More Thoughts About Thinking the Unthinkable, Part I

GUEST: Irwin Redlener, M.D.
VTR: 04/22/2004

I’m Richard Heffner, your host on The Open Mind. And in a sense this program is an extension of one we did just a year ago about “thinking the unthinkable, in order to do something about it”.

My guest then and really the intellectual presence behind this Open Mind and others to follow, was Dr. Ralph Gomory, the redoubtable President of the Alfred P. Sloan Foundation who has wisely insisted that “you can’t ask people to agree that the threat of terrorism is huge and leave it at that. You have to give them something concrete they can do. Because their question is going to be, ‘what can I do about it?’”

Well, here on The Open Mind, therefore that is precisely what I want to ask a number of expert guests on occasional programs over the months to come; from their respective disciplines and vantage points just what practical measures can we Americans take to protect ourselves against terrorism – biological, chemical, nuclear – and in whatever other forms sick minds can conjure up to injure us.

Appropriately, we start with concern for our children and my guest today is pediatrician Irwin Redlener, who helped organize the American Academy of Pediatrics’ taskforce on terrorism and who is associate Dean and Clinical Professor at Columbia’s Mailman School of Public Health; directs the university’s national center on disaster preparedness.

Since 9/11 Dr. Redlener has emerged as one of our nations leading authorities on terrorism and disaster preparedness; has been foremost in calling attention to the special vulnerabilities of our children to chemical and biological agents, and I want to ask him whether this nation has “listened up” sufficiently? Have his fellow pediatricians? Has the medical community generally? Have American hospitals? Have we as citizens and parents? Have our political leaders.

Now I know that in frustration, Dr. Redlener was quoted recently as bemoaning the simple fact that it’s too long after 9/11 for the United States still to be having these discussions. “Preparedness,” he said, “is the right place on the continuum between mindless complacency and all-consuming paranoia.

Still, I think perhaps I first ought to ask my guest today whether he at all feels that sharing the real and immediate concerns he has about our actual state of preparedness for future acts of terrorism is too likely to be counter-productive, too likely to frighten Americans into doing none of the practical things we might be doing. What about that?

REDLENER: I think it’s an excellent point. And I think the challenge has been to find that appropriate place to stand on; to say, “We understand the real world has created some dangers and some risks for us that we didn’t even think about much before September 11th of 2001, but now they’re here and now we’re talking about them all the time; now we’re watching television and seeing the evidence of terrorism as it has reached virtually everywhere, globally, and we understand that these are real risks for ourselves and our families.”

And as a pediatrician and as a father and grandfather I am concerned as you just indicated as others are, that, you know, how far do we want to go with this? Do we want to create a level of anxiety about this that would interfere with our ability to do what we need to do to go to school, to have fun, to plan vacations, to think about the future. And all of these things are in “the mix” as we make decisions about what we recommend to people.

So we conclude this … it’s never really concluded … so that where we are at the moment, let me put it that way, is that we do think a prudent amount of thinking and preparing is okay. Just as it’s okay to get to a point where you don’t even go for a ride in a car with your children without strapping them in the car seat and putting the seat belt on, we think it should become just a normal course of business, not anxiety provoking, to have some basic sense of what we would do in an emergency; that we’ve thought about in advance, so in case something happens … by the way, whether it’s terrorism or a natural disaster, which for many parts of the country is a real threat as well, we, we do have to spend some time thinking about our safety in the event of a crisis.

HEFFNER: Now, just between the two of us, no kidding … honest to God … do you think it’s possible to strike that kind of balance? Do we have examples, where in the past, people have done that?

REDLENER: Yes, actually there’s a lot of examples, in fact, in the country over the last many years for example. Let’s say we lived in an earthquake prone area in California, or the tornado belt, or hurricane alley down in South Florida … it is completely appropriate and everyone accepts the fact that you could have … wake up in the morning and get a hurricane warning …coming in the next 24 or 36 hours and people are prepared for that in a mental way. They, they understand what they have do, that they are going to have to evacuate a particular area; that they’ll have to have their supplies to a certain extent with them; they want to know where their valuables are. This becomes a normal course of the way people live in areas of risk from natural disasters.

So, we’re basically expanding that model, and say, “Yes, well, now we live in a world where World Trade Centers were taken down by jetliners used as weapons of mass destruction and we, we want just to make sure that to the extent that we can, without overbearingly, horribly affecting our normal way of living; that we’ve done what we can do … and just a reasonable example of this. We had a black out last summer; my own Mom at 81 years of age was, was at Grand Central Station and we had to figure out how to find out where she was and go get her and how can we get back to the city and there were traffic issues. And we had been in, in advance of that, talking about what we’d do for preparedness in general, and we figured out who was going to go get her, where we were all going to met; we had a mindset that was ready to deal with this very, very minimal crisis, but we eventually found Mom at Grand Central and brought her up to the house in Westchester.

And, and, it’s just a matter of “Are we ready to be able to function in a crisis, should one occur.” Whether it’s something like a black out, or something far worse than that. But, yes, there’s examples, I think, that are, that are relevant all over the place now.

HEFFNER: Well, you used the example, of course, and you do in your writings and your speaking of the seat belt …

REDLENER: Yes.

HEFFNER: We anticipate that to protect our children, certainly …

REDLENER: Yes.

HEFFNER: … we’re going to use seat belts. What are the “seat belt” parallels when we come to the matter of catastrophe; come to the matter … I mean you talk about natural events … tornadoes, hurricanes …

REDLENER: Right.

HEFFNER: … earthquakes …

REDLENER: Right.

HEFFNER: … but we’re focused now …

REDLENER: On terrorism.

HEFFNER: On this great evil of terrorism.

REDLENER: Yeah.

HEFFNER: What are the practical guides that you offer?

REDLENER: Well, it’s, it’s really fairly straightforward. And there’s two categories of things that we do. The first thing is that in, in thinking about what we might do or what we might need to know at the time of a crisis requires a meeting, almost literally, of the family. The Redlener family had such a meeting a year and a half ago.

We got everybody; most of us live in the same general area. We all met together and said, “What would we want to know?”. Well, we’d want to know “Where are the kids?” at the time a crisis might happen. Where, where do people work? Who could pick up children at school if other people couldn’t get there? And where would we go once we picked up kids? How would we get information circulated?

And that leads to several decisions about some systems and back-up systems for how we would make sure that loved ones, especially those who are dependent, like elderly relatives in a nursing home, say; or children in school, certainly. And we had a system in mind, an availability of people who could go, deal with those who, who needed, who need help.

And related to that, of course, would be making sure that we knew where to call for information about each other. So we’d have a central phone number that was local and another phone number that we could use as an information resource of a friend or family member, not in this area so in case the phone systems were down here, we could find somebody … a way to get an external connection, outside this area as well.

HEFFNER: Let me, let me stop you there. That, that I gather relates to the notion … to the fact, that it’s frequently easier …

REDLENER: Yeah.

HEFFNER: … to get to someone from Manhattan to someone else in Manhattan …

REDLENER: Yes.

HEFFNER: … through someone in Los Angeles.

REDLENER: Exactly. It has to do with the, the way the infrastructure for communication is set up and sometimes the local service might not be available, but the long distance service might be available.

So, having that second number, outside of the area is, is a good thing to do. So that’s one of the things that … this has to do with the thinking and strategizing and people coming together with a sense of how they’d function in such an emergency.

And then the second part is this issue of the supplies and things that you’d like to have with you in case there was a scenario that, say, required people to stay in their homes, being sheltered in place for a few days while a crisis came and was dealt with.

So that just means, “Well, what do we need?” And we know that we need a certain amount of water per person, it’s usually a gallon of water, per person, per day … more of less. We need to have some food that won’t spoil. We need to have flashlights with batteries. Radios that can work, either crank-powered or battery powered. And some basic necessities. Prescription drugs if you happen to need those. So we find a place in the house to keep those things that we might need. And similarly the certain things we might want to have at the work place, or in the car, or both. For example, at the work place to have shoes that you could put on that would be suitable walking a greater distance than you usually would. And some dried foods or maybe a couple bottles of water. Again, a flashlight. And so assembling those things as physical acts … you’re asking me what we should specifically do. And, and those are called “Go Packs” or other things. But having some emergency supplies at the work place, in the car, and especially at home, would be the things that we do.

And that’s basically it. But there’s another very key point here, Richard, which has to do with the planning process itself may be more important than the plan.

HEFFNER: That meeting for your family.

REDLENER: Yeah. Because what that does, it gets us psychologically prepared to cope in the case of a crisis. So, if something were to happen that would interfere with our carefully laid out plan, whatever it might be, we’ve put ourselves in a mindset of … we’ve practiced the mental exercise of getting ready to do something in the event of an emergency. And I think that’s good.

And actually that applies not only for families, but for emergency workers as well. You can’t possibly imagine and plan for every conceivable contingency. It’s just … there’s just too many possibilities of horrible things that could happen. But what we’re interested in is what’s happening up here (points to forehead) and can we figure out how we’d function in such a time.

HEFFNER: Now, children, in particular …

REDLENER: Yes.

HEFFNER: Your particular concerns about children. What are the practical steps, items, etc?

REDLENER: Right. Well, there are a couple things about children and terrorism, or children in disasters, but I want to focus on terrorism because that’s really what’s on our minds these days.

And the first thing is that we know, this is now medically speaking as a pediatrician, I’m talking, that many of the weapons that could be used in terrorism, biological, nuclear, chemical can affect children differently than, than might affect adults. And secondly, the treatment for children affected by those kinds of agents might be entirely different.

So, it’s been important since 9/11 to really be focused on the planning process to make sure that the planners have absorbed the information that they need to know about what children might need that’s different from adults. And make sure that those particular child specific plans are in place. And we’re making significant progress along those lines.

HEFFNER: What are the differences?

REDLENER: Well, let me give you a couple of examples. There are many things that could happen, say with chemical weapons or radiological weapons where people might not … might need to be what’s called “decontaminated”. And that’s just a fancy planning word for being washed off so that the actual physical contaminants that are on the person’s clothing or body would be washed off. So you go to a decontamination unit, probably in a hospital emergency room, and for an adult you’d basically take … you’d remove your clothes, you’d be showered off and you’d move through and that would happen rather quickly.

For small children, especially for infants, those showers are usually cold water; you could put a child into hypothermic shock from a cold water shower. And then you have a baby who’s in really serious trouble beyond the exposure to whatever the agent was. So you need a special kind of decontamination unit that doesn’t use cold water. And secondly, you can’t just put a one-year old by herself or himself in a, in an adult decontamination shower, they have to be designed so a parent could sit there with the child on the lap. So physically you could see that we have to design the units differently for children than we do for adults. That would be one issue.

The second issue might be that the antibiotics used in response to this particular kind of biological weapon might be entirely different. Certainly the dose is always going to be different for really small babies. And the emergency workers need to know about that.

So, as we go down the line there are many, many differences. Children … there are certain nerve agents that when sprayed into the environment tend to settle towards the ground. So the closer your breathing zone, your nose and mouth is to the ground, the more concentrated dose you’re going to get. So, somebody half your size is going to get significantly more intake of the noxious material per breath than you might get because it’s more dilute where your breathing zone is.

So children would be subject to a more rapid potentially response to such an agent. So, knowing those kinds of things are the types of things that we’re infusing now into the general planning process.

HEFFNER: What do you mean when you say, “infusing into the general planning process”?

REDLENER: Well, all of this …

HEFFNER: That’s a wonderful euphemism …

REDLENER: It is. It’s … and I apologize for that … but, but … here’s what it really means. So, right now we have all the states, all 50 states and many localities, certainly like New York City, which is one of the best examples in the country of doing this … have been engaged now in very extensive planning for what would happen in disasters from everything; from training health and public health and emergency workers, to creating caches of, of supplies and equipment that they might need in an emergency.

But what we want is that those people that are responsible for those plans and those preparations to include those things which we think are essential to have in case there are child victims of such attacks. And that’s, that’s really what we mean; we mean sitting down with them, giving them information, “let me look at your plan; while you’re making this kind of decision about what would happen for large numbers of people exposed to chemical weapons, we want to tell you that if there are small children involved, you’ll have to add these particular notions to your planning process” and that’s really what we’re talking about.

HEFFNER: Who are “we”?

REDLENER: Which “we”; you mean the “we” …

HEFFNER: “We” doing this.

REDLENER: “We” who are talking …

HEFFNER: “We” doing this.

REDLENER: Oh, “we” …

HEFFNER: “We” informing …

REDLENER: I see …okay. Well, there’s several things that are happening now. One is that there are centers like ours called the National Center for Disaster Preparedness, which has a program on pediatric preparedness, which is up at the Mailman School of Public Health at Columbia. This is the Center that I direct. So, there are a couple of centers, one in Boston, one here and I guess we’re the preeminent ones. But, but the other part of the “we” has to do with the pediatric organizations, like the American Academy of Pediatrics, most importantly that has had a Taskforce on terrorism beginning about a month after 9/11 actually. And that organization, the AAP, the pediatricians, have been actually working on many, many guidelines and templates for dealing with, with the possibility of terrorism and children.

HEFFNER: Now, you and I know that the Association may do this …

REDLENER: Yes.

HEFFNER: … are the pediatricians, in turn, doing it, by and large?

REDLENER: No yet. The pediatricians …

HEFFNER: Not yet?

REDLENER: No. No. What’s happened is, it’s not just pediatricians, but all of the systems, many of the public health systems around the country, the hospitals, are inundated with the same problems they had on September 10th. So …

HEFFNER: Right.

REDLENER: … after a very intense wave of enthusiastic embracing of what has to be done for preparedness, there has definitely been a … let’s say a diminishing sense of urgency. It’s now just, for many situations, many places and hospitals, another thing on a list of very intense and compelling priorities.

HEFFNER: That’s scary as hell.

REDLENER: It is scary. It is scary and we’re trying to work on that and this is one of the big things that we’re worried about nationally, is that what is happening both to the level of interest and resources coming for preparedness, but the other side of the coin, actually interestingly is that we’re also worried that the pendulum could swing and has swung in some situations, the other direction, so that there’s so much attention on the preparedness for terrorism that other basic public health needs have been lost in the wake of that.

And many of the rural states, for example, I’ve spoken to the health department directors for West Virginia and other places, where they say that when they were compelled by the Federal government to do smallpox vaccination planning, well the two people they’d have in a health department in a rural country in West Virginia had to be diverted from tuberculosis control, or childhood immunizations to spend 90% of their time thinking about smallpox vaccines.

So, the whole thing is actually a mess. There is very, very little in the way of hard core direction or benchmarks set by Federal authorities that give us some sense of how to organize priorities and make sure that we get the, the preparedness done without interfering with the basic public health agenda.

HEFFNER: You will, you will resent what I say …

REDLENER: Probably not, but go ahead, I can take it.

HEFFNER: How could it be, how could the pediatric profession …

REDLENER: Yeah.

HEFFNER: …how could “you people” …

REDLENER: Yeah.

HEFFNER: … permit this to happen? Or … permit it not to happen?

REDLENER: Well, it … well, first of all the pediatric … the American Academy of Pediatrics, as an organization is very focused. And it’s great … I mean if you go to their website, there’s a tremendous amount of information available … talks being given all over the place. But I thought you were asking on the … at the grass roots pediatrician level …

HEFFNER: Yeah.

REDLENER: … do the pediatricians in New York, in their offices … what have they done to prepare themselves … and …

HEFFNER: And the answer?

REDLENER: … that is, we really don’t know, we don’t think much has been done and that’s because they wake up in the morning and they go to the office and they have 43 kids scheduled and sick call and kids with all kinds of problems, and violence in schools and ADD and infections and all the things that confronted them prior to 9/11 in horrendously busy atmospheres in their offices, with pressures from the hospital and all the things that they’ve been dealing with and now we’re saying, “And by the way, you need to learn about smallpox and anthrax and the treatment for Sarin gas exposure”. And it’s just, it’s just incredibly difficult to break that through without interfering with the rest of their agenda. I’m not making an excuse for them, I’m just sort of telling you what I think is, is the reality for people.

In fact, the same thing is true for hospital administrators or even people in the public health work force. You know, but … the example I’ve used, Richard, it’s like a guy my age having a heart attack. I mean I have a very, very busy schedule, but I have a heart attack, so I get to the hospital, I get treated, hopefully you survive, and you get out and the doctor says, “You have to change your lifestyle, you can’t work so hard. You have to change your diet. And you have to come see me and you’re going to get these tests.” And I didn’t have time for that in my schedule before I had the heart attack. I never could have imagined … but you have to make room for it. You just have to fit it in, even though you were busy before-hand.

And really that’s what we’re telling people about getting ready for the possible … the possibility of terrorism. It’s like the, the … it’s like programmatic equivalent of having a heart attack. You didn’t asked to be exposed to terrorism, but you are and now we need you to somehow fit it in with your other priorities, because it really is that important.

HEFFNER: Could the Federal government be effective in this area? I gather it isn’t.

REDLENER: Well, the Federal government, it could be effective; it would take a President and I mean this literally, to bring his Cabinet Ministers in and saying “We’re nowhere near where we should be in terms of preparedness in the United States and this is a travesty more than 2 and a half years after 9/11. And starting tomorrow morning, you will do the following …”; now there already is some sort of national or Federal plan for preparedness, which has not really been implemented, or even fully approved yet …

HEFFNER: That’s real preparedness.

REDLENER: We’ve got to get that out there, we’ve got to tell the States what to do; we don’t want 50 states inventing their own preparedness plans, we don’t want the wheel re-invented in every country and city in the United States … and here’s what we’re going to do. And in the absence of that kind of central direction around a central plan, it is almost impossible, I don’t care who you put in charge of it, unless there’s a national commitment at the highest possible level, it’s just not going to happen, there’s too many competing priorities.

I was speaking to people who deal with fire departments in New York State; there’s more than a hundred, I don’t remember the exact number, but quite a few fire departments in jurisdictions throughout the United States … in a sense each one of them is functioning on their own; they’re buying whatever equipment the Chief thinks they need; they’re buying different kinds of personal protective equipment; there’s very little guidance about what’s the best and what every fire department should have. It’s just kind of random, random activities related to terrorism or preparedness as opposed to focusing on a plan that everyone has circled the wagons around.

HEFFNER: All right, if there is that confusion, if there isn’t that focus, how could we today, how could you today focus for our viewers on where they can get all of the specific information that is available at this time?

REDLENER: Well, there’s several good sources. They can go to a couple of government sites and … the Office of Emergency Management for New York City has excellent information available. The Red Cross does. As does FEMA and the Federal Government under the Department of Homeland Security. So one could go to those sites, get information about what one should do personally. You could also go to the American Academy of Pediatrics site … AAP.org and get access to all of those other sites that I just mentioned.

HEFFNER: In traditional form, repeat the site …

REDLENER: AAP.org … American Academy of Pediatrics. And they can be directed there to information about what families can do and what we should think about with respect to children. And we haven’t even gotten to the issues about the psychological effects on kids of all of this and what we need to worry about there. But, but there is much that people can do, including, by the way, which won’t be on the site, but I’m going to tell you here, which is that … when the next time they go to their pediatrician’s office, ask the pediatrician what he or she knows about what kids need to know about, or what families need to know about with respect to children and terrorism. And just kind of probe a little bit and that, you know, that’ll maybe help remind doctors … my colleagues, that it really would be a good idea to, to get informed about what they need to know.

HEFFNER: All right. We have a minute or so left … potassium iodide …

REDLENER: Yes.

HEFFNER: What do you have to say?

REDLENER: Well, potassium iodide is a relatively benign drug or medication that one could take and one should take in the immediate aftermath of a exposure to certain kinds of radioactive materials of the type that might be released in a nuclear “event” so to speak. And what it does, is it binds up certain sites in the thyroid gland that help prevent thyroid cancer in children in particular, that might result from exposure to, to radiologic agents that get absorbed in the thyroid gland.

HEFFNER: Do you keep it available in your home?

REDLENER: I do. I do.

HEFFNER: Should people with or without children …

REDLENER: Yes, they should if they’re anywhere within 50 to 100 miles of a nuclear power plant, which we certainly are here, I think it’s prudent to do so. Because it really must be administered within the first few hours of exposure to do any good. And it does work. I mean it doesn’t deal with radiation sickness; it doesn’t save you from radiation problems except in the case of thyroid cancer. But it’s a serious issue that could be dealt with in that way.

HEFFNER: We could go on forever and perhaps we should, but we’ve come to the end of our program. Thank you so much for joining me today.

REDLENER: A pleasure to be here.

HEFFNER: And thanks, too, to you in the audience. I hope you join us again on this subject, and if you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.