Balancing 'hysteria and suspicion': Doctors face new responsibilities in 'bioterrorism era'

December 16, 2004

ST. LOUIS -- The emergence of bioterrorism as a threat is creating new responsibilities for the medical community and, for the first time in history, is putting physicians at the forefront of managing disaster, according to an article by Saint Louis University researchers in The Lancet.

"Unlike other forms of terrorism, in which an acute exposure or traumatic injury is rapidly inflicted and quickly recognized, such as the 9/11 attacks, bioterrorism may involve an incubation period of days or even weeks," says Bruce W. Clements, MPH, associate director of the Institute for Bio-Security at Saint Louis University School of Public Health, and the lead author of the article.

"During these events, patients will turn to their most trusted adviser on health issues -- their doctors -- who will be expected to recognize sometimes rare conditions and take appropriate action. This means doctors will be the tip of the sword -- not the military, not the police, not the firefighters."

Clements presents his argument in an article published in the Dec. 18 issue of the medical journal, The Lancet.

Clements, and his co-author R. Gregory Evans, Ph.D., MPH, director of the Institute for Bio-Security at Saint Louis University, argue that this transfer of first-responder status puts greater responsibility on doctors, a responsibility that they currently are not prepared to shoulder.

"They will be in the driver's seat deciding how an outbreak will be managed so they must be trained for it," Clements says. "The challenge lies in finding the balance between suspicion and hysteria."

Clements says it is a delicate balance because most potential bioterrorism agents listed by the Centers for Disease Control and Prevention (CDC) -- such as those that cause smallpox, anthrax, botulism, plague, tularemia -- initially present in patients as flu-like symptoms.

"You don't want to walk into your doctor's office with flu-like symptoms and be told you might have Ebola," says Clements. "On the other hand, if you were exposed to something exotic, such as a biological agent, you would hope your physician has a high enough index of suspicion that he or she may take the extra moment to consider something unusual or atypical."

Clements and Evans urged medical schools to incorporate more information about bioterrorism into their curriculums to prepare doctors to meet the diagnostic challenge.

In addition, continuing medical education programs and community drills (such as a simulated smallpox scenario Evans and Clements developed for the CDC for use by state and local health departments) are critical in preparing doctors, they said. The exercises are designed to help physicians see how things may unfold in an atypical outbreak of smallpox and how different their work environment might be.

"In a bioterrorism incident, physicians will have to interface with the FBI and other government agencies that they've never had to speak with before," Clements says. "This type of communication doesn't come naturally. It's learned."

While physicians stand at the forefront of preparing for bioterrorism threats, Clements and Evans point out in their article that physicians have contributed to the creation and proliferation of these weapons -- both wittingly and unwittingly.

"Ethics must be integrated into all medical school courses, not just a few lectures in the first or second year of training," says Evans, a professor of environmental health.
The Institute for Bio-Security at Saint Louis University School of Public Health was established in 2000 with funding from the CDC. The Institute's original mission was preparing for bioterrorism or an emerging infectious disease. The mission was expanded in 2002, however, to include preparedness for all aspects of bio-security. Saint Louis University School of Public Health is one of only 36 fully accredited schools of public health in the United States and the nation's only School of Public Health sponsored by a Jesuit university.

Saint Louis University

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