Cybercare: A System for Confronting Bioterrorism

We need a system that will enable us to mobilize all of our health care resources rapidly wherever they are needed.

Everything is not okay. On September 11, the realm of possibility suddenly expanded to include the unthinkable, and we were reminded that there are people who are willing and able to inflict massive civilian casualties in the United States. Moral repugnance is no longer a sufficient deterrent. September 11 also demonstrated that we cannot rely on prevention. We must be prepared to respond to a whole host of catastrophic contingencies.

The anthrax scare shortly thereafter introduced us to the threat of deadly biological agents. We were lucky this time, but 12 nations are known to possess, or are suspected of possessing, offensive biochemical weapons. The characteristics that make biological devices unwieldy as weapons of war--such as silence, incubation time, and uncontrollability--make them effective options for bioterror. Biological agents differ from their chemical and nuclear counterparts in a number of important ways: (1) they are easy to conceal; (2) if they are contagious, infected people can spread the disease; (3) the first responders exposed are likely to be health professionals rather than the traditional emergency personnel; (4) the longer an epidemic goes unrecognized and undiagnosed, the more difficult it is to control its effects. A well executed dispersal of an infectious pathogen would have devastating effects, and the psychological fallout and panic would be even worse.

As long as we value our personal freedoms, intelligence and law enforcement will never be perfect. In any case, although preventive measures are necessary, they can never be sufficient--no one can anticipate every contingency. In addition, because the intelligence community operates covertly, it can do little to allay popular fears or restrain panic. To meet this threat, we need a new strategy that brings together our command, communication, and control technologies. We must be able to mobilize all of our health care resources rapidly wherever the threat appears, even if it appears in many places simultaneously. During a crisis, there is no time to invent a response. We must be prepared, and right now we are not.


Threats
Six biological agents are most suitable for "weaponization": plague, tularemia, botulinum (toxin), the hemorrhagic fevers, anthrax, and smallpox. Three of the six, plague, the hemorrhagic fevers, and smallpox, can be transmitted from person to person. We will briefly discuss two of them--anthrax and smallpox--as examples.

Anthrax is caused by a bacterium, Bacillus anthracis. Infection can be manifested in three different forms: inhalational, cutaneous, and gastrointestinal anthrax. The mortality rate of occupationally acquired cases of anthrax in the United States is 89 percent. A 1993 report by the U.S. Congressional Office of Technology Assessment estimated that between 130,000 and 3 million deaths could follow the aerosolized release of 100 kg of anthrax spores upwind of the Washington, D.C., area--lethality matching or exceeding that of a hydrogen bomb (OTA, 1999). The military has a vaccine for anthrax, but current supplies are limited, production capacity is modest, and sufficient quantities of vaccine cannot be made available for civilian use for several years. Depending on the strain, anthrax usually responds to ciprofloxacin, doxycycline, or penicillin. However, anthrax exposed to less than lethal levels of any of these antibiotics is capable of developing resistance.

Smallpox, a disease caused by the variola major virus, was declared eradicated from the world as a naturally occurring disease in 1997. Routine vaccinations were discontinued in the United States in 1972 and in the rest of the world by 1979. Thus the vast majority of people everywhere have either never been vaccinated against the disease or have only partial immunity from vaccinations that were administered decades ago. Historically, the fatality rate from outbreaks of smallpox has been about 30 percent, but it is higher among the unvaccinated. Smallpox vaccine has been out of production for 30 years, and the government is not sure how far its reserve of 15 million doses can be diluted. There is no proven, effective, specific treatment for smallpox.


Current Level of Preparedness
In testimony before the Senate Appropriations Subcommittee on Labor, Health and Human Services, and Education and Related Agencies, Tommy G. Thompson, Secretary of the U.S. Department of Health and Human Services, described our preparedness for a biological attack:

Let me characterize our status this way: we are prepared to respond --[September 11] is the first time our emergency response system had been tested at this extreme level, and it responded without a hitch . . . We were prepared to move rapidly to contain and treat any problematic disease . . . Our response encouraged me. It should encourage this committee and the Congress. And it should encourage the American public that we do have the ability to respond.

However, Thompson also noted, "Granted, we did not find any signs of bioterrorism."

The first sizeable simulation of a national response to a biological attack took place in May 2000. The exercise, named TOPOFF because it involved top officials from all levels of government, involved a simulated, covert dispersal of an aerosol of plague at the Denver Performing Arts Center that was discovered three days later when plague was first diagnosed among a wave of flu-like cases that cropped up in the Denver health care system.

On Day 1, a diagnosis of plague was confirmed by a state laboratory and the Centers for Disease Control (CDC). By Day 2 there was a state-wide shortage of ventilators and antibiotics. A federal "push pack" with antibiotics and other medical supplies arrived later that day, but transporting them from the Denver airport proved to be problematic. On Day 3 the state borders of Colorado were closed, but the question of feeding the four million inhabitants had not been thoroughly addressed. By the end of that day, overwhelmed by the influx of patients, medical care in Denver was beginning to shut down. On Day 4 there were an estimated 3,700 cases of plague and 950 deaths. At that point, the simulation was terminated. According to Thomas V. Inglesby, M.D., senior fellow at the Johns Hopkins Center for Civilian Biodefense Studies, "There were ominous signs at the end of the exercise. Disease had already spread to other states and countries. Competition between cities for the national pharmaceutical stockpile had already broken out. It had all the characteristics of an epidemic out of control."

The next major simulation, in June 2001, called Dark Winter, involved a simulated outbreak of smallpox in Oklahoma City. During the 13 days of the exercise, the disease spread to 25 states and 15 other countries. According to the ANSER Institute for Homeland Security, the lessons learned from this exercise were: (1) an attack on the United States with biological weapons could threaten vital national security interests; (2) current organizational structures and capabilities are not well suited for managing a biowarfare attack; (3) there is no surge capability in the U.S. health care and public health systems, the pharmaceutical industry, or the vaccine manufacturing industry; (4) dealing with the media will be a major, immediate challenge for all levels of government; (5) containing the spread of disease will present significant ethical, political, cultural, operational, and legal challenges (ANSER, 2001).

Both simulations were based on the assumption that current stores of antibiotics and vaccines would be effective against the biological agent. However, a group of researchers in Australia recently demonstrated that this assumption may no longer be valid. In an attempt to produce a contraceptive vaccine for mice using the mousepox virus, scientists discovered that "virus-encoded IL-4 not only suppresses primary antiviral cell-mediated immune response but also can inhibit the expression of immune memory responses" (Jackson et al., 2001). In other words, the trial substance not only made the disease more virulent by suppressing the immune system, but also rendered the vaccine ineffective.

The results of these and other experiments are widely available because, unlike the work of nuclear physicists or cryptographers working on national security, the work of biologists is not regulated. As more and more bioengineered bugs are created and tested, information about the science (e.g., genomic data) and equipment (e.g., DNA sequencers and synthesizers) used to create such organisms is becoming increasingly accessible. Considering the malign uses of data generated in legitimate projects, health care and defense experts are raising questions about this easy accessibility. Before we begin to regulate access to data, however, someone must determine which data are potentially dangerous (Aldous, 2001).

In short, we are not prepared to respond to a biological attack. We have been lucky so far, but luck cannot be the foundation for a public health or national security policy. We must seriously rethink the way we approach the whole notion of responding to a biological attack.


The Response
Four major challenges were revealed in the TOPOFF and Dark Winter exercises: (1) inefficient decision making (officials participated in conference calls with 50 to 100 people, which was highly inefficient and led to significant delays in action); (2) lack of coordination of emergency management (the absence of predetermined guidelines led to chaotic attempts at interagency communication); (3) lack of priorities and logistics for allocating resources (problems were encountered in accepting and distributing federal resources at the local level); and (4) security (especially at health care facilities, for enforcing a quarantine).

In a real emergency officials will need real-time information tools that enable them to collect information and analyze it rapidly. The primary elements of an effective response to a biological attack must in-clude: (1) detection/diagnosis; (2) quarantine/security; (3) resource mobilization/allocation; (4) panic management/media relations; and (5) command and control.


Cybercare
Cybercare, a new concept that takes advantage of the best new technologies, would be able to address all of these elements from the systems level to the specifics. The U.S. Department of Justice tasked the Institute for Security Technology Studies (ISTS) at Dartmouth College to make recommendations for planning a response to bioterrorism as part of its grant to study emerging terrorist threats. In January 2001, ISTS organized a conference that generated recommendations to strengthen and supplement public health infrastructure and formulate a national response plan to a terrorist attack. The plan would integrate a number of emerging technologies that collectively became known as "cybercare" (Rosen and Lucey, 2001).

Cybercare involves telemedicine, telesurgery (Madhani, 1997), telementoring, and distance learning systems. It also includes virtual reality simulators, augmented reality (Blackwell et al., 1998), datafusion, computer patient records, clinical information systems, and software intelligent agents. Cybercare can be thought of as cyberspace plus health care, a way of creating an entirely new environment for health care at a distance.

Detection/Diagnosis
There are two basic ways of detecting a biological attack. The first is to analyze epidemiological data; the second is to analyze biological samples in the field. The first was tested at President George W. Bush’s inauguration in January 2001. A Defense Advanced Research Projects Agency (DARPA)-developed software program, known as ENCOMPASS (the enhanced consequence management planning and support system) was used to track the health conditions of all individuals who were treated at area military treatment facilities, Veterans Affairs medical clinics, civilian hospitals, and first aid stations between January 10 and February 4 in Washington, D.C., and surrounding counties. Participating health care personnel filled out brief forms when seeing patients to note whether they showed any of seven specific symptoms or complaints that might be indicative of outbreaks of illnesses, such as those caused by biological warfare agents. ENCOMPASS created a database of patient health records and matched spikes in certain clinical symptoms with specific geographic areas. At the inauguration, it detected a seasonal "outbreak" of the flu (Pueschel, 2001).

Laboratories around the country are trying to develop a portable detector that can diagnose field samples. The Lincoln Laboratory at the Massachusetts Institute of Technology (MIT) is developing a microchip combined with mouse B cells to detect individual pathogens (Pescovitz, 2000). Efforts are under way to increase the speed, sensitivity, and cost-effectiveness of such a detector. Other laboratories are also experimenting with innovative detection/diagnosis devices.

At the 2002 Winter Olympics in Salt Lake City, a combined approach called RAPID will be used. The system, which was developed by the U.S. Air Force in conjunction with Idaho Technologies, is a web-based surveillance system that analyzes patient records and uses 50-pound, backpack-sized portable laboratories to analyze field samples using polymerase chain reaction technology (Ault, 2001). Someday, large databases managed by intelligent software agents may be used to predict attacks before they happen (Graham-Rowe, 2001).

Quarantine/Security
In the event of a sizeable bioattack, some form of quarantine will be necessary. The major obstacle to imposing a quarantine is political, but even if it can be imposed, it will be difficult to enforce. Robots could be used for surveillance and, possibly, for enforcement (although we have a long way to go culturally for this to happen). Once a quarantine has been imposed, cybercare will be the most effective way of bringing in and managing outside resources as will be discussed in the next section.

Resource Mobilization/Allocation
In June 2001 another conference was held by ISTS on logistics and interagency communication in response to a hypothetical bioterror attack in Hanover, New Hampshire. As Figure 1 shows, resource mobilization was the primary challenge. The black line represents the estimated requirement for personnel in response to a biological incident involving 5,000 casualties infected with tularemia. Although available local resources (dashed line) would respond quickly, they would fall far short of the need, and they would rapidly become less effective from burnout. State and federal resources (gray line) would begin to reach the scene one to two days later. A severe shortage of resources during days five through eight would essentially preclude an effective response and would result in misery and chaos. The late-arriving state and federal personnel could deal with the horrendous aftermath but would not be involved in the direct response. The aftermath might be comparable to the result of an instantaneous nuclear explosion, and the mounting chaos would unfold before the eyes of the world on CNN for four or more days. Thus, overcoming the shortfall in resources in days five through eight would be critical to responding effectively to a biological incident. Keep in mind that tularemia is not even a contagious agent (Rosen et al., 2001).

The cybercare system would work on a one-to-one level, bringing together local providers in the affected areas and distant experts. At the same time, it would work on the highest level, enabling emergency workers to gain control over a large-scale disaster as quickly as possible (Figures 2 and 3). The system would provide real-time simulators for determining, on the run, the best options for deploying available resources. As the TOPOFF exercise showed, it can be much easier to get resources to an area in need (e.g., from Washington, D.C., to the Denver Airport) than to distribute the resources effectively.

In the event of a smallpox attack, remote monitoring will be important. To minimize the spread of infection, patients should be isolated in their homes or other nonhospital facilities whenever possible. Considering that doctors can only offer palliative care and support therapy, patients could reasonably remain at home. Ideally, remote monitoring could be done by robots, which could bridge the virtual and physical worlds.

A robot manipulated remotely could also distribute vaccines or gas masks. A company in Massachusetts, iRobot, has developed robots that can be controlled over the Internet and outfitted with cameras, as well as an array of sensors. One model, the Cobalt 2, could revolutionize videoconferencing by adding the controllable, physical presence of a robot. Telepresence, as it is called, enables a remote user to interact with and manipulate a distant environment as though he were physically present (Lanier, 2001).

Robots are already being tried in search-and-rescue operations. Immediately after September 11, 18 experimental robots were brought to New York from the University of South Florida to be used at the World Trade Center. Although they did not locate any survivors, the robots were small enough and durable enough to go places humans and dogs could not go. The robots were armed with a variety of sensors for locating survivors (e.g., heat sensors). In addition, the robots were expendable (Trivendi, 2001).

In a biological crisis, whatever actions can be performed remotely should be for several reasons. First, a remotely operated performer can move resources rapidly because it moves through virtual rather than physical space. Second, the operator can simultaneously call upon a large pool of resources regardless of time or place. Finally, the human operator avoids the risk of exposure to the hot zone. As artificial intelligence and other technologies improve, robots will become increasingly capable and autonomous.

Panic Management/Media Relations
This is the only element of the response to a biological attack that would be largely outside the realm of cybercare. However, to prevent panic outside of the hot zone, the public must be told what steps are being taken and assured that the situation is (or soon will be) under control. This can be done with effective information gathering and dissemination. To prevent panic within the hot zone, remotely operated robots could perform crucial tasks and minimize rescuer exposure.

Command and Control
This is the most important and complex element of the cybercare system. Indeed, it is the brains of the whole operation. Cybercare is a matrix that combines a number of different technologies in a telecommunications space. Ideally, a seamless connection would be maintained between information technologies connected to the physical world through robotics and information technologies connected to the virtual world. In a cybercare system, these two worlds would be different ways of expressing information technologies, either locally or at a distance.

In the cybercare model, sensors would gather information from many sources, including robots, software agents, human agents, medical records, epidemiological data, and resource data to name a few. The information would be conveyed in many forms: voice, data, video, or a combination of the three. The network ferrying the data must be flexible, redundant, expandable, largely wireless, and allow for high bandwidth; the massive amount of incoming data must be processed continually. To avoid information overload, the data would be filtered by intelligent software as well as faster-than-real-time simulations that could predict the outcomes of certain actions. Manipulating the mass of data will also require a new interface—a three-dimensional virtual space, such as a datacube, perhaps (Figure 4). This same interface would enable the remote manipulation of the hot zone. Over time, some parts of the cybercare system, such as robots and intelligent software, would become increasingly autonomous.

Command and control would coordinate the activities of competing federal, state, and local agencies, in addition to facilitating individual doctor-to-patient remote interactions. Therefore, like the rest of the cybercare system, command and control would be somewhat decentralized. The cybercare system would not dictate specific connections; rather, it would facilitate intracontinental connections. By condensing time and space, it would make possible a faster, broader, more coordinated, and ultimately more effective response to an attack.


The Future
Most of the technologies described so far are either available today or will be in a few years. As the system evolves, virtual reality will become the preferred mode of interaction and will be more closely coupled with physical reality to create a hybrid, augmented reality. When telepresence is replaced by teleimmersion, a user will have difficulty distinguishing between the local and remote environments. The ultimate goal is not to remove humans from the loop but to enable humans to use their time and abilities efficiently and to protect them from harm. Robots will become more integrated into normal society. They might, for example, be hung on walls, much like fire extinguishers, and, in an emergency, deploy automatically and act completely autonomously. Whole cities might someday be covered in millions of sensors the size of dust particles. Eventually nanotechnology will change the rules once again.


Conclusion
We don’t mean to minimize the institutional barriers that will have to be overcome for cybercare to become a reality. As Secretary Thompson said after September 11, public health is a "national security issue." The decentralization of health care delivery will be good for national security and, ultimately, in the interest of the U.S. government. At a similar time in history, Winston Churchill, deeply troubled by England’s lack of preparation for World War II, said, "The responsibility of ministers for the public safety is absolute and requires no mandate. It is in fact the prime object for which governments come into existence."

A terrorist attack designed to cause catastrophic levels of casualties by spreading a contagious disease or chemical or radiation illness across America must be met with a health care system prepared to respond to worst-case scenarios and provide the surge capacity we will need in hours, not days. A cybercare system would protect the health of Americans, protect our economy, and, ultimately, protect our way of life. The creation of this new system will require a large-scale project that will certainly be expensive--but not as expensive as doing nothing. In addition, initial costs might be made up for in future savings. A cybercare system would take advantage of our strengths and could be developed rapidly if we start now.

In the interim, the infrastructure and technologies developed for a cybercare system would greatly improve the delivery of everyday health care. Reaching a remote, dangerous site is not very different from reaching a remote, rural site, and the technologies for a cybercare system would greatly increase access to health care. Whether it is designed to respond to a nuclear, chemical, or biological attack, a natural disaster, or simply to minimize travel costs and increase routine access to care, cybercare will be our future health care.


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