strategic medical intelligence - toxicology

Strategic Medical Intelligence

Michael Allswede DOFederal Bureau of Investigation

Pittsburgh

Terrorism Con Plan

“Crisis management is predominantly a law enforcement function and includes measures to identify, acquire and plan the use of resources needed to anticipate, prevent, and/or resolve a threat or action of terrorism. In a terrorist incident, a crisis management response may include traditional law enforcement missions such as intelligence, surveillance, tactical operations, negotiations, forensics, and investigations, as well as technical support missions such as agent identification, search, render safe procedures, transfer and disposal, and limited decontamination. In addition to traditional law enforcement missions, crisis management also includes assurance of public health and safety

Strategic Biological Weapons

Bioterrorism Elements

Terrorist VictimAgent/SyndromeInterventions

The Terrorist Test

Political goals must be advanced by killing of AmericansPolitical conviction of the individuals must be serious enough to accept consequences of killing AmericansMust possess knowledge and skills needed to store, plan, and execute a credible WMD attack

International Terrorism

Terrorist Stratification

International-TransnationalReligious or Nationalist MotivationsState supported

DomesticSpecific political agendaDefensive posture

“Lone Wolf”Ted Kaczynski

International-Transnational

Examples:Russian “Mob”Middle Eastern Groups“Red Army” FactionsIndependence MovementsRogue Nations

Capable of obtainingSignificant Funding and Expertise

International Terrorism

Domestic GroupsExmples:

“Christian Identity”American NaziKKK, CSA, Aryan NationsNational Alliance, Freemen, Michigan Militia

Defensive PostureWish to live an un-fettered lifeHave policy goals

Lone WolfSingle persons acting on their conscience

Ted KaczynskiLarry C Ford Theme oriented

“Leaderless Resistance”Timothy McVeighInspired by books or speechesRichard Butler of Hayden Lake ID

Victim SelectionNon-Targeted Population Attack

Gases or aerosols in open airWater ContaminationFood Supply interruption

TargetedSpecific Product ContaminationClosed Space releaseContact Contamination

PNC Park, Pittsburgh PA

Agent Selection

StealableNaturally OccurringEasy to ManufactureLimited Access

Bacillus Anthracis on Blood Agar

Three Threats Paradigms

International Transnational GroupsState-supported, potentially exotic pathogensPopulation targeting

“Lone Wolf” IndividualsLimited by their access and abilitiesWildcard targeting

Domestic GroupsCommon pathogensAssassinations-Small volume targeting

Pre-2001 BT Model ICBM Missile Defense Model

NORAD Anti-ICBM

Civil Defense

CIA National Disaster Response

Pre-Launch Intel Launch Detonation Deaths Recovery

Pre-2001 BT Model

Pre-Release Intel Release Symptoms develop in Population

Disease Diagnosis

Public Health

Response“Bad Day”

Deaths Occur Recovery

Proposed BT Model

Pre-Release Intel Release Symptoms develop in Population

Deaths Occur Recovery

Integrated Public Health-Medical ResponseIntelligence

Sharing

Syndromic Surveillance

Surveillance of at risk

populations

Pre-positioning Medical Assets

Law Enforcement Investigations

WARNING: Math and Science Ahead

The Pittsburgh Matrix

Above all

Resources

Augmented

Capacity

Surge

Capacity

Current

Capacity

Pre Release Release Symptom

Occurrence

Illness

Occurrence

Deaths/Epide

mic

Allswede, MP, Watson SJ., AHRQ Partnership for Quality, 2002

PM Hypotheses

The primary drivers of survivorship in Bioterrorism response are:

Victim load relative to available capacityTimeline of Detection

Timeline and Capacity-Victim Load combinations can be used to value resources and assess critical gaps within a system

UPMC Costs of Care

0

200

400

600

800

1000

OfficeIn PtICU

Anthrax Survival Benefit

Above all

Resources 92% 80% 10%

Augmented

Capacity 100% 100% 84% 43%

Surge

Capacity 100% 100% 83% 50%

Current

Capacity 100% 100% 83% 50%

Pre Release Release Symptom

Occurrence

Illness

Occurrence

Deaths/Epide

mic

Allswede, MP, Watson SJ., AHRQ Pittsburgh Matrix, 2002

Supplemental Hypotheses

Better Technology

Triage of Resources

Augmented Capacity

Surge Capacity

Current Capacity

Pre Release Release Symptom Occurrence Illness Occurrence Epidemic

System Preparedness

Allswede, MP, Watson SJ., AHRQ Partnership for Quality, 2002

Homeland Security Analysis Critical Intervention Points

Critical Capabilities

Critical Resources

EMS-Medical Establishment, Nat. Lab. Response System

EMS-Medical Establishment, Public Health

Security Services

University R+DCIA, FBI, Analysts MMRS

Symptoms in Target

Deaths-Epidemic

Pre-event Intel

Release Illness in TargetDetectors,

Rads-existing

Chem-developing

Bio-R+D

Syndromic Surveillance

Medical Practitioners

Quarantine

Mass Treatment

Strat. Med. Intel

Interdiction

Medical Practioners

Lab Analysis

Bioterrorism Big Three

Public Health

PrivateMedicineLawEnforcement

Big Three Domains

Control of Population

Primary Treatment

Analysis and Advisement

Evidence Focus

Individual Victim focus

Population focus

Enforcement and Arrest

Primary Data Collection

Investigative Powers

Law Enforcement

Private Medicine

Public Health

Strategic Medical Intelligence Mandate

Provide Physician WMD advisement to regional MMRS-Public HealthDevelop/Implement Medical Monitoring of Target Groups Provide real-time patient analysisDevelop Intelligence-surveillance strategies

Strategic Medical Intel

Case Investigations

Targeted Surveillance

Legal IssuesMedical

Public HealthConLaw

Intelligence

Realtime Modeling

SWAT-WMD TrainingPersonal Safety

Strategic MitigationLocal Response

Interdiction

Macro IssuesStrategic Capabilities

Decision SupportInterdictionQuarantine

Mass Treatment

Community Response

Strategic Medical IntelligenceInstitute

Intelligence: Physician Advisement

Interpret WMD Threat InformationWMD Educational ProgrammingPhysician Consultations

MMRS, and SMIEMS PreparationsSpecial Resources

What Do We Look For?

Intelligence

Special liaison to “dual use” facilities in your areaReceive confidential concerns of area officials and citizensTransmit concerns to FBI for analysis and threat assessment

Intelligence: Sentinel Groups

PopulationsMass Transit CommutersDomestic Relations

Spousal, Inheritances, Minorities

Racial, Religious, EthnicPolitical

Right Wing/Left WingSpecial Interest

Abortion rights, Ecology, Fur TradeHomosexual, Alternative Lifestyles

ServicesMedical

Emergency, ID, Public Health, Police

SWAT, Investigative, HomicideEMS

Event Staff, Catchment areas

Special EventsElections, Polling PlacesSports EventsCivic EventsCultural Events

FederalATF, FBIJudges, OfficialsPresidential

VIP’s State, LocalOpposition LeadersLabor Leaders

City ServiceBus Drivers, Garbage CollectionCoroners

Intelligence: Pre-Event Indicators

Behavior ReportingRecruitment AttemptsRepressed, angry, PersonalityIdeaology of Concern

Suspicious EventsDigital-Hand-Arm AmputationsSudden Deaths in Healthy PeopleToxidromesUnusual Culture Reports

Reporting: Legal Basis

Similar to the MANDATED reporting of homocidal-suicidal ideation, and child abuse“Impaired Physician” reports by physicians is common because of risk to community

Interdiction

Prevention is more important than prosecution

Larry Wayne Harris Prosecution statues are not well defined by case law

Patriot Act

Interdiction: Calder Article Calculator

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Community Response: Analysis of Patients

Determine credibility of potential WMD eventsObtain needed law enforcement historical dataAssist incarcerated potential terrorist illness care and analysis

SMI’s Team Response to WMD

WMD EVENT

TRAINING

SYNDROMIC SURVEILLANCE

HUMAN INTEL

LIAISON LE/PH/HOSP

EXPERT ASSESSMENT/EVAL

LINK ANALYSIS INTERVIEW

ASSISTANCE

MONITOR TRENDS

LIAISON LE/PH/HOSP

INVESTIGATIVE ASSISTANCE

PRE-EVENT THREAT ASSESSMENT POST-EVENT

Pre-Event PlanningA highly contentious political rally is scheduled for your city.Law enforcement has been informed that credible threats of anthrax are possible.What should be the medical response?

Pre-Event Planning

Working with local planners, the rally attendance is estimatedMedical facilities are queried as to their bed counts, numbers of antibiotics, and available personnel to assess civic healthcare capacityAssess critical resource shortage and apply cost coefficient to estimate preparation costs.

Urban League, Pittsburgh, PA, 2003

Attended by President BushTargeted by Domestic and International Groups

SMI Process

Assess threats, credibility, avenues of attack to project victim distributionMonitor victims at likely healthcare facilitiesFirst case workup and firm detection without delay

Benefits of SMI

Formalized relationship with MMRS, State Police, and local Public Health authoritiesTrained and credentialed network of mutually supporting physicians familiar with law enforcement, emergency management, and communications

My Motto