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• What has been done to improve intelligence and surveillance? Baltimore's Mayor Martin O'Malley says preparedness involves three fronts: intelligence, security, and emergency response. Does your region have a local intelligence network so that surrounding jurisdictions can share information? Look for any steps that have been taken since 9-11 that might improve the chance for early detection of a terrorist attack and a quick response. Baltimore, for example, has established a surveillance system that could provide early warning of a possible bio-terror attack. The city's health commissioner now receives a daily log of all paramedic and emergency room calls, plus over-the-counter pharmaceutical sales that could indicate an up tick in flu-like symptoms. The surveillance report also tracks elementary school attendance rates, and counts dead animal carcasses, to spot patterns that could suggest an outbreak. Does your city have an early warning system in place? What about law enforcement actions related to terrorism since September 11? TRAC, the Transactional Records Access Clearinghouse, has enforcement data online.
  
  
• What can be learned from the past? Eight years ago, Milwaukee had no warning system in place when its water supply was contaminated by cryptosporidium. One hundred thousand area residents became sick with what appeared to be stomach flu, a thousand were hospitalized and more than one hundred died. Baruch Fischhoff of the Center for Integrated Study of Human Dimensions of Global Change at Carnegie Mellon University says the public health system failed to detect the outbreak for several weeks because most people who got sick treated themselves with over-the-counter medications. It wasn't until pharmacists began to notice a run on products to treat upset stomachs and reporters began asking questions of local government officials that the health department finally put two and two together. Is your city any better prepared to detect an outbreak than Milwaukee was in 1993?
  
  
• How safe is your water supply? Monica Schoch-Spana of Johns Hopkins University's Center for Civilian Biodefense Studies says that water systems designed to protect against e-coli outbreaks are "good enough" to prevent the spread of a biotoxin being used as a weapon. "[Terrorists] would have to put an impossible amount in for you to get a lethal dose at the end of the tap," she said. But she says water systems must be sure they can take care of "regular bugs," so it's probably worth investigating your area water systems.
  
  
• Has your city done a vulnerability assessment? To be prepared, O'Malley says, a city needs to count its assets, rank them in order of susceptibility to attack, and secure them. Baltimore's list includes railway tracks and stations, highways, airports, water systems, chemical facilities and hazmat storage locations, as well as locations where crowds might gather such as sports stadiums.
  
  
• What's being done to protect assets, and at what cost? O'Malley says the biggest security expense for Baltimore has been for police overtime to guard vulnerable assets. The city has not and will not cut back on regular police patrols, he says, and he denies that shifting security priorities might have led to a spike in homicides after 9-11. O'Malley's theory is that "tit for tat" drug killings went up because the purity of drugs on the street was cut in half after the attacks, when transportation was disrupted and the supply was down. The additional security against terrorist threats already has cost the city $5 million. Unless the federal government provides some funding, O'Malley says, the city faces a $20 million dollar hole in its budget. "We'll have to balance the cost against whether we close a recreation center or a library," he says. How are your city's crime rate and budget being affected?
  
  
• What is the threat of a chemical attack? Bruce Blair of the Center for Defense Information believes the danger of a deliberate chemical release along the lines of the Bhopal disaster has been underreported. "[This] represents a threat that is more dangerous from the standpoint of casualties and the accessibility of materials," he said, compared to a biological attack. Many water treatment systems use chlorine, which they store in tanks out in the open, in unsecured areas. Baltimore is now changing from chlorine to bleach, to reduce the risk that "some jerk with a hand grenade could wreak havoc," says O'Malley. Is your city planning similar steps?
  
  
• How prepared are your local hospitals and shock trauma system for a possible attack? Schoch-Spana says flatly that the public health system in the U.S. is totally unprepared to handle an epidemic, which she says would inevitably result from large-scale bio-terrorism. Her greatest worry is an aerosol release of a toxin like smallpox--a communicable disease that cannot be treated--that would result in the largest number of sick and dying. People are more vulnerable to toxins today, she says, because they have built up resistance to antibiotics, most people live in crowded cities, and the world is hyper-mobile, meaning that pathogens can move quickly. "If there were a release, it's a global problem instantaneously," Schoch-Spana says. From a public health standpoint, the response to an unannounced bio-terror attack would involve several phases. First, of course, would be to recognize the outbreak--easier said than done, given that most American doctors have no experience with diagnosing an epidemic. If the Milwaukee experience is any guide, the news media could serve as the first line of detection. Then health professionals would need to track victims and their contacts, diagnose new cases and treat, vaccinate, or isolate victims. Schoch-Spana says the health system has almost no "surge capacity" to deal with an outbreak, especially of a contagious disease. Hospitals have few isolation rooms, and little in the way of stockpiled drugs or supplies that would be needed in an epidemic. The American Hospital Association says it would cost more than $11 billion to get hospitals up to speed.
  
  
• What's the greatest threat we face now? That depends on how you ask the question. The biggest risk of all, says CDI's Blair, is that terrorists could get their hands on a nuclear bomb and deliver it, but getting one would be a daunting challenge. On the other hand, Blair does worry that terrorists could get their hands on what they need to make a bomb, given the lax security in the former Soviet Union. Or they could secretly enrich low-grade uranium into bomb-grade material, using off the shelf technology, and could then set off a "dirty bomb" using nothing more sophisticated than dynamite. The good news, if there is any, is that a dirty bomb is so radioactive it could be detected fairly easily in transit. But Blair is also concerned about cyber-nuclear-terrorism, saying it's a serious possibility that terrorists could hack into the electronic control system for Russian or even U.S. nuclear weapons, and send a launch order that would look legitimate. With U.S. and Russian forces still on hair trigger alert, Blair says the risk is high that a rogue launch could lead to nuclear war. "Our system is still totally geared to the Cold War," he says. "It's an oddity and a danger." He believes the U.S. should change the rules and allow more time for deliberation if a launch is detected.
  
  
• How much information should be made public? Mayor O'Malley clearly was not pleased when the Baltimore Sun newspaper printed a map showing the location of chemical storage areas and how far contamination would spread if each were hit. But he does believe in sharing information with the public. "What causes the most panic is when information gets out incorrectly," he says. Schoch-Spana believes that the public can handle information that might be frightening. "There is a cultural stereotype that people will panic," she says. "The fear is unfounded." As evidence, she cites what happened during the anthrax scare. People were afraid, she says, but not irrational. "Over-protectiveness offends the public, and undermines trust," she says. On the other hand, she advises journalists not to approach the threat of bio-terrorism by looking at particular pathogens. "Tell the story about systems of response and their problems," she says.
  
  
• Where are some systems that work well? Schoch-Spana says New York City is Exhibit A. The public health system was battle tested before the anthrax scare, having dealt with the West Nile virus. Los Angeles, she says, has handled disasters of every sort and as a result has good coordination of law enforcement and public health. In San Antonio, she says there's a good combination of military assets and civic responsiveness. And she praises the state public health department in Minnesota. How does your city or state compare?

Baltimore Mayor O'Malley, Monica Schoch-Spana, and Bruce Blair spoke to participants at a Knight Center for Specialized Journalism seminar, December 6-7.

Baruch Fischhoff spoke at a conference sponsored by the Foundation for American Communications, the National Academy of Engineering, and the National Academy of Sciences Institute of Medicine, in association with RTNDF and the Associated Press Managing Editors, December 6.