Hillel W. Cohen, Robert M.
Gould, and Victor W. Sidel
Cohen, Hillel W.; Gould, Robert M.; Sidel, Victor W,
Bioterrorism 'Preparedness': Dual Use or Poor Excuse?, 115(5) Public
Health Reports 403 (Sept,2000)
In their Viewpoint in the July/August 2000 issue of Public Health Reports,
M. R. Fraser and D. L. Brown express concerns about the risk of
bioterrorism and the adequacy of bioterrorism preparedness.(1) They are
not alone. Bioterrorism appears regularly on public health conference
agendas, government advisories, and lists of health care challenges. The
US federal budget for fiscal year 2000 allocated more than $10 billion
to counter terrorism, including more than $1.5 billion specifically for
bioterrorism.(2) Enormous attention in the media as well as medical and
health journals reflects, and perhaps amplifies, widespread concern. But
is this concern justified?
Fraser and Brown list a number of potential threats to public health:
food inadvertently contaminated with hepatitis A virus; a large outbreak
of influenza; water pollution caused by floods; 'the willful
contamination of food products with Salmonella'; and a 'terrorist's
release of aerosolized Bacillus anthracis (anthrax) in a city
center.'(1) This list mixes fact and fiction and requires closer
attention. Virus contamination, flu outbreaks, and water pollution are
three of many public health problems that actually occur in the US every
year and claim hundreds or even thousands of lives.
In contrast, willful Salmonella contamination is not a common
problem.
Rather, mention of this potential threat is a veiled reference to the
only documented bioterrorist episode ever to take place in the US--a
solitary incident in Oregon in 1984 that caused 751 mild illnesses and
no deaths.(3) Inclusion of an
anthrax incident is even more misleading since it is totally fictional.
No such incidents have occurred, and the likelihood of one occurring is
remote. Militarized anthrax spores are so difficult to manufacture that
only a handful of countries with large military-industrial
establishments (including the US and the former Soviet Union) have ever
developed the capacity. It is highly unlikely that military
establishments with any hypothetical stockpiles would share these with
terrorist organizations outside their control. Anthrax spores are
difficult and dangerous to handle, and would-be users may be more likely
to hurt themselves than others.(4) Despite numerous fictional scenarios,
hoaxes, and false scare stories about anthrax being readily available
through the Internet, the fact remains that there has never been a
confirmed use of anthrax spores, anywhere, by anyone, in a military or
terrorist attack.
Proponents of bioterrorism preparedness must rely on fictional
scenarios since real cases of terrorism using biological or chemical
agents have been so exceedingly rare. In addition to the aforementioned
Oregon incident involving a biological agent, there have been only two
recent documented episodes of terrorism using a chemical agent--both
carried out by the Aum Shinrikyo cult in Japan using sarin nerve gas in
1994-1995, resulting in a total of 19 fatalities.(5) Can three incidents
in almost 20 years with a total of 19 deaths constitute
a major threat to public health? Compare those numbers to the real
challenges our health system faces. In the United States alone, an
estimated 76 million illnesses from foodborne disease occur each year,
resulting in 325,000 hospitalizations and 5,000 deaths.(6) Each year in
the US there are approximately 60,000 chemical spills, leaks, and
explosions, of which about 8,000 are considered 'serious,' resulting in
about 300-400 deaths.(7) Despite these staggering numbers, neither
foodborne disease nor chemical spills has received a fraction of the
publicity and attention given to bioterrorism.
Fraser and Brown argue that funding bioterrorism preparedness
programs '... should allow for the development of a dual-use response
infrastructure that improves the capacity of local public health
agencies to respond to all hazards....'(1) They further state that
'using bioterrorism initiatives to build the capacity of local public
health systems is an efficient and effective use of limited public
health resources'(1)
A recent analysis of bioterrorism preparedness spending reveals that
of the $1.5 billion allocated specifically for bioterrorism, $222
million (15%) has gone to programs that could be included in Fraser and
Brown's concept of dual use--building the public health infrastructure
for all hazards.(8) The rest has been spent on what could be called
'dual-useless' items such as
military and police exercises. Can a 15% allocation to public health be
considered an efficient use of limited funds?
Wasted resources are not the only problem. In the last several years
the US Department of Defense has tried to vaccinate all active duty
personnel with an anthrax vaccine. The vaccine has never been proved
useful against the weaponized spore form of inhalation anthrax, and many
soldiers have complained of adverse reactions from the vaccine. The
manufacturer (a for-profit concern) was plagued with safety problems and
tainted by a potential conflict of interest (a former Joint Chiefs of
Staff head is a principal stockholder).(9)
While the military is spending millions to manufacture an unproven
and potentially unsafe anthrax vaccine, and millions of doses of
smallpox vaccine are being produced to protect against an eradicated
disease, the supply of influenza vaccine is not secure.(10) Annually,
even without a vaccine shortage, there are approximately 20,000 deaths
and 110,000 hospitalizations in the US directly or indirectly related to
influenza.(11) Such upside-down priorities are not coincidental. Viewing
public health challenges through the lens of bioterrorism necessarily
distorts the picture. Fraser and Brown note that 'the idea of working
with the National Guard, the Department of Defense, and other military
groups may seem foreign to many public health practitioners.'(1) This is
understandable since the track
record of the military on public health concerns has been abysmal.(12)
Public health advocates have long been in a (losing) competition with
the military for funding.
Is 'dual use' simply a euphemism for 'trickle down'? Have public
health advocates given up hope of ever overcoming the unequal funding
competition, now believing that the only answer is to attach real public
health needs as a caboose to the military-spending gravy train? It is
perhaps possible to interpret the 85% waste in bioterrorism funds as a
15% gain for public health. The approach may seem pragmatic, if not
overly optimistic. However, subordinating public health needs to what is
essentially a military and law-enforcement agenda comes with many risks
and a heavy price.
Public health planners collect incidence and prevalence data in order
to set priorities. Designing preparedness programs for unlikely
bioterrorism events is at best wasteful. Manufacturing the wrong
vaccines and stockpiling the wrong medicines may have far-reaching
opportunity costs. Research and development on potential bioterrorism
agents increases the risk of deadly accidents with these agents. Worse,
other countries may not believe Pentagon assurances that its biological
and chemical agent research programs are defensive only, and may begin
or accelerate their own programs as a deterrent--engendering a new arms
race in deadly pathogens and
toxins. Space does not permit a full explanation of these and other
risks, which we have discussed in detail elsewhere.(13,14) Public health
educators and practitioners should be especially concerned that
bioterrorism programs could prove a disaster by miseducating the public
as to the real threats to public health. Do we really want members of
the public to be anxiously looking under their beds for terrorists while
corporate negligence creates havoc with unsafe food handling, misuse of
antibiotics, industrial accidents, and pollution? Will xenophobia and
anti-immigrant hysteria, exacerbated by bioterrorism scare stories, stop
mosquitoes at the border? Even simple measures such as teaching children
to wash their hands and adults to handle food properly would prevent
more infections and save more lives than a thousand bioterrorism drills.
Perhaps the $10 billion allocated to anti-terrorist programs for this
year could be better used to provide clean water and sanitation to all
who lack these basics. According to a recent report from the United
Nations, $10 billion for safe water could cut by up to one third the
current 4 billion diarrhea cases worldwide that result in 2.2 million
annual deaths.(15)
The end of the Gold War was supposed to open the way for a peace
dividend for public health, among other needs. The dividend never
materialized, and the public health infrastructure has continued to
suffer from neglect. One must ask
if bioterrorism preparedness is just an excuse--a plausible threat--to
justify excessive military budgets, including an estimated $4.5 billion
per year for the continued development of nuclear weapons.
Brown and Fraser note with concern that 'only 5% of local public
health agency directors that were surveyed reported that all appropriate
members of their staff had received comprehensive bioterrorism
training.'(1) Perhaps these overworked and underfunded staff members are
too busy dealing with real public health problems to indulge in training
drills to search for and destroy phantoms.
Let's get our priorities straight and work to build national and
international public health systems that can adequately handle the daily
health crises we already face or are likely to face in the future.
Funding public health by means of 'dual-use' bioterrorism programs may
prove to be a misguided stratagem that interferes with building urgently
needed public health capacity.
