It Can Happen Here

Friday, April 30, 1999

Defending against biological weapons employment and improving consequence management (CM) capabilities are commendably high priorities for our national leadership. To make these aspirations a reality, commitment and funding must be translated into an active and practical defense and, perhaps more important, a viable CM program. To illustrate the need for this effort, let’s begin with two possible scenarios.

NIGHTMARE ONE

I will set my first scenario at an indefinite time, call it the year 18. Imagine a situation like America experienced at the time of Desert Storm. Assume that in the year 18 country X has invaded another country and that America has responded by mobilizing its armed forces. This involves gathering our active-duty troops and reservists at various places in the United States for staging.

In one of those places, Fort Riley, Kansas, the troops begin to get sick. The sickness presents itself at first as a typical flu-like experience and is, by and large, ignored by the troops as they go about their business. By ignoring the illness in its early stages, however, they become more ill and more prone to infecting other people. Ultimately, there is a serious outbreak at Fort Riley. The doctors treat the sickness like they treat flu—aspirin, bed rest, decongestant, and so on.

In a few days many people get sicker; a significant number of them die. Postmortem examinations reveal that their lungs have filled with a transuded fluid—that is, a liquid that does not suggest the presence of bacteria but that is indicative of a viral infection. Then, abruptly, the illness goes away, and we continue with our mobilization and send troops abroad. But a few weeks later, just as suddenly, it breaks out again and more people die. It infects American troops abroad, allies, and, to some degree, even infects troops of country X.

The disease then reappears in the United States. For example, at Fort Drum, New York, more than 10 percent of the soldiers on duty are incapable of functioning because of the illness. As the illness spreads to the civilian population, Americans begin dying by the tens of thousands. Within a couple of months, deaths in the United States exceed one million.

What is the impact of this on decision makers? Quite likely they will think about biological weaponry and retaliation. Let us suppose that it can be shown that X, in this case, has experimented with biological weapons and has developed a variety of biological weapon techniques, although it has not exhibited capabilities directly related to this particular illness. As the illness spreads and deaths mount, the pressure for nuclear retaliation will rise. The arguments for using nuclear weapons in this circumstance will be extreme and strong. The desire for retaliation will be intensified further when the FBI arrests two people, clearly agents of country X, attempting to introduce a different biological agent into the United States.

Imagine yourself in the role of a decision maker. Are you on the brink of nuclear warfare? Now take a step back. I have modeled the year 18—the time in which this scenario is set—after an actual year: 1918. What I described was the Spanish flu epidemic in the United States as it was experienced in that year—with an initial outbreak at Fort Riley, spreading to U.S. troops overseas and then to their allies, and, eventually with a more virulent form of the disease, returning to America. Deaths in the United States reached 600,000 in 1918, which equates to about 1.4 million in today’s population. Biological attack was not merely a remote suspicion in 1918—during World War I German agents inoculated horses with glanders disease in New York before they were shipped to France. It’s uncertain what effect the glanders disease attack had on the logistical efforts of the Americans and their allies, but the human cost of the naturally occurring influenza virus was devastating.

That scenario may seem dated and unfair, but an influenza outbreak is a realistic example—it could easily happen again. Dr. Joshua Lederberg, for example, has emphasized the importance of preparing against a flu recurrence, pointing out that we are not dramatically better prepared scientifically than we were in 1918. Of course, we know about viruses now; we didn’t know about viruses then. We have antibiotics now. But antibiotics deal with bacteria; bacterial infection is only an opportunistic second-order effect of viral infection.

Of course in today’s world a sample of the virus would soon be sent down to the Centers for Disease Control (CDC) to be carefully assessed—and when that analysis was complete, it would become apparent that we were dealing with a new and more virulent form of virus. But when the change in the virus’s sequencing and its degree of mutation were determined, it would still be unlikely that we would be able to resolve whether we were confronting a man-made change in sequencing or a natural occurrence. Bear in mind that if retaliation, especially nuclear retaliation, were being contemplated, a high degree of certainty would likely be demanded. The years of forensic work that went into determining culpability for the explosion of Pan Am flight 103 over Lockerbie, Scotland, provide an inkling of the standard of proof required for determination of biological attack.

The difficulties that arose in Hong Kong in 1997, when a new variant of influenza (H5N1) was discovered, illustrate the massive epidemiological effort needed to address a previously unknown pathogen. Scientists ultimately determined it to be derived from an avian, or bird-based, flu transiting to become a human-based flu in a way that was previously unprecedented.

In another context, we know that natural occurrences can be thought of as biological attacks. In 1977 when Rift Valley fever broke out in Egypt, Egyptian newspapers alleged that the disease was the result of an Israeli plot. In fact, on first examination, there was strong reason to believe that this outbreak was not a natural occurrence. The disease is named Rift Valley fever because it occurs almost exclusively in Africa’s Great Rift Valley. Prior to the 1977 outbreak in Egypt, Rift Valley fever had been largely confined to Kenya and South Africa. An in-depth investigation ultimately determined that the building of the Aswan Dam had altered the migration of the animal population that carries this illness. So a “natural,” or at least non-malicious, epidemic can readily be confused with a man-made occurrence.

NIGHTMARE TWO

Once again, X has invaded another country in a Desert Storm–like scenario. The United States mobilizes and begins a bombing campaign to try, as in Desert Storm, to soften the aggressor. Suppose the White House receives a written threat from a terrorist group in the United States, along with a vial of anthrax. The letter states that the authors regard the bombing of country X as an immoral act—not because it is an act of warfare, but because it kills civilians. Because the bombing campaign is killing X’s civilians every day, the letter’s authors say they intend to retaliate by killing civilians in the United States until the bombing campaign is halted. They will do it by biological attacks on four unnamed U.S. cities with an unspecified agent, but they are enclosing anthrax to show their seriousness and credibility. They also provide a code to authenticate future communications.

Shortly after that, the United States receives information from country X about a terrorist group that is preparing to wage biological attacks on American cities. The leaders of the government of country X say that they regard this as anathema. However inappropriate our bombing campaign is in their view, they assert that they are entirely opposed to a biological attack and regard it (like the U.S. bombing campaign) as contrary to all legitimate rules of warfare. Since they regard this terrorist threat as immoral, they are providing the United States with all their information about this group, which unfortunately is extremely limited and of little help.

The president of the United States summons various experts in the biological weapons field to advise him. They are confronted with some serious difficulties. One dilemma relates to the limited preparations available to counter this threat. Another relates to how to employ the resources that are on hand when a threat is clear but its character and location are undefined. The difficulty is accentuated when a second message is received from the terrorist group—validated by its code. It indicates that they have selected one city among the four and want to make its name known to decision makers. That city is San Jose.

At this point does the president say anything to the citizens of San Jose? Does the United States take preparatory action? What should it consist of? Assume that an intelligence assessment is made that, among other things, the threat here is credible. Suppose the president asks, “Should I be stockpiling antibiotics?” In 1999 he would be told that the population of San Jose is 900,000 and that the antibiotic supply for the entire nation would last approximately three weeks if given exclusively to the citizens of San Jose. The president will then have to decide whether he wants to do this or to take partial measures that might provide a modicum of help to more people.

If he does treat San Jose, what does it mean in terms of preparations and resources in the unnamed cities? If he makes a public announcement, what is the effect on San Jose and, for that matter, on the bombing campaign? What is the psychological effect on the American people? Note that, at this point, our national security apparatus and, to the extent this situation becomes known, the American public are likely to be severely stressed. And that is so even if an attack never occurs.

FIVE LESSONS

Let me conclude by suggesting five points that are important to bear in mind in thinking about the biological threat.

1. Biological warfare can be richly ambiguous. It blurs distinctions. Definitively determining whether an outbreak is an attack or a naturally occurring disease can be a tough challenge. Distinctions between state and non-state actors are critical but often insidious. Moreover, distinctions between home and abroad are no longer operable. Importantly, note that in neither of the two incidents that I described was there an actual biological attack. The difficulties and ambiguities of these circumstances—about what is happening and whether you are being attacked, whether a pathogen is natural or man-made—give rise to wholly different consequences than many other forms of warfare. They need to be incorporated into our thinking.

2. Discussions about nuclear deterrence usually assume that we would know whether or not we were being attacked by biological weapons. Asserting a credible nuclear deterrent is vastly more difficult in ambiguous circumstances. Of course, the threat of nuclear retaliation may have some significant role to fulfill. You can subdue the inclinations of states to use terrorist groups as cat’s paws, but in my view it would be foolish to over-rely on deterrence.

3. Note that in these scenarios the duration is different than in other types of potential terrorist attacks. Biological attack is not an incident; it is an extended series of events, even in the circumstance of a single attack. In the example that I have just given, an attack that never materialized had consequences that appeared over a period of weeks. As a result, the consequences are extremely complex.

4. The crucial arena of activity is consequence management. It is unlikely that all biological weapon attacks will be thwarted or deterred. What is more believable is that success will come by managing the consequences of an attack and limiting its effects. Consequence management cannot be mastered by the single silver bullet of the multivalent vaccine, by the ability to find an effective nuclear deterrent, or by some prevention device or detector. It is, in very substantial measure, an issue associated with panic, mass psychology, and public health. During the sarin attack in Tokyo, medical facilities were confronted with an influx of the “worried well” (hypochondriacs and those who were unsure of their exposure to the agent). These healthy but burdensome patients outnumbered truly sick patients by a ratio of four to one, rapidly overwhelming the available medical infrastructure and personnel. The skills required to deal with such a situation are unique and demanding. They are not common to the military psychology or to the existing bureaucracy. They require new ways of thinking and responding.

5. The kinds of issues raised by these scenarios cross every type of traditional boundary. Our hardest problems are often encountered in overcoming bureaucracy and precedent in attempting to work across these boundaries. These scenarios have touched upon how the United States would respond with our intelligence apparatus, military forces, FEMA and the Public Health Service, and federal and local law enforcement authorities. The complexities of coordinating such an effort are enormous. Discussion among people who do not normally talk to one another will need to take place, and those engaged in such conversations will have difficulty understanding—and sometimes be uncomfortable with—one another.

If the events described above occurred today—as well they could—we would have a world that has benefited enormously from the progress made over the last several years. We have first responders trained in some significant measure, the beginnings of antibiotic stockpiles, and units like the Marine Corps’ Chemical-Biological Incident Response Force in place. We have a higher degree of attention paid to the work done at the United States Army Medical Research Institute of Infectious Disease and the CDC. Most significantly, we have a coordinator in the White House and serious presidential interest. But the fact is that the United States is still vulnerable to severe injury because even now we are far from where we need to be.