plague war
Interview: michael osterholm
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Michael Osterholm, Ph.D. is the State Epidemiologist at the Minnesota Department of Health. He also serves as Chair of the Committee on Public Health and the Public and Scientific Affairs Board. He is one of the country's most out-spoken advocates of developing national emergency preparedness for biological weapon attacks.

How fearful are we that terrorists will eventually use biological weapons in an attack on the United States?

If you had to take all the public health problems that confront us today (there are many that will kill thousands and thousands of people in the future), but there is none that I believe will actually cause the panic and the death like bio-terrorism will, and that's a given.


The DoD concluded recently that the biological warfare threat was  one area in which the US has found itself to be the most vulnerable. This was said repeatedly at a symposium on the subject  held in Atlanta, Georgia, in March 1998. More than 2,000 delegates from 70 countries were present, many of them military officers. We have three things happening today that make the likelihood that a biologic agent will be used [on] civilian populations all coming together. One, we have a number of different terrorist groups that have different ideologies; they have different reasons for wanting to do something, but they want to do it.

Number two, the infectious agents are increasingly available. The Internet has helped facilitate the mail order nature of obtaining these kinds of agents. And number three, the kinds of devices that we need to disseminate these agents in buildings, subways, and whole cities are now readily available, and in large part, have been improved because of the kind of micronization we do today with computers and so forth. We actually have created the devices to make these aerosols very effective.

With biologic weapons, [there is] the potential for them to actually have a kind of echo impact, where the illnesses may occur for weeks after the initial hit. And the potential for some agents, particularly smallpox, where the transmission can occur from [one] generation to another generation, means it's the kind of bomb that continues to go off. From that standpoint, they represent a very different type of terror and panic, one which, in many cases, is much more appealing than just the initial kind of hit and tragedy.

Appealing to who and why?

If you're a terrorist, you basically have a point of view that terrorism is your outcome. You're trying to either wreak havoc for political purposes, religious purposes, or you're just mentally unstable and believe that death is an outcome. Biologic agents even add a little bit of a twist to that, in that they add the panic and fear that we've seen so often with other infectious agents problems, whether it be plague in India, HIV in health care workers, even with our food supply and the consideration there. None of those could really match the kind of fear and panic that will occur in a community if we have a respiratory transmitted biologic agent perpetrated on the population by some individual.

Why panic? We've all seen hurricanes. We've had earthquakes. We've had horrendous things that have taken place like the Oklahoma City bombing. Why are we fearful of the panic in this case?

Part of the issue of panic is, it's irrational fear by individuals that something's going to happen to them. Infectious agents are and will continue to be that mysterious source of great panic. We saw it with HIV. We actually saw it just recently this spring, when we had the situation with the two individuals in Las Vegas who were arrested with anthrax vaccine in their trunk. Even though there wasn't a single human illness associated with that, we had major TV networks cutting into it. We had the mayor of New York City holding repetitive news conferences. That's what panic is all about. And while bombs clearly can create panic, infectious diseases almost spread it.

How attractive are these weapons to terrorists, and why?

All of us would like to say that they're not attractive, in part, because they've only rarely been used in the past. But there are a number of factors coming together, namely, the disintegration of any kind of control over a number of these weapons in foreign countries that have developed them for biological warfare purposes, not necessarily for civilian purposes. Now these are available to individuals. And given that fact, we believe that they will be [attractive]. Just as we went from the dynamite bomb to Semtex, the next level of ... panic weapon is going to be a biologic agent.

Why is biological weaponry so different?

Biologic weapons will likely be the ultimate weapon, because first of all, it's now available. Number two, it kills very well. And number three, it spreads. And the fact that you can put that all together makes for the kind of panic that we've seen around non-biological terrorism events, but involving infectious agents.

Why are we afraid terrorists will see this as the ultimate weapon?

The primary purpose of terrorists is to cause terror. Infectious agents have historically been the greatest source of terror in all of society, dating way back to the Middle Ages and before. Today, we know the kind of terror that can occur with a manmade event around a biologic weapon. And it has an obvious appeal to terrorists.

Why do you think terrorists would think that this weaponry is better than a fertilizer bomb in the back of a van?

The use of biologic agents by a terrorist is really the ultimate rock in the gear. It is a way to bring down a society, not only in terms of death and the kinds of illnesses we could see, but the panic that will ensue across states, that will ensue throughout commerce in general, is the very nature of what terrorism is all about. So the potential to take it to the next level is very real.

What is the history of biological warfare weapons.

There are a number of examples in history of the use of biological terrorism, most often in wars. This would be an example where someone would take bodies that have died from plague and throw them over the walls of cities and castles to infect those inside. We have well-documented experiences of giving the Native Americans blankets with scabs from persons who had smallpox, to try to spread smallpox in those populations. And we even have, unfortunately, examples from both World War I and World War II, where the Germans and the Japanese did extensive work with biologic agents and attempted to transmit infectious agents.

So this is an old story. Why the concern today over the new wave of bio-terrorism and biological weaponry?

Bio-terrorism is both a very old and a very new situation. It's very old in that it's been used for centuries in very crude and most often very inefficient ways. Today, what we have is a very different situation. We have for the first time terrorists in a number of different forms who want to cause terror. Number two, we have infectious agents, and our ability to grow them in quantities that we never had before, that make them very efficient and effective killers. And we now have the devices that make it very easy to fill a subway or a large building or, for that matter, fly over an entire community and expose millions and millions of people. That didn't exist before now.

Let's discuss what some of the agents are, what symptoms they cause, and why that makes them a great weapon. First, smallpox.

Smallpox is caused by a virus that has not circulated in the human population for more than 20 years. About a third of the people who contract it will die. Today, most of the world's population is susceptible to it. Because it can be easily transmitted in the air, it makes a great weapon. And more importantly, once people become infected with it, they themselves now become capable of transmitting it to others. Even a few thousand cases of smallpox could very quickly mushroom into tens to hundreds of thousands of cases, just because of that (we call) secondary transmission.


Anthrax is caused by a bacteria that can be transmitted in several different ways, but the most important one from a bio-terrorism standpoint is via the respiratory route, or basically being in the air. It causes an illness where for the first several days you have flu-like symptoms, really not that sick. You may actually even experience a day of getting better, and then suddenly you crash. Virtually 100 percent of people with anthrax on the third or fourth day of illness will die from it.

Why is it a good weapon.

Anthrax is a great weapon in terms of its potential use in large populations. You can disseminate it over entire cities via airplane. It is very stable in the environment. And the infectious dose is so low that you can infect most of the people who are in that city.


Plague is another bacterial-caused infectious disease. It causes a type of pneumonia in a number of patients. It is fatal in a large number of them, if not caught not early. And it's very easily transmitted through the air.

Why is it a good weapon?

Plague makes a very good weapon because it's very easy to put into the air, and it causes lots of deaths.

How impressive is it that mankind basically beat smallpox?

Smallpox is probably the most misunderstood human condition of this century. Very few people realize that more than 500 million people have died from smallpox since 1900, despite the fact that it hasn't even been around since 1978. That's more than all the wars, HIV infection, and swine flu combined. Yet, because it hasn't been in the developed world countries for most of the last half of the century, and for the whole world for the last 20 years, we somehow have forgotten how lethal and how absolutely horrible it is as a disease.

How horrendous is it even to imagine that someone might now dig it up and use it as a weapon?

Probably the worst crime that humans can commit against other humans is to bring back smallpox after all we did to rid it from the world. Smallpox is not only a grotesque disease in how it looks, with these horrible pustules and the disfiguring kind of disease, but it's a horrible disease in that it kills a third of the people who get it. And they themselves are often highly infectious to others who are near them. So for us to bring it back after all we did to eradicate it really goes against the very nature of why are we human.

Draw for me a scenario, which you have written about before, of how smallpox could be put in a major international airport. What could be done, and what would be the effects?

Because of the great advances we've made in what we call aerosol particle technology--the ability to make very fine particles that float in the air forever (and we need that today in the computer chip industry and a lot of other industrial purposes), we unfortunately can have it used for taking very small amounts of fluid-like material--we're talking about three tablespoons--and filling an entire mall, an entire subway area, an entire airport concourse with millions of infectious doses, in such a way that the whole device would fit into a heat thermostat box that could very easily be attached with Velcro strips quickly on and off the wall, and no one would even know when it was there. That type of information is in the hands of the people out there that can do that. And that's why we're so concerned that it's going to get done.

That sounds like science fiction, not fact. Is that at all possible?

One of the great advances that we've made in society, besides the Internet and computers and all the kinds of electrical gadgets we have today, is we've also made it possible to create devices that can transmit a great deal of infectious material into large public settings. And the entire device size is only that of a heat thermostat box. That's not science fiction. That's easily doable. You can actually go to a series of electronics stores in any large community in this country, and put that kind of device together.

Continue with the scenario. A box is put into an airport. What happens?

If a terrorist wanted to infect thousands and thousands of people, it would be very easy to do ... with the right infectious agent (which is now increasingly available through mail order Internet), with this type of device, put it in a public setting, come back two days later, after the infectious agent has been exhausted out through the building, retrieve the device, go home, and watch eight to ten days later when the first cases of smallpox start to happen, or three to five days later when the first cases of anthrax start to happen. That is not only something that is easy to imagine, but we have a great fear that people are planning that very type of situation right now.

What happens and how do we respond?

If there was even a very limited release of smallpox in a public setting today, make no mistake about it, it would be the closest thing to a living hell we've probably ever known. We would basically see hundreds, maybe thousands of people who would come down with a life-threatening illness, who would expose all the other people who were around them, including the health care workers who are now taking care of them. And of course, many of these health care workers, recognizing what they were dealing with, would now likely panic and leave the scene of the hospital or the care setting that they're in. And we believe we'd just see a total chaos occur.

Draw a picture. The first people come to the emergency room. How do we figure out what's going on and what happens next?

Eight to twelve days later, people would start coming to emergency rooms with fever, chills, in some cases vomiting, not yet necessarily showing a rash, although some might. They'd be sent home with having the flu. It's at the time then of three or four days into their illness that they would really start showing this rash. That's at the same time that they become highly infectious themselves. It would still be days before anyone would recognize that this chicken-pox-like illness is really smallpox. However, within the next five to seven days, these people would become severely ill. About a third of them would die, and we would be overwhelmed in any medical care setting with even just a few cases. No one could even imagine what it would be like if there were hundreds or thousands of cases.

If it is smallpox, would we just vaccinate everybody?

The only way we could respond to a smallpox outbreak today is to literally circle it, much like you'd try to circle a wildfire. When I say circle it--we would have to try to make sure that all the people around a given case are immune. This is the same way that we have eradicated smallpox from the world some 20 years ago. That would require that we have millions and millions of doses of vaccine, something that just doesn't exist today in the world.

What do you mean?

For the last 20 years, we have taken great pride in that we eradicated probably the greatest scourge of mankind. And in doing so, we've let down our guard. We've not maintained the kinds of vaccine supplies that we would need, should someone ever bring it back. And today, as a result of that, there literally are just millions of doses.

What's available today and what can we do about it?

In the United States today, we have somewhere probably between seven and ten million doses of smallpox vaccine. We're not even sure, because some of it is in a condition [where] it's not clear whether or not it's even going to be effective. We have no ability in this country today to manufacture smallpox vaccine. It would require a Manhattan Project of incredible effort to even hope that we could have vaccine in the next two to three years. During that time, this country will remain extremely vulnerable to anyone who uses smallpox, not only in the first attack but all the subsequent waves that will occur afterwards.

How does such an attack create a perfect scenario for the use of blackmail, even if they don't use the agent?

If someone really wants to use smallpox today, and they have access to it, there is no way to necessarily stop them. The best we could hope to do is limit the number of deaths and limit the panic. The only way we're going to be able to do that is to have sufficient vaccine supplies in this country, that if need be, we could very quickly vaccinate millions and millions of people so that even if a terrorist wanted to use these infectious agents such as smallpox, they would not be effective.

Is there a distinction between the ability to grow anthrax or smallpox, and the ability to weaponize it?

There's actually a lot of difference in the expertise to actually grow these particular infectious agents (such as anthrax or smallpox), and actually have availability of them. Today, smallpox is very limited. Anthrax we can get from any number of different sources. But once you do have the agent, regardless of what type you have, what we've not done is develop the type of weaponry, the kind of aerosolizers that actually make it quite easy for people to be successful in delivering whatever the infectious agent is.

Are you telling me it's really easy, that anybody could get their hands on this? Explain.

When I was in high school, twenty-some years ago, I couldn't have imagined making a pipe bomb. It was just beyond anything I had access to. With the days of McGuiver and the Internet and so many things now in the public domain and libraries, high school students will tell you it's not difficult to build a pipe bomb. Take that same scenario and look at the issue of infectious agents transmitted by aerosolizing devices. Twenty years ago, we couldn't have done it. Today, what's in the public domain and how to do these is such that even a relatively inexperienced individual could put one of these together quite easily.

The general thought out there is that smallpox was eradicated years ago, and that it only exists in two different places: the CDC and one place in Russia. Is that correct?

One of the greatest scientific fallacies that exist today is that smallpox is only in two laboratories, both secured, here in the United States and in the former Soviet Union. We know that it's in multiple locations in the former Soviet Union; that it is in North Korea, and likely in Iraq, and possibly other countries.

How scary is that?

There could be no greater human tragedy than the return of smallpox. The fact that there are now multiple locations that could potentially use this agent as a biologic weapon has to be, without a doubt, one of the greatest tragedies that could exist in human society.

How easy is it to transport biological weapons across the lines of the borders of countries?

Where humans can go, infectious agents will follow. Today, crossing any border, going through any airport, through any metal detector, as long as I have an ink pen in my coat pocket that writes, but has a compartment where you could store an amount of infectious agent barely visible to the human eye, you have the ability to move literally large weapons.

Are we prepared?

Today in the United States there is a tremendous amount of activity that's going on around the issue of bio-terrorism. For those of us that are out in the field and have to prepare for it, I would only conclude that there's been very little real action that actually has occurred that would allow us to be prepared. We don't have the vaccines. We don't have the antibiotics. We don't have the local planning. We don't have much in place beyond a lot of rhetoric and a lot of activity that many of us would ask: "So what?"

What's the first line of defense and how will that stack up against such a threat?

Today, if someone explodes a device or uses a chemical warfare agent, individuals will know immediately that something happened, and their first responders (fire, police, and other typical first responders) will be on the scene. If a biologic agent is released, if it's anthrax, it will be several days before the first cases show up; if it's smallpox, it will even be potentially several weeks. Then the first line of sight of that kind of situation will be emergency rooms. It will be urgent care. It will be doctors' offices. It won't be the first responders. And only if public health has in place the kind of adequate surveillance or the ability to pick up all those cases and bring them together in a way that we can meaningfully say something's happening in this community, will we really be able to respond to this kind of a situation.

So what is Washington's role?

As a state epidemiologist, it's my job to make sure that epidemics don't occur in our communities. As someone who's also been very involved with issues around national preparedness for bio-terrorism, I can tell you that very little to almost nothing has been done at the state or local level to prepare public health, to prepare medical providers, to provide for care teams for a biologic event. What we keep seeing are these people in these space suits from federal agencies, who keep saying, "We will come in and help. We will take care of things." In the first instance, that will be so far after the fact that it will almost be needless.

You lay out a scenario where there doesn't seem to be a lot of solutions to. How much of a problem is our lack of preparedness at this point?

As frightening as bio-terrorism is, what is equally frightening is the fact that we still don't get it in this country. We still believe that if we put more money into our military, [if] we put more money into first responder programs, we will somehow prepare ourselves for bio-terrorism. It won't happen. It's going to be at the emergency room level, in the medical care area, in the health departments, in our vaccines, in our antibiotics. If we don't have those, we have nothing to prepare for bio-terrorism. Right now it is so scary because that is the mode that we continue to operate in.

You hear that the president is very involved with this situation. There is a lot of money being thrown around right now. Why doesn't Washington get it?

I like to believe that policy makers and those in this area are logical people, people who are concerned about the issues around bio-terrorism. Despite the fact that for the last three years a number of us have pleaded with policy makers in Washington to accelerate, to even begin working on the development of new smallpox vaccines, to begin providing for anthrax vaccine, to actually consider, where would we get all the antibiotics we need when we have a big potential exposure, nothing's been done on that. What's very frustrating is, despite having explained all of this, what is it going to take to get people to move?

If it is so clear-cut, why aren't they acting on this?

The million dollar question today in Washington is: What is it going to take to get policy makers to see that all the money that we're throwing into bio-terrorism has really had very limited impact on our ability to prepare out there. And what's happened is, people have confused activity with action. Hopefully, we're about to turn the corner where people finally see that without talking to the state and local health departments, without talking to the local emergency management people, without developing the national programs for vaccines and antibiotics, we will remain unprepared for bio-terrorism.

Let's talk about the B'nai B'rith false alarm in Washington a year ago. What happened there and why is it an important event.

Recent events around possible hoax situations, including the B'nai B'rith in Washington DC, letters that were sent to individuals that had powders in them, and even the situation with the anthrax vaccine in the trunk of the car in Las Vegas, all begged the question of what does it take to be prepared for bio-terrorism. [It is] very unlikely that we will ever have a terrorist come forward, expose large numbers of people, and then declare within hours, maybe even a day, that they did it. Therefore, the first responders won't be there. They won't be the ones that will be on the scene. It will be the public health and the medical communities that will first pick this up.

What is the way they responded to the B'nai B'rith specifically? How was it incorrect and what does that tell us?

What's really frightening about the beliefs of much of our governmental system to responding to bio-terrorism is that somehow rushing in, in space suits, with sirens, will deal with the bio-terrorism problem. Even if someone did send an envelope with anthrax spores in it, the chances of those actually causing disease are very small. You have to have a way of disseminating that particular agent. That in itself shows a lack of understanding by many of our first response agencies of the country. It shows even to the extent that the federal government as a whole doesn't understand what does it take to transmit the agent, and what does it take to respond to it.

How would you contain it and how did they err?

In a situation where you have an infectious agent like smallpox or anthrax or another one in a box, it's very simple. You don't have to come in and decontaminate the entire area unless that's been aerosolized, unless it's in the entire room. At that point, you'd go and destroy it in any kind of laboratory, like we do our everyday stocks of these same infectious agents. It doesn't require the same kind of immediate first responder response like you'd think of with a bomb or a potential chemical weapon release.

The size of a disaster such as this, what added difficulty does that in itself cause?

On one hand, the size of a biologic terrorism event is somewhat meaningless, because even five or six cases will result in a panic that I don't think any of us can predict. On the other hand, if you're trying to provide the medical resources, the care, you could very easily outstrip all the intensive care beds in a major metropolitan area with just a very small event, which then would require additional medical services being provided, which would then just ping-pong throughout the medical system.

So what's the result?

With even a small biologic terrorism event with one of the serious agents (such as anthrax or smallpox), even a few cases will cause widespread panic; but more than that, it will cause a major disruption in the medical care system. We will find in some metropolitan areas that we won't even have close to the number of hospital beds that we'd need to care for these people, which then in turn will only further fuel the panic.

The structure falls apart. What happens to the community?

Several of my colleagues and I have tried to walk through these scenarios time and time again. We've looked at them as we would handle any other public health disaster, as we've done in the past. Unfortunately, each and every time, given the resources we have now, given the kinds of authorities we have now, we come down to basically complete chaos and panic. In many instances, the only thing that would probably prevail is martial law. I don't think this country has yet prepared to realize that we may face that in the future.

What do we need to do in this country to shake ourselves up, to get the information that we need to make sure that we can handle the threat?

First of all, I don't think that many of us believe we can really handle the threat. What we can try to do is manage it. And that's a big difference. But right now, we can't even manage it, because too many of the people making the major policy decisions about where we spend our money, how we prepare ourselves, have no real understanding of what it's like at the state or local level, where this event will occur. Until we see a change in the federal government approach to including the input from the state and local level, I think we'll continue to see this mismanagement of what we need for future planning around bio-terrorism.

Beyond that, do we need to bring the finest minds in, that usually are brought in to research weaponry?

One of the real problems we have today is that this issue has been largely taken over by the beltway bandits of Washington DC. There are a lot of people making a lot of money on national preparedness for bio-terrorism, and frankly, they're contributing almost nothing. What we don't need is more money to go into the same areas. What we need is a fresh look at this. We need the people who have staffed these kinds of outbreaks, not caused by terrorists but by Mother Nature for the last decade; bring them together and say, "How would you respond?" We need the local beat cop, the kind of person that's going to be out there trying to keep order when one of these things happens. So far, that kind of input has not only not been sought, but when it's been provided, it's been summarily dismissed.

Last March, President Clinton ordered a table top exercise for federal officials. Why?

I think the president is genuinely concerned about this issue. I think he really cares. We believe that this administration cares. The problem has been translating a care into action that means something. That's been where there's been a big disconnect. The table top exercise is a good example. A number of table top exercises have been prepared by various agencies of the federal government. Some of them were so factually incorrect, or not based in the reality of what really happens out in the field, that they were really a large waste of time. And one of the concerns we have is, if we're going to plan around this, then let's be realistic. But to be realistic, you have to ask the people who are out there in the fields (the beat cop, the state epidemiologist, the emergency room physician), "How would it happen? Tell us." And then we can plan around how to respond.

What's the purpose of a table top exercise like this?

A table top exercise is a series of modules put forward to say "what if," and then discuss "what if." Each one of them takes us further into an imaginary kind of event. Those are only helpful if those imaginary events are close to the reality of how something would really happen. So if you're starting to plan around something that is so illogical, or just wouldn't happen out there, it doesn't matter what conclusions you reach--they're meaningless.

But in this case, from the reports, what did we learn from it?

The table top exercises to date show that we are absolutely not prepared to even begin to respond to bio-terrorism, let alone control it.

One of the lessons from the table top exercises that have been conducted over the last year is that this country is not only ill prepared to respond to bio-terrorism, but that the planning activities that we need to better prepare ourselves are not in place.

What do you mean when you say that things fall apart?

In the last four months, I've been involved with three different table top exercises. In each one of them, when it came down to the really difficult aspects of the vaccines, the antibiotics, who would do what--every one of them failed miserably, because we either didn't have the resources, or no one really knew what to do or how to do it, or how to even begin to prepare for it.

If these table tops fail, what does that mean about our real ability once it actually takes place?

Table tops are actually artificially easy, because we build control into them. And when they fail, you can only imagine what the real event will be like.

What do you find on the Internet that's so scary?

The Internet today is the vehicle that brings terrorists together in ways that make intelligence very difficult to intercept. It brings infectious agents to people who otherwise would not have access to them. And also, it furthers the information out there for people who wouldn't quite know how to prepare something, and now they can go to a cookbook on the Internet. In the anonymity of their own home, they can figure out how to do it.

What fears come with the millennium?

The irony of it is, most people today are very concerned about the computer bugs with the year 2000. Those of us in the area of biologic warfare and terrorism are very concerned.....The goal of the millennium cults is to see civilization end in the year 2000, and to take us to the next level. If you want to effectively do in large number of people in a very cost-effective way, biologic agents are the obvious answer. Our information would suggest that in fact that is a primary weapon that is being sought out by a number of different millennialist cults.

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