Public Health Experts Plan for the Unthinkable
By Neil Osterweil
Reviewed By Charlotte Grayson
In his first inaugural address in 1933, President Franklin Delano Roosevelt inspired a battered nation with these words: "The only thing we have to fear is fear itself -- nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance."
Instilling fear is a terrorist's stock in trade. But as FDR knew, the best antidotes to unreasoning, unjustified terror are knowledge, strength, and preparedness. Seventy years after he spoke those words to a nation beaten down by the Great Depression, we again face an uncertain economic future, and the even grimmer prospect of biological terrorism.
It has an ancient and dishonorable history: In the Dark Ages, armies used catapults to fling plague-ridden corpses over castle walls. In 1763, British commander Lord Geoffrey Amherst ordered the distribution to Native Americans of blankets that had been used by victims of smallpox. And in more recent times, biological weapons were used against livestock and civilians during both World Wars.
"In theory, biological weapons could be even more devastating than chemical or nuclear weapons. That's because some of them can spread far beyond the initial point of release through ongoing and multiplying human-to-human transmission," write David Ropeik and George Gray, PhD, from the Harvard Center for Risk Analysis in their book Risk: A Practical Guide for Deciding What's Really Safe and What's Really Dangerous in the World Around You.
The U.S. Centers for Disease Control and Prevention (CDC) divides biological agents into three categories -- A, B, and C -- based on their ability to wreak havoc on the population at large. Category A or "high priority" agents are those that can be easily transmitted through human contact, have a high death rate and the potential for a major public health impact, may cause widespread panic and disruption, and require special public health measures. Agents in this category are in alphabetical order:
- Tularemia (rabbit fever)
- Viral hemorrhagic fevers (such as Ebola virus)
Where's There's Ill Will, There's a Way
As the attacks of September 11, 2001 made starkly evident, terrorists may try to strike at civilian targets such as high-rise buildings, transportation hubs, sporting events, and public spaces such as malls.
Terrorists might choose to spread an infectious disease by facilitating person-to-person contact, or by deploying agents that have been "weaponized." For example, an infectious disease that normally infects the skin could be turned into an aerosol or powder form that could then be sprayed over a wider area, said an emergency response expert from the U.S. Department of Health and Human Services, who spoke with WebMD on background.
There are several notorious examples of small-scale biological and or chemical attacks in recent memory. In 1984, followers of the Indian guru Bhagwan Shree Rajneesh deliberately contaminated salad bars in 10 restaurants in Western Oregon; more than 700 people were poisoned. The group supposedly carried out the act, said to be the first documented case of bioterrorism in modern U.S. history, as a test of a plan to contaminate the local water supply. Their alleged motive was to prevent people from voting against cult-backed candidates in a county election.
In 1995, the fringe Japanese group Aum Shinrikyo spread the deadly nerve gas sarin in the Tokyo subway system, causing 12 deaths and more than 5,500 injuries.
"The scenarios are numerous. That is the problem," notes Jennifer Leaning, MD, professor of international health at the Harvard School of Public Health in Boston, one of 19 academic institutions funded by the CDC to develop public health strategies for coping with bioterrorism.
In a written reply to questions from WebMD, Leaning noted, "there are many pathways [for terrorist acts] -- think air and water. Then think of all the networked systems we live in -- the mail system was just one. The possible ingenuity a terrorist might employ, of relying on a system that already disseminates things, is what troubles many of us."
Leaning contends that it is "virtually impossible" to fully protect food and water supplies in a country as large and complex as the United States.
Easier Said Than Done
It is somewhat reassuring to know, say public health experts, that most biological agents are difficult to convert into weapons that can do large-scale damage, and they usually require special laboratory techniques and equipment to make them into a form that is easy to spread through the air.
For example: The CDC notes that in the anthrax scare of autumn 2001, only 22 people were infected with either the inhaled or skin (cutaneous) form of anthrax, and there were only five deaths, despite the fact that 85 million pieces of mail passed through the processing centers in New Jersey and the District of Columbia through which the contaminated envelopes also traveled.
As the HHS official told WebMD, it would take massive quantities of biological agents to even begin to contaminate a large municipal reservoir, because the toxin would otherwise be highly diluted and therefore very weak. Even then, the disease-causing agents would probably be killed by chlorination or filtered out of the water through the normal treatment process.
Similarly, the HHS expert said, poisoning of the food supply would have to occur fairly high up in the chain of production, such as a processing plant, for an intended biological weapon to have a large-scale impact.
And even such highly contagious and deadly agents as smallpox, while terrifying, can be contained if doctors remain vigilant for signs of infection and public health measures such as quarantine and vaccination are set into motion at the first sign of trouble, infectious disease experts say.
The Department of Homeland Security recently issued terrorism-preparedness guidelines that mirror natural disaster-readiness guidelines. The agency recommends that citizens have adequate supplies of food and water, battery-operated flashlights and radios, but also duct tape and plastic sheeting for sealing off windows and doors and presumably sealing out infectious agents or chemical contaminants.
Public health experts, the people who will be at the frontlines of any major public health alert, emphasize that anti-bioterrorism efforts involve far more than emergency response teams, ambulances, and vaccination programs.
"While people are intrigued by the rocket-science nature of biological weapons and whether it's a virus or chemical, sometimes we are killed by the very basics -- this person didn't know the phone number for that person, and didn't call them," says Deborah Prothrow-Stith, MD, professor of public health practice at the Harvard School of Public Health.
She notes that rescue efforts following the World Trade Center attack in New York were hampered by incompatible police and fire-department communications systems. Similarly, an analysis by Japanese researchers that followed the Tokyo subway attacks determined that rescue efforts were hampered by a lack of adequate decontamination facilities and by the fact that emergency response personnel -- police, fire, hospitals and government -- acted independently of one another and without central coordination.
The HHS official tells WebMD that doctors are one of the most important components of the bioterrorism alert system. They must be vigilant for anything out of the ordinary, such as a patient who has a respiratory infection from a type of bacteria or virus that normally infects the skin. In addition, physicians, emergency response personnel, nurses, and others must quickly notify the appropriate public health authorities so that action plans can be implemented.
Prothrow-Stith says that public health preparedness must include:
- Connectivity -- making sure that all of the agencies needed to respond to an event are known to each other and able to communicate easily with one another
- Emergency drills and exercises that test both emergency action plans and the existing public health system. If there is a statewide flu vaccination program, for example, that could be the basis for an emergency smallpox vaccination program, she notes.
- Coordination among various emergency response systems and public health agencies to ensure mutual understanding of resources, command structures, and integration of information.
- Ensuring that citizens in all communities receive adequate public health information and access to information sources and services. Disparities that exist in healthcare access and delivery under normal circumstances will become magnified during an emergency, Prothrow-Stith cautions.
- Families should also develop individual disaster plans that include information about whom to contact, where to gather in case of an emergency, etc.
Like it or not, Leaning tells WebMD, "the bottom line is that the threat is now higher than it has been in the past; the responses we are developing will help reduce the damage; but we are now and will remain vulnerable to greater insecurity than what we might have imagined prior to September 11."
Originally published Feb. 13, 2003.
Medically updated Feb. 3, 2004.
SOURCES: Jennifer Leaning, MD, professor of international health, Harvard School of Public Health, Boston • Deborah Prothrow-Stith, MD, professor of public health practice, Harvard School of Public Health. • Ropeik, David and Gray, George: Risk: A Practical Guide for Deciding What's Really Safe and What's Really Dangerous in the World Around You. • CDC • Okumura, T. et al: "Lessons Learned from the Tokyo Subway Sarin Attack, Prehosp Disast Med 2000;15(3):s30.
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