“Shallow men believe in luck or in circumstance. Strong men believe in cause and effect.” Ralph Waldo Emerson
“I pass with relief from the tossing sea of Cause and Theory to the firm ground of Result and Fact.” Winston S. Churchill, The Story of the Malakand Field Force
“Since leaving Moscow, I have encountered an alarming level of ignorance about biological weapons. Some of the best scientists that I’ve encountered in the West say it isn’t possible to alter viruses genetically to make reliable weapons, or to store enough of a given pathogen for strategic purposes, or to deliver it in a way that assures maximum killing power. My knowledge and experience tell me that they are wrong.” Ken Alibek, physician, microbiologist, biological warfare expert, former First Deputy Director of Biopreparat and author of Biohazard
Natural evolutionary forces have produced a complex array of deleterious microorganisms, viruses and biological toxins that are capable of generating disease and death among plant, animal and human populations. Centuries before humankind ever conceived and accepted the germ theory of disease, biological warfare was waged in ancient battlefields, and natural pandemics created swaths of death across continents. Causes of contagion were not known, however, the overall effects among panic -stricken populations, such as 14th century Europe, were stark and frightening realities attributed to the miasma theory of disease or relegated to the wrath of an unforgiving God.
The brilliant scientific achievements stemming from the minds and efforts of microbe hunters such as Louis Pasteur and Robert Koch, gave the world a comprehension of microbiology and infectious diseases, which generated tremendous strides toward the prevention, control and cure of some of the world’s most dreaded maladies. In addition to decreasing human morbidity and mortality, these discoveries led to vast improvements in animal and plant health, and subsequently, increases and grand accomplishments in agricultural productivity, water and food sanitation, vector control and other milestones in nutrition, environmental and public health, industrial-scale brewing and widespread production and use of life-saving antibiotics and vaccines.
The scientific, medical and technological knowledgebase of microbiology, originally intended to combat infectious diseases and enhance the quality of life, had quickly been perverted to a form “public health in reverse”, or as the former director of Russia’s formidable bioweapons program, Biopreparat, Dr. Ken Alibek, once stated “to destroy vital activity”, i.e. life functions. Microbiology became known to some military planners and scientists as “military biology” or “black biology”, denoting the offensive use of microorganisms. Microbial genetics, virology, immunology and molecular biology soon made it possible to manipulate and modify microbial and viral agents, and even modulate immune responses with profound implications for medical science, public health and, of course, biowarfare (BW).
The militarization, stockpiling and deployment of life forms and their toxins would eventually be prohibited by international treaty, however, this would not prevent nation-states from pursuing and acquiring offensive biological weapons research, development and production programs, and stockpiling BW agents for use on the battlefield or for selective target missions, such as political assassinations, ethnic, religious or racial “cleansing” schemes.
Due to the proliferative growth and widespread availability of microbiological and biotechnological knowledge, techniques and expertise worldwide, and the increasing willingness, sophistication and activities of various criminal and terrorist factions, including so-called “lone wolf” actors, the possibility and probability of BT attacks are increasingly plausible. The availability and use of dual-use technology and dissemination techniques are commonly available, and the ability to overtly or covertly attack civilian populations with debilitating or lethal BT agents is certainly a realistic threat. As a non-conventional threat, the use of BW agents in warfare, conflicts and to commit biocrimes and acts of bioterrorism (BT) is not without precedent, and remains one of the most ominous and heinous global shadows ever to be cast upon civilization .
Epidemiology is the study of disease in populations and is often referred to as “the basic science of public health” and is not limited to infectious diseases, but, may be applied to all diseases and injuries. In an epidemiological crisis or event involving an infectious agent or a biotoxin, such as anthrax or botulinum toxin, a determination must be made: “Is this a naturally occurring outbreak or a BT event?”. In the public health arena, this involves “shoe leather epidemiology” or field epidemiology, which essentially combines case investigation techniques with scientific and medical knowledge and skill-sets. The epidemiological investigation is the quintessential “whodunit” of public health, which also asks, “what is it?”
In a BT investigation, forensic epidemiology comes into play, as this sub-specialty investigates nefarious disease causation. A single case of pulmonary (inhalational) anthrax, for example, would serve as a strong red flag that this is not a usual occurrence and is suspect, yet, a prompt and comprehensive investigation needs to be conducted to rule out a naturally acquired infection vs. an intentional attack. One need only to compare and contrast the October 2001 mail-borne anthrax events, with the sole case of pulmonary anthrax diagnosed in an individual in possession of a drum made with animal hide contaminated with Bacillus anthracis. The first obviously an intentional dissemination, while the second, which also invoked full emergency and investigative responses, was deemed a non- BT event. Similarly, several victims presenting to hospital with flaccid descending paralysis whom have eaten at a certain restaurant could indicate a botulism outbreak has occurred from either an accidental/natural or intentional food-borne poisoning.
In essence, are there sufficient findings and facts that can support the suspicion or conclusion that an outbreak is intentional vs. natural?
- Has there been a threat communicated to law enforcement and acknowledged as credible? Has an individual or group taken credit for an infectious disease outbreak?
- Have clusters of victims displaying similar signs and symptomatology been presenting to hospitals and/or health clinics?
- Has syndromic surveillance and/or environmental sampling and monitoring systems, e.g. BioWatch, indicated a rise in the incidence of a certain infectious disease syndrome, changes in community health trends, or is there environmental evidence of a BT agent attack, e.g., sick, dead or dying animals, presence of dissemination devices such as sprayers, culture media, incubators or detection of a select agent by environmental sensors and /or laboratory confirmation?
- Any recent assessments that may indicate a credible biological threat in the area?
- Disease with an unusual geographic or seasonal distribution (i.e., tularemia, plague in a non-endemic area or influenza in the summer)?
- Is there presence or absence of fever? (Key feature that distinguishes an infectious process from a biotoxin or chemical poisoning).
- Are there upper respiratory symptoms or signs of pneumonia in clusters presenting to health care facilities?
- Is there higher than expected morbidity and mortality associated with a common disease and/or failure of patients to respond to traditional therapy?
The aforementioned are some of the “clues” and indicators which may point to a BT release in a community, however, it must be noted that many BT-related illnesses may mimic influenza or other infectious diseases, therefore, other factors must be taken into consideration, such as geographical or seasonal distribution.
A BT attack requires a high level of cooperation between law enforcement and public health to achieve their respective objectives:
- Life safety and security of responders and providers at all levels and the general public.
- Identification and characterization of the biological agent.
- Prevention of infectious spread, containment, medical & protective countermeasures.
- Prevention and mitigation of public panic, effective, accurate and timely risk communication and public information.
- Crime scene management, biohazardous evidence collection and preservation/forensics.
- Apprehension and successful prosecution of perpetrator(s).
As such, bioterrorism investigations become a joint, cooperative venture of infectious disease epidemiology and criminal investigations. The epidemiological “footprint” of an outbreak becomes part of a crime scene investigation, and an important investigative tool to public health and law enforcement efforts.
Similarly, law enforcement officials, their investigative techniques and leads are important for successful apprehension and prosecution of the bioterrorist(s), however, their integration with the public health community becomes essential to ensure an effective and appropriate overall response to a BT event. This would include enforcing public health law and quarantine, providing security, obtaining forensic evidentiary materials ,including representative environmental samples of suspected substances, assisting the public health team with tracking and locating individuals ,escorting samples to public health laboratories and ensuring chain of custody. In suspect outbreak events, public health epidemiologists and law enforcement authorities conduct overlapping investigations. They must both fully comprehend their commonalities and differences when conducting joint, parallel investigations. Both groups must rely upon each other’s skill sets and expertise without becoming confounded and hindered by professional turfs or jurisdictional limitations.
Intelligence and information sharing, for example, is crucial in joint epidemiological -criminal investigations, and it is prudent to have a “cleared” epidemiologist embedded within a law enforcement operation, as well as a seasoned criminal investigator with pre-existing expertise in terrorism- related investigations, integrated into a public health Emergency Operations Center (EOC). To enhance mutual cooperation and unfettered, timely exchange of information, matrices have been developed by joint planning groups that would assist both public health and law enforcement communities.
These matrices address the following:
- Phases –Pre-suspicion, suspicion of a biological incident, incident management, resiliency and recovery.
- Known information – Information that each group has during the specific phase of the biological incident.
- Needed information – Information that each group needs to obtain to effectively conduct its investigation during the specific phase of the biological incident. It is the information that the public health community would need from the law enforcement community or the law enforcement community would need from the public health community.
- Actions – Steps that should be taken by each community to obtain the information or to identify what information can be readily obtained (i.e., public health to obtain law enforcement information).
It is absolutely essential that the planning and preparedness process involve a multidisciplinary approach including key players in the public health and law enforcement communities. This fosters mutual respect and cooperation, elicits expertise, identifies roles and responsibilities, and provides the framework for the overall game plan to be enacted during a crisis or event. During an actual crisis or event is not the time to foster amicable relationships and mutual cooperation between agencies. These are achieved during pre-planning and preparedness activities, such as group meetings, training and exercises. Also, public health and law enforcement liaison officers are critical components of any joint investigative team.
Remembering that life-saving medical interventions and public health countermeasures take precedence, law enforcement actions and criminal investigative processes must not interfere with the medical and public health response. Similarly, if an emergency medical, rescue or epidemiological response team must enter a “hot” or suspect area, the scene must be assessed and “rendered safe”, i.e. releases must be stopped and contained, the area assessed and cleared of secondary devices and any active threats, such as shooters or suicide bombers must be neutralized.
Emergency medical personnel, health care providers and public health professionals must be cross-trained in recognizing and preserving potential forensic evidence, including blood and bodily fluids, contaminated clothing and other fomites (both for evidence preservation and infection control purposes), maintaining appropriate chain-of-custody according to FBI or other applicable evidence protocols and procedures, maintaining situational awareness, decontamination procedures ,and personal protective equipment and countermeasures. EMS, health providers and public health must also be aware that the perpetrator(s) of a BT attack may be among their casualty loads.
In cases of agroterrorism, where an animal or plant pathogen may have been disseminated to impair or destroy agricultural productivity, other stakeholders become engaged in the investigation, including veterinarians, plant pathologists, local, state and national agricultural services, as well as public health, environmental protection and various law enforcement agencies.
Overall, the integrated resources of law enforcement and public health are critically important in both crisis and consequence management of BT events.
Clearly, emerging and evolving biological threats, such as Ebola viral hemorrhagic fever, chikungunya viral disease, Middle Eastern Respiratory Syndrome (MERS), monkeypox, Severe Acute Respiratory Syndrome (SARS), various strains of Highly Pathogenic Avian Influenza (HPAI), anthrax, biotoxins and other agents continue to cause illness, morbidity, mortality and fear, and are an increasing threat to global health and security. The widespread use of biotechnology with the ability to genetically modify organisms, or create synthetic constructs, adds a worrisome dimension to the proliferation of biological weapons and the threat of bioterrorism.
Novel microorganisms may be designed for antibiotic or antiviral resistance, to elude detection and diagnosis, to decimate or escape immune responses, or possibly to act as a carrier vehicles for potent biomolecules or virulent pathogens. The intentional dissemination of such agents in terrorism scenarios will continue to pose formidable challenges to public health, health care, law enforcement and national security assets.
International efforts geared towards non-proliferation must be expanded and vigorously enforced, intelligence and interdiction activities, likewise, need to be increased and enhanced worldwide. Infectious diseases as natural outbreaks, biowarfare or bioterrorism do not recognize international borders, nor do they discriminate among their victims. Global public health preparedness for natural outbreaks and pandemics fortify preparedness for bioterrorism, and preparedness efforts for bioterrorism strengthens readiness for naturally occurring infectious disease events. The gaps between detection, diagnostics and rapid treatment are being closed by advances in biodefense, however, more needs to be done in these areas.
To close, the following is offered to the reader.
“In vast laboratories in the Ministry of Peace, and in experimental stations, teams of experts are indefatigably at work searching for new and deadlier gases; or for soluble poisons capable of being produced in such quantities as to destroy the vegetation of whole continents; or for breeds of disease germs immunized against all possible antibodies.”-George Orwell,1984.
May the world never know this, and may the opposite become eternally true for generations to come.