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Author: Joseph M. Rosen; C. Everett Koop; Eliot B. Grigg
We need a system that will enable us to mobilize all of our health care resources rapidly wherever they are needed.
Everything is not okay. On September 11, the realm of possibility suddenly expanded to include the unthinkable, and we were reminded that there are people who are willing and able to inflict massive civilian casualties in the United States. Moral repugnance is no longer a sufficient deterrent. September 11 also demonstrated that we cannot rely on prevention. We must be prepared to respond to a whole host of catastrophic contingencies.
The anthrax scare shortly thereafter introduced us to the threat of deadly biological agents. We were lucky this time, but 12 nations are known to possess, or are suspected of possessing, offensive biochemical weapons. The characteristics that make biological devices unwieldy as weapons of war--such as silence, incubation time, and uncontrollability--make them effective options for bioterror. Biological agents differ from their chemical and nuclear counterparts in a number of important ways: (1) they are easy to conceal; (2) if they are contagious, infected people can spread the disease; (3) the first responders exposed are likely to be health professionals rather than the traditional emergency personnel; (4) the longer an epidemic goes unrecognized and undiagnosed, the more difficult it is to control its effects. A well executed dispersal of an infectious pathogen would have devastating effects, and the psychological fallout and panic would be even worse.
As long as we value our personal freedoms, intelligence and law enforcement will never be perfect. In any case, although preventive measures are necessary, they can never be sufficient--no one can anticipate every contingency. In addition, because the intelligence community operates covertly, it can do little to allay popular fears or restrain panic. To meet this threat, we need a new strategy that brings together our command, communication, and control technologies. We must be able to mobilize all of our health care resources rapidly wherever the threat appears, even if it appears in many places simultaneously. During a crisis, there is no time to invent a response. We must be prepared, and right now we are not.
Six biological agents are most suitable for "weaponization": plague, tularemia, botulinum (toxin), the hemorrhagic fevers, anthrax, and smallpox. Three of the six, plague, the hemorrhagic fevers, and smallpox, can be transmitted from person to person. We will briefly discuss two of them--anthrax and smallpox--as examples.
Anthrax is caused by a bacterium, Bacillus anthracis. Infection can be manifested in three different forms: inhalational, cutaneous, and gastrointestinal anthrax. The mortality rate of occupationally acquired cases of anthrax in the United States is 89 percent. A 1993 report by the U.S. Congressional Office of Technology Assessment estimated that between 130,000 and 3 million deaths could follow the aerosolized release of 100 kg of anthrax spores upwind of the Washington, D.C., area--lethality matching or exceeding that of a hydrogen bomb (OTA, 1999). The military has a vaccine for anthrax, but current supplies are limited, production capacity is modest, and sufficient quantities of vaccine cannot be made available for civilian use for several years. Depending on the strain, anthrax usually responds to ciprofloxacin, doxycycline, or penicillin. However, anthrax exposed to less than lethal levels of any of these antibiotics is capable of developing resistance.
Smallpox, a disease caused by the variola major virus, was declared eradicated from the world as a naturally occurring disease in 1997. Routine vaccinations were discontinued in the United States in 1972 and in the rest of the world by 1979. Thus the vast majority of people everywhere have either never been vaccinated against the disease or have only partial immunity from vaccinations that were administered decades ago. Historically, the fatality rate from outbreaks of smallpox has been about 30 percent, but it is higher among the unvaccinated. Smallpox vaccine has been out of production for 30 years, and the government is not sure how far its reserve of 15 million doses can be diluted. There is no proven, effective, specific treatment for smallpox.
Current Level of Preparedness
In testimony before the Senate Appropriations Subcommittee on Labor, Health and Human Services, and Education and Related Agencies, Tommy G. Thompson, Secretary of the U.S. Department of Health and Human Services, described our preparedness for a biological attack: