U.S. Commission on Civil Rights

U.S. Commission on Civil Rights

Briefing on Bioterrorism and Health Care Disparities

March 8, 2002

Presentation by Dr. Mohammad Akhter, Executive Director of the American Public Health Association

Proceedings

CHAIRPERSON BERRY: Now we have our guest with us. And the staff extended an invitation to the American Public Health Association and their executive director, Dr. Mohammad Akhter.

Would you please come forward, Dr. Akhter. And welcome, and thank you very much for coming.

Dr. Akhter's biography is in the material that you were given. But I'll note that he is executive director of the American Public Health Association. He previously was a senior advisor at the U.S. Department of Health and Human Services. And in addition to his position at the APHA, he is a physician with board certification in preventive medicine. He's a clinical professor at Georgetown University Medical School. He is also an adjunct professor of international public health at George Washington University, School of Public Health. He has held many public health leadership positions, including director of the Missouri State Department of Health and health commissioner here in the District of Columbia. And that had to be a tough job.

Dr. Akhter, the Commission has long been concerned about issues of health care disparities in general. And then with the recent issues around bioterrorism that is perpetrated or might be perpetrated against the United States, we had some discussion about the urgency of this problem and about inadequacies that may be there in our health systems and whether underserved communities in particular would be appropriately served if there were a massive bioterrorist attack.

So we re pleased that you were willing to come and have this brief discussion with us. Then we will have some questions, perhaps, and some exchanges as we proceed to try to understand this issue. So thank you very much for coming.

DR. AKHTER: Thank you for inviting me. Good morning. Indeed, a pleasure to be here this morning, to be speaking to you all, to provide you with some information and some ideas that might lead to prevention of potential abuses of the civil rights for the people.

The threat of bioterrorism is real. And I say this from the information that I have been discussing with the various government agencies, with the public health community.

I'm a member of a professional organization. Just like there's an American Bar Association, American Medical Association, there's an American Public Health Association, about 55,000 members working in the federal government, state government, and the local government, providing services to the people to ensure that the water that you drink is clean, that the air you breathe is safe, and that food you eat is not contaminated, and the children will go to school and have immunizations done.

And so I speak from very ground-level information, as well as information from our federal government agencies. And what we know at the moment is the threat is real for bioterrorism. There are several reasons for that.

The first one is that we are at war against the terrorists. And our President tells us it's going to be a long war. And the terrorists can any time strike back at us. And this is one of their ways of, really, attacking our population centers.

The second reason for the threat being real is that there are at least 15 or 16 countries around the world that have, or potentially have, the access to bioterrorism agents former states of the Soviet Union, for one; the Iraqi people. We know for sure the Iraqi government had tons of anthrax, and they weaponize it. And many of those states are not really keeping a good tab on these weapons or this anthrax. And they could just fall into the hands of the terrorist.

The third reason for us being concerned is the terrorists of today have a lot of money and a lot of connections. And there are 1,000 labs around the world, about half of them in the United States, the other half around the world, that are capable of maintaining and growing these organisms. And there are very few controls checks and balances on those labs and people who work in those labs. And finally, we have still not caught the culprits who were responsible for the anthrax attack. Those folks are still out there.

And so recognizing the threat is real, there's been a bipartisan effort in the United States government to prepare our nation against any eventuality that if there is an attack, that we are fully prepared.

And of all other potential disasters that might happen, the bioterrorism disaster is a very separate and different kind of category for a variety of reasons. If there s an earthquake, if there's a bomb blast, there's a sound, there's smoke, there's dust, there's lightening. But in a bioterrorist attack there is none of those. It's a silent attack. The first time you find out is when somebody gets sick, and we find out, oh, yes, anthrax attack. Because we can't see it; it's invisible.

The second thing is that, in any other attack, the attack takes place at one time, and it's over. They hit our buildings September 11. We knew this is it. We need to really take care of it. We need to do what we need to do. In a bioterrorist attack, every single case that takes place is a separate attack. It keeps taking place from time to time. Where next? We just don't know. And particularly, if they use an infectious agent where disease can spread from one person to another, it then becomes many attacks that continue to take place time after time. And so that's really a concern.

The reason I'm saying this is that for dealing with bioterrorist attacks, you need to have long-term medical care and follow-up for the folks. And that's why it becomes so important. And we need to have it all around the country for all people. Because with bioterrorism, people could attack anywhere, and they can do anything they may choose. They can pick the time, they can pick the agent, they can pick the place. It's up to them, so we need to be prepared.

I'm very pleased to tell you that our government has done a terrific job since September 11, at all levels, in preparing ourselves and dealing with this eventuality the President, the Congress. The federal agencies have allocated resources. Our intelligence today is much better. We have monies going from the federal government to state and local governments to really prepare themselves and start developing their plans.

But there are some inherent problems within our system as we enter this new century that we need to be aware of and need to be careful.

The first issue that I want to bring to your attention is the issue of a safety net. There are 40 million Americans who are uninsured; there are many who are underinsured. They don't have access to care. So we cannot simply say in a bioterrorist attack, Go to your private doctor and get your Cipro. It just will not happen. And even if you provide them the Cipro, like the government has planned on doing that we give them the push pack and say, everybody get a pack of Cipro, and we deliver it to you, how about if they have a reaction? How about if that Cipro is not good for them? How about if they have another complication? Where should they go? So we need to have that mechanism in place.

It's not only the issue of not having health insurance; it's also the issue of not having services available. There are many areas that our government has identified as underserved areas, many of them in rural America, but many of them in the inner-city areas, where there is no facility available. Physically there's not many doctors, private health commissioners in Washington, the nation's capital. Not long ago, in 91, for 78,000 children living east of the river, there were only four pediatricians who would take Medicaid. Now, how do you suppose those people will get the service?

And so it's the issue of not having the insurance and also not having the access to care. And I think somewhere we need to prepare for this, because if they don t have a good safety net today when there's peace, tranquility, what would happen if, God forbid, there's a big disaster? That safety net is going to be torn to shreds because demand on services will be so great. So that's my first point to you.

My second point today deals with our state and local public health infrastructure. These are the people at the state and local level. These are the county health directors, the city health departments, the state health departments.

For many years, the United States has been a country where we've been very fortunate to have no epidemic, no major outbreaks, there have been small outbreaks. So over a period of time, we have sort of taken the money away from those health departments to do other things. And so as we entered the century, we find we have the shells of health departments. For example, New York City would have 100-plus public health nurses. You'll find that now there are a handful of them there because the need wasn't there. But with a bioterrorist attack and seeing these consequences, it becomes important that we rebuild these health departments and really do them well. We can rebuild them or build what's there already. But we need to make sure that we do it in such a way that the people in underserved areas and minorities living in the inner city get the service.

The effectiveness of the health department is very evident. We have made tremendous progress in improving the infant morality rate and the death rate from heart disease and other areas. Our people are healthier today than they've ever been in the history of the United States of America. But yet, because we're a land of immigrants there are a lot of minorities, today 25 percent of all Americans are of racial and ethnic descent by 2030, 40 percent; and by 2050, half of all Americans are going to be of racial and ethnic descent Asian Americans, Chinese Americans, African Americans, Hispanic Americans. And the public health system has not been able to reach these people because their experience with disease and death is very different today. There are disparities in health status.

The infant mortality rate for the African Americans, for example. If you start to look at it in one of our best states in the United States Minnesota infant mortality rate in that state for the entire state is the lowest in the nation, very good. But the infant mortality rate for the African American is the highest in the same state.

And similarly, you look at the heart disease rates, cancer rates, and diabetes rates, they are all higher among the minority populations. The highest infant mortality rate is among the Native Americans in the United States.

Let me just put it the other way. The life expectancy for Americans is 77 years right now, as a nation as a whole. When you come to African American women, it's five years less. When you come to African American men, it's eight years less. When you come to the Native Americans, it's 10 or 12 years less than the other folks.

We live in the same country, we pay the same taxes, we breathe the same air, and we enjoy the same food, but here there are these disparities that exist. And there has been a little disconnect between the public health departments ability to reach into these populations with culturally sensitive ways of providing them the service how they could live healthy, how they could grow up to be healthy, what to do in terms of other services that they need to have access to. And so we will always have the struggle as a state health commissioner in Missouri. As a state health commissioner here in the nation's capital, you always have the struggle with reaching out to these folks.

In a time of emergency, it becomes even more important that we have an ability to reach out to these people so that folks don't just simply stay home and not get the care that they need, that we have the access to. And I think we need to make sure that as we build up the capacity of the health department, that we build up this capacity of outreach, the ability to be able to communicate with the minority population so that they will not disproportionately suffer in view of the bioterrorist attacks.

And my last point this morning deals with the states that are now considering new legislation that will give the states the authority to quarantine people, to take other people's property in time of a bioterrorist attack. This is something that every state felt that we just need to strengthen our existing rules and regulations. And therein lies the problem, how do you balance the need of the state, the need of the country, and need of the people who will be quarantined? How do you make that decision of which population to quarantine, which population not to quarantine?

And our view is that what we should have, Madam Chairperson of the Commission, is that the quarantine be the last resort, the option that's available, to manage that population, whether it's providing treatment to that population, whether it deals with vaccinating that population, we should try that to contain the disease; that the quarantine be the last resort. But if there's nothing else that's available this is really the only way that we can contain the disease sure enough we should do that. And when we provide the treatment to the people, that we should not do things differently; that we treat a certain group of people differently, or certain people have preference over the others, but the management of a disaster and the provision of treatment should be based upon the needs of the individual, not the position or the economic status, or the authority of the individual, and that that be really made part of their plans.

And I present this to you today because every state is now required by the federal government to submit a plan, a plan that's medically correct, that s administratively sound to deal with the terrorism. And that plan will then come to the federal government, the federal government will review that plan, and will provide the funding to the states.

Every state has been given 20 percent of their share of the funding for bioterrorism. Eighty percent will be given to them when they submit their plan. And as we speak today, the date for submission of the plan is May 15, that every state must submit their plan by that date. And as the federal government starts to review that plan and the federal government has said that they will make their decision within 30 days of receiving the plan they must look at not only the expediency and the medical effectiveness of the plan, but also the potential that the civil rights of any individual or group are not violated in the process. Their assurance is that every effort will be made to really make that happen. And one of the ways to make that happen is to bring representatives and such people to the table to really be part of the planning process.

Madam Chair, I stop here. And thank you and members of the Commission for this opportunity this morning. And if there are any questions or comments, I'd be delighted to answer them for you. Thank you again.

COMMISSIONER MEEKS: Thank you very much.

CHAIRPERSON BERRY: That was wonderful. That was the clearest expression I've heard of these issues.

Commissioner Meeks, and then Commissioner Edley, and then Commissioner Thernstrom.

COMMISSIONER MEEKS: I'm from Pine Ridge Indian Reservation, so this really brings up a lot of questions to me. One, the tribes don't usually have a relationship with the state, and the state doesn't have jurisdiction over the tribes. It's a government-to-government relationship which the tribes have with the federal government.

Do you know how the tribes are included in this plan?

DR. AKHTER: At the moment, the way the resources have been provided, it is the federal government providing resources to the states. There are few large cities that the federal government is giving special attention to. To my knowledge, there's not a special allocation, if you will, for the tribes to prepare for this major event.

COMMISSIONER MEEKS: Do you know if the Indian Health Service is included in this plan? Has it been to the table on this?

DR. AKHTER: I'm not aware of the fact, whether they are on the table or not. I'm sure they are involved at some level, but I don't know what level. This has been, basically, taking the resources and giving it to the states, and saying, states, you prepare the plan for the people in your state.

CHAIRPERSON BERRY: Elsie, I read in the just to intervene, I read in the newspaper somewhere that some of the tribes were complaining about this, because they didn't think they should have to go through the state. And somebody was trying to figure out how to fix it.

Commissioner Edley?

COMMISSIONER EDLEY: Thank you. Great. I mean, really. Great.

I guess I want to focus on the last sort of issues that you were talking about, the issues of treatment, quarantine, etc. And here's the dilemma as I see it.

I think from a civil rights perspective, we're used to the problem that political processes may not work to protect the interests of minorities and disadvantaged populations. On the other hand, the literature is full of studies demonstrating not just disparities but disparate treatment by medical professionals of minorities, discrimination.

So when an event breaks out, I'm not quite sure who to trust to make these decisions about who gets quarantined, or what institution, or how the shredded safety nets get repaired, and what the priorities are going to be.

Do you see my problem? If you trust the politics, then you worry about the people with little political power getting the short end of the stick. If you trust the health care professionals, who are not really accountable to anybody, then you may see in this crisis situation what the literature tells us happens in emergency rooms namely, minorities getting the short end of the stick or not getting the same kind of treatment that middle-class Anglos would get.

So I'm puzzled about how in this time of crisis one creates a decision-making mechanism in which we can have confidence from a civil rights perspective. Because, otherwise, you remember all the suspicions about whether the black postal workers, because they were minorities, were going to be treated the same way as the largely white Capitol Hill staff.

COMMISSIONER BRACERAS: Well, they weren t.

COMMISSIONER EDLEY: And there's a question of whether they will be, and then there's just a question of whether, whatever the facts may be, whether the public is going to have confidence that the decision making is fair.

DR. AKHTER: Commissioner Edley, this is the crux of the matter. This is a wonderful question. It is not only whether they are treated, but also what kind of perception people develop in the process. And here is what I would recommend or suggest.

There need to be protocols developed in a very public way. We are never going to be able to deal with bioterrorist agents if we leave the decision making to the politicians, or to the medical people, or to the public health people, or to the police, or whoever else. There has to be a great amount of cooperation and collaboration between the people and their government in the time of crisis. We need people to operate, we need public education, we need to work with the people. We need to bring them to the table, and it has to be done very transparently.

We say, Folks if there is an outbreak, here is a protocol. This is how everybody living in the city will be notified. And so this same process. This is how those people where the impact is will be treated. Here are the protocols. This is where you will go get your medication. It will be the same medication. So that we make this for our nation a very transparent way. I need to have this transparency to be able to get the support of the people. Without the support of the people, I can have all the medicine, I can have all the knowledge, I will not be able to work this thing through. And gaining the confidence of the people is by having the transparency, having these protocols, having people's participation into the process so that everything is open.

The public knows. I think everybody living in Washington D.C. Dr. Walks and I spoke about this. Everybody should know living in Washington, D.C., that in case of crisis what will happen, how will they be notified, where should they go to get the treatment, and how the follow-up will be done, so that it's the same. We are prepared. It doesn't matter what color you are, it doesn't matter what race you are, it doesn't matter what part of the city you live that we have prepared for our city a plan. We will go down and just sort of implement that plan.

Would we make some mistakes? Yes, sir. Surely. There always will be. But if we can make this very transparent up front, I think the likelihood of us making a mistake will be very small.

CHAIRPERSON BERRY: Commissioner Thernstrom?

COMMISSIONER THERNSTROM: Well, I doubt that there's any disagreement on this Commission that too many people are uninsured in this country. I know in New York, if you're self-employed and you want, not decent, but half-way decent health insurance, you have to pay more than $500 a month, which is an extraordinary amount for most people. And all of us are concerned, of course, about infant mortality rate disparities and so forth.

But it seems to me that access to health care and health insurance and so forth is really a separate question, or largely separate question, in general, from access in the context of an emergency, when hospitals will obviously be open to everybody and hospitals are open. I mean, what Commissioner Edley is suggesting is open hospitals don't solve the problem because there s disparate treatment. But, obviously, in an emergency, hospitals are open to everybody needing emergency care.

And if there is discrimination in the emergency rooms once people arrive and I agree, by the way, that there need to be plans. And I would hope that the federal government and the state governments are engaged in that kind of planning. But if there is discrimination in the emergency room, which I hope is not true but if it's true, I'm not sure what the answer to that is in the way of regulations or anything that is a piece of paper that doesn't really respond to the problem.

DR. AKHTER: Very good question, very fundamental question.

As I said earlier, if the issue was one-time care you give somebody, you're done with. I would feel very comfortable saying, Oh, yes, you could go, you could get the care, it's done with. The issue in bioterrorism is long-term follow-up. Even in anthrax, a 60-day follow-up. People are going to be taking the Cipro for 60 days. In other infections, maybe longer. Sometimes the people who have nightmares and mental health problems tend to suffer two years long follow-up.

And so the issue for me I separate the issues of having universal coverage in our nation. But the issue to me is some kind of pronouncement that tells the population, that tells the health care providers that, Folks, in the case of an emergency, somebody's going to pay for it. It will be taken care of. You go to the hospital emergency room, you go to a private doctor. If it is related to this emergency, this disaster, long term it will be paid for.

Hospitals are wonderful institutions. They would love to serve the people for a day or for two days. But once you have a long-term commitment where there's no money coming in, they're also business institutions. And I've spoken to the hospitals, spoken to managed care organizations. If their institutions are going to be filled with people who are not going to be paying, then their own survival is also at stake.

So what I'm saying in this is that one of the ways to maintain and to assure that everybody's taken care of is to really give these assurances. And the only people who can do that is the federal government who says, Folks, in case of emergency, it doesn't matter whether you have insurance or not, whether you're covered by HMO or by somebody else, you will be taken care of. And I think that will go a long way in allaying the fears.

COMMISSIONER THERNSTROM: So what you're saying is suppose we have a terrible bioterrorism threat in this country anthrax, whatever, there are other possibilities, obviously, a whole range of them you could imagine masses of people being affected by this, and the federal government ignoring the need to respond by taking care of these people in a sustained way?

DR. AKHTER: Yes, it is very true. As we speak today, it is true. I'll tell you this. If there are people who have mental health problems because of the 9/11 incident, and they don't have health insurance, who is taking care of them? Who has provided the insurance, that, yes, it will be paid; they can go to a mental health professional to get the service? We know that from our members and from our leaders. We've spoken with the providers of the service the doctors, the hospitals and there is this concern at the bottom of all of this. They re willing to serve their community to the best of their ability. And they will do a great job. But to sustain providing services without having any way of, really, up-front assurance that they'll be compensated is a very important thing.

COMMISSIONER THERNSTROM: But mental health would be very different than a smallpox epidemic. I mean, surely, nobody would say, we're going to let smallpox spread throughout the nation. I mean, it's just not possible.

DR. AKHTER: I know. This sort of seems to you the hypothetical thing that nobody will do I think logically that is very true. But in realistic terms, if you don't have health insurance, as we speak today, you are three times less likely to seek care when you're sick versus if you have health insurance. So if a person doesn't have the health insurance, and he feels bad, and he has little hives, and he has this fever coming on, he stays home, spreads the disease to others.

On the other hand, if you have the assurance this is truly the issue of this is, can we assure our people and our providers that in case of disaster that there's a mechanism for which you'll be taken care of. And I think we need to say that up front, not leave it in some suspense that maybe somebody will, maybe somebody won t.

CHAIRPERSON BERRY: Vice Chair, and then Commissioner Meeks.

VICE CHAIRPERSON REYNOSO: First of all, I thought that your suggestion of a protocol is really very good, because it would bring everybody in to make those decisions. And somebody would have to at least violate the protocol if they re going to not be treating people equally.

But I have sort of a present type question. Out in California, we have two crises right now in California. One is the closing of emergency rooms in hospitals, and the other is the lack of a sufficient number of nurses. They've just moved some legislation to try to increase the number of nurses in California. But I ve seen nothing that's been done in terms of the emergency rooms. I've just read an article about all of the emergency rooms that have closed down for economic reasons in California.

To me, emergency rooms and nurses seem to be such a vital part of what to do in case there's a bioterrorism attack. So we're concerned about a bioterrorism attack, and yet, at least for now, at least as I hear in California, we re allowing some of the structure that would be necessary to be weakened.

Is California exceptional or are those things happening throughout the country?

DR. AKHTER: Commissioner, California is a little bit ahead than the rest of the country.

VICE CHAIRPERSON REYNOSO: Don't tell me that.

DR. AKHTER: But it is happening to some degree in other places too. The emergency rooms are overcrowded. I mean, we know that we close emergency rooms many times. We divert patients to the other places because we're too busy in one place or the other. But certainly the federal government our President, our Congress has done a great job in making the funds available to create additional capacity.

VICE CHAIRPERSON REYNOSO: To reverse those trends.

DR. AKHTER: To reverse those trends and say, here is the money to create the hospital capacity, and we're working with the hospital association to really look at and say we need to have the capacity. And that's two types of capacity. One is the emergency rooms themselves, that you have the capacity, in a community there's enough capacity to be expended in time of emergency to be able to take care of the folks. The second one is inpatient capacity in the hospital. That's also the same situation, where people wait in the emergency room because they can't find a bed up on the floor to be admitted in the hospital. And so that's in the works. It will be taken care of.

CHAIRPERSON BERRY: Commissioner Meeks?

COMMISSIONER MEEKS: Your point is well taken about people that are not insured. In the public health system they're so understaffed. I can give you just an example from a couple of weeks ago. And this is a rural area, reservation. She drove 50 miles to get a pap smear. Got there, they had a shortage of nurses, and they closed the clinic for the day. So people really do not go unless they I mean, that's why the death rate on reservations is so much higher.

So how is this going to address this staffing issue? Are these public health I mean, because that's where people are used to going to if they don't have insurance.

DR. AKHTER: Yes. There are two issues here. One is having the staff nursing shortage, for example. The President has done a great job putting money in his budget, saying here is the money, provide incentive, get more people to become nurses. Let s start this pipeline going. So one is the creating of manpower. So that's one issue.

But there's another issue that's equally important. If we want to distribute today in Washington, D.C., Cipro to the entire city, all the doctors, all the nurses, all the staff will not be enough. We need to train volunteers. And that's part of the process; that we train volunteers who become the extension from the public, who become the extension of the public health system so they can go out and provide the service in case of an emergency. God forbid, in a major disaster, there will not be enough people to do the work at a level that we do today in the hospitals or in the clinics. We will need to rely on a lot of volunteers to be able to tie ourselves over.

CHAIRPERSON BERRY: Commissioner Wilson?

COMMISSIONER WILSON: Thank you, Madam Chair.

First of all, I just want to thank you very much for your very lucid and thorough talk today. It's been very illuminating. Just a couple of points before I ask you the actual question.

In relation to what Commissioner Thernstrom was pointing out, what you're really saying is that it's not just the government that has to have the structure; it's if people don't have insurance, they're not going to move towards helping themselves, which I think is a very important point.

My question is, you were just talking about volunteers. Are these people being trained now? Is there a program to call up volunteers or to enlist the help of volunteers?

DR. AKHTER: Many hospitals, many medical institutions already have volunteers working. If you go down there, people doing the transport are volunteers. Sometimes people manning the front desks are volunteers. There's now money being made available through the federal government to the states and the local jurisdictions to formally do public education and to train volunteers to be able to have those people available in the community, and that they be done in such a way that could be identified in time of disaster, that they have a special cap after they complete their training or a special jersey they wear so that we can recognize they're part of the team and not somebody just going to interrupt the flow. So, yes, those plans are in the works.

COMMISSIONER WILSON: Because I'm assuming that the number of volunteers who are working in hospitals now wouldn't begin to be effective. I mean, you would need a massive number of volunteers.

DR. AKHTER: This is absolutely correct.

COMMISSIONER WILSON: It would seem to me that a large-scale campaign should be in the works for that now.

DR. AKHTER: Yes.

COMMISSIONER WILSON: But my central question that I had was that you passed over this quickly, and I would like you to talk a little bit more about it. I was somewhat alarmed at this. When you were talking about the issue of quarantining and some states I don't know if I heard you correctly taking property.

DR. AKHTER: Yes.

COMMISSIONER WILSON: Do you want to elaborate on that a little bit?

DR. AKHTER: Yes. We are a nation where the civil rights have been very much important as our nation's correcter, saying we just need to maintain people's civil rights, we need to have really minimum intrusion into the lives of the people. And the kind of authority that you have for example, I as health commissioner will have the authority to take an individual who is not taking his or her medication for tuberculosis and is dangerous to the other people.

I will take them and put them at the D.C. General Hospital for treatment. But as soon as they become noninfectious and they're no longer spreading the disease, which is in a month or six weeks, then I could not hold them any more. I need to let them go so that they could go back in the community, they will not take their medication again. They'll get back on their other drugs, alcohol, whatever their personal situation was. Then I will sometimes again take these people back in again and do that.

Now, there are folks in our society homeless people, mentally ill people who are out there where we maintain their rights as much as anybody else's rights. And the same is true of the properties. There may be a danger because something has happened in their property. We want to keep the property completely clean and ensure that it poses no threat to the community or to the nation as a whole.

And so the states are looking at their laws, and for the first time strengthening those laws so there's a clear-cut authority; that in a time of national emergency that the state has a clearly defined law to quarantine a group of people or to take over a property that will be in the best interest of the people.

And I think the issue here is to create a balance, that there is an appropriate decision-making process by which you will do this and not be done by fear, and not be done differently in the state of Missouri compared with the nation s capital; that we have a mechanism in place where we do this thing in some recognized, pre-agreed manner. Let's put it this way.

COMMISSIONER WILSON: But let me ask you this. If you follow this line of reasoning, that if people do not have insurance, and for the most part, then, would not be compelled, or would not feel the need, or would not feel the entitlement to go and get help for themselves, those are the people who are basically poor in this country. And not to say that those are the people who would have property. But supposing they did have property, it would seem to me that those would be the people who would more likely have their property seized.

DR. AKHTER: I don't think the property's being seized because they're not cooperating. I think the property's being seized because something has happened in that building. There's anthrax exposure in the building. And right now we don't have such clearly defined authority that we can take over the building. The post office building, yes. The government building, you can shut it down. But if it's a private building, what do you do? You want to make sure that it s clean, and you want to make sure it's safe for the public that is going to be doing business there, but also for the community.

COMMISSIONER WILSON: So once they seize it, they come in and, basically, decontaminate it?

DR. AKHTER: That's correct. So they will do the cleaning, and have that authority to be able to do that, without going through a lengthy court process.

CHAIRPERSON BERRY: Commissioner Thernstrom?

COMMISSIONER THERNSTROM: So if you were to pose these concerns to Tom Ridge, the Homeland director, to members of his staff, what would he say? Wouldn't he say, we agree that sorry about that. Since the mic was not on, I'll repeat the question.

If you were to pose these concerns articulate these concerns to Governor Ridge, Homeland director, to his staff, wouldn't he say, we agree that there absolutely has to be plans in place, and that is precisely what we're doing?

I mean, I raised the smallpox before because, obviously, anthrax is not an easily communicable disease, but smallpox is. And if there wasn't a proper response on the part of government public authorities as well as physicians and the health community this is a disease that could have devastating effects spreading throughout the population.

Isn't this something that is on Ridge's plate already? And are you saying, yes, but I don't really have confidence in this operation?

DR. AKHTER: No. I have all the confidence in Tom Ridge. But his plate is too big. There are too many things on the plate. The first thing is survival of our nation on the plate. Okay? That's the first part of the plate. Then there are other things as you go along the line the port security, the business security, and other things. And then finally you get down to it. It is a little bit further down the plate. And he's not the only one who really would be responsible. It's the state governments, the governors, the local governments.

And what happens is, that if there are other people who are watching, we just don t make the mistakes that we might otherwise make, not intentionally sometimes unintentionally, things happen that we put something together because this is what it is. So we believe that when these plans are being developed at the state and local levels, that if they're done in such a way that's transparent, there's participation of the people, there are the right protocols, that we will have a much better way of really protecting all of this. And ultimately, the plans are reviewed not only in terms of their medical effectiveness, their administrative efficiency, but also in terms of their ability to balance the need of the state or jurisdiction and the need of the people.

CHAIRPERSON BERRY: Dr. Akhter, we are very grateful to you for being here to have this discussion. And I was most interested in all the points you made, but one of them, which is that the bioterrorism issue is a subset of concern about the access to health care generally whether there are facilities, or the people are served, all those points you made. Which fits in with the concern the Commission has had a long time about what is the reason for disparities in health care race, class? Is it anything? What is it? And maybe we can have at some point another discussion about the general issue of health care disparities.

But I want to very much thank you for coming and appreciate it very much.

DR. AKHTER: My pleasure. Anytime. If there's any question I could answer for you, I'd be delighted. Thank you again very much.