The attacks on America couldn't have come at a worse time for healthcare.

Since September 11 the threat of biological and chemical terrorism has put our entire country on high alert. It is no longer unthinkable that a biological or chemical attack could infect thousands and expose hundreds of thousands simultaneously in multiple locations.

It's also no secret that the scarcity of health care workers was getting worse over the past few years and these labor shortages were showing no signs of going away. Now with the real threat of bio-terrorism, many positions on the front lines of health care are unfilled and back-ups are virtually non-existent. As is the case with antibiotic and vaccine supplies, our health care system is short workers. Unlike antibiotics and vaccines, workers cannot be manufactured, trained, or replaced as easily or quickly.

Government and public health officials do not exude confidence when they speak about our ability to respond to a large, unannounced attack. Tommy Thompson, Secretary of Health and Human Services, in early October reported, "we have not been aggressive enough in preparing our country for bio-terrorism". A few days earlier Mohammad Akhter, Executive Director of the American Public Health Association, warned, "when it comes to a larger (biological) attack, then we are not prepared."

Mr. Akther then cited, or more appropriately indicted, our national and state health departments. The reality is that approximately ten percent of the health departments in the United States do not even have e-mail. If a bio-terrorist attack occurred on a Friday afternoon, Akhter reported to Congress, there would be no report of it until Monday morning under the current staffing profile of most health departments. Patients could be showing up in hospitals and doctors offices days before our health care providers have been notified of an exposure.

These public statements, like many others during recent weeks, intended to ease public fears have been focused on the identification of the biological agent, isolation of the exposure, and the availability of vaccines and antibiotics. Little attention, at least publicly, is being given to the growing need for more and more health care workers, while the incumbent workforce is increasingly dissatisfied with their jobs and leaving the profession at an alarming rate.

In the event of a bio-terrorist attack, emergency rooms will be inundated under an avalanche of infected or exposed people requiring treatment and healthy people demanding preventive medicines. As a result, there would be a surge in need for trained personnel who can diagnose and treat rare diseases, and also for isolation areas and rapid mobilization of special drugs and vaccines.

Even before the attacks, hospitals could barely address the volume of patients on an emergent basis. Reports of ambulances arriving at emergency rooms only to be diverted away due to overcrowding, and floors of hospitals being closed due to understaffing were becoming commonplace news since the late 1990' and past year.

But even if emergency rooms and health departments are optimized to handle the crush of people, there may be nowhere for infected or injured patients to go. Many hospitals are already frustrated by employee vacancies that exceed 20% and turnover rates are even higher. In a June 2001 American Hospital Association survey hospitals reported average vacancies of 9 percent in housekeeping and 11 percent for registered nurses.

Vacancies for laboratory technicians, who will be required to draw blood and analyze the results, were averaging 12 percent. The results of a 2001 Clinical Laboratory Management Association member survey showed that 64 percent of respondents did not have enough qualified personnel to staff their workload and 89 percent reported the number of new graduates in their region was insufficient.

Competing for top honors in the number of budgeted but unfilled positions are radiological technologists at 18 percent and pharmacists, who will be needed to prescribe the antidotes, antibiotics, and medicines, at 21 percent.

Shortages do not stop here but go right to the very top of hospitals. Industry analysts estimate there exists a 40% gap between the supply of healthcare executives talent pool and the demand for candidates to fill new positions and replace retiring leaders.

We're also approaching the winter season, a time when emergency rooms are normally filled to capacity with patients presenting with common respiratory infections and broken bones. Compound all of this with the financial implications of providing care to an increasing pool of uninsured due to recent layoffs, and our strained health care system is bending very close to its stress point.

An appropriate and adequate response for recruitment, retention and training efforts will require a lot of money and funding. But a key consequence of the Sept. 11 attacks has been the continued downturn in the stock market, which has drastically reduced non-operating revenue. Any deterioration of non-operating revenue directly reduces the hospitals' debt service coverage, 60% of which is produced from non-operating revenue, according to Fitch, the international bond rating agency.

So faced with understaffing, under-preparedness, and under-funding, our healthcare system is on the brink of attack while it is being called upon to defend us against what may be the largest scale hostile act on the American people in our history.

During this past summer and before September 11 Mary Anne Kelly, executive director of the American Society for Healthcare Human Resources Administration, acknowledged that "we have our work cut out for us", referring to the efforts her organization would need to make to win the war for talent. Her comments now appear to be a gross understatement of the situation.

Dr. Ira S. Wolfe is founder of Success Performance Solutions and President of Poised for the Future Company. Success Performance Solutions is a consulting firm, based in Leola, PA, specializing in matching, managing, motivating and retaining employees in many industries including healthcare extending from Pennsylvania to Hong Kong.