CHAPTER 11 BIOTERRORISM AND BIODEFENSE FOR AMERICA’S PUBLIC SPACES AND CITIES Brian Hanley and Birthe Borup The Black Death swept through Europe from 1347 to 1350, killing 60 per1 cent of the entire population, around 50 million people, and changing history (see Figure 11.1). “During the 14th century the black death struck 2 Florence and wiped out three of every four people in the city.” This was the backdrop for Giovanni Boccaccio’s writing The Decameron: The plight of the lower and most of the middle classes was even more pitiful to behold. … Since they received no care and attention, almost all of them died. Many ended their lives in the streets both at night and during the day; and many others who died in their houses were only known to be dead because the neighbors smelled their decaying bodies. Dead bodies filled every corner. Most of them were treated in the same manner by the survivors, who were more concerned to get rid of their rotting bodies than moved by charity towards the dead … Such was the multitude of corpses brought to the churches every day and almost every hour that there was not enough consecrated ground to give them burial … Although the cemeteries were full they were forced to dig huge trenches, where they buried the bodies by hundreds. Here they stowed them away like bales in the hold of a ship and cov3 ered them with a little earth, until the whole trench was full. Other accounts of this period are equally dramatic. For example, Johanes Nohl wrote, From all countries it is reported that gravediggers threw infected matter from their carts so as to stimulate the epidemic which for them was a time of luxury … The worst of all is that the rich, higher town officials and all persons vested with official authority flee among the first at the outset of the Bioterrorism and Biodefense for America’s Public Spaces and Cities Figure 11.1 255 Estimated Population of Europe during the Black Death plague, so that administration of justice is rendered impossible and no one can obtain his rights. General anarchy and confusion set in and that is the 4 worst evil by which the commonwealth can be assailed. And according to Fray Toribio Motolinia, They died in heaps, like bedbugs. … as it was impossible to bury the great number of dead, they pulled down the houses over them so that their homes become their tombs. … Many others died of starvation because they were all taken sick at once, they could not care for each other, nor was there anyone to 5 give them bread or anything else. Smallpox and other European diseases sweep through the Indian nations in Mexico in the 1500s, killing on the order of 50 percent to 90 percent of all native inhabitants. Earliest records from colonists in New England record fatality rates of 90 percent to 95 percent among American Indians exposed to European diseases such as smallpox and influenza (see Fig6 ure 11.2). Such is the power of natural diseases, able to cripple nations or remove them completely from our world. Imagine a similar epidemic sweeping through the United States today, spreading from person to person, and killing indiscriminately, perhaps even aided by people who see it as giving them advantage and a better life than they had. And now imagine that this disease did not come from nature, but that it was introduced willfully by man, maybe even created by him. Such is the power of biological warfare: a power so great as to render nations and cultures powerless, or to nearly erase them from our earth. This has been demonstrated on or near United States soil, from American Indians of the sixteenth through the 7 eighteenth centuries, to Pacific Islanders of the twentieth century. Methods and techniques for biological warfare have become so readily available, so well understood and inexpensive worldwide, that it is simply a matter of time before they will be applied effectively by states and Figure 11.2 Major Disease Pool Competition and Biological Warfare Time Line Bioterrorism and Biodefense for America’s Public Spaces and Cities 257 nonstate actors. As the price tag for biological weapons development and deployment drops, even small terrorist groups can easily acquire the means for a biological attack. A survey conducted in May 2005 by one of the authors of this chapter indicated that less than $10,000 would be needed to assemble a laboratory with highly sophisticated capabilities. Since biological weapons are capable of such high death rates, they can seriously damage or even bring down entire nations. Natural disease pools, prior to the development of modern medicine, were a primary 8 determinant of the outcome of long-term conflicts. Those disease pools 9 have been deliberately used in warfare as well. It is worth noting that, from an evolutionary point of view, a population that is resistant to, yet supports the propagation of deadly diseases wins out against a newly contacted population that is not resistant. Thus, there is a benefit to being susceptible enough to support propagation of a disease, but resistant enough in the population as a whole that the population can survive as a group. Such disease pools have been basic to guiding the long-term out10 come of military conquests and conflicts prior to modern medicine. Most public health scenarios consider casualty rates of 2 percent to 3 percent of the total population to be catastrophic. The scenarios considered in this chapter include but also far exceed that. In the modern era, the effect of high casualty rates from disease can be seen on the less developed countries of Africa from the HIV plague. Infection rates in subSaharan Africa are over 7 percent, with 2.3 million deaths per year, and 11 over half of the total population with AIDS worldwide. This has led to legions of orphans who have provided cannon fodder for wars in the region and other ill effects. UNICEF has estimated that by 2010 there will be as many as 18 million children in sub-Saharan Africa orphaned by 12 AIDS. Thus, it should be understood that the effects of disease can be highly destructive for societies in various ways. DEATHS FROM WAR VERSUS DISEASE Compared to war, diseases have killed far more people. For example, in 13 the United States alone, 36,000 people per year die from influenza, and 14 18,000 people per year are now dying from HIV/AIDS. (This rate has risen, fallen, and risen again.) In general, infectious disease rates in the United States dropped during the twentieth century; however, rates have varied, from 797 deaths per every 100,000 people in 1900 to 36 deaths per 100,000 in 1980, with a dramatic peak in 1918 due to the influenza pan15 demic. From 1981 to 1995, the mortality rate increased to a peak of 63 deaths per 100,000 in 1995 and declined to 59 deaths per 100,000 in 16 1996. Today, that number of roughly 60 deaths per 100,000 people translates to approximately 180,000 Americans dying each year of infectious disease under normal conditions. 258 Public Spaces and Social Institutions Overall, in the last 100 years, approximately 10–18 million people have 17 died from infectious diseases alone in the United States Compare that with the number of Americans who have died due to wars over the last century: • World War I—118,000 dead • World War II—300,000 dead • Korean War—34,000 dead • Vietnam War—59,000 dead • Iraq War—2,000 dead • Total—less than 520,000 In other words, all twentieth century wars combined have killed approximately 5 percent of the number of Americans who have died of disease during the same time period. Using the Centers for Disease Control and Prevention (CDC) estimates for influenza deaths, at least 1 million and probably more than 1.5 million Americans died from influenza alone during the second half of the twentieth century. For the United States, influenza alone killed three times the number of people in just 50 years of low-level mortality (nonpandemic) than died from all wars combined during the whole century. Worldwide, estimates vary for the number killed in war. Zbigniew Brzezinski cataloged between 167 and 175 million “lives deliberately 18 extinguished by politically motivated carnage.” However, looking at just three diseases in the twentieth century, that number is probably eclipsed. It is not possible to cite precise statistics for malaria, influenza, and HIV for the entire twentieth century, since even today deaths are estimated. But according to the CDC, malaria deaths today currently account for 19 700,000–2.7 million deaths each year, though other estimates are a bit 20 higher. In any case, it is reasonable to estimate that approximately 120 million people worldwide died of malaria in the twentieth century. There was only a short hiatus in the years immediately following World War II when malaria mortality dropped to low levels because of the application of DDT (dichloro-diphenyl-trichloroethane). For HIV/AIDS, an 21 estimated 11.7 million deaths had occurred by 1997. From influenza, just 22 the 1918 pandemic killed 50 million people around the world. This brief review gives us a number of around 180 million people dead from malaria, HIV, and the 1918 influenza pandemic alone. However, outside of the extraordinary pandemic in 1918, the worldwide yearly normal death toll from influenza is unlikely to be below 500,000 per year, and quite possibly is over 1 million per year; in the United States alone, 36,000 people die each year. The United States contains roughly 5 percent of the total population of the world, so if that Bioterrorism and Biodefense for America’s Public Spaces and Cities 259 death rate holds true for the world as a whole, then one would expect 700,000 people worldwide to die of influenza. Since the United Stataes has better health care than developing nations of the world, the true number is most likely higher. Thus, the flu has killed a lot of people over the course of a century, most likely producing another 30–80 million fatalities. If this figure is added to the previous observations, between 220 million and 250 million people have died from these three major diseases alone. It is for this reason that many physicians say, “Nature is the greatest terrorist.” Approximately 2,750 died in the New York World Trade Center attack, 23 with exact numbers unlikely to ever be known precisely. In Spain, 202 24 died in Madrid’s train bombing, and approximately 50 in London for a rough total of around 3,000—less than 10 percent of the 36,000 people 25 who die each year from influenza in the United States alone. This is why there should be concern about bioterrorism. Diseases that nature has provided, combined with the ingenuity of men, could easily exceed deaths from all other causes in just one serious incident. All other terrorist attacks from bombs and planes will pale in comparison. In addition, in the modern world, man is capable of doing more than what 26 nature is likely to do with bioterrorism. Thus, it is a frightening reality that extremist groups like al Qaeda are actively seeking bioterrorism capabilities. FUNDAMENTAL PRINCIPLES There are seven fundamental principles of biological warfare: (1) Any virus whose DNA sequence is known can no longer be considered eradicated. (2) New organisms not found in nature can be engineered. (3) The focus of biological warfare is populations, not individuals. (4) To be maximally successful, the attack must go unnoticed until the population’s health system is overwhelmed by cases of infection. (5) The attacker needs to have a motive and the means to carry out the attack. (6) The attack must be carefully prepared. (7) Murphy’s Law, that anything that can go wrong will go wrong, applies to attackers during the preparation and the attack. The most fundamental principle of biological warfare today is that any virus whose DNA sequence is known can no longer be considered eradicated. Since the DNA sequences of dangerous viruses are published, and nucleotide synthesis is capable of reproducing them at will with an ease growing by leaps and bounds, it is, while not yet trivial, a reasonably straightforward matter to assemble the required equipment and cell cultures to produce small seed culture amounts of almost any virus. For as long as our world maintains the technological capability for synthesis of nucleotide chains of sufficient length, this will remain true. Consequently, attack by any known sequenced organism must be considered plausible. 260 Public Spaces and Social Institutions In the modern world, the attacker would not need to acquire the virus, such as smallpox, from cold storage, but could synthesize it. The second principle is that for every known disease, there is some unknown number of organisms that could be engineered that could be more deadly than the wild type. Given the demands of evolution on microorganisms to spare their own host population or face extinction themselves, it is a near certainty that any organism that is able to kill more than 30 percent of a total population in today’s medical milieu (note that this is not 30 percent of those infected) will be an engineered organism, most likely with human logistical help to infect the population. (Note the difference between sparing any specific host or person and sparing enough of the host population to allow the disease parasite to survive.) Our knowledge of the mammalian cell and of the human immune system has become very sophisticated. Engineering a deadly disease organism, while definitely not trivial, is a much more tractable problem than it once was, and it is becoming more so at a rate that is disquieting. For instance, advances in genetic engineering in the past ten years have made it possible to create enzymes with novel activities. These enzymes 27 can either synthesize chemicals generally not found in nature, synthesize 28 29 known chemicals with greater efficiency, or degrade chemicals. Using these techniques it is possible to create new organisms (virus or bacteria) that can be used in biological warfare. These organisms could produce toxins (potentially in high quantities) that our immune systems are unable to cope with, killing us outright, or weakening us so that we become susceptible to other diseases. The genetically modified organism could also be made resistant to antibiotics or other medication by having enzymes that degrade the antibiotics. This could create supergerms that modern medicine would be unable to kill effectively. However, this is not the limit of what modern molecular biology makes possible. The third principle is that in biological warfare, individuals are not the focus, populations are. While there are methods and techniques for delivering or making organisms for the purpose of specific assassination of individuals, and these could be a small, maybe crucial, part of a larger warfare scenario, they are not in themselves going to win a war anymore than snipers will in conventional warfare. What matters is the degree of penetration of a population by an agent, and the amount and type of desired casualties produced in the population by the agent. Fourth, to be successful, a biological attack must either overwhelm the capacity of the target population to respond to the attack or evade the ability of the target population to diagnose that an attack has taken place until it is too late. A corollary to this is that the difficulty of either overwhelming a health care system or evading detection of the agent probably rises with the percentage of the population the attacker desires to eliminate. However, this latter should not be cause for overconfidence. Bioterrorism and Biodefense for America’s Public Spaces and Cities 261 Fifth, as in any serious crime, an attacker must have both motive and capacity to carry out the attack. Accidental development, production, and deployment are exceedingly unlikely. While stating that motive and capacity are necessary may seem to be a tautology, it leads us to carefully examine who has the means and who has the motive. In today’s world it no longer requires the resources of nation-states to conduct serious biological warfare as it did in the relatively recent past. Nation-states certainly can do so, but the means to develop and produce them has such a low cost, that small non-state actors can afford it. Nation-states face the problem that, if they use them, they will suffer heavy conventional retaliation. Individuals and transnational terrorists do not have this problem of retaliation, since, if nation-states could retaliate effectively, they would already have done so and terrorism would not be a problem in the first place. Consequently, when examining motive, we must look beyond the classical motives of national militaries and examine both the record of attacks and attempted attacks that have occurred and the pattern of action of small groups and private individuals for violent activism. The sixth principle is that in order to conduct an attack, several things are necessary. The organism must be acquired or developed. The organism must be cultured or reproduced by some means, and finally, the organism must be deployed according to an effective plan of attack. Interdiction is possible at any point in the process, as are errors or mistakes by potential attackers. Dangerous viruses have significant handling problems, which may be, for an attacker, one of the most difficult issues to deal with, though this should also not be cause for overconfidence. In addition, to accomplish a successful attack, the attackers will need two more things. They will need to test their organism’s effectiveness, and they will need to create a plan for effective deployment. Intuition and luck can produce quite a number of casualties, but only a well-developed plan will ensure a successful high-level attack (high mortality rate of target population), unless the attacker gets lucky. In general, the higher the level of attack to be carried out, the greater the degree of testing and planning required to be successful. The last principle of biological warfare is that Murphy’s Law (that anything that can go wrong will go wrong) applies to attackers without a 30 doubt. Every actual deployment has had serious problems. The Japanese in World War II dropped plague-bearing fleas on China from airplanes. It is unclear that any illness resulted from this. In 1991, Shoko Asahara’s group in Japan sprayed anthrax from a building in Tokyo with no result because the variety used was a nontoxic lab strain. Asahara sent followers to Africa to collect a sample of the Ebola virus during an epidemic, which they failed to obtain. In 1984, Ananda Sheela of the Rajneesh group in Oregon directed the spraying of Salmonella typhimurium on a salad bar and succeeded in making people ill. However, her alleged attempts to 262 Public Spaces and Social Institutions assassinate a district attorney failed. Any individual or group who decides to launch an attack has a high probability of making a serious mistake, which is all to the good. POSSIBLE ATTACKERS In the United States biological weapons are generally thought unreliable for militaries because of the problem of blowback—i.e., that the attackers themselves could get sick. This is, however, a debatable classification since no such blowback has occurred in practice in the twentieth century, even when biological weapons have been deployed, though biological warfare, per se, has never occurred on an unrestricted scale in the twentieth century. Other nations and their leaders are also unlikely users of biological weapons. In the modern world with its nuclear weapons and highly developed conventional military capabilities, the problem for a nation considering the use of biological weapons is the problem of retaliation. A nation-state discovered to be conducting serious biological warfare against a nuclear power, or even knowingly harboring those who are, is quite probably committing suicide. The degree of threat to the world as a whole from such a nation would result in very serious consequences based on consensus among leading nations. But this balance of power is specific to nations and their leaders. For the purpose of this calculation, national leaders are quite rational and, therefore, unlikely to use biologi31 cal warfare overtly. However, using intercontinental ballistic missiles (ICBMs) carrying biological weapons after attacking another nation with nuclear weapons was an integral part of warfare doctrine of the Soviet 32 Union. Since any organism can be obtained, and new attack organisms can be engineered with budgets potentially accessible to individuals, this means that we can no longer exclusively focus on the motives of nation-states and their leaders. In fact, the most likely initiators of a serious biological warfare attack are small religious groups, activist groups, and “armies of one” (for example, Theodore John Kaczynski, Ph.D., aka the Unabomber). The basics here are leadership and doctrine. Since the close of World War II, all biological attacks of known origin have been carried out by religious organizations run by a charismatic leader. Of the known attacks, one occurred in Oregon at the command of Ananda Sheela, an aide to Bhagwan Rajneesh. It is possible that this attack was carried out without Rajneesh’s knowledge, as he was the one who blew the whistle on it. The other attack was carried out at the command of Asahara in Japan. His group sprayed a raw extract of anthrax culture from a rooftop in Tokyo, which accomplished nothing except the creation of an exceedingly bad smell that attracted the attention of the citizenry Bioterrorism and Biodefense for America’s Public Spaces and Cities 263 and police. The 2001 U.S. letter attack using anthrax powder is the only known biological attack that actually caused deaths. Since it is possible (though not certain) that al Qaeda carried out this attack, the attack may eventually be classified as an attack by a religious group. None of these attempts was meant to kill a large fraction of a population. There has also been a possible attempt to acquire Yersinia pestis and anthrax for weapons use by an Aryan Nations member, microbiologist Larry Harris in 1995 33 and 1998. A biological attack will not occur without a leader who gives the orders or approves of the plan. It is possible for an attack to occur without doctrine supporting it; however, this is more difficult. There will generally be a chain of reasoning justifying an act of such magnitude. In the case of Rajneesh’s lieutenant, Ananda Sheela, her motive was political power to advance her guru’s interests, in the context of evidence that she may have embezzled millions from Rajneesh. In the case of Asahara, the motive was the glory of Aum Shinrikyo that Asahara might rule on earth. This latter is a common enough motive in history. The “army of one” (e.g., the Unabomber) also conforms to these basics, just rolled into one body. Ted Kaczynski was his own philosopher king, and he conducted his campaign within the framework of a doctrine that he had made for himself. That doctrine excuses his acts as the Unabomber, sending exploding packages through the mail to people he considered key technology boosters, killing three of them and maiming others, as a necessary evil. The sort of individual who would conduct a biological attack is probably going to fit the profile of a mass murderer, the type that distances himself or herself from their victims. THE MOTIVE AND ORGANIZATION OF THE ATTACKER Its global reach and its ability to inflict damage should not be underestimated, This enemy seeks to acquire weapons of mass destruction and will certainly use such weapons if they obtain them … They experimented with anthrax in Afghanistan. They tried to develop crude chemical weapons in Afghanistan. … This is not my guess, this is what they say. It’s well known 34 they want to do this, and they’ll stop at nothing. —General John Abizaid In the modern world the primary biological weapons threat is probably small to midsize terrorist groups and individuals, perhaps in clandestine league with rogue states. This section of the chapter examines several basic rationales that can serve as the basis for a biological attack and discusses their organization. A political terrorist group such as al Qaeda may have a doctrine of war against a nation or nations and carry out various terrorist acts of 264 Public Spaces and Social Institutions war. Al Qaeda declared war on the United States several times, but was ignored until 9/11. This type of network is probably going to be 35 organized in a “small world” manner, as al Qaeda is. Such networks are primarily social in their recruitment and motivation, not an outgrowth 36 of poverty, trauma, and ignorance. Poverty and ignorance have long been understood to be correlated with revolution and conventional war; however, they do not appear to be primary drivers for terrorists of al Qaeda and its affiliated groups, which is a significant shift in thinking. A religious group can have the doctrine that it must dominate all others and rule the world. The doctrine usually demands this rule because it is for the good of all, it is what its “god” wants, and therefore extraordinary means are reasonable. Rajneesh is reported to have talked of the desirability of establishing a spiritual dictatorship, though this is not central to his 37 writings and is not part of the Hindu roots from which he came. Asahara 38 believed that he was the “divine emperor” of the world, though similarly, this was definitely not part of the Buddhist culture he claimed to be representing. In the continuum of such groups, there are outliers on the religious fringe that have engaged in dangerous terrorist attacks. There is every reason to believe that such attacks may happen again from the same type of source and possibly be extremely effective. Doctrines of world domination are known among atheistic utopian movements, and we have seen mass death resulting from this type of doctrine in the reign of Pol Pot in Cambodia and Joseph Stalin in the USSR. If a group is short of its goal of domination, a biological weapon that can reach the goal may be used. An ecological rationale for deploying a biological weapon is rationally justifiable. Believing there are too many people in the world, such a rationale proposes to kill a large fraction, or all people to save the planet. A private individual could decide to do this, as could an ecoactivist fringe group. METHODS OF SELF-PROTECTION FOR ATTACKERS There are three primary methods by which attackers could protect themselves from being infected and even killed by their own biological weapons. The first method is sterile technique and hygiene, coupled with a knowledge of the precise nature of their virus. Some types of viruses can be handled only this way. The second method is to culture a nontoxic form of the same virus and deliberately make sure that everyone involved with conducting the attack has been infected with it. In this way, the developers could provide themselves with a “live vaccine” against the virus (albeit one not meeting FDA standards), although it may even kill some of them. Such odd events could potentially be investigated as possible indicators of a clandestine Bioterrorism and Biodefense for America’s Public Spaces and Cities 265 bioterror plot. Or, the developers could simply culture and kill the virus and inject it into themselves. This killed vaccine technique was used by the Soviet Union’s bioweapons program with success. Most of the time, this would be effective enough for those already willing to take huge risks. Lastly, the developers could collect drugs for treatment and run a few human prisoner trials or trials on volunteers from inside their organization to see if the drugs work before releasing the virus. It is probable that antiviral drugs would be unreliable protection; however, if nothing else is available, an attacker could resort to such a protection as it could at least raise the survival rate of the attackers to a significant degree. In most cases, it is highly probable that attackers would want to have some protection from their creation. Thus, one goal of intelligence gatherers working on biological terrorism should be to determine what method of self-protection any attackers are using. Of course, none of these selfprotection methods have any meaning to the suicide terrorist, like those who have conducted many of the Islamic extremist attacks in the past decade. For them, dying in the attack is part of the plan. As Bruce Hoffman, Robert Pape, and other scholars have noted, this explains why suicide terrorism is perhaps the most worrisome threat to homeland security offi39 cials today. THREE SCENARIOS OF BIOLOGICAL WARFARE Three basic categorical scenarios of biological warfare can be identified, based on the amount of the target population that is killed. Each scenario suggests a different set of motives for the attacker, as well as a different choice of weapons. In the low-level scenario, anywhere from a small number to 10 percent or 15 percent of the target population is killed. This scenario would be desirable to a rational terrorist attacker intending to create fear, economic repercussions, and extort compliance with demands. Historically, when used on the West, such forms of terrorism have 40 worked over time. Societies grow tired, and leaders tend to break ranks and cut deals to favor their citizens due to the classic “prisoner’s dilemma” of game theory. Political parties attack each other using the fatigue created by terrorism on opponents for advantage in elections. Even the United States could play a role in the prisoner’s dilemma problem and be unwilling to support drastic measures against a perpetrating group, as long as that group did not intentionally direct its attack against the United States, much as France, Ital,y and Germany have played this kind of role in the Middle East relative to the Palestine Liberation Organiza41 tion, Hamas, and Hezbollah. Prior to 9/11, the United States turned a blind eye to extremist fund-raising within our nation’s borders for 266 Public Spaces and Social Institutions Palestinian paramilitary groups. Existing terrorist groups are well aware of the huge gap between rhetoric and action, and they are very experienced at this kind of international extortion. They have the advantage of long-term one-man or junta-style rule, which do not require democratic process, and consequently are able to operate past the time horizon of election cycles in the West. Such groups could be willing to unleash such a catastrophic but still low-level biological weapon. In addition, the attackers would have a good chance to get away undetected, because in general biological weapons have a gap of days to weeks between when the attack occurs and when it is detected. This gives the perpetrators time to cover their tracks, as demonstrated by the anthrax attacks. The fear induced by these diseases would likely result in massive attempts at retaliation against those who deployed them, if they were known, at least the first few times it occurred. However, since terrorists do not gain much by attacks that they do not claim, it is less likely, though not impossible, that they would resort to the phenomenally draconian attacks discussed below. At the medium-level scenario anywhere between 15 percent and 45 percent of the target population would die. At this level of attack things become murkier. From a game theory point of view, this type of weapon is a poor choice for a first strike if the attacker is not a nation-state intending to follow up in some manner. From the viewpoint of a terrorist striving to create fear for political gain, it is so draconian in its effect that the people it was deployed on could be motivated far beyond the ordinary, and world opinion could potentially tolerate otherwise intolerable measures such as the use of nuclear weapons to utterly eliminate an attacking group. As with all biological weapons, barring an announcement, it could be difficult to figure out exactly who was responsible. It is a commonly held belief that terrorism is not well planned—a series of desperate acts. This is false. It is another form of war, carefully planned 42 for very specific goals by its leaders. The rank and file may be, in some cases, desperate, not terribly bright, and the like—simple-minded cannon fodder. But the leadership plans their acts at least as carefully as a bank robbery is planned. In the United States, the airliner attacks on 9/11 were carried out by educated people with good life prospects, quite the opposite of the common thinking. Again, we must understand that for a classical terrorist group, if no responsibility is taken or assumed, there is usually little purpose to the attack. Most of terrorist warfare is conducted for the benefit of the public relations war in the media. Consequently, there are issues with this type of scenario, which would have difficulty being claimed. The scenario would not necessarily be claimed, however, if the attack was a failed attempt to destroy a nation or nations. The logistics of intentional inoculation of the target populations to the degree that would probably be required to achieve such high levels of Bioterrorism and Biodefense for America’s Public Spaces and Cities 267 casualties could be a serious weak point for the perpetrators. Logistics tend to conform to Murphy’s Law. Large-scale and complicated deployment logistics are more probable to leave a forensic trail that could be followed and are much more prone to failures that allow interdiction prior to or during an attack. The number of connections tends to rise logarithmically with the size of a network organization, not linearly. Thus, deployment logistics with double the number of people involved will tend to be much more than twice as difficult to pull off successfully. Some would argue that since an attack of this type could potentially cause blowback and kill much of a nontarget population, it would not be rational to use it. However, this does not take into account the apocalyptic fervor of radical martyrdom-seeking groups who may feel themselves to be living among fellows who are not properly following the one true path, and hence not important. Nor does it take into account the type of value system that considers the human race itself to be an environmental blight upon the planet. An additional argument against believing it would be irrational to deploy this type of attack is that perpetrators would have the option of secreting themselves in caves or distant desert regions and take quarantine precautions with any arriving visitor until the plague had spent itself. Such a strategy is only marginally more dangerous to the leadership of a group than was attacking the World Trade Center. Thus, the views of the type of rational actors connected to viable nationstates must be discarded when considering small splinter groups and individuals. At the highest-level scenario, 50 percent to 95 percent of the population would die, as occurred for native civilizations of North America in the sixteenth century, and for other civilizations in Europe and Asia during the spread of the Black Death. From a game theory viewpoint, this moves into the range of a first strike weapon intended to defeat a nation and is similar to nuclear weapons in this way. (The USSR had follow-up 43 with biological warfare warheads integral to their nuclear doctrine. ) Deployment of such a weapon becomes more complex and is, again, more likely to leave a trail to follow; the organism and attack plan becomes much harder to develop, and it may not be possible for some groups to complete. In favor of such an attack is that, absent sophisticated detection equipment, by the time a sophisticated virus was detected and understood to be a problem, it could be too late. Lacking specific plans, it might be impossible for the nation to retaliate should it decide to do so. Additionally, there is still the problem of whom to retaliate against, as the proper party may not be known and, in some cases, may have died intentionally in the attack. Intentional mass suicide by fanatics is not unknown. For this type of attack, the probability is low that it would be claimed outright. 268 Public Spaces and Social Institutions BIOLOGICAL WEAPON TYPES There are three basic types of biological weapons: biologically produced toxins such as botulinum toxin, bacterial diseases such as the bubonic plague or anthrax, and viral diseases such as smallpox or influenza. Biologically produced toxins are essentially a type of chemical weapon, and they are not contagious. This type of weapon could be used for a low-level scenario such as the theoretical attack described in Proceedings of the National Academy of Sciences, where the milk supply is inoculated 44 with botulinum toxin and kills tens of thousands of people. Bacterial and viral diseases can be contagious and thus potentially spread among the target population, killing even people who were nowhere near the original attack site. There are many ways in which biological weapons can be deployed. They can be applied to human populations directly, such as by spraying or—as everyone is now aware—some can simply be sent through the mail. They can be applied to food animals or farm plants, which could either make the humans consuming the food sick or destroy the food supply for the humans. The results of such an attack were demonstrated by an incident in Ethiopia in 1888, where the Italian army introduced rinderpest into Africa during its Ethiopia campaign. Some say this was intentional, some say it was accidental. What is known is that 90 percent of the cattle died that year in that part of Africa. The result was that between 60 percent and 90 percent of the people of the region starved to death and much cultivated land reverted to bush. The biological weapon could be applied directly to the food itself, such as before distribution to grocery stores or cafeterias or at the retail location. A weapon could be encapsulated in various ways developed for pharmaceutical delivery, applied to anything from clothing to paper money, to fragments in a suicide bomb, or perhaps released into the ventilation system of a subway or building. It could be injected into homeless people or mixed with illegal drugs to infect users. The specific way to apply the biological weapon 45 depends upon the organism and what the attacker desires to achieve. BASIC STRATEGIC ELEMENTS OF BIOLOGICAL WARFARE The method by which a target population is infected by a biological weapon is called the initiating vector. There are a number of types of possible initiating vectors: aerosol, material on a surface, through the food or water supply, through injection, or intentional person-to-person contagion. Taken alone all of these methods are of limited scope and highly unlikely to have fatality rates that are very high, unless the agent is contagious. The scope may be the size of a city or, even conceivably, some Bioterrorism and Biodefense for America’s Public Spaces and Cities 269 degree of coverage of an entire state. For instance, if an attacker sprayed an entire city such as San Francisco with weaponized anthrax (anthrax ground to 5 micron powder), using the methods developed successfully 46 by the U.S. Navy, the city and communities in its wind pattern swath for the time of the attack would be the only area affected, since anthrax has virtually no level of contagion. Make no mistake; properly done, such an attack could kill a million or more people. However, it would not go significantly beyond the first level of infection experienced by those directly attacked. Person-to-person contagion is what will kill millions, tens of millions, perhaps billions of people. In the modern era, with reasonably effective antibiotics and sanitation, the most likely weapon to cause very large numbers of deaths are viruses, because bacteria are too easy to control. FUNDAMENTALS OF BIOLOGICAL WARFARE DEFENSE FOR PLANNERS Planners for a local region should keep in mind that the higher the level of the attack, the more likely it is that a city or town will be on its own. If casualties are excessive across a large region, the ability of federal and volunteer agencies such as the Federal Emergency Management Agency or the Red Cross will be highly compromised. Thus, it makes sense for local planners to put some thought into what they would do in such a situation. Casualties are a primary concern for any response planner. The first priority for any responsible unit is how many casualties there are, who and where they are, and how this will affect their ability to operate effectively. If response units are unable to function, they cannot play a role in helping. Biological weapons defense is like public health in general with one main additional element. As with any public health matter, each individual needs to be able to avoid becoming infected by taking basic steps. The additional element is that with biological weapons, attempts can be made to try to detect perpetrators before and while they carry out their plans. Intelligence personnel need to learn to detect signs that a clandestine bioweapons lab exists. They should also attempt to monitor the operations of people who have the motive and potentially the capacity for a biological attack. The earlier one can detect a dangerous organism, the earlier one can respond to it. As in fire suppression, if nobody reports a fire to the fire department, it can get out of control. The thought process is the same as for setting up a secure perimeter. Just as there is no security without detection, there is no security without the ability to respond to events. All walls can be breached, and there is nothing different about disease monitoring systems. Current day monitoring systems are set up to notice death events, mostly in healthy adults and children. For a serious attack 270 Public Spaces and Social Institutions scenario, by the time the first deaths appear, things should be—from the attacker’s perspective—on track. Monitoring for dangerous organisms falls into three major categories: instrumentation, public health epidemiology, and human intelligence work. Sophisticated air monitors for use over cities, stadiums, and in other public spaces are useful in that they are one of the few ways to detect an attack as it is happening by aerosol application. There are low-cost manual options available for sale, which can work, that can be found through Internet searches for those locales unable to afford expensive air monitors. The basic limit of this instrumentation is that it will not detect what it was not designed to detect—i.e., a new disease could go unnoticed. Public health and the medical system is the most fundamental aspect of biodefense at all levels. It should be the first priority before all others for those in a limited funding situation. Public health is what finds those odd cases that could indicate an epidemic is about to start. Public health is also the segment which is going to find a disease which is “off the charts” that an instrument will not notice. Care should be taken to find a way to shore up public health and disease monitoring so that it reaches all segments of society. It is in the strata of society not served by medical care that an epidemic is most likely to take hold and gather steam invisibly. (In point of fact, this is already occurring due to inattention and fail47 ure due to natural disease, albeit in relatively minor ways at present.) Like forest fires, epidemics are easiest to stop in the earliest stages. Once epidemics really get rolling, the task becomes very difficult, if not impossible, and expands to a pandemic relatively easily. Once a biological weapon has been detected, the modes of contagion need to be identified, and a plan of action to stop the spreading of the disease must be established. The most contagious diseases can survive on a 48 surface for periods from minutes to, in extreme cases, weeks or months. The primary ways a significant bioweapon disease is likely to enter the body are through eye or pulmonary contact. Hand to eye or aerosol to eye works because eye membranes are a prime way for viruses to enter the body. Hand to mouth and aerosol to mouth are another way, as well as hand or aerosol to food and then into the body, or hand or aerosol to nose membranes and lungs. While determining the mode of contagion, a general response that focuses on cleanliness of hands and surfaces, avoiding touching hands to eyes, nose, and mouth without washing, and possibly the use of filter masks is in order. Training people not to touch their eyes, nose, mouth, or food without careful washing of their hands will go a long way toward interrupting the spread of infection. Wearing of simple masks can help by lowering the amount of discharge through the air. Nonrated masks (ordi49 nary surgical masks, not N95-rated ) will be of some use for avoiding inhaling droplets containing contagious organisms, but primarily they Bioterrorism and Biodefense for America’s Public Spaces and Cities 271 help to contain spreading of disease from the wearer to others. All masks need to be replaced regularly and either disinfected or disposed of in a sanitary manner or they can become a problem in and of themselves. A mask that is left on a person’s face for long periods of time and reused without disinfection can harbor infectious organisms in its fabric, which stays nicely warmed and damp from breathing—a great environment for most organisms to survive. Such a mask can itself become a possible health hazard in an area where infectious disease is present. Diseases spread by feces, blood, semen, or other secretions are easily preventable in an educated population and thus not a likely major bioweapons threat in the developed world. (However, as we have seen with HIV, just because a disease is quite preventable does not mean it will not spread significantly in a population.) 50 Person-to-person contagion takes place through networks of people. Deal with the infectious connections between people and you will deal with the disease transmission. This is the principle of quarantine as well as sanitation and disease barriers such as masks, gloves, and eye protection. Quarantine is a powerful means of stopping the spread of disease if applied effectively, but if done badly, an attempted quarantine can make 51 things worse. Quarantines have standards that should be met. As defined by Ross Upshur, a public health expert at the University of Toronto, these are the following: 1. Standard of harm: clear and measurable harm to others will occur from the disease. 2. Least restrictive: use of [the] least restrictive means appropriate to the goal of disease control. 3. Reciprocity: if society asks people to accept loss of liberty, society has an obligation to help them. 4. Transparency: authorities have an obligation to communicate clearly the reasons for quarantine and allow for discussion and appeal of decisions. Per Upshur, given the above four standards being met, small-scale quarantines such as that for SARS have been quite effective with mostly volun52 tary compliance. (Upshur records 22 involuntary detentions out of more than 3,000 voluntarily requested detentions during the SARS epidemic, a voluntary compliance rate of better than 99 percent.) Public health planners should think intelligently about where and how most disease transmission occurs in their communities by type of illness. This is a significant aspect of quarantine planning and goes toward fulfilling the second standard that quarantines should be least restrictive. For example, in Japan, holding young children at home during influenza epidemics and vaccinating healthy children has decreased mortality in the 53 elderly. The basics of what constitutes effective and ineffective 272 Public Spaces and Social Institutions interruption of disease transmission is something all public officials can grasp. A community giving this some serious thought will be ahead of the game. Poorly implemented quarantine is worse than nothing at all. Anyone considering imposition of quarantine on a large scale should understand that what people are ordered to do and what they actually do are often quite different things. This is one of the reasons for using the four principles above as standards. People motivated to escape quarantine have lied about their condition and thereby spread a contagious disease in past plagues. People who become desperate because they feel they have been forgotten, or think they are certain to die if they do not escape, are likely to act in a manner that can make real quarantine not only impossible, but make any attempt to impose such a quarantine a sure way to spread the disease even faster. This can become a very serious matter in a largescale biological attack pandemic. A vaccination program is a different method of interrupting the network of transmission from person to person. Vaccination will work if a vaccine is available. The problem with vaccines is that they take time to develop and are unlikely to be available for novel organisms. There are techniques that may possibly be applied in a high-level scenario to attempt to vaccinate with a quickly developed, perhaps problematic vac54 cine. However, detailed discussion of vaccines is beyond the scope of this chapter. 55 Care should be taken to always look forward during an epidemic. Accurate information on where things stand is crucial, but this should not be allowed to turn into a hindsight exercise by officials or responders. An epidemic is like a slow-motion tsunami. Try to stay five to ten infection cycles ahead of an epidemic with logistics. Understand that even if all new infections stop on any particular day, those incubating the disease have yet to show themselves. Since each infection usually takes 5 days or so for the newly infected person to become infectious in his or her turn, this means trying to keep 25 to 50 days’ forward projection on estimates, supplies, facilities, and personnel. Rare outliers can develop a disease much later than expected, which can potentially reignite an epidemic. Planners should understand the legal tools that they have, as well as the public health network that is set up. Basic recommendations include the following: 1. Basic public health is very easy to let go, onerous, and rather thankless. For these reasons there must be regular reviews and visits to public health offices and personnel to evaluate whether any portion of a locale’s population is falling through the cracks. This includes homeless who live in public spaces, illegal immigrants, and others who are poor or marginal, particularly if they may come into contact with the public. Prostitutes, drug addicts, drug dealers, Bioterrorism and Biodefense for America’s Public Spaces and Cities 273 slum dwellers, and others who shy away from authorities should not be overlooked, and some method of accommodating access to them by public health officials must be made. To do so may require working out deals between public health officials, police, and the local district attorney’s office to aid in accomplishing full coverage. It should be possible to coordinate with the health care system in the area that serves the rest of us. 2. Get local government, district attorneys, police, forensics, public health officials, and others appropriate to meet together to improve communications and understanding of issues. All parties should have a basic grasp of the law, what can happen, how contagious disease works, who is responsible for what, and what the challenges are for other departments. In the midst of an epidemic crisis is not the time to be setting up systems and figuring out what to do, and higher level state, federal, or transnational officials may or may not be 56 prepared. 3. Develop and review plans that do not leave out scenarios wherein federal and state agencies may be incapable of helping for a prolonged period. 4. Keep public areas sanitary and clean. This most basic of steps is, nevertheless, of great importance for public health in cities and public spaces. 5. Have on hand basic protective gear appropriate to an epidemic. Basic gear includes gowns, gloves, N95-rated respirator masks, eye protection, and disinfectant. As many people as possible should be trained in sanitation, infection routes into the body, how to scrub clean, use of basic protective gea,r and habits appropriate to an infectious area. As a note, high-end isolation suits are sometimes desirable, but they require careful maintenance, and they are quite cumbersome and hot to wear. A person can be comfortable in shirtsleeves in freezing temperatures inside an isolation suit. (Personnel who decontaminate illegal drug production labs know all about the problems with wearing such equipment.) Additionally, medical personnel have survived epidemics of Ebola in Africa while using standard gear and less, even simple washing with soap together with liberal use of disinfectants like Clorox. Personnel under the same circumstances using protective gear have died awful deaths from simple mistakes such as brushing their eyes before washing their hands. 6. Keep apprised on current recommendations made for dealing with any epidemic or pandemic potential disease that is believed to be of significant probability. In the current public health environment, this means awareness of the need to stockpile oseltamivir (used in the treatment of the infection caused by the flu virus) or similar drugs. CONCLUSIONS AND RECOMMENDATIONS FOR RESEARCH No type of attack except nuclear weapons has as much capacity to create mass death as bioterrorism. For terrorist groups unable to field large numbers of nuclear tipped ICBMs, even nuclear weapons are relatively small when compared to bioterrorism potentials. The historical and potential capability of disease and bioterrorism to create mass death quite 274 Public Spaces and Social Institutions simply boggles the mind when examined carefully. The fact is that tens of thousands of people die each year of infectious disease already. This will continue, and we must prepare for the inevitable incidence of both manmade and natural infectious disease plagues that make large inroads into our population. It is difficult for those of us in this modern era to conceive, but overwhelming plagues are possible. Death rates of 50 percent to 95 percent have not occurred on a large scale in the past 100 years, but they have occurred on a small scale on the islands in the Pacific in the cur57 rent era as recorded by Thor Heyerdahl. Even relatively minor biological attacks outlined in this chapter would be considered catastrophic by any reasonable yardstick. The most fundamental priority for biodefense is to support public health in order to make disease problems visible as rapidly as possible. Public health with disease is like transparency of accounting in finance. If you cannot see it, you cannot do anything about a problem. Of special concern is ensuring that public health officials contact, monitor, and treat the invisible uninsured, the poor, the illegal immigrant, the prostitute, the underclass drug abusers, the homeless, and similar people relative to infectious disease. This underclass is the most vulnerable to epidemic disease, least likely to take precautions, and most in need of money, causing them to go to jobs while infectious and seriously ill. Most important, this underclass physically permeates our society virtually everywhere. These people clean our offices, work as nannies, get picked up as day labor for all kinds of projects, make beds in hotels, prepare food in kitchens, clean our cars, enter our homes as maids or ladies of the night, and lie in doorways at night all while society looks the other way. They are the most likely to be malnourished, weakened from fatigue, overwork, or drug use, and most likely to be ignorant and fearful of authorities. They are, in short, the perfect invisible network for epidemic disease to take hold in and get passed on to the more wealthy layers of our society. That disease can be natural or man-caused. A smart attacker will understand their value for penetrating into our society. There is no substitute for good human intelligence in bioterrorism. Proposing to detect bioterrorism before or even at the outset of an attack is mostly impossible by any other means. (The one known exception is aerosol attack if a monitored organism is used.) Consequently, improvements in intelligence gathering and detective work should be made in the area of biological weapons. These people should be trained in biological weapons development and scenarios, so that they are capable of understanding what is going on in a laboratory they may encounter. They need to be able to work with and understand the types of scientist personalities that they will meet. They should be good at human networking and developing trust in the scientific community. However, they must also be cognizant of dark human motivations and capable of dealing with them. Bioterrorism and Biodefense for America’s Public Spaces and Cities 275 A highly controversial area of bioterrorism intelligence gathering, particularly domestic, is targeting of select religious cults for infiltration or monitoring. Monitors can be recruited from the organization, or, in select cases, infiltrators could be placed. The reason is simple; such groups have been the source of most bioterror attacks and attempts of known origin in the past 50 years. The constitutional issues in the United States are not small. However, in this case we can correctly say that “The Constitution is not a suicide pact.” These organizations are not primarily made up of hardened criminals, 58 but of alternate theology idealists. In most cases of religious cults, since members of such groups are typically poor, there is always a wide range of adherence to the tenets, and many find themselves wanting to feel more powerful over time, a simple recruitment by advertisement or site visits followed by “social recruitment” or payment of members to be monitors could be quite effective. Improvements in technological monitoring/diagnostic capability are an area that biodefense needs to continuously develop. The reason for this is that the main line of defense is prevention of new infection and containment of existing infections, not treatment. That means that the earlier infection can be diagnosed, the more likely it is that the infection can be prevented from spreading to others. Again, the transparency metaphor in finance is an apt one. Even today, infectious disease “accounting” would not pass muster for a finance accountant. What accountant would accept that somewhere between $700,000 and $2.7 million is spent on a program? And yet, that is what our disease statisticians are able to account for about malaria deaths, through no fault of their own. We can do better, and we should. Two high-return proposals for improvements in disease monitoring follow: • Backing the development of low-cost consumer use disease diagnostics. This would create a device about the size and cost of a cell phone, which could be used by any consumer to diagnose what organisms are infecting them. This device would have to be capable of diagnosing hundreds of disease organisms simultaneously. The disposable diagnostic element should cost no more than $5 each, preferably less. With 17 million mothers in the United States, such a device could be popular enough with consumers to self-fund once it got rolling. An early patriotic push to get people to buy and use them once they have sufficient breadth of enough diagnostic ability could also work to get a critical mass of users for mass production self-sustenance. This will function as a kind of DEW (Distant Early Warning radar for incoming ICBM and enemy aircraft) line for disease in the public. It should provide much improved public health information and improve our ability to track infectious disease of all types. Such devices could be based on either antibody or DNA/RNA detection using today’s technology. 276 Public Spaces and Social Institutions A device of this kind faces serious business obstacles and needs government intervention to be deployed. Laboratories do not want to lose business to a consumer device, which in fact has prevented a major European supplier from fielding a consumer diagnostic device of this general class. A further problem is that venture capitalists want to see patent protection for a product. While there are a variety of technologies that have patent potential, there are many that do not that could be equally effective and less expensive. This tends to curtail private investment at the critical stages past initial conception. Last, there are serious regulatory hurdles, and the cost of certifying each separate diagnostic test is large. Multiply those hurdles and certifications by 100 to 500 organisms and one has a prohibitively high investment cost with too little return on investment for the level of perceived risk for private money—hence the need for government involvement. • The proposal of the Viral Defense Foundation to sample excess blood serum across the country and analyze it for viruses is the most sensible mass-monitoring proposal on 59 record. The purpose of this effort is twofold. First is to establish a baseline of true morbidity (i.e., what is really normally present in humans) from which to compare. Second is to allow us to have a chance to detect pathogens that may not be immediately obvious and to do so quickly in order to allow rapid response. To accomplish this at a reasonable cost requires further research and development in mass sequencing of viruses to identify them. That research and development is occurring. This project will represent an ongoing cost, well worth the investment for epidemiology data and biodefense. This elegant approach avoids the inherent “needle in a haystack” problem of monitoring the environment that is home to astronomically large numbers of microorganisms, mostly benign. Additionally, there is a need for improvements to vaccine development and pro60 duction that are technical, financial, and regulatory. Current efforts have begun to stimulate vaccine providers to be willing to put research and development money into influenza, smallpox, and other vaccines. It is good that legislators have begun to grapple with the issues. That should continue and expand. Also, focus should be put on how to quickly develop and deploy a useful—even if imperfect—vaccine against novel pathogenic viruses for use in extreme situations. With the note that not all viruses can have a vaccine, this research should set a goal of initiation to deployment in 21 to 28 days or better, which is a number currently considered impossible. While it may be an impossible standard to meet, there is reason for this goal, and challenging goals do have a way of eventually being met once seriously sought. The reason for this three to four week deployment goal is that if a novel pathogen is engineered and deployed successfully in a high-level sophisticated attack, a short time may be available to interrupt its spread before an epidemic takes hold. However, if it does take hold, epidemics have a cycle time dependent on the time it takes for the pathogen to cause Bioterrorism and Biodefense for America’s Public Spaces and Cities 277 a new individual to become infectious, which is, with most viruses, approximately five to seven days. The number of potentially infected people will tend to rise logarithmically, but after three to four weeks, there will still be a large proportion of the population as yet uninfected. There would be several basic aims of this high-speed vaccine development research. One is to identify ways that are reasonably reliable at presenting antigens in a way that causes the adaptive immune system to respond, one possible example being the work of Verardi et al. and Yilma 61 et al. It should not, however, be construed that the mentioned methods are the only or best, since this is a new area to explore. Another aim is to identify ways to get the vaccine produced and out to the population rapidly. (One example strategy is to use a modified live virus and have those who receive the initial vaccine become the culture medium for intentionally spreading the vaccine virus.) Also, this research should identify vaccine methods of this kind that are likely to cause minimal casualties from the vaccine itself. The vaccine produced in this way would be used only in the most unusual circumstances, when it would be the best option available to deal with a high-level biowarfare attack. Research and study in this area is needed. Improved, longer wearing, and comfortable isolation suits should be developed. Current technology in this area dates back half a century in its concept. The equipment is hot, clumsy, and prone to rips, tears, and abrasion. It needs careful maintenance. It does not seal itself or respond to damage even for a short period of time. The surfaces require careful decontamination after use, as they are not self-cleaning in any way. Additionally, current protective gear is very expensive. We can do better in all respects, and we should. We should aim to make comfortable, longwearing, virtually self-maintaining gear available to the general public at a price they can afford. Disease organisms, used as bioweapons, have a terrible capacity to cause harm. Officials and responders who do find themselves in the midst of a serious epidemic, be it man-made or natural in origin, are not powerless even if they have little or nothing to address it with. If they understand how infectious disease spreads, and how the specific disease they are experiencing spreads, then they can do their best to interrupt the chain of transmission from person to person. The primary work in this area is very practical, focused on prevention and seeing to it that no segment of society is allowed to “fall off the radar.” Prevention by straightforward measures such as soap, water, cleanliness, and disinfectants interrupt the spread and are excellent methods because viral diseases are generally quite difficult to treat. There are few drugs available, though they do exist. Cleanliness, treating patients for symptoms with supportive therapy, and teaching people how to avoid infecting themselves can work. However, no one should be fooled by the basic nature of much that is necessary to 278 Public Spaces and Social Institutions address bioterrorism into not taking it seriously. Our high-tech age has a tendency to do so. Addressing bioterrorism is a pragmatic combination of simple low-tech methods with very advanced high-tech methods where it makes sense. Last, we should never forget: disease has reshaped the politics of the world multiple times already—we are all descendants of the survivors. Disease is likely to do so again. World-changing disease in the modern world is most likely to appear from the hand of man. We must be prepared. ACKNOWLEDGMENTS This discussion will be considerably expanded in a forthcoming book on biological warfare and biodefense by the authors. NOTES 1. Ole Jorgen Benedictow, The Black Death 13461353: The Complete History (New York: Boydell Press, Woodbridge, Suffolk, & Rochester, 2004). 2. Giovanni Boccaccio, The Decameron (New York: Dell, 1972). 3. Ibid. 4. Johannes Nohl, The Black Death (New York and Evanston: Harper & Row, 1969). 5. Fray Toribio Motolinia, Historia de los indios de la Nueva Espana, trans. Elizabeth Andros Foster (Berkeley, CA: Cortes Society, 1568). 6. William Bradford. Of Plimoth Plantation 1620–1647 (New York: Modern Library, 1981); and Henry F. Dobyns, Their Number Become Thinned: Native American Population Dynamics in Eastern North America (Knoxville: University of Tennessee Press, 1983). 7. Bradford, Of Plimoth; Dobyns, Their Number Become Thinned; James Axtell, “Europeans, Indians, and the Age of Discovery in American History Textbooks,” American Historical Review 92 (1987): 627; Alfred Crosby, Ecological Imperialism: The Biological Expansion of Europe, 900–1900 (Cambridge: Cambridge University Press, 1993); Thor Heyerdahl, Aku-Aku (Chicago: Rand McNally, 1958); Charles M. Segal and David C. Stineback, Puritans, Indians, and Manifest Destiny (New York: Putnam, 1977); and Russell Thornton, American Indian Holocaust and Survival: A Population History since 1492 (Norman: University of Oklahoma Press, 1987). 8. Bradford, Of Plimoth; Dobyns, Their Number Become Thinned; Axtell, “Europeans, Indians, and the Age of Discovery”; Crosby, Ecological Imperialism; Heyerdahl, Aku-Aku; Segal and Stineback, Puritans, Indians, and Manifest Destiny; and Thornton, American Indian Holocaust and Survival. 9. Laurie Garret, Betrayal of Trust: The Collapse of Global Public Health (New York: Hyperion, 2000). 10. Jared Diamond, Guns, Germs and Steel: The Fates of Human Societies (New York: W. W. Norton and Company, 1999). Bioterrorism and Biodefense for America’s Public Spaces and Cities 279 11. Avert.org. World estimates of the HIV and AIDS epidemics at the end of 2004 (2005) http://www.avert.org/worldstats.htm (accessed October 12, 2005). 12. “Africa Aids Orphans ‘May Top 18m,” BBC News, October 25, 2005, http:// news.bbc.co.uk/2/hi/africa/4373576.stm (accessed November 3, 2005). 13. Centers for Disease Control and Prevention (CDC), “Influenza: The Disease,” 2004, http://www.cdc.gov/flu/about/disease.htm (accessed October 29, 2005). 14. United Nations, “AIDS: Report on the Global HIV/AIDS Epidemic,” December 1997. 15. Gregory Armstrong, Laura Conn, and Robert Pinner, “Trends in Infectious Disease Mortality in the United States during the 20th century,” Journal of the American Medical Association 281 (January 6, 1999): 61–66. 16. Armstrong, Conn, and Pinner, “Trends in Infectious Disease Mortality.” 17. Ibid. 18. Zbigniew Brzezinski, Out of Control: Global Turmoil on the Eve of the TwentyFirst Century (New York: Scribner, 1993). 19. CDC, “Malaria Facts” (National Center for Infectious Diseases, Division of Parasitic Diseases, 2004). http://www.cdc.gov/malaria/facts.htm#WorldMalaria (accessed October 29, 2005). 20. B. Hearn, “Malaria Clock” (2002), http://www.junkscience.com/ malaria_clock.htm (accessed October 27, 2005). 21. UN, “AIDS: Report on the Global HIV/AIDS Epidemic,” December 1997. 22. CDC, “Information About Influenza Pandemics” (2005), http:// www.cdc.gov/flu/avian/gen-info/pandemics.htm (accessed October 29, 2005). 23. Phil Hirschkom, “New York Reduces 9/11 Death Toll by 40,” CNN, October 29, 2003, http://www.cnn.com/2003/US/Northeast/10/29/wtc.deaths (accessed October 27, 2005). 24. Maria Jesus Prades, “Three Charged In Madrid Bombing,” CBS News, March 19, 2004, http://www.cbsnews.com/stories/2004/03/22/world/ main607757.shtml (accessed October 27, 2005). 25. CDC, “Influenza.” 26. This chapter covers scenarios that range from relatively low (less than 1 percent of the targeted population dying) to those at the high end of very serious military significance (up to 95 percent of the targeted population dying) that could result from bioterrorism. For general background reading on public health issues, the reader is referred to Laurie Garret, Betrayal of Trust: The Collapse of Global Public Health (New York: Hyperion, 2000); and Jared Diamond, Guns Germs and Steel: The Fates of Human Societies (New York: W.W. Norton and Company, 1999). 27. Sun Ai Raillard et al. “Novel Enzyme Activities and Functional Plasticity Revealed by Recombining Highly Homologous Enzymes,” Chemistry & Biology 8 (September 2001), 891–98; and Jon E. Ness et al. “Synthetic Shuffling Expands Functional Protein Diversity by Allowing Amino Acids to Recombine Independently,” Nature Biotechnology 20 (December 2002): 1251–55. 28. Keith A. Powell et al. “Directed Evolution and Biocatalysis,” Angewandte Chemie International (English Edition) 40 (November 5, 2001): 3948–59. 280 Public Spaces and Social Institutions 29. Larry P. Wackett, “Directed Evolution of New Enzymes and Pathways for Environmental Biocatalysis,” Annals of the New York Academy of Sciences 864 (December 13, 1998), 142–52; and Linda A. Castle et al., “Discovery and Directed Evolution of a Glyphosate Tolerance Gene,” Science 304 (May 21, 2004), 1151–54. 30. Judith Miller, Stephen Engelberg, and William Broad, Germs: Biological Weapons and America’s Secret War (New York: Simon & Schuster, 2001). 31. Arnold M. Ludwig, King of the Mountain: The Nature of Political Leadership (Lexington: University Press of Kentucky, 2002). 32. Ken Alibek and Stephen Handelman, Biohazard: The Chilling True Story of the Largest Covert Biological Weapons Program in the World—Told from the Inside by the Man Who Ran It (Random House, New York, 1999). 33. Larry Henry, “Harris’ Troubled Past Includes Mail Fraud, White Supremacy,” Las Vegas Sun, February 23, 1998, http://www.lasvegassun.com/dossier/ crime/bio/harris.html. 34. Testimony of General John Abizaid, senior officer in Central Command, to the Senate Armed Services Committee on September 29, 2005; see Jim Garamone, “Will, Resolve Key to Defeating Terror, Leaders Say,” American Forces Information Services, September 29, 2005, http://www.defenselink.mil/news/Sep2005/ 20050929_2885.html; and David von Drehle, “Wrestling with History,” Washington Post, November13, 2005, W12. 35. Marc Sageman, Understanding Terror Networks (University of Pennsylvania Press, Philadelphia, 2004). 36. Ibid. 37. Rick A. Ross, “Osho/Rajneesh” (Jersey City, NJ: The Rick A. Ross Institute, 2001), http://www.rickross.com/groups/rajneesh.html (accessed October 29, 2005); and Christopher Calder, “Osho, Bhagwan Rajneesh, and the Lost Truth” (2000), http://home.att.net/~meditation/Osho.html (accessed October 29, 2005). 38. Robert J. Lifton, “‘In the Lord’s Hands’—America’s Apocalyptic Mindset,” World Policy Journal 20, no. 59 (Fall 2003). 39. For example, see Bruce Hoffman, The Logic of Suicide Terrorism: Lessons from Israel that the U.S. Must Learn,” The Atlantic Monthly (June 2003); and Robert Pape, The Strategic Logic of Suicide Terrorism, in Homeland Security and Terrorism: Readings and Interpretations, ed. Russell Howard, James Forest, and Joanne Moore (New York: McGraw-Hill, 2005). 40. Alan M. Dershowitz, Why Terrorism Works: Understanding the Threat, Responding to the Challenge (New Haven and London: Yale University Press, 2002). 41. Dershowitz, Why Terrorism Works. 42. Dershowitz, Why Terrorism Works. 43. Ken Alibek and Stephen Handelman, Biohazard: The Chilling True Story, 1999. 44. Lawrence M. Wein, and Yifan Liu, “Analyzing a Bioterror Attack on the Food Supply: The Case of Botulinum Toxin in Milk,” Proceedings of the National Academy of Sciences 102 (July 12, 2005): 9984–89. 45. For more on this topic, please see the forthcoming volume by the authors of this chapter. Bioterrorism and Biodefense for America’s Public Spaces and Cities 281 46. Miller, Broad, and Engelberg, Germs: Biological Weapons and America’s Secret War. 47. Laurie Garret, Betrayal of Trust: The Collapse of Global Public Health (Hyperion, New York, 2000). 48. Ibid. 49. This designation means that the mask is 95 percent effective against any particle that is over 1 micron. 50. Gerardo Chowell and Carlos Castillo-Chavez, “Worst Case Scenarios and Epidemics,” in Bioterrorism: Mathematical Modeling Applications in Homeland Security, ed. Carlos Castillo-Chavez and H.T. Banks (Philadelphia: SIAM, 2003), 35–51; Stephen G. Eubank, “Social Networks and Epidemics” (Los Alamos National Laboratory, 2003), http://www.ima.umn.edu/talks/workshops/11-3-6.2003/ eubank/eubank.ppt (accessed October 28, 2005); and Matt J. Keeling and Ken T. D. Eames, “Modeling Dynamic and Network Heterogeneities in the Spread of Sexually Transmitted Diseases,” Proceedings of the National Academy of Sciences 99 (2002): 13330–35. 51. Ross E. Upshur, “Principles for Justification of Public Health Intervention,” Canadian Journal of Public Health 93 (2002): 101–3. 52. Ibid. 53. W. Paul Glezen, “Influenza Vaccination for Healthy Children,” Current Opinion in Infectious Diseases 15 (June 2002), 283–87. 54. Paulo H. Verardi et al., “Long-term Sterilizing Immunity to Rinderpest in Cattle Vaccinated with a Recombinant Vaccinia Virus Expressing High Levels of the Fusion and Hemaglutinin Glycoproteins,” Journal of Virology 76 (January 2002): 484–91; and Tilhun D. Yilma et al., “Inexpensive Vaccines and Rapid Diagnostic Kits Tailor-Made for the Global Eradication of Rinderpest, and Technology Transfer to Africa and Asia,” Developmental Biology 114 (2003): 99–111. 55. Jaro Kotalik, “Preparing for an Influenza Pandemic: Ethical Issues,” Bioethics 19 (August 2005): 422–31. 56. Bradley T. Smith et al., “Navigating the Storm: Report and Recommendations from the Atlantic Storm Exercise,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science 3 (2005), 256–57. 57. Thor Heyerdahl, Aku-Aku (Chicago: Rand McNally, 1958). 58. David G. Bromley and Anson D. Shupe, Strange Gods (Beacon Press, Boston, 1981). 59. Norman G. Anderson and Leigh Anderson, VIROME project—Rapid Detection/Rapid Response (Kensington, MD: Viral Defense Foundation, 2003), http://www.viraldefense.org (accessed November 10, 2005). 60. Jaro Kotalik, “Preparing for an Influenza Pandemic”; Lars Noah, “Triage in the Nation’s Medicine Cabinet: The Puzzling Scarcity of Vaccines and Other Drugs,” South Carolina Law Review 54 (Winter 2002): 371–403; K. Groeneveld and J. van der Noorda, “Use of Antiviral Agents and Other Measures in an Influenza Pandemic,” Netherlands Journal of Medicine 63 (October 2005): 339–43; Thomas C. Jones, “A Call to Restructure the Drug Development Process: Government OverRegulation and Non-Innovative Late Stage (Phase III) Clinical Trials are Major Obstacles to Advances in Health Care,” Science and Engineering Ethics 11 (October 282 Public Spaces and Social Institutions 2005): 575–87; and Monica Shoch-Spana, Joseph Fitzgerald, and Bradley R. Kramer (UPMC Influenza Task Force), “Influenza Vaccine Scarcity 2004-05: Implications for Biosecurity and Public Health Preparedness,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science 3 (2005): 224–34. 61. Paulo H. Verardi et al., “Long-Term Sterilizing Immunity,”; and Tilhan D. Yilma et al., “Inexpensive Vaccines.”