Emerging Infectious Diseases
[Volume 5 No.4 / July - August 1999]


Special Issue

Bioterrorism: How Prepared Are We?

Donna E. Shalala
U.S. Secretary of Health and Human Services

Richard Preston's The Cobra Event, which he dedicates to public
health professionals, weaves a chilling, but compelling tale about a
lone terrorist's attack on Manhattan with a genetically engineered
virus. Preston's thought-provoking novel raises a logical question:
How do we successfully contain and combat the threat of
bioterrorism? To meet this emerging threat, we must address four
important challenges.

The first challenge is to be aware that an act of bioterrorism could
happen. Its likelihood is entirely unknown, and an attack may never
occur. However, we have seen terrorism emerge as one of the
thorniest problems of the post-cold war era, and we have seen that
terrorists are always searching for new weapons. We have already
seen sarin nerve gas released in the Tokyo subway. Somewhere,
sometime in the future, terrorists may well threaten to use, or
attempt to use, a biological weapon against the United States.
When discussing the possibility of a terrorist attack in the next few
years, the president unequivocally stated, "This is not a cause for
panic. It is cause for serious, deliberate, disciplined, long-term
concern." In other words, we must not be afraid, but we must be
aware.

Once we are fully aware that bioterrorism could happen, our second
challenge is to be prepared. That is why the Department of Health
and Human Services (HHS) is spending $158 million this fiscal year
to prepare for bioterorrism and why the president has proposed
increasing that investment by an additional $72 million in his Fiscal
Year 2000 budget.

This investment will fund our ongoing Anti-Bioterrorism Initiative.
To increase our level of preparedness, the initiative is expanding its
activities in a number of key areas: surveillance, medical and public
health response, building a stockpile of drugs and supplies, and
research and development. We are improving and strengthening the
U.S. public health surveillance network by enhancing our capability
to detect and report outbreaks, conduct epidemiologic
investigations, perform laboratory tests to identify biological agents,
and communicate necessary information and advisories rapidly
through electronic technology.

We are enhancing our medical and public health response capacity
by spearheading an administrationwide effort to develop
infrastructure at the local level by establishing in major American
cities medical response teams to deal with the consequences of
bioterrorism. We are also expanding our capacity to provide
prophylaxis, medical care, and infection control on a massive scale.
We are creating, and will be maintaining, an unprecedented national
stockpile of drugs and vaccines for civilian use in case of a
bioterrorist attack.

Finally, we are accelerating our research and development of rapid
diagnostics, drugs, and vaccines, so we can more effectively
address the threats and consequences of a bioterrorist attack. In
addition, we will continue our work on the genome sequencing of
organisms most likely to be used as bioweapons, so that we can not
only quickly identify the biological agent, but also develop effective
therapies. Our efforts in surveillance, medical and public health
response, stockpile provision, and research and development will
increase significantly our preparedness for bioterrorism.

If we want to be truly prepared, our third challenge is for the public
health and medical communities to take the lead in our fight against
bioterrorism. In a conventional terrorist attack, local "first
responders," such as the police, firefighters, and paramedics,
constitute the first line of defense. With bioterrorism, the public
health and medical communities stand directly on the front lines.
How well we respond to a threat or attack will depend on the
preparedness of our public health and medical communities. For
example, if a bioterrorist threat is issuedperhaps someone claims
to have released a deadly pathogen in a public placephysicians
must be able to recognize and report cases that come to attention in
emergency rooms and doctors' offices; public health officials must
be able to conduct investigations to establish the likely site/time of
exposure, the size and location of the exposed population, and the
prospects for secondary transmission; and appropriately traned
laboratory personnel must be available to identify the biological
agent. Whether the release of a bioweapon is announced or
surreptitious, affected persons may not have symptoms for days or
even weeks, and by then they would be geographically dispersed.
Quarantine is not practical because only one of the most common
biological agentssmallpoxis communicable. Even with
smallpox, it would be impossible to know whom to quarantine
because of the spread of disease by secondary transmission and the
difficulty in accurately identifying those who have been exposed. A
strong electronic communications network would be needed to
piece together early reports, as well as epidemiologic and
laboratory data, to determine what had happened so that public
health and law enforcement officials can take prompt action. The
Centers for Disease Control and Prevention would play an
important role in this process because of its particular expertise in
surveillance, infectious disease, and public health. Everyonefrom
the physicians who first see victims to the scientists who identify the
infectious agentsmust coordinate their efforts.

That brings me to the fourth, and final, challenge: We must all work
together. In the fight against bioterrorism, the federal government,
particularly HHS, has a leadership role. Among other things, we
need to support state and local planning efforts, provide training at
every level, develop an infrastructure for delivering mass medical
care, and offer expertise to our communities.

This is a fight we certainly cannot win by ourselves. Across the
board, we must forge new working partnerships among health,
public safety, and intelligence agencies. We need unprecedented
cooperation among the federal government, state and local health
agencies, and the medical community. We must ensure that plans
for managing the medical consequences of terrorist acts are well
integrated and coordinated with other emergency response systems.

Close collaborative efforts are necessary also because microbes do
not respect boundaries of culture, language, or territory. An act of
bioterrorism cannot be contained by any national border or barrier.
When it comes to microbes, we are not protected, in the words of
the Indian poet Tagore, "by narrow domestic walls." Since these
organisms recognize no boundaries, in our battle against them,
neither can we. Because we share a common future, we must share
a common resolve. As Dr. Gro Bruntland, the director-general of
the World Health Organization, has said, when it comes to public
health and safety, "Solutions, like the problems, have to be
global..." As we work together to counter bioterrorism, we must
pool our will and our resources to meet the challenges.

Emerging Infectious Diseases
National Center for Infectious Diseases
Centers for Disease Control and Prevention
Atlanta, GA

URL: ftp://ftp.cdc.gov/pub/EID/vol5no4/ascii/shalala.txt

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