Biomedical Weaponry - A Medical Faux Pas

Just as a “disasters are an opportunity for development”, the Second World War is known to give birth to “huge advances in medical knowledge and surgical techniques”. This article would provide you with the highlights in history of the friendly use of medicine out of which some good and bad has resulted. If I poisoned your fields with bio-agents as an answer to your attempt to poison mine; it can be dually regarded as good and bad. Biological warfare is a deliberate use of various agents to spread disease amongst plants, animals, humans and everything and anything.

Some of the most common, deadly agents known to have wiped out populations are as follows: Among bacteria are Anthrax, Plague, Tularemia, Brucellosis, Q Fever. Among viruses are Smallpox, Viral Equine Encephalitis and those responsible for Hemorrhagic Fever (Filo/Flavi Viruses); and toxins include Ricin, Botulinum, Mycotoxins and Saxitoxin.

Wars forced companies to develop highly effective medicine and techniques on an industrial scale. Pre-war penicillin discovery by Sir Alexander Fleming increased the chances of survival of appalling casualties and henceforth the treatment. In addition to pioneering the work on skin grafts and blood transfusion, refining in the war years were preventive medicine for malaria, tetanus, gangrene, pneumonia and gonorrhoea.

Poor man’s atom bomb: The Romans attempted the first ever use of biological weapons (BW) by poisoning water supply of the enemies using battered animals. Later, this thought was elaborated by the Mongols in 1346 who used corpses infected with plague instead of animals to stretch a bigger picture. In 1710, the Russians defeated Swede enemies by plague-infected corpses. The British didn’t lag behind who in 1767 aided the Indians with blankets initially used to protect smallpox victims.

 A popular weapon, Anthrax was first used by the Germans in 1916. They also used Glanders, which is an infectious disease cause by Bacterium Burkholderia Mallei to infect equestrians and feed to allied forces. Romanian sheep, Argentinean mules and American horses, all had been used to feed the human agenda.

The Japanese stepped in to poison Soviet water supply with intestinal typhoid at the former Mongolian Border in 1937. Ever since, Japan began its Offensive program in to which at least 10,000 prisoners have given their lives to. Japanese plague-fans dropped rice and wheat mixed with plague carrying fleas over China and Manchuria.

In 1942, the US began their Biological Offense program. Various tests were conducted henceforth in San Francisco and New York. Germans too tasted the use of offense in 1945 followed by Iraq which embarked to develop a biological offensive program which included toxins like botulium toxin, aflatoxin and anthrax.

In 2001, the anthrax attacks in the United States, also known as Amerithrax, occurred over the course of several weeks beginning on Tuesday, September 18, 2001, one week after the September 11 attacks. The Daschle Letter contained 2gm powder in an envelope, containing 100 billion – 1 trillion spores (10 (11) – 10 (12) cfu) were mailed to several media offices and two Democratic U.S Senators, killing 5 people and infecting 17 others.

Several reasons may advocate bioterrorism. A biological agent self-replicates within the victim, has relatively low costs of production, requires a small dose (1gm of toxin could kill over 1 million people), appropriate particle size and stability in aerosol, ease of dissemination, insidious symptoms, prolonged incubation period and difficult detection. Owing to multiple feasibility features, a biological attack could be planned and placed on a moving or stationary position. Also, the ease of modes (frozen/dried) and methods of delivery (bomblets) have also been described.

 BW still depends upon the susceptibility of the aggressors and Mother Nature; temperature and sunlight, environment persistence of some agents like anthrax, relatively longer incubation period, advanced and specialized infrastructure for development among others maybe limiting parameters. Not only are a wide variety of biological agents genetically being modified to withstand antibiotics and other treatment regimens, but also mocking sensitive detection systems. I find it extra-ordinary to have SARS, MERS and other challenging diseases with resistance patterns escalating regions. Some difficult whereas some easy to grow; incapacitating agents like VEE, Bacillus Anthrax, Plaque, Yersinia and various forms that cause Hemorrhagic fever have high fatality rates once established in a non-immune host.

Viruses are quite attractive weapons from a both engineering/harvesting technique which is a rather effortless and treatment complexity. If you sense an unusual disease entity, large numbers of civilian and military casualties, aerosol route, morbidity limited to the localized geographical area, multiple dead animals; run for your lives! The unusual pattern of victims showing at a health site and vague clinical features should raise suspicion for a covert biological poisoning. Accessible laboratory screening should be implemented immediately and common bio-agents should be cultured by standard methods until specifications can be made available.

 More specific methods include Mass spectrometry for toxins, antibody and antigen tests, DNA probes and Detection of metabolic products. Vaccines, anti-virals, antibiotics and other antidotes should be available en masse to avoid overwhelming supplies. Common sources like food and water should be protected, vector control measures, indoor movement, issuing Personal Protective Equipment may all be temporary measures.

 Conventional decontamination methods like chemical, heat or UV may also be utilized. Such detention tactics are deemed impractical and reason for terrorists to continue to implement attacking strategies. Development of the public health systems, public education and programs (workshops/drills), governmental incentives for research and development into biological attack and countermeasures since biological weapons are now being engineered; all have been undertaken to forbid the use of biological weapons.

 The strategies have been targeted to enhance disaster preparedness and response capacity, when initiatives should strictly be taken to promote preventive tactics, interdicting arsenal, registering/documenting purchases, imposing strict penalties and regular screening and inspection of suspected regions. Disaster management should come into action when a biological intervention is suspected. Disaster Management should be an Integrated System of Hospital Management.

 Dr.RezwanNaseer, General Director of Punjab Emergency Service (Rescue 1122) proposed a Disaster Preparedness program. Dr.Naseer anticipated a safety community development program through injury prevention research, school safety program, community safety officers and teams etc. The program is to expand to other provinces of Pakistan; in KPK, AJK, GB and Baluchistan.

Dr.SherazAfridi, Accident and Emergency – Khyber Teaching Hospital, introduced a MIMS course, Major Incident Medical Management Support. The aim of such a service was to provide the knowledge and skills needed to effectively manage the scene of a major casualty incident supported by a “Methane Message” for better understanding.

M: My call/sign/name. Major incident STANDBY or DECLARED.

E: Exact Location.

T: Type of Incident.

H: Hazards, present and potential.

A: Access and egress.

N: Number of severity of casualties.

E: Emergency services – present and required.

 Certain systems which have been developed to detect biological attack are: SMART (Sensitive Membrane Antigen Rapid Test) JBPDS (Joint Biological Point Detection System) BIDS (Biological Integrated Detection System) IBAD (Interim Biological Agent Detector) and The Tactical Biological Standoff Detection System. Bio-terrorism Outlawing Washington Conference (1921–1922), the Geneva Conference (1923–1925), and the World Disarmament Conference (1933) forbade the use of BW.

However, The Geneva Protocol did not prohibit the development, production and stockpiling of biological weaponry. Failure to decommission the arsenal is perhaps best illustrated by the super powers. There are several events in history of a seemingly incidental or offense free warfare, while pushing agendas for peace, sponsoring and staging attacks and establishing grounds for hostile purposes. When our great doctors, health workers, activists and freedom fighters rising to the challenge of the civilian war magnificently are being shut out from raising their voice, who am I write this peace on warfare when the global voices are now silent?

 There remains no time to ponder anxiety, panic or psychological effects among the civilians in attempt to train them against a possible biological attack, applying to both attacking and attacked nations. Rampant bio-agent use for a personal crusade has indoctrinated the methods and availability of sophisticated techniques without considering the consequences. For instance, product tampering (Tylenol tampering cases of the 1980s); attacks on specific ethnic population; sabotage of specific food item (the lacing with cyanide of Chilean grapes in March 1989); attacks directed at one of a country’s agencies or departments (anthrax mailings in 2001). Whether you call it an arms trade or a defense fair, weapons regardless of their kind will continue to be sold to the dictators, which would follow military intervention and a flow of protesters wrapped in an anti-intrusion agenda; giving rise to nothing but massacre; an exhausting merry-go-round.

The Government Luncheonette

My practical venture, ideally the taste of reality began when I stepped out as a fresh graduate embarking on a journey to minus insult to injury, joining a government hospital as per PMDC requirements for a stretch of 12 months. A new graduate sticks out like a sore thumb and so did I. After braving the series of delays in the entrance exam, I was finally handed out my choices for the year. 

Ideas of lending a helping hand to help fill the void and several other encouraging designs were running through my veins. At the time, I felt like a ninja, perhaps a doctor without a border. With most of the government vainness out in the open, how vulnerable was I? Highlighting a series of events and outcomes, I have divided the government setting into 8 subcategories, each with its own surprises.

 The Parfait Healthcare Delivery System:Hospital and hygiene go hand in hand. The sanitary situation in every department lacks even the generic rules of waste disposal method. Beginning from basic techniques, there lacks a concept of waste segregation.

 The containers are not color coded differentiating them from sharps and other forms of risk waste which burdens the waste management plan. The risk waste like pharmaceutical, genotoxic and chemical waste fall into the same bin which is mishandled thereby adding to the health risk. The ambulating services within the hospital responsible for moving patients from one unit to another don’t meet the standards as quite.

 The vain chain to making a request via land line towards the main office to the arrival of the ambulance is enveloped in endless delays pushing caretakers to take charge and conduct the patients to the desired destination. Often, there were several intensive care patients within the unit required shifting with oxygen; sadly, both the nursing attendants and oxygen showed no avail. Patients referred from the main emergency to the corresponding department are seen stretching across the hospital, braving the heat and confusion.

 The blood bank and laboratory are perhaps the only operating units with order. However, collection units servicing the admitted patients in every department had been closed a year ago due to which all samples are directed to the main laboratory by the patient/patient’s attendants, even an arterial blood gas sample dipped in ice-cold water. According to a local perspective, the laundry and food services have little to offer too.

The Individual Unit: A doctor too is a human being you know, and hence a potential candidate entitled to safety, security, privacy and well-being. Through the course of my rotations in the major departments, there were no private rooms assigned for interns, let alone for boys. We either shared a room with the members of the opposite sex or didn’t have a room at all and therefore took shelter in the nursing staff’s shack where we were not welcomed.In the brighter cases where we had a place to settle down after prolong duty hours, the restrooms were devoid of a necessity called water (I didn’t complain of the hygiene at all at this point). Moreover, the rooms often became flooded with the senior on call duty doctors with the juniors compromising their happy hour or adding to the pile. Attacks on personal lockers and unrestrained theft were next that rocked my world.

The Nursing Posse: Here I would like to speak of “some and not all” nursing staff who fail to deliver nursing care and indulge in illegal practices of selling off the healthcare goods to make a handsome living. Every department is allotted a budget that covers certain departmental expenses. Some turn over their departments into a new system, others drive the budget into their pockets. Mostly, I was requested to return used voiles and document disposables consumed at a duty the next morning to a senior staff member. The staff member at various events refused to handout important healthcare materials deemed necessary for post-operative patients and insisted they be ordered by the attendants of the hour. Ruckuses were often sparked following an ample spending on their behalf which was totally justified. On the flip side, some staff members remained true to their responsibilities and did more than their capability to offer help.

The O.T Blues: The sketch of an operation theatre felt like a blue area, highly disinfected, with limited personnel and a protocol that followed. If you should know everything, the theatres were often crowded with interns more than desired. Moreover the practice of proper theatre specific attire including a foot and head gear, scrubbing details and bringing unauthorized personal articles were far from supervision. The advent of disposable gowning and draping is a dream which is yet to come true. Given the resources, I believe the hospital still makes the most of it. However, the smallest details of observing proper measures before, during and after a procedure need a reality check. In the unlikely event of an instrument/machinery running out of order is only followed by a feud and the blame game. Also, patient privacy is still misunderstood and incompletely sought after and the concept of medical ethics in the OT has a supporting role to play.

 The E.R Bloom: The emergency from a distance gave me the chills. It’s been updated into a new building, with central conditioning system instated, separate areas of major trauma departments including a resuscitation room, emergency serial reporting and a theatre. I believe the ER should be a place with absolutely no shortcomings. To begin with, the patients and scores of attendants scramble and split to locate stretchers to put them out of their misery. In case you require wheelchair, you would have to ambulate at least 10 times to find the right person to reason with. Once in, the patients meet their amateur interns and are treated in accordance with the emergency decrees and senior reporting.

 In the morning when most seniors and head staff report to duty, things maintain order. However, as the sun dusks, the ER becomes an independent entity which has rendered the ER helpless and in-efficient. The freedom proceedings range from disappearing from duty hours, making medical supplies in need unavailable, illegal medico-legal practices, misguiding the patients in terms of remote access and pharmaceutical crimes. Not to mention the security of the healthcare workers which often falls into great danger when important personnel, drunkards or criminals arrive for healthcare delivery in the wrath of night. The security officials allocated for their purpose are found napping and sipping in their booths. Obviously, surveillance and profiling hasn’t worked.

The Secret Society: This society only comes to being in events of an emergency. By that I mean foreigners touring for funds/donation, senior accountability, employment/sacking, greetings from highlife, and… can’t think of anything else.The patient welfare fund doesn’t approve of your poverty unless the secret society authorizes. Serology, MRI, thyroid/bone scanning and others forms of expensive reporting harbor bad news to the unfortunate masses. Also, in the event of a mass/multiple casualty when reporters gather around for scoop, the personnel arrive for a routine visit touching only the outskirts of the area. To my surprise, there were more than single units reserved for mass emergencies. These rooms were equipped with automatic monitoring systems, in-built laboratory, quick serial assessment structures and restrooms. I discovered this mode of personalized care when it played host to an official who presented with a low blood-sugar level.

 Us: Speaking so much of the bitter truth, I have thought of nothing positive except the doctors. Because doctors do not discriminate, healthcare belongs to everyone!