Bioterrorism and the public health response.

The threat of a terrorist attack on the civilian population of the United States has provoked an unprecedented response among both security and public health professionals in a very short time. The emphasis on bioterrorism presents both opportunities and challenges for preventive medicine and public health. On the one hand, this may be an historic opportunity to build public health infrastructure after years of decline. On the other, it may distract governments from badly needed investment in public health agencies required to perform their more traditional duties. The response to the perceived threat of bioterrorism has been very impressive. A disproportionately large investment is being made in bioterrorism preparedness, including $158 million by the Department of Health and Human Services in Fiscal Year 1999.1 A competitive grant program to support capacity building to counter biological threats closed in May 1999; it will fund 62 eligible jurisdictions across the United States for infrastructure development in preparedness, surveillance, laboratory evaluation of chemical and biological threats and training. No less than three national meetings were held on the topic in 1999. The most important, the First National Symposium on Medical and Public Health Response to Bioterrorism, on 16–17 February in Arlington Virginia, sold out all available seats. Next, the major debate at this year’s World Health Assembly was the destruction of smallpox stores in the two remaining legal depositories. Both pro and con sides to the debate, however, were in complete agreement that a significant threat exists today of purposeful reintroduction of smallpox into the world through bioterrorism.2 Many schools of public health have added material on bioterrorism to their curriculum; a survey is forthcoming from the Association of Schools of Public Health. How much of the bioterrorism threat is hype? Is this an overreaction? Is concern over bioterrorism diverting funds and distracting governments from funding public health agencies for the primary duties they were set up to perform? Is bioterrorism hijacking the public health agenda? The considered answers after due reflection and study of the issues3 are “some,” “no,” and “not necessarily,” respectively. Unfortunately, too much of the bioterrorism threat is real.3 A bioterrorist attack on the civilian population of the United States is possible and growing more likely. The Institute of Medicine (IOM) reviewed the evidence and produced the most definitive report yet available for the health sector. The IOM strongly advocated an increased investment in preparedness, while admitting that an optimal, effective response was nearly impossible.4 Biological agents make formidable weapons of mass destruction. A visit to the former biological warfare installation of the Japanese army in Manchuria was sufficient to persuade this author of the potential horror of the deliberate release of biological agents, even in this day and age. The effect of a bioterrorist attack on the civilian population of a major city is terrible to contemplate. Public health agencies can do little to prevent widespread and horrible suffering. The perpetrators of such a deed would go down in history as criminals against humanity. However, such an odious historical legacy may be perversely attractive to sociopaths and the unbalanced, obsessed few who will not stop at any measure to advance their political, religious or cultural cause. Many biological agents have or could be used as biological threats. Each has its own limitations. The two agents most likely, for technical reasons, to be used in a terrorist attack on civilians are smallpox and anthrax. Smallpox is most likely to be obtained in a clandestine manner from laboratories in the former Soviet Union. Anthrax is more accessible. Both are easy to culture and disseminate. Smallpox has the advantage, for purposes of terrorism, of person-to-person transmission now that very few people in the world remain immune. Both are terrifying in the suffering they cause. Neither are likely to be identified quickly when the first cases appear, because both resemble nonspecific influenza-like illnesses in their prodromal stages. In the opinion of many observers, anthrax is likely to be the agent of choice for a civilian attack. Smallpox attacks would require a connection with some organized network that could access contraband cultures, presumably smuggled out of Russia. In all probability, a criminal or extremist group has already tried to do this. If smallpox is unavailable, anthrax is a cheap and From the School of Public Health and Health Services, The George Washington University Medical Center, Washington DC Address correspondence and reprint requests to: Dr. T.L. Guidotti, The George Washington University Medical Center, School of Public Health and Health Services, Dept. of Environmental and Occupational Health, Ste. 201, 2300 K St. NW, Washington, DC 20037. E-mail: Eohtlg@gwumc.edu.