Biowar

By Mary Beth Brown, BS RN.*

I’m writing this report as the Hart Senate office building, which has been closed for months, is being re-opened. The War on Terrorism is progressing well in Afghanistan, and daily headlines have been diverted from the home front war on Bio-terrorism to the international good news about success in the war. This respite of stories about Bio-terrorism may comfort the American psyche, but it is a story that you as an individual ignore at your own risk.

A Wall Street Journal reporter bought a looted computer in Kabul and it was full of terrorist plans to create biological weapons. This has been a major part of Bin Laden¨s efforts. His scientists were busy perfecting a homemade version of nerve gas.

The great American Anthrax scare is an important warning of the risks you and I face in our future. If we fail to heed this warning we will have been foolish. The purpose of this report is to clearly evaluate the risks. As an experienced medical professional I have used all of my training to evaluate the situation for you. After we evaluate the risks, I will use my training to give you a plan of action. This plan of action will help you prepare for the risks we face.

If you trust the federal government and the so-called public health system to tell you the truth and take care of you in the advent of a bio-war battle, you are misinformed. The government and academics are already discussing who should die. These protectors of the public health will become the gatekeepers who will decide who lives and who dies. You place yourself in their care at great risk to yourself and your loved ones.

EXERCISE DESIGN

Participants

• 12 former senior government officials portrayed members of a National Security Council responding to an evolving epidemic crisis. Former Senator Sam Nunn played the role of the President of the United States.
  
• 5 distinguished representatives from the media acted as journalists during a mock press conference within the exercise.
  
• 50 individuals with current or former policy or operational responsibilities related to biological weapons preparedness observed the exercise.

Structure

• The exercise simulated a time span of about 2 weeks and was divided into three segments (December 9th, 15th, and 22nd) as NSC meetings.
  
• Key players obtained information on which to act through a variety of channels:
  
  
  
  • Briefings to the NSC meeting by exercise controllers playing the roles of deputies or special assistants.
    
  • Newspaper summaries and video news clips as stories "broke" and were seen by the nation over the course of the epidemic.
    
  • Memos on issues or events within the purview of an individual’s position or agency.
  
  
  
  
• NSC members debated and acted upon a range of policy options. Decisions made in one segment structured possible alternatives in the subsequent segments.

SCENARIO HIGHLIGHTS

Segment 1, December 9, 2002

• Situation
  
  
  
  • Iraq suspected of reconstituting its bioweapons program. Iraqi forces moving into offensive positions along the Kuwait border.
    
  • 20 confirmed smallpox cases in Oklahoma. Additional, suspected cases in Georgia and Pennsylvania.
  
  
  
  
• Key Issues and Decisions
  
  
  
  • What is best containment strategy with only 12 million doses of vaccine?
    
  • Who are priority vaccine recipients (e.g. military or civilian, all or some states, critical personnel and family members)?
    
  • What to tell the public?
  
  
  
  

• Situation
  
  
  
  • 2000 cases in 15 states; isolated cases in Canada, Mexico and the U.K.
    
  • Dwindling vaccine supply, overwhelmed healthcare system, social unrest.
    
  • International borders closed to US trade and travel; some state borders closed.
    
  • Intense media coverage; scrutiny and criticism of government response.
    
  • Sporadic violence against minorities who appear to be of Arabic descent.
  
  
  
  
• Key Issues and Decisions
  
  
  
  • How to meet homeland security and disease containment needs while maintaining international commitments?
    
  • What alternative epidemic controls (e.g., quarantine, travel restriction) are possible? What about economic disruption and civil rights infringement?
    
  • What assistance can the federal government offer states? What is the role of the National Guard?
    
  • Is the nation at war?
  
  
  
  

Segment 3, December 22, 2002

• Situation
  
  
  
  • 16,000 cases in 25 states with 1000 deaths; 10 other countries with reported cases.
    
  • Grim predictions: within 3 weeks as many as 300,000 total victims -1/3 to die.
    
  • Uncertainty whether new cases are due to identified contacts, contacts not vaccinated in time, ineffective vaccine, new attacks or some combination.
    
  • Depleted vaccine supplies, with no new stocks ready for 4 weeks.
    
  • National economy suffering; food shortages; states restrict nonessential travel.
  
  
  
  
• Key Issues and Decisions
  
  
  
  • What containment strategy with no vaccine?
    
  • Can continuity of government be maintained?
    
  • If unknown perpetrator finally discovered, what kind of response by US?
  
  
  
  

CAVEATS

• Lessons synthesized by Johns Hopkins Biodefense staff were based upon review and analysis of the following:
  
  
  
  • Important comments and decisions made by exercise participants.
    
  • Subsequent Congressional testimony from key participants.
    
  • Interviews with key participants.
  
  
  
  
• Lessons in this document reflect the conclusions and interpretations of the Johns Hopkins Center for Civilian Biodefense Studies and do not necessarily reflect the views of the participants or the other collaborating organizations.
  
• Dark Winter was a not for attribution without permission from individual participants’ exercise. Where comments are attributed, permission has been obtained from participants.

LESSONS OF DARK WINTER

1. Leaders are unfamiliar with the character of bioterrorist attacks, available policy options and their consequences:
   
   
   
   • The consequences of a bioterrorist attack would be substantially different from the terrorist events of September 11, 2001.
     
   • The senior decision-makers in Dark Winter were largely unfamiliar with the sequence of events that would follow bioterrorist attacks.
     
   • Key decisions and their implications were dependent on public health strategies and the possible mechanisms to care for large numbers of sick people – issues not typically briefed or studied in the national security or defense community.
   
   
   
   
   
   
   
   "We are used to thinking about health problems as naturally occurring problems outside the framework of a malicious actor… If you’re going against someone who is using a tool that you’re not used to having him use – disease -and using it toward – quite rationally and craftily, but using it toward an entirely unreasonable and god awful end – we are in a world we haven’t ever really been in before." – Senior Dark Winter Participant

   "This was very revealing to me – that there is something out there that can cause havoc in my state that I know nothing about, and for that matter, the federal family doesn"t know a whole lot either." – Senior Dark Winter Participant

   "My feeling here was the biggest deficiency was, how do I think about this? This is not a standard problem that I’m presented in the national security arena. I know how to think about that, I’ve been trained to think about that… – a certain amount of what I think went [on] around this table was, "I don’t get it. I’m not in gear in terms of how to think about this problem as a decision-maker. So then I get very tentative in terms of what to do." – Senior Dark Winter Participant

   "…this was unique…[you know] that you¨re in for a long term problem, and it’s going to get worse and worse and worse and worse and worse." – Senior Dark Winter Participant

2. Following a bioterrorist attack, leaders’ key decisions would depend on data and expertise from medical and public health sectors:
   
   
   
   • In Dark Winter, even after the smallpox attack was recognized, decision-makers were confronted with many uncertainties and wanted information that was not immediately available. (In fact, they were given more information on locations and numbers of infected persons than would likely be available in reality.)
     
   • For example, it was difficult to identify the locations of the original attacks; know how many persons were exposed; find out how many were hospitalized and where; or, keep track of how many had been vaccinated.
     
   • This lack of information critical for leaders’ situational awareness in Dark Winter reflects the fact that few systems exist for rapid flow of this type of information in the medical and public health sectors in US.
   
   
   
   
   
   
   
   "What’s the worst case? To make decisions on how much risk to take…whether to use vaccines, whether to isolate people, whether to quarantine people…I’ve got to know what the worst case is." – Senior Dark Winter Participant

   "You can’t respond and make decisions unless you have the crispest, most current, and the best information. And that’s what strikes me as a civil leader…that is…clearly missing." – Senior Dark Winter Participant

3. The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options:
   
   
   
   • In Dark Winter, smallpox vaccine shortages had significant impact on the response available to contain the epidemic, as well as the ability of political leaders to offer reassurance to the American people.
     
   • Emergency (crash) vaccine production strategies were untested and uncertain. Populations in affected states were frantic to get the vaccine, while populations in unaffected states were worried that no vaccine would be left by the time the epidemic spread to their communities.
     
   • The increasing scarcity of smallpox vaccine led to violence and flight by persons desperate to get vaccinated, and it had great impact on the decisions taken by political leaders.
   
   
   
   
   
   
   

   "We can’t ration…Who do you choose and who do you not choose to get vaccinated?… People are going to go where the vaccine is. And if they know that you’re going to provide the vaccine to my people, they’ll stay to get vaccinated. I think they’ll run if they think the vaccine is somewhere else." – Senior Dark Winter Participant

   "…[I]f we had had adequate vaccine supplies,…we would have had more strategies to help deal with this thing and help control the epidemic." – Senior Dark Winter Participant

4. The US health care system lacks the surge capacity to deal with mass casualties:
   
   
   
   • In Dark Winter, hospital systems across the country were flooded with demands for patient care. The demand was highest in the cities and states directly attacked, but victims were geographically dispersed, with some having traveled far from the original site of attack.
     
   • The numbers of people flooding into hospitals across the country included people with common illnesses who feared they had smallpox as well as the worried well.
     
   • The challenges of distinguishing the sick from the well, of rationing scarce resources, and of shortages of health care staff worried about becoming infected or about bringing infection home to their families all imposed a huge burden on the medical system.
   
   
   
   
   
   
   

   "…[W]e think an enemy of the United States could attack us with smallpox or with anthrax – whatever – and we really don’t prepare for it, we have no vaccines for it – that’s astonishing. That¨s like, for me, in [my state], where we do have tornadoes, to be assiduously studying hurricanes, or not studying tornadoes." – Senior Dark Winter Participant

   "It isn’t just [a matter of] buying more vaccine. It’s a question of how we integrate these [public health and national security communities] in ways that allow us to deal with various facets of the problem." – Senior Dark Winter Participant

5. To end a disease outbreak after a bioterrorist attack, decision-makers will require ongoing expert advice from senior public health and medical leaders:
   
   
   
   • The leaders in Dark Winter were confronted with rapidly dwindling supplies of smallpox vaccine and an expanding smallpox epidemic. Some advised imposition of geographic quarantines around affected areas, but the implications of these measures, e.g. cessation of normal flows of medicines, food and energy supplies, and other critical needs, were not clearly understood at first.
     
   • In the end, it is not clear that such draconian measures would have led to more effective interruption of disease spread.
   
   
   
   
   
   "…[A] complete quarantine would isolate people so that they would not be able to be fed, and they would not have medical [care]… So we can’t have a complete quarantine. We are, in effect, asking the governors to restrict travel from their states that would be non-essential. We can’t slam down the entire society." – Senior Dark Winter Participant

    

6. Federal and state priorities may be unclear, differ or conflict, authorities may be uncertain, and constitutional issues may arise:
   
   
   
   • In Dark Winter, tensions rapidly developed between state and federal authorities in multiple contexts.
     
   • State leaders wanted control of decisions regarding imposition of disease containment measures – e.g. mandatory vs. voluntary isolation and vaccination; closure of state borders to all traffic and transportation; when or if to close airports. Federal officials argued that such issues were best decided on a national basis to ensure consistency and to give the president maximum control of military and public safety assets.
     
   • Leaders in states most affected by smallpox wanted immediate access to smallpox vaccine for all citizens of their states, but the federal government had to balance these requests against military and other national priorities.
     
   • State leaders were opposed to federalizing the National Guard on which they were relying to support logistical and public supply needs. A number of federal leaders argued that the National Guard should be federalized.
   
   
   
   
   
   "My fellow governors are not going to permit you to make our states leper colonies. We’ll determine the nature and extent of the isolation of our citizens…you’re going to say that people can’t gather. That’s not your [the federal government’s] function. That’s the function, if it’s the function of anybody, of state and local officials." – Senior Dark Winter Participant

   "Mr. President, this question got settled at Appomattox. You need to federalize the National Guard…" – Senior Dark Winter Participant

   "We’re going to have absolute chaos if we start having war between the federal government and the state government." – Senior Dark Winter Participant

    

7. The individual actions of US citizens will be critical in ending the spread of contagious disease – leaders must gain the trust and sustained cooperation of the American people:
   
   
   
   • Dark Winter participants worried that it would not be possible to forcibly impose vaccination or travel restrictions on large groups of the population without their general cooperation.
     
   • To gain that cooperation, the president and other leaders in the Dark Winter exercise recognized the importance of persuading their constituents that there was fairness in the distribution of vaccine and other scarce resources, that the disease containment measures were for the general good of society, that all possible measures were being taken to prevent the further spread of the disease, and that the government remained firmly in control despite the expanding epidemic.
   
   
   
   
   
   
   
   "For one thing, the federal government has to have the cooperation from the American people. There is no federal force out there that can require three hundred million people to take steps they don’t want to take." – Senior Dark Winter Participant

KEY PARTICIPANTS

Tara O’Toole and Thomas Inglesby of the Johns Hopkins Center for Civilian Biodefense Studies, and Randy Larsen and Mark DeMier of Analytic Services Inc. (ANSER) were the principal designers, authors and controllers of the DARK WINTER exercise. John Hamre of the Center for Strategic and International Studies (CSIS) initiated and conceived of an exercise wherein senior former officials would respond to a bioweapon induced national security crisis. Sue Reingold of CSIS managed administrative and logistical arrangements for the exercise. General Dennis Reimer of the Memorial Institute for the Prevention of Terrorism (MIPT) provided funding for exercise.

I quoted this report extensively so that you could understand directly from the participants report how limited the ability of the United States government is to control a bio-terrorist attack. This simulation provides all the reasons I need to not depend on the public health system in a risky situation. We need to all prepare ourselves for a bio-terror attack.

The lessons that are articulated by the participants are slightly different from the lessons I would have taken home from this exercise. They admit that the officials that are making decisions in a situation like this are not qualified. They are not prepared for an attack, which actually gets worse over time. Even the horrible consequences of September 11th didn’t get worse, they improved with each passing hour. What I mean is that the dead were dead soon after the buildings collapsed. Within hours we were watching rescues not more deaths. For the 24 hours after the immediate attack the death toll kept getting smaller. With a biological agent attack the deaths accelerate day after day.

These unprepared government officials will quickly be forced to decide who lives and who dies. They will choose other government workers to live. They will be characterized as essential for basic governmental services. While many of us may not consider these services important, government workers always consider government work essential. Vaccines and medications will first go to protect other government workers.

Finally, they will overreact to the point of possibly starving certain populations by quarantining so widely that essential foodstuffs will not be delivered. When an attack like this comes you will be on your own.

Envy is one of the greatest motivators for evil during the long march of world history. Countless wars have been fought over envy. Humans always look across the fence post and see a better condition. In the case of Arabs, Persians and other slaves to Islamic authoritarianism the view is accurate. Islamic regimes have enslaved countless millions. Liberties and self-rule are not a part of the Islamic tradition.

What many Western and American citizens do not understand is that in addition to being a religion, Islam is a political philosophy or structure of laws and governance. Muhammad, in addition to being a prophet, was a conquering hero. In addition to authoritarianism the Islamic world also accepts other behaviors that are far outside the modern norm. A part of the Islamic world accepts abuse of women, polygamy, forced religious conversions and slavery.

Relationships between men and women in much of the Islamic world are dysfunctional. The separation of the sexes has lead to all different types of pathologic behaviors such as homosexuality and rape.

I discuss this in a paper on biological warfare only because I want you to understand that these behaviors are a breeding ground for the type of sociopath, which is capable of committing acts of unspeakable horror against others. If you have been gang raped as a child you may also have a desire to strike back at others that don’t face your traumas. You might also hate those that you envy.

By restricting economic freedom, authoritarian rule has bred poverty. Clearly a lack of economic freedom has lead to a world of economic hardship, and even starvation. Many of the young people that grow up in poverty have seen the leaders and tribal sheiks wallowing in oil wealth. Many associated this disparity not to the proper cause, a lack of freedom. Instead they believe it is the result of America’s economic policies. Demagogues have used socialist and Anti-American rhetoric to stay in power and deflect questions about local incompetence.

Another possible source of bio-terrorism may be domestic extremists. The Unabomber was a classic example of an environmentalist extremist that felt human death was very justifiable in the cause of protecting the environment. Other domestic terrorists may be emboldened by the success of the anthrax killers.

If you still think the threat of bio-terrorism is slim then please read the following analysis written by experts in the magazine, Foreign Affairs:

"If the device that exploded in 1993 under the World Trade Center had been nuclear, or had effectively dispersed a deadly pathogen, the resulting horror would have exceeded our ability to describe it. Such an act of catastrophic terrorism would be a watershed event in American history. It could involve loss of life and property unprecedented in peacetime and undermine America’s fundamental sense of security, as did the Soviet atomic bomb test in 1949. Like Pearl Harbor, this event would divide our past and present into a before and after. The United States might respond with draconian measures, scaling back civil liberties, allowing wider surveillance of citizens, detention of suspects, and use of deadly force. More violence could follow, either further terrorist attacks or U.S. counterattacks. "

– FOREIGN AFFAIRS (Nov/Dec 1998), p. 81

Dr. Michael Osterholm was for years the epidemiologist for the state of Minnesota. In his book, LIVING TERRORS: WHAT AMERICA NEEDS TO KNOW TO SURVIVE THE COMING BIOTERRORIST CATASTROPHE (Delacorte, 2000), he writes:

"As I will show, an attack with a highly contagious agent like smallpox could kill hundreds of thousands of people and could travel from city to city as easily as people do. Even a microbe like anthrax that doesn’t spread from person to person could easily kill more than 100,000. We are, in other words, at the brink of a new age: what some experts call catastrophic terrorism (p. xix). "

While I want you to know the worst case scenarios, I also want to encourage you not to be driven to distraction by these possibilities. Guard yourself and never let the voices of unreasoned fear direct your paths. Instead take the reasonable precautions that I have outlined.

Your checklist of action items will prepare you for the worst, and if the worst is avoided you will have many nights of peace knowing you are prepared. Also for those of us that live in earthquake states like California, we also can take comfort in the knowledge that with these supplies we know we are prepared for any crisis.

1. Store cash money for at least 8 weeks of bills or more if you can afford it. This cash should be in bills no larger than 20’s.
   
2. Store and rotate dry groceries and canned food, which will last your family for at least three months. If you have children and grandchildren that are not prepared for hard times, save some extra to meet their needs. Make sure you have dishes with meat such as Tuna, Meat Chili, Stew and Soups. (Make sure you have a mechanical can opener.)
   
3. Purchase a six-month supply of personal necessities such as soap, shampoo, deodorant, make-up, etc.
   
4. Keep some camping equipment in good repair. Have a cook stove, lanterns, and if possible keep at least twenty-gallons of fuel.
   
5. Prepare a six-month supply of medicine and have a good first aid kit available.
   
6. If you have pets, please have a six-month supply of food for each one.
   
7. If you have a fireplace or wood stove, order a good supply of wood to help fight the cold. Evaluate how vulnerable you are to the cold in your climate. If you live in South Florida you won’t need as much wood as if you live in Minnesota.
   
8. Make sure you have warm clothes and blankets.
   
9. Store at least 55 gallons of water per person. Water is the first requirement of life, and water utilities are some of the most vulnerable to terrorists. Also sporting good supply stores have portable water purifiers which are compact and inexpensive.
   
10. Finally have flashlights, a portable radio and lots of batteries. I suggest a radio with a small hand crank generator. They work great, and then you don’t need to worry about the batteries going bad.

Peggy Noonan is one of my favorite writers, and she recently wrote a piece on how to organize a safe room. Here is what she advised on the Wall Street Journal web site, in an article published on November 2nd entitled "We are all Soldiers Now" for those of you that would like to read the entire article. She recommends creating a safe room in your house:

"So: a safe room. Find the room with the thickest walls and fewest or smallest windows and doors in your house or apartment. Make do with what you have. If you live in a one-room studio apartment, that"s your safe room. If you have a secure room in the middle of the house, that’s your safe room. Basement with thick walls and little windows? Safe room. (If you live in a big apartment building, ask the owner/super/board head, whatever happened to the old fallout shelters big buildings used to have? They still exist. They’re often the laundry room. Maybe the one in your building can be turned into a communal safe room.)

OK. You’ve figured out where your safe room is. What to have in it? You start with tape. My Israeli guy told me to buy two-inch-wide blue 3M Scotch tape, and tape any openings that allow air into the safe room. Tape the window frames, the door frames. I asked him if I could use gray gaffer’s tape as it seems sturdier and more . . . fume-stopping. He said: Sure. So I bought both. And two big rolls of blue and two big rolls of gray are in my safe room, along with heavy scissors, a utility knife and a box cutter.

Question: Um, if you tape everything shut and sit there with your kids and breathe, won’t you, um, run out of oxygen?

You probably won’t be there long enough.

If we are hit by a chemical attack, the chemicals will in time disperse into the air. If we are hit by a bio attack, you’ll stay there as long as you can and then get out. If it’s a dirty bomb with radioactive material, you get into the safe room as soon as you can and stay there a few hours after the blast. And then you get out of Dodge.

A safe room isn’t a place to live but a place to duck the incoming.

Still, you want to have plenty of stuff in it in case you need it, and as the place where everyone in the family knows you keep it. Get big plastic containers of water, enough for everyone in your family for a few days to a week. (I think: Get too much. Too much bottled water may turn out to be a good thing, and in any case will likely get drunk along the way.)

Keep flashlights in the safe room, with backup batteries and backups to the backups. Have bandages and medicines more can’t hurt, might help. Whatever prescription medication you may be on, get a month’s supply and put it in the safe room. In California they call this making an earthquake pack: everything you need to get through a few days with systems going down.

For communications, you want a battery-operated radio, a ham radio if you have it. Two good ideas. Get a crankable radio in case your electricity goes down, you can get them off the shelf at consumer electronics stores. Those walkie-talkies that people started using the past few years (I think the most well known is made by Motorola) could be a great thing to have in a safe room or outside it. They have a radius of a mile or two, a lot of people use them, and you can find out a lot on their shared channels. Peter Black again: They can be a short-term communications network if the lights go off for a while.

A lot of us noted a few weeks ago that when the World Trade Center was hit, the phones in New York stopped working reliably, but the Internet stayed up. Why? Because it was, essentially, designed by our defense establishment to stay up. If you have wireless Internet access, a Blackberry or whatever, it goes into the safe room with you."

So if you prepare and are vigilant, and follow these important safety tips you will be safe. The price of liberty is eternal vigilance, and we will not allow the thugs of the Middle East to take our freedom away.

* Mary Beth Brown (BS RN) is a Registered Nurse and Chairman of two Citizens United Foundation projects, the American Medical Commission and the National Citizens Legal Network. A graduate of the University of Washington, she was a founder of the Mothers Campaign for Family in that state, and has testified before the State Senate on education, child and family issues. She currently resides in Santa Barbara, California, with her husband Floyd and three school-aged children.

Citizens United Foundation is a 501(c)(3) tax exempt organization, dedicated, in part, to educating the public on important public policy issues. Nothing in this report should be construed as necessarily reflecting the views of Citizens United Foundation or as an attempt to aid or hinder the passage of any legislation before Congress. Tax deductible contributions from individuals and corporations are welcome and encouraged.