briefing: Q&A with Arthur Reingold, public health expert
talks about what preparations we've made, quarantining and forced
vaccination, and the long-term sickness of the public health
31 October 2002
By Bonnie Azab Powell and Jeffery Kahn, Public Affairs
BERKELEY - Most of us have stopped worrying about getting
sick from opening our mail, but the threat and fear of bioterrorism
has not abated. Evidence has mounted that the 2001 anthrax attacks
were not the work of a rogue individual, but of a sophisticated
foreign terrorist organization. Without question, Iraq has biological
weapons. And in early October, the federal Centers for Disease
Control and Prevention (CDC) recommended that more than 500,000
hospital workers around the country receive vaccinations in
case of a smallpox attack.
even if we had the perfect piece of detection equipment,
we have bigger issues: how much would they cost, how many
trained people are needed to run them, where do you put
them — in Las Vegas but not in Reno? in San Francisco
and L.A. but not in Redding?' —Professor Art Reingold, director of Berkeley's
Center for Infectious Disease Preparedness
We decided to ask UC Berkeley public-health expert Arthur Reingold,
M.D., about the nation's state of readiness for biological attacks.
Head of the epidemiology division at the School of Public Health,
Reingold recently received a $2.8 million grant to establish
a new Center for Infectious Disease Preparedness, part of a
national network of academic centers that will train emergency
personnel. Before joining UC Berkeley's faculty, he was assistant
chief of the Special Pathogens Branch of the CDC's Bacterial
In October of last year you said
that the U.S. was far less prepared than it could be for a bioterrorism
attack. Do you think that's still true? What progress have we
Basically, it's still true. There are two aspects of this preparation:
general public health preparedness and things that are specific
to bioterrorism, like smallpox vaccinations. We're much better
prepared for the latter. As a nation we've commissioned large
quantities of a modern smallpox vaccine and have large stores
of the old vaccine, which we've learned can be diluted and still
give protection. And we're at least talking about getting plans
in place for how you use the vaccine and how you vaccinate people.
There are moneys going to medical facilities to try and improve
their level of readiness, funds are being spent to develop central
repositories of drugs and various kinds of medical equipment
that could be flown somewhere within hours. Those kinds of quick-response
things are certainly in the works; some existed before 9/11
and some have been expanded greatly since then.
So if you're talking about specifics for things like smallpox,
those are happening at a speed that's maddeningly slow, incredibly
fast, or just about right, depending on your point of view.
What about developing systems that
can detect an attack before people get sick?
Technology that can detect organisms in the
environment using an air or a soil sample has been advancing
over the last several years; the military has had such technology
as far back as the Gulf War. Obviously those efforts have been
given added impetus from the Department of Defense. Such devices
still have some marked limitations, some of which may be amenable
to engineering and some that won't. They're still not 100 percent
specific — there are organisms that look like anthrax
that some of the machines cannot tell apart — so we're
likely to have false positives. But even if we had the perfect
piece of detection equipment, we have bigger issues: how much
would they cost, how many trained people are needed to run them,
where do you put them — in Las Vegas but not in Reno?
in San Francisco and L.A. but not in Redding? Where in San Francisco?
we'll probably have to rely on the traditional public health
means of detection, where the doctor is first to identify an
Most likely. In a battlefield situation, with a finite area,
monitoring the environment makes sense, but when you're talking
about trying to protect the entire U.S., clearly there a lot
of decisions still to be made. But what people like about that
idea is that we may be able to detect the problem before people
get sick: using people as the sentinel canaries obviously lacks
in public health who do the kind of work I do, the much more
central issue is about monitoring of illness in the population,
for example if someone does something terrible like sprinkle
salmonella in a salad bar or spray smallpox virus in JFK airport.
If you accept the notion that some people — at least one
— have to get sick before we can detect the problem, then
the question is how good is the existing system for detecting
that, what are the communications that are available, what's
being done to improve those factors. It's not just whether we're
prepared for bioterrorism, but whether the basic public health
infrastructure in general is ready to detect and respond quickly
The infrastructure is still woefully inadequate
in some ways, and that's a problem. It's better than it is in
most countries. It's been good enough to serve the country and
society reasonably well, but it's certainly not nearly as good
as it could or should be, and the reason for that is a fundamental
lack of interest in paying for public health at the local and
Public health has been under-funded for decades. Health departments
have fewer people than they should, and those they do have are
not as well trained as they should be. The salaries are low,
the infrastructure is bad, the staff support is poor, and the
opportunities for continuing education are almost nonexistent.
While there are some wonderfully talented people working in
public health, they're not there because of all the great things
public health has to offer them.
After 9/11, we learned that many public health departments don't
have email or fax machines. Have we at least improved the communications
There's been a longstanding effort to improve the electronic
communication of data for reporting of diseases, so that if
a doctor sees a case of tularemia or plague, say, he or she
transmits that information electronically via the Internet in
a secure manner. That information would then be rapidly shared
from the county to the state to the CDC (national level). For
several years now, the CDC has been working on moving from a
very archaic 19th-century approach in which doctors fax or mail
in these cards. But connecting all these doctors and counties
and states is not a trivial challenge: there are enormous issues
around hardware, software, security, privacy, and training individuals
to use it. We're a while away from adopting electronic reporting
have never forcibly vaccinated someone against their will
in this country. We have in other countries, in the smallpox
eradication program in South Asia in the 1970s. I am pretty
sure we would not permit that here.' —Professor Art Reingold
In the meantime,
what we have in place is a system where doctors and labs and
nurses and other health professionals have requirements to report
things to the county health department, which reports to the
state. But all the laws about reporting diseases are state laws,
not federal. So if the CDC wants to make a particular disease
reportable, it has to coordinate with 50 different states.
The system does a reasonable job of detecting and responding
to problems. Some small outbreaks might get missed. But when
you start talking about bioterrorism, would the system detect
an anthrax or a smallpox attack? Absolutely.
Would the system detect an attack
rapidly enough to contain it?
That's the 64-dollar question, and it depends on a lot of imponderables.
If somebody were to spray anthrax over New York City, how "rapid"
is rapid enough? And what is "contain"? Some people
will die. The only question is, what proportion of those deaths
would be preventable by earlier detection and a certain series
of actions unfolding.
State legislatures are debating whether to adopt what's
called the Model State Emergency Health Powers Act, which would
give them the legal power to test people against their will,
vaccinate them, quarantine an area, and seize property to be
used as treatment facilities. Are those kind of actions necessary?
Aren't they already legally available to health officials?
You have to be careful in lumping all these measures together.
In terms of quarantine, my guess is that the laws exist that
would allow the health department to close bridges, limit movement,
and have forcible quarantine. As
a public health person, I guess I think if we truly had something
like a smallpox outbreak in California, such measures would
be reasonable. Historically, we’ve been willing to limit
the movement of people to prevent the spread of infection. So
if somebody refuses to take their tuberculosis medication, there's
a legal basis for restraining them in their home, jail, or the
hospital until they complete their treatment — we can't
otherwise protect the public from someone walking around coughing
out multi-drug-resistant TB.
Forced vaccination is not in the same league, however. We have
never forcibly vaccinated someone against their will in this
country. We have in other countries, in the smallpox eradication
program in South Asia in the 1970s. I am pretty sure we would
not permit that here.
caveat that I'm not a lawyer, my understanding is that virtually
every state has laws that give the health commissioner of department
powers like those to protect the public's health. Now, many
of those laws are 100 years old or more and have never been
tested in court. But I think that in an emergency if somebody
were to say, "I don't care what you say about the smallpox,
I'm still getting on that airplane," we'll need some public
health authority to prevent that. Maybe certain civil libertarian
groups would not agree, but I think most of the public would.
what circumstances do you quarantine people and limit movement?
Who has the authority to do what? Right now such emergency actions
still need public discussion, with politicians and community
leaders and all types of people involved.
the idea of bioterrorism keep you awake at night?
Well, I've always had a certain skepticism about this topic.
However, the anthrax attacks of last fall if nothing else say
that perhaps one can be too sanguine. Maybe the people who say
it's not "if" but "when" have the better
sense. But since it's absolutely impossible to me to predict
whether there will be other bioterrorism attacks or what agent
will be used where, I can't assess the risks or therefore calculate
the benefits of spending billions of dollars to be better prepared
for this, say, to vaccinate people for smallpox.
I do know
that we have lots of other health problems needing attention,
and so there are trade-offs. State budgets are in the tank.
California and other states have had to freeze hiring, freeze
travel, and cut costs wherever they can. So at the same time
that parts of the health department are getting better, others
are being slashed. What you have now is more people doing smallpox
surveillance and fewer people working on tuberculosis or sexually
transmitted diseases, because those areas are frozen or being
all the other cuts going on, are things better than they would
have been in the absence of those federal dollars? Sure. There
are improvements in some ways that are directly related to public
health, but I can't say there's a net improvement.
But I sleep soundly every night, and I get up each morning assuming
there will not be a smallpox outbreak in Berkeley. I hope that
I am right. This is a pretty crazy world these days.