If a terrorist launches a smallpox attack on the United States,Richard Raymond intends to call 10 helicopter pilots, two Sudaneseinterpreters and a Salvadoran immigrant who practiced medicine 35years ago.
Quirky as the list may sound, it helps explain why Nebraska'schief medical officer is credited with putting his state in theforefront of an unprecedented national effort to prepare for abiological attack.
Long before local officials in other parts of the country were addressing the daunting task, Raymond was already figuring he wouldneed the Air Ambulance Service to rush patients and supplies acrosshis 77,000-square-mile state.
He realized months ago he'd need Sudanese interpreters -- alongwith Hispanic, Vietnamese and Native American Indian leaders -- toovercome cultural barriers in this surprisingly diverse part of thecountry. And the Salvadoran immigrant whom Raymond recruited for anew public health strike force is the only person in Nebraska who hasseen smallpox firsthand, making him invaluable for confirming anoutbreak.
'It is easier to do this now and be proactive than when people maybe panicking,' he said. 'That's why we've put together a strike forcethat can go in and provide health care, investigate cases and set upclinics.'
The job of national defense may rest with the Pentagon, but in thepost-Sept. 11 era of homeland security, state and local officialssuch as Raymond face enormous new burdens as the nation's front-lineprotection against attacks with the smallpox virus or otherbiological weapons.
Because Raymond started planning before getting specificinstructions from Washington, Nebraska is far along in resolving themyriad practical details of responding to a biological attack. Theefforts by Raymond and his colleagues offer an early look at the workahead in the other 49 states and highlights the challenges that mustbe overcome not just in major urban centers, but even the remote andrural corners of the country.
'Nebraska has really shown an enormous amount of foresight forresponding to these new threats,' said Jerome M. Hauer, who isoverseeing bioterrorism planning at the U.S. Department of Health andHuman Services. 'They really have become a model for other states.'
Raymond and his team knew from the outset that they needed todevelop medical, technical and logistical expertise to detect andrespond to a biological attack. But the Nebraska experienceillustrates that less obvious challenges, unique to each state --geography, communications, weather patterns and cultural differences -- are equally important in preparing for bioterrorism.
For months, President Bush's top advisers -- torn between thepotential dangers of an intentional release of the deadly virus andthe known risks of the vaccine -- have debated who should bevaccinated against smallpox.
In the meantime, states are struggling under a Dec. 1 deadline toprepare for two scenarios: inoculating a limited number of medicalworkers prior to an attack who could then diagnose and treat earlycases, and vaccinating the entire population within a week of anattack.
That means identifying not only the clinic sites but also thepersonnel to collect medical histories, administer vaccine, monitorside effects and handle security -- for 280 million Americans. It isan extraordinary challenge, particularly for public healthdepartments more accustomed to tracking routine flu outbreaks during9-to-5 business hours, said Hauer.
With an infusion of $8.8 million in federal money, Nebraska hashired eight additional county health directors, upgradedlaboratories, bought computers and fax machines for the state's 85hospitals and approved Raymond's Public Health Strike Team, theeclectic group he will summon in the event of an attack.
The preparations range from the sophisticated lab equipment beinginstalled at the University of Nebraska Medical Center to therudimentary color-coded telephone tree Becky Rayman has devised forthe East Central District Health Department, based in Columbus, Neb.
What makes the effort here especially noteworthy -- and thechallenge for other states so overwhelming -- is the seeminglyendless array of small, but necessary, details. Like FredMassoomi's'Go Kits.'
The kits contain the pens, clipboards, batteries, extension cords,signs, walkie-talkies and ID badges needed to convert a churchbasement or school gym quickly into a temporary clinic, capable ofinoculating 5,000 people a day. Massoomi, pharmacy operationscoordinator at Methodist Hospital in Omaha, is in charge ofassembling a kit for each of the city's 21 emergency vaccinationsites. He plans to draw maps with the precise location of each kit sothat in case of a biological attack, frantic volunteers won't wastetime hunting for them.
'This is a huge job,' said Carol Allensworth, chief planner at theDouglas County Health Department and one of Massoomi's partners atthe Omaha Metropolitan Medical Response System. 'We are looking to beable to mobilize a clinic very quickly, in a matter of hours.'
Since the day hijacked planes were flown into the Pentagon and theWorld Trade Center, the Bush administration has worried about arevival of germ warfare.
'I remember the alert we got at exactly 12:31 Central time onSeptember 11,' Raymond said, describing the warning from the Centersfor Disease Control and Prevention. 'Due to current events, CDC is onheightened alert status to monitor for any possible unusual diseasepatterns associated with today's events, including chemical andbiological agents.'
In the French and Indian wars of the 18th century, smallpox was astunningly effective weapon; British soldiers used contaminatedblankets to decimate the native Indian population. Until it wasdeclared eradicated in 1980, the highly contagious, incurable diseasekilled about one-third of the people who contracted it. Routinevaccinations, however, were stopped in 1972, in part because ofserious, sometimes fatal, reactions.
Administration officials have not quantified the likelihood of asmallpox attack, but they have indicated it is among the most fearedweapons today. The Pentagon, preparing for possible war with Iraq,has ordered the first 1 million doses of vaccine for soldiers headedoverseas. Israel, meanwhile, has reinstituted vaccination foremergency medical workers.
In America, the simple question of whom to vaccinate has turnedout to be among the most nettlesome. Several state healthcommissioners say political pressures make the task particularlyunappealing.
Raymond decided to draw up a list in increments of 500 doses. OnAug. 15, his deputy, Joann Schaefer, convened a meeting at MahoneyState Park with medical experts and representatives from thehospitals, National Guard, Indian tribes, police, fire and emergencyrescue squads.
'We gave them some pop and said, 'Okay, we need a list of whoshould be vaccinated,' ' Schaefer said. Projecting a computerspreadsheet on a nearby wall, the group began drawing up the list,starting with the strike force -- 170 people across the state whowould investigate suspected cases, treat patients and open the firstvaccination clinics.
Some choices were obvious, Schaefer said. Epidemiologists, labworkers, police and the ambulance pilots comprise the heart of thestrike force. Workers at the state's two largest health departments -- based in Omaha and Lincoln -- infectious disease specialists,interpreters, representatives of the Indian tribes and Arturo Coto,the man who treated smallpox in El Salvador in the 1960s, completethe team.
The remaining 330 doses would go to the state's hospitals -- sixdoses for large facilities, three for rural hospitals. The list canbe expanded to 1,000 or 1,500, although some Bush administrationsources suggest a much broader pre-attack plan would give Nebraska asmany as 5,000 doses.
'The first 500 was the hardest,' said Schaefer. 'If we get 5,000,it will be like Christmas.'
Under federal emergency plans, the CDC is responsible fordelivering vaccine and other medical supplies to states within 12hours of an attack. But states must distribute the material, which instorage could consume 12,000 square feet, or about half the size ofthe main hangar at the Nebraska Air National Guard base in Lincoln.
'Most of what we do is move cargo,' said Maj. Bob Yager, the civilengineer on the base who is assisting the strike force. The runwayscan handle any military aircraft, and although the Guard would haveother duties during an attack, Yager has offered a dining hall,medical clinic and vehicle shed to health officials.
Both the state and some counties have agreements with privatetrucking companies to deliver supplies to five hubs and more than 25smaller towns across Nebraska. Hotels have been contracted to storethe supplies, and state planners are identifying nursing homes andother buildings that could provide backup hospital beds, particularlyin rural areas.
Although the prospect of vaccinating all 1.7 million residents ina week would be unprecedented, public health workers say they havedrawn on previous experiences, such as the rubella outbreak of 1999.
To contain the disease, public health workers announced they wouldgo directly to meatpacking plants to vaccinate workers. But theoutbreak coincided with Operation Vanguard, a major roundup by theImmigration and Naturalization Service, and immigrants in the plantssuspected the rubella vaccinations were a trick. Work attendancedropped 25 percent.
Next time, Schaefer said they would approach immigrant communitiesin their own language, with local leaders they know and trust.
'We don't think it's realistic to expect them to come and fill outpapers at a government site with people in uniform,' she said.'They're afraid they'd be deported.'
