Preparing for and Preventing Bioterrorism
Strengthening the U.S. public health infrastructure is the key to enhancing the nation's safety.
The tragic events of September 11th, followed by the recent anthrax incidents, have made us painfully aware of our nation's vulnerability to terrorism, including bioterrorism. Although once considered a remote concern, the possibility that a biological agent might be intentionally used to cause widespread panic, disease, and death is now a common concern. Whether the event involves an unsophisticated delivery system with a limited number of true cases, as we have seen with the current anthrax scare, or a carefully orchestrated attack with mass casualties, the prospects are frightening. As the United States mobilizes to address an array of overlapping foreign policy, infectious disease, and national security threats, it must make sure that a comprehensive program to counter and prevent bioterrorism ranks high on the priority list.
The threat of bioterrorism is fundamentally different from other threats we face, such as conventional explosives or even a chemical or nuclear weapon. By its very nature, the bioweapons threat, with its close links to naturally occurring infectious agents and disease, requires a different strategy. Meaningful progress against this threat depends on understanding it in the context of epidemic disease. It requires different investments and different partners. Without this recognition, the nation's preparedness programs will be inadequate, and we may miss critical opportunities to prevent such an attack from occurring in the first place.
Biological terrorism is not a "lights and sirens" kind of attack. Unless the release is announced or a fortuitous discovery occurs early on, there will be no discrete event to signal that an attack has happened, and no site that can be cordoned off while authorities take care of the casualties, search for clues, and eventually clean up and repair the damage. Instead, a bioterrorism event would most likely unfold as a disease epidemic, spread out in time and place before authorities even recognize that an attack has occurred. Recognition that an attack had occurred would emerge only when people began appearing in their doctor's office or an emergency room with unusual symptoms or inexplicable disease. In fact, it may prove difficult to ever identify the perpetrators or the site of release--or even to determine whether the disease outbreak was intentional or naturally occurring.
The first responders to a bioterroism event would be public health officials and health care workers. Unfortunately, in many scenarios, diagnosis of the problem may be delayed, because medical providers and labs are not equipped to recognize and deal with the disease agents of greatest concern. What is more, effective medical interventions may be limited, and where they exist, the window of opportunity for successful intervention would be narrow. The outbreak is likely to persist over a prolonged period--months to years-- because of disease contagion or continuing exposure. The speed of recognition and response to an attack will be pivotal in reducing casualties and controlling disease.
Not only are biological weapons capable of causing extraordinary devastation, but they are relatively easy to produce, inexpensive, and capable of causing significant damage even when small quantities are delivered by simple means. In addition, information about how to obtain and prepare bioweapons is increasingly available through the Internet, the open scientific literature, and other sources. Opportunities for access to dangerous pathogens can be fairly routine; some of these organisms are commonly found in nature or are the subject of legitmate study in government, academic, and industry labs. Furthermore, bioweapons facilities can be hidden within legitimate research laboratories or pharmaceutical manufacturing sites.
Developing a response
Although there are enormous challenges before us, many of the elements of a comprehensive approach are relatively straightforward. Some of the necessary activities are already under way, though they may need to be expanded or reconfigured; other programs and policies still need to be developed and implemented.
Perhaps most fundamental to an effective response is the understanding that public health is an important pillar in the national security framework and that public health professionals must be full partners on the U.S. security team. In fact, the president should appoint a public health expert to the National Security Council, and Governor Ridge must include public health experts among his key staff in his new Office of Homeland Security.
Today, experts agree that there is an urgent need to increase the core capacities of the public health system to detect, track, and contain infectious disease. State and local public health departments represent the backbone of our ability to respond effectively to a major outbreak of disease, including a bioterrorist attack. Yet these public health agencies have never been adequately supported or equipped to fulfill this mission. In fact, many hesitate to call the array of health structures at the state, county, and local level a public health "system," because years of relative neglect and underfunding have left them undercapitalized, fragmented, and uncoordinated.
Upgrading current public health capacities will require significantly increased and sustained new investments. First and foremost, this means providing resources to strengthen and extend effective surveillance systems that can rapidly detect and investigate unusual clusters of symptoms or disease. This will entail expanding and strengthening local epidemiologic capabilities, including trained personnel and increasing laboratory capacity to rapidly analyze and identify biological agents. In addition, communication systems, including computer links, must be improved to facilitate collection, analysis, and sharing of information among public health and other officials at local, state, and federal levels. Beyond these critical domestic needs, successful strategies must also include a renewed commitment to improving global public health.
To improve detection, it is essential that physicians and other health care workers be trained to recognize unusual disease or clusters of symptoms that may be manifestations of a bioterroist attack. This must also include strengthening the relationship between medicine and public health so that physicians understand their responsibility to report disease or unusual symptoms to the public health department. Physicians must know whom to call and be confident that their call will contribute to the overall goal of providing information, guidance, and support to the medical community. Health care professional organizations, academic medical institutions, and public health officials must come together to develop appropriate training curricula, informational guidelines, and most important, the working partnerships that are critical to success.
Those same partnerships will be very important in addressing another critical concern: the urgent need to develop emergency plans for a surge of patients in the nation's hospitals. We must enhance systems to support mass medical care and develop innovative strategies to deliver both protective and treatment measures under mass casualty and/or exposure conditions, especially when there may be an additional set of very difficult infection-control requirements as well. This will require careful advance planning since most hospitals are operating at or near capacity right now. Systematic examination of local capabilities and how they can be rapidly augmented by state and federal assets must be part of this effort.
Federal health leadership will be important in this effort to define needs and provide model guidelines and standards; federal resources may also be essential to support planning efforts and to create the incentives necessary to bring the voluntary and private health care sector fully on board. However, the final planning process must be undertaken on the local or regional level, engaging all the essential community partners and capabilities. It is critical to remember that the front line of response, even in a national crisis, is always local. Thus, across all these domains of activity, we must make sure that we have adequate capacity locally and regionally, which can then be supplemented as needed.
Another important example of this involves access to essential drugs and vaccines. A large-scale release of a biological weapon may require rapid access to quantities of antibiotics, vaccines, or antidotes that would not be routinely available in the locations affected. Given that such an attack is a low probability and unpredictable event in any given place, it would hardly be sensible or cost effective to stockpile supplies at the local level.
As we ramp up our public health and medical capacity to respond to bioterrorism, we should continue to strengthen our national pharmaceutical stockpile so that vital drugs and equipment can be rapidly mobilized as needed. The federal Centers for Disease Control and Prevention (CDC) has the responsibility to maintain and oversee use of this stockpile, which currently represents a cache of supplies located in strategic locations across the country that can be delivered within 12 hours to any place in the nation. Current concerns make it clear that the nature and quantities of materials maintained in the stockpile must be enhanced, and the stockpile contents should be periodically reviewed and adjusted in response to intelligence about credible threats. New investments in the stockpile should also include contractual agreements with pharmaceutical manufacturer's to ensure extra production capability for drugs and vaccines in a crisis as well as heightened security at the various storage and dispersal sites.
Beyond simply having the drugs and vaccines available, we must develop plans for how those critical supplies will be distributed to those who need them. CDC needs to provide strong leadership and support for state and local health departments to undertake contingency planning for distribution. We must also think about the broader mobilization of essential drugs, vaccines, or other materials in the event that they are needed outside the United States. Although this may raise complex diplomatic issues, especially when the necessary pharmaceutical is in short supply, addressing potential global need is essential for political and disease-control reasons.
To make sure that the United States can remain strategically poised, further investments must be made in biomedical research to develop new drugs, vaccines, rapid diagnostic tests, and other medical weapons to add to the arsenal against bioterrorism. We must learn more about the fundamental questions of how these organisms cause disease and how the human immune system responds so that we can develop better treatments and disease-containment strategies. It is also essential that we improve technologies to rapidly detect biological agents from environmental samples and develop new strategies and technologies to protect the health of the public.
Scientists will need the full support and encouragement of the public and the government confront this threat. Success will entail research endeavors and collaboration involving numerous government agencies, universities, and private companies. Looking to the future, an effective, well-funded research agenda may give us the tools to render the threat of biological weapons obsolete.
An ounce of prevention
Stopping a biological attack before it happens is obviously the most desirable way to avoid a crisis. The first step in blocking the proliferation and use of biological weapons is to significantly bolster our intelligence. The intelligence community could use additional scientific and medical expertise to help enhance the quality of data collection and analysis. This will require greater partnership and trust between the intelligence community, law enforcement, and public health and biomedical science. These disciplines do not routinely work together, and their professional cultures and practices are not easily merged. Nonetheless, greater coordination of effort is very important to our national defense and must be an element of our nation's developing homeland security strategy.
Sadly, we must recognize that the possibility of bioweapons threats emerging from legitimate biological research is certainly real and embedded in the very science and technology that we herald in laboratories around the world. Vigilance is needed to ensure that the tools of modern genomic biology are not used to create new and more dangerous organisms. This is a complex challenge, for no one would want to impede the progress of legitimate and important science. However, we also have a responsibility to face up to a very real set of concerns. With leadership from the scientific community, we must begin to examine what opportunities may exist to constructively reduce this threat.
Related to this, we must continue to reduce access to dangerous pathogens by helping the scientific community improve security and ensure the safe storage and handling of these materials. Over the past five years, new regulations and requirements have tightened access to biological materials from culture collections in the United States and strengthened the government's ability to monitor the shipping and receipt of dangerous pathogens through a registration process, which also requires disclosure of the intended use for the agents. These are important steps, but more can and should be done to assure that our nation's laboratories have adequate oversight of the use and storage of these materials.
International cooperation will be essential to achieving these goals. The safety and control methods developed for domestic must be extended across the globe if they are to make a real and enduring difference. Coupled with this, we should enhance efforts to provide socially useful research opportunities to scientists who had been employed in the Soviet Union's bioweapons program. Many of these scientists are under- or unemployed, and it is in our interest to see that economic need does not drive them to peddle their knowledge to potential terrorists. We must also support efforts to help them secure or destroy potentially dangerous materials. The U.S. government has supported such efforts through the Cooperative Threat Reduction (CTR) program, but these programs desperately need to be strengthened and expanded. Opportunities to extend the reach of the program to include university and industry R & D collaborations will also be essential to long-term success.
In the final analysis, it may prove impossible to prevent future bioweapons attacks from occurring, but planning and preparation could greatly mitigate the death and suffering that would result. As a nation, we need comprehensive, integrated planning for how we will address the threat of bioterrorism, focusing both on prevention and response. We need to define the relative roles and responsibilities of the different agencies involved, and identify the mechanisms by which the various levels of government will interact and work together. The new Office of Homeland Security is well situated to take on this task. Congress and the president must give this office the resources and authority necessary to develop and implement protective measures. Likewise, federal officials must vigorously pursue interantional cooperation in this effort.
The United States has always been willing to meet the requirements and pay the bills when it came to our defense systems and security needs. We must now be willing to do the same when it comes to funding critical public health needs. Public health has too often received short shrift in our planning and public funding. This must change. Congress and the public need to understand that strengthening disease surveillance, improving medical consequence management, and supporting fundamental and applied research will be essential in responding to a biological weapons attack in this nation or anywhere in the world. These investments will also enhance our efforts to protect the health and safety of the public from naturally occurring disease. We have a chance to defend the nation against its adversaries and improve the public health system with the same steps. We cannot afford not to do this.
Margaret A. Hamburg is vice president for biological programs at the Nuclear Threat Initiative in Washington, D.C. She was assistant secretary for planning and evaluation in the Department of Health and Human Services during the Clinton administration and before that New York City commissioner of health.