U.S. Commission on Civil Rights

U.S. Commission on Civil Rights

Bioterrorism and Health Care Disparities

March 8, 2002

This briefing paper was prepared by the Commission's Office of Civil Rights Evaluation for the information of the Commissioners. The findings and recommendations are those of the staff.

The recent cases of anthrax contamination have raised numerous questions regarding the nation's health care system, especially as it relates to the prompt emergency medical treatment of hundreds or perhaps thousands of individuals. Of special concern to the U.S. Commission on Civil Rights is equitable treatment for all groups regardless of socioeconomic status, English-language proficiency, ethnicity, or race.[1]

With this review, the Commission's interest, focusing on the rights of protected classes, is that all Americans receive medical treatment that is equally prompt, sufficient, and systematic in the event of a biological attack on the United States. The U.S. Commission on Civil Rights has long been concerned with health care disparities, and recent events serve to make the urgency of the problem more stark. The following discussion incorporates some of the Commission's main concerns.

1.  How is the federal government making sure that all Americans are served fairly and equitably by the health care system and receive medication and treatment without class distinction?

In testimony before Congress in May 2001, Assistant Secretary for Health and Surgeon General Dr. David Satcher stated that disparities in the burden of illness and death continue to exist for African Americans, Hispanics, American Indians, Alaska Natives, and Asian Pacific Islanders when compared with the U.S. population as a whole. According to Dr. Satcher, the infant mortality rate for African Americans is more than double that of white citizens. The rate of death due to heart disease is 40 percent higher for African Americans than for whites, while for all cancers it is 30 percent higher. Lastly, the death rate among African Americans due to HIV/AIDS is more than seven times that for whites, just slightly higher than the homicide rate of six times. Mortality rates for other minorities mirror these disturbing trends.[2]

A report by the Institute of Medicine (IOM) argues that [d]espite the nation's vast riches and enormous resources, certain populations continue to fall outside the medical and economic mainstream and have little or no access to stable health care coverage. [3] These populations include the more than 44 million people without health care coverage (an increase of 11 million over the past decade), low-income underinsured individuals, Medicaid beneficiaries, and patients with special health care needs who rely on safety net providers for their care. . . . New studies forecast that, absent major reform, the number of uninsured will continue to grow substantially. [4]

A second report by IOM found that racial and ethnic minorities in the United States frequently receive lower quality health care than nonwhites. Although other studies have shown that lack of health insurance and lower income levels contribute to disparate treatment, this study demonstrates that racial and ethnic minorities receive less care despite having equivalent insurance and income. The report establishes that these disparities have historically existed and continue to exist. Factors that may contribute to unequal treatment are stereotyping, biases, and uncertainty on the part of health care providers. In the last instance, a health care provider is not culturally knowledgeable about what a patient may find acceptable in that social encounter. Also possibly contributing to inadequate health care for minorities are the conditions in which many clinical encounters take place. Contemporary clinical encounters are characterized by high time pressure, cognitive complexity and pressures for cost-containment, according to the study. These factors and numerous others create an environment designed to provide disparate treatment.[5]

Proposals by the federal government to eradicate disparate health care include the Department of Health and Human Services (HHS) coordinated effort to eliminate gaps in six areas contributing to this disparity by the year 2010. The six areas identified by HHS are diabetes, HIV/AIDS, infant mortality, immunizations, cancer screening and management, and cardiovascular disease. To reach this goal, HHS in its 2001 budget included $5.5 billion in subsidies for measures that focus on improving the health of minorities, a net increase of $720 million from the previous fiscal year.[6] Another stated initiative of the federal government is to improve the health care infrastructure and remove obstacles preventing minority populations from accessing health care. A third initiative is Healthy People 2010, a program promoting wellness and disease prevention on a national scale, which includes a primary goal of eliminating health disparities.[7] Additionally, in December 2000, culturally and linguistically based discrepancies in health care were addressed by HHS Office of Minority Health via the publication of recommended national service standards on these issues.[8]

Despite the very real threat of biological attack on the United States, HHS has not established which population groups will be the first to be treated when supplies are limited.[9] However, the General Accounting Office (GAO) does not believe that individuals lacking health insurance will be denied treatment if a biological attack occurs. The critical determinants for providing treatment will be whether an individual has been exposed to a biological contaminant. Furthermore, the needed drugs will be provided from a national pharmaceutical stockpile maintained by the federal government and not via normal health insurance coverage.[10]

2.  How is the federal government making sure that there is access to public health care in rural or underserved urban areas?

A 1999 study by the U.S. Commission on Civil Rights reported that [r]acial and ethnic minorities are more likely than whites to live in areas [whether rural or urban] that are medically underserved. [11] This study further stated that disparate treatment in the health care system could be viewed in the adverse effects of hospital closures and relocations to suburban communities on the minority population. [12]

A report by the Urban Institute states that numerous proposals over the last several years have argued for a limited service model for rural hospitals. That is, rural hospitals will play a complimentary role to urban ones by limiting the services they provide. The various problems created by the limited service model include an increase in the percentage of uninsured or publicly insured patients for rural hospitals as wealthier, insured individuals seek medical attention in urban hospitals providing more thorough service. The report also establishes that rural hospitals treat a larger number of underinsured patients, because rural areas typically include more self-employed, thus self-insured, individuals (e.g., farmers). Finally, the institute reports that, like the uninsured who live in urban areas, the rural uninsured seek medical attention at community health centers, hospital emergency rooms, local health departments, and private providers. However, since rural areas typically have fewer health care providers than urban areas, the safety net in rural areas generally includes almost all providers in the community; that is, the health care infrastructure in a rural community is the safety net. [13]

The federal government has undertaken several efforts to improve health care for underserved populations. For example, HHS State Office of Rural Health program is providing matching grants to the state health offices of all 50 states for the treatment of rural populations. Its Rural Outreach and Network Development programs help rural communities find innovative ways to stretch and coordinate their scarce health care dollars. HHS also supports five rural health research centers around the country. Additionally, HHS is conducting numerous other programs that bring services to rural areas, such as Community Health Centers.[14]

Regarding Native Americans, many of whom live on reservations in rural areas, HHS received a $214 million increase for the Indian Health Service (IHS) in fiscal 2001, thus increasing IHS budget to $2.6 billion. The increase was allocated for more comprehensive clinical and environmental health activities, stronger injury prevention programs, increased mental health and more opportunities for Native Americans to visit doctors and dentists. [15]

For minority populations, both in rural and urban settings, HHS National Cancer Institute (NCI), for example, spent nearly $125 million on minority research programs addressing cancer in 1997. However, the Institute of Medicine found a lack of strategic planning at NCI, thus calling into question the effectiveness of its programs.[16]

Lastly, the National Association of Counties (NACo) conducted a nationwide survey of counties with functioning county level governments to determine their ability to respond to emergency situations.[17] Of the 3,066 counties that fit this definition, approximately 34 percent provided a response. The percentage of respondents was highest (28 percent) among counties with between 10 and 24,999 residents, while lowest (2 percent) among those with 500,000 or more residents. Naturally, counties with 500,000-plus residents are fewer in number to begin with.

The survey results paint a bleak scenario, as less than 10 percent of respondents stated they were fully prepared to respond to a biological attack. Even worse, less than 5 percent were confident they could adequately respond to a chemical attack.[18] Furthermore, although 94 percent of respondents have plans for dealing with natural disasters, only 49 percent have plans addressing possible terrorist activities. As may be expected, 80 percent of counties with one million or more residents have instituted plans to deal with a chemical attack, while only 22 percent of counties with fewer than 10,000 inhabitants, typically in the most rural areas of the country, have plans to deal with all possible terrorist activities. It must be noted that the 80 percent arrived at for counties with a million or more inhabitants is solely applicable to a chemical attack; no data are available concerning a biological attack, and the percentage of those fully prepared for either possibility is nominal. Finally, 21 percent of respondents have no preparations for a biological attack, while 43 percent have no response plans for a chemical attack.[19]

As is evident, the nation's counties are not prepared to adequately, if at all, respond to biological or chemical attacks. NACo has sought the aid of Congress and the Bush administration in drastically improving this situation.[20]

3.  After the anthrax attacks in 2001, officials seemed to advise members of the public to call their private doctors. What should an American do if he or she doesn't have a regular doctor or health insurance?

Examining the number of minority individuals lacking health insurance in the United States, a national study found that roughly 11 percent of non-Hispanic whites were uninsured in 1999, compared with 33 percent of Hispanics and 21 percent of African Americans. Additionally, compared with 10 years ago fewer African American and Latino working adults are provided health insurance by their employers.[21] As noted by a Commission researcher, [t]he nation's health care safety net has, by default, cared for many of the uninsured. However, as the number of uninsured grows, this safety net is being strained beyond endurance.[22]

In the event of a mass anthrax attack, the federal government, through the efforts of HHS, will respond by providing appropriate antibiotics from its stockpile to wherever they are needed. Furthermore, the government advises against asking one's doctor in advance for antibiotics, because these will be made available by the government when needed.[23] Reiterating this point, the GAO states that the needed drugs will be provided from a national pharmaceutical stockpile provided by the federal government and not via normal health insurance coverage. Additionally, the Centers for Disease Control and Prevention's (CDC) policy is to vaccinate only those individuals who have been exposed to a contaminant, not the universal populace, regardless of the quantity of vaccine available, according to the GAO.[24] One HHS official states that HHS policy of selective vaccination may change once enough vaccine becomes available.[25]

Lastly, the distribution of pharmaceuticals and treatment of affected individuals is, apparently, a multilevel process including the federal, state, and local governments. At the federal level, HHS Office of Emergency Preparedness (OEP) is developing the Metropolitan Medical Response Systems (MMRS). MMRS encompasses public contractual relationships permitting the use of existing emergency response systems emergency management, medical and mental health providers, public health departments, law enforcement, fire departments, EMS and the National Guard to provide a unified response to a mass casualty event. To date, OEP has contractual agreements to develop MMRS with 97 municipalities. Furthering its distribution and treatment abilities,

OEP also coordinates the National Disaster Medical System (NDMS), a group of more than 7,000 volunteer health and support professionals who can be deployed anywhere in the country to assist communities in which local response systems are overwhelmed or incapacitated.

In the event of a biological attack, 44 Disaster Medical Assistance Teams (DMATs) consisting of these volunteers would be responsible for providing on-site medical triage, patient care and transportation to medical facilities. In addition to DMATs, there are four National Medical Response Teams (NMRTs) that possess their own pharmaceuticals and the ability to detect biological contaminants, decontaminate victims, provide medical care and remove victims from the scene. Three NMRTs respond nationally, while the fourth is permanently situated in Washington, D.C.[26]

At the state and local levels, the procedures for distribution of pharmaceuticals and treatment of affected individuals, as well as the general level of readiness, vary among localities. The state of Illinois currently appears to have the most organized system. Illinois has contracted with pharmaceutical packagers and distributors so that the drugs it receives from the national pharmaceutical stockpile can be redistributed into 1.5 million individual doses within 24 hours. It took the National Guard in Colorado several days to accomplish this feat during a trial run. To date, Illinois is the only state to have implemented this system.[27] On a local level, Chicago has enacted a system in which pharmaceuticals will be distributed at hundreds of schools and clinics as opposed to more centralized and less numerous locations, such as hospitals. By distributing drugs from these more localized and numerous facilities, Chicago officials believe the public will be less liable to panic in the event of an emergency.[28] Conversely, the state of New Hampshire is one which needs to improve its plan for dealing with a biological or chemical attack. A state commission that examined New Hampshire's preparedness recommended that the state increase its ability to treat individuals at public health labs and hospitals, increase its statewide distribution of emergency medical supplies, and establish a statewide hospital mutual-aid agreement. Additionally, it was recommended that the state's ability to distribute medications from national stockpiles and treat affected individuals with these drugs be enhanced.[29]

4.  Initially, officials seemed to minimize the anthrax incidents as isolated, not related to terrorism, the result of anthrax occurring naturally in the environment, and not a threat to postal workers. Events proved that none of this was the case. What is the government now doing to more accurately forecast and establish a clear plan to respond to bioterrorist attacks?

An examination of the government's efforts in the first days of the outbreaks highlights several problems. When the initial case of anthrax appeared, federal officials failed to realize that it was the first indication of a serious public health threat, as can be seen from the following timeline:

• October 9. After the CDC confirmed the first case of anthrax in a Florida man, Secretary of Health and Human Services Tommy Thompson suggested that he most likely contracted the disease through outdoor activities. This theory proved to be untrue when the origin was traced to a letter sent to his place of employment, American Media.

• October 12. NBC announced that news anchor Tom Brokaw s assistant tested positive for anthrax after receiving a suspicious letter.

• October 13. Two doctors notified New Jersey state health officials that their patients, both postal workers undergoing treatment for skin lesions, likely handled the letter.

• October 14. Another postal worker at the Hamilton plant that processed the NBC letter developed flu-like symptoms.

• October 15. Anthrax spores were found at a post office that handled mail for American Media. This discovery did not prompt the testing of any other postal facility. Anthrax also was found in a letter sent to Senate Majority Leader Tom Daschle. Public health officials acted quickly and decisively to address the contamination of the U.S. Senate. Forty members of Senator Daschle's staff were tested immediately; over the next two days, hundreds of members of Congress and Hill staffers were offered testing and medication.

• October 18. Test results from two New Jersey postal workers with skin lesions came back positive for skin anthrax. The FBI and CDC began environmental testing at the plant at which they worked. The assumption was still that only those who touched a contaminated letter were at risk. Neither the state nor federal government assumed any responsibility for the medical treatment of the postal employees, indicating that they should seek treatment from their own doctors.

• October 19. The State of New Jersey Department of Health became increasingly concerned because of the outbreak at the Capitol and changed its recommendations. It urged all postal employees at the Hamilton and West Trenton facilities to take antibiotics. But the department persisted in stating that postal employees should seek treatment from their own private doctors or a nearby hospital.

• October 20. Anthrax was discovered in the mailroom of another office building on Capitol Hill.

• October 21. Officials confirmed that one employee of the Brentwood post office in Northeast Washington, D.C., had been diagnosed with inhalation anthrax. In New Jersey, 13 of 23 samples taken by federal officials at the Hamilton facility tested positive for anthrax contamination.

• October 22. Officials announced that two postal workers from the Brentwood facility died of inhalation anthrax. The government abandoned its position that only those who touched mail would likely become sick.

• October 23. Federal health officials said that in the future they would more aggressively test and treat postal workers who may have come in contact with contaminated letters or packages. Finally, testing of thousands of postal workers was ordered.

The government, in order to enhance the nation's ability to detect and respond to a biological attack, has announced some new initiatives. For example, the CDC is upgrading the nation's public health laboratory and epidemiological capacity, and HHS via its Office of Emergency Preparedness is expanding its efforts to develop medical response capabilities at local and national levels. [30]

However, the slow response toward testing and treating workers at the postal processing facilities in New Jersey and Washington, D.C., raises questions of equitable treatment and appropriate response. Some have argued that officials . . . acted less swiftly to defend the blue-collar, often minority workers of the Postal Service than they had the white-collar, mainly white world of Capitol Hill. Officials have countered that the government honestly believed no contamination had occurred at Brentwood.[31] Furthermore, Tom Ridge, director of the Office of Homeland Security, states:

[S]oon after the first case of anthrax surfaced [at the Brentwood facility], CDC placed its medical surveillance team on the highest alert. This medical survey team monitors emergency room logs every day all across the country. The purpose of the service is to track potential trends. When we put them on alert, we wanted them to track trends dealing with anthrax-like symptoms.[32]

Finally, when it is determined that a biological attack has occurred, the CDC states that it will rapidly deploy pharmaceuticals to the affected population. Once a determination has been made as to the specific biological or chemical agent, subsequent deployment of pharmaceuticals will be geared toward treatment of this specific agent.[33]

5. 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 providing 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. [34] In this capacity, 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.[35]

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.

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.[36]

The CDC report recommended that this plan be refined and implemented by 2004.[37]

CDC responded to the anthrax crisis with the following, among other efforts: CDC has established a secured web-based system for states to report weekly summaries of their bioterrorism-related activities [with] eight to 30 full-time personnel [engaged] in . . . responses in each state conducting investigations of bioterrorism threats. Furthermore, CDC and state and local public health agencies are continuing epidemiologic and laboratory investigations of bioterrorism-related anthrax. [38]

Despite the CDC's expertise and existing role in responding to a biological attack upon the United States, under Presidential Decision Directive 39 the Federal Bureau of Investigation [FBI] [is] the lead agency for the crisis plan [while] . . . the Federal Emergency Management Agency [FEMA] [is responsible for] ensuring that the federal response management is adequate to respond to the consequences of terrorism. [39] The crisis aspect, directed by the FBI, is not addressed in this paper, because it pertains to criminal investigations and not medical treatment after an attack. FEMA's role is that of consequence management, which encompasses efforts to provide medical treatment and emergency services, [evacuating] people from dangerous areas, and [restoring] government services. Primary responsibility for providing consequence management falls to state and local authorities, with FEMA playing a supporting role. However, the FBI is the agency charged with principal authority in case of biological attack and must be supported by [a]ll federal agencies and departments, as needed. . . . [40]

The newly created Office of Homeland Security is charged with developing and coordinating the implementation of a comprehensive national strategy to secure the United States from terrorist threats or attacks. Inclusive in this mandate is the responsibility to coordinate development of monitoring protocols for use in detecting the release of biological, chemical, and radiological hazards. . . . [41] Additionally, this office is collaborating with the CDC, the Food and Drug Administration and the National Institutes of Health . . . to support and encourage research to address scientific issues related to bioterrorism. [42]

Despite all these efforts, the federal government's current state of preparedness led GAO to conclude that the federal response to a biological attack operates under an umbrella of various policies and contingency plans. [43] Echoing the GAO's concerns are numerous other individuals. Dr. Victor Sidel, professor of social medicine at Albert Einstein College of Medicine in New York, for example, believes that the United States may place too much control over public health matters in the hands of military and law enforcement officials. [44] One federal official states that as far as he is aware, the federal government has no master emergency plan established to deal with a biological attack.[45]

However, it must be noted that the federal government will not be directing the distribution of vaccines in the wake of a biological attack unless the Secretary of HHS declares a public health emergency. Responsibility for distribution of pharmaceuticals falls to state and local officials.[46] As previously discussed, the system currently in place appears to be a multilevel one.[47] At the federal level, HHS Office of Emergency Preparedness (OEP) is establishing a system that will unite federal, state, and local entities in responding to a biological or chemical attack.[48] However, the choice of locations for the distribution of pharmaceutical supplies to the affected population appears to reside with individual states and, more specifically, local governments. In Chicago, for example, city officials have decided to distribute drugs from the more localized and numerous schools and clinics as opposed to more centralized and less numerous locations, such as hospitals.[49] Finally, as GAO explained, the responsibility for distributing pharmaceuticals has been left to state and local officials, but the vaccination policy rests with CDC. Currently, CDC's policy is to vaccinate only those individuals who have been exposed to a contaminant, not the universal populace, regardless of the quantity of vaccine available.[50] However, one HHS official states that HHS policy of selective vaccination may change once enough vaccine becomes available.[51]

Turning to fiscal matters, the Bush administration's fiscal year 2003 budget requests $5.8 billion for the CDC. This is a decrease of $1 billion (or 15 percent) from fiscal 2002 and is primarily due to a major one-time purchase of vaccines and other pharmaceuticals to combat bioterrorist threats in fiscal 2002. A total of $1.6 billion will be directed at CDC bioterrorism preparedness, a net decrease of $661 million from fiscal 2002. Furthermore, the budget reflects a one-time decrease of $757 million in the costs associated with the procurement of vaccines and pharmaceuticals in fiscal year 2002. Of the $1.6 billion for bioterrorism preparedness, $940 million is for state and local bioterrorism preparedness, the same as in fiscal 2002. The amount of $159 million is aimed at upgrading CDC's scientific response ability through the acquisition of additional equipment and personnel, including the Rapid Response and Advanced Technology (RRAT) Lab at the National Center for Infectious Diseases. RRAT specializes in the triage and analysis of biological specimens as potential agents of terrorism. A proposed $400 million of the $1.6 billion is for the addition of 286 million doses of smallpox vaccine, to be available by the end of fiscal 2002, to the National Pharmaceutical Stockpile. To assist states in distributing stockpile supplies, $65 million will be made available. CDC's budget also includes $18 million for continued research evaluations of the anthrax vaccine used to inoculate military personnel, and offered to postal workers and congressional staff. [52]

The administration's budget also includes $1.8 billion for the National Institutes of Health (NIH). This money will fund countermeasures developed by NIH, in coordination with the Office of Homeland Security and the Office of Public Health Preparedness (OPHP), aimed at neutralizing bioterrorist threats from micro-organisms such as smallpox, anthrax, tularemia, and plague.[53]

Lastly, the budget includes $37.7 billion for the Office of Homeland Security, an increase of $19.5 billion from fiscal 2002. Of that amount, $3.5 billion is for the nation's first responders, who include police, firefighters, and Emergency Medical Teams. A total of $11 billion is for border security, an increase of $2 billion, while nearly $6 billion will be directed at defending against bioterrorism. Efforts geared toward intelligence-gathering and improved coordination between agencies will receive $700 million in funding. And $200 million will be used to create Citizens Corps, which will help communities to be better prepared for terrorist attacks.[54]

6.  Has the CDC named a new assistant secretary for bioterrorism, as has been discussed in media accounts? If so, what is that office's role?

On July 10, 2001, HHS Secretary Tommy Thompson introduced Dr. Scott Lillibridge as his special assistant for bioterrorism. The department s news release said, Lillibridge will coordinate anti-bioterrorism efforts across the department and will report directly to Secretary Thompson. Dr. Lillibridge previously coordinated CDC's bioterrorism response effort.[55] On November 1, 2001, Dr. Lillibridge began reporting to Dr. Donald A. Henderson, who was selected as director of the newly created OPHP. This office will work with all HHS agencies to enhance the response to anthrax attacks, and any other biological attacks that may occur.[56] Finally, one HHS official states that to the best of his knowledge there is no proposal to create an assistant secretary for bioterrorism position because OPHP could possibly serve the same purpose.[57]

7. How will the problem of articulation between civilian and military organizations be resolved? For example, which agency will stockpile medication? Which agency will distribute it?

Under the National Pharmaceutical Stockpile Program a repository of life-saving pharmaceuticals, antidotes, and medical supplies, known as 12-Hour Push Packages are maintained. These packages are suitable for use in any emergency, including a bioterrorist attack. The CDC and the OEP both maintain stockpiles.[58] The stockpiles maintained by CDC will take up to 12 hours to deploy. . . . OEP's stockpiles will deploy simultaneously with its National Disaster Medical System (NDMS), and the three NDMS teams can be at an airport (commercial or military) and be ready to board within five hours of notification. [59] As concerns the military, the Marine Corps Chemical and Biological Incident Response Force, for example, may be deployed to assist civilian communities. . . . [60] However, regarding the small pox vaccine, Dr. Nathan Stinson, director of HHS Office of Minority Health, states that while both HHS and the military are stockpiling it, the Department of Defense would limit the use of the military stockpile to the armed forces.[61] Still, according to the White House and the Office of Homeland Security, [t]he U.S. Government has [a total of] eight stockpiles or push packages containing 50 tons of medical supplies that can be anywhere in the United States within 12 hours or less. It takes nine semi-trucks to haul the supplies. [62] Lastly, many states are developing independent pharmaceutical stockpiles. In states where this is occurring, the state health department will be 're sponsible for keeping the stockpiles of vaccines. Management of these stockpiles is at the discretion of the particular state.[63]

8. What role and responsibility does HHS Office for Civil Rights (OCR) bear?

The Commission's Office of Civil Rights Evaluation submitted questions to HHS/OCR regarding OCR's role in preparing for and responding to a biological attack. The questions were forwarded to Dr. Donald A. Henderson.[64] However, one HHS official states that HHS/OCR is currently fulfilling its mission.[65] A review of OCR's Web site on March 13, 2002, did not provide any information regarding efforts to prevent unequal treatment in the delivery of medical services in the wake of a biological attack. Of course, if one considers OCR s mission statement it is readily clear that this office should ensure that unequal treatment does not occur. This statement reads:

The Department of Health and Human Services, through the Office for Civil Rights, promotes and ensures that people have equal access to and opportunity to participate in and receive services in all HHS programs without facing unlawful discrimination. Through prevention and elimination of unlawful discrimination, the Office for Civil Rights helps HHS carry out its overall mission of improving the health and well-being of all people affected by its many programs.

This mission is communicated throughout the Department and is reflected in the customer service nondiscrimination objectives that have been developed in the Department's strategic plan. Ensuring the nondiscriminatory provision of services funded by or provided directly by the Department is a continuing challenge to all of the Department's employees.

STAFF FINDINGS

1. The stated goal of the CDC's Federal Response Plan is to provide comprehensive, integrated training designed to ensure core competency in public health preparedness and the highest levels of scientific expertise among local, state, and federal partners. [66] It was recommended that the plan be implemented by 2004.[67] The Commission finds that the plan is oriented to administrative processes and not to the active provision of health care to the American population. Details about how the plan will be implemented have been nonexistent. The plan makes no provisions for low-income Americans, those living in rural areas, or those who may require language assistance. Furthermore, the 2004 timeframe for implementation is inadequate, since recent events have proven that the need for a plan is present.

2. Many within the public and private sectors find that our nation's public health system is deeply flawed, perpetually underfunded, lacking political support, and encumbered by antiquated laws.[68] The Commission finds no evidence substantially refuting this impression. Simply stated, more funding and political support especially as underserved populations are concerned are required. A crisis exists that has left a vast number of Americans, primarily the poor, women, and language, racial, and ethnic minorities, unprotected and uncared for by our nation's medical system. The current and very real threat of a biological attack has brought this crisis to the forefront of public issues necessitating immediate action.

3. As concluded by the Commission, [d]iscrimination in health care delivery, financing and research continues to exist. [69] Disparate treatment links the poor, the limited-English proficient, the non-English speaking, and certain ethnic and racial groups in a system that does not provide them adequate health care and, quite often, fair consideration during nonemergency periods. Our review finds that the government does not have a plan to ensure that all groups, be they economic, language, ethnic, or racial, will receive prompt, sufficient, and systematic treatment following a biological attack.

4. The federal government must take immediate steps to correct its biological terrorism response plan, which GAO found in disarray. Specifically, GAO established the existence of an uncoordinated, redundant system that requires streamlining and clear responsibilities and authority. From its mission statement, the Office of Homeland Security will coordinate the executive s branch efforts to detect, prepare for, prevent, protect against, respond to, and recover from terrorist attacks within the United States. [70] Still, it is not clear from our review which agency will serve as the coordinating body for the numerous independent efforts directed at treating individuals exposed to biological contaminants. Moreover, it is doubtful that government initiatives announced thus far will resolve the problem of redundancy and haphazard coordination.

5. Government officials have not demonstrated the existence of a comprehensive plan for delivering treatment into all segments of the nation s population in the event of widespread bioterrorism. Although state and local entities will have decision-making authority as to the dispersal of vaccines, unless the Secretary of HHS declares a public health emergency, the question remains whether those often ignored by society (the homeless, the socially underserved, the least economically viable) will be provided with adequate treatment and treated like all other segments of society.

6. The National Association of Counties (NACo) reports that counties throughout the nation are unprepared to respond to a biological or chemical attack. In a national survey of counties with functioning county level governments, to determine their ability to respond to emergency situations, NACo found that 21 percent of the counties that responded had no preparation for a biological attack, while 43 percent were unprepared for a chemical attack.[71]

STAFF RECOMMENDATIONS

1. 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.

2. 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.

3. 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 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.

4. 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.

5. The CDC should develop model emergency response plans for state and local jurisdictions that take into account 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.

6. 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.

7. 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.[72]

8. 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.[73]

9. 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.[74]