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How Our Progress Since 9/11 Has Benefitted Public Health Efforts

The events of 9/11 will forever be engrained in our memories. The attacks on the twin towers, Pentagon, and the anthrax attacks which followed were unimaginable at the time. Ten years after these tragic events, what’s changed?

September 11 Newspapers and Headlines

We now know that terrorist threats are ever present and that our nation must be in a constant state of vigilance in order to protect our communities. We’ve come a long way since 2001 in bolstering our nation’s ability to prepare for and respond to catastrophic events whether natural, accidental, or intentional. We are also learning more and more every day that the resources we need for the big disasters are much the same as the ones we use for everyday public health activities.

Check out my list of top 5 accomplishments in the years after the 2001 attacks:

5. A much-needed global perspective that acknowledges that pandemics or terrorist threats don’t stop at geographic borders. A number of programs have been established to rapidly detect and contain emerging health threats, including bioterrorism threats. Programs like CDC’s Global Disease Detection are increasingly focused on building local capacity to support global efforts directed at preparedness and response for disease outbreaks. This means identifying potential outbreaks or threats where they emerge and before they have a chance to spread globally.

Screen shot of a sample CDC Health Alert message 4. Improved communication and information sharing. Response efforts following the 9/11 and anthrax attacks lacked the kind of integrated communication and unified command needed for a large scale response. Information critical for decision making was not shared between agencies and there were difficulties keeping local, state, and federal officials informed. Today we have systems such as Epi-X and the Health Alert Network (HAN), which allow health officials to access and share information quickly with other professionals and the public. In addition, public health departments in every state have established relationships and conducted exercises with key emergency management players such as law enforcement, fire departments, and hospitals.

3. Establishment and expansion of federal resources. The 2001 anthrax attacks were a wake up call to the realities of bioterrorism. Scientists in laboratories and doctors in hospitals had to be ready at all times to identify illnesses related to bioterrorism and treat victims of these attacks. This is no small feat as illnesses linked to bioterrorism often mimic the symptoms of more common maladies. Not to mention, once a cause is identified treatment is not always something readily available.

Man in an air tight suit looking at samples on a light boardBefore 1999, CDC performed all tests to detect and confirm the presence of biological threat agents such as anthrax. This took up valuable time when every second counted. Today, more than 150 laboratories across the nation belong to CDC’s Laboratory Response Network and can test for biological agents, saving both time and money. Additionally, CDC’s Strategic National Stockpile now ensures the availability of key medical supplies and all states have plans to receive, distribute, and dispense these assets. To help prevent improper use of select agents and toxins (e.g., anthrax, Ebola virus, botulinum), CDC’s Division of Select Agents and Toxins helps provide oversight by licensing, registering, and identifying entities working with these agents.

2. Federal funding for states and localities to build and strengthen their ability to prevent and respond to disasters. The events of 2001 revealed our vulnerability to the use of weapons of mass destruction and made public health a new participant in the national security discussion. Significant investments were made in state and local preparedness and response infrastructure, planning, and capability development for “routine” outbreaks and in the face of large scale disasters and epidemics. Today CDC provides funding to all 50 states, 4 metropolitan areas, and 8 territories. Grantees use this money to support laboratories, outbreak investigations, and risk communication among other things.

Health department staff moving boxes of medical supplies1. Following the 2001 attacks there was a cultural shift in how we think about national security. It had become apparent that public health played an important role in national security. The terrorist attacks changed the way state and city health departments worked and interacted with other agencies and sectors. Health departments are increasingly becoming accepted as equal partners by traditional first responders, including law enforcement, fire departments and emergency medical services. These interactions are supported by the incorporation of public health components into the National Response Framework and Nation Incident Management System (the “playbooks” federal, state, and local responders use to plan for and respond to emergencies).  Our ability to respond to disasters is strengthened with each area of government working together.

Looking Ahead

Progress made in preparedness over the last decade has benefitted routine and surge responses, saving lives and preventing illness and injuries. There is growing recognition that preparedness and core (“routine”) public health investments are synergistic. Large scale and unpredictable disasters and disease outbreaks require many of the same routine surveillance, laboratory, risk communication, and other core public health capabilities and systems. Although we are better prepared today we continue to face new challenges with fewer resources. Looking ahead we must increase our focus on communities and better define and enhance community and local resilience. We also need to enhance our focus on vulnerable population that require additional assistance during emergencies and finally, improve the evidence base for preparedness activities to show that work before a disaster really does pay off.

More Information

Read my article on how public health has changed since September 11, 2001 in a special issue of the journal Lancet commemorating the 10th anniversary of the 9/11 attacks.

For more information on how CDC is helping communities like yours, visit Find out what you can do to help your family prepare an emergency at

*This blog post was originally published at Public Health Matters Blog*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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