We have three things happening today that make the likelihood that a biologic
agent will be used [on] civilian populations all coming together. One, we have
a number of different terrorist groups that have different ideologies; they
have different reasons for wanting to do something, but they want to do it.
Number two, the infectious agents are increasingly available. The Internet has
helped facilitate the mail order nature of obtaining these kinds of agents. And
number three, the kinds of devices that we need to disseminate these agents in
buildings, subways, and whole cities are now readily available, and in large
part, have been improved because of the kind of micronization we do today with
computers and so forth. We actually have created the devices to make these
aerosols very effective.
With biologic weapons, [there is] the potential for them to actually have a
kind of echo impact, where the illnesses may occur for weeks after the initial
hit. And the potential for some agents, particularly smallpox, where the
transmission can occur from [one] generation to another generation, means it's
the kind of bomb that continues to go off. From that standpoint, they represent
a very different type of terror and panic, one which, in many cases, is much
more appealing than just the initial kind of hit and tragedy.
Appealing to who and why?
If you're a terrorist, you basically have a point of view that terrorism is
your outcome. You're trying to either wreak havoc for political purposes,
religious purposes, or you're just mentally unstable and believe that death is
an outcome. Biologic agents even add a little bit of a twist to that, in that
they add the panic and fear that we've seen so often with other infectious
agents problems, whether it be plague in India, HIV in health care workers,
even with our food supply and the consideration there. None of those could
really match the kind of fear and panic that will occur in a community if we
have a respiratory transmitted biologic agent perpetrated on the population by
some individual.
Why panic? We've all seen hurricanes. We've had earthquakes. We've had
horrendous things that have taken place like the Oklahoma City bombing. Why are
we fearful of the panic in this case?
Part of the issue of panic is, it's irrational fear by individuals that
something's going to happen to them. Infectious agents are and will continue to
be that mysterious source of great panic. We saw it with HIV. We actually saw
it just recently this spring, when we had the situation with the two
individuals in Las Vegas who were arrested with anthrax vaccine in their trunk.
Even though there wasn't a single human illness associated with that, we had
major TV networks cutting into it. We had the mayor of New York City holding
repetitive news conferences. That's what panic is all about. And while bombs
clearly can create panic, infectious diseases almost spread it.
How attractive are these weapons to terrorists, and why?
All of us would like to say that they're not attractive, in part, because
they've only rarely been used in the past. But there are a number of factors
coming together, namely, the disintegration of any kind of control over a
number of these weapons in foreign countries that have developed them for
biological warfare purposes, not necessarily for civilian purposes. Now these
are available to individuals. And given that fact, we believe that they will be
[attractive]. Just as we went from the dynamite bomb to Semtex, the next level
of ... panic weapon is going to be a biologic agent.
Why is biological weaponry so different?
Biologic weapons will likely be the ultimate weapon, because first of all, it's
now available. Number two, it kills very well. And number three, it spreads.
And the fact that you can put that all together makes for the kind of panic
that we've seen around non-biological terrorism events, but involving
infectious agents.
Why are we afraid terrorists will see this as the ultimate weapon?
The primary purpose of terrorists is to cause terror. Infectious agents have
historically been the greatest source of terror in all of society, dating way
back to the Middle Ages and before. Today, we know the kind of terror that can
occur with a manmade event around a biologic weapon. And it has an obvious
appeal to terrorists.
Why do you think terrorists would think that this weaponry is better than a
fertilizer bomb in the back of a van?
The use of biologic agents by a terrorist is really the ultimate rock in the
gear. It is a way to bring down a society, not only in terms of death and the
kinds of illnesses we could see, but the panic that will ensue across states,
that will ensue throughout commerce in general, is the very nature of what
terrorism is all about. So the potential to take it to the next level is very
real.
What is the history of biological warfare weapons.
There are a number of examples in history of the use of biological terrorism,
most often in wars. This would be an example where someone would take bodies
that have died from plague and throw them over the walls of cities and castles
to infect those inside. We have well-documented experiences of giving the
Native Americans blankets with scabs from persons who had smallpox, to try to
spread smallpox in those populations. And we even have, unfortunately, examples
from both World War I and World War II, where the Germans and the Japanese did
extensive work with biologic agents and attempted to transmit infectious
agents.
So this is an old story. Why the concern today over the new wave of
bio-terrorism and biological weaponry?
Bio-terrorism is both a very old and a very new situation. It's very old in
that it's been used for centuries in very crude and most often very inefficient
ways. Today, what we have is a very different situation. We have for the first
time terrorists in a number of different forms who want to cause terror. Number
two, we have infectious agents, and our ability to grow them in quantities that
we never had before, that make them very efficient and effective killers. And
we now have the devices that make it very easy to fill a subway or a large
building or, for that matter, fly over an entire community and expose millions
and millions of people. That didn't exist before now.
Let's discuss what some of the agents are, what symptoms they cause, and why
that makes them a great weapon. First, smallpox.
Smallpox is caused by a virus that has not circulated in the human population
for more than 20 years. About a third of the people who contract it will die.
Today, most of the world's population is susceptible to it. Because it can be
easily transmitted in the air, it makes a great weapon. And more importantly,
once people become infected with it, they themselves now become capable of
transmitting it to others. Even a few thousand cases of smallpox could very
quickly mushroom into tens to hundreds of thousands of cases, just because of
that (we call) secondary transmission.
Anthrax.
Anthrax is caused by a bacteria that can be transmitted in several different
ways, but the most important one from a bio-terrorism standpoint is via the
respiratory route, or basically being in the air. It causes an illness where
for the first several days you have flu-like symptoms, really not that sick.
You may actually even experience a day of getting better, and then suddenly you
crash. Virtually 100 percent of people with anthrax on the third or fourth day
of illness will die from it.
Why is it a good weapon.
Anthrax is a great weapon in terms of its potential use in large populations.
You can disseminate it over entire cities via airplane. It is very stable in
the environment. And the infectious dose is so low that you can infect most of
the people who are in that city.
Plague.
Plague is another bacterial-caused infectious disease. It causes a type of
pneumonia in a number of patients. It is fatal in a large number of them, if
not caught not early. And it's very easily transmitted through the air.
Why is it a good weapon?
Plague makes a very good weapon because it's very easy to put into the air, and
it causes lots of deaths.
How impressive is it that mankind basically beat smallpox?
Smallpox is probably the most misunderstood human condition of this century.
Very few people realize that more than 500 million people have died from
smallpox since 1900, despite the fact that it hasn't even been around since
1978. That's more than all the wars, HIV infection, and swine flu combined.
Yet, because it hasn't been in the developed world countries for most of the
last half of the century, and for the whole world for the last 20 years, we
somehow have forgotten how lethal and how absolutely horrible it is as a
disease.
How horrendous is it even to imagine that someone might now dig it up and
use it as a weapon?
Probably the worst crime that humans can commit against other humans is to
bring back smallpox after all we did to rid it from the world. Smallpox is not
only a grotesque disease in how it looks, with these horrible pustules and the
disfiguring kind of disease, but it's a horrible disease in that it kills a
third of the people who get it. And they themselves are often highly infectious
to others who are near them. So for us to bring it back after all we did to
eradicate it really goes against the very nature of why are we human.
Draw for me a scenario, which you have written about before, of how smallpox
could be put in a major international airport. What could be done, and what
would be the effects?
Because of the great advances we've made in what we call aerosol particle
technology--the ability to make very fine particles that float in the air
forever (and we need that today in the computer chip industry and a lot of
other industrial purposes), we unfortunately can have it used for taking very
small amounts of fluid-like material--we're talking about three
tablespoons--and filling an entire mall, an entire subway area, an entire
airport concourse with millions of infectious doses, in such a way that the
whole device would fit into a heat thermostat box that could very easily be
attached with Velcro strips quickly on and off the wall, and no one would even
know when it was there. That type of information is in the hands of the people
out there that can do that. And that's why we're so concerned that it's going
to get done.
That sounds like science fiction, not fact. Is that at all possible?
One of the great advances that we've made in society, besides the Internet and
computers and all the kinds of electrical gadgets we have today, is we've also
made it possible to create devices that can transmit a great deal of infectious
material into large public settings. And the entire device size is only that of
a heat thermostat box. That's not science fiction. That's easily doable. You
can actually go to a series of electronics stores in any large community in
this country, and put that kind of device together.
Continue with the scenario. A box is put into an airport. What
happens?
If a terrorist wanted to infect thousands and thousands of people, it would be
very easy to do ... with the right infectious agent (which is now increasingly
available through mail order Internet), with this type of device, put it in a
public setting, come back two days later, after the infectious agent has been
exhausted out through the building, retrieve the device, go home, and watch
eight to ten days later when the first cases of smallpox start to happen, or
three to five days later when the first cases of anthrax start to happen. That
is not only something that is easy to imagine, but we have a great fear that
people are planning that very type of situation right now.
What happens and how do we respond?
If there was even a very limited release of smallpox in a public setting today,
make no mistake about it, it would be the closest thing to a living hell we've
probably ever known. We would basically see hundreds, maybe thousands of people
who would come down with a life-threatening illness, who would expose all the
other people who were around them, including the health care workers who are
now taking care of them. And of course, many of these health care workers,
recognizing what they were dealing with, would now likely panic and leave the
scene of the hospital or the care setting that they're in. And we believe we'd
just see a total chaos occur.
Draw a picture. The first people come to the emergency room. How do we
figure out what's going on and what happens next?
Eight to twelve days later, people would start coming to emergency rooms with
fever, chills, in some cases vomiting, not yet necessarily showing a rash,
although some might. They'd be sent home with having the flu. It's at the time
then of three or four days into their illness that they would really start
showing this rash. That's at the same time that they become highly infectious
themselves. It would still be days before anyone would recognize that this
chicken-pox-like illness is really smallpox. However, within the next five to
seven days, these people would become severely ill. About a third of them would
die, and we would be overwhelmed in any medical care setting with even just a
few cases. No one could even imagine what it would be like if there were
hundreds or thousands of cases.
If it is smallpox, would we just vaccinate everybody?
The only way we could respond to a smallpox outbreak today is to literally
circle it, much like you'd try to circle a wildfire. When I say circle it--we
would have to try to make sure that all the people around a given case are
immune. This is the same way that we have eradicated smallpox from the world
some 20 years ago. That would require that we have millions and millions of
doses of vaccine, something that just doesn't exist today in the world.
What do you mean?
For the last 20 years, we have taken great pride in that we eradicated probably
the greatest scourge of mankind. And in doing so, we've let down our guard.
We've not maintained the kinds of vaccine supplies that we would need, should
someone ever bring it back. And today, as a result of that, there literally are
just millions of doses.
What's available today and what can we do about it?
In the United States today, we have somewhere probably between seven and ten
million doses of smallpox vaccine. We're not even sure, because some of it is
in a condition [where] it's not clear whether or not it's even going to be
effective. We have no ability in this country today to manufacture smallpox
vaccine. It would require a Manhattan Project of incredible effort to even hope
that we could have vaccine in the next two to three years. During that time,
this country will remain extremely vulnerable to anyone who uses smallpox, not
only in the first attack but all the subsequent waves that will occur
afterwards.
How does such an attack create a perfect scenario for the use of blackmail,
even if they don't use the agent?
If someone really wants to use smallpox today, and they have access to it,
there is no way to necessarily stop them. The best we could hope to do is limit
the number of deaths and limit the panic. The only way we're going to be able
to do that is to have sufficient vaccine supplies in this country, that if need
be, we could very quickly vaccinate millions and millions of people so that
even if a terrorist wanted to use these infectious agents such as smallpox,
they would not be effective.
Is there a distinction between the ability to grow anthrax or smallpox, and
the ability to weaponize it?
There's actually a lot of difference in the expertise to actually grow these
particular infectious agents (such as anthrax or smallpox), and actually have
availability of them. Today, smallpox is very limited. Anthrax we can get from
any number of different sources. But once you do have the agent, regardless of
what type you have, what we've not done is develop the type of weaponry, the
kind of aerosolizers that actually make it quite easy for people to be
successful in delivering whatever the infectious agent is.
Are you telling me it's really easy, that anybody could get their hands on
this? Explain.
When I was in high school, twenty-some years ago, I couldn't have imagined
making a pipe bomb. It was just beyond anything I had access to. With the days
of McGuiver and the Internet and so many things now in the public domain
and libraries, high school students will tell you it's not difficult to build a
pipe bomb. Take that same scenario and look at the issue of infectious agents
transmitted by aerosolizing devices. Twenty years ago, we couldn't have done
it. Today, what's in the public domain and how to do these is such that even a
relatively inexperienced individual could put one of these together quite
easily.
The general thought out there is that smallpox was eradicated years ago, and
that it only exists in two different places: the CDC and one place in Russia.
Is that correct?
One of the greatest scientific fallacies that exist today is that smallpox is
only in two laboratories, both secured, here in the United States and in the
former Soviet Union. We know that it's in multiple locations in the former
Soviet Union; that it is in North Korea, and likely in Iraq, and possibly other
countries.
How scary is that?
There could be no greater human tragedy than the return of smallpox. The fact
that there are now multiple locations that could potentially use this agent as
a biologic weapon has to be, without a doubt, one of the greatest tragedies
that could exist in human society.
How easy is it to transport biological weapons across the lines of the
borders of countries?
Where humans can go, infectious agents will follow. Today, crossing any border,
going through any airport, through any metal detector, as long as I have an ink
pen in my coat pocket that writes, but has a compartment where you could store
an amount of infectious agent barely visible to the human eye, you have the
ability to move literally large weapons.
Are we prepared?
Today in the United States there is a tremendous amount of activity that's
going on around the issue of bio-terrorism. For those of us that are out in the
field and have to prepare for it, I would only conclude that there's been very
little real action that actually has occurred that would allow us to be
prepared. We don't have the vaccines. We don't have the antibiotics. We don't
have the local planning. We don't have much in place beyond a lot of rhetoric
and a lot of activity that many of us would ask: "So what?"
What's the first line of defense and how will that stack up against such a
threat?
Today, if someone explodes a device or uses a chemical warfare agent,
individuals will know immediately that something happened, and their first
responders (fire, police, and other typical first responders) will be on the
scene. If a biologic agent is released, if it's anthrax, it will be several
days before the first cases show up; if it's smallpox, it will even be
potentially several weeks. Then the first line of sight of that kind of
situation will be emergency rooms. It will be urgent care. It will be doctors'
offices. It won't be the first responders. And only if public health has in
place the kind of adequate surveillance or the ability to pick up all those
cases and bring them together in a way that we can meaningfully say something's
happening in this community, will we really be able to respond to this kind of
a situation.
So what is Washington's role?
As a state epidemiologist, it's my job to make sure that epidemics don't occur
in our communities. As someone who's also been very involved with issues around
national preparedness for bio-terrorism, I can tell you that very little to
almost nothing has been done at the state or local level to prepare public
health, to prepare medical providers, to provide for care teams for a biologic
event. What we keep seeing are these people in these space suits from federal
agencies, who keep saying, "We will come in and help. We will take care of
things." In the first instance, that will be so far after the fact that it will
almost be needless.
You lay out a scenario where there doesn't seem to be a lot of solutions to.
How much of a problem is our lack of preparedness at this point?
As frightening as bio-terrorism is, what is equally frightening is the fact
that we still don't get it in this country. We still believe that if we put
more money into our military, [if] we put more money into first responder
programs, we will somehow prepare ourselves for bio-terrorism. It won't happen.
It's going to be at the emergency room level, in the medical care area, in the
health departments, in our vaccines, in our antibiotics. If we don't have
those, we have nothing to prepare for bio-terrorism. Right now it is so scary
because that is the mode that we continue to operate in.
You hear that the president is very involved with this situation. There is a
lot of money being thrown around right now. Why doesn't Washington get it?
I like to believe that policy makers and those in this area are logical people,
people who are concerned about the issues around bio-terrorism. Despite the
fact that for the last three years a number of us have pleaded with policy
makers in Washington to accelerate, to even begin working on the development of
new smallpox vaccines, to begin providing for anthrax vaccine, to actually
consider, where would we get all the antibiotics we need when we have a big
potential exposure, nothing's been done on that. What's very frustrating is,
despite having explained all of this, what is it going to take to get people to
move?
If it is so clear-cut, why aren't they acting on this?
The million dollar question today in Washington is: What is it going to take to
get policy makers to see that all the money that we're throwing into
bio-terrorism has really had very limited impact on our ability to prepare out
there. And what's happened is, people have confused activity with action.
Hopefully, we're about to turn the corner where people finally see that without
talking to the state and local health departments, without talking to the local
emergency management people, without developing the national programs for
vaccines and antibiotics, we will remain unprepared for bio-terrorism.
Let's talk about the B'nai B'rith false alarm in Washington a year ago. What
happened there and why is it an important event.
Recent events around possible hoax situations, including the B'nai B'rith in
Washington DC, letters that were sent to individuals that had powders in them,
and even the situation with the anthrax vaccine in the trunk of the car in Las
Vegas, all begged the question of what does it take to be prepared for
bio-terrorism. [It is] very unlikely that we will ever have a terrorist come
forward, expose large numbers of people, and then declare within hours, maybe
even a day, that they did it. Therefore, the first responders won't be there.
They won't be the ones that will be on the scene. It will be the public health
and the medical communities that will first pick this up.
What is the way they responded to the B'nai B'rith specifically? How was it
incorrect and what does that tell us?
What's really frightening about the beliefs of much of our governmental system
to responding to bio-terrorism is that somehow rushing in, in space suits, with
sirens, will deal with the bio-terrorism problem. Even if someone did send an
envelope with anthrax spores in it, the chances of those actually causing
disease are very small. You have to have a way of disseminating that particular
agent. That in itself shows a lack of understanding by many of our first
response agencies of the country. It shows even to the extent that the federal
government as a whole doesn't understand what does it take to transmit the
agent, and what does it take to respond to it.
How would you contain it and how did they err?
In a situation where you have an infectious agent like smallpox or anthrax or
another one in a box, it's very simple. You don't have to come in and
decontaminate the entire area unless that's been aerosolized, unless it's in
the entire room. At that point, you'd go and destroy it in any kind of
laboratory, like we do our everyday stocks of these same infectious agents. It
doesn't require the same kind of immediate first responder response like you'd
think of with a bomb or a potential chemical weapon release.
The size of a disaster such as this, what added difficulty does that in
itself cause?
On one hand, the size of a biologic terrorism event is somewhat meaningless,
because even five or six cases will result in a panic that I don't think any of
us can predict. On the other hand, if you're trying to provide the medical
resources, the care, you could very easily outstrip all the intensive care beds
in a major metropolitan area with just a very small event, which then would
require additional medical services being provided, which would then just
ping-pong throughout the medical system.
So what's the result?
With even a small biologic terrorism event with one of the serious agents (such
as anthrax or smallpox), even a few cases will cause widespread panic; but more
than that, it will cause a major disruption in the medical care system. We will
find in some metropolitan areas that we won't even have close to the number of
hospital beds that we'd need to care for these people, which then in turn will
only further fuel the panic.
The structure falls apart. What happens to the community?
Several of my colleagues and I have tried to walk through these scenarios time
and time again. We've looked at them as we would handle any other public health
disaster, as we've done in the past. Unfortunately, each and every time, given
the resources we have now, given the kinds of authorities we have now, we come
down to basically complete chaos and panic. In many instances, the only thing
that would probably prevail is martial law. I don't think this country has yet
prepared to realize that we may face that in the future.
What do we need to do in this country to shake ourselves up, to get the
information that we need to make sure that we can handle the threat?
First of all, I don't think that many of us believe we can really handle the
threat. What we can try to do is manage it. And that's a big difference. But
right now, we can't even manage it, because too many of the people making the
major policy decisions about where we spend our money, how we prepare
ourselves, have no real understanding of what it's like at the state or local
level, where this event will occur. Until we see a change in the federal
government approach to including the input from the state and local level, I
think we'll continue to see this mismanagement of what we need for future
planning around bio-terrorism.
Beyond that, do we need to bring the finest minds in, that usually are
brought in to research weaponry?
One of the real problems we have today is that this issue has been largely
taken over by the beltway bandits of Washington DC. There are a lot of people
making a lot of money on national preparedness for bio-terrorism, and frankly,
they're contributing almost nothing. What we don't need is more money to go
into the same areas. What we need is a fresh look at this. We need the people
who have staffed these kinds of outbreaks, not caused by terrorists but by
Mother Nature for the last decade; bring them together and say, "How would you
respond?" We need the local beat cop, the kind of person that's going to be out
there trying to keep order when one of these things happens. So far, that kind
of input has not only not been sought, but when it's been provided, it's been
summarily dismissed.
Last March, President Clinton ordered a table top exercise for federal
officials. Why?
I think the president is genuinely concerned about this issue. I think he
really cares. We believe that this administration cares. The problem has been
translating a care into action that means something. That's been where there's
been a big disconnect. The table top exercise is a good example. A number of
table top exercises have been prepared by various agencies of the federal
government. Some of them were so factually incorrect, or not based in the
reality of what really happens out in the field, that they were really a large
waste of time. And one of the concerns we have is, if we're going to plan
around this, then let's be realistic. But to be realistic, you have to ask the
people who are out there in the fields (the beat cop, the state epidemiologist,
the emergency room physician), "How would it happen? Tell us." And then we can
plan around how to respond.
What's the purpose of a table top exercise like this?
A table top exercise is a series of modules put forward to say "what if," and
then discuss "what if." Each one of them takes us further into an imaginary
kind of event. Those are only helpful if those imaginary events are close to
the reality of how something would really happen. So if you're starting to plan
around something that is so illogical, or just wouldn't happen out there, it
doesn't matter what conclusions you reach--they're meaningless.
But in this case, from the reports, what did we learn from it?
The table top exercises to date show that we are absolutely not prepared to
even begin to respond to bio-terrorism, let alone control it.
One of the lessons from the table top exercises that have been conducted over
the last year is that this country is not only ill prepared to respond to
bio-terrorism, but that the planning activities that we need to better prepare
ourselves are not in place.
What do you mean when you say that things fall apart?
In the last four months, I've been involved with three different table top
exercises. In each one of them, when it came down to the really difficult
aspects of the vaccines, the antibiotics, who would do what--every one of them
failed miserably, because we either didn't have the resources, or no one really
knew what to do or how to do it, or how to even begin to prepare for it.
If these table tops fail, what does that mean about our real ability once it
actually takes place?
Table tops are actually artificially easy, because we build control into them.
And when they fail, you can only imagine what the real event will be like.
What do you find on the Internet that's so scary?
The Internet today is the vehicle that brings terrorists together in ways that
make intelligence very difficult to intercept. It brings infectious agents to
people who otherwise would not have access to them. And also, it furthers the
information out there for people who wouldn't quite know how to prepare
something, and now they can go to a cookbook on the Internet. In the anonymity
of their own home, they can figure out how to do it.
What fears come with the millennium?
The irony of it is, most people today are very concerned about the computer
bugs with the year 2000. Those of us in the area of biologic warfare and
terrorism are very concerned.....The goal of the millennium cults is to see
civilization end in the year 2000, and to take us to the next level. If you
want to effectively do in large number of people in a very cost-effective way,
biologic agents are the obvious answer. Our information would suggest that in
fact that is a primary weapon that is being sought out by a number of different
millennialist cults.
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