Concluding remarks:

Challenges on security and preparedness in the society under the threat of bioterrorism

The empirical basis

Seen from a public health point of view, there has been no major threat from bioterrorism up to now. Even if there have been some real terrorist incidents by use of biological agents affecting humans, none of them has up to now had disasterous consequences as to public health.

When evaluating incidents there is a big challenge in sorting out the real terrorist incidents from situations made by mad or sensation seeking persons, mishaps or accidents when handling dangerous biological material, “natural doseases” or even “nothing” – situations characterised by fear induced by misinterpretation of observations e.g. of “white powder”.

Even though the empirical basis up to now is optimistic, we must admit that there has been much perceived public fear, which in itself might constitute a public health problem or even worse, lead to societal destabilisation.

This lead me to the conclusion that our experiences show that medical and microbiological evidence is necessary, but not enough to handle suspected incidents of bioterrorism.

The terrible scenarios

As we have heard here today, there is a huge variety of possible scenarios in which biological agents can lead to severe impact on public health world wide. The possible set of consequences is also complex. But not only complex: There is a subtle set of causes, many of them based on individual or group specific values, when different persons and groups promote the probabilities and effects of potential incidents.

Therefore evaluation of the possible and terrible scenarios challenges the “independent” position of the public health officer on different levels in the community. Certainly one can question if governmental employees can be or shall be “independent” in these matters!

The importance of medical intelligence

Medical intelligence related to bioterrorism certainly is based upon microbiological knowledge. But topics related to public health and risk assessment and management, including communication, are of great importance. Even more important is the ability to evaluate the professional knowledge in the perspective of the political context.

Sir Winston Churchill is said to have formulated these four questions on intelligence after the collapse of Singapore during World War II:

· Why didn’t I know?

· Why wasn’t I told?

· Why didn’t I ask?

· Why didn’t I tell what I knew?

In this perspective it is important, especially from the global public health point of view, to question the “western ignorance” (cfr. the lecture on influenza given by professor Lars R. Haaheim here today). It is important to remember that what is seen as terrorism by us, may be regarded as just and timely actions by others. One measure to handle by the public health officer is to make arenas for the exchange of professional knowledge and assessment of the medical situation.

Redundancy of health care systems

Probably the most effective redundancy in health care systems focusing upon bioterrorism is made by putting the responsibility to handle such situations on the systems and personnel who is running the every-day preparedness. This is the basis of the Norwegian system, cfr. the lecture given by dr. Preben Aavitsland.

If the ordinary systems shall be able to handle situations with possible impact on the security of a whole society, they have to feel massive support from superior authorities. I stress the word support, as it probably is not enough with ordinary “bureocratic” governing systems from the central health authorities.

At least the health care systems must have plans so that they are able to run new tasks and work with shorter time limits than usual, including plans for establishing services 24 hrs 7 days per week.

The slogan by health personnel and microbiologists related to bioterrorism should be: “It is something in it for me; yes it is!”

High credibility health authorities

From organisational theory we know that to get loyal employees in knowledge based enterprises the leaders have to communicate explanation on tasks, support engagement by individuals and make expectations clear. The core value when trying to establish an organisational culture characterised by these words is transparency, i.e. people in the organisation has to adhere to a set of common values and in addition understand the professional judgements underlying the decisions made by the leaders. If the leaders are able to create this transparency, I feel confident that this not only will be important to the employees in the organisation, but also be spread outside to other professionals and the community.

My conclusion is therefore that regarding bioterrorism, as well as other crises in the community, the authorities cannot act only through enforcement of legal requirements in critical situations. The authorities have to accept continuous public scrutiny through a “open” relationship with the professional community and the public. It is too late to show good will when the crisis strikes. It has to be prepared by living an “organisational life” in public scrutiny every ordinary day!