The Nightmare of Bioterrorism

TOOLS IN HAND

As the twenty-first century begins, the following nations possess biological weapons: Iraq, Iran, Syria, Libya, China, North Korea, Russia, Israel, Taiwan, and possibly Sudan, India, Pakistan, and Kazakhstan. The list cuts across lines of ideology, politics, and geography. In addition, according to intelligence sources in Europe and the United States, militant political groups across the globe are now developing or seeking to purchase biological weapons for terrorist use.

Meanwhile, the sophistication of biological weaponry has improved by leaps and bounds. Until 1985, all of the world's biological-weapons makers were stuck with the same list of pathogens and toxins that could kill thousands of enemies and be delivered with missiles or large-scale aerosol systems. Each nation knew the list and stocked antidotes and vaccines. It was a standoff.

But biology in the last decade has been what physics was in the 1940s and 1950s: a field of exponential discovery. What seemed impossible in 1980 was accomplished by 1990 and, by 2000, had become ho-hum fodder for high school biology classes. By the late 1990s, a massive pool of bioengineers, equipped with genetic blueprints to guide their efforts, had emerged. Determining the genetic sequence of a virus, such as Ebola, was no longer much of a feat. In 1998, scientists at the Frederick Cancer Research Center in Maryland determined, at the genetic level, exactly how anthrax kills human cells.

In response to such advances, Western militaries hardened their defenses against biological warfare as they vaccinated troops, stockpiled antitoxins, stored appropriate antibiotics, purchased protective suits and masks, practiced war-game drills involving biological weapons, and supported research on potential microbe-detecting devices. But no one had a master plan for dealing with the collateral impact of biological weapons on civilians located around the combat zone -- or the deliberate impact of bioterrorist damage inflicted on an unsuspecting community. Were a terrorist to disperse the smallpox virus, for example, populations that were once universally vaccinated would now be horribly vulnerable. Today the U.S. government stows only about 15.4 million doses of the smallpox vaccine -- enough for less than seven percent of the American population. The World Health Organization (WHO) keeps another 500,000 doses in the Netherlands, and other national stockpiles total about 60 million more doses of varying quality and potency. If the smallpox virus were released today, the majority of the world's population would be defenseless, and given the virus' 30 percent kill rate, nearly two billion people could die.

The picture worsened in 1999, when scientists discovered that the U.S. samples of the smallpox vaccine had severely deteriorated. Originally made in the 1970s by the Wyeth pharmaceutical company, the samples were stored at the Centers for Disease Control and Prevention (CDC) in Atlanta in the form of freeze-dried crystals parceled out in 100-dose quantities inside vacuum-sealed glass tubes. The tubes were further sealed with rubber stoppers secured by metal clamps. To their dismay, CDC investigators discovered condensation in many of the glass tubes, indicating that the rubber stoppers had decayed and vacuum pressure had been lost. Such vaccine supplies can no longer be considered safe for human use. Although the rest of the world's vaccine reserves have not undergone similar scrutiny, experts do not have much confidence in those either. Furthermore, the world's supplies of bifurcated needles -- uniquely designed for scratch-administering the smallpox vaccine on human skin -- have been depleted, and companies are no longer interested in manufacturing such specialized devices.

The world is thus completely vulnerable to a smallpox attack. The last time a mass emergency vaccination took place in the United States was 1947, when a traveler from Mexico spread smallpox to New York City. Vaccines were then readily available, and 6.35 million New Yorkers were immunized in less than four weeks. In 1961, a similar vaccination campaign was administered following a smallpox outbreak in England: 5.5 million people were immunized in a month's time. A decade later, smallpox cases in Yugoslavia prompted the rapid vaccination of 20 million people in that country. Were a smallpox crisis to emerge today, none of these efforts could be repeated.

LETHAL LAG TIME

Even if large stockpiles of the smallpox vaccine could be collected immediately, they would be of limited value for two reasons: only several days after infection would individuals develop recognizable symptoms, by which time thousands -- even millions -- would have been exposed; and only several days or weeks after vaccination would individuals develop sufficient antibodies to stave off infection.

For other diseases preventable by vaccine, such as anthrax, the lag time between inoculation and the development of powerful antibodies could be far longer -- up to a year, even with boosters. And of course, immunization efforts would be useless against vaccine-resistant pathogens, such as those created by Soviet scientists working on anthrax weapons. Furthermore, a determined bioterrorist could simply try a succession of microbial weapons -- or use a cocktail at the outset -- defying even the best-organized vaccination programs.

The cost of a delayed response to an anthrax attack would be staggering, explains CDC economist Martin Meltzer: in a model city of 100,000 people, the number of "deaths is 5,000 if you start [a vaccination program] on day one [after the attack], versus 35,000 on day six." Cities large and small, then, should start stockpiling relevant antibiotics, vaccines, and general medical supplies.

But even if cities were well equipped for a bioterrorist attack, they would still have a difficult time recognizing that such an attack had occurred. Local authorities "probably aren't going to be able to recognize it has happened ... until the incubation period is over," says Clark Staten, executive director of the Emergency Response and Research Institute in Chicago. "And by then, you've got it spread over a wide area. And it may take longer to recognize there's a pattern going on."

Once an outbreak is recognized, an epidemiologist would be dispatched to identify the cause. If the pathogen were fairly common, like Clostridium botulinum (the bacterium that causes botulism, a fatal food poisoning), local hospital laboratories could probably identify the culprit first. But if the microbe were rare, like those that cause anthrax, Q fever, Ebola, smallpox, or plague, local facilities would probably be unable to diagnose the problem. With precious time passing, people dying, and disease possibly spreading, local officials would then await word from the diagnostic labs at the CDC. If the suspected pathogen were highly deadly, like the smallpox virus, the analysis would be handled in the CDC's Special Pathogens laboratory, which is normally staffed by fewer than a dozen highly specialized scientists. And during a crisis, it would be difficult to find qualified supplementary staff to scale up operations. During the 1995 Ebola outbreak in Zaire, for example, the lab was staffed by a mere six scientists WHO toiled around the clock trying to identify the presence of the lethal virus in some 30,000 tissue, blood, plant, insect, and animal samples. In the case of a bioterrorist attack, valuable time -- and lives -- might be lost during such an arduous process.

In a large urban center, the true costs of a bioterrorist attack might be the consequences of panic, such as a stock market collapse in New York or a commodities market crash in Chicago. At a 1998 Senate hearing on bioterrorism, then Minnesota State Epidemiologist Michael Osterholm warned against underestimating the degree of panic such an event would provoke:

[A] single case of meningitis in a local high school causes enough fear and panic to bring down a whole community. ... Now imagine you're telling people, "This is going to unfold for eight weeks, and I can't tell you if you're going to die." And with every symptom ... real or imagined, [people are] going to think, "I've got it! I'm going to die!"

A TELLING SCENARIO

In February 1999, the Johns Hopkins Center for Civilian Defense Studies enacted an elaborate bioterrorist scenario in Crystal City, Virginia. The details played out over a tense eight-hour period in a room packed with public health, military, and law enforcement personnel. Under the scenario, the vice president of the United States makes a speech at a prestigious university located in a fictional town dubbed Northeast. It's April 1. Eleven days later, a 20-year-old student who attended the vice president's speech shows up in the university hospital's emergency room with flu-like symptoms: high fever, muscle aches, fatigue, headache. She is sent home with aspirin and the old maxim: get some rest and drink plenty of fluids.

Two days later, the young woman returns to the hospital, now fighting for her life. And a janitor who cleaned up after the vice president's speech turns up with the same symptoms. By six o'clock that night, April 13, the hospital's infectious disease expert gingerly voices an outrageous conclusion: both patients have smallpox.

Since smallpox was officially eradicated in 1977, and remaining samples of the virus exist only in Atlanta and Siberia under lock and key, there can be but one conclusion: someone has stolen laboratory samples of the virus and deliberately released them in a bioterrorist attack aimed at the vice president of the United States.

Under this scenario, more than 15,000 people die of smallpox worldwide within two months, and epidemics rage out of control in 14 nations. All global supplies of the smallpox vaccine are depleted, and it will take years to manufacture enough to save humanity. The global economy teeters on the brink of collapse as nations close their borders and sink into isolation, barring all Americans from entering their countries. In the city of Northeast, utter chaos reigns, and the National Guard enforces martial law over the city's two million residents. Similarly, government authority either breaks down or reverts to military-style control in cities all over the world as smallpox claims lives and pits terrified citizens against one another. Meanwhile, back in Northeast, a top smallpox expert scribbles projections on the back of an envelope and gently slides it in front of the state governor: within 12 months 80 million people worldwide will be dead.

"We blew it," declared California's top public health scientist, Michael Ascher, commenting on the fictional scenario. "It clearly got out of control. Whatever planning we had ... didn't work. I think this is the harsh reality [of] what would happen."

BUDDING BIOTERRORISTS

Although most people remain ignorant of the issues raised in that scenario, handfuls of Internet-hooked extremists, right-wing militia members, psychologically imbalanced belligerents, and postmodern fascists are well versed in the fine points of bioterrorism. Recipes for producing botulinum and anthrax are posted on the Web. Books describing biological-warfare assassination techniques are readily available. Some private militia groups train to use biological weapons.

Indeed, law enforcement leaders claim that religious cults and militant political groups are likely to engage in biological terrorism. After all, they argue, the first bioterrorist attack in America was carried out by members of an Oregon-based religious cult led by Bagwan Shree Rajneesh. The cult members, hoping to disrupt an upcoming county election, contaminated local salad bars with salmonella, infecting hundreds of Oregonians.

Perhaps it is the tone of some militants' rhetoric that sparks the most concern. In The Poisoner's Handbook, for example, Maxwell Hutchkinson suggests that readers poison or kill Internal Revenue Service workers by filling out phony tax-return forms and lacing them with a mixture of ricin (a poisonous protein) and dimethylsulfoxide (DMSO) -- a concoction Hutchkinson claims is 100 percent lethal. "The purpose of all this is to disrupt the operations" of the IRS, Hutchkinson writes. "If done on a large enough scale, it would serve two purposes -- it would make it more difficult for the IRS to operate efficiently, thus helping tax cheats and tax protesters. It might also awaken the politicians to the depth of resentment felt by the taxpaying public."

Fortunately, Hutchkinson is a lousy chemist: only simple chemicals -- not proteins such as ricin -- can dissolve in DMSO. But the depth of Hutchkinson's antagonism is unmistakable: he suggests that readers kill Catholics by soaking their rosary beads in Phytotoxin abrin, a toxin derived from a rare bean; he writes that botulinum is "fun and easy to make"; and he urges survivalists around the world to hone their skills, readying themselves for biological warfare in the coming Armageddon.

RAISING THE BAR

In response to such threats, Congress has passed a number of laws aimed at making it harder for anyone -- domestic or foreign -- to attack America with biological weapons. In 1989, Congress passed the Biological Weapons Act, outlawing the possession, trade, sale, or manufacture of a biological substance "for use as a weapon." In 1991, it enacted an embargo, soon enforced against Iraq, barring U.S. companies from trading with countries believed to be developing biological weapons. After the 1995 Oklahoma City bombing, Congress passed the Anti-Terrorism Act of 1996, allowing federal authorities to arrest anyone WHO even "threatens" to develop or use biological weapons. And the following year, by order of Congress, the CDC named 24 infectious organisms and 12 toxins as "restricted agents," the use or possession of which requires a federal permit. Although these measures now provide legal instruments for federal law enforcement officials, it is impossible to judge how effectively they have, or have not, deterred biological terrorism.

The Clinton administration hoped to stave off the worst threats by training the National Guard and local hazardous-material defense teams to rapidly respond to bioterrorist attacks. But the teams, comprising elite local police squads and fire department personnel, handled chemical and biological threats as if they were roughly synonymous -- a fatal mistake, according to biologists. Having been trained in classical techniques for limiting the spread of lethal chemicals, the defense teams assumed that a visible source of contamination could be identified, that exposed individuals could be isolated, and that a toxin could be swiftly cleared out of the environment with water or neutralizing chemicals. None of these assumptions holds true for lethal microbes, biologists argue, because their long incubation periods in potentially contagious human beings render it nearly impossible to identify and contain a source. Furthermore, "washing" an area contaminated with pathogens might only spread them.

Congress has sought technological solutions as well, allocating money for Department of Defense (DOD) research on devices that might sniff out bugs and sanitize contaminated areas. First in line was the Navy's TagMan, a sophisticated gene scanner that could, in less than half an hour, determine whether a liquid sample contained any of several known pathogens. But the system had significant limitations: weighing 300 pounds, it was hardly portable. And it could not detect pathogens of high "biohazard levels" -- precisely the most worrisome microbes. Most significant, the device could not analyze air samples.

In 1998, Congress also gave the DOD's Defense Advanced Research Projects Agency (DARPA) $2 billion to sponsor wild and crazy science projects -- ideas so far-out that standard civilian funding sources would not consider them. These projects included $61.6 million of bioweapons defense efforts, the foremost of which was the development of a fast, cheap, safe, and portable way to sample air for the presence of nasty pathogens. Most of the research focused on unique genetic attributes of bacteria and viruses.

One project involved trying to grow human nerve cells on microscopic chips that would change color or light up if they detected a neurotoxin, such as botulinum. Several laboratories -- notably the Argonne National Laboratory in Chicago -- tried to develop chips lined with thousands of pieces of bacterial DNA to serve as probes. Argonne's goal was to build a bacteria detector small enough to be handheld, akin to a police radar gun. But research director Eli Huberman said such a device "is years away from mass production or for widespread use." Furthermore, neither Argonne nor any other research group envisioned sampling the air for viruses. Even DARPA's wild thinkers could not imagine how that could be done.

Even the simplest technological defense against biological weapons has proven to be too much for DOD contractors. In the spring of 2000, DOD officials revealed that the protective suits U.S. troops had relied on during the Persian Gulf War (and that still form the basis of soldiers' defense against deadly microbes) were defective. At least five percent of the 900,000 suits the DOD had purchased during the 1990s were useless, and the reliability of the entire inventory was suspect.

It seems unlikely, then, that a technological quick fix will soon be found. The three immediate American responses to bioterrorism -- military defense, hazardous-material defense teams, and high-technology sensors -- appear to be seriously flawed.

WHO'S IN CHARGE?

Consider this hypothetical scenario: the Red Army terrorist group successfully releases drug-resistant anthrax spores in the Bourse station of the Paris Metro at 8:00 am on a warm Wednesday in June. What would be the role of the French military, Sureté (the French intelligence service), the Paris police, or any number of high-tech sensory devices? None.

The most important responders would not be the military or law enforcement officials. They would be the doctors, epidemiologists, ambulance drivers, nurses, and bureaucrats of the Paris public health system. It is they who would note -- days after the actual attack -- that large numbers of Parisians appeared to be ill, suffering similar symptoms. With further questioning they would perhaps realize that all the ailing individuals routinely took the same Metro train or stopped at the same station. Whether or not anyone would ever discover that terrorists had sprayed a lethal biological mist in the Bourse Metro station, it would be the public health workers who would track down and treat the patients, dispense appropriate drugs, determine whether the outbreak was spreading from the Bourse source, and analyze the microorganism for any special attributes.

Yet military-like responses have dominated Western government thinking, sparking recent outcries among defenders of civil liberties. During role-playing episodes in 1998-99, the DOD claimed the right to seize command during a bioterrorist attack -- a constitutionally shaky move. And on February 1, 1999, Defense Secretary William Cohen announced the creation of a special command within the DOD designed to coordinate responses to domestic bioterrorist attacks. Cohen's plans echoed the popular 1995 movie Outbreak, in which the U.S. Army declared martial law and took full control of an American city to limit the spread of an airborne form of the Ebola virus. Civil-liberties advocates responded to Cohen's announcement with indignation: Such a clear violation of the Constitution might be OK for Hollywood, they cried, but not for the real world.

President Clinton had tried to obviate such worries in his January 22, 1998, speech to the National Academy of Sciences. "We will be aggressive," he said, referring to his administration's response to the bioterrorist threat. "At the same time ... we will remain committed to uphold privacy rights and other constitutional protections, as well as the proprietary rights of American businesses. It is essential that we do not undermine liberty in the name of liberty." That day Clinton requested congressional approval of a $10 billion antiterrorism program, including $86 million for improving public health surveillance, $43 million for research on vaccines for anthrax, smallpox, and other potential bioweapons agents, and $300 million for stockpiles of essential drugs and vaccines. The proposed expenditures doubled the previous year's bioterrorism budget.

The job of building the nation's drug and vaccine warehouse fell to Margaret Hamburg, assistant secretary for the U.S. Department of Health and Human Services. She had to race to catch up with the DOD and the FBI. Public health was a late entrant to the bioterrorism field, she said, and significant dangers lurked in the developing antiterrorist infrastructure. Beyond the civil liberties issues that had already been voiced, Hamburg warned, "we don't want public health to be identified with the CIA and FBI activities. ... We in public health need to have public trust and confidence."

Already, local public health departments were having a hard time responding to fake bioterrorist attacks. Claiming to have dropped off or shipped an anthrax-containing device suddenly became chic at the turn of the millennium. Terrorism expert Jessica Stern counted 47 such hoaxes in the United States since 1992. In all 47 cases, local fire and police authorities reacted seriously, decontaminating thousands of people and appearing on the scenes dressed in full-body protection suits. And Stern's list was by no means comprehensive.

Secretary of the Navy Richard Danzig warned that panic, in and of itself, is becoming the new terrorist tool. "Only through a new union of our public health, police, and military resources," he said, "can we hope to deal with this dangerous threat." But Hamburg worried that the police and FBI responses actually encourage such false alarms. It seems that bioterrorist hoaxes attract the type of individuals WHO enjoy watching fire departments douse buildings they have set afire. "When an envelope comes in saying 'This is anthrax,' we don't need the fire department in full protective gear on site," Hamburg insists. "What we need is to discreetly move the envelope to a public health laboratory for proper analysis. Mass decontamination and quarantine only [add] fuel to the fire of the hoax perpetrators, and it's totally unnecessary in terms of public health."

DIFFERENT DRUMMERS

It is obvious that public health, law enforcement, and defense officials have very different priorities in the event of a bioterrorist attack. For public health workers, the paramount concerns are limiting the spread of infection, identifying the cause of the disease, and if possible, treating and vaccinating the public. Law enforcement agents, however, are in the business of stopping and solving crimes -- and the scene of any bioterrorist incident is, first and foremost, a source of evidence. Managing a response to an outbreak thus poses a conflict of interest, since the police and the FBI would, by mandate, focus on detaining witnesses and obtaining evidence, even if those efforts ran counter to public health needs.

Even within the military itself, priorities blur when it comes to bioterrorism. The DOD's primary mission is to protect the United States against military foes. A secondary concern is to defend the health of American troops. How those priorities square with intervening -- and indeed, commanding -- responses to domestic bioterrorist attacks is not at all clear.

What is even less clear is how a public health system can respond to bioterrorism without destroying the basis of its credibility. When a public health system needs to intrude on individuals' lives to protect the larger community, it does so in limited ways and usually under the hard-and-fast promise of confidentiality. During an epidemic, for example, individuals may be asked to submit to blood tests and medical exams, and their medical charts may be scrutinized -- but all under the promise of confidentiality. In the long term, a public health system protects the community by monitoring disease trends, which requires tracking who has which diseases. Again, this information is generally stored under confidential or anonymous terms. On a global level, the WHO and a variety of other groups keep count of nations' diseases, monitoring for the emergence of new epidemics. After the 1995 Ebola outbreak in Zaire, for example, the WHO sought to create a more rigorous surveillance system and pushed countries to be more open about epidemics in their populations.

All of these functions, in all tiers of public health systems, require the maintenance of a crucial social contract: the individual or country agrees to openly disclose information for the sake of the larger community's health. In return, public health authorities promise never to abuse this trust, maintaining discretion and protecting patient privacy.

But the fear of bioterrorism threatens to destroy that vital social contract, which is not shared by law enforcement and defense officials. The closer a public health system draws to the other two systems, the greater the danger that it will lose credibility in the eyes of the public. Indeed, suspicions already run high in many American minority communities, prompting widespread belief that such microbes as the aids virus were created by the U.S. Public Health Service, the National Institutes of Health, or the CIA with the intention of obliterating key minority populations.

Some public health advocates are convinced that no marriage between their profession and law enforcement could ever work and have denounced all efforts to heighten concerns about bioterrorism. One prestigious group argues that "bioterrorist initiative programs are strongly reminiscent of the civil defense programs promoted by the U.S. government during the Cold War ... [that fostered] the delusion that nuclear war was survivable."

For many older public health leaders, the bioterrorism scare evokes nasty memories of Cold War cover-ups and censorship. By adopting the bioterrorism issue, they warn, public health officials are buying into a similar framework of paranoid thinking. Indeed, in 1999, biologists working in national laboratories found, for the first time, their work facing censorship in the wake of allegations of Chinese espionage at the Los Alamos National Laboratory. The Department of Energy (DOE), which oversees the national labs, clamped down so hard in 1999 that the National Academy of Sciences warned that the future of U.S. scientific enterprise could be imperiled. Although the DOE's primary concern was computer and nuclear secrecy, the threat of bioterrorism prompted the agency to broaden its new security restrictions to embrace basic biology research as well.

Many advocates argue that the public health system's role in the fight against bioterrorism can be comfortable only if it is an equal partner of the law enforcement and defense communities. One of the loudest voices speaking on behalf of public health in this regard is Michael Osterholm. In his new book, Living Terrors, Osterholm argues that "the overuse of the term 'weapons of mass destruction' (WMD) has done a great deal to stunt the necessary attention to the looming threat of biological terrorism." The WMD terminology places defense against bioterrorism in the hands of the military and the police, Osterholm insists. And that means, he says, "our priorities are really screwed up."

Osterholm's proposed solutions go to the heart of a larger public health agenda: to enhance the readiness and capacities of local, state, and federal health departments for responding to both natural and deliberately created epidemics. After all, Osterholm argues, it is impossible to tell at its outset whether an epidemic is a natural or ghoulishly unnatural event.

The new administration must work out these tensions among public health, law enforcement, and military authorities. The Clinton administration offered a broader definition of national security, bringing emerging infectious diseases and the aids pandemic under the security umbrella. That allowed agencies more traditionally concerned with terrorism, such as the National Security Council, the CIA, and the FBI, into the public health arena. A new administration may seek to redefine national security in more classic nation-state terms, or to sharpen the public health focus on diseases that directly affect terrorism and warfare. The future balance of authority and influence in the fight against bioterrorism will undoubtedly hinge on a new administration's larger view of national security.

Public health's role in the bioterrorism issue will also be better defined when its leaders come up with a clear consensus on what exactly they want. The issue is so new to most public health officials and raises so many uncomfortable questions that the profession is currently unable to speak with a clear, united voice. In contrast, the law enforcement and military communities appear comparatively determined and direct in their views of the bioterrorism threat and their desired responses to it.

In a historic speech in Atlanta during the winter of 1998, D. A. Henderson, head of Johns Hopkins University's Working Group on Civilian Biodefense, beckoned public health officials to jump on board a train already in motion, conducted by the law enforcement and defense communities. Less than a year later, public health had boarded the train, but only as a passenger. The train was fueled by an $8.4 billion budget in fiscal year 2000, yet public health was allotted a mere 3.7 percent of those funds, according to a recent study by the Stimson Center in Washington, D.C. With such comparatively paltry funding, it is no wonder that public health found itself sitting at the back of the train, watching the scenery race by as other government players steered the locomotive's course. Unless this changes, the train is going to crash.