The answer may be both.
Tom Ridge, former Homeland Security secretary, and Joe Lieberman, former senator, are co-chairing a Blue Ribbon Study Panel on Biodefense hosted by Hudson Institute and the Inter-University Center for Terrorism Studies. They wrote in Roll Call that “our nation is dangerously unprepared to prevent or respond to” attacks with biological and chemical weapons, citing recent cuts in funding for readiness efforts.
The Gravest DangersThe list of agents that officials and experts worry about most “is populated by bacteria and viruses that have found their way into state weapons programs,” said Rocco Casagrande, managing director of Gryphon Scientific in Takoma Park, Md. These are agents that could be disseminated to thousands of people – for example, with an aerosol attack or through the food supply. Here’s a summary of some of the agents that cause the most concern:
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They discussed the recent Ebola outbreak, which “spread because we and the rest of the world did not manage the disease properly” — and ask what would happen if an infectious agent were deliberately released.
Taking a longer view, however, experts say the United States has indeed made progress.
The terrorist attacks of 9/11, followed by the mailing of anthrax that fall, focused a lot of attention and money on how to prevent, prepare for and recover from such an attack.
Bioterrorism has not always been part of the curriculum in medical school, for example, but is now included in textbooks on infectious diseases, said Dr. Robert J. Leggiadro, an adjunct professor of biology at Villanova University and board-certified physician in pediatrics and pediatric infectious diseases.
However, Casagrande agrees that funding has gotten less secure and the focus has waned in recent years, especially on the public health side. (Law enforcement, he said, is still working on preventing attacks.)
“I worry that a lot of that initial energy and emphasis has waned,” Casagrande said. “A lot of places are losing focus. Equipment is getting old, consumables are reaching their shelf life, and plans have gone unexercised in a lot of cases.”
As years pass without major attacks, attention — and funding — gets redirected.
“People are very excited about these events when they occur, and then it’s no longer in the news, and other issues come up,” said William Karesh, executive vice president for health and policy at the EcoHealth Alliance, a nonprofit science-based health and conservation organization. His work focuses on the links between ecology and health. “The emphasis and funding and pressure to do something go away.”
People sometimes point to problems in how a small-scale problem was handled — for example, a person who returns from traveling with a contagious illness — and assume this means the government is unprepared for a major outbreak.
But “A lot more systems would be engaged if it was super-serious,” Casagrande said. For example, he said, recognizing an unusual illness if there are just a few cases — and determining whether it’s the result of an attack or naturally occurring — is “really, really difficult.” But in a large-scale attack, there could be dozens or even hundreds of people affected at once. “It would be hard to miss that, as opposed to just one guy showing up at one hospital.”
One of the issues is that many of the agents, such as anthrax or plague that could be used for a biological attack, also exist in the environment. The first step, Leggiadro said, is to diagnose the disease. A diagnosis of smallpox, which does not exist outside of labs, would be an “international emergency,” he said. “For the others, you need to figure out if there’s a benign cause.”
Firefighters with Clackamas Fire District #1 evacuate victims of a simulated bioterrorism attack from the Armed Forces Reserve Center during the Portland Area Capabilities Exercise Setter at Camp Withycombe in Clakamas, Ore., May 22. Photo by Flickr/OregonMilDep/Staff Sgt. April Davis, Oregon Military Department Public Affairs.
Karesh, who does a lot of work with emerging infectious diseases, especially their links to wildlife, said understanding disease hot spots can help authorities predict where and under what conditions diseases are most likely to emerge.
“If you’re surprised by every disease event, you’re running around chasing all the wrong things,” Karesh said. “If something occurs in an unusual place or under unusual conditions, it leads you to think it was either intentional or accidental,” such as a lab error.
Much of the preparation for infectious disease outbreaks will pay off regardless of the cause of the outbreak, Karesh said. “It doesn’t matter whether it’s intentional or accidental or natural — we need to be equally prepared.”
Many of the roles played by federal, state and local emergency management agencies would be similar in any kind of attack or disaster, whether it’s a chemical or biological weapon, a bomb or a hurricane. But there are a few government roles that are specific to public health disasters.
One of the main roles is mass prophylaxis, Casagrande said. If there is a biological attack using a bacterial agent, for example, “getting antibiotics out into the population can make or break your response because you can prevent the illness in a large number of people. Otherwise you could end up treating thousands of the critically ill.”
The federal government keeps stockpiles of drugs such as antibiotics and vaccines that would be needed to respond to various biological or chemical attacks. State and local governments are in charge of distributing them in case of an emergency. The goal is to be able to distribute antibiotics, for example, to everyone who needs them within 48 hours — an extremely challenging goal, Casagrande said.
Actually distributing the drugs to a panicked population could prove extremely difficult, said Casagrande. Among the questions that must be addressed:
If a local government has identified specific places for distribution but the agent involved could cause contamination, should officials wait to see where the contamination is before setting up the distribution sites?
“Either way there’s a downside,” Casagrande said. Testing first risks overburdening a smaller number of sites and not getting the drugs to everyone in time. But going ahead with the distribution could expose more people as they come to contaminated areas to receive the drugs.
If the plan calls for distributing drugs over multiple days, does everyone wait in line? If so, how will they be sheltered and fed? If not, is there a lottery system for determining the order of distribution? What is the most effective use of security personnel?
In an emergency, law enforcement will have many competing priorities, like keeping order at hospitals and, in the case of an attack, tracking down the perpetrators, in addition to helping secure distribution centers.
State and local governments have their own strategies for handling these issues, said Casagrande, “but some strategies are better than others.”
Biological or chemical weapons can be very sophisticated or extremely simple. Some attacks may cause economic harm by targeting livestock or crops (even if the illness is not transmitted to people this way).
For terrorists, Karesh said, “it’s not about the outcome — it’s about the psychological disruption.”
The most sophisticated attacks would come from groups, such as governments, with a lot of money: “You could design and build a very sophisticated device to spread the organism of your choice in some effective way,” said Karesh. “If you don’t have any money, you could just walk into a cow field where there’s foot-and-mouth disease and then come to the United States and walk around with your same muddy boots and introduce foot-and-mouth disease. All you need is a pair of shoes and an airline ticket.” A foot-and-mouth disease outbreak, he noted, would devastate U.S. cattle ranchers.
Getting antibiotics out into the population can make or break a response. Photo by Shutterstock.com.
How can government at all levels be more prepared to respond to an outbreak caused by chemical or biological agents? Karesh offers a number of areas for focus and change:
Create stable policies and funding. “We see this roller coaster of investments in the most recent crisis, and three years later there’s no more support or funding,” Karesh said. “Essential programs shouldn’t just come and go. We deserve stable, long-term approaches.”
Centralize leadership. Karesh sees a need for “strategic thinking at the highest levels of government,” with one person ultimately in charge rather than spreading responsibility over many departments.
Strengthen communications between human health experts and those focused on animal health and the environment. When someone shows up in an emergency room with anthrax, “the traditional approach is that we need to notify everybody, thinking this may be a terrorist attack,” Karesh said. If the human and animal health experts talk to one another, though, health officials may discover that anthrax has been found in sheep and cattle in the area, leading doctors to ask the patient about exposure to those animals. On the other hand, if the agricultural specialists say they haven’t seen any anthrax locally in years, that could send the investigation in a different direction.
“It’s about preparedness, having your network of people you can trust,” Karesh said. This means less time wasted when an emergency occurs. “You don’t want to be meeting each other and exchanging business cards during a crisis.”
Focus on patterns. Since authorities can’t monitor everything all the time, it makes sense to use data to narrow the focus. For example, some areas of the world have a higher risk of producing diseases than others, and travel patterns make it possible to predict which areas of the United States are most likely to receive people from those areas.
Act on lists of pathogens of highest concern. Now that the government and other researchers have identified agents to be most concerned about, emergency management and public health officials at all levels should make sure they understand their role.
“Does everybody understand how they appear?” Karesh said. “Do we have medical countermeasures prepared, and do we have the supply chain to make sure those are available fast enough?”
