The Anthrax Letters: The Attacks That Shocked America (42 page)

What exactly does his job entail? I asked. “My overall responsibility is to coordinate the White House oversight on health and bioterrorism and biodefense-related issues,” he answered.

Dr. Bernard, hair sprinkled with gray, leaned back and rubbed his eyes beneath thinly framed glasses. He puts in long hours but expressed satisfaction with the progress he has seen. He fired off an agenda of issues he attends to, from checking on food safety and vaccine development to securing congressional appropriations for biodefense programs. “Lately I’ve been working on the BioWatch and BioShield programs,” he said, in his crisp manner of speech. Both are recent initiatives announced by President Bush. BioWatch involves developing sensors for distribution around the country to detect a possible biological attack, and BioShield supports development of medical treatments of diseases caused by biological weapons.

Bernard amplified on his assertion that the country is now better prepared:

Bernard’s sanguine view was echoed by John Iannarelli, an agent of the Federal Bureau of Investigation. Now in the bureau’s public communications office, Iannarelli previously had been a counter-terrorism field agent. He readily acknowledged that coordination among government agencies was weak in the fall of 2001. “But since 9/11, we are in continuous contact with our counterparts in police, fire, and other local agencies,” he said. We spoke in the spring of 2003, and he noted that 1,245 FBI agents were now working with 650 state and local police agencies in joint terrorism task forces. The 60 JTTFs in every region of the country were double the number that existed 18 months earlier. “We are dramatically better prepared to deal both with prevention and response,” he said emphatically.

Another initiative that could have been mentioned is the new Emergency Command Center in the Office of the Secretary of Health and Human Services. Commander Roberta Lavin has worn the navy blue uniform of the U.S. Public Health Service since 1991. Trained as a nurse practitioner, she had been chief of field operations for immigration and health services. “And then on October 12, 2001, they brought me over here.” Her eyes swept across the large work area that had not existed before she arrived. Down the hall from Secretary Thompson’s office, Lavin heads the Emergency Command Center, which connects HHS by computer and telephone to local medical response teams around the country.

The Emergency Command Center was ordered set up just after Bob Stevens’s anthrax was connected to bioterrorism. A week later the project was under way, and soon after, computer screens were blinking with data. On a late October day in 2002, operators were sitting in front of a half dozen of the 16 computers lined up in rows of four. Lavin offered a smile of assurance and said, “If there was a special reason, an emergency, all the seats would fill quickly.”

On the front wall of the Command Center were two 6-foot-wide television screens, one tuned to CNN, the other to Fox News. On the wall to the right, another large screen displayed dozens of names, addresses, and contact telephone numbers. In a Tennessee drawl Lavin explained that the image on that screen was the default image on the computers. But each computer can scroll up or down to show hundreds of other names. “The names are of DMAT leaders and other local team members,” she said. Lavin stretched the acronym to sound like “deemat,” which stands for “disaster medical assistance team.” Beyond these lists, the Command Center operators are in continuous contact with Web sites and emergency health facilities around the world. D. A. Henderson, who had been standing silently behind us, piped in: “They are monitoring for any unusual health incidents, anywhere—an unusual disease, an unusual number of illnesses.”

The Command Center provides the HHS secretary with immediate access to 72 DMATs around the country. Each team would be expected to field 35 members in case of emergency. A team has about 100 members, so there is plenty of backup. The computer shows which members at any moment are on alert, which are otherwise available, and which are unavailable. Lavin explained:

Has the center ever had to activate any teams? I asked. “Oh yes,” Lavin answered. “We anticipated possible emergencies a few times this past year. The most recent was from a major hurricane. We predeployed several emergency response teams for that.”

How about for a biological attack? “Not for any actual biological incident in process because there has not been any since the fall of 2001,” she answered. “But we have activated for preplanned events like the IMF.” Lavin was referring to recent meetings of the International Monetary Fund in Washington, D.C., at which some protestors were violent. The HHS Emergency Command Center, along with other federal agencies, had response teams in place for possible disruptions, including bioterrorism.

Henderson expressed satisfaction with the command center and spoke of additional activities. He and others in the Office of Public Health Preparedness have been overseeing the distribution of more than $1 billion from HHS to the states for bioterrorism readiness. Under Henderson and Jerry Hauer’s direction, the office developed a list of 17 criteria that each state had to meet to receive funding. States began submitting requests in June 2002 after startup money became available. The criteria range from designating a state director of bioterrorism preparedness to producing time lines for preparedness plans. The aim is to enhance communications between laboratories and officials, drug distribution, hospital readiness, and more.

“I’ve been pleasantly surprised by how quickly the states have responded,” Henderson said. He mentions as well the buildup of the National Pharmaceutical Stockpiles. Twelve repositories around the country each contain 96 tons of materials—antibiotics, vaccines, surgical supplies—available in case of a mass casualty attack. “It takes a Boeing 747 to move one complete stockpile,” Henderson said. The materials could be brought to a location in 6 to 12 hours.

All this is not to ignore gaps in the nation’s ability to respond to a bioattack. Training and equipping police, fire, and emergency medical personnel to deal with bioterrorism must be continuous. While funds have become available to deal with a range of biothreat issues, some people worry that the burst of support may not be longstanding. “We’re doing better than we were,” Henderson said, “but preparedness is a long-term process and I’m not sure everyone realizes that.”

A sustained process is exactly what health officials at local levels are thinking about. In November 2002 the National Association of County and City Health Officials, NACCHO, reported the results of a survey titled “One Year Later: Improvements in Local Public Health Preparedness Since September 11, 2001.” It was based on 342 responses from the 1,600-odd local public health agencies around the country. “Nearly all,” the report said, “are moving forward to prepare their communities for bioterrorism.” And there was common recognition that preparedness was a multiyear task that needed sustained investment.

About half the respondents indicated that during the previous year they had improved their communications with fire, police, and emergency personnel. Several had engaged in drills and had obtained new technology and equipment. But many felt their staff size was inadequate and that they needed more training.

Six month later, in March 2003, I spoke with the directors of several local agencies. The collective message was that preparations to deal with an attack were better than 18 months earlier but still lacking in some areas. Dr. Lloyd Novick, health commissioner for Onondaga County in upstate New York, said his office had improved disease surveillance and developed a good community response plan for the half million people he serves. “But whether the preparedness is satisfactory is still a question,” he said.

For Brian Letourneau, health commissioner for Durham County, North Carolina, “There is no question that we’re better off. We routinely meet with police, fire, hospitals, all the players.” Still, he worries about the chaos that might ensue if there were a mass evacuation. Carol Moehrle, public health director for five northern Idaho counties, received $400,000 to enhance biopre-paredness for the 120,000 people in her district. Her department has been able to add five positions, including an epidemiologist and information and planning personnel. “We are doing very well,” she said.

Not all officials were as sanguine. Ron Osterholm is public health director in Cerro Gordo County, Iowa (population 46,000). He echoed the same concerns as Dr. Rex Archer, who heads the health department of Kansas City, Missouri, and is responsible for a population of 500,000. Both said that awareness and understanding in their communities about bioterrorism are much increased. But resources remain scarce. Archer noted the irony that his department added six people to work on bioterrorism through new federal funding. But in the past 18 months, because of budget cuts, 30 other positions were eliminated, including five in the sexually-transmitted diseases area. “Every few months we’ve been losing some of our disease detectives,” he said.

From her vantage point as the bioterrorism coordinator for NACCHO, Zarnaaz Rauf suggested that the mixed impressions I received were quite representative. “Most local officials do feel better prepared than a year and a half ago,” she said, “but they’re not where they want to be.” Still, as Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told me, the anthrax letters “triggered a constellation of events that have moved us forward dramatically.”

Tibor Tóth, a Hungarian diplomat, is a tall man who takes lengthy strides. His warmth and energy are more evident in private conversation than during the long, tedious sessions over which he has been presiding since 1994. That was the year that several nations began meeting under United Nations auspices to try to strengthen the 1972 Biological Weapons Convention. About 60 of the 147 state parties to the treaty have been participating. For 6 years the Ad Hoc Group, as it is called, had been gathering three or four times a year for week-long meetings in Geneva.

The 1972 convention was the first international agreement to ban an entire category of weapons. Established 3 years after the United States renounced its own offensive biological weapons program, the agreement requires all parties to the treaty to renounce theirs. Those states undertake “never in any circumstances to develop, produce, stockpile or otherwise acquire or retain” biological agents or toxins—except in quantities and types for peaceful purposes. The noble aim of the treaty is enshrined in its determination “for the sake of all mankind, to exclude completely the possibility of bacteriological (biological) agents and toxins being used as weapons. ”

A broadly recognized weakness of the treaty is its silence on how to verify compliance. Unlike the more recent Chemical Weapons Convention, which was established in 1993 to ban chemical weapons, the biological treaty contains no formal provisions for monitoring or independent inspections. It simply urges that nations consult and exchange information with one another and that allegations of noncompliance be brought to the attention of the UN Security Council. Since 1975, when the biological treaty went into effect, conferences of member states have been held every 5 years to review its effectiveness.

Successive review conferences determined that the treaty was hobbled by the absence of provisions to promote compliance. By the mid-1990s, these concerns intensified as information surfaced about the huge scope of the former Soviet and Iraqi biological programs. Those two countries had been violating the convention even though the Soviet Union was one of the original parties to it and Iraq had signed it. U.S. intelligence estimated that they were among at least 10 countries that were developing germ weapons. These revelations helped give rise to the Ad Hoc Group. After the Fourth Review Conference, in 1996 the Ad Hoc group vowed to produce a protocol on verification within 5 years. That way a document could be considered for adoption at the next review conference, which was scheduled for the end of 2001.

By the time of the final Ad Hoc Group meeting in Geneva, Switzerland, in July 2001, a 210-page document was in hand. Known as the chairman’s text, it was a product of Tibor Tóth’s efforts to draw from the mix of proposals and objections offered during the previous 6 years. Many nations anticipated that some version of the text would be approved and sent on to the Fifth Review Conference. Among its key provisions were procedures by which a country would host international inspections of its military and commercial facilities to assure others that they were in compliance with the treaty.

At the July 2001 meeting, more than 50 states indicated general support for the chairman’s text. But the United States resisted the tide. Ambassador Donald Mahley, the U.S. representative, declared that the “current approach” was not capable of “strengthening confidence in compliance with the Biological Weapons Convention.” The United States thought that cheating could still go undetected, that U.S. biodefense efforts could be jeopardized, and that the confidentiality of proprietary business information might not be protected. When the U.S. delegation indicated it would no longer participate, the meeting collapsed. The United States was strongly criticized, less for failing to support the chairman’s text than for its refusal to consider a revised document in
any
form. “We will therefore be unable to support the current text, even with changes,” Mahley said.

By the time the Fifth Review Conference convened in November 2001, the United States was reeling from the recent jetliner and anthrax letter attacks. But acrimony about the U.S. position on the protocols remained at high pitch. Before the 3-week conference ended, the divisiveness prompted its suspension without agreement on a final document. A year later, in November 2002, the review conference reconvened. Tibor Tóth, now chairman of the conference, was able to cobble together a consensus for further talks but not about the protocol. With U.S. concurrence, meetings in the next few years would deal with narrowly specified issues, such as ways to mitigate the effects of a bioattack and a code of conduct for scientists.

The U.S. rejection of the protocol continued to prompt criticism. In the January/February 2003 issue of the
Bulletin of the Atomic Scientists
, two biological arms control experts, Mark Wheelis and Malcolm Dando, wrote an article titled “Back to Bioweapons?” The authors speculated that the U.S. rejection may have been inspired by some “offensively oriented” operations that the country wanted kept secret. They based their suspicions on recent disclosures of U.S. activities, such as the production of dried, weaponized anthrax spores for defensive testing.

Alan Zelicoff is a research scientist at the Sandia National Laboratories where he works on the issue of biological weapons nonproliferation. He dismisses the Wheelis/Dando conjectures as baseless. His access to classified documents about the extent of the U.S. biodefense work prompted him to say in an e-mail: “Never (that is to say, not once, not ever) have I had any suspicion that the US biodefense program was intended in ANY way to develop weapons for use on the battlefield.”

Indeed, Wheelis and Dando’s provocative speculation falls far short of proof that the U.S. is engaged in illegal research. Still, refusal by the United States to negotiate a protocol to strengthen the Biological Weapons Convention creates a risk in its own right. In the absence of an effective international agreement, the proliferation of germ weapons becomes more likely. A strengthened treaty is not just a recitation of rules and procedures. It is a statement of values. It reaffirms the precious international norm that germ weapons cannot be tolerated in civilized society. While sometimes violated in practice, this norm has long historical roots.

Although the specter of biological weapons has grown in recent years, the fact remains that germs have rarely been used as weapons of war or terrorism. In the 20th century the only confirmed use of biological agents against humans in battle was by Japan against China. In the 1930s and 1940s the Japanese dropped ceramic bombs containing plague-infested fleas over Chinese villages from low-flying airplanes. Thousands of Chinese reportedly died from the plague. Apart from warfare, a few instances of bioter-rorism have been recorded. But the only known large-casualty event in the United States was the 1984 poisonings with
Salmonella typhimurium
in Oregon restaurants by the Rajneesh cult.

Explanations for the infrequent use of biological weapons range from presumed difficulty in making them to uncertainty about their effectiveness. But another reason deserves to be underscored, the sense of repugnance that these weapons engender.

In pretechnical and advanced societies alike, health has been deemed a self-evident value. In the 4th century B.C., Hippocrates observed that “health is the people’s most valuable possession.” More recently, in his landmark book,
On Aggression
, the Nobel Prize-winning Austrian ethologist Konrad Lorenz noted that the “sanctity of the Red Cross is about the only one of the laws of nations that has always been more or less respected by all nations.” In all societies, much capital is spent to ward off illness. Thus, efforts to deliberately make people sick contravene a deep-seated human value. No wonder the use of biological weapons has been disparaged as public health in reverse and is deemed abhorrent.

In appealing to the conscience of mankind, the treaties that ban biological and chemical weapons reinforce preexisting inclinations against their use. Strong agreements that provide for verification and punishment of cheaters are as necessary as laws that proscribe other immoral behavior. But salutary policies need not be limited to strengthening and enforcing treaties. Another approach, especially relevant to biological weapons, emerged in the 1980s in the form of a quest for health. It harks back to the smallpox eradication campaign led by D. A. Henderson in the 1960s and 1970s.

In October 1984, in the midst of civil war, President Napoleon Duarte of El Salvador invited Jim Grant for lunch. Grant was the craggy director of the United Nations Children’s Fund, UNICEF. He had been presiding over an immunization campaign against polio and other diseases in Colombia, and Duarte wanted him to do the same for children in El Salvador. Journalist Varindra Tarzie Vittachi reported the following conversation in his book
Between the Guns
. With his Cheshire cat grin, Grant said that a cease-fire in the war against the rebels might enable him to implement such a program for Salvadoran children.

Duarte turned to a general next to him: “How long do you think I would remain as president if I asked for a cease-fire as Mr. Grant suggests?” “Oh, about 3 days,” the general chuckled. Duarte explained to Grant that calling for a cease-fire would “give too much status to the rebels.”

“What if we arrange for the rebels to agree unilaterally not to shoot on those days?” Grant responded.

Duarte contemplated the idea. Instead of a cease-fire, perhaps his troops could observe a period of
tranquillidad
. Thus was born a program called “days of tranquillity.”

From 1985 to 1990, when the civil war ended, UNICEF, joined by the Pan American Health Organization and the local Catholic Church, arranged for three cease-fires a year between the government and the guerillas. During these days of tranquillity, the aim was to give every child in the country immunizations and booster shots.

The Salvadoran experience emboldened international health officials to encourage similar truces elsewhere—in Uganda, Lebanon, the Philippines, and Sri Lanka. Whether the immunization ceasefires helped resolve the conflicts is uncertain. But the programs contributed to the worldwide effort to eradicate polio, which declined by 80 percent between 1988 and 1997.

The connection of days of tranquillity to the prevention of biological warfare should be obvious. One can scarcely imagine a program more likely to reinforce the notion of abhorrence about using biological agents for hostile purposes. A party that suspends fighting in order to eradicate disease one day is far less likely to try to spread disease the next.

Days of tranquillity should be celebrated as humanitarian battles
against
pathogens. Of course, heralding such events cannot guarantee good behavior everywhere. But it would graphically reinforce the notion that the use of germs as weapons contravenes an essential value of humanity. Days of tranquillity underscore the notion that biological weapons are unacceptable among civilized people.

The increased threat of bioterrorism, as exemplified by the anthrax letters, is a dismal reminder that that norm is fragile. Strengthening the Biological Weapons Convention would be one way to reaffirm the norm. Programs like the days of tranquillity are another. Severe punishment of offenders is yet another. Some terrorists might try to use germs as weapons anyway. But if institutional barriers are set high and condemnation is assured, many would be less likely to do so.

Meanwhile, the consequences of the 2001 anthrax attacks must still be addressed. Through the pain of the events, much has been learned, though much remains uncertain. Was Ernie Blanco’s full recovery—unique among the 11 inhalation cases—attributable to his having received extraordinary doses of ciprofloxacin? Were the two “outlier” cases—the women in New York City and Connecticut who died—unusually susceptible to trace amounts of spores? Will an anthrax-contaminated letter tucked in a kitchen drawer infect someone years from now? Were the 11 inhalation cases identified by the CDC the only such cases?