Monica Schoch-Spana

Bioterrorism policy discussions and response planning efforts have tended to discount the capacity of the public to participate in the response to an

A Curtailing the human suffering associated with a catastrophic infectious disease outbreak presents two key operational challenges for health professionals: caring for the sick and dying and halting the outbreak. In providing for these two central activities, one can assume a manager's point of view, aptly engaged in a calculus of supply and demand. If x grams of anthrax, then y numbers of the sick and dying and z amounts of hospital beds, vaccines, antibiotics, and so on. Such a perspective is necessary in thinking through the range of potential effects and best- and worst-case scenarios and providing for the optimum protection of populations. A complementary point of view is that of the histo- rian who attempts to understand an outbreak as it unfolds in real human time, discerning the complex effects of infectious disease as it works its way through the lives of individuals, families, and institutions. In the event of a catastrophic epidemic initiated by a biological attack, would we be able to tend to large numbers of ill and dying people? Although the US health care system has never faced a scenario so chilling, history affords us a sobering glimpse of the burdens associated with a large-scale, lethal epidemic.1 In 1918 and 1919, the Spanish influenza outbreak sickened one of every four Americans and caused more than 500,000 deaths in this country alone and more than 40 million worldwide. This devastation resulted from a disease with an estimated case mortality rate of 2.5%. The possible effects of a biological attack involving the agents of greatest concern are even more grim: The esti- mated mortality rate for untreated pneumonic plague approaches 100%; un- treated inhalation anthrax, 90%; and smallpox, 30%. Influenza overtook the United States in three lethal waves, incapacitating our cities at its peak in the fall of 1918. Baltimore, like other major cities, was heavily affected. Two-thirds of pandemic-related deaths occurred in October alone. More than 3,000 people succumbed to the disease. A severe worker shortage curtailed industrial production and government services. At least 25% of police officers, postal workers, sanitation workers, and firefighters failed to report for duty. Transportation, food supply, and communication networks were equally in peril. Gravediggers, also afflicted with flu, could not keep up with the demand for burials. Morgues were overflowing, some handling 10 times their normal capacity.

The 1918–1919 influenza pandemic (Spanish flu) had catastrophic effects upon urban populations in the United States. Large numbers of frightened, cri