Jan/Feb/Mar 2003 - Volume 2, Issue 1

Smallpox Lecture Bioterrorism Lecture Series at Benedictine University

Reviewed by Margaret O’Leary

James C. Hagen, Ph.D., M.P.H., Deputy Executive Director of the DuPage County Health Department, spoke about the threat of smallpox at the Associated Colleges of Chicago Area (ACCA) Spring Seminar Series on Bioterrorism on March 4 in the Tellabs Lecture Hall. Hagen’s talk encompassed 10 areas relating to smallpox ranging from historical background to use as a biological weapon, prevention and vaccination.

Hagen lamented that times are trying in public health today. Approximately 90 percent of his time is devoted to bioterrorism. He wears two phones, one that directly connects him to the DuPage County Emergency Operating Center (EOC, also called the “bunker”) 24 hours per day, seven days per week. He worries about his responsibility for detecting an acute event of bioterrorism and protecting the 1 million inhabitants of DuPage County through provision of antibiotics or vaccinations, depending on the biologic agent, within two or three days.

Surveillance is a top priority, which has recently been improved through implementation of an Internet system in which hospitals can report suspicious illnesses to the public health department in real time. Work on bioterrorism has shifted limited public health resources from usual public health areas such as prevention, chronic diseases and education.

Smallpox is an ancient disease. Variolation is the process imported to England from China in the 1700s by which dried scabs from smallpox patients were introduced through the skin or mucous membranes in an attempt to provide immunity to smallpox. Mortality was 1 percent with variolation, and some people became ill with smallpox and were therefore infectious to others. Jenner invented vaccination in 1798 by using live cowpox to immunize people. The variola poxvirus is very large and comes in two forms: variola major (class of smallpox with highest mortality) and variola minor (milder disease with 1 percent mortality).

The incubation period of smallpox from infection to prodrome is between seven and 17 days. It is well transmitted in the air and is highly infectious requiring less than 10 virions to cause infection and less than 15 minutes of exposure. Transmission usually requires faceto- face contact unless the virus is airborne through ventilation systems. The virus can be transmitted via fomites (linens, clothing). Rash is the marker of the disease. However, infected persons can transmit the disease when they have fever even before the rash becomes apparent. There is no carrier state. All bodily secretions are infectious. Immunity wanes with time after vaccination. Virtually everyone in the United States lacks immunity to smallpox today.

Factors that allowed naturally occurring smallpox to be eradicated from the world were its slow rate of spread, effective and relatively safe vaccine, no animal/insect vectors, no significant carrier state (those infected either die or recover), it is infectious only with symptoms, prior infection provides lifelong immunity, and international cooperation.

Smallpox presents clinically as a centrifugal rash, meaning it is most pronounced on the extremities and face. The severity of the rash predicts outcomes of the disease. Most rashes are discrete and semi-confluent. The last case of naturally occurring smallpox was in 1977.

Clinical presentation of a person with centrifugal rash and fever is sufficient for diagnosis during an outbreak. Ninety percent of people will have a typical clinical syndrome of a febrile prodrome followed by a rash. Laboratory methods include electronmicroscopy, culture on chick membranes or cell culture, and PCR (polymerase chain reaction) at reference laboratories. The differential diagnosis for smallpox rash is chicken pox, which is not a poxvirus at all and presents as a centripetal rash, meaning most lesions are on the trunk of the body, not its extremities.

Smallpox is attractive as a bioweapon for the following reasons: it can be produced in large quantities; it is stable for storage and transportation; it is stable in an aerosol form; it has a high mortality rate; it is highly infectious and spread person-to-person; and most of the world has little or no immunity. Although the CDC and Russia are supposed to be the only two places that have smallpox, this is almost certainly not true any longer.

Vaccination is performed with a bifurcated needle that is dipped into the vaccine and then scraped on the skin 15 times. The vaccine is nearly 100-percent efficacious and lasts for 5 to 10 years as long as there is a successful vaccination reaction “take.” There are numerous side effects and approximately one-third of vaccinated persons will become ill enough with fever that they need to stay in bed for one or two days. Sequencing of vaccinations is necessary when vaccinating the workforce. Most first responders worry most about their families with risks for being vaccinated, contracting vaccinia from the vaccination site. One in a million vaccinated persons will die as a result of the vaccination. Vaccinia immune globulin (VIG) is available to treat reactions, but should not be used routinely because it is not readily available.

Hagen recommends that all Americans visit their physicians to obtain advice about their suitability for smallpox vaccination. People who are at high risk for post-vaccination complication are pregnant women, children under 1 year of age, young adults receiving the vaccination for the first time and people with altered immune states (HIV, AIDS, cancers, steroid-dependence for asthma, autoimmune diseases). Although the vaccination will not be available to the general public until Phase III of the federal vaccination program, possession of information about suitability for vaccination will help facilitate the vaccination process if and when it occurs. This is particularly applicable to the situation in which a bioterrorist smallpox attack occurs and millions of Americans must be rapidly vaccinated.

Infection control is a vital Hagen Smallpox Lecture component of outbreak management. People with smallpox are infectious from approximately one day before the rash erupts (look for lesions in the mouth) until all skin lesions have scabbed over three to four weeks later. The ring vaccination strategy is a primary strategy to stop transmission that depends on prompt identification of contacts. This was the principal global eradication strategy in the 1960s and 1970s. Its effectiveness depends on people being relatively stationary, which will be difficult to assure in the United States if smallpox aerosol is released in a mall. Mass vaccination is probably preferable to ring vaccination in the United States

. People will be protected against smallpox only if they receive the vaccine within three to four days of exposure to smallpox, NOT to the development of symptoms. The vaccine will be ineffective when given to people with symptoms.

Hagen discussed “Dark Winter,” a tabletop exercise conducted in 2001 by the federal government that involved the virtual release of smallpox in three malls in the United States. The outcome was dismal in terms of demonstrating the country’s level of preparedness and capability for response. TOPOFF 1 (Top Officials) followed in 2002 and involved the virtual release of plague in several cities in the United States. Again, the level of preparedness and capability for response was not high. TOPOFF 2 is scheduled for this May and will involve the collar counties and Chicago. Hagen discussed the reluctance by health care workers in Phase II and first responders to become vaccinated with vaccinia vaccine.

The main problem with smallpox preparedness and response in DuPage County and elsewhere in the United States, according to Hagen, is that public health, medical facilities, the Federal Bureau of Investigation and other organizations live in “silos” and do not communicate well with one another. During the anthrax bioterrorist attack in September and October 2001, for example, the public health department “did not have its act together,” according to Hagen. The F.B.I. referred people to the public health department, which then referred the people to hospitals.

Successful Smallpox Disaster Drill at RML Specialty Hospital Raises Important Questions

By Karen Beem and Jonette Marino

On January 24, 2003, Karen Beem, RN, MS and Jonette Marino, RN, quality improvement manager and nurse manager, respectively, at RML Specialty Hospital, shared with the Suburban Emergency Management Project (SEMP) task force their experiences preparing for, conducting, and critiquing their hospital’s smallpox disaster drill on December 6, 2002.

RML Specialty Hospital was originally built as a tuberculosis sanitarium and is located at a major regional and Illinois freeway intersection (Interstates 294 and 55). Currently an affiliate of Rush-Presbyterian-St. Luke’s Medical Center and Loyola University Medical Center, RML is one of 270 long-term acute care hospitals in the U.S. This designation is unique and requires a minimum patient length of stay (LOS) of 25 days (average LOS for RML is 40.5 days). The Joint Commission on Accreditation of Healthcare Organizations accredits RML as an acute care hospital meaning that it must comply with the lengthy and rigorous set of acute care hospital standards.

The RML Specialty Hospital daily census fluctuates between 65 and 80 patients, which is a fourfold increase since 1996. Medical staff members provide onsite care to patients 24 hours per day/seven days per week. Approximately 50-55% of patients use ventilators at any given time. The hospital owns 43 ventilators and on occasion rents additional ventilators to serve its population of patients.

According to state regulations, every hospital must have an ED. Although RML is located in Illinois Department of Public Health (IDPH) Emergency Medical Services (EMS) Region VIII, it is not a participant. It is a Level IV or standby emergency department (ED) with an ED census of two (2) patients/month. RML views its customary role with regard to ED patients as triaging them and then calling 9-1-1 for patient disposition. Patients with acute myocardial infarction have presented to the hospital in the past. Paramedics do not bring patients to RML and there are no direct admissions to RML. Rather, patients are admitted to RML as referrals only. RML has three programs: ventilator, complex wound, and the Rehabilitation Institute of Chicago’s medically complex program.

Organizing the Disaster Drill

Hospitals must conduct two disaster drills per year and, since 9/11, one of the drills must assess the hospital’s capability to respond to a bioterrorism attack. RML adopted the Hospital Emergency Incident Command System (HEICS) in 1998. The disaster preparedness team assembled to prepare for and conduct the drill included the manager of quality improvement, director of facilities, manager of infection control, two nurse managers, and a respiratory manager. Initially the employee health nurse was also made part of the team in the event that the drill would involve setting up a vaccination station to vaccinate employees. Subsequently, the scope of the drill was narrowed, and the employee health nurse was not needed.

The disaster preparedness team selected smallpox as the biological agent for the drill for three reasons: (1) its occurrence in.a patient would require immediate and coordinated response from the medical and public health systems, (2) hospital staff and patients would have virtually no immunity to it, and (3) recognition of it can be delayed. The objectives of the drill were (1) to recognize smallpox, initiate the appropriate response and contain exposure, (2) implement the hospital’s new lockdown policy, and (3) identify people at risk of exposure to the agent.

Beem noted the importance of identifying a beginning and an end to the drill. The beginning of the RML drill was when a victim with smallpox walked in the front door of the hospital, which is the lobby, and was greeted by the receptionist. The end of the RML drill was completion of hospital lockdown and a phone call to IDPH. Beem and other staff at RML noted that once IDPH was notified, responsibility for smallpox management of the patient would transfer to IDPH and Centers for Disease Control and Prevention (CDC).

Marino noted that drill preparation brought up many questions. Lockdown would be challenging for this 50 year old building: RML as a result of its history as a tuberculosis sanitarium has many entrances, windows that open, and a layout with four arms that do not connect. Employees at risk for exposure from a single smallpox patient walking into the hospital today would include the lobby receptionist, the clinical nurse supervisor, some staff, and potentially many chronically ill inpatients with multiple co-morbidities.

The team identified many issues relative to minimizing exposure. Should the entire facility be quarantined or only the portion deemed to have been contaminated? How long will people need to be quarantined in the hospital? Twelve hours? Twenty-four hours? Two to three weeks? The team looks to CDC to make the determination. To minimize exposure, the team had to establish as part of the lockdown procedure a plan to control the movement of people (EMS, media) on the property. RML employs one security officer per shift for the facility through a contract service; in the event of a true exposure, additional staff resources would be needed to lockdown the hospital and visitors would not be allowed to enter the facility. The team also questioned would EMS respond to a request to pick up and transfer a patient with a rash that looks like smallpox? Also, would IDPH and CDC issue a mandate that the patient remain at RML Specialty Hospital in order to reduce further contamination into the community?

The one negative pressure room in the old ED was converted to an office long ago. The team had to determine where would the patient with suspected smallpox be placed during evaluation and decision for disposition? Would the patient remain in the ED or be moved to a negative pressure room? To reach the three additional negative pressure rooms in the hospital would entail moving the patient up elevators and through hallways. A decision to do this would expose many more people. This raised more questions. How long must corridors through which smallpox patients have been wheeled be taped off before they can be used again? How does one decontaminate the one x-ray room if it is used to obtain a chest x-ray, for example, on the patient with the rash that might be smallpox? Team members plan to explore re-opening the negative pressure ventilation room in the old ED area.

Facility Issues

Beem identified four facility issues that were very important in containing the spread of the smallpox: lockdown and security, staff training, ventilation system, and contamination barriers. The facility has four wings (A, B, C, D) and approximately 20 sites—18 leading to the outside and two interior—that were identified as posts requiring staffing to control traffic and contain people in certain areas. Both clinical and non-clinical staff were trained to function at the posts. According to research, the team learned that 10 percent of people attempt to leave a facility upon announcement of lockdown. Thus, three RML staff members play-acted this role during lockdown in the drill. One staff member successfully “escaped” when another staff member left his post to answer the telephone.

The ventilation system question was, where are the interconnections? What sections of the facility are at risk for contamination through the heating and air conditioning systems for a smallpox patient standing in the lobby? What ability do we have to close off duct systems that may be blocks away but still within the hospital?

Conducting the Drill

The scenario was of a Hinsdale METR A commuter who brought his ill wife to RML Specialty Hospital before boarding the train to go to work. The patient had a cough, fever, facial rash, sore throat and headache. The HEICS system was activated when the receptionist and clinical supervisor recognized the possibility of smallpox in the hospital. The containment area was the hospital lobby and nearby ED. All persons within 6 to 7 feet of the lobby and the corridor connecting with the ED were considered to be at risk for exposure. Did anyone leave the building? Each of the 11 department managers was responsible for determining where his or her staff members were at the time of the exposure. Records of people’s whereabouts were kept in anticipation of the CDC team’s arrival to make the determination of who in the hospital could leave and who had to stay. This document and other assessment tools are available on the CDC website (www.cdc.gov).

Isolation procedures were initiated, including appropriate personal protective equipment (PPE) for contact and airborne precautions. The PPE included gloves, gown and N95 mask. Facility Operations personnel efficiently shut down the ventilation system and erected lobby containment barriers with Visquine plastic and duct tape to prevent staff from entering this area. The IDPH POD hospital was notified by phone and media attention was anticipated. The actual hospital lockdown time was eight minutes. Rooms for the anticipated CDC staff were readied.

Critique of the Experience

Marino noted that people’s ingenuity in the face of a potential disaster is impressive. There was nothing that the disaster drill team had not anticipated. Next steps include developing better traffic control. The front lobby had been successfully contained but what if a visitor with smallpox who was bundled up in clothing made his way to a patient room in the D wing?

Internal communication was an issue. Certain staff did not hear the overhead speakers or see the Code Lockdown message on their computers because they were at lunch or in the bathroom. The receptionist failed to place back-up calls to staff in the remote areas of the hospital. The team learned that the ED would require a second telephone line to accommodate calls from the Command Center and other posts.

External communication to outside agencies was somewhat problematic. One objective of the drill was to test the procedure for contacting various state and local agencies. During the eventplanning phase, RML Specialty Hospital placed preliminary calls to these agencies to discuss roles and responsibilities. Every agency contacted seemed to have a different answer as to what to do and whom to call and the sequence of the calls. By design, the drill designated RML staff members to contact the EMS POD Hospital, then the Illinois Emergency Management Agency (IEMA) and then the local public health department. On the day of the drill, the switchboard at one agency would not take the call initially because a meeting was going on—could he get back to RML in a couple of hours? The RML staff person persuaded the official that he should take the call. The other two agencies were extremely helpful and asked what could they do for RML? RML staff looks forward to clarification of the interface between the site of patient care and local and supra-local agencies.

Managing off shift human resources was an issue. In the event of an actual lockdown during nonbusiness hours, Marino raised a concern as to whether there would be enough personnel to man 20 stations? A contingency plan for the non-business hours is under development.

Decentralization of responsibility was an issue. Everyone assumed that nurses and physicians knew what to do in a disaster and indeed, they responded well. But the drill revealed that non-clinical staff members, such as accounting personnel, require additional training to learn how to secure their environment against a lethal pathogen like smallpox.

What about all the vendors that provide contract services ? The planning team identified a number of questions that as yet remain unanswered. Being a specialty hospital, RML has no onsite laboratory. How will specimens be collected and transported for the potentially exposed patient? Will the laboratory accept blood specimens from a smallpox patient? Will the laundry service continue to bring clean linens and remove soiled linens from a hospital caring for a smallpox patient? How will food supplies be delivered? What are the ramifications for trash removal?

Documentation issues were identified. How do we provide the next level of care providers with documentation of patient care at RML? Currently the ED uses paper records, which would become fomites if transferred outside of the quarantined area. Should a computer be installed for use in the ED that evaluates two patients per month? Should a mobile computer be wheeled in for use during care of a smallpox patient? How does one decontaminate a computer that has been exposed to smallpox?

Legal issues were considered. Can other employees staffing posts hold a potentially exposed hospital employee, visitor, vendor, and others in the hospital against his or her will? The answer is no. However, once IDPH and the CDC come onsite, quarantine can be enforced, as appropriate. The team determined that the best thing to do before officials from IDPH or CDC arrive is to obtain identifying information from the departing persons so that follow up can be conducted at a later time.

The disaster drill at RML was extremely helpful to staff in elucidating areas for improvement and further research where answers were not yet available, even from the experts.

Who Is Alan Brunacini?

By Margaret O’Leary

Alan V. Brunacini, well known to anyone who has been in the fire service for any length of time, is the founder of modern-day fireground Incident Command System (ICS).

Brunacini has been a member of the Phoenix Fire Department (PFD) since 1958. After holding the positions of firefighter, engineer, captain, battalion chief, and assistant chief during his first 20 years, he was promoted to fire chief in 1978. He heads a fire department with more than 1,600 personnel that services more than 1 million customers. In addition, the PFD dispatches for 21 fire departments in the Phoenix metropolitan area as well as responds to these same surrounding communities in the automatic aid program.(1)

Brunacini is a 1960 graduate of the Fire Protection Technology program at Oklahoma State University and earned a degree in political science at Arizona State University in 1970. He graduated from the Urban Executives Program at the Massachusetts Institute of Technology in 1973, and earned a Master of Public Administration degree from Arizona State in 1975. Brunacini is past chairman of the board of directors of the National Fire Protection Association (NFPA), the first active fire service member to hold this position in NFPA’s 93 year history.

The original ICS system was developed by FIRESCOPE (Firefighting Resources of Southern California Organized for Potential Emergencies), a group of fire control agencies in California, and was intended for the management of very large, multi-jurisdictional fire incidents rather than for routine fire emergencies. Brunacini revised the ICS model in 1985, making it applicable to smaller fire emergencies in addition to larger ones.(2) Brunacini also changed the incident command function to include specialized advisors, expanded the operations function to include routine fire department response demands such as the deployment of hazardous materials teams, and incorporated explicit connections to emergency operations centers and police agencies. Figure 1 shows a typical fire department incident management system. Brunacini has authored “Essentials of Fire Department Customer Service” and “Fire Command.” Both are highly regarded books by the firefighter and Emergency Medical Services administrative communities in the United States.(3-4).

1. http://www.phoenix.gov/FIRE/brunacini.html
2. Tierney K, Lindell M Perry R: Facing the Unexpected: Disaster Preparedness and Response in the United States. Washington, DC: Joseph Henry Press. 2001. p 209-210
3. http://www.amazon.com/exec/obidos/tg/detail/
-/0879391278/qid=1048035173/sr=1-1/ref=sr_1_1/104-7363596- 8907968?v=glance&s=books
4. http://www.amazon.com/exec/obidos/tg/detail/-
/0877655006/qid=1048035293/sr=1-2/ref=sr_1_2/104-7363596- 8907968?v=glance&s=books

Anthrax Lecture Bioterrorism Lecture Series at Benedictine University

Reviewed by Margaret O’Leary

Clinical microbiologist Robbin Traver, who manages the microbiology laboratory at Central DuPage Hospital (CDH) in Winfield, spoke about anthrax during the Associated Colleges of Chicago Area (ACCA) Spring Seminar Series on Bioterrorism February 18 in the Tellabs Lecture Hall at Benedictine University.

Anthrax comes in three clinical forms—inhalational, cutaneous (skin) and gastrointestinal. For people with suspected anthrax disease, laboratory testing is essential to diagnosis. Tests may include cultures of the blood and spinal fluid, cultures of tissue or fluids from affected areas, microscopic examination of tissue and PCR (polymerase chain reaction) testing that amplifies trace amounts of DNA.

Persons with an anthrax exposure to or contact with an item or environment contaminated with Bacillus anthracis, regardless of laboratory test results, should be considered for antibiotic (prophylaxis) treatment. Either exposure or contact is the basis for initiating such treatment. Culture of nasal swabs is used to detect anthrax spores that may be resting in the nose. Nasal swabs can occasionally document exposure but cannot rule out exposure to anthrax. In other words, a negative nasal swab test does not mean that exposure has not occurred. For this reason, the routine use of nasal swabs to assess anthrax exposure is now questioned.

Anthrax screening specimens are sent to various laboratories. The Centers for Disease Control and Prevention (CDC), in collaboration with the Association of Public Health Laboratories and the Federal Bureau of Investigation (FBI), established the Laboratory Response Network (LRN) to develop federal, state and local public health laboratory capacity to respond to bioterrorism events. This multi-level network of public health laboratories provides essential diagnostic capabilities in all state, territorial and large metropolitan areas; regional capability to ensure quality through strategically selected laboratories; and a centralized, state-of-the-art national quality control laboratory – the Rapid Response and Advanced Technology Laboratory – located at CDC to rapidly and accurately identify any agent used in a biological terrorist attack.

Special packaging is required for transport of suspected bioterrorism pathogens grown at Level A laboratories like the one where Traver works. In the event that such a bioterrorism pathogen is isolated at his hospital laboratory, Traver is expected to personally deliver the specimen to a higher-level laboratory in Chicago.

The Origin of the Incident Command System

By Margaret O’Leary

California has long had a vested interest in emergency management systems design, implementation and improvement. California’s geography and progressive urbanization provide many opportunities for disasters including mudslides, earthquakes, tsunamis, floods, frosts and fires.

The southern California wildland conflagrations in 1970 were one of the worst in its long history of disastrous fire seasons. More than 500,000 acres of watershed and timber were burned, most of them in the short period during September and October. Sixteen lives were lost and more than 700 homes and other structures were burned. Fire damage and suppression costs were $233 million. Flooding followed denudation of the watersheds.(1)

Much effort was devoted to the abatement of the conflagration fire problem through improved fire control during the 1970s and 1980s. Fire control activities included fire prevention activities, development of organizational structures and procedures for multi-fire and multi-agency fire suppressions, increases in fire control forces and their efficiency, and improvements in firefighting techniques and equipment.

The contribution of organizational problems was especially acute when fire size became very large. Problems arose between agencies that differed in organizational structure and power to act – especially during the confusion of multiple fires of major proportions.(2) As a result, a group of several fire control agencies created FIRESCOPE (Firefighting Resources of Southern California Organized for Potential Emergencies), which developed and field-tested under the auspices of the Federal Emergency Management Agency the management of crisis incidents through use of its new creation – the Incident Command System (ICS). The ICS involved four components: operations, logistics, planning and finance. It aimed to reduce ambiguity about lines of authority in emergencies by assigning responsibility for incident management to the agency representative who was first on the scene when an emergency developed.(3)

The ICS is increasingly appropriated for the management of emergencies other than fires including both natural and technological disasters. The ICS and its four-function, crisis-management framework have been widely diffused among emergency management agencies and other crisis-relevant organizations both at local and supra-local levels. A sampling of organizations using ICS include the State of New York(4), the U.S. Coast Guard(5), the State of California(6), and the Occupational Safety and Health Administration, which requires departments in states that have adopted OSHA standards to use an ICS at all hazardous materials incidents.(7)

Variations on the original ICS have developed over the years. Two of the most important variations are California’s Standardized Emergency Management System (SEMS)(6) and Phoenix Fire Department Chief Alan V. Brunacini’s(7) fireground incident command system. (see pages 6-7).

1. www.ucfpl.ucop.edu/UWI%20Documents/074.PDF, pgs 1-2
2. www.ucfpl.ucop.edu/UWI%20Documents/074.PDF, pg 4
3. Tierney K, Lindell M Perry R: Facing the Unexpected:DisasterPreparedness and Response in the United States. Washington, DC: Joseph Henry Press. 2001. p 209-210.
4. http://www.nysemo.state.ny.us/ICS/explain.htm
5. http://www.auxetrain.org/icsintro100.htm
6. http://www.oes.ca.gov/oeshomep.nsf/10884826d3b7edaa882565f000
5adc7f/256716f5845f9f8f88256aa800737dc3?OpenDocument 7.
www.osha.gov 8. http://www.phoenix.gov/FIRE/brunacini.html

“On Top of the World” is the poignant story of the impact of the 9/11 attacks on Cantor Fitzgerald, the New York brokerage which lost 658 employees trapped eight floors above where a jet struck Tower One (the north tower) of the World Trade Center. Not one of the employees survived. The book was written by Tom Barbash, a novelist and college friend of Cantor Fitzgerald CEO Howard Lutnick. Lutnick survived because he took his son to his first day of kindergarten that morning instead of going directly to work.

Some readers will recall that Lutnick became the center of a firestorm because members of the media questioned the sincerity of his public appearances and denounced his method of compensating families. The company that traded $200 billion a day in commodities futures survived the sudden death of more than 65 percent of its New York employees and its New York headquarters, which is a story unto itself. No American company has ever seen such destruction.

But one of the most compelling parts of “On Top of the World” is the short but important treatment it gives to what motivated people to visit all of the hospitals in Manhattan on September 11 and 12 seeking news of their loved ones and co-workers. From the perspective of many hospital staff, particularly those who work in the country’s emergency departments, the convergence of people on the hospital after a disaster is often attributed to “panic.” We have no evidence-based research on the degree to which this happens, why it happens, and, if it does happen, how to remedy it so that hospitals can function more smoothly during social disruption.

Panic is defined by Webster’s as a sudden and groundless fright; terror inspired by a trifling cause or a misapprehension of danger, especially when accompanied by unreasoning or frantic efforts to secure safety. According to Barbash’s account, the Cantor Fitzgerald people who went to the hospitals were not panicked. Rather, they were methodically and intensively seeking or providing information about Cantor Fitzgerald survivors. Joe Asher, a young attorney who had worked for Cantor Fitgzerald for years, rode his mountain bike all around Manhattan the first night carrying names of employees to all the hospitals.

Nancy Shea had spoken to her husband, Joe, a senior manager at Cantor Fitzgerald, twice after the plane hit his building. He said, “You’re not going to believe it. Some plane just crashed into the building.” He was aggravated more than frightened because he had been through this in 1993 when a bomb exploded in a parking garage beneath the building. When she did not hear from him again and received no information by phone, television or radio all day, she and one of Joe’s brothers biked into Manhattan to look for him—perhaps he was injured and had been transported to one of Manhattan’s hospitals.

Like Joe Asher, Nancy and Tom found that every hospital was filled with doctors and nurses awaiting patients, but very few patients ever arrived. People either got out of the towers relatively unscathed or did not get out at all. Each hospital had a master list of hospitalized patients that had been gathered from all the hospitals. The lists were the same at each hospital. The Shea’s rode from location to location for hours until 2 a.m. without any luck finding Joe. They finally rode downtown toward Ground Zero where they met the “wall of blue” – police and armed National Guard who turned them away.

How Central DuPage Hospital Collaborated with the U.S. Postal Service in the Carol Stream Facility Anthrax Scare

by Margaret O’Leary

One of the greatest challenges facing hospitals today is improving their level of integration with community organizations to manage complex social disasters such as the October 2001 contamination of the postal system with anthrax. Robert Chase, M.D., Chief Science Officer at Central DuPage Hospital (CDH), shares his memories of the emergent integration of CDH with local, county and federal organizations to successfully manage the anthrax scare at the U.S. Postal Service’s Carol Stream mail sorting facility.

Chase recalled that in the hours after the terrorist strikes on the World Trade Center and Pentagon, CDH quickly convened its senior and middle management to develop and implement strategies for attaining three goals: communicate government directives to hospital employees, refocus distracted employees on patient care by providing current information during the day, and ramp up the system’s ability to respond to a potential incident.

Initial focus by CDH management was on preparedness to receive mass trauma casualties through potential attacks on Argonne and Fermi National Laboratories, which were recognized as imminent potential targets. Prior to 9/11, hazard vulnerabilities formally identified by CDH were more limited in scope including industrial accidents, train wrecks and internal hospital disasters. Chase noted that on 9/11 CDH was in the process of “migrating to a hospital Incident Command System, but had not yet completed that work, so in reality our ICS didn’t yet exist. Instead, the current emergency preparedness mechanism was engaged.”

The anthrax issue crept up quietly approximately six weeks later when the Army Corps of Engineers authorized a company specializing in biohazard facility testing to begin testing (“sweeping”) the 400,000- square foot facility, which handles 3.5 million pieces of mail per day. Astonished employees looked on as four fully-suited hazardous materials experts obtained specimens throughout the plant.

Tim Ratliff, spokesman for the Northern Illinois District of the U.S. Postal Service, said that the extensive swabbing of sorting machinery was a precautionary measure to gauge the extent of the anthrax threat. Mail pieces routed from Washington, D.C. to zip codes beginning with numbers 601 or 603 passed through the Carol Stream facility on their way to their final destination.

The Carol Stream mail facility was the first facility to undergo testing in the Chicagoland area. Anthrax testing expected to last three days required five days as new protocols were developed. Ratliff noted that the Carol Stream postal facility received increased media coverage because it was the first site to undergo testing. Once the protocols were established, testing of other postal facilities in the Chicagoland area was completed in three days or less with much less media scrutiny.

With anthrax contamination of the Carol Stream postal facility a real possibility (by October 24, five postal workers on the East Coast had been hospitalized with anthrax and two had died), many of the approximately 1,600 postal employees worried about infection. The U.S. Postal Service needed a source of expertise to answer questions and help build infrastructure to manage the event at the Carol Stream postal facility. Ratliff called his infectious disease specialist brother-in-law, Dr. Chase, to ask for advice and the cooperation of CDH in designing and implementing a coordinated approach to testing postal employees for anthrax exposure. CDH quickly agreed to be the postal facility’s medical resource for the anthrax threat.

Some postal employees had already sought testing for anthrax or advice at the DuPage County Public Health Department. Health officials explained that the department did (and does) not provide testing or medical services related to anthrax or exposure to other biological agents. Postal employees were referred to their doctor or encouraged to go to the nearest emergency room if they felt ill. Other employees sought testing for anthrax at CDH’s Convenient Care Centers. Surprised health professionals telephoned the main hospital seeking information on an anthrax scare.

The “Procedure for Anthrax Screening” developed by Chase and others included four segments: Plan Activation, Conference Center Organization, Testing Implementation and Plan Deactivation and Communication of Results to Authorities. The hospital’s laboratory microbiology staff obtained testing and specimen processing protocols from resource laboratories. They also secured access to a large supply of nasal swabs and culture plates which they were prepared to package into test kits. Environmental Services staff members, upon notification by the Laboratory Relief Supervisor, were responsible for transporting the test kits from storage areas to the CDH Conference Center.

DuPage County Public Health Department officials were aware that CDH was functioning as the resource for the postal facility, according to Chase. The anthrax screening process was considered to be “well-controlled.” As a result, there was little impetus to directly share information about the screening with other health care organizations in the region.

On November 5, 2001, the DuPage County Health Department released a press report stating that “no anthrax was found in the Carol Stream postal facility.” Thus, the emergent creation of the system to process and possibly treat a large number of postal employees was not used.

Chase articulated several lessons learned from the 2001 experience. First, as a result of the experience the need for ongoing integration of hospitals with community agencies and facilities became clear. The medical expertise and infrastructure development rapidly provided by Chase and others at CDH for Northern Illinois District of the U.S. Postal Service senior management quickly stabilized a situation characterized by uncertainty and the potential for misinformation and inappropriate action.

Second, the need for hospitals to communicate with one another during the early stages of a potential or actual disaster needs further exploration. In the event that anthrax was isolated in the Carol Stream facility, capacity planning would become paramount in successfully managing the needs of a potentially large exposed population.

Third, interest in preparedness waned among many organizations after the immediate anthrax scare was over, a major recurring theme in 50 years of disaster research. How to counteract this trend toward apathy is an ongoing challenge.

Fourth, linkage of the postal facility with CDH as partners in the anthrax incident was based on a fortuitous existing relationship between Chase and Ratliff. This “coincidence” exemplifies the importance of preexisting networks in meeting the needs of the emerging and evolving situation during disasters.

Fifth, the systems approach to the situation at CDH permitted recognition of the need to offload the emergency department by setting up a diagnostic and therapeutic area elsewhere on the campus.

Sixth, the Carol Stream postal facility situation involved a known threat and agent in an identifiable population under controlled diagnostic and therapeutic conditions. Other bioterrorism situations are bound to be less clear and therefore more difficult to successfully manage.

OFFICIAL MINUTES OF THE SUBURBAN EMERGENCY MANAGEMENT PROJECT (SEMP) TASKFORCE MEETING January 24, 2003 Good Samaritan Health and Wellness Center, Downers Grove, Illinois

Members in attendance: Yvette Alexander, Kathy Anderson, Jeffery Bacidore, Jackie Bailis, Karen Beem, Jim Bondi, Peter Burchard, Sandy Churchill, Roger Day, Jacek Franaszek, Michelle Godfrey, Alan Gorr, Deb Hellmuth, Jack Hickey, Joseph Jaras, Alan Kaplan, Bridget Kasch, Barry Keefe, Louise Kuhny, Larry Langston, Anthony Mannino, Jonette Marino, Kristine Messitt, David Meyers, Pat Mullen, Dennis O’Leary, Margaret O’Leary, Bob Palmer, Valerie Phillips, Lynn Polhemus, Joyce Richards, Jim Sakelakos, William Santulli, Jean Sloboda, Keith Stegman, Laurie Stevens, Herb Sutherland, Brian Svazas, Gregg Waitkus, Kevin Weeks,

Staff in attendance: Alan Kaplan, David Meyers, Margaret O’Leary, Joyce Richards

I. WELCOME AND INTRODUCTIONS

Task Force Chair Margaret O’Leary, MD, MBA, called the Suburban Emergency Management Project’s fifth meeting to order at 8:37 a.m. Recounting the DuPage County health care organizations that hosted earlier SEMP meetings, she noted that January 24th marked the taskforce’s final scheduled meeting, and that communication and interactive developmental work among taskforce members would henceforth be accomplished electronically. She explained that Securitas, the project’s newsletter, would be accessible exclusively via SEMP’s website, and that forthcoming work on medical protocols would make use of a newly established asynchronous interactive website that would be demonstrated later during the meeting.

Dr. O’Leary introduced and thanked William Santulli, Good Samaritan Hospital’s chief executive, for hosting the meeting. Mr. Santulli extended his own welcome and thanks to the taskforce for its efforts to make life safer for those who reside and work in DuPage County.

II. SEMP WEAPONS OF MASS DESTRUCTION (WMD) PROTOCOL DEVELOPMENT UPDATE

Alan Kaplan, MD, MMM, FACEP, Edward Hospital’s vice president/chief medical officer and SEMP’s coprincipal investigator, summarized Illinois’ diverse WMD preparedness initiatives and offered a blueprint for the WMD medical-protocol-development work that lies ahead. He pointed out that while well-intentioned initiatives have proliferated, they’ve served primarily as think tanks and mechanisms for networking, communication, and education. These initiatives include those undertaken by such groups as the

• Illinois Terrorism Task Force (ITTF),
• Bioterrorism Committee to ITTF,
• EMS/Hospital Work Group,
• POD Hospital Meeting,
• Health Resources and Service Administration (HRSA) Hospital Committee,
• Pediatric Hospital Task Force,
• Illinois Medical Emergency Response Team, and
• First Responder Tactical Response.

Local (metropolitan Chicago) initiatives -- in addition to SEMP -- include those that have been organized by the DuPage County Advisory Committee, local community mayors and managers, the Metropolitan Chicago Healthcare Council (MCHC), and the Mutual Aid Box Alarm System (MABAS -- an Illinois/Wisconsin firefighters association that assures essential emergency equipment transport).

Dr. Kaplan explained that while such groups’ efforts have made disaster preparedness somewhat better than it was a year ago, accomplishments remain poorly communicated outside of the groups themselves, existing plans still fail to comprehensively address a disaster’s first 48 to 72-hour aftermath, and they still lack adequate execution mechanisms, communication systems that reach end users, and coordination among key agencies, government offices, and healthcare providers.

Turning to the need for WMD guideline development identified at SEMP’s November 15th, 2002 meeting, Dr. Kaplan discussed obstacles that thwart hospital efforts to create sustainable, user-friendly WMD disaster plans; and he re-emphasized the plans’ critical need to combine flexibility and ease of access with interorganizational consistency and ongoing staff education. He reminded SEMP members of their roles within the five independent workgroups established to develop the protocols/guidelines through use of SEMP’s asynchronous website, and introduced proposed formats to facilitate systematic protocol activation in a hospital (see “Appendix H: WMD Medical Protocol”) and development of a uniform, agent-specific set of critical elements for each individual protocol (see “WMD Agent-specific Medical Protocol”).

To assess both formats’ ease of use, content, and layout, the taskforce conducted an exercise that simulated the demand for immediate responses to emergency patients presenting with symptoms possibly caused by exposure to unidentified biological or chemical agents. At the exercise’s conclusion, members’ recommendations concerning the protocol-activation format included • address surveillance at the format’s front end, • include exposure history, general epidemiology, • clarify the sequence of precautions to be taken, • assess transit risk and waste stream, and • provide for activation of the hospital disaster plan before moving to mandatory calls. Recommended additions to the medical-protocol format included • information regarding which hospitals in the community have the greatest strengths in specific areas, • photos of symptoms or website addresses where photos can be found, • agent-specific personal protective equipment (PPE) and isolation requirements, • incubation and contagion periods, and • housekeeping protocols. These recommendations will be considered for inclusion in forthcoming revised drafts of these forms.

III. WEBCT ACCESS DEMONSTRATION

Through use of an online Internet connection, SEMP grant coordinator Joyce Richards provided an overview of the steps involved in accessing the interactive asynchronous website created to facilitate SEMP’s WMD protocol development. Her instructions addressed the use of passwords and user IDs, firewalls and ports to be opened, and individuals to contact for assistance.

IV. A CASE STUDY IN CRISIS COMMUNICATION: THE REAGAN ASSASSINATION ATTEMPT

Dennis S. O’Leary, MD, president of the Joint Commission on Accreditation of Healthcare Organizations, reconstructed the steps taken at Washington, DC’s George Washington University Medical Center to manage media relations during President Ronald Reagan’s emergency surgery and hospitalization following the assassination attempt of March 30th, 1981. As the institution’s vice president for medical affairs, Dr. O’Leary became the spokesman who communicated the president’s fate to the rest of the world.

The bullet that lodged in Mr. Reagan’s chest caused significant blood loss and tissue damage. He was on his way to surgery within 40 minutes of arrival, by which point the secret service had established an elaborate communications post in the hospital waiting room. The media were housed separately in a designated section of the medical school. After three hours in surgery, the president was stable and in recovery, and it was time to brief the press. But the president’s press secretary, James Brady, was fighting for his own life after somehow surviving the passage of a bullet through his brain.

Although not briefed on what to tell the media, Dr. O’Leary spent several minutes describing the president’s condition and reassuring the public that he was stable and making progress. As the president’s condition continued to improve, the hospital continued to provide reports, including 22 press releases issued over the course of his stay.

Dr. O’Leary shared press photos from the period, along with his thoughts concerning factors essential to dealing successfully with the media in crisis situations:

• If possible, develop relationships with media representatives early (ie, before the onset of a crisis) — have trusted people tell the story.
• When talking to the press, speak at the simplest level in straightforward terms free of medical jargon.
• Put yourself in the reporters’ shoes: what do they need to hear ?
• Stay sensitive to the media’s deadlines. They have a story to produce on time.

As his presentation came to a close, Dr. O’Leary responded to taskforce members’ questions: SEMP member: How was the hospital secured ? DSO: The Secret Service played an instrumental role in securing the hospital’s entrances. Planning and training for that operation were essential. SEMP member: Were there any fears about possible information leaks ? DSO: Yes, but staff turned out to be very “well behaved.” SEMP member: How was information about the president reported to hospital staff? DSO: GW is a small hospital — and it has a grapevine that’s superb.

V. RESPONSE TO A POSSIBLE SMALLPOX EXPOSURE: A LONG-TERM ACUTE CARE HOSPITAL DISASTER DRILL The insight gained through a recently conducted disaster drill at a small DuPage County specialty hospital was highlighted for the taskforce by Karen Beem, MS, RN, and Jonette Marino, RN, BSN, who serve, respectfully, as Manager, Quality Improvement, and Nurse Manager, at RML Specialty Hospital in Hinsdale, Illinois.

A former TB sanitarium with an aging physical plant, RML has been operating as a long-term acute-care facility since 1995. Average length of stay exceeds 25 days, and the average daily census is 65 to 80. Its Level IV standby emergency department treats about two patients per month, and it does not participate in the county’s emergency medical system. No admissions come directly through the ED, which is an area that lacks negative airflow capability. RML adopted the Hospital Emergency Incident Command System (HEICS) in 1998; and in the event of a regional disaster, it would be called on to receive patients from neighboring hospitals.

The drill was devised to evaluate the hospital’s ability to recognize and respond to a patient presenting with a high index of suspicion for smallpox — a disease whose widespread outbreak could trigger chaos potentially overwhelming to local healthcare resources. After describing the extensive planning issues associated with the drill’s implementation, Ms. Beem and Ms. Marino explained the “next-step” opportunities for improving the hospital’s responsiveness identified during the post-drill debriefing:

1. Improve traffic control in the hospital’s immediate vicinity.
2. Develop a lockdown procedure for non-business hours.
3. Consider moving the ED to a location with negative airflow capability.
4. Decentralize aspects of responsibility for disaster-management functions.
5. Allocate capital funds for text pagers, electromagnetic doors, and public-address-system improvements.

The debriefing also disclosed unanswered questions surrounding patient care and other issues, including:

1. Would RML actually admit a patient presenting with such symptoms ?
2. If so, how should services such as lab, radiology, and ambulance transfer avoid contamination ?
3. What exposure-reduction controls would be needed for trash and food-tray removal, or the hand-tohand transfer of potentially contaminated paper records ?
4. How should resources be allocated for off-shifts ?
5. Would the hospital be quarantined ? If so, how should building entry and exit be controlled ? How would quarantine impact laundry and food-service functions and deliveries of pharmaceuticals and medical supplies?

As taskforce members were quick to reflect, not only RML but hospitals throughout the region have yet to fully address the gamut of concerns a single diagnosis of smallpox could readily unleash.

VI. TOPOFF UPDATE

Jack Hickey, safety officer, Edward Hospital and Health Services, Naperville, Illinois, described plans underway for the May 12, 2003 nationwide implementation of TOPOFF2 — a multi-agency, multi-jurisdictional, realtime, limited-notice WMD response exercise. As Mr. Hickey explained, the exercise’s goal is to improve government officials’ and agencies’ capabilities for providing an effective, coordinated, strategic response to all aspects of a WMD attack, both at home and abroad (the name “TOPOFF” stands for Top Officials). Edward is the only DuPage County hospital scheduled to participate, which it plans to do for 56 hours. Led by the Department of Justice, the Department of State, and the Federal Emergency Management Agency, TOPOFF2 — like its predecessor TOPOFF, conducted in May 2000 — will ask participants in a simulated WMD attack scenario to produce an integrated, coordinated response that addresses

• law enforcement,
• homeland security,
• infrastructure protection,
• public information,
• command and control,
• crisis and consequence management,
• medical/public health, and
• resource management.

Those involved in the exercise will receive little warning about the type of WMD employed or the terrorist attacks’ specific location, date, and time. Participating hospitals will receive “paper” patients via fax; and the Metropolitan Chicago Healthcare Council is currently engaged in identifying local participants who will pose as attack “victims.”

As Mr. Hickey reiterated, TOPOFF’s leaders are confident that -- short of an actual attack -- such exercises are the best way to train responders, measure preparedness, and identify areas for improvement. In so doing, they hope to accomplish the following:

• Assess and strengthen the role of all organizations, including non-traditional partners, in crisis and consequence management.
• Create broader operating frameworks of expert federal, state, and local crisis and consequence-management systems.
• Validate authorities, strategies, plans, policies, procedures, protocols, and synchronized capabilities.
• Build a sustainable, systematic, national exercise program in support of national domestic preparedness strategy and international response strategies.

TOPOFF’s organizers expect to achieve these goals by increasing top US officials’ understanding of national response systems’ strengths and weaknesses that emerge under real-time stress — a process that will begin with assessment of the exercise’s successes, shortcomings, and lessons learned.

VII. ADJOURNMENT The chair thanked taskforce members and staff for their participation in the meeting, reminded protocoldevelopment- workgroup members to log on to the asynchronous website, and invited everyone to enjoy refreshments provided in honor of the taskforce’s achievements, to date. The meeting adjourned at 2:40 pm.

Respectfully submitted, David Meyers February 3, 2003

Who is William Langewiesche, the fireman’s scourge who wrote “American Ground: Unbuilding the World Trade Center,” the most compelling and impertinent rendering of the World Trade Center saga published to date? He looks young from his picture on the inside of the book jacket, lives in Davis, the agricultural university town in California’s hot Central Valley, and is a licensed pilot. He writes for Atlantic Monthly and has published a couple of books before “American Ground,” including one about the Sahara desert and another about what goes on along the Mexican border with the United States. He also wrote the Atlantic Monthly article published November 2001 entitled “The Crash of EgyptAir 990,” which with factual certainty, rather than emotion, determined that the crash was caused not by any mechanical failure but by a pilot’s intentional act.

He prefers to travel alone, relying on friends and acquaintances to put him in touch with locals. “I travel like a little mouse,” he says. He tries to be as anonymous as possible, wearing his hair neither too long nor too short, not wearing blue jeans nor carrying a backpack but dressing unobtrusively. He uses public transportation and doesn’t travel with an assistant or photographer. He finds the very idea of pack journalism abhorrent.

He is the only writer who was permitted unrestricted, aroundthe- clock access to the World Trade Center site, the rescue workers and laborers there, and the meetings of city officials, engineers, construction companies and consultants. Like just about everything else that happened during the response to the WTC disaster, emergent collective behavior was at the root. Emergent collective behavior is human conduct in which people jointly create new norms, new structures and a new social order. The collective behavior is extrainstitutional, not unrelated to previously established structure and norms but transcending, opposing or modifying them and in so doing generating new forms.

Langewiesche relates how he got onto the site. The Atlantic’s editor-in-chief, managing editor and he discussed how the magazine should react to the WTC disaster. “We decided several things. One, that the EgyptAir piece, which was almost done (and which was in a way an interesting reflection on the September 11 attack), should be rushed to completion, which we did. Second, as soon as the airlines started flying, I should go to New York and take a look at whether the cleanup and recovery effort would be an interesting story.

“So I went to New York as soon as the airlines started flying, and I visited the site. I talked my way past the National Guard at a checkpoint (I’m used to doing things like that), and I surveyed the situation. It was extremely chaotic, and it was clear to me that most of the efforts underway at the time were ineffectual. The bucket brigades were not getting the job done because the debris was extraordinarily compact and heavy. You could not get at it with your bare hands or with hand tools. You needed heavy equipment.

“So the question was, who was going to be bringing the equipment in? I started asking about it, and I got word that there was this outfit called the New York City Department of Design and Construction (DDC) and that this guy, Kenneth Holden, was the commissioner of it. So I fired off two faxes. One went to the Office of Emergency Management, which was the nominal agency in charge of the site (I never heard anything back). The other went to the guy with the heavy equipment – Kenneth Holden at the DDC.

American Ground continued from page 19 “In the meantime, I went down to police headquarters and looked into getting press credentials. But when I got to the press credentialing office there were these long lines of reporters, and after spending about an hour there I just walked away. It was very clear to me that if I had to go through normal channels, it wasn’t going to be worth it.

“But when Kenneth Holden received our fax he immediately called up and said, ‘I’ve been an Atlantic reader for a long time, and I’ve read your stuff and bought your books.’ The guy was basically a huge fan, so he made it happen. He called City Hall and talked to the mayor’s people and got special approval for me to come on the site as a writer without anything identifying me as a member of the press. I was given the same credentials as any engineer with full access to every part of the site, as well as full access to the meetings and to the files. Holden was so open with me that it was infectious. Other people got to be very open with me as well.”

What are some of Langewiesche’s observations of the response and recovery process? Two DDC bureaucrats – Holden and his lieutenant, Michael Burton – emerged as the leaders of the effort. The DDC, created in 1996 by Mayor Giuliani to oversee building and repairing the municipal infrastructure, employed 1,300 people and had a $3.7 billion budget. But it lacked the political clout of the uniformed services (fire and police) and the prestige of the city’s small but highly visible Office of Emergency Management (OEM), which sustained a direct hit during the attack.

Holden and Burton were “bit players” at first, because the OEM was supposed to be coordinating the response and the main search and rescue response belonged to the Fire Department. But over the first few days, Holden and Burton were able to bring New York’s enormous construction energies to bear on the site, which was key to moving the response forward.

The city’s official and secret emergency plans, written before the attack, called for the Department of Sanitation to clean up after a building collapse. In one of the many incomparable stories to come out of the experience is the one in which a “woman involved in writing the latest versions – a mid-level official in the OEM – mentioned to one of the contractors a week after the WTC collapse that she still did not quite know what the DDC was. She found her way to the headquarters room on the second floor of Public School 89 where Holden and Burton were talking one afternoon during the first week. She came up to them and said, ‘Who told you to get involved?’ Holden looked at her in disbelief. He was exhausted. He said, ‘We’re kind of busy now. Why don’t you come back in six months and ask that question.’” (page 118)

Langewiesche’s assessment of the firemen’s behavior at the site over time; the hazard of the failing “slurry wall” that was all that kept the tidal water out of the pit; the Battle of the Badges; and the “dance of the dinosaurs” are stories you will want to read first-hand. Keep this writer in mind in the future when you want clear-headed, evenly-written prose that provides sharp and sometimes difficultto- handle, but true, sociological insights into important events in U.S. and world history.