Symposium sponsored by:

Johns Hopkins Center for Civilian Biodefense Studies

Department of Health and Human Services

Infectious Diseases Society of America

Intentional Epidemics as a Human Rights Issue
Scott Lillibridge, MD

DR. HAMBURG: Our next speaker is Dr. Scott Lillibridge. He is the Director of the Bioterrorism Preparedness and Response Program at CDC. That program was established to lead and manage the national public health preparedness effort for biological terrorism, and he came to that with a strong background in disaster assessment and epidemiology due to his service at CDC and the National Center for Environmental Health. He is a graduate of the EIS program, board certified in family medicine, and he's going to talk to us about a slightly different aspect of the problem than we've discussed so far. He's going to talk about intentional epidemics as a human rights issue. Scott?

DR. LILLIBRIDGE: Thank you. Well, let me just start off and say it's a pleasure to be here, and this has been a fine conference over the past two days hearing and meeting with old friends, hearing about new issues. And I've got to tell you, it's a pleasure for me to step out of the box as a program manager of bioterrorism preparedness and response and to begin to talk about another issue that I've wanted to address for some time. Thankfully, my agency director stuck out -- stepped out yesterday and provided the overview of the program, and talked about our progress over the last two years and some of our important partners.

What I would like to talk about today is the humanitarian assistance issue associated with bioterrorism preparedness and response. This is a little different than the billing, and they told me to take license and go ahead and speak my mind, so I'll take that as a charge to move forward. And maybe this will be a sea story, but --

(Laughter.)

-- at any rate, let me just go through this. I'd like to thank Dr. D.A. Henderson for his leadership and assistance to the bioterrorism initiative at CDC over the past several years, and also Dr. Peggy Hamburg, Assistant Secretary for Planning and Evaluation, for her leadership in the Department and helping us get our program moving on many, many occasions, and providing that essential coordination at the DHHS level. Thank you.

Anyway, I'm also proud of our accomplishments at CDC and working with our collaborators at the state and local level. One of CDC's collaborative organizations or activities that I'd like to really emphasize is that, as we move through the public health networks at the state and local level, and work with different constituencies, it has come to my attention that in the relief community human rights activists, and in the American Public Health Association, they have expressed humanitarian concerns over the past several years concerning bioterrorism preparedness by the U.S. Government.

In addition, from where I sit as program manager of the bioterrorism program at CDC, I can tell you that to fully galvanize the public health community we're going to need to have some concerns on the humanitarian issues that are so important in the implementation, in the saving of lives, and the curtailing of an epidemic at the state and local level. I'm going to tell these perspectives were honed through my experience in international humanitarian relief with refugees and displaced populations over the past decade and involved work in civil wars in places ranging from Rwanda to Liberia.As I look back, I remember that these were difficult places to work. There was little agreement concerning the optimum course of emergency programming. There was duplication of effort. There was programmatic confusion and a fair amount of rivalry between relief agencies.

In some cases, regional epidemics plagued the area of response in the wake of civil conflict. In one respect, you might argue this was the perfect training for a bioterrorism preparedness and response obligation that I obtained from CDC. Well, I'd like to state my case and begin to frame this, exactly what we do in public health and how this unfolds as we begin to implement this program. And in the second year of implementation, it's becoming clear that we need to shift the focus a little bit and continue to include issues of intelligence gathering, law enforcement, national security, but we must begin to think about some of the focus on treatment, controlling epidemics, and responding to the humanitarian medical needs of civilian populations. And let me just use this as case in point.
Let me go over the initial presentation that characterized our daily travail in one of the nation's few bioterrorism preparedness and response units located here at CDC. Over this weekend, late at night -- and many of these are late at night -- we were awoke or involved in a state that required assistance when another anthrax hoax was perpetrated.

And I've got to tell you, I'm really quite proud that over the time of the past year and a half, that we were able to mobilize. And I'd like -- wish you were in on these conversations. The FBI usually conducts a conference call. We're able to bring state and local health officers into the conversation, along with laboratorians from CDC, experts, people from USAMRIID, as well as different people from the management and bioterrorism program at CDC, and to through a quick threat assessment and review of the scenario. And I'd like to sort of characterize what we talk about and how these unfold, because it's so important in setting up the case that what we're doing is not purely intelligence gathering or defense work. We're doing some real honest public health work at the grass-roots level. The dilemma on this weekend was that samples that were tested locally were equivocal, suggested the possibility that there might be a positive sample in an anthrax hoax. This is a new wrinkle, because, as you know, most anthrax hoaxes are inert and rapidly turned off at the state and local level.

Well, the conversation involved the transportation of lab samples, organizing lab coordination, dialoguing with state and local health officials to do the following: one, help them make recommendations; two, help them organize a lab strategy to rapidly turn off or get more clarity on this hoax event, or potential hoax event. And I can tell you that the conversation, 100 percent of this conversation, were on the health-related -- health sector related humanitarian assistance capacities that could be marshalled to help the state and local community make the diagnosis and treatment recommendations.

We are constantly talking about national security, national threats, biosensory research, a whole range of things in the bioterrorism arena. However, working on this full-time on a national program engaged in countless response activities, hoax events, planning exercises, I can tell you I spend almost 100 percent of my time on the health sector humanitarian issues talking about controlling the epidemic and augmenting medical services. That's a far cry from the way we've approached this in the past two or three years.The problem, from where I sit, or my standpoint, is that while the other sectors are extremely important and well developed and often well funded, that we, as a nation, are still viewing bioterrorism preparedness from a traditional law enforcement, defense, national security construct.

I am extremely pleased to hear during the content of the conference a number of alternatives to sort of vend the angles on intelligence gathering to look at new ways to work with law enforcement, treaty verification, and policing, or looking at some of the issues of monitoring bioscience. Those are extremely refreshing, but it has not been my experience over the past two years. While those sectors are important, I would like to say that consistently, if you sit down and you think about it, once a release has occurred in the population of a biologic agent, job one -- and this is really important because it helps organize the things that follow -- job one is to control the epidemic and do all of the things in detection and surveillance and lab that you need to do, control the epidemic, and augment health services at the local level to help address the humanitarian needs for the affected population.

In the absence of a proper consideration for the health sector humanitarian goals that ensured primacy towards these activities that are designed to save lives and prevent the spread of disease, our national decisions on spending, programming, and response seriously risk over time straying further and further away from the medical and public health exigencies or needs that would truly benefit populations once an event like this happens.

Again, not to minimize the prevention aspects of treaties violations, intelligence gathering, and preparedness in the military sector, but saying when things happen in the civilian community I think the dynamic changes a little bit, and job one moves into epidemic control and augmenting medical services.

The purpose of my talk today is to point out areas in bioterrorism preparedness where the lessons in our humanitarian service or assistance endeavors in the health sector may provide some information on the future implementation of this program as it relates to the health sector. I have chosen a few topics that have very direct relations to the program that we have implemented over the past two years. They involve real examples, real dilemmas, real things that need to be solved at the state and local level if you're really going to save lives.

Now, the reason I'm sort of harping on this or staying on this is that no time in the last two years have I walked into an interagency meeting at a fairly senior level, or a major exercise, or a major drill, or a major discussion, where we sat down at the table and were advised that something had been released, and approached it with the question of, what's best to control the epidemic? And how can we save the most lives? Well, we have a lot of information on competing factions that may be in charge of different things. But, again, if we readjust the rheostats slightly to these humanitarian needs, I think it will help focus resources and to understand this in a different light.

I'd like to talk about, first, bioterrorism and epidemic preparedness. I think bioterrorism is a term that is most useful to characterize the threat or criminal activity in the security intelligence and military and law enforcement arenas. However, once an agent or a biologic agent is released in the population, what we do and what most closely relates to the kind of enterprise that we engage in in the health sector is -- epidemic preparedness and response is more descriptive.

Where does this kind of thinking lead to if you begin to say, "Describe what you do as epidemic response and preparedness"? It leads to decisions on the after-the-fact limb where investing in public health infrastructure and capacities at the state and local level may be critical to attain the humanitarian goals of saving lives and preventing the spread of diseases.

Now, that's extremely important if you're looking at the pie, at the very top of the pyramid, and beginning to divide the resources and build infrastructure and figure out which department, which activities need to be enhanced, which ones need to be modified. Sticking on job one, saving lives, I think that's fairly consistent and fairly important.

The second issue I wanted to mention is that, among all possibilities to develop in capacities in the health sector, the development of dual-use capacities in the public health sector that can be used during an emergency, but are honed during the routine times, are also extremely important. Now, George Poste mentioned about bioscience having an edge for the potential for offensive and defensive purposes. I'm talking about public health capacities of surveillance, laboratory activities, enhancing information, and planning at the state and local level -- things that would be very, very difficult to use for anything besides public health activities.

The third thing that I want to mention -- and this is key, because at some point in time you have to look at what you're doing and say, "Are we getting the job done?" Because in -- we're in our second year. We're involved in serious implementation of this program, and I think the key question from the humanitarian standpoint would be -- has to do with the quality of our adjustment over time. As resources move into the state and local level, I think the key question is, are we better prepared at the local level to handle an epidemic and to augment medical services? The very area where the life-saving activities need to occur.

Remember that the federal government will come in somewhat later than the locals, will bring activities, people, consultants, but largely the survival would be determined -- what happens at the local level. So I think that's an extremely important way to begin to look at the summation of our activities. Again, not to minimize the contribution of the other sectors, but to say that what we do in epidemic preparedness or in the health sector has a humanitarian element that's extremely important and needs to stay focused on live-saving and the other things that we do to control the epidemic.

Now, how do these strategies or these strategic epidemic preparedness and response directions compare or relate to the programs and ideas that arise when one approaches bioterrorism preparedness from the different perspectives of the 20 other U.S. Government agencies and departments that have a piece of this action? Well, the answer is -- and I think you can go to Amy Smithson's report number 35 -- and see that maybe not very well. We don't seem to be as coordinated as we could. And I think with a little bit of a cover towards saving lives and controlling the epidemic, I think you get a little bit of coordination on the response side, and you get better draw from the intelligence and the leverage capacities of the Department of Defense and the other components that play a role in national response. I've got to tell you, I think that's extremely important.

The second issue I want to bring -- tie up today and begin to talk -- and I mention in view of a humanitarian assistance role -- is it is clear that the national pharmaceutical stockpile that is being created by CDC will never be able to cover all contingencies for all people at all locations at the same time. No surprise to anybody. Realistic strategies for the use of this commodity as a health resource will require that managers consider how best to control the epidemic and manage victims. In the absence of consideration for the humanitarian goals of do no harm, help the greatest numbers, how can we build a consensus to properly implement this resource? The guidelines that will be most useful in determining the answers to these questions should be based on science of disease control, but must also satisfy our humanitarian expectations of compassionate and rapid care to alleviate the suffering in our fellow citizens. Without some method to assure our citizens that these items will be doled out with at least some consideration to the humanitarian needs, how do we seek to alleviate mass suffering and get consensus during a time of crisis? I think those are extremely important and certainly need to be considered as we develop the component of the stockpile.

Let me move to the other issue of assisting other nations. And I think there are some compelling reasons why we need to be involved in international activities, working overseas, and develop some international capacity -- is that within the health sector of the U.S. bioterrorism preparedness program the initiative is primarily a domestic one in origin. There is no clear mandate in the monies that we receive for us to develop our international response capacities, to enlist global partners, and to share a substantial response burden with other nations to respond to epidemics in civilian populations affected by bioterrorism. Since most of the strategic threats that might point to the United States hail from outside our borders, international collaboration on preparedness seems to be extremely important. In addition, due to the contagious nature of this, borders seem to have little relevance in controlling the spread of disease. I can think of three important reasons why we need to be engaged internationally, and begin to think about that as part of our bioterrorism preparedness activities. One, it's an extension of our normal epidemic assistance activities overseas. The U.S. Government, CDC, other components in the military, probably assist other nations about 60 or 70 times a year in major outbreaks. Currently, they're working in Rift Valley, ebola, things overseas that are happening on a weekly or monthly basis. They often work directly with ministries of health or through the WHO. I think that's an extremely important thing to continue. The second issue is that assistance to the international organizations to investigate allegations of biowarfare or bioterrorism, or unexplained deaths, are going to be extremely important, and we have some resources to do that. I think those are probably things that were going to need to help and begin working on if we're going to engage in verification, follow up, and the kinds of things that help shed light on the potential use of bioterrorism. Three, as mentioned by Guenael Rodier, support for WHO and epidemic preparedness related to bioterrorism, and all its components of information sharing, response, training, working with regions, seem extremely important.

The last area I want to get into and address certainly is some issue that deals with issues of conventions, laws, rules, and grass-roots activism. And I want to get that framed properly. I think we're still looking at a lot of these issues as treaty verification, inspection, tracking of shipments of goods, and we speak of many of the legal issues related to bioterrorism. I think that's okay, and we should look for better conventions. While these tools may be helpful, the reality is for the moment that these new threats related by bioterrorism continue to mount more rapidly than do our medical and public health response measures. So in the meantime, I think there are some things that we can do. George Poste -- not George Poste, but Ambassador Butler mentioned that there are things that people can do to change the norm in consideration about bioterrorism. I believe the medical and public health community can be very effective in promoting the attitude that biowarfare and bioterrorism is unacceptable. I think we should begin doing more to galvanize our public health associations -- ASHTO, territorial health officers, at the local level, CSTE and APHL, and the infectious disease professional organizations, such as IDSA, SHEA, and EPI. It will be far easier and effective to mobilize and benefit from these groups if we can turn the national preparedness efforts more towards the importance of controlling epidemics and augmenting medical services, and a little bit less away from the way it's been until public health got engaged about two years ago, as only an intelligence Department of Defense or a law enforcement construct. I think you need all of those things, and all of those sectors need to be healthy at the same time for optimum preparedness.

Lastly, I see some important lessons from the recent global campaign to eliminate land mines. This movement largely had its origin outside of government and had a military that had military or private sector financial interest in continuing to manufacture these devices. Over a period of about a decade, this group was able to bring together NGOs, governments, private sector partners, and many others into an effective coalition to address the growing worldwide land mine problem. This activity was extremely effective and can be credited with limiting the proliferation of certain types of devices and bringing this attention to the world in a way that individual governments can't do as effectively sometimes.

The point I want to make is that without grass-roots humanitarian activism added to the mix as another partner, it will be difficult to maintain a focus on moving public opinion of nations or groups that are developing or holding these types of capacities away from those goals. Stockpiles may continue to exist, along with the endless debate on how to negotiate or sanction these entities or nations. I think we need to reach out and broaden our coalition of partners in this effort, and it may be time to bring the NGOs in to pick up a piece of the bioterrorism preparedness and response mantra.

In conclusion, let me just run down a few things that have happened over the last two years, and summarize what I've said and the importance of keeping this initiative moving. As I look back in the health sector, which is the sector that we work in at CDC, I can tell you that a lot of things have happened that weren't here and capacities have been built over the past several years. We have new laboratories. We have new capacities in our divisions. We have hired new experts in pathogens that we weren't previously working with on a routine basis, such as anthrax. And there has been a whole host of new activities -- the health network, stockpiling activities. And all in all, we have about 100 people working full-time in this area. This is an explosive, dramatic increase in our attention on this important area, and there's been a lot of things accomplished.

Also, at the state and local level in the health sector, I am pleased to go to the states, and there are at least a dozen states that have absolutely stunning programs where people have taken public health leadership. They are looking at methods to control the epidemic. They have plans to augment medical services. They have health facility preparedness activities. And there is lots of activities happening, and I'm still pleased with that. But I will say that unless there is some in the national mantra, in terms of national consideration, we consider some of the humanitarian assistance issues, I think we will get off track a little bit about saving lives, controlling the epidemic, and augmenting medical services. Again, one of the components at the table -- not the only one, but certainly one that is worth mentioning once an epidemic is moving through the population.

Well, there's a few general guidelines, and I'd like to just go down these quickly before I part, and say that it seems to me that the medical and public health community can be very effective in explaining this issue to public health -- authorities, politicians, decisionmakers, and the idea -- spreading the idea that biowarfare, bioterrorism, is indeed unacceptable. I think that this is a very complex issue, and the understanding at the state and local level outside of health is not very high. And it's a very difficult issue to explain, and there's going to be great value in having this group enlisted in taking up that role.

The second issue is that in bioterrorism preparedness and response on behalf of the civilian population, job one, once something has happened, has to be to control the epidemic through all the steps of detection, surveillance, response, etcetera, and augmenting medical services. Those are the two key things.

We need to be more effective in making that case and having the other components of the government -- the federal government -- in national response help leverage their capacity to achieve those goals. I think that's very -- extremely important for our survival.

The third thing is we need to develop national and international surge capacities to respond to epidemics, and I think that we don't quite yet have the optimum national or international surge package ready. These capacities need to be broadened to keep the focus on humanitarian goals of epidemic control and medical services at the time of a bioterrorism crisis, and to effectively harness these activities of other departments. I think Dr. Rodier from WHO gave a splendid overview of the activities related to bioterrorism preparedness and response, and we need to work more effectively with WHO's communicable disease divisions in promoting their regional training, surveillance, lab coordination, on the kinds of things we could do to help respond to an international outbreak.

And, lastly, I think major stockpile decisions concerning the development and employment of this commodity should be based on public health science for the purpose of rapidly stopping the spread of disease and treating victims. This issue should be more openly debated in a scientific manner, with a realistic appraisal of threats to our population. I think those are going to be extremely important, and keeping some of the focus of that debate on the humanitarian usefulness will be critical to save lives.

With that, I'd like to close with one or a few thoughts and say I'm going to return back to CDC with my colleagues to a place where the phone rings late a night, the weekends, and we get reports of everything from anthrax in Florida to small pox in Nepal. These are real events where we had multi-agency coordination, consultation, some degree of either laboratory or professional mobilization, where there is concern for unexplained deaths on a daily basis, where alert health officers make reports and we stand ready to provide some degree of surge capacity, to assist those in need. I will tell you that there is substance in this work, and that new territory is being chartered in the health sector. Without a proper humanitarian framework at the national level, I'm afraid our efforts will not best target the infrastructure we need to build to address the vulnerability in our population to bioterrorism. And our national investment will be significantly diminished.

With that, I'd like to close, tell you thank you for your time, and tell you it's been a splendid year of working together, particularly with our state and local colleagues, Dr. D.A. Henderson, and Dr. Peggy Hamburg. Thank you so much.

(Applause.)