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Tom Inglesby, MD We now begin the portion of the program entitled "Epidemic Response Scenario: Decision Making in a Time of Plague." The objective of the scenario that we will present is to illuminate what we believe are three of the most critical and complex issues that might arise in the management of an epidemic following a biological weapons attack on civilian populations. These three issues are: scarcity, containment of contagious disease, and decisionmaking processes. By scarcity, we mean conditions, even if local or temporary, which limit or constrain the availability of essential, potentially life-saving resources such as health care professionals, antibiotics, vaccines, equipment, or other logistical capabilities. By containment, we mean a spectrum of measures that might be used to limit the spread of contagious disease. These measures range from the use of simple surgical masks to isolation of infected patients, and range to travel advisories, prohibition of public gatherings, mandatory immunization, or forced quarantine of entire areas. And by decisionmaking processes, we mean those that deserve attention because a bioweapons attack could force collaboration among a diverse array of individuals, organizations, and professional communities, who do not typically interact. The format of the morning -- of the rest of the time will be, first, a few facts on plague; then, introductions of the remaining panelists that you do not now know; and then I will read the first segment of the scenario, and we will begin discussions. Dr. O'Toole will lead the conversation. Let me start, actually, with introductions. First, each panelist has been asked to assume a very specific role for the exercise and to rely on his or her judgment and experience to react to the scenario and make necessary decisions.
We've asked the panelists to be as specific as possible and to do their level best to remain in their roles. Moving from left to right, you all know Jerry Hauer from yesterday, Michael Osterholm, Ken Bloem. Steve Cantrill, fourth in the line, is Associate Director of Emergency Medicine at Denver Health Medical Center in Denver, Colorado. He is an internationally-renowned expert on disaster management. He was intimately involved in the Denver Top Off exercise, and he will play the role of emergency medicine physician. Let me back up. Jerry Hauer will play the role of state emergency manager/director -- management director. Mike Osterholm will play the role of state health commissioner of the affected state. Ken Bloem will play the role of hospital CEO. Steve Cantrill, as you just heard, will play the role of emergency medicine physician. We come to the Honorable Jack Marsh, who is the former Secretary of the Army, former four-term member of Congress from Virginia. He was Assistant for National Security Affairs for Vice President Ford and served in President Ford's cabinet. He was Assistant Secretary of Defense for Special Operations and Low-Intensity Conflict. He has numerous public service distinctions and awards, and serves on the National Gilmore Commission to the President and Congress, the Commission that is the advisory committee on domestic terrorism. He is also a lecturer on terrorism at a local university. He will play the role of governor in this scenario. Moving down the row, we have Jeffrey Smith, who is partner at the law firm of Arnold & Porter. He served as general counsel of the CIA and chief of the Clinton transition team at the Department of Defense in 1992. He is former general counsel for the Senate Armed Services Committee, designated by Senator Nunn to the Iran Contra Committee and Senate Select Committee on Intelligence. He has lectured and written extensively on national security and international law and is a member of the Council of Foreign Relations. He will play the role of national security advisor. Moving down the row, we have Laurie Garrett, who you well know from the last presentation. She will play the role of senior CNN correspondent. (Laughter.) I suspect she will do a good job of that. (Laughter.) Moving down the row, we have Assistant Secretary Hamburg, who you well know from this morning, who will play the role of secretary of HHS, not a far jump for her. And then, finally, we have David Fidler, who will play the role of state attorney general. And my esteemed colleague, Dr. O'Toole, will play the role of professional moderator, and she will be fairly direct in her questions and her lead -- her facilitation of the conversation. Okay. A few facts about plague. Plague generally is regarded as one of the most concerning biological weapons that might be used. Time from exposure to a plague aerosol to the development of symptoms would be about one to six days. Persons would develop pneumonic plague, which is an atypical rare form of plague. And death would follow symptoms from exposure somewhere between one to five days after exposure. Symptoms of pneumonic plague would essentially resemble other forms of severe pneumonia at first -- hemathesis, or bloody sputum; fever; cough; chest pain. Patients are rapidly ill and quickly would require intensive care units. The diagnosis of plague is not simple. It would require specialized testing at labs that know how to do this. There are no specific hallmarks of the disease, at least initially, so this would require some clinical suspicion of plague before specimens were appropriately sent to the right laboratories. The treatment of plague -- plague is a treatable disease, if treated with the proper antibiotics. Unfortunately, some of the antibiotics that we would reach for to treat typical pneumonias would not be effective against plague pneumonia or pneumonic plague. Survival is possible with pneumonic plague if treatment is begun early. Person-to-person transmission is possible by the respiratory route. Fortunately, we believe this is uncommon. However, we know it has occurred between close contacts in history. Simple masks prevent transmission, at least as far as we know. The evidence is limited. And there is no vaccine available to prevent transmission. Segment one, the CDC has confirmed six cases of plague in Goodtown, an east coast city with a population of one million, a metro area population of 2.5 million. Over the past two days, an estimated 100 persons have died with plague-like symptoms. As many as 500 more have presented to hospitals and doctor's offices in Goodtown and surrounding East State with symptoms consistent with pneumonic plague. All casualty estimates are considered highly uncertain. No common source of the illness has been identified. Since naturally-occurring plague has never been reported in this region of the country, a biological weapon attack is strongly suspected as the cause. There is growing fear and shock in the city as word quickly spreads that "A weapon of mass destruction may have been used against the innocent civilians of Goodtown." All ICU and hospital beds in the city and surrounding towns are full. Ambulances are having difficulty returning to the volume -- or responding to the volume of 911 calls. Hospitals are reporting dwindling antibiotic supplies and are struggling to keep up with the flood of patients. They are urgently asking for more personnel and resources. Local and national media are reporting that plague is loose in Goodtown and that the health care system is struggling. The local newspaper headline reads, "Faceless Enemy Attacks Goodtown With Germ Weapons." There is wide speculation on the location of the attack, the identity of the attacker, and the number of people exposed and likely to die. Media reports make references to the Black Death -- the plague epidemic that killed one-third of the population in Europe in the 14th century. Good news. In modern times, antibiotics can treat plague. Bad news. The Black Death was mostly Bubonic, was not easily transmissible, whereas the Goodtown outbreak is pneumonic plague, which can be spread from person to person by cough. The governor has called on his cabinet to draft a plan to pinpoint the source of the outbreak and bring it under control, and to address the emergent health care needs of his state. He has requested that CDC immediately release an antibiotic Push Pack from the national pharmaceutical stockpile to provide urgently needed antibiotics. Lastly, Goodtown's plague outbreak is occurring in the context of a growing overseas crisis. A close U.S. ally is being threatened by invasion. The U.S. has pledged its support to its ally and is moving naval vessels into the area. Some commentators are linking the apparent bioweapons attack with this international crisis. DR. O'TOOLE: Dr. Osterholm, you are the state health commissioner, and you know at this point there are cases consistent with plague in 14 counties of the state, and patients with a reasonable case definition in over 20 hospitals. There are no common exposures identified as yet, despite a hard press by your staff to find commonalities among the victims. What are you thinking now? And what are the most important public health directives to execute? DR. OSTERHOLM: Well, first of all, I'm going to make the assumption right off the bat that it's some type of a bioterrorist event, because knowing the epidemiology of plague you wouldn't expect to see what you're seeing here if it was a naturally-occurring event as such. So I'm going to lean heavily towards that side. I think the second thing is going to be is I'm going to be a middle person in a chain of communication that's going to become critical very quickly. And so I have to relate to my governor. And depending on which state you're from, it may be very important to whether your attorney general gets along with your governor, because that obviously is going to become an issue. And right now, in my state, that doesn't happen very well where my governor gets along with his attorney general. So it's a situation where you have to be very sensitive to how the information flow is going, because often it's going to be the governor. The first thing I would do is look at what resources I need to really understand what is happening, and how do I get those resources and identify them, as well as beginning to talk about how do we deal with the care issues and the containment issue. DR. O'TOOLE: Dr. Cantrill, you are the chief of emergency medicine in University Hospital. Approximately one-quarter of your staff are calling in sick for the third shift. You are seeing three times as many patients as you normally see. You've already admitted twice as many patients by 3:00 p.m. as you normally do. What are you thinking and doing? DR. CANTRILL: Well, obviously, just trying to keep the hospital operational, and especially the ED and the upstairs services becomes the major issue. We've had multiple people who have called in sick, not only amongst the professional staff, but we have about one-third of our food service people. Two-thirds didn't show up.
We have about 20 percent of our housekeeping folks that have showed up for work. So we have a real problem, not only at the professional level, but just the infrastructure level of trying to keep the hospital role in force. I've got my CEO, who is working on that for me right now. (Laughter.) DR. O'TOOLE: Mr. Bloem? Mr. Bloem, you are the CEO, and your head of emergency medicine is telling you that he is overwhelmed, he needs more staff and more resources. How do you know if the hospital is truly overwhelmed and whether or not you should call the state health commissioner or the governor and ask for permission to refuse to see further patients until you can stabilize the current situation? MR. BLOEM: Well, the fact of the matter is there is no way that I'm likely to know in any definitive way. In fact, this is the early December season. Flu season has already begun. My hospital has been on bypass, meaning the ambulances from time to time are frequently rerouted from my hospital to other hospitals in the community. And now suddenly Dr. Cantrill tells me that we are on a state of bypass, but all of the hospitals are on bypass, or at least the red lights are starting to blink. I'm walking the halls trying to talk with the chiefs of medical services, surgical services, Dr. Cantrill, and find out, can we continue? But it's a little unclear. There are probably 40 or 50 hospitals in this metropolitan area of Goodtown, and presumably of the 500 patients that have shown up, 200 or so, let's say, have shown up in doctor's offices. I'm not ready yet to call the governor, but I'm getting real close to it. DR. CANTRILL: We have a major problem, just with the number of dead bodies. You know, our death rate is normally about 1.1 a day. We've had 10 deaths in the last two days. Our morgue will only hold eight bodies.
We have problems, really, all over, and we're not talking about, you know, just bypass. I have right now 250 people in my waiting room demanding care. We're starting to worry about institutional security here, and about the necessity to lock it down because they're about ready to come over the counter, because they're not being seen in a timely fashion. And I've got an exhausted staff. DR. O'TOOLE: Governor Marsh, you are about to go onto local and national television live. What questions do you want answered before you face the cameras, and who are you going to call for answers to your queries? MR. MARSH: Well, first, I wish my opponent had won his contest. (Laughter.) MR. MARSH: And, secondly, why am I hearing about this so late from my medical people? Because today, under the present scenario, crisis situations and terrorism -- terrorism is presumed to be a crime. And the lead federal agency is the FBI, so we ought to get them in here right away because they are the lead federal agency if, as it is perceived to be, that this is a crime. So I think we're going to have to get the FBI in here. The people that I need also to hear from are my adjutant general. We need to get our press people in here to meet, because we're going to have to prepare some sort of a statement to -- DR. O'TOOLE: Your press people are all home sick. (Laughter.) MR. MARSH: Well, I'm not feeling well myself. (Laughter followed by applause.) MR. MARSH: Where is CNN now? (Laughter.) DR. OSTERHOLM: Well, I think at this point I would attempt very hard to lobby the governor to, first of all, hopefully have some faith in the Health Department; and, second of all, to dismiss this idea that he wants to go to his adjutant general as his lead consultant on this area. And I would try to convince him that this is going to unfold as a biological issue. This is what you can anticipate. And it's that old adage that you don't skate to where the puck where is; skate to where it's going to be. And I would try to tell him, this is what's going to happen tomorrow and the next day and the next day, and this is why you want to do what you want to do. Just don't react to the moment. And I think, actually, that would be a very important thing. And who wins that battle in the first 12 to 24 hours of information coming in is likely to set the tone for how much of the first three to five to seven days is going to go, and I think that's what this -- DR. O'TOOLE: Which battle is this now? DR. OSTERHOLM: Pardon? DR. O'TOOLE: Which battle? DR. OSTERHOLM: The battle between who takes control of this situation. DR. O'TOOLE: Okay. So we're at five minutes into the scenario and we've got a turf battle on our hands. (Laughter.) DR. O'TOOLE: Is that what you're saying? DR. OSTERHOLM: I wouldn't say it's a turf battle. What I would try to say is that I think we, as a public health system, owe our elected officials hopefully a pre-outbreak review, so that they understand where it's going to go. But let's say we haven't had that opportunity. What we need to do is say that everyone will have a political role. So it's not as if there's -- all of us aren't going to be involved. But it's what is it you need, for what reasons, and when do you get them? And when you start talking about the issue of understanding what's happened, he wants more information. Well, how do you get that? The Army is not going to go out, and the National Guard is not going to go get that. If you want to understand -- MR. MARSH: I have to take issue with you on that, because under the new structure of the National Guard in defense on biological weapons, there are capabilities placed in the states with biological capabilities. They originally were called raid teams, but they've gotten away from that name. But there are capabilities in the National Guard that are being trained to respond to biological situations. Secondly, you have resource teams in both the United States and the Marine Corps, and in the Department of the Army, and in the Air Force, that can be made available to these types of situations. I'm not saying that we have to use them, but your access to them is going to be through your adjutant general, who will go up through his chain of command into the Office of Domestic Support in the Pentagon, and into FEMA. DR. O'TOOLE: Mr. Emergency Management Director? MR. HAUER: Yes. In point of fact, our civil support team in the state we're in right now is 22 people, and they have some moderate biodetection capability, but that's about it. They still haven't gotten a field deployable PCR. So everything really has to work through the Department of Health, from both an outbreak perspective, an epidemiological perspective. We will be calling through FEMA, the Federal Emergency Management Agency, requesting that at this point probably not C-birth, because C-birth doesn't have the capability. But certainly we'd be requesting some medical support be put on standby, because we don't know how far this thing is going to go. I'd be depending on Mike at this point in time to rely on some potential casualty estimates. If Mike was telling us and telling the governor that this thing could be just the tip of the iceberg, that it would -- at this point in time it would be in our best interest to go through FEMA and to go through HHS to get, one, MMRS put on standby, to get NDMS put on standby. To address Steve's concern about bodies, we would ask for a D-morgue team to assist with management of fatalities. And those are the recommendations we'd be making to the governor at this point in time. I'm not convinced at this point that C-birth would give us any additional capability, because, again, this is not a chemical incident; it's a biological incident. DR. O'TOOLE: Okay. MR. HAUER: C-birth doesn't deal with those quite as handily. DR. O'TOOLE: Okay. Ms. Garrett? MR. MARSH: If I can interrupt, he has pointed out one of the problems you have to deal with, because in some states the principal emergency advisor to the governor is the adjutant general. That's, I think, in 22 states.
In other states, the adjutant general goes through another designated individual. But the point he's making, you might do that in one state, but that might not be the route you would follow in another state. So there is a need for a uniformity among the states on how do you manage internally in the state these emergencies. They've worked it out very, very well, but it's different from state to state. And based on the state authorities of the governors, and those vary from state to state. DR. O'TOOLE: Ms. Garrett, you hear rumors from your friends in the medical profession and long-time contacts in the Health Department that there aren't going to be enough antibiotics available in the next 24 to 48 hours to take care of all of the health care professionals in the city, and all of the public safety officials, and all of the patients who are already sick, let alone their contacts. Who are you going to call, and what questions are you going to ask, from among the people on this stage? MS. GARRETT: Well, probably I already know that there isn't enough antibiotics because I've done my background work. I know from past epidemics and from all of the reports that that's the probable outcome. I will call the health commissioner, so I'm on the phone with Dr. Osterholm. DR. O'TOOLE: Please have the conversation. MS. GARRETT: He's not available. DR. O'TOOLE: Oh. (Laughter.) MS. GARRETT: And I tried to say, "Look, this is Christina Amapour. Put him on the phone." But that -- (Laughter.) MS. GARRETT: He is not available, and the press officers are putting me on hold, and so on and so forth. So I can't get the answer out of the Health Department. So I'm probably -- if I'm at CNN, I have a whole staff working for me, so I've instructed a whole bunch of these young interns to start calling pharmacies all over in Goodtown and find out if they have -- are we assuming it's tetracycline we're looking for, or cipro, or what? DR. O'TOOLE: There's rumors it could be any of those. MS. GARRETT: Okay. So I'm going to ask -- I'm going to have them calling pharmacies to ask, "How are you stocked with cipro and tetracycline?" I also am going to be calling HHS because I've heard somewhere in my piles of information and background, or something I checked on the internet, that there is supposed to be somebody at HHS that's responsible for stockpiling something or other. And so I'm going to call them up and say, "What the heck is going on?" And I'm probably going to be, again, going through a press officer at HHS, who is, again, going to say, "Well, I have to get back to you on that." And I'm going to say, "I'm on deadline." And they're going to say, "We're going to try," and I'm not going to hear from them for two or three hours. DR. O'TOOLE: Okay. Madam Secretary, you hear reported on CNN about an hour and a half later that there is a shortage of antibiotics in Goodtown. (Laughter.) DR. O'TOOLE: What are your concerns at this point, and what do you do? DR. HAMBURG: Well, I am pissed because nobody from within my organization has informed me that there is any kind of problem in Goodtown at all. (Laughter.) DR. HAMBURG: But I quickly contact my people, and I don't accept as an answer that they're not available. And I speak with the Director of the CDC, and the bioterrorism initiative director there, and also get the Director of the Office of Emergency Preparedness into my office to give me an update on what's going on, and to ask the question of what does our Department need to do now. Clearly, we're already engaged. We sent some people from the CDC I think, if I listened correctly, in the early stages of this. But the question immediately comes up about, can we do more, both in terms of our expert personnel at CDC and our laboratory capacity, to provide a confirmatory diagnosis and backup support? Also, of course, the question of the stockpile. We have a crisis going on, and we have a limited supply of antibiotic. And we do have a civilian stockpile -- DR. O'TOOLE: Okay. DR. HAMBURG: -- of pharmaceuticals. If I could just add one thing, there is an open question about when that stockpile can be deployed when there -- if the stockpile was created under the bioterrorism initiative, and we have not yet declared -- our suspicions are this is bioterrorism, but it's -- it hasn't formally been declared a bioterrorist event. My inclination, as a leading health official, is that there's a public health need, and we have a stockpile, and we're going to get that stockpile released if that's what the state officials want. DR. O'TOOLE: Okay. Let's move on. DR. INGLESBY: December 2nd, the next day. A day later, estimates are that there are now more than 300 dead from pneumonic plague in Goodtown and surrounding East State, a growing percentage of them children. An estimated 1,500 state residents may now be sick with plague. Firm numbers remain difficult to obtain, given the pace of the outbreak, and the lack of rapid and reliable diagnostic tests. Neither the location of the attack or the identity of the attacker have been discovered. State officials cannot firmly rule out that more than a single attack has occurred in Goodtown. The media reports the story of four members of one family developing plague with two already dead. There is speculation that one of the family members passed it to the others. At the same time, it's also reported that there are insufficient isolation rooms in hospitals to keep all of those with suspect pneumonic plague separated from other patients. Some persons with plague systems are being kept in hospital hallways, wearing surgical masks. Others are reported to have been coughing in hospital waiting rooms and doctor's offices while waiting to be seen. Interviewed citizens of Goodtown report a growing fear of catching plague from others, and complain that the government is not doing enough to prevent the spread of infection. The media are also reporting that many people are beginning to leave the Goodtown metro area by car. Some are leaving because of fear of ongoing attacks. Some are afraid of catching plague from a stranger. Some are in pursuit of antibiotics to protect themselves or their family members. And some are leaving in fear of possible civil disruption. Talk radio is reporting on fastest routes out of the city. A number of traffic fatalities have occurred in the exodus. Security has become a growing concern in Goodtown and East State. Sporadic violence occurring around hospitals and pharmacies has escalated with reports that vital antibiotics are scarce or not available. Antibiotic distribution centers require particular attention. Meanwhile, on the other side of the country, in West State, 50 people have died of what appears to be pneumonic plague. And at least 200 are ill with plague-like symptoms. The analysis suggests a second separate bioweapons attack. There are also reports of 75 cases of suspect plague in 10 additional states. Most of these individuals had recently been in East State or West State. West State has now officially requested a delivery of the national pharmaceutical stockpile. And, finally, the media reports that antibiotic supplies are being set aside for the protection and treatment of military forces. Navy ships continue to steam toward the shores of the beleaguered U.S. ally. Its threatening neighbor has increase its warlike rhetoric and is advising the U.S. to tend to its own internal disease matters rather than intrude where it is not welcome. DR. O'TOOLE: Mr. State Attorney General, you have been told that there are not enough antibiotics to go around, and there is an argument going on between the state health commissioner and the state emergency management director, regarding how they should prioritize existing antibiotics. And there's another heated discussion that's ongoing that has to be resolved in the next five minutes, so that you can advise the governor with respect to whether or not force should be used to isolate people who are symptomatic and may be contagious. What is your advice to your colleagues in the health professions, and what do you suggest the governor be told with regard to forcible isolation? MR. FIDLER: Well, my first -- I guess I have some political reactions first. I just returned from an ABA junket in Honolulu. (Laughter.) MR. FIDLER: I returned to my office, and I had absolutely no messages from either the health commissioner or the governor's office about this, although this seems to be spinning out of control, particularly in connection with law enforcement issues. And I think that the lawyers need to be brought into this immediately because this is going to trigger authorities that the governor has to issue. In terms of the priority in connection with antibiotics, I need instructions from my political bosses and the health commissioner as to how -- the proper way to ration the antibiotics. And then I have to go find some staff, who I understand most of my staff is home sick as well, to dig up whether we have any legal -- whether the governor or anybody has any legal authority to take those sorts of decisions. The only public health contact that I've had in my stay or my reign as a state attorney general is in connection with tobacco litigation. None of -- (Laughter.) MR. FIDLER: None of my staff has any idea about these issues of containing infectious diseases. I also need instruction on the public health side as to whether compulsory treatment, compulsory isolation, is a proper public health policy in connection with this particular -- I have no idea. So I need some hard, clear, fast instructions, and then I need authority from the governor to dig up some lawyers, hopefully not literally, to help me -- (Laughter.) MR. FIDLER: -- to help me figure out whether there's sufficient authority for the governor to take the actions that he has got in mind. And I'm also concerned about state-federal turf actions. I'm hearing in the press that the state wants to call in the feds. I'm nervous about that because it's the state that has the constitutional responsibility to protect public health. But I'm getting no instructions from anybody. DR. O'TOOLE: Okay. Mr. State Health Commissioner, what are your thoughts on mandatory isolation and separation of family members? DR. OSTERHOLM: Well, let me just say, if any attorney general really acts like that, I pity the state that elected him. (Laughter.) DR. OSTERHOLM: Because I think that that's not the case. Typically speaking, an attorney general -- and to make this realistic -- typically will be in the loop, because the lawyers that represent state agencies are actually supplied by the state attorney general's office. So even if you have a Republican governor and a Democratic attorney general, the attorney general's office -- and I think that's uniform throughout the 50 states -- so my lawyer is one of your employees. So that would have already been in place. So I think that part of the issue is what he decides is what my lawyer is attempting to get him to support. And so where the real nub comes as to how we get antibiotics, or what we do on this issue, is how you work it out at the state agency level. And I think that's true for city government. The city government lawyers -- I don't know if they come out of the city attorney's office assigned to agencies or if they are employed by the agencies, but it's a combination employed by the agency. So I think that the point here is that, from a realistic how we're going to deal with this issue, hopefully this isn't unfolding as you just suggested. Having said that, I think how we're going to get the antibiotics is this is also a time where we've got to convince the governor, because the governor is going to be the air traffic controller in this situation in our state. We've got to convince him that he needs to have professionals dealing with -- DR. O'TOOLE: Try. DR. OSTERHOLM: Governor, we -- DR. O'TOOLE: Have a conversation. DR. OSTERHOLM: Governor, right now, you know, we're in the middle of a big crisis, and you're going to have to trust the professional staff you have around you, because it's all you've got right now. And what we're telling you -- and I would hope that the emergency management health commissioner should be like hand and glove working together. And what we're telling you is we need to get the federal organizations in here, because this is the resources we're going to need. But having said that, we've got to keep a tight reign on them because of the issue of how it would mesh in with our system. Otherwise, they can kind of come in like the calvary and take over, so here is our plan.
And I would come together with the emergency management person and try to devise a plan for federal interaction, send it to you, and then have you be the champion of it and carry it through, so that it has the weight of the governorship and you're trusting the emergency management and health commissioner to be the ones telling you what ought to be done. DR. CANTRILL: And to make this realistic, though, in most places, most states, state health does not work with emergency management. They may not even know of each other. MR. HAUER: I would disagree with that. When I was a state director in Indiana -- DR. CANTRILL: I said in some states. MR. HAUER: Yes. In most of the states these days, particularly because of the interactions on things like the MMRS, not 100 percent, but there is good interaction between the emergency management folks and the state health folks. It's getting -- it has gotten better. I wouldn't have said that 10 years ago. Ten years ago, they didn't talk to each other. There was a total disconnect. DR. CANTRILL: During Top Off, that was not demonstrated in our state, which we just may be a little behind the times. So that's -- DR. OSTERHOLM: I think the last 12 months. The last 12 months in this country one of the real pluses that has occurred is that there's still not a good working relationship in each instance. But I think there is very few states where the leading health -- public health people are not now working much more closely with the emergency management and vice versa. And I think that's been one of the real pluses since the last symposium. DR. O'TOOLE: Governor? MR. MARSH: I agree with that recommendation, because the time is now to start triggering possible access to federal forces, and I could do it in one of two ways. I can, one, issue an emergency declaration, or I can seek a declaration of the -- assistance under disaster -- disaster certification or an emergency situation. May want to go with emergency first in order to get them up and moving, but there are an enormous number of federal agencies that have to come up to speed on this. And there are some federal statutes from which there may be money. For example, the Stafford Act. But we need to -- we need to give a heads up to the federal system. It will make it easier if we do have to introduce forces. There will be a difference of opinion as to -- on quarantine and who has the authority for quarantine. DR. O'TOOLE: Are you going to take the decision to make the quarantine -- are you going to make the quarantine decisions yourself? MR. MARSH: In some states, the -- DR. O'TOOLE: You, now, here. MR. MARSH: Right. DR. O'TOOLE: Are you going to make the -- MR. MARSH: It depends on whether the -- it depends on whether the director of health feels that a quarantine is necessary. And sometimes in a state they have the authority to do it in conjunction with the governor. The governor does not have that authority exclusively. There is also a question that the federal government, under HHS and the CDC, can come in and impose a quarantine and bypass the state. These are vague areas of the law that need to be resolved. DR. O'TOOLE: Mr. National Security Advisor, you now have governors of two states calling the White House, both worried that there are finite amounts of antibiotics in the national pharmaceutical stockpile, and both worried that their people won't get what they need. What are you thinking about now, and what are you -- you're about to see the President in five minutes. What are you going to advise her? MR. SMITH: Well, actually -- (Laughter.) MR. SMITH: Actually, I'm not about to see the President because yesterday I advised her that after seeing Laurie's report on CNN that I had appointed myself the head of the U.S. delegation for the negotiations currently underway in Paris on the preservation of important cultural properties. (Laughter.) MR. SMITH: And I left yesterday afternoon for Andrews Air Force Base. (Laughter.) MR. SMITH: Like my governor here, I would be happy not to have to deal with this. The question of making federal resources available to the state in this circumstance is, as everybody has said, very confusing. Fortunately, as the national security advisor, it's not entirely my responsibility. I would -- as the national security advisor, the first thing I would do is to put in motion several things. One is the responsibility is to find out, do we know if this is an intentional attack? And, if so, who did it? And for that I would convene a meeting requiring the head of the -- the director of Central Intelligence, the head of the Defense Intelligence Agency, the director the FBI, some representative of the attorney general, and others, to come together and to quickly get on top of it and find out what's going on, what degree of proof do we have. I would direct the joint staff to begin preparing some sort of retaliatory response, and I would worry a great deal about the activities going on overseas at the moment, as to whether or not this is perhaps a diversionary attack, given the fact that U.S. forces are steaming toward a crisis. And one of the things I would also immediately worry about thereafter is, to the extent DOD resources are made available, or are going to be asked for by my colleague in HHS, if Peg is going to ask the Department of Defense to make DOD resources available, are they needed for overseas deployment? And, if so, somebody is going to have to make a horrible decision about whether these resources are used for domestic purposes, held in reserve, sent with the forces overseas. And we also have all of the press in the White House press room demanding to hear from the President, and the President is going to be under enormous pressure to speak to this issue immediately. So I've got about eight or nine things I have to worry about. I neglected Congress. Nobody has mentioned Congress. Clearly, the administration will have to brief Congress to make sure that they are comfortable with what is going on, because everybody has said they don't like surprises. Congress doesn't like it either, so we'd have to bring Congress into it. We would have to get the State Department involved to tell our allies about what's going on, because they're going to want to know. So it's -- I will be very wise to have gone to Paris. (Laughter.) DR. O'TOOLE: Did you have something? MR. HAUER: Yes. While all of that's going on, we're sitting down here in Goodtown trying to manage this thing, and waiting for federal assets. We are now trying to plan through the next 48 and beyond trying to figure out what resources we're going to get. We've got to figure out about antibiotic distribution, and we cannot manage it on our own. We are in over our heads at this point in time. We do not have enough staff. We do not have enough medical staff in the hospitals. They are starting to burn out. Steve and Ken are calling, asking for security in the emergency rooms. We have problems with crowds in the emergency rooms. Our police department is working 16-hour shifts. We have got to get some answers from the federal side. We've already got the National Guard providing the limited assets they can, but they really don't have any organic medical assets that we can use. We've got to get the reserves in or DOD, and we're going to need to pretty quickly to understand what kind of federal assets are coming in, because we've got a major evolving crisis, and we're not getting any answers from the feds on what we can expect. And I understand there's another theater of operations overseas, but we have got to get some answers from the feds. DR. O'TOOLE: Ms. Garrett, what are you reporting at this point? MS. GARRETT: By now, at CNN, this is obviously -- when I talk about competing data points, there is no competing data point here. This is it. We've pretty much preempted covering absolutely anything else, giving only minor coverage. We've created teams, much as you have seen in the coverage of the Florida thing. You've seen team reporting. You've seen the legal teams. They come on there with their legal expertise reporting. Your political teams come on with your political, and so on and so forth. And we've got teams. The first -- the primary team is, who did it? That team involves our national security/State Department reporter, our people who have sources at FBI and law enforcement. And we've already decided in the newsroom to take a quick look around the globe and see where we've got the biggest trouble spots, and we're aware because our DOD -- our Pentagon reporter has told us, that U.S. naval operations are responding and moving to a region where there's a standoff between a so-called rogue nation, a nation we've had a history of problems with, and its neighboring state, which is threatening to invade. We're wondering if that might not be involved, and we've flown Christina Amapour over there. She's on her way now. (Laughter.) MS. GARRETT: And meanwhile, we are among those in the White House press room demanding statements from White House Press Office -- Press Secretary Jody Powell. And Jody is in a panic, and I can't get any information. She keeps saying, "We'll be updating you." And we've got another team that is specifically deployed to Goodtown. They've been sent in. And since we know it -- plague is the agent, we've gone ahead and told them, because we've called our CNN physician and asked what they should do -- and they're prophylaxing with tetracycline. We're hoping that's adequate to cover our insurance policies to -- (Laughter.) MS. GARRETT: -- make sure our reporters are okay. And we've also sent some -- a team out to the west coast. These people are broadcasting live. They're coming in -- Bernie Shaw and Judy Woodruff will say, "And now we go to Goodtown," and they're constantly, constantly updating, and constantly looking for footage, fresh footage.
We've got film crews combing all over, trying to get pictures of people who are sick, of the hospitals, of beleaguered staff, of meetings, and we're constantly going back and forth between all of these. Similarly, we've got our FBI reporter desperate to get Louis Freeh, or whoever it is now, on the phone or on camera. And we're thinking about -- we've got -- as part of the question of who did it, we've got at least one staffer who is doing nothing but monitoring the internet for traffic on all those sites where the wackos are. And we know the wacko sites, because we monitor them all the time. (Laughter.) MS. GARRETT: So now we're looking to see if -- you know, what the wackos are saying, if any of them look like likely candidates for having executed this event. So, basically, at this point, this is a massive news operation. Nobody is going to be going home early tonight or any time in the next few days. And we've got people in Washington, Goodtown, West Coast, and some neighboring major cities that are doing nothing but monitoring police scan and emergency radio transmissions. So we know absolutely every single thing you guys are saying. (Laughter.) DR. INGLESBY: On that note, let's move to Segment 3. (Laughter.) DR. INGLESBY: Across the U.S., there are now more than 3,000 dead. This is four days after the first plague case reported. Some 15,000 are sick, with symptoms consistent with this disease. There are cases spread throughout multiple cities in 15 states and in foreign countries. In several cities, shootings have occurred over the distribution of antibiotics. In most affected states, the National Guard has been called in to provide for the secure distribution of antibiotics and medical resources and to ensure the continued safety of hospital operations. The site of an armed military presence in U.S. cities has provoked protests about curtailment of civil liberties, but at the same time some governors are requesting additional support from the Department of Defense in the provision of supplies, personnel, and security. There is wide state-to-state variation and isolation policies and actions. In some states, anyone with symptoms that could be plague are placed in mandatory isolation under guard. Many are being boarded, treated, and isolated at hotels, because hospitals have been unable to manage the burden. So far, all persons forcibly isolated have been given appropriate medical care and received antibiotics. Health and law enforcement officers have been asked to actively search for cases of plague. There are reports of persons violently refusing to submit to isolation or threatening violence when authorities attempt to separate family members. In other states, there have been no attempts to impose mandatory isolation, and voluntary isolation policies are still in effect. There is no way to assess whether mandatory or voluntary isolation has been more effective overall. Like other states, each state is deciding whether to impose restrictions on public movement, including possible curfews; possible prohibition on meetings of more than a few people; possible closure of highways, airports, or train stations. The governors of non-affected states have called for temporary cessation of all traffic out of states with plague cases. Some states contiguous with east and west states have established highway checkpoints and are refusing entry to non-residents. Internationally, some countries have stopped allowing the arrival of U.S. flights. U.S. warships are off the coast of its ally. The ally has been invaded. It is expected that the President will be making an announcement shortly regarding the possibility of a U.S. military response. DR. O'TOOLE: Okay. I'm going to back up a little bit to the beginning of this segment chronologically. The confusion over who has authority to do what in Goodtown, and in East State, has delayed decisions about whether or not to institute mandatory quarantine or isolation procedures, home curfews, etcetera. The State Emergency Management Director, the State Health Commissioner, the Secretary of HHS, are now on a conference call with the governor, trying to advise you, Governor, as to whether or not you -- it has been determined by the Attorney General that you do have the authority to institute curfews and isolation procedures of all kinds. And the question on this phone conference is whether or not these kinds of mandatory isolation procedures and quarantines are a good idea. Would you four people please have this conversation? Dr. Osterholm, what do you think? DR. OSTERHOLM: Go ahead. MR. HAUER: Thanks. Well, I think the first issue is, can we enforce it? We certainly -- you know, if Mike feels and makes the recommendation that isolation of some type is necessary, the question I would have is -- you know, and I'd certainly defer to his judgment on the decision as to whether we need it. The question is: how do we enforce it? And to what degree do we enforce it? How much force do you use to keep people in their homes -- DR. O'TOOLE: Okay. MR. HAUER: -- when people want to go out? And I'd certainly like to understand how we -- when we either use the National Guard, because they haven't been federalized so we can use them for law enforcement purposes at the local level, and our local police, how we can go about it. I think that's the issue we -- that I'd ask Mike and the Attorney General. DR. OSTERHOLM: I think at this point, from the science side, it's going to require a kind of whole new way of thinking. And what I mean by that is is that it's okay to be right and win the battle, but if you're wrong and lose the war it didn't really matter. What I mean by that is I may come up with the ideal plan for quarantine, for isolation, that meets all of the scientific rigors, but it doesn't meet the societal/political rigors of what we need at the time. And so I think what's going to really be important is to come up with something you can show that you can do and you do it well. And one of the things we're going to have to get comfortable with, as a society and as a public health group and as a medical group, I'm sitting with colleagues right here right now that have never understood the concept of acceptable losses. Now, a couple of colleagues farther down the aisle do, because in the military "acceptable losses" is considered a part of the norm. We're going to have to figure out, what can we do for isolation and quarantine that isn't forcible, so people recognize we're doing it, is going to have the most impact for the bang, and is not going to mean that we're going to get every one of them or that we're going -- we're going to let certain things go that we would ideally scientifically not let go. And we'll accept those as losses, and potentially people getting infected as a result of that and dying. But at least we're in charge. And right now, more importantly than anything else, somebody has got to be in charge. DR. O'TOOLE: Governor, what would you like to know in terms of how you make this decision? MR. MARSH: The problem that we're moving into here is a serious gap between federal and state authority. The governor has that authority for quarantine. He can control the traffic on the streets, and he can expropriate property. He can do all of those things. But in the field of quarantine, there is federal legislation that authorizes quarantine at the federal level. I think it's done through HHS and CDC, if I'm not mistaken. But there is a question as to whether it can preempt the state authority and do that. We are in a -- in this situation, it's so grim the governor, in my view, should go ahead and do it and argue about it later. But you have a situation where if the feds come in first and preempt -- now, I understand that the regs, that the quarantine regs, for that federal statute have not been finely promulgated. And so what I'm saying to you, there is some very serious gaps, and that has been pointed out by other speakers here -- DR. O'TOOLE: Okay. MR. MARSH: -- between federal laws for emergency assistance and also state laws. DR. O'TOOLE: Okay. Dr. Hamburg, in the last three hours, the Congress has rushed through a law giving the federal government clear authority to impose quarantine on states over state authority. Under what conditions would you impose quarantine, and what types of quarantine would you be thinking about? DR. HAMBURG: Well, I think the concept of quarantine, where you enclose a whole city or set of communities, is -- you know, theoretically, it would be nice to contain the disease; you could more effectively control it. But I think it is, just as Mike very eloquently just explained, just not a practical reality. And as Secretary of HHS, I think I would be clearly striving very, very hard to do the right thing from a public health perspective, but also concerned about the political context in which it was going to occur, and trying to also think about a national perspective and recognizing that we already have two separate localities where these issues are emerging. We may have more. We are not, as a nation, going to be able to really invoke multiple quarantines across the country and enforce it. We need to think about what makes sense to try to contain and control the disease as practically as possible, with very, very limited resources. We would have to take every single support person in Goodtown and the state to try to possibly enforce quarantine, and then we'd have all the issues about, how would we get the people food and, you know, care for them while we're enforcing it. And then, of course, you know, the images I think. If we didn't have panic before, I think we would absolutely have panic as CNN, you know, blasts out to the entire world, you know, pictures of distraught mothers screaming that they can't get to their children who are across the town -- the state or county line, etcetera. So I just think -- thinking about quarantine as an actual containment is a very limited utility. If you had told me there was an airplane that had just flown into the Goodtown airport, and there was someone on it with a known highly communicable respiratory disease, and the officials there didn't want to do anything about it because they thought it might interfere with tourism in Goodtown, I might suggest that quarantine there might be appropriate until we could identify what the medical problem was, treat the people who were affected and/or exposed, and then move on. But here I think we have to think about more viable approaches to disease containment. I think clearly I would recommend or put in place bans on public gatherings. I would recommend people stay at home if they're not sick, would make recommendations about various sorts of restrictions of travel, but I would not try to impose a true quarantine in the sort of classical sense. DR. O'TOOLE: Okay. DR. OSTERHOLM: Tara, can I add an important point here? Because I think that there's an issue here that for the audience would be very helpful. The governor is wrong. (Laughter.) DR. OSTERHOLM: The federal -- unless you did pass this legislation in three hours, the federals do not have quarantine authority, other than people coming from outside the country. And it's -- MR. MARSH: There's a federal statute on it. But there is no regs? DR. OSTERHOLM: There is not on state health quarantine. I know it -- MR. MARSH: Well, state. This is federal -- DR. OSTERHOLM: No. But I'm talking about at the state level where you can apply it. And my job, as a good public health practitioner, is going to be right now -- if there's an issue that I know, and I know it well, and I think all of the people in this audience -- part of the authority has to come from the bottom up, and it has to be manifest in someone like the governor. But we're not doing our jobs if we let the governor go off and make a mistake. And it's, in the long run, going to hurt us all. So I think that one of the things we have to do is be empowered to say, what do we really know at our staff level jobs, and in that position there? And we may have to get into a -- you know, the governor is somebody I revere as my boss, but I'm going to sit here and say, "God dammit, you're wrong. And this is what you've got to do. And if you don't do it, then go find somebody else to do it." DR. O'TOOLE: And your advice at this point is, look, we can't enforce a quarantine. We can't enforce a home curfew. We don't have any place to isolate people. The best we can do is give, basically, warnings and advice as to how the people ought to behave to protect -- DR. OSTERHOLM: And I've got to -- DR. O'TOOLE: Is that your advice? DR. OSTERHOLM: And I -- yes. Well, it may be different than that to some degree, but what I'm saying is I've got to have a governor that's going to go with me, because either I know it or I don't know it. Either that, or hire somebody that knows it, but do that well before this happens. And the point being, though, is that we have to get our elected officials comfortable with it. So when the emergency management guy comes in and says, "This is what it is. You know, I'm a career guy. I know this stuff. And I'm telling you, what you're doing, you're going down the wrong path here." You've got to have our elected officials that can trust the people who are the professionals there. And so I may argue with my governor behind closed doors and tell him, "If you do this, you're a fool." But the point is, he's got to have enough confidence in it to let it happen. And I think -- so I would really have disagreed with you vehemently on this quarantine issue because it would have diverted us off into something that would have been I think very injurious to the overall process where we're going. PARTICIPANT: But you would not quarantine? DR. OSTERHOLM: Oh, I would quarantine. But the feds don't have any authority or responsibility here, and -- DR. O'TOOLE: Now, wait a minute. I'm confused. You just said you'd quarantine? DR. OSTERHOLM: No. It's that the -- as Peggy and I both said, it's a relative term. What do I mean by "quarantine"? Quarantine is when I take every person who has been possibly exposed -- DR. O'TOOLE: What do you mean by "quarantine"? You just said you would -- DR. OSTERHOLM: Well, I think in this case, clearly, for those people who are infected, and we have evidence that they may be infected, and they are coughing, we have to do something to move them out of the transmission mode. And we need to somehow isolate them. Now, the classic concept of quarantine -- and this is, again, for the audience -- where did quarantine come from? Quarantine didn't come from watching sick people. Quarantine came from watching ships coming into harbor that might have sick people who would get sick, and they would watch well people, and so there are still a lot of meanings to quarantine. DR. O'TOOLE: Let me cut to the chase here, though. DR. OSTERHOLM: Yes. DR. O'TOOLE: We have expanding numbers of plague cases. We have not instituted any kind of isolation procedures other than advising people to stay home if they are sick. DR. HAMBURG: Well, I thought we had already -- DR. O'TOOLE: Stay home if they are well. DR. HAMBURG: -- implemented isolation procedures for people who were sick -- DR. O'TOOLE: Who were in the hospital. DR. HAMBURG: -- outside of doors, and all kinds of things. DR. O'TOOLE: Well, I thought actually -- that's what I was trying to clarify. I thought Mike had just changed the scenario to say that was -- DR. OSTERHOLM: No, I haven't changed it. I would try to do -- DR. O'TOOLE: Okay. All right. DR. OSTERHOLM: -- those kinds of things. But classic quarantine -- DR. O'TOOLE: Okay. DR. OSTERHOLM: -- is much more extensive. Like Yugoslavia was a good example of quarantine. DR. O'TOOLE: We have to interrupt this because your argument with the governor is interrupted by a call from the national security advisor. (Laughter.) DR. O'TOOLE: Governor, the neighboring state is actually posting its -- posting National Guardsmen at the highways, preventing residents of your state from coming in for fear that they will spread the contagion. Mr. National Security Advisor, you are being asked to help the governor figure out what to do about this problem; plus, you are now worried about how this burgeoning situation in East State and West State might affect national strategic flexibility. What are you thinking? What is your conversation with the governor? MR. SMITH: My conversation with the governor is that we really have a mess here. (Laughter.) MR. SMITH: And that the issue of whether taking the two facts that you've presented -- one is what to do about the National Guard in the neighboring states that are now seeking to quarantine you. I don't know, candidly, what the legal authority would be for a governor to call out the National Guard to do that. But it does seem to me that you folks down there have got to get control of this real fast, and the idea that one governor would use the National Guard to block and protect his own state I think is politically unacceptable. And somehow or another we've got to find a way to work together and find a common solution to this that we all agree on and that requires leadership, not only in the White House but also among the governors. So I don't know what the answer is, but we've got to figure this out. Secondly, with respect to the impact overseas, you're absolutely right. We have been receiving intelligence reports suggesting that this is, in fact, part of an effort to divert us from our activities in defense of our allies, and the Secretary of Defense and the DCI are saying to the President, "Mr. President, you've got a real choice to make here. How do you want us to proceed?" We don't want to be intimidated by the act of a couple of terrorists from pursuing our national agenda, because the signal that would send, not only to our allies but to everybody else around the world, that the United States can be easily diverted from its national interest by plague attacks at home. Now, admittedly, there have been a lot of deaths, but as of today we only have -- what do we have? 500 dead? 3,000 dead. Now, that's clearly a national tragedy, but your job is to think long term, and do you want us to -- because we don't have enough resources to do both the activity overseas and the activity at home, what do you want us to do, Mr. President? Madam President, I beg your pardon. And my recommendation to you is to try to find some way to do both, because we've got to respond to the domestic situation, but at the same time we cannot let the United States be held hostage by these kind of activities. DR. O'TOOLE: Okay. On that note -- | 
