Defining the public health response to terrorism in 2004 is a potentially difficult task. While members of the emergency services reiterate that they respond to the consequence, not the cause, recognition is dawning that there are some distinguishing features of planning to respond to terrorism - particularly in the event of a mass casualty attack.
While the police have suggested that the UK has been used to terrorism for many years and that responders should use this experience as a basis from which to move forward, the National Health Service (NHS) appears to be taking a different approach. A recent Department of Health (DoH) publication indicated the emergence of a re-evaluated viewpoint on terrorism. "Now new threats exist…Dealing successfully with the new threats will require more than simply scaling up the major incident plans of individual agencies," it states.
The Home Office echoes the sentiments of the DoH, believing: "The enhanced threat of terrorism producing mass casualties justifies a new dimension to planning and to the management of the consequences of CBRN [chemical, biological, radiological and nuclear] releases."
An act of terrorism using biological or chemical agents - either on their own or as part of a mass casualty attack - would alter the response at many levels. This is not a premise for scaremongering, nor is it an attempt to suggest that members of the UK health services are not doing a remarkable job. However, mass casualty incidents (such as the terrorist attacks of 11 September 2001) could lead to circumstances that earlier planning simply did not contemplate.
The first to respond
The 11 September attacks altered perceptions of terrorism. Hypothetical scenarios were receiving serious consideration that may once have been dismissed as ridiculous. In some circumstances, exaggerated variations of these scenarios may have developed but the fact remains that risks from terrorism had changed. As the UK National Audit Office (NAO) observes: "An assessment of risks post-11 September placed chemical and biological incidents higher than previously and identified the need to plan for mass casualties at a much larger scale than hitherto."
A deliberate attack using chemical or biological (CB) agents would have some unique characteristics. Agents used could be very toxic and may leave immediate NHS staff in unfamiliar territory with regard to the toxicity of the substance and the effect it had on victims. As one author points out: "When large numbers of people suddenly and inexplicably become ill and die, the very social and moral basis of society is threatened."
For this to happen, the objective of terrorism would have been accomplished. A mortality rate of 20% in cases of cutaneous anthrax, or 30% in cases of the variola major form of smallpox, could have a devastating physical and psychological impact on a population, even if the outbreak were successfully contained. For this reason, those who are first on the scene of any incident and those who are receiving casualties need to be fully trained and aware of the situations they might face. The Royal Society recommends that there should be an increase in "the general awareness of all healthcare staff by training, particularly in the detection and management of chemical or biological agents" to ensure "a rapid and effective medical response" to a CB incident.
While emergency services are trained to deal with a range of incidents and in many cases their duties remain the same, the DoH says it should be recognised that in an incident where lives are endangered, "the involvement of terrorists does mean that there are some important differences."
In comparison with a natural disaster or an industrial or transport accident, casualties directly resulting from an attack could outnumber any previous numbers that the health service may have prepared to deal with. It has been announced that general practitioners are to receive clinical action cards informing them about the treatment of patients who had been affected by a biological attack. However, without general basic training for those who are first to respond, measures such as the issuing of clinical action cards will leave people vulnerable to misdiagnosis or a delayed response. While the effects of a biological attack begin to show themselves, it is essential that a diagnosis be made as quickly as possible.
Plans should take into account that for the worst cases, supportive therapy may be needed. Coupled with this is the necessary monitoring of patients after they have completed treatment. In a society which does not have to deal with natural outbreaks of deadly diseases such as yellow fever or ebola, it is essential to examine the preparedness of the UK health service to respond to a chemical or biological terrorist attack. A reliance on existing knowledge and facilities may not be enough if the worst case scenario occurred. The government suggests that: "Optimally, patients should have medical care available upon discontinuation of antibiotics, from a fixed medical care facility with intensive care capabilities and infectious disease consultants."
As well as finding the resources for aftercare, it is also problematic securing knowledge about those members of the population who may not be able to receive certain vaccinations before an incident or following an outbreak. Vaccination for some agents is simply not possible. Smallpox vaccination, for example, is potentially unsafe for those suffering with eczema, HIV or who are pregnant. Education before the event is essential. In the aftermath of a bioterrorist attack, health service staff would probably be stretched to the maximum, leaving no room for the inaccurate administration of vaccines.
While the DoH’s categorisation of certain levels of incident suggests greater forethought about dealing with chemical and biological terrorism or mass casualty incidents, it also indicates the extent to which the health services would be stretched. The DoH describes Level II incidents as affecting "potentially hundreds…of people, possibly also involving the closure or evacuation of a major facility" and requiring a "collective response by neighbouring trusts." However, Level III incidents are categorised as "events of potentially catastrophic proportions that severely disrupt health and social care… and that exceed even collective capability within the NHS."
Such an assessment shows that perceptions are changing and highlights the need for continuing development of an efficient multilevel response. While it would be irresponsible to focus all attention on CB attacks, it would be disastrous to believe that they could not occur.
A multilevel response to a major incident involves many actors. The evidence of changing threat perceptions since the 11 September attacks has accentuated the need to understand better the importance of every person responding to a major incident. To a large extent the NAO’s claim may be true that "London is now better prepared than before 11 September". Research shows that the health services are better equipped and more aware but faults remain with some equipment and there are gaps in training and communication. The responses required for incidents such as major rail crashes may have served as good practice for CB responders, yet a different level of criticality applies in responding to CB terrorism as a successful response relies on all involved.
A mass casualty incident or hazardous substances incident on a large scale would challenge the NHS in London. While the London Resilience Team has reported that the capital retains 10 incident response units capable of decontaminating 400 people per hour, there must be first-rate communication and co-ordination. The need for acute local and national response networks is underscored by the fact that following a chemical attack, people may not be willing to wait to be decontaminated. Equally, there may not be enough facilities for decontamination - a large number of self-referred patients could present themselves at hospitals and other healthcare facilities. One of the concerns noted by the US Army Medical Research Institute of Infectious Diseases was the containment of local disease cycles, particularly with cases of plague and other communicable diseases. For this reason a constant flow of communication, diagnosis, treatment and information is essential and must be facilitated at all levels to protect the population and healthcare workers.
While London may have been declared to be better prepared, in 2002 NAO research revealed that across the UK, the "NHS response lacked effective leadership and co-ordination". Also, some Emergency Planning Officers (EPOs) and members of the emergency services have complained that changes in emergency planning have been London-centric in the assumption that a large-scale terrorist attack would not occur elsewhere in the UK.
Perception of response
A recent study into the local responses to terrorist attacks asked Category 1 responders if the 11 September terrorist attacks had changed their perception of risk. An overwhelming majority said it had. This mode of thinking appears to have remained since 2002, when NAO research found that, after 11 September, "many NHS trusts identified new or increased risks, mainly in relation to chemical, biological and mass casualty incidents".
Funding began to flow but whether it was correctly assessed and distributed at a local level remains questionable. One-third of NHS trusts told the NAO in October 2002 that the allocation from the DoH of £5 million (US$8.9m) for the NHS did not enable them to "adequately meet their requirements for personal protection equipment and decontamination facilities".
While funding was considered to be lacking, information flows were also considered to be inadequate, suggesting that preparation and perception did not develop in parallel. The NAO found in 2002 that 25% of health authorities had not included arrangements for a mass casualty incident. A major DoH study revealed that:
It is evident that while perceptions have changed (and to some extent increased) of the risks that the UK faces, the effort to educate and inform first responders lags behind. The issue of training and re-training for health service workers began to be addressed in 2004. The BBC reported on 17 June that accident and emergency staff "are being sent on two-day courses to bring them up to speed on the biological agents that could be used by terrorists," adding that "Hospital consultants specialising in communicable diseases are to receive extra training to ensure they are also up-to-date."
However, at the same time, health responders still complained of the lack of available time and funding. While the NHS nationally appears to be making progress, locally some first responders remain unsure of what is expected of them in the event of a terrorist attack.
Central guidance at local level
If the terrorist attacks of 11 September altered some approaches to emergency planning, the review prompted by the attacks was arguably too hasty and the objectives it created incompatible with capabilities. The Emergency Planning Unit was quick to issue guidance across a range of hazards after 11 September. However, NAO research discovered that some NHS trusts found the revised guidance on the subject of a chemical or biological attack "confusing and unco-ordinated".
Home Office guidance recognises that established plans for dealing with fatalities may not be suitable where contamination has resulted from a terrorist attack. Yet members of the emergency services continue to complain of the ambiguous nature of guidance and the lack of training for all staff to respond appropriately to CB terrorism. Guidance on Dealing With Fatalities in Emergencies, the joint publication by the Home Office & Cabinet Office, offers some guidance on steps to be taken in the event of bodies being contaminated with CBRN materials and touches on the regulations for the transportation and storage of victims.
However, according to some members of the Ambulance Service Association, elementary co-ordination is still lacking, as "there is no single defined guidance or policy for the management of contaminated bodies". In the period after a chemical or biological attack, such weaknesses within the health service could prolong and accentuate any dangers to the public. Government objectives need to be translated into practical training and equipment delivery if the UK’s health service is truly ready to respond.
Communicating with other agencies
Chemical or biological terrorist attacks could create rapid and unpredictable consequences. Communication between first responder agencies and aftercare providers is therefore of particular importance. The DoH stresses that "good lines of communication between police and the health service must be established at the planning stage and reviewed at least annually".
However, an NAO study reveals that police representatives are not involved in all exercises. In fact, involvement is on an ad hoc basis - with invitations issued courtesy of whoever is organising the exercise. Furthermore, it was found that almost 40% of health authorities had not sent plans to the local police service and 20% had not agreed their mass casualty plans with the police following 11 September. Notably, 20% of health authorities had not participated in exercises carried out by the police. When questioned by the NAO, members of the health service claimed that there was a need for "access to mass decontamination and protective clothing, a need for improved training and a requirement for better liaison with police, local authority and other organisations".
Training, education and rigorous plans alone are not enough, as any response to a CB attack will require more than the skills of the health service. The RAND think tank notes that "unlike smaller emergencies, a major disaster can cover a wide geographic area, present many highly varied hazards and take from several days to several months to contain".
Without adequate co-ordination among the relevant agencies, the anticipated response may be splintered and ineffective in practice. Nor is effective co-operation among counterparts in different agencies enough. Plans that remain untested are in danger of losing value.
The London Resilience Team said in May 2004 that the emergency services "are well equipped, well trained, and exercise regularly".
The implication was that little had changed and existing plans were being rehearsed to ensure that everybody understood their role when responding to a terrorist incident. Unfortunately, research shows that this confidence is misplaced in certain areas. Members of the NHS, for example, continue to express concerns over inadequate training and access to equipment needed when responding to a chemical or biological attack.
The Health Protection Agency says that health authorities should possess contingency plans "for dealing with numbers of patients that overwhelm their normal resources". Assuming that plans are adequately revised and implemented, the matter of testing them in exercises brings further complaints from NHS staff about finding time to undertake exercises for scenarios that may not happen.
This is a disappointing perception. The value of exercises was highlighted in recent research, which found that 97% of Category 1 responders regarded exercises as providing valuable learning experiences for participants; 93% claimed that exercises greatly enhanced co-operation structures.
The DoH says that "all staff, from managers to those delivering acute care, require appropriate training if incidents are to be managed effectively and safely". While many Category 1 responders deal with the consequence rather than the cause in establishing effective management of a chemical or biological attack, it is important that complacency from central government and regional health services does not pervade planning for the future. Central government must ensure that it provides health responders with the necessary means to support their demand that "organisations must ensure that all that could be done has been done during the planning process, training and exercising".
A progressive - if slightly inward-looking - assessment by the DoH and HPA indicates that they have recognised the need to consider security threats more meticulously than before. As RAND notes: "Because of its uncommon scale and complexity, a major disaster changes the nature of a response operation in itself." Responding to any major incident can prevent challenging tasks but a revision of existing guidance and the application of a renewed approach are crucial to an effective and swift response following a CB terrorist attack.
For this reason, health responders in the UK must continue to revise plans, communicate on a more regular basis with other agencies and take time to acknowledge the fundamental requirements of those who will be first on the scene and last to deal with the casualties of a CB attack.
Alison Dale is Junior Research Fellow of the ESRC (Economic and Social Research Council) Domestic Management of Terrorist Attacks Programme at De Montfort University specialising in terrorism and Weapons of Mass Destruction