Running head: RESPONDING TO A WIDESPREAD BIOTERRORISM EVENT 1

The Readiness and the Effectiveness of the U.S. Healthcare Delivery System in Responding to a

Widespread Bioterrorism Event

Anna Hall

Devry University

Health Service Systems

HSM541

Dr. Eric Oestmann

June 16, 2018

RESPONDING TO A WIDESPREAD BIOTERRORISM EVENT 2

Abstract

What is bioterrorism? Bioterrorism is a form of terrorism where there is the intentional

release of biological agents (bacteria, viruses, or other germs). This is also referred to as germ

warfare. Terrorism is defined by the United States government as the "unlawful use of force and

violence against persons or property to intimidate or coerce a government, the civilian

population, or any segment thereof, in furtherance of political or social objectives." The term

"terrorism" does not imply what weapon is being used. In addition to biological agents, terrorists

can also utilize traditional weapons (guns), chemical agents and nuclear bombs.

While a biological agent may injure or kill people, animals, or plants, the goal for the terrorist is

to further their social and political goals by making their civilian targets feel as if their

government cannot protect them. Many biological agents are found in nature; however, they can

be modified by the terrorist to make them more dangerous. Some of these agents can be

transmitted from person to person, and the infection may take hours or days to become apparent.

There is a lot of interesting topics when it comes to bioterrorism and all of them are very

important for us to know what are the biological agents that can be utilized for bioterrorism,

what are the causes of bioterrorism in food, what are other sources for detailed information on

bioterrorism, how can we prepare ourselves for a bioterrorism attack, what are the warning signs

of a bioterrorism attack, what should we do if there has been a bioterrorism attack, how do we

know if somebody has been exposed to a bioterrorism agent, should we have some antibiotics on

hand just in case we get exposed, does the U.S. healthcare delivery system ready and prepared

for a widespread bioterrorism event.

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The Readiness and the Effectiveness of the U.S. Healthcare Delivery System in Responding to a

Widespread Bioterrorism Event

Bioterrorism

Biological agents are organisms or toxins that can kill or incapacitate people, livestock

and crops. A biological attack is the deliberate release of germs or other biological substances

that can make you sick.

There are three basic groups of biological agents that could likely be used as weapons:

bacteria, viruses and toxins. Biological agents can be dispersed by spraying them into the air,

person-to-person contact, infecting animals that carry the disease to humans and by

contaminating food and water.

Before a Biological Threat

A biological attack may or may not be immediately obvious. In most cases local health

care workers will report a pattern of unusual illness or there will be a wave of sick people

seeking emergency medical attention. The public would be alerted through an emergency radio

or TV broadcast, or some other signal used in your community, such as a telephone call or a

home visit from an emergency response worker.

The following are things you can do to protect yourself, your family and your property

from the effects of a biological threat:

 Build an Emergency Supply Kit

 Make a Family Emergency Plan

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 Check with your doctor to ensure all required or suggested immunizations are up

to date for yourself, your children and elderly family members.

 Consider installing a High-Efficiency Particulate Air (HEPA) filter in your

furnace return duct, which will filter out most biological agents that may enter

your house

During a Biological Threat

The first evidence of an attack may be when you notice symptoms of the disease caused

by exposure to an agent. In the event of a biological attack, public health officials may not

immediately be able to provide information on what you should do. It will take time to determine

exactly what the illness is, how it should be treated, and who is in danger.

Follow these guidelines during a biological threat:

 Watch tv, listen to the radio, or check the Internet for official news and

information including signs and symptoms of the disease, areas in danger, if

medications or vaccinations are being distributed and where you should seek

medical attention if you become ill.

 If you become aware of an unusual and suspicious substance, quickly get away.

 Cover your mouth and nose with layers of fabric that can filter the air but still

allow breathing. Examples include two to three layers of cotton such as a t-shirt,

handkerchief or towel.
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 Depending on the situation, wear a face mask to reduce inhaling or spreading

germs.

 If you have been exposed to a biological agent, remove and bag your clothes and

personal items. Follow official instructions for disposal of contaminated items.

 Wash yourself with soap and water and put on clean clothes.

 Contact authorities and seek medical assistance. You may be advised to stay away

from others or even quarantined.

 If your symptoms match those described and you are in the group considered at

risk, immediately seek emergency medical attention.

 Follow instructions of doctors and other public health officials.

 If the disease is contagious expect to receive medical evaluation and treatment.

 For non-contagious diseases, expect to receive medical evaluation and treatment.

 In a declared biological emergency or developing epidemic avoid crowds

 Wash your hands with soap and water frequently.

 Do not share food or utensils.

After a Biological Threat

Pay close attention to all official warnings and instructions on how to proceed. The

delivery of medical services for a biological event may be handled differently to respond to

increased demand.

The basic public health procedures and medical protocols for handling exposure to

biological agents are the same as for any infectious disease. It is important for you to pay

attention to official instructions via radio, television, and emergency alert systems.
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What are the biological agents that can be utilized for bioterrorism?

While any germ, bacteria, or virus could potentially be utilized by terrorist, there are a

number of biological agents that have been recognized as being more likely to be utilized. The

reason for these agents being of concern is based on their availability to terrorists and the ease by

which these agents can be disseminated. The U.S. Centers for Disease Control and Prevention

(CDC) has developed a classification system for biological terror agents, which is available on

their web site (Categories). The classification is based on the likelihood of the agent being used

and the risk posed by each agent. The agents (and the diseases they cause) are listed in table 1,

including hyperlinks for those wishing to learn more about a specific agent or disease. However,

it is almost impossible for most people to memorize all the details about each of these agents. It

is more important for the general public to understand the risk of bioterrorism and the

appropriate response to a terrorist attack.

BIOTERRORISM AGENTS AND THE DISEASES THEY CAUSE

Disease caused by
Biologic agent
the agent

Bacillus anthracis Anthrax

Clostridium botulinum toxin Botulism

Yersinia pestis Plague

Variola major Smallpox

Francisella tularensis Tularemia

Filoviruses (for example, Ebola, Marburg) and arenaviruses (for Viral hemorrhagic
example, Lassa, Machupo) fevers
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BIOTERRORISM AGENTS AND THE DISEASES THEY CAUSE

Disease caused by
Biologic agent
the agent

Brucella species Brucellosis

Epsilon toxin of Clostridium perfringens Food poisoning

Salmonella species, Escherichia coli O157:H7, Shigella Food poisoning

Burkholderia mallei Glanders

Burkholderia pseudomallei Melioidosis

Chlamydia psittaci Psittacosis

Coxiella burnetii Q fever

Ricin toxin
Ricinus communis (castor beans)
poisoning

Staphylococcal enterotoxin B Food poisoning

Rickettsia prowazekii Epidemic typhus

Vibrio cholerae Cholera

Cryptosporidium parvum Cryptosporidiosis

Alphaviruses (for example, Venezuelan equine encephalitis, eastern

equine encephalitis, western equine encephalitis) and flaviviruses (for
Viral encephalitis
example, West Nile encephalitis, Saint Louis encephalitis, dengue
fever)

Influenza virus Influenza

MDR TB and XDR

Mycobacterium tuberculosis
TB
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Here’s a medical journal about Anthrax, Then and Now. We all know that there was a

case about it years ago.

“Anthrax, Then and Now”

Medical Author: Michael C. Fishbein, MD

Medical Editor: Leslie J. Schoenfield, MD, PhD

Revising Medical Editor: Jay W. Marks, MD

Experts have said that it is a matter of when, not if, a large act of bioterrorism carried out

in the U.S. Why "bio" terrorism? Biologic weapons are cheaper and more devastating than

chemical weapons and maybe even nuclear weapons. Deadly quantities of infectious agents are

easy to hide, transport, and spread throughout the population. Indeed, the U.S. already

experienced a bioterrorism attack. In 2001, powder containing the bacterium called anthrax was

distributed through the U.S. mail. Altogether, 22 people became infected with anthrax. These

people lived in South Florida, New York City, New Jersey, Maryland, Connecticut,

Pennsylvania, Virginia, and Washington, DC. Eleven people seem to have inhaled the anthrax,

and 11 others were infected through the skin. The FBI and CDC (Center for Disease Control) are

still investigating this outbreak.

Because of this outbreak, most Americans are now aware of the infectious disease called

anthrax. Most are also aware that it is usually a disease of animals and that it is a rare cause of

disease or death in humans. (Human Pathology, 1978).

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What are the causes of bioterrorism in food?

There are number of bacteria and bacterial toxins that could potentially be used to infect

the food supply. These include Clostridium botulinum toxin, Clostridium perfringens toxin,

Salmonella species, Escherichia coli O157:H7, Shigella, and Staphylococcal enterotoxin B. The

one that is most dangerous and most likely to be used in bioterrorism is Clostridium botulinum

toxin, which causes botulism.

What are other sources for detailed information on bioterrorism?

There are many different government-based web sites that have up-to-date information

on bioterrorism. These include the following:

1. U.S. Centers for Disease Control and Prevention

2. http://www.bt.cdc.gov/bioterrorism

3. United States Food and Drug Administration

4. http://www.fda.gov/oc/opacom/hottopics/bioterrorism.html

5. United States Department for Homeland Security

6. http://www.ready.gov/be-informed

7. How can I prepare myself for a bioterrorism attack?

8. The American Red Cross, in cooperation with the CDC, has developed a detailed

plan that gives people the proper steps to take to prepare in the event there is a

bioterrorism attack

(http://www.redcross.org/preparedness/cdc_english/home.asp).
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The first step starts long before there is an attack. People must have appropriate supplies

stored in a safe place in their house, where they work, and even in their cars. Although

individuals may want to vary the list based on their needs, the list taken from the American Red

Cross' web site (see below) is a good place to start. A similar list can be found on the U.S.

Homeland Security web site (http://www.ready.gov/build-a-kit). These supplies may also be

invaluable to have on hand during natural disasters, which are more likely to occur than a

terrorist attack.

 Water: 3 gallons for each person who would use the kit and an additional 4

gallons per person or pet for use if you are confined to your home

 Food: a three-day supply in the kit and at least an additional four-day supply per

person or pet for use at home (You may want to consider stocking a two-week

supply of food and water in your home.)

 Items for infants, including formula, diapers, bottles, pacifiers, powdered milk,

and medications not requiring refrigeration

 Items for seniors, disabled people or anyone with serious allergies, including

special foods, denture items, extra eyeglasses, hearing aid batteries, prescription

and nonprescription medications that are regularly used, inhalers, and other

essential equipment

 Kitchen accessories: a manual can opener, mess kits or disposable cups, plates

and utensils, utility knife, sugar and salt, aluminum foil and plastic wrap,

resealable plastic bags

 A portable, battery-powered radio or television and extra fresh batteries

 Several flashlights and extra fresh batteries

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 A first aid kit

 One complete change of clothing and footwear for each person, including sturdy

work shoes or boots, rain gear, and other items adjusted for the season, such as

hats and gloves, thermal underwear, sunglasses, and dust masks

 Blankets or a sleeping bag for each person

 Sanitation and hygiene items: shampoo, deodorant, toothpaste, toothbrushes,

comb and brush, lip balm, sunscreen, contact lenses, any medications regularly

used, toilet paper, towelettes, soap, hand sanitizer, liquid detergent, feminine

supplies, plastic garbage bags (heavy-duty) and ties (for personal sanitation uses),

medium-sized plastic bucket with tight lid, disinfectant, and household chlorine

bleach

 Other essential items: paper, pencil, needles, thread, small A-B-C-type fire

extinguisher, medicine dropper, whistle, and emergency-preparedness manual

 Entertainment: including games, books, favorite dolls, and stuffed animals for

small children

 A map of the area marked with places you could go and their telephone numbers

 An extra set of keys and IDs: including keys for cars and any properties owned

and copies of driver's licenses, passports, and work-identification badges

 Cash, coins, and copies of credit cards

 Copies of medical prescriptions

 Matches in a waterproof container

 A small tent, compass, and shovel

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What are the warning signs of a bioterrorism attack?

Although the government continues to search for an early detection system for biological,

chemical, and radiation terrorist attacks, none of these systems have been perfected. The medical

community is advised to look out for unusual diseases not typically seen in the area. Other

potential clues that raise suspicion for a bioterrorism attack include new types of antibiotic

resistance in bacteria, because some biologic agents are modified (weaponized) to make them

more lethal, unusual numbers of cases of a disease, and atypical presentation of diseases.

The public should constantly be vigilant for bioterrorism. Events that might suggest an

attack including a large number of ill or dead people in a small geographic area, multiple dead

animals of different species, and patients with multiple different diseases, indicating a mixed

attack.

What should people do if there has been a bioterrorism attack?

If you think that you have been exposed to a biological agent, the most important thing to

do is to quickly remove your clothing and wash off your skin. Most biological agents cannot

penetrate intact skin. Showering with soap and water will remove most agents from the skin. If

you have already inhaled or ingested the agent, decontamination using soap and water may not

help you but might help prevent exposing other family members or coworkers.

If the biological agent has been released into the air but you do not believe (or do not

know) you have been exposed, you can utilize masks to help prevent inhalation of the agent. The

problem is that standard surgical masks offer little protection. Specialized high-efficiency
RESPONDING TO A WIDESPREAD BIOTERRORISM EVENT 13

particulate air (HEPA) masks are available that offer better protection; however, they are more

expensive, not easily found, and should be fitted to the person using them.

The two most important tools used by public health officials will be isolation and

quarantine. Isolation is keeping people known to be ill away from other people. Quarantine is

keeping people who may have been exposed away from other people. The problem is that many

times we may not know who has been exposed. In these cases, the public health officials will

likely recommend that everyone stay in their homes and avoid all public gatherings. By doing

this, we will isolate those sick and quarantine those infected but who do not yet have symptoms.

Those cities that utilized this technique during the Spanish flu pandemic of 1918 had much lower

rates of death than did cities that did not practice good quarantine procedures.

If there has been a bioterrorism attack, the first important step is to get information

immediately from the news media as to the right course of action. For some terrorist attacks, it

may be correct to try and leave the area; however, for other events, it may be more appropriate to

shelter in place. With bioterrorism, there may be the possibility of transmission of disease from

one human to another (for example, measles, influenza, avian flu, smallpox, plague, and viral

hemorrhagic fevers). In the case of either a bioterrorism attack or just a natural outbreak, it may

be necessary to avoid contact with infected people or just remain inside in a period of time until

the infected people are no longer contagious. Again, the key action is to understand the

recommendations from public health officials as delivered through the news media.
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How do we know if we have been exposed to a bioterrorism agent?

The symptoms of illness caused by the different bioterrorism agents are frequently very

nonspecific. Many of the agents cause a "flu-like" illness. These symptoms would include fever,

cough, nausea, vomiting, and headache. It is very hard to differentiate many of the different

diseases initially, and tests to confirm the diagnosis often must be done at specialized state

laboratories and may require weeks until the results are received.

It is best to stay informed through news media on what symptoms to look for and when to

seek medical care. The health care system simply cannot handle every member in the community

demanding to be tested for the disease. Many diseases do not even have a treatment other than

supportive care which can often be done at home.

Should we have some antibiotics on hand just in case we get exposed?

While there are a few biological agents that can be prevented by taking antibiotics (for

example, anthrax), it is not recommended that you stockpile antibiotics. Antibiotics have a

limited shelf life and would likely be unusable by the time an attack might occur. Also, there are

many different types of infectious agents, each requiring different antibiotics. All drugs,

including antibiotics, have side effects, and taking them inappropriately could cause more harm

than good.

Because the likelihood of a biological attack is small, it is better to wait until there has

been an attack before getting medications. The U.S. government has stockpiles of drugs that will

be immediately flown into a community that has experienced a biological attack (these supplies
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are rotated to keep them current). Additionally, many large communities also have stockpiles of

medications for emergency use.

Bioterrorism and Drug Preparedness

To help prepare our country for possible bioterrorism attacks, FDA is working with other

federal agencies to make sure adequate supplies of medicine and vaccines are available to the

American public. This page provides links to the most current information on drug therapy and

vaccines, plus advice on purchasing and taking medication.

Counterterrorism and Emerging Threats

FDA plays a critical role in protecting the United States from chemical, biological,

radiological, nuclear, and emerging infectious disease threats. FDA ensures that medical

countermeasures (MCMs)—including drugs, vaccines and diagnostic tests—to counter these

threats are safe, effective, and secure.

FDA Medical Countermeasures Initiative (MCMi), an FDA-wide initiative to coordinate

medical countermeasure development, preparedness, and response.

Medical countermeasures, or MCMs, are FDA-regulated products (biologics, drugs,

devices) that may be used in the event of a potential public health emergency stemming from a

terrorist attack with a biological, chemical, or radiological/nuclear material, or a naturally

occurring emerging disease.

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MCMs can be used to diagnose, prevent, protect from, or treat conditions associated

with chemical, biological, radiological, or nuclear (CBRN) threats, or emerging infectious

diseases.

MCMs can include:

 Biologic products, such as vaccines,

blood products and antibodies

 Drugs, such as antimicrobial or antiviral

drugs

 Devices, including diagnostic tests to

identify threat agents, and personal protective equipment (PPE), such as gloves,

respirators (face masks), and ventilators

What is FDA’s role in supporting the development of medical countermeasures?

Through the FDA Medical Countermeasures Initiative (MCMi), FDA works

with partners at all levels of government—local, state, national and international—to support

MCM-related public health preparedness and response efforts. FDA is part of the U.S.

Department of Health and Human Services (HHS) Public Health Emergency Medical

Countermeasures Enterprise (PHEMCE), which coordinates MCM-related efforts across HHS

and USG interagency partners.

FDA also works with non-government organizations, universities and research centers,

and industry to further the development of MCMs for public health emergency preparedness.

How are MCMs accessed and used in emergencies?

Depending on the emergency and public health need, during a public health emergency,

MCMs may be provided by the Strategic National Stockpile (SNS), which is overseen by the
RESPONDING TO A WIDESPREAD BIOTERRORISM EVENT 17

Centers for Disease Control and Prevention (CDC), or through state and local stockpiles or other

pharmaceutical caches. MCMs are usually dispensed or administered by health care workers and

public health responders under official federal, state, and/or local emergency response plans.

In some cases, at the time of a public health emergency, MCMs may be approved by

FDA and will be used in approved ways during a response. Some MCMs may not be approved

yet, or they may be approved but not for the indication under consideration during the

emergency.

Because of its role in regulating medical products, and the nature of some of these

products, FDA may need to use special authorities to allow the use of such MCMs in impacted

populations during or in anticipation of emergencies. Mechanisms FDA can use to allow the

emergency use of MCMs include the Emergency Use Authorization (EUA) authority and several

authorities related to the emergency use of approved MCMs.

What is the Animal Rule?

Before a medical product can be approved by FDA, the sponsor must demonstrate

efficacy—that the product works. In some cases, such as developing MCMs for potential

bioterror threats, human challenge studies (exposing people to the threat agent) would not be

ethical or feasible.

In these cases, FDA may grant approval based on well-controlled animal studies, when

the results of those studies establish that the drug or biologic product is reasonably likely to

produce clinical benefit in humans. The product sponsor must still demonstrate the product’s

safety in humans.
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FDA is committed to protecting national health and security. We are working to foster

the development and availability of medical products that will be needed to counter a public

health emergency, no matter its origin.

The FDA Medical Countermeasures Initiative (MCMi) mission includes:

A robust MCM regulatory science program creates

the data necessary to support regulatory decision-making

A collaborative effort to modernize the legal,

regulatory and policy frameworkestablishes effective

policies and mechanisms to facilitate timely access to

available MCMs

A professional development program helps FDA

meets the regulatory challenges posed by new science and

technology developments
RESPONDING TO A WIDESPREAD BIOTERRORISM EVENT 19

The last terrorist attack was the September 11 bombing in New York., The United States

has never been prepared in such a state of alert. The use of biological weapons could be the

greatest treat because of the portability and the easy distribution of the agents. The U.S.

healthcare system is not fully capable of handling a biological terrorist attack because of funding

needed to prepare for such disasters, resources to operate and overcome, and effective

communication with the different agencies that would be involved. What modifications and

adjustments does the U.S. healthcare delivery system need to implement to ensure that we will

be 100% ready and prepared for bioterrorist attack? Now that the government knows such

attacks are possible, is there a national emergency plan in place for health care delivery? If so,

what is the plan? Who is responsible for it? Which agency has the lead role? What other agencies

have major roles? What is the command-and-control structure? Has the government made sure

that one agency is responsible for coordinating the efforts of all other agencies? What authority

resides with the newly established Office of Homeland Security? Are the responsibilities

transferred from other agencies, or new? Are the authority and responsibility for combating

bioterrorism clearly designated at the federal level? If not, by when will these be established?

According to the GAO, “under the Federal Response Plan, CDC is the lead [HHS]

agency provides assistance to state and local governments for five functions:

(1) health surveillance, (2) worker health and safety, (3) radiological, chemical, and

biological hazard consultation, (4) public health information, and (5) vector control.
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The CDC has established a process to prepare public health agencies for a biological

attack. The steps in this process are:

 Enhance epidemiologic capacity to detect and respond to biological attacks.

 Supply diagnostic reagents to state and local public health agencies.

 Establish communication programs to ensure delivery of accurate information.

 Enhance bioterrorism-related education and training for health care professionals.

 Prepare educational materials that will inform and reassure the public during and

after a biological attack.

 Stockpile appropriate vaccines and drugs.

 Establish molecular surveillance for microbial strains, including unusual or drug-

resistant strains.

 Support the development of diagnostic tests.

 Encourage research on antiviral drugs and vaccines.

For responding to a biological attack, the CDC has issued broad plans in its biological

and chemical terrorism preparedness and response report indicating it will:

 Assist state and local health agencies in organizing response capacities to rapidly

deploy in the event of an overt attack or a suspicious outbreak that might be the

result of a covert attack.

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 Ensure that procedures are in place for rapid mobilization of CDC terrorism

response teams that will provide on-site assistance to local health workers,

security agents and law enforcement officers.

 Establish a national pharmaceutical stockpile to provide medical supplies in the

event of a terrorist attack that involved biological or chemical agents.

Recommendations and Proposals:

Government officials must act swiftly to develop a plan for stockpiling and distributing

medicine and delivering treatment to all Americans. Such a plan must be developed and

announced through the mass media to ensure public confidence and that appropriate actions are

taken by health care providers and the public in the event of an emergency. This

recommendation also applies to those states developing pharmaceutical stockpiles.

HHS through its Office of Public Health Preparedness must keep the public informed

about its efforts to enhance HHS’ response to anthrax and other biological threats. This can be

done via public service announcements on television, radio, and the print media, via HHS’ Web

site, through mass mailings and billboards, and as a specific request to news agencies to provide

this information. A national toll-free desk must be established to field questions and respond to

the public’s requests for information about health care threats.

HHS must ensure that states and localities are adequately prepared to deal with a

biological or chemical attack. A valid assurance would include a detailed and sufficient plan of
RESPONDING TO A WIDESPREAD BIOTERRORISM EVENT 22

action for quickly locating and treating an affected population in the wake of a biological or

chemical attack. Inclusive in this plan would be specific locations for distribution of

pharmaceutical supplies and the active notification of the public regarding these locations.

Adequate plans must be subjected to a national review and confirmation from HHS on a scale of

one to five, with five being the highest rating, and recertification would be required on a yearly

basis. Plans receiving a rating of less than five, or failing to receive any rating, would be

provided a six-month period in which to improve one scale rating or achieve a rating of one, and

a year to achieve a five rating. Ratings would be tailored to the needs of individual states and

localities depending on their characteristics.

An underlying weakness of the nation’s health care system is that it ignores the nexus

between population group membership and the receipt of health care. Health care disparities

exist between various population groups. Past failures to take disparities into account give rise to

questions about the government’s readiness to treat all Americans if bioterrorism escalates. The

federal government must take minority health disparities into consideration and immediately

alter the nation’s health care infrastructure accordingly.

The CDC should develop model emergency response plans for state and local

jurisdictions that will take variations in resources and infrastructures. Additionally, partnerships

must be created between well-prepared states (such as Illinois) and others (such as New

Hampshire) to help jurisdictions found lacking increase their competency levels.

RESPONDING TO A WIDESPREAD BIOTERRORISM EVENT 23

Federal, state, and local governments must identify, recruit, and train a network of

multilingual volunteers and personnel who can be deployed to assist with limited-English-

proficient populations in the event of a biological attack.

Following a bioterrorist attack, the federal government must ensure that everyone,

regardless of race, ethnicity, and socioeconomic class, is provided with long-term medical care.

To accomplish this, it is necessary that federal, state, and local governments and health care

providers develop relationships and the mechanisms to communicate with and inform racial and

ethnic minorities.

Protocols for responding to a bioterrorist attack must be established by federal, state, and

local governments and health care professionals. These protocols must clearly state, among other

points, how everyone in a city will be notified following a bioterrorist attack and that everyone

will receive the same treatment regardless of race, ethnicity, and socioeconomic class.

The deterioration of the health care “safety net” over many years demands that the

number of trained health care volunteers be increased. More health care volunteers are not only

required in the event of a bioterrorist attack but are also needed to combat the long-term

reduction of health care financing disproportionately affecting minorities.

RESPONDING TO A WIDESPREAD BIOTERRORISM EVENT 24

References