Implications for Public Policy of the Threat from Bioterrorism

INTRODUCTION

In the summer of 2001, U.S. government officials faced a desperate situation. Tests conducted by the Centers for Disease Control had confirmed that a group of patients, suffering from fever and an increasingly angry rash, was infected with smallpox. On the first day of the outbreak, twenty cases were confirmed in Oklahoma, with more suspected in Atlanta and Philadelphia. Smallpox had not been seen in the U.S. since 1949 and officially the disease had been eradicated worldwide. The chances of this being a natural outbreak were therefore remote. An investigation soon confirmed what everyone feared: the United States had been deliberately targeted with the smallpox virus. Six days after the first case, the number of people known to have contracted the disease rose to 2,000, with 300 known fatalities. Across the country, daily life was grinding to a halt. The nation’s borders were closed, and schools were shut down indefinitely. Food shortages were becoming commonplace, as was violence against those of Arabic appearance. And this was only the beginning. The National Security Council estimated that three months into the epidemic, three million people would be infected. One million would be dead.

The scenario above formed the basis of an exercise known as “Dark Winter” that brought together top government officials to war-game their reactions to a smallpox attack on American soil.[i] The script for the exercise was no wild fantasy, but rested instead on established scientific knowledge of the characteristics of the smallpox virus. The results were alarming to say the least.

But “Dark Winter” was just one demonstration of the destructive potential of a biological attack. As Director of the Belfer Center for Science and International Affairs (BCSIA) at Harvard University’s John F. Kennedy School of Government, I have participated in a number of studies that reached a similar conclusion: the threat posed by bioterrorism is real and deadly serious.[ii] The aim of this paper is to review the options for policymakers and informed citizens seeking to meet this new challenge.

FROM FICTION TO FACT

In the past, the idea of terrorists employing biological weapons appeared more in the colorful world of science fiction than in serious discussions of public policy. Novels such as Richard Preston’s The Cobra Event and Hollywood blockbusters such as Outbreak helped cement wilder notions of a biological attack in the popular consciousness. Yet this view has been overtaken by actual events. Examples of terrorists deploying and attempting to deploy biological agents against civilian targets are no longer mere science fiction, but established facts. The most recent demonstration of this came in the fall of 2001, when letters containing anthrax were mailed to the U.S. Senate and selected media organizations. Key government buildings, including both houses of the U.S. Congress, were shut down for days as investigators struggled to identify genuine spores of bacteria among the avalanche of suspicious white powders that had been reported by anxious staff and members of the public. As fear spread, the number of people taking the antibiotic CIPRO for possible anthrax exposure, at the urging of government officials, soon exceeded 10,000. Ultimately, five people succumbed to the disease; and despite a massive investigation by U.S. law enforcement agencies, at present, not one suspect has been arrested. The anthrax mailings were not the first attempt at modern biological terrorism and, unfortunately, we have no reason to believe that they will be the last.

In 1984, the Rajneeshee cult deliberately contaminated salad bars in Wasco County, Oregon, with salmonella bacteria, leading to 751 confirmed cases of the illness. In the early 1990s, the Japanese doomsday cult Aum Shinrikyo developed anthrax spores and experimented with aerosolized botulinum toxin. Yet the technology employed was crude and attempts to disperse these agents proved harmless. More recently, detailed notes on anthrax production were recovered from Al-Qaeda training camps in Afghanistan. After 9/11, Osama bin Laden’s spokesman, Sulaiman Abu Ghaith, declared that Al-Qaeda had “the right to kill four million Americans” in response to casualties he claimed had been inflicted on Muslims. Given such a commitment, Al-Qaeda’s willingness to use biological weapons, were they to acquire the means and the opportunity to do so, should not be underestimated. When announcing a smallpox vaccination program for selected military personnel and healthcare workers in December of last year, President Bush rightly stressed that it is only “prudent to prepare for the possibility that terrorists who kill indiscriminately would use disease as a weapon.”[iii]

While the situation in the short term gives cause for concern, a longer-term perspective appears even more disturbing. We are currently witnessing a revolution in biological science that rivals the nuclear revolution in significance. As my BCSIA colleague, biochemistry professor Matthew Meselson, has noted, “Virtually every major technology has been exploited not only for peaceful purposes but also for hostile ones.”[iv] Have we reason to doubt that biotechnology will be any different? The horror of “designer germs,” where pathogens are genetically engineered to enhance their deadly effects or evade current vaccines, is often raised in some quarters. While the resilience of these so-called “superbugs” outside of a test tube environment remains unproven, the future potential of this technology cannot be ignored.

REDUCING THE THREAT

The threat from biological terrorism may be real, but, like other threats to our security, it can be significantly reduced if we adopt the appropriate policies. Comparisons are often made between bioweapons and other weapons of mass destruction. Indeed, under optimal conditions, a biological attack could be at least as deadly as a nuclear assault. Yet this is where the parallel ends. To counter bioterrorism, the Cold War paradigm of deterrence through the threat of massive retaliation is of limited use. First, contemporary international terrorist groups such as Al-Qaeda, who are committed to mass casualty terrorism, have no return address, and thus feel relatively invulnerable to retaliation. Second, a biological attack would most likely be covert rather than overt. Given the fact that biological agents have no unique signature readily identifying their respective sources, it would be extremely difficult to determine the perpetrator of such an attack. Indeed, it may even be difficult to distinguish a naturally occurring outbreak of disease from a deliberate biological assault. Such uncertainty makes retaliation practically impossible.

In place of traditional deterrence, proposed policy responses to bioterrorism fall into two categories, namely, limiting the availability of bioweapons and their precursors and biodefense of the homeland.

LIMITING AVAILABILITY

In 1972, 144 world leaders committed their nations to the Biological and Toxin Weapons Convention (BTWC), prohibiting the international production, retention and transfer of biological weapons. Yet despite this agreement, today there exist sufficient national stockpiles of biological weapons to wipe out the world’s population many times over. How has this come about? Some countries with suspected biological arsenals, such as Sudan and Israel, have simply refused to commit to the BTWC. Other nations chose to sign the treaty, but then secretly violated it. The Soviet Union’s Biopreparat biological weapons research and production program, which was not revealed to the world until the end of the Cold War, is testament to how successful a nation can be in concealing its biological warfare secrets. At its peak, this program employed thousands of scientists and produced hundreds of tons of the world’s deadliest germs. With no verification mechanism built into the BTWC, it was possible for the Soviet Union, and others, to violate the treaty at will.

Tackling the relative abundance of biological weapons at the national level requires a more effective arms control agreement. First, the BTWC would need to be given teeth through a strengthened and rigorous inspection regime capable of verifying a country’s commitment to the treaty. To build confidence, it would be critical that intrusive inspections be accepted by all parties, including the United States. Second, the U.S. would have to pressure all countries to sign up to the amended treaty, close allies such as Israel included. If everyone is required to abide by the treaty, there can be no excuses for non-compliance. If exceptions can be made for some, then why not for others? The advantages of this approach are clear. Working to eliminate state arsenals would remove the most obvious source of ready-made weapons for potential bioterrorists. We would no longer need to worry about rogue nations covertly opening their biological arsenals to terrorists or leaving them vulnerable to theft. Under an effective arms control regime, there would be nothing left to steal.

A major stumbling block results from the dual-use nature of much biotechnology. In other words, it is very difficult to distinguish biological research programs with a military objective from those intended only for peaceful purposes. This problem becomes acute in the area of biodefense research—the Bush Administration’s principal objection to strengthening the BTWC. In a world of uncertainty, prudence requires that governments do everything they can to defend their population against a biological attack. Defensive biological research, including the development of new vaccines or treatment drugs, is a key component of this. Governments will argue that this research must be shrouded in secrecy not only to avoid disclosing their methods and intelligence sources, but also to prevent bioterrorists designing around the countermeasures being developed.

The logic of this argument is that, to ensure a prudent defense policy, defensive research must be off limits to any third-party inspections. Yet the line between defensive and offensive biological research is perilously thin. In the mid-1990s, under the “Clear Vision” program, the CIA developed replicas of former Soviet bioweapons to determine how to defend against them. Under a strengthened BTWC, what is to stop, say, North Korea from recategorizing biological weapons research programs as part of a “defensive” effort to understand more about the “threat” they face? The answer to this slightly contrived example lies in a careful determination of what a nation can and cannot legitimately designate as defensive and thus keep secret. Yet while it is possible to draw some distinctions, at the margins, nothing is black or white.

In the shorter term, there is a more immediate and perhaps more manageable challenge for arms control policy. With the end of the Cold War came the demise of the Soviet Biopreparat program. This left thousands of weapons scientists unemployed and huge stockpiles of biological agents with minimal security. Fortunately, policymakers have not been blind to this potential gold mine for bioterrorists. Through the Cooperative Threat Reduction Program, the U.S. Congress has provided substantial funding to help secure and eventually destroy stocks of deadly agents and to find new, peaceful employment for former bioweaponeers. For the fiscal year 2004, the proposed budget for biological weapons proliferation prevention in the former Soviet Union is a little over $54 million, a welcome increase from previous years. Yet securing the human and technological remnants of such a massive biological weapons program is a daunting task, which has been complicated by the refusal of the Russian authorities to allow inspectors into some former bioweapons facilities. In the future, this will require patient but active diplomacy and sustained financial support.

Getting rid of existing bioweapons and their immediate precursory materials would clearly reduce the options available to an aspiring bioterrorist. It would not, however, eliminate them completely. Given biological seed stock, common laboratory equipment, and some fairly elementary scientific expertise, an individual could grow deadly pathogens with relative ease. Working out how to convert these agents into a viable biological weapon capable of causing mass casualties is more challenging, yet far from impossible. As science continues to advance and previously restricted knowledge becomes more widely diffused, the pool of those with the necessary expertise will inevitably grow.

Some steps have already been taken to tackle this issue. In 1996, the U.S. placed strict limits on access to germ banks, and tightened these laws even further after 9/11. Yet there are still hundreds of culture collections around the world with less stringent controls. The Australia Group has made some progress in limiting exports of dangerous pathogens, yet it remains possible for a determined terrorist to circumvent these measures.

Ultimately, we should remember that almost all biological agents exist in nature, some with alarming abundance. Therefore, while limiting access to pathogens is a useful start, we must also focus on restricting what individuals do with nature’s more sinister offerings. To this end, scholars at the Harvard Sussex Program on Chemical and Biological Weapons Limitation have proposed a draft international convention, criminalizing the development and retention of biological weapons. Individuals who conduct such activities would be considered “hosts human generis, enemies of all humanity.”  Through harnessing international law, such a convention would promote and require cooperation between nations in prosecuting offenders, whether they are agents of a state, members of a terrorist group, or lone individuals.

BIODEFENSE OF THE HOMELAND

While limiting the ability of terrorists to obtain or develop bioweapons is crucial, this policy must be complemented by the development of a comprehensive biodefense strategy at home. The largely unrecognized good news is that, through this second approach, massively destructive bioterrorism is preventable. Completely removing the ability of a determined terrorist to attack the U.S. with biological agents is not possible. Preventing such an attack from killing hundreds, thousands, or even millions of Americans is possible—if, and only if, the U.S. is determined to make this so.

A comprehensive defense against WMD bioterrorism requires (1) early identification of the agent through information systems and sensors that collect and combine clues rapidly, (2) hardening the population against infection from pathogens by vaccination, readiness for wider-area vaccination, and therapeutics, (3) a modernized nationwide public health system that is agile and able to adapt in combating attacks, and (4) leadership in government and the public health system that can facilitate credible communication with the American public.

Unfortunately, there is still a great deal of work to be done in each of these four crucial areas. I will devote the remainder of this essay to highlighting the most pressing issues.

Early Identification

Spotting outbreaks of disease early is critical to effective treatment and containment. To achieve this, one approach is to focus on observable patient symptoms. In this area, our initial priority should be a major investment in training for our doctors and nurses to enable them to recognize the early stages of the often uncommon diseases favored by bioterrorists. After all, in many instances, the first medical professional to come into contact with victims of a biological attack will be an emergency clinician. But this need not always be the case. Some deadly diseases begin with less serious symptoms, which do not appear to require an emergency room visit. Back in April, the National Journal reported the success of a pilot project between the Centers for Disease Control and selected private health plans to address this issue.[v] Realizing that individuals often report minor symptoms to their family doctor first, the CDC funded the collation of this information. It was then analyzed by CDC epidemiologists, who were able to identify statistical spikes in common diseases. The principal drawback with this type of monitoring is that symptoms must appear before the alarm can be sounded. In some cases this may take several days, a dangerously large amount of time when trying to control an outbreak.

By contrast, an alternative approach is to use advanced technology to identify a biological attack before anyone gets sick. In June, scientists based at the Pacific Northwest National Laboratory succeeded in enhancing the effects of an enzyme that has considerable potential for sensing biological agents. This breakthrough was one of many attempts to develop a new generation of biosensors capable of detecting dangerous concentrations of pathogens in the atmosphere, which could give public health workers an invaluable head start in the race to contain an imminent outbreak of disease. Although the high cost of developing this technology cannot be ignored, the results so far are encouraging and deserve further investigation.

Hardening the population

Hardening the population against infection requires careful planning for the development and deployment of vaccinations and effective treatments. Our first step must be to build on the progress that has already been made in enhancing the National Pharmaceutical Stockpile. Equally important, however, is working out how to move supplies from the stockpile swiftly to wherever they are needed. Although we now have national plans for transporting the drugs across the country, there is an urgent need for individual states to draw up plans for receiving the bulk shipments, dividing them into smaller packages, and distributing the drugs locally.

Yet deciding how to use our existing drugs to protect the population against WMD bioterrorism presents a dilemma that goes well beyond logistics. The critical issue is when to make use of the drugs available. One option is to wait for illness to develop before deploying the relevant treatments. The alternative approach is to try to preempt biological attack by using vaccines to produce immunity against disease. At first glance, the latter might seem a superior strategy, particularly for diseases such as smallpox where there is no treatment available except early vaccination. Nevertheless, as the recent U.S. smallpox vaccination campaign illustrates, preemptive treatment can prove highly problematic.

The aim of this campaign was to vaccinate 500,000 healthcare workers, preparing them to care for the victims of any future smallpox attack. Despite plans to complete these voluntary vaccinations by March 31, 2003, fears about the vaccine’s side effects limited progress to such an extent that, as of August 8, 2003, only 38,257 people were vaccinated. For two out of every one million people vaccinated, the side effects could be as serious as death, but it appears to have been the more common and less threatening complications that put off potential volunteers. Healthcare workers were particularly concerned that their private health care plans would not cover the costs of treating even minor illnesses. Many workers would not even be compensated for taking time off work to recover. At the end of April, President Bush signed a law to address these issues; however, this has not yet boosted the number of people volunteering for the vaccination. Ultimately, the campaign has been undermined by the failure of the Administration to provide a convincing argument that the unknown threat of attack outweighs the known threat posed by the vaccine’s side effects.

Like the vaccination for smallpox, many vaccines have unpleasant side effects, raising important questions about their use. For some diseases no vaccines exist at all. In response, President Bush has proposed a $5.6 billion spending program, known as Project BioShield, to develop new, safer vaccines and treatments. This may sound encouraging, but there remains an important objection. There are dozens of known pathogens that could be used in a biological attack. Are we to develop and stockpile vaccines for every conceivable pathogen? And even if, many years and trillions of dollars down the road, we did develop these vaccines, what would we do about those pathogens that naturally mutate or those that have been genetically altered to evade treatment?

Working on improving vaccinations and treatment for agents known to be particularly attractive targets for bioterrorists is important, but must be balanced by the need to invest our limited resources in other biodefense measures. As Matthew Meselson stresses, we should not underestimate what can be achieved using well established preventative techniques and therapeutics.  The SARS outbreak, for example, was not brought under control by a new wonderdrug, but by traditional isolation techniques and a stress on basic personal hygiene. Focusing attention on such measures would not only help guard against bioterrorism, but also would prove hugely beneficial to the general state of public health.

A modernized nationwide public health system

The ability to detect pathogens and the availability of treatment drugs must be integrated within modernized public health structures to create an organized capacity for responding to bioterrorism. Our principal aim should be to produce a public health system that is sufficiently robust in order to prevent an infectious disease outbreak, whether natural or terrorist-inspired, from becoming an epidemic. While it may not be possible to reduce the death toll of a bioterrorist attack to zero, the ability to stop a disease reaching epidemic proportions would, in effect, prevent biological weapons from being used as weapons of mass destruction.

According to Senate Majority Leader Bill Frist, who is also a distinguished M.D., the first priority must be to improve “training, communication and coordination between the various parts of our public health system.”[vi] While some parts of our government bristle with the latest technology, our public health system appears to have been left behind. Frist reveals that, astonishingly, one in every five of our public health offices does not even have access to email.[vii] If we hope to engender a new culture of cooperation and coordination between the different elements of our health system across the country, we must first provide them with the equipment they need to communicate efficiently.

Effective communication systems will ensure that details of new disease outbreaks can circulate swiftly, and that the necessary drugs can be dispatched promptly from the National Pharmaceutical Stockpile. Yet administering these drugs to those who need them is no easy task. We must therefore designate venues in advance for the triage, containment, and treatment of large numbers of infected citizens. Developing this so-called “surge capacity” will be an expensive and major undertaking, yet ultimately it promises to produce enormous benefits for public health and national security.

Leadership in government

Politicians also have a direct contribution to make in managing the aftermath of a biological attack. Working closely with our public health leaders, they must be prepared to communicate effectively with an anxious public. While it has often been assumed that a biological attack would lead to widespread public panic, this need not be the case. To many people, the idea of being attacked with invisible, deadly biological agents is, understandably, very frightening. Yet we know from the field of risk communication that the best way to prevent this fear from translating into panic is by providing accurate information from a trustworthy source. While the credibility of our politicians is often a matter of heated debate, in the event of bioterrorist attack these politicians must be ready to rise to the occasion. In preparation, aspiring leaders could do far worse than to study the widely acclaimed performance of New York Mayor Rudolph Giuliani in the aftermath of the terrorist attacks of September 11, 2001. In times of crisis, the public looks for leadership. So long as our leaders communicate openly and honestly and treat citizens with the respect they deserve, the chances of widespread panic can be minimized.

CONCLUSION

The combination of terrorists who are determined to kill as many civilians as possible, the tremendous destructive potential of biological agents, and the growing availability of scientific knowledge is a legitimate cause for concern. But while the threat from bioterrorism is real, there is much we can and should do to guard against it. I have argued that our approach must be twofold. First, we must make it as difficult as possible for terrorists to get their hands on biological weapons. Through a more effective arms control policy, we must reduce and eventually eliminate national stockpiles, removing an obvious source of ready-made bioweapons. We must also tackle the activities of the entrepreneurial bioterrorist by limiting access to collections of seed stock and ensuring that any unauthorized attempt to gain access to them becomes a crime of the utmost gravity under international law.

Second, we must complement this approach with direct measures to protect our homeland. An effective capacity for biodefense at home draws together disease monitoring, the availability of vaccines and treatments, a robust public health system, and government leadership to ensure that outbreaks of infectious diseases will not become mass epidemics. The challenge we now face is to develop such a capacity and return the threat of mass casualty bioterrorism to the world of science fiction, where it rightly belongs.

[i]For more details on the “Dark Winter” exercise, see the website of the John Hopkins Center for Civilian Biodefense Strategies. Available at: http://www.hopkins-biodefense.org/

[ii]Belfer Center for Science and International Affairs (BCSIA) publications on this topic include: Lederberg, Joshua, ed., Biological Weapons: Limiting the Threat (Cambridge, Mass.: The MIT Press, 1999); Tucker, Jonathan B., ed., Toxic Terror: Assessing Terrorist Use of Chemical and Biological Weapons (Cambridge, Mass.: The MIT Press, 2000); and Falkenrath, Richard A., Robert D. Newman, and Bradley A. Thayer, America’s Achilles’ Heel: Nuclear, Biological, and Chemical Terrorism and Covert Attack (Cambridge, Mass.: The MIT Press, 1998).

[iii]Cited in Ceci Connolly and Dana Milbank, “U.S. revives smallpox shot,” The WashingtonPost, December 14, 2002.

[iv]Meselson, Matthew, “Bioterror: What Can Be Done?” in Silvers, R. and B. Epstein, eds., Striking Terror: America’s New War (New York: The New York Review of Books, 2002), p. 259.

[v]M. Serafini, “Health plans search for bioterror symptoms,” National Journal, April 19, 2003.

[vi]Frist, B. When Every Moment Counts: What You Need to Know about Bioterrorism from the Senate’s Only Doctor (Lanham, Md.: Rowman & Littlefield, 2002), p.161.

[vii]Ibid.