AMA 15th National Conference 2003 Speech to Medical Response to Terrorism Plenary Session Dr Kerryn Phelps, AMA President

Welcome to a very important session at this conference - the Medical Response to Terrorism.

When I attended the World Medical Association's meeting on Bioterrorism in Washington last year, the USA had faced the shocking reality of the World Trade Centre attacks and the release of anthrax through the US postal system.

The very week of the WMA meeting there was a sniper active in the area terrorising communities by indiscriminately picking off innocent victims.

That week I met with the US Surgeon-General, Dr Richard Carmona, who impressed upon me the importance of consciousness-raising of the need for preparedness of the Australian medical profession, and the need for us to work with government and the intelligence community.

So here we are.

Recent events have increased the Australian public's awareness of the risk and possibility of terrorist attacks occurring against Australian interests.

Historically, terrorists were more interested in making high profile

political statements, but in recent times it appears that the goal is not so much high visibility but high casualties to make a political point.

With today's terrorists having access to increasingly deadlier weapons, the face of terrorism is changing...for the worst.

This is most clearly demonstrated by the use of commercial airlines in the September 11, 2001, attacks on the World Trade Centre in New York.

Closer to home, we saw the bombing of the Sari nightclub in Bali in October 2003.

While not an act of terrorism, the global experience with Severe Acute Respiratory Syndrome (SARS) has also demonstrated what could occur with the intentional release of a biological agent by a terrorist group.

This picture of the future is a sobering one.

Terrorism is a concern to medical practitioners, as acts of terrorism require doctors to provide care to the victims and to be vigilant as the frontline of detection in the event of biological or chemical terrorism. The nature of the care required will be dependent on the type of weapons used. Biological

Crude biological warfare has been around for many hundreds of years.

Biological weapons capable of significant impact are currently difficult to obtain.

It is a highly technical process to concentrate cultured organisms and prepare them in a form that can be widely disseminated.

The consequences of a successful biological weapon release would be catastrophic. In fact, some authorities consider the risk of release of a biological weapon the most dangerous terrorist threat in the world today.

The difficulty for medical practitioners in this situation is that many of the agents used have subtle initial presentations with non-specific symptoms such as fever, chills, headache, or cough.

It is likely, therefore, that a patient with these symptoms initially will present to a general practitioner, clinic, or emergency department.

The critical role of emergency physicians and general practitioners in a biological terrorism event will be their early recognition of the disease or in raising suspicion of a possible release of a biological agent.

This critical early recognition will possibly save many exposed patients who have not yet developed a clinical illness.

It will also enable health care workers to institute appropriate infection control measures to protect themselves.Chemical

Chemical terrorism could involve several agents.

Examples include:

• sarin gas that was used in the Tokyo subway attack
• mustard gas
• choking agents such as chlorine
• and other agents such as hydrogen cyanide.

Like biological agents, most of these require significant investments in chemical production capability to produce sufficient quantities that could be used in a terrorist attack.

The consequences of chemical terrorism will be similar to those of an accidental chemical release from a damaged tank or from an industrial explosion.

It is far more likely that a community will confront the effects of an accidental - rather than an intentional - toxic chemical release.

Whether resulting from accidental or intentional release of toxic chemicals, some exposed victims may die before rescue. Others will require medical treatment to survive.

Contaminated patients with varying degrees of chemical exposure may either self-present or will be brought directly to emergency departments for medical care.

Contaminated casualties present a toxic hazard to receiving emergency department personnel.

Without adequate staffing or appropriate funding for personal protective and decontamination equipment, emergency department personnel will not be able to provide appropriate specific or supportive medical care.Conventional Explosives

Conventional explosives have been the weapons most frequently used by terrorists because they are the easiest to obtain, create, and use.

Recent examples include homicide/suicide bombings in Israel, Morocco and Saudi Arabia, and the attacks last year in Bali.

The medical consequences of terrorism using conventional explosives include death and/or acute injury and destruction of critical infrastructure such as buildings, roads and utilities.

Health care needs of blast victims include immediate surgical and non-surgical trauma care, follow-up medical care, forensic disposition of bodies and body parts, and mental health care.

Doctors and hospitals must be prepared to treat hundreds or thousands of trauma cases, and their response may be complicated by loss of utilities such as electricity and water, difficulty reaching hospitals, or even damage to hospitals in a community. Nuclear and Radiological Terrorism

Nuclear and radiological terrorism are very different events.

Nuclear terrorism would involve the deliberate detonation of a nuclear weapon. Consequences would include fatalities and injuries resulting from the initial explosion and subsequent fires, as well as immediate and long-term effects of radiation exposure.

Some assessments suggest that the difficulty of obtaining the materials needed for a nuclear device and the extraordinary technical challenge of building a functioning nuclear weapon make this the least likely form of terrorism.

Radiological terrorism would involve the deliberate contamination of an area using radioactive materials.

For example, a terrorist could use conventional explosives to disperse a radiation source - so-called 'dirty bombs' - such as a spent nuclear reactor fuel rod.

The technical challenge is far less than that of nuclear terrorism.

Fortunately, the consequences would be less, as well, being limited to the longer-term effects of radiation exposure and the challenge of decontaminating those exposed and the contaminated area.

Very few doctors have any experience with true mass casualty events such as which may occur after a terrorist attack.

Experience can be gained from overseas incidents and disaster medical services to improve the capability of Australian disaster medical responses and ensure they are consistent with international best practice.

Our discussion today is happening at a critical time in world history...and a critical time in Australia's history. Some say we are a 'target'. We must be prepared.

I now welcome the first speaker:Mr Clive Williams

Clive Williams is director of terrorism studies at the Australian National University's Strategic and Defence Studies Centre, and is a specialist on terrorism and politically motivated violence.

Mr Williams has a career background in Defence Intelligence. His last position in Defence, until October 2001, was as Director of Security Intelligence.

Mr Williams has a BA Honours in Political Science and a Masters Degree with Honours in Criminology - both from the University of Melbourne.

He has worked and lectured internationally on terrorism-related issues for over 20 years, and has run a terrorism course at ANU since 1996.

I now welcome Clive to make his presentation on "Prospects for Macroterrorism", in which he will review the prospect of terrorist use of chemical, biological, radiological and nuclear weapons...Dr David Cooper

Our second speaker today is Dr David Cooper. He is the Director of the NSW Health Counter Disaster Unit.

Following his medical undergraduate training, internship and RMO years in Newcastle, David was a senior medical officer in the RAAF, where he specialised in aeromedical evacuation and disaster planning.

On leaving the RAAF, David was a registrar in emergency medicine at Liverpool and Royal North Shore Hospitals where he learnt the importance of trauma and critical care systems.

On gaining his Fellowship he was appointed as the Director of Emergency Services at Coffs Harbour Base Hospital and the Director of the Critical Care Network for the Mid North Coast Health Service.

Upon returning to Sydney, he became the Director of Emergency Services for Western Sydney Area Health Service.

In 2000, David was appointed as medical commander of the disaster teams for the Sydney Olympics and, following the tragedy of September 11, was seconded to NSW Health, with a specific charter to ensure our preparedness for terrorist attack.

David has led Health resources through a number of major incidents and disasters, including Operation Biohazard, the bushfire emergencies, the Albury bus crash, the Waterfall train disaster, and the Bali tragedy.

I now welcome David to give an overview of what are some of the issues relevant to the medical community in the event of terrorist attack in Australia...Dr Len Notaras

Our third speaker is Dr Len Notaras.

Len has been the Medical Superintendent of Royal Darwin Hospital since 1994, and Northern Territory Principal Medical Consultant since 1997.

He has held a range of senior health positions in NSW and the Northern Territory.

He is a member of a number of peak national groups such as the National Safety and Quality Council in Health Care, Australian Healthcare Association, and a board member of the Australian Council for Health Standards.

Len has enjoyed a diverse career, which involves medicine, law enforcement, the military and private enterprise, and this is further reflected by degrees in Medicine, Law and Arts, Commerce, and Masters in History and Hospital Management.

He is a Senior Lecturer with the Northern Territory Clinical School and Associate Fellow of the College of Health Service Executives.

He was directly involved in the inception and development of the Northern Territory Clinical School.

For Len, the successful Bali response was the culmination of a recruitment and building process which "fashioned" one of the nation's most capable and enthusiastic clinical teams.

I now welcome Len to give some reflections on his experiences in the aftermath of the Bali bombings...

Our three speakers will now join me for a media conference on their presentations and the issues surrounding a medical response to terrorism.

The media conference will be in the Hyde Park Room.

Following afternoon tea, I invite you back here for Part Two of this session when we will invite questions from the floor.

I'd ask you to please be back here promptly at 3.30pm to ensure we get started on time and get to hear as many of your questions as possible.

Thank you.