The New Normalcy

Wednesday, January 30, 2002

Aftermath: The Bioterror Threat

The Age of Anxiety

Americans are feeling anxious, edgy, and vulnerable—with good reason. The appearance of cases of anthrax, innumerable hoaxes and false alarms about terrorist attacks, the specter of terrorists using smallpox, combined with the contraction of the U.S. economy and spiraling unemployment, have disrupted our lives. And the mixed messages we’ve gotten from officials—be vigilant but return to your routines; we have no idea about the source of the anthrax, but everything is under control—are little help.

Many people report emotional instability, difficulty sleeping and concentrating, and unease about various activities, including entering tall buildings, traveling, and opening mail. Some in the most affected regions of the country are increasingly resorting to antianxiety drugs; prescriptions for these medications have risen sharply in New York and Washington, D.C. According to NDCHealth, a company that collects data for the health care industry, the number of new prescriptions for alprazolam (the generic version of Xanax) was 22 percent greater in the Washington area and 12 percent greater in New York during the week ending September 28, compared to a year earlier (nationally, these prescriptions were up 6.3 percent). Prescriptions for diazepam (the generic version of Valium) increased 14 percent in Washington and 8 percent in New York, compared to the same week last year (nationally, the increase was 3 percent).

Americans are feeling anxious, edgy, and vulnerable—with good reason.

Our individual angst is likely to get worse before it gets better. President Bush, Secretary of Defense Rumsfeld, and other government officials have reminded us repeatedly that there will be no quick, definitive victory against this adversary, no D-Day invasion, no signing of a peace treaty on the deck of a battleship. More acts of terror against American civilians—adulteration of foods, Oklahoma City–style bombs, or other means—would not be surprising. And these could emanate not only from foreign terrorists but from homegrown crazies who have personality disorders, bear grudges, or are seeking their 15 minutes of fame.

The media have only added to the frenzy of fear. Months before the September 11 attacks, Tad Friend wrote in the New Yorker that "it often seems that there is only one show on television, ‘Dateline NBC: 48 Hours of 20/20, PrimeTime Thursday,’ and that this show endlessly repeats one basic story: The Thing That Went Terribly Wrong." Well, now that something has gone terribly wrong, the networks—especially the cable news networks—are desperate to fill the broadcast day with accounts of the endless, continuous, relentless—and often inaccurate—details. For example, Detroit television station WXYZ-TV aired a report questioning the security of the laboratory of University of Michigan pathologist James R. Baker, inaccurately identified as an "anthrax researcher." (He has, however, worked in the past with the harmless related bacterium Bacillus cereus, which is used to make food additives and medicines.) When the TV crew attempted to enter Baker’s laboratory, they were blocked by a locked door and, later, challenged by lab personnel. But scenes of the reporter freely entering an adjacent laboratory, even though it is used to study hearing, left the impression that university labs were vulnerable. The video, which aired several times over two days, forced university public relations officials to work frantically to calm public fears about campus security.

We must, as a nation, undertake various measures to prevent, prepare, and respond to bioterrorism, just as we did to the letter bombs of the now-imprisoned Unabomber, Ted Kaczynski. There are also things that we, as individuals, can do to manage and reduce anxiety while remaining appropriately vigilant. This is important because hypervigilance and sustained anxiety cause stress—which predisposes us to infections, gastritis, ulcers, headache, and suicide—and lower productivity.

The idea of biological warfare, which boasts a long and sordid history, elicits the kind of images that George Orwell called "vague fears and horrible imaginings." It involves organisms that cause illnesses like "the black death," or bubonic plague, which is caused by the bacterium Yersinia pestis. In the fourteenth century, an army besieging Kaffa, a Russian Black Sea port, catapulted plague-infected corpses over the city walls. In the eighteenth century, at the end of the French and Indian Wars (1754–63), British soldiers distributed blankets that had been used by smallpox patients to American Indians and caused a devastating epidemic. Japan used plague and other bacteria against China in the 1930s and 1940s. And in 1984 more than 750 people suffered food poisoning in Oregon after members of a cult, attempting to disrupt the results of a local election, spread salmonella bacteria on salad bars in four restaurants.

Human-to-human transmission of anthrax has never been reported. Anthrax is not contagious in the manner of some viruses such as influenza and rhinoviruses.

Although bacteria and other microorganisms can sicken or even kill an individual, their ability to spread and cause "secondary" cases—infection of household or community contacts—is often limited. A worldwide threat from an "Andromeda strain" is largely the stuff of science fiction for a sound biological reason: Bacteria and viruses need living hosts to provide shelter and sustenance if they are to survive and thrive and therefore cannot kill those hosts too quickly or too often.

During the past half century, university and government laboratories working with infectious agents that cause diseases such as anthrax and bubonic plague have unintentionally performed what amounts to small-scale biological warfare "experiments"—in other words, laboratory accidents in which organisms were released.

The outcomes of these incidents are revealing. The U.S. Centers for Disease Control in Atlanta, which tracks such incidents in its own laboratories, recorded 109 laboratory-associated infections during the period 1947– 73 but not a single secondary case. The National Animal Disease Center reported a similar experience, with no secondary cases occurring in either laboratory or nonlaboratory contacts of 18 laboratory-associated cases during the period 1960–75.

The medical literature similarly reveals only a handful of persons secondarily infected. In 1948–50, six cases of Q fever (a disease caused by intracellular parasites called Rickettsia) were reported in employees of a commercial laundry that handled linens and uniforms from a laboratory that conducted research with the agent; one case of Q fever in a visitor to a laboratory; and two cases of Q fever in household contacts of a laboratory scientist. A secondary case of a disease caused by an Ebola-like virus in the wife of a primary case was presumed to have been transmitted sexually two months after the husband’s discharge from the hospital in 1967. One case of Monkey B virus transmission from an infected animal-care technician to his wife apparently resulted from contact of the virus with a break in her skin. Finally, three secondary cases of smallpox were reported in two laboratory-associated outbreaks in England in 1973 and 1978.

An important part of moving forward in this new era—tentatively and uncertainly at first, perhaps—will be learning to manage our fear.

The occurrence of anthrax, caused by the bacterium Bacillus anthracis, in industrial settings is also instructive. Historically, workers involved with certain animal products were at highest risk, but only 18 cases of inhalational (lung-introduced) anthrax were reported in the United States from 1900 to 1978, with the majority occurring in goatskin, wool, or tannery workers. Human-to-human transmission of anthrax has never been reported. Thus, anthrax is not contagious in the manner of some viruses such as influenza and rhinoviruses (which cause most common colds) or tuberculosis, which is caused by the bacterium Mycobacterium tuberculosis.

Considered solely from the medical and epidemiological vantage points, smallpox is probably the most feared and potentially devastating of all infectious agents. Smallpox spreads from person to person, primarily via droplets or aerosols expelled from the throat of infected persons, by direct contact, and via contaminated clothing and bed linens. It is fatal in perhaps a third of previously unvaccinated victims. However, the likelihood of smallpox virus being used by terrorists is considered very low; and even were it to occur, techniques and technology (that is, stockpiled vaccine) are available to prevent an epidemic. The following are relevant facts:

• Smallpox virus no longer occurs in nature but is limited to two legitimate repositories, one in the United States, the other in Russia (and perhaps illegitimately in a very small number of other countries). It is, therefore, very difficult to obtain, and also to cultivate and disseminate.

• Smallpox is not immediately contagious. It becomes contagious only after an incubation period and appearance of the characteristic rash, by which time the victim is prostrate, bedridden, and probably hospitalized. Therefore, the scenario in which a terrorist infects himself and spreads the disease widely through the population is not realistic.

• Although smallpox vaccination in the United States ended in 1972, individuals who were vaccinated before that time retain significant immunity from these immunizations, both against contracting smallpox and against a fatal outcome in case of infection.

• Public health authorities have at their disposal various proven epidemiologic and medical interventions. Early detection, quarantine of infected individuals, identification of contacts, and focused, aggressive vaccination—an approach dubbed "quarantine-ring vaccination"—are the essential elements of a control regime. Approximately 15 million doses of smallpox vaccine are now available in the United States, and data suggest that these could be diluted fivefold, to yield about 75 million doses. Federal officials have recently negotiated contracts to obtain approximately 150 million additional doses.

• The government has taken steps to cope with the possibility of a terrorist attack involving smallpox by educating doctors to recognize the disease and by vaccinating small teams of experts who can rush to any part of the country to contain and treat a suspected outbreak.

Preparing for the Unthinkable

What can we do to prevent and prepare for additional bioterrorism?

As Stanford physicist and Hoover fellow Sidney Drell has said, "We’re not going to solve the problem of terrorism. We’re going to have to learn how to live with it."

First, law enforcement, military, and intelligence agencies must expand their intelligence-gathering on nations and terrorist groups capable of launching attacks with biological agents.

Second, local police and paramedics should be trained to consider the possibility of biological weapons in incidents where large numbers of people suddenly become ill. Such incidents require behavior that is different from emergency workers’ usual instincts: During conventional hostage situations and after explosions or earthquakes, the correct course is often to get as close to the incident as rapidly as possible; however, for biological or chemical exposures, it may be important for those responding initially to avoid becoming additional victims, either by donning appropriate protective gear or by medical prophylaxis and treatment.

From the medical and epidemiological vantage points, smallpox is probably the most potentially devastating of all infectious agents.

Third, health care facilities must have emergency plans in place for sudden large numbers of contaminated or infected individuals. These plans must include rapid recognition of the incident, staff and facility protection, patient decontamination and triage, drug and other therapy, and coordination with external agencies. Practicing physicians and other health care workers should receive written reminders about the symptoms of infection with biological warfare agents; very few have seen—or been taught by someone who has seen—even a single case of anthrax, smallpox, or plague.

Finally, police departments and public health authorities need to formulate strategies for various contingencies, which should include stockpiled protective clothing, designated laboratories for rapid diagnosis, a procedure for notifying hospitals and transporting patients to them, and arrangements to obtain expert advice on short notice.

Much of what public health workers and institutions need to do to combat bioterrorism is similar to confronting natural disease outbreaks, such as Legionnaire’s disease, influenza, and food poisoning. By far the greatest threat to individuals is not from criminal acts but from common naturally occurring infections, so everyone should be immunized against influenza and hepatitis A and B, and people over 55 (and those with any chronic disease) also should get the pneumococcus vaccine.

This kind of vigilance and planning would reflect the admonition by Louis Pasteur, the father of bacteriology, that "chance favors only the prepared mind." But these societal measures are not in themselves sufficient. For one thing, government planners, intelligence operatives, law enforcement officers, and health professionals cannot do the entire job themselves. Individuals—civilians—are an important part of the solution. "Solution" may, however, not be the right word, because, as Stanford physicist and Hoover fellow Sidney Drell has said, "We’re not going to solve the problem of terrorism; we’re going to have to learn how to live with it." Indeed, many of us do, already, under certain circumstances. Americans in the military or diplomatic service who are posted to various bases and embassies around the world, as well as many employees of international companies, adapt and learn how to cope with their circumstances. What constitutes safe and appropriate behavior varies from place to place: Kiev is different from Khartoum, Rome from Ramallah.

Another way to think about the need to cope with new and increased threats to our well-being—especially the kinds of "low probability, high-impact" events represented by car bombs on bridges or attacks with bioterror agents—is that they are highly context-specific. In other words, we adjust our thresholds of concern according to what common sense and recent events tell us. If you were to cut an avocado in half and find a black bruise on the periphery, you’d probably simply cut away the blemish—unless there had been a recent rash of terrorists’ injecting cyanide into fresh fruits and vegetables in supermarkets, in which case you might decide to discard the fruit.

As Americans try to define collectively and individually what Vice President Dick Cheney has called the "new normalcy," we need to find ways to manage the normal feelings of anxiety and vulnerability that result not only from fear of terrorism directly, but from concerns about the slowing economy and increasing unemployment.

Franklin D. Roosevelt’s observation that "the only thing we have to fear is fear itself" reflects that feelings of anxiety and vulnerability are normal in extraordinary times but that they can be debilitating to our lives, both individually and collectively. An important part of our moving forward to define the new normalcy will be to manage our fear.