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March Issue |
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by Margaret A. Hamburg
Protecting our nation from attacks with biological weapons requires
strengthening and coordinating our public health infrastructure, medical
services, and research projects.
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U.S. Army personnel simulate a nerve agent attack during a nuclear,
biological and chemical warfare exercise in the Republic of Korea.
 he tragic events of September
11, 2001, followed by the anthrax incidents, have made us painfully aware of our
nation's vulnerability to terrorism, including bioterrorism. The possibility
that a biological agent might be intentionally used to cause widespread panic,
disease, and death is now a common concern.
Whether the event involves an
unsophisticated delivery system with a limited number of true cases or a
carefully orchestrated attack with mass casualties, the prospects are
frightening. As the United States mobilizes to address an array of overlapping
foreign policy, infectious disease, and national security threats, it must give
high priority to a comprehensive program to counter and prevent attacks with
biological weapons.
Bioterrorism differs
fundamentally from other threats, such as conventional explosives and even
chemical or nuclear weapons. By its very nature, the bioweapons threat, with its
close links to naturally occurring infectious agents, requires a different
strategy. Meaningful progress against this threat depends on understanding it in
the context of epidemic disease. It requires different investments and partners.
Without this recognition, the nation's preparedness programs will be inadequate,
and we may miss critical opportunities to prevent such an attack.
Biological terrorism is not a
"lights and sirens" type of assault. Unless the release of the
pathogenic agent is announced or a fortuitous discovery occurs early on, there
will be no signal of alert and no site cordoned off while authorities take care
of casualties, search for clues, and repair the damage. Instead, such an assault
would most likely unfold as a disease epidemic, spread out in time and place,
well before it is recognized as a deliberate strike.
Recognition of the attack would
emerge only as people began appearing in doctors' offices and emergency rooms
with unusual symptoms or inexplicable diseases. In fact, it might prove
difficult to ever identify the perpetrators or the site of release--or even to
determine whether the disease outbreak was intentional or naturally occurring.
The first responders to an act
of bioterrorism would be public health officials and health-care workers.
Unfortunately, in many scenarios, diagnosis of the problem may be delayed
because medical providers and labs are ill equipped to recognize and deal with
the disease agents of greatest concern. Effective medical interventions may be
limited, and, where available, the window of opportunity for successful
intervention would be narrow.
Moreover, the outbreak may
persist for months or years because of disease contagion or continuing exposure.
Thus, recognizing and responding quickly to an attack will be pivotal in
reducing casualties and controlling the problem.
Biological weapons are
relatively easy to produce, inexpensive, and capable of causing significant
damage even when small quantities are delivered by simple means. In addition,
information about how to obtain and prepare bioweapons is increasingly available
through the Internet, the open scientific literature, and other sources.
Opportunities for access to
dangerous pathogens can be fairly routine. Some of these organisms are commonly
found in nature or are the subject of legitimate study in government, academic,
and industry labs. Furthermore, bioweapons facilities can be hidden within
legitimate research laboratories or pharmaceutical manufacturing sites.
Developing a response
 lthough enormous challenges lie
ahead, many elements of a comprehensive approach are relatively straightforward.
Some of the necessary activities are already under way, though they may need to
be expanded or reconfigured. Other programs and policies still need to be
developed and implemented. @Normal:Perhaps most fundamental to an effective
response is the understanding that public health is an important pillar in the
national security framework and that professionals in this area must be full
partners on the U.S. security team. In fact, the president should appoint a
public health expert to the National Security Council and include such experts
among key staff in the new Department of Homeland Security.
Today, professionals recognize
the urgent need to increase the core capacities of the public
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Biological agents of disease can be safely handled in Safe-T-Dome, a
tabletop, vacuum-sealed unit manufactured by Banthrax Corporation.
health system to detect, track, and contain infectious disease. While there is
an array of health structures at the state, county, and local levels, they have
never been adequately supported or equipped to respond to bioterrorist attacks.
In fact, many hesitate to call them a public health "system," because
years of relative neglect have left them underfunded, fragmented, and
uncoordinated.
Upgrading current public health
capacities will require significant new investment. First and foremost, it means
extending effective surveillance systems that rapidly detect and investigate
unusual clusters of symptoms. This process will entail strengthening local
epidemiologic capabilities, including training more personnel and enhancing
laboratory capacity to quickly identify biological agents.
In addition, communications
systems--including computer links--must be improved to facilitate the
collection, analysis, and sharing of information among public health and other
officials at the local, state, and federal levels. Successful strategies must
additionally include a renewed commitment to improving global public health.
To improve detection, it is
essential that physicians and other health-care workers be trained to recognize
unusual diseases or clusters of symptoms that may be manifestations of a
bioterrorist attack. In addition, the relationship between medicine and public
health must be strengthened, so that physicians understand their responsibility
to report disease or unusual symptoms to the public health department.
Health-care professional organizations, academic medical institutions, and
public health officials must come together to develop appropriate curricula,
guidelines, and working partnerships that are critical to success.
Those partnerships will be
important in addressing another concern: the urgent need to develop emergency
plans for a surge of patients in the nation's hospitals. We must find a way to
provide large-scale medical care and protection under conditions of widespread
exposure and numerous casualties. Careful advance planning will be needed, given
that most hospitals are operating at or near capacity right now.
Federal health leadership will
be important in this effort to define needs and provide model guidelines and
standards. Federal resources may also be essential to support planning efforts
and create incentives to bring the voluntary and private health-care sectors
fully on board. The final planning process, however, must be undertaken on the
local or regional level, engaging all the essential community partners and
capabilities. The front line of response, even in a national crisis, is always
local.
A significant aspect of this
effort involves access to essential drugs and vaccines. Large-scale release of a
biological weapon may require rapid access to quantities of antibiotics,
vaccines, or antidotes that may not be routinely available in the locations
affected. Given that such an attack is unpredictable and the probability of
occurrence at any particular place is low, it would hardly be sensible or
cost-effective to stockpile supplies at local sites.
To rapidly mobilize vital drugs
and medical equipment, a national pharmaceutical stockpile was developed by the
federal Centers for Disease Control and Prevention (CDC). This cache of
supplies, portions of which are stored at separate strategic locations, can be
delivered within 12 hours to any place in the nation.
Current concerns make it clear
that the nature and quantities of materials in the stockpile must be enhanced,
and the contents should be periodically reviewed and adjusted in response to
intelligence about credible threats. New measures should include contractual
agreements with pharmaceutical manufacturers to ensure higher productivity in a
crisis. There also needs to be adequate security at the various storage and
dispersal sites.
Moreover, we must develop plans
for distributing those supplies with leadership and support from the CDC. We
must also think about the broader mobilization of essential drugs, vaccines, or
other materials in the event they are needed outside the United States. Although
this may raise complex diplomatic issues, especially when the necessary
pharmaceutical is in short supply, it is essential to address the potential
global need.
To make sure that the United
States remains strategically poised, further investment must be made in research
to develop new drugs, vaccines, diagnostic tests, and other medical weapons to
add to the arsenal against bioterrorism. We must learn more about the
fundamental questions of how the pathogenic organisms cause disease and how our
immune system responds in order to develop better treatments and
disease-containment approaches. We should also improve methods to rapidly detect
biological agents from environmental samples.
Scientists will need the full
support of the public and the government to confront this threat. Success will
entail collaboration involving numerous government agencies, universities, and
private companies. Looking to the future, an effective, well-funded research
agenda may give us the tools to render the threat of biological weapons
obsolete.
An ounce of prevention
 topping a biological attack
before it happens is obviously the most desirable way to avoid a crisis. The
first step in blocking the proliferation and use of biological weapons is to
significantly strengthen our intelligence community with additional scientific
and medical expertise. Greater partnership and trust between the intelligence
community, law enforcement, the public health sector, and biomedical science are
required. While these disciplines do not routinely work together, greater
coordination among them must be an element of our nation's homeland security
strategy.
Sadly, we must recognize that
the possibility of bioweapons threats is embedded in the very science and
technology that we herald in laboratories around the world. Vigilance is needed
to ensure that the tools of modern genome-related biology are not used to create
new and more dangerous organisms. This is a complex challenge, for no one wishes
to impede the progress of legitimate science. Yet we also have a responsibility
to face up to a real set of concerns. With leadership from the scientific
community, we must examine opportunities to constructively reduce this threat.
Related to this objective, we
must reduce access to dangerous pathogens by helping the scientific community
improve security. Over the past five years, new regulations in the United States
have tightened access to biological agents from culture collections and
strengthened the government's ability to monitor the shipping of dangerous
pathogens through a registration process, including disclosure of their intended
use. These are important steps, but more should be done to ensure that our
nation's laboratories have adequate oversight of these materials.
To make a real difference, the
safety and control methods developed domestically must be extended across the
globe by cooperative means. Given that many scientists who once worked on the
Soviet Union's bioweapons program are now underemployed, it is in our interest
to help them find useful research opportunities, so that economic need does not
drive them to peddle their knowledge to potential terrorists. We must also
support efforts to help them secure or destroy potentially dangerous materials.
The U.S. government has
supported such efforts through the Cooperative Threat Reduction (CTR) program,
but programs of this nature desperately need to be strengthened and expanded.
Opportunities to extend the reach of the CTR to include university and industry
collaborations will also be essential for long-term success.
In the final analysis, it may
prove impossible to prevent future bioweapons attacks, but planning and
preparation could greatly mitigate the resultant suffering and death. As a
nation, we need comprehensive, integrated planning to address the threat of
bioterrorism, focusing on both prevention and response. We need to define the
responsibilities of the different agencies involved and identify the mechanisms
by which various levels of government will work together.
The United States has always
been willing to meet the requirements and pay the bills when it came to our
defense systems and security needs. We must now be willing to do the same in
funding critical public health needs. Public health has too often received short
shrift in our planning and public funding. This must change.
Congress and the public need to
understand that strengthening disease surveillance, improving medical
consequence management, and supporting fundamental and applied research are
essential in responding to a biological weapons attack in this nation or
elsewhere in the world. These investments will also enhance our efforts to
protect people's health and safety from naturally occurring disease. We have a
chance to defend the nation against its adversaries and improve the public
health system with the same steps. We cannot afford to neglect it.
On the Internet
Center for the Study of Bioterrorism
www.bioterrorism.slu.edu
MEDLINEplus: Biological and Chemical Weapons
www.nlm.nih.gov/medlineplus/biologicalandchemicalweapons.html
MLANET Bioterrorism Bibliographies and Resources
www.mlanet.org/resources/caring/resources.html
NIAID Biodefense Research
www.niaid.nih.gov/dmid/bioterrorism
USAMRIID's Medical Management of Biological Casualties Handbook
www.biotech.law.lsu.edu/blaw/bluebook/Bluebook--htm.htm
This article was adapted with permission from Issues in Science and Technology, "Preparing for and Preventing Bioterrorism," Winter 2001-02, pp. 27-30. Copyright 2002 by the University of Texas at Dallas, Richardson, Texas.
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