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7 Public Health Disasters and Preparedness Flood barriers and sandbags on a flooded street where emergency responders in orange apparel are patrolling. Marc Bruxelle/iStock/Thinkstock Learning Outcomes After reading this chapter, you should be able to Identify federal, state, and local agencies involved with terrorism, emergency preparedness, and emergency response. Outline the types of disasters and the public health responses for each. Explain the core functions of public health as they are applied to emergency situations. Analyze the effectiveness of emergency response and preparedness, including the associated ethical issues. Smoke rising from the World Trade Center during the September 11, 2001, attack in New York City. Greg Martin/SuperStock The September 11, 2001, attacks on the World Trade Center changed the way Americans viewed terrorism. Even though terrorist attacks were not new to the United States, September 11 provided a vivid example of how vulnerable the country could be in times of crisis. For many people in the United States and around the world, September 11, 2001, marked the beginning of an era of terrorism. After the destruction of New York City’s World Trade Center towers, the attack on the Pentagon, and the plight of Flight 93, Americans seemed no longer exempt from the terrorism occurring in other parts of the world (Yeboah, Chowdhury, Ilias, Singh, & Sparks, 2007). In reality, terrorism has occurred on American soil since the early 1800s. Some would argue that terrorism began when Christopher Columbus arrived in America and the struggle between white Europeans and the Native Americans began. Regardless of when it began, it is not a new concept. What is relatively new is bioterrorism, which entered the global scene only in the mid-1980s (Resnick, 2013). An examination of the history of terrorism and bioterrorism over the last 50 years explains the past and current responses of the United States to these incidents and to other disasters, both manmade and natural. This also allows an exploration of the role of public health in these emergencies, with a focus on the principles of emergency response and preparedness and the agencies charged with coordinating efforts to keep the nation safe. The chapter also analyzes emergency response and preparedness for all types of disasters. While this chapter describes terrorist attacks and disasters, it concentrates on the role of public health in coordinating responses, actions, relief, and clean-up efforts to maintain the health of the nation as well as the environment. 7.1 Governmental Agencies and Emergency Response Although terrorism has occurred in the United States at least since the 1800s, U.S. vulnerabilities were tested to the limit in 2001 with the events of 9/11 and subsequent anthrax attacks. Since that time, the nation’s protocols for preparing and handling all emergencies have evolved significantly. In the event of a national emergency—terrorist attack, bioterrorism threat, or disaster—certain procedures are followed, and numerous governmental agencies take immediate action. The Department of Homeland Security (DHS) The Department of Homeland Security (DHS) was created in response to the terrorist attacks that occurred on September 11, 2001. It provides protections from domestic and international terrorism, and its primary mission is to protect the American homeland (Koenig, 2003). From a public health perspective, its creation means improved emergency preparedness and cooperation with all levels of government. In fact, the American Public Health Association helped develop the roles and responsibilities for this new department, which was created and passed under the Bush administration in 2002 (Late, 2002). In the event of an emergency, the Department of Homeland Security takes the national lead and guides upwards of 23 federal agencies that are also involved with coordinating efforts during a national emergency. These 23 federal agencies all play an important role in the health and safety of the nation’s population. There are three key systems that operate to assist in a national emergency. Functioning separately yet coordinated under a partnership of federal agencies, these systems are the National Disaster Medical System (NDMS), the National Pharmaceutical Stockpile, and the Metropolitan Medical Response System: NDMS is a federally orchestrated partnership between the U.S. Department of Health and Human Services, Homeland Security, the Department of Defense, and Veterans Affairs. NDMS fills in the gaps in medical needs and response in the event of a national disaster (U.S. Department of Health and Human Services, 2018b). The National Pharmaceutical Stockpile, which handles drugs and medical supplies for use during disasters, falls under the U.S. Department of Health and Human Services and the CDC. In late 2018, the stockpile is expected to relocate under the Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response. That office ensures that the nation can recover from a disaster by collaborating with hospitals, health care coalitions, firms, community members, and governments to improve readiness and response to emergencies (U.S. Department of Health and Human Services, 2018a). The Metropolitan Medical Response System, which develops or enhances emergency preparedness in dealing with “weapons of mass destruction” (e.g., bioterrorism) (Late, 2002, p. 5), is an operational system at the local level. It operates within program cities in contract agreements with the U.S. Department of Health and Human Services’ Office of Emergency Preparedness (Institute of Medicine, 2002). The largest entity included under the DHS is the Federal Emergency Management Agency (FEMA), which responds under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (P.L. 93-288). This act, which went into effect in the fall of 1988, contains significant responsibilities for preparedness and response in the event of any emergency. Refer to A Closer Look for more details on this act. A Closer Look: The Robert T. Stafford Disaster Relief and Emergency Assistance Act The Disaster Relief Act of 1970 was the first federal law to establish a permanent emergency relief program in the United States. Signed into law by President Richard Nixon, the Disaster Relief Act of 1970 was intended to provide funding to those affected by natural disasters. The 1974 Disaster Relief Act would amend the Disaster Relief Act of 1970 to further extend assistance from the federal government to states, local communities, and individuals in the event of a disaster such as a tornado (Wolley & Peters, 2018). President Richard Nixon found that the increasing number of major disasters, mostly natural disasters, were financially hurting businesses, organizations, individuals, and communities across the nation. The original act (of 1970) provided financial relief to help rebuild. It included four key items: 1) a property tax revenue maintenance plan for those whose tax bases were destroyed through the disaster, 2) the authority to repair or replace damages to public buildings, 3) improvements to the loan programs that assist people in the event of loss from the disaster, and 4) authority for the federal government to assist with lessening the effects of the disaster. The most recently amended act, now known as the Robert T. Stafford Disaster Relief and Emergency Assistance Act, encompasses far more than natural disasters. The law states: It is the intent of Congress, by the Act, to provide an orderly and continuing means of assistance by the Federal Government to State and local governments in carrying out their responsibilities to alleviate the suffering and damage which result from such disasters by: Revising and broadening the scope of existing disaster relief programs; Encouraging the development of comprehensive disaster preparedness and assistance plans, programs, capabilities, and organizations by the States and by local governments; Achieving greater coordination and responsiveness of disaster preparedness and relief programs; Encouraging individuals, States, and local governments to protect themselves by obtaining insurance coverage to supplement or replace governmental assistance; Encouraging hazard mitigation measures to reduce losses from disasters, including development of land use and construction regulations; and Provide Federal assistance programs for both public and private losses sustained in disasters. (FEMA, 2016, p. 1) Source: Federal Emergency Management Agency. (2016). The Stafford Act, as amended and emergency management-related provisions of the Homeland Security Act, as amended. Retrieved from https://www.fema.gov/media-library-data/1490360363533-a531e65a3e1e63b8b2cfb7d3da7a785c/Stafford_ActselectHSA2016.pdf Numerous amendments were made to the Stafford Act as a result of the 2004 Hurricane Katrina disaster. This affected several sections of the act, including firearms policies, detailed administrative functions, and community disaster loans. As a result of these amendments, two additional acts were passed: the Pet Evacuation and Transportation Standards Act of 2006 and the Security and Accountability for Every Port Act of 2006 (FEMA, 2016). The former addresses the needs of pet owners and those with service animals (GovTrack, 2006), and the latter addresses safety and security needs at all United States maritime facilities (U.S. Government Printing Office, 2006). Federal Emergency Management Agency (FEMA) The mission of the Federal Emergency Management Agency (FEMA) is “to support our citizens and first responders to ensure that as a nation we work together to build, sustain, and improve our capacity to prepare for, protect against, respond to, recover from, and mitigate all hazards” (FEMA, 2017a, footer). FEMA has a long history. It began, under no particular organizational name, through the Congressional Act of 1803, which is often considered the nation’s first piece of disaster legislation. The act was passed so that funds could be released to assist a New Hampshire community recovering from a devastating fire. Unfortunately, disaster relief remained very fragmented as the nation endured various earthquakes, floods, and hurricanes. It was clear that there was a growing need for disaster relief across the nation. In fact, according to FEMA (2017b), more than 100 federal agencies were historically involved when disasters and emergencies hit the nation, making consistent relief efforts difficult to manage. The Three Mile Island nuclear power generating station in Pennsylvania. Dobresum/iStock/Thinkstock In March 1979, the Three Mile Island nuclear power plant leaked radioactive gas from one of the plant’s reactors, inciting President Carter to bring together the varied disaster relief agencies under FEMA. In an attempt to consolidate efforts, two groups were created to provide larger relief: 1) the Reconstruction Finance Corporation in the 1930s (FEMA, 2017b) to provide disaster loans to cities to repair or rebuild public buildings following disasters, mainly of the natural kind, and 2) the Federal Disaster Assistance Administration, to help with housing and urban redevelopment after a disaster. But it wasn’t until the 1970 Disaster Relief Act, mentioned earlier, and its amendment in 1974 that the United States had consistent and permanent federal relief during times of emergency. In 1979, following the Three Mile Island nuclear meltdown disaster, President Jimmy Carter ordered disaster relief agencies to work under one central command: the Federal Emergency Management Agency. Since then, many of the disasters FEMA has responded to have been manmade emergencies, such as the Exxon Valdez oil spill, the 9/11 terrorist attacks, the 2013 Boston Marathon bombing, and the massive 2017 shooting at the Route 91 Harvest festival in Las Vegas. FEMA’s main role is to coordinate efforts of preparedness, response, and recovery. The components of FEMA include the Office of Response and Recovery, the Federal Insurance and Mitigation Administration, the Mission Support Bureau, Protection and National Preparedness, and the United States Fire Administration. Depending upon the nature of the disaster, FEMA dispatches the protocol designed to handle the emergency. More on FEMA’s actual responsibilities is covered later in this chapter. Centers for Disease Control and Prevention (CDC) The Centers for Disease Control and Prevention (CDC) works with FEMA to assist with various disasters such as natural/weather disasters, bioterrorism, chemical emergencies, outbreaks/incidents, mass casualties (explosions), and radiation emergencies. While its website is the primary public source for emergency information, in terms of both personal response and preparedness, the organization also plays a key role in disaster situations. The CDC has two primary functions in the event of an emergency: public health preparedness and medical preparedness. The former helps the United States, including individuals and communities, protect against health emergencies. The latter works with the health care system to ensure it is prepared to handle and recover from a health emergency. A romaine lettuce field. Comstock Images/Stockbyte/Thinkstock In 2018, epidemiologists from the Office of Public Health Preparedness and Response (OPHPR) pinpointed the source of an E. coli outbreak—romaine lettuce from a grower in Arizona. As the response arm of the CDC, the Office of Public Health Preparedness and Response (OPHPR) provides strategic direction and coordination of efforts to prepare and respond to a crisis. The OPHPR helps coordinate all protocols such as deployments, travel, and providing support staff. One example is its response to a foodborne outbreak, such as the 2018 E. coli outbreak in romaine lettuce (Belluz, 2018; CDC, 2018b). In this case, the OPHPR initiated the protocols to stop the spread of the virus, including deploying epidemiologists to investigate the source(s) and eventually recalling all infected lettuce. These actions led investigators to the source: a romaine lettuce grower in Yuma, Arizona. Before the source was finally discovered and stopped, 98 people from 22 states were sickened (Belluz, 2018; CDC, 2018b). Response to the anthrax scares of 2001 prompted the CDC and OPHPR to develop a training course on the communications efforts needed during a bioterrorism attack. The CDC focused on enhancing cooperation with all emergency response teams and minimizing widespread panic (Courtney, Cole, & Reynolds, 2003). During the actual crisis, the CDC provided field investigators to determine the spread of the disease and the potential for stopping its progress in those already infected. The goal was to lessen the impact by confining the infected as much as possible. A central command center provided the link between the field agents and other emergency responders, as well as to the community at large. In addition, the CDC provided the potentially exposed with a 60-day course of antibiotics to combat further spread of the deadly weapon both domestically and abroad (Malecki et al., 2001). According to Polyak et al. (2002), the CDC’s epidemiologists, laboratory scientists, and clinicians were asked to assist with anthrax inquiries around the world, eventually responding to 130 requests from 70 countries and two territories. The results helped alleviate worldwide panic, prevent unnecessary antibiotic treatment, and enhance international surveillance of bioterrorism events. Health Resources and Services Administration (HRSA) The main function of the Health Resources and Services Administration (HRSA) in the event of a disaster is to distribute grants to presidentially declared disaster areas. Only through FEMA can HRSA provide financial assistance (HRSA, 2012). According to the HRSA guidelines set by FEMA, the disaster funds can be used only after local emergency management assistance cannot handle the expenditure alone (HRSA, 2012). Six steps must be followed in order to acquire disaster funding from HRSA: Local government responds first. If overwhelmed, the local government must initially seek state funds. The state responds with resources such as the National Guard or other financial resources. Damage assessment is performed through local, state, federal, and volunteer agencies to determine losses and recovery needs. The state’s governor requests a Major Disaster Declaration, with state funds allocated to recovery. FEMA evaluates the request and recommends action from the White House. The president approves or denies the request, a process that could take a few hours or weeks, depending on the scope of the disaster. Food and Drug Administration (FDA) The United States Food and Drug Administration (FDA) oversees the development of human and veterinary products and monitors the food and blood supplies for the United States (U.S. FDA, 2017). Operating under the FDA, the Office of Counterterrorism and Emerging Threats (OCET) facilitates the development of safe and effective medical countermeasures in the event of a terrorist or bioterrorist attack (U.S. FDA, 2017). As part of its duties, the OCET is charged with coordinating emergency use activities as well as communication efforts within and outside the agency. Among the OCET’s many counterterrorism programs are the following (U.S. FDA, 2017): Animal and Veterinary Products and Counterterrorism—Monitors animal foods and veterinary drugs for safety and handles various other food and drug concerns. In the event of an emergency, this agency has numerous responsibilities to ensure safe food and drugs for the United States. Two of these responsibilities include the prevention of further distribution of contaminated feed and timely approval of animal drugs in the event primary facilities are overtaken or lost. Biologic Product Security—Focuses on the safekeeping of stockpiles of biological products such as medical supplies, bacterial and viral vaccines, and blood. It also works to expedite the development and licensing of products that will diagnose, treat, or prevent diseases following exposure to bioterrorism agents. Drug Preparedness and Bioterrorism—Ensures there are adequate supplies of medicines and vaccines to protect the American public in the event of a bioterrorism attack. Food Defense—Works with many agencies across the nation to protect the food supply by reducing the risk of food and cosmetic supplies tampering in the United States. Medical Devices (Emergency Situations)—Distributes appropriate medical devices in the event of an emergency, such as diagnostic equipment and tests, surgical tools, and personal protective equipment. While this is applicable to all emergencies, it was intended to focus on natural phenomena such as extreme weather (floods, hurricanes, tornadoes, and earthquakes). National Institutes of Health (NIH) The National Institutes of Health (NIH) comprises 27 institutes and centers, each focused on a different aspect of health research (National Institutes of Health, 2017b). All of these agencies have their own focal points in the event of a disaster, but a description of each is beyond the scope of this textbook. However, there is one program that has been especially helpful during acts of terrorism. The NIH’s Institute of Neurological Disorders and Stroke (NINDS) operates NIH CounterACT (NINDS, 2018). This program focuses on developing new and improved medical countermeasures that will prevent, diagnose, and treat conditions caused by chemical threats (NINDS, 2018). For example, substances that could be used as biological weapons include arsenic trioxide, hydrogen sulfide, cyanide, tetramine, bromine, and ammonia (NINDS, 2018). The NIH supports efforts to find treatments and vaccinations to counteract the effects of exposure to such substances. Federal Bureau of Investigation (FBI) The Federal Bureau of Investigation (FBI) is the federal agency on the front line in all terror acts. Its employees investigate acts and potential acts of terror. The Bureau comprises multiple operations, including Joint Terrorism Task Forces, the Terrorist Screening Center, the International Human Rights Unit, and the Weapons of Mass Destruction Directorate (FBI, n.d.). It also operates training programs for their employees and for others in law enforcement. Programs include but not limited to bomb detection, vehicle operations, and firearms skills. While working with these agencies, among many others, the FBI provides protection for the nation’s borders and seaports, colleges and universities, food supply, and human rights and freedoms (FBI, n.d.). Located in field offices scattered throughout the country, the FBI’s main function is to protect, investigate, and help dismantle extremist networks worldwide (FBI, n.d.). State and Local Agencies Homeland security and emergency services are available in every state and in the District of Columbia. Most of them are set up to work closely with state governments, state health departments, law enforcement, and other public health and safety organizations. Each state has its own set of emergencies. For example, the plains states deal with drought, states on the East Coast often suffer from hurricanes, the mountain states experience snowstorms and avalanches, and earthquakes occur regularly on the West Coast. Regardless of the type of emergency or the state in which it occurs, local government entities typically trigger the emergency response. Local law enforcement and fire departments are often the first dispatched groups. If the event is too difficult or overwhelming for local entities to contain, these groups connect with their state officials. At each level of response, the mission of homeland security and emergency response is to lead, coordinate, and support public health and safety. 7.2 Types of Emergencies An emergency for one person may be a simple problem for another. FEMA distinguishes between the terms hazards, disasters, emergencies, and other similar words (FEMA, 2008). A hazard is something that is potentially dangerous and is likely the main cause for a disaster or emergency. A threat is an indication of possible harm or danger. Threats can be naturally occurring (a tornado or hurricane), manmade (chemical explosions or industrial accidents), or intentionally human caused (terrorist acts). While FEMA’s training manual lists 18 individual definitions of “emergency” (FEMA, 2008), the state of Rhode Island Department of Emergency Management (n.d.) has defined the word in the simplest of terms: An emergency is an incident that threatens public health, safety, and welfare. A person with an umbrella standing outside during a snowstorm. kudou/iStock/Thinkstock A state of emergency might be declared if one or more states in a geographic region experience conditions that create a threat to public health, safety, or welfare, such as the dangers associated with extreme weather or forest fires. States of emergency are categorized as occurring locally, statewide, or nationally (FEMA, 2008). Local emergencies are confined to a geographical region of a state such as a city, county, or municipality. A state of emergency is confined to one or more states within the nation. A state of war emergency is declared when any part of the nation is threatened or attacked by an enemy. All emergencies require emergency preparedness, which encompasses all activities that are planned and implemented to manage an emergency. These include not only the individuals and responsibilities of emergency response teams, but also the community’s readiness to fulfill an emergency action plan. An emergency response is the tactical planning and subsequent activities used to protect the public’s health (environment and life). Included within this definition are evacuation plans, escalation protocols, damage reporting and assessment, medical team dispatch, salvage, search and rescue, and hazardous materials response and control. Escalation protocols, which are necessary in an emergency, ensure that all emergency response personnel carry out their roles and responsibilities effectively and appropriately to protect the nation and promote the health and well-being of the American people. They are intended to prevent harm and reduce the risks of further danger and damages from the declared emergency. Technological, Manmade, and Chemical/Radiation Emergencies FEMA (2008) has identified nuclear waste disposal spills, toxic substances, hazardous materials accidents, utility failures, pollution, epidemics, explosions, and fires under this category. On its lengthy list of chemical/radiation hazards, the CDC (2018a) has included poisons from plants or animals, blood agents, lung/pulmonary agents, poisonous metals, nerve gases, toxic alcohols, solvents, and radiation exposure. An example is the Three Mile Island nuclear meltdown, which occurred on March 28, 1979 (Smithsonian National Museum of American History, n.d.). This was considered the United States’ worst nuclear power plant accident, where radioactivity leaked from one of the reactors into the surrounding community near Harrisburg, Pennsylvania. Table 7.1 shows a chronological list of some of the major manmade disasters that have occurred within the United States. Table 7.1: Major manmade disasters in the United States The static table has been replaced by an interactive timeline. The first federal declaration of a disaster from a manmade cause came out of New York State in the neighborhood of Love Canal in Niagara Falls (Binns, 2004). It took nearly 26 years to fully clean up after toxic waste infiltrated the area starting in the 1920s. See Case Study: Love Canal: The First Federal Disaster Area from Manmade Causes for more details. Case Study: Love Canal: The First Federal Disaster Area From Manmade Causes The Love Canal disaster, which occurred over the course of 50 years, was one of the most significant industrial waste dumping incidents in the nation. In the 1920s, William T. Love attempted to build a canal in a neighborhood in Niagara Falls, New York. The neighborhood was eventually renamed Love Canal. When the plans failed, the large canal area became a dumping ground for garbage, including some toxic waste. In the 1940s, Hooker Chemical Company started emptying its industrial waste products into the canal and covering it with dirt. It was estimated that more than 80 different toxins were dumped into the canal. In 1953, Hooker Chemical eventually sold that land to the local school district (with a price tag of only $1) for the construction of a new school. Two years later, a 25-foot area surrounding the school disintegrated, exposing the various toxic chemical drums left by Hooker Chemical. These drums had apparently filled with rainwater, in which the children played. Furthermore, when the city began constructing new sewer lines for low-income housing, sections of the abandoned canal broke, releasing more toxic waste into the system. According to one report, “Love Canal residents reported exploding rocks, strange odors, and blue goo that bubbled up into basements” (Mother Nature Network, 2018, para. 3). However, the most immediate concern was the increase in asthma, miscarriages, mental disabilities, and numerous other health problems that plagued the residents of Love Canal; 56% of children born between 1974 and 1978 suffered from birth defects that were directly connected to the toxins from Love Canal. This was the first time in the nation’s history that an area was declared a federal disaster area from manmade causes. In 2004, cleanup efforts were complete, and the neighborhood was taken off the National Priorities List by the Environmental Protection Agency. Sources: Binns, J. (2004). Remediation: Cleanup complete at Love Canal. Civil Engineering, 74(12), 22–23. Mother Nature Network. (2018). America’s 10 worst man-made environmental disasters. Retrieved from http://www.mnn.com/earth-matters/wilderness-resources/photos/americas-10-worst-man-made-environmental-disasters/the-pla Popkin, R. (1986). A new urgency: Hazardous waste cleanup and disaster management. Environment, 28(3), 2–6. Natural Disasters and Severe Weather Both the CDC (2018a) and FEMA (2008) have identified earthquakes, floods, hurricanes, tornadoes, tsunamis, blizzards, drought, volcanoes, mudslides, and extreme heat under the category of a natural disaster. The worst earthquake in the history of the United States took place on March 27, 1964, in Prince William Sound, Alaska (United States Geological Survey [USGS], n.d.). According to the USGS, the earthquake, with a magnitude of 9.2, and its associated tsunami, took 128 lives and caused more than $311 million in damage. Communities affected by the earthquake included Anchorage, Portage, Kenai, Kodiak, and Wasilla (USGS, n.d.). The quake was felt throughout most of Alaska, as well as parts of Canada. Table 7.2 lists some of the major natural disasters in the United States. Natural disasters occur across the country, but some states sustain more severe weather incidents than others. See Case Study: Iowa: A Magnet for Natural Disasters for details. Table 7.2: Major natural disasters in the United States The static table has been replaced by an interactive timeline. Case Study: Iowa: A Magnet for Natural Disasters Since 1990, Iowa has experienced 41 presidentially declared disasters, most of which involved severe weather (Iowa Homeland Security, n.d.-a). From 1951 to 1970, Iowa experienced 10 flooding emergency declarations. In the 1970s and 1980s, another 10 declarations were made for flooding and severe storms. The 1990s brought 11 severe weather emergency declarations. From 2000 to 2017, the state had 28 presidential declarations of severe weather emergencies (Iowa Homeland Security, n.d.-a). Iowa’s emergency management practices began in 1965 as the State Civil Defense Agency (Iowa Homeland Security, n.d.-b). This organization coordinated emergency response and recovery efforts for disasters such as floods and storms. The 2009 Code of Iowa, Chapter 29C, outlines the responsibilities for Iowa’s emergency management team, now known as the Iowa Homeland Security and Emergency Management Division (HSEMD) under the Iowa Department of Public Defense (Iowa Homeland Security, n.d.-a). Iowa’s HSEMD operates like FEMA at the federal level, but only within the boundaries of Iowa. It supports local entities as they plan for and respond to emergencies. The division also provides training, technical assistance, communications, and other emergency preparedness and response for municipalities within Iowa’s 99 counties. HSEMD is the coordinating body for all emergencies within Iowa. See Figure 7.1 for an illustration of its organizational structure and support. Figure 7.1: Emergency management structure in Iowa How does the organizational structure of Iowa’s HSEMD help it to plan for and respond to emergencies within the state? An interconnecting figure demonstrating the flow of information and management from the governor of Iowa to the Homeland Security advisor and HSEMD administrator, to HSEMD, and from there to the local, state, and executive state policy and advisory bodies. Source: Adapted from “Emergency Management Structure in Iowa,” by Iowa Homeland Security, n.d. (http://www.iowahomelandsecurity.org/about_HSEMD/EM_structure.html). While relatively new, Iowa’s emergency management system is well designed. It operates 13 separate programs focused on protecting the health and well-being of its residents. Some of these programs include a Citizen Corps, Critical Infrastructure team, E-911 system, School Safety Program, and Threat Information and Infrastructure Protection Program. Today, Iowa is still forward thinking in its protection efforts, as it has added terrorism to its responsibilities. The Threat Information and Infrastructure Protection Program works with the federal government to ensure the safety of public and private infrastructure in order to protect against the threat of terrorism or bioterrorism. Its Intelligence Fusion Center was developed post–9/11 to enhance efforts of information exchange to maintain public safety (Iowa Homeland Security, n.d.-b). There are 72 fusion centers in the United States, one in each state and 22 in major urban areas. The Fusion Center in Iowa is at the capital, Des Moines. Source: Iowa Homeland Security & Emergency Management. (n.d.-b). Iowa disaster history. Retrieved from https://www.homelandsecurity.iowa.gov/disasters/iowa_disaster_history.html Internal Disturbances and Mass Casualties FEMA (2008) has described internal disturbances and mass casualty emergencies as riots, large-scale prison breaks, demonstrations or strikes that lead to violence, and acts of terrorism. The CDC (2018a) has added bombings to this list. Probably the most vivid example of an emergency in this category is that of the April 15, 2013, Boston Marathon bombing. Three people died and nearly 200 people were injured when two pressure cooker bombs exploded near the finish line of the Boston Marathon (CNN Library, 2017). While the number of people affected by this incident was far less in comparison with the terrorist attacks of 9/11, it is still considered a mass casualty event because of the multitude of people affected, along with the potential for producing multiple deaths. It was not only an emergency-type “act of terrorism” as defined by FEMA, but it also involved mass casualties (which includes both injuries and deaths) as identified by the CDC. National Security Risks A national security risk is outlined by four specific actions: 1) The agent used must be easily disseminated or transmitted by humans; 2) the result involves significant death rates, pointing toward a major public health impact; 3) the act causes public panic; and 4) the resulting incident requires public health preparedness and response in a specified manner. Both terrorism and bioterrorism constitute a national security risk. See Spotlight on Public Health Figures to learn more about one vice president’s role following the September 11, 2001, terrorist attacks. Spotlight on Public Health Figures: Dick Cheney (b. 1941) Former Vice President Dick Cheney speaking at a conference in Washington on February 10, 2011. Alex Brandon/Associated Press While serving as vice president, Dick Cheney played a pivotal role in national security after the September 11, 2001, terrorist attacks in New York City. Click each of the questions provided to learn more about Dick Cheney. Who is Dick Cheney? Dick Cheney was born in 1941 in Nebraska to agricultural parents. Cheney attended Yale University on a full scholarship but dropped out due to poor grades. He eventually graduated with bachelor’s and master’s degrees in political science from the University of Wyoming. He began his political career in the Wyoming Senate. His family’s political positioning was aligned with the Democratic Party, yet he eventually transitioned to a conservative viewpoint and later declared his affiliation with the Republican Party. What was the political climate at the time? Cheney was 4 years old when World War II ended. He was alive during the Korean and Vietnam wars and many other international conflicts in the mid- to late 20th century. During his tenure in politics, the nation was plagued by heightened tension between Middle East regimes and the United States. This was the era of Saddam Hussein and Operation Desert Storm against Iraq. There were numerous terrorist attacks on United States soil: the 1993 World Trade Center bombings in New York; the 1993 Central Intelligence Agency bombing in Langley, Virginia; the 1995 Oklahoma City bombing; and the 1996 Olympic bombing in Atlanta. Furthermore, the House of Representatives impeached President Bill Clinton in 1998, and the 1999 trial before the Senate forced Americans to question the political ethics of the government. At the turn of the new century, the nation suffered the deadliest terrorist attack on American soil: the suicide flights that crashed into the World Trade Center towers, reducing them to a pile of debris on the ground of central New York City. It was an extremely turbulent time in politics and international affairs, punctuated by the resulting crumbling economy that followed these events. What was his contribution to public health? Cheney served as vice president during the first George W. Bush administration, which was in leadership during the attacks of September 11, 2001. While Cheney was a high-ranking political figure, it was his role in national security that separated him from other vice presidents in history. In an effort to restore international relationships and repair damage allegedly done by past administrations, he built a national security team that was larger than that of any other administration. After the development of a national security team, the vice president was managing one of the largest staffs in the government. Cheney’s leadership raised national security standards, and following the attacks of 9/11, the nation was well positioned to tackle the ever-increasing terrorism and bioterrorism issues that ensued. What motivated him? Political analysts and historians speculate that Cheney’s dissatisfaction with the “ivory tower,” or academic, way of thinking motivated him. During his college years, he witnessed many protests and believed that many of those people did not even understand the issues they were protesting. It was his belief that people joined protests just to get involved, not because they knew the full purpose of the protest. He felt he could advocate for the people for the right reasons. Cheney believed that advocacy should be used for a distinct purpose—a key point. For that reason, he was successful in effecting change. Some have noted that Cheney was willing to use his position and power to get things done, and that he was not worried about the political consequences of his actions. He was driven, never apologizing for his actions nor removing himself from the controversy. Sources: Biography.com. (n.d.-a). Dick Cheney biography. Retrieved from https://www.biography.com/people/dick-cheney-9246063 Council on Foreign Relations. (2008). Presidents and the National Security Council. Retrieved from https://www.cfr.org/interview/presidents-and-national-security-council Dreyfuss, R. (2006). Vice squad. Retrieved from http://prospect.org/article/vice-squad-0 Gale Group. (2003). The 1990s government, politics, and law: Overview. Retrieved from https://www.encyclopedia.com/social-sciences/culture-magazines/1990s-government-politics-and-law-overview Terrorism Terrorism is an act of violence against innocent civilians or unarmed groups/individuals by national, secretive, or undercover groups (United States Code, 2005). International terrorism involves the citizens of more than one country, and a terrorist group is any group that practices international terrorism. While the present decade is experiencing terrorism through radical Muslim, Islamist, ISIS, and al-Qaeda terrorist groups, the United States has seen other groups come and go over the past two centuries. These groups include the Ku Klux Klan, pro-slavery groups, Jewish extremists, leftist militants, Black militants, Puerto Rican nationalists, Palestinian militants, and many others. Figure 7.2 shows that acts of terrorism have increased steadily over the years, with a sharp incline from the 1950s to the 1980s. This in part reflects improved surveillance. It is possible that more terrorism occurred prior to the 1950s but is not reflected here because of lack of quality surveillance. The United States has seen 70 confirmed acts of terrorism from 2010 to 2018, and that number is likely to increase further. Figure 7.2: Confirmed acts of terror in the United States, 1800s–2010s The number of terrorism acts within the United States has dramatically increased since the 1800s. This increase in action is what has prompted stronger emergency preparedness and response protocols for both terrorism and bioterrorism acts. Line graph depicting the number of confirmed acts of terror between 1800 and 1899 and then for each decade from 1900 to 2010. After the 1950s, the numbers jump from single- to double-digit numbers. While there were only four confirmed acts for the 1800s (a span of 99 years), there were a total of 70 confirmed acts during the 2010s (a span of 10 years). Source: Data from “Terrorist Attacks and Related Incidents in the United States,” by Johnston Archives, 2017 (http://www.johnstonsarchive.net/terrorism/wrjp255a.html). Terrorism, both domestic and international, has occurred in the United States for centuries. Recent news reports of various activities over the last decade have brought this type of emergency to the public’s eye. However, it is important to recognize that these acts of terrorism occurred as long ago as 1837 (Resnick, 2013). Table 7.3 lists some of the major acts of terrorism in the United States. Table 7.3: Terrorism in the United States, 1800–2017 The static table has been replaced by an interactive timeline. Bioterrorism Bioterrorism is terrorism using agents and organisms that pose a risk to human life, thus also posing a national security risk. FEMA (2008) has identified this type of threat as nuclear, conventional, chemical, or biological warfare. The CDC (2018a) considers bioterrorism to be terrorism with the use of biological agents and/or diseases such as anthrax or smallpox. The 2001 anthrax attacks following the terrorist attacks on 9/11 were considered this type of an emergency (Higgins et al., 2003). Other such emergencies on American land include the Revolutionary War (mainly along the East Coast states), the Civil War (nearly the entire nation), and World War II (Hawaii and the attack on Pearl Harbor). For example, during the American Civil War, one side would intentionally pollute wells and other water sources used by the opposition with animal carcasses or similar contagions to weaken the enemy and gain an advantage (Riedel, 2004). There have not been many of these attacks, especially bioterrorism events, in the United States in recent history. Bioterrorism agents can be sorted into three categories, by toxicity levels: Category A agents constitute a national security risk because they fall under all four specified actions that define a national security risk. Category B agents are second in priority and are not nearly as deadly, although they can result in moderately increased disease acquisition among the human population. Category C agents could cause an emerging infectious disease that has the potential for high deaths. Large quantities of biological agents can sicken and kill a population quickly. Funding for bioterrorism surveillance has greatly increased, and the last publicized case of such an act was in 2013. Ongoing efforts to reduce and respond to bioterrorist attacks has remained a priority since the start of the 21st century (Grundmann, 2014). Table 7.4 provides details on the most notable bioterrorist attacks in the United States. Table 7.4: Bioterrorism in the United States Year(s) Incident Terrorist/terrorist group 1970s Alphabet Bomber & Chemical Warfare: Muharem Kurbegovic sent toxic chemicals through the mail to a Supreme Court justice and threatened to use nerve gas at the Capitol and against the president. This was before the bombing in 1974 (Anti-Defamation League, 2005). Antigovernment; Yugoslavian-born terrorist 1972 Chicago Water Supply Thwarted Attack: Two college students, Allen Schwander and Stephen Pera, planned to poison the city’s water supply with typhoid and other bacteria (Anti-Defamation League, 2005). R.I.S.E. (acronym undefined) 1984 Rajneeshee Bioterror Attack: The Rajneeshee movement infected salad bars with Salmonella in 10 Dalles, Oregon, restaurants; 751 people were sickened, 40 hospitalized (Klietmann & Ruoff, 2001). Rajneeshee terrorist group 2001 Anthrax Attacks: Infected letters were mailed to media and congressional offices by biologist Bruce Ivins, who was attempting to bring attention to his anthrax vaccine program (Higgins et al., 2003). No group affiliation 2013 Ricin Attacks: Actress Shannon Guess Richardson sent letters laced with ricin to President Barack Obama, Senator Roger Wicker (R-Miss.), and a judge in Lee County, Mississippi (Ward, 2013). Richardson had intended to implicate her estranged husband, with whom she was embattled in divorce proceedings, in the crime. No group affiliation Energy and Material Shortages FEMA identifies energy and material shortages as a unique emergency type, whereas the CDC does not list them among its emergencies. These situations include strikes, price wars, labor problems, and resource scarcities. A good example of this type of emergency occurred in the 1970s when gasoline shortages struck the nation. The Federal Power Commission had the authority to regulate the prices of natural gas sold to interstate pipeline companies (Breyer & MacAvoy, 1973). The price wars prompted a nationwide gasoline shortage in both 1973 and 1979, causing long lines at the pump and product rationing. Interestingly, the maximum speed limit was reduced to 55 mph to conserve gas, and, in order to further cut energy consumption, daylight saving time was introduced beginning in 1974 (Myre, 2012). Because of the Arab oil embargo, President Richard Nixon signed the Emergency Daylight Saving Time Energy Conservation Act of 1973 into law, in an effort to conserve energy during the winter months (American Presidency Project, 2018). It was estimated to save an equivalent of 150,000 barrels of oil a day (American Presidency Project, 2018). The hope was that by adding more hours of light each day, consumption of electricity for lamps and even stereos would drop. An early report from the United States Department of Transportation found that national electricity usage dropped by about 1% during daylight saving time (Harris, 2018). Recent Outbreaks and Incidents The CDC identifies outbreaks when various diseases occur more often than expected. An example of a recent outbreak was the 2010 outbreak of Salmonella from infected eggs distributed across 14 states: Arkansas, California, Illinois, Indiana, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Texas, and Wisconsin (CDC, 2018a). The outbreak started on May 1 and ran through November 30, infecting approximately 2,000 people with Salmonella. Epidemiologists investigated reports of illnesses in 11 states and identified 29 different restaurants that had served the infected eggs, which were traced back to two Iowa farms: Wright County Egg of Galt, Iowa, and Hillandale Farms of New Hampton, Iowa (CDC, 2018a). It also classifies hurricanes as incidents in this category, as well as in the natural disasters section. 7.3 Public Health Core Functions and NIMS Various agencies at all levels of government play a role in emergency response and preparedness. While each agency has a specific role, they all work under the same grand schematic outlined by the Department of Homeland Security. Core Functions Public health organizations’ key functions are assessment, policy development, and assurance. In the public health role of emergency preparedness, these three elements are intertwined with the 10 essential public health services (Chapter 2), which provide the foundation to maintain the health and safety of the nation’s population: Monitor health status to identify and solve community health problems. Under this service, emergency response teams across government and nongovernmental agencies monitor the activities surrounding potential harms to the United States. The harms under surveillance include threats of terrorism, as well as weather and natural disasters. For example, the Food and Drug Administration is charged with ensuring that the food supply is not only safe from bioterrorism threats but also grown free of disease and safely prepared for distribution. Manmade crises—such as explosions or oil spills—are also protected under public health monitoring systems. Through the Occupational Safety and Health Administration, regular monitoring of safe conditions at various worksites maintains the health of not only employees but also the local community (U.S. Department of Labor, n.d.). Diagnose and investigate health problems and health hazards in the community. The most common example of diagnosing and investigating community health is through the annual influenza tracking system. The CDC tracks and investigates disease outbreaks, maps areas of high risk, and provides vaccines for protection. In the event of a bioterrorism attack, the CDC’s role is the same, but it performs emergency actions. It investigates the toxic pathogen and works quickly to secure an antidote (CDC, 2017z). For example, the CDC maintains a stockpile of vaccines against smallpox, known to be a possible bioterrorism weapon. This essential service is considered part of the assessment role provided by public health. Through diagnosing the scope of a disaster, as well as investigating the health issues surrounding the disaster, public health officials tap into their role of assessment. A woman reading a newspaper warning of the anthrax attacks in New York City, October 13, 2001. David LeFranc/Gamma-Rapho/Getty Images Communication efforts are one of the CDC’s chief concerns in an emergency situation. Consistent, measured feedback is necessary to keep the public calm and informed. Inform, educate, and empower people about health issues. Obtaining information and communicating it effectively during a crisis is crucial. People have an urgent need to know what is going on in the midst of a crisis, and a lack of knowledge could cause widespread panic. To combat this, the CDC sets up a command center specifically in times of crises (Courtney et al., 2003). Risk communications in times of crisis fall on a short timeline. The goal is to accurately inform, to avoid panic, and to protect the people and not interfere with the investigation. In the event of a terrorist attack, the nation’s public communication systems are monitored. Too much information could breach the nation’s security, but too little information could cause mass panic. The job of informing and educating during emergency times is difficult, but the CDC has solid protocols in place to provide necessary information to protect the public (Courtney et al., 2003). Those communications vary depending on the emergency. For example, during the 2001 anthrax attacks, the CDC managed communications efforts, receiving nearly 800 inquiries from news reporters that week (Robinson & Newstetter, 2003). In the following month, the CDC handled an average of 900 calls from the media for updates (Robinson & Newstetter, 2003). One of the nation’s most well-known surgeons general was a superb communicator in times of potential panic. While not associated with a specific terrorist or physical disaster, C. Everett Koop was a master of communication strategies during the AIDS/HIV scare. (See Spotlight on Public Health Figures for more about Koop’s work.) Mobilize community partnerships and action to identify and solve health problems. In the event of an emergency, teams are dispatched not only to provide communications support but also for epidemiological support for investigative purposes. Remember, epidemiology is the science that studies the determinants of health among a population. One of the CDC’s primary functions during emergencies involves distributing public health resources. In the 2001 anthrax scares, the CDC sent teams of medical personnel and epidemiologists to the scene, along with supplies of vaccines and other medical resources to assist with the crisis (Malecki et al., 2001; Polyak et al., 2002). Develop policies and plans that support individual and community health efforts. Emergencies often require quick thinking. Sometimes, protocols must adapt to the crisis at hand, which was the case for the anthrax scare of 2001. Several work practices were reevaluated and staff roles redefined at the CDC following the anthrax attacks (Robinson & Newstetter, 2003). This example reflects this particular public health service in action, as it prompted the development or revision of policies. Policies are often developed because of poor responses or failed attempts at successful emergency preparedness. This essential service is considered part of the policy development role of public health. Through modifications of plans and the development of new and improved policies following disasters, public health officials fulfill their role as policy developers. Enforce laws and regulations that protect health and ensure safety. The lead agency in national emergencies is the Office of Homeland Security. The public’s health is the most important focus of this agency. Through the laws and regulations set forth under the rules of the Stafford Act, the public’s health and safety is protected (FEMA, 2007). An example of enforcement activities could be seen during the Boston Marathon bombings in 2013. The Office of Homeland Security took charge of the incident, utilizing agents from the FBI to coordinate the activities. One of the two men accused of the attack was arrested under the rules and regulations of the FBI, working in conjunction with Homeland Security agents. (The other was killed in a shootout with police.) Link people to needed personal health services and assure the provision of health care when otherwise unavailable. This works in conjunction with the fourth public health service, mobilizing teams into action. The CDC, along with state and local health agencies, ensures that medical help and other services are accessible and available during an emergency (Malecki et al., 2001; Polyak et al., 2002). Assure competent public and personal health care workforce. Public health agencies (particularly the CDC) require extensive training of their workforce (Courtney et al., 2003). Practice exercises and mock drills help assure the public that personnel will be ready and able to handle most crises—at the state and national levels (Courtney et al., 2003; Robinson & Newstetter, 2003). Because of this commitment to training, the CDC and other public health agencies that are dispatched during an emergency will be competent in their crisis responsibilities. The most recent training course developed by the CDC is known as CDCynergy, a communications-specific course that teaches emergency responders how to prepare for crisis communications (CDC, 2010). Furthermore, the CDC routinely offers online or onsite training relating to various emergencies, such as risk management, emergency preparedness, and law and ethics during emergencies (CDC, 2018a). This essential service is part of the assessment role provided by public health services. Building a competent team of public health professionals—particularly adept in emergency services—fulfills public health’s third main function, assurance. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Evaluation is an important part of public and community health. Whether developing a program, assessing needs, or responding to an emergency, public health officials must evaluate how to serve the public in the most effective manner. In emergencies, the evaluation takes place following the crisis or mock exercise. In most cases, lessons learned from past events inform future responses (Robinson & Newstetter, 2003). This evaluation provides feedback and support for the changes or development of policies to improve public health’s effectiveness. Research for new insights and innovative solutions to health problems. As mentioned earlier, the Office of Counterterrorism and Emerging Threats (OCET), operating under the FDA, facilitates the development of safe and effective medical countermeasures in the event of a terrorist or bioterrorist attack (U.S. FDA, 2017). The FDA has extensive research facilities where it focuses on countering acts of terrorism. The Department of Homeland Security is also researching new insights and solutions to combat terrorism. OSHA and FEMA continuously aim for improvements and new methods for coordinating response and relief efforts (FEMA, 2008; U.S. Department of Homeland Security, n.d.; U.S. Department of Labor, n.d.). Spotlight on Public Health Figures: C. Everett Koop (1916–2013) C. Everett Koop speaking at a committee meeting in Montpelier, Vermont, on November 10, 1997. Toby Talbot/Associated Press C. Everett Koop was the 13th U.S. surgeon general and published a report about the first cases of AIDS in 1986. Click each of the questions provided to learn more about C. Everett Koop. Who is C. Everett Koop? Charles Everett Koop was born in 1916 as the only child of a banker and business manager. He was a self-proclaimed "oddball" (U.S. National Library of Medicine, n.d.-b, para. 2), mainly because he had no desire to be with his school-aged peers. He spent the majority of his time with extended family, with whom he was very close. His family encouraged his desire to become a doctor, primarily a surgeon. He was fascinated with the various instruments he saw in his own doctor’s office and longed to use them himself. He earned his medical degree from Cornell Medical College and eventually served as surgeon-in-chief at Children’s Hospital in Philadelphia. His work in public health began when he was confirmed as the 13th U.S. surgeon general in 1981. He lived until the age of 96. What was the political climate at the time? The 1900s ushered in a time of political unrest in the United States. Koop was born during World War I and lived through World War II, the Korean War, and the Vietnam War. He survived the Great Depression and saw the resurgence of the economy after Roosevelt's new policies. During his life, the discovery of a newly infectious disease stymied the nation: acquired immune deficiency syndrome. HIV/AIDS guided Koop to the various political activities he is best known for during his time as surgeon general. What was his contribution to public health? Koop became the 13th U.S. surgeon general around the same time that the Centers for Disease Control reported the first cases of a new disease known as AIDS. His greatest accomplishment in this area was the 1986 publication of "The Surgeon General's Report on Acquired Immune Deficiency Syndrome." He was the first federal authority to provide evidence-based advice on how Americans could protect themselves against this deadly virus. Beyond this report, he developed a national mailer as an emergency preparedness effort. Titled "Understanding AIDS," it was sent to every household in the United States to explain AIDS, how it was contracted, and how it could be prevented. Millions were sent via postal service (as email and social marketing were not available in the 1980s) to the nation's residents. This public health education is significant because the nation’s population was struggling to understand the disease, and it helped to quell widespread panic. Rarely have national mailing campaigns been as successful. What motivated him? It is unknown if there was one particular motivating force that led Koop toward tackling a public health crisis. His interest in surgical instruments led him down the path of becoming a surgeon, but his work as the U.S. surgeon general was likely encouraged through the eyes of his nominator: President Ronald Reagan. Reagan saw how Koop had devoted his career to treating individuals and felt he could expand his knowledge to work on improving the health of the nation. Koop resigned from the U.S. surgeon general position in 1989 after serving two terms and went back to work with children and the National Safe Kids Campaign. Sources: Koop, C. E. (1988). Understanding AIDS. Retrieved from https://profiles.nlm.nih.gov/ps/access/qqbdrl.pdf U.S. National Library of Medicine. (n.d.-b). The C. Everett Koop papers. Retrieved from https://profiles.nlm.nih.gov/ps/retrieve/Narrative/QQ/p-nid/84 The National Incident Management System (NIMS) The National Incident Management System (NIMS) is considered one of the world’s leading management systems for monitoring and protecting populations. NIMS was originally issued on March 1, 2004, by the Department of Homeland Security to provide consistent management across all governments during emergencies of a national scope (U.S. Department of Homeland Security, 2008). Throughout its use in times of disaster, it has undergone numerous revisions for clarification, enhancements, and improved response. The most recent document revision was approved in 2008 and includes additional details on eliminating redundancy, expanding intelligence roles, clarifying the role of the incident command system (ICS), and emphasizing teamwork among all agencies (government and nongovernment) for the benefit of the general public (U.S. Department of Homeland Security, 2008). NIMS is a proactive approach to guide all emergency crews—public and private—in an effective manner. The United States Department of Homeland Security (2008) has defined the system as a means of working “seamlessly to prevent, protect against, respond to, recover from, and mitigate the effects of incidents, regardless of cause, size, location, or complexity” (p. 13). NIMS provides the specific processes that incident management personnel must follow. Refer to Table 7.5 for an overview of the system. Table 7.5: Overview of NIMS What NIMS is What NIMS is not A comprehensive, nationwide, systematic approach to incident management, including the incident command system, multiagency coordination systems, and public information A response plan A set of preparedness concepts and principles for all hazards Only the incident command system or an organization chart Essential principles for a common operating picture and interoperability of communications and information management A communications plan Standardized resource management procedures that enable coordination among different jurisdictions or organizations Only applicable to certain emergency management/incident response personnel Scalable, so it may be used for all incidents (from day-to-day to large-scale) Only used during large-scale incidents A dynamic system that promotes ongoing management and maintenance A static system Source: From National Incident Management System, by United States Department of Homeland Security, 2008, Washington, DC: FEMA Publications, Catalog Number 08336-1. The system was built following the 9/11 attacks as part of the responsibilities of national protection. While the response to 9/11 was never condemned, behind-the-scenes incidents prompted the need for a significant strategic system to guide emergency workers and volunteers during times of disasters. This coordination involves both private and public organizations, as well as governmental agencies that respond to emergencies. Unfortunately, when put into action, the system failed miserably, as noted after Hurricane Katrina. See Case Study: Hurricane Katrina: A NIMS Failure. NIMS contains five main components: preparedness, communications and information management, resource management, command and management, and ongoing management and maintenance (U.S. DHS, 2008). Component 1: Preparedness. This describes the measures that should be developed and incorporated into preparedness programs to enhance overall preparedness for all response activities. This component is aimed at organizations such as fire and police departments, public health entities, governmental agencies, and businesses and corporations for emergencies and focuses on national policy to identify and prioritize critical infrastructure and key resources to prevent and mitigate the effects of emergencies. Component 2: Communications and Information Management. This focuses on the application of flexible communications and information systems that will work seamlessly during an emergency. It stresses the development of procedures that are interoperable, reliable, scalable, portable, and resilient. The system recommends that communities build an emergency communications system that gathers all necessary information (traffic, weather, damage, resources, etc.) for decision-making and public dissemination. Component 3: Resource Management. Effective deployment of personnel and supplies is necessary in times of emergency, and managing the distribution of such resources requires proper planning to be quick and efficient for the public’s health and safety. Such resources include medical supplies and vaccines, as well as basic survival items such as food and water. Systems need to be in place to manage these resources in the event of a disaster, from the local level to the national scene. National resources include transportation, medical care, search and rescue, food and water, energy, animal and agricultural issues, and volunteers and donations. Component 4: Command and Management. Not every person can be in charge, so it is critical to develop a command and management center at the local, state, and national levels. This component provides the basis for establishing an incident command system (ICS). An ICS is much like an organizational chart, detailing which entity reports to which. Within each entity is another organizational chart that lists the chain of command. The president of United States leads the largest national emergencies. At the local level, that person could be the mayor, fire chief, or whoever is designated by the emergency plan. The ICS design is based on 14 management characteristics: common terminology, modular organization, management by objectives, incident action planning, manageable span of control, incident facilities and locations, comprehensive resource management, integrated communications, establishment and transfer of command, chain of command/unity of command, unified command, accountability, dispatch/deployment, and information/intelligence management. Component 5: Ongoing Management and Maintenance. This component focuses on two sections, the National Integration Center (NIC) and Supporting Technologies. The NIC was established to provide ongoing management and maintenance for NIMS. The NIC is responsible for collecting and analyzing all potential revisions to NIMS and also for leading the development of training and exercises to enhance NIMS’s overall effectiveness. Supporting Technologies focuses on research and development of the various science practices and technologies that may enhance and improve NIMS. This includes improvements in communications, monitoring, response, and mitigation. Case Study: Hurricane Katrina: A NIMS Failure The view from a U.S. Air Force helicopter flying over flooding caused by Hurricane Katrina. Air Force Public Domain/SuperStock The effects of Hurricane Katrina tested the nation’s ability to manage emergency response efforts between state and federal agencies. One year after its implementation, NIMS was tested under the disaster area left behind due to Hurricane Katrina. Storm Overview The weather system first developed over the Bahamas as a tropical storm on August 24, 2005. The National Weather Climate Data Center, a branch of the National Oceanic and Atmospheric Administration (NOAA), had predicted the storm would become a major hurricane and make landfall in the central part of the Gulf of Mexico. On August 25, the system became a Category 1 hurricane, with sustained winds of 74 miles per hour. It crossed over the southern tip of Florida with wind speeds at 80 mph. The next day, Katrina became a Category 3 hurricane with sustained winds of 125 mph. It continued to strengthen as it moved over the warm waters of the Gulf. As the system moved through the Gulf, it grew into a Category 5 hurricane (the highest category on the Saffir–Simpson scale, with sustained winds of at least 170 mph). Eventually, the hurricane dropped back to a Category 3 before it struck the shores of the Gulf Coast over New Orleans. For at least a day before making landfall, the storm’s rain and winds were felt across the Gulf Coast from the panhandle of Florida to the southwestern coastal areas in Louisiana. Katrina made landfall on Monday, August 29. More than an inch of rain per hour fell for 3 consecutive hours; it slowed to a half-inch per hour for the next 5 hours. It was estimated that more than 10 inches of rain fell over southeastern Louisiana and southwestern Mississippi during the course of the storm as it approached, made landfall, and retreated up the mid-Atlantic states. Actual Disaster Management When the system became a Category 1 hurricane, FEMA mandated an evacuation of several coastal areas in Louisiana. That same day, Louisiana Governor Kathleen Blanco called on 4,000 National Guard troops to assist. The following day, all of New Orleans was alerted to a mandatory evacuation. Also, the Superdome (the stadium that is home to the New Orleans Saints pro football team) became an emergency shelter for those who either had no means of evacuating or refused to leave. It was estimated that approximately 22% (about 100,000 people) of the 458,000 New Orleans population did not evacuate, with about 20% of those 100,000 people relocating to the Superdome. The remaining 80% stayed in their homes or other locations. At the Superdome: Generators allowed limited lighting of the arena, but there were no other amenities. With no operational restrooms or subsequent alternatives, the facility quickly overflowed with human urine, feces, and garbage. There was no food, water, or medical supplies. At the Convention Center: Emergency crews rescued stranded residents from rooftops and attics, transporting them to the center. The Convention Center also lacked water, food, medicines, and utilities. Eventually, conditions at the Center became similar to conditions at the Superdome. In hospitals and nursing homes: Patients and staff members were stranded without power or other vital services. Conditions were grim as places ran out of food, water, and medicine. On the streets: New Orleans looked like a war zone, only not from gunfire or explosions but from flooding and high winds. Dead bodies floated down flooded streets. Many people drowned at home because they were too frail to evacuate or move to higher ground. Bodies were found drowned in attics, the highest place to which people could escape. As a result of a failure/inability to evacuate, one nursing home lost 35 elderly patients. At the Houston Astrodome: As conditions were obviously uninhabitable at both the Convention Center and the Superdome, Houston opened its doors to evacuees 5 days after the hurricane hit. By the end of the day on September 3, both facilities in New Orleans were evacuated to Houston. NIMS Failure The true test of the system, which looked effective on paper, occurred during Katrina. One of the most dominating features of the failure occurred mid-crisis, when NIMS inadequately handled leadership and authority concerns. Sometime during the search and rescue, operations halted because the federal government stepped in to take control. At that time, the states and local parishes were well organized in their recovery efforts and did not see the need to relinquish control. As a result, disaster relief and recovery efforts came to an abrupt halt until the “who’s in charge” question was addressed. The federal government had claimed prime authority over the disaster, stating that it presented a threat to national security. Once authority was lost, states would have a difficult time regaining control, and hence the battle for situational control began. While it should have provided guidance on authority lines as well as chain-of-command procedures, NIMS did not address these issues. It had suggested that collaboration should be employed in times of emergencies but did not outline the best practices. Historically, states and local governments had taken care of their own in times of disaster effectively—with aid and assistance through the federal government, not overall control. Research on the NIMS system found that this lack of leadership left the wounded city of New Orleans in the aftermath of the devastation longer than necessary. This significant NIMS shortfall is likely what caused the slowing of rescue and recovery operations; inadequate food, water, and medical supplies for those sheltered in the Superdome and the Convention Center; and the sanitation deficiencies at all shelter locations. While the 2004 NIMS document called for a unified command with joint decision-making, these concepts were either ignored or avoided during Katrina. It was the mass public, those who were to be protected, that suffered, with thousands dying and even more wounded and sick. Although this gross negligence of joint leadership hurt the people within the city of New Orleans, it was also the impetus to prompt significant changes to NIMS. According to Lester and Krejci, “NIMS has the potential to become an effective vehicle for promoting the change necessary within the collaborating organizations. NIMS can help provide an environment that stresses common interests and training toward truly collaborative decision making” (2007, p. 87). Sources: National Oceanic and Atmospheric Administration. (2005b). Hurricanes and tropical storms – August 2005. Retrieved from https://www.ncdc.noaa.gov/sotc/tropical-cyclones/200508 Brinkley, D. (2006). The great deluge: Hurricane Katrina, New Orleans, and the Mississippi Gulf Coast. New York, NY: William Morrow/HarperCollins. Lester, W., & Krejci, D. (2007). Business “not” as usual: The National Incident Management System, federalism, and leadership. Public Administration Review, 67(Suppl. 1), 84–93. 7.4 Emergency Response and Preparedness In addition to the core functions of public health, the emergency response teams also follow eight key principles and strive for accreditation, which provides a federal “nod of approval” that an organization or entity is prepared and willing to act in the event of an emergency. This section reviews the past and current alert system for terrorism attacks, which emergency response teams must understand as they prepare for such disasters. FEMA representatives survey damages on a street in Duryea, Pennsylvania, after floods caused by Tropical Storm Lee in September 2011. Alex Brandon/Associated Press FEMA focuses on emergency preparation, management, response, and recovery at every level. Training programs help individuals learn how to successfully respond to disasters, such as the floods caused by Tropical Storm Lee. FEMA provides extensive details on handling emergencies at every level, from the individual to the federal government. Some of the key benefits of such training is empowering individuals—emergency management personnel, communities, and organizations—to develop an emergency response and preparedness plan, the best defense for tackling disasters. While NIMS is a best practice system that is utilized by national, state, and local governments, its foundations came through FEMA training programs, including the independent study course “Fundamentals of Emergency Management” (FEMA, 2018). One of the most critical pieces of managing an emergency revolves around the planning for one. FEMA (or the role of FEMA) has existed for more than two centuries, evolving into the nation’s most knowledgeable entity on emergency preparation, management, response, and recovery. This section will present the principles of emergency management along with the importance of accreditation for emergency management agencies. Eight Principles of Emergency Management In 2007, FEMA’s Emergency Management Institute’s Higher Education Project agreed upon eight specific principles for emergency management that are now used to develop a doctrine for emergency management personnel. Principle 1: Comprehensive The International Association of Emergency Managers (IAEM) (2007) has noted that understanding all types of emergencies will help agencies better prepare for what damages and harms could occur. This consists of four specific components: hazards, phases, impacts, and stakeholders. All hazards must be reviewed and treated independently, including biohazards, natural harms, and terrorism: “Treating all hazards the same in terms of planning resource allocation ultimately leads to failure” (IAEM, 2007, p. 5). The four comprehension phases are mitigation, preparedness, response, and recovery (IAEM, 2007). Emergency managers must review not only human impact, but also environmental and infrastructure impact. Key stakeholders include the emergency response teams and agencies as well as potentially affected businesses, individuals, and the general public. Principle 2: Progressive Research and disaster surveillance has shown that disasters are becoming more frequent and common (IAEM, 2007). Emergency preparedness and response must not remain stagnant in its preparations and response. Continuous planning, drills, and exercises will enable disaster response to be progressive rather than reactive moving forward. As an example, climate change includes warmer, wetter weather and unstable atmospheric pressure (Bergholt & Lujala, 2012). Some researchers believe that the rising temperatures and volatile atmospheric conditions are directly related to increasing storm severity and frequency in hurricanes, floods, and fires (Bergholt & Lujala, 2012). Principle 3: Risk-Driven Every community in the United States has a different risk level. For urban areas, the risks are greater for human life and infrastructure; in rural areas, the risks are greater for agriculture and environment. Regardless of the risk, emergency management preparedness personnel must review and understand the risks across the nation. This requires setting policies and priorities that are based upon threats to lives, property, and the environment (IAEM, 2007). Principle 4: Integrated Integration aligns the goals and objectives of response among all emergency responders, the communities, and the stakeholders. According to the IAEM (2007), “Unity of effort is dependent on both vertical and horizontal integration” (p. 6). In brief, local emergency response programs must be aligned with the state, and state programs must be aligned with federal programs. When all local programs are integrated within a community, this is known as horizontal integration. When local, state, and federal integrate, this is known as vertical integration. Full integration will provide increased protection and quicker recovery efforts in the event of an emergency because every responder will understand his or her role in an emergency. Principle 5: Collaborative Collaboration works in conjunction with integration in that individuals, local governments, state governments, and federal emergency management personnel work together and succinctly for one purpose: to mitigate the emergency and assist those affected by it as defined by their specific role. This approach ensures a smooth transition from the status quo to optimal emergency response. The best advice for this principle can be summed up by a statement from Michael D. Selves in an oral testimony before the United States House Subcommittee on Emergency Management of the Committee on Transportation and Infrastructure: “If we shake hands before a disaster, we won’t have to point fingers afterwards” (IAEM, 2007, p. 8). Principle 6: Coordinated All activities surrounding emergency response and planning must be synchronized at all levels to ensure a smooth outcome (IAEM, 2007). This involves elements including planning, response, recovery, and communications. Principle 7: Flexible With the increased number and types of disasters occurring in the United States, all emergency management teams must be flexible in their plans and responses. The most obvious phase for flexibility comes with response (IAEM, 2007). Responding to natural disasters, such as hurricanes and tornadoes, requires a certain type of organization; responding to a terrorist attack of unknown proportions requires team flexibility as information becomes available. Principle 8: Professional This principle points toward acting and responding in a professional manner before, during, and after an emergency. It focuses on five key elements: code of ethics, professional associations, board certification, specialized body of knowledge, and standards and best practices. The IAEM (2007) stresses each of these elements for emergency management personnel in its training programs. Emergency Management Accreditation Program (EMAP) The Emergency Management Accreditation Program (EMAP) provides the fundamentals of emergency management. This program offers standards for processes used in emergencies such as prevention, mitigation, preparedness, response, and recovery (EMAP, 2017). It also provides accreditation to organizations (such as fire departments, hazardous materials teams, police departments, and health departments) operating with a set of standards that have been developed as best practices for preparing for and responding to disasters. Through this accreditation process, emergency management groups can focus on the same principles, making collaboration and cooperation more evident in the event of a disaster. These standards for accreditation address the following areas: Program management Administration and finance Laws and authorities Hazard identification, risk assessment, and consequence analysis Hazard mitigation Prevention and security Planning Incident management Resource management and logistics Mutual aid Communications and warning Operations and procedures Facilities Training Exercises, evaluations, and corrective action Crisis communications, public education, and information (EMAP, 2017) The Department of Homeland Security Advisory System (2002–2011) Former Homeland Security Chief Tom Ridge explaining the DHS Advisory System on March 12, 2002. AFP/Getty Images Former Homeland Security Chief Tom Ridge explains the DHS Advisory System on March 12, 2002. The five levels were replaced by a three-level system in 2011 to provide a more clear-cut feedback mechanism to the public. To easily and quickly disseminate information about threats or a risk of a threat to all levels of government and to the American people, the United States Department of Homeland Security (n.d.) devised a color-coded system of alerts known as the DHS Advisory System. Established in March 2002, the alert system provided a unified message for evaluating conditions of threats or potential dangers: Green—Low: This level indicated there were no imminent threats to the nation. For Homeland Security personnel, it meant that training and protective planning continued as usual. Blue—Guarded: This level showed a general risk of a terrorist attack. It indicated that emergency response procedures should be updated and reviewed. Public communications were outlined and utilized as necessary. Yellow—Elevated: This indicated that there was a significant risk of a terrorist attack and surveillance of critical locations would increase along with implementing emergency response plans, when necessary. Orange—High: This level indicated a high risk of terrorist attacks. Security efforts with the military and law enforcement would ensue, and preparations for relocation of citizens would commence. Red—Severe: This indicated a severe risk of a terrorist attack and that NIMS would be put into effect. This included dispatching emergency response teams to specific sites as well as closing public and government facilities and working to address critical emergency needs such as medical aid. After 2011, the system became known as the National Terrorism Advisory System (NTAS). The National Terrorism Advisory System (2011–Present) On April 20, 2011, Secretary of Homeland Security Janet Napolitano announced that the National Terrorism Advisory System (NTAS) had been revised to provide a more credible and clear mode of public communications on terrorism (U.S. Department of Homeland Security, n.d.). Rationale Behind the Changes The new system provides a more timely and effective means of alerting the public to credible terrorist threats by using only three specific levels rather than the five levels in the color-coded system. According to the Homeland Security Advisory Council’s Task Force on the advisory system, the color-coded system was confusing, as it was difficult to ascertain the differences between “guarded” at the blue level or “elevated” at the yellow level, and “high” at orange versus “severe” at red (Homeland Security Advisory Council, 2009). The task force noted in its report that “there is a disturbing lack of public confidence in the system” (Homeland Security Advisory Council, 2009, p. 2). The report also noted that in the post–9/11 era, there will never be a condition in the United States where the threat level will fall below “guarded” (Homeland Security Advisory Council, 2009). Thus, the norm is considered “guarded,” with three new levels being created whose meanings are clearly defined and outlined. The New Advisory System Because the United States will remain on “guarded” status under normal conditions, the Office of Homeland Security will issue an alert only when a threat is possible and credible. These alert levels are shown in Table 7.6. Table 7.6: New NTAS alert system Threat level Interpretation Imminent threat Warns of a credible, specific, and impending terrorist threat against the United States. This is the highest level in the new system and indicates that there is information on timing and location of the threat. Elevated threat alert Warns of a credible terrorist threat against the United States. This indicates there is a credible threat, but no specific information is available on timing or location. Sunset provision An individual threat alert is issued for a specific period and then automatically expires. It may be extended if new information becomes available or the threat evolves. Source: From “National Terrorism Advisory System,” by U.S. Department of Homeland Security, n.d. (https://www.dhs.gov/national-terrorism-advisory-system). The alerts will provide the public with a summary of the threat, information to help with public safety initiatives, and steps that communities and individuals should take to prevent or respond to the pending threat. It is important to note that some threats will be released only to law enforcement or areas that could be affected by the pending threat. Alerts are issued through state and local entities as well as the media and public broadcasting stations. In addition, the NTAS system posts its alerts on its website as well as two social media outlets: Facebook and Twitter (U.S. DHS, n.d.). Bioterrorism Preparedness There is not much difference for public health professionals in preparing for an emergency and preparing for bioterrorism. From the public health perspective, the preparedness for bioterrorism lies in ensuring the amount and availability of an antidote or vaccine. In addition, distribution methods are also part of this preparation. Biological Agents Besides blatant attacks on the United States as witnessed on 9/11, the United States still deals with biological agents that have turned into weapons, such as botulism, anthrax, and smallpox. These biological agents are highly toxic and, if spread in a large area, could easily annihilate a population. Enemy countries of the United States know this, and as a result, the nation is on alert for such bioterrorism weapons. Table 7.7 is a complete list of the specific agents the CDC has identified that could potentially harm the United States. Table 7.7: Bioterrorism agent categories Category A Agents that pose the highest national security risk Anthrax (Bacillus anthracis) Botulism (Clostridium botulinum toxin) Plague (Yersinia pestis) Smallpox (Variola major) Tularemia (Francisella tularensis) Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo]) Category B Agents that are second highest for national security risk Brucellosis (Brucella species) Epsilon toxin of Clostridium perfringens Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella) Glanders (Burkholderia mallei) Melioidosis (Burkholderia pseudomallei) Psittacosis (Chlamydia psittaci) Q fever (Coxiella burnetii) Ricin toxin from Ricinus communis (castor beans) Staphylococcal enterotoxin B Typhus fever (Rickettsia prowazekii) Viral encephalitis (alphaviruses, e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis) Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum) Category C Agents that are still potent but have the lowest priority Emerging infectious diseases such as Nipah virus and hantaviruses Source: From “Bioterrorism Agents/Diseases,” by Centers for Disease Control and Prevention, 2017b (https://emergency.cdc.gov/agent/agentlist-category.asp). Chemical Agents Like their biological counterparts, chemicals can also pose potential harm to human life and the environment. Table 7.8 offers a partial list of these agents. Table 7.8: Bioterrorism chemical agents Ammonia Arsenic Arsine (SA) Barium Benzene Bromine Bromobenzylcyanide (CA) (riot control agent) Carbon monoxide Chlorine (CL) Chloroacetophenone (CN) (riot control agent) Chlorobenzylidenemalononitrile (CS) (riot control agent) Chloropicrin (PS) (riot control agent) Chromium Cyanide Digitalis Distilled mustard (HD) Ethylene glycol Fentanyls and other opioids Hydrogen chloride Hydrogen cyanide (AC) Hydrogen fluoride (hydrofluoric acid) Mercury Mustard gas (H) Nicotine Nitrogen mustard Opioids Phosphorus—elemental, white, or yellow Potassium cyanide (KCN) Ricin Selenium Sodium cyanide (NaCN) Source: From “Bioterrorism Agents/Diseases,” by Centers for Disease Control and Prevention, 2017b (https://emergency.cdc.gov/agent/agentlist-category.asp). Because biological weapons often are undetectable in their early stages, they can cause significant harm long before the infectious agent is detected. This is not the case for chemical weapons, so they tend not to be used in attacks as often. However, chemical weapons are still utilized, as in the 1995 attack in the Tokyo subway system, when liquid sarin, which was developed in the 1930s by Nazi Germany, was released in the busy subway. The terrorists filled plastic bags with sarin and punctured them to release the toxin, killing 12 people and injuring more than 6,000 (Rivera, n.d.). There have been no major incidents of chemical toxins used in attacks in recent U.S. history, but the most commonly known chemical warfare was the use of the substance code-named “Agent Orange,” during Vietnam by the United States Air Force. Its chemical name is 2,3,7,8-tetrachloro-dibenzo-para-dioxin, or TCDD, and it is a combination of herbicides used to destroy foliage in Vietnam to uncover hidden enemy troops (Aspen Institute, n.d.). While it did what it was intended to do, it had the consequence of sickening thousands of troops on both sides (United States and North Vietnam), as well as causing civilian issues such as fetal defects, miscarriages, and neurological illnesses (Aspen Institute, n.d.). Unfortunately, the United States is still handling health concerns from Vietnam veterans. Bioterrorism and Ethics There are two areas of ethics related to bioterrorism: the ethical manner in which public health responds to acts of bioterrorism and the research that may actually promote bioterrorism. In health care, there are three critical responsibilities: detection, containment, and treatment (Wynia & Gostin, 2004). Detection: This task revolves around public health’s ability to monitor and perform adequate surveillance after an attack (Wynia & Gostin, 2004). These activities are generally discovered from reports through the health care system. It is possible that detection might fail if people do not have access to care or do not understand that their symptoms are associated with an act of bioterrorism. If doctors or emergency rooms fail to report incidents—even just one—the disease could spread. The other detection issue involves access to care. The United States has struggled to provide easy access for its population and thus may be remiss in ensuring that bioterrorism threats are stopped quickly before they spread (Wynia & Gostin, 2004). A patient in an isolation or quarantine room. Shironosov/iStock/Thinkstock Health care workers can help contain the spread of infectious disease by placing affected persons in isolation or quarantine. Containment: This task involves ensuring that appropriate measures are taken to reduce the risk of exposure to others. Containment might fail if physicians treating those affected do not act quickly and effectively to reduce the spread of infectious diseases from bioterrorism acts. Public health often cannot contain an outbreak as rapidly as necessary (Wynia & Gostin, 2004). Without quick containment—either in the form of isolation or quarantine—the disease cannot be stopped from reaching epidemic proportions. Ethically speaking, there should be a stronger role in terms of information sharing between public health officials and medical practitioners to determine the fast containment of diseases from bioterrorism. Treatment: Health care workers are commonly the second wave of infected persons in the event of a bioterrorism attack (Wynia & Gostin, 2004). Treatments may fail if there is no duty for providing health care in the event of an emergency. At first, medical team members may not know what they are handling and, thus, contract the disease themselves. The Hippocratic oath requires physicians to treat all medical conditions, but the problem lies in the high cost of doing so in bioterrorism events. Some hospitals in New York City have announced that they will not accept victims of bioterrorism because of that very cost. Health care providers have a legitimate fear of contracting deadly diseases from those infected by bioterrorism agents, and the hesitation to treat is understandable. Historians note that fear also caused poor medical treatment during the Black Plague and the more recent HIV epidemic (Wynia & Gostin, 2004). Ideas for bioterrorism often stem from existing scientific research. For example, smallpox has been eradicated with a vaccine, but the disease can also now be regenerated to become much deadlier and resistant to vaccines. Hence, smallpox could be manufactured as a weapon. It has been suggested that some scientific studies, especially those surrounding genetics and the human genome, be kept under high guard because of the potential public health threat and national security breach. Biotechnology could become the deadliest weapon because it could create a disease that would wipe out the population. So what should be kept secret, and what should be made public? Perhaps the more salient ethical dilemma is determining the continuation of biological research at all. While researchers in this area could eradicate many infectious diseases or perhaps stumble onto a cure for cancer or AIDS, both allies and enemies will see the work. A procedure that would reduce the risk of such research contains four key elements, none of which strongly addresses the issue of reducing the publication of potentially harmful research: Scientific studies are submitted through a stringent peer-review process, which protects the integrity of the scientific community. Without such rigorous processes, scientists would not be able to further advance biomedical research. The scientific community recognizes the prospect of bioterrorism and understands that its published information may be abused when placed in enemy hands, committing to “dealing responsibly and effectively with safety and security issues that may be raised by papers submitted for publication, and to increasing our capacity to identify such issues as they arise” (Miller & Selgelid, 2008, p. 39). Scientific journals consider the appropriateness of papers that are published, taking into consideration topic, design, and timeliness. The scientific community recognizes that there may be times when potential dangers will outweigh the potential benefits from publication. It is committed to ensuring that published research will maximize the benefits and minimize risks of misuse. Researchers Somerville and Atlas (2005) proposed an ethical code for research publication in 2005, but it was never adopted in the United States. They included a warning system for potentially harmful research and a censorship process to restrict detrimental biological studies from publication. Since then, many countries around the world have adopted modified versions of the Somerville and Atlas Code of Ethics for research in biotechnology in order to reduce or quell bioterrorism (Rapport, 2018). The United States has yet to adopt one. Experts have strongly recommended that policies be developed to block harmful research from getting into the wrong hands. The scientific community is looking toward the National Security Agency (NSA) to do just that. According to the NSA’s values, the agency seeks to improve and modernize the security of sensitive information systems in an effort to protect against bioterrorism (NSA, 2018). Right now, the United States is limited to voluntary censorship of potentially harmful research. Critics say that may not be enough (Miller & Selgelid, 2008). Summary & Resources Chapter Summary Several key agencies at various government levels play crucial roles during an emergency: the Department of Homeland Security, the Federal Emergency Management Agency, the Centers for Disease Control and Prevention, the Human Resources and Services Administration, the Food and Drug Administration, the National Institutes of Health, and the Federal Bureau of Investigation. Thanks to the various protocols set forth, especially the National Incident Management System (NIMS), each agency plays a role in managing and preventing emergencies. This ensures that all bases are covered and that no two agencies are duplicating efforts. Emergencies that fall under the domain of public health include manmade hazards such as chemical spills and fires, natural disasters such as floods and hurricanes, internal disturbances such as bombings or prison breaks, attacks of bioterrorism such as anthrax attacks, energy shortages, and outbreaks. The core functions of public health—assessment, policy development, and assurance—provide a basis for emergency response and preparedness. In emergency management, assessing the needs following a disaster, providing policies to mitigate a disaster, and following up with assurances for problem resolutions are the foundations of public health work. Assessment, policies, and assurances can also be found in prevention activities. A good example occurred in the national assessment of Hurricane Katrina and learning what precautions would be needed to prevent widespread damages should a hurricane of that magnitude ever strike again. One policy that followed was the redevelopment of the National Incident Management System, and the assurances continue to be found through evaluation of NIMS as it operates in smaller disasters. Practice drills also provide feedback on the protections and prevention activities. Furthermore, the 10 essential services of public health work within the core functions to provide support in emergency preparedness and response. The eight principles of emergency management are comprehension, progressive, risk-driven, integrated, collaborative, coordinated, flexible, and professional. Comprehension means to take into account all hazards, phases, stakeholders, and impacts relevant to disasters. Progressive means to anticipate future disasters and walk through protections and preventive measures. Risk-driven applies risk-management principles to priorities and resources. Integrated ensures unity of all efforts locally, statewide, and federally. Collaborative creates a sustainable relationship among all stakeholders involved. Coordinated means to synchronize all the activities to achieve a common purpose. Flexible involves using innovative approaches to solving disaster issues. Professional focuses on evidence-based approaches to education, training, ethics, and continued improvements. Bioterrorism acts use chemicals or even diseases as a means to kill a population. There are different categories of agents that can be used in bioterrorist or chemical attacks. Category A includes botulism and anthrax, B includes food safety concerns such as E. coli and Salmonella, and C involves newly emerging diseases such as hantaviruses. A large question remains: Is the United States truly prepared for a large-scale bioterrorist attack? It is uncertain unless it is tested. Disasters are bound to happen, but the most critical point from the public health standpoint is to prepare for the worst and hope for less. Regardless of what type of disaster occurs, the importance lies in solid plans for emergency response and preparedness. Critical Thinking and Review Questions Describe the work of at least two agencies involved in emergency preparedness and response. Explain the Disaster Relief Act of 1970 and why it was so important for the United States. Explain the difference between a national security risk and a state of emergency. Consider the biological agents from the Category A list. Describe an incident of an outbreak occurring as a result of exposure to one of those agents and the national response. What is the difference between terrorism and bioterrorism? Review the old and new National Terrorism Advisory System (NTAS). Which do you believe worked better for the United States and why? Consider the four key elements of security research and publication. How do these four elements actually reduce the risk involved with conducting and publishing research? NIMS contains five main components: preparedness, communications and information management, resource management, command and management, and ongoing management and maintenance. Explain how each one builds upon the next for smooth operation in times of emergencies or disasters. Consider the eight principles of emergency response and preparedness and apply their use in the event of a massive wildfire that is threatening a large portion of California. Based on your research and what you have learned in this course, why do you believe the United States is prepared or not prepared for a large-scale bioterrorist attack? Additional Resources FBI counterterrorism timeline https://www.dni.gov/nctc/timeline.html Visit the FBI’s online counterterrorism guide. It outlines known issues of terrorism dating back to the 1960s and provides details about the world’s more dangerous groups. The Federal Emergency Management Agency https://www.fema.gov/ Visit FEMA’s website to view more details on preventing and mitigating disasters across the United States. Key Terms bioterrorism Terrorism using agents and organisms that pose a risk to human life, thus also posing a national security risk. Category A agents Certain bioterrorist elements that, when released into the population, pose a national security risk. They include anthrax, botulism, plague, and smallpox. Category B agents Bioterrorist elements that are not as deadly as Category A agents but that can result in moderately increased diseases among the population. These include Salmonella, E. coli, cholera, and ricin. Category C agents Bioterrorist elements that could cause an emerging infectious disease, such as hantavirus. emergency An incident that threatens public health, safety, and welfare. emergency preparedness Encompasses all activities that are planned and implemented to manage an emergency. emergency response The tactical planning and subsequent activities used to protect the public’s health. escalation protocols Procedures that ensure that all emergency response personnel carry out their roles and responsibilities effectively and appropriately to protect the nation and promote the health and well-being of the American people. hazard Something that is potentially dangerous and is likely the main cause of a disaster or emergency. international terrorism Terrorism involving the citizens of more than one country. local emergency Emergency that is confined to a geographic region of a state such as a city, county, or municipality. National Incident Management System (NIMS) One of the world’s leading disaster management systems for monitoring and protecting populations. national security risk Outlined by four distinct actions: 1) The agent used must be easily disseminated or transmitted by humans; 2) the result involves significant death rates, pointing toward a major public health impact; 3) the act causes public panic; and 4) the resulting incident requires public health preparedness and response in a specified manner. state of emergency Emergency that is confined to one or more states within the nation. state of war emergency A condition that is declared when anywhere in the nation is threatened or attacked by an enemy of the United States. terrorism An act of violence against innocent civilians or unarmed groups/individuals by national, secretive, or undercover groups. terrorist group A group that practices domestic and/or international terrorism. threat An indication of possible harm or danger.