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November 9, 2001 Bioterror exposes cracks in public health system

By Katherine McIntire Peters

From the December 2001 issue of Government Executive.

When a group of Mongol invaders besieged a Genoese trading colony on the Black Sea in 1346, they devised an ingenious way to clear the city. They lobbed the corpses of plague victims over the city walls, unleashing destruction far beyond the range of their catapults. The Genoese lucky enough to escape by sea to Sicily brought the deadly plague bacteria with them. Before the decade ended, the Black Death, which had already ravaged China and the Middle East, swept across Europe, killing as much as half the population.

When historians look back on the emergence of inhalation anthrax as a weapon in the fall of 2001, they won’t see an anomaly, but rather the continuation of a pattern. The history of warfare and the history of disease are intertwined. A century after the Black Death ravaged Europe, smallpox, spread innocently at first but later with deliberation, played a pivotal role in the European conquest of the New World, killing 80 percent of the indigenous population in some areas. During World War II, Japan used biological weapons against a dozen Chinese cities, killing an estimated 10,000 people.

Anthony Cordesman, an expert on terrorism and biological warfare at the Center for Strategic and International Studies in Washington, says the anthrax attacks on Americans that started in October shouldn’t be particularly surprising. “It’s certainly dramatic that we’ve come under biological attack for the first time. It’s dramatic that it has been sustained and that the targeting has been well-chosen and sequential, so that there has been a steady cumulative buildup in the impact. But it’s difficult to say some new threshold has been crossed.”

What is clear, Cordesman says, is that the United States is not well prepared to deal with the consequences of terrorism involving biological agents. “This isn’t a contingency anymore, it’s a reality. We have to plan for that and we have to have a serious defense and response capability. That’s very different from dealing with this as something that might happen.”

The daunting nature of defending against and coping with a germ attack is obvious. In early October, after a Florida man died of anthrax and it became clear that others in New York and Washington had been exposed to the deadly bacteria, government officials were caught off guard by the overwhelming demands of the outbreak. The news media and the public had an insatiable appetite for information, and when government officials couldn’t provide it, plenty of “experts” were standing by to fill the gap. The result was a proliferation of conflicting and often erroneous information, some of it put out by government officials themselves. Laboratory scientists began operating around the clock in a valiant effort to keep pace with the growing demand for anthrax tests. Doctors prescribed antibiotics for thousands of Americans, sometimes as much to ease panic as to protect against the threat of anthrax.

Adding significantly to the stress and confusion was the fact that much of what officials thought they knew about how anthrax is spread and how it affects human health was based on research done years ago under very different circumstances. The infection of photo editor Robert Stevens in Florida was the first case of inhalation anthrax in the United States in 25 years. Health and Human Services Secretary Tommy Thompson publicly declared the case was “isolated,” and speculated that Stevens had contracted it drinking from a stream—information that quickly proved false. Likewise, just days before two postal workers in Washington died of the disease, experts at the Centers for Disease Control and Prevention said that anthrax spores found in a letter to Senate Majority Leader Tom Daschle, D-S.D., posed so little threat to postal workers they did not need to be tested for the disease.

Retired Gen. Dennis Reimer, former chief of staff of the Army and now the director of the Oklahoma City Memorial Institute for the Prevention of Terrorism, says the learning curve is steep when it comes to bioterrorism, and public officials need to be very careful about what they present as fact. “The American people will stay with the government while [officials] are working their way through some tough problems, if we say we don’t know the answer yet. Where you start to get into trouble is where you say one thing and it turns out to be another. This whole thing about communicating with the American people is a very big issue. The challenge the government faces is how do you communicate the seriousness of the event without causing panic. We haven’t had a lot of experience with that.”

But as shocked and outraged as government officials are over the anthrax threat, many privately say the situation could have been much worse. As awful as anthrax is, it is not contagious. If it is diagnosed early enough, it is treatable. Many experts fear the future will bring far worse incidents of bioterrorism, and they worry that federal agencies, state and local health officials and ordinary Americans won’t be prepared.

Growing Threat

Biological agents—the bacteria, viruses and toxins that are the building blocks of disease—have a long and uneven history as weapons. They are notoriously deadly, potentially more so than nuclear weapons. They are relatively easy to obtain—hundreds of laboratories around the world have inventories of deadly pathogens. And compared to other weapons designed to kill masses of people, biological weapons are inexpensive to produce. But they are difficult to deploy reliably. Stabilizing biological agents and deploying them covertly, without endangering the perpetrator, requires expertise not widely held.

In the early 20th century, many nations began extensive experiments with biological weapons. The United States was a relative latecomer to the field and didn’t begin serious research on germ warfare until the middle of World War II. The potential to inflict damage on an adversary was obvious; less clear was how to protect one’s own troops from disease while spreading it among the enemy. Because the technical challenges of deploying biological weapons on the battlefield were so great, the prevailing attitude among American war planners was that the military value of these weapons was marginal. In addition, the fact that nations were engineering ways to deliberately spread diseases while scientists around the world were devoting their lives to wiping out some of the same diseases became increasingly untenable among many world leaders.

Amid growing doubts, President Richard Nixon ended the U.S. germ warfare program in 1969. Then, in 1972, the United States and the Soviet Union, along with more than 100 other nations, signed the Biological Weapons Convention. Signatories agreed to end their germ warfare programs, although they retained the right to continue research into defensive measures against such weapons. The United States destroyed its stockpile, along with most, if not all signatories, except for the Soviet Union. The Soviets, U.S. officials later learned, continued their germ warfare program with a vengeance, developing tons of anthrax and the bacteria that cause botulism, plague and other deadly diseases, even loading some agents into missiles aimed at American cities.

U.S. intelligence agencies learned of the germ warfare program in the late 1970s, but the full scale of the program was not known until 1992, when Ken Alibek, its deputy director, defected to the United States. Alibek’s claims about the extent of the Soviet program were so shocking that some military and intelligence personnel believed he was exaggerating. As U.S. officials began to substantiate Alibek’s statements through scientific exchange programs in the 1990s, the reality began to sink in—the United States’ defensive capabilities were no match for the germs engineered by the Soviets.

Military officials were already worried about Iraq’s biowarfare program, however. In the buildup to the Persian Gulf War it became painfully clear to military commanders that U.S. and allied troops were vulnerable to a germ attack from Iraq. Taking out Iraqi President Saddam Hussein’s crop-dusting fleet—Iraq was believed to have tested how to spread anthrax with crop dusters—was a top priority in the early air strikes of the war.

In 1999, Alibek published Biohazard (Random House Inc., New York), a detailed account of Soviet successes in engineering antibiotic-resistant versions of some of the world’s oldest, deadliest diseases, including anthrax, smallpox and viruses causing hemorrhagic fever. Today, Alibek is researching ways to boost the immune system to defend the body against infectious disease. In October, he signed a contract with the National Institutes of Health to conduct cellular research that could lead to defenses against anthrax.

“I cannot unmake the weapons I manufactured or undo the research I authorized as scientific chief of the Soviet Union’s biological weapons program,” Alibek says. “I do what I can to mitigate their effects.” But many of Alibek’s former colleagues are believed to be working in Iraq, Syria and other of what the State Department calls “nations of concern.” The collapse of the Soviet Union put thousands of germ warfare scientists out of work, dozens of whom are believed to be actively involved in foreign weapons programs.

Unheeded Warnings

“Ken Alibek warned us two years ago that America was not taking the bioterrorism threat seriously,” says Curt Weldon, R-Pa., a senior member of the House Armed Services Committee. Weldon has long advocated programs to boost preparedness against unconventional threats, but he acknowledges that part of the reason federal programs have been inadequate and poorly managed is lack of leadership on the part of Congress.

“Today in Congress there are over 26 separate committees and subcommittees that oversee funding for homeland defense—all with separate jurisdictions. We must change that. We must coordinate that and modify the way we oversee the spending of tax dollars so that [local officials] have a clear way of obtaining resources to implement the required actions to deal with the threat,” Weldon says.

A number of laws and presidential directives in recent years have attempted to strengthen defenses against the proliferation and use of nuclear, chemical and biological weapons of mass destruction and boost the nation’s preparedness to deal with the aftermath of an attack. In 1996, Congress passed the Defense Against Weapons of Mass Destruction Act, which required the Defense Department to train local and state officials most likely to be first to respond to such an attack. The same year, Congress passed the Antiterrorism and Effective Death Penalty Act, which authorized the attorney general to provide training and equipment for improving the capabilities of metropolitan fire and emergency service departments to respond to terrorist attacks. The two laws increased the federal role in ensuring state and local preparedness, but to many officials, they also increased confusion about division of responsibilities among levels of government at a time when the threat of bioterrorism was becoming increasingly apparent.

Long before anthrax started showing up in mail rooms across the country, federal officials understood that the risk to civilians of a biological attack was as great or greater than the risk to military personnel. In a July 1997 interview with Government Executive, David Franz, who was then commander of the U.S. Army Medical Research Institute of Infectious Diseases at Fort Detrick, Md., said battlefield threats are easier to defend against than terrorist attacks against civilians, especially those involving biological weapons. “The opportunity to prepare for a specific terrorist incident will be extremely rare—much like preparing for an emerging disease outbreak. Unless we happen to have excellent intelligence, we can only be prepared to respond after the fact,” Franz said.

The Army institute is the only facility in the United States where medical research is conducted to develop drugs and vaccines that can counter the use of biological agents that have been engineered for use as weapons. But despite the growing biological threat and the institute’s critical role in medical research, its funding and staff have been cut by nearly one-third over the past decade, even as anti-terrorism programs proliferated across the federal government as a result of the 1996 legislation.

A number of studies have shown that federal bioterrorism training programs are redundant, poorly coordinated among departments, and confusing to state and local officials. Amy Smithson, a chemical and biological warfare expert at the Henry L. Stimson Center, a national security think tank in Washington, says the federal role has been counterproductive. “Dozens of federal entities have been fiercely competing for the missions and money associated with the unconventional terrorism response, an unfortunate circumstance that has resulted in redundant capabilities, wasteful spending and, at the local level, confusion as to which agency would spearhead the federal component of a response,” Smithson says.

In “Ataxia: The Chemical and Biological Terrorism Threat and the U.S. Response,” an October 2000 report co-written by Smithson, she writes that the federal government’s lack of preparedness for dealing with bioterrorism is inexcusable:

“The minute the U.S. government had knowledge that another nation had not only weaponized contagious biological agents . . . but also had a doctrinal concept of attacking an opponent’s civilian populace, then it was incumbent upon Washington to throw U.S. biodefense programming into high gear to safeguard the health of soldiers and civilians alike.”

“Confirmation of the U.S. government’s intelligence about the Soviet biowarfare program began with high-level defections in the late 1980s and early 1990s, yet Washington did not escalate efforts to develop new licensed vaccines and stockpile existing vaccines until 1996 and 1998, respectively. Nor did the government make any move to resuscitate the country’s long-neglected disease surveillance system until 1998,” Smithson wrote.

Federal preparedness programs are a “fractured mess,” Smithson wrote. Federal agencies seem more intent on securing larger budgets than in devising coherent, integrated plans to defend against and respond to a terrorist attack, she says. “An absurdly small slice of the funding pie has made it beyond the Beltway.”

Health Care Crisis

Nowhere are the gaps more apparent than in the public heath system, which operates more like a loose collection of like-minded organizations than an integrated system. The challenge posed by bioterrorism is that it is highly unlikely an attack will be perceived at the time it happens. Instead, people will start getting sick and begin seeking care from their private physicians or local hospitals and clinics. A pattern of illness may not become apparent for weeks. If the disease is contagious, it would likely spread exponentially, eventually overwhelming the local medical system.

That’s what happened during two recent national exercises designed to test the health care system’s response to a biological attack. An exercise in June 2000 simulated the release of plague in Denver, while another exercise a year later simulated the release of smallpox in several cities. The results were clear: In both cases the medical system collapsed, the public lost faith in government officials and the disease spread like wildfire.

Reimer helped plan the smallpox exercise, called Dark Winter. He says it was designed to test the range of issues officials would face--such as how to legally quarantine people across different jurisdictions, how to distribute a limited number of antibiotics and vaccines, and how to keep public order in the face of mass hysteria. Some exercise participants estimated that the hypothetical outbreak would have resulted in 1 million deaths.

“It was a worst-case scenario to force people to deal with some of the policy decisions they would have to deal with if smallpox was introduced,” Reimer says. But it doesn’t take a worst-case scenario to see serious gaps in health care.

The nation’s response to annual bouts of influenza offers a clear warning to those concerned about preparedness for terrorists wielding infectious disease as a weapon. The flu is predictable and vaccine is widely available prior to the onset of flu season. Nonetheless, 20,000 Americans die annually as the result of flu, and flu season nearly always stresses hospitals beyond their capacity. For years, health care officials have been warning of the possible emergence of a more deadly flu virus for which vaccine will be ineffective—something akin to the 1918 influenza pandemic that killed 20 million people worldwide, including 550,000 Americans—in which case hospitals couldn’t come close to caring for all those who would come down with the disease.

It’s also instructive to consider the outbreak of West Nile Virus in New York City in 1999. Local, state and federal laboratories were overwhelmed for months while they were inundated with requests for tissue analyses of hundreds of ailing patients, who were experiencing swelling of the brain, disorientation and other unusual symptoms. At the same time, hundreds of birds were dying across the city—they were carrying the West Nile Virus, it turned out, although it took months for officials to recognize the link. What was worse, more than 20 patients were admitted to metropolitan hospitals before one doctor reported the strange outbreak to the city’s public health department.

After New York public health officials notified the Centers for Disease Control and Prevention in Atlanta, the CDC initially misidentified the disease, which is common in the Middle East and Africa, but had never been seen in North America. Given that the outbreak occurred in New York City, which has what is widely believed to be one of the best public health systems in the country, officials elsewhere worried about how they would have fared in a similar situation.

According to the General Accounting Office, the CDC received only $155 million for bioterrorism preparedness programs in 2000—out of a federal counterterrorism budget of nearly $10 billion. About $40 million of CDC’s budget was awarded to state and local health departments for surveillance, epidemiology, laboratory work and communications programs. Officials agree that much more is needed if public health officials are to recognize and identify disease outbreaks soon after they occur.

Dr. Tara O’Toole, deputy director of the Center for Civilian Biodefense Studies at Johns Hopkins University, told an audience at the Center for Strategic and International Studies in August that the nation’s 5,000 hospitals are poorly equipped to handle even relatively minor disease outbreaks. During flu season in 1999, for instance, three-quarters of the Los Angeles emergency rooms were so full for 10 days they had to re-route ambulances to other facilities. The Maryland Secretary of Health found that Baltimore, home to two major medical centers and medical schools, could not handle even 100 people needing to be put on ventilators overnight.

The fact that authority for public health is vested in the states poses a serious problem in the event of a bioterrorist attack, said O’Toole. “CDC has to be invited in to do anything in the states, although CDC certainly has the expertise that we would want to use in the event of an epidemic,” she said. “State and local health care departments are not necessarily well-glued together either, and there is a big disconnect between the public health system and the medical system. Doctors do not think to call their local public health officer when they find an infectious disease.”

What’s more, few physicians are trained to diagnose the pathogens thought to be most likely used as bioweapons. “Most American doctors have not seen anthrax or smallpox or pneumonic plague,” she said.

The conventional wisdom is that only one in 10 cases of infectious disease is reported to public health officials. Even when doctors think to call their local health department, there might not be anybody there, she said. “People in public health departments do not have beepers; they do not have computers on their desks for the most part. When there was an outbreak of Cryptosporidiosis, [an intestinal infection caused by a parasite] in Milwaukee a few years ago that eventually sickened 400,000 people, the Milwaukee Health Department did not have one fax machine. They had to walk down the hall and borrow one, ironically, from the Office of Economic Development,” O’Toole says.

All things considered, public officials handled October’s anthrax outbreak pretty well, says Cordesman. But the situation highlighted the weaknesses of the bioterrorism response system.

“We were warned again and again by public health officials that the system was inadequate and that they’d have to improvise and that there were many areas where we simply didn’t know what to do and we’d run out of resources very quickly,” says Cordesman. “We’ve spent a long time slowly weakening the public health system, and we ended up paying for it.”

-- Martin Thompson (, November 11, 2001

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