Bracing Armageddon

BRACING
FOR
ARMAGEDDON?
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BR ACING
FOR
ARMAGEDDON?
Th e S c i e n c e a n d P o l i t i c s
of Bioterrorism in America
William R. Clark
1
2008
3
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Library of Congress Cataloging-in-Publication Data

Clark, William R., 1938–
Bracing for armageddon? : the science and politics of bioterrorism
in America / William R. Clark.
p. cm.
Includes index.
ISBN 978-0-19-533621-4
1. Bioterrorism—United States. 2. Bioterrorism—United States—Prevention.
3. Biological weapons. I. Title.
HV6433.35.C53 2008
363.325’30973—dc22 2007040445
1 3 5 7 9 8 6 4 2
Printed in the United States of America

on acid-free paper
Acknowled gmen t s
I would like to extend my profound thanks to a number of

individuals who shared their time and expertise with me dur-
ing the preparation of this book: Dr. Milton Leitenberg, Center
for International and Security Studies, School of Public Policy,
University of Maryland; Dr. Jeanne Guillemin, Boston College
and Senior Fellow, MIT Security Studies Program; Dr. Alan
Pearson, Biological and Chemical Weapons Program, Center
for Arms Control and Non-Proliferation; Dr. Laurene Mascola,
Chief, Bioterrorism Preparedness Unit, Los Angeles County; Mr.
Frank Simione, Vice President of Management and Compliance
Services, American Type Culture Collection; Dr. Ray Zilinskas,
Center for Nonproliferation Studies, Monterey Institute for
International Studies; Dr. Seth Carus, Deputy Director, Center
for the Study of Weapons of Mass Destruction, National Defense
University; Dr. James G. Hodge, Jr., Executive Director, Center
for Law and the Public’s Health, Johns Hopkins University; Dr.
Amy Smithson, Center for Nonproliferation Studies, Monterey
Institute of International Studies (Washington, D.C.); Dr. Bryan
McDonald, Center for Unconventional Security Affairs, University
of California, Irvine; Dr. Susan Wright, History of Science and
International Relations, University of Michigan.
Preface
Over the past two decades, an enormous effort has been mounted
by numerous federal and state agencies to prepare America to
defend against the possibility of a bioterrorist attack. This effort
jumped ahead at warp speed following the horrendous World
Trade Center and Pentagon attacks of September 11, 2001, fol-
lowed by the postal anthrax scares just a few weeks later. Five
people died in these latter incidents, considered by some to be
the opening salvos in a new form of terrorism brought to our
shores. By the end of 2008, the United States will have spent
nearly fi fty billion dollars upgrading almost every conceivable
aspect of our ability to respond defensively to a catastrophic
bioterrorism attack.
Concerns about bioterrorism in America, while certainly justi-
fied in many respects, have at times and in some quarters risen
almost to the level of hysteria. Part of the reason for this is doubt-
less the conflation of bioterrorism with a larger “war on terror.”
Declaring war on something is a time-honored way in American
politics to raise an issue to a level of unquestionable urgency.
Another part of the terror of bioterrorism is that, unlike terror-
ism using other weapons—bombs, chemicals, nuclear devices—
bioterrorism is based on things we cannot see and few of us
understand. We rely on scientific experts to explain them to us,
adding yet another layer of uncertainty, both for the public and
for our political leaders. Science is not always objective, and sci-
entific experts themselves have differing points of view—political
v i i i • P R E FACE
points of view—about bioterrorism, just as they have differing

points of view about global warming, or stem cell research, or the
beginnings of life.
America in fact faces bioterrorism from not just one but two
sources: from other humans who would use deadly biological
weapons to attack us for political or ideological reasons, and
from nature, which periodically unleashes biological pathogens
on us for reasons that have nothing to do with human affairs,
but that terrorize us nonetheless. We remain prey to infectious
disease pandemics like the 1918 influenza outbreak, which killed
perhaps a hundred million people worldwide, and the yet unre-
solved threats posed by the viruses causing SARS and H5N1
avian flu.
Both of these biological threats to our security and well-being,
the political and the natural, are real. History makes clear that
natural bioterrorism—pandemics—will, like earthquakes, tsu-
namis, and hurricanes, absolutely recur periodically, with the
potential for catastrophic physical, social, and economic damage.
What has been lacking in our approach to the threat of political
bioterrorism to date is an assessment of exactly how real it is.
How likely is it that America will experience a bioterrorist attack
that could bring this country to its knees? What would it take
to mount such an attack? Who could do it, and what weapons
would they use? How would bioterrorism compare with the dam-
age America would suffer from other forms of terrorism, or from
a natural pandemic like that of 1918? How much of our resources
as a nation should we spend preparing for each? How do we know
when we are safe, or at least as safe as we can realistically expect
to be, from these threats? These are hard questions.
Given the numerous instances of outright terrorism over
the last two decades of the twentieth century and on through
September 11, 2001, it may not be surprising that our percep-
tion of the threat of bioterrorism has at times verged on the
hysterical. Fear is not necessarily a bad thing; hysteria is almost
always counterproductive. Fear is a response dictated by nature
to ensure survival, and as we will see in the chapters that follow,
we have responded vigorously to nature’s command. Not always
rationally, but certainly vigorously.
PR EFACE • i x
But it is time now to move toward a more mature view of bio-

terrorism, to tone down the rhetoric and see it for what it actu-
ally is: one of many difficult and potentially dangerous situations
America—and the world—face in the decades ahead. What have
we actually gotten for the tens of billions of dollars we have spent
so far on bioterrorism defense? Was this money well spent? No
nation has infinite resources, and we must accept that we will
never be able to make ourselves completely safe from every threat
we face. We will have to make rational assessments of those threats
we can identify, and apportion our resources as intelligently and
effectively as we can to deal with them. In this book we look at the
scientific, political, legal, and social facets of bioterrorism that
can guide us as we attempt to bring this particular threat into a
more realistic perspective for the twenty-first century.
Con t en t s
Acknowledgments
[v]
Preface
[vii]
Chapter 1
Tales of a Dark Winter: A Play in Three Acts
[3]
Chapter 2
A Brief History of Bioterrorism
[21]
Chapter 3
Agents of Terror
[41]
Chapter 4
Genetically Modified Pathogens
[57]
Chapter 5
The Ultimate Bioterrorist: Mother Nature!
[71]
Chapter 6
Agroterrorism: The Very Food on Your Plate
(and the Water in Your Glass)
[93]
xii • CON T EN T S
Chapter 7
America Responds
[109]
Chapter 8
Political, Legal, and Social Issues in a
National Health Emergency
[133]
Chapter 9
The Politics of Bioterrorism in America
[149]
Chapter 10
Assessing the Threat
[161]
Notes
[191]
Glossary
[201]
Index
[207]
BRACING
FOR
ARMAGEDDON?
chapter 1
Tales of a Dark Winter

A Play in Three Acts
The following “play” was performed in the summer

of 2001. It may seem somewhat dated from our perspective in
2008, especially with the departure from the world political scene
of Saddam Hussein. But it had a major impact on the thinking—
visceral as well as intellectual—of those charged with considering
how America should respond to the possible threat of bioterror-
ism. It is worth watching this play once again. Admission is free.
A C T I . D E C E M B E R 9 , 19 9 9 . 7: 0 0 P M
Members of the National Security Council file into a brightly lit
conference room for what promises to be a long and difficult meet-
ing. It will certainly be that, but not for the reasons they think.
Most members attending this evening have spent the better
part of the day organizing their thoughts about the items on
this evening’s agenda, several of which are going to require a
clear U.S. response in the days ahead. Tension has been rapidly
escalating between China and Taiwan. China recently test-fired
medium-range ballistic missiles by arching them over Taiwanese
airspace. The Taiwanese are reacting furiously. But since then
there has been another peculiar and potentially dangerous inci-
dent. A number of pig farms in Taiwan have experienced serious
outbreaks of foot-and-mouth disease. Rumors are circulating in
4 • B R ACI N G F O R A R M AG E D D O N?
the Taiwanese press and other media that this was a deliberate
biological weapons attack mounted by China against Taiwanese
agriculture. China is vigorously denying the accusation, but tem-
pers are rising on both sides.
In what looks like a potential coup, the FBI has worked with
Russian police and intelligence agencies to arrange a “sting”
operation that netted a senior Al-Qaeda operative as he was
attempting to purchase fi fty kilograms of plutonium in Russia.
This individual had also made inquiries about obtaining certain
biological warfare weapons produced some years earlier by Soviet
Union laboratories. The United States needs to craft a careful
plan about how much of this to make public and how much to
keep under wraps. The Russians are already beginning to leak
information that many on the U.S. side want kept classified.
And Saddam is at it again. After the lifting of military and eco-
nomic sanctions against Iraq six months ago and the ending of
the no-fly-zone restrictions, Hussein has been going all out to beef
up his military, across the board. There is now hard intelligence
that he has imported materials that could be used for chemical
and biological weapons. Moreover, at least three former Soviet
biological weapons specialists are known to be in Iraq, and pre-
sumed to be working at Iraqi weapons facilities. The Joint Chiefs
of Staff are very worried about this development. Most worrying
of all, however, Iraqi troops and equipment are starting to filter
off toward the border with Kuwait. That country, together with
Bahrain and the United Arab Emirates, is requesting deploy-
ment of Western forces in the region to forestall another 1991
adventure on the part of Saddam Hussein. A coherent strategy,
involving several key allies, will have to be formulated quickly.
There may not be time to get to the other issue pressing on
everyone’s mind and time: Y2K.
As the President’s national security advisor rises from his seat
next to the President to signal the start of the meeting, the room
falls silent. He has a videocassette on top of the stack of papers in
front of him. He and the President had been in hushed, heads-
together conversation since they came into the room, and the
advisor looks decidedly more solemn than usual. We can sense
people in the room sitting forward ever so slightly in their chairs
as he begins to speak.
TA L E S O F A DA R K W I N T E R • 5
“Before we begin this evening, I’d like you to see a video-

tape we just copied in the last half hour of news coming out of
Oklahoma City. This is from a local station, but I expect it will be
on all the major networks, including CNN internationally, before
the hour is out.”
He hands the cassette to an assistant, who moves to a tape
machine near a large TV screen at one end of the room. The
security advisor resumes his seat next to the President.
The images that come on the screen are mostly of two
Oklahoma City news anchors. Someone keeps switching between
them and shots taken outside a large brick hospital. It isn’t clear
if these latter are supposed to be live shots or file footage. A pic-
ture of a man in a white coat comes on briefly, then flashes off
again. He looks like a doctor, but says nothing—the station is
obviously trying to assemble a story on the fly.
Back to the anchors. In the past few hours, it appears one
person has been diagnosed—“with a high degree of certainty”—
with smallpox. That in itself would be a major story, since no
one has been diagnosed anywhere in the world with smallpox for
over twenty-five years. But there are now rumors circulating that
as many as a dozen more persons are under surveillance in area
hospitals, suspected of having the same disease. The Centers
for Disease Control and Prevention (CDC) in Atlanta have been
alerted, and we learn that officials there are scrambling to get
flights to Oklahoma City.
A low buzz goes around the room as members of the council
begin whispering to each other. The tape plays out, offering little
hard information about what kind of response is being mounted
locally. No doctors or any other health authorities speak during
the remainder of the tape.
The security advisor signals for the TV to be turned off. He sits
down, and the President stands up and looks around the table.
“In view of the potential extreme urgency of this situation, I
am setting tonight’s agenda temporarily aside. I talked just a few
minutes ago with the Secretary of Health and Human Services,
who confirms that we do indeed have smallpox in Oklahoma City.
In fact the latest word I have is that there may be cases showing
up in Pennsylvania and in Georgia as well, although these cases
have not yet been confirmed to me by the Secretary.
“This is extremely serious. As I’m sure most of you know, small-

pox no longer exists in nature. As I understand it, it’s just about
impossible that this case—these cases, it now appears—arose
either naturally or by accident. There is no smallpox virus stored
anywhere near Oklahoma City. We are at this point assuming
the virus was introduced deliberately, by foreign state- or non-
state-sponsored operatives. We are considering this a bioterrorist
attack on the United States.”
There are audible inhalations, and more than a few paling
faces, around the table. The President pauses for a moment to let
this sink in, then pulls some handwritten notes from his jacket
pocket and spreads them in front of him.
“I’m told that much of the United States is extremely suscep-
tible to smallpox. Vaccinations were halted some thirty years
ago. Those who were vaccinated before that time probably have
only minimal resistance to the disease today. The same is true
of much of the rest of the world. We anticipate that this news,
once circulated, will cause considerable alarm, probably panic,
in many places. Mostly here at first, but likely spreading abroad
as well.
“I’m also told that given the incubation period for this virus,
the attacks responsible for the cases we’re seeing now probably
took place somewhere between one and two weeks ago. No coun-
try or group has yet claimed credit for this attack. The FBI and
CIA have no leads at the moment. What’s going on may be related
to decisions we have made or are considering making with respect
to the current situation in the Middle East. It could be intended
to distract the leadership of this country, or to intimidate our
civilian population. We just don’t know at this point.
“Governor Keating of Oklahoma has been in Washington this
week on state business, and agreed to come here tonight to brief
us on what he knows about the events in his state. He’s under-
standably eager to get back to Oklahoma City. Governor?”
The Governor states that Oklahoma City hospitals are already
experiencing overflow from persons worried about their health
status, and this seems likely to mushroom in the days to come. At
the same time, some hospital personnel are leaving their posts to
be with their own families. This could very quickly lead to a health
care crisis. Emergency disaster plans are being implemented as
quickly as possible. The Governor says he has implored the CDC

to release smallpox vaccine; he would like to be able to assure his
state’s 3.5 million residents they will all receive immunizations
against smallpox. He ends by stating he has declared a full-blown
state emergency, and requests the President to immediately
declare a federal state of emergency in Oklahoma as well.
At this point an assistant to the Secretary of Health and
Human Services (HHS) stands up to present a hurriedly pre-
pared background talk on smallpox. He confirms that the last
natural case of smallpox in the United States occurred in Texas,
in 1949. Public health officials ceased offering smallpox vaccina-
tions to the general public in 1972. Best estimates are that at least
80 percent of the current U.S. population has no effective protec-
tion against smallpox. The United States at present has about 12
million reliable vaccine doses. Some portion of that has been set
aside for the U.S. military, which might be called upon to go into
areas where chemical and biological weapons could be used.
Smallpox is highly contagious, he says, passed from person
to person by aerosols—small, germ-laden droplets breathed
or coughed into the air. The average number of new persons
infected by an uncontrolled infected person is estimated at ten,
but could be as high as twenty. Isolation of infected patients and
immunization of their contacts can help greatly in controlling
spread of the disease. The disease itself, once it sets in, is untreat-
able. The historical mortality rate from smallpox in this country
is about 30 percent. Current hospital bed capacity in the United
States could probably not handle more than a 10 percent increase
in patient load.
A member of the Council raises his hand. “Twelve million
doses of vaccine. That seems like a lot, but probably isn’t. Do we
know how much of that is committed to the military?”
The Secretary of Defense responds from across the table. “We
have requested that 2.5 million doses be held in reserve for pos-
sible use by troops deployed to the Middle East. We have every
reason to believe that at least Iraq, and possibly other countries,
may be in possession of weaponized smallpox virus. God knows
what else.”
Another question from the table for the HHS representative.
“And how do you propose to use the rest?”
“That’s something we hope you will discuss here this evening.

Basically there are three general strategies for distributing drugs
or vaccines in major medical crises, depending on supply. In the
‘ring’ strategy, enough vaccine would be provided to immunize
emergency personnel in the affected area, plus known contacts of
the primary victims. The second option is to ship enough vaccine
to the affected cities to treat their entire populations, holding
the rest in reserve until we see what happens. The third option
is essentially the second option, except that the remainder of the
vaccine would be distributed immediately, on a per capita basis,
to states not yet affected. They could use it as they see fit.”
“And a follow-up question here. Do we have any idea of how
many people were exposed?”
“Actually, we don’t. And because it happened probably about
ten days ago, we may never know. We’ll just have to wait and see
how many cases develop.”
The Attorney General raises his hand. “I can see some tricky
legal questions down the road here. Who’s going to be running
the show as we develop a response? What is the federal govern-
ment’s role in this situation, aside from providing vaccine? What
are the states’ roles? Who’s going to coordinate all this? Who has
final authority, and where?”
FEMA Director Hauer responds. “My office certainly has a
lead role in coordination of efforts at all levels. But I already see
a number of points that will need clarification. . . .”
An aide slips into the room to hand the President a memo,
which indicates that now there are twenty confirmed smallpox
cases in Oklahoma City. Fourteen other cases in that city are
suspected, and first reports from Philadelphia and Atlanta show
seven and nine cases suspected in those two cities. The CDC
now has people on-site in Atlanta and Philadelphia, and about
to arrive in Oklahoma City. The CDC has 100,000 vaccine doses
prepared for immediate shipment to each of the three cities.
As the First Act ends, the Council members begin discussing
what the government should do and collecting questions that will
need answering as soon as possible. The lights go down, and we
see in our program notes that they debated for another hour and
a half, closing with a strong appeal to the President to make a
public announcement as soon as possible and to follow up with
regular reports to the public as long as the emergency lasts. The

people will need to be willing allies of the government, and the
government will need to earn their confidence with full and fre-
quent disclosures of exactly what is happening to them.
A C T I I . D E C E M B E R 15 , 1 P M
The Deputy National Security Advisor begins the meeting by

reviewing television and press coverage of the smallpox crisis in
recent days. Many of the fears expressed at the first meeting are
apparently being more than realized.
Over 2,000 cases of smallpox have now been reported in fi f-
teen states. At least 300 people are already dead, and mount-
ing numbers are reaching a terminal stage of their disease.
Congress is demanding swift action to seek out and punish those
responsible.
Hospitals in several cities are completely overwhelmed, partly
from the increased caseloads of patients who need to be isolated,
and partly from the fact that a large number of workers are refus-
ing to enter hospitals for fear of catching the disease and passing
it on to their families and friends.
Isolated cases of smallpox have shown up in several foreign
countries; all are traceable to one of the three primary outbreak
locations in the United States. Some countries are already clos-
ing their borders to U.S. goods and to U.S. citizens unless they
have proof of recent vaccination.
Ghastly pictures of smallpox victims, including children, are
routinely appearing in all media outlets, further driving the
mounting panic evident everywhere. These images are being
broadcast worldwide, including on Al Jazeera.
Vaccine distribution has been chaotic, and vaccine doses that
have been shipped from CDC are being used up at an alarm-
ing rate. Riots have broken out near some distribution centers,
requiring police and National Guard troops to guarantee the
safety of public health workers.
In Oklahoma, the governor has closed all schools and col-
leges and cancelled all sporting events for the foreseeable future,
as well as other public gatherings. He is considering closing
shopping centers and certain large businesses as well. The eco-

nomic toll stemming from such action is unfathomable, but pub-
lic safety may well require it. Food shortages are beginning to
show up in some of the harder-hit areas, as truck drivers refuse
to enter them.
The President takes over the meeting to present a few addi-
tional brief remarks on the current situation.
“As far as any of us can determine, the events we are now
experiencing, which are spreading rapidly, all stem from the
three primary attacks in Oklahoma, Pennsylvania, and Georgia,
somewhere around December 1. Neither the FBI nor any of our
intelligence agencies has yet developed any hard leads on the
origin of these attacks, or who might have carried them out. We
are completely convinced this was not a case of domestic terror-
ism. The only supplies of the smallpox virus in the United States
are in the CDC in Atlanta, and I have been assured and reas-
sured that these are under extremely strict control. The facility
housing them has been examined, and there is nothing at all to
suggest these stocks have recently been disturbed. So I think we
can put domestic bioterrorism to rest as an explanation for what
happened.
“Our intelligence people feel the most likely source is some of
the smallpox virus originally stored in Moscow, and maintained
there after the collapse of the Soviet Union. Our people have
long worried about the security of that stockpile. We have no rea-
son to believe the Russians themselves had any hand in this, at
least as a state. But we are concerned that some of their scien-
tists who have access to these materials may have taken some of
the virus with them when they moved to other states looking for
employment. Many rogue states would dearly love to get their
hands on biological agents such as smallpox, and we believe that
former Soviet scientists work in a number of these states.
“Dr. O’Connor from Health and Human Services will now
update us on the status of our response to these attacks. Dr.
O’Connor?”
“Thank you, Mr. President. A detailed epidemiological analy-
sis carried out by our staff indicates that all three initial attacks
took place in crowded shopping malls, probably on a weekend.
Exactly how the virus was released is unknown at present.
“The number of new cases per day is leveling off at present,

but as second- and third-round infections begin to show up—any
day now—we expect these to rise, and very sharply.
“We are rapidly running out of vaccine. A million doses were
sent to each of the three primary attack states. Half a million
doses are being sent to each of twelve other affected states. Two
million doses have been set aside for the military. That leaves us
with just over a million doses. We expect that to be gone within
a day or two. Gearing up for new vaccine production, even waiv-
ing the normal FDA procedures in this case, will take months. So
we have no hope of producing our own vaccine in the very near
future. We have contacted other countries for loans from their
existing stocks. Great Britain has pledged half a million doses;
Russia is considering a loan of five million doses.
“We have issued guidelines on the use of existing vaccine
stocks, asking that they be used only to immunize first responders—
police, fi re, National Guard, hospital personnel, HazMat units—
as well as verified immediate contacts of confirmed victims.
But ultimately that is a decision for individual states. There
is a shortage in all states of individuals willing to help trace
down patient contacts for potential immunization, for the
same reasons workers refuse to go into hospitals. We under-
stand pressures on distribution systems and personnel have
been enormous, and we have no idea whether our guidelines
are being adhered to.”
The Attorney General interrupts. “Can we get clarification on
some of these issues? We’re providing the vaccine; certainly we
have the authority to say how it is to be used?”
“I suppose if we were to set up federal vaccination centers in
each city, we could control how the vaccines are administered,”
the President replied. “But short of that, I don’t see what we could
do. But let’s get CDC and HHS to chime in on this.” He nodded
to the Secretary of Health and Human Services, and signaled for
Dr. O’Connor to continue.
“Health care systems in some of the harder-hit cities are being
rapidly overwhelmed. Refusal of health care workers to enter
hospitals remains a severe problem. As far as I know these people
have all been offered the vaccine, but the response has not been
encouraging.
“There are not nearly enough isolation facilities to house

infected patients. The National Guard is helping to erect military
hospital tent units to house smallpox patients, but at some point
we may run out of those. Also, we are finding that many families
are trying to move relatives with non-smallpox problems out of
hospitals treating smallpox patients.
“We are seeing misinformation being passed along—presum-
ably unintentionally—by media of all types. For example there
have been several charges that people in poorer sections of cities
are not getting equal access to vaccinations. But we are also see-
ing outrageous Internet scams trying to sell drugs for treating
smallpox. Such drugs simply do not exist. HHS has established a
secure website with accurate information about smallpox that we
hope the public will use.
“Schools are now closed almost nationwide. This is putting an
additional strain on families with two working parents. Public
gatherings of all kinds are also being prohibited. These steps
are essential for controlling spread of the disease, but some
are already beginning to question their necessity in light of the
extraordinary disruptions they cause. People are also being asked
to voluntarily restrict their travel. This may be working, but it is
possible that in the near future such restrictions will have to be
made mandatory.”
“What about quarantining?” the Attorney General asked.
“It’s being carried out irregularly. There is clear authority for
quarantining in essentially every county of every state, but people
are proving to be extremely resistant. It’s one thing to confine
the occasional person with whooping cough to their house for a
few days, and nail a sign on their door. It’s another, psychologi-
cally, to put up barriers around entire sections of a city.”
“I suppose we should have prepared people for this in the first
day or two of the outbreak.”
“Yes, I agree. That’s about all I have to say for now. Thank you all
for your attention. I’ll pass you along now to Mr. Hauer, Director
of FEMA.”
“Thank you, Dr. O’Connor. I have only a few brief remarks.
FEMA is also receiving reports that the health care systems in a
number of states are reaching a crisis point. Delivery of health
care to non-smallpox patients is seriously eroding. In Oklahoma,
for example, twenty of 138 hospitals have closed their doors to

further admissions of any kind. This is probably illegal, but that
is a state matter.
“The National Guard in many states is doing an outstanding
job of providing security and delivering supplies where commer-
cial truckers won’t go, but their numbers are not sufficient to do
everything that’s needed. The Red Cross has set up numerous
shelters with food and water, but like hospitals they’re having a
hard time finding people to staff them.
“The National Disaster Medical System is not working particu-
larly well in this situation. The system calls for hospitals in unaf-
fected areas to accept overflow patients from crisis regions, but
the last thing we want to do is transport active smallpox patients
long distances and implant them in unaffected areas. The thirty-
person volunteer medical teams that are part of the system have
provided only modest support over the past week. Again, many
volunteers are proving reluctant to go into heavily infected areas,
where they are needed most. Also, many of these people have
been co-opted by their home states.
“We are now seeing individual states beginning to close their
borders with surrounding states. This raises some real issues with
respect to the national interstate highway system and interstate
commerce, which is a federal issue. We need to discuss what we
can do to keep these highways open, and not just to federal traf-
fic, which probably won’t be interfered with. This is already hav-
ing a disastrous effect on the shipping of food and goods, with
economic consequences we can all imagine. I hope the Council
will address this issue quickly, or refer it immediately to appropri-
ate agencies.
“I believe that is all I have to say for the moment.”
A C T I I I. D E C E M B E R 22
The meeting opens with another review of recent events as

reported in the media, presented by the Deputy National Security
Advisor.
“We now have over 15,000 active cases of smallpox in twenty-

five states. The vast majority of these have come up in just the past
few days. The CDC anticipated this, and made sure media do not
portray this as additional attacks. We are seeing the spread of
the virus from the initial round of infections earlier this month.
There are now smallpox outbreaks in at least ten other countries
traceable to the outbreaks here.
“All media are reporting the mounting economic damage from
the initial attacks. There are reports that international investors
and banks may be liquidating their positions in American finan-
cial instruments, real estate, and businesses.
“As casualties mount from the second wave of infections,
particularly in Georgia and Pennsylvania, we see many people
moving out of those areas, trying to find places free of the dis-
ease. Some of those people are bound to be infected, and this
may hasten the spread of disease to new areas. In Atlanta and
Philadelphia most businesses and banks are now closed.
“Public opinion polls show about half of Americans would sup-
port an all-out nuclear attack on any foreign country found to
be responsible for these attacks. The same polls show tremen-
dous anger with government at all levels for failure to halt the
epidemic.
“Canada and Mexico have now completely sealed their bor-
ders with the United States. Nearly all countries worldwide are
refusing entry to American citizens, even with proof of recent
smallpox vaccination. American goods are being turned back
from all foreign ports of entry.
“We are starting to see armed clashes between police and
National Guard units and civilians, and among civilians them-
selves. Some people have violently resisted removal of clearly
infected family members to isolation units. Others have attacked
mortuaries and morgues, trying to recover remains of loved ones
to avoid mandatory cremation. In a number of cases individu-
als have used armed force to drive away persons they suspect of
being infected.
“The President will now say a few words.”
“Thank you, Randy. I will announce today that I have already
signed an executive order waiving normal FDA testing proce-
dures so that U.S. pharmaceutical companies can immediately
begin production of smallpox vaccine. Every step will be taken to

assure safety of these vaccines, but I have granted the companies
involved immunity from civil or criminal prosecution should the
vaccines cause harm. We must do this, or risk catastrophic con-
sequences. The companies, the FDA, and the CDC will closely
monitor those to whom the new vaccines are given for signs of
any problems. The bad news is that although the companies will
all work twenty-four-hour shifts if necessary, we will not see the
new vaccine for at least five to seven weeks.
“I just want to remind you that as we focus much of our energy
and attention on the smallpox epidemic, and how best to use
scarce federal resources to help states with their battles on that
front, we must also discuss urgent questions arising from the
worsening situation in the Middle East. I may have more to say
about that later in this meeting. We are all somewhat reassured
to see that the China-Taiwan situation seems to be cooling off, at
least for now.
“I will now ask Dr. O’Connor to give us an update from HHS
and CDC on progress of the epidemic. Dr. O’Connor.”
“Thank you, Mr. President. A few days ago, we had about 2,000
total smallpox cases. Today we have 16,000 cases, from which
we can expect around 5,000 fatalities. We anticipate another
30,000 cases over the next week. In another two-three weeks, as
we see third-round cases start to appear, we could see as many
as 300,000 active infections, with 100,000 deaths. Our smallpox
vaccine supply, including loans from Great Britain and Russia,
was exhausted two days ago. As the President just indicated, we
will be slogging through this crisis without vaccine for at least five
weeks—well beyond the anticipated third round.
“The magnitude of the burst of second-round cases represents
a failure to identify, immunize, or isolate infected persons before
they passed the virus along to others. The third-round burst we
expect in the coming weeks will represent a failure to identify
second-round victim contacts and to vaccinate or isolate them
before they passed it on. This is rapidly becoming the number-
one issue in containing this epidemic, and as the number of
infections expands we simply may not be able to keep up with it.
We estimate the 16,000 cases confirmed as of this date will have
made on average a hundred contacts during their contagious
stage, before they were diagnosed and isolated. That’s 1.6 million
contacts to trace down and deal with. We probably have man-
power to deal with less than a tenth of that.”
The Director of FEMA looks up. “Where do you see this
ending?”
“That depends on many factors, mostly on how quickly we see
new vaccine production and how many doses will be available
over what time span. Our current projections, which assume
new vaccine production stays on schedule and that the vaccine
is fully effective, are that by mid-February we will have seen—
conservatively—a total of three million cases of smallpox, with
an anticipated total of one million deaths.”
An aide to the President enters the room and hands him two
messages. The room falls quiet as the President reads these. He
rises to speak.
“This morning, three American news outlets received identi-
cal anonymous letters demanding that all U.S. troops be pulled
out of the Middle East, and all U.S. warships leave the Persian
Gulf. If we do not do this, there will be additional attacks, this
time with anthrax and plague in addition to smallpox.”
The President looks around the silent table.
“That’s not all. Each of the letters also contained a printout of
the genetic blueprint of a virus. This was immediately faxed to
the CDC, which as you know has sequenced the blueprint of the
virus recovered from our smallpox victims.”
He holds aloft the second message.
“The two blueprints are identical. This is very, very real.”
The final curtain comes down, and the house lights go on.
So where was this play performed? Did anyone ever see it?
This “play” was performed only once, across the days of June
22–23, 2001, a little over eleven weeks before September 11. Only
the cast and about fifty or so government officials ever saw it. It
wasn’t a play, of course. It was a government exercise called Dark
Winter, one of a number of such exercises carried out to test
America’s ability to respond to major health emergencies arising
from terrorist-caused disasters involving radiological, chemical,
or biological weapons (Box 1.1). These exercises have probed
interactions and communications among responding agencies
BOX 1.1
Exercises in Bioterrorism
Exercise When What

1
TOPOFF I May 2000 Plague
Dark Winter June 2001 Smallpox
Sooner Spring April 2002 Smallpox
TOPOFF II May 2003 Plague
Atlantic Storm2 January 2005 Smallpox
TOPOFF III April 2005 Plague
This is a partial list of such exercises. Several of these also tested

responses to chemical and radiological attacks.
1
TOPOFF is an acronym for “Top Officials.”
2
Atlantic Storm was an extension of Dark Winter to an interna-
tional stage. Brad Smith et al., “Navigating the Storm: Report and
Recommendations from the Atlantic Storm Exercise,” Biosecurity and
Bioterrorism 3(2005):256–267.
and their senior leaders, adequacy of communication across lines

of authority, the ability of public health officials to respond at
the local level and of hospitals to mobilize emergency supplies
and generate beds, and many other aspects of how government
agencies at various levels would function during a response to a
catastrophic event.
Dark Winter was mounted by a formidable array of produc-
ers: the Johns Hopkins University Center for Civilian Biodefense
Strategies, the Center for Strategic and International Studies,
the Analytical Services Institute of the Department of Homeland
Security, and the Oklahoma National Memorial Institute for the
Prevention of Terrorism.
Only some of the “actors”—those presenting information
about the terrorist attack and its sequelae—actually had scripted
lines. The other players—about a dozen in all—were real-life,
senior-level policy makers, drawn from various parts of the fed-
eral government to play the roles of key government officials
and members of the National Security Council. (The Governor

of Oklahoma, Frank Keating, was actually recruited to play
himself.)
It was enacted at Andrews Air Force Base, outside Washington,
D.C. Most of the participants were simply asked to react to facts
pouring in to them in the form of mock news releases and videos,
and to factual information, assessments, and estimates provided
orally or as written memoranda.1 They were asked to make imme-
diate decisions that would shape the response of the federal gov-
ernment to the events unfolding first in Oklahoma, and shortly
across the entire nation. After extensive discussion, and calls for
additional information or clarification, they sketched out a series
of recommendations for presentation to the President. Decisions
and recommendations made at the end of one “Act” (NSA meet-
ing) were incorporated on the spot by the producers into the
scripting of subsequent meetings. The NSA members also had to
participate in a mock press conference with five real-life journal-
ists partway through the exercise.
The responses of the government officials taking part in this
exercise were exhaustively analyzed by the “producers,” and a
number of conclusions were drawn: Senior-level decision makers
were unfamiliar with bioterrorism, and did not know what options
were available to them in the event of an attack; information flow
in an event of this type was totally inadequate; the United States
had essentially no smallpox vaccine; the U.S. health care system
was woefully unprepared to deal with a catastrophic health emer-
gency, whatever its source; the respective roles, responsibilities,
and authorities of the federal versus state governments in situa-
tions of the type were completely unclear.
No one involved in this exercise could have imagined that
less than three months later America would experience a
real-life terrorist attack of unprecedented magnitude. Partly,
perhaps, as a reaction to exercises like Dark Winter, the gov-
ernment rushed special teams trained to detect the kinds of
germs used in biological weapons to New York, Washington,
and Pennsylvania to determine if the airplane attacks had been
accompanied by release of deadly viruses or bacteria. None
were found. But barely a month later came news that must have
sent chills down the spine of everyone who had played even a
minor role in Dark Winter. A person or persons unknown had

disseminated deadly anthrax spores through the U.S. postal sys-
tem. This attack would eventually kill five people and seriously
injure a dozen more and cause substantial social and economic
disruption.
Dark Winter and related exercises were intended to put a real
scare into government policy makers and members of Congress.
Together with the events surrounding September 11, there is no
doubt they did. These exercises have been rightly criticized for
presenting extreme scenarios, often inflating the capabilities of
terrorists or the human threat of various pathogens.2 Unrealistic
statements about the threat posed by bioterrorism continue to
this day, at the highest levels of government.
One result of this heightened state of fear, at best only mar-
ginally based in reality, is that an enormous effort has been
mounted by numerous state and federal agencies to prepare
America to defend itself in the event of a catastrophic bioterror-
ist attack. This effort has coincidentally contributed to a modest
improvement of our ability to respond to nature’s own form of
bioterrorism: infectious disease pandemics like the 1918 influ-
enza outbreak, which killed perhaps a hundred million people
worldwide, and the yet unresolved threats posed by the viruses
causing SARS and H5N1 avian flu. Almost everyone now agrees
that the health threat posed by outbreaks of emerging pathogens
is certainly as great as, and probably greater than, that posed by
bioterrorism. Bioterrorism is often characterized as an event of
low probability but high consequence. Pandemic influenza, like
a magnitude 8 earthquake in California, is an event of near cer-
tainty, with unimaginable consequences (chapter 4).
At some level bioterrorism remains a threat, and no one is pre-
pared to dismiss it out of hand. The question policy makers now
face is: how much preparation is enough? How do we know when
we are safe, or at least as safe from bioterrorism as we can reason-
ably expect to be? This is not an easy question. Since September
11, tens of billions of dollars have been spent upgrading almost
every conceivable aspect of our ability to respond to a bioterror-
ism attack. The underlying programs continue to be sold to the
Congress and the American public largely by playing on fears of
bioterrorism.
But our resources are not infinite, and hard decisions have to
be made about the relative risks posed by bioterrorism in com-
parison to other challenges America will face in the years ahead.
In this book we will look at the scientific, social, legal, and politi-
cal facets of bioterrorism that are shaping, and will continue to
shape, decisions about how we deal with a much wider range of
potentially terrifying threats facing us at the beginning of the
second millennium.
chapter 2
A Brief History of
Bioterrorism
Exercises like Dark Winter provided political

leaders with frightening insights into what a real bioterrorist
attack might look like, but even more importantly, how woefully
inadequate our ability was to respond to any large-scale health
emergency, including a bioterrorist attack. As mentioned earlier,
the exercises themselves have been rightly criticized as exagger-
ating certain aspects of what such an attack might look like, par-
ticularly in terms of the technological capabilities imputed to the
terrorists.1 But they certainly served to jumpstart a major upgrad-
ing of public health and emergency management services at all
political levels, all across America.
Terrorism is a word rarely heard in English-speaking coun-
tries until a few decades ago. Modern political usage of the
term stems from the French Revolution, one phase of which the
French refer to as la Terreur. Current usage was undoubtedly
shaped by the string of airliner hijackings in the Middle East in
the 1960s and ’70s, of which one partisan allegedly said “[The
hijackings] did more for our cause than twenty years of pleading
[before the U.N.].”
These hijackings were occasionally referred to by the media
as terrorism, and the hijackers as terrorists. The rise of groups in
the 1960s and ’70s such as the Red Brigades, the Black Panthers,
and the Baader-Meinhof Gang left no doubt that the use of ter-
ror and violence against civilians to achieve political ends was
real. But certainly after the first bombing of the World Trade
Center in 1993 and the 1995 destruction of the Murrah Federal
Building in Oklahoma City, these words were used with increas-
ing frequency in the United States. Since September 11, 2001,
they have become a part of the daily American vocabulary.
Attention to a cause is usually a major objective of most terror-
ism. As one expert put it, for the most part “terrorists want a lot
of people watching, not a lot of people dead.”2 Terrorism achieves
its effects not simply through violence but through an appar-
ent randomness, or at least unpredictability, of violence that can
produce uncertainty, fear, even panic in targeted populations.
There are many definitions of terrorism (Box 2.1), just as there are
many means of carrying out terrorist acts. Terrorists are generally
accepted to be groups operating independently of formally recog-
nized states, although they may accept support from states. The
phrase “transnational groups” is in current vogue for many terror-
ist organizations.
The major forms of terrorism of concern to contemporary gov-
ernments, aside from organized assassinations and bombings,
are those involving nuclear, chemical, and biological weapons,
also referred to as weapons of mass destruction (WMD). The use
of biological organisms or their toxins to sow terror in a civilian
population is called bioterrorism.
Bioterrorism is an offshoot of biological warfare, and like
most progeny it differs somewhat from its parent. The main dif-
ference is that biological warfare is a highly organized aggressive
activity carried out by one state against another, usually through
a military arm, using biological agents to kill, disable, or disorga-
nize people to achieve a largely military goal. However, in spite of
the fact that most industrialized countries had intense biological
weapon development programs in the early and middle twenti-
eth century, there are very few documented instances of the use
of bioweapons in modern warfare. We will discuss reasons for
this in later chapters.
Bioterrorism, while using many of the same agents and tac-
tics as biological warfare, is a more ad hoc activity carried out by
individuals or political groups against other political groups or
A B R I E F H I S T O R Y O F B I O T E R R O R I S M • 23
BOX 2.1
Some Official Definitions of Terrorism
United Nations Any act intended to cause death or serious

bodily injury to a civilian, or to any other
person not taking an active part in the
hostilities in a situation of armed conflict,
when the purpose of such act, by its nature
or context, is to intimidate a population, or
to compel a government or an international
organization to do or to abstain from doing
any act.
U.S. State Premeditated, politically motivated violence
Department perpetrated against noncombatant targets
by subnational groups or clandestine agents,
usually intended to influence an audience.
U.S. Defense The calculated use, or threatened use, of
Department force or violence against individuals
or property to coerce or intimidate
governments or societies, often to achieve
political, religious, or ideological objectives.
U.S. Federal The unlawful use of force or violence
Bureau of against persons or property to intimidate
Investigation or coerce a government, the civilian
population, or any segment thereof, in
furtherance of political or social objectives.
states, with a mixture of objectives (Box 2.2). As with other forms

of terrorism, harming or killing individual human beings may
be only part of the aim. Among other goals, panic and its atten-
dant social and economic disruption are valued outcomes, as
are bringing media attention to a particular political cause and
recruiting more individuals to that cause. These goals, it should
be noted, do not require killing or harming mass numbers of
people. Several coordinated, perhaps sequential, small attacks
could be every bit as effective as a single mass attack.
BOX 2.2
Bioterrorism Defined
Bioterrorism is the intentional use of any naturally occuring

microorganism, virus, infectious substance, or biological prod-
uct, or any bioengineered component of any such microorgan-
ism, virus, infectious substance, or biological product, to cause
death, disease, or other biological malfunction in a human, an
animal, a plant or another living organism in order to influence
the conduct of government, or to intimidate or coerce a civilian
population.
(Based on the Model State Emergency Health Powers Act; see chapter 8)
It is important to distinguish between bioterrorism, as we have

defined it so far, and what we might call “biocrime.” Biocrimes
may involve many of the same agents as bioterrorism and biologi-
cal warfare, but the aims are always much narrower—short-term
gains for a restricted number of individuals. Once the immediate
gain is achieved, the activity ceases. For example, after the postal
anthrax attacks in 2001 (which we will discuss below), there were
literally thousands of hoaxes, where harmless white powder was
mailed to a wide variety of individuals, for a wide variety of rea-
sons. In many cases it was simply a joke, but given the anxiety
caused to the intended target and the substantial investment of
police time committed to investigating these incidents, they cer-
tainly qualify as biocrimes.
In other cases, for example white powder sent to abortion
clinics together with threatening notes, the intent was clearly
intimidation in promotion of an ideological goal, which could
be considered bioterrorism. These distinctions become impor-
tant when we try to assess the overall magnitude and threat of
bioterrorism against civilian populations. As discussed below, we
still cannot say whether the postal anthrax attacks were bioter-
rorism or a biocrime, because we don’t know who carried out
these attacks, and thus we do not know the motives.
Various forms of biological warfare have a long if occasion-

ally crude history, including dipping arrowheads and spear
points into rotting cadavers or feces, or lobbing entire diseased
corpses over town or castle walls. The perpetrators obviously had
little understanding of what they were doing, so it may be less
than accurate to call this biological warfare. But they must have
thought it worked, or they wouldn’t have done it.
And once the basis for infectious diseases was uncovered at
the end of the nineteenth century, it didn’t take long before bio-
logical warfare became a highly precise science. By World War
I, and on through World War II, virtually every major military
power—including the United States—and even a few minor
ones had created scientific research units dedicated to the
development of ever more lethal biological weapons. However,
with the exception of Japan during its occupation of China and
Manchuria, there was no extensive use of biological agents against
either military or civilian targets during World War II, although
the Allies seriously discussed carrying out several such attacks
against Germany. In the United States the War Department (pre-
cursor of today’s Department of Defense) established a special
biological warfare facility at Fort Detrick, Maryland. This facil-
ity still operates as the U.S. Army Medical Research Institute of
Infectious Diseases, although it no longer develops biological
weapons, focusing instead on defense against such weapons,
among other activities.
Biological weapons, more than any other weapon type, bring
out the fear factor when used for terror purposes. They are poorly
understood by the public, they are invisible, and they are totally
indiscriminate in their action. Attempts to co-opt the weapons
and methodology of biological warfare for terrorism were prob-
ably inevitable, and they were predicted by numerous scientists
and politicians in many different countries in the decades after
World War II. They became a reality in the last two decades of the
twentieth century. We will focus here on several of these events,
which collectively have shaped most of the debate about bioter-
rorism in the United States.
The first use of a biological agent as a terror weapon in the
United States involved the Rajneesh cult in Oregon, in 1984. The
second major attempt involved another cult, Aum Shinrikyo, best
known for its use of the nerve gas sarin in a Tokyo subway in
1995, though the group had also worked extensively with bio-
logical agents. And finally, the dissemination of anthrax spores
through postal service facilities in the United States represents
the most sophisticated attempt yet to adopt the tools of biological
warfare to terrorism, in the United States or anywhere else.
T H E R A J N E E S H C U L T, O R E G O N , 19 8 5
In 1981 the Rajneesh cult,3 founded by a displaced Indian mystic

named Bhagwan Shree Rajneesh, purchased a 60,000-plus-acre
ranch in north central Oregon, not far from the city of The
Dalles (population 11,000). The Rajneesh commune soon grew
to several thousand souls, who enjoyed various degrees of success
in their search for peace and enlightenment, in an atmosphere of
easy drugs and sex. But the Bhagwan clearly flourished. He accu-
mulated ninety Rolls Royces, five private jets, and a helicopter.
Not content with having built a thriving community on their
own land, cult members gained electoral control of the nearby
small (population 75) town of Antelope in Wasco County. They
named their new town Rajneesh and quickly converted it to their
own needs and ends, to the utter disgust of the mostly retired
locals. Soon, perhaps growing weary of life in such a small town,
Rajneeshees began vying for seats on Wasco County boards and
commissions. Reaction at the county level was mixed, but mostly
negative. A few saw potential downstream benefits from the influx
of money and reasonably educated people, but most shared the
views of their compatriots in Antelope.
In mid-September 1984, a dozen people who worked in or had
recently eaten in several restaurants in The Dalles became ill
from food poisoning. One of these restaurants, a Shakey’s Pizza
franchise, was co-owned by a member of the Wasco County land-
use board, but this raised no particular flags at the time. The
number of victims grew over the following week, and the biologi-
cal culprit behind it was soon identified by public health officials:
Salmonella enterica typhimurium, a bacterium commonly causing
food poisoning.4 Everyone was treated with appropriate antibiot-
ics, no one died, and the incident seemed to have subsided.
But a week later it was back. This time ten restaurants were
involved. Local health services, including medical laboratories,
were overwhelmed. The only hospital in The Dalles quickly ran
out of beds. The number of persons who became ill soon exceeded
700, considerably beyond what might be expected in a commu-
nity of this size for a normal outbreak of salmonella poisoning.
The city called the Centers for Disease Control and Prevention
(the CDC) in Atlanta for help. By the time help arrived, local
health officials determined that most or all of the affected peo-
ple had eaten at salad bars, and restaurants were immediately
advised to stop serving salad. They did.
There followed an exhaustive investigation of all suppliers of
salad vegetables and dressings to local restaurants. Everything
came up clean; even the local water. Preliminary reports from
state and federal health investigators stated that the poisonings
were most likely caused by accidental incursions of salmonella
into the food supply of the restaurants involved. Even the CDC
felt that food handlers were the most likely source for introduc-
tion of the bacteria into the salad bars. Some locals, in particu-
lar another member of the Wasco County land use committee,
believed the Rajneesh cult was somehow involved, but lacking
any hard evidence or direction from health authorities, investi-
gations into this possibility eventually fi zzled out.
The involvement of the Rajneeshees became clear only as the
result, a year or so later, of internal squabbles within the cult. The
Bhagwan himself implicated some of his lieutenants in the affair,
and called for a government investigation, after which he beat a
hasty retreat to India. Authorities found abundant evidence at the
commune of not only S. enterica typhimurium but a fairly sophisti-
cated medical research laboratory and evidence that the cult had
considered employing other deadly pathogens, including HIV—
the AIDS virus. They had purchased salmonella essentially over
the counter, from a Seattle scientific supply house. Among their
intended victims, in addition to various county officials, was U.S.
Attorney Charles Turner, the top federal prosecutor in Oregon.
He was to be spared infection with salmonella. Cult members
planned to shoot him. They failed. But they also intended to use
their cultured salmonella to poison the Dalles water supply in the
days before an upcoming election. The grand plan, as it turned
out, was to reduce the number of Wasco County citizens able to

vote, thereby increasing the influence of Rajneeshees. For vari-
ous reasons, this never came about.
Probably no more than a dozen Rajneeshee leaders were fully
aware of or involved in the salmonella poisonings. Seven cult
members were ultimately indicted in various murder or attempted
murder conspiracies. The cases against the conspirators came to
a close only in 2005, when the last of these returned from self-
imposed exile in Germany and surrendered to authorities.
While the Rajneesh incident gained national and international
attention among those who had been predicting bioterrorism in
America, it could be argued that what happened in Oregon was
not so much a form of bioterrorism as a simple criminal attempt
to manipulate a specific civilian population and its various civil
agencies through malicious intimidation—a biocrime. There
was no discernible political aim beyond an attempt by a few mem-
bers to influence a single election and to expand their power and
influence within the cult, and perhaps the intimidation or pos-
sible elimination of some individuals. Still, many of the features
of bioterrorism were there: preparation and crude weaponiza-
tion of a human pathogen, delivery of the pathogen to intended
victims, and serious social and psychological disruptions in the
targeted population.
A U M S H I N R I K Y O , J A P A N 19 8 5 –19 9 5
If you missed this first wake-up call, some would say, your atten-
tion may have been sharpened a decade later by events in Japan,
involving a messianic cult called Aum Shinrikyo (“Supreme
Truth”). Aum Shinrikyo is known mostly for its release of sarin
nerve gas in the Tokyo subway system in March, 1995. This attack
killed twelve people and injured perhaps a thousand more, some
seriously.5 In a preliminary run-up to this attack, cult members
had carried out a previous gassing in the provincial town of
Matsumoto that killed seven.
But Aum Shinrikyo did not limit itself to nerve gas as an agent
of terror. A subsequent detailed investigation into their activi-
ties in the years preceding the subway attack revealed that cult
scientists had also endeavored to develop lethal biological terror

weapons as early as 1990, preceding their work with sarin. The
cult was completely broken up and eliminated immediately after
the subway attacks, and never did manage to produce an effective
weapon based on biological agents. But not for lack of trying.
The difference between the Rajneeshees and Aum Shinrikyo
is like the difference between a mom-and-pop corner grocery
and a nation-wide supermarket chain. Aum was founded in 1984
by Chizuo Matsumoto, the son of a tatami mat weaver. Shortly
after starting Aum, he changed his name to Shoko Asahara. He
was blind in one eye at birth, with only limited vision in the other
eye, and was considered legally blind. In spite of his handicap—
possibly in part because of it—in school he was aggressive and
bullying. As a young adult he was a determined entrepreneur
with little regard for the law. By his early twenties he had amassed
a significant personal bankroll through a series of acupuncture
clinics and meditation centers that were largely clever scams.
After a period of rather cynical exploration of various spiritual
movements, he decided to found one of his own. We will never
know his motives for choosing this path; his spiritual and philo-
sophical utterances were, throughout Aum’s existence, utterly
erratic and disorganized.6
With his otherworldly looks, facilitated by his near-sightless
gaze and long, flowing black hair, Asahara became a mesmeriz-
ing, even charismatic figure. And Aum Shinrikyo quickly grew to
become one of the larger and more influential of the “new age”
organizations in Japan. Based on absolute, unquestioning adher-
ence to the whims and dictates of Asahara, the cult eventually
had a membership in the tens of thousands. Among the many
thousands who lived in Japan, about 1,400 chose to transfer all of
their assets to Aum Shinrikyo and live in Aum compounds. All of
the leaders of the cult were drawn from these members.
At its peak in the early 1990s, Aum controlled hundreds of
millions of dollars, had extensive real estate holdings in Japan as
well as offices abroad (including one in Manhattan), and oper-
ated as many as twenty businesses, many of which were nothing
more than fronts to foster the cult’s illegal activities.7 Even at the
end, when the police finally raided Aum headquarters, they found
eight million dollars in cash and twenty-two pounds of gold!
3 0 • B R ACI N G F O R A R M AG E D D O N?
After a visit by Asahara and his staff to Russia in 1992, where

they staged numerous revival-style public meetings and pur-
chased a radio station to spread the Aum gospel, another thirty
thousand members were added to the cult’s rolls—exceeding
the number of adherents at home. Within Japan itself, Aum cult
members were drawn largely from the middle and upper-middle
classes. Laborers and service workers had too few assets to be of
interest to Aum’s leadership. Most members were young, and a
large number were college-educated. When interviewed after the
cult’s collapse, many confessed to a sense of alienation from what
they perceived as Japan’s materialistic, work-oriented culture,
which left them little time to explore themselves and other ways
of looking at the world. Most also craved a sense of community
and belonging which they found lacking in their daily lives.
Importantly, many of those drawn to Aum Shinrikyo had back-
grounds in science and technology, having graduated from, or
at least having attended before dropping out to join Aum, some
of Japan’s best scientific programs and graduate schools. A brief
look at a few members of Aum’s scientific staff will give a sense of
the quality of people they were able to recruit:
Masumai Uchiya—trained in organic chemistry at Tsukuba

University.
Toro Toyoda—left a graduate program in particle physics at
Tokyo University to join Aum.
Ikuo Hayashi—cardiovascular surgeon trained at Keio University
and at Mt. Sinai Hospital in New York
Seiichi Endo—doctorate in molecular biology; did research in
viral genetic engineering at Kyoto University before leaving to
join Aum.
Hideo Murai—advanced degree in astrophysics from Osaka
University; did research for Japanese steel company.
Aum also recruited from among their membership numerous

mid-level technicians and laboratory workers with various levels
of scientific expertise.
The research facilities built by Aum Shinrikyo for developing
biological weapons were located in their main compound near the
village of Kamikuishiki at the base of Mt. Fuji, in a building on the
east side of Tokyo, and at Mt. Aso in Kyushu province. No expense

was spared in ordering the most up-to-date scientific equipment
for working with viruses and with bacteria and bacterial toxins.
One of the first biological agents they tried to weaponize was
botulinum toxin, one of the deadliest human poisons known:
three billionths of an ounce may be fatal in humans. This nerve
toxin is produced by a common soil bacterium, Clostridium bot-
ulinum, and cult scientists attempted to isolate the toxin from
bacteria gathered nearby and grown in culture flasks in their
own laboratory. Following protocols developed in the 1930s and
’40s, they attempted to harvest and concentrate the toxin from
bacterial growth medium and convert it to a form that could
be sprayed from a high-pressure nozzle. This material was actu-
ally used in attacks against the Japanese Parliament, portions of
the Tokyo airport, and even the headquarters of the American
Seventh Fleet in Yokohama. None of these attacks produced any
casualties. A second generation of botulinum toxin was used in
an attempt to kill the royal family during the wedding of the
crown prince, again without results.
The cult’s scientists subsequently turned their attention to
production of weapons-grade anthrax. As we will discuss in the
next chapter, anthrax is particularly deadly in its spore form: dry,
hard, dust-like particles that are easily carried great distances by
even the lightest of winds and can be inhaled to produce the
most lethal form of the disease.
The cult used large fans to disseminate what they believed
was a highly purified preparation of anthrax spores from the top
of a building adjoining their laboratory in Tokyo. Aside from a
sickening stench and a few cases of mild illness in people and
pets close to the building, there were no effects of the attack.
No cases of anthrax were reported or detected. Had they pre-
pared a fully potent batch of infectious anthrax spores, and dis-
seminated it properly, it is likely that thousands—possibly tens
of thousands—of people would have been killed. Obviously that
was their intent. A second attempt to spread anthrax, this time
around the Imperial Palace, was carried out a few months later,
again with no effect. Subsequent investigations suggested they
had cultured a relatively harmless anthrax strain normally used
for animal vaccinations (and thus by definition unable to cause
disease), and in addition had likely failed to convert it to the more

deadly spore form of anthrax.
Members of the cult’s scientific staff traveled far and wide
in their attempts to procure lethal biological weapons. During
Aum’s many trips to Russia, particularly after the fall of the Soviet
Union, attempts were made to ferret out sources for every con-
ceivable sort of weapon, including even jet fighters and nuclear
bombs! In 1992, cult members traveled to Zaire after an outbreak
of hemorrhagic fever, trying to find a source for the Ebola virus.
They also apparently attempted to work with a rickettsial agent
causing the dreaded Q fever. Fortunately, none of these efforts
bore fruit.
All in all, Aum Shinrikyu carried out around a dozen terrorist
attacks with biological weapons, every single one of which failed
to produce significant casualties. We will examine some of the
reasons for these failures in chapter 9. But first, let’s look at the
third wake-up call, one that, while more limited in scope than
that provided by Aum Shinrikyo, is in many ways more chilling:
the dissemination of anthrax spores through the U.S. Postal
Service shortly after the terrorist attacks of September 11, 2001.
A M E R I T H R A X 2 0 01
The dissemination of anthrax spores using the U.S. Postal

Service in September and October of 2001 is the most serious
attempt to carry out an attack on U.S. soil using a bioweapon.
The FBI code name for the still ongoing probe into these attacks
is Amerithrax. The Amerithrax attacks also provide our first real
glimpse into what might happen when determined terrorists pro-
duce, or otherwise acquire, high-grade human pathogens and
use them effectively. These attacks killed five people and injured
at least sixteen others, some of them seriously.
As we will discuss in more detail in chapter 3, anthrax spores
can cause disease in two different ways, depending on how
they enter the body. If the spores settle on exposed skin, and
if the skin is even slightly damaged at the point of contact, the
spores can penetrate the skin and cause cutaneous anthrax. This
form of anthrax in humans responds well to currently available
antibiotics, and fatalities are now almost unheard of. On the

other hand, if spores are inhaled and enter the body through the
lungs, inhalation anthrax will ensue. This form of anthrax is dif-
ficult to treat, and more deadly. None of the persons contracting
cutaneous anthrax in the 2001 attacks died. Nearly half of those
with confirmed inhalation anthrax died. Certainly many others
came into contact with anthrax spores during Amerithrax, but
for a variety of reasons (unabraded skin; timely administration of
antibiotics) did not develop detectable infections.
As far as we know, the letters containing anthrax spores were
mailed in two batches from New Jersey. The first batch, prob-
ably containing five letters, was postmarked September 18, 2001,
and sent to news organizations in Florida (American Media,
Inc.) and New York (ABC, CBS, NBC, and the New York Post).
Only the letters to the New York Post and NBC were recovered
for forensic analysis. A second batch of at least two letters was
mailed on October 9. One was received in the office of Senator
Tom Daschle (D-SD), and a second addressed to Senator Patrick
Leahy (D-VT) was found a few weeks later among undelivered
Senate mail. Both of these letters were recovered for scientific
analysis.
No harm was done to the individuals to whom the letters were
addressed. The targeted individuals rarely opened their own
mail. With one or two possible exceptions, the victims of these
attacks were office personnel or other associates of the primary
targets, or people working in postal facilities through which the
contaminated letters had been processed. Whether this “collat-
eral damage” was intended or even envisioned by the terrorist or
terrorists is unknown.
As a result of the attacks, one Senate office building was
closed for several months for decontamination. Two major East
Coast postal sorting facilities were closed for several years during
clean-up procedures. This kind of social and economic disrup-
tion must be included when we add up the toll of attacks with
bioweapons.
After more than five years of intense investigation by the FBI
and postal inspectors, over 9,000 interviews, and the issuance of
over 6,000 subpoenas, investigators still do not know (or at least
are not saying) who carried out these attacks. For that reason,
we do not know if they were truly bioterrorism or simply a bioc-

rime. But because of their proximity in time to the World Trade
Center and Pentagon attacks of September 11, initial focus was
on foreign terrorists. It seemed a reasonable assumption that the
two incidents could be related.8 It now seems more likely that
one or more highly skilled American scientists were responsible,
directly or indirectly, for at least the production of the anthrax
used, and probably for its dissemination. The FBI leaked the
name of one scientist who has been the subject of an intense but
inconclusive investigation for nearly six years. An undisclosed
number of other “persons of interest” are said also to be under
active investigation.
The anthrax spores used in the Amerithrax attacks distinguish
these incidents from all others we have experienced. Unlike the
harmless vaccine strain used by Aum Shinrikyo scientists, at least
some of these spores were from a highly virulent form of anthrax,
and milled into a fine powder ideal for dissemination by a num-
ber of means. FBI tests showed that the spores had been gener-
ated in the past two years but did not indicate where. Had Aum
Shinrikyo had spores of this quality, events in Japan might have
taken an entirely different turn.
The strain of anthrax used in these attacks is maintained
mostly in university and defense institute research laboratories,
and is very difficult (today impossible) to obtain casually. All
experts now agree that the spores found in at least the Senate
letters were very pure and highly potent. It is less certain whether
they had been treated with chemical reagents that would maxi-
mize airborne dispersal. The experts are also nearly unanimous
that the spores could only have been produced in a very high-
tech, fully equipped laboratory by a person or persons expert
in every aspect of growing anthrax bacilli and converting them
to spores. The spores may have been stolen from one of these
facilities and disseminated through the mails by an unskilled
person, but they were very unlikely to have been made by a non-
scientist in a garage laboratory, and certainly not in a cave in
Afghanistan.
There are numerous genetic substrains of anthrax, and these
can be identified by their individual DNA fingerprints. It is known
where each of these substrains was produced and by whom. But
prior to the Amerithrax incidents, researchers readily exchanged

their strains among themselves, keeping at best casual records of
their exchanges, and often none. Every laboratory in the United
States that works with anthrax, including in particular the gov-
ernment’s own Fort Detrick facility in Maryland, has been exten-
sively investigated by the FBI. Many foreign laboratories have also
cooperated in this investigation. But to date, the FBI has been
unable to identify (or at least has not done so publicly) the exact
source of the anthrax strain used in the 2001 attacks.
Amerithrax provided us our first—albeit modest—glimpse of
what bioterrorism in America might look like. It is not entirely clear
that this was in fact a bona fide bioterrorist attack, since we don’t
yet know the motives of the perpetrator(s). But it played another
role whose importance cannot be overstated. A growing chorus
had been slowly developing in the United States over the preced-
ing decade, warning—with only partial success—of the dangers
of bioterrorism. The juxtaposition of Amerithrax and exercises
like Dark Winter against the background of this chorus and the
attacks on the World Trade Center tilted the American political
mind down a path we are still treading. We would spend tens of
billions of dollars over the next eight years trying to find our way.
Between the Rajneesh episode of 1984 and the 2001 postal
service anthrax attacks, there were two other incidents involv-
ing the use—or at least the acquisition for presumed intended
use—of biological weapons by U.S. citizens. Although most ordi-
nary Americans barely noticed nor long remembered what hap-
pened, these cases remain very much on the minds of lawmakers
and law enforcement agencies throughout the country.
T H E M I N N E S O TA PAT R I O T S C O U N C I L
One such incident involved a group of disgruntled right-wing

individuals loosely grouped into a subunit of something called
the Minnesota Patriots Council. Their particular cell was active
in and around Alexandria, Minnesota in the early 1990s.9 A
group of a half-dozen or so individuals, all men, with a variety
of complaints against numerous symbols of local, state, and fed-
eral authority, plotted several means of seeking revenge against
those they felt were responsible for their manifold failures in life.
They set out to amass various weapons, including bombs—and a
potent plant-derived toxin called ricin. Highly purified ricin is,
on a gram-for-gram basis, probably a hundred times more deadly
than sodium cyanide, and a lot more toxic than cobra venom.
They obtained the ricin by responding to an advertisement
in a white-supremacist magazine published in Oregon. The ad
sketched the virtues of an “assassination kit” based on ricin, which
turned out to be a dozen or so castor beans (the natural source
for ricin, which they were offering for one dollar per bean) plus
instructions for extracting and purifying the toxin. The instruc-
tions also suggested ways to make it more easily penetrate the
skin, or how to disperse it as a powder.
None of the conspirators had any background in chemistry or
biology, but one of them was familiar with solvents of the type
involved in extracting the ricin and volunteered to carry out its
purification. They did manage to produce a white powder which
they assumed to be ricin, and kept it stored in a jar in a garage.
Although they talked about several potential targets for their poi-
son and ways to deliver it, they never actually used it. As a result
of dissension within the group and the defection of one of the
members, the powder was turned in to the local sheriff’s office
and made its way to an FBI testing lab. Its identity was confirmed,
leading ultimately to the arrest of four of the group. They were
tried under the 1989 Biological Weapons Anti-Terrorism Act
(chapter 6), which makes it a felony for U.S. citizens to produce,
acquire, stockpile, or possess for use as a weapon any biological
agent for which there is no discernible justification for peace-
ful purposes. They all received prison sentences of several years.
They were the first persons to be convicted under this Act.
This case showed that it in the early 1990s it was still relatively
easy to obtain at least some biological agents suitable for conver-
sion to a biological weapon, notwithstanding that it is now (and
was at the time, although this was probably not known to the
individuals involved) a federal crime to do so. Ricin extraction
from castor beans (which could presumably even be grown at
home) is not that difficult, and detailed instructions for doing so
are easily available through the Internet. The FBI recovered less
than a gram of powder, which was judged to be about 5 percent
pure. Still, that might have been enough to kill a hundred or

more people if used effectively.
A LONE RANGER EPISODE . . .
Our final tale concerns an unusual individual named Larry

Wayne Harris. Harris has an interesting pedigree: a member of
an anti-government sect called the Christian Patriots, an officer
in the neo-Nazi group Aryan Nations, and a trained microbiolo-
gist who carries out “research” on weaponizable pathogens in a
home laboratory.10 Raise any flags?
In May 1995, with the Aum Shinrikyo story still unfolding in
the headlines, Harris ordered three vials of freeze-dried Yersinia
pestis, the bacterium that causes bubonic and other forms of
plague, from the ATCC. In order to do so, he printed up a fake
letterhead on a home computer, using a made-up scientific
laboratory name, his home address in Lancaster, Ohio, and an
Environmental Protection Agency license number assigned to
his employer, a microbial testing company in nearby Columbus.
Somewhere along the way, someone at ATCC became suspi-
cious and alerted the CDC in Atlanta, which in turn contacted
public health authorities and the police in Lancaster. The police,
armed with a warrant and backed by a HazMat unit, raided his
home, confiscated the Y. pestis, and arrested Harris.
Harris’s adult life seems to consist of an endless web of fabri-
cated stories. He claimed at various times to have been trained in
biological warfare by the U.S. Army (he wasn’t); to have worked
as a bioweapons expert for Batelle Labs (he didn’t); to have been
under contract to the CIA (they deny it, as Harris said he would
expect); to have trained Pentagon officials in the fine points of
biological weaponry (no record); to have worked at Fort Detrick
(he didn’t); to have had extensive contacts with Iraqi bioweapons
scientists (extremely doubtful). And so on, and on, and on.
Harris eventually pleaded guilty to a federal wire-fraud charge
and received a $50 fine and eighteen months’ probation. A cou-
ple of years later, while still on probation, he became involved in
a complex scheme involving a machine supposedly able to kill
microbes both inside and outside the body. Harris represented
himself to others in the scheme as working for both the CIA and
FBI as a bioweapons expert. He was expressly forbidden to do
this as a condition of his probation. When Harris claimed he was
going to test the machine against weapons-grade anthrax, one of
the conspirators panicked and called the FBI. Harris was arrested
again, this time in Las Vegas, by FBI agents accompanied by a
HazMat unit and several military units specializing in bioweap-
ons, weapons of mass destruction, and ordnance disposal.
Harris did have anthrax in his possession, but like the Aum
Shinrikyo anthrax, it was a strain used for vaccinating animals,
harmless to humans. The apparent ease with which he was able
to circumvent then-current procedures guarding access to these
agents was a wake-up call in itself to agencies presumed to be reg-
ulating them. Harris was tried again in federal court, for viola-
tion of his probation. His probation was extended by five months,
and he was released.
It’s hard to take Harris’s shenanigans very seriously, and per-
haps no one would have, except that they followed by only weeks
the Aum Shinrikyo gas attacks in Tokyo and the bombing of the
Murrah Federal Building in Oklahoma City. And it was quickly
apparent that Aum scientists had seriously pursued plans to use
bioweapons. Unquestionably, these events triggered a distinct
uptick in the awareness of elected officials and policy makers,
at all levels, of the threat and potential dangers of all forms of
terrorism, but particularly bioterrorism. And they contributed to
the burst of programs and federal spending aimed at mitigating
these threats that we will examine in chapter 6.
These documented instances of the use of biological weapons
(bioweapons) make clear that to date we have seen more biocrime,
both in America and in the world at large, than what we would
think of as actual bioterrorism. The perpetrators range from dis-
gruntled individuals acting for a variety of idiosyncratic motives,
through loosely defined groups often acting around religious
themes. Their skills ranged from essentially zero to moderately
sophisticated. The number of people they killed and injured is
small by comparison with other, deadlier forms of political ter-
rorism. And yet we have spent tens of billions of dollars to defend
ourselves against bioterrorism.
So just how much of a threat is bioterrorism, in the context

of the other challenges America will face in the twenty-first cen-
tury? Where would the likely perpetrators of a bioterrorist attack
come from? Who would they be? What can we do to protect our-
selves? These are some of the questions we will address in the
remainder of this book. Let’s begin by first looking not at the
“perps” themselves, but at the deadly agents they would likely use
to terrorize us.
chapter 3
Agents of Terror
The biological weapons available to would-be

bioterrorists today are by and large those developed during the
middle decades of the twentieth century, when most major coun-
tries were making offensive weapons for state-sponsored bio-
logical warfare. By the end of the 1960s, popular and political
opposition to biological and chemical weapons was growing, in
the United States and throughout the world. In 1969, the National
Security Council undertook a review of domestic programs for
these weapons, with input from a broad range of military and
civilian authorities, including the scientific community. Similar
reviews and discussions were taking place in other countries.
On November 25, 1969, President Richard Nixon announced
that the United States would immediately and unilaterally cease
production, and foreswear future use of, all offensive biologi-
cal weapons. This might not have been an entirely altruistic
move. The United States enjoyed an overpowering superiority in
offensive nuclear weapons, and elimination of biological weap-
ons could be seen as depriving “rogue” states of a potentially
important weapon of their own. Moreover, the U.S. military had
decided that bioweapons were probably not worth the trouble. In
addition to being difficult to produce, they were undependable
in the varying environments in which they might have to be used.
They could as easily blow back into the faces of the troops having
to use them.
After an additional two years of domestic and international

discussions, in April 1972 President Nixon signed an inter-
national agreement commonly referred to as the Biological
Weapons Convention (BWC), slated to come into full effect in
1975. Eventually, over 150 countries would sign it. During this
interim period, the United States began systematic destruction
of existing stockpiles of biological weapons and converted its
major research facility at Fort Detrick to studying ways to protect
American military and civilian populations against biological
weapons in the future.
This latter step proved to be a wise precaution, since, as many
reluctant supporters of the BWC had predicted, a number of coun-
tries continued their bioweapons programs after the 1975 effec-
tive date for this convention.1 And to some extent the knowledge
gained about how to control and contain outbreaks of a range
of pathogenic organisms or their toxins (including some, such
as Ebola virus and HIV, that were not even known at the time of
the BWC) has already proved useful, for example in responding
to the Amerithrax attacks. Unfortunately, it is entirely possible
that some of the facilities still working with weaponizable patho-
gens, albeit for defensive purposes, may themselves be a source of
deadly materials for future bioterrorists.
In the United States, the Centers for Disease Control and
Prevention (CDC), a branch of the Department of Health and
Human Services (HHS) centered in Atlanta, Georgia, is the pri-
mary federal agency responsible for coordinating all scientific,
medical, and public health aspects of the federal response to
potential and actual bioterrorism. In 1999 the CDC commissioned
a detailed study of “critical biological agents” that would be most
problematic in bioterrorist attacks. Those pathogens that proved
to be of the greatest concern, based on factors such as lethality,
ease of dissemination, contagiousness of the resulting disease, lack
of preparedness of physicians and public health personnel to deal
effectively with an outbreak, and ability to induce panic and social
disruption, were given a Category A designation. An additional
group of agents, of lesser lethality or more difficult to dissemi-
nate, were judged to be of moderate risk at present, and placed
in Category B. Finally, the commission identified several emerg-
ing infectious disease agents for which there is no present history
AG E N T S O F T E R R O R • 43
of use as bioweapons but which conceivably could be misused for

such purposes in the future. These were placed in a still-evolving
Category C. The CDC agents, and the diseases they cause (where
defined), are listed in Table 3.1. All of these pathogens are periodi-
cally reviewed and assessed, and the list is subject to change.
In the sections that follow we take a closer look at the microbes
and toxins on the CDC A list and selected agents from categories
B and C.2 While the descriptions of some of these agents can be
very frightening, it should be noted that as natural elements of
our environment they actually cause very little illness and death
in the United States. In a sense, that is part of their potential
value as weapons—there is virtually no natural immunity to
these agents among the general population, and doctors have
little experience in diagnosing and treating them.
ANTHRAX
Anthrax is a disease caused by a bacterium, Bacillus anthracis. It

affects animals, mostly grazing herbivores such as sheep, goats,
and cows. Humans are vulnerable to anthrax infection, but we
have learned over the centuries how to avoid it, and veterinar-
ians are skilled at keeping domestic livestock free of the disease.
Prior to the early part of the twentieth century, anthrax was an
occasional problem among people working with wool, hides, and
other parts from animals infected with anthrax. However, fewer
than 250 cases of naturally acquired anthrax in humans have
been reported in the past fifty years in the United States. In less
developed parts of the world, the number of annual new cases of
anthrax is considerably greater. Anthrax is not contagious; there
are no known cases of transmission of anthrax from one human
being to another.
Anthrax is deadly: the mortality rate for untreated anthrax
can range from 20 to nearly 100 percent, depending on the form
of infection (see below). But what makes anthrax so deadly, and
potentially useful as a bioweapon is that B. anthracis forms spores.
Most bacteria, when they run out of food, simply starve to death.
A few bacteria, however, are able to enter a state of suspended
animation—to convert to bacterial spores. Spores do not carry
out any metabolism, do not need water, and are very resistant to
heat and many toxic chemicals. Properly prepared, they are hard,
dry particles that can be dispersed in air. When they land on a
surface possessing moisture and nutrients—human skin or lungs,
for example—they rapidly revert from spores to normal bacterial
cells in a process called germination. Ungerminated spores can
survive in soil or on inert surfaces for several decades.
In inhalation anthrax, spores settle into the lungs, and within
hours, actively dividing bacteria migrate through lymph and
blood to other parts of the body. It doesn’t take long before
anthrax bacteria have spread everywhere. They then release
toxin molecules which can seriously damage a wide range of tis-
sues and organs. Depending on the number and quality of spores
inhaled, symptoms of disease can appear anywhere between a few
days and a week or two. Initial symptoms are similar to those of
the flu and may be misdiagnosed. But once it sets in, the disease
accelerates very rapidly, with high fevers, vomiting, and diarrhea.
The body is quickly overcome by bacterial toxic shock, which can
be followed by coma and death.
A hundred years ago, mortality in untreated inhalation
anthrax could easily approach 100 percent. But the Amerithrax
incident, if it can be thought of as having an upside, suggests
that rapid diagnosis and aggressive treatment with antibiotics3
can reduce mortality to somewhere in the 50 percent range. Part
of what makes anthrax so hard to manage clinically is that even
after the bacteria have been killed, the toxins they have released
(Box 3.1), which are not affected by the antibiotics, remain in the
system for at least a day or two, and continue to cause damage.
Spores settling on healthy skin are unlikely to cause a prob-
lem, but they can enter the body through cuts or abrasions and
cause cutaneous anthrax. Once inside, some spores will germinate
locally and cause redness and itching that can develop into local
skin ulcers; these eventually turn a deep, coal-like black color,
whence the name anthrax (from the Greek word for coal). Many
spores will spread to other parts of the body, germinating as they
go. However, death from this form of anthrax, even untreated,
rarely exceeds 25 percent. With prompt antibiotic treatment,
mortality is rare. None of the Amerithrax victims with the cuta-
neous form of anthrax died.
BOX 3.1
Toxins released by anthrax bacteria
Edema toxin Causes massive leakage of water from blood

vessels into tissue spaces. Inhibits white blood
cells involved in fighting infections.
Lethal toxin Causes massive inflammation of body tissues,
leading to systemic shock.
SMALLPOX
Today it is hard to imagine that smallpox was once one of the

deadliest diseases on this planet, exceeding even the plague in
the cumulative number of people killed throughout history. In
the twentieth century alone, it is estimated half a billion people
may have died of smallpox. When contracted through the lungs,
by breathing in air into which an infected person had sneezed or
coughed, it routinely killed a third of unvaccinated individuals
well into the twentieth century, and left the rest badly disfigured
for life. Smallpox can also be spread by person-to-person physical
contact, although the resultant disease is less fatal.
Smallpox in humans is caused by a virus, Variola major.4 It is
one of a relative handful of human pathogens that has no known
animal or insect reservoir (a host in which it can reproduce
without causing disease, or at least death.) In its present form, it
appears to be entirely dependent on human beings for its propa-
gation and survival.
In the course of a V. major infection, viruses settle into airway
tissues and are swept along into regional lymph nodes. After a
week to ten days, various combinations of fever, chills, and achi-
ness appear. When the virus reaches the skin (from the inside
out, as it were), a rash appears, followed by the formation of mul-
tiple, closely packed blisters on all parts of the body, but particu-
larly the face and neck. This may not occur until ten to seventeen
days after initial infection. These blisters also form in the mouth
and throat, where they break easily, dumping their viral load into
the saliva. This aids in the further spread of the virus into the
general population through coughing and sneezing.
V. major was probably endemic in the human species for thou-
sands of years. From the eighteenth century—in some parts of
the world, even earlier—it was kept under partial control through
the natural immunity of recovered victims and by various forms
of active vaccination. It was the absence of both natural and vac-
cine-induced immunity that made Dark Winter possible.
V. major is the first (and so far only) disease-causing microbe
to be purged from the human species, by a worldwide immuniza-
tion campaign launched by the World Health Organization in
1967. The fact that V. major could not retreat into an animal res-
ervoir during this campaign was probably a factor in its eradica-
tion. Today V. major officially exists only as frozen stockpiles at
the CDC in Atlanta and in a former biological warfare research
center near Novosibirsk, in Russia.
Immunizations for smallpox over the years have never been
carried out with V. major—it is too deadly—but rather with a
closely related orthopoxvirus called vaccinia, which causes cow-
pox in cattle. A relative of V. major, vaccinia is the virus used by
Edward Jenner at the end of the eighteenth century to become
the first person to induce immunity to a disease in humans, and
is the origin of the term vaccination.
Vaccinia is injected in a fully viable form. In humans it induces
a mild local reaction at the site of injection that usually resolves
in seven to ten days. Protection from subsequent infection by
V. major after vaccinia immunization is excellent, but with even
the least pathogenic forms of this virus, about 1.6 cases per mil-
lion immunizations progressed from mild reaction to more seri-
ous disease and occasional deaths, which is why vaccination for
smallpox in the United States was halted in 1972.
Smallpox is on the CDC Category A list because of its high
mortality rate, and because V. major spreads very efficiently as an
aerosol. The virus is relatively stable, and as a viral disease, small-
pox is essentially untreatable.5 As with anthrax, there is enough
residual public awareness of the deadliness of smallpox that news
of its spread in a terrorist attack would likely generate considerable
panic and social disruption. Since for the past thirty years or so
almost no one in this country has been vaccinated against small-

pox, the U.S. population is highly vulnerable to this disease.
PL AGUE
References to the plague in human history date back to at least

500 bc, although we don’t really know if that plague was the same
as the great pandemics that swept Europe and Asia in the Middle
Ages, which are what we recognize as plague today. There were
several major and many minor pandemics in Europe in the four-
teenth through eighteenth centuries. They were deadly. Although
we have no precise figures, somewhere between 100,000,000 and
200,000,000 people are estimated to have died.
The non-spore-forming bacterium Yersinia pestis has been asso-
ciated with the European outbreaks, and Y. pestis DNA has actually
been extracted from dental remains found in graves of persons
dying from the plague. We still see occasional incidents of Y. pestis
plague, with several thousand new cases arising annually through-
out the world. There have been about 400 cases in the United
States since 1950, mostly in the Southwest.
Y. pestis can cause several types of disease in humans, depend-
ing on how the infection is acquired. Bubonic plague results when
a human is bitten by an insect, usually a flea, carrying Y. pestis
acquired from previously biting an infected animal. In urban areas,
the most common animal carriers are rats and squirrels and the
occasional house cat. Y. pestis can also jump from animal fleas into
fleas feeding on humans, which greatly aids human-human spread
of the disease. In the Middle Ages, most people had fleas in abun-
dance. Prior to the introduction of antibiotics in the 1940s and
’50s, fatality rates of 50 percent or more were not uncommon.
A few days after infection, the typical symptoms of a microbial
infection set in: fever, chills, and general achiness, by-products
of activation of the immune system. As the bacteria continue to
replicate inside regional lymph nodes, the nodes become greatly
enlarged (called buboes) and very tender. They can grow as much
as four inches across.
If the bacteria spill out of the lymph nodes and enter the
general blood circulation, numerous other tissue compartments
become involved, and the infection is even more lethal (septice-

mic plague). Blood vessels are destroyed, resulting in gangrene
in the extremities; this is probably the origin of the term “Black
Death” for plague. Prolonged infection can also trigger shock, a
common cause of plague death. If the bacteria invade the lungs
(secondary pneumonic plague), the infection is almost always
fatal, and the bacteria spread more readily from person to per-
son through sneezing and coughing.
The second major form of plague, primary pneumonic
plague, is particularly deadly. It occurs when Y. pestis is taken in
directly through the respiratory system as opposed to an insect
bite. Untreated mortality rates approach 100 percent. Symptoms
set in within a day or two after inhalation of infectious Y. pestis,
and are initially indistinguishable from other forms of aggressive
pneumonia. Experience in diagnosing and treating pneumonic
plague is very limited in the United States. Moreover, many cur-
rently used antibiotics have never really been tested against Y.
pestis in humans.
There have been no documented attempts to use Y. pestis as
a bioterrorism agent. However, in 1995, a microbiologist was
arrested for fraudulently obtaining large amounts of plague bac-
teria with no obvious legitimate scientific purpose. And in 2004,
a respected physician- scientist at Texas Tech University was sen-
tenced to two years in prison for grossly mishandling and illegally
shipping to Tanzania vials containing infectious Y. pestis—on a
commercial airliner, no less! No connection with bioterrorism
was alleged or proved.
BOTULISM
Botulism is caused by a protein toxin released by several strains

of bacteria of the genus Clostridium, including the eponymous
C. botulinum. This toxin is the most lethal biological poison
known—100,000 times more poisonous than sarin gas.
Natural infection by C. botulinum can occur by eating contami-
nated food, usually vegetables, though the name botulinum in
fact derives from the Latin for sausage (botulus), a common food
contaminated by C. botulinum in former times. The poisonous
effect of food contaminated with this bacterium is due entirely to

the toxin, which it readily secretes into its surroundings. C. botu-
linum can also enter through wounds, for example in the foot,
when walking in soil harboring this bacterium. The toxin itself
will not penetrate unbroken skin.
Botulinum toxin is a neurotoxin that prevents the brain from
telling muscles when to contract. Within twelve to seventy-two
hours after ingestion (depending on dose), individuals begin
experiencing muscular weakness, and have difficulty seeing,
speaking, and swallowing. Treatment almost always requires
extended stays in intensive care units. While there may be some
initial sense of giddiness, the brain and associated mental func-
tions are not impaired. But within hours the muscles, including
those that control breathing, just cannot do work. Death usually
comes quickly from respiratory failure.
There are seven genetically distinct strains of C. botulinum,
each producing a slightly different neurotoxin, given the desig-
nations A through F. Almost all cases of botulism in humans are
caused by toxin types A, B, and E.
Intact C. botulinum bacteria were fed by the Japanese to pris-
oners during their occupation of Manchuria in World War II.
The results, as far as they are known, were uniformly lethal. The
Aum Shinrikyo cult in Japan, as we have seen, attempted to carry
out attacks in Tokyo in the 1990s using botulinum toxin, but
were unsuccessful. Research on aerosolized botulinum toxin as a
possible biological weapon was carried out by the United States
and other countries over the years, but the toxin was never used.
United Nations inspectors determined during the 1990s that
Iraq had prepared about 5,000 gallons of concentrated toxin,
some of which was reported by inspectors to have been loaded
onto missiles, ready for use.
TULAREMIA
Tularemia is caused by a bacterium, Francisella tularensis, named

for its discoverer, Edward Francis, and the place of its discovery,
in 1911, in Tulare County, California. There are two major strains
of F. tularensis, Type A and Type B. Type B is the most virulent,
being among the most infectious pathogens known. It had been

associated with a variety of plague-like diseases in animals such
as deer-fly fever, rabbit fever, and tick fever, among others, all of
which are now grouped as various forms of tularemia. Humans
can be infected by contact with F. tularensis in the wild, although
such incidents are relatively rare (only about 200 cases per year
in the United States), and humans do not readily transmit the
resulting infection to others.
The most serious incidents of tularemia in humans come from
inhalation of bacteria, often through handling of contaminated
hay or other grains. “Inhalation tularemia” requires only a few
bacteria to cause serious illness, whereas infection through other
routes usually requires exposure to millions of bacteria. Because
of the low incidence of inhalation tularemia in the United States,
a large outbreak of this disease in a concentrated area might take
a while to diagnose properly, but would lead to an immediate
suspicion of bioterrorism.
Tularemia was investigated by several countries between 1930
and 1970 as a potential biological warfare agent. It is thought to
have been genetically altered to an even more deadly form by the
Soviets in 1986, which would make it the first such agent to be so
modified. The bacterium can be concentrated into a paste, which
can be freeze-dried and then milled into a fine powder suitable
for distribution through the air.
HEMORRHAGIC FE VER VIRUSES
Hemorrhagic fever viruses (HFVs) are, if not the most deadly of

human pathogenic microbes, certainly the most dramatic. The
CDC has designated nine HFVs as potential bioterrorism agents
(Table 3.1). We focus here on only two of these, the Ebola and
Marburg viruses. Both of these viruses are fairly recent additions
to the repertoire of human pathogens, and not much is known
about their interaction with their human hosts. There have only
been a dozen or so outbreaks of these viruses since their discover-
ies in 1967 (Marburg) and 1976 (Ebola).
We do not know what animals serve as reservoirs for these
viruses; bats are one likely candidate. Several nonhuman
Ta bl e 3.1 CDC Classification of Potential Bioterror Agents

Category Agent Disease
A B. anthracis Anthrax
V. major Smallpox
Y. pestis Plague
F. tularensis Tularemia
C. botulinum (neurotoxin) Botulism
Ebola, Marburg viruses1 Hemorrhagic fever
B Brucella sp. Brucellosis

E. coli O157:H7 Food poisoning
B. mallei Glanders
B. pseudomallei Meliodosis
C. perfringens ε−toxin
C. psittaci Psittacosis
C. burnetii Q fever
R. communis Ricin poisoning
Staphylococcus sp. enterotoxin B Food poisoning
R. prowazekii Typhus
Alphaviruses (various) Viral encephalitis
V. cholera Cholera
C Nipah virus
Hantavirus
MDR 2 M. tuberculosis Drug-resistant TB
Yellow fever virus Yellow fever
Avian influenza virus H5N1 Pandemic influenza
1
Other hemorrhagic fever viruses in Category A include Lassa fever virus; four
New World arenaviruses; Rift Valley Fever virus; Omsk hemorrhagic virus;
Kyasanur Disease virus.
2
MDR = multi-drug resistant.
primates, such as rhesus monkeys and macaques, are fully sus-

ceptible to Marburg and Ebola infection and would be unlikely
reservoirs—their mortality rate is close to 100 percent. Once one
person has been infected, transmission to others occurs through
contact with fluids or tissues from previously infected individu-
als. Although the disease is contagious, infected individuals are
usually quickly isolated and do not live long, so widespread epi-

demics are rare.
Ebola and Marburg viruses would certainly fulfill the CDC
requirement that an agent have the potential to cause “public
panic and social disruption.” Through books and films in the
last dozen years, as well as regular media coverage of outbreaks,
these viruses may have, along with anthrax, the highest public
profile of the Category A agents. Because of the high mortality
rate, the fear factor may be even greater than for anthrax.
As of mid-2005, 1,848 cases of HFV in humans caused by Ebola
had been reported to the WHO, with 1,287 fatalities (69.9%); 354
cases of Marburg HFV had been reported, with 288 deaths (81.3%).
Almost all of these cases arose in Africa. Many have been traced to
transmission through unclean clinical syringes, a common prob-
lem in rural Africa; the resulting mortality in these cases was 100
percent. We might hope mortality would be somewhat lower in
industrialized countries, but make no mistake: these viruses are
far and away the most lethal pathogens on the CDC’s A list.
The Soviet Union was alleged to have produced aerosolized
versions of HFVs, including Ebola and Marburg viruses, for bio-
logical warfare. These were never used, and we have no idea how
effective aerosolized HFVs would be. Aerosolized HFVs are rela-
tively stable and cause disease in nonhuman primates, and it is
presumed they would do the same in humans.
The popular depiction of humans being literally melted away
from the inside out draws on a good deal of dramatic license,
but these are undeniably ghastly diseases. Blood vessels as well as
blood cells are rapidly destroyed once the virus begins to spread
in the body, causing massive internal bleeding. But organs such
as the liver and kidneys are also severely damaged. Symptoms
of hemorrhagic fever include the usual early signs of any micro-
bial infection, but these are quickly followed by widespread body
rashes and blood spots in the skin, blood seepage from various
orifices, convulsions, delirium, and a rapid descent into shock and
coma. There are no anti-viral drugs effective against Marburg
and Ebola. Both viruses severely dysregulate the human immune
system, leaving most victims with no innate resistance. For the
few people who survive, there is a long period of impairment of
numerous body functions.
Attempts to produce an effective vaccine against Ebola and

Marburg had been generally unsuccessful until 2005, when
a research group centered in Canada developed a DNA-based
vaccine that is very potent against both Ebola and Marburg. Just
one injection protected monkeys from infection by either virus.
It is possible that with further work this vaccine could also be
made effective for other A-list HFVs. More work needs to be done
before human trials can begin, but this vaccine looks extremely
promising.
SELEC T IONS FROM T HE CDC

B AND C LISTS
R i c i n To x i n
Ricin toxin (usually just called ricin) is a protein extracted
from castor beans harvested from the plant Ricinus communis
and pressed to obtain castor oil. In purified form, ricin can be
extremely poisonous; a dozen or so beans contain enough toxin
to kill an adult human. It works by blocking protein synthesis
inside cells, causing them (and eventually the tissues and organs
they make up) to fail. It can be prepared as a dry powder or as an
aqueous liquid. If inhaled as a powder, symptoms set in within a
few hours, including chest pain, difficulty in breathing, coughing,
and nausea. The lungs gradually fill with water, blood pressure
drops, and at high enough dose the victim dies of a combination
of shock and respiratory failure. Swallowing ricin results in vom-
iting and diarrhea, leading to rapid dehydration. Hallucinations,
seizures, and other neurological problems may occur. With a suf-
ficiently large dose, liver and kidney function may cease, leading
to death.
Part of the attraction of ricin as a bioterror agent is that there
is no diagnostic test for it, once ingested, and no antidote. Most
countries developing bioweapons experimented with ricin, but
no weapons appear to have been manufactured or used. Ricin
was used in the assassination of a dissident Bulgarian writer,
Georgi Markov, in London in 1978 (Box 3.2).
BOX 3.2
A Bioterrorist Assassination
Georgi Markov was a Bulgarian writer and dissident who fled

Sofia for England in 1969. Working for Radio Free Europe and
the BBC, he wrote stinging articles about the Bulgarian regime.
With KGB help, it was decided to assassinate him. At a bus stop
near Waterloo Bridge in London, in September 1978, an agent
stabbed him with an umbrella tip which was actually a gas-driven
gun. Markov died three days later. At autopsy, a 1.5-mm pellet was
found, but its significance was not clear. A similar pellet found in
another assassination attempt in a Paris Metro (the victim lived)
proved to contain highly pure ricin. An examination of Bulgarian
records after 1990 and other evidence suggested a Dane of Italian
origin was the likely assassin. He was never formally charged with
the crime for lack of evidence. The statute of limitations will run
out in 2008, at which time we may learn more.
Sta p h y l o c o c cu s E n t e r o t ox i n B
Enterotoxin B is a protein toxin secreted by various strains of the
common food bacterium Staphylococcus aureus. It works by hyper-
activating the immune system, triggering excessive release of
numerous chemicals which in moderate doses help regulate the
immune system’s response to many microbes but which, in great
excess and duration of action, can cause severe damage.
Enterotoxin B is a classic and potent agent of food poison-
ing, causing intense intestinal cramps, nausea, vomiting, and
diarrhea within a few hours of ingesting staphylococcus-tainted
food. In amounts normally associated with this mode of intake,
the symptoms are self-limiting and disappear within twenty-four
hours.
Enterotoxin B has been studied as a potential bioweapon
because in its highly purified form it can be made into a stable,
easily aerosolized powder which, when inhaled, can lead to pro-
found incapacitation through acceleration and intensification of
the symptoms described above. With concentrated intake of pure
enterotoxin, the symptoms are no longer self-limiting, the loss of
fluids can become crippling, and the result may be toxic shock
syndrome and death. There is no vaccine to enterotoxin B, and
no antidote, since under normal conditions of food poisoning
there is no danger to health.
Q Fe v e r
Q fever is caused by a rickettsia-like bacterium, Coxiella burnetii.
It is found in many domesticated animals but does not cause
disease. They thus serve as a reservoir for this bacterium, which
can cause disease in humans. Natural infections in humans
occur mostly in people working around farmyards or slaugh-
terhouses, where waste products from infected animals become
ground down, dried, and eventually airborne. The bacteria are
very stable and can be inhaled by animals or humans. Passage of
C. burnetii between humans is very rare, and Q fever is thus not
considered contagious.
Natural infections with C. burnetii can be acute or chronic. Acute
infections are characterized by high fever, lethargy, vomiting, diar-
rhea, and weight loss and can last several weeks. If not treated
promptly, acute Q fever may also progress to crippling headaches,
liver problems, and speech and hearing difficulties. Most cases
respond well to antibiotic treatment, and mortality is rare.
Chronic Q fever may have the above symptoms in varying
degrees for six months to many years, and patients with this form
of the disease usually develop heart problems as well. Chronic
infections are very difficult to treat, and mortality can approach
60 percent. Because of the ability of C. burnetii to become air-
borne and its general hardiness, it has been considered a good
candidate for use in bioterrorism. Aum Shinrikyo is known to
have been interested in this pathogen, although there is no evi-
dence they succeeded in making useful preparations of it.
H a n tav i r u s e s
Hantaviruses are an example of an agent that has never been
used as a bioweapon, for terrorist purposes or otherwise, but
which the CDC is definitely keeping an eye on for one simple
reason. In our limited experience so far with this virus, the death
rate appears to be between 30 and 40 percent. In 2005, for exam-

ple, there were only thirty-four confirmed cases in the United
States, but ten of these resulted in death. The natural reservoir
for hantaviruses is various rodents, such as field mice.
Initial symptoms are hard to distinguish from other microbial
infections, but within a few days dry cough, diarrhea, and dizzi-
ness, together with a drop in blood pressure and a racing pulse,
suggest something out of the ordinary. Detailed examination
of the blood and a complete cardiopulmonary workup provide
additional indications of hantavirus.
Wh at a bo u t HI V ?
The question is often asked: “Why wouldn’t bioterrorists use
HIV as a weapon? Why isn’t it on the A list?” Unquestionably, the
release of HIV over a large metropolitan area could generate a
maximum fear effect. And as we know all too well, all but a tiny
handful of us are defenseless against HIV, with no vaccine on
the immediate horizon. So the fear factor probably extends to
would-be terrorists themselves, both domestic and foreign. They
may be extremely reluctant even to get into the same room with
HIV. Another factor is that the incubation period with HIV, before
frank (full-blown) AIDS sets in, is six to ten years. Suspiciously
large numbers of new cases would likely not be apparent for sev-
eral years at a minimum. The immediate public relations sensa-
tion so craved by terrorists would be lost.
Still, the overall psychological impact on affected populations
could be enormous. In the end, the main thing preventing use
of HIV is that this is an exceptionally fragile virus. Exposure to
anything other than a warm, wet human body disables it within
a matter of hours. Aerosolization would almost certainly cripple
it. Laboratories working with HIV must take enormous care to
keep their strains viable. It is, in fact, a poor candidate for even
the CDC’s C list.
chapter 4
Genetically Modified
Pathogens
It has been said more than once that military forces

are usually trained to fight the last war. Most of the pathogens
on the CDC lists are in that mode—pathogens we already know
from having explored their use, and defenses against them, in
previous times. All of them exist in nature, and have changed
very little since humans began studying them. The threat of bio-
terrorism based on these pathogens has stirred intense research
into the development of new vaccines and drugs to defend against
them, and we have made remarkable progress.
In fact, it is likely that within not too many years, we will have
effectively neutralized most if not all of the CDC agents as poten-
tial bioterror weapons. But we should not assume that these are
the only biological weapons that might be used against us. For
some time now, scientists have been asking what the next gen-
eration of bioweapons might look like and how we can prepare
ourselves to defend against them.
Do we really have to worry about a “next generation” of biologi-
cal weapons? After all, didn’t the Biological Weapons Convention
of 1972 effectively shut down research into offensive biological
weapons? Maybe. We think our own government has stopped
such research, and we hope that others have done the same.
But we don’t really know. And how do we define research into
biological weapons, particularly if we’re trying to think outside

the box of today’s arsenal?
Concern about new bioweapons systems arises from advances
in technology, in a field known as molecular biology, that permit
genetic modification of existing pathogens, or even creation of
new pathogens from scratch. Genetically modified pathogens could
be made resistant to existing antibiotics or vaccines. They could
be made more stable, or more easily weaponized. They could be
equipped with new toxins or other molecules that make them
even more deadly. Extension of these same technologies could
even be used to recreate ancient pathogens that no longer exist
in nature, or to create new ones never before seen.
All of these technologies depend to a large extent on the revo-
lution in molecular biology known as recombinant DNA. This
refers to the ability to cut a piece of DNA out of one source and
splice it into DNA from a different source—or more to the point,
to take a gene from one living thing and put it into another.
The recombinant DNA revolution began in 1973 when scien-
tists cut out a gene from toad DNA and inserted it into the DNA
from a benign form of E. coli bacteria that lives in the human gut.
The bacteria promptly began making the corresponding toad
protein. Such a thing had never been done before. It was clear
to anyone who cared to think about it that biology was going
to change, big time. Other scientists began recombining DNA
taken from a virus called SV-40, which causes cancer in monkeys.
The resulting recombinant genomes1 were, in effect, totally new
life forms—never before seen among organisms that had evolved
naturally over eons of time.
The problem was that E. coli lives, among other places, in the
human gut. And SV40 can infect humans. How would these new
life forms behave? How would we interact with them, and they
with us? There was no evidence that such experiments were in
fact dangerous, but the suggestion was made that scientists might
want to suspend further experimentation until everyone could
get together for a talk.
A meeting to discuss the implications and possible risks of
recombining the DNA of living organisms took place at the
Asilomar Conference Center near Monterey, California, in 1974.
All of the major laboratories working with recombinant DNA
G E N E T I C A L LY M O D I F I E D PAT H O G E N S • 59
were invited, along with representatives of the federal agencies

funding such research. To forestall possible charges of a scien-
tific elite meeting behind closed doors to decide the biological
fate of humanity, the press was invited to attend as well. Many
issues, some highly emotional as well as scientific, were aired in
the formal sessions, but to an even larger extent over meals, in
the common rooms where people gathered in the evenings, and
in strolls along the spectacular adjoining beaches. Would the
creation of recombinant genomes interfere with normal evolu-
tionary processes? Do human beings have the right to reach into
nature and create new life forms?
But a few, even at the time of the Asilomar Conference, looked
ahead to an even less comforting possibility—that someday,
someone could decide to use recombinant DNA technology to
modify human pathogens in ways that would make them more of
a threat than they already were. And indeed, such genetic altera-
tions were not long in coming. There is compelling evidence that
the Soviet Union pursued this line of research quite extensively
in the 1980s and maybe even into the 1990s. We learned a great
deal about their various bioweapons programs from Soviet defec-
tors who had worked on them.2 These were for the most part well-
educated, smart, technically competent scientists who have since
contributed a good deal to our own biodefense programs.
Their activities, organized under a government apparatus
known as Biopreparat, are thought to have involved dozens of
laboratories, with hundreds if not thousands of scientists and
technicians. At one time or another, they produced genetically
enhanced versions of most of the pathogens on the CDC’s A and
B lists. F. tularensis, perhaps the least dreaded of the A-list patho-
gens, was one of the first to be engineered, in 1983. They had at
least one strain of anthrax resistant to the antibiotic Cipro. They
claimed to have created a strain of Y. pestis resistant to ten differ-
ent antibiotics. In addition to antibiotic and vaccine resistance,
they also allegedly produced germs capable of crippling a per-
son’s immune system or turning the immune system against the
nervous system (Box 4.1). Most of these worked well in animals
but as far as we know were never tested against humans.3 Plans
were even floated to create viruses that carried not disease, but a
whopping dose of Prozac!
BOX 4.1
Partial List of Genes Used To Modify Pathogens
Genes to induce disease

Encephalitis genes
Myelin basic protein gene
Ebola vp24 gene
Marburg NP gene
Genes to produce physiological alterations

β-Endorphin gene
Angiogenin gene
Insulin gene
Thymosin gene
Genes to perturb immune system

Interferon genes (α, β, γ)
TNF α, β genes
IL-2 gene
It would take a relatively short time to produce new variants

of CDC A-list pathogens in first-rate molecular biology labs like
those the Soviets had. But if such a new germ were used in a bio-
terrorist attack, it could take a good deal longer for responding
authorities to figure out, first of all, that such a change had in
fact been made, and then to devise and test a strategy to neutral-
ize it.
SYNTHE TIC BIOLOGY
Our concerns about possible threats posed by these new tech-

nologies have taken a surprising new turn with the emergence,
through the coalescing of various DNA manipulation techniques,
of the new field of synthetic biology. Classical recombinant DNA
experiments focus largely on the insertion of discrete pieces of

DNA, usually a gene or a portion of a gene, from one organism
into the genome of another. In synthetic biology, entire portions
of the genome of one organism are recombined with varying
portions of another to create new hybrids or, most impressive of
all, to create an entire organismal genome from scratch, starting
with the basic building blocks of DNA called nucleotides. Let’s
look at three examples of what can be done using these newer
techniques.
Poliovirus
Polio (poliomyelitis) is a paralytic disease caused by a virus—called
simply poliovirus—that attacks and destroys nerve cells in the spi-
nal cord. The disease no longer occurs naturally in the United
States. Through the early 1950s, it was common to see about 20,000
cases annually, but the development of polio vaccines in the mid-
1950s reduced that dramatically. The last natural case of polio in
the United States occurred in 1979. Since 1980, the only cases to
appear have been picked up in other countries, or resulted from
the oral polio vaccine, which was discontinued in 2000. The WHO
declared Europe polio-free in 2006. Poliovirus, like the smallpox
virus, exists only in humans, with no animal reservoir, so the stated
WHO goal of complete global eradication of the poliovirus in the
coming decade, through an intense immunization campaign,
seems realistic.
But now we’re not so sure.
Poliovirus is a picornavirus: it has a tiny (pico) RNA (rna)
genome. Only 7,741 nucleotides are required to make its entire
genome; the smallpox virus, by comparison, takes more than
185,000 nucleotides. In 2002, scientists at the State University of
New York at Stony Brook reported making a complete, infectious,
pathogenic poliovirus, essentially in a test tube, from its chemical
building blocks—nucleotides—which are not on anyone’s select
list.
The precise RNA nucleotide sequence had long been known—
poliovirus was one of the most intensely studied of human
viruses. Using the published sequence of the virus, the research-
ers enlisted a private company, via the Internet, to manufacture
individual small segments of the poliovirus genome, and then

stitched these together to get a complete viral genome. When
this synthetic genome was placed into human cells in culture, it
directed the production of intact poliovirus, which was shed into
the culture dishes. When these “frankenviruses” were injected
into mice, they caused paralysis and death indistinguishable from
naturally occurring poliomyelitis. This was the first time that a
virus capable of infecting living cells was created from chemical
materials entirely in a laboratory. But it wouldn’t be the last.
M X174
In 2003, a group of scientists at a research institute in Maryland
carried out a similar set of experiments with a virus that infects
not animals but bacteria. Such viruses are called bacteriophage
(ϕ). The one generated by this group, called ϕX174, is even tinier
than poliovirus (5,386 nucleotides). It has been used in numer-
ous famous experiments over the years; it was the first genome
to be duplicated from another genome copy entirely in a test
tube (1967), and the first genome to be sequenced in its entirety
(1978). The basic strategy used to make the ϕX174 genome from
scratch was similar to the poliovirus work, but the efficiency was
ten times greater. The team is moving forward to synthesize a
complete bacterial genome—a chromosome—some 300,000
nucleotides in size. If they accomplish this, and can succeed in
getting their artificial chromosome into a cell, they will have a
chance to be the first to actually create life itself, beginning with
raw chemicals, in a laboratory.4
Influenz a A Virus
The flu virus is well known to just about everyone. Like polio-
virus, the flu virus is a small RNA virus, with only eight genes
(versus our 30,000 or so). For the most part, it causes annoying
but, for reasonably healthy people, nonthreatening flu each year.
However, it has an ability (like the AIDS virus, HIV) to rearrange
itself from time to time, confounding our immune systems. The
immunity we build up one year may not recognize the form of
the virus that comes our way the next year. And sometimes the
flu virus can generate variants that are more than just annoying;
they can be very deadly, as with the 1918 influenza virus that
caused a worldwide flu pandemic, killing up to a hundred mil-
lion people (chapter 5).
The 1918 form of the flu virus has not been seen since the
pandemic it triggered subsided, and is presumed to no longer
exist in nature. But its tiny RNA genome, recovered from pre-
served autopsy materials and from a corpse buried since 1918 in
the Alaska permafrost, has brought it back. In 2005, a group of
researchers from four different universities and institutes pub-
lished a rather startling version of the “from scratch” experiments
in the journal Science. Using the sequence for the 1918 H. influenzae
genome, they built up progressively larger subsequences and
finally stitched them together to make an intact viral genome.
When viruses produced from this genome were used to infect
human cells in culture, they grew at a rate fifty times faster than nor-
mal flu strains. When used to infect mice, the reconstructed 1918
strain not only reproduced itself at an accelerated rate but proved
to be a hundred times more lethal than normal flu strains. And
when injected into macaque monkeys, it caused a rampant disease
that began killing the monkeys in a matter of days. The remaining
animals were euthanized because of extreme suffering.
Scientists are now studying exactly what happened in these
monkeys, in an attempt to understand the sequence of events
in humans attacked by this and similar viruses. It appears that
the incredible damage wrought by this virus came about in part
because it triggered a huge overreaction by the host immune
system, and may be yet another expression of what is known as
immunopathology, where the damage done during an infection is
caused as much by the immune system that is supposed to defend
us as by the invading microorganism.5
One major concern associated with synthetic biology is that
much of the synthesizing of DNA or RNA sequences used in
the creation of functional genomes is now done by commercial
companies. Originally a time-consuming laboratory procedure
requiring constant oversight by experienced scientists, much
of this work is now carried out very rapidly by fully automated
machines. These machines are available in many major universi-
ties as well as in private biotechnology firms. In principle, anyone
with enough money has access to the latter, and the former are,
at least at present, under rather loose control.
In the summer of 2004, several hundred scientists carrying
out research in synthetic biology gathered at MIT for the First
International Conference on Synthetic Biology. This is a de facto
way of recognizing the existence of a discrete line of scientific
inquiry as a new scientific field. The meeting was called to pro-
mote interactions among researchers in the new field. Program
topics ranged over a wide spectrum of cutting-edge technical
and conceptual advances.
The possible abuse, by terrorists or other biological “hackers,” of
the tools used by synthetic biologists was not itself a programmed
topic of discussion, but it worked its way into several formal pre-
sentations and many sidebar discussions throughout the meeting.
The clear requirements in the 2002 Bioterrorism Act for close
regulation of certain pathogens and for licensing of users and sup-
pliers of select agents were well known to most of the attendees.
There was considerable informal discussion about the extent to
which aspects of synthetic biology relating to the synthesis or re-
engineering of potential pathogens could or should be regulated.
A second, less formal gathering of synthetic biologists took
place the following summer in Berkeley, California, but this time
discussions of legal and ethical issues generated by the new field
made their way onto the formal program. Ghosts of Asilomar
Past must have wafted throughout the symposium. Speakers
sometimes felt it necessary to phrase their remarks in terms of
the “realpolitik” of post-9/11 America.
The Second International Conference on Synthetic Biology was
held at UC Berkeley in May 2006. Again the main focus was on
technical and scientific exchanges, but this time the legal and tech-
nical aspects of the field were recognized in a session that was also
a formal part of the program. Outside the lecture halls, intense
informal discussions about regulatory issues, particularly among
senior scientists, were a hallmark of the meeting. After the confer-
ence was over, the organizers prepared a “white paper” on security
and legal issues, with recommendations for how the field should
proceed.6 Some of the proposals are shown in Box 4.2. This paper
was published on the Web for comment by the larger scientific and
general public, after which a formal position paper will be issued.
BOX 4.2
Proposals for Increasing the Safety of
Synthetic Biology Research
1. Improve the ability of current software used by companies

that generate DNA segments to spot sequences related to
known “select agent” pathogens.
2. Require all commercial DNA companies to scrutinize
each order for DNA with respect to source of the order,
credentials of the orderer, etc. Researchers should boycott
companies that do not undertake such scrutiny.
3. Create interdisciplinary groups to address challenges
arising from advances in synthetic biology, especially legal
and security issues.
4. Support ongoing dialogues with all stakeholders to develop
and analyze how best to regulate synthetic biology research
without crippling it.
Environmental groups are already arming themselves to

oppose synthetic biology entirely, or at least to have it regulated
extremely tightly.7 At the UC Berkeley Conference, a letter signed
by thirty-five environmental groups, trade unions, and bioethi-
cists implored the attendees to work for strict national and inter-
national controls on their research. Aside from concerns they
may share about bioterrorism, they are worried about the effects
that genetically altered microbes might have should they escape
or be accidentally released back into nature. So are many scien-
tists. The Third International Conference is slated for 2007, in
Zurich. It is likely that in the future, environmental groups will
be invited to sit at the table.
COUNTERMEASURES
By the late 1990s, both the CIA and the Pentagon were becoming
seriously concerned that the United States could be vulnerable
to the types of bioweapons the Soviet Union was known to have
been working on after the 1972 Biological Weapons Convention

finally went into effect in 1975, including genetically modified
pathogens. In the late 1990s, the CIA created a special project
called Clear Vision to review everything that was known about
Soviet ventures into modified pathogens and their delivery sys-
tems. Clear Vision would also gather and evaluate all intelligence
leads about work on genetically modified pathogens in other
countries considered potentially hostile to the United States.
Some scientists working in Clear Vision tried their hand at
designing virtual (computer-generated) pathogens, to get a
sense of what kinds of genes might be moved into and out of a
pathogen to make it more deadly, or resistant to vaccines and
drugs. The Soviets, they believed, had spliced a gene for diphthe-
ria toxin into a plague genome, creating a genuine monster of a
pathogen. They were also thought to have stitched in genes that
blocked a victim’s immune system from responding, depriving
the victim of any first-line defense and greatly speeding up the
action of the altered pathogen. Clear Vision scientists wanted to
find ways to rapidly detect, identify, and counter these mutant
killers. In order to do so, they wanted to build live models of
them in the laboratory.
Many officials and even some scientists outside the project
began to worry that engaging in this kind of research could move
the United States itself perilously close to violation of the 1975
Convention, which forbids signatory states to “develop, produce,
stockpile, or otherwise acquire or retain microbial or biological
agents, or toxins, that have no justification for prophylactic, pro-
tective or other peaceful purposes.” By 2001 the program had
ground to a halt over such concerns.
But the biodefense concerns embodied in Clear Vision
were carried forward in new form when the Department of
Homeland Security created the National Biodefense Analysis
and Countermeasures Center (NBACC), located at Fort Detrick,
Maryland, in 2005. The NBACC is composed of two parts. The
National Bioforensic Analysis Center will act as the lead govern-
ment agency in analyzing materials recovered from any bioter-
rorism attack site. For the most part, this would consist of rapid
analysis of the DNA of recovered pathogens or chemical analysis
of any toxin, either of which could determine whether the material
had been altered and provide “fingerprints” pointing to possible

origins of the materials.
The Biological Threat Characterization Center will carry for-
ward much of the work of Clear Vision. In what is being called
“science-based risk assessment,” scientists at the NBACC will have
as a principal goal anticipating the development of previously
unknown bioweapons and devising methods to counter them.
They will conduct analysis of the current scientific literature in
the area of genetic engineering, as well as intelligence reports
about scientific centers in countries estimated to have the poten-
tial (and the political will) to engage in the production of new
bioweapons.
The NBACC will also be looking at technologies to rapidly
detect genetically altered pathogens, faster ways of developing
drugs and vaccines that might be used against them, and more
effective pathogen decontamination procedures for dealing with
the aftermath of an attack with such pathogens.
Although assurances have been provided that safeguards are
in place to be certain that NBACC researchers do not violate
the 1975 Convention, some scientists and government officials
remain concerned. In the course of carrying out their mission,
will NBACC scientists engage in the production of genetically
modified pathogens themselves, in order to study them and find
ways to defeat them? What about the accidental escape of these
agents from the labs creating them? We know that accidental
contaminations with the SARS virus caused several cases of this
disease in Asia, and it is now clear that the 2007 outbreak of foot
and mouth disease in Britain in 2007 was due to escape of that
virus from a nearby research facility.
And could such pathogens ultimately find their way into the
hands of disgruntled American scientists, as was likely the case
with the anthrax spores used in Amerithrax? (Which, by the way,
if true suggests that the United States is in fact engaged in their
production, a violation of the 1972 Biological Weapons Control
Act!) It has been argued that the very existence of such facilities
further increases the likelihood of escape of potentially lethal
agents into the environment.8
Other scientists think that the number of possible permuta-
tions of genetic modifications that could be made to the large
number of pathogens already in existence, plus the creation of

new ones, is essentially unlimited, and it will never be possible to
anticipate all of them. But for now, at least, it seems the NBACC
is going to try.
What does all this mean for the ability of America to defend
itself against bioterrorism in the twenty-first century and beyond?
Will it be possible for terrorists to order up the components of
the 1918 flu virus, assemble it, and unleash it on entire cities?
Are we going to be facing viruses that escape immune detection
in individuals previously vaccinated against the native form of
the virus? What about inserting cassettes of genes conferring
resistance to multiple antibiotics into the genomes of plague or
anthrax bacteria? These are technologies that already exist, right
here, right now.
A lot depends upon what federal regulatory agencies, and the
scientists who use these technologies, do to make certain they
do not fall into the wrong hands. A great many responsible sci-
entists are concerned. Even private companies who make a lot of
money generating the tiny RNA or DNA segments used to cre-
ate viruses in the laboratory are eager to develop some sort of
oversight mechanism, to ensure their services are not co-opted
by would-be terrorists.
Some also would like to see controls placed on publication
of data that could be used by terrorists. This may not be pos-
sible. The very kinds of technological advances that are cause
for biosecurity concerns will underlie some of the most impor-
tant medical advances we have ever known, and progress in this
field depends on the free flow of information among scientists
around the world through scientific and medical journals as well
as internet databases. It is unthinkable to impede this exchange
of information. These journals and databases are, however, open
to the entire world, including scientists who may wish to harm
the United States or its allies.
But even given the free availability of information about how
to manipulate the DNA of potentially deadly pathogens for the
wrong reasons, how likely is it that terrorists who would like to do
us harm can actually use these technologies to create new super-
weapons to use against us? It is probably not as likely as Senator
Frist once told the world:
A few technicians of middling skill using a few thousand dollars

worth of readily available equipment in a small and apparently
innocuous setting [could] mount a first-order biological attack. It
is even possible to synthesize virulent pathogens from scratch, or to engi-
neer and manufacture prions. . . . 9 (Emphasis added.)
We’ll return to this point in chapter 10.

chapter 5
The Ultimate Bioterrorist:

Mother Nature!
The agents of bioterrorism we discussed in chapter 3

have a common feature that distinguishes them from other agents
of terror, such as explosives, chemicals, and nuclear devices: they
are themselves not the product of human invention. They arose
in nature. Most of them, at one time or another, have given rise
to events—often repeatedly, throughout history—that closely
resemble what we imagine a bioterrorist attack would be like.
These events occurred without human causation, as a result of
the constant attempts of various microbes to invade the human
body and use it as a place to rear their young.
In fact, the greatest threat we face from biological agents of
death today is not from humans—it is from nature itself. A bio-
terrorist attack that could kill hundreds, possibly thousands, of
Americans is a possibility, but, as we will discuss in chapter 9, one
with low probability. A pandemic caused by a naturally occurring
biological pathogen that could kill tens of thousands, possibly
millions of Americans is an absolute certainty. Natural pandem-
ics1 are a regularly occurring phenomenon throughout history.
Historically, the most problematic pathogens for humans
have been Yersinia pestis (plague) and the smallpox and influenza
viruses. Our understanding of the natural ecology of Y. pestis in
human and animal hosts makes it pretty unlikely we will ever
100
Deaths, thousands
50
25
1980
1990
Figure 5.1 Deaths from seasonal flu in the United States by year.
again face a natural plague pandemic. The smallpox virus no

longer exists in nature. But we remain, after decades of study,
terribly vulnerable to killer flu pandemics. Even seasonal flu still
kills on average between 35,000 and 40,000 people in the United
States each year (Figure 5.12). Three flu pandemics in the twenti-
eth century—one major and two minor—claimed well over half a
million lives in the United States alone, and almost certainly over
100,000,000 worldwide.
The uncertainty about exactly when a lethal flu pandemic could
strike and the resulting social and economic disruption, in addi-
tion to the large numbers of deaths and illnesses even a moderate
pandemic would cause, are in every way comparable to the uncer-
tainty and consequences of a successful bioterrorist attack. Yet a
reasonable wager would be that nine out of ten Americans fear
the latter much more than the former. Why that might be will be a
thread running through much of the rest of this book.
Our societal responses to a bioterrorist attack with the patho-
gens on the CDC lists are for all practical purposes the same as
our responses would be should any of these agents, or any other
pathogenic microbes, known or unknown to us now, make their
way into the human population and create a natural epidemic
or pandemic. The major difference between how such an event
T H E U LT I M AT E B I O T E R R O R I S T: M O T H E R N AT U R E! • 73
would affect us today and the situation even a hundred years ago
is the presence in many countries of strong public health systems.
These same public health systems will also provide our major
defense against the results of a bioterrorist attack.
To give some impression of what a natural pandemic might
look like, let’s take a look at several situations of relatively recent
history: the three influenza pandemics of the twentieth century,
the SARS pandemic of 2003, and the still uncertain health crisis
that could be caused by the H5N1 variant of the avian flu virus.
T H E 1918 I N F L U E N Z A P A N D E M I C
We don’t know exactly where the strain of influenza virus caus-

ing this pandemic arose. Most likely it was somewhere in Asia,
probably China. It may have emerged as early as January of that
year, or even earlier. Influenza outbreaks came in several waves
during 1918. The first washed ashore in February in Spain, thus
giving rise to the popular term “Spanish flu.” This flu proved
to be highly contagious, but the resulting disease was relatively
mild. The one that would kill so many people didn’t arrive until
September.
Although the 1918 pandemic coincided with the latter months
of World War I, emergence of the virus was not caused by the
war itself in the sense that it was developed or used as a weapon.
Certainly crowded, dirty trenches and a general lack of hygiene
everywhere—especially military camps—hastened the spread
of natural outbreaks in areas where the war still raged. Half of
American fighting men in this war died of the flu—not from
artillery shells, bullets, or poison gas. Mysteriously, the pandemic
ended very shortly after the war.
When it was over, barely a year after it began, close to a third
of the world’s population may have been infected. We don’t really
know how many people died worldwide. Estimates have ranged
from twenty-five million to fi fty or even a hundred million—pos-
sibly as much as several percent or more of the world’s popula-
tion at that time. Precise medical record keeping was still less
than perfect in the United States and Europe, and practically
nonexistent in many parts of the world. An estimated twenty
million people in the United States were infected, and between

six and seven hundred thousand people perished—slightly more
than have died after twenty-five years of AIDS, and more than
have died in all U.S. wars through Vietnam.
All evidence suggests that two or three pandemic-level flu
events per century is the historical norm. The death rate in even
the more serious seasonal flu outbreaks—the kind we see almost
every year—is around a tenth of one percent of those infected; the
death rate during the 1918 pandemic was twenty-five times that.
Virulence at this level was not recorded before 1918 (although
it may well have occurred) and has not been seen since. One of
the striking features of this influenza outbreak is that so many
of its victims were between twenty and forty years of age, in the
prime of life (Figure 5.2); the flu is normally most deadly for the
.
C
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75
Age in years
Figure 5.2 Proportional distributions by age. (A) Rate of infections in

the 1918 pandemic; the disease struck across all age groups, although the
young were particularly susceptible. (B) Rate of deaths in the 1918 pandemic;
surprisingly, the death rate in individuals 1–40 years of age was extremely
high, by comparison with (C), the rate of deaths seen in a standard outbreak of
influenza. (Based on data presented in Jeffery K. Taubenberger and David M.
Morens, “1918 Influenza: The Mother of All Pandemics,” Emerging Infectious
Diseases 12(2006):15–22.)
very young and the very old. The 1918 flu was also active during
the spring and summer, whereas flu is usually a problem only in
winter months.
The disease symptoms were like those of the flu generally—
fever, achiness in joints and muscles, dizziness and weakness—
but they were unusually harsh. Most people in fact recovered,
but for too many others, death could come within just a few days
of the onset of symptoms. Hemorrhaging in the lungs was com-
mon, causing victims to spit up quantities of blood-laced froth.
As breathing became more difficult, many patients turned blue
from lack of oxygen. Pneumonia could set in after a few days,
was essentially untreatable, and was the most common cause of
death.
All influenza viruses that have been involved in human epi-
demics or pandemics are of the influenza A viral group (Box 5.1).
Influenza B and C viruses cause relatively mild cold- or flu-like
symptoms in humans. Influenza A viruses are thought to have
originated in aquatic fowl, and find a natural reservoir in many
BOX 5.1
Influenza Viruses
There are three major groups of influenza virus:
Influenza C: not uncommon, but rarely causes serious disease in

humans.
Influenza B: less common, but can cause disease in humans,
especially in children or the elderly.
Influenza A: The most common flu virus. Can cause disease
ranging from sniffles to major human pandemics. Also infects
birds, pigs, and horses.
Each influenza A viruses displays two surface molecules
recognized by the immune system: H and N. There are 16
different possible H molecules, and 9 different N molecules.
Viruses combining H1, H2 and H3 with N1 or N2 are
responsible for most of the flu in humans, although cases
based on H9N2 are known.
types of birds, where they live in the gut, causing little or no

damage.
Like HIV, flu viruses use RNA rather than DNA to build their
genetic blueprint. Unlike DNA viruses, RNA viruses do not “proof-
read” their blueprint when it is copied from one generation to
the next, resulting in a very high mutation rate—a characteristic
of both HIV and flu viruses. That is what has made it difficult to
develop effective vaccines for both of these pathogens.
Current strains of avian flu viruses have come into balance
with their bird hosts. They do not kill them, and can enjoy a long
and productive lifetime within their hosts. Thus, most mutations
of their genetic blueprint are harmful, disrupting the balance
between virus and host, and are selected against. Nonetheless,
occasional mutations do arise in avian flu viruses that result in
highly pathogenic forms that result in destruction of large num-
bers of birds before the viral mutants eventually disappear.
Influenza A also infects pigs as well as humans. Humans are
not ordinarily infected directly by A-type viruses that pass back
and forth among birds, but occasional mutants arising in birds
or in pigs can produce a variant that is able to infect human cells.
In both cases, the virus settles into the lungs, where, being com-
pletely foreign, it is vigorously attacked by the immune system.
The rapid mutation rate of RNA viruses is now an advantage, as
it changes rapidly in a thousand different directions, trying to
escape immune destruction and live at peace with its new host.
Within the A group, viruses can be further classified based
on two types of molecules they all display on their surface: the
H (hemagglutinin) molecule, and the N (neuraminidase) mol-
ecule. These are viral proteins involved in the initial infection
of target cells (H) and the escape of newly formed viruses from
infected cells (N). The H proteins interact with receptors on host
cells and promote entry of the viruses into them. That is one rea-
son true avian viruses rarely cross into humans: they are selected
to recognize bird cells, not human cells.
Influenza A viruses have sixteen possible different H molecules
they can display, and nine different N molecules. Each strain of
influenza A is named based on the combination of these two mol-
ecules that it uses: H1N1, H5N1, H7N7, etc. H1, H2, and H3 are
most commonly found in viruses that infect humans, usually in
combination with N1 and N2. Analysis of the recovered samples

of the 1918 virus discussed in the last chapter showed it was of
the H1N1 strain, and it is thought to have migrated directly from
birds to humans.
But at the time of the 1918 pandemic, scientists hadn’t even
identified viruses as pathogenic agents distinct from bacteria—
that would not happen until the 1930s.3 The lungs of many who
succumbed to the 1918 flu were full of bacteria, so it was assumed
at the time this was yet another bacterial disease. We now know
that heavy viral infections, particularly of the airways, are often
accompanied by secondary bacterial infections, including the
pneumococcal infections frequently associated with the pneu-
monia seen in late-stage flu. At any rate, since neither drugs that
could slow the internal spread of the flu virus nor antibiotics to
treat bacteria were available in 1918, it would have mattered little
to have correctly diagnosed the causative agent. And of course
there was no influenza vaccine available, or ventilators to assist
with breathing.
The lack of any effective treatment also meant that public
health measures were limited more or less to those that were
present already in medieval times. Public health as a recognized
medical discipline was still in its infancy in 1918, at least in the
mind of the public, and compliance with official public health
recommendations was irregular at best. It was understood that
the disease was spread through aerosols generated by sneezing
and coughing, and affected individuals were isolated at home
or in segregated areas of hospitals. Entire groups of people and
physical locations were often quarantined—military bases, pris-
ons, and asylums, for example.
Hospitals overflowed with victims, and the scarcity of doctors
and nurses caused by their recruitment into the war was com-
pounded by the unwillingness of many who might have helped
minister to the sick to even enter the hospitals. Medical and
nursing students with little experience were often thrust into the
fore of battles against the pandemic. Patients were confined to
their beds, usually surrounded by bedsheets strung up to limit
the spread of contagious aerosols. Both health care workers and
patients wore masks. Isolation and quarantining of victims led
to hostile interactions between the public and health and public
safety officers. Disposal of infected bodies became problematic—

some communities even resorted to open trench mass burials,
which again met with strong public resistance.
In the hardest-hit communities, such as Philadelphia, there
was severe social and economic disruption. In that city, 11,000
people died in the first month alone. The lack of any national
uniformity of public health standards meant that each state, city,
and county basically made up its own rules. Schools and busi-
nesses were closed in many cities, as were bars and theaters of
all sorts. Public gatherings were banned. Churches generally
remained open, but congregants were urged to sit as far apart as
possible. In some cities, even large weddings and funerals were
forbidden, and people were not permitted in government build-
ings or on public transportation without a face mask. It was a
time of enormous chaos.4
Although the story of the 1918 influenza pandemic lacks the
stridency and militaristic drama of exercises like Dark Winter
and Atlantic Storm, it certainly stands alongside them in terms
of damage done in terms of human lives lost, social collapse, and
economic disaster. But one very big difference leaps out in this
comparison: the 1918 pandemic actually happened. And tens of
millions of people died.
T H E P A N D E M I C S O F 19 57 A N D 19 6 8
After the 1918 pandemic ended, flu reverted to its usual pattern
of seasonal appearances. Most authorities think the pandemic
H1N1 strain passed from humans into pigs, where it clearly was
not as virulent. Milder versions of H1N1 must have arisen in pigs
and passed back to humans, or mutated within humans them-
selves; at any rate, relatively benign H1N1 became the dominant
FluA variant in humans for the next forty years.
Of course no flu variant or flu season is ever trivial; even today,
with both vaccines and drugs to control the virus and antibiot-
ics to manage secondary bacterial infections, tens of thousands
of people in the United States (probably a million worldwide) still
die each year from complications of seasonal flu. But the next flu
outbreak after 1918 to rise to the status of a worldwide pandemic
came in 1957, triggered by a variant of the flu virus originating

in Guizhou province in China, where it first infected humans in
1956. It was commonly referred to as the “Asian flu.”
Like most flu pandemics, including the one in 1918, this one
was triggered by a viral variant that few living at the time had
ever encountered. The prevalent H1N1 strain, probably while
in pigs, appears to have interacted with an avian flu virus from
ducks to produce an H2N2 variant. (The H and N genes and one
other viral gene were from the bird virus; the rest of the genes
were from the human virus.) This may be the first time a flu virus
variant containing N2 had entered the human population in at
least two generations, since there was no immunity to it among
humans.
This new form of the virus was able to cause pneumonia in
humans entirely on its own, without help from secondary bacte-
rial infections of the lungs, although such infections did occur.
Children were especially vulnerable to infection, and schools
became major venues for spreading the disease. Many schools
closed at least briefly, although relatively few children died. On the
other hand, this virus was particularly deadly for persons with lung
or heart disease, and took a high toll among the elderly. It was also
very dangerous for women in the third trimester of pregnancy.
It has been suggested that this virus may have infected as many
or more people as the 1918 variant, but the availability of a vac-
cine by May of that year,5 as well as antibiotics and improved pub-
lic health services, contributed greatly to a reduction in overall
mortality. Still, the toll it exacted—70,000 deaths in the United
States and 2,000,000 to 4,000,000 worldwide—was certainly
horrendous.
The H2N2 Asian flu virus largely displaced the H1N1 variant
circulating among humans after 1918 and continued to cause flu
outbreaks for several years after 1957, with a particularly serious
eruption in 1958 involving disproportionately the elderly. But as
increasing numbers of people built up immunity to it, through
immunization or natural exposure, it gradually became less of a
problem. It essentially disappeared after 1968, when it was largely
supplanted by the infamous Hong Kong flu variant.
The 1957 version of the H2N2 virus almost made it back into
the human population in 2004–05. A U.S. laboratory accidentally
included it in influenza test kits sent to other laboratories through-

out the world. Fortunately, after an alert laboratory in Canada
recognized the mistake, the kits were immediately recalled, and
no one appears to have been infected.
Eleven years after the Asian flu, a third pandemic emerged
from the Chinese mainland, becoming known as the Hong Kong
flu.6 This time the culprit was an H3N2 variant of the influenza A
virus. (The H3 and one other gene were of bird origin; the rest of
the genes were human.) It first came ashore on the West Coast in
the United States, probably with troops returning from Vietnam.
From there it spread eastward, although not all states were ulti-
mately affected except for sporadic cases. Although about 20
percent of people in affected countries became infected (an esti-
mated 50,000,000 in the United States), this was a relatively mild
pandemic, with only about 34,000 excess deaths7 in the United
States and 700,000 to 1,000,000 worldwide. But once again, the
elderly were hardest hit. Drugs that we have now to lessen the
impact of flu—amantadine, rimantadine, ostelamivir (Tamiflu),
and zanamivir (Relenza)—were not yet available. Less deadly
forms of the H3N2 Hong Kong flu virus variant evolved over the
next few years and are still the dominant form causing seasonal
flu in humans to this day.
There are a number of reasons for the relative mildness of the
Asian and Hong Kong flu pandemics. Neither variant in these
latter outbreaks appear to have induced the same kind of vio-
lent response by the immune system, with collateral damage to
normal tissues, thought to have been responsible for much of
the damage seen with the 1918 H1N1 virus. Moreover, there had
been continued improvements in flu vaccines used to control
spread of flu viruses and in the antibiotics used to treat bacterial
complications. The H3N2 variant of 1968 was immunologically
cross-reactive with the H2N2 variant from 1957, and so people
exposed to H2N2 over the intervening years may have had some
degree of immunity to the Hong Kong virus. Also, the Hong
Kong virus struck many American cities right at the December-
January school break, reducing transmission among students.
Some schools and colleges closed slightly early or delayed re-
entry until the flu had subsided to reduce spreading to the larger
population.
So the twentieth century saw early on one of the deadliest flu

pandemics in recorded history, and later gave rise to two more pan-
demics of decreasing intensity. Does this mean that flu pandemics
are on their way out as a threat to humans? Would that it were so!
We are now staring down the barrel at a new flu variant coming to
us from birds that has the potential to equal or exceed the devasta-
tion wrought by the 1918 virus. We first saw this virus—this time
an H5N1 variant—in 1997. But between that time and the pres-
ent, we went through another pandemic with a completely differ-
ent virus—SARS. Before we look more closely at H5N1 flu, let’s
take a moment to explore what happened in the SARS pandemic
of 2003–04.
T H E S A R S (SE V E R E AC U T E R E S PI R AT O R Y
S Y N D R O M E ) PA N D E M I C O F 20 03 – 0 4
The first cases of what would come to be known as SARS

were detected in China at the end of 2002. Several people in
Guangdong province showed up at clinics and hospitals with
severe flu-like symptoms. At the time, there was nothing to mark
this as the emergence of a new and deadly disease that would even-
tually affect over 8,000 people in thirty countries, killing 774 of
them. These numbers, from official World Health Organization
records, may not tell the whole story. It is likely that more peo-
ple in China were involved, and may have died, but either went
unnoticed and unrecorded or were incorrectly diagnosed. There
is evidence that SARS was present in China prior to 2002. For
example, a subsequent analysis of 938 blood samples collected in
Hong Kong in 2001 for unrelated purposes showed evidence that
17 of these individuals had been exposed to SARS.
The first few patients subsequently identified as having SARS
apparently recovered, and may not have passed the disease on to
others. But within a month or two many other such cases showed
up in China and began to worry authorities. It takes time to fig-
ure out, in a situation like this, that what one is seeing in the
clinic is not just another outbreak of a slightly nastier flu, but a
new, different, and more deadly disease. China’s public health sys-
tem, while adequate, is not yet quite on a par with most Western
countries. That fact, coupled with the penchant of Chinese

authorities for trying to keep disturbing news out of the press,8
slowed the development of awareness in the rest of the world that
a major new health threat was arising. China did not alert the
WHO until February 2003, by which time several dozen cases
had been detected. China subsequently issued a public apology
for its slowness in dealing with the SARS crisis.
Hong Kong was particularly hard hit early in the developing
pandemic, as was Singapore. SARS had minimal impact in the
United States. Only eight people were diagnosed with SARS; all
of these had recently been in countries with verified SARS out-
breaks. None died. However an American businessman traveling
in Asia in early 2003 died of SARS in a Hanoi hospital. There
was, moreover, a more serious importation of SARS into Canada,
particularly Toronto. Of 251 cases officially diagnosed, 44 died.
Nearly half of these were hospital or other medical personnel,
and some hospitals in that city had to be quarantined. A high
percentage of the 300 deaths in Hong Kong were also among
health care workers. The public health systems in both cities were
all but brought to their knees.9 Both cities also experienced seri-
ous economic disruptions and restrictions on travel.
These events, together with a better picture of what was hap-
pening in China, contributed to the sounding of a global health
alert by the WHO. Public health agencies in countries through-
out the world then issued alerts of their own, and began the seri-
ous work of preventing further spread of this new disease. The
SARS pandemic peaked in May 2003, rapidly subsiding as the
resulting containment measures took effect. The epidemic was
essentially over by mid-2004 after a brief recurrence in China.
SARS is spread either through the air by sneezing and cough-
ing aerosols or by direct contact with bodily fluids. As with many
other contagious respiratory diseases, symptoms usually appear
within two to three days of exposure to the triggering patho-
gen. The causative agent in the case of SARS is a newly emerged
variant of the coronavirus, one of many viruses that can induce
human colds. This never before seen variant, now called SARS-
CoV, was first identified in March 2003 as a possible cause of
SARS. An extraordinarily intense WHO-financed investigative
campaign in laboratories around the world quickly confirmed
this, and on April 16, a month before the pandemic peaked, the
WHO announced SARS-CoV as the official causative agent in
SARS.
SARS-CoV was found a short time later in bats and civets in
Guangdong province. It seems likely that SARS-CoV jumped to
humans either through bat bites or through eating the meat of
civets or other small mammals. Meat from civets, a carnivorous
cat-like animal common in Asia, can be found in numerous meat
shops throughout Guangdong. Whether bats or civets are a natu-
ral reservoir for SARS-CoV is unclear.
The symptoms of SARS are similar to the flu: fever, general-
ized achiness, lethargy, abdominal discomfort. There is usually a
dry cough early on, and there may be shortness of breath, both of
which would be unusual for the flu. Fever usually peaks in most
patients four days after onset of symptoms, lung abnormalities
are revealed by X-ray at day six, and oxygen sufficiency may be
critically low at day 8. This latter may be particularly crucial in
people over sixty, where fatality rates often approach 50 percent.
In children and young adults, fatalities rarely exceeded 10 per-
cent of those infected.
There was no vaccine available for this previously unknown
viral variant, and flu drugs were ineffective against it. So the only
interventions available at the time were traditional public health
measures: making people aware of the symptoms and encourag-
ing early self-reporting; identifying and isolating infected individ-
uals and their first-degree contacts; urging the public to increase
personal hygiene, and to wear face masks where appropriate;
encouraging “social distancing” (avoiding mass gatherings) and
closing schools where necessary; increasing surveillance at ports
of entry for symptomatic individuals. Travel advisories warning
people away from infected areas such as Toronto and Hong Kong
were also issued by most governments.
Some of these measures seem to have been effective in places
like Hong Kong, Singapore, and China proper. Government
authorities in these cities tend to be a bit more heavy-handed in
enforcing public health edicts, and this may have been effective
in limiting the contagion emerging from these areas. It appears
to have been less effective in Toronto. Only a few of the milder
recommendations were issued by U.S. officials. An analysis of the
effectiveness of these various measures in containing the SARS

pandemic has been published.10
SARS is a much slower moving infection within a population
than the flu, offering more opportunities for intervention. But
there is in fact no rapid, clear test that could be used in a doctor’s
office or small clinic to determine whether someone with what
appears to be a bad case of the flu may actually have SARS. As the
2002–03 pandemic progressed, the major factor in determining
whether people presenting themselves at a clinic or doctor’s office
with serious flu-like symptoms might have SARS was whether they
had recently been in contact with someone who did have SARS or
had traveled in a location where SARS was prevalent.
Laboratory testing could now conclusively identify SARS-CoV
as the causative agent, but anyone even suspected of having SARS
would likely be immediately placed in isolation, closely moni-
tored, and given intense supportive therapy as needed until test-
ing was completed. SARS cases can proceed rapidly into severe
breathing difficulties and an insufficiency of oxygen, leading to
respiratory collapse (acute respiratory distress) and a require-
ment for ventilator-assisted breathing.
As with most diseases caused by viruses, there is at present
no specific treatment to control SARS-CoV. Indomethacin and
interferon have been reported to be effective in the laboratory,
but there is as yet no supporting evidence for the efficacy of these
drugs in the clinic. There is also no vaccine presently available
that protects against SARS-CoV, although several promising vac-
cines are under development, and one is currently being tested
in human clinical trials being supervised by the U.S. National
Institutes of Health. Researchers throughout the world are work-
ing steadily to develop a defensive armamentarium should the
SARS virus ever reappear.
OUR WORST NIGHTMARE? THE

P O S S I B I L I T Y O F A N H 5 N1 F L U P A N D E M I C
As noted earlier, influenza A viruses live most of the time in the

gut of birds without sickening or killing them. But occasionally,
random mutations arise in these viruses that can trigger a severe
form of avian flu, killing large numbers of birds. In the wild, these
mutations can wreak havoc in isolated flocks, but the resulting
explosions are usually self-extinguishing given the large spacing
between flocks and their constant movement from place to place.
Once the infected birds or even whole flocks die out, the lethal
variant of the virus can disappear.
But modern methods of rearing poultry for commercial pur-
poses result in huge concentrations of birds in very constricted
spaces. Spread of mutant viruses can be extremely rapid in such
populations, and the only solution to containing an outbreak
is the immediate, compulsory destruction of every bird in the
infected compound, whether symptomatic or not. Even then,
shipment of infected live birds to other locations prior to con-
firmation of an outbreak (or even afterwards, in the interest of
limiting financial loss), as well as movement of contaminated
equipment, truckers and other workers between farms, can result
in entire regions having to destroy enormous numbers of birds.
Such was the case in Hong Kong in 1997, with the emergence
of a deadly avian flu variant of the type H5N1. This variant did
not sit benignly in the gut of birds it infected, but penetrated into
every organ and tissue of the body. This is thought to be due to
changes in the H molecule, which determines which cell types
the virus can invade. The result was rapid physiological collapse
and death. In former times such outbreaks were referred to as
“fowl plague.” Only in the 1950s were they recognized as a form
of avian flu. Since that time there have been a dozen or so out-
breaks, usually involving viruses bearing the H5 or H7 forms of
hemagglutinin.
The 1997 Hong Kong outbreak, which involved several poul-
try farms, was finally quashed after the destruction of tens of
thousands of birds, and it seemed that H5N1 would likely fade
into the sorry history of fowl plague. But in May of that year,
a three-year-old boy in Hong Kong was admitted to a hospital
with a respiratory infection that quickly progressed into pneu-
monia. But as with birds, the H5N1 that had infected him spread
far beyond the lungs. He went on to develop Reye’s syndrome,
acute respiratory distress, and kidney and liver failure. He died
a few days later. The medical staff at the hospital, stunned by the
violence of his disease, were determined to find out what had
caused it. Throat washings taken from the boy had been saved,
and were analyzed for a wide range of viruses and bacteria.
None of the tests detected anything. Samples were sent to WHO
labs in London and Rotterdam and to the CDC in Atlanta. The
Rotterdam lab was the first to come back with an answer: the
throat washings were positive for the H5N1 variant of the avian
influenza virus.
Since H5N1 had never been seen in humans before, exten-
sive tests were carried out to see if a mistake had been made
or the throat washings had been secondarily contaminated.
Several labs around the world joined this effort, and it was soon
absolutely clear that the young boy had indeed succumbed to a
primary infection with the H5N1 virus. Further analysis of the
boy’s virus showed that it was virtually identical to the H5N1 flu
virus involved in the recent local poultry outbreak, and that it
had passed to him without modification in an intermediate host
such as pigs. The clinical description of his illness and death
were hauntingly familiar to those who had studied the 1918 flu
pandemic.
Public health authorities in Hong Kong immediately tested
other members of the boy’s family, as well as medical staff that
had attended him in the hospital. None of his family members
showed any signs of having been in contact with the virus,11 but
one of his nurses and some of his playmates did. Wider testing
picked up a number of poultry workers who also showed signs of
having harbored the virus. None of these had showed any signs
of a flu infection. But when samples of the virus isolated from
the boy’s throat washings were tested on an experimental poultry
flock in Georgia, the entire flock underwent an immediate and
violent death from catastrophic influenza. From that point on, it
was agreed that all work with the Hong Kong H5N1 virus must be
carried out in high-security biocontainment laboratories, such as
those designed to work with soil samples brought back from the
moon or with CDC A-list pathogens.
In the months after the boy’s death, no further cases emerged,
and public health authorities began to hope his death might have
been a fluke. It was unclear how or even whether he had passed
the virus directly to others around him. It could not be ruled
out that those who had contact with him and showed positive for
H5N1 had not independently picked it up from poultry. And he

was the only one to have become ill.
But the message to infectious disease specialists was clear.
Here was a virus that could—did—kill a human being, and it
had passed directly from birds into humans. What would happen
if this new H5N1 virus infected a human during the normal flu
season, and that person was also carrying one of the relatively
benign seasonal flu viruses such as the current H3N2 variant?
The viruses could well recombine, producing a hybrid variant
with H5N1’s lethality and the ready human-to-human transmis-
sibility of a seasonal flu virus.
A few months later, any hope that the death of the three-year-
old child had been a one-shot occurrence disappeared forever.
Over a period of several weeks, a total of seventeen more chil-
dren and adults were admitted to hospitals with signs of a violent
pneumonia and were found to be infected with H5N1. Five died.
As in the 1918 pandemic, it appeared that most of those who died
were previously healthy adults. That was the only sense in which
the initial three-year-old victim may have been a fluke. Most of
those who became seriously ill in this round had had contact
with poultry; there was still no reason to suspect human-human
transmission of H5N1.
And then, almost immediately afterward, poultry began dying
again on Hong Kong farms, and even in live-chicken markets in
the middle of the city. Public health authorities moved swiftly. As
soon as H5N1 was confirmed as the cause and it became apparent
that up to a quarter of the territory’s poultry were infected, they
decreed that all of Hong Kong’s poultry must be destroyed—over
a million and a half birds. The economic cost would be stagger-
ing, but there was no hesitation. The government ordered it done
immediately.
Since its initial detection in Hong Kong in 1997, the H5N1
variant has spread to birds in over fi fty countries (Figure 5.3). As
of April 2007, the WHO had confirmed 291 cases of transmis-
sion to humans, with 172 deaths. A partial history of the spread
of H5N1 and its interaction with humans is shown in Table 5.1.
The mortality rate in humans known to be H5N1-infected has
hovered at about 60 percent for the past decade, making it at
least twenty-five times more deadly than the 1918 H1N1 flu virus.
200
Human
deaths
from H5N1
100
Countries
.
with H5N1
in birds .
. .
.
.
.
2003 2004 2005 2006 2007
Figure 5.3 Cumulative spread and human deaths from H5N1 avian flu.
Victims so far have been predominantly women and children,

but this could simply reflect their representation among individ-
uals handling poultry.
The first (and so far only) confirmed case of human-to-human
transmission occurred in Indonesia in 2006. A child contracted
H5N1 from handling poultry and subsequently passed the virus
to six other family members. No further spread outside the family
was documented.12 It may be that this family had a genetic altera-
tion that made them more susceptible to human-human transmis-
sion. But it is this possibility—a genetic alteration in the virus itself,
particularly in the H protein which determines initial entrance of
the virus into cells—that gives world public health officials night-
mares. It is what happened in 1918, and it could happen again.13
How would we handle an outbreak of transmissible H5N1
influenza in the human population? The ideal solution would
be a vaccine that is at least as effective as the current vaccines for
seasonal flu. We don’t have such a vaccine yet, but one that may
offer partial protection has recently received FDA approval. The
vaccine used an inactivated H5N1 virus isolated from humans
infected through contact with birds. In healthy individuals, anti-
body levels judged sufficient for protection were induced in about
Ta b l e 5 .1 A Partial Summary of H5N1 Avian Flu Outbreaks Affecting

Humans
When Where What
1997 Hong Kong Epizootic in poultry. Eighteen
humans infected, probably
from poultry. Six died.
2003 China, Hong Kong Two Hong Kong family members
returning from China
developed H5N1 pneumonia.
One died. Method of infection
unknown.
2003–04 Thailand, Vietnam Epizootic in poultry; first case
of possible human-human
transmission reported.
2005 China, Cambodia, Epizootics in poultry; first
Thailand, Vietnam, instance of possible infection
Indonesia of humans from ducks.
2006 Azerbaijan, China, Epizootics in poultry; swans may
Cambodia, Egypt, have been source in some cases.
Djibouti, Thailand,
Iraq, Turkey
2006 Indonesia First confirmed instance of
human-human transmission.
A child who probably picked
up the virus from poultry
passes it on to six other family
members.
2007 India Two separate poultry farms
infected.
2007 Africa Togo becomes seventh African
country with H5N1 outbreak.
2007 Great Britain Over 100,00 H5N1-infected birds
culled
For a complete timeline of avian influenza, see the WHO website http://www.who.int/csr/
disease/avian_influenza/timeline_2007_04_20.pdf.
As of April, 2007, 291 confirmed cases, 172 deaths (see http://www.who.int/csr/disease/
avian_influenza/ country/cases_table_2007_04_11/en/index.html for updates).
half of those immunized. Current seasonal flu vaccines protect

90 percent or more of recipients.
And to achieve even this level of protection required two injec-
tions of a rather large amount of the vaccine, spaced one month
apart. So this vaccine is far from ideal, but it is all we have at the
moment, and it is being stockpiled as a stopgap measure by the
federal government while research into a more effective vaccine
proceeds at a rapid pace. Enough of the recently approved vac-
cine for twenty million people is currently available. University
and drug company researchers are working furiously, supported
by federal funds, to develop a more effective vaccine. The gov-
ernment has already drawn up a prioritization list for who will
receive H5N1 vaccines during an epidemic crisis.14
There are four drugs currently approved by the FDA for miti-
gating the impact of influenza A infections (Box 5.2). Amantadine
and rimantadine stop the virus from replicating after it enters
the cell; Relenza and Tamiflu block the ability of newly made
viruses to exit from the infected cell. There is already evidence
that amantidine and rimantidine are ineffective against the
H5N1 virus as it presently exists. Relenza and Tamiflu are effec-
tive against current H5N1 strains, and are being stockpiled by
both the federal government and individual states.
But the problem for both vaccines and antiviral drugs is that
the H5N1 variant that presently exists, even in those cases where
it has migrated into humans, is not the one we have to worry
BOX 5.2
FDA-approved Anti-influenza Drugs
Generic name Trade name Approved

*
Amantadine Symmetrel 1966
Rimantadine** Flumadine 1993
Zanamivir Relenza 1999
Ostelamivir Tamiflu 1999
*
Available as generic
**
Available only as an inhalant
about. As a minimum, some sort of mutation will have to occur in

one or more genes of existing forms of H5N1 to allow it to spread
easily among humans. A second mutation, allowing it to jump
more readily from birds to humans, would really put us in deep
trouble. It is possible, some think even likely, that these muta-
tions could alter the ability of current H5N1 vaccines to block the
virus. The effect of these mutations on the sensitivity of the new
mutant(s) to antiviral drugs will also have to be assessed.
So we won’t really know what we are dealing with, what it is we
will have to protect ourselves against, until such mutations actu-
ally occur. The new mutants will have to be isolated and studied
in the laboratory, and plans devised for the most effective vac-
cines and drugs. Laboratories and manufacturers around the
world are poised to do this, and to do it on a 24/7 basis. But it
will still take time. It is entirely possible that when such a mutant
arises, we will be on our own for as much as six months before
drugs or vaccines are available.
How bad could an H5N1 pandemic be? We won’t know that
either until we have the miscreant mutant in hand. It could be
more lethal than current H5N1 strains, or less lethal. If it main-
tained its present lethality, a third of the people in the world
became infected, and half of those died—the math is pretty
straightforward. Remember, H5N1 as it exists now, when it infects
humans, is about twenty times more lethal than the 1918 virus.
Dr. Anthony Fauci, Director of the National Institute of Allergy
and Infectious Diseases, considers the threat of an H5N1 flu pan-
demic greater than that of bioterrorism.15
We have the experience of those who managed the 1918 out-
break with nonpharmaceutical interventions to guide us.16 And it
is possible that with our improved ability to manage influenza-like
diseases—we now have mechanical ventilators to assist with breath-
ing17; we know better how to manage secondary respiratory bacte-
rial infections and pneumonia; we will (hopefully) have anti-flu
drugs—we could reduce the lethality of infections considerably.
Maybe we could cut it in half. But that could still mean a billion
people dead worldwide, fifty million in the United States. That
would pretty much bring the world as we know it to a standstill.
There is reason to be concerned.
chapter 6
Agroterrorism
The Very Food on Your Plate
(and the Water in Your Glass)
In the Dark Winter scenario we replayed in chapter 1,

you may have overlooked one of the items placed on the hypothet-
ical agenda that was disrupted by events in Oklahoma City and
elsewhere: Taiwan had accused China of having purposely spread
foot-and-mouth disease virus over several pig farms. Animal and
crop pathogens have been a part of the biological warfare arma-
mentarium of nearly every country that ever had a bioweapons
program. Such an attack could certainly be plausible.
In the context of something like a smallpox attack, you might
think this seems like small potatoes, barely getting onto the radar
screen. You’d be wrong. If the true purpose of bioterrorism is
social and economic disruption and the spread of fear and uncer-
tainty across as many people as possible for as long as possible,
disruption of food and water supplies can be a major weapon.
That form of bioterrorism is called agroterrorism.
Agroterrorism is a threat not only to the daily bread and
meat that goes on our plates and the water we wash it down
with. Serious interruption of our domestic food or water supply
is actually a rather low-probability outcome of an agroterrorism
attack. The major impact would be economic. The United States
is a major supplier of food to the world, and agricultural exports

account for a sizeable portion of America’s trade income—about
$50,000,000,000 per year. Contamination of American food
supplies, which feed a sizeable portion of the world community,
could bring about economic disaster the likes of which have not
been seen since the Great Depression. And it would affect not just
farmers and agribusinesses who grow food for export. The collat-
eral damage stemming from interference with this sector of our
nation’s business would ripple through the rest of our economy
like a hot knife through butter.
A N I M A L TA R G E T S O F T E R R O R I S M
To get a feel for what an agroterrorism attack could do, let’s cre-
ate our own Dark Winter scenario—we’ll call it Dark Summer,
since that’s when an agroterrorism attack would most likely take
place. And we’ll replace smallpox released in shopping malls with
one of the deadliest animal pathogens, foot-and-mouth disease
virus, released on four major agribusiness cattle farms in differ-
ent states.1
One hot July day in 2003 workers on one of these farms
notice cattle starting to limp as they move around the fields. On
another farm, cows that are being milked balk when hooked up
to the milking machines, and workers notice blisters on their
teats. Veterinarians are called, and discover blisters inside the
mouths of the cattle as well. Like physicians with smallpox, these
vets have never seen this disease before except in textbooks, but
immediately recognize it for what it is: foot-and-mouth disease
(FMD), last seen in the United States in 1929. The vets immedi-
ately alert the CDC; over the next thirty-six hours, veterinarians
from all four sites have reported in. It is clear this is a terror-
ist attack, although whether foreign or domestic terrorists are
involved is unknown.
The President is alerted by the Secretaries of Agriculture and
Health and Human Services, and immediately calls his National
Security Council into emergency session. He cancels all but his
most essential business for the next two days. The President
and his council are joined by CDC officials and the Secretary
AG R O T E R R O R I S M • 95
of Agriculture, who arranges for an expert on foot-and-mouth

disease to address the assembled roomful of officials. Other key
personnel are invited as well. The FMD expert rises to speak.
Foot-and-mouth disease, she tells them, is caused by a virus,
called simply foot-and-mouth disease virus (FMDV), related to
the polio virus that affects humans. It is more infectious than
the smallpox virus. It infects cloven-hoofed animals: cattle, pigs,
goats, and sheep among domesticated animals, as well as deer
and elk in the wild. The disease is highly contagious but affects
different animals differently. Among domestic herds, pigs and
cattle are highly susceptible, sheep and goats less so. The latter
two get only mildly sick at most, and can serve as a reservoir for
the virus, which must be taken into account in any containment
strategy. Humans are not made sick by FMDV, but they can trans-
port the virus on their person for several days, and can spread it
through inhalation and aerosol generation. This, too, must be
taken into account.
Adult pigs and cattle do not usually die from FMD infections,
but they become ill and severely disabled. They cannot repro-
duce, cannot nurture their young, and cannot be used as a food
source, since all of their tissues and organs are laden with virus
that could find its way back into the environment. The adults usu-
ally recover in two to three weeks; younger animals may die. The
disease spreads rapidly, primarily as an exhaled aerosol, since
the lungs, too, are full of virus.
Since FMD has been absent from the United States for nearly
seventy-five years, American cattle, like most American citizens
when it comes to smallpox or H5N1 influenza, have no natu-
ral immunity to FMD. They are also not routinely immunized
against FMD. Given the absence of the virus in North America, it
would be difficult to justify the expense of maintaining an active
vaccination program, particularly since the currently available
vaccine does not induce strong immunological memory. Periodic
booster shots are required to maintain good immune defenses,
which would add to the cost of such a program. We are not alone
in this situation. Nearly all of Europe—at least the membership
of the EU—has exactly the same policy.
“Another complication,” she says, “is that there are about
sixty different forms of the virus; each would require a different
vaccine. Also, current FMD vaccines do not prevent infection,

but protect the animals enough to keep them from becoming
sick. That means vaccinated animals that are later infected, but
seem to have resisted the virus, can continue to harbor the virus
and spread it to other animals. Since they are not sick, it is impos-
sible to spot them. Animals leaving farms or feed yards looking
perfectly healthy could still be carrying the virus, and they can
continue to carry it for a year or more. For that reason, no coun-
try that is FMD-free will accept animals or any parts of animals
from vaccinated herds. So the United States does not vaccinate,
and in fact we don’t even make a vaccine in this country.”
A hand goes up from the floor. “So if we don’t have a vaccine,
how do we stop this damned thing?”
“I didn’t say we don’t have a vaccine; only that we don’t make
it here. There is a collection of vaccines based on various forms
of killed FMDV, made in other countries and stored at a vaccine
bank on Plum Island, off the coast of Long Island in New York. It
is possible that in some scenarios of containing an outbreak, we
might want to resort to a vaccine.”
Another participant chips in. “So I take it vaccination is not
your first choice in the current situation. What is?”
“Standard procedure at the present time is to immediately
quarantine all cloven-hoofed livestock on a farm or feedlot where
FMD is suspected, and on all farms within a three-kilometer
radius. No animals in or out. If laboratory tests confirm FMD, all
cloven-hoofed livestock on those lots or farms will be destroyed.
Any cloven-hoofed wildlife found in the vicinity of those lots or
farms will also be destroyed. The resulting carcasses will be bur-
ied or burned. What we are doing is similar to the ‘ring vaccina-
tion’ procedure that might be used in an outbreak of smallpox
or pandemic flu in humans. We are trying to create in essence a
firebreak around a raging contagion.
“The farms themselves will have to undergo extensive chemical-
based decontamination. The virus will be everywhere: in manure
heaps, on equipment, in the soil. These farms will be closed down
for many months. Also, no persons will be allowed to leave farms
where destruction of livestock is ordered without undergoing a
thorough decontamination procedure themselves. As I indicated
earlier, humans can definitely carry the virus to other livestock
areas. We may have to consider quarantine of such persons until

they are tested, to be sure they are not carrying.
“We will expand this process in new rings, or enlarge older
rings until we have each outbreak under control. The resources
that may have to be committed could be huge. We may need help
from the National Guard, for example. I would just remind all of
you that we have about a hundred million head of cattle in this
country, and around seventy million pigs.
“If there are no further questions, I’ll pass you back to the
Secretary, who will brief you on anticipated political and trade
issues.”
The Secretary of Agriculture spreads some papers in front of
him, and rises to speak.
“The tests Dr. Hofman talked about have already been per-
formed, and are positive at all four sites. Livestock on those farms
are now being destroyed. While most of America will understand
this has to be done, the images that we will all be seeing on tele-
vision and in newspapers and magazines in the coming days are
going to be very upsetting, and will likely generate some domestic
discontent. We must make every effort to communicate to news
media outlets the absolute necessity of these grave steps, and ask
them to help us educate the public to this fact.
“These images will also be seen worldwide, of course, and in
some quarters are likely to generate as much celebration as com-
miseration. They will be on CNN and BBC, but also Al Jazeera.
What will be shown, of course, is not terrorists attacking and
contaminating American food supplies, but Americans killing,
burning, and filling mass graves with American livestock. It will
be an ugly sight, and a story that can be told in several ways. It
surely will be.
“The farms involved in the first-round action sites, two of
which are actually feedlots, have an estimated 220,000 affected
livestock. Most of these are on the feedlots; these are our weakest
link in a situation like this, because of the large number of ani-
mals and extreme crowding. We’re lucky more feedlots weren’t
hit.
“It will take several days to slaughter all of the livestock
involved. We fully expect that several, perhaps all, of the infected
sites will spill virus into surrounding farms. These will be
intensely monitored, and any sign of disease or any positive tests

in even asymptomatic animals will lead to imposition of a three-
kilometer circle and destruction of all at-risk livestock. We simply
cannot predict at this time where this process will stop. We can
also expect considerable resistance to wholesale slaughter from
affected farm families and from corporations that operate most
of the larger pork and cattle facilities. All of them stand to lose a
great deal, even though we have compensation programs to help
them through this.
“The initial effect of this on the domestic food supply will
probably be minimal. We have already begun tracing animals
that have been shipped from the affected farms, and these will
be pulled back and destroyed, as will all susceptible livestock or
other animals with which they have come in contact. Any meat,
milk, or other animal products processed from animals at these
farms during the past two weeks will be recalled and destroyed. It
is likely we will still see some leakage of virus from these animals
and animal products into the general environment. The entire
agricultural and veterinary apparatus in this country is now on
high alert to spot additional outbreaks.
“But many people will very likely stop eating any and all meat
from susceptible species, even though infected meat, even if
eaten raw, would have no effect on humans, other than to pos-
sibly make them at least temporarily carriers of the virus.
“More devastating for us, of course, is that all foreign countries
will—within a day or so, if they haven’t already—immediately block
all imports of American animal and other farm products. This will
extend beyond the affected species, since poultry and other farm
animals could be harboring virus. It will also extend at least several
months after our last confirmed case. Most industrialized nations,
like us before this happened, are and want to remain FMDV-free.
And no FMDV-free country will accept FMDV-vaccinated livestock,
either, by the way. We have no complaint; we would do exactly the
same if this were happening in another country.
“We may also see some interference with U.S. citizens trav-
eling to FMDV-free countries, unless they can prove an urban
(as opposed to rural) residence here. It is possible they may be
required to undergo some sort of decontamination procedure
or even quarantine. We’ll have to see how this plays out. And
FMDV-free countries will likely discourage their citizens from

visiting the United States on anything less than urgent business,
and subject them to various decontamination procedures upon
their return.
“The economic cost of this attack, although largely invisible to
the public, at least at first, has the potential of being huge. I would
remind you that in the aggregate, agriculture is one-sixth of our
total gross domestic product—well over one trillion dollars.
“We will be faced with not only the cost of a containment pro-
gram, but the loss of a very large sector of our export market, plus
the cost of importing animal products for our own markets if a
sizeable portion of our own population also boycotts American
meat. Transporters, distributors, restaurants—all are going to be
hit hard. Layoffs will be inevitable. The final costs, of course, will
depend on how far this contagion spreads and how long it takes
to control it. We can anticipate that it will be at least some num-
ber of months after we have contained it before our agricultural
exports are accepted in FMD-free countries. We will lose tourism
dollars. The final cost will be well into the billions.”
We’ll leave the assembled officials to their labors. We don’t
really need to run this play to its final act. Various government
exercises carried out to simulate an agroterrorist act with FMDV
have generated some possible outcomes. Crimson Sky estimated
that thirty-eight million animals could end up having to be slaugh-
tered in a moderate attack. This is about the number of animals
slaughtered yearly for domestic and export consumption. Silent
Prairie concluded that even a limited FMD attack would likely
spread to forty states before it could be fully contained, with a
loss of nearly fifty million animals. So somewhere between thirty
million and fi fty million livestock could have to be killed. No one
is quite sure how we would do that, or even if we could. But it
would have to be done.
Neither of these exercises appears to have included the cost
to the American economy due to shutdown of U.S. food exports,
which would certainly be total. No country would agree to import
anything that had been on an American farm. The loss of jobs in
various industries tied to agriculture would be enormous. Many
of the farms remaining in family hands would likely be repos-
sessed or sold. It would take years to rebuild herds.
Great Britain went through a real-life Dark Summer in 2001,

except the FMD outbreak was natural, rather than resulting from
a terrorist attack. No one is entirely certain how FMDV got into
the country, which had been FMDV-free since 1967. Most assume
it was through illegal import of meat from a country with ongoing
FMDV problems. Initially, the virus infected pigs on a single farm.
Sheep present an adjacent farm then became infected, probably
through a virus-laden aerosol, and were shipped to other agricul-
tural locations before the outbreak had been confirmed.
A pandemic took off from there. British authorities used a ring
containment procedure like that described above: quarantine, fol-
lowed by slaughter of all animals in infected herds.2 The procedure
was fully publicized in all media outlets, and the constant pictures
of vast funeral pyres of slaughtered animals were traumatic for a
great many people. The outbreak was 95 percent contained in
about three months, but not fully extinguished for nearly a year.
Humans and vehicles were later found to have been major carri-
ers, and contributed significantly to spread of the disease.
The virus spread to at least two other European countries
(France and Holland), probably through infected animal prod-
ucts processed and shipped before the outbreak was recognized.
Britain suffered a total boycott of its agricultural products for
many months. Many of us returning by air from Britain remem-
ber being questioned by our own agricultural people about
where we had visited, and being made to step through pans of
disinfectant as we passed through Customs.
Before it was over, Britain had destroyed nearly eleven million
animals on over nine thousand farms. The estimated cost to the
national economy has been estimated at between forty and fi fty
billion dollars. Most of this loss was from collateral damage in
the non-agricultural sector.
AG R I C U LT U R A L CR O P S A S
TA R G E T S FO R T E R R O R I S M
Terrorist destruction of agricultural crops is at once simpler

and more difficult than bioterrorist attacks on humans or ani-
mals. It is simpler, because America’s croplands are enormous
and open. The number of acres that are under the watchful eyes
of a farmer and his family, who might detect the presence of a
stealthy stranger scattering strange powders or loosing insects
(either alone, which would be damaging enough, or carrying a
plant pathogen), has become vanishingly small. Soybeans, for
example, are planted in over seventy million acres in the United
States. Many of the largest agricultural fields are unguarded and
largely unobserved most of the year.
Yet their very vastness makes it difficult to infect more than a
small portion of the nation’s crop at any one time. A crop dusting
airplane might extend a terrorist’s reach, but would raise imme-
diate suspicions on even the largest, most remote farmlands. And
while there are pathogens for plants as deadly and inexorable
as any for humans, they are harder to detect, have longer incu-
bation times before disease appears, and tend to spread more
slowly. They can take months or even years to be detected and
verified. Watching plants die, like watching them grow, doesn’t
make for very exciting TV coverage.
But while the psychological effect of an agroterrorist attack on
plant crops might not reach the level of seeing animals slaugh-
tered and burned every night on the news, the damage ultimately
done to our economy and to our social structure could be nearly
as significant. The television coverage would be less dramatic for
the terrorists as well, of course, but depending on their aims—
they could be domestic as well as foreign, after all—destruction
of major portions of American agricultural crops could certainly
have the desired effect. Although the possibility of the domestic
food supply being seriously disrupted, at least during the year
of an agroterrorist attack, is slim, there could be substantial fol-
low-up disruption. The costs of destroying tens of thousands of
acres of crops, and ensuring eradication of the pathogen, could
be huge. Export markets could be devastated. Layoffs within the
agricultural industry itself, economic disruptions in a major sec-
tor of the economy rippling outward, decreased confidence in
the food supply, fear of eating contaminated food,3 all are pos-
sible consequences of a terrorist attack on our crops.
It is also possible that terrorists could attempt to contaminate
our crop food supply not in the fields, but at various points in
the harvesting, processing, and distribution systems. This has the
advantage of having large portions of our crops or their prod-

ucts concentrated in one place, the crop equivalent of a feed-
lot, in a sense, rather than scattered around the nation. And it
is not entirely necessary that terrorists even be in the country to
spread crop pathogens; they could be inseminated into fertiliz-
ers or other crop-enhancing products imported into the United
States.
The pathogens terrorists might use to destroy crops are largely
those that destroy crops naturally each season in the course of
a normal agricultural cycle. Existing, naturally occurring plant
diseases already cost the U.S. economy over $30,000,000,000
each year. Tilletia indica causes a disease of wheat called Karnal
bunt. A major (natural) outbreak of this disease in 1996 threat-
ened the entire U.S. wheat export market. The infestation was
brought under control, at great expense and with considerable
crop loss. But all of this is factored into the cost of doing busi-
ness; we already pay for it at the supermarket. On the other hand,
orchestrated, nationwide terrorist attacks with T. indica could
well bring the domestic and export wheat markets to their knees
in this country, with an incalculable economic impact that would
affect every American.
A N D A B O U T T H AT G L A S S O F WAT E R . . .
Not only did medieval armies lob rotting carcasses over castle
walls, they also stuffed them into the wells and cisterns of their
enemies. People can go weeks without food before succumbing,
but only a few days without water. Public health authorities, as well
as terrorism experts, have warned repeatedly that the nation’s
water supply is a potential target for bioterrorists. The potential
for serious damage is clearly there—to human health, to agricul-
ture, and to every sector of our economy that uses water. And in
the end, that is virtually every sector.
There are over 160,000 water systems delivering water to U.S.
customers; 350 of these serve populations of 100,000 or more,
and are considered the most likely potential targets for terror-
ism. About half of our water comes from underground sources,
and half from surface sources. The federal agency charged
with making sure rotting corpses or other possible bioterrorist

weapons are not stuffed into our drinking water supply is the
Environmental Protection Agency (EPA). Title IV of the 2002
Bioterrorism Act directs the EPA, in coordination with the
Department of Homeland Security, to work with all water utilities
serving more than 3,300 customers to carry out terrorism vul-
nerability assessments. The initial assessments have been largely
completed. The EPA has also drawn up plans for a monitoring
system, called WaterSentinel, to detect chemicals and biological
agents in our water supplies. Such a system is every bit as impor-
tant as monitors for airborne pathogens, but the technology is
still lagging, and funding has been slow. The plan has yet to be
implemented.4
The classic fear most of us have of terrorists emptying vials
of deadly poison into city reservoirs turns out not to be terribly
likely, mainly because of the enormous dilution factor involved.
The amounts of chemical that would have to be added to even
a modest-size reservoir to reach a chemical concentration toxic
to humans in a glass of drinking water approaches boxcar-size
loads, making this method of attack highly impractical. While
the same is generally true of biological agents, many microbes
can not only survive in water, but actually multiply using nutri-
ents commonly found in most water sources.
We know what can happen when the water supply to metro-
politan areas is contaminated with human pathogens, through
numerous incidents of accidental intrusion of pathogens into the
water supply. The city of Milwaukee, Wisconsin, uses water from
Lake Michigan as one source of its drinking water supply. Water
from the lake is passed through a series of purification steps at
two city water purification plants before entering the drinking
water distribution system. In late March 1993, citizens and some
city officials began noticing an increasing turbidity of tap water,
particularly on the city’s south side.
In early April, hospitals and clinics began reporting increas-
ing numbers of people coming in with gastrointestinal problems,
including severe cramps, persistent diarrhea, and vomiting. It
always takes a day or two to realize there is a problem, because
some level of these symptoms are normally seen on a daily basis
in large cities. It takes another day or two to figure out what the
problem is. In this case, analysis of patient stool samples indi-

cated the presence of massive amounts of the intestinal parasite
Cryptosporidium, and its source was traced to the city’s drinking
water.
The initial water filtration system at one of the two city plants
had failed. The plant was possibly also affected by an unusual
amount of runoff from rivers and streams into the lake, dragging
with it larger than normal amounts of waste products, especially
from livestock fields. Ultimately, over 400,000 people were made ill,
roughly half of those who had imbibed local water. (Many healthy
people remain unaffected by Cryptosporidium; older people, sick
people, and those with impaired immune systems are at highest
risk.) Over 4,000 people required some hospital treatment, and 54
people died. More than 700,000 work days were lost, and the cost
to the community has been estimated at up to $100,000,000.
In another natural disease outbreak, traceable entirely to
contaminated runoff water, the culprit was the bacterium E. coli
0157:H7, an agent on the CDC “B list” of potential biowarfare
pathogens (Table 3.1), and Campylobacter. Both cause symptoms
similar to the parasite Cryptosporidium, but the diarrhea caused
by the E. coli is usually bloody. In the five-day period May 8–12,
2000, the small rural town of Walkerton in Ontario, Canada,
experienced five and a half inches of rain, which came after a
long period of drought. Three and a half inches fell on May 12
alone. This combination of events was described as a “once-in-a-
hundred-years event.”
Walkerton obtains its water from a series of local wells. These
wells rely on natural filtration of groundwater in underlying aqui-
fers, and chlorination of surface water entering the wells. There
are no formal purification plants operating. During the excessive
rainfall, manure from nearby fields was carried by surface water
into the wells, overwhelming the ability of the chlorine to deal
with the accompanying bacteria. E. coli 01577:H7 is common in
animal manure, and a major concern about runoff from grazing
fields into water systems. The result was that many hundreds of
people were made ill, and seven died. Estimates of the overall
costs of this incident also approach $100,000,000.
These cases make clear that we would indeed be vulnerable to
bioterrorism through our water systems. There are several points
BOX 6.1
Introduction of Biological Agents Into the Water Supply
Primary sources Lakes, rivers, streams, dams

Intake points Points of entrance of primary
source water into purification
plants; shared water wells
Water distribution systems Water pipes running throughout
cities
Stored purified water Reservoirs, cisterns, water tanks
Commercial water Bottling plants, carboys, bottles
Recreational waters Lakes, swimming pools
at which pathogenic agents could be introduced by terrorists into

our water (Box 6.1). The most likely targets for deliberate water
contamination would be water intake points and water distribu-
tion systems. Recreational waters are also of some concern for
pathogens that can cling to skin and hair.
H O W C A N W E P R O T E C T O U R S E LV E S ?
The openness of our croplands and the tremendous concentra-

tion of our livestock (80 percent of our cattle at any one time are
concentrated in a half dozen or so feedlots) make agriculture a
prime target for terrorists. Many crops are similarly concentrated
in a limited number of huge processing plants. Weaponization
and delivery of crop and livestock pathogens requires considerably
less sophistication than biological attacks on human targets living
in metropolitan areas, and pose no risk for those who use them.
We also know that terrorists linked to Al-Qaeda have looked very
closely at our water supply and delivery systems. Documents and
computer drives recovered from Al-Qaeda sites in Afghanistan
contained a surprising number of detailed maps and operating
procedures for water systems in several American cities.
And we need not worry only about foreign terrorists. Some of

the more militant domestic groups opposed to the slaughter of
animals for food, or to the increasing cultivation of genetically
modified crops, could turn to terrorism to force their agendas
onto the table of national discussion. In a sort of “covert agro-
warfare,” both the United States and the United Kingdom have
invested in programs to develop bioweapons capable of taking
out specific crops in other countries—specifically coca plants in
South America and poppy plants in the Middle East.
As with bioterrorism against humans, federal authorities have
taken a number of steps to improve our ability to defend our-
selves against agricultural terrorism, whatever the source.
Bet ter Control of Potential

A g r o t e r r o r i s m Pat h o g e n s
The National Research Council concluded, in a 2002 report
titled Countering Agricultural Bioterrorism, that the threat of terror-
ism against U.S. animals, crops, and the water supply is very real,
because of both the social disruption it could cause and the eco-
nomic damage it could do. But this report also recognized that
it is not feasible to make and have on hand the scientific tools to
counter every threat. On the other hand, as with human patho-
gens, we can identify those plant and animal pathogens that have
the potential to cause the greatest harm to American agriculture
and do everything possible to make sure these agents do not fall
into the wrong hands.
The Department of Health and Human Services, together
with the U. S. Department of Agriculture (USDA), has drawn
up a “select list” of agricultural pathogens that are to be kept
under extremely strict control. All of the restrictions placed
on human pathogens in terms of licensing of distributors and
users and tracking and reporting of all select agents also apply
to the designated agricultural agents. These are agents which,
if they escaped uncontrolled into the agricultural environment,
could cause serious damage to the domestic food supply and to
America’s ability to sell food abroad. Some of these agents have
been designated by the CDC and the USDA as potential agroter-
rorism agents (chapter 7).
Th e S t r a t e g i c P a r t n e r s h i p P r o g r a m
The Department of Homeland Security, the Department of
Agriculture, the FDA, and the FBI joined together in 2005 to cre-
ate the Strategic Partnership Program Agroterrorism Initiative.
Teams representing each of these agencies travel around the
country meeting with state and county representatives, as well
as individual private agricultural enterprises, to identify where
the vulnerabilities in our agricultural infrastructures lie and how
we can best ameliorate those vulnerabilities. Questions for dis-
cussion include how best to detect actual or potential agroter-
rorist attacks and how to deal with them once they occur. For
example, from economic, political, and social points of view,
is mass destruction of livestock in outwardly growing “rings”
the most effective way to deal with something like a foot-and-
mouth disease outbreak, or might there be a more imaginative
way to use vaccines, perhaps in conjunction with mass destruc-
tion? Clarifying and strengthening the respective roles of state
and federal governments, and providing closer communications
between government at all levels and the private sector during
emergencies, are also top priorities.
Individual acts of bioterrorism, whether directed at human or
agricultural targets, are low-probability events. Nevertheless, any
agroterrorist attack, if carefully planned—and if successful—
could cause substantial damage that could take years to recover
from. How much do we invest in protecting ourselves? How much
to protect our livestock? Our crops? That is a very difficult policy
question, but to the extent we decide to invest in bioterrorism
defense, agroterrorism certainly cannot be ignored.
chapter 7
America Responds
In 1989, partly as a result of America’s participation

in the 1972 International Biological Weapons Convention, but
also in response to growing concerns about terrorist use of bio-
logical weapons, Congress passed the first of a series of bioterror-
ism acts, this one entitled the Biological Weapons Antiterrorism
Act of 1989. This Act spelled out the first restrictions on access to
biological weapon agents by individuals:
Sec 175a. Whoever knowingly develops, produces, stockpiles,
transfers, acquires, retains, or possesses any biological agent,
toxin, or delivery system for use as a weapon, or knowingly assists
a foreign state or any organization to do so, shall be fined under
this title, or imprisoned for life or any term of years, or both.
This is the law under which members of the Minnesota Patriots

Council were tried and sentenced for manufacturing and pos-
sessing ricin, even though they never used it. Subsequent sec-
tions of this Act provide a legal basis for searches and seizures of
biological agents and spell out conditions for use of such agents
by scientists engaged in studies within recognized research insti-
tutions with appropriate institutional and granting agency over-
sight. Provisions of the Act were clearly targeted toward persons
buying, making, or possessing dangerous human pathogens that
have “no apparent justification for prophylactic, protective, or
other peaceful purposes.”
The next significant piece of legislation to appear had the

grim title Antiterrorism and Effective Death Penalty Act of 1996.
It focused primarily on strengthening and streamlining federal
law governing imposition of the death penalty in certain terror-
ism cases. It was spurred largely by the Oklahoma City bombing
and the first World Trade Centers attack in 1993, and was given
a further boost by the Aum Shinrikyo incidents in 1995. The Act
also made it easier for victims of terrorist acts to be compensated
for their losses, and authorized them to sue foreign governments
in federal courts if those governments could be shown to have
supported terrorists who harmed them.
Title V of this Act focused additional attention on transfer of
and trafficking in biological agents that could be used by ter-
rorists, and was to a significant degree impelled by the activities
of the Rajneeshees, the Minnesota Patriots Council, and Larry
Wayne Harris (a credit he will doubtless add to his resumé!).
In the final stages of drawing up the Act, unfolding knowledge
of Aum Shinrikyo’s attempts to create bioweapons added to a
sense of urgency in Congress to create stronger controls. The
Department of Health and Human Services (HHS) was directed
to draw up a list of exactly which biological agents were to be pro-
hibited by federal law from possession by unauthorized individu-
als. This resulted in the HHS “Select Agents” list (see below).
The ink had hardly dried on the 1996 Act, and its full implemen-
tation was still underway, when the United States was struck by the
attack on the World Trade Center and the subsequent Amerithrax
incidents of 2001. The General Accounting Office, in a report pre-
pared for Senator Bill Frist, concluded that this episode in our
history with bioterrorism revealed glaring weaknesses in the state
of preparedness of our emergency and public health systems to
deal with even moderate-scale bioterrorist attacks. In response,
a large-scale, bipartisan effort initiated in 1999 was brought rap-
idly to completion, in the form of the Public Health Security and
Bioterrorism Preparedness and Response Act of 2002 (which
from here on out we will refer to as the 2002 Bioterrorism Act).
Intended to be amended on a regular, ongoing basis, it provides a
blueprint for upgrading American preparedness to deal with cata-
strophic biomedical emergencies. It incorporated, modified, and
extended many of the features of the 1989 and 1996 Acts.
A M E R I C A R E S P O N D S • 111
BOX 7.1
Key Provisions of the Public Health Security and
Bioterrorism Preparedness and Response Act of 2002
Title I Calls for the upgrading of public health services

at every level to deal with catastrophic health
emergencies. Decrees creation of detailed state
and local response plans, training of emergency
response personnel, improvement of hospitals to
deal with catastrophic events, creation of national
stockpiles of medicines and vaccines.
Title II Defines biological agents and toxins deemed to
pose a particular threat to humans. Sets strict
regulations for controlling access to these agents
and toxins, requires licensing of both suppliers and
users, and establishes criminal penalties for their
unauthorized possession or use.
Title III Defines steps to be taken to protect domestic food
and drug supplies.
Title IV Describes steps to be taken to secure the domestic
water supply.
The 2002 Bioterrorism Act is over 100 pages long1; its most
important features are shown in Box 7.1. Although aimed pri-
marily at preparing public health services to deal with a bioter-
rorist attack, part of selling it to Congress and the public was that
it would also help prepare for any large-scale infectious disease
crisis. The vast majority of cities and counties in America are
equally underprepared for any major flu pandemic, and H5N1
was already on the radar screen.
Title II of this Act incorporates and extends the Select List of
pathogenic agents deemed likely to be involved in catastrophic
health incidents (Table 7.1), and refines the provisions cover-
ing their use. Since the 2002 Act came into effect, only certain
licensed laboratories are able to distribute materials from the
Select List, and only licensed end users are authorized to pur-
chase them. Companies like ATCC (American Type Culture
Ta bl e 7.1 The Department of Health and Human Services/USDA Select

List of Agents and Toxins
Abrin Lassa fever virus

Bacillus anthracis* Marburg virus
Botulinum neurotoxins* Monkeypox virus
Brucella abortus* Nipah virus*
Brucella melitensis* Ricin
Brucella suis* Rickettsia prowazekii
Burkholderia mallei* Rickettsia rickettsii
Burkholderia pseudomallei* Rift Valley fever virus*
Clostridium botulinum* Saxitoxin
Clostridium perfringens toxin* Shigatoxin*
Coccidioides immitis* South American hemorrhagic fever
Coccidioides posadasii viruses (5 types)
Conotoxin Staphylococcal enterotoxins*
Coxiella burnetii* T-2 toxin*
Crimean-Congo hemorrhagic Tetrodotoxin
fever virus Tick-borne encephalitis viruses
Diacetoxyscirpenol (5 types)
Eastern equine encephalitis virus* Variola major and Variola minor
Ebola virus Venezuelan equine encephalitis
Francisella tularensis* virus
Hendra virus* Yersinia pestis
Herpes B virus
Influenza virus (1918 variant)
Bold type: agent also appears on the CDC list of most dangerous potential bioterrorism
agents (chapter 3).
*Agent also of concern for agricultural terrorism (chapter 6).
Collection), one of the largest U.S. suppliers of both microbial

and animal cell lines, is an example of a company certified by the
CDC for transferring Select List agents to authorized research-
ers. In order to receive CDC certification to transfer these mate-
rials, ATCC had to submit extensive documentation about how
it records and stores these materials internally, who has access
to them, and security measures in place to prevent unauthor-
ized movements both within and outside of ATCC. Each time
someone tries to purchase a Select List agent, ATCC must file

a special form with the CDC, and the individual requesting the
agent must do the same. CDC then verifies that this individual
has previously filed all of the necessary paperwork to receive the
requested agent and notifies ATCC of its decision regarding the
requested shipment. The possibility that someone other than
a vetted researcher in an authorized institution could obtain a
Select List agent from ATCC is just about zero.
The whereabouts of every trace of these agents must now be
recorded and a paper trail created following their movement
within both the transferring company and the researcher’s home
institution. Possession of, or trafficking for any purpose in, these
agents and toxins outside the proscriptions of the Act is subject to
stiff criminal penalties. Some of these agents and toxins are on the
Category A list of the Centers for Disease Control and Prevention,
as materials of particular concern in bioterrorism (chapter 3).
The cases of bioterrorism and biocrime we examined in
chapter 2 are just a small part of the many cases of terror, using
bombs and gas as well as biological agents, that have become
part of the background noise of modern political and social life.
Bioterrorism is admittedly part of that noise, and has the poten-
tial to do substantial damage. But what will be the likely source of
that bioterror? Will it come from without, like the 1993 and 2001
World Trade Center attacks? Or will it come from within, like
most of the cases we explored earlier? That is what we will spend
much of the rest of this book examining. But to paraphrase a
famous cartoon character of years past, ‘We have met the enemy—
and so far, he is mostly us!’
CR E AT IN G A N IN F R A S T R U C T U R E: T H E
S T R AT EG I C N AT I O N A L S T O CK PIL E A N D
PROJEC T BIOSHIELD
Th e S t r a t e g i c N a t i o n a l S t o c k p i l e
As part of strengthening our public health emergency response
systems, Congress asked HHS in 1999 to create the National
Pharmaceutical Stockpile to speed medical supplies and materials
to the sites of major health emergencies anywhere in the United

States within twelve hours. The response to this call was rapid,
and indeed CDC, a branch of HHS, was able to do just that
immediately after the World Trade Center attacks of 2001. A
fifty-ton, pre-packed shipment of medical supplies reached New
York City within seven hours of being called upon, in one of the
few non-military aircraft flying in American airspace that night.
This same Stockpile was called upon again in the Amerithrax
attacks just weeks later, when a hundred cases of medical supplies
for dealing with anthrax were shipped to Florida.
In March of 2003, the National Pharmaceutical Stockpile
was expanded and upgraded to become the Strategic National
Stockpile (SNS),2 and the Department of Homeland Security
became a partner in its management. The official mission of
SNS is to “ensure the availability and rapid deployment of life-
saving pharmaceuticals, antidotes, other medical supplies, and
equipment necessary to counter the effects of nerve agents, bio-
logical pathogens, and chemical agents.” The budget for SNS
reflected its recognized value and expanded role. The National
Pharmaceutical Stockpile was initially funded at $50,000,000
per year. The current annual budget for SNS is around ten times
that.
CDC has created ready-to-go “Push Packages,” pre-packed
cargo containers that can be transported by surface or air to any
site in the United States within the twelve-hour delivery target.
These contain a wide array of medicines and supplies that could
be used in a bioterrorist attack, but to some extent in a number
of other health emergencies as well. Twelve such Push Packages,
each consisting of 124 separate cargo containers weighing a total
of 94,000 pounds, are stashed in climate-controlled warehouses
at strategic (and secret) locations around the country. Their
medicine contents are rotated on a regular basis to assure fresh-
ness. Arrangements for their shipment have been made by special
contract with both United Parcel Service and Federal Express. A
Push Package will fit into one wide-bodied cargo plane or seven
large 18-wheeler cargo vans. The CDC asks that all states have
a dedicated, climate- controlled facility of 12,000 square feet to
receive and temporarily store Push Package materials, and spe-
cific plans for their utilization.
Push Packages also come with a team of technicians who are

thoroughly familiar with the contents and organization of each
of the cargo containers, to assure rapid retrieval and efficient
deployment of emergency supplies. Once a Push Package arrives,
however, its contents become state property, and state and local
health authorities direct their use and distribution. It is expected
that at the end of an emergency using Push Packages, any left-
over medicines and supplies will be melded into the state’s health
care system.
Push Packages are built primarily for speed of response. Early
in an emergency, the exact scope and nature of the situation may
not be entirely apparent. Subsequent aid, once authorities have a
clear picture of the emergency and their needs for dealing with
it, can be more tailored. In most cases, this aid may come directly
from drug companies and manufacturers that are partnered
into the SNS program and maintain their own “vendor-managed
inventories” (VMI) for emergency distribution. Company X, for
example, will guarantee always to have on hand for immediate
shipment 250,000 doses of vaccine A or antibiotic B. The advan-
tage of VMI is that the government does not have to maintain
huge stockpiles of drugs with short shelf lives. Drugs rotated out
of storage would have to be destroyed and replaced. This prob-
lem is bypassed through VMI by drawing on the manufacturer’s
own constantly replenished inventory.
In those cases where the exact nature of a health emergency
is known early on, the SNS response may bypass Push Packages
altogether and go directly to VMI. For example, supplies of cipro-
floxacin (Cipro) were supplied directly and quickly through the
VMI component of SNS in response to the Amerithrax attacks.
More than 30,000 people received Cipro or equivalent antibi-
otics. The relatively low numbers of casualties in that situation
are thought by many to be due to the immediate availability and
essentially unlimited amounts of these drugs.
Like many of America’s countermeasures against bioterror-
ism, SNS is a dual-purpose enterprise. It strengthens our pre-
paredness for natural outbreaks of biological catastrophe as well
as man-made incidents. In early 2006, for example, HHS autho-
rized the purchase of 2.2 million and 3.8 million doses, respec-
tively, of the antiviral drugs zanamivir and Tamiflu, bringing to
26 million doses the amount of antiviral drugs in SNS. Some

of the antiviral drugs being stocked are also useful against viral
pathogens on the CDC’s A and B lists, but in any case we will have
an increasingly broad spectrum of such drugs to draw upon in
any major health emergency.
Fe e d i n g t h e B e a s t : P r o j e c t B i o S h i e l d
Project BioShield, signed into law in July 2004, was created to
ensure an adequate flow of new and existing drugs, antiserums,
and vaccines into the SNS armory, particularly those used for
agents on the CDC A list, as well as medicines to protect against
chemical and radiological attacks. SNS would also be the natural
repository for drugs or vaccines intended to prepare for an avian
influenza pandemic.
BioShield establishes funding for two main functions: research
into the development of new vaccines and drugs to meet the threat
of anticipated catastrophic health emergencies, and a standing cash
source to purchase these new drugs and to replace existing SNS
Push Package medicines and materials as they expire. Like SNS
itself, this fund is overseen jointly by the secretaries of HHS and
Homeland Security. Research grants processed through BioShield
receive expedited review and decisions about funding.
The Food and Drug Administration (FDA) is also a partner
in BioShield, helping to identify areas in which more research is
needed. The FDA interacts extensively with the pharmaceutical
industry as the chief overseer of clinical trials and is well posi-
tioned to help expedite research and testing of new drugs and
materials destined for the SNS; it has the authority to put promis-
ing drugs and vaccines on a developmental fast track. The FDA
would also play a key role in determining whether the possible
benefits of using a particular drug or vaccine, which might still
be in the developmental process during a national health emer-
gency, could outweigh the risks posed by the emergency itself.
BioShield has been criticized by industry partners, and by
some in government, for a provision that requires companies to
actually produce an effective vaccine or drug before receiving
any compensation from BioShield. Most of the research demon-
strating efficacy of a drug or vaccine on a laboratory scale has
usually been done in university research laboratories, paid for

by federal research grants. But companies must take the labora-
tory findings and scale them up to industrial standards, as well as
meeting tough FDA safety and efficacy guidelines. This can be an
expensive process, and technical problems can be encountered
in the scale-up which cannot be predicted from the preparatory
research done in universities. This has caused some major drug
companies to decline to engage in BioShield projects, leaving
smaller and less experienced companies to fill the need.
This aspect of BioShield is of continuing concern to HHS,
the FDA, and company leaders. As Congress adjourned at the
end of 2006, a bill was passed (the Pandemic and All-Hazards
Preparedness Act) providing $1,000,000,000 over two years to
aid companies in early-stage research on needed drugs and
vaccines. Use of these funds will be overseen by a new branch
of NIH, the Biomedical Advanced Research and Development
Authority (BARDA). This Act also clarifies the lead role of HHS,
to the exclusion of Homeland Security, in the health and medical
aspects of all public health emergencies.
S TA N D I N G G UA R D: T H E B I O WAT CH A N D
BIOSENSE PROGRAMS
Among the lessons gleaned from the Amerithrax incidents was

the need to identify when a bioterrorist attack has occurred as
early as possible. Most pathogens have a significant incubation
period inside a host before disease symptoms appear. By that
time, the pathogen has expanded billions of times within the
body, and the resultant disease may be difficult to control.
While we may never know the exact sequence of events dur-
ing Amerithrax, it was probably at least a week after the anthrax
spores were disseminated that the first infected individuals began
showing up at local hospitals. Even then, unfamiliarity of medical
personnel with anthrax resulted in additional delays before cor-
rect diagnoses were made and appropriate treatments initiated.
These delays in combination likely resulted in some deaths that
could have been prevented if action had been initiated sooner. If
doctors and hospitals had been warned to be on the lookout for

anthrax cases, with symptoms clearly described, earlier detection
of active infections could have been made. Prompt administra-
tion of antibiotics such as Cipro or other medications—even on
a prophylactic basis—could have slowed the spread of disease
within individuals and reduced fatalities. SNS resources could
have been mobilized more rapidly. That is the rationale behind
the BioWatch Program.
BioWatch, established in 2003, is essentially a network of
early warning biosensors under the overall supervision of the
Department of Homeland Security. The network consists of three
main components: sampling, analysis, and response.3 Each of
these components is overseen by a separate agency. Sampling is
overseen by the Environmental Protection Agency (EPA), which
has placed filters capable of trapping airborne pathogens into its
already established system for monitoring air quality. Analysis of
these filters is carried out every twenty-four hours in regional test-
ing laboratories4 under supervision of the CDC. During a given
twenty-four hour period, filters within the sensors are imprinted
with the time and automatically replaced every hour, to pinpoint
the exact time of an attack.
Details of the BioWatch program are understandably vague,
for security reasons. The initial round of installation of sensors
included approximately thirty cities, with an assumed eventual
goal of covering perhaps a hundred metropolitan areas. While
some sensors are associated with existing EPA air quality moni-
toring stations, it is thought that many others are not. Siting of
permanent sensors is a highly sophisticated science, utilizing sat-
ellite imagery and detailed climatic data from the U.S. Weather
Service. So-called “special event” sensors are more mobile, and
can be tailored to specific sites. Mobile sensors were strategically
placed in venues for the 2002 Winter Olympics in Salt Lake City,
for example. Special sensors have also been set up in major postal
handling facilities.
BioWatch sensors have triggered several alarms to date, in
San Diego, Washington, D.C. and Houston. The Houston and
Washington incidents involved F. tularensis, the bacterium that
causes tularemia; the alarm in San Diego was caused by Brucella
sp. Both pathogens are present to some extent in the natural
environment. In all three cases, the levels detected were below

those officially set to trigger a full response, but local health
authorities were alerted to be on the lookout for specific symp-
toms. Exhaustive analysis of all data suggested that these three
occurrences were natural rather than the result of any overt
action.
The BioWatch Program is not without its critics. It has been
pointed out that it would have had no impact on the Amerithrax
attacks, because the spores were all released within buildings,
and would not have reached EPA sensors mounted in the affected
metropolitan areas. Defenders counter that at the very least,
knowledge that such detection systems exist could lessen the
likelihood that terrorists would mount a major outdoor attack in
large cities.
Concern has also been expressed about the cost of equipping
and maintaining a large network of sensing stations, especially
in the labor-intensive data analysis phase. The Department of
Energy is currently working on a completely autonomous patho-
gen detection system that could drive down the costs of analysis,
and reduce even further the incidence of false-positive and false-
negative incidents. But BioWatch is not one of the “dual-purpose”
components of recent improvements in American public health
preparedness. It is aimed solely at managing a bioterrorist attack.
If bioterrorism is a low-probability/high-consequence event,
how much is it worth to buy the extra security that BioWatch
costs U.S. taxpayers? Current estimates are that it costs about
one to two million dollars to install a BioWatch system in each
metropolitan area, and about two million dollars a year in each
area to maintain the system and process samples. The benefits
of early detection depend on the pathogen used in an attack.
Most cost-benefit estimates have been based on analyses of an
anthrax attack, because that is what we know most about. But
anthrax, while deadly, is not infectious. The benefit of early
detection in the case of an infectious agent like smallpox could
be significant.
The BioSense Program is a still-evolving program with the
objective of using computer-based systems for analyzing reports
of health-threat incidents from major metropolitan centers
across the United States. The purpose is to provide the earliest
possible alarm that unusual disease patterns may be emerging,

whether they result from terrorism or from natural outbreaks.
Participating medical centers will share their own computerized
records of illness reports with the BioSense Program, which will
develop new electronic tools for spotting potentially important
clusters of disease incidents that require further and immediate
analysis. Many of the software programs to do this are still in a
developmental stage, but when fully operational are expected to
add critical hours to days in the public health response to emerg-
ing outbreaks.
The federal government has established a set of goals that
states should meet in order to consider themselves prepared to
deal with catastrophic health emergencies. It must be admitted
that many states are still struggling to meet these goals; as of 2006,
only one (Oklahoma) had met all ten preparedness benchmarks
(Box 7.2).5 Still, the United States has made impressive progress
in the past half-dozen years in building a stockpile of drugs, vac-
cines, and equipment that would greatly limit the damage terror-
ists might inflict on us with bioweapons. This doesn’t mean we are
completely immune to bioterrorist attacks, but the knowledge that
the damage done by such attacks would be considerably less than
might have been hoped for just a few years ago, together with the
technical difficulties in producing an effective bioweapon, could
be a major deterrent for many terrorist groups.
Total federal spending on programs to defend us against
bioterrorism are shown in Figure 7.1.6 The amounts indicated
do not include spending for Project BioShield, which totals
about $3,300,000,000 across the period shown. If the 2007 and
2008 amounts hold, the United States will have spent about
$45,000,000,000 on biodefense since 2001.
T H E N AT I O N A L S T R AT EG Y FO R
PA N D E M I C I N F L U E N Z A , 20 0 6
It’s been a favorite mantra over the past two decades among those
urging America to move forward more forcefully in its prepara-
tion for a bioterrorist attack: “It’s not a question of if,” they say, “but
BOX 7.2
Preparedness Scores (by State)
4 5 6 7 8 9 10
California Alaska Colorado Delaware Alabama Kansas Oklahoma
Iowa Arizona Indiana Florida Kentucky
Maryland Arkansas Louisiana Georgia Michigan
New Jersey Connecticut Massachusetts Hawaii Missouri
D.C. Mississippi Idaho Montana
Maine Nevada Illinois Nebraska
Ohio New Mexico Minnesota South Dakota
Pennsylvania No. Carolina New Hamp. Texas
So. Carolina Oregon New York Virginia
Rhode Island No. Dakota Washington
Utah Tennessee West Virginia
Vermont Wyoming
Wisconsin
States are listed under the total number of ten federal benchmarks for bioterrorism preparedness they have met.
For a complete discussion of the ten federal benchmarks, see note 5.
6
Dollars (Billions)
2001 2002 2003 2004 2005 2006 2007* 2008**

Fiscal Year
Figure 7.1 Biodefense spending by fiscal year. *Estimated. **Requested.

Excludes funding for BioShield.
when.” That could conceivably be true with regard to bioterror-

ism; it is an absolute certainty with natural pandemics. As of April
2007, H5N1 had appeared in wild or domestic birds in over fi fty
countries, including the United States (in wild swans in Michigan
in August 2006, and in wild ducks in Pennsylvania and Maryland
in September of that year). Hundreds of millions of birds world-
wide have died from the virus, or been culled. The virus is so
widespread in Southeast Asia that it is now considered endemic
there. As the number of birds infected with H5N1 increases, the
odds of a mutation occurring that makes either bird-human or
human-human transmission easier increases accordingly. And
that spells pandemic.
The past record is clear: pandemics are simply a fact of life that
we must adjust to, like death and taxes—and, yes, global warm-
ing. We cannot say the next pandemic will be caused by H5N1,
although for now that seems the most likely candidate. Nor can
we say when the next pandemic will be, or how severe, any more
than we can say when the next bioterrorist event might be or how
much damage it could cause. But if it’s true that we need a plan to
deal with bioterrorism, it is even more true that we’d better have
a plan for the next pandemic.
True, the several Acts we have talked about so far in this chap-
ter also help us prepare to defend ourselves against a pandemic.
But the bulk of the effort and money generated by these Acts
have been directed specifically against the threat of bioterror-
ism. Many in this country have long argued that this is a bit like
the tail wagging the dog. Bioterrorism may be a threat, they say,
but one of low probability and indeterminable cost. Natural pan-
demics are a slam dunk. And now those who think pandemics
should have a plan of their own to line up behind have one. Its
supporters are confident that actions taken under its prescrip-
tions will more than adequately prepare us for a bioterrorism
attack. Finally, they say, the dog is wagging the tail.
The National Strategy for Pandemic Influenza (NSPI), drawn
up by the Homeland Security Council, was presented to the pub-
lic in several stages beginning in November 2005.7 NSPI takes a
wider aim than the previous bioterrorism acts, as articulated in
the opening document: a pandemic health crisis will necessitate
a strategy that
extends well beyond health and medical boundaries, to include

the maintenance of critical infrastructure, private sector activi-
ties, the movement of goods and services across the globe, and
economic and security considerations. . . . [NSPI] guides our pre-
paredness and response to an influenza pandemic with the intent
of (1) stopping, slowing or otherwise limiting the spread of a pan-
demic to the United States; (2) limiting the domestic spread of a
pandemic, and mitigating disease, suffering and death; and (3)
sustaining infrastructure and mitigating impact to the economy
and the functioning of society.
According to the official Implementation Plan for NSPI, pre-

sented in May 2006, NSPI
provides a high-level overview of the approach the Federal

Government will take to prepare for and respond to a pandemic,
and articulates expectations of non-Federal entities to prepare
themselves and their communities.
10 Figure 7.2 Funding

for the National Strategic
Pandemic Influenza plan.
*Estimated. **Requested.
Dollars (Billions)
(6.06)
(1.50)**
(0.11) (0.18)*
2005 2006 2007 2008

Fiscal Year
President Bush asked Congress for $7,100,000,000 over sev-

eral years to fund the aims of NSPI; it appears that Congress
may supply somewhat more, and about 90 percent of that will be
allocated to HHS (Figure 7.2). The Pandemic and All-Hazards
Preparedness Act of 2006, referred to earlier, requires HHS to
set influenza pandemic public health preparedness standards for
states, and defines penalties for failure of states to do so.
Oversight of the federal effort to implement NSPI will rest
jointly with the Department of Homeland Security and HHS.
DHS will coordinate federal operations, resources, and commu-
nications with state, local, and private entities. The Secretary of
HHS will be the federal spokesperson on all public health and
medical issues.
NSPI and its Implementation Plan define three major pillars
of America’s response to the threat of a catastrophic influenza
pandemic. These do not define three sequential actions we must
pursue to manage a pandemic crisis, but rather three interacting
concerns that affect each action we take:
• Preparedness and communication—Activities that
should be undertaken in advance of a pandemic to
ensure we are as prepared as we can be, and clear com-

munication of the roles and responsibilities expected
of all levels of government and individuals in managing
the crisis;
• Surveillance and detection—Domestic and international
monitoring systems to provide continual tracking of
potential pandemic viruses, so that we have the earli-
est possible warning of a pandemic that may reach the
United States;
• Response and containment—Actions to limit the spread
of a pandemic once it is officially declared, in order to
mitigate the health, social, and economic consequences
to the American people.
The Implementation Plan sets forth a number of steps the United
States must take to meet these goals.
P R E PA R E D N E S S A N D C O M M U N I C AT I O N
D e v e l o p a n d S t o c k p i l e Va c c i n e s
Currently there are two substrains of H5N1 wreaking havoc
among birds. A limited amount of vaccine has been prepared
against one of them, as discussed in the last chapter, and is cur-
rently being stockpiled. Work on a vaccine for the second sub-
strain is proceeding apace. Both of these will be “best-guess”
pre-pandemic vaccines. We won’t know if they are effective against
the pandemic H5N1 variant until that variant actually arrives.
The goal is to have enough pre-pandemic vaccine to immunize
20,000,000 people. The hope is that pre-pandemic vaccines will
be useful in slowing spread of a pandemic until a vaccine specifi-
cally tailored to the pandemic agent can be prepared.
In addition, the federal government will provide financial
assistance to upgrade existing vaccine production facilities in the
United States, and to build new ones if necessary. The govern-
ment, through NSPI, will also fund research into more rapid and
effective procedures for producing vaccines. In the 1970s, there
were two dozen vaccine manufacturers from which America
could buy flu vaccines; today there are five. A large proportion
of our seasonal flu vaccines come from other countries. In the

event of a worldwide flu pandemic, we may not be able to rely
on those resources. Those of us over sixty (the primary demo-
graphic group for flu vaccination) remember what happened in
2004, when one of the overseas facilities had to shut down; the
United States had less than 40 percent of the needed doses of flu
vaccine that year, and millions went without a seasonal flu shot.
Stockpile Antiviral Drugs and

Other Supplies and Equipment
The domestic goal is to have enough drugs such as Tamiflu or
Relenza in federal and state repositories to treat 25 percent of
the population, or about 75,000,000 people. As of spring 2006,
enough courses of Tamiflu to treat about 20,000,000 people had
been stockpiled.8 Antivirals will also be positioned, under inter-
national control, near pandemic high-risk countries. Emphasis
has been on Tamiflu, since this drug can be used to prevent infec-
tions in persons at high risk at the site of an outbreak as well as
treat those already infected. Influenza A viruses are rapid muta-
tors, and substrains resistant to any particular drug could arise
under pressure from that drug. NSPI thus also supports research
into developing new antiviral drugs, which are usually less easy to
escape from by mutation on the part of the virus.
Finally, NSPI will provide funds to purchase up to 6,000 new
ventilators, 50,000,000 surgical face masks, and 50,000,000 N95
respirators9 for domestic use. Many more ventilators would be
needed to handle even a moderate pandemic; suffocation dur-
ing pneumonia was the most common cause of death during the
1918 pandemic. But it’s a start.
C o o r d i n a t e Fe d e r a l , L o c a l ,
a n d Stat e R e s p o n s e s
The most important way that a pandemic will differ from a bio-
terrorist attack is that the latter, like a major earthquake or hur-
ricane, will be a localized disaster, with rapidly mobilized help
rushing to the site from all around the country. In the United
States, the full force of protections such as the Strategic National
Stockpile, VMI, FEMA, and other federal and state resources can
be focused rapidly on the site of the attack. A pandemic, by defi-
nition, will spread rapidly to many sites throughout the world and
within the United States itself, with both domestic and foreign
“hot spots” shifting constantly. The NSPI emphasizes that a pan-
demic will be more like a full-scale war than a terrorist attack,
and goes on to state:
in a pandemic, conditions would make the sharing of resources

and burdens even more difficult. . . . in the event of multiple simul-
taneous outbreaks, there may be insufficient medical resources or
personnel to augment local capabilities.
Thus authorities are already warning that every level of our

polity—individuals, families, cities, counties, and states—must
develop self-sufficiency plans to protect and sustain themselves
as long as possible. In a serious pandemic, there may be little or
no help flooding in from anywhere for quite some time. To this
end, NSPI is organizing a series of Dark Winter–like exercises in
every state to test preparedness for a pandemic, and states are
expected to conduct similar exercises at county and city levels.
E n h a n ce C o m m u n i c at i o n s a n d
Public Awareness
As in a bioterrorist attack, but on a much broader scale, it will
be extremely important that accurate information and advice
that the public trusts and follows be made available. But unlike
a bioterrorist attack, a pandemic will stretch over a much lon-
ger period of time, on the order of months at the least, and up
to a year or more. People who give out information or advice
should themselves be experts in the areas they are discussing,
and should be retained throughout the crisis for purposes of
public continuity. Inadvertent misrepresentation of facts in such
situations can be disastrous. Information to be distributed must
take into account the changing ways in which people access
information in an information technology society. It will also
be important to provide U.S. citizens with accurate, up-to-date
travel advisories.
SURVEILL ANCE AND DE T EC T ION
D e t e c t i n g a n E m e r g i n g Pa n d e m i c
A key element underlying the NSPI is to identify as early as pos-
sible, at the initial site of a potential pandemic anywhere in the
world, the precise identity of the underlying virus. Speed is of
the essence: all three twentieth-century flu pandemics, although
of widely varying severity, engulfed the entire globe in just a few
months. Identification of a virus can be done rather quickly, but
it may take a week or so for experts to be convinced that the viral
variant has all of the elements necessary to cause a pandemic:
the ability to pass readily from animals to humans, the lack of
any immunity to the variant in the human population, and ready
transmission of the variant between human beings. Absolute cer-
tainty before sounding an alarm is critical: the last thing anyone
wants, for as long as such a crisis looms over us, is a false alarm,
leading to a massive worldwide mobilization that has to be with-
drawn. This would result in a loss of confidence within the public
and a more tentative response when a real pandemic emerges.
The United States will work with other countries and with the
WHO and other international agencies to track the wanderings of
H5N1 or other flu A variants as they travel the world with migra-
tory birds. To this end also, the United States will greatly increase
monitoring of migratory birds as they pass through its own terri-
tory. As we have seen, birds harboring H5N1 have already been
detected in the United States.
I d e n t i f y i n g a n d Tr e a t i n g
Infected Individuals
Once a pandemic is underway, speed of identification of infected
individuals is of the utmost importance. In the case of influenza,
infected persons can begin spreading the virus to others in as
little as forty-eight hours after infection. Estimates are that the
number of persons infected will likely double every three days in
crowded locations. There are test kits available to public health
officials that can analyze fluid samples for the presence of influ-
enza virus in about an hour. Unfortunately they cannot as yet
distinguish different variants. NSPI is supporting research into

making these tests faster and more specific.
C o n t r o l l i n g t h e P a n d e m i c I n t e r n a t i o n a l ly
It will be in the interest of the United States to work to prevent,
and participate in controlling, a pandemic that may surface in
another country, to prevent or at least slow its spread to this coun-
try. The United States, through NSPI, has already established
an International Partnership on Avian Pandemic Influenza.
Through the partnership, and in cooperation with international
health agencies, the United States will assist countries deemed
at high risk for a pandemic outbreak to develop state-of-the-art
monitoring facilities and to improve veterinary facilities, among
other things.
Va c c i n e P r o d u c t i o n
One of the most important outcomes of early detection and
definitive identification of a pandemic influenza variant will be
the ability to begin immediately to design and produce a vaccine
specifically tailored to control of this variant. All other responses
at the beginning of a pandemic are aimed at slowing its spread
by other means until such a vaccine is available. NSPI is thus also
providing funds to enhance the ability of vaccine manufacturers
anywhere in the world to respond with all possible speed once
the variant is identified.
R E S P O N SE A N D C O N TA IN M E N T
Interestingly, the NSPI rests almost entirely on the assumption

that a pandemic would arise outside the United States, and the
response and containment plan is formulated accordingly. Much
of the initial discussion in Chapter 5 of the Implementation Plan
focuses on “securing the borders.” But it is not at all inconceiv-
able that the crucial mutation(s) required to create a worldwide
pandemic could arise in wild or domestic birds right here in
America. And while in many ways response and containment
actions would be the same, many of the social and economic dis-
locations resulting from a pandemic arising here would be differ-
ent from one arising outside the United States. (For example, see
the Dark Winter scenario in chapter 1).
In terms of protecting human health, the Implementation
Plan rightly states that
The cardinal determinants of the public health response to a
pandemic will be its severity, the prompt implementation of local
public health interventions, and the availability and efficacy of
vaccine and antiviral medications. [Health measures will be]
determined by the ability of the pandemic virus to cause severe
morbidity and mortality, and the availability of and effectiveness
of vaccines and antiviral drugs.
Surge Capacit y
One of the greatest challenges, for pandemics as well as for bio-
terrorist attacks involving contagious pathogens, is the problem
of medical surge capacity. In both cases, shifting either patients
or resources to other locations will be very difficult, often impos-
sible. Again, local self-reliance will be the word of the day. Yet for
the past ten years we have been forced to slim our medical ser-
vices to a bare minimum as we have attempted to control health
care costs. As a result we have almost no extra local capacity to
meet a nationwide health crisis.
NSPI will work with states and communities to develop plans to
deal with the surge in demand for health care personnel, supplies,
and equipment. States are urged to identify, certify, and register
in advance—now, not when a crisis arises—health care volun-
teers who can be called upon when the time comes. These could
include retired doctors and nurses, physician assistants, emer-
gency medical technicians, and former military medics, among
others. The demand for hospital beds will certainly greatly out-
strip the few empty beds in most communities, and alternatives
must be planned for. Triage will likely be necessary to be sure per-
sons receiving beds, medicines, and medical attention will benefit
from them. Demands for health care by those not affected by the
pandemic virus must somehow continue to be met.
We are continuing to fund bioterrorism preparedness at about

$8,000,000,000 annually, the same rate at which it has been
funded since 2004. NSPI has requested at least $7,000,000,000 to
get its programs off the ground. The General Accounting Office
can be expected to point out to our politicians that this may be
an excellent opportunity to review the projects and funding in
both programs and weed out needless duplication. The major
focus of both remains the upgrading of public health and emer-
gency medical services to deal with catastrophic health crises. We
will soon have increased our protection against bioterror threats
to a point where additional defenses may not justify the cost. We
are far from that point with respect to dealing with a major pan-
demic, which has different requirements, but NSPI marks a real
beginning.
chapter 8
Political, Legal, and

Social Issues in a National
He alth Emergency
During the Dark Winter exercise of June 2001,

one of the questions the unscripted participants had to grapple
with was: who is running the show in a nationwide health crisis?
Is it the federal government, or individual states? If it’s a joint
effort, who’s responsible (and has the authority) for what? Would
it matter whether the crisis was precipitated by a natural outbreak
of deadly disease or by a terrorist attack interpreted as a hostile
action against the United States?
These are not questions that would arise in other modern
industrialized nations, all of which have centralized, dominant
governmental public health structures. It is a question in the
United States of America in the twenty-first century because of
our unique origin as a confederation of independent states that
happened to occupy a common continental land mass. It could
possibly become a question one day in the continually evolving
European Union. They will have the advantage of having watched
us struggle with questions of this type for over 200 years.
In the United States, it is generally agreed that preservation
of the public health is a power granted to individual states, as
an exercise of their constitutionally guaranteed policing powers.
But after the events of September 11, 2001, and especially in the
wake of the subsequent postal anthrax attacks along the East
Coast, both the executive and legislative branches of the fed-
eral government took steps to strengthen the U.S. public health
response to catastrophic biological events, from whatever source.
The Public Health Security and Bioterrorism Preparedness Act
of 2002 (chapter 7) was one response, setting out what the fed-
eral government was prepared to do and what states were urged
to do. This Act was given added impact by the creation of the
Strategic National Stockpile and Project BioShield.
Reform was clearly needed. Existing public health laws in most
states can charitably be described as a patchwork. Internally,
many state laws evolved reactively, stitched together in an ad hoc
fashion from responses to crises each state had experienced in
its past. Each state’s past experiences having differed, there was
little conformity among states. Few state public health laws incor-
porate new health information and technology into their legal
underpinnings until new situations requiring new approaches
actually arise. Most also do not take into account changes in fed-
eral (and even their own state) laws dealing with issues such as
privacy or patients’ rights until a specific challenge is raised.
Even prior to September 11, there had been calls for a major
overhaul of the public health system in the United States, which
had been stretched to its limits dealing with the AIDS crisis begin-
ning in the early 1980s. The prestigious Institute of Medicine in
1988 issued a major report calling for upgrades in the ability of
public health systems to deal with large-scale health emergen-
cies.1 The federal government finally asked the Center for Law
and the Public’s Health, a consortium of faculty experts from
Johns Hopkins University and Georgetown University, to draft
a model for states’ reactions to such crises, particularly with
respect to laws that govern what state-level emergency respond-
ers and public health officials can and cannot do. Work on this
document was well underway when the September 11 attacks
occurred; the Amerithrax events and the public health crisis that
followed gave added urgency to the Center’s efforts.
One of the most important powers needed in catastrophic
health crises concerns coercive powers: mandatory medical
examinations and treatment of at-risk individuals, for example,
I S S U E S I N N AT I O N A L H E A LT H E M E R G E N C Y • 135
or compulsory isolation or quarantining of infected persons, or

even confiscation of contaminated property or human remains.
Individual states have approached these questions in a continu-
ing ad hoc fashion, with little regard for public health law in sur-
rounding states. Jurisdictional disputes can usually be resolved
with time, but in a bioterrorist attack, or a potential pandemic
involving agents like the SARS or H5N1 avian flu viruses, time
is the one thing we certainly will not have. The paralysis that
can set in when local, state, and federal jurisdictions are unclear
was glaringly apparent in the fumbled responses to Hurricane
Katrina in 2005. The present tribalistic nature of individual state
public health systems and laws could be a major impediment to
rapid, coordinated, and effective federal-state response to a cata-
strophic health emergency. It could cost human lives.
The result of the work done by the Center for Law and the
Public’s Health is called the Model State Emergency Health
Powers Act. It was crafted by the two faculties involved, but with
extensive input from a workshop of public health, emergency ser-
vices, and national security experts. A draft proposal coming out
of these efforts was then circulated nationwide to an even broader
range of public health and emergency response experts for addi-
tional review and comment before submission to the CDC.
It was called a Model Act because it was intended only as a guide-
line for states to consider as they crystallize their own thinking
about what powers they might have to assume in a catastrophic
health crisis along the lines of a Dark Winter. Subsequently con-
sidered and debated in nearly every state in the Union, the Act
provoked considerable debate and even some opposition, reveal-
ing fundamental splits in the way many Americans (and their
legislators) view the role of government in anything other than
building roads. As in so many other American debates, the schism
lay between collective action in the face of emergencies and pro-
tection of individual privacy and property rights; between con-
centration of power in the hands of an executive and individual
choice in decision making.
The Act is intended to prompt states to develop comprehen-
sive and integrable plans to deal with catastrophic health emer-
gencies, and to define clearly the legal bases for actions by state
and local agencies charged with handling such crises (Box 8.1).
BOX 8.1
Key Provisions of the Model Act
Article I Purposes and definitions.

Article II Planning for a public health emergency. Calls
upon each governor to appoint a Public Health
Emergency Planning Commission; requires
Commission to present Governor with a plan for
responding to public health emergencies.
Article III Detecting and tracking health emergencies.
Requires immediate reporting by doctors,
pharmacists, and veterinarians of unusual health
occurrences that might suggest a health emergency.
Article IV Declaring a state public health emergency.
Empowers Governor of each state to declare a public
health emergency. Grants the Governor emergency
powers to suspend certain regulatory laws; to shift
responsibilities and personnel within state agencies;
to mobilize the National Guard; to seek aid from
other states and from federal government.
Article V Special powers: property. Would grant governors
broad powers to seize, condemn, or order the
decontamination of property; to seize materials
and property required to meet the emergency; to
place health care facilities under control of state’s
public health agency; to control disposal of human
remains; to institute and control rationing of
health-related products.
Article VI Protection of persons. Grants governors the power
to compel examination, testing, and treatment of
affected individuals, and quarantining or isolation
of individuals and specific geographic areas.
Article VII Communication. Requires each state’s public
health authorities to inform the people of the state,
on a regular basis and by all available means, about
the declaration of an emergency, its expected or
estimated duration, steps being taken to control
the emergency, steps individual citizens should take
to protect themselves and their families.
The vast majority of states acted swiftly and have now upgraded
their own systems and collaborated with other states to develop
effective mutual aid plans.
In all of its provisions, the Model Act bends over backwards to
show sensitivity to religious or ethnic attitudes, as well as to per-
sonal and medical privacy concerns. The powers conferred under
full implementation of this Act are intended to be triggered only
in an extreme emergency, and to expire with the emergency.
There is ample precedent in American law for the temporary
suspension of civil liberties. But if we are to prepare ourselves
adequately for a real Dark Winter or a 1918-like flu pandemic,
there are a number of issues apart from training first responders
and stockpiling vaccines that we need to consider.
SOCIAL AND ECONOMIC CON T INUI T Y

I N A N AT I O N A L H E A LT H CR I S I S
Neither a bioterrorism attack nor a nationwide flu pandemic will

degrade our nation’s physical infrastructure, but both—and in
particular a widespread and long-lasting pandemic—will place
an uncommonly severe strain on our social and economic infra-
structures. Large-scale absences of employees involved in health
care services, in provision of utilities (gas, water, electric), and in
public safety, transportation, and many other critical areas will
strain our social structure to its very limits.
Maintaining continuity, and some sense of normality under
these conditions, will require careful planning. The National
Strategy for Pandemic Influenza recommends that public and
private employers anticipate up to 40 percent of their employ-
ees being unable to function at various times throughout a pan-
demic crisis. Not all of these may be ill. Some may be tending
to family members who are ill; some may simply refuse to work
in places they think are rife with disease. We can expect similar
problems, although probably of shorter duration, in the event of
a bioterrorism attack.
Private and public enterprises must begin to plan now for
continuation of essential functions in major health crises, for
their own and for the public good. We may have to practice
social distancing—basically, keeping people wherever possible out
of sneezing distance from one another in work spaces, schools,
churches, and other public gatherings. People may be required
to wear face masks in public—free supplies of these should be
stockpiled in appropriate places. Alternate worksites should be
explored to avoid employee crowding; people should be encour-
aged whenever possible to work at home via computer. Businesses
and government offices will need to establish conditions for del-
egating authority and responsibilities as employees at all levels
are removed from the workplace due to illness or family crises.
Of particular concern will be the ability of public safety offi-
cials to respond adequately to civil disturbances and breakdowns
in public order. As was laid out in the Dark Winter exercise, these
might arise as health care facilities are overwhelmed or as people
vie for limited supplies of vaccines or antivirals. Individuals may
try to force themselves or family members into health care facili-
ties ahead of others; they may also try forcibly to remove family
members from health care facilities where they have been iso-
lated or quarantined. Stress brings out the best in some people,
but the worst in others. This will place a further strain on police,
whose own ranks may have been thinned by illness.
Deciding who has access to scarce medical supplies and treat-
ment (medical triage) will present a major dilemma. For either a
bioterrorist attack or a natural pandemic, we may find ourselves
in a situation where there are not enough drugs or vaccine to
treat everyone who, under ideal conditions, might have access to
these treatments. Particularly in the case of a pandemic, initial
supplies of a true pandemic vaccine (as opposed to pre-pandemic
vaccines; see p. 125) will likely be insufficient to treat everyone
who wants it. In the case of influenza, we do have drugs for treat-
ing infected persons. But if transport of medical supplies becomes
disrupted in the chaos of the pandemic itself, getting these drugs
to where they are most needed may result in localized shortages.
Decisions will have to be made in such situations about who gets
the limited supplies available. How will these decisions be made,
and who will make them?
The overriding principle is in theory simple: drugs and vac-
cines should be distributed in such a way as to minimize the
number of people dying. But that does not necessarily mean giv-
ing them to sick people lined up at the clinic door on a first-
come, or even most-sick, first-served basis. Here are some of the
considerations decision makers will have to juggle.
• Health care workers (doctors, nurses, emergency medi-

cal technicians) are essential to keep hospitals and clin-
ics operating. Each such individual may be instrumental
in saving dozens, maybe hundreds, of lives. Protecting
these individuals will greatly increase the number of
people who can be saved overall.
• People charged with maintaining civic infrastructure—
those who know how to keep water, gas, and electricity
coming; those involved in public safety (police and fire);
those who know how to keep a city operating on a day-
to-day basis—all of these will be critical in assuring that
the cities and communities in which we will have to wage
our battle against lethal pathogens continue to function.
The chaos and confusion that would ensue should we
lose these people would certainly end up costing many
more lives than necessary.
• Hard decisions will still have to be made among those
presenting themselves at the clinic door. This is the most
emotionally traumatic form of triage (from the French
trier—to sort out), and it means deciding whether the
individual presenting can recover without treatment,
needs treatment and can likely be helped by it, or is too
advanced in a disease to benefit from treatment. This
may apply to things like ventilators or other scarce ICU
equipment, as well as to vaccines and medicines.
Triage is not a perfect science, but there are some guidelines,

especially for pandemic influenza. Flu vaccines are best if given
before infection, and certainly will have no impact on disease
beyond forty-eight hours after someone is infected—just about
the time they begin displaying symptoms. Persons already show-
ing signs of the flu may thus be turned away from vaccination
stations. Antiviral drugs are a little less certain. They work best
in the first two to three days of infection; if someone is showing
signs of advanced disease, the drugs probably should not be

wasted. They may be given a placebo to ease their anxiety and
move them on through the line, but not a drug that could truly
save someone else’s life.
The federal government, through NPSI, has committed to
drawing up a set of recommendations to assist states and local
governments in determining how scarce medical resources
should be distributed. It is anticipated that states and communi-
ties may adopt these as authority for triage procedures. As of this
date these guidelines have not yet been made public.
But even with federal guidelines, these are still terrible deci-
sions for someone to have to make, knowing full well that often
they must make them using on-the-spot intuition and impression
rather than hard laboratory evaluation. People will resist deci-
sions not to treat them, some violently. But in many situations
these decisions will have to be made, and those forced by circum-
stance to make them must be protected and held immune from
any liability. There is an entire field of legal inquiry that deals
with shielding those charged with making these and other deci-
sions in emergency situations.
A number of other unique legal issues will also likely emerge
in a national health crisis. There will almost certainly be indi-
viduals who will try to profit from the crisis by selling, on the
Internet or by other means, useless “medicines” or pieces of
medical equipment claimed to be necessary to protect against
whatever pathogen is threatening. If smallpox or Ebola were
used in a bioterrorism attack, there are at present no drugs that
will help. But many people will not know that. If vaccines or
antimicrobial drugs exist but are unavailable, desperation may
drive some people to find unorthodox sources to fill their per-
ceived needs. Some of the remedies obtained in this fashion
will doubtless be bogus, but packaged to look like bone fide
pharmaceutical products. Aside from being worthless, they may
lead those who buy and use them to believe they are protected
from disease and to take risks that endanger themselves and
others. False claims and worthless merchandise pass through
the Internet every day. Law enforcement officials may or may
not have time to deal with this problem, but it could very well
cost lives.
The law will also be tested in a national pandemic, or in a bio-

terrorist attack involving a contagious pathogen, in dealing with
a highly contentious public safety issue: the forcible confinement
of infected people—quarantine.
QUARANTINE
Quarantine goes back at least as far as the biblical Old Testament.

Leviticus counsels us to isolate lepers and burn their garments.
This advice was taken to heart during the fourteenth-century
episodes of bubonic plague. The word quarantine itself derives
from the Italian quaranta giorni, the forty-day period of isolation
for ships, their merchandise, and often their crews and passen-
gers after their arrival in European ports if they were coming
from plague-ridden cities. In local towns and cities where plague
had broken out through flea bites (see chapter 3), mandatory
isolation of people in their homes or in secluded locations was
common. In one form or another, and for an increasing number
of contagious diseases, quarantine was a common practice well
into the twentieth century.
In the United States, quarantining was originally established
as a colony (later state) right, which the federal government tried
at various times to preempt to deal with outbreaks of diseases
such as yellow fever and cholera. Through a long series of legal
maneuvers, states and their counties ended up as the primary
agencies responsible for domestic quarantine. But the federal
government still retains full authority to impose isolation and
quarantine on both U.S. citizens and foreign nationals to prevent
importation of contagious disease (Box 8.2) at international ports
of entry located in individual states. The main agency in charge
of federal quarantine is the CDC’s Division of Global Migration
and Quarantine. The U.S. Customs Service and the Coast Guard
provide enforcement if required. Violation of federally imposed
quarantine under these conditions is a criminal offense. The
federal government also claims the right to impose quarantine
within states in situations that threaten interstate commerce.
The use of quarantine as a public health measure gradually
fell off as our understanding of infectious disease became more
BOX 8.2
Contagious Diseases Subject to
Quarantine at U.S. Ports of Entry
Cholera Plague Tuberculosisa Yellow fever

Diphtheria Smallpox Influenzab VHFc
a
infectious forms only
b
pandemic forms ony, e.g., H5N1 avian flu
c
viral hemorrhagic fever
refined. By the early twentieth century we knew that not all infec-
tious diseases (diseases caused by a bacterium, fungus, parasite,
or virus) are contagious (readily passed from one person to
another.) The expanded development of vaccines, especially for
children, generated populations largely immune to most infec-
tious diseases, further reducing the need for quarantine.
Still, many people alive today remember a time when quaran-
tine signs would go up on the doors of homes sheltering someone
in the midst of a contagious infection. Today, on those occasions
when such steps are necessary, we tend to use the term isolation
for the segregation of contagiously infected individuals. Patients
with active tuberculosis are routinely isolated in hospitals. This
is not normally a controversial procedure. The term quarantine is
generally reserved for the segregation of individuals or groups of
individuals presumed to be or suspected of being contagiously
infected, until found to be free of disease. Mandatory quarantine
is an action that can provoke a range of civil rights sensitivities,
and for which health officials are most concerned about legal
precedent and authority, particularly if violation of quarantine
could be treated as a criminal offense.
The United States came perilously close to flirting with
quarantine in the early years of the AIDS crisis. Once HIV was
identified as the cause of AIDS and it became clear that AIDS
was a communicable infectious disease, some groups called
for the wholesale roundup and physical quarantine of all HIV-
infected individuals. Cuba is the only state that has physically
quarantined HIV-infected individuals almost since the inception

of the AIDS pandemic. But in Germany, a federal judge called for
tattooing HIV-infected persons and placing them in quarantine.
A noted American conservative commentator published an opin-
ion piece in The New York Times advocating the same procedure
here.
But in general, there has been little public support for such
measures throughout the world. In the United States, twenty-five
states did revise their public health laws to allow various forms
of restraint for persons who knowingly continued to engage
in behaviors that endangered others after they learned they
were HIV-positive. Fewer than a dozen HIV-infected persons
were actually placed into physical detention of any kind. More
commonly, they were required to attend counseling sessions,
as a result of which in most cases they voluntarily altered their
behavior. Nineteen of these same states also enacted criminal
statutes making continued HIV-related behavior endangering
others a crime (reckless endangerment was a common charge
in such cases).
The issue of quarantining came up again during the SARS
pandemic. In China, Hong Kong, and even Canada, large num-
bers of persons were in fact placed under formal quarantine. In
China, around 10,000 persons were quarantined, with the threat
of possible execution for those breaking their quarantine before
they were officially cleared. In the United States, President Bush
signed an executive order adding SARS to the list of commu-
nicable diseases subject to federal quarantine at ports of entry.
The few confirmed SARS cases in the United States were subject
to normal hospital isolation. Eighty-five individuals suspected of
being infected apparently all cooperated in some form of vol-
untary but monitored isolation. Given the restricted number of
cases in this country, quarantining on a scale that would threaten
civil liberties never became an issue. But if an H5N1-derived form
of avian flu infectious for humans should begin to approach epi-
demic status here, quarantine could become a procedure public
health officials want to use.
The heterogeneity of state laws affecting isolation and quar-
antine, and the ambiguity of the relationship between federal
and state law in these matters, worries many public health
experts. The imposition of quarantine could result in numer-

ous civil rights actions which, in a prolonged emergency like
a pandemic, could compromise an effective response. That is
why Article VI of the Model Act specifically, and in some detail,
addresses the issue of quarantine. It would grant to state pub-
lic health authorities the legal right to impose quarantine, and
make failure to comply with authorities a misdemeanor crime.
The state may also determine who has direct personal access
to quarantined individuals, when, and under what conditions.
Unauthorized people entering a quarantined building or area
could themselves be subject to quarantine. To the extent pos-
sible, individuals subject to quarantine would likely be confi ned
to their own home—together with their family. But if the num-
bers get overwhelming, those quarantined could end up being
housed together in special areas.
The issues of isolation and quarantine have come up
again recently with the emergence of drug-resistant forms
of Mycobacterium tuberculosis, the causative agent of TB. AIDS
patients are particularly susceptible to TB, and as TB-infected
AIDS patients are treated with ever more powerful doses of
TB-fighting drugs, we are seeing the emergence, through muta-
tion, of so-called multi-drug-resistant strains of M. tuberculosis
(MDR-TB), and the even more deadly extreme drug-resistant
strains (XDR-TB strains).
In South Africa, fifty-two of fifty-three HIV-positive patients
infected with these new TB strains died over a three-month period
in 2005. There is less experience with these strains in healthy indi-
viduals, but cases have arisen. In late 2006, a man with MDR-TB
who consistently refused to follow instructions for containing his
disease was forcibly incarcerated in an Arizona jail cell to protect
the public.4 In late May 2007, a man in the United States some-
how became infected with what was initially thought to be an
XDR-TB strain. He was allowed to leave the country, traveling to
several other countries and then back to the United States before
authorities caught up with him and placed him under formal fed-
eral quarantine, 5 the first time this had been invoked since 1963.
M. tuberculosis, even the XDR strains, are slow growing, and he
apparently had not reached the stage where he was infectious.
Public health authorities are examining their procedures to see
why he was not placed under immediate surveillance or quaran-

tine in the United States before traveling, or forcibly incarcerated,
upon recommendation of the CDC or the State Department, in
any of the cities he passed through. This individual was subse-
quently found to have MDR-TB rather than XTR-TB.
Quarantined individuals are guaranteed certain rights by the
Model Act. They have the right to petition an appropriate court
for relief, and the quarantining authority is obligated to inform
them of this right and to provide information on how to do so.
Quarantine beyond a ten-day period would automatically require
court review and written approval. Quarantined persons cannot,
for obvious reasons, appear in person to argue their own cases,
but must be represented by a proxy.
While quarantining may indeed be necessary to prevent
spread of an epidemic, this practice does have some inherent
dangers. Persons subject to quarantine, remember, do not them-
selves show any sign of disease. If they did, they would be imme-
diately isolated. Quarantined persons are only considered likely
to be infected. So there is a real risk, in fact a likelihood, that
some portion of those quarantined in their homes or in groups
do not actually harbor the infectious agent. As soon as those
who are truly infected exhibit disease symptoms, they will be
removed to an isolation unit. But in the meantime they may have
spread the infectious agent to others with whom they were quar-
antined, but who were not in fact infected at the time of their
quarantine.
Imagine yourself in a situation of group quarantine—forced
into close proximity with other persons who appear to authori-
ties to be, as you are presumed to be, at high risk of being
infected. You may feel strongly that you are not. But authorities
know that if they don’t choke off this epidemic at its source,
and quickly, it will become a pandemic, and thousands—maybe
millions—will die. What would you do if you were someone in
authority, expected to do whatever is necessary to control the
epidemic for the public good? What would you do if you were
quarantined and still in apparent good health, and for good
reason desperate to remain that way? These questions may well
be asked one day, and it behooves us all to think about them
ahead of time.
C O M P U L S O R Y VAC CI N AT I O N:
P R O B A B LY N O T
Vaccination is widely viewed as one of the most cost-efficient and

effective public health strategies. There is no question that vac-
cination has reduced deaths from infectious disease over the past
hundred years, particularly among children and young people.
Smallpox was completely eliminated as a naturally occurring
human infectious disease through a worldwide immunization
program. Infectious diseases that formerly laid waste to as many
as 10 percent of children before the age of three are now a dis-
tant memory. Yet today, a growing number of Americans resist
the practice of vaccination, particularly compulsory vaccination
of children as a condition for entering school. Such feelings cross
all categories of race, education, gender, and income; about one
in eight Americans declare themselves opposed to compulsory
vaccination. Similar proportions of the populations of most
European countries have traditionally opposed compulsory
vaccination.
Since 1980, all fi fty U.S. states have laws compelling vaccina-
tion of children against various vaccine-preventable diseases
before they can be admitted to school. The particular vaccine
requirements vary from state to state—only polio, diphtheria,
and measles immunizations are required in all fi fty. Moreover, all
fi fty states allow exemptions for medical reasons—a genetically
impaired immune system, for example, and status as a transplant
recipient or chemotherapy patient are everywhere allowable
exemptions. But forty-eight states grant exemptions for religious
beliefs, and twenty allow exemptions for personal philosophical
reasons. Philosophical opposition to vaccination has been a rap-
idly growing reason for requesting exemptions in recent years,
fueled largely by a suspicion that vaccines may not be safe for
even completely healthy children.
Concern about vaccine safety has been a longstanding unify-
ing theme for opposition to vaccination. Consider the following
excerpt from a book written in 1900:
The vaccination practice, pushed to the front on all occasions
by the medical profession, and through political connivance
made compulsory by the state, has not only become the chief
menace and gravest danger to the health of the rising genera-
tion, but likewise the crowning outrage upon the personal liberty
of the American citizen. . . . Compulsory vaccination, poisoning
the crimson currents of the human system with brute-extracted
lymph under the infatuation that it would prevent small-pox, was
one of the darkest blots that disfigured the last century. 6
For almost any vaccine, if one goes far enough back in the
record, instances of harm caused by a vaccine can be found.
More recently, there has been a persistent concern expressed
about the standard single-shot vaccine MMR (measles/mumps/
rubella) routinely administered to schoolchildren in most states.
A paper published in 1999 raised the possibility that this vaccine
might be responsible for an increase in autism-spectrum disor-
ders noted during the 1990s. This was a well-reasoned hypoth-
esis, and it triggered an immediate and intense investigation. It
also caused a large number of parents to insist that this vaccine
not be administered to their children, and many school districts
honored their request. After several years of very intense study,
it was concluded from epidemiological and laboratory data that
such an association does not exist. The original paper and its
claims were withdrawn by the authors. Nevertheless, to this day
an unfortunately large number of parents still refuse to allow
their children to be exposed to this vaccine.
Overall, it is beyond question that the risks posed to a child by
vaccination are thousands, if not millions, of times less the than
potential harm that can come from an infectious disease tear-
ing through an unvaccinated young body. But the other thread
that runs—deeply—through the opposition of many individuals
today can also be found in the statement above, made over a hun-
dred years ago: compulsory vaccination is viewed as “the crown-
ing outrage upon the personal liberty of the American citizen.”
In this view, the right to expose a child to enormous medical
risk is part of the “personal liberty of the American citizen.” The
book containing these and other strong statements was the bible
for a good half-century of a small but persistent element that
fought compulsory vaccination in this country tooth and nail.
Just punch “compulsory vaccination” into the World Wide Web,
and read articles like “Give Me Liberty, Or They May Give Me

Death.”
Not only are individuals protected from a particular microbe
by bolstering their immune systems; when populations are immu-
nized, individuals—even those not immunized—benefit from
the huge reduction in the frequency of that microbe in the vac-
cinated general population. Decisions of individual parents to
withhold vaccination of their children pose a grave threat not
only to their own children but to every child that comes into con-
tact with their children. In either case, this is not a victimless
decision; it affects all of society. That is the basis on which court
after court has upheld compulsory vaccination laws.
Given that the diseases cause by bioterrorism or pandemic
pathogens can have mortality rate ranging up to 60 to 80 per-
cent, most people will likely be willing, even eager, to be vac-
cinated. But past experience suggests there will be some who
for medical or religious or philosophical reasons will decline to
be vaccinated. What are we to do in such cases? What if one in
eight persons thought to be infected refuses vaccination? How
much will that compromise attempts to contain an epidemic
that could kill untold numbers of innocent people? The provi-
sions of the Model Act, if adopted, would provide a legal basis
for forced vaccinations, but it is hard to imagine someone being
physically restrained while a medical worker forces a needle into
his or her arm.
chapter 9
The Politics of
Bioterrorism in America
How did we arrive at our current national posture

regarding bioterrorism, especially in the context of other chal-
lenges our nation faces in the twenty-first century? The fear of bio-
terrorism has driven our leaders to spend over $40,000,000,000
since 2001 to defend us against it, even amid persistent doubts
about the magnitude of the threat it poses.
Although concerns about bioterrorism clearly predate 2001, it
is also clear that part of what has driven the near hysteria about
bioterrorism since that time is its conflation with a larger “war
on terror.” Declaring war on something is a time-honored way in
American politics to raise an issue to a level of unquestionable
urgency. In some cases, like Nixon’s “War on Cancer,” apotheosis
of an idea to a warlike status can summon up the afterglow of
America’s performance in World War II and harness America’s
energy for a noble purpose. More often, unfortunately, it breeds
anxiety and fear. The White House says it has identified over
80,000 potential terror targets in America but for security reasons
cannot say what those targets are. Zbigniew Brzezinski has made
the point that the war on terror has actually created a climate of
fear in America.1
Another part of the terror of bioterrorism is that unlike other
weapons of terror and mass destruction—bombs, chemicals,
nuclear devices—bioterrorism is based on things we cannot see

and few of us understand. We are reliant on scientific experts
to explain them to us, and that adds yet another layer of uncer-
tainty, both for the public and for political leaders. Science is not
pure, and scientific experts themselves have differing points of
view—political points of view—about bioterrorism, just as they
have differing points of view about global warming, or stem cell
research, or the beginnings of life.
One of the reasons the United States was willing to sign the
Biological Weapons Convention in 1972 was that our military
establishment (and those of most other nations) had, on a mostly
practical basis, lost interest in the utility of bioweapons. They
were difficult to use and to control and, based as they were on
biological organisms, subject to the vagaries of the differing envi-
ronments in which they might have to be used. The instances
of use of biological weapons in warfare are scant indeed, and
showed no particular advantage over conventional weapons. Still,
pressure to consider these same bioweapons as potential tools in
the hands of unskilled terrorists continued to build long after
the military decided to pass on them. How did this happen?
The pathway from rejection of bioweapons by our military to
their whole-hearted embrace by our politicians as putative weap-
ons of choice for terrorists wanting to harm us is long and com-
plex, and almost entirely political. A few of the major events that
helped shape this transition in our national thinking are sum-
marized in the paragraphs that follow.2
19 8 5
One of the early high-level alarms about the potential of biot-

errorism to cause major damage to an America ill-prepared to
defend itself against a catastrophic health threat is sounded. It
comes from a special committee of the prestigious U.S. National
Academy of Sciences, chaired by the distinguished Nobel lau-
reate and then President of Rockefeller University, Dr. Joshua
Lederberg. The subsequent report from this committee cites ter-
rorist use of even low-level biological weapons against American
civilians as a significant threat.
T H E P O L I T I C S O F B I O T E R R O R I S M I N A M E R I C A • 151
Lederberg, a microbial geneticist with impeccable credentials,

had been an early and forceful advocate of an international treaty
banning biological weapons. He had participated in the key 1975
Asilomar meeting and was one of the first, and most persistent,
to warn of the dangers of bioterrorism and the possibility that
the new field of genetic engineering could produce biological
weapons of unimaginable destructiveness. He also served as a
consultant to numerous intelligence and defense agencies, and
would be a particularly influential voice among those urging the
United States to take the threat of bioterrorism more seriously.
At the same time, he was among the first to raise the specter of
emerging natural pathogens as a major health threat.
19 9 2
Defection to the United States of Soviet bioweapons expert

Kanatjan Alibekov (later known as Ken Alibek). Alibekov had
worked in biological weapons programs for nearly two decades,
and at the time of his defection was second in command of
Biopreparat, the Soviet agency for bioweapons research. He
paints a picture of a massive Soviet effort, with tens of thousands
of scientists at dozens of laboratories, working to develop new
biological weapons and improve existing ones—notwithstanding
that the Soviet Union was a signatory to the 1972 Biological
Weapons Convention. He says the Soviets assumed we were doing
the same. In addition to work on all of the conventional patho-
gens that would soon show up on the lists drawn up by the CDC,
he tells his debriefers that the Soviets were also working on devel-
oping genetically modified pathogens for weapons use.3
Although Alibekov’s defection will not be known to the
American public until 1998, the essence of what he has to say
about the Soviet program quickly disseminates through the higher
levels of the administration and Congress. It will have a profound
influence on policy makers from that point on. Alibekov convinces
numerous U.S. politicians and institutions to sponsor a variety
of anti-bioterrorism research projects, with himself at the helm,
although most of these projects—along with much of the “hard
intel” he passed on to his debriefers—will later be discounted.4
19 9 2 , 19 9 3
Public awareness of bioterrorism is elevated by two reports issued

from the Congressional Office of Technology Assessment (OTA).
These reports address terrorism in general, but find that bio-
logical weapons might well be more attractive to terrorists than
even nuclear devices. Both reports declare biological weapons in
the hands of terrorists not only possible but likely, and urge the
United States to prepare its civilian population to withstand such
attacks.5
In a subsequent OTA report issued in 1993, the statement is
floated that an airplane disseminating 100 kilograms (about 225
pounds) of anthrax spores over a major metropolitan area could
cause between one million and three million deaths. Although
almost immediately challenged by any number of bioweapons
experts, this figure, quoted repeatedly over the next ten years,
contributes substantially to a growing hysteria about the dan-
gers of bioterrorism. Later that year, Dr. Lederberg urges the
Department of Defense “to take the initiative, together with the
Centers for Disease Control and Prevention, in formulating a
comprehensive plan for civil defense against a biological warfare
attack.”6
19 9 5
The first major push in Congress to address the threat of bioter-

rorism comes through the collaboration of two U.S. senators, Sam
Nunn (D-GA)7 and Richard Lugar (R-NB). They had previously
worked together to design legislation enabling the United States
to work with the Russian government to stem the flow of former
Soviet weapons of mass destruction and technical expertise to
states hostile to the United States. In late 1995, Nunn and Lugar
open hearings that result in a report entitled Global Proliferation of
Weapons of Mass Destruction. These hearings are stimulated largely
by the recent Aum Shinrikyo episode, and focus on the possible
use of WMD, including bioweapons, as agents of terror against
Americans on American soil.
Most of those who testify about bioweapons at these hearings

support Lederberg’s point about the woefully inadequate prepa-
ration of the U.S. public health and emergency response systems
to deal with the consequences of any kind of terrorism attack,
but bioterrorism attacks in particular. The overwhelming tone
of the hearings is that a bioterrorism attack on American soil
is a foregone conclusion: not a matter of if, but when. The Aum
Shinrikyo story and the antics of Larry Wayne Harris are put for-
ward as harbingers of things to come, and will be major factors
in increasingly loud calls for America to mobilize its ability to
defend itself against biological attacks.
19 9 5
William Patrick (among others) speaks at a high-level meeting

called by the Clinton White House to discuss the implications of
the Aum Shinrikyo affair. Patrick, who headed a major section
at Fort Detrick when it was still researching weapons for biologi-
cal warfare, has unassailable credentials as a bioweapons expert.
He was also a major debriefer of Ken Alibek after his defection.
Patrick makes a very persuasive case for the reality of the threat
of bioterrorist attacks in the United States, presenting a hypo-
thetical attack on the World Trade Centers using weaponized
botulin toxin dispersed through the buildings’ ventilation sys-
tem. He will continue to sound warnings about the dangers of
bioterrorism across the next decade.
19 97
Public awareness of the perceived threat of bioterrorism grows

considerably when in August of this year the Journal of the American
Medical Association devotes most of an entire issue to the subject.
Numerous op-ed pieces in the journal by luminaries such as
Joshua Lederberg and Defense Secretary William Cohen sug-
gest that bioterrorism on American soil almost certainly cannot
be averted. Various articles in this issue of the Journal describe
the history of biological warfare, provide brief descriptions of
conventional agents used in bioweapons, advise physicians on the

clinical recognition of bioterrorism victims, predict the psycho-
social consequences of a bioterrorist attack, and explore a num-
ber of related topics.
This focus of a highly regarded American medical journal on
the still somewhat esoteric topic of bioterrorism receives tremen-
dous attention in media outlets in America and throughout the
world. Several months later, on an ABC news program, Secretary
Cohen holds up a five-pound bag of sugar and declares that if it
contained anthrax spores and were dumped over Washington,
D.C., half the inhabitants of that city would be killed. One
imagines his choice of a target city is not lost on his political
colleagues.
19 9 6 – 9 8
Two books and a television program affect the thinking not only
of the public but of politicians. The Cobra Event describes release
of a genetically engineered form of the smallpox virus that
attacks the nervous system.8 Tom Clancy’s Executive Order pres-
ents a bioterrorist attack with an aerosolized Ebola virus.9 Both
books describe in lurid detail not only the effects on humans of
the pathogens involved, but the extensive social and civic break-
down that follows the attacks. President Clinton confessed to
having been greatly affected by The Cobra Event.10 An hour-long
ABC Primetime Live program called “Germ Warfare: Weapons of
Terror” parades a series of experts declaring a bioterrorist attack
in the United States to be a near certainty.
19 9 8
The Institute of Medicine, part of the U.S. National Academy

of Sciences, releases a report generally agreeing with the notion
that bioterrorism presents a major threat to the American peo-
ple, and points out that a great deal needs to be done to prepare
the American public health and emergency response systems to
deal with it.11 The report notes that although this would require
a huge investment of money, the upgrades that would result were

long overdue, and would benefit Americans even if a bioterror-
ism attack never occurred, especially in terms of being able to
defend themselves against emerging natural pathogens. HIV,
and the devastation it continues to cause in the United States
and around the world, is cited as a prime example.
19 9 9
The Johns Hopkins Center for Civilian Biodefense Studies is

established. The most prestigious of several such groups estab-
lished with federal support, this multidisciplinary group of fac-
ulty makes the strongest and most coherent case for increasing
preparedness for a bioterrorism attack. Their numerous policy
papers, and exercises such as Dark Winter and Atlantic Storm,
provide a major resource for those urging increased spending
for bioterror defense.
As the millennium approached, wrote Jeanne Guillemin, an
international security expert at MIT,
influential politicians and consulting experts broadcast apocalyp-

tic visions of thousands, even hundreds of thousands of Americans
dying from unnatural, intentional epidemics of anthrax, small-
pox, or some newly devised disease, invisibly inflicted by barba-
rous foreigners.12
2 0 01
And then, of course, came September 11, and the subsequent

anthrax attacks with their implications for the potential of
bioterrorism.
Having listened to the growing chorus of dire warnings by
impeccably credentialed scientific and terrorism experts, of
which the above is but a brief sampling; having only months
before digested summary reports from the Dark Winter exercise;
having been told by Alibek and our own intelligence agencies
that former Soviet bioweapons scientists were almost certainly
working in rogue states to produce tools for bioterrorists to use

against defenseless American cities—what were American politi-
cal leaders to do?
If they supported a massive effort to build a credible defense
against bioterrorism, as so many were calling for, and a bioter-
rorism attack never materialized, the worst that could happen
is they might be accused of having squandered taxpayer dollars.
Another federal boondoggle for companies that profited from the
resulting buildup; hardly news. As one writer put it, “we should
not have to wait for the biological equivalent of Hiroshima to
rally our defenses.”13 And besides, the politicians could always
claim it was the defenses they had built that had discouraged ter-
rorists from even trying.
But if they opposed spending billions of dollars on creating a
bioterrorism defense, and an attack occurred, and thousands—
perhaps tens of thousands—of people died, what then? Would any-
one praise them as prudent defenders of fiscal responsibility? Not
likely. They would probably go down in history as the most incom-
petent set of leaders this or any other country had ever produced.
Criminally negligent; maybe, in the minds of the public and subse-
quent historians, just this side of war criminals.
What would any of us have done?
What the U.S. government did was invest over $40,000,000,000
after September 11 to upgrade America’s ability to defend itself
against a bioterror attack. To some extent, this action also
improved our ability to defend ourselves against any major out-
break of disease, including a flu pandemic. But closer scrutiny
has led some government groups and many outside experts to
raise serious questions regarding the usefulness of our prepara-
tions to defend ourselves against bioterrorism,14 and indeed the
magnitude of the threat of bioterrorism itself.
Beginning as early as 1997, the Government Accountability
Office (GAO), a nonpartisan agency created by Congress to ana-
lyze the cost and effectiveness of federally funded programs,
issued a series of cautionary statements about the growing
funding for anti-terror programs generally, arguing that spend-
ing priorities had not been established. They also expressed
concern that sound risk-assessment studies had not been
carried out, goals had not been defined, and there was little
coordination of spending on the many programs that had been

approved. The GAO also questioned the likelihood of chemical
and biological weapons use by terrorists, given the complexity
of their production and utilization.15 Two years later the GAO
warned that risk assessment studies still had not been carried
out, particularly for expenditures to combat bioterrorism, the
dangers of which it continued to question.16
Individual political and scientific experts also raised caution-
ary flags about the direction and magnitude of our efforts to
defend against bioterrorism. Milton Leitenberg, trained as a sci-
entist and an arms control expert, prepared a detailed analysis
of the Aum Shinrikyo episode, in which he showed that far from
representing the dawn of a new and dangerous world in which
“anyone could do it” bioterrorism would be a major threat to
humanity, it suggested something far different:
Aum utterly and totally failed [to produce biological weapons],

after no small expenditure of time and money. . . . The experience of
Aum is . . . in marked contrast to the legions of statements by senior
US government officials and other spokesmen claiming that the
preparation of biological agents and weapons could be carried out
in “kitchens,” “bathrooms,” “garages,” “home breweries,” and is a
matter of relative ease and simplicity. 17
This point was echoed by Amy Smithson, when she was Director
of the Stimson Center’s Chemical and Biological Weapons
Nonproliferation Project:
The subject of unconventional [biological] terrorism was tailor-

made for hyperbole, and unfortunately much of what has been
said has made it difficult to ascertain the gravity of the uncon-
ventional terrorist threat. Taken together, the technical realities,
actual case histories, and statistical records of terrorist behavior
with chemical and biological substances undercut the rhetoric
considerably and point not to catastrophic terrorism but to small
attacks where a few, not thousands, would be harmed.18
Brian Jenkins, a terrorism expert with the RAND Corporation,

has repeatedly questioned the magnitude of the threat posed by
bioterrorism. He points out that, with the possible exception of
Al-Qaeda, there has been no indication that terrorist groups have

seriously considered the use of bioweapons as agents of terror.
But even Al-Qaeda’s interest in bioweapons for terror purposes
is open to question. Consider the following statement by Ayman
al-Zawahiri, left behind on a computer in Kabul, Afghanistan
after Al-Qaeda members had fled in 2001:
The enemy starting thinking about [biological and chemical]
weapons before WWI. Despite their extreme danger, we only
became aware of them when the enemy drew our attention to
them by repeatedly expressing concerns that they can be pro-
duced simply with easily available materials.19
Terrorism expert Bruce Hoffman summed up the years of
frantic governmental spending on bioterrorism after it took off
in the late 1990s:
[Bioterrorism] was where the funding was, and people were stick-
ing their hands in the pot. It was the sexiest of all the terrorism
threats and it was becoming a cash cow. So the threat of bioterror-
ism became a kind of self-fulfilling prophecy. It was archetypical
Washington politics in the sense that you generate an issue and it
takes on a life of its own.20
Many tried to remind us that the real biological threat to

Americans is, and will continue to be, emerging pathogens—
viruses like HIV, and possibly H5N1 avian influenza, or other
pathogens that may cross into the human species in the future,
and against which we have no innate immunity. We have known
about the threat of an H5N1 pandemic since the late 1990s. Had
we spent $40,000,000,000 directly on preparing ourselves to
deal with the threat of emerging pathogens, rather than many
of the quasi-military defense items associated with bioterrorism,
we would probably be as well prepared for a bioterrorist attack,
and certainly better prepared for a natural pandemic. But would
we have done it—would we have spent all that time and energy
and money—without the visceral response evoked by a more eas-
ily visualized attack by hypothetical bioterrorists, without the
umbrella of a “war on terrorism”?
That is an intriguing question, to be sure. Perhaps it is simply
that threats from pandemics, like those posed by earthquakes,
tornadoes, and hurricanes, can be viewed as part of the natural

order of things. At some level we expect to be hurt by them, even
killed. It’s part of living on a still turbulent planet. Bioterrorism,
on the other hand, is an attack on us by other humans, using a
natural pathogen or something derived from one as a weapon,
for the sole premeditated purpose of trying to harm or kill us.
That gets our blood running.
Fair enough. But our response to bioterrorism has not been to
seek out and destroy potential bioterrorists and their weapons.
Some of that is doubtless happening off the public’s radar screen,
but that is not what we have spent $40,000,000,000 on. We have
spent that money to prepare ourselves to survive a bioweapons
attack by vaguely defined (but usually bearded and turbaned)
foreign terrorists. So what is our bottom line? Is it to defeat bio-
terrorists, or is it to save lives? Our actions point clearly to the
latter. Preferably both, of course. But then why in the world do
we think we should just lie down and wait to die in a natural
pandemic?
Perhaps it’s that word natural again.
An increasing number of voices are telling us it is time to move
toward a more mature view of bioterrorism, to tone down the
rhetoric and see it for what it actually is: one of many difficult and
potentially dangerous situations America—and the world—face
in the decades ahead. No nation has infinite resources, and we
must accept that we will never be able to make ourselves com-
pletely safe from every threat we face. We will have to make ratio-
nal assessments of those threats we can identify, and apportion
our resources as intelligently and effectively as we can to deal with
them. Our final chapter takes a small step in that direction.
c h a p t e r 10
Assessing the Thre at
Make no mistake—a bioterrorist attack could happen.

But how likely is it that it will happen? No one can ever know for
sure; that is why some level of preparation is certainly essential. On
the other hand, a crippling pandemic caused by a variant of the
H5N1 flu virus, or some emerging pathogen we haven’t yet heard
of, certainly will strike us at some point. The question we must ask
ourselves—and our leaders—is, what are the most intelligent and
effective ways we can prepare ourselves for each of these unpre-
dictable threats, and how much of our limited resources should we
invest in defending ourselves against each?
In this chapter, we try to assess the threat of bioterrorism in three
ways. First, we ask what we have learned from the three episodes of
bioterrorism or biocrime described in chapter 2 that may be of use
in judging the likelihood of future bioterrorist attacks. Second, we
look at the possible pathogens terrorists might use against us, and
how well prepared we are to defend against them. Finally, we ask
who could—who would—carry out a bioterrorist attack against us.
I . W H AT H AV E W E S E E N S O FA R , A N D
W H AT H AV E W E L E A R N E D ?
Wh at We H av e Seen
t he r a jnee sh cult, oregon, 1984
Although it is arguable whether the attacks mounted by the
Rajneesh cult should be considered bioterrorism, they have
enough of the elements of what we might expect in a real bioter-

rorist attack that they are worth at least a brief visit.
What did it take to mount the attack? The agent,

in this case Salmonella enterica typhimurium bacteria, was distrib-
uted directly, by hand, onto salad bar foods by cult members.
It appears to have been in the form of a simple suspension of
bacteria in a broth, carried in a closed culture tube, and poured
directly onto the food. This is certainly an efficient method of
delivery, but has obvious limitations for terrorists looking for dra-
matic TV footage.
Where did the biological agent(s) come from? The

original salmonella cultures were traced to a scientific supply
house in Seattle, of the type that normally supplies such cul-
tures to university and medical center research laboratories, but
would, at the time, sell them to anyone who ordered them. The
Rajneeshees also purchased additional dangerous pathogens
from the American Type Culture Collection (ATCC), a large
East Coast facility that supplies medical and scientific labs world-
wide with all sorts of cells—human, animal, and bacterial, plus
viruses—for research purposes. The pathogens acquired by the
Rajneeshees included those causing typhoid fever, gonorrhea,
dysentery, and the CDC A-list pathogen Francisella tularensis. As
far as is known, no large-scale production of these agents was
carried out by the cult.
Today it would be impossible for an ordinary person to order
any of these agents commercially, and difficult to pilfer them from
a lab. The 2002 Bioterrorism Act requires both sellers and buyers
of Select List pathogens to have a license. Moreover, laboratories
that are approved to purchase Select List pathogens for research
are responsible for what happens with them, and are required
to secure them and to keep strict records of additions, removals,
expansion, and transfers to other licensed laboratories. Failure
to account fully for every organism under a laboratory’s control
could result in suspension of that laboratory’s license. While a
determined individual might still find a way to get at a lab’s stock
of Select List pathogens, it is much, much harder today than it
was in 1984, or even 2001.
A S S E S S I N G T H E T H R E AT • 163
Who prepared the agents used in the attack? Growth

of an ordinary bacterium like S. enterica typhimurium can be
carried out by anyone with a college-level laboratory course in
microbiology. At the Rajneesh compound, a nurse (who would
have had such a course) was the director of the Rajneesh Medical
Corporation, which consisted of a clinic, a pharmacy, and a
state-licensed medical laboratory. The cover provided by this lat-
ter facility made it relatively easy to order and receive biological
materials and equipment. The laboratory was staffed by at least
one licensed medical technician, who would have been specifi-
cally trained to grow bacteria.
One of the most important things we learned from the
attempts of the Rajneesh cult to use bioterror to influence local
politics was that, on the limited scale on which these individuals
were working, with a pathogen requiring little skill to prepare for
the uses they intended, they were able to cause substantial social
and economic disruption in a small demographic area for a short
period of time.
We also see in miniature in this episode what can happen
when public health services are overwhelmed in an acute emer-
gency. The only hospital in The Dalles, Mid-Columbia Medical
Center, had just 105 beds at the time, with only about a dozen
empty. A total of 45 people required hospitalization over a
roughly ten-day period. Health care resources during this time
were severely strained, reducing the level of care available to oth-
ers who required medical attention. Today, under the same con-
stant pressure to streamline health care experienced all across
America, Mid-Columbia has half the beds it had in 1984.
aum shinrik yo, 1995

Attempts to use biological terror agents for the furtherance of
religious or political goals were taken to a new level by the Aum
Shinrikyo cult. They mounted what is still described as the largest,
most expensive effort ever seen by a non-state entity to develop
biological weapons for the express purpose of mass murder.
The two pathogens Aum Shinrikyo tried most seriously to
develop into lethal bioweapons were anthrax spores and botu-
linum toxin. Both are many magnitudes more deadly than the
salmonella used by the Rajneeshees; botulinum toxin is the most
poisonous biological substance known. Anthrax spores are con-

sidered by the CDC to be at the top of the list of weaponizable
bacteria.
Aum Shinrikyo carried out at least seven bioterror attacks, four
with anthrax and three with botulinum toxin. In each case, by
their own subsequent admission, the goal was mass murder—as
many casualties as possible. Had they succeeded in developing
true weapons-grade pathogens and workable delivery systems,
cult members could have killed thousands, perhaps tens of thou-
sands, of people—certainly many more than died in the sarin
gas attacks. A close study of their failure to achieve their aims
may have a great deal to tell us about the shape of bioterrorism
in the future.
What was required to mount the attacks? To prepare

and execute successfully the kinds of bioterrorist attacks Aum
Shinrikyo was aiming for requires solving an equation in three
variables: state-of-the-art laboratory facilities; enough money for
equipment and supplies; and people with the knowledge, experi-
ence, and technical skills to carry out the program.
The cult had one or more modern, well-equipped scientific
research laboratories. These were well stocked with supplies
used in microbiology research. Whether they were equipped and
stocked properly for production of bioweapons cannot be ascer-
tained from the descriptions we have. Clearly they had more than
enough money available to undertake bioweapons production.
But someone would have had to know precisely what is required
to set up such a laboratory. That is where the people component
of the above equation comes in. It is true that compared with the
Rajneeshees, Aum Shinrikyo had an impressive staff of scientists
in the inner circle. But were they up to the task? With all of their
impressive credentials, what kind of preparation did they really
have to develop and deploy weapons-grade anthrax and botuli-
num toxin?
The backgrounds of many of the leaders of Aum Shinrikyo
are only sketchily known. Seiichi Endo was the cult’s Minister of
Health and Welfare, and played the lead role in trying to develop
biological weapons. He had a doctorate in molecular biology and
apparently did research in virology at Kyoto Medical School, one
of the better biomedical research centers in Japan. He would

have had some experience, perhaps considerable experience,
in handling microorganisms. As a trained research scientist, he
would also have had the ability to read the scientific literature
and in principle extract from it everything needed to work suc-
cessfully with both anthrax and botulinum toxin, including all of
the problems one normally encounters in this kind of work.
Why did they fail? Aum Shinrikyo had money, laboratories,

and a number of highly trained scientists. So why did they fail,
after several years of trying, to produce a functional bioweapon?
Aum Shinrikyo’s foray into bioweapons began with botulinum
toxin. Seiichi Endo collected C. botulinum from soil on the Japanese
island of Hokkaido and used this as starting material for the isola-
tion and purification of botulinum toxin. This is one of two ways
to acquire deadly biological agents for use as a weapon; the other is
to steal them from a university or government laboratory carrying
out research with these organisms.
University and government laboratories that undertake iso-
lation of pure materials from microorganisms harvested from
nature know that it requires a full range of skilled scientists who
are experienced in each of the many phases required for isola-
tion and purification of microbial products. For example, in the
case of botulinum toxin, it is not enough to know that it is made
by a bacterium called C. botulinum that lives in soil. As we have
seen, there is not just one C. botulinum; there are at least seven
different strains of this bacterium, each producing a different
neurotoxin. Only three of these are toxic in humans. There are
even regional substrains of these strains, each differing from the
others in tiny but possibly important ways. It takes a real expert to
properly identify the right germ to begin working with.
A specialized microbiology research laboratory will also have
skilled protein biochemists, who can take a crude extract of bac-
terial toxin and put it through the many rigorously controlled
steps needed to bring the toxin to a purity hopefully approach-
ing 100 percent. Preparations of toxin contaminated with left-
over bacterial cell-wall products, for example, may trigger a
violent immune response which, while not directed specifically
at the toxin, may in fact promote a generalized elevated state of
nonspecific immunity in affected individuals that could destroy

the toxin. This is a persistent (but well understood and con-
trolled) problem in vaccine production.
It is also necessary to know something about the stability of the
toxin in various degrees of purity so that it can be stored without
losing potency. In the case of botulinum toxin, highly purified
preparations are actually less stable than cruder preparations.
Sometimes chemical preservatives may be added, but attaining
just the right formulation of preservatives is tricky, and the for-
mulas are among the best-guarded secrets of most bioweapons
programs. Various methods of storage must also be tested, and
the exact conditions for maintaining stability over time must be
rigorously observed. But even under the best conditions, at ambi-
ent temperatures and humidity most biological preparations
cannot be maintained beyond a month or two.
Then there is the problem of choosing a method of delivery
that assures widespread dissemination of the toxin without dam-
aging it. Here it is crucial to consult with a biotechnologist, a
combination of biologist and engineer. Should the material be
spread from a low-flying aircraft? Wafted by fan from the back
of a moving truck or the roof of a building? Pushed through a
high-pressure spray nozzle? This requires knowledge of both the
material being disseminated and the mechanics of various dis-
seminating devices. The effect of dissemination on potency of
the toxin must be precisely determined.
And finally, one needs a knowledgeable meteorologist as part
of the team. Wind strength and direction, temperature, mois-
ture, and UV radiation from the sun, as well as many components
of automobile and industrial air pollution, can have a profound
effect on botulinum toxin. Wind must be considered not only
in terms of lateral direction but in terms of temperature-driven
updrafts as well. UV radiation from the sun can greatly reduce
the viability of many biological reagents. Failure to take all of
these variables carefully into account can decrease manyfold the
effectiveness of aerosolized bioweapons.
Endo also encountered serious problems producing weap-
onized anthrax. It appears that in this case, he chose the second
method for acquiring dangerous pathogens: he probably stole
them. Investigations by the Tokyo police suggested that Endo
had most likely obtained his anthrax seed cultures through a

lower-level cult member with ties to a local university.
Getting anthrax bacteria (however acquired) to grow in the
laboratory requires considerable knowledge of the requirements
of different strains. This usually comes from years of experience,
judging when cultures must be subdivided and recognizing from
the appearance of the cells themselves what more may be needed—
or perhaps what is present in excess—for optimum growth. These
are not things necessarily picked up in a university-level microbi-
ology lab course.
Even more skill is required to convert expanding cultures
to conditions that encourage a high degree of spore formation
without killing off huge amounts of bacteria. The conditions
that trigger spore formation are often lethal for the bacteria if
not managed properly. But even under the best of conditions,
there will be more bacteria (living or dead) than good spores,
and both living and dead bacterial cells must be gotten rid of in
order to end up with the highest possible degree of pure spores
that will germinate upon settling into human lungs.
Conversion of even high-grade anthrax spores to a form that
can be efficiently disseminated is another very tricky task. Ideally,
the spores should be released as a cloud of very dry individual
spore particles that stay aloft in the air as long as possible. This is
an important finishing step, which can be accomplished in a vari-
ety of ways, including coating the spores with electrostatic agents
that cause them to repel one another and not form clumps. Single
spores and small clumps of a few spores will stay aloft for some
time upon dispersal, increasing the possibility of inhalation, but
larger clumps will settle too quickly to the ground or other sur-
faces. Moreover, larger spore clumps, even if inhaled, tend to be
less infectious because they get trapped in the hair and cilia that
line the human airway and are destroyed.
So first of all the spores must be dried, which if not done prop-
erly can easily damage them. And once dried they must be stirred
gently to break up any large aggregates, which can lead to loss of
even more spores. Finally, truly weaponized spores would have
to be coated with an electrostatic agent. But Endo chose instead
to spray a liquid slurry of what he hoped was a lethal batch of
anthrax spores from the roof of the cult’s eight-story laboratory in
the Kameido region of Tokyo. This was almost certainly doomed

to failure. As Jonathan Tucker has pointed out,
The capability to disperse microbes and toxins over a wide area as
an inhalable aerosol . . . requires a delivery system whose develop-
ment would outstrip the technical capabilities of all but the most
sophisticated terrorists. Not only is the dissemination process for
biological agents inherently complex, requiring specialized equip-
ment and expertise, but effective dispersal is easily disrupted by
environmental and meteorological conditions.1
A sample of the material sprayed that day was collected by police,

and was finally analyzed at an American university in 1999.2 It
was found to contain a low level of anthrax spores and anthrax
bacteria, plus many other types of bacteria that may or may not
have been part of the material sprayed from the cult’s building.
A DNA analysis of the anthrax material showed that it was from
the Sterne 34F2 strain, used to vaccinate farm animals against
anthrax. It is essentially completely harmless in humans.
But even had Endo managed to steal a highly lethal strain of
anthrax, given the form of his preparation (liquid slurry), its
poor quality, the means used to disseminate it, and the lack of
attention given to weather conditions, the amount of damage
done to humans even in the immediate vicinity of the building
would have been minimal at best. Delivery of weaponized bio-
logical agents presented a formidable challenge that remains a
serious barrier to the use of biological weapons to this day. As
even William Patrick, a staunch advocate of a vigorous bioterror-
ism defense program, admits,
A dry [anthrax] product with the desired properties requires seri-
ous development with skilled personnel and sophisticated equip-
ment . . . [While] Iraq successfully produced high quality liquids of
anthrax and botulinum A toxin in quantity, their efforts to weap-
onize their agents were crude and far from successful. . . . By anal-
ogy, if a dedicated nation such as Iraq had problems with agent
delivery and dissemination, it follows that terrorists would also
experience these problems, and at a higher level of intensity. 3
So the reason for failure of Aum Shinrikyo’s failure can be

summed up in three words: people, people, people. It wasn’t a
lack of facilities. It wasn’t a lack of money. It was a lack of people

with years of experience in a dozen different scientific and engi-
neering specializations, either as active participants or as con-
sultants. As Amy Smithson, a chemical and biological weapons
expert now with the Center for Nonproliferation Studies, has
written:
True, almost any scientist can produce a toxic chemical or grow
a biological agent in a laboratory beaker, but the scientists most
likely to overcome the demands of causing mass casualties are the
particularly innovative and dedicated ones, the types who excel in
the creative environments of industry and academia. That mod-
ern-day Thomas Edisons and Madame Curies would flock to the
next Shoko Asahara or Timothy McVeigh begs skepticism.4
While there were a few among the Aum leadership with advanced
training in various scientific and medical fields, none were expe-
rienced in microbiology or other biological sciences directly
impinging on bioweapons development. None had the biotech-
nology background for large-scale pathogen production. None
had the engineering skills to produce an efficient weapons deliv-
ery system.
Some in the U.S. government saw the evidence of Aum’s dab-
bling in production of bioweapons as trumpeting a dangerous
new escalation in the global threat of bioterrorism. Others saw it
as evidence that producing effective bioweapons was not trivial,
and likely beyond the capabilities of even the most technically
sophisticated terrorists. The latter view did not prevail.
a meri t hr a x, 20 01
The anthrax attacks of September through early November of
2001 are very different from anything we have seen before in the
short history of modern bioterrorism, here or anywhere else. The
scale of the Amerithrax attacks was modest, in some ways even by
comparison with the Rajneesh caper. But it was more deadly; five
people died, and a dozen or so more were seriously injured.
What did it take to do it? The quality of the anthrax spore

preparations found in at least some of the letters tells us this was
not done along the lines of the Minnesota Patriots Council and
their homemade ricin. They were not made by an amateur micro-

biologist or a survivalist chemist.
The Amerithrax terrorist(s) possessed a lethal form of
anthrax—a purified spore preparation, completely dry and
finely dispersed into individual spores or very small clumps of
spores prior to dissemination, although they appear not to have
been treated with electrostatic agents. 5 The anthrax spores sent
to Senators Daschle and Leahy were, if not of the very highest
level of purity and potency, certainly good enough to cause very
serious problems. They were likely made in a government or pos-
sibly university research facility highly specialized in producing
anthrax spores.
The choice of delivery system for the Amerithrax incident har-
kens back to the Rajneeshees. It bypasses all of the complications
of choosing a dispersal device, and the damage such a device
might cause. It obviates all of the hard-to-assess vagaries of the
weather. It involves delivering the final weapon by hand; even
better, by the hands of others—unsuspecting postal workers. As
with the Rajneeshees’ salmonella, the efficiency of this method
is high: each of the recovered envelopes that could be tested had
less than one gram of spores—enough to kill dozens of people,
under the right conditions, and maybe more. It would be very
difficult to achieve anywhere near that efficiency by wafting the
spores through the air.
In the end, the most unsettling aspect of Amerithrax is that
it was likely not carried out by a foreign terrorist. At present, all
evidence suggests it was most likely an American scientist, who
was either working or had worked in an American laboratory—
possibly even a government laboratory—who carried out these
attacks. The failure of the FBI to identify the individual involved
suggests this was a highly sophisticated person who knew exactly
what it would take to cover his or her tracks.
W h a t H a v e W e L e a r n e d S o Fa r ?
Those who think deeply about America’s response to bioterror-
ism should be very clear about one thing. It is almost inconceiv-
able that any terrorist organization we know of in the world today,
foreign or domestic, could on their own develop, from scratch, a
bioweapon capable of causing mass casualties on American soil.

It just isn’t going to happen. The isolation and purification of the
requisite pathogens from nature, although theoretically possible,
is far beyond the ability of all but a handful of advanced scientific
laboratories in the world. So is development of a mass-scale deliv-
ery system for most pathogens.
It is still conceivable that terrorists could somehow manage to
steal a high-grade pathogen and use a low-tech delivery system,
as in Amerithrax. They could infect themselves, or coat their
clothing, with unweaponized contagious agents like smallpox or
Ebola and walk around in a crowded shopping mall sneezing on
or rubbing up against unsuspecting citizens. Or terrorists might
obtain a completed bioweapon, ready for use, from a third party.
We will discuss that possibility shortly. But first, let’s have a look
at the pathogens terrorists might try to use against us, however
obtained.
II. AGEN T S O F T ER RO R: A R E W E R E A DY
T O D E F E N D O U R S E LV E S ?
The above assessments of pathogen production or procurement

and weaponization by terrorists suggest it will be extremely dif-
ficult to prepare and deploy an effective bioweapon. But admit-
tedly, “almost inconceivable” is not the same as “absolutely
impossible.” What if someone succeeded? How well have the
preparations described in chapter 7 prepared us to survive a
bioweapons attack? Let’s begin with the CDC A list.
Smallpox
Smallpox comes closest to posing a threat that could equal a
1918-like flu pandemic, or the one we fear could develop from
the H5N1 avian virus. The Dark Winter exercise described in
chapter 1, among other things, convinced political leaders that
the United States needed to stockpile smallpox vaccine. Since
2001, about 100,000,000 additional doses of smallpox vaccine,
based on the strains of vaccinia virus used up through the 1970s,
have been produced and placed into the SNS. That is enough to
vaccinate about one third of the U.S. population.
Nearly 200,000,000 additional doses of vaccine based on a
less pathogenic form of vaccinia virus have also been produced,
but have not yet passed the final hurdles in clinical testing.
Nevertheless, the vaccine looks promising, so these doses have
been packaged for use. The FDA would decide whether to deploy
this vaccine in the event of a catastrophic smallpox attack on the
United States. Given that the mortality rate for smallpox is about
30 percent, it seems likely most people would consent to accept
the risk.
There is also a drug (SIGA 246) that strongly suppresses pox
virus replication in animals. This drug had FDA approval for fast-
track testing in humans, and Phase I clinical trials are currently
underway. The addition of an antiviral drug to our armamen-
tarium against smallpox will be an enormous step forward in
defending against the possibility of a devastating terrorist attack
with this agent.
It must be remembered that what made the Dark Winter sce-
nario possible was the absence of smallpox vaccination in the U.S.
population for the preceding thirty years, and only weak residual
natural immunity. We cannot at present take smallpox off the list
of bioterror threats but, with adequate supplies of an effective vac-
cine to contain outbreaks, we may very well, in the next year or
two, be able to make it unattractive to terrorists as a bioweapon.
Anthra x
Since anthrax is caused by a bacterium, it can be treated by
antibiotics. Cipro is the only antibiotic formally approved by
the FDA for treating anthrax infections, but several other cate-
gories of antibiotics are known to be effective. Because anthrax
infections are so rare in the United States, most currently avail-
able antibiotics have never undergone rigorous clinical trials for
efficacy against anthrax. But there is now enough Cipro, along
with other antibiotics, in the Strategic National Stockpile and
on reserve through pharmaceutical vendors to quickly contain
any bioterrorism incident involving anthrax.
Anthrax is not contagious, but we would like to have an effec-

tive anthrax vaccine to immunize persons in the vicinity of an
anthrax attack. The only anthrax vaccine currently licensed for
human use is called AVA. Unfortunately, it must be administered
over a period of eighteen months to reach full effectiveness, and
requires annual booster shots to maintain that effectiveness.
Clearly this is less than ideal for managing a large-scale anthrax
attack. Research on a better vaccine is proceeding with high pri-
ority in a large number of government and private laboratories
around the world.6 In the meantime, the United States, through
Project BioShield, has placed AVA into the Strategic National
Stockpile. A total of 10,000,000 doses have been deposited in
SNS as of May 2006.
Pl ague
Plague is also contagious, though less so than smallpox or the
flu. Although at least bubonic plague can be treated effectively
by antibiotics, containing its spread after a bioterrorist attack and
preventing its evolution into a pandemic require that a vaccine
be available. Moreover, recent outbreaks of plague in Madagascar
and India, which were treated with antibiotics, indicate the emer-
gence of drug-resistant strains of Yersinia pestis, the bacterium
causing plague.
Since 2000, the United States, Great Britain, and Canada have
been working cooperatively on development of a new plague vac-
cine, aided by Project BioShield. They have produced a candidate
vaccine based on two recombinant proteins from Y. pestis.5 This
vaccine can completely block transmission of flea-borne plague
in mice, even when Y. pestis is given intranasally to mimic aerosol
exposure. Tests have also been carried out in monkeys, which tol-
erated the vaccine well and produced plague antibodies. Such a
vaccine would likely not be used to treat infected individuals but
to prevent spread of the disease in the larger population.
The vaccine has now entered clinical trials; the first batch of
volunteers, in whom the vaccine is being tested for safety, were
immunized in late 2005. The trials appear to be going well, but
as we go to press, definitive results have yet to be reported out.
If these vaccines are approved and enter the SNS, we can feel
reasonably confident that plague will also become very unattract-

ive as a bioterrorist weapon.
Botulism
At present, standard treatment for poisoning by botulin toxin
consists of botulin antitoxin, a preparation of antibodies to the
toxin produced in animals, usually horses. There is a plenti-
ful supply of this antitoxin worldwide; a contract was recently
awarded by the Department of Health and Human Services to
a firm in Canada to place additional doses into the Strategic
National Stockpile.
Because botulin toxin poisoning is not contagious, there is
less urgency for a vaccine. There is a vaccine currently licensed
for use, but for a variety of reasons it has been used only to
immunize researchers working on botulism and a limited num-
ber of military personnel who might face risk of exposure to
botulin toxin. A new vaccine is currently undergoing clinical
trials, and could be available for deposit in SNS in the next few
years.
Tu l a r e m i a
The only current vaccine for tularemia, called LVS, was obtained
in 1956 from the Soviet Union, where it had been used success-
fully to immunize humans against the disease. Methods for pro-
ducing the vaccine were further developed at the Salk Institute.
Although tested in a few military personnel, where the U.S. ver-
sion appeared to be effective with just a single injection, this vac-
cine has never received an FDA license for general use.
The National Institutes of Health has issued two new grants
under Project BioShield totaling $60,000,000 to fund research
into new vaccines for tularemia. But at best, a licensed new vac-
cine for tularemia is years away. Should there be a bioterrorist
incident involving F. tularensis in the meantime, it would likely be
managed with early intensive antibiotic therapy. The FDA might
also decide to allow use of the existing LVS vaccine, perhaps in
an intranasal aerosol form, as a supplementary treatment.
E b o l a a n d M a r b u r g Va c c i n e s
The Ebola and Marburg viruses are capable, under some condi-
tions, of causing outbreaks of extremely deadly disease. However,
although the underlying viruses have been around for over thirty
years, we have not seen a major epidemic, let alone a pandemic.
Even in the sometimes crude public health systems in which some
of these outbreaks have occurred, the infections have been rela-
tively easy to contain in the absence of a vaccine.
This gives us confidence that our public health systems should
also be able to contain an outbreak should these viruses be used
in a bioterrorist attack in the United States. Nevertheless, we will
not feel completely comfortable until we have an effective vac-
cine that will limit spread of the disease.
Intensive research into possible vaccines for hemorrhagic fever
viruses began in earnest in the mid-1990s, and in 2003 these
efforts began to bear fruit. Several vaccines that provide excellent
protection against both viruses in mice and monkeys have been
produced using highly imaginative procedures for vaccine pro-
duction.6 At least one of these vaccines has been approved in the
United States for clinical trials in humans. More trials will likely
begin in the next year or two. Once a vaccine has been approved by
the FDA and placed into the SNS, concern about the use of these
two viruses as terrorist bioweapons will be greatly diminished.
The United States has made impressive progress in the past
half dozen years in building a stockpile of drugs and vaccines that
would greatly limit the damage terrorists might inflict using CDC
A-list bioweapons. This doesn’t mean we are completely immune
to terrorist attacks with these weapons, but the knowledge that
the damage done by such an attack would be considerably less
than terrorists might have hoped for just a few years ago, together
with the expense and tremendous difficulty involved in mounting
an attack, could be a major deterrent for many terrorist groups.
W h a t a b o u t G e n e t i c a l ly
Engineered Biowe apons?
We have not seen so far any genetically altered human pathogens
that have approached the stage of weaponization. The former
Soviet Union engaged in research into these kinds of weapons,
but there is no data suggesting they ever actually produced a

functional weapon. What would it take to achieve that?
As we said before, people—people with many different kinds
of deep theoretical and technical expertise—are absolutely nec-
essary to generate conventional bioweapons based on patho-
gens, such as anthrax, that have been studied for fi fty years or
more. This is triply true for genetically modified pathogens.
Dissemination of statements like the following show a lack of
understanding about what it would take to produce a high-qual-
ity, fully functional, deliverable biological weapon based on a
genetically modified pathogen.
Today, anyone with a high-school education can use widely avail-
able protocols and pre-packaged kits to modify the sequence of a
gene or replace genes within a microorganism; one can also pur-
chase small, disposable, self-contained bioreactors for propagat-
ing viruses and microorganisms. Such advances continue to lower
the barrier to biologic-weapons development.7
This is reminiscent of the statement by Senator Frist. In fact,

anyone who has ever worked in a molecular biology research lab
will tell you that the likelihood that an individual with little or
no advanced training, or a group of terrorists, no matter how
well funded or ideologically committed, would be able to design,
assemble, and weaponize a genetically engineered pathogen has
to be just about as close to zero as you can get.
As mentioned in chapter 4, the first researchers to reconstruct
a pathogenic virus from scratch in a research laboratory actually
had the subunits of the virus’s genome synthesized for them by
a commercial laboratory. They simply e-mailed the published
sequence for the full genome to the company, indicating which
subunits they needed to have synthesized. Some weeks later, the
company mailed the finished subunits back to the lab, where
they were assembled into functional viruses.
Could terrorists do the same thing? Possibly, although prob-
ably not in the United States. As with controls already in place
for restricting access to standard pathogens, it is already next
to impossible for someone not associated with a credentialed
research laboratory to purchase this kind of service from the
private sector. Biotech firms, who stand to profit from this kind
of business, are themselves in the vanguard of developing such

controls, and with federal help will soon have them in place.
Terrorists could possibly find access to the needed materials in
second-or third-world biotech companies, where such controls
might not be in place.
But having subunits of a viral genome in hand and having a
complete, fully functional virus in hand are two different things.
You don’t just stir the fragments around, shake a few times, and—
voilà!—out pops a virus. Orchestrating the correct alignment of
the subunits in a finished assembly is a highly sophisticated pro-
cess involving a great many very complicated steps.
And there is still the same problem that terrorists would have
even with standard pathogens. Having in hand a highly puri-
fied, highly lethal biological pathogen of whatever origin, one
of nature’s own or one created de novo by humans in a modern
research laboratory, is not the same as having a functional bio-
weapon. It is just the first step. As Ken Alibek, the former Soviet
bioweapons expert, has said,
The most virulent culture in a test tube is useless as a weapon
until it has been put through a process that gives it stability and
predictability. The manufacturing technique is, in a sense, the
real weapon, and it is harder to develop than individual agents.8
As technology continues to improve, and more and more steps

are automated, it is possible that someday relatively unskilled
individuals will be able to genetically engineer a devastating
pathogen, and turn it into a highly effective lethal weapon. In
an infinite universe, anything is possible. Just don’t hold your
breath.
So, are we ready to defend ourselves? Box 10.1 suggests how
the threat of bioterrorism today with various possible pathogens
might compare with the threat level immediately after September
11. In compiling these estimates, we take into account improve-
ments since 2001 in public health response to major health emer-
gencies, pathogen surveillance and control, and other measures
described in chapter 7, as well as recent acquisition of vaccines
and drugs.
Such comparisons are obviously open to all sorts of discus-
sion and disputation, but that shouldn’t stop us (or anyone else
BOX 10.1
Assessing the Threat: CDC A-list Pathogens (by Disease)
Pathogen Threat level Rationale
2001
Smallpox 8 extremely contagious; very
little vaccine; no drugs
Anthrax 5 dangerous, but difficult to
produce; some antibiotics
Plague 6 moderately contagious
Botulism 4 not contagious; toxin
difficult to produce
Tularemia 3 was never that much of a
threat
Hemorrhagic 4 contagious, but no natural
fever pandemic has emerged
Genetically 3 technology beyond
modified terrorists
pathogens
2008
Smallpox 3 adequate vaccine; drugs
in pipeline
Anthrax 2 greatly increased stocks of
antibiotics
Plague 2 numerous vaccines in
pipeline
Botulism 4
Tularemia 3 should be manageable
with antibiotics
Hemorrhagic 2 vaccines in pipeline
fever
Genetically 2 technology beyond
modified terrorists
pathogens
who’d like to make a case) from trying. And note that none of
the proposed current threat levels are zero; we aren’t completely
out of the woods yet for any of these pathogens. In an infinite
universe . . .
III. W HO WO ULD D O I T ?
Although most experts consider a bioterrorist attack a low-proba-

bility event, not even the harshest critics of America’s response to
the threat of bioterrorism to date are willing to take the possibil-
ity of such an attack entirely off the table. So where, then, would
such an attack come from?
Individuals
When we think of individuals and bioterrorism, we are really
talking about domestic terrorism. It is difficult to imagine an
individual foreign terrorist producing and weaponizing a patho-
gen and bringing it to the United States to mount a deadly attack
with no other help. But we are already reasonably certain that
an individual per se is capable of mounting a bioterrorist attack
(or at least of committing a biocrime) against us, because all evi-
dence suggests the Amerithrax perpetrator acted alone.
The damage done in the Amerithrax attack, in the larger
scheme, was limited, but it needn’t have been. What if, instead of
mailing anthrax spores to a handful of people, he or she had sent
letters to 500 or 5,000 people, in ten different locations across
the country? This is not beyond what a single determined indi-
vidual could do. We might have seen a thousand dead instead of
five, approaching the level of losses sustained in the World Trade
Center and Pentagon attacks. The magnitude of the response
to such an attack, mounted by the federal government and state
and local responders, would perforce have been enormous, as
would the resulting social and economic disruption. The fear
and uncertainty generated among the public would have made
any terrorist proud.
America has a history of lone avengers, individuals who believe
they have a quasi-divine mandate to right some perceived wrong
done in the world, usually to them. If some people die in the

process, well, so be it. Collateral damage. In recent years, we have
the examples of Theodore Kaczynski and Timothy McVeigh to
remind us what determined loners can do in their quest for “ jus-
tice.” And it is almost impossible to stop the actions of single indi-
viduals. Most never committed a crime before, never came onto
the radar screen of those looking out for the public’s security.
We may have to live with them as the price of a free and open
society.
To the extent that creation and deployment of a bioweapon
is an extraordinarily difficult task for even the most determined
organized groups, we can feel reasonably assured that an individ-
ual, acting alone, is unlikely to be able to mount a major biologi-
cal attack against America any time soon. But Amerithrax did
happen, and that will rightly never be far from the minds of bio-
security analysts and our political leaders. Steps have been taken
to assure that commercial access to pathogens of the quality used
in that attack are placed beyond the reach of even the relatively
few who know where to look for them in the first place. But as
discussed in chapter 4, the recent renewed research into new and
genetically modified pathogens for weapons defense, in addition
to possibly violating the 1972 Biological Weapons Convention, also
greatly increases the chance that these agents could accidentally—
or purposely—make their way into the environment, and into
the wrong hands.
And Amerithrax did happen. We will have to leave it at that.
Groups
When it comes to the possibility of bioterrorism by groups in
America, there are groups and there are groups. Domestic
groups like the Minnesota Patriots Council, the Aryan Nations,9
the Identity Christians (an inspiration to Timothy McVeigh),
and the innumerable so-called “militias” of overweight, middle-
aged men that tramp through the woods on weekends all remind
us that the disaffected do not always act alone. But like those
who do, these groups generally believe they are acting to right
some sort of wrong. As Jessica Stern, of the Council on Foreign
Relations, has written:
The most likely [domestic terrorists] are religious and extreme

right-wing groups and groups seeking revenge who view secular
rulers and the law they uphold as illegitimate. They are uncon-
strained by fear of government or public backlash, since their
actions are carried out to please God and themselves, not to
impress a secular constituency. . . . [T]heir ultimate objective is to
create so much fear and chaos that the government’s legitimacy
is destroyed.10
She might have added to her list some of the groups acting
with a more leftist orientation. We have seen acts of violence
committed by “ecoterrorists” in defense of nature, or opposed
to perceived urban overdevelopment or gas-guzzling cars. There
are those who are passionately opposed to nuclear power plants,
genetically modified crops, or animal experimentation. It is always
possible that some of the more extreme of these groups could
resort to major acts of terrorism based on the use of bioweapons,
although in the past such groups have generally refrained from
using lethal force.
On the other hand, given the background of September 11,
and to the extent most of these people are championing causes
to which they hope to recruit large numbers of their fellow citi-
zens, it would seem unlikely that groups of either the right or
left would use any form of terrorism as a tool. They usually care
about their cause, and such an act could destroy that cause in the
public eye for decades to come. But who knows?
But when we speak of groups and the possibility of bioterror-
ism, of course the large pink elephant in the room is Al-Qaeda
and its various cells, offshoots, and copycats. Much has been
made of the fact that materials relating to biological weapons
were recovered from Al-Qaeda training camps near Kandahar,
Afghanistan, in December 2001. Milton Leitenberg has described
these findings in detail in a recent analysis.11 Among the items
found were books on biological warfare and on microbiology,
dating mostly from the 1950s and ‘60s. These would have pro-
vided some information relevant to bioterrorism, but that infor-
mation would have been far from cutting-edge. There were also
articles from scientific journals, some fairly recent at the time, on
pathogens such as B. anthracis, Y. pestis, and C. botulinum, as well
as hepatitis viruses. Among the papers found were clear indica-

tions that Al-Qaeda had recruited at least one PhD-level scientist
to help them, although apparently mostly for procuring addi-
tional scientific information. There were no references to genetic
engineering or recombinant DNA.
Also found were letters indicating Al-Qaeda may have sent
someone to the U.K. with an unspecified amount of money for
purchasing vaccines, perhaps for immunization of anticipated
laboratory workers. There were also letters containing crude dia-
grams showing the general layout of a laboratory, a list of some
equipment, and references to the need to train people to work
in laboratory work. The writer was probably a Pakistani scientist;
the intended recipient may have been an Egyptian. The writer
says he had visited a laboratory in the U.K. where research on
pathogens was carried out, and had attended scientific confer-
ences on pathogens.
Another individual, identified as a Malaysian with a bachelor’s
degree in clinical laboratory science from a California university,
appears to have been involved with developing plans for a bio-
weapons lab for Al-Qaeda in Afghanistan. He may have tried to
obtain pathogen cultures. He was arrested in Malaysia on other
charges, and there is no evidence he ever accomplished anything
in the laboratory.
While all of this shows that Al-Qaeda was seriously investigat-
ing the possibility of building bioweapons, nothing among the
recovered materials or any other subsequent intelligence gath-
ered suggests it had ever gone beyond the planning stages, or that
any pathogenic strains had been obtained or established in an
Al-Qaeda–associated laboratory. There is certainly no indication
they had put together a scientific team of the caliber necessary
to assemble and deliver a bioweapon capable of inflicting mass
casualties. They had not even come close to achieving what Aum
Shinrikyo achieved, which was something less than impressive.
It is important to remember that single, mass-casualty attacks
may not necessarily be the most effective, from a terrorist groups’
point of view. Multiple smaller attacks, especially if spread out
over time, and perhaps involving livestock and water as well as
human targets, might be much more effective in promoting a
sense of uncertainty, of helplessness and vulnerability, in a civilian
population. The economic disruptions could be enormous. We

still have to prepare ourselves for that.
In the end, what may well stop groups like Al-Qaeda from using
bioweapons to achieve their aims against us is that it is just too
much trouble. Not only are biological weapons exceedingly dif-
ficult to build and operate, the United States has now developed
vaccines or drugs to counter most known conventional patho-
gens. Countermeasures for the rest should be available over the
next few years. We have the Strategic National Stockpile, Push
Packages, and vendor-managed inventories, as well as the abil-
ity to deliver these materials and more to an attack site within
a matter of hours. We could suffer casualties, yes, but not mass
casualties. Conventional bombs and chemicals are much easier
to obtain and use, and can achieve much the same ends with less
risk. Sophisticated terrorist groups may well agree with virtually
all professional of the military establishments around the world
that actually had effective bioweapons in hand: they are simply
not worth the bother. For at least the near future, bioterrorism
for Al-Qaeda and its ilk may be a non-starter.
Stat e s
What about so-called rogue states? Might they undertake the
development of biological weapons, and use them themselves in
covert operations against the United States or give them to ter-
rorists to use (Table 10.1)?12 Many universities in some of these
countries have impressive levels of expertise in microbiology,
molecular biology, and recombinant DNA technology. A num-
ber of their scientists were trained in the United States, Europe,
Japan, or Korea, or even Cuba. There may exist, within some of
these states, sufficient animosity toward the United States that
pulling together the necessary experts and convincing them to
attempt to develop genetically engineered bioweapons and appro-
priate delivery systems could be possible. This would take years,
and huge amounts of money, for an uncertain outcome. It is not
clear that even Iraq, which had an extensive, state-supported bio-
weapons program through the 1990s, had developed an effec-
tive delivery system for the most deadly conventional pathogenic
Ta bl e 10.1 Some Potential State Suppliers of Bioweapons

Country Comments
China Despite denials, suspected of having transferred bioweapons
technology to Iran and other countries.
Cuba Has sophisticated biotechnology industry, is suspected by
some of having well-developed bioweapons program.
Egypt Strong university microbiology programs. Allegations by
Israel of bioweapons program.
Iran Strong biotechnology base. Believed to be pursuing
bioweapons program.
Kazakhstan Home to many former Soviet bioweapons facilities. Status
of these uncertain. Has never formally renounced
bioweapons reserach.
Libya Formerly had bioweapons program. Current status uncertain.
N. Korea Presumed to have strong bioweapons program, but no reliable
intelligence.
Pakistan Strong biotechnology base. Status of bioweapons programs
uncertain.
Russia Strong background in bioweapons. Current status uncertain,
particularly with respect to plague.
Syria Good pharmaceutical infrastructure. Status of bioweapons
programs uncertain.
Uzbekistan Houses several former Soviet bioweapons facilities. Presumed
to still hold stockpiles of many Select List pathogens.
agents, and no evidence at all that they had developed a weapon

based on genetically engineered pathogens.
Would such states have the political will to underwrite such
a program in the face of certain massive retaliation by the
United States if they were discovered as the authors or facili-
tators of an attack against us? But perhaps more to the point,
could political leaders in these states, which are rarely free
and open democracies, live with the uncertainty that one day
their terrorist proxies might very well turn these same weapons
against them, in order to bring down what the terrorists con-
sider a corrupt or “infidel” government? That would give almost
all of these countries pause. The consensus among almost all
terrorism experts is that the likelihood of rogue states placing

high-grade bioweapons in the hands of terrorist groups is also
just about zero.
So who would do it? To the extent that bioterrorism would
ever be used against the United States, all bets are that it would
come from organized terrorist groups such as, yes, Al-Qaeda.
But it is very clear there is a huge, multifaceted barrier between
us and a successful bioterrorist attack by any group. That bar-
rier consists of the extreme difficulty of any such group build-
ing an effective bioweapon on their own and the improbability
of any organized state providing them with such a weapon.
It is conceivable that eventually, as some of the technologies
involved are simplified, these difficulties could be overcome
to some extent. But there is still the problem our own and
other militaries had with state-of-the-art bioweapons provided
to them ready-made by their own governments: they are diffi -
cult to use and control, and have less impact than chemical or
nuclear weapons. So why bother?
We are also buffered by the impressive improvements we have
made in order to absorb the impact of such an attack, should one
happen. Although our public health system still has a way to go,
it is in much better shape now than it was after 2001. And again,
we now have stocks of vaccines and medicines that would greatly
blunt the consequences of a bioterrorist attack. We would be bet-
ter off with a few more vaccines, but we are close to having them.
The certainty that even a large-scale bioterrorist attack would
have the desired effect is much less now than it was ten years ago.
BIOTERRORISM IN CONTEX T
Bioterrorism is a threat in the twenty-fi rst century, but it is by

no means, as we have so often been told over the past decade,
the greatest threat we face. The best way to look at bioterrorism
is from a terrorist’s point of view. If the aim is to kill as many
people as possible, there are better—and, more importantly,
simpler—ways to do it. If our leaders didn’t draw the correct
conclusions from Aum Shinrikyo, the terrorists probably have.
After spending two years and millions of dollars trying to
develop an effective bioweapon, the Aum people just gave up

and used gas. Even that wasn’t terribly effective, but it worked.
If the aim is to cause social and economic disruption, bioter-
rorism could do the trick, but there is nothing to suggest that
the level of disruption, the level of fear and uncertainty sowed,
would be any greater as a result of an attack with bioweapons
than with well-placed bombs, or even gas.
Alarmist rhetoric may have been necessary to push the issue of
bioterrorism out into the open where it could be examined, and
appropriate steps taken to meet the challenge. We have examined
it, somewhat compulsively, and we have responded—rather exces-
sively. Undoubtedly, in the process, there were those who saw
an opportunity to enhance their personal wealth or power. But
clearly most of those raising the alarm were motivated by genuine
concern for our national well-being. It was a real issue; it is a real
issue. And it is pointless to blame the politicians who overreacted.
As we said in the last chapter, they may have had little choice.
But it is time to move on now to a more realistic view of bioter-
rorism, to tone down the rhetoric and see it for what it actually is:
one of many difficult and potentially dangerous situations we-
and the world—face in the decades ahead. And it is certainly
time to examine closely just how wisely we are spending billions
of dollars annually to prepare for a bioterrorist attack. No nation
has infinite resources, and we must accept that we will not be able
to make ourselves completely safe from every threat we face. So
we will have to make rational assessments of those threats we can
identify, and apportion our resources as intelligently and effec-
tively as we can. Here are just two of the things beside bioterror-
ism we will need to consider.
E merg in g a nd R e- emerg in g
Infectious Dise ases
Lest we forget, the world as we speak is in the midst of one of
the most serious natural pandemics since 1918: HIV/AIDS.13
Roughly 15,000 per year still die of AIDS each year in this coun-
try (Figure 10.1). As 2005 drew to a close, the World Health
Organization estimated that 40,000,000 people worldwide were
HIV-infected or had full-blown AIDS. The vast majority of these
200,000
150,000 New HIV infections (estimated)

Full-blown AIDS cases diagnosed
AIDS deaths
100,000
50,000
93
81
87
92
94
95
98
99
01
04
83
84
85
86
91
96
97
03
00
5
88
02
82
89
80
90
0
20
20
19
19
Figure 10.1 The HIV/AIDS pandemic in the United States.

will die prematurely of their disease. AIDS has already killed over
25,000,000 people worldwide. These numbers are beginning
to approach those of the 1918 flu pandemic, and no cure is in
sight.
Two other infectious diseases, tuberculosis and malaria,
account for 4,000,000 deaths annually worldwide. While malaria
is essentially unknown in the United States, TB still kills a thousand
people each year in this country. AIDS patients are particularly
susceptible to TB, and as TB-infected AIDS patients are treated
with ever more powerful doses of TB-fighting drugs, we are see-
ing the emergence, through mutation, of so-called multi-drug-
resistant strains of M. tuberculosis, as well as the even more deadly
extreme drug-resistant strains (XDR-TB strains). As recounted in
chapter 8, XDR-TB is lethal in immunocompromised individuals,
and could be spread to others once they become symptomatic.
In late May of 2007, a man in the United States thought to be
infected with an XDR-TB strain was somehow allowed to travel
to half a dozen other countries before finally being quarantined
upon his return to the United States.
And as we have seen, the world—including the United States—is
now faced with the possibility of a form of avian flu (H5N1) that
could, should it mutate or recombine with a common form of the
human influenza virus in an individual simultaneously harbor-
ing both viruses, produce a virus that could equal the devastation
wrought by the 1918 influenza virus—50,000,000 deaths or more
worldwide before a pandemic played out. The impact of this on
the American way of life we are so concerned about defending
against terrorists is simply beyond the ability of any of us to com-
prehend. It is by far the most serious biological threat we face in
the years ahead. The United States is finally mobilizing to meet
this challenge; it has budgeted $7,000,000,000 to help prepare
for the possibility of a worldwide H5N1-related pandemic. We
can only hope that the same passion to act can be roused in our
political leaders that was mustered for bioterrorism.
Admittedly, some of the money the United States has spent on
preparing for bioterrorist attacks will enable us to respond more
effectively to the threats posed by existing and emerging infec-
tious diseases. It’s time, however, to refocus our attention—and
our resources and creative energies—more specifically toward
some of nature’s own threats, rather than depending on spin-offs

from our concerns about bioterrorism.
G l o b a l Cl im at e Ch a n g e
It is now beyond dispute that the world, including the United
States, is in for a period of global climate change whose extent
cannot be predicted, and whose impact in terms of food supply,
pathogen flow between species, and general social and economic
disruption can only be guessed at. What is indisputable is that
carbon dioxide levels have been rising steadily in the earth’s
atmosphere since at least 1960, and the surface temperature of
the earth is rising in parallel. Glaciers and ice caps, which supply
drinking and irrigation water to 40 percent of the earth’s inhab-
itants, are disappearing at an accelerating pace.
It’s essential that political arguments about what or who is
causing global warming now take a back seat to discussions of
how we are going to meet the challenges it forces on us. While
assessments of bioterrorism, and to some extent even natural pan-
demics, are built on hypotheticals, global warming is happening,
right now, and it will continue to happen for some time—maybe
decades, maybe centuries. The social and economic disruptions
accompanying a bioterrorist attack do not even show up as a sin-
gle pixel on the screen of what will happen when the world’s gla-
ciers are gone and sea levels have risen twenty feet.
Will we see the same vigorousness (and even hysteria) brought
to discussions of the increasingly severe hurricanes that will arrive
along our southern and eastern seaboards in the years ahead?
Have we really absorbed the lessons of Katrina? Do we really
think the number of American lives lost in these kinds of events
will be piddling in comparison to a bioterrorist attack? Will we
see the same concerns raised about crop loss and economic dis-
ruption from increased temperatures and decreased water sup-
plies that were raised about the possibilities of agroterrorism?
And what if we are struggling with the major social disruptions
brought on by global warming and a major influenza pandemic
at the same time? Could America as we know it survive?
None of this means that we should not continue to take pru-
dent steps to defend ourselves against attacks with bioweapons.
We have lost five people so far to bioterrorism in this country. It is

possible we could lose more if terrorists were to one day succeed
in mounting a major attack using bioweapons. It has become a
commonplace for most of us to say our world changed forever on
September 11, 2001. Some politicians have told us the American
way of life itself is in jeopardy; others, that September 11 was
the first battle of World War III. This presumably is a war based
on terrorism, and the terrorists, they tell us, are becoming ever
more sophisticated.
The reality is that since September 11 terrorism of all types
against the United States, on U.S. soil has not become easier;
it has become a great deal harder. Part of the reason for that is
the six to seven billion dollars per year we have spent over the
past five years to upgrade our defenses. But how much longer
should we continue to spend at that rate for biodefense? Has this
become a permanently renewable check we must write each year?
Let’s hope the GAO continues, and even increases, its already
critical scrutiny of biodefense spending, and forces Congress to
take a stronger oversight stance.
In the meantime, we continue to lose fifty thousand people a
year just to AIDS and seasonal flu. And we are facing challenges
in the years ahead that make bioterrorism pale by comparison. So
let us put bioterrorism in context. Even those who argued most
strongly for a vigorous effort by the United States to defend itself
against bioterrorism never considered bioterrorism more than a
low-probability, high- consequence possibility. Realistic assessments
of what is involved in making and using a bioweapon suggest the
probability is even lower than many thought. Efforts made over
the past decade to better defend ourselves against an attack, what-
ever its probability, have reduced the anticipated consequences.
It’s time to move on to other things.
Not e s
Chapter 1
1. You can read the official final script of the Dark Winter exercise
at http://www.upmc-biosecurity.org/pages/events/dark_winter. The
information in this chapter was extracted (with minor dramatic
license) from this script and from a published follow-up analysis
of the exercise: Tara O’Connor, Michael Mair, and Thomas V.
Inglesby, Shining Light on “Dark Winter,” Clinical Infectious Diseases,
34(2002):972.
2. The transmission rate of ten for a primary smallpox outbreak,
for example, is likely half or less of that depicted in Dark Winter:
Raymond Gani and Steve Leach, “Transmission Potential of Smallpox
in Contemporary Populations,” Nature 414(2001):748. See also H.
Pennington, “Smallpox and Bioterrorism,” Bulletin of the World Health
Organization (2003) 81:762. Also, improvements in home as well as
hospital care developed while the disease was still prevalent seem to
have been ignored. For a detailed critique of exercises such as Dark
Winter, and in particular Atlantic Storm, see Milton Leitenberg,
Assessing the Biological Weapons and Bioterrorism Threat (Carlisle
Barracks, PA: U.S. Army War College, Strategic Studies Institute,
2005), 48–59. Available free at www.strategicstudiesinstitute.army.
mil
Chapter 2
1. See for example Leitenberg, Assessing. We will discuss this issue fur-
ther in chapter 10.
2. Brian Jenkins, “Will Terrorists Go Nuclear?” Orbis 29 (Autumn
1985):511.
3. Numerous accounts have been written about the Rajneesh cult,
but the most accurate is probably that found in Seth Carus, “The
192 • N O T E S T O PAG E S 26 – 43
Rajneeshees,” in Toxic Terror: Assessing Terrorist Use of Chemical and

Biological Weapons, ed. Jonathan B. Tucker (Cambridge, Mass.: MIT
Press, 2001).
4. We will look more closely at the biological agents used in these and
other attacks, and additional agents considered by the U.S. govern-
ment as being of particular concern, in chapter 3.
5. Claims that upwards of 5,000 were injured in these attacks are
clearly exaggerated. Most of these excess claims were the so-called
“worried well,” who reported to hospitals to determine whether they
might have been affected.
6. For a detailed history of Shoku Asahara and the Aum Shinrikyo
cult, see David E. Kaplan and Andrew Marshall, The Cult at the End
of the World (New York: Crown Publishers, 1996).
7. Like the Rajneeshees, Aum Shinrikyo established seemingly genu-
ine businesses and medical facilities that made it easier to order
potent chemicals and biologicals without raising suspicion.
8. This connection may have been suggested by the belief (later largely
discounted) that the terrorists who bombed the World Trade Center
in 1993 had included potassium cyanide in the explosive device
they used.
9. For details of the Patriots Council and the Alexandria incidents,
see Jonathan B. Tucker and Jason Pate, “The Minnesota Patriots
Council,” in Toxic Terror, ed. Jonathan B. Tucker (Cambridge, Mass.:
MIT Press, 2001).
10. For more details on Harris, see Jessica Eve Stern, “Larry Wayne
Harris, 1998” in Tucker, Toxic Terror.
Chapter 3
1. Countries alleged to have continued their programs include China,
Egypt, India, Iran, Iraq, Libya, North Korea, Soviet Union/Russia,
South Africa, South Korea, Syria, and Taiwan. Iraq, South Africa,
and Russia may no longer have functional programs. Dispersal of
former scientists working in the Russian/Soviet Union program
to “rogue states” remains a major concern. For further details see
Jeanne Guillemin, Biological Weapons: From the Invention of State-
sponsored Programs to Contemporary Bioterrorism (New York: Columbia
University Press, 2005); Ken Alibek, Biohazard: The Chilling Story of
the Largest Covert Biological Weapons Program in the World (New York:
Random House, 1999).
2. For more information on the pathogens discussed here, and the
body’s immune response to them, see William R. Clark, In Defense
N O T E S T O PAG E S 44 – 69 • 193
of Self: How the Immune System Works in Health and Disease (New York:
Oxford University Press, 2007).
3. Antibiotics effective against anthrax include ciprofloxacin (Cipro),
tetracyclines such as doxycycline, and certain penicillins, like pro-
caine penicillin G. To be effective, however, these drugs must be
administered very early in the infection, especially in the case of
inhalation anthrax. Rapid treatment of inhalation anthrax could
probably reduce mortality even more.
4. Viruses do not usually receive a Latin genus–species designation, ordi-
narily reserved for bacteria and other cellular forms of life. However,
the causative agent of smallpox was long presumed to be a bacterium,
and the name given to the hypothetical agent, V. major, stuck after it
was determined to be a virus.
5. The only viral diseases for which we have virus-specific drugs are
the herpes viruses, the influenza virus, and HIV.
Chapter 4
1. A genome is the entirety of the DNA taken from a given organism,
which in effect contains the full blueprint for the construction and
operation of that organism. A recombinant genome is one that also
contains one or more genes from a different organism.
2. Alibek, Biohazard. See also Janet R. Gilsdorf and Raymond A.
Zilinskas, “New Considerations in Infectious Disease Outbreaks:
The Threat of Genetically Modified Microbes,” Clinical Infectious
Diseases 40(2005):1160.
3. For a detailed discussion of what we know about the Soviet foray into
genetically modified pathogens, see footnote 2 and Judith Miller,
Stephan Engelberg, and William Broad, Germs: Biological Weapons
and America’s Secret War (New York: Simon and Schuster, 2001).
4. This has now been accomplished with the genome of Mycoplasma
genitalium. See Karen Kaplan, “A Step Closer to Creating Life Out
of Chemical Soup.” Los Angeles Times, January 5, 2008.
5. For a fuller discussion of how the immune system is often the real
culprit in disease, see Clark, In Defense of Self.
6. See http://dspace.mit.edu/bitstream/1721.1/32982/1/SB.v5.pdf
7. See for example http://www.etcgroup.org/article.asp?newsid=563
8. Hillel W. Cohen, Robert M. Gould, and Victor W. Sidel, “The
Pitfalls of Bioterrorism Preparedness: The Anthrax and Smallpox
Experiences,” American Journal of Public Health 94(2004):1667.
9. Quoted in Leitenberg, Assessing.
194 • N O T E S T O PAG E S 71– 88
Chapter 5
1. Epidemic is usually defined as a sudden, rampant spread of an infec-
tious disease among humans within a single country, or possibly
adjoining countries. When the disease involves a large number of
countries or more than one continent, we use the term pandemic.
The corresponding terms for movements of infectious diseases
among animal populations are epizootic and panzootic.
2. Source: www.globalaging.org/health/us/fluaids.htm
3. In the first decades of the twentieth century, scientists did realize
that some infectious agent existed that was much smaller in size
than a bacterium, capable of passing through an extremely fine
filter that trapped bacteria and incapable of being seen in a micro-
scope, but they had no idea what it was. They referred to these
agents as viruses. The influenza virus itself was discovered in 1933.
4. For an excellent and detailed account of the havoc wrought in the
United States and elsewhere by the 1918 flu pandemic, see Gina
Kolata, The Story of the Great Influenza Pandemic of 1918 (New York:
Simon & Schuster, 1999).
5. An influenza vaccine was developed shortly after World War II, and
by the mid-1950s most doctors and public health officials were famil-
iar with its use.
6. Although the earliest cases were reported from the relatively open
Hong Kong, officials there insisted this flu originated in the more
secretive People’s Republic of China, probably in the adjacent prov-
ince of Guangdong.
7. Over those that would be expected from normal seasonal flu.
8. In fact, for quite some time information about SARS in China was
issued by the propaganda arm of the Chinese Communist Party
rather than the government’s Health Ministry.
9. For a detailed analysis of the pandemic as it played out in Hong
Kong and Toronto, see C. David Naylor, Cyril Chantler, and Sian
Griffiths, “Learning From SARS in Hong Kong and Toronto,”
Journal of the American Medical Association 291:2483–87.
10. David M. Bell, “Public Health Interventions and SARS Spread,”
Emerging Infectious Diseases 10(2004):1900–06.
11. Anyone who has recently been infected by an influenza virus will
have antibodies in their blood specific for that particular virus, and
these can be readily detected in a simple laboratory test.
12. In addition, it has now been shown that a pregnant H5N1-infected
woman had transmitted the virus to her fetus. See J. Gu et al.,
N O T E S T O PAG E S 88 –103 • 195
“H5N1 Infection of the Respiratory Tract and Beyond: A Molecular

Pathology Study.” Lancet (2007) 370:1106.
13. For a Dark Winter–like description of what an H5N1-based pan-
demic could look like in a major metropolitan area like New York,
see Irwin Redlener, Americans At Risk (New York: Knopf, 2006),
29–36.
14. See http://www.pandemicflu.gov/vaccine/prioritization.html#Draft
GuidanceonAllocatingandTargetingPandemicInfluenzaVaccine
15. H. Markel et al., “Nonpharmaceutical Interventions Implemented
by U.S. Cities During the 1918–1919 Influenza Pandemic,” Journal
of the American Medical Association (2007) 298:644.
16. Quoted in Scott Shane, “U.S. Germ-Research Policy Is Protested By
758 Scientists,” New York Times, March 1, 2005.
17. Although not nearly enough to deal with a flu pandemic. There are
roughly 100,000 ventilators in the United States; during a typical
seasonal flu outbreak, the vast majority of these are in use. A major
pandemic could easily require double the present number.
Chapter 6
1. The government actually carried out an agroterrorism exercise in
two sessions in 2002 and 2003. This exercise, called Silent Prairie,
was considerably scaled down from Dark Winter; there was no role-
playing, for example. Whether because of perceived lack of public
interest or for other reasons, few analytical details of this exercise
have appeared in print. An even more abbreviated exercise called
Crimson Sky has also not been made public. For Dark Summer
I have drawn on what is known of these two exercises, as well as
the very real British FMD outbreak of 2001. The excellent RAND
Report by Peter Chalk, Hitting America’s Soft Underbelly: The Potential
Threat of Deliberate Biological Attack Against the U.S. Agriculture and
Food Industry (MG-135-OSD, 2004), is also a valuable resource.
2. Vaccination was used in a few regions, but created complications
when the epidemic was over in other regions because of the uncer-
tain status of the vaccinated animals (see Dark Summer scenario
above).
3. Most plant pathogens are harmless in humans, but there are some
that can affect humans. For example, aflatoxin, made by a plant
fungus, can cause liver damage and cancer in humans.
4. For an excellent and detailed analysis of potential terror threats to
our water supply, see J. Nuzzo, “The Biological Threat to U.S. Water
196 • N O T E S T O PAG E S 111–126
Supplies: Toward a National Water Security Policy,” Biosecurity and

Bioterrorism 4:147 (2006).
Chapter 7
1. The complete Act can be viewed at http://www.fda.gov/oc/
bioterrorism/bioact.html
2. For more information on the SNS, go to http://www.bt.cdc.gov/
stockpile/. It is clear that concerns about bioterrorism (even before
the Amerithrax incidents) were a major impetus in the creation of
SNS. Initial funding for expanding SNS was provided through the
Bioterrorism Act of 2002.
3. A detailed description of BioWatch is contained in Congressional
Research Service Report RL 32152, available at www.fas.org/sgp/
crs/terro/RL32152.html
4. Each of these laboratories is part of the Laboratory Response
Network for Biological Terrorism, a network of a hundred or so
laboratories established in 1999. Certified in advance by the CDC,
they now cover every major metropolitan area.
5. For a complete analysis of state preparedness for catastrophic
health emergencies, see http://healthyamericans.org/bioterror06/
BioTerrorReport2006.pdf
6. For a detailed analysis of the most recent bioterrorism budget, see
http://www.armscontrolcenter.org/resources/fy2008_bw_budget
.pdf
7. The complete NSPI can be viewed online: www.whitehouse.gov/home-
land/pandemic-influenza.html; www.pandemicflu.gov/plan/pdf/
panflu20060313.pdf; www.whitehouse.gov/homeland/pandemic-
influenza-implementation.html. An analysis of the early actions
taken under NSPI can be found in Stephen S. Morse, “The U.S.
Pandemic Influenza Implementation Plan at Six Months,” Nature
Medicine 13(2007):681–84.
8. The number of actual pills (as opposed to courses) required would
depend on how the drug is used. Someone thought to be infected
would take one course, or two pills per day for five days. Those want-
ing to protect themselves against possible infection would take con-
secutive courses until the possibility of infection recedes.
9. These are standard OSHA-approved respirators used by many
craftspeople, and available to the public at outlets such as Home
Depot for a very modest cost.
N O T E S T O PAG E S 134 –152 • 197
Chapter 8
1. Institute of Medicine, The Future of Public Health (Washington, D.C.:
National Academy Press, 1988).
2. The complete Act can be viewed at http://www.publichealthlaw.net
3. Authorized under U.S. Code 264, Title 42.
4. Nicholas Riccardi, “The Man in the Leg Irons and Mask,” Los Angeles
Times, May 2, 2007.
5. John Schwartz, “Tangle of Conflicting Accounts in TB Patient’s
Odyssey,” New York Times, June 2, 2007. This individual’s TB was
later determined to involve a somewhat less deadly, but still danger-
ous, MDR (multi-drug-resistant) strain of M. tuberculosum.
6. J. M. Peebles, Vaccination a Curse and a Menace to Personal Liberty,
With Statistics Showing Its Danger and Criminality (Battle Creek, Mich.:
Temple of Health Publishing, 1900).
Chapter 9
1. Zbigniew Brzezinski, “Terrorized by ‘War on Terror’,” Washington
Post, March 25, 2007.
2. For an excellent account of the intense political battles during the
1980s and ’90s that underlie much of the current official view of
bioterrorism, and from which some of what follows was taken, see
Susan Wright, “Terrorists and Biological Weapons: Forging the
Linkage in the Clinton Administration,” Politics and the Life Sciences
25(2007):57–115. See also Guillemin, Biological Weapons.
3. For a detailed account of Alibekov’s defection and debriefing by
U.S. intelligence experts, see also Judith Miller, Stephan Engelberg,
and William Broad, Germs: Biological Weapons and America’s Secret War
(New York: Simon and Schuster, 2001).
4. David Willman, “Selling the Threat of Bioterrorism,” Los Angeles
Times, July 1, 2007.
5. U.S. Congress, Office of Technology Assessment, Technology Against
Terrorism: The Federal Effort (Washington, D.C.: U.S. Government
Printing Office, July 1991); U.S. Congress, Office of Technology
Assessment, Technology Against Terrorism: Structuring Security
(Washington, D.C.: U.S. Government Printing Office, January
1992).
6. Quoted in Wright, “Terrorists and Biological Weapons,” 68–69.
7. Senator Nunn had played the role of the President in the Dark
Winter exercise.
198 • N O T E S T O PAG E S 154 –170
8. Richard Preston, The Cobra Event (New York: Ballantine, 1997).

9. Tom Clancy, Executive Orders (New York: Putnam, 1996).
10. Wright, “Terrorists and Biological Weapons,” 83–84.
11. National Academy of Sciences, Institute of Medicine, Improving
Civilian Medical Response to Chemical or Biological Terrorist Incidents,
Interim Report on Current Capabilities (Washington, D.C.: National
Academy of Sciences, 1998).
12. Guillemin, Biological Weapons, 149–50.
13. Steven M. Block, “The Growing Threat of Biological Weapons,”
American Scientist 89(2001):28–37.
14. For a critical analysis of some of the spending in the defense against
bioterrorism program, see Redlener, Americans at Risk, chap. 7.
15. Government Accountability Office, Combating Terrorism: Federal
Agencies’ Efforts to Implement National Policy and Strategy, Report No.
GAO/ NSIAD-97–254, September 1997.
16. Government Accountability Office, Combating Terrorism: Need for
Comprehensive Threat and Risk Assessments of Chemical and Biological
Attacks, Report No. GAO/NSIAD-99–163, September 1999.
17. Milton Leitenberg, “Aum Shinrikyo’s Efforts to Produce Biological
Weapons: A Case Study in the Serial Propagation of Misinformation,”
in Terrorism and Political Violence 11(1999):149–58.
18. Amy Smithson and Leslie-Anne Levy, Ataxia: The Chemical and
Biological Terrorism Threat and the US Response, Stimson Center report
no. 35, October 2000, 282.
19. Alan Cullison, “Inside Al-Qaeda’s Hard Drive,” Atlantic Magazine,
September 2004.
20. Quoted in Wright, “Terrorists and Biological Weapons,” 100.
C h a p t e r 10
1. Jonathan B. Tucker and Amy Sands, “An Unlikely Threat,” Bulletin
of the Atomic Scientists 55(1999):46–52.
2. See Hiroshi Takahashi, et al., “Bacillus anthracis incident, Kameido,
Tokyo, 1993,” Emerging Infectious Diseases 10(2004):117–20.
3. William Patrick, “Biological Terrorism and Aerosol Dissemination,”
Politics and the Life Sciences 15(1996):208–10.
4. Smithson and Levy, Ataxia, 280.
5. See Gary Matsumoto, “Anthrax Powder: State of the Art?” Science
302(2003):1492–97.
N O T E S T O PAG E S 173 –186 • 199
6. For details of new strategies for vaccines against natural or man-

made pathogens, see Clark, In Defense of Self.
7. David A. Relman, “Bioterrorism—Preparing to Fight the Next War,”
New England Journal of Medicine 354(2006):113–152.
8. Alibek, Biohazard, 97.
9. A visit to the Aryan Nations website is instructive. Their official
motto now is “Violence Solves Everything,” and they speak, ironi-
cally, of “Aryan Jihad.”
10. Jessica Stern, “The Prospect of Domestic Bioterrorism,” Emerging
Infectious Diseases 5(1999):517–22.
11. Leitenberg, Assessing.
12. For a detailed discussion of state biological weapons programs, see
www.nti.org
13. After living with HIV/AIDS for nearly thirty years, it may be time
to stop using the term pandemic and to begin thinking of HIV as an
infectious agent that is endemic in the human population.
Glossa ry
Aerosol: A system of particles suspended in a gas or fog, dispers-

ible in the air.
Agroterrorism: Terrorism involving the alteration or destruction
of crops or domesticated farm animals.
Amerithrax: FBI code name for the post–September 11 anthrax
attacks.
Antibiotic: Substance produced by one microbe that kills or dis-
ables other microbes.
Antibody: A protein found in blood, produced in response to
invasion of the body by a microbe or other foreign biological
entity, capable of recognizing that entity and promoting its
elimination.
Antiserum: Serum (q.v.) containing antibody.
Antiviral (drug): Chemical substance interfering with reproduc-
tion or function of a virus.
Antitoxin: Antiserum made against a bacterial toxin.
Aquifer: A geological formation containing water.
Bacillus: Rod-shaped bacterium.
Bacteriophage: A virus that infects bacteria.
202 • G L O S S A R Y
Bacterium: The structurally simplest single-cell organism.

Biocrime: The use of biological weapons for criminal purposes.
Biopreparat: Umbrella organization overseeing all bioweapons
research in the Soviet Union.
Biosensor: A federal program for the design and placement of
detectors for the collection and identification of biological agents
used in terrorism.
Biotechnology: The mechanical and engineering technology
used in the manufacture of medicines and medical devises.
Bioterrorism: The use of biological weapons for political, social,
or economic terrorism.
Buboes: Largely obsolete term for enlarged lymph nodes.
CDC: Centers for Disease Control and Prevention.
Chromosome: Structure in the nucleus of a cell containing the
cell’s DNA and genes.
Cipro: Ciprofloxacin, a wide-spectrum antibiotic useful in treat-
ing anthrax.
Contagious: Capable of being passed between and among peo-
ple and/or animals (said of a disease or disease agent).
DNA fi ngerprint: DNA sequences used to establish identity (or
non-identity).
DNA sequencing: Determination of the nucleotide sequence in
DNA.
DNA vaccine: A vaccine in which microbial DNA is used rather
than the microbe itself. The host produces microbial proteins
from the DNA, which then induce an immune response in the
host.
Edema: Local swelling resulting from failure to drain lymph
fluid from tissue.
Epidemic: A sudden, rampant spread of an infectious disease
among humans within a single country, or possibly adjoining
countries.
G L O S S A R Y • 203
Epizootic: Epidemic in animal populations.

Feedlot: Location where animals are maintained in close quar-
ters and fed in preparation for slaughter.
Gene: Unit of DNA encoding information for production of a
protein or RNA.
Genetic engineering: The planned alteration of a DNA
sequence.
Genome: The entire set of DNA sequences defining an individ-
ual organism, used to direct that organism’s reproduction and
function.
Germination: The conversion of a plant seed or bacterial spore
to a viable organism.
Hemorrhagic fever: Inflammatory state, usually virally induced,
accompanied by excessive bleeding.
HIV: Human immunodeficiency virus.
Immunopathology: Disease caused by the immune system itself.
Incubation period: Period between infection and first appear-
ance of clinical symptoms.
Infectious disease: Disease caused by infectious, pathogenic
microbes.
Isolation: Confinement of an individual known to have a conta-
gious disease.
MDR-TB: Moderately drug-resistant tuberculosis.
Microbe: A single-cell living organism.
Microbiology: The study of microbes.
Microorganism: A living organism that can only be seen with the
aid of a microscope.
Molecular biology: The chemistry and biology of DNA.
Morbidity: Illness.
20 4 • G L O S S A R Y
Mutation: An induced or natural alteration in the sequence of

DNA.
Natural immunity: Immunity acquired as a result of natural
exposure to a microbe.
Neurotoxin: A toxin altering function of a nerve cell.
Nucleotide: The basic chemical building block of DNA.
Pandemic: Spread of a disease through a large number of coun-
tries, or more than one continent.
Pathogen: A biological agent causing disease.
Pathogenic: Causing disease.
Prophylactic: Preventative.
Reservoir: In epidemiology, an animal species that can harbor a
human pathogen without itself contracting a lethal form of the
disease caused by that pathogen in humans.
Respirator: A protective mask to limit intake of harmful sub-
stances through the airways.
Quarantine: Confinement of an individual presumed to have a
contagious disease.
Recombinant DNA: DNA artificially created by chemically com-
bining DNA from two different sources.
Recombinant protein: Protein made from recombinant DNA.
SARS: Severe acute respiratory syndrome.
Septicemia: Large numbers of bacteria in the bloodstream.
Sepsis: Condition in which microbes (usually bacteria) replicate
within the body with no control by the immune system.
SNS: Strategic National Stockpile.
Social distancing: Maximal spacing of people to reduce person-
person transmission of disease.
Spore: Hard, dry, compacted form of a bacterial cell.
G L O S S A R Y • 205
Surge capacity: Ability to increase any critical component of a

coordinated response.
Synthetic biology: Creation of new life forms from existing forms,
or from scratch.
Tamiflu: A commercially available anti-flu drug (trade name of
oseltamivir phosphate).
Toxic shock: Physiological shock caused by release of bacterial
toxins.
Toxin: In microbiology, a chemical released by a parasitic microbe
that is harmful to its host.
Triage: Sorting, especially of patients according to their need for
care.
Vaccination: Immunization with all or part of a pathogen,
intended to build immunity before natural exposure to the
pathogen.
Vaccine: A killed microbe, or some portion thereof, used to pro-
voke protective immunity to that microbe.
Ventilator: Mechanical device to assist breathing.
Virulent: Highly infectious.
WMD: Weapons of mass destruction (biological, chemical, or
nuclear).
XDR-TB: Extremely drug-resistant tuberculosis.
Inde x
ABC News Corporation, 33 Asilomar meeting, 1974, 58,

Agroterrorism, 93–107 64, 151
Alibekov, Kanatjan (aka Ken ATCC (American Type
Alibek), 151, 153, 155, 177, Culture Collection), 37,
197 111–113, 162
Al-Qaeda, 105, 158, 181, 182, 184 Atlantic Storm, 17
Al-Zawahiri, Ayman, 158 Aum Shinrikyo, 28–32, 34, 38,
Amantadine, 80, 90 49, 55, 110, 152,153, 157,
American Media, Inc., 33 163–169, 182, 185
Amerithrax (2001 postal attacks),
32–35, 42, 44, 67, 110, 113, Baader-Meinhof Gang, 22
117, 119, 169–170, 179 Bacillus anthracis, 43, 181
Anthrax, 28, 43–45, 155, 172–173 Bacteriophage φX174, 62
cutaneous, 29, 44 Biocrime, 24, 28, 33, 38
germination, 44 Biological warfare, 22
inhalation, 33, 44 Biological weapons, 41
spores, 19, 43, 152, 163, 167 stability of, 177
toxins, 45 weather, effect on, 166
vaccine, 173 Biological Weapons Anti-
Antiterrorism and Effective terrorism Act (1989), 36,
Death Penalty Act 109
(1996), 110 Biological Weapons Convention,
Army Medical Research International (1972), 42,
Institute, 25 57, 109, 150, 151, 180
Aryan Nations, 37, 180 Biomedical Advanced Research
Asahara, Shoko, 29 and Developmental
Asian flu. See Influenza, Asian Authority (BARDA), 117
208 • I N D E X
Biopreparat, 59, 151 Dark Winter, 16, 32, 78, 155, 172
BioSense, 119–120 Daschle, Thomas, 33, 170
BioShield, 116–117, 173, 174 Deer-fly fever, 50
Bioterrorism defined, 24 Diphtheria toxin, 66
BioWatch, 117–119 DNA, recombinant, 58, 182
Bird flu. See Influenza, avian DNA fingerprints, 34
Black Death, 48 Doxycycline, 193
Black Panthers, 21
Botulinum Ebola virus, 32, 42, 50, 154, 171
antitoxin, 174 vaccine, 175
toxin, 31, 49, 153, 154, 166, 174 Endo, Seiichi, 30, 164
vaccine, 174 Environmental Protection
Botulism, 48–49, 174 Agency (EPA), 103, 118
Brucella sp., 118 Enterotoxin B, 54
Brzezinski, Zbigniew, 149 Escherichia coli, 58
0157:H7, 104
Campylobacter, 104 Executive Order, 154
Carus, Seth, 191
Castor beans, 36 Fauci, Anthony, 91
CBS News Corporation, 33 Flu. See Influenza
Center For Civilian Biodefense Food and Drug Administration
Strategies, JHU, 17 (FDA), 116
Center for Nonproliferation Foot-and-mouth disease, 3, 67,
Studies, 169 94–100
Centers for Disease Control and Great Britain, 100
Prevention (CDC), 27, 42 vaccine, 95–98
category A-C pathogens, virus, 95
42–43, 51 Fort Detrick (Army Medical
Christian Patriots, 37 Research Institute), 25,
Cipro (ciprofloxacin), 118, 35, 37, 42, 66, 153
172, 193 Fowl plague, 85
Clear Vision, 66 Francisella tularensis, 50, 59,
Clostridium botilinum, 31, 49, 118, 162
165, 181 Frist, William, 68, 110, 176
Cobra Event, The, 154
Cohen, William, 153 Genetic engineering, 57–69,
Coronavirus, 82–83 175, 182
Council of Foreign Global warming, 189–190
Relations, 180 Government Accountability
Cowpox, 46 Office (GAO), 156
Coxiella burnetii, 55 Guillemin, Jeanne, 155, 192,
Cryptosporidium, 104 197, 198
I N D E X • 20 9
Hantaviruses, 55–56 International Partnership

Harris, Larry Wayne, 37–38, on Avian Pandemic
110, 153 Influenza, 129
Hayashi, Ikuo, 30
Health and Human Services, Jenkins, Brian, 157
Department, 42 Jenner, Edward, 46
Hemagglutinin, 76 Johns Hopkins University,
Hemorrhagic fever, 32, 50–52 17, 155
vaccines, 175
viruses, 50–53 Kaczynski, Theodore, 180
HIV (human immunodeficiency Karnal bunt, 102
virus), 27, 42, 56, 62, 155, Kyoto Medical School, 164
158, 186
Hoffman, Bruce, 158 Leahy, Patrick, 33, 170
Homeland Security, Lederberg, Joshua, 150–151,
Department of, 17, 66, 152, 153
114, 117, 118 Leitenberg, Milton, 157, 181, 191,
Hong Kong flu, 79 193, 198, 199
Hurricane Katrina, 189 Lugar, Richard, 152
Identity Christians, 180 Malaria, 188

Immunopathology, 63 Marburg virus, 50
Indomethacin, 84 vaccine, 175
Infectious diseases, emerging, Markov, Georgi, 53–54
186–189 Matsumoto, Chizuo, 29
Influenza McVeigh, Timothy, 180
Asian flu, 79 Minnesota Patriot’s Council,
avian flu, 84–91, 116, 120–131, 35–37, 109, 169, 180
188 Model State Emergency Health
H5N1 virus, 19, 73, 121, 128, Powers Act (2003)
158, 161 Murai, Hideo, 30
humans, in, 85–88 Murrah Federal Building, 22, 38
vaccine, 88
viruses, 76, 84–91 National Biodefense Analysis
“Hong Kong” flu, 79 and Countermeasures
1918 pandemic, 19, 63, 73–78, Center, 66
86 National Strategy for Pandemic
1957, 1968 pandemics, 78 Influenza (2006), 120–131
seasonal, 72, 88 NBC News Corporation, 33
“Spanish flu,” 73 neuraminidase, 76
vaccines, 79, 80 New York Post, 33
viruses, 62–63, 68, 75, 80 Nunn, Samuel, 152
210 • I N D E X
Office of Technology Ricinus communis, 53

Assessment, 152 Rimantadine, 80, 90
Ostelamivir (Tamiflu), 80 Ring containment, 96, 100
“Rogue” states, 183
Pandemics, 71
Pandemic and All-Hazards Salmonella enterica
Preparedness Act typhimuriam, 26, 162, 163
(2006), 117 Sarin nerve gas, 29, 48
Pathogens SARS (Severe Acute Respiratory
agricultural, 106 Syndrome), 19, 81–84
CDC lists, 51 vaccine, 84
genetically modified, 57–69 virus (SARS-CoV), 67, 82
Patrick, William, 153, 168 Select Agents List, 110, 111
Penicillin, 193 Smallpox, 5, 45–47, 72, 155, 171
Picorna virus, 61 vaccine, 171
Plague, 47–48, 71, 173 Smithson, Amy, 157, 169, 198
bubonic, 37, 47, 173 Social distancing, 83
pneumonic, 48 Spanish flu, 73
septicemic, 48 Staphylococcus aureus, 54
Plum Island, 96 Staphylococcus enterotoxin B, 54
Pneumococcus, 77 Stern, Jessica, 180
Pneumonia, 77 Strategic National Stockpile
Poliovirus, 61 (SNS), 113–115, 173,
Postal Service anthrax attacks. See 175, 183
Amerithrax Surge capacity, 130
Primetime Live, 154 SV-40 virus, 58
Prozac, 59 Synthetic biology, 60–65
Public Health Security and
Bioterrorism Preparedness Tamiflu, 90, 115, 126
Act (2002), 103, 110–113, Terrorism, definitions of, 21–22
162 Tick fever, 50
Push Packages, 114–115, 183 Tilletia indica, 102
TOPOFF exercises, 17
Q fever, 32, 55 Toxic shock, 44
Quarantine, 77, 98, 100 Toyoda, Toro, 30
Transnational groups, 22
Rabbit fever, 50 Triage, 130
Rajneesh Cult, 26–28, 110, Tuberculosis, 188
161–163, 170 extremely drug–resistant
Red Brigades, 21 (XDR-TB), 188
Relenza, 80, 90, 126 multi-drug resistant
Respirators, N95, 126 (MDR-TB), 188
Ricin, 36, 53 Tucker, Jonathan, 168, 198
I N D E X • 211
Tularemia, 49–50, 174 Wasco County, 26

inhalational, 50 Water contamination, 102–103
vaccine, 174 WaterSentinal, 103
Turner, Charles, 27 Weapons of mass destruction
(WMD), 22
Uchiya, Masumai, 30 World Trade Centers attacks
1993, 22, 110
Vaccines, 58, 116, 129, 185 2001, 35, 110
MMR (measles/mumps/ Wright, Susan, 197, 198
rubella), 147
pre-pandemic, 125 XDR-TB (extremely
production, 166 drug-resistant
Vaccination, 6 tuberculosis), 188
compulsory, 147
ring, 96, 100 Yersinia pestis, 37, 47, 59, 71,
Vaccinia virus, 46, 171 173, 181
Variola major, 45–46
Vendor-managed inventories Zanamivir (Relenza), 80, 115
(VMI), 115 Zilinskas, Raymond, 193

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BRACING

Copyright © 2008 by Oxford University Press, Inc.

Published by Oxford University Press, Inc.

Library of Congress Cataloging-in-Publication Data

Printed in the United States of America

I would like to extend my profound thanks to a number of

points of view—about bioterrorism, just as they have differing

But it is time now to move toward a more mature view of bio-

Tales of a Dark Winter

The following “play” was performed in the summer

“Before we begin this evening, I’d like you to see a video-

“This is extremely serious. As I’m sure most of you know, small-

quickly as possible. The Governor says he has implored the CDC

“That’s something we hope you will discuss here this evening.

regular reports to the public as long as the emergency lasts. The

The Deputy National Security Advisor begins the meeting by

shopping centers and certain large businesses as well. The eco-

“The number of new cases per day is leveling off at present,

“There are not nearly enough isolation facilities to house

for example, twenty of 138 hospitals have closed their doors to

The meeting opens with another review of recent events as

“We now have over 15,000 active cases of smallpox in twenty-

begin production of smallpox vaccine. Every step will be taken to

Exercise When What

This is a partial list of such exercises. Several of these also tested

and their senior leaders, adequacy of communication across lines

and members of the National Security Council. (The Governor

minor role in Dark Winter. A person or persons unknown had

Exercises like Dark Winter provided political

United Nations Any act intended to cause death or serious

states, with a mixture of objectives (Box 2.2). As with other forms

Bioterrorism is the intentional use of any naturally occuring

It is important to distinguish between bioterrorism, as we have

Various forms of biological warfare have a long if occasion-

In 1981 the Rajneesh cult,3 founded by a displaced Indian mystic

out, was to reduce the number of Wasco County citizens able to

scientists had also endeavored to develop lethal biological terror

After a visit by Asahara and his staff to Russia in 1992, where

Masumai Uchiya—trained in organic chemistry at Tsukuba

Aum also recruited from among their membership numerous

east side of Tokyo, and at Mt. Aso in Kyushu province. No expense

disease), and in addition had likely failed to convert it to the more

The dissemination of anthrax spores using the U.S. Postal

antibiotics, and fatalities are now almost unheard of. On the

we do not know if they were truly bioterrorism or simply a bioc-

prior to the Amerithrax incidents, researchers readily exchanged

One such incident involved a group of disgruntled right-wing

pure. Still, that might have been enough to kill a hundred or

A LONE RANGER EPISODE . . .

Our final tale concerns an unusual individual named Larry

So just how much of a threat is bioterrorism, in the context

The biological weapons available to would-be

After an additional two years of domestic and international

of use as bioweapons but which conceivably could be misused for

Anthrax is a disease caused by a bacterium, Bacillus anthracis. It

Edema toxin Causes massive leakage of water from blood

Today it is hard to imagine that smallpox was once one of the

almost no one in this country has been vaccinated against small-

References to the plague in human history date back to at least

become involved, and the infection is even more lethal (septice-