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Center of the Crisis

Stunned and frightened by anthrax terrorism attacks, the nation turns to D.A. Henderson and the School's center for civilian biodefense strategies for answers.

By Brian W. Simpson

September 11th marked the beginning of a dark autumn.

From the moment the second hijacked passenger plane pierced the World Trade Center's south tower in an attack that would ultimately kill thousands, researchers at the Center for Civilian Biodefense Strategies realized its deeper significance. What D.A. Henderson and his colleagues had spent years talking about, warning about, and preparing for — bioterrorism — suddenly burst from the realm of the purely hypothetical.

As she watched the first television images of fire and collapsing glass towers, Tara O'Toole, MD, MPH '88, understood the attack's implications for bioterrorism. "We were thinking about it right from the beginning," says O'Toole. The attack "demonstrated immediately these terrorists were sophisticated, organized, and capable of doing complex activities and using high technology. That seemed to us to counter directly the opinion of some that bioweapons were beyond the reach of terrorists. 

"The other line crossed was they were clearly able and willing to kill large numbers of people," says O'Toole, who became the Center's director on Oct. 30 following Henderson's departure to become director of the Office of Public Health Preparedness (see Welch Wanderings).

The terrorists also proved they were willing to fight America in a new way: using targeted attacks at vulnerable points on U.S. soil, while avoiding U.S. military might — a concept called asymmetric warfare. And biological weapons, according to O'Toole, are a "classic asymmetric type of weapon." 

So, on Oct. 4, when the anthrax stories first began trickling in about the infection of a photo editor in Florida and then his coworker, and later an NBC employee in New York, and staff in the U.S. Senate majority leader's office, and postal workers in Washington, the deeper meaning dawned on us all: this fall would be unlike any other.

In 1995, the year that sarin gas attacks in the Tokyo subway killed 12 and sickened thousands, President Bill Clinton made counter-terrorism a top priority. Millions of federal dollars poured into the departments of Justice and Defense and other agencies to strengthen counter-terrorism. But bioterrorism was a poorly understood, minor concern at the time.

"In fiscal year 1998, I think the whole budget for bioterrorism in the Department of Health and Human Services was about $2 million," says Henderson. (It has since grown to $175 million. Estimates for next year's allocation start at $1.4 billion.)

From 1993 to 1995, D.A. Henderson was a deputy assistant secretary at the Department of Health and Human Services (HHS) and served on various defense and intelligence committees. "The thing that was of great concern to me was there was nobody there from medicine or public health. Almost nobody," says Henderson. "They were not doing anything in preparation for an epidemic, which was what bioweapons would cause."

A mere 100 kilograms of anthrax released from a plane above a metropolitan area could spread an invisible, odorless cloud of spores that could kill 130,000 to 3 million people, according to one government study. Large outbreaks of anthrax, plague, botulism, tularemia, or smallpox could cripple cities.

Henderson knows epidemics and brought the highest possible public health credentials to the committees. He led the successful global smallpox eradication campaign from 1966 to 1977, and subsequently was the School's dean from 1977 to 1990. Familiar with the devastating power and sweep of epidemics, he set out to spur government officials to start thinking about and preparing for biological terrorism.

At a 1997 symposium sponsored by the Infectious Diseases Society of America, Henderson led a presentation on the threat of biological weapons. The meeting drew more interest and more requests for speaking engagements. With funding from the School and the School of Medicine, Henderson, MD, MPH '60, started the Center for Civilian Biodefense Studies. O'Toole and Tom Inglesby, MD, joined him in a mission to influence government and public policy regarding bioterrorism. The Center would be part think-tank, part research center, and part bioterrorism information clearinghouse.

"We were pretty much lone voices," Henderson recalls. "The idea that this was a real problem or could be a real problem was just not appreciated at all. There was nobody doing anything on this at the Centers for Disease Control, the National Institutes of Health. There was nobody in the secretary's office [at HHS] doing anything about it."

From the beginning, they devoted much of their time to raising national awareness of the bioterrorism threat through congressional testimony and debriefings, publication in scientific journals, and lectures. They also organized elaborate bioterrorism response training events. In June 2001, one such event called Dark Winter posited a smallpox bioterrorism attack on U.S. citizens. Former government officials acted as members of the National Security Council dealing with the attack. The exercises revealed key gaps in the nation's bioterrorism preparedness, months before it would have to respond to the real thing.

Now, Henderson and the Center are international focal points of information on bio-terrorism. They draw diverse pleas for information: a U.S. Army master sergeant wants to know how much radiation it takes to kill anthrax spores, or a Union Pacific railroad official has questions about environmental control for critical buildings. At a House intelligence committee meeting, O'Toole recently testified on the use of microchips to medically diagnose bioweapons pathogens. Media interview requests flood in daily from Newsweek, CBS News, the Japanese newspaper Asahi Shimbun, The Economist, Reuters, and dozens of others. "We can't even begin to return 10 percent of the phone calls," Henderson says.

With a dearth of solid information about anthrax, the response to this fall's anthrax attacks — which at press time had killed four and infected 17 — revealed the lack of federal government preparation. Law enforcement and public health authorities have not cooperated seamlessly. Tom Ridge, newly installed director of the Office of Homeland Security, initially downplayed the danger posed by the letter to Senator Tom Daschle. And the Bush administration has been criticized for not protecting postal workers sooner, two of whom have died from anthrax.

"It's not surprising they aren't performing like a well-oiled machine," says O'Toole. "We're learning as we go. We haven't invested enough in bioterrorism preparedness to really know what we're dealing with."

Anthrax is a particularly difficult challenge because so little is known about it. Inhalation anthrax has historically been associated with people who have inhaled its spores while working with contaminated animal hides, wool, and fur. There have been only 18 cases of inhalation anthrax in the U.S. in the 20th century, and most of those occurred before the age of antibiotics. More information about inhalation anthrax was gleaned from an anthrax release at a Russian bioweapons facility in 1979 (see Anthrax: Filling in the Blanks). Local, state, and federal law enforcement and public health officials, therefore, had little experience to draw on.

Most doctors only knew of anthrax infections from textbooks. "How much clinical experience do we have treating people with anthrax in the U.S.? There's none," says Inglesby, now the Center's deputy director. "Clinicians are not trained to look for it. We have limited diagnostic tests in the tool kit to tell us it is or it isn't anthrax."

While clinical experience with anthrax is limited, knowledge is being acquired daily, Inglesby says. "We actually know enough to make some serious recommendations and we have made them," he says.

What's been lacking in the government's bioterrorism response has been a sound strategy for communicating the risks and dangers to the public, notes Monica Schoch-Spana, senior fellow at the Center and a medical anthropologist. "You know how they screwed up? Their first message was, 'Don't panic,'" Schoch-Spana says. "It's paternalistic. It's not helpful." People want an honest assessment of the situation so they can make informed decisions to safeguard their families, says Schoch-Spana, PhD, who has done extensive research on the 1918 Spanish flu epidemic, scouring the history for clues to how the public and medical and public health communities respond to a devastating outbreak of infectious disease.

"There is an assumption that the dominant response of the public is panic," Schoch-Spana says. "That is a myth." To help overturn that misconception, Schoch-Spana organized a rapid response research team to study World Trade Center volunteers who flooded Ground Zero. She hopes the study will document for government officials how the public can adjust and respond to new threats. In a worst case scenario of bioterrorism involving mass casualties that overwhelm medical facilities, the government would have to turn to the public for help anyway, argues Schoch-Spana. People would have to treat family members and themselves at home in that situation, and they would depend on public health officials to clearly articulate the problem and provide practical information on infection control and medical care.
Inglesby agrees that an effective communication strategy is essential: "As [former Senator] Sam Nunn said in Dark Winter, 'There's no way to demand 300 million people do something unless they're absolutely persuaded that it's in their best interests, and you're doing everything possible to help them.'"

In addition to researching better communication strategies, the Center is guiding other long-term government responses through briefings to key congressional committees, the vice president, and high-level officials at the departments of Defense, State, and HHS. "We've been trying to get them to understand in specific terms, with price tags attached, what the medical and public health systems need in order to respond to a biological or chemical attack," says O'Toole.

The Center, respected for its independent, objective views in partisan Washington, has helped shape the current debate in Washington on how best to prepare the nation for future bioterrorist attacks. (A bill sponsored by Senators Bill Frist and Edward Kennedy is currently being drafted that will spend an estimated $2 billion or more on improvements to the National Pharmaceutical Stockpile, Centers for Disease Control and Prevention laboratories, vaccine research, and public health infrastructure.)

In the future, the Center will also be working with scientists whose legitimate discoveries can be twisted for darker purposes. "As we learn of the virulence of microorganisms, we have the capacity to make better drugs and vaccines," says O'Toole. "We also have the capacity of building more virulent microorganisms.

"Biology is losing its innocence as it grows in power," she says. The Center has recently secured funding to start a dialogue in the scientific community about keeping science advancing while protecting against its deliberate misuse.

For D.A. Henderson, the genie is out of the bottle. Anthrax, plague, botulism, tularemia, and the disease he defeated in 1980 — smallpox — will remain threats for many autumns to come.

He has felt no grim satisfaction that others now understand the dangers of bioterrorism. Shuttling between endless meetings and briefings in Washington, tackling his new responsibilities at HHS, and patiently handling rounds of interviews at the office and at home, he only has time to help direct the current concern over bioterrorism to the most effective results.

On a recent, harried Saturday morning at home, he fielded phone calls from the BBC, a Japanese reporter, and the chief of staff for the secretary of HHS, all while being photographed and interviewed by yet another reporter. The book he's been meaning to write on the smallpox campaign waits for his attention. The bioterrorism papers he wants to write have been shelved. His new position requires a 24-hour-a-day commitment.

Like everyone else, Henderson longs for the way things were before. "I really was rather enjoying where we were until this hit," he says.

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