PROF. BRENNER: We'll now hear from Dr.
Steven J. Hatfill. He's been connected with the National
Institutes for Health for some time, working on child
health development and the laboratory for cellular and
molecular biophysics. He's a medical doctor with
certification in hematology and pathology. He has a
Ph.D. degree in molecular cell biology [Lie #1]. He has a
diploma in aviation medicine [Lie #2]. He has a diploma in
diving and submarine medicine [Lie #3] . He has served with the
U.S. Army Special Forces [Lie #4] . He was on a 14-month [Lie #5] duty
as medical officer and science team leader [Lie #6] at the
Antarctic research station. He also conducted research
while there for the NASA Johnson Space Center Solar
System Exploration Division [Lie #7]. He's been involved in
research involving serious problems such as Lyme
disease, Ebola and the Marburg virus. Dr. Hatfill.
DR. HATFILL: We've heard the threat today
from Dr. Alibek, Dr. Patrick, and Dr. Huggins for
biological threats of biological terrorism. We've heard
conventional countermeasures. We've heard of a number
of programs of advanced countermeasures. It now
becomes necessary to discuss worst-case scenarios and
that concerns ways of management, or possible ways of
management, of large areas covered by biological agent.
I've been working with Brigadier General Third
Army Medical Command in the United States Army
Reserve to try to develop a system for flexible and rapid
transportation of mass casualties from a contaminated
area to a rear area while maintaining life support and
critical care functions for the casualties.
When we're dealing with a large area of
coverage event, this can be exceedingly complex. A
single area of a city may be affected or multiple areas of
the city at the same time or closely thereafter, and
terrorists may be involved with both chemical weapon
release as well as with the biological agent.
One of the most dramatic open source
experiments that have been described for a large area of
coverage occurred on September 21, 1950, where a naval
vessel did an open air simulation test releasing spores of
the same size and weight as anthrax, but nonpathogenic
to humans, over the city of San Francisco. This was
conducted off a naval vessel two miles offshore and the
results are illustrated in this diagram. Had this occurred
with actual anthrax, there's a possibility that several
hundred thousand people could have contracted a fatal
pulmonary infection.
These types of dispersal scenarios in the most
part are covert. There's no indication that a biological
agent release has occurred until the incubation period for
the particular disease has expired. This is a typical case
history. An emergency department, normal operations
and patients begin to appear. The terrorist event has
occurred the week before. The incubation period for the
agent is now open and these previously healthy
individuals start coming in requiring rapid intensive care
including mechanical life support, mechanical
ventilation.
The situation of a large area of release in many
ways would resemble a modern battlefield, disrupted
lines of communication, poor coordination. Any changes
that were apparent in peacetime would tend to be
amplified during their affect during the natural biological
agent pattern.
Consequently it is illustrative to look at how
massive casualties have been handled on the battlefield
before. In the 1850s, we saw the first large-scale
systematic development of ways of transporting casualties
from a high concentration on the battlefield to a low
concentration in rural areas. This was during the
Crimean War. The British Army instituted an eight-mile
railway line during this conflict. This was also the time
when the Florence Nightingale nurses came into effect in
the first early field ambulances.
This concept became so effective that by the
early 1900s during the Boer War in South Africa, the
British army had prepositioned a number of specialized
hospital trains all along the areas of fighting. Each of
these passenger cars has been converted to handle up to
25 stretcher cases, and these were prepositioned along
39
different areas of the conflict. Patients were brought to
these trains and taken to various treatment centers.
The concept was further developed and by the
onset of World War I, was in a highly effective manner.
Patients could be taken directly from the trenches in the
battlefields moved by an organized ambulance system,
and deposited in what had now become hospital trains.
Some of these cars contain surgery units or
supporting care to stop bleeding, regain respiration, and
resuscitate the patient. There were also provisions for
walking cases and for other casualties. The system was
so effective that during the four days of the battle of the
Somme, there were 13,392 cases that were transported
from the front-line battlefields to rural hospital areas in
France.
Special frames were developed to cushion the
patients as they rode on the trains. This is one of the first
hospital trains in operation.
By World War II, a number of trains were in
operation both on the battlefront and for cities, because of
advances in air power, cities now became a target,
specifically London. Hospital trains were used to
evacuate thousands of casualties from London hospitals
to outlying areas, in addition to receiving casualties from
across the channel and redistributing it within the
country.
This is an interior of one of these trains. It's a
three-tiered system to provide adequate access to the
patients for their transportation.
This was even continued up until the 1950s with
the British Army of the Rhine. This was the advent of
federal medical transportation medication; the hospital
trains went into disuse. At this time there's only one in
use in England which is used by a reserve army medical
unit.
With a biological attack, these patients are going
to require even more intensive care than trauma
management. This is a slide of inhalational anthrax. We
only have a few hours once predominantly respiratory
symptoms develop. The patient needs to be intubated;
they need to be mechanically ventilated. Their blood
pressure needs to be supported with medications.
Some cutaneous cases may appear. This is
cutaneous anthrax, the vegetative bacteria multiplying in
the blood stream and the tissues release a number of
toxins, with a massive edema, malignant edema.
Over 50 percent of those exposed to the agent
plume end up with inhalation anthrax. Over 50 percent
of the inhalation anthrax develop cases associated with
hemorrhagic meningitis. This is the membrane covering
the brain. A great deal of these patients will be brought
in as casualties probably all having epileptic fits.
Surrounding area and surface contamination is possible
as well as intestinal cases may appear. This is
hemorrhagic infection of the lymph nodes and intestines
and a small destruction section of the bowel through
disruption of his blood supply.
Until recently, the medical trains would not
have been sufficient for the mass evacuation of casualties
from a high concentration attack area to rear definitive
area treatments. Recently, Northrop Grumman has come
out with a specialized stretcher. This is called LSTT
stretcher. It stands for Life Support and Trauma
Transport. Essentially, this is a self-contained unit with
a giant ventilator I.V. fluid infusion pump and with full
monitoring capability. Patients put on the stretcher can
be intubated, stabilized, and transferred.
The second concept that's become important is
that of intermodal transportation. This is the use of
containers of goods or contents by a variety of different
methods.
This can be by land, air, and sea in standardized
containers. There's a whole subsection of the container
transport industry, and they will make containers how
you want. If you want a bathroom in it, they'll put a
bathroom in it. If you want it a certain size, they'll
construct it a certain size, economically and
standardized. There are some methods for
unaccompanied freight, and at the bottom slide you can
actually have these on lorries, semi-trailer trucks, that are
driven on and then off again.
By combining the systems, it becomes possible
to design a disaster car, a disaster evacuation train. The
train would look something like this. Head cars are the
ones that stay with the containers. They transport the
rest of the train. This is a locomotive, a container for
medical personnel. Bulk stores, which could feature
antibiotic stores or injectors with deployable vaccination
stations. And a staff and manned control
communications and intelligence sections.
The staff car could act as the nucleus of a
command center to coordinate effectively with first
responders.
For a proper coordinated response, it's
envisioned that the first responders, the fire, police, and
ambulances need to be connected with military resources,
with government and state resources, and with satellite.
Currently, a piece of technology called the alert
system has been developed by the Texas Department of
Transportation. Essentially, this is a laptop computer
built into the trunk of a patrol car. It's digital and
operating on the mobile system. Already digital images
have been transmitted from a patrol car in Florida to a
patrol car in Alexandria. This allows some
interoperatability between all first response vehicles.
By linking into the Internet, a commonality can
be provided. A previous mass casualty or possible mass
casualty incident such as the World Trade Center or
Oklahoma City bombing shows that the cellular system
tends to go down right after an accident. Everybody's
trying to log on and use it, and the system collapses. The
40
train would carry a useful piece of technology with it.
Manufactured by Celltel, this is a mobile system. Unless
you have a chip for your cell phone, you cannot talk.
This entire system provides a satellite link to
other federal responders in transit to the site as well as
coordinating local first responders. This will cover about
a 60-mile radius.
Maps of each area can be used so all response
forces are clearly in contact with each other. You can
play road status, you can put meteorological and weather
information on these maps and GPS coordinates are part
of the alert system.
Defense Special Weapons Agency have an
enormous amount of experience modeling downwind
areas. They have computer programs that can model
fairly quickly possible downwind affected areas.
The second section of the train would be the
intensive care patient cars. The intensive care ward
coaches would be specially built containers with a shock
absorbing system able to handle the LSTT stretchers. It
can be mounted on lorries or it can be driven on and off
with a semiattached tractor-trailer. Patients would be
brought from out of the WMD site on the LSTT
stretchers. They would then be loaded into these special
containers. A center monitoring station, this has already
been designed, and one doctor and five or six orderlies
could effectively monitor 40 or 50 patients. These things
can be driven off or taken straight to the facility.
The last portion of the disaster train would
consist of cutout cars. These would be left on-site. It
features a security element, another command control,
communications information element, ambulance trucks
with the LSTT stretchers already loaded that can drive
into the site and bring the patients back to the side of the
train and a deployable field hospital.
The inside of these hospital cars can be made to
different sizes. Along with this comes a mortuary
embalming station. This was originally developed by
Arms Corps in South Africa with the concept that
patients are embalmed onsite. This negates mass burials
or graves. The remains are preserved. It can handle 800
bodies an hour. The bodies are embalmed, put into body
bags, and stored at room temperature for later burial
when the incident is over.
The system would work like this: If these trains
are placed -- and we'll estimate you'll need somewhere
around 27 trains to cover the United States -- but if all
other traffic is cleared off of the rails, you'll be no more
than four to six hours rail travel to a major metropolitan
area.
Notification. We are estimating this will be the
Reserves or the National Guard handling these trains.
The train would travel to the disaster site to a
predetermined spot. It will be loaded. Ambulances and a
helipad will be set up back on the train, and an on-site
army field site hospital would be deployed. The patients
would be brought out on the LSTT stretchers and then
loaded onto the train. From there, the train would leave
full.
This is an artist's conception of such an incident.
This deploying field hospital is covered with a charcoal
and peroxide blanket. Patients are brought out of the
area by air or by ambulances on the train on the LSTT
stretchers. These can be at a positive pressure or
negative pressure. We show the assistants here in Level
A gear because a chemical attack could have occurred at
the same time, and the patient is loaded onto the
containers and we distribute it out of the incident site.
The disaster train concept could provide a
number of things. The ability to rapidly transport large
quantities of antibiotics, vaccines, personnel and
protective equipment to a WMD site within a matter of
hours, the ability to rapidly transform sitting stretcher
and critical care patients on life support from congested
nonfunctional hospital areas to health care facilities
outside of the target area.
And this response capability would be
independent of normal road transportation. Some
scenarios suggest that with a large area of coverage, one
third of the population may attempt to flee the city. This
could mean both sides of the beltway congested.
Bringing these medical facilities in by train, that avoids
this traffic jam. The country could be at war at the same
time. There could be limited air assets. It provides,
above all, a starting point to coordinate other federal
response forces. Thank you very much.
Questions and Answers
PROF. BRENNER: We now commence the
discussion period.
Q. My question is to the last gentleman. I'm
Dave Ruppe with Defense Week. How much would this
concept that you just described cost for the U.S. to place,
and also a more general question for the three of you:
Who exactly, what agency is in charge of developing or
is currently advocating organizing civilian research and
development and equipment purchasing efforts, all of
that? I see the military has several agencies doing it for
that side, but who's actually responsible on the civilian
side?
DR. HATFILL: Answer to the first part of your
question, we've had some talks with Northrop Grumman,
and we estimate that each train would cost approximately
half that of an F-14 jet fighter. For two squadrons of
fighters, it would cover 27 cities. We'll have 27 trains
which would cover a number of cities. It would be statebased.
Each train would be responsible for four or five
metropolitan areas.
PROF. BRENNER: Would any panelist care to
comment on the question?
COL PARKER: As far as who has the overall
responsibility for the programs for everything that might
41
be directed towards bioterrorism, I think that's difficult to
say. I don't know that answer. There are several
agencies. The DOD, of course, has had an RD effort in
biowarfare defense for a number of years. And now there
are other agencies that have been doing good work, The
NIH, for example, has a very robust infectious disease
R&D program.
So certainly, all of what goes on and a lot of
things that go on in an RD program for infectious disease
are, of course, some of the technologies that are
applicable to bio defense. And some of the basic
knowledge that comes out of that is going to be
something that should be tapped and is very useful.
There are other agencies, the Department of Energy has
some efforts, so there's just a number of agencies. We
may not be the perfect ones to ask that question to.
Q. Who would be a good person to ask that
question?
DR. WINEGAR: Are you primarily focusing
on R&D efforts? It's a very distinct difference.
Q. I guess both.
DR. WINEGAR: Now, I think there is no one
person on R&D efforts. As Gerry indicated, certainly the
Department of Energy, Health Services, DOD, a number
of agencies each have their own R&D budgets. The
procurement side is a whole different issue, and I know
that's come to the forefront lately in the aftermath of
some of the training and the awareness that's been
provided to some of the target cities. People are left with
the information, but none of the supplies.
And that's a real deficiency right now, because
none of the cities has budgeted for this type of equipment
or medical antidotes or anything. Certainly, the DOD
has some stockpiles of some particular vaccines and that
type of thing but not enough for everybody, and that's
clearly, partly, I would think, the responsibility for Public
Health Service or Office of Emergency Preparedness,
FEMA, a number of different agencies. And I guess the
bottom line is we're all sort of working together to
identify what the highest priorities are, both in R&D and
in procurement.
COL PARKER: I think it's important although
the answer to the R&D didn't sound very good. On the
other hand, there is a lot of interagency communication,
collaboration, so that there's not unnecessary duplication.
Part of the scientific process is there is going to be some
parallel efforts and complementarity. That's just part of
the scientific process. There is a lot of communication
and collaboration on some of these efforts that at least
have some cross areas.
Q. Kyle Olson, Research Planning,
Incorporated. First of all, my compliments to George
Washington University and the Potomac Institute for
Policy Studies for sponsoring this session today. There's
been a lot of interesting points made and offered. In a
sense, it's a shame that we had to wait till now to discuss
them because some of the earlier presenters already had
to leave. In fact, most of the points I wanted to make are
addressed to issues made this morning.
Let me just toss them out in a hurry. First of all,
I think I'd like to challenge the assessment made by Dr.
Oehler regarding the likelihood that large groups pose
the greatest threat. I think that, in fact, small groups are
not likely to have the wherewithal or the technical skill to
execute an effective attack. I think we get clouded or
confused and to some extent we can, I think, even lead
ourselves astray, if we focus on our own example and fail
to take the right lessons out of that.
Aum Shinrikyo was a large-scale endeavor, and
certainly they had a lot of research to put into a biological
terrorism effort. On the other hand, you can argue
equally well it was a large relatively well-funded
misguided effort which lacked the technical background.
Bottom line, Aum Shinrikyo were not strong in life
science. They were very good at electronic engineering
and other things, but biological science was not an area
where they were tremendously successful in their efforts.
I think that another point that was made was
that the technology has not suddenly transformed the
threat, and I think in a sense that's true. Certainly,
nothing that presented itself as a biological threat 20
years ago has been radically changed by some new
breakthrough technology, at least not in terms of looking
at the anthrax danger or smallpox or any of the others.
What has happened, though, is technology has not
transformed the problem, but has empowered people that
were not potentially a threat before.
As we move into this new century, we have to
recognize that technologies that were formerly the
province of only the very sophisticated, these
technologies are increasingly found in the general
environment. And as was presented earlier today, these
technologies are available at universities and other
centers around the country.
I think that Brad Roberts did a very nice job of
citing a number of very useful quotations this morning.
Let me cite a noted philosopher, Mel Brooks, in his
definitive piece, Young Frankenstein, when he said that a
riot is an ugly thing, and I think it's time we had one. I
think that some of the hue and cry over the bio-chemical
threat may be at some times overdrawn, and at the same
time, given the total absence of any conversation or
discussion or serious evaluation of that threat for the
better part of the last two or three decades, I think it's
been a very transforming experience in that respect.
Let me point out that one of the inevitable
problems that we also have in a setting like this, and
there's no way around it, is the collision of military
doctrine-based concerns and domestic terrorism-based
concerns. What is applicable in one situation does not
necessarily have a direct application in another.
42
Concerns about the ability of terrorists to build weapons
capable of delivering a strategic blow do not necessarily
correspond to concerns that first responders in the cities
have regarding the likelihood that a terrorist could come
up with something, even if it's just a pump spray, that
could take out a conference room or a symposium or an
arena of people.
Going one step beyond that, we also have to
recognize that the biological terrorist threat, as we
continue to talk about it, I think it serves us well because
it alerts us to the danger. There's a potential boomerang
there. That is as we raise the flag of terrorism to new
heights, we create a situation in which our inability to
differentiate between the naturally occurring and the
man-made can potentially create a false trigger in
people's minds. Case in point, the naturally occurring
outbreak of hemorrhagic fever in a major Indian city
today would probably raise levels of concern regarding
deliberate biological attacks the factor in South Asia to
relatively unprecedented levels. Again, thank you for the
conference. Thank you for the opportunity to discuss
these things.
PROF. BRENNER: Any panelist like to
respond?
MR. SIEGRIST: Kyle, I'm glad you spoke up.
Who did you direct that first one to about the size of the
group?
DR. OEHLER: I obviously didn't make my
point clearly. What I was trying to say is we need to look
for vulnerabilities. Large groups have different
vulnerabilities. I wasn't trying to say that large groups
are more dangerous. I'm saying that if a group is large
enough that it has all these technologies in it more
vulnerable to counter traditional terrorist efforts, such as
the counter terrorist center and the FBI and others are
specialists at. They're more vulnerable to being
penetrated. Small groups, which are harder to penetrate,
don't have all the technologies. My point is that we need
to look at where the vulnerabilities are, and try to put in
place programs to exploit those vulnerabilities.
PROF. BRENNER: Other questions. I'll ask
one of Dr. Hatfill. Can you give us an explanation of
what kind of chain of command we're looking at for these
27 trains? Who do the people report to and who controls
them and what's the organization structure? Is it civilian,
military or hybrid?
DR. HATFILL: It would be hybrid with some
qualifications on that. The DOD seems intent in
involving the National Guard in that with respect to the
rapid assessment teams. A pre-placed train on a siding
would be an ideal place for these RAID teams to operate
from. You can move three people very rapidly anywhere
and in the midst of a WMD crisis in one of our
metropolitan areas, it would be useful if the top three
people of the RAID team could advise, see what the first
responders are doing, is there a need for follow-on forces,
is there a need for greater federal intervention and this --
you're not going to do too much with 22 men in a WMD
incident. If it's a small-scale event, local authorities
should be able to handle it. If it's a large-area coverage,
these RAID teams would be trained in NBC
reconnaissance detection and could very rapidly call the
disaster train in as a follow-on force.
PROF. BRENNER: Do we have additional
questions or comments?
Q. Yes, David Mahoney with Defense News. I
have a question. At certain levels it seems with different
asymmetric threats, bioterrorism, obviously, being one of
them, at what level is there a breakdown between sort of
the traditional way the military has looked at threats as
over there somewhere before it’s projected to start being
threats where we really have to start worrying about a
mix between civil defense as an aspect of military defense
against outside aggression? I'd like to open this up to any
of the panelists who spoke today.
COL PARKER: It's a good question, and I think
a good topic to bring out and talk about and discuss. I
guess in my own mind and my own thinking, in fact, I've
begun from just the military perspective, we've always
thought in our BW defense program about the battlefield
scenario, but certainly over the last few years that has
also gone into force protection scenarios. You know, we
have to provide protection for our troops in their
barracks, as an example, and WMD and a bioterrorism
event may be something we need to not only think about
for the battlefield, but also force protection and that same
concept then, also that can be extended in our thinking
and planning for protection against a place where
civilians live, as opposed to where soldiers are. So where
that line is, I think, is going to get fuzzier. The
battlefield versus civilian protection and force protection.
I think we need to broaden our way that we think about it
and not stay in these boxes of battlefield versus civilian
protection because there's a lot of overlap. And a lot of
that intellectual thinking can be brought to bear for both
of those scenarios.
DR. HATFILL: We are living as a species at
this time in population densities that have never ever
been seen before. This brings in the concept of emerging
diseases. We're seeing on the average every two to three
years one new pathogen we never really recognized
before or a variant strain of a known pathogen. And as
we live in these terribly increased densities, which are
projected to increase even further in the next century, the
whole concept of the emerging infectious disease
becomes a major public health problem. Anything that
we spend on biological weapons defense can have direct
transference to the concept of public health and infectious
disease management.
PROF. BRENNER: Additional comments.
Q. Yes. Captain Lisa Forsythe, U.S. Army.
My question is for any of the panelists. Have you
43
analyzed our existing plan such as the Federal Response
Plan and how the Emergency Support Functions and
those Lead Federal Agencies such as the Department of
Transportation has an ESF leadership role and how DOD
fits into our current plans and how we support those
plans, not necessarily DOD taking a lead such as the
railroad system but actually supporting Department of
Transportation in those leadership roles that have already
been established?
DR. HATFILL: The National Security Council
has formulated an interagency working group to address
these problems. When is the handoff from FBI to
FEMA? How will federal assets coordinate with state
and local -- there is a working group at present working
on this.
DR. ROBERTS: There's the broader question
of the role of the Department of Defense in supporting a
national response to the bioterrorism problem as opposed
to the narrow question of the role that it plays in the
emergency response plan. I think while it's appropriate
to flag the concrete and specific issues in the emergency
response plan, we should also be sure to provide the
context here. And that is, as you know, the department
originally responded to the first PDD, the Presidential
Decision Directive in this area, four or so years ago
began to focus more seriously on its role and support of
domestic responses to terrorism, and there has been a
biocomponent of that I think this was given a big impetus
by the Defense Science Board Summer Study a year ago
which talked about the transnational threat and spelled
out potential new roles for the Department in supporting
the larger mission of the nation combating terrorism.
There have been various follow-on endeavors to that and
most recently re-collected and reorganized in the latest
PDDs, which carry forward this process. So I just
wanted to make sure that we didn't set aside this question
of the larger context within which the Department
supports the larger governmental strategy.
PROF. BRENNER: I'm going to call on
Professor Yonah Alexander to close the proceedings and
I’ll express my appreciation for you all being a very
conscientious and attentive audience.
Steven J. Hatfill. He's been connected with the National
Institutes for Health for some time, working on child
health development and the laboratory for cellular and
molecular biophysics. He's a medical doctor with
certification in hematology and pathology. He has a
Ph.D. degree in molecular cell biology [Lie #1]. He has a
diploma in aviation medicine [Lie #2]. He has a diploma in
diving and submarine medicine [Lie #3] . He has served with the
U.S. Army Special Forces [Lie #4] . He was on a 14-month [Lie #5] duty
as medical officer and science team leader [Lie #6] at the
Antarctic research station. He also conducted research
while there for the NASA Johnson Space Center Solar
System Exploration Division [Lie #7]. He's been involved in
research involving serious problems such as Lyme
disease, Ebola and the Marburg virus. Dr. Hatfill.
DR. HATFILL: We've heard the threat today
from Dr. Alibek, Dr. Patrick, and Dr. Huggins for
biological threats of biological terrorism. We've heard
conventional countermeasures. We've heard of a number
of programs of advanced countermeasures. It now
becomes necessary to discuss worst-case scenarios and
that concerns ways of management, or possible ways of
management, of large areas covered by biological agent.
I've been working with Brigadier General Third
Army Medical Command in the United States Army
Reserve to try to develop a system for flexible and rapid
transportation of mass casualties from a contaminated
area to a rear area while maintaining life support and
critical care functions for the casualties.
When we're dealing with a large area of
coverage event, this can be exceedingly complex. A
single area of a city may be affected or multiple areas of
the city at the same time or closely thereafter, and
terrorists may be involved with both chemical weapon
release as well as with the biological agent.
One of the most dramatic open source
experiments that have been described for a large area of
coverage occurred on September 21, 1950, where a naval
vessel did an open air simulation test releasing spores of
the same size and weight as anthrax, but nonpathogenic
to humans, over the city of San Francisco. This was
conducted off a naval vessel two miles offshore and the
results are illustrated in this diagram. Had this occurred
with actual anthrax, there's a possibility that several
hundred thousand people could have contracted a fatal
pulmonary infection.
These types of dispersal scenarios in the most
part are covert. There's no indication that a biological
agent release has occurred until the incubation period for
the particular disease has expired. This is a typical case
history. An emergency department, normal operations
and patients begin to appear. The terrorist event has
occurred the week before. The incubation period for the
agent is now open and these previously healthy
individuals start coming in requiring rapid intensive care
including mechanical life support, mechanical
ventilation.
The situation of a large area of release in many
ways would resemble a modern battlefield, disrupted
lines of communication, poor coordination. Any changes
that were apparent in peacetime would tend to be
amplified during their affect during the natural biological
agent pattern.
Consequently it is illustrative to look at how
massive casualties have been handled on the battlefield
before. In the 1850s, we saw the first large-scale
systematic development of ways of transporting casualties
from a high concentration on the battlefield to a low
concentration in rural areas. This was during the
Crimean War. The British Army instituted an eight-mile
railway line during this conflict. This was also the time
when the Florence Nightingale nurses came into effect in
the first early field ambulances.
This concept became so effective that by the
early 1900s during the Boer War in South Africa, the
British army had prepositioned a number of specialized
hospital trains all along the areas of fighting. Each of
these passenger cars has been converted to handle up to
25 stretcher cases, and these were prepositioned along
39
different areas of the conflict. Patients were brought to
these trains and taken to various treatment centers.
The concept was further developed and by the
onset of World War I, was in a highly effective manner.
Patients could be taken directly from the trenches in the
battlefields moved by an organized ambulance system,
and deposited in what had now become hospital trains.
Some of these cars contain surgery units or
supporting care to stop bleeding, regain respiration, and
resuscitate the patient. There were also provisions for
walking cases and for other casualties. The system was
so effective that during the four days of the battle of the
Somme, there were 13,392 cases that were transported
from the front-line battlefields to rural hospital areas in
France.
Special frames were developed to cushion the
patients as they rode on the trains. This is one of the first
hospital trains in operation.
By World War II, a number of trains were in
operation both on the battlefront and for cities, because of
advances in air power, cities now became a target,
specifically London. Hospital trains were used to
evacuate thousands of casualties from London hospitals
to outlying areas, in addition to receiving casualties from
across the channel and redistributing it within the
country.
This is an interior of one of these trains. It's a
three-tiered system to provide adequate access to the
patients for their transportation.
This was even continued up until the 1950s with
the British Army of the Rhine. This was the advent of
federal medical transportation medication; the hospital
trains went into disuse. At this time there's only one in
use in England which is used by a reserve army medical
unit.
With a biological attack, these patients are going
to require even more intensive care than trauma
management. This is a slide of inhalational anthrax. We
only have a few hours once predominantly respiratory
symptoms develop. The patient needs to be intubated;
they need to be mechanically ventilated. Their blood
pressure needs to be supported with medications.
Some cutaneous cases may appear. This is
cutaneous anthrax, the vegetative bacteria multiplying in
the blood stream and the tissues release a number of
toxins, with a massive edema, malignant edema.
Over 50 percent of those exposed to the agent
plume end up with inhalation anthrax. Over 50 percent
of the inhalation anthrax develop cases associated with
hemorrhagic meningitis. This is the membrane covering
the brain. A great deal of these patients will be brought
in as casualties probably all having epileptic fits.
Surrounding area and surface contamination is possible
as well as intestinal cases may appear. This is
hemorrhagic infection of the lymph nodes and intestines
and a small destruction section of the bowel through
disruption of his blood supply.
Until recently, the medical trains would not
have been sufficient for the mass evacuation of casualties
from a high concentration attack area to rear definitive
area treatments. Recently, Northrop Grumman has come
out with a specialized stretcher. This is called LSTT
stretcher. It stands for Life Support and Trauma
Transport. Essentially, this is a self-contained unit with
a giant ventilator I.V. fluid infusion pump and with full
monitoring capability. Patients put on the stretcher can
be intubated, stabilized, and transferred.
The second concept that's become important is
that of intermodal transportation. This is the use of
containers of goods or contents by a variety of different
methods.
This can be by land, air, and sea in standardized
containers. There's a whole subsection of the container
transport industry, and they will make containers how
you want. If you want a bathroom in it, they'll put a
bathroom in it. If you want it a certain size, they'll
construct it a certain size, economically and
standardized. There are some methods for
unaccompanied freight, and at the bottom slide you can
actually have these on lorries, semi-trailer trucks, that are
driven on and then off again.
By combining the systems, it becomes possible
to design a disaster car, a disaster evacuation train. The
train would look something like this. Head cars are the
ones that stay with the containers. They transport the
rest of the train. This is a locomotive, a container for
medical personnel. Bulk stores, which could feature
antibiotic stores or injectors with deployable vaccination
stations. And a staff and manned control
communications and intelligence sections.
The staff car could act as the nucleus of a
command center to coordinate effectively with first
responders.
For a proper coordinated response, it's
envisioned that the first responders, the fire, police, and
ambulances need to be connected with military resources,
with government and state resources, and with satellite.
Currently, a piece of technology called the alert
system has been developed by the Texas Department of
Transportation. Essentially, this is a laptop computer
built into the trunk of a patrol car. It's digital and
operating on the mobile system. Already digital images
have been transmitted from a patrol car in Florida to a
patrol car in Alexandria. This allows some
interoperatability between all first response vehicles.
By linking into the Internet, a commonality can
be provided. A previous mass casualty or possible mass
casualty incident such as the World Trade Center or
Oklahoma City bombing shows that the cellular system
tends to go down right after an accident. Everybody's
trying to log on and use it, and the system collapses. The
40
train would carry a useful piece of technology with it.
Manufactured by Celltel, this is a mobile system. Unless
you have a chip for your cell phone, you cannot talk.
This entire system provides a satellite link to
other federal responders in transit to the site as well as
coordinating local first responders. This will cover about
a 60-mile radius.
Maps of each area can be used so all response
forces are clearly in contact with each other. You can
play road status, you can put meteorological and weather
information on these maps and GPS coordinates are part
of the alert system.
Defense Special Weapons Agency have an
enormous amount of experience modeling downwind
areas. They have computer programs that can model
fairly quickly possible downwind affected areas.
The second section of the train would be the
intensive care patient cars. The intensive care ward
coaches would be specially built containers with a shock
absorbing system able to handle the LSTT stretchers. It
can be mounted on lorries or it can be driven on and off
with a semiattached tractor-trailer. Patients would be
brought from out of the WMD site on the LSTT
stretchers. They would then be loaded into these special
containers. A center monitoring station, this has already
been designed, and one doctor and five or six orderlies
could effectively monitor 40 or 50 patients. These things
can be driven off or taken straight to the facility.
The last portion of the disaster train would
consist of cutout cars. These would be left on-site. It
features a security element, another command control,
communications information element, ambulance trucks
with the LSTT stretchers already loaded that can drive
into the site and bring the patients back to the side of the
train and a deployable field hospital.
The inside of these hospital cars can be made to
different sizes. Along with this comes a mortuary
embalming station. This was originally developed by
Arms Corps in South Africa with the concept that
patients are embalmed onsite. This negates mass burials
or graves. The remains are preserved. It can handle 800
bodies an hour. The bodies are embalmed, put into body
bags, and stored at room temperature for later burial
when the incident is over.
The system would work like this: If these trains
are placed -- and we'll estimate you'll need somewhere
around 27 trains to cover the United States -- but if all
other traffic is cleared off of the rails, you'll be no more
than four to six hours rail travel to a major metropolitan
area.
Notification. We are estimating this will be the
Reserves or the National Guard handling these trains.
The train would travel to the disaster site to a
predetermined spot. It will be loaded. Ambulances and a
helipad will be set up back on the train, and an on-site
army field site hospital would be deployed. The patients
would be brought out on the LSTT stretchers and then
loaded onto the train. From there, the train would leave
full.
This is an artist's conception of such an incident.
This deploying field hospital is covered with a charcoal
and peroxide blanket. Patients are brought out of the
area by air or by ambulances on the train on the LSTT
stretchers. These can be at a positive pressure or
negative pressure. We show the assistants here in Level
A gear because a chemical attack could have occurred at
the same time, and the patient is loaded onto the
containers and we distribute it out of the incident site.
The disaster train concept could provide a
number of things. The ability to rapidly transport large
quantities of antibiotics, vaccines, personnel and
protective equipment to a WMD site within a matter of
hours, the ability to rapidly transform sitting stretcher
and critical care patients on life support from congested
nonfunctional hospital areas to health care facilities
outside of the target area.
And this response capability would be
independent of normal road transportation. Some
scenarios suggest that with a large area of coverage, one
third of the population may attempt to flee the city. This
could mean both sides of the beltway congested.
Bringing these medical facilities in by train, that avoids
this traffic jam. The country could be at war at the same
time. There could be limited air assets. It provides,
above all, a starting point to coordinate other federal
response forces. Thank you very much.
Questions and Answers
PROF. BRENNER: We now commence the
discussion period.
Q. My question is to the last gentleman. I'm
Dave Ruppe with Defense Week. How much would this
concept that you just described cost for the U.S. to place,
and also a more general question for the three of you:
Who exactly, what agency is in charge of developing or
is currently advocating organizing civilian research and
development and equipment purchasing efforts, all of
that? I see the military has several agencies doing it for
that side, but who's actually responsible on the civilian
side?
DR. HATFILL: Answer to the first part of your
question, we've had some talks with Northrop Grumman,
and we estimate that each train would cost approximately
half that of an F-14 jet fighter. For two squadrons of
fighters, it would cover 27 cities. We'll have 27 trains
which would cover a number of cities. It would be statebased.
Each train would be responsible for four or five
metropolitan areas.
PROF. BRENNER: Would any panelist care to
comment on the question?
COL PARKER: As far as who has the overall
responsibility for the programs for everything that might
41
be directed towards bioterrorism, I think that's difficult to
say. I don't know that answer. There are several
agencies. The DOD, of course, has had an RD effort in
biowarfare defense for a number of years. And now there
are other agencies that have been doing good work, The
NIH, for example, has a very robust infectious disease
R&D program.
So certainly, all of what goes on and a lot of
things that go on in an RD program for infectious disease
are, of course, some of the technologies that are
applicable to bio defense. And some of the basic
knowledge that comes out of that is going to be
something that should be tapped and is very useful.
There are other agencies, the Department of Energy has
some efforts, so there's just a number of agencies. We
may not be the perfect ones to ask that question to.
Q. Who would be a good person to ask that
question?
DR. WINEGAR: Are you primarily focusing
on R&D efforts? It's a very distinct difference.
Q. I guess both.
DR. WINEGAR: Now, I think there is no one
person on R&D efforts. As Gerry indicated, certainly the
Department of Energy, Health Services, DOD, a number
of agencies each have their own R&D budgets. The
procurement side is a whole different issue, and I know
that's come to the forefront lately in the aftermath of
some of the training and the awareness that's been
provided to some of the target cities. People are left with
the information, but none of the supplies.
And that's a real deficiency right now, because
none of the cities has budgeted for this type of equipment
or medical antidotes or anything. Certainly, the DOD
has some stockpiles of some particular vaccines and that
type of thing but not enough for everybody, and that's
clearly, partly, I would think, the responsibility for Public
Health Service or Office of Emergency Preparedness,
FEMA, a number of different agencies. And I guess the
bottom line is we're all sort of working together to
identify what the highest priorities are, both in R&D and
in procurement.
COL PARKER: I think it's important although
the answer to the R&D didn't sound very good. On the
other hand, there is a lot of interagency communication,
collaboration, so that there's not unnecessary duplication.
Part of the scientific process is there is going to be some
parallel efforts and complementarity. That's just part of
the scientific process. There is a lot of communication
and collaboration on some of these efforts that at least
have some cross areas.
Q. Kyle Olson, Research Planning,
Incorporated. First of all, my compliments to George
Washington University and the Potomac Institute for
Policy Studies for sponsoring this session today. There's
been a lot of interesting points made and offered. In a
sense, it's a shame that we had to wait till now to discuss
them because some of the earlier presenters already had
to leave. In fact, most of the points I wanted to make are
addressed to issues made this morning.
Let me just toss them out in a hurry. First of all,
I think I'd like to challenge the assessment made by Dr.
Oehler regarding the likelihood that large groups pose
the greatest threat. I think that, in fact, small groups are
not likely to have the wherewithal or the technical skill to
execute an effective attack. I think we get clouded or
confused and to some extent we can, I think, even lead
ourselves astray, if we focus on our own example and fail
to take the right lessons out of that.
Aum Shinrikyo was a large-scale endeavor, and
certainly they had a lot of research to put into a biological
terrorism effort. On the other hand, you can argue
equally well it was a large relatively well-funded
misguided effort which lacked the technical background.
Bottom line, Aum Shinrikyo were not strong in life
science. They were very good at electronic engineering
and other things, but biological science was not an area
where they were tremendously successful in their efforts.
I think that another point that was made was
that the technology has not suddenly transformed the
threat, and I think in a sense that's true. Certainly,
nothing that presented itself as a biological threat 20
years ago has been radically changed by some new
breakthrough technology, at least not in terms of looking
at the anthrax danger or smallpox or any of the others.
What has happened, though, is technology has not
transformed the problem, but has empowered people that
were not potentially a threat before.
As we move into this new century, we have to
recognize that technologies that were formerly the
province of only the very sophisticated, these
technologies are increasingly found in the general
environment. And as was presented earlier today, these
technologies are available at universities and other
centers around the country.
I think that Brad Roberts did a very nice job of
citing a number of very useful quotations this morning.
Let me cite a noted philosopher, Mel Brooks, in his
definitive piece, Young Frankenstein, when he said that a
riot is an ugly thing, and I think it's time we had one. I
think that some of the hue and cry over the bio-chemical
threat may be at some times overdrawn, and at the same
time, given the total absence of any conversation or
discussion or serious evaluation of that threat for the
better part of the last two or three decades, I think it's
been a very transforming experience in that respect.
Let me point out that one of the inevitable
problems that we also have in a setting like this, and
there's no way around it, is the collision of military
doctrine-based concerns and domestic terrorism-based
concerns. What is applicable in one situation does not
necessarily have a direct application in another.
42
Concerns about the ability of terrorists to build weapons
capable of delivering a strategic blow do not necessarily
correspond to concerns that first responders in the cities
have regarding the likelihood that a terrorist could come
up with something, even if it's just a pump spray, that
could take out a conference room or a symposium or an
arena of people.
Going one step beyond that, we also have to
recognize that the biological terrorist threat, as we
continue to talk about it, I think it serves us well because
it alerts us to the danger. There's a potential boomerang
there. That is as we raise the flag of terrorism to new
heights, we create a situation in which our inability to
differentiate between the naturally occurring and the
man-made can potentially create a false trigger in
people's minds. Case in point, the naturally occurring
outbreak of hemorrhagic fever in a major Indian city
today would probably raise levels of concern regarding
deliberate biological attacks the factor in South Asia to
relatively unprecedented levels. Again, thank you for the
conference. Thank you for the opportunity to discuss
these things.
PROF. BRENNER: Any panelist like to
respond?
MR. SIEGRIST: Kyle, I'm glad you spoke up.
Who did you direct that first one to about the size of the
group?
DR. OEHLER: I obviously didn't make my
point clearly. What I was trying to say is we need to look
for vulnerabilities. Large groups have different
vulnerabilities. I wasn't trying to say that large groups
are more dangerous. I'm saying that if a group is large
enough that it has all these technologies in it more
vulnerable to counter traditional terrorist efforts, such as
the counter terrorist center and the FBI and others are
specialists at. They're more vulnerable to being
penetrated. Small groups, which are harder to penetrate,
don't have all the technologies. My point is that we need
to look at where the vulnerabilities are, and try to put in
place programs to exploit those vulnerabilities.
PROF. BRENNER: Other questions. I'll ask
one of Dr. Hatfill. Can you give us an explanation of
what kind of chain of command we're looking at for these
27 trains? Who do the people report to and who controls
them and what's the organization structure? Is it civilian,
military or hybrid?
DR. HATFILL: It would be hybrid with some
qualifications on that. The DOD seems intent in
involving the National Guard in that with respect to the
rapid assessment teams. A pre-placed train on a siding
would be an ideal place for these RAID teams to operate
from. You can move three people very rapidly anywhere
and in the midst of a WMD crisis in one of our
metropolitan areas, it would be useful if the top three
people of the RAID team could advise, see what the first
responders are doing, is there a need for follow-on forces,
is there a need for greater federal intervention and this --
you're not going to do too much with 22 men in a WMD
incident. If it's a small-scale event, local authorities
should be able to handle it. If it's a large-area coverage,
these RAID teams would be trained in NBC
reconnaissance detection and could very rapidly call the
disaster train in as a follow-on force.
PROF. BRENNER: Do we have additional
questions or comments?
Q. Yes, David Mahoney with Defense News. I
have a question. At certain levels it seems with different
asymmetric threats, bioterrorism, obviously, being one of
them, at what level is there a breakdown between sort of
the traditional way the military has looked at threats as
over there somewhere before it’s projected to start being
threats where we really have to start worrying about a
mix between civil defense as an aspect of military defense
against outside aggression? I'd like to open this up to any
of the panelists who spoke today.
COL PARKER: It's a good question, and I think
a good topic to bring out and talk about and discuss. I
guess in my own mind and my own thinking, in fact, I've
begun from just the military perspective, we've always
thought in our BW defense program about the battlefield
scenario, but certainly over the last few years that has
also gone into force protection scenarios. You know, we
have to provide protection for our troops in their
barracks, as an example, and WMD and a bioterrorism
event may be something we need to not only think about
for the battlefield, but also force protection and that same
concept then, also that can be extended in our thinking
and planning for protection against a place where
civilians live, as opposed to where soldiers are. So where
that line is, I think, is going to get fuzzier. The
battlefield versus civilian protection and force protection.
I think we need to broaden our way that we think about it
and not stay in these boxes of battlefield versus civilian
protection because there's a lot of overlap. And a lot of
that intellectual thinking can be brought to bear for both
of those scenarios.
DR. HATFILL: We are living as a species at
this time in population densities that have never ever
been seen before. This brings in the concept of emerging
diseases. We're seeing on the average every two to three
years one new pathogen we never really recognized
before or a variant strain of a known pathogen. And as
we live in these terribly increased densities, which are
projected to increase even further in the next century, the
whole concept of the emerging infectious disease
becomes a major public health problem. Anything that
we spend on biological weapons defense can have direct
transference to the concept of public health and infectious
disease management.
PROF. BRENNER: Additional comments.
Q. Yes. Captain Lisa Forsythe, U.S. Army.
My question is for any of the panelists. Have you
43
analyzed our existing plan such as the Federal Response
Plan and how the Emergency Support Functions and
those Lead Federal Agencies such as the Department of
Transportation has an ESF leadership role and how DOD
fits into our current plans and how we support those
plans, not necessarily DOD taking a lead such as the
railroad system but actually supporting Department of
Transportation in those leadership roles that have already
been established?
DR. HATFILL: The National Security Council
has formulated an interagency working group to address
these problems. When is the handoff from FBI to
FEMA? How will federal assets coordinate with state
and local -- there is a working group at present working
on this.
DR. ROBERTS: There's the broader question
of the role of the Department of Defense in supporting a
national response to the bioterrorism problem as opposed
to the narrow question of the role that it plays in the
emergency response plan. I think while it's appropriate
to flag the concrete and specific issues in the emergency
response plan, we should also be sure to provide the
context here. And that is, as you know, the department
originally responded to the first PDD, the Presidential
Decision Directive in this area, four or so years ago
began to focus more seriously on its role and support of
domestic responses to terrorism, and there has been a
biocomponent of that I think this was given a big impetus
by the Defense Science Board Summer Study a year ago
which talked about the transnational threat and spelled
out potential new roles for the Department in supporting
the larger mission of the nation combating terrorism.
There have been various follow-on endeavors to that and
most recently re-collected and reorganized in the latest
PDDs, which carry forward this process. So I just
wanted to make sure that we didn't set aside this question
of the larger context within which the Department
supports the larger governmental strategy.
PROF. BRENNER: I'm going to call on
Professor Yonah Alexander to close the proceedings and
I’ll express my appreciation for you all being a very
conscientious and attentive audience.
"Who killed Cock Robin?" "I," said the Sparrow,
"With my bow and arrow, I killed Cock Robin."
"Who saw him die?" "I," said the Fly,
"With my little eye, I saw him die."
"Who caught his blood?" "I," said the Fish,
"With my little dish, I caught his blood."
"Who'll make the shroud?" "I," said the Beetle,
"With my thread and needle, I'll make the shroud."
"Who'll dig his grave?" "I," said the Owl,
"With my pick and shovel, I'll dig his grave."
"Who'll be the parson?" "I," said the Rook,
"With my little book, I'll be the parson."
"Who'll be the clerk?" "I," said the Lark,
"If it's not in the dark, I'll be the clerk."
"Who'll carry the link?" "I," said the Linnet,
"I'll fetch it in a minute, I'll carry the link."
"Who'll be chief mourner?" "I," said the Dove,
"I mourn for my love, I'll be chief mourner."
"Who'll carry the coffin?" "I," said the Kite,
"If it's not through the night, I'll carry the coffin."
"Who'll bear the pall? "We," said the Wren,
"Both the cock and the hen, we'll bear the pall."
"Who'll sing a psalm?" "I," said the Thrush,
"As she sat on a bush, I'll sing a psalm."
"Who'll toll the bell?" "I," said the bull,
"Because I can pull, I'll toll the bell."
All the birds of the air fell a-sighing and a-sobbing,
When they heard the bell toll for poor Cock Robin.
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