Post-9/11 Challenges of a Crisis 

D. A. Henderson

This article is part of Crossroads in Biosecurity: Steps to Strengthen U.S. Preparedness, published by the Center for Biosecurity September 8, 2011 to mark the 10th anniversery of the 2001 anthrax attacks. Full document | Printable PDF

               
The attacks on the U.S. on September 11, 2001, startled the country with a brutal demonstration that the nation was a fully susceptible target for terrorism. Two oceans and permeable borders provided little protection. A newly inaugurated administration began a confused scramble to mobilize the limited available emergency resources and to comprehend the anatomy of the disaster. But there was more to come. Intelligence intercepts suggested that there would be a second event—a biological attack. Until then, national planning, let alone preparations, for an attack by terrorists had been negligible.

Before 2001

Few will recall that little more than a decade ago, the possibility of biological terrorism was neither anticipated nor understood by professionals or the civilian community. The effects of a nuclear attack were documented and tangible, and chemical accidents were not uncommon, but the potential catastrophe of an epidemic following the deliberate release of a biological pathogen was difficult to comprehend. A surprising number dismissed the prospect out of hand.

At that time, there were remarkably few in public health or medicine who were concerned about biological weapons or the challenges for preparedness and response. Until the late 1990s, the medical community regarded the subject of biological weapons as morally repugnant. Only a handful of laboratories were engaged in research pertaining to the organisms of greatest concern. One of the very few groups struggling with issues of preparedness and response was our Center for Civilian Biodefense Studies (later called the Center for Biosecurity). The Center began its work in 1998 and subsequently received generous support from the Alfred P. Sloan Foundation. Its primary concerns were the national and community-wide planning and response necessary for dealing with biological agents that were the most likely candidates for use. The government’s concerns at that time were principally nuclear threats and the special problems they posed. The lack of interest in biological terrorism was not surprising as the leadership in counterterrorism was provided primarily by physicists. Few had a background in biology and even fewer in public health or medicine.

It was widely acknowledged at that time that smallpox and anthrax were the 2 most likely and potentially catastrophic agents that could be used. They were known to have been the preferred organisms of a previously secret Soviet bioweapons program. However, it was impossible to rule out the possibility that other governments or terrorist groups might have obtained relevant expertise and specimens. Smallpox was the primary concern. It could readily spread from person to person, there was no treatment, and the death rate was 30%. It could be contained only by preventive vaccination. At least three-fourths of the world’s population was without protective immunity. Subsequent to smallpox eradication, vaccination had been stopped in the U.S. and in other parts of the world; vaccine production laboratories had been dismantled. Only a few countries retained stores of vaccine. The U.S. itself had only 15 million doses of freeze-dried vaccine that had been produced in 1978. Discussions with vaccine manufacturers in 1999 revealed that the earliest possible delivery time for additional supplies was 5 years.

The situation with regard to anthrax was not much better. Substantial quantities of antibiotics had recently been procured and stockpiled for emergency use subsequent to an outbreak. The only available vaccine was a crude, whole-cell preparation that had been developed and licensed 40 years earlier and required 6 doses to be given for protection. A new recombinant vaccine developed by the Army was promising but had not yet reached production.

Community preparedness was sadly deficient. Beginning in 1995, modest federal support had been provided to 120 major cities to develop emergency response teams—police, fire, and emergency rescue personnel. The Department of Defense developed strategy and provided training. The need for health personnel was not foreseen; the Department of Health and Human Services was not included in the planning, nor was it given support. Compounding the problem was the fact that academic medical centers then regarded biological weapons as morally repugnant and disdained both relevant teaching and research. There were few staff at CDC or NIH who were engaged in coping with the threat of biological weapons.

The threat only began to be appreciated little more than 3 years before the September 11, 2001, attack. Modest federal resources were made available to begin to build an emergency stockpile, to develop federal response capabilities, to alert hospitals and medical personnel to the threat and needs for response, and to offer encouragement to understaffed health departments to develop plans.

By the end of September 2001, the country was only beginning to appreciate that bioterrorism posed a threat and to appreciate how desperately unprepared it was, when, on October 4, a case of anthrax was reported.

The 2001 Anthrax Attacks

On October 4, 2001, Florida health officials reported an anthrax case—a 63-year-old photo editor from Fort Lauderdale. The patient was desperately ill with pneumonia and meningitis and had been hospitalized. He died a week later. Where he might have acquired the infection was a puzzle. Anthrax pneumonia could result only from inhaling anthrax spores, but no such spores had ever been detected anywhere east of the Mississippi River. State and federal officials sought in vain to find a source for infection. Little thought was given to the possibility that this could be the result of a terrorist attack.

But then, a week later, on October 12, a case of cutaneous anthrax in an NBC network employee was diagnosed in New York and reported. Her illness actually had begun on September 25. She recalled having opened a threatening letter that had been sent to the network and that it had powder in it. The letter was retrieved; anthrax spores were present. It was the first recognition that a bioterrorist attack had taken place. The eventual outcome was 22 cases of anthrax, including 5 who died. All had been exposed to1 of at least 5 envelopes bearing anthrax powder.

Coast-to-Coast Chaos

Chaos soon prevailed and extended from coast to coast. There were countless reports of suspicious white powder that ranged from powdered sugar on donuts to talcum powder. Specimens flooded the few laboratories capable of identifying anthrax. A diverse array of professionals and technicians became involved, including public health and medical personnel, emergency response and management teams, the FBI, environmental experts, civilians and military staff, and public and private laboratories. The media cast a wide net and gathered fragments of information wherever they could be found—from knowledgeable sources and self-anointed experts alike. Handheld diagnostic instruments were peddled aggressively by entrepreneurs. They proved to be little more accurate than tossing a coin. However, every positive reading heightened the alarm. The discovery of a suspect white powder in an office or school often led to a mass evacuation of the inhabitants to be “decontaminated” by having everyone pass through a shower—a procedure taught to first responders for dealing with a chemical release, but meaningless for coping with a biological attack.

Compounding the chaos was the fact that there was, at the time, no designated authority with responsibility for overseeing and coordinating the diverse activities, no agreed-upon strategic plan for responding to a bioweapons attack, no established communication network for informing the press and public. Events moved far too quickly to ensure the full and knowledgeable involvement of states and local communities and to ensure the execution of an agreed-upon and coordinated action plan that aligned federal assets and actions with those of states and local communities. Fortunately, the attack was a limited one and extended over a very short span of time.

And Then?

The anthrax outbreak dramatized the potential for chaos and meaningless expenditures of time and money when leadership is lacking, seriously divided, or simply confused. Congress responded quickly to strengthen capabilities. By January 2002, it had passed an emergency appropriation of $3 billion to be used by the Department of Health and Human Services (HHS) for preparedness planning, education, response, and research. Additional resources were made available to other agencies as well— including the Federal Emergency Management Agency and the Departments of Defense and Justice. Of the $3 billion HHS appropriation, $1 billion was provided to state and local health departments for community planning and organization. Emergency communications equipment and special operations centers facilitated new response plans. Funds were made available to hospitals to help in developing emergency responses to cope with large numbers of casualties. Vaccines, drugs, and equipment for a national stockpile were purchased, and a targeted program of relevant laboratory research was funded.

The flurry of activity was impressive, but, as the initiatives grew and more agencies were funded, the overall program became increasingly fragmented with problematic overlaps of activities and perceived responsibilities in some areas and serious omissions in others. Eventually, however, interest and concern gradually ebbed, and funds and energy began to be diverted to other activities. It was a reaction similar to that following other catastrophes. Without an identified strong base of authoritative and articulate leadership, erosion of the national effort was pronounced.

Where to Go from Here

The National Biodefense Science Board in its 2010 review of the effort to acquire medical countermeasures offered a succinct criticism that is broadly applicable to preparedness as a whole: “The [initiative] to date can be characterized as a good effort conducted by talented people, but currently lacks centralized leadership with authority, is poorly synchronized by agencies within HHS (as well as across Departments), and is under-resourced.”1

After the attacks of September 2001, the dark cloud of probable additional attacks hovered over those of us with responsibilities for national preparedness. The perpetrator was unknown, but it seemed likely that he might possess additional quantities of anthrax powder. It could be distributed in many different ways and in different places. There was a need for strategic plans ready to be implemented immediately as soon as an attack was identified, plans that were known to and shared by all, including state and local authorities. These plans would have to be developed within the context of a national strategic policy that identified the probable range of threats and the resources the nation could afford to expend in support of supplies and infrastructure. Ten years later those plans have yet to materialize.

For the different threats, it would be necessary to decide what was best suited to deal with each. For smallpox, patient isolation and protective vaccines are essential; antiviral drug research might provide a useful therapy. For anthrax, antibiotics and specialized, intensive clinical care resources are vital, but patient isolation is not required. An inexpensive and safe anthrax vaccine might be useful for protecting groups at special risk, but research would be required to develop one suitable for widespread use. And what other agents deserve special attention?

Practical problems in implementing preventive and control measures need to be worked out. However, few have been enthusiastic about wrestling with the difficult practical problems of execution, let alone have the experience to do so. For example, when cases of smallpox are discovered, how extensive should the vaccination program be? Should all hospital personnel be vaccinated? What about first responders? Perhaps all essential personnel? Schoolchildren? Commuters on trains or buses? All who visit the city? All people in the state? The quandaries with anthrax are even more difficult—on discovery of an attack in a city, should the population in the entire affected area be advised to evacuate or to shelter in place? If a large block of office buildings is considered to have been contaminated, should workers be allowed to reenter? Should they be given antibiotics until after the building is cleaned? How should the buildings be cleaned? State and local health personnel need answers to these questions in order to finalize plans that are ready for immediate implementation.

As we remind ourselves of the terrible events of just a decade ago and the fear and anxiety they provoked, we must take stock of what has been accomplished and what has not. To be adequately prepared to cope is no less urgent today than it was then. There is still a lot to be done.

Reference

1. National Biodefense Science Board. Where are the Countermeasures? Protecting America’s Health from CBRN Threats. March 2010. Available at: http://www.phe.gov/Preparedness/legal/ boards/nbsb/meetings/Documents/nbsb-mcmreport.pdf. Accessed August 24, 2011.