Dr. Stephen Morse is Founding Director and Senior Investigator for the Center for Public Health Preparedness at the National Center for Disaster Preparedness. He also serves as an Associate Professor of Clinical Epidemiology at Columbia University.
A Leading Bioterrorism Expert Discusses Dangers & What You Can Do
Al-Qaeda still maintains a global presence and is vastly increasing in number. This is a sobering fact, but there is one other fact that is absolutely frightening. Recent data from federal government agencies, such as the C.I.A. and the F.B.I., indicate that their weapons of choice have been upgraded to include chemical, biological and possibly nuclear agents, as the terrorist organization and many of their offshoots now focus on generating casualties on a worldwide scale.
In an attempt to prevent or contain these potential threats, various crisis management centers and offices have been developed across the country and the globe through state and local governments. In the United States, the most widely recognized and respected of these facilities is the National Center for Disaster Preparedness (NCDP), a resource center at New York City’s Columbia University. The center is dedicated to the study, analysis and enhancement of the nation's ability to prepare for and respond to major disasters, including terrorism. According to the center’s website, “Particular areas of interest include readiness of the health and public health systems, health workforce and citizen readiness, disaster communications, national preparedness benchmarks and the needs of special populations.”
G-Man: The U.S. has thwarted a number of planned attacks since September 11. However, Michael Chertoff, former Secretary for the Department of Homeland Security, has stated to the media and the public that another attack is imminent. He also noted that the intelligence gathered indicates it will involve bioterrorism. Doctor, are you confident that your center and staff will be able to control or contain an attack of this nature?
Dr. Morse: You can never be prepared enough, and there’s no room for complacency. So, I wouldn’t ever use the word “confident”. It takes a lot of moving parts to make preparedness and response work. “Consequence management” -- controlling and containing the effects of an attack -- is a partnership of many agencies working together. Our center is here to provide information, scientific expertise, and training. For example, during the anthrax letter attacks of 2001, we spoke at community forums, handled almost 200 media inquiries, and provided training to doctors. This facility is part of a national network of Centers for Public Health Preparedness, now numbering about 40 nationwide, set up by the Centers for Disease Control and Prevention (CDC) in 2000.
At our institution in general, and at our city and state health departments, there has been a lot of attention to emergency preparedness. The anthrax attacks of 2001 that followed soon after 9/11 were very stressful for all concerned. These crises certainly should have sent the message that we need to be prepared for unexpected – even once unthinkable -- disasters. Obviously, health departments at every level (local, state, and federal), and the healthcare system, will have a very big role to play here, along with other agencies. Much will depend on the quality of the public health system (and the healthcare system), so it’s critical to sustain this system and keep it well oiled. I think my colleague, Dr. Irwin Redlener, puts it very well: “Events like 9/11, the anthrax attacks, and Katrina have been termed “wake-up calls”, but often seem more like snooze alarms. In addition to sustained funding, well trained people are essential.”
G-Man: Why are you so confident that your center will be able to handle a crisis situation if you’ve never experienced one in real time?
Dr. Morse: Although we haven’t experienced a large-scale attack, we did have the anthrax letters in the fall and winter of 2001. The incident was harrowing and painful, but it shed light on the many areas where we all need to do better. We have also had various natural infectious disease outbreaks in the last few years – both unexpected (West Nile; SARS in a number of places outside the United States), and more familiar (flu) – which have some of the same characteristics, including surprise. Of course, a large bioterrorist attack would be more challenging, at many levels. Since 2001, the government has greatly increased spending at both the federal and local levels for emergency preparedness, including readiness for bioterrorism and pandemic influenza. There have been a number of training and practice exercises. So, I think we’re further along. Am I completely confident? Of course not because there’s still a lot of work to do, and preparedness has to be a constant process.
G-Man: Are you equally confident that similar facilities across the nation will perform in the same capacity during crisis situations?
Dr. Morse: Everyone will do their best, of course, but there will be differences. Some are very well prepared now, while other places are still getting started. This will depend on resources and having well trained personnel with the right skills, in particular. In recent years, especially since 9/11, local agencies and healthcare facilities have been encouraged to plan for unusual emergencies and to develop mutual aid agreements to share resources. Programs such as “Project Public Health Ready” for local health departments, works with a network of Centers for Public Health Preparedness to support them with training and assistance, and special federal funding for hospital preparedness and the states have helped bring many health departments and healthcare facilities to at least a basic level of preparedness. But it’s still not a seamless system, and we really need to keep at it. In a major attack, in addition to the sheer numbers of people who will need help, there will be challenges such as communication between jurisdictions, coordinating different agencies, and getting accurate information as rapidly as possible.
G-Man: When the “Bird Flu” crisis was being discussed in America, government officials and a number of leading scientists conducted press conferences to note the effectiveness of Tamiflu in combating the illness. If the intelligence gathered by the C.I.A., F.B.I., Department of Homeland Security and the Centers for Disease Control and Prevention clearly mentions the chemicals terrorists plan to use in an attack, have any sample vaccines or antidotes been produced? If so, why hasn’t the information been conveyed to the public?
Dr. Morse: There’s no simple answer. It will really depend on what we get hit with, and we will probably not know many details in advance. The key is early recognition and quick response. In some cases, we may have effective antibiotics (or antiviral drugs) and vaccines. Many of the bacteria we often mention as bioterrorism threats, like anthrax, can be treated successfully IF we identify the victims and get to them early enough. The same is true in the case of smallpox, which is a virus, and some others. We have vaccines for some of these infections as well. In other cases, such as flu pandemic, it may take months to produce a vaccine. Until then, we’ll be recommending good hygiene, avoiding crowds, staying home as much as possible, and perhaps drugs like Tamiflu, if appropriate.
For chemical agents, we do have specific antidotes for some of them, and prompt medical treatment can help save many lives even when we don’t have a specific antidotal. Again, rapid identification and response is the key. You pose an excellent question, G-Man. Why don’t we provide more information to the public? I firmly believe that we should. It’s one of the most important things we can do. I think it’s often forgotten in the heat of the debate, or authorities are afraid of frightening people or saying the wrong things. We all need to become much better at educating the public and keeping everybody as well informed as possible. By the way, the CDC website is a very good source of information. Your readers can get information at www.bt.cdc.gov/
G-Man: The public has a right to know about the horror and devastation associated with this type of attack, so don’t sugarcoat your response to this question. Can you present at least two worst-case scenarios, the signs and/or symptoms, and an approximation of how many would die as a result?
Dr. Morse: I’m afraid anyone with a little imagination can come up with lots of possible scenarios. One of the simplest may be a plane flying over a city and releasing anthrax. The World Health Organization estimated that 50 kilograms (about 100 pounds) of anthrax released this way in a city of 5 million would probably cause 250,000 cases and 100,000 deaths, with possible effects for 10 miles or more. This was a very conservative estimate. Anthrax, when inhaled, starts as a flu-like illness, then (usually after a temporary improvement in the patient’s symptoms) progresses in a few days to a severe pneumonia and then rapidly moves to affect almost all the organs. About half the victims get meningitis, an inflammation of the lining covering the central nervous system, with a lot of hemorrhaging there. Untreated, inhalation anthrax is about 90% fatal.
Personally, I worry about a natural event: influenza pandemics. A pandemic is an epidemic that essentially covers the world. The greatest known influenza pandemic, in 1918-1919, claimed over 500,000 lives in the United States, and probably at least 50 million worldwide. Many were healthy young adults. We hope that’s the rare exception, but if a pandemic of that severity happened today, according to CDC’s calculations, it would be likely to cause almost 2 million deaths in the U.S. alone.
G-Man: If Al-Qaeda cells launch a chemical, biological or small-scale nuclear attack in the U.S., what does the center suggest people do if they’re in these settings: on the street or at an outdoor sporting event; on a train (underground during rush-hour); on an airplane; in an office building; in a car (while on a bridge) or in their homes?
Dr. Morse: First of all, remember that for any individual, the statistical chances that it will happen to you personally are very, very small. An exception is the natural outbreak of pandemic influenza, which will infect a large percentage of the population. It’s a matter of being in or near the area when the attack is occurring or, hopefully, not being there. These three types of attacks (chemical, biological, or nuclear) are different in important ways.
A chemical attack usually shows its results very quickly. If you see people suddenly stricken, the key is to get to a location that has fresh air as quickly as you safely can, wherever you are, and make sure you are not running in the direction of the wind. If I were in a car, I’d roll up my windows and turn off the air conditioning until I can get further away. In a plane, which is enclosed, open the air vents to bring in outside air, get as far away from the source as possible and cover your nose and mouth with a moist cloth. You can also use your scarf or necktie. Covering your nose and mouth is generally recommended for all these events, although they probably don’t do that much (biological is a possible exception). Then, seek medical attention if you start feeling ill, having breathing difficulties, or any skin or eye irritations.
Biological attacks are not immediately obvious. Even if you see someone running around spraying something, which is highly unlikely, who knows what they’re spraying? The illness from a bio-attack will take several days to develop, for some (like smallpox) even up to a couple of weeks. Many start as “flu-like illnesses” that rapidly get worse. I’d suggest seeking medical attention for a flu-like illness that makes you feel sicker than the flu usually does and comes with abdominal pain, chest pain, or a spreading rash, especially if you don’t have a runny nose. Call your doctor immediately. Chances are, if you were exposed, so were others, and the attack may already have been identified by the time you get sick.
Radiological dispersion devices (“dirty bombs”) may not be immediately obvious either. You may be aware of the explosion but may not know it had radioactive material in it. This may be discovered later when law enforcement or public health authorities check the bombed area for radioactivity. If you were too far to be affected by the explosion, that is, fairly far away, you’ll probably okay. Get away from the area, and seek medical evaluation.
A “small” nuclear explosion (NOT a “dirty bomb”, but a real nuke) is a different story. According to Graham Allison at Harvard, a 10-kiloton atom bomb (a fairly small one – roughly the equivalent of the bomb used in Hiroshima during World War II) would instantly vaporize anyone, and almost everything, within 1/3 of a mile from the blast site. At ¾ mile, most people would be killed or seriously injured, and there would be severe damage to buildings. At a 1-mile radius, there would be considerable injury or death from radiation and firestorms. Allison’s website www.nuclearterror.org allows you to generate a map of this for any U.S. zip code of your choice. If you can see the blast, DO NOT look at it. If you’re well over a mile away, try to move on if you safely can in a direction away from the wind (just as for a chemical attack).
The radiation goes in all directions, but the radioactive particles and fire will mainly follow the wind. If you’re in a car, getting away may be difficult due to traffic jams. In most cases, it will make little difference – if you’re far enough away, you may not be affected in any case. Stay in the car and roll up the windows. When feasible, recognizing that the hospitals will be busy with people much worse off, seek medical attention. People who received a moderate dose of radiation develop “radiation sickness” (vomiting, diarrhea, loss of hair, and other symptoms) days to weeks after, depending on the dose, and need immediate medical attention.
G-Man: There are many hospitals in low-income communities, nationwide, that aren’t equipped to handle triage situations, let alone a national catastrophe, because of financial constraints. Does the center have a plan in place that will enable people in underserved areas to receive the appropriate care and treatment in an emergency situation?
Dr. Morse: In the long term, ensuring access to care is a government responsibility. There is a need to make sure everyone has good access to healthcare. That should be a right, not a privilege. However, many excellent hospitals are in low-income communities (our own hospital is an example) or have outreach programs. Except possibly for rural areas, most will have the same chance at the emergency room as everyone else. However, there may be big differences in the education and information members of these communities receive. Our center, as well as others, is working on how best to inform and educate different ethnic communities so they can get good information they trust.
G-Man: Are there any “home remedies” or marketed products that may serve as a defense against chemical or biological agents?
Dr. Morse: In general, no. First, remember that, tragic as these events are, the chance of you or your family being directly in the danger zone is very small. I think the best defense is to keep well informed, both before any attack and while the event is going on. Incidentally, there are very few products I could recommend without reservations. There are no real lines of defense against chemical or biological attacks, and companies are cashing in on public concern by selling “protection devices” at inflated prices. Many of them are of poor quality. A high efficiency mask, FDA approved N-95 type respirator, which is good for protection against biological attack, is now available over the counter at many pharmacies and chain stores. But in a biological attack, it’s often impossible to know when to put it on and when it’s safe to take it off. Moreover, the masks are very uncomfortable! This sort of problem occurs with almost every product.
In most cases, you won’t be in the danger area anyway, and by time the attack is recognized it makes no sense to start taking precautions. If you are fairly near but not in the danger zone, try to stay indoors as much as possible, keep the windows closed if you can, and close off the outside air supply for the air conditioning until your local authorities give the “all-clear” in your area. Some people like indoor “HEPA” air filters. They can be useful, especially for biological events, and they also help with allergies. However, the filters must be properly maintained. In general, keep informed and updated, and adapt to the situation.
G-Man: What can people do to protect very young children and pets?
Dr. Morse: I think the most important thing is to have a family emergency plan. Emergencies may happen when the children are in school, for example. Ask the school authorities whether they will shelter the children there, or expect parents to come pick them up. It helps to know in advance so you can plan accordingly. A form can be downloaded at http://www.ready.gov/america/index.html.
G-Man: Given an attack of this magnitude, one could assume that many areas would be quarantined and that large quantities of food would be contaminated. Thus, people would not be able to shop or could unknowingly consume noxious products already in the home. What do you suggest people do in this case?
Dr. Morse: Many experts recommend keeping at least several days’ supply of canned non-perishable food and bottled water. In most cases, these items will be safe to consume, especially if stored in enclosed areas like a closet or pantry. And if you don’t need medical attention, staying at home is often the best option.
G-Man: Finally, in your honest opinion, how likely is it that a large-scale bioterrorism attack will occur on U.S. soil in the next two to three years?
Dr. Morse: Anyone who says they can predict this with any accuracy is either naive, a charlatan, or clairvoyant. With that said, the honest answer is I can’t say for sure when an attack of this nature will occur. It could take more than two to three years. However, I can say with utmost certainty that it will happen.
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