By Sydney J. Freedberg Jr. and Marilyn Werber Serafini

From the National Journal, Nov. 10

In a way that the far bloodier September 11 attacks did not, the anthrax assault has required unprecedented collaboration: among law enforcement, emergency management, and public health officials; among federal, state, and local government; and between government at all levels and the medical community. If the attacks-by-mail did America any kind of favor, it was to highlight how many weak links there are in the chains that bind these agencies to each other in a crisis-links that must be strengthened before a far heavier blow breaks them apart completely.

Consider Clifford Ong, Indiana's new statewide counter-terrorism coordinator, appointed two weeks into the crisis as the Hoosier version of national Homeland Security chief Tom Ridge. Ong's office, intended to be the state's central clearinghouse for anthrax information, first learned about Indiana's most serious anthrax scare, not through official channels, but from the media. Although about 600 miles from any confirmed case of anthrax, Indianapolis happens to have one of the only two facilities nationwide that repair and recycle post office sorting machines-including a tainted printer from Trenton, N.J. State authorities did not even know the repair plant was there until a subcontractor called asking for advice about how to handle machinery possibly exposed to anthrax. The state then tested for anthrax at the repair plant, and the report came back negative. Ong relaxed. But he didn't know that the main contractor at the plant had asked the U.S. Postal Service to come and do its own test. This second test, performed by an out-of-state lab, came back positive. Suddenly, there was anthrax in Indiana, and yet state authorities weren't told. Reporters in Washington were. Ong had to field the frantic calls.

"Our problem isn't locally," said Ong, who has long worked with the local U.S. district attorney and the FBI field office. "Washington seems to respond within the Beltway to national media without any concern that we have local media.... It puts us in somewhat of a defensive position."

This snafu-just one of many-shows how vital information can fall into the cracks between organizations, into blind spots where fear can flourish like mold inside a wall. Considering that just four people died of anthrax in one month, the average American was far more likely to be struck by lightning, which kills 80 to 100 people every year, than to contract the disease. The point is that anthrax is not contagious-but fear is. "The medical problem was actually pretty small," said Jack Harrald, the director of the Institute for Crisis, Disaster, and Risk Management at George Washington University in Washington. "The terror problem, in terms of managing people's fear, was pretty huge-and not very well managed."

The failure of government, medicine, and media to respond to fears and ignorance about anthrax with real understanding led to millions of dollars in losses-to businesses that had to find substitute mail carriers or evacuate their workplaces for testing, as well as to local governments that had to respond to every emergency anthrax scare. In Los Angeles, where hazardous-materials responses increased 300 percent in mid-October, "we received a call from an employee at a doughnut shop that there's a white, powdery substance on the floor," said Deputy Chief Darrell Higuchi, of the Los Angeles County Fire Department. The shop, of course, sold doughnuts with powdered sugar. "Yet," said Higuchi, "you feel for the callers, because they are scared."

Fear thrives on ignorance. But there is no effective, authoritative, nationwide system to communicate information about bioterror. Nor is there a single national spokesperson for the public's health. Indeed, some have criticized the Bush Administration for failing to designate someone as the voice of the anthrax crisis, even acknowledging White House reluctance to call on Surgeon General David Satcher, a leftover Clinton Administration appointee. Instead, information has moved through dozens of parallel and poorly coordinated channels of communication: The Centers for Disease Control and Prevention talks to state health officers, the FBI to local sheriffs, the Federal Emergency Management Agency to disaster officials, medical associations to their members. But when people in different fields, such as police and physicians, must work together, or when there simply is no state or local counterpart to a federal agency, the channels are less clear-as Ong found out in dealing with the Postal Service. The system simply isn't set up to share information.

In fact, civil liberties laws often forbid necessary communication. Said Lawrence Gostin, the director of the Center for Law and the Public's Health, a joint project of Georgetown University and Johns Hopkins University: "The law thwarts vital information-sharing vertically from federal to state, and horizontally between law enforcement, emergency management, and public health."

The biggest gap is between government and the medical community. A CDC alert on bioterrorism, sent to state health officials just after September 11, had still not reached many local emergency rooms a week later. And the crucial linchpins between doctors and officials-local public health offices-are notoriously overworked and short of funds. As many as one in five public health offices do not even have e-mail, said Sen. Bill Frist, R-Tenn., a physician. Many localities still collect epidemiological data on disease outbreaks only by asking doctors to send postcards through the mail-hardly an ideal approach in any fast-moving outbreak, let alone one that strikes at the postal system.

Anthrax has finally kick-started efforts to revive public health systems, after decades of neglect. In North Carolina, for example, the Legislature is about to allocate millions of dollars to replace reporting by postcard with high-speed, highly secure electronic links. Ultimately, the network will connect not only local officials, but also every hospital, pharmacy, and doctor's office in the state.

New funding and new networks are essential first steps. But in a country where almost all health care is provided by the private sector-indeed, where most critical terrorist targets, from Internet servers to nuclear plants to sports arenas, are privately owned-defense against terrorism probably cannot be achieved by a new agency, a new program, or a new technology. True "homeland security," most experts say, will require an overarching system that links not just every level and agency of government, but also the private sector, nonprofit groups, and the general public. Computers and the Internet will be vital in helping to set up this new national network, but it will be the intangible connections between people working together in a common cause that will really make the new system work.

The Broken Linchpin

If it sometimes seems as if the world has turned upside down since September 11, that's because it has. Terrorism has upset the traditional pyramid of who protects whom. No longer do the Pentagon's armed troops bear the brunt of foreign blows. Whether the danger comes from airliners-as-bombs or from anthrax envelopes, local firefighters, medics, and police respond long before Washington can act. But even the local emergency teams come second to the scene. In a terrorist attack, the first responder is the ordinary citizen-the airline passenger who decides to rush the hijackers, the mailroom clerk who notices a suspicious package, or anyone who wonders whether these flu-like symptoms they're feeling might be anthrax. It is their decisions, prudent or paranoid, that trigger the government response. Said Peter Probst, a former Pentagon and CIA official, "The first line of defense is an educated, engaged public."

That word, "educated," signals where things start breaking down. Even those officials who should be best equipped to inform have stumbled over their own statements, and each other's-and that includes Surgeon General Satcher and Health and Human Services Secretary Tommy G. Thompson.

"You've got Satcher saying one thing, Tommy Thompson saying another, and the CDC saying a third," fumed one local official who spoke with National Journal. One day the word is to put everyone on Cipro, the next day not, the third day it's another antibiotic altogether. "There isn't a consistent message."

With that confusion at the top, many officials, never mind ordinary citizens, admit turning to the news media as their first source of knowledge. But as reporters themselves grope in the dark for information, and constantly face the pressure for round-the-clock, up-to-the-minute coverage, they may magnify inconclusive clues, or even outright rumors, into major scare stories. There was so much misinformation about anthrax early on, said one congressional staffer well versed in bioterror, "the first few days, I was kicking the television a lot."

Many confused citizens dialed 911, just to be sure. Far more fell back on the second line of defense: their doctors. Physicians are still trusted more than most other professionals. And even though only a handful of American doctors have ever seen a case of inhalation anthrax (the last U.S. case was in 1978), most rushed to learn what they could. Until recently, medical education on bioweapons has been minimal. But after September 11, well before the first anthrax case in Florida, sensitivity to terror of all kinds was so high that the major medical associations quickly rallied to upload data to their Web sites and downlink teleconferences to their members.

That information probably saved lives. Had Florida photo editor Bob Stevens died in August, said Randall Larsen, director of the Anser Institute for Homeland Security, a consulting group in Northern Virginia, "it's highly unlikely he would have been diagnosed as dying with anthrax, because they weren't looking for it." Before September 11, when authorities sent anthrax samples to four medical laboratories as a test of their bioterrorism alertness, three of the labs just threw the samples out, mistaking the anthrax bacteria for contamination on the slides. In another test, out of a roomful of doctors at Johns Hopkins medical center, just one recognized an X-ray of a strange chest inflammation as characteristic of anthrax. Even after the September 11 attacks, HHS Secretary Thompson initially suggested that Stevens's death was due to a freak natural cause. But doctors were on high enough alert by then to spot the symptoms.

Although the professional medical associations could deluge their members with basic references on anthrax, they lacked the quick communications systems to collect and broadcast up-to-date data on the ever-changing outbreak. In fact, since most associations serve only a single medical specialty-and even the mighty American Medical Association serves fewer than half of all doctors-they could not even help share information among different types of doctors in a given community.

The painstaking, county-by-county collation of data gathered from individual physicians has always fallen to local public health offices-the traditional American defensive line against disease. But emergency officials, medical associations, and independent experts alike all agree that the public health infrastructure has long been, to quote one congressional staffer, "the forgotten stepchild." These local offices are perpetually short on funds, technology, and-above all-personnel. They are burdened with laws written to guard against 19th-century scourges such as syphilis and tuberculosis, and few of these laws even require doctors to report outbreaks of likely bioweapons such as anthrax, much less the subtler indications of spreading disease.

"Suppose there's a run on anti-diarrhea medication. How would we know that? If there are a lot of absences from school or work, how would we know that?" said Georgetown University's Gostin. "We need a public health agency to be able to get information from the private sector."

New York City, considered a national model, does keep hourly tabs on such things as sales of the anti-diarrheal Kaopectate. Los Angeles hospitals are linked by computer to share diagnosis data. But most areas lack such sophisticated "disease surveillance" systems, even in states that have really tried. Virginia, for example, connects its local health offices across the state by computer, said George Foresman, a Virginia emergency management official, but the state's effort to bring private practices into the network stalled because "we just had not been able to secure the funding."

The problems are not only fiscal. Even with a $1.4 million federal grant, Michigan found the private sector deeply reluctant to share information. "We've asked pharmacies if we could monitor what antibiotics are going out," said Dr. Sandro Cinti, of the University of Michigan medical center, "but they didn't want to give away that information."

In the absence of even such imperfect electronic systems, most public health officials collect data the old-fashioned way: slowly. In some places, doctors' offices fill out and mail in forms to health agencies; in other places, they call in, and local officials must laboriously enter the information by hand, and then in turn mail another piece of paper to the state health office. Conversely, when Illinois authorities, who have invested heavily in linking public health offices to local hospitals, wanted to send every physician in the state advice on anthrax, they had to take the licensing board's master list of addresses and mail every one of them a letter. There was no comprehensive e-mail or electronic system.

"The information-gathering and decision-making loop isn't fast enough," said Clark Staten, the executive director of the Emergency Response & Research Institute in Chicago. "The bad guys can move faster than the good guys-at the present time." And during that lag, fear can spread, and people can die.

More Than Medical

Even in a better-than-average flu season, doctors may run out of vaccine and hospitals out of beds. In some cities last year, said Sen. Edward Kennedy, D-Mass., "they had sick patients that couldn't even be treated in the emergency rooms-they were out in cars."

Any major natural disease outbreak overtaxes American medicine. But biological terrorism takes the complexity an octave higher. Each scattering of spores is obviously a public health problem. But it is also evidence of a crime-and of a hazardous material in the environment. Anthrax not only requires close "vertical" cooperation among federal, state, local, and private medical organizations, it also cuts horizontally across functional lines. Ordinary disease can be dropped neatly into an organizational box marked "medical." Bioterrorism requires out-of-the-box cooperation among public health professionals, private doctors, law enforcement agencies, firefighters, emergency management systems, and even foreign intelligence agencies.

This kind of jurisdiction-crossing is so alien to American government that it is often outright illegal. If the Central Intelligence Agency had somehow found out beforehand about the anthrax-laced letter addressed to Senate Majority Leader Thomas A. Daschle, for example, it may not have been allowed to warn health officials until after it was sent, according to James Hodge, the project director of the Center for Law and Public's Health. To protect civil liberties, said Hodge, "there's a firewall between intelligence agencies and public health."

Even when there's no legal obstacle to collaboration, many of the various agencies lack the experience, the contacts, or the procedures to work together. Both the U.S. Postal Inspection Service and the Centers for Disease Control are trying to track the anthrax letters to their source. The two agencies share information, but they don't share people: Instead of combining forces, detectives and doctors are on two separate teams following different methods to reach the same goal.

Sometimes, the lack of coordination could have even worse consequences. "When I was the health commissioner of New York, I had no clue who was the head of the FBI office, and he had no clue who I was," said Margaret Hamburg, who went on to become HHS's top bioterror official under President Clinton. "The last thing they want to be doing is exchanging business cards in the middle of a crisis." Yet, that is just what often happened with the anthrax scare.

In the District of Columbia, for instance, where traditional federal-local complications compounded all the other problems, the initial confusion and inconsistencies in testing and treatment for Capitol Hill staff versus postal workers boiled over into racially tinged fury. One community forum turned, unfairly, into a pillorying of D.C. public health chief Ivan Walks. Soon Dr. Walks and Mayor Anthony Williams were holding joint press conferences with Postal Service officials and the CDC. But those relationships had to be set up on the spot-and the public health office still does not have a full-time representative in the District's interagency Emergency Operations Center.

D.C.'s problem is not uncommon. "We somehow managed to leave the public health system ... outside the emergency system," said Harrald, at D.C.'s George Washington University. Emergency managers, firefighters, and police have largely overcome past problems of coordination by planning and training together before disasters, and by jointly staffing command posts during times of crisis. Such a combined system cranked into action in New York City on September 11. "The federal government had thousands of people moving in the right direction 20 minutes after the second tower was hit," Harrald said. "We know how to do this. That's the good news."

The bad news is that, in most places, no one told public health officials the good news. In D.C., "it took a long time before the emergency room at [George Washington University] hospital and the emergency room at Children's Hospital and the attending physician of the Capitol and the CDC had the same picture of what they were dealing with," Harrald said. "I'm not throwing stones at individuals. The problem is that we didn't set the systems up before the event."

The American Answer

In the first month of anthrax attacks, the country's system of defenses against bioterror often seemed to be no system at all, only chaos. Fortunately, reality is more nuanced, and more heartening, than that. True, there is no one coherent national system. But there are systems-all partial, all imperfect, but needing mainly to be strengthened and brought into an overarching structure. Senate Health, Education, Labor, and Pensions Committee Chairman Kennedy and panel member Frist last year co-sponsored the Public Health Threats and Emergencies Act of 2000, which authorized $540 million a year to strengthen the public health infrastructure and to better recognize and respond to bioterrorism attacks. Congress has not yet funded the new law, but already the two Senators have upped their request to $1.4 billion a year.

The final sum needed for homeland security will surely be much higher. But "we're not going to create a whole new Department of Defense," with a $350 billion budget and staff of 3 million, said David McIntyre of the Anser Institute. "We're going to play with the chips that are on the table."

"The pieces are there," said Frist. The task is taking the pieces that exist-federal, state, local, and private-"and coordinating them in a seamless way. It can be done." In Frist's own field, transplant surgery, moving precious organs quickly across the country and then ensuring that patients' bodies do not reject the new tissue require far-flung hospitals and diverse disciplines to work closely together-and they do it, every day.

High on Capitol Hill's agenda is a massive reinvestment in the nation's long-neglected public health system. Top priority is a secure, high-speed electronic data-link for doctors and public health officials who are now scrawling disease reports on postcards. The CDC already has an electronic Epidemic Information Exchange system to share outbreak alerts among federal, state, and local public health officials, as well as the military. And long before September 11, the CDC had given all 50 states seed money to start work on a National Electronic Disease Surveillance System to link all 2,000-plus local health offices around the country. This network could automatically and swiftly share, for example, the results of a crucial diagnostic test. Ultimately, it could also tap into hospitals and even private practices. But for now, the surveillance network does not actually exist. A bare-bones "base system" is scheduled to begin in 20 states in 2002. That seemed plenty fast-before September 11. Now, lawmakers are likely to hit the gas.

But strengthening public health is only half the battle, because public health officials will still get their information from the private sector. The real challenge is to track-from every hospital, every doctor's office, and every pharmacy around the country-the telltale upticks in certain symptoms, or prescriptions, that although seemingly innocuous in isolation, could signal an impending crisis. It is a daunting task.

Yet it is also mostly done already. Insurance companies routinely require doctors to code each diagnosis and report it electronically for reimbursement, keeping electronic tabs on everything from pharmaceutical sales to major surgeries. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) made such reporting systems mandatory nationwide, though a significant 43 percent of doctors are not yet hooked up. In its patient-privacy rules, the act also has a little-known exception that requires doctors to share data on threats to public health.

Medical information companies are already on the Hill touting software solutions. A properly designed system could tap into the existing streams of data, strip off names and other individual identifiers, and crunch the numbers into trends. To be sure, such an early-warning system might well find false patterns. An upsurge in sales of certain drugs might indicate an outbreak of disease, or it could simply reflect effective advertising. Conversely, the system might miss a real outbreak if doctors consistently misdiagnosed as flu the ambiguous early symptoms of, say, anthrax-the reason why D.C.'s Walks is currently working on a system that codes not just final diagnoses but actual symptoms as well.

Still, the most sophisticated computer is only a tool. The most important linkages are among people. And in small ways, that linking process has already begun, too. Tom Ridge has held teleconferences with all 50 state governors. Local officials and medical associations are reaching out to one another, often through e-mail. And a FEMA program called "Project Impact" gives local governments grants and training to bring together different agencies, businesses, and community groups for disaster planning. Mayor Susan Savage of tornado-prone Tulsa, Okla., says that Project Impact simply but systematically asks, "What does the private sector bring to the table that can complement public resources?" On September 11, for example, when 800 airline passengers were stranded at the Tulsa airport, the city mobilized everything from public buses for transportation to local preachers for counseling, pulling resources freely from the public, private, and nonprofit sectors.

Officials, legislators, and experts increasingly agree that such bottom-up approaches are the model for homeland security. Imposing a single national system from the top down is not only impractical, it is probably unwise. What makes more sense is a "network of networks," an overarching system that lets each local government or private group tailor its approach to its own unique needs-within the overall framework.

A prototype nationwide network of networks has actually already been built. Unfortunately, it was promptly taken apart soon after. Late in 1999, when the public and private sectors alike were fretting that their computers might crash once the year hit "00," then-Secretary of State Madeleine K. Albright visited the national Y2K crisis center and exclaimed, "You could really run the world from here."

Like a terrorist, the Y2K bug threatened to strike unpredictably at any target: federal, state, local, or, in the vast majority of cases, private. Imposing a top-down structure to address the potential threat was impossible, recalled John Koskinen, Clinton's Y2K coordinator: "You need to build off existing structures, and not create new ones." So Koskinen pulled together existing networks-government agencies, corporations, trade associations, and industry groups-in a loose but comprehensive confederation that reached into every threatened sector, with himself as the lead spokesman.

"The year-2000 preparations were a pretty good dress rehearsal" for the kind of coordination required since September 11, said David Vaughan, a Texas public health official. JoAnne Moreau, the emergency preparedness director of Baton Rouge, La., agreed: "We developed relationships with agencies and companies and factions that we never knew would have some kind of role."

The lesson that Y2K holds for homeland defense is that the federal government cannot, need not, and probably should not, do everything. Of course, without strong guidance from Washington, the thousands of private and local-government responses could create an irrational tangle, like an ill-tended garden. The federal role is to fertilize the growth and, when necessary, prune it back. "There are 1,800 separate legal jurisdictions in the United States, and the American people and the Constitution like it that way," said David Siegrist of the Potomac Institute for Policy Studies think tank. "The federal government needs to offer incentives ... and set standards."

In a shadow war with an amorphous foe, America can prevail only by empowering individuals and small groups to innovate-because it is they, and not any federal official, who will be on the front lines. Thirty years ago, noted McIntyre, if a child showed up at school beaten black and blue, teachers might think, "Tough parents," and move on. Today, they would report the possible abuse-and thereby set various responses in motion. A public similarly well-educated to watch for something genuinely wrong in their world would go a long way, not just toward calming panic, but toward stopping terrorists before they strike.

"We don't want to be people who watch each other. We want to be people who watch out for each other," said McIntyre. "It's the distinction between a controlled society and a civil society. A civil society requires citizens. And in good times, maybe we forgot that."

We have certainly been reminded now.

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