CBRNE: What Would Ramazzini Have to Say?


Bernadino Ramazzini was born in Capri, Italy in 1633. While still a medical student at the University of Parma he penned a treatise on the diseases of occupations published  in 1700; De Morbis  Artificam Diatriba (Diseases of Workers).  Ramazzini   has been credited with being “The Father of Occupational Medicine”. 

Ramazzini, being a very progressive physician, analyzed the tradecrafts and work environments of workers in a variety of occupations and deduced that occupations and the work environment can influence health and disease.  Ramazzini, and his predecessors such as Hippocrates (“The Father of Medicine”) and Paracelsus (“The Father of Toxicology”) made great preliminary strides in what has become known as the medical specialty of occupational and environmental medicine (OEM).

Environmental and occupational medicine are uniquely wide-ranging medical specialties that consider the impacts of work and the environment on human health. Work plays a major role among our many human activities.  In the work environment, individuals can be exposed to toxic and corrosive industrial chemicals toxic dusts and aerosols, biohazards, hazardous physical agents, such as ionizing radiation, mechanical trauma and emotional and traumatic stress. Any of these exposures may induce disease and disability immediately or with a latency period of years to decades.

Environmental and occupational medicine are specialties confronting rapid change. Each year, Forensic_Toxicology_Research_Laboratoryhundreds of new synthetic chemical compounds are developed by the chemical industry and are added to the 80,000 chemicals and to the over 10,000,000 mixtures, formulations and blends already in commerce. On several occasions, inadequately tested and  harmful toxic substances have been released into the workplace and the environment without proper adequate prior assessment for their potential for toxicity.

Workers are typically the first to be exposed, and the consequences of exposures to both well-known agents, as well as untested substances and technologies fall most heavily on the vulnerable members of our society, such as infants, children and the elderly.

As recent events have elucidated , all workers in all occupations are at risk from terrorist actions and political violence. This includes the more recent and prevalent use of firearms and improvised explosive devices (IEDs). Terrorism and political violence, with the potential use of CBRN agents, has emerged as a complex, multifaceted threat largely as the result of converging issues in security,  international relations and public health, which include the following:

  • Changes in the international order
  • Changes in the ideology and “practice” of terrorism and political violence
  • Changes in the capacities and capabilities of health care systems and the public health infrastructure to cope.

In the realm of terrorism and political violence, OEM  has risen to the challenge by providing specialized medical and health and safety expertise in emergency preparedness, consequence management community resiliency and recovery.

Non-conventional threats such as CBRN agents deployed in acts of terrorism targets workers, as well as communities at large. The high population density of many worksites lead to increased vulnerabilities to a terrorist attack and can generate a complex matrix of injuries and illnesses, including chronic impairment and disability.

Sadly, the morbidity and mortality of associated with the September 11, 2001 terrorist attacks reflects this conclusion. Approximately 3,000 WTC_5_and_7individuals perished and 7,000 were injured in the attacks on the World Trade Center (WTC). Three-hundred and forty-three emergency responders from the New York City Fire Department (NYFD), and over thirty police officers perished in the aftermath of the catastrophic structural collapse. During the 24 hours after the collapse, an additional 240 FDNY responders sought emergency medical treatment .

Many surviving responders remain affected with respiratory dysfunction due to inhalation of toxic dust and some have died due to environmental exposures to a myriad of toxic airborne substances, including asbestos, toxic combustion by-products and heavy metals. The tragedy also reveals that a large amount of responders  were not provided with NIOSH-approved respirators to afford emergency crews, recovery workers and site clean-up and remediation personnel adequate respiratory protection. Initially, of those who wore respirators 58% wore disposable dust masks that may have not been certified  by the National Institute for

Occupational safety and Health (NIOSH). In addition, a large psychological “footprint” was left010911-N-AV833-039 behind causing responders and others to suffer from the effects of traumatic stress. Post-traumatic stress disorder remains prevalent among responders to the 9/11 attacks. The losses among workers were also realized at the Pentagon, as well as the effects of traumatic stress and injuries suffered.

The post 9/11 bioterrorism attacks utilizing weaponized Bacillus Anthracis in October 2001 also were within the scope of OEM providers. In the anthrax attacks, nine workers developed inhalational anthrax disease, three of whom died and nine developed confirmed or suspected  cutaneous disease. Thousands more individuals potentially were exposed at work and were given prophylactic antibiotics. According to the Census of Occupational fatalities for 2001, deaths from the events of September 11 represent about one third of the occupational fatalities for 2001.

As the medical specialists “devoted to prevention and management of occupational and environmental injury, illness and disability ,and promotion of health and productivity of workers, their families, and communities”, OEM physicians, occupational health nurses and other related professionals contribute much to the prevention, preparedness, mitigation, response, community resiliency and recovery to both natural and man-made events. OEM providers and health and safety professionals have a critical role to play in the overall health and medical preparedness and response to terrorism events and technological disasters involving hazardous materials. OEM professionals have a key role in the discussion and planning process for potential terror attacks and technological hazards such as nuclear and chemical manufacturing facilities. Both sectors are extremely vulnerable to attack or catastrophic failures. Add the threat of cyberterrorism against these sectors, and you have an even stronger prescription for disaster.

In the workplace, for example, occupational and environmental health professionals can bio detectionaccess and interact with large numbers of employees in an organized and specific fashion to facilitate the accurate and appropriate dissemination of technically accurate medical information and risk communication. OEM professionals can provide expert consultative services on appropriate types and levels of personal protective equipment (PPE) for first responders, first receivers (health care personnel), public health stakeholders and employees in a wide range of occupational settings.

OEM providers and ancillary personnel are expert in assessing health risks and conducting environmental exposure assessments, as well as providing guidance on appropriate decontamination procedures .

Among the many ways that OEM providers and allied personnel can, and have contributed are:

  • Assisting responders to prepare
  • Collaboration with community emergency planning and preparedness efforts
  • Planning for bioterrorism and emerging infectious disesase outbreaks
  • Collaboration with public health stakeholders to prepare for chemical, radiological and nuclear accidents and terrorism
  • Educating and training the workforce,ie awareness or operational knowledge and skill sets
  • Occupational medical surveillance
  • Risk communication
  • Maintenance of occupational medical records
  • Selecting appropriate personal and facility protective equipment and countermeasures
  • Providing expertise on appropriate decontamination procedures
  • Providing rehabilitation during actual disaster events ,drills and exercises,eg.,maintaining and monitoring of hydration status

In many activities, including chemical surety/demilitarization and weapons decommissioning operations efforts world-wide, the OEM provider has unique expertise to protect the health and safety of workers assigned to these  occupational environments. Our biodefense capabilities pose a challenge to OEM professionals assigned the task of contributing their expertise in the field of biosafety. Indoor air quality issues  caused by CBRN agents or the contamination caused by technological disasters related to hazardous materials releases also are issues which must be addressed  from OEM  and health and safety perspectives.

The fields of occupational and environmental medicine and occupational and environmental sciences have grown in and the complex challenges faced by the providers and researchers in these fields continue to expand as our threats to homeland and global security increase. Bernadino Ramazzini and his predecessors would be proud to see that their astute observations and concepts developed into such an important medical and scientific field. Moreover, they would be humbled in knowing that their work would eventually lead to the health, safety and well-being of so many workers and communities and towards  preparedness and response  to CBRNE threats and technological disasters.


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Frank G. Rando possesses over 30 years of real world experience as a public safety professional,clinician, educator ,emergency and crisis manager ,author and consultant in the areas of tactical ,disaster and operational medicine, weapons and tactics, law enforcement /criminal investigations ,counterterrorism, hazardous materials management and emergency response ,toxicology, environmental safety and health,and health care and public health emergency management .