Preparing for the worst: Are America's doctors ready?

How many physicians know what to do after a biological or chemical attack on their community?

Not many, according to Jeffrey W. Runge, MD, the recently appointed chief medical officer at the U.S. Dept. of Homeland Security.

"When I go out to talk to medical societies and medical groups, I ask them: How many of you have read your county's disaster plan? How many have seen your hospital's disaster plan? Do you know your role if there is a biological attack on your community, or a dirty bomb, or chemical attack?"

The response has surprised him, he told AMNews. "I'm afraid not many hands go up."

Dr. Runge has been urging doctors to reach out to their local public health departments and to get connected to their communities' emergency preparedness efforts so they'll know what to do in the event of a terrorist attack, flu pandemic or large-scale natural disaster such as Hurricane Katrina. "Every physician -- whether they're office-based or hospital-based -- needs to understand what their role is should their services be needed in a disaster."

Dr. Runge warned that local communities likely will be on their own, at least initially, in providing emergency medical response after a catastrophic event. "People can't expect help from the federal government in the first hours after an attack."

Doctors should find out before disaster strikes how their community plans to respond, how they fit into those plans, and who they can contact with questions and concerns, he said.

"We need to weave our private medical practitioner community into the fabric of preparedness."

That has been Dr. Runge's core message to physicians in his first six months in the newly created position of Homeland "top doc."

It is a message that should resonate with many doctors, not just emergency physicians.

Internists realize that many patients who are injured or exposed during a catastrophic event are likely to present to physicians' offices, rather than to hospital emergency departments, said John Mitas, MD, deputy executive vice president and chief operating officer of the American College of Physicians.

"Internists will be key players," Dr. Mitas said. "But if they're not thinking about it, not prepared, and don't think they have resources readily available, they may not be as effective as they could be."

Dr. Runge said all doctors should ask themselves: "If they see a chest x-ray and suspect anthrax, do they know who to call? Do they know the name of their local health director? Do they have him on speed-dial?"

Every medical staff should have someone who knows how to get in touch with local poison centers for advice on suspected chemical attacks and weapons discharges, he said. They should have ready access to infectious disease colleagues well-versed in such concerns as weaponized anthrax and bubonic plague.

"With the threats that we face, we simply cannot wait for a disaster to be exchanging business cards."

Dr. Runge has struggled to manage expectations about what he can accomplish at DHS.

Some observers would like to see him weave the "fabric of preparedness" much tighter at the department itself, where medical preparedness activities have been dispersed among its many different branches -- from the Federal Emergency Management Agency to the U.S. Coast Guard -- with little coordination.

They also would like to see various federal agencies -- including Homeland Security, Health and Human Services, Defense and Veterans' Affairs -- pulled together more effectively.

But Dr. Runge is careful to emphasize that his resources and authority as chief medical officer are limited.

"Our office is a young office," he said, when asked what has been accomplished to date. "We are under-resourced for the task at hand."

Dr. Runge has a five-member staff and a $2 million budget. Compared that with the 700-member staff and $650 million budget he oversaw in his previous position as head of the National Highway Transportation Safety Administration.

"We're working 14 hours a day, and every problem takes 18 hours a day," he said.

President Bush has proposed raising the chief medical officer's budget to $5 million in fiscal 2007. Dr. Runge said he would use the additional funding, if approved, to hire more staff.

"We need people to do the work," he said.

Looking for leadership

DHS Secretary Michael Chertoff established the office in July 2005 as part of a broad reorganization of the department. Dr. Runge came into the position in early September, barely a week after Hurricane Katrina roared onto the Gulf Coast, exposing major gaps in the nation's emergency response capabilities.

To many observers -- including physicians and public health experts -- the appointment of a chief medical officer at DHS was a welcome decision and long overdue. Before Dr. Runge's appointment, the department lacked a centralized medical structure.

That contributed to its multiple failures during Hurricane Katrina, said Shelley Hearne, DrPH, executive director of the Trust for America's Health, a nonpartisan public health advocacy group in Washington, D.C.

"If you look at what happened with Katrina, there was redundancy among several emergency management systems and also efforts to reinvent the wheel in the midst of the crisis," Dr. Hearne said. "There was not a clear game plan for the health response."

There still is no clear game plan, she said. In December 2005, the trust gave the federal government a grade of D+ on its post-9/11 public health emergency preparedness.

Across the board, medical preparedness activities are not well-coordinated, said James J. James, MD, DrPH, MHA, director of the American Medical Association's Center for Public Health Preparedness and Emergency Response.

"All the different efforts on preparedness really suffer from a lack of integration in planning and operation, especially between the public and private sectors."

Dr. James, who met with Dr. Runge in December, said it would be helpful if someone in the Bush administration -- whether it is Dr. Runge, the U.S. surgeon general or someone else -- could bring together all of the various elements involved in medical preparedness. "We want to see someone in federal government who is knowledgeable, capable, who carries the mantle of top doc and can actively play a role in overseeing some of this."

Defining the role

But whether that will be Dr. Runge's job remains to be seen.

The exact nature of his role at DHS is still unclear, said Scott Lillibridge, MD, who heads the Center for Biosecurity and Public Health Preparedness at the University of Texas Health Science Center in Houston.

"The question is, will DHS organize this into an effective office that has operational, policy, and budgetary control over the health components throughout DHS, or will he be a health adviser and that's all?"

Dr. Lillibridge hopes it will be the former, but some physicians are concerned that Dr. Runge's office is evolving toward the latter.

"Many people in emergency care circles thought that someone with his credentials, coming into an agency that is so critical to the safety of the country, would have substantially more resources than it looks like he's had," said Arthur Kellermann, MD, MPH, a trustee at the American College of Emergency Physicians.

ACEP representatives met with Dr. Runge in October 2005 and later sent him, at his request, a list of recommendations for improving medical preparedness. Among their top concerns is the limited surge capacity in the nation's hospital emergency departments, said Dr. Kellermann, who chairs the Emergency Medicine Dept. at Emory University School of Medicine in Atlanta.

Metro areas such as Atlanta have six to 10 hospitals diverting ambulances on any given day, he said. "So how in the world are we supposed to handle another Olympic Park -- which was a pretty minor-league bombing, as bombings go -- compared to a much larger terrorist attack, not to mention a major outbreak of influenza or another biological agent?"

ACEP hopes that Dr. Runge, who is board-certified in emergency medicine, can bring high-level attention to the issue.

Dr. Runge is noncommittal. "We do talk about it, and surge capacity is a huge issue. But it's HHS' issue." He said the Dept. of Homeland Security would "work toward generating requirements around surge capacity," but that his office first would need to see hard data on the problem.

Dr. Runge has spent the bulk of the past six months working on pandemic flu preparedness.

"My time has been just sucked up with avian flu. But if we do things right on avian flu, we will be much better prepared for a biological attack because the systems that you use to deal with medical needs are the same for both."

When asked to describe his role at DHS, he said his "immediate mission is to make sure the secretary gets the best possible incident management advice to drive his decision-making in the event of a disaster of medical significance."

In the event of a catastrophe, he will be "at the secretary's elbow," Dr. Runge said, "making sure our response elements, namely the National Disaster Medical System and our relationships with first responders, are where they need to be."

Being visible to the public is not part of the job. "HHS has to step up and have the spokesperson, and that spokesperson should be a doctor."