The Anthrax Letters: The Attacks That Shocked America (21 page)

Within 45 seconds of the time of release, bacteria had spread everywhere, including onto the breathing filter of the tester’s mask. The report suggests that the study’s “dramatic results” demanded better preparation for an attack with germs sent by mail. “It is only a matter of time until a real ‘anthrax letter’ arrives in some mail room,” the report concluded.

As eminently correct as that observation proved to be, another of its admonitions fell short. Failure to seal an envelope’s corners, according to the report, “could also pose a threat to individuals in the mail handling system.” True. But the implication is that bacteria would not escape from a well-sealed envelope. A month later, during the anthrax letter crisis, investigators realized that the 1- to 3-micron spore particles were leaking not through leaky flaps but through 20-micron pores in the paper envelope.

In its concluding paragraph the DRES report noted that similar experiments had recently been conducted by another agency in Canada, the Ottawa-Carleton First Responder Group. In that study, titled
Investigation on the Dispersal Patterns of Contaminants in Letters,
the Ottawa-Carleton group placed fingerprint powder in envelopes. The results were similar. Even when the envelopes were not physically opened, powder leaked out and caused “contamination in the immediate area.”

The risk of anthrax in the mail was also assessed in William Patrick’s 1999 study for the Scientific Applications International Corporation. The report is not publicly available, but Patrick shared information about it with William Broad, a
New York Times
reporter. Patrick indicated that a puff of aerosol bacteria emerging from an envelope could be lethal. But there apparently was no indication in his report, or in the two Canadian studies, that cross-contamination could magnify the potential for death.

Just how long would a contaminated mailbox retain spores? Kathy Nguyen’s and Ottilie Lundgren’s mailboxes tested negative for anthrax. But the tests were undertaken days after the women’s diagnoses and probably weeks after an infected mail item would have arrived in their boxes. If a slightly contaminated letter left spores in a mailbox, how long might it take for subsequent deliveries and retrievals to clear the spores from the box?

Late in 2002, I conducted a study to help answer that question. Published in the
Journal of Public Health Management and Practice
(September 2003), it is titled “Persistence of a Mock Bio-agent in Cross-Contaminated Mail and Mailboxes.” The study included three trials, each conducted in the same manner. A trial would begin with the placement of 1 gram of a mock biological agent and a sheet of paper in a prestamped postal envelope, much like those used in the real anthrax mailings. The agent, called “Glo Germ,” is a fine white powder composed of 5-micron particles that approximate the size of anthrax spores. The particles are fluorescent and strikingly visible under an ultraviolet light. Glo Germ is used to check hygienic and infection control practices in hospitals and among food handlers. It has also reportedly been used by the U.S. Army as a tracer in mock germ warfare tests.

After sealing the envelope flap and its corners with tape (as was done with the real anthrax letters), the envelope is placed in two Ziploc plastic bags, one inside the other. The bags are shaken and squeezed, to simulate the turbulence caused by a mail sorting machine. The letter is then removed and replaced with six uncontaminated letters. Again, the bags are shaken. The six letters are removed from the bags and placed in a rural mailbox much like the one used by Ottilie Lundgren. After 3 minutes, the letters are removed from the mailbox. Fluorescent particles on the letters and on the floor of the mailbox are counted.

The exercise is repeated: Nine more deposits and retrievals in the same mailbox are performed, each with a new batch of six uncontaminated letters. After each “mailing,” the letters and the floor of the mailbox are examined for the presence of particles.

The first six letters in each trial are the only ones that have had direct contact with an originally contaminated letter. Not surprisingly, the total number of particles in each of these initial batches was high—exceeding 50 particles. In all three trials, the number of particles—that is, the level of contamination—decreased in the course of the 10 mailings.

Particle counts on the floor of a mailbox after the first mailing varied in each trial. In the first trial the figure exceeded 50, in the second it was 32, and in the third it was 24. The enumeration of particles was in part subjective because some of the fluorescent spots appeared as smudges rather than discreet points. (A smudge may have represented several particles or otherwise been an artifact, but each was recorded as one particle.) Still, the trend was clear. After the fourth or fifth mailing, traces of fluorescent particles were largely absent from the letters. While traces in the mailboxes themselves persisted somewhat longer, their numbers also declined with successive mailings. Indeed, in the first trial, after the tenth mailing, no particles were visible in the mailbox. In the other two trials, after 10 mailings, two particles remained in each.

This exercise demonstrates that successive placements and removals of letters in a mailbox may cause a decline in the number of residual bioagent particles. It supports the mail-related explanation for the anthrax infections of Kathy Nguyen and Ottilie Lundgren. The women may well have been exposed to anthrax in cross-contaminated mail despite the apparent absence of spores in their mailboxes or among their personal belongings weeks afterward. The pool of spores that they were exposed to may have been very small. And the few spores that remained after exposure could have been cleared away during subsequent contact with uncontaminated items.

These observations provide a sense of both comfort and unease. It is clear that cross-contamination of mail sharply declines with successive placements and retrievals in a mailbox. After just a few mailings, even though some bio-agent might still be found in a mailbox, newly placed letters remain largely free of particles. Moreover, the box itself becomes decreasingly contaminated during successive mailings. Exactly where all the particles end up is uncertain. But most do not attach to the letters and are probably swept into the air as the letters are withdrawn. Assuming small numbers, they could settle into the ground beyond detection or, if indoors, be swept from surfaces during later cleaning.

Still, the fact that anthrax spores are very durable, and the chance that some people are susceptible to infection from a very small amount, is disturbing. Tiny quantities of spores from the anthrax letters could have found niches in homes around the country. While most people would appear not to be vulnerable, the fate of Kathy Nguyen and Ottilie Lundgren reminds us that some people might well be. Years from now a few anthrax spores on a piece of long-saved mail, or on another cross-contaminated surface, might yet infect a vulnerable person. The legacy of the 2001 anthrax letters could linger long into the future.

The anthrax letters generated a host of unexpected findings and changed assumptions. Conventional wisdom about anthrax infection before the attacks was subjected to reassessment in many areas—diagnostics, surveillance, gravity of the disease, manner of treatment, effectiveness of transmission by mail. Perhaps the greatest overall effect has been the nation’s altered mind-set about bioterrorism. In consequence of the actual experience, almost no one doubts the likelihood that there will be more such attacks. Complacency has given way to concern. And no one on the planet better exemplifies the changed manner of thinking than Dr. Donald Henderson.

A
few blocks from Charles Street in Baltimore, near the undergraduate campus of Johns Hopkins University, the neighbor hood abounds with handsome single-family brick homes. On Sunday afternoons in September, residents are usually relaxing, perhaps watching football on TV. But on Sunday, September 16, 2001, Dr. Donald Ainslee Henderson, like many of his neighbors, was still thinking about the terrorist attack 5 days earlier or, more specifically in his case, about what might happen next. “Tara, Tom, and I had been talking since right after September 11,” he says, “and we felt there was likely to be another event.”

D.A., as Henderson likes to be called, was referring to Dr. Tara O’Toole and Dr. Thomas Inglesby, director and deputy director, respectively of the Center for Civilian Biodefense Strategies. Not surprisingly, the likely “event” they had in mind was one involving a germ weapon. The center is a think tank at Johns Hopkins that Henderson founded in 1998 with Dr. John Bartlett, chief of infectious diseases at the Hopkins Medical School. Its avowed aim is to help develop policies “to protect the civilian population from bioterrorism.” Among the growing number of biodefense centers at academic institutions—New Jersey’s University of Medicine and Dentistry, George Mason University, St. Louis University, and the Universities of Louisville, Minnesota, South Florida, and Texas—the one at Hopkins stands apart. Not only was it the first, it also was the beneficiary of Henderson’s unusual credentials.

For 14 years, beginning in 1977, Henderson served as dean of the Johns Hopkins School of Public Health. But before then he had already become a legendary figure in public health. From 1966 to 1977 he directed the World Health Organization’s campaign to eradicate smallpox. His last year as director was the last year that a naturally occurring case of smallpox occurred anywhere in the world.

As he sat at home that Sunday afternoon, the phone rang. “Dr. Henderson? This is Eric Noji at the Department of Health and Human Services [HHS]. Secretary Tommy Thompson asked me to call.” Dr. Noji, a specialist in “disaster medicine,” had recently come up from the Centers for Disease Control and Prevention to help develop an Emergency Command Center in the secretary’s office. “Secretary Thompson would like you to come over for a meeting at 7 o’clock.” Henderson had worked in the previous administration as deputy assistant secretary at HHS under Donna Shelala. He had never met Thompson and much appreciated the invitation. “Seven tomorrow morning? Or do you mean tomorrow evening?” Henderson asked.

“No, no. Tonight,” Noji answered.

Henderson caught the sense of urgency. “Yes, of course I’ll be there.”

Soon after, he was driving south on Interstate 95 for the hourlong trip to Washington, D.C. Once in the city, he worked his way quickly along Independence Avenue—Sunday traffic is light. As he approached 3rd Street, the open mall on the left offered a stunning view of the Capitol building. To the right, still on Independence Avenue, stood the Hubert H. Humphrey Building, the headquarters of HHS. The seven-story structure, constructed 25 years earlier, is covered with recessed windows that give the appearance of a giant waffle.

Henderson parked on the street and walked to the building. As he entered the lobby, high on the wall to his left he could see a portrait of Humphrey and a gold-leaf inscription. The text declares that the manner in which a government treats children, the elderly, the sick, and the needy is, in Humphrey’s words, “the model test of a government.” Six floors up, Henderson got off the elevator and turned right. Before him was a glass partition beyond which lay the red-carpeted suite of Secretary Thompson.

He was escorted into Deputy Secretary Claude Allen’s conference room. Propped up on a rectangular conference table were a computer and a monitor—a rudimentary command center soon to be vastly expanded. A couch stood in front of one wall, and soft chairs were off to the side. “I’m very glad you’re here,” Secretary Thompson said to Henderson. They were joined by Allen, Noji, and Scott Lillibridge, who had just been appointed director of the command center.

Thompson began the discussion by inviting comments about the current situation. The general feeling was that there would be a terrorism sequel to the September 11 attacks. But what form would it take? Henderson recalled the moment:

The secretary rose from his seat and paced back and forth. “He was obviously extremely distressed,” Henderson said. Then, referring to his contacts in the White House, Thompson said, “They just don’t understand.”

“What don’t they understand?” Henderson asked.

“Biological weapons,” Thompson answered. Secretary Thompson repeated his concern, emphasizing that the country was “unprepared, grossly unprepared for a biological attack.”

During the next weeks, Henderson was repeatedly invited back to confer about the possibility of further terrorism. Then, on October 4, Bob Stevens, in Florida, was diagnosed with anthrax. The same day federal and state authorities publicly dismissed bioter-rorism as a likely cause of Stevens’s illness. Thompson himself emphasized that the case was an isolated incident. He implied that Stevens might have contracted the disease from water: “We do know that he drank water out of a stream when he was traveling to North Carolina last week.” When Henderson heard this, he was mystified.

Thompson’s statement was uninformed. Water is not known to convey anthrax, and drinking would be unlikely to cause the inhalation form of a disease. Having minimized the possibility of bioterrorism, the secretary was later criticized as being naïve, as not appreciating the serious implications of the incident. In fact, according to Henderson, Thompson’s concerns were very real. Henderson realizes this view seems “contrary to what came out when Thompson got on television and assured everybody that everything was in great shape.” But Henderson is convinced that Thompson did not believe everything he was saying publicly: “He did what I have seen happen in many disease outbreaks. The political figure gets out in front and says, ‘Everything is under control. Please relax.’ You know, to calm everybody down. And that isn’t necessarily the right thing to do.”

What would Henderson have advised the secretary to say that first day?

A few days later the presence of anthrax spores was confirmed on Stevens’s computer keyboard and elsewhere in the American Media building, where he worked. By then, as anxiety heightened about the source of the anthrax, Henderson had again been summoned by Thompson. From that time forward, Henderson began spending most of every day on the sixth floor of the Humphrey Building. On November 1 the Secretary announced the establishment of the Office of Public Health Preparedness, which would be organized and directed by Dr. Henderson.

Henderson, then 73, had agreed to serve for 6 months. In May 2002 he stepped down and was succeeded by Jerome Hauer, who previously had overseen the Office of Emergency Management for New York City. Henderson continued on as Secretary Thompson’s principal science adviser. His new schedule still had him catching the 7:10 a.m. train out of Baltimore. But now he was usually home by early evening, only an 11-hour work-travel day. Not like his half year as director when he was working “day in, day out, evenings, without letup,” he said.

D.A. Henderson grew up in Lakewood, Ohio, outside Cleveland. He attended Oberlin College and in 1954 graduated from medical school at the University of Rochester. He had planned to become a cardiologist but, facing the military draft, decided to volunteer for 2 years of government service. He applied to the Communicable Disease Center (forerunner to today’s CDC) and between 1955 and 1957 was assigned to its Epidemic Intelligence Service. The EIS had been created out of concern that American troops might be exposed to germ weapons.

By the time Henderson joined the EIS, the Korean War was over and “interest in biological weapons had disappeared,” he said. (In fact, between 1949 and 1969 the United States was developing and stockpiling biological weapons, as were the Soviets, but the public knew little about those programs.) Henderson’s interest shifted from cardiology to epidemiology and infectious diseases, and he went on to receive a master’s degree in public health from Johns Hopkins. Then in 1961 he returned to the CDC as director of disease surveillance. More than three decades would pass before he and the CDC would again be thinking about bioweapons and bioterrorism. But a year after the anthrax attacks, he was thinking about little else.

At 11 a.m. on a clear day in November 2002, following a presentation on smallpox vaccine at the Chemical and Biological Arms Control Institute in Washington, D.C., Henderson arrived at the Humphrey Building. As he got off the elevator on the sixth floor, he turned left. Down the hall and around the corner, he reached a door marked 636G. He swiped a card to gain entry to the Office of Public Health Preparedness. Jerry Hauer, then the assistant secretary for public health preparedness, waved a greeting from his spacious office on the left. At the end of a short corridor, Henderson entered his own office and hung his dark suit jacket on a coat rack. The bookshelves were nearly empty and the absence of pictures and decorations suggested a condition of impermanence. A large American flag hung from a pole next to his desk. He glanced at a white table fan. “Circulation is not that good here on warm days,” he chuckled.

Even the hottest days are more comfortable than those he had spent in the tropics in the 1960s and 1970s. As director of the Global Smallpox Eradication Campaign, he traveled from his comfortable Geneva headquarters to spare regional offices around the world—Senegal, the Ivory Coast, Indonesia, India. Etched in his memory are the oppressive heat and humidity. “When I would try to write my reports, sweat would pour down my arm.” He raised his right arm and went through the motions of a long-ago ordeal. “I’d wrap my arm with a towel and prop my arm up to stop the flow.” The reports were often drenched anyway.

Henderson is a big man. His 6-foot-2-inch frame remains imposing even as he sinks into a seat at the conference table near his desk. When he leans back and clasps his hands behind his head, his tie and suspenders shift forward. A smile accentuates the crow’s feet behind his gold-rimmed glasses. I asked how he came to head the smallpox eradication effort. “In 1961, I had returned to the CDC and become head of the surveillance program. Three years later we began assisting in a measles vaccination campaign in six countries in Western and Central Africa. Then we decided to include smallpox vaccinations as well.” During the next few years, the campaign against measles made little headway, but the smallpox effort was more successful. As the number of new cases began to fall in Guinea, Nigeria, Sierra Leone, and elsewhere, the program was expanded to include 20 countries. Meanwhile, the 20th anniversary of the United Nations was approaching and the organization declared in 1965 that the following year would be the “International Cooperation Year.”

“And then there came a surprise,” Henderson said. His deep baritone rumbled like a low-decibel motor: “President Johnson decided he wanted the U.S. to take an initiative showing international cooperation. Some people from the Public Health Service suggested an effort to eradicate smallpox in the 20 Central and West African countries. And the president decided to go with that.”

The initiative soon expanded to the breathtaking goal of eliminating smallpox everywhere. The idea sounded especially appealing because of the unusual devastation wrought by the disease. During the first 10 days of infection a person shows no sign of illness. But by the end of the second week, fever is accompanied by crushing headache and backache. Rashes begin to appear on the face, trunk, and limbs. They erupt into boils that turn the body into a terrain of pus-filled mounds. As many as 30 percent of smallpox victims die.

The fatality rate for smallpox is lower than for inhalation anthrax. But unlike anthrax, smallpox can be transmitted from person to person. If a boil is scratched open, the oozing pus that glazes the surface can infect anyone who touches it. And with every cough a victim releases viruses into the air that can infect someone in the vicinity. Survivors of smallpox are forever stamped with deep scars, the remnants of the ubiquitous postules.