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Published: 16/01/2003, Volume II3, No. 5838 Page 14

Whether the threat is real or imagined, the NHS is obliged to demonstrate a state of readiness in the event of bioterrorist attack.How is it faring? Mark Gould reports The prime minister set the scene with a doom-laden Christmas message to the armed forces, which foretold all manner of international terrorist threats for 2003.

And the new year was barely underway when news of the discovery of traces of the toxin ricin, in a flat above a north London pharmacy, gave new life to tabloidland's fevered speculation about bioterrorism sweeping the country.

Ricin is infamous for its use in a poison-tipped umbrella by the assassin of Bulgarian defector Georgi Markov in London in 1978. But poisons experts say four tonnes sprayed across London in aerosol form would be needed to create mass casualties.

While London has suffered decades of terrorism and remains at risk, it has never been subject to chemical, biological or nuclear attack. And the message from the NHS is 'do not panic; the capital is as well prepared as it can be to deal with real or imagined threats'.

But director of public health for London Dr Sue Atkinson admits there is a 'difficult balancing act' between making people aware of, and protecting them from, a potential risk while not making us too scared to get out of bed.At the same time, public health doctors cannot afford to neglect their regular work.

'When we found there was ricin, we had to make people aware of the situation and we have sent out details via the usual e-mail cascade. You have to strike a balance and look at the risks we take in everyday life, like smoking or even driving.We all take on these risks subconsciously so that they become part of the background.

'While ricin was used as a oneoff assassins weapon to kill Markov, experts say it would be difficult to use it to inflict harm on significant numbers.'

Dr Atkinson says that 'three or four' of London's 32 primary care trusts have yet to carry out tests of their emergency plans.

'We could always do more given the background, and given that PCTs are rather new many are still putting together their emergency plans and some haven't tested them yet.'

But she admits it is impossible to protect the UK against every possible biochemical threat. 'Plans have been modified in the light of recent experience - including 9/11 - but realistically we are never going to be 100 per cent perfect.'

Dr Atkinson says that the bulk of London PCTs share borders with local authorities, and the Metropolitan Police now has commanders at borough level.

'And we now a rota system so we have public health experts on the joint health advisory cell [a specialist medical group set up at the request of a police commander for the area affected by an incident]. I am not saying everything is perfect, but we have got the building blocks in place.'

Dr Bobbie Jacobson, former director of public health for East London and the City health authority and now director of London Health Observatory, says that some of the scares do not bear closer inspection.

'When you look at all those scares about posting anthrax spores in the US, Porton Down [Ministry of Defence chemical and biological research institute] showed that It is an extremely inefficient way of infecting large numbers of people, so it is quite reassuring to know that these spores will not be travelling down the Tube tunnels.'

Dr Jacobson says that a recent test on the London Underground simulating the release of the nerve gas sarin in an attack on the Tokyo underground in 1995, which killed 12 and injured thousands, convinced her that responses are probably as good as they can be.

'The UK has a got a properly established public health system with environmental health departments in local authorities and PCTs all linked to a national system that has practised and trained for just these sorts of event. I think we have a better chance of reacting in an appropriate manner to these risks than most - certainly better than the US. The NHS is one unified NHS providing for the health and welfare of the whole population.'

The London Ambulance Service agrees. A spokesperson says: 'We are better prepared [for a terrorist incident] than ever, but that is not to say there are not difficulties.

While we are on the front line of regular NHS work, we are also part of the emergency services and have to work closely with police and fire services.'

University College London Hospitals trust in central London is closest to many central London terrorist targets. The trust dealt with major incidents including the 1993 IRA bombing of Bishopsgate in the City, the 1999 Soho pub bombing and the 1999 Paddington rail crash.

Accident and Emergency consultant Dr Annie McGuinness says the trust regularly updates and practises the major incident plan. 'Over the last year, we have acted promptly to ensure major incident policy covers potential nuclear, chemical and biological threats, and recognising the need for different plans of action to effectively deal with any event.'

The trust has two decontamination chambers, 10 personal protection suits, a trained decontamination team and staff drills. Money for the new equipment came from£5m allocated by the Department of Health last year which has been spent across England and Wales on 7,250 personal protection suits and respirators and 350 decontamination units.

However Dr McGuinness says the key is finding a balance.

'As with any trust, we are as prepared as we can be given the resources and facilities to hand.

We strive towards best practice, but we remain non-alarmist for the benefit of staff and patients.'