Dr. Cohen is Assistant Professor, Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, New York, Dr. Sidel is Distinguished University Professor, Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine and Montefiore Medical Center and Dr. Gould is President, SF-Bay Area Chapter, Physicians for Social Responsibility, San Francisco.

Drs. Cohen, Sidel and Gould have written this article in response to a previous TheDoctorWillSeeYouNow.com article on bioterrorism.

—The Editors

Bioterrorism. The word itself sounds scary. Novels and movies have portrayed shadowy figures spreading deadly disease among an unsuspecting public. Government officials and public health figures repeatedly issue warnings about the terrible threat. While the potential threat has been widely publicized, there has been little discussion of the risks of the suggested responses.

From the statements of public officials and media coverage, one might think that bioterrorism incidents have done tremendous damage and have increased dramatically in recent years. Actually, examples of bioterrorism have been very rare. The only documented terrorist use of a biological agent was in Oregon, where in 1984 a religious cult allegedly contaminated several salad bars with salmonella, with hundreds of illnesses but no deaths. The only documented terrorist uses of chemical agents were in Japan where a religious cult used Sarin, a nerve gas, killing seven people in the suburb Matsumoto in 1994, and used it again in 1995 in a Tokyo subway killing 12 people and injuring many more.

Is It Hype?
These same cases are cited over and over, in virtually every article and speech on bioterrorism. In another article on TheDoctor, the author cites these incidents but adds a few more. His list of what he calls "bioterrorist attacks around the world" begins with the 1979 "accidental release of anthrax spores from a Russian military base" and ends with a series of scares, threats and hoaxes, mostly concerning anthrax.

In the context of everyday public health problems, the actual morbidity and mortality from bioterrorism have been minuscule.

The Russian accident illustrates the dangers of manufacturing and storing biological and chemical weapons, as does the release of VX nerve gas at a U.S. military base in Utah in 1968 that killed thousands of sheep, although no people were in the area. These were tragic accidents but not "bioterrorist attacks."

Listing anthrax hoaxes as if they were attacks is also misleading. Anthrax samples are not easy to obtain and samples that are available are not particularly dangerous. The dangerous, weaponized version that uses anthrax spores are only possessed by a handful of governments with large military establishments. All the scare stories about bioterrorism may have helped make anthrax hoaxes more common. As long as the public is led to believe the unsupported notion that an anthrax attack is likely, then many more such hoaxes should be expected.

Removing hoaxes and military accidents from the list of bioterrorist attacks leaves a worldwide incidence, over 16 years, of 751 illnesses and no deaths from a food-borne contaminant and 19 deaths and scores of hospitalizations from the nerve gas events in Japan. How does the public health burden of these dramatic and deplorable incidents compare with that of 'ordinary' diseases and accidents?

In the United States alone, there are an estimated 76 million illnesses from food-borne disease each year, with 325,000 hospitalizations and 5,000 deaths. Also each year in the U.S. there are approximately 60,000 chemical spills, leaks and explosions, of which about 8,000 are considered 'serious', with about 300-400 deaths. In the context of everyday public health problems, the actual morbidity and mortality from bioterrorism have been minuscule.

How then has bioterrorism been presented as a major threat to public health? Presentations on the topic generally open with 'scenarios' — fictional accounts of what 'could' happen. The Centers of Disease Control and Prevention produced a video that shows a shadowy, fictional terrorist with a parcel of deadly biological agents that could kill thousands or even millions. In 1998, U.S. Secretary of Defense William Cohen held up a five-pound bag of sugar on a national television broadcast and declared that if the sugar were anthrax, the organisms could kill half the population of Washington D.C. Presentations like these do get the attention of the listeners. But are they based on any reasonable assessment of risk?

The Real Risk?
In order to make a reasonable estimate, it is useful to distinguish between very different types of potential incidents. The most frightening is the use of chemical, biological or nuclear agents in a manner that would cause huge devastation and tens of thousands or even millions of casualties. Dr. Carey writes, "ironically, the threat of a massive chemical or biological attack, especially with certain infectious agents such as smallpox and anthrax, exists because of the achievements of modern medicine that have eradicated these scourges."

On the contrary, it is not modern medicine that has created the risk of such catastrophes but the practices of modern warfare. Ever since the devastation of Hiroshima and Nagasaki, the world has been well aware of this danger. The various international treaties and conventions against nuclear, chemical and biological weapons proliferation reflect the recognition by even those states in possession of such weapons that their use could bring about self-destruction, as well as the destruction of the intended targets.

Biological and chemical weapons of the kind and amounts that could cause catastrophic casualties are extremely difficult to obtain and still harder to deploy. Only countries with nuclear weapons capability and a relatively few others with large military establishments have had that capacity.

It has been suggested that political terrorists would not be motivated to use catastrophic weaponry since such actions would bring universal condemnation even from those who might otherwise sympathize with their cause. Even if so motivated, it would be difficult for terrorist organizations, working in secret and without government support, to develop capacities that only a limited number of states have had the resources to acquire. Any government's putative desire to allow allied political organizations access to such weaponry would be constrained by reasonable fears of retaliation from targeted states in possession of robust military power.

As distinct from catastrophic terrorism, smaller scale incidents — similar to those that occurred in Japan or Oregon — could reasonably be considered within the capabilities of organizations or individuals. While these occurrences have been extremely rare, with only three such incidents recorded, re-occurrences cannot be ruled out. Nonetheless, once the scale of potential casualties has been reduced from the tens of thousands of the fictional scenarios to the number that might be seen if smaller scale incidents did recur, then the competing benefits and risks of appropriate interventions can be rationally weighed and discussed.

In the event that a new terrorist incident takes place, which is not impossible, it is likely that proponents of massive investment in anti-terrorism will claim that even more investment should have been made in their pet projects. Will they stop to consider how these investments might have been used more effectively for education, nutrition, housing and immunizations against prevalent diseases to protect the health and well-being of the world's people? So far, however, fear has prevailed and dubious anti-terrorism programs have been implemented with little discussion.

A Case In Point: The Anthrax Vaccination Program
As described in a previous article, the U.S. Armed Forces embarked on a program to vaccinate all 2.4 million active duty and reserve members against anthrax. Soldiers were not informed of potential risk and have not been allowed to decline the vaccine. The vaccine being used has been proven effective in human studies only for cutaneous anthrax, which is transmitted by working infected animals and their hides, a hazard for some veterinarians and tanners. Consequently the vaccine has been limited to use among a narrow population at high risk of exposure.

It is not clear that the vaccine would be effective against inhalation anthrax, the militarized form. A rational military immunization program would have required evidence of significant risk that the troops would be exposed to anthrax; that they might be exposed to a particular strain for which the vaccine is efficacious; and that the vaccine is safe for mass inoculation. Very little evidence was produced for any of these, much less all of them together.

Some military personnel, fearing side effects, have refused to participate, have been disciplined and some threatened with court martial.

A number of adverse events following inoculation with the current vaccine have been reported. The program was temporarily halted after manufacturing quality issues came to light. Some military personnel, fearing side effects, have refused to participate, have been disciplined and some threatened with court martial.

Their protests prompted a congressional subcommittee investigation and the subsequent report characterized the anthrax vaccination program as having "uncertain safety", "untested efficacy" and as an "unmanageably broad military undertaking built on a dangerously narrow scientific and medical foundation." The fact that the sole manufacturer of the vaccine is owned in part by a former head of the U.S. Joint Chiefs of Staff underscores the danger that conflicts of interest and profit motives may also play a role in this and similar undertakings.

The only previous mass-scale anthrax immunization was conducted during the Gulf War-but the Pentagon has not made records available of those who received the vaccine and if any had short or long-term adverse outcomes.

However, during the Gulf War, another experimental drug was given, without consent, to U.S. troops during the Gulf War. The drug, pyridostigmine bromide, was supposed to be an antidote enhancer that would give protection against a nerve agent, Soman.

(Interestingly, while some suspected Iraq to be in possession of Sarin nerve agent, there was no evidence to suggest that Iraq had Soman or had weaponized it. Although Soman and Sarin are in the same organophosphate class of chemical agents, the limited evidence from animal tests on the efficacy of pyridostigmine bromide suggested that pyridostigmine makes individuals more vulnerable to Sarin, such that "the DOD [Department of Defense] scientists who studied pyridostigmine and sarin therefore concluded that pyridostigmine should only be used when the chemical warfare threat is soman.")

A recent Pentagon-sponsored Rand Corporation study has indicated that pyridostigmine bromide cannot be excluded as a potential factor in thousands of cases of illnesses collectively known as Gulf War Syndrome. Exaggerated concerns over bioterrorism with ill-advised counter-measures could similarly increase the risk of adverse outcomes.

Notwithstanding the problems that have plagued the current anthrax vaccination program, the Pentagon has announced preparations for a similar program with smallpox vaccine. Does this make any sense? A pediatrician, quoted in the bioterrorism article raises an important issue, "Every vaccine carries with it the risk of a negative, even serious, reaction and there is always a trade off between the risk from vaccination and the risk from contracting the disease itself; in the case of smallpox it is an easy call because there is virtually zero risk of anyone becoming infected with the disease."

Is Preparedness a Waste of Resources?
It's not hard to imagine a disaster scenario, no matter how unlikely the reality would be. In the absence of facts, the speculative question is asked, "What if the unthinkable and highly unlikely event does occur?"

We are told that bioterrorism preparedness is the answer. Decades ago, "nuclear preparedness" was promoted in the same way. Fallout shelters were built and stocked with supplies. Evacuation drills and emergency broadcast signals were tested. Such "preparedness" measures were later discredited as useless and wasteful. There is no reason to believe that bioterrorism preparedness will be any different.

Or a Convenient Excuse?
In addition to wasting resources, fear of bioterrorism — based on hypothetical and speculative scenarios — can be an excuse for suspect policy recommendations driven by profit and political agendas that are not consistent with national and international public health efforts.

For example, the Environmental Protection Agency (EPA) has announced plans to limit public disclosure of potentially hazardous industrial chemical sites that is mandated by the Clean Air Act. This action supposedly addresses concerns that bioterrorists could use such information to attack the sites. However, the new EPA policy severely compromises the public's fundamental right to know about the potential toxic chemical threats from nearby plants.

The issue of bioterrorism can also be used to excuse illegal military actions.

The effect of the EPA policy will be to insulate corporations responsible for such facilities from public pressure to clean up hazardous facilities or to institute more effective safeguards to prevent accidents and illness. We should not forget that in 1984, the same year as the Oregon salmonella incident, a leak at a Union Carbide plant in Bhopal India resulted in thousands of deaths and many thousands of serious injuries.

The issue of bioterrorism can also be used to excuse illegal military actions. The U.S. cruise missile attack on a pharmaceutical factory in the Sudan violated international law. The excuse was an allegation that the factory was producing biological or chemical warfare agents for a terrorist organization. The allegations were quickly shown to lack substance and news accounts have revealed that State Department officials knew even before the bombing that there was no reliable evidence to sustain the allegations.

Such facts, however, did not prevent the destruction of a facility that provided half the medicines for the North African region. Who takes responsibility for the consequent death and disability in that already under-served region?

Is the Cure Worse Than the Disease?
Another new and dangerous bioterrorism initiative underway is the expansion of research facilities that study potential biological and chemical warfare agents. Known as Biosafety Level IV facilities, highly toxic agents such as smallpox and ebola virus can be stored and studied in them. Until recently, such activities were known to have taken place at a CDC facility in Atlanta and at the Army's Fort Detrick in Maryland. Under the new program, the public was informed that Plum Island, a Department of Agriculture laboratory on the edge of the New York metropolitan area is being 'upgraded' to Level IV and an unknown number of others are being opened. It is claimed these facilities will study ways to defend against potential biological and chemical warfare agents.

There are very grave dangers in these efforts. Are these facilities immune to accidents and leaks either at the facilities themselves or during the transport of pathogens? A researcher at a Ft. Detrick USAMRID lab was taken ill with a case of glanders, a disease that is considered a potential biowarfare agent. The researcher had spent considerable time in his community before the diagnosis was made. Had the disease been one that could be transmitted person-to-person, the incident could have led to many illnesses.

Worldwide experiences with presumably fail-safe facilities such as nuclear power plants should remind us that accidents can and do happen. More Level IV facilities will tend to increase the chance that an accident could occur. The chance of an accident may be remote, but perhaps less remote than the threat these facilities are supposed to guard against.

Even without an accident or leak, the new facilities may be dangerous. Will the military establishments of other countries be sure that facilities for studying pathogens of potential military use will be used only for defensive purposes? Might some governments speculate that the blurred line between defense and offense could be crossed, leading those governments or their military forces also to undertake such 'defensive' measures? It has recently been revealed that the Soviet Union's chemical and biological weapons programs were spurred by reports about the U.S. program — reports purposely given to the Soviets by an American double agent working for the F.B.I.

The perception of other nations that U.S. "defensive" measures have significant offensive potential is exemplified by global reaction to the U.S. proposal to deploy a new anti-missile system that would violate, amend or scrap the 1972 Anti-Ballistic Missile (ABM) treaty. The proposal was rebuffed in the United Nations General Assembly, which voted 80 to 4, urging all countries to maintain and respect the treaty.

The vote reflects concern that abrogating the treaty, even in the name of defense, may rekindle the nuclear arms race and destabilize the current balance. Subsequently, China announced that a U.S. missile defense program would be viewed as a threat to China's national security and would lead to counter-measures, including building more nuclear missiles. The bioterrorism program to build more 'defensive' Level IV facilities may likewise rekindle an arms race in biological and chemical warfare agents. Such a path could actually increase the risk of the catastrophic use of these agents in war.

The multi-billion dollar programs to "counter" bioterrorism are already underway. The CDC, the U.S. Public Health Service and numerous county and state departments of public health have all become engaged in this campaign. Institutes to study bioterrorism have been established and schools of public health are being encouraged to set up core curricula to study it. How has it happened that such a huge, coordinated public health intervention has been undertaken with scant evidence, little public debate and no independent review?

Such a path could actually increase the risk of the catastrophic use of these agents in war.

Public health and medical professionals need to insist that these possibly risky programs be halted or postponed until there can be a scientific assessment of the real risks of bioterrorism and a full and independent examination and public debate on the risks and benefits of proposed interventions.

The Real Public Health Challenge
While evidence of risk from bioterrorism is scanty, there is plenty of evidence of real needs, challenges and risks to the public's health. Much more attention and substantial resources are needed to improve national and international abilities for the surveillance of disease outbreaks and environmental insults. Such outbreaks and insults have been and, one can expect, will continue to be largely from natural causes, accidents and negligence.

If adequate systems are in place to prevent these outbreaks and to find and respond to those that occur, then in the unlikely event of bioterrorism, the in-place system would be able to handle these bioterrorist assaults adequately. Any "likely" (given past experience none are "likely") incident will probably be small-scale and the medical response (as distinct from the police response) indistinguishable from ordinary accidents or outbreaks. In the Oregon case cited earlier, the local health department insisted it was an ordinary outbreak until a disaffected cult member suggested otherwise a whole year later!

Creating a system that is oriented to the rare or phantom case will leave the public vulnerable to the ravages of commonplace diseases and accidents, along with preventable illness and death.

Primary prevention, actions to prevent disease outbreaks before they occur, need to be given priority. We must also keep in mind that disease patterns evolve and new or re-emerging challenges can be expected to occur. For example, some experts fear that, as a consequence of the warming trends of global climate change, there are indications that malaria has moved beyond its traditional zones. Instead of spending hundreds of millions of dollars to chase hypothetical bioterror threats, why not fund alternative and sustainable energy sources that would allow cuts in fossil fuel consumption that many experts believe underlie the climate changes?

In addition, alleged threats from bioterrorism would be better met by strengthening the conventions on chemical and biological weapons. Public health would be better served by developing more rigorous enforcement of these treaties than by turning over health policy leadership to military and law enforcement agencies that have shown a propensity to threaten civil liberties.

The very rationale for nation-states or organizations developing what has been termed "poor man's nuclear weapons" would be undercut by a vigorous move by the nuclear weapons states towards abolishing nuclear weapons, as advocated by numerous political and military leaders, as well as health organizations including the American Public Health Association and the American Medical Association.

True global disarmament would free a tremendous amount of resources for the food, shelter and healthcare that would do more for the eradication of diseases than the reactive and ill-considered bioterrorism campaigns that could well become self-fulfilling prophecies of disaster.