The Anthrax Letters: The Attacks That Shocked America (41 page)

Dr. Shmuel Shapira, deputy director general of Hadassah Hospital in Jerusalem, seemed relaxed despite the anticipation of an American-led invasion of Iraq. It was late February 2003, and he remembered well that during the first Gulf War, 12 years earlier, Iraq had fired 39 Scud missiles into Israel. Initial fears that the Scuds might be carrying biological or chemical poisons turned out to be unfounded. Now, however, worries had revived. Citizens were lining up around the country to obtain gas masks and other paraphernalia in anticipation of a germ or gas attack.

Shapira is in charge of mass casualty coordination for the hospital. He mentioned Israel’s particular expertise in this area. “Unfortunately, we’ve had a lot of experience these past 2 years,” he said. In the previous 25 months, 2,100 victims of terrorism were brought to Hadassah Hospital, one of about 30 major hospitals in Israel. None of the attacks involved nonconventional weapons, but they provided valuable, if bitter, training experience. “We handled as many as 100 terror victims in a single day at our hospital alone,” he said.

Shapira mentioned the array of preparations in place for a surge of victims of chemical or biological weapons—from the line of 50 outdoor showers to wash them down to stocks of antibiotics and antidotes. In minutes, lounges, foyers, and corridors could be converted into emergency facilities. Extra beds and medications were at the ready, stored below ground level in the hospital’s buildings. Embedded in the ceilings of some lobbies was electrical wiring along with pipes that carried oxygen, water, and other necessities for emergency care. Rows of tubes could be dropped in an instant from the ceiling next to newly placed beds. Dr. Shapira said that the 1,050-bed capacity in Hadassah’s complex of buildings could be doubled in an hour.

Although trained as an anesthesiologist, Shapira is now engaged largely in hospital management. His tan wooden desk seemed outsized for his small office. As he hung his arm over the back of his chair, his tie flopped below his button-down collar. Tufts of black hair above his ears framed a bald center. In accented English, Shapira answered my questions: Is Israel doing anything differently in anticipation of an Iraqi attack than it did 12 years ago?

“We were quite prepared for a chemical attack then but not really for biological. We’re much better prepared for a bioattack now.”

How so?

“In the first place, we have more stocks of antibiotics to treat agents like anthrax and plague. But also, we’re ready for smallpox, which was not the case in 1991.”

At the time we spoke, 18,000 Israeli first responders had been vaccinated for smallpox with plans to vaccinate another 22,000. Several hundred vaccinated personnel were having their blood drawn to extract something called Vaccinia Immune Globulin, or VIG. This is a substance in the blood of vaccinated people that can be used to treat individuals who suffer adverse reactions from the vaccine’s live
vaccinia
virus.

Stockpiles of smallpox vaccine were in place around the country. If a single case of smallpox were diagnosed in Israel, schools, recreation halls, and gymnasiums would immediately be turned into vaccination clinics. Trained crews would work day and night to vaccinate all 6.2 million Israelis in only 4 days. (A vaccination administered within 4 or 5 days of the time of exposure to smallpox still provides protection or reduces the severity of illness.)

Do citizens know where to go for vaccinations? I asked. “No, they don’t know now,” Shapira responded. But if a case were discovered, “people will get instruction through the media—where to go, when to go.” Shapira’s voice is muscular, adding a sense of authority to his description. “For instance, if the family name begins with A to H, you go to such-and-such location until 7 p.m.” The plan is in place, he said. Then an afterthought: “Certainly people will be scared. There will be anxiety.”

Speaking of anxiety, I asked if he was particularly anxious about a biological event. He admitted to worrying, even while maintaining that the threat level was low. He spoke again of Israel’s experience with “conventional” terrorism. He also noted that doctors have had occasional experience with insecticide poisoning. (Some insecticides are organophosphates, in the same chemical class as nerve agents, though far less potent.) But biological warfare agents are a different matter: “I mean, there are some agents that no one has probably seen. I am not sure if there is even one physician in Israel who has ever seen smallpox. Anthrax? Cutaneous, maybe, but not inhalation anthrax.”

Boaz Ganor, an Israeli terrorism expert, told me that America’s bout with bioterrorism in 2001 was followed closely in his country. “Definitely, the anthrax letters raised the awareness of people here.”

While in Israel I visit a Patriot missile base on the outskirts of Tel Aviv. Nearly 300 American soldiers had recently arrived to work with Israeli counterparts in anticipation of a missile attack from Iraq. I sat with some of the Americans over lunch in a large white tent. The tent was 200 feet from a communications center—a portable station with computers and launch controls. The station was covered with a huge swath of olive-colored camouflage netting. “I’m Tony Baez from Buffalo, New York,” said a strapping young soldier between bites of beef and rice. His smile glistened with large white teeth. Like the other G.I.s, his uniform was a maze of brown and green, pants tucked into high-laced boots.

I asked about the small duffel bag under the table next to his feet. “It’s my protective suit,” Specialist Baez answered. Similar duffels were carried by every soldier there, ready to be opened on a moment’s notice. They rehearse several times a day. “We can put the mask on in 8 seconds,” said another soldier at the table. The mask was part of a hood that drapes over the shoulders and is secured to the face underneath by a rubber strap. “Putting on the rest of the gear takes 9 minutes,” he added. It takes that long because the outer garment needs to be fastened in orderly sequence with snaps, straps, and ammunition belt.

Outside the tent a Captain Smith pointed to two launch pads in the ravine 50 yards away. The pads were facing east, the direction from which Iraqi missiles would be fired. At what point in the trajectory would the Patriots intercept an incoming Scud? I asked. “We’d hope to make a hit at least a thousand feet above the ground, no lower than 500 feet,” he answered. The assumption was that any biological or chemical agents would be destroyed or dissipated by an impact that high. He added a word of assurance that the Patriots in Israel now were more reliable and accurate than those used in the 1991 Gulf War.

The Americans soldiers and their Israeli hosts seemed resolute. There was broad understanding that whether in the form of military assault or terrorism, Israel was quite prepared to deal with a biological or chemical attack. The situation in the United States, with its vastly larger population and territory, was more problematic.

In the spring of 2002 the Johns Hopkins Center for Civilian Biodefense Strategies moved into expanded quarters. On the 8th floor of a red brick office building facing Baltimore’s Inner Harbor, the center’s staff of 20 churns out position papers and reports. Articles, book reviews, and listings of events and conferences appear in
Biodefense Quarterly
, which the center has published since 1999. The center’s leaders were principal contributors to highly influential articles in the
Journal of the American Medical Association
on managing bioterrorism attacks. D. A. Henderson, when director, was the lead author of “Smallpox as a Biological Weapon” and Tom Inglesby, deputy director, of “Anthrax as a Biological Weapon.” Tara O’Toole, the current director, was among the coauthors of both.

Soft green carpeting runs throughout the Hopkins center into cubicles and offices that line the corridors. On an overcast day in October 2002, I joined with seven of the professional staff in the conference room for lunch and discussion. Dr. O’Toole said the center is most concerned about developing protection “from an aerosolized mass-casualty attack.” Wearing a green cardigan sweater and black shirt, she spoke earnestly. “I want our national leaders to understand that biological weapons are a strategic threat to the United States, and that hasn’t happened yet.” None of the staff questioned her assessment.

O’Toole’s negative view of the country’s response to the anthrax attacks in 2001 is unforgiving: “I think the CDC [Centers for Disease Control and Prevention] was terrible. The official response was a national security travesty.” Her blond hair was closely trimmed and her smile was taut. Her voice remained at low volume, but the intensity of her delivery filled the room. I ask about the new leadership at CDC, the new director. She responded:

O’Toole is distressed that few people appreciate the dimensions of the bioterrorism threat and that the nation is not positioned to respond to an attack.

Monica Schoch-Spana, a senior fellow at the biodefense center, says that after the September 11 attack the center began getting phone calls from people worried about biothreats. “You know, there wasn’t even a ‘FAQ’ [list of frequently asked questions and answers] on bioterrorism on the CDC Web site until after the anthrax outbreak.” O’Toole adds that neither the CDC nor any other official agency has produced an after-action report.

Tom Inglesby entered the conversation. “In the first few days after the anthrax attack, the CDC did a credible job. They closed the loop with Larry Bush and Jean Malecki in confirming the first anthrax case in Florida.” Inglesby, like O’Toole, is a physician—his medical degree is from Columbia University; hers from George Washington University. He is thin, scholarly; he also holds an appointment in clinical medicine at Johns Hopkins. Wearing a tan shirt and brown tie, he spoke rapidly. “But after the early days, the CDC did not respond well. They didn’t get information out quickly, and often they did not get accurate information out at all. That’s the concern here.”

I asked if everyone at the table agreed. Affirmative nods—everyone was on message: The nation lacks a coordinated program to protect the citizenry. So what exactly should we be doing? I looked to O’Toole. Until then her comments had flowed seamlessly. Now she glanced at the wall beyond the end of the table and reflected. She honed her answers after each of my prompts.

“First, we need to hear an announcement of sustained commitment,” O’Toole said.

From whom? I asked.

“From the president. Researchers need to know that funding for their work will continue beyond the short term.”

What else?

“A more explicit articulation of the nature of the threat.” She related this to her conviction that people do not understand the gravity of the situation. “And then,” she continued, “we need the medical and public health communities better prepared. They should be ready for mass casualties.”

Is there more?

“We need local as well as national stockpiles of medicines in case of a biological attack. We need to expand the capacity of the public health system.”

O’Toole scorned current research approaches to bioterrorism. “We need to marshal our best scientists for this, but that hasn’t happened.” A lot of money is now supporting work that is not especially imaginative, she said, and for research that is not particularly helpful. The research has been labeled “bioterrorism” so that it could draw funding.

Coming away from the Hopkins biodefense center, one feels appreciation for the valuable studies that its staff has been producing. Further, their concerns about preparedness echo the conclusions of a task force of the Council on Foreign Relations that were released around the same time. (The task force was chaired by former Senators Gary Hart and Warren Rudman, and its report was darkly titled
America Still Unprepared—America Still in Danger.
) The American people remain vulnerable to a bioattack. But the notion that the nation is little better prepared now than during the anthrax attack surely is an exaggeration.

For Kenneth Bernard the difference in preparedness is “like night and day.” “We are dramatically better prepared now,” he said. Dr. Bernard, 54, is an assistant surgeon general with the U.S. Public Health Service. Since November 2002 he has been director of health and bioterrorism in the White House Homeland Security Council. In March 2003 we met in his office. Above his desk, to the right, hung a poster of Mount Everest, a reminder of his time in the 1980s when he was a health adviser to the Peace Corps in Nepal. Now he is consumed with the weighty challenge of helping to protect this country.