color code.

Then and now

Denise Rodgers, M.D., of New Brunswick, N.J., former president of the Society of Teachers of Family Medicine, is among those whom the bioterrorism scare has affected directly. In 2001, she volunteered to staff a hot line to answer questions about anthrax. "The thing for me that is the scariest is the realization of just how unprepared as a country we really are," she said at the time.

Flash forward to 2004. All around her, Rodgers sees improvements. For instance, the local health center now features a negative pressure room for biological agents, she says.

Yet she remains noncommittal when asked if the country is better prepared.

"We don't know how well the communication systems are working that are in place, so we don't know what's going on in real time," she says. "And then there's the second issue: We don't know how well the messages to the public have made it to diverse communities, such as Spanish-speaking populations or poor communities."

And when the threat level changes, "I have no idea what to do with it," she says.

Code Orange!

When the threat level changed in late December to Code Orange, the CDC e-mailed an alert via the Health Alert Network, its highest level of messaging, to remind public health agencies and clinicians to be prepared to respond to terrorist events. The alert included information on bioterrorism, chemical agents and radiation/nuclear agents.

The CDC created the network (see http://www.phppo.cdc.gov/han/) in the late 1990s, but it wasn't used until after the terror attacks of Sept. 11, 2001, says Donna Garland, coordinator of CDC's emergency communications system. "The network's effectiveness and utility became clear at that point. It has become part of the network's process to send health alerts when there is a change in the country's threat status. We refresh our audiences on information they should have."

The government also has ramped up its communications efforts via telecommunications. After the CDC was roundly criticized for not responding quickly to concerns over anthrax, a new call center was created: the Public Response Service (http://www.cdcresponse.org), says Edgar Villanueva, health promotions coordinator for the American Social Health Association, a contractor that operates CDC call centers.

In addition to federal resources, FPs should not discount the importance of state and local health agencies, says Campos-Outcalt. "If there's anthrax, it will be the local health department that tells physicians how to respond."

Acting locally

Rodgers is not alone in feeling heightened anxiety when the threat level changes. "If the level changes, it means they've learned something, and we're never sure what they've learned," says Ray Weinstein, M.D., of Dale City, Va. He founded the Potomac Hospital/Greater Prince William County Chem-Bioterrorism Preparedness Committee in 1999, long before the topic of bioterrorism was on the radar screen of most health professionals.

Weinstein, too, finds the Homeland Security warning system leaves something to be desired: "The threat level really does not adequately address the threat of a biological or chemical weapon because an attack can come without warning and probably will."

The best defense is education for front-line physicians, he says, lamenting the lack of spending in this area.

"There are only two ways to mitigate the threat: Prevent it, which FPs can do little about, and identify it early, which FPs can do," says Weinstein.

To reach writer Toni Lapp, e-mail tlapp@aafp.org.

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