With one Florida man dead of anthrax and another exposed, frightened Americans want to know if something even worse than the horrific events of September 11 now lies ahead of us. Could terrorists loose bioweapons of mass destruction upon us: anthrax and smallpox, botulism and plague, invisibly airborne? The answer -- which is perhaps more frightening still -- is that the experts can't say.
This past spring, researching bioterrorism for a book about emerging infections, I spoke to Jonathan Tucker, director of the Chemical and Biological Weapons Nonproliferation Program at the Monterey Institute of International Studies in Washington, D.C. Tucker, a thoughtful man who has written recent books about toxic weapons and about the resurging threat of smallpox, told me then that while low-tech terrorist strikes such as food poisonings were always possible, a major bioattack wasn't plausible. In order to inflict large numbers of deaths, Tucker explained, terrorists must possess technical expertise, the organizational discipline to keep their plan secret, and the motivation to kill large numbers of people indiscriminately. When we spoke again in early October, he agreed that the September 11 murderers obviously met the last two criteria. But do they have technical expertise? Are scientists in Iraq or other biowarfare havens tutoring them? No one knows.
However, both experts who expect a large-scale attack and those who believe it a remote possibility do agree on two points: The threat of biological weapons is indisputably growing, and our public-health system would buckle under a massive epidemic.
Bioterrorism agents kill in gruesome ways -- via suffocating pneumonia, septic shock, massive hemorrhaging, or paralysis. At the Centers for Disease Control and Prevention (CDC), the worst of the worst are known as Category A agents. These are the deadly organisms readily spread in the environment or transmitted from person to person that could cause public panic and social upheaval and that require special public-health precautions. Among them are the agents that cause smallpox, anthrax, and plague. They are dreaded for good reason.
Smallpox radiates in ever-widening waves. Every silently infected person in the first swell of cases can infect as many as 10 or 15 more, who, unless quarantined, can infect others at the same steep rate. If the smallpox virus were released as a weapon at one site, the disease could spread globally within six weeks. After the virus incubates for about 12 days, victims suddenly feel weak, feverish, and achy. Deep, dense lesions appear on the face, arms, and legs, leaving depigmented scars on survivors. As with many viral diseases, there is no treatment once symptoms appear. One third of victims die. (Though talk has abounded lately about suicide terrorists infected with smallpox, victims don't become contagious until the rash appears, by which time they would be far too ill to roam around.) A vaccine administered within a few days of exposure can prevent or significantly reduce subsequent symptoms. Unfortunately, existing vaccinations don't provide permanent immunity; after about 10 years, their effectiveness wanes. In the United States, where immunizations ended in 1972 (shortly before smallpox was officially declared eradicated from the face of the earth), most residents have lost their protection against this disease, as have most people around the globe.
Just as horrifying would be an anthrax epidemic, which is the greater fear at the time of this writing. Anthrax begins with fever, fatigue, and cough, and goes on to cause abruptly labored breathing and eventual shock, leading to death. The infection spreads not person to person but by hardy spores. Inhalational anthrax, contracted when spores enter the lungs, had not been seen in 25 years in this country until early October, when one confirmed case and another possible one were reported among co-workers in a Florida office. It's certain that this was not an accident. But as this article goes to press, we know no more than that about its cause.
As seems to be happening in Florida, potential anthrax victims can be treated prophylactically with antibiotics. The difficulty is identifying an outbreak in time. A delay of treatment even by hours can dramatically decrease the chances of survival.
Other potential biowarfare agents are just as frightening. When plague bacteria infect the lungs, they cause a highly contagious form of the disease known as pneumonic plague, which kills by respiratory failure and shock; antibiotics are practically useless if taken more than a day after symptoms begin. Bacterially derived botulinum toxins are the most lethal compounds known; as little as one gram of aerosolized botox could kill more than 1.5 million people by paralysis that creeps down from the shoulders and eventually halts breathing. Hemorrhagic fevers, such as the enigmatic Ebola or Marburg, begin with fever and fatigue and lead to bleeding from every orifice. Moreover, molecular biology could infinitely expand the biowarfare armamentarium with techniques that can insert genes from one organism into another to create hybrids that are more lethal, sturdy, and elusive to the immune system. All told, for the 50 top bioweapon pathogens, there are vaccines or treatments for only 13. The advantage, in other words, lies with the offense.
But the real question is whether terrorists have mastered the methods of madness needed to spread these infectious agents broadly.
"Toxic Archipelago"
However repugnant biological warfare may seem to us, it has a long history. Romans, Persians, and other ancients tossed carrion into wells and reservoirs to taint their adversaries' drinking water. In 1346, the three-year siege of the Black Sea port of Kaffa ended when attacking Tatars catapulted bodies of bubonic plague victims over the city walls; fleeing victims may have brought the Black Death to Western Europe. In 1763, the commander in chief of the British forces in North America, who was preoccupied with a restive coalition of Indians on the western frontier, hit on the idea of sending smallpox-infested blankets as gifts to the "disaffected tribes."
But it was the twentieth century that saw the heyday of biowarfare. From 1932 to 1945, the Japanese army conducted a massive biowarfare program, raining pathogens on China and killing an estimated 10,000 prisoners. Between 1949 and 1969, the U.S. military staged 239 open-air experiments over populated areas, from San Francisco to Minneapolis, to learn how clouds of bacteria would drift and decay in the environment. It was in 1969 that President Richard Nixon ordered the unilateral dismantling of the American bioweapons program. Three years later, the United States and the Soviet Union signed the Biological Weapons Convention, which states that signatory nations will not develop, produce, stockpile, or otherwise acquire biological weapons. Almost immediately after, the Soviet Union embarked on the largest bioweapons buildup in its history.
At its peak in the late 1980s, the Soviets' "toxic archipelago," as it has been called, employed upwards of 65,000 researchers and technicians at 50-plus labs and testing sites. The deputy director of Biopreparat -- who, after defecting, adopted the Westernized name Kenneth Alibek -- has testified that the program cooked up 2,000 strains of anthrax alone, produced 20 tons of smallpox virus each year (enough to kill the human population many times over), and combined known deadly viruses to enhance their properties for warfare. A few agents were ready to be mounted in intercontinental bombs and ballistic missiles. Though nobody knows how many Soviet scientists took their expertise to other countries, interviews with those who remained suggest that soon after the Soviet Union's collapse some of these bioweaponeers may have gone to Iran, Iraq, China, and possibly North Korea.
Talent and Technology
The recipes for brewing and storing tiny particles of deadly infectious agents used to be among the most closely guarded secrets of the U.S. and former Soviet militaries, and it was widely assumed that amateurs couldn't master them. Biologic agents spread most easily in the form of dry particles one to five microns in diameter; in this form, they act like a gas, slowly settling in the air and making their way deep into the lungs and thence into the bloodstream. The trick is to devise formulations that prevent these living organisms from dying, desiccating, decaying, clumping, or losing their virulence on exposure to the atmosphere.
Have other nations or organizations now cracked those secrets? Will the diffusion of modern technology make it easier for neophytes to do so?
Pending what we learn about the Florida anthrax cases, the best evidence that bioterrorism might be easier said than done is still the rarity of such attacks and the artless quality of the incidents so far documented. The most tenacious, if inept, bioterrorists of recent vintage belonged to the Aum Shinrikyo cult in Japan, which staged the 1995 sarin attack on the Tokyo subway that killed 12 and injured more than 1,000. Before that chemical assault, the group had 10 times tried and failed to sow disease by dispersing the anthrax bacterium and botulinum toxin. In the United States, there has still been only one successful broadscale bioterrorist attack, and it was decidedly low-tech. In 1984, members of the Rajneeshee cult--in a practice drill for a plan to swing a local election -- poured vials of Salmonella into salad dressings and coffee creamers at 10 restaurant salad bars in the Dalles, Oregon.
Yet even before questions were raised in Florida, Raymond Zilinskas, a senior scientist at the Monterey Institute, was worried about such experimental technologies as aerosolizers, which are currently being tested to spread vaccines to large flocks of chickens. "That's going to be off-the-shelf to farmers in the not-too-distant future," he said. Epidemiologist Michael Osterholm -- who shaped a stellar Minnesota public-health department that regularly outshone federal investigators on national-outbreak investigations -- has pointed out that there are already off-the-shelf technologies that make bioterrorism easier. As Osterholm, now director of the University of Minnesota Center for Infectious Disease Research and Policy, and journalist John Schwartz outline in their book Living Terrors, a malevolent individual could use rapid-fasten Velcro strips to attach what appears to be a thermostat box to a wall in a crowded suburban mall. Inside, a microaerosolizer no larger than a pack of gum, powered by a store-bought camcorder battery, could spew a few tablespoons of fluid--say, smallpox virus--into an invisible mist. Thousands would inhale the virus in the Muzak-filled ground zero.
The debate over the bioterrorism threat hinges on the spread of technical expertise and technological shortcuts. Observers who are skeptical that Osama bin Laden's network could currently carry off germ warfare point to the lack of talent in his camp. "It's not like Einstein and Madame Curie are rushing to join these terrorist organizations," says Amy Smithson, director of the Chemical and Biological Weapons Nonproliferation Project at the Henry L. Stimson Center in Washington, D.C. And no rogue-state sympathizer would be foolish enough to lend its own expertise to such terrorists. Even during the Gulf War, Iraqi President Saddam Hussein observed certain boundaries. He had both biological and chemical weapons, and he didn't use them. Nor did the Soviet Union draw on its vast bioweapon stockpiles during the Cold War. "It's not the moral restraints on the terrorists [that one relies upon]. It's the moral restraints on the leaders of nation-states," says Smithson. "It's pretty clear that al-Qaeda and its types have no problem with suicidal missions. But the purpose of a nation-state is to perpetuate itself."
Those who counter that the biowarfare threat looms large dismiss these arguments as naive. Last month's numbing events only strengthened the convictions of Tara O'Toole, a physician and deputy director of the Johns Hopkins Center for Civilian Biodefense Studies. Bioterrorism "was a risk on September 10," says O'Toole. "What we saw on September 11 is that terrorists are indeed quite well organized and sophisticated and capable of carrying out complex deeds requiring planning and determination -- and that they're willing to cross the so-called barrier of moral repugnance and kill thousands of civilians without warning."
As for technical expertise: "There's no question in our mind," O'Toole told me well before the two anthrax cases were reported, "that organized terrorists could mount at least a small bioterrorist attack now." How big would "small" be? In her estimate, "dozens or hundreds of people being infected in an indoor aerosol release -- maybe more than one of those. . . I agree that it's unlikely terrorists could create the kind of very efficient and accurate weapon that the U.S. had in the 1960s right now. I'm not so sure that will be impossible five years from now, given how technology is moving forward and simplifying the steps that you would need to isolate, harden, and disperse these organisms." Raymond Zilinskas agrees. "I still worry about the lone operative, the disgruntled or crazed scientist," he says. "That problem is going to grow, because as the population of microbiologists and biotechnologists grows, the absolute number of people that go bad would also grow."
Just because we have no tangible proof that terrorists possess biological weapons doesn't mean that they don't. Absence of evidence isn't evidence of absence -- as recent history shows. Not until the West got the lowdown from Soviet defectors in the late 80s and early 90s did it begin to fathom the vastness of the Soviet bioweapons enterprise. Even the accidental release of anthrax spores in 1979 from a Soviet military facility in the Ural Mountains -- a mishap that killed scores of people -- failed to tip off Western authorities. Likewise, the dimensions of the Iraqi biowarfare machine were unknown until UN inspectors started poking around after the Gulf War. "I am not reassured that we don't know about a teeny-weeny operation, possibly happening somewhere in the Mideast in the mountains of Afghanistan," says O'Toole. "And I don't think many people believe the CIA has tremendous expertise in these matters. It's very difficult to find these kinds of weapons before they're used, as everybody will admit." Here in the United States, it wasn't until after the fact that investigators found mountains of evidence that airline hijackings were about to take place -- hardly an encouraging precedent.
Public Health
Ironically, it was the Cold War preoccupation with germ warfare that gave birth to one of the jewels of modern public health: the CDC's Epidemic Intelligence Service, or EIS. In 1951, its first crack team of disease detectives trained and hit the road. Today, we know these gumshoes as the experts who helped figure out Legionnaires' disease, hantavirus pulmonary syndrome, toxic shock syndrome, the Jack in the Box outbreak of E. coli, and countless other mysteries. But the impetus behind forming the team was the prospect of biowarfare, as the very image of an "intelligence" corps conducting disease "surveillance" suggests.
On September 11, that original mission was dramatically revived. Within hours of the World Trade Center attacks, EIS officers fanned out to hospitals throughout New York City and looked for evidence of novel disease syndromes. The CDC issued a nationwide alert to doctors and laboratories to watch out for unusual symptoms and pathogens. The Department of Health and Human Services authorized shipments from the never-before-tapped National Pharmaceutical Stockpile, a massive cargo of antibiotics, ventilators, and other emergency supplies created specifically to counteract a chemical or biological attack.
If we were to face biowarfare, gas masks and private reserves of ciprofloxacin would be pretty much useless (gas masks because they would have to be donned immediately; cipro because it doesn't work against many pathogens). Only a robust public-health system -- one that instantly registers aberrant syndromes and anomalies in infection rates, figures out the problem, and quickly intervenes -- could actually curb the spread and devastation of the disease. In an ideal world, state and local health departments would continually collect data from hospitals and labs; pharmacies would report spikes in over-the-counter drug sales; doctors and nurses would immediately recognize the unfamiliar symptoms of biowarfare agents; laboratories would perform rapid tests that would unmask an intentionally released pathogen; extra hospital beds and emergency supplies would be in place; a wide range of vaccines and antibiotics would be stockpiled; officials would know in advance precisely the decisions -- about vaccinations, quarantines, travel restrictions -- that they would make in a crisis.
Our current system isn't up to the job. Today's hospitals are short on beds and even on drugs for common infections. There's no slack in the system -- no "surge capacity," in public health jargon -- should hundreds or thousands of people suddenly get sick. If hospitals run out of beds during an unremarkable flu season -- and they regularly have in recent years -- they would be hopelessly besieged after a broad biological-weapon release.
In late September, the General Accounting Office confirmed that the U.S. public health-care system is unprepared for germ attacks. The system is fragmented and its staff poorly trained for biowarfare. Federal agencies don't even agree on which pathogens pose the biggest danger; while the CDC considers smallpox a pre-eminent threat, the FBI doesn't even include the disease on its list. All public health is local. But in the event of a bioterrorist attack, as the GAO's report asserts, "cities would probably be on their own for the first 24 to 72 hours." According to the Stimson Center, the federal budget for combating terrorism in fiscal year 2001 is $9.7 billion; of that, less than $100 million goes to public-health infrastructure and surveillance. "The federal government has got it bass-ackwards to date," says Amy Smithson. "They do not seem to comprehend that lives are saved in a disaster by locals" -- and that this is what the federal defense against bioterrorism must support.
To start wrapping their minds around the practical challenges of bioterrorism, health officials for the past few years have staged "tabletop exercises," during which they rehearse their decisions and actions around a table as a scripted, hypothetical attack unfolds. The results have not been reassuring. In a 1998 exercise based on an outbreak of a fictional smallpox/Marburg virus along the U.S.-Mexican border, hospitals faltered under the strain and an international political crisis exploded. In a 2000 drill that centered on a hypothetical release of pneumonic plague in Denver, the virtual antibiotic distribution center was badly short-staffed, food supplies dried up, the epidemic spread abroad, and within days thousands of hypothetical victims died.
This past June, in an exercise dubbed "Dark Winter," a mock National Security Council (with the roles played by retired senior-government officials) grappled with a fictional smallpox outbreak. Over a simulated time span of about two weeks, vaccines ran out, officials bickered over quarantine measures, and 6,000 Americans were dead or dying. And that's without the panic that would race through the population in a real attack.
Toward the end of the Clinton administration, the federal government started taking bioterrorism seriously. Because of its investment, state health departments now have more labs that can handle dangerous pathogens, and a nationwide system now exists that can genetically identify the organisms used in possible terrorist attacks. But that's just a start. Not enough money has flowed down to local health departments and hospitals, the so-called "first responders." These departments need innovative and ongoing early-warning systems for disease. "An emergency system that's dusted off and used only during a rare event isn't going to work," says Tara O'Toole. "These systems have to be part of our daily routine if they're going to operate during [a] crisis."
Public health has long been considered a poor second cousin to curative medicine. Indeed, it's a bitter joke in the profession that a master's in public health is the only degree that reduces one's salary. So strapped for money are many health departments, they still track outbreaks with pushpins and maps and they have no one staffing the phones on weekends. Transforming this creaky system into one that can handle germ warfare is a Herculean task. But it is work that will pay us back double, because while girded for intentional malice, a sound public-health system is also ready to spring into action for other contingencies. While Americans are transfixed by fears of high-tech scourges, unintentional diseases will keep cropping up: untreatable staph infections, insidious food-borne ailments, exotic illnesses ferried by insects from the other side of the globe, the next AIDS. Bracing against biological weapons will protect us from all of them.
