Is Bioterrorism the Most Terrifying Public Health Problem? [The ScienceBlogs Book Club]

Mark Pendergrast writes: Instead of responding to last week's commentaries on this book club blog about my book, Inside the Outbreaks, I want to throw out a controversial idea that runs counter to what many public health commentators apparently believe. So I expect some disagreement here. (I will post responses to the commentaries as "comments" on each commentary. So go back and take a look at what I wrote there, please.)

Fears of bioterrorism are overblown. We should be spending much more money, time, effort, and print (including e-print) on naturally occurring outbreaks, epidemics, and human behavioral risk factors. At least, that is one of my conclusions after researching and writing the history of the Epidemic Intelligence Service, which is a kind of microcosm of public health events over the past half century.

The EIS was created in 1951 in the crucible of Cold War paranoia during the Korean War. Alexander Langmuir masterfully played the fear card in order to fund the EIS, and he named it in a suitably military-type way, with "intelligence" meaning the same thing for outbreaks that it did for the then-recently created Central Intelligence Agency. One could say that the EIS is a kind of medical CIA, except that EIS officers do not usually act under the cloak of secrecy.

There is no question that Langmuir took the threat of biological warfare extremely seriously. But he was also savvy enough to realize that by playing up such Cold War fears, he was more likely to secure funding. Thus the earliest EIS officers were on a sharp lookout for any indication of unusual outbreaks that might have been caused intentionally. Over the years, a few incidents have been considered as possible bioterrorism events. One of the earliest was investigated by EIS officer Jerry Barondess (EIS 1951-1953), who was stationed in Philadelphia, "where putatively I was defending the Northeast," he recalled.

"One day I got a call from Atlanta. Alex said there was an epidemic of fox rabies in Broadax, PA. Go and look into that. I was a smart aleck. I said, 'Do you think the Communists are coming into the foxes in Broadax?" He told me to just shut up and go. It turned out, a couple of weeks before, in broad daylight, near Valley Forge, a fox came out of trees, teetered across a quarter mile of open ground, approached an elderly woman knitting on her porch, and snarled at the old lady, who shouted Shoo and he ran away. A couple of days after that, a fox worried a cow. A few days later, a dead fox was found to be rabid. There were no human cases yet. So I was called in. It turned out that nearby there was an old very distinguished and highly fumigated hunt club, the White Marsh Hunt, that hunted foxes. This was a faux British kind of thing, bugles and horns. Having reduced the fox population to an unacceptable level, they had imported a bunch of foxes from somewhere near Utica, I think, a few weeks before. So it was not the Russians, it was the White Marsh Hunt."

In 1984, EIS officers investigated a Salmonella outbreak in The Dalles, Oregon. Their case control study implicated the salad bars in various restaurants around town, but they couldn't link them epidemiologically. The restaurants didn't purchase produce from the same farms, and there were no employees who worked at multiple restaurants. Nor did customers roam from eatery to eatery. That turned out to be bioterrorism, committed by the nearby Rajneeshee cult in a dress rehearsal for a larger event in which they hoped to debilitate local voters in order to maintain the cult's tax-exempt status. Excerpt from Inside the Outbreaks:

EPO director Carl Tyler refused to allow [EIS officers] Török and Tauxe to publish their article on the investigation, afraid that it would provoke "copy-cat" events, as the Tylenol-cyanide poisonings had in 1982.
A decade later, in the wake of the 1995 Aum Shinrikyo sarin gas attacks in the Tokyo subways, Török and Tauxe were finally allowed to publish their paper on the salad bar contamination, the first major bioterrorism event in the United States.

As the turn of the 21st century approached, there were widespread fears of bioterrorism as part of the millennial fever. From the book:

On October 30, 1998, EIS officer Marshall Lyon got a call from a worker at a Planned Parenthood clinic in Knoxville, Tennessee, which had received a letter that said, "You've just been exposed to anthrax. You will die within 24 hours." Over the next hour, he got calls about identical letters sent to clinics in Louisville, Kentucky, and Indianapolis, Indiana. Lyon tried to calm the callers, telling them that if there was nothing in the envelope but the letter, anthrax exposure seemed unlikely.
All the centers had also called 911, bringing police, firefighters, emergency medical services, the FBI, and Hazardous Materials (HAZMAT) units to the clinics. By the time Lyon flew to Indianapolis on Monday to assess the situation, it was clear that the letters were hoaxes. Yet when another Indianapolis clinic received a similar letter that day, the scenario repeated itself. Then in Los Angeles on December 17, 1998, two anthrax letters were mailed to city offices, followed within the next week by phone warnings to a private business and a large federal building, from which 1,500 employees were evacuated. Lyon flew out. "It kind of boggled my mind," he recalled. "There was no assessment of the threat credibility." Lyon tried to preach some common sense. "You have to temper your response," he said, "or you will go broke."
Over the next few months, dozens of hoax letters, many containing talcum powder or white flour, arrived at schools, courthouses, media outlets, abortion clinics, and an IRS office.

Fortunately, this rash of hoax letters spurred the CDC to form a bioterrorism task force and to create a state-of-the art anthrax lab. My favorite non-bioterror scare occurred in conjunction with New Year's Eve. Here is that little section.

In October 1999, the FBI issued a warning about terrorism linked to the turn of the century. The same month, Hot Zone author Richard Preston published an article in the New Yorker, speculating that the recent West Nile virus outbreak might have been the work of a terrorist. Preston quoted an Iraqi defector who said that Iraqi dictator Saddam Hussein had boasted that his labs could produce a West Nile virus "capable of destroying 97 percent of all life in an urban environment."
EIS officer Kristy Murray had already concluded that the West Nile epidemic in New York City was not premeditated and she knew that a 97 percent mortality rate was absurd. With near-hysteria in the air over the Y2K bug that would supposedly wipe out computers as dates turned on Jan. 1, 2000, Murray got a call from Pennsylvania health authorities. The trucker who had delivered the ball to Times Square for the New Year's Eve celebration had just died of a rapidly fatal pneumonia, and so had his wife. Murray had nightmare visions of the giant glittering ball slowly descending at midnight, spraying deadly fumes over thousands of celebrants. But she learned, to her relief, that the trucker had carried a wall, not a ball - someone had misheard the word and panicked. The trucker and his wife were already unhealthy and morbidly obese. The 20th century went out with a routine bang, not a fatal hiss.

We know, of course, that exactly 50 years after the creation of the EIS, its officers did investigate a major bioterror event when real anthrax letters began to kill and sicken people. In my chapter, "Full Circle," I wrote in detail about that investigation. At chapter's end, I concluded:

Ottilie Lundgren was the last anthrax victim of the 2001 bioterror spree. A total of 22 people had been infected, half of them with inhalational anthrax, and five inhalational victims had died. Of the 146 then-current EIS officers, 136 helped with at least one part of the investigation. Nearly a third of them went out twice, and some were redeployed four or five times.
Prompt investigation and prophylaxis undoubtedly prevented other anthrax infections and deaths. No health authorities had any way of knowing how many letters had been sent out to what locations, or whom they would infect. "What shook me," EIS officer Kevin Winthrop said, "is how one individual could drop a few letters in a mailbox and nearly shut down a country."
As a result of the anthrax investigation, blowers were no longer used to clean sorting machines, letters were irradiated, and other safety measures put in place. There was some good news, too. Untreated, the case fatality rate for inhalational anthrax from the letters approached 50 percent -- less than the expected 85 percent rate - but when promptly treated, all but a few patients survived. ...[A FEW CUT PARAGRAPHS HERE]
In the wake of the anthrax letters, the Bush administration and Congress threw billions of dollars into bioterror preparedness, much of it going to the CDC and to state health departments. HHS Secretary Tommy Thompson called for an EIS officer in every state, but some states had weaker public health infrastructure and lacked good supervisors. Instead, EIS alums called Career Epidemiology Field Officers (CEFOs) were posted to such states, though they focused primarily on terrorism and emergency response.
The new bioterror money undoubtedly improved preparedness for many potential public health emergencies, but other problems were underfunded, according to EIS alum Barry Levy, editor of the 2003 book, Terrorism and Public Health. "These bioterror initiatives have, in general, distorted public health priorities," complained Levy, "and drained human and financial resources away from addressing current public health problems, including tobacco- and alcohol-related diseases, gun-related injuries and deaths, HIV/AIDS, and mental health disorders."

So, I repeat, bioterrorism fears are overblown. I think this is because of bioterrorism's sexy nature, not only for the media, but for public health figures. It's exciting to worry about. And there are certainly realistic fears that some of the smallpox that the Soviets were secretly brewing may get into terrorist hands, and it could be released in a way that would create an epidemic and cause many deaths.

Even if that bleak scenario were to come true, however, we would probably be able to contain the epidemic relatively quickly. We know how to conduct surveillance-containment, and we know how to vaccinate against smallpox.

Then there is the idea that some mad scientist is going to use genetic engineering to create a new killer strain that will cause a pandemic. The June 2010 issue of Scientific American ran an article, "Terror in a Vial," asserting that the concern over nuclear bombs is old-fashioned, "an approach unsuited to the modern reality." Instead, the authors believe we should be worried about bioterrorism. "Terrorists no longer need to steal deadly pathogens when common-place genetic engineering techniques could turn a benign microbe into a killer or synthetic biology tools might be used to build a virus from scratch."

Maybe, but I think natural selection is a far more potent device to create microbes to take advantage of the burgeoning human herd. There will be 9 billion of us in another 40 years. I don't think terrorists or any humans are smart enough to create a microbe that could do worse than nature already does. And if they did, it would be likely to be treatable and not easily transmissible. Much better to worry about nuclear bombs.

What we really need is a well-funded public health system that conducts comprehensive surveillance for infectious as well as toxic agents. Bioterrorism will be spotted as part of that effort. Every year approximately 36,000 people die of seasonal flu-related causes. Yet no one seems unduly concerned.

And as I pointed out near the end of Inside the Outbreaks, our biggest challenges are modifying our own behaviors:

Humanity's worst problems are self-inflicted. Why do members of Homo sapiens self-destruct? According to World Health Organization, the top two global killers, accounting for nearly a third of all mortality, are ischaemic heart disease (blocked arteries) and cerebrovascular disease (insufficient blood to the brain, strokes), both of which are often caused by smoking, obesity/poor diet, and lack of exercise.
In 2004, four authors (including EIS alum Jim Marks) estimated recent "actual causes of death" in the United States - i.e., the underlying behavior or agent responsible for human demise. The top culprit was tobacco, accounting for 18.1 percent of all U. S. deaths, followed by obesity and poor diet (15.2 percent), with excessive alcohol consumption third (3.5 percent). .... [SNIP]
How could EIS officers get people to modify their drinking habits and diets, get more exercise, and quit smoking? They could provide important surveillance data and studies, but ultimately, argued EIS alum Tom Farley in his co-authored 2005 book, Prescription for a Healthy Nation, the cure would involve modifying our environment to make it easier and more appealing to walk, run, bike, and buy or grow healthy foods. "Health is political," he wrote, advising that "it will take fighting in Congress to get the booze ads off television, arguing in the town council to build sidewalks or fix the recreation equipment in the park, or calling state legislators to ban smoking in all restaurants.".... [SNIP]
And so EIS officers continue to engage with such problems, confirming that poverty, social injustice, and frustration are at the root of many health issues. Those who are most vulnerable are the underprivileged, the malnourished, the unvaccinated, refugees. ...[SNIP]
Looming over all other problems is global warming. ...In 2008, EIS alum Mike St. Louis co-authored a summary article on the potential public health impacts of global warming. "The most severe consequences of climate change will accrue to the poorest people in the poorest countries," he wrote, "despite their own negligible contributions to greenhouse gas emissions." Malnutrition, unsafe water, and heat waves will increase. Coastal megacities - Mumbai, Lagos, Shanghai, Dhaka, Tokyo, New York - will be vulnerable to sea-level rise and infiltration of freshwater with saltwater.⢠Diseases carried by mosquitoes may shift to currently temperate climes. Waterborne infections such as cholera could spread. Armed conflict is likely to escalate as people fight over scarce resources or ban desperate refugees. Also, by 2050, the human population is projected to grow from its current 6.8 billion to over 9 billion.

So that's why I am not unduly concerned about bioterrorism, though that does not mean I think we can afford to ignore its possible occurrence, either. -Mark Pendergrast


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