Discussion

It is clear from these results that few undergraduate medical students in the UK and the Republic of Ireland currently receive any teaching about biological weapons and bioterrorism. There may be some similarities to the situation that has already been recognised at the United Nations level with respect to the wider scientific research community, namely that there are widespread deficiencies in the education of scientists, including life scientists, with respect to their background knowledge about and understanding of bioterrorism and biowarfare and how scientific research into this field might lead to adverse consequences.21

The importance of recognising such diseases in the field has been acknowledged in the UK. For example, in 2001, a UK Parliament document stated that ‘Some diseases occur so infrequently in nature that the appearance of just one case may be suggestive of deliberate release’ and went on to say that ‘UK clinicians are also being alerted to watch out for tell-tale symptoms and presentations’.23

This is because if genuine instances of bioterrorism are not identified as soon as possible, valuable time is lost that might help to ensure that the overall impact of such incidents is minimised and possible repeat events prevented.

However, the first place where persons suffering from the effects of biological weapons are likely to interact with doctors is in accident and emergency departments or primary care, and the doctors who initially encounter such persons in those settings may be likely to be relatively junior or may have spent only a short time training within specialist hospital settings.13 Furthermore, there is currently little evidence of any research in the literature exploring whether or not more senior doctors have had any training in this field since qualifying.

Accordingly, if one was to wish to ensure that the highest possible proportion of qualified doctors working in the UK or the Republic of Ireland have acquired at least a basic knowledge of biological weapons, bioterrorism and related matters by the time they start working as doctors with the public and to avoid a knowledge vacuum in this area, the only way this could be guaranteed would be for there to be some teaching incorporated into the undergraduate curriculum.

Leaving such training entirely to the postgraduate stages, unless it is mandatory and robustly enforced, means that a significant number of medical graduates may never receive any training about biological weapons and bioterrorism, which in turn may seriously hamper their abilities to recognise such events for what they are as early as they might be and alert the appropriate authorities. There exists evidence from British accident and emergency departments that postgraduate training and preparedness in this field is currently not as strong as it could be.13

Unlike in the USA, to date, very little research has been undertaken on this subject in the UK and Ireland, and the teams are very grateful to those colleagues at the 34 medical schools (34/38—89.47%—of those approached) who completed the questionnaire, whether identifiable or anonymous. We have no knowledge as to why four of the organisations approached did not wish to participate.

Duplicate responses seem unlikely. Virtually, all schools of medicine that chose to respond were happy to provide the name of their organisation, and only two chose to remain anonymous. Given that situation, even if there were to be any duplicate responses, their overall impact on the results would be small.

The issue of whether or not there could have been any ambiguity in the questionnaire leading to confusion among respondents must be considered.

Questions 1, 2, 7, 8 and 9 are very clear in their intent and virtually all respondents provided answers.

In the case of question 3, five respondents gave no answer, which, given the clarity of the wording of the question, suggests that, at the time of answering, they did not know if there were any plans in place, an option which was not given to them, while they had elected not to make further enquiries within their own medical school in order to establish if there were any such plans in place or not—as if they had, one would have anticipated that they would have been able to provide a yes-or-no answer. It is not known why respondents would not have sought to establish the internal situation within their own organisation more clearly rather than failing to provide an answer.

Eleven respondents provided answers to question 4, which is of interest as only six had stated in question 2 that they provided some specific teaching on bioterrorism and just four had answered in question 3 that there were plans in place to introduce some teaching. These are two main interpretations for this. First, it is possible that when they came to question 4, while some respondents may have recognised that their own institutions actually did provide some teaching that was relevant to the specific areas listed, it was not currently considered to be part of any specific teaching on bioterrorism, but was instead a component of other areas of teaching, for example, the clinical syndrome caused by anthrax and/or the microbiological aspects of anthrax might be taught as part of mainstream clinical medicine. Second, it is possible that some respondents answering question 4 were answering having given a yes answer either to question 2 (‘Does the undergraduate medical curriculum at your university include any specific teaching on bioterrorism?’) or to question 3 (‘If no (to question 2)—are there any plans to introduce any specific teaching on bioterrorism?’). That said, and whatever answers had been given to questions 2 and 3, only 11 respondents had subsequently chosen to provide an answer, and the answers given indicate that at the present time only a small minority of the UK and Ireland's medical schools currently cover any of the specific areas of knowledge enquired about.

Questions 5 and 6 attempted to establish if medical schools had appropriately qualified persons on their staff to deliver teaching on biological weapons and bioterrorism. Whatever be their prior answers, only seven respondents answered in the affirmative that they had such persons on their staff, and only seven gave any information regarding the specific academic areas in which their organisations did possess such expertise. It is possible that some respondents did not possess adequate knowledge about the range of activities within their own organisations to be able to provide answers regarding the information requested—if this was the case with some, it is not known why they chose not to seek out the necessary information. Also, it is possible that some medical schools currently possess absolutely no expertise whatsoever in some, and even all, of the specific areas enquired about. Furthermore, it should be borne in mind that even if an individual medical school did not currently provide any teaching about biological weapons and bioterrorism to its undergraduate students, and even if they had no plans at the present time to introduce any, this does not necessarily mean that there would not be any persons among their staff who do possess knowledge of the relevant areas. Overall, it seems clear that most UK and Irish medical schools currently do not possess high levels of expertise in these fields of study among their staff.

Of relevance to this work is understanding why topics relevant to biological weapons and bioterrorism are not currently taught, and the free text responses provide some insights into the possible reasons why this might be the case. Free text responses from the UK make it clear that one of the major reasons for not including bioterrorism in their courses is because it is not included in ‘Tomorrow's Doctors’, the 2009 recommendations of the UK's General Medical Council (GMC) for what should be included in degree courses.24 Of note is that other documents of relevance emanating from the UK or Irish governments and quangos, the European Union, the United Nations and papers describing North American experience are not mentioned in the free text responses, the implication of this being that it may be possible that other documents looking at this same issue but from different perspectives might not have been considered. Other reasons given for not incorporating these topics into courses include the relative rarity of such events, a lack of time and a view that it is a postgraduate subject and not appropriate for undergraduates. Some responses state that they plan to look again at whether or not the subject should be included.

The results of this survey reveal that at the moment most UK and Irish medical schools spend relatively little time teaching medical students about this area of knowledge, and many do not provide any teaching at all. Furthermore, any period of time that is allocated to teaching would cover mainly the clinical and laboratory elements, rather than contextualising this area of healthcare needs by providing teaching on the ethical, social, legal and political dimensions. Furthermore, many medical schools stated that they did not have members of staff with particular expertise in fields associated with the use of biological weapons and bioterrorism, a finding that has clear implications not only for teaching but also for research in this field.

Furthermore, it is clear that although UK medical schools have considerable freedom to decide what to include within their undergraduate medical curricula, at present many do not appear to look too far beyond ‘Tomorrow's Doctors’, the 2009 recommendations of the UK's GMC,24 which currently do not give any consideration to any aspect of terrorism although, interestingly, some medical schools stated in their free text responses that they had been prompted by this survey to look again at the issue.

In the Republic of Ireland, the submitted responses reveal that of the six medical schools, two included quite substantial teaching on biological weapons and bioterrorism but the others do not do so. At least one Irish medical school stated in their free text responses that they had been prompted by receiving this survey to look at this issue.

The world is not becoming a safer place—Harrison and Wolf25 have calculated that between 1870 and 2001, the frequency of wars between states increased steadily by 2% a year on average, and in the 1990s the frequency of wars between states rose by 36% per year, while since 9/11 terrorist attacks have continued to be common and widespread around the world.26 While Parliament in the UK in 2001 expressed concern over the potential for a terrorist attack using biological weapons,24 and in 2003 the Chief Medical Officer for England and Wales endorsed the need to ensure that the country possessed effective means to address the risks associated with biological agents,12 the United Nations still felt it important to repeat similar warnings in 2012.27 Given that UK and Irish medical schools do not just train doctors for the UK and Ireland, maintaining a broad international perspective would seem important.

As things stand, while acknowledging the many demands placed on undergraduate schools of medicine when it comes to formulating an effective curriculum, in the biological weaponry and bioterrorism field, many medical schools in the UK and the Republic of Ireland are not currently contributing significantly to the formal knowledge acquisition process among their undergraduates. Accordingly, if concerns still exist at the national governmental and supragovernmental levels, it may be wise for this matter to be revisited and examined by the relevant agencies, such as the GMC and the HSE (Ireland),14 and any gaps in teaching skills, research activity and funding that cause concern identified and remedied.

Furthermore, in 2003, the Chief Medical Officer for England and Wales also highlighted the importance of ensuring that the country has the means to deal effectively with the risks posed by chemical and radiation hazards,12 and the widespread absence of teaching time spent on weaponised chemicals and the use of radiation as a weapon suggest that the situation may be similar to bioterrorism, although more work would be needed to establish the present overall situation.

With respect to the strengths of this work, this is the first study in either the UK or the Republic of Ireland to look at this issue, and the response rate was very high. The main limitation is that not all medical schools provided responses to all the questions posed, and the reasons for this are currently not known.

The survey provides sufficient data to indicate that more in-depth studies are warranted to establish more clearly if it is in the best interests of the public and patients for clinicians to be receiving at least some teaching about biological weapons and other WMD at undergraduate level, or if keeping the current system of leaving such training until the postgraduate stages of training is the most effective option. In addition, while many researchers joining the WMD research community (of whom a proportion will be medically-trained clinicians) enter it at the Masters and Doctorate levels, the aforementioned high-level concerns reported regarding the existing deficiencies in the education of researchers with respect to their background knowledge about and the understanding of bioterrorism and biowarfare, and how the research into this field is undertaken and the results disseminated21 indicate that research designed to determine the best stages in researchers’ careers to introduce more training about and deeper insights into the broader issues surrounding WMD, as well as to monitor the efficacy of such training, would be valuable. For example, it may be that earlier, improved and augmented training of all medically trained individuals working within research teams engaged in studying WMD-related topics represents one way of improving on what is considered by some to be the currently unacceptable situation.