Bioterror in the
Age of By D a niel M. Ger s t e i n
Biotechnology Library of Congress
U.S. Army M190 chemical warhead section containing demonstration Sarin bomblets, 1943
his powerful statement from the most recent Commission on the The Commission believes that unless the world community acts decisively and Prevention of Weapons of Mass T Destruction (WMD) Prolifera- with great urgency, it is more likely than not that a weapon of mass destruction tion and Terrorism serves as ample warning of the dire threats faced by the United States will be used in a terrorist attack somewhere in the world by the end of 2013. and indeed the world from a bioweapon successfully deployed by a determined and The Commission further believes that terrorists are more likely to be able knowledgeable terrorist. In thinking about the potential for such a bioterror attack, to obtain and use a biological weapon than a nuclear weapon. The Commission several important questions serve to frame the discussion. Do terrorists have the desire believes that the U.S. government needs to move more aggressively to limit the to employ WMD, and in particular biological weapons? Under what conditions might bio- proliferation of biological weapons and reduce the prospect of a bioterror attack.1 logical weapons be an attractive choice for use by terrorists? Would they have the requisite knowledge, equipment, and organizational Dr. Daniel M. Gerstein is a Strategist and Policy Expert with significant operational experience. He has capacity to mount a biological warfare (BW) written extensively about national security. This article is based on his most recent book, Bioterror in the 21st attack? Would they be successful in such an Century: Emerging Threats in a New Global Environment (Naval Institute Press, 2009).
78 JFQ / issue 57, 2 d quarter 2010 ndupress.ndu.edu GERSTEIN attack? What could we do to mitigate the Second, terrorists are continually some might consider related to an insur- effects of a bioterror attack? searching for new means to facilitate increas- gency rather than terrorist action. Still, the This article provides a framework for ingly violent and spectacular attacks that will increases in violence and number of attacks understanding the potential for a BW attack gain visibility for and further their causes. are worth considering. A statement by noted now and in the future by a terrorist or terrorist Attacks have become more frequent and terrorism expert Brian Jenkins summarizes organization. In developing this framework, more violent. Prior to the Embassy bombings the trends in terrorism: the findings hinge less on the technical capa- in Kenya and Tanzania in the late 1990s, bilities than on the intentions of the potential for instance, global casualties from terrorist Over the past three decades, terrorists have perpetrator. State use of biological weapons attacks were fewer than 500 per year.4 The multiplied the number of their victims by an in either large-scale strategic scenarios or as Embassy bombings caused casualties in order of magnitude every 15 years. In the 1970s, tools of assassination is not examined directly, the thousands, and then the attacks of 9/11 the bloodiest incidents involved tens of fatali- although the framework could have equal ties. By the 1990s, hundreds were killed and application to a state BW program. no agreed definition of the incidents increased. In 2001, the number reached the thousands, and today we fear sce- The Potential Perpetrator terrorist has been developed, narios in which tens of thousands might die.6 Terrorism is a term that evokes strong and the word has been used emotions. Events of 9/11 brought terrorism to seemingly interchangeably Third, general agreement now exists that the forefront of the national security debate in with other terms such as terrorists are “rational” actors. Their actions the United States and arguably throughout the insurgent, illegal combatant, may not be understood by their victims or the rest of the world. Despite this increased atten- and freedom fighter governments and law enforcement agencies tion during the intervening period, the debate that attempt to deal with these threats, but has seen little increased clarity. they are far from random irrational acts. One No agreed definition of terrorist has been caused over 3,000 deaths with many more noted expert identifies alienation, humilia- developed, and the word has been used seem- injured. In compiling terrorism trends for tion, demographics, history, and territory as ingly interchangeably with other terms such 2008, the National Counterterrorism Center grievances that motivate terrorists.7 as insurgent, illegal combatant, and freedom (NCTC) identified 11,770 attacks that killed Fourth, and related to their rational fighter. The result is a politicization of the term 15,765 (see figure 1).5 A note of caution is actor status, terrorists have constituencies that hinders global cooperation and confuses in order for the reader who might want to they must satisfy. High violence strategies that the issue. This can be seen in a discussion of directly compare the casualty figures. The indiscriminately kill and maim large numbers the rationality of the terrorist. Many believe different counting rules and definitions of people are not desirable as a long-term that terrorists are pathologically damaged, certainly contribute to some of the disparities tactic. Likewise, failure to adequately gain vis- violent sociopaths who employ violence for noted. Additionally, the NCTC data include ibility and promote a cause will likely be seen their own perverted outcomes. Others believe attacks in Iraq and Afghanistan, which as ineffective by these constituencies. This that terrorists are calculating and highly rational actors with real or perceived griev- Figure 1. Terrorism Statistics (2008), National Counterterrorism Center ances, employing a range of strategies from Dead: 15,765 political actions to violence in order to achieve Number of attacks: 11,770 desired outcomes. Some have gone as far as to 5 826
suggest that it is possible to reach a negotiated 5,528 settlement with terrorists, in the same way that one might reach a postconflict settlement fol- lowing a state-to-state conflict.2 4,594 4,354 Regardless of the exact definition or the rationality of the terrorist, several important trends serve as the foundation for
this analysis. First, terrorism is not a new 2,987 phenomenon and has a long historical pre- cedence. The direct origin of the term can be traced to the time of the French Revolution, although the period beginning in the 1970s is of the most interest for our discussion. It is during this period—with emphasis on the 978 762 774 718 post-9/11 period—where we see the conflu- 370 352 ence of the use of high violence strategies, the 292 rise of global terrorist organizations fueled Africa East Asia and Europe and Near East South Asia Western by globalization, and increasing religious Pacific Eurasia Hemisphere radicalization.3 ndupress.ndu.edu issue 57, 2 d quarter 2010 / JFQ 79 FEATURES | Bioterror in the Age of Biotechnology will serve as both a motivating influence and technical) which previously limited terrorist The use of biological weapons is not a moderating factor that will feature promi- use of WMD are eroding.”8 a new tactic and in fact predates the under- nently into the bioterror question. standing of disease. The history of biological Fifth, the question of whether a terrorist What Is Biological Warfare? warfare can be traced back to medieval will employ a unique means such as biologi- Biological warfare is the intentional times including the siege of Caffa on the cal weapons is directly related to the ability use of microbes to cause disease in a target Crimean Peninsula, the use of blood-laced to develop the capabilities, intentions, and population. Microbes are inherent in all life arrows against enemies, and the catapulting knowledge necessary for perpetrating a bio- forms and include bacteria, viruses, protozoa, of human and animal carcasses into enemy terror attack. Some terrorist groups will likely algae, and fungi. While some microbes are encampments and fortifications during the find it outside of their operational envelope Crusades. to employ such a technique. Others may find whether a terrorist will The modern history of biological development of these capabilities too techni- weapons includes programs by some 20 cally challenging. Still others may determine employ a unique means such states beginning in the 1940s to the present. that use of these weapons may present an as biological weapons is Often-cited efforts include the Japanese use of existential threat to the terrorist should the directly related to the ability BW against China and captured prisoners in attacked nation employ a massive retaliatory to develop the capabilities, the World War II period; the massive Soviet effort (assuming, of course, that the perpetra- intentions, and knowledge program that continued through the end of tors can be identified). necessary for perpetrating a the Cold War; and the programs and coopera- Finally, terrorism today does not repre- tion among Canada, the United Kingdom, sent an existential threat to the United States bioterror attack and the United States that began in the 1940s or our friends and allies. However, this could and continued until the United States uni- change should terrorists develop or acquire responsible for causing disease, many others laterally denounced biological weapons and the capability for conducting a WMD attack serve vital functions for supporting all forms toxins in 1969. The modern history of BW using either nuclear or biological weapons. of plant and animal life. In BW, the attempt is also includes the Biological Weapons Conven- In a harbinger of what the future might hold, to effectively and efficiently deploy weapons tion (BWC), which was the first arms control Bruce Hoffman noted ominously that “many composed of biological material to attack a treaty that banned the use of an entire class of of the constraints (both self-imposed and target and achieve a desired objective. weapons for offensive purposes. Also part of
9/11 brought terrorism to forefront of national security debate U.S. Air Force (Michelle Leonard) U.S. Air Force
80 JFQ / issue 57, 2 d quarter 2010 ndupress.ndu.edu GERSTEIN this history is the limited success the BWC has Even once the initial agent, deployment factor in considering the agent for weaponiza- had with regard to halting the development method, formulation, and manufacturing tion. Consider that for the disease tularemia, of offensive BW capabilities by some of the process have been determined, success in the the LD50 is approximately 50 organisms, while convention’s signatory nations. attack ultimately depends on the meteorologi- for anthrax it is approximately 8,000 spores. The history of bioterror incidents is also cal conditions when the weapon is deployed. However, there are always tradeoffs to be instructive. One study concluded that from What is the wind speed? Will the weapon made. Francisella tularensis, the organism 1900 to 2003, there were only 77 total inci- be deployed in a city or open terrain? What responsible for tularemia, is highly susceptible dents. The data do not encompass state-spon- time of day? Is there an inversion that would to the environment and experiences biological sored BW or hoaxes.9 The hoaxes in particular keep the agent on the ground and therefore be decay at a rate of 2.5 to 5 percent per minute would include a large number of “incidents” more effective against the intended target? (depending on meteorological conditions and as they tend to outnumber actual events by These questions relate to the poten- the weaponization of the pathogen), while as much as 100 to 1.10 The small number of tial effectiveness of the biological weapon; Bacillus anthracis, the anthrax organism, is incidents and the uniqueness of each limit the however, another set of considerations is a hearty spore that experiences virtually no ability to draw definitive conclusions from the directly related to the effectiveness of the biological decay. data. Instead, each requires analysis to deter- attack. They include the concentration, dose, The final consideration of target mine the key parameters and outcomes that susceptibility is another important factor. defined it and ultimately the success or failure once the initial agent, Ultimately, the success of an attack will be of the attack. An important note is that during deployment method, determined by whether the deployed BW combat operations in Afghanistan in 2001, weapon will infect the target population in documents were seized indicating al Qaeda’s formulation, and the appropriate manner to cause disease. If interest in developing a BW capability; few manufacturing process have the target population has been vaccinated or details have emerged concerning the intended been determined, success in is not susceptible to the weapon or if protec- purpose of the weapons or how far their devel- the attack ultimately depends tive measures have been taken, the attack will opmental effort have progressed. on the meteorological fail. For example, if an anthrax attack against In understanding BW, several factors conditions when the weapon troops is initiated, but the soldiers all have contribute directly to the ability to develop personal protective equipment and have been and employ an effective biological weapon, is deployed vaccinated against the pathogen, the attack including the agent or pathogen, deployment most likely will not be successful. method, formulation, manufacturing process, stability, and target susceptibility. In consider- An important note is in order at this 11 and meteorological and terrain conditions. ing these factors, the goal of the bioweapon- point. When terms such as LD50 and ID50 are It is instructive in understanding the eer is to have the highest concentration of used, they normally are based on what the potential for a bioterror attack to appreci- organisms per milliliter or gram (depending medical and public health community knows ate the choices that must be made. Will the on whether a liquid or dry formulation is about the effect of the naturally occurring agent be a bacteria, virus, or toxin? Should used) of material. Another consideration is strains of the bacteria and viruses. But what a contagious or noncontagious pathogen be the lethal dose (LD) or infective dose (ID), if the biological material has been altered selected? Should a lethal or an incapacitating which is normally measured in LD50 and ID50, such that fewer particles cause disease or the agent be used? These initial decisions begin to respectively, and relates to the dose required virulence of the material reduces the incuba- determine the type of attack that will be pos- to cause mortality or infection in 50 percent tion time? This would be the likely goal of a sible and even the manner in which it should of the people exposed. This becomes a major bioweaponeer. be conducted. In examining the deployment method, will the agent be delivered by aerosol, vector, food, or water? Will the pathogen be deliv- ered using an explosive device or a spray nozzle? The formulation of the pathogen is also important. Will a wet or dry agent be used? Will the material be stabilized to make it more efficient and able to remain airborne for a longer period? What is the manufactur- ing process? How and in what quantities will the material be grown to mount an attack against the envisioned target? Will the mate- rial be dried and milled? What size are the particles? Do they support efficient respira- tory infection or are they too large to be
inhaled and remain deeply embedded in the and Prevention Centers for Disease Control alveoli within the lungs? Photomicrograph of Bacillus anthracis bacteria ndupress.ndu.edu issue 57, 2 d quarter 2010 / JFQ 81 FEATURES | Bioterror in the Age of Biotechnology
This previous set of questions contains effort and prevented a successful attack.12 In quotes Kathleen Bailey who, after interviewing a mix of operational and technical issues that yet another anecdote that alludes to the dif- professors, graduate students, and pharma- the bioterrorist would need to master for a ficulties of developing a biological weapons ceutical manufacturers, concluded that several successful attack. It also serves as fodder for capability, Jerzy Mierzejewski, the retired biologists with only $10,000 worth of equip- those who claim that developing a BW capac- director of the Polish biological defense labo- ment could produce a significant quantity of ity is a nontrivial task too difficult for a terror- ratories who spent his career working with biological agent.14 In fact, the U.S. Government ist to master. But what are the facts? Clostridium botulinum, lamented that “one conducted an experiment in which a small culture cycle would produce toxin that was team of experts was tasked with determin- Dual-use Technologies lethal and a few months later the next would ing the feasibility of developing an “anthrax” Central to the question of the potential not, and so on over the years.”13 weapon using readily available capabilities and for a bioterror attack is the ability of the terrorist to develop a viable BW capability, one study concluded that capabilities in several key implying mastery of the biology, the technol- technologies are experiencing a doubling every 6 months—a ogy for dispersing the pathogen, and the development of a scenario aligned with the 400 percent increase per year objectives sought. Some believe that the technology is too Others argue that the development equipment. The initiative—Project Bacchus— sophisticated for mastery by a terrorist and of biological weapons is almost trivial. One was sponsored by the Defense Threat Reduc- that specialized capabilities are required. author wrote that producing biological tion Agency (DTRA) and demonstrated that Advocates of this position state that other weapons was “about as complicated as manu- the development of these capabilities is not terrorists such as Aum Shinrikyo and the facturing beer and less dangerous than refining particularly complex or costly.15 Rajneeshee cult failed to acquire, process, heroin.” In seminar presentations a few years Does this important issue really come weaponize, and successfully deploy a biologi- ago, former Central Intelligence Agency Direc- down to a question of whom one believes? cal weapon. In another example, a postdoc- tor James Woolsey claimed that “a B-plus high Other insights can be gleaned from examining toral student was given a year to develop school chemistry student” could produce bio- the trends in biotechnology that are placing this scenario using the pathogen Francisella logical agents, and at a January 2000 meeting ever increasing knowledge and capabilities in tularensis. At the end of that period, when the he described producing biological agents as the hands of more people around the globe, results were briefed, the student had made being “about as difficult as producing beer.” In undoubtedly including some who would use three fatal errors that would have doomed the her book The Ultimate Terrorist, Jessica Stern the technology for other than noble purposes.
Members of Georgia National Guard CBRNE response force conduct search, extraction, and decontamination drills U.S. Air Force (Dennis J. Henry, Jr.) (Dennis J. Henry, U.S. Air Force
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In fact, many believe that we have moment, but the Age of Biotechnology will the five steps. This framework forms a matrix entered the Age of Biotechnology. On the face likely make this development possible in the that allows us to consider this two-sided equa- of it, such a statement means little without future. Couple this with the ready availability tion in detail (see figure 2). For our purposes, further examining the likely impact for key of the genomic sequences from a wide variety the matrix has been color-coded to reflect our technologies that could be used for the benefit of disease-causing pathogens and organisms, ability to affect each of the bioterrorist’s neces- of humankind or just as readily turned into and one can easily predict the potential for sary steps. A useful exercise is to look at the deadly weapons of mass destruction. artificially developing pathogens, manipulat- matrix in greater detail to gain an understand- One study conducted by the Department ing current pathogens to make them more ing of the potential for a bioterror incident and of Defense (DOD) concluded that capabilities virulent, or perhaps developing antibiotic-/ our ability to positively affect outcomes. in several key technologies are experiencing antiviral-resistant pathogens. Our ability to prevent a terrorist from a doubling every 6 months—a 400 percent Attempts to control or limit advances in acquiring, processing, and weaponizing bio- increase per year. Areas experiencing such biotechnology seem fruitless with an industry logical material is limited. Deadly pathogens increases include cell growth chambers and that has such potential for improving the are naturally occurring, and with the prolifera- fermenters, encapsulization and stabilization, quality of life and that comprises such a large tion in the life sciences of knowledge, equip- the human genome, pathogen efficacy, DNA part of the U.S. and global economies. Addi- ment, and capabilities, these collective steps engineering, sensors, vaccines and antibiotics, tionally, the dual-use nature of biotechnol- have experienced a lowering of thresholds that and nucleic acid synthesis.16 ogy—that is, the very capabilities that allow allows for more biotechnology in the hands of By way of an example, the rate of vaccine for developing prophylaxes and treatments a larger number of people, some of whom may development doubled every 5 years from 1940 and can be employed just as effectively for desire to employ these capabilities as weapons. to 1970. From 1970 to 1980, the rate increased developing biological weapons—results in a Equipment for fermentation, freeze drying, fivefold such that the time to double the capa- conundrum that we cannot fail to recognize. and milling—which can be found readily in bilities in the field of vaccines was 1 year. Over local hardware stores or ordered from the the next 20-year period from 1980 to 2000, Framework for Analysis comfort of one’s home—allows for developing the time to double in capability decreased to Successful employment of a bioterror and weaponizing these biological capabilities. 6 months. Another field, DNA engineering, weapon implies that a lone terrorist or ter- This is not to say that all pathogens will be not even in existence until 1982, has doubled rorist organization has mastered five steps: available to all terrorists. International efforts in capacity every 6 months since. This area is acquire, process, and weaponize a pathogen, to prevent biological proliferation activities critically important to a variety of biotechni- and plan the attack and deploy the weapon such as the Australia Group and the Prolifera- cal advances including gene therapy, vaccine so as to cause disease in a target population. tion Security Initiative have limited effective- development, and sensors, as well as the poten- However successful, employment of a bioterror ness given that pathogens are naturally occur- tial of ominously increasing the virulence of a weapon should not be considered in isolation, ring and that the equipment requirements pathogen. The same is true for encapsulization but rather should be thought of as a two-sided for processing pathogens are not particularly and stabilization, which have potential for proposition where our capabilities in prepared- sophisticated. Some will prove to be too dif- enhancing personal protection and therapeu- ness and response as articulated in the Depart- ficult or dangerous to work with; however, tics as well as making BW weapons more effec- ment of Homeland Security’s doctrine of a determined terrorist hoping to develop a tive and stable in the environment.17 prevent, protect, respond, and recovery interact basic BW capability would see thresholds As an example of what the future might to either facilitate or hinder the terrorists’ lowered. In short, biological material suitable hold, a recent article discusses the develop- capabilities in varying degrees across each of for use in an attack has become less technically ment of an artificial polio virus synthesized with nonliving components combined using Figure 2. Bioterror’s Two-sided Equation specialized equipment and chemicals.18 While Homeland Prevent Protect Respond Recover this early work provides a proof of concept, Security genetic engineering and combinatorial BW Step Prevention and Protection: chemistry in the future will allow for large- Acquire anticipate, preempt, detect, and deter threats scale, rapid synthesizing of peptides, poly- nucleotides, and other low weight molecular Process material, allowing for manipulation of the Response and Recovery: coordinated, comprehensive Federal very building blocks of life. The polio virus, response and mount a swift and effective with its relatively simple structure and 8,000 Weaponize recovery effort base pairs in its genomic sequence, provides a glimpse into the possibilities as well as Scenario highlighting the potential for the develop- Development (Planning) Significant ability to affect ment of, for instance, the smallpox virus in Some ability to affect Deployment this manner. Artificial development of the Virtually no ability to affect smallpox virus, with 200,000 base pairs and Not applicable a considerably more complex structure, in Note: Knowledge for the terrorist cuts across the other five steps. this manner remains out of reach for the ndupress.ndu.edu issue 57, 2 d quarter 2010 / JFQ 83 FEATURES | Bioterror in the Age of Biotechnology challenging and therefore made these biologi- employ the BW weapon against a population of deterrence and countermeasures to ensure cal capabilities more readily available. that had been fully immunized against the adequate coverage of important locations and Impacting the terrorists’ ability to pathogen. Development of vaccines and thera- facilities. acquire, process, and weaponize a pathogen is peutics can have an important deterrent effect Examining the last two categories, also limited by the modest requirements for as well. Likewise, conducting an attack against respond and recover, we reach two important developing a BW capability. Unlike nuclear a building that has defensive measures built conclusions. First, these actions have no appli- weapons that have a requirement for highly into the air handling system would probably cability to the terrorists’ ability to acquire, specialized equipment and radioactive material not result in a successful attack and therefore process, or weaponize a biological weapon. with a large footprint and distinctive signature, would also serve as a deterrence measure. Second, these areas offer the greatest potential BW weapons can be constructed in a small, Developing and fielding new real- for us to affect outcomes with well considered confined space with little need for complex time sensors that provide a detect-to-warn and emplaced programs. equipment and no discernible signature. In capability will also be important. Today, the Response begins with the ability to sense fact, the DTRA study conducted as part of current suite of sensors, such as those in the that an attack is in progress or has occurred. Project Bacchus established this clearly. BioWatch19 program, are detect-to-treat with It is related to our sensor technology as part of the BioWatch program, but also includes terrorists desiring to acquire, process, and weaponize a improved biosurveillance, stockpiling of critical pathogen such as anthrax would likely be deterred if they treatments and vaccines, increased resilience in the health care system to handle surge require- intended to employ the BW weapon against a population that ments envisioned from a bioterror attack, had been fully immunized and trained and ready first responders. The BioSense20 and BioShield21 programs are a start We do have some ability to prevent ter- relatively long periods between exposure and at improving biosurveillance and stockpiling, rorists from successfully planning and deploy- establishing that an attack has occurred. This respectively, but more can and must be done. ing such weapons. For example, buildings can period may be as long as a day or more. In the The readiness of our public health com- be designed to prevent employment of biologi- future, new age biotechnological capabilities munity and first responders is also a vital link cal weapons in certain scenarios. Standoff dis- should begin to allow for real-time detection in this system. Homeland Security Presiden- tances and limiting access to air intake systems that will permit warning of the attack as it is tial Directive 21, “Public Health and Medical will limit use of biological weapons against occurring so people can be moved out of the Preparedness,” of October 2007 identified the these types of hardened targets. attack area and begin receiving immediate four most critical components of public health In the category of protection, we do have treatment, and potential victims can be pre- and medical preparedness as biosurveillance, greater ability to affect outcomes. Terrorists vented from entering contaminated areas. countermeasure distribution, mass casualty desiring to acquire, process, and weaponize Protection also implies the employment care, and community resilience.22 a pathogen such as anthrax would likely be of risk-based strategies to determine where Today, we have no national biosurveil- deterred from doing so if they intended to attacks are most likely, and the deployment lance system. Rather, we have a collection of state and local systems that have been cobbled Marines prepare samples in simulated chemical together and that continue to rely on the capa- lab during Chemical Biological Incident Response bilities of astute clinicians, doctors, and public Force demonstration health personnel. The picture is even worse globally as much of the reporting is spotty and incomplete at best, and even subject to politicization. Certainly, we have the technical capability to develop an automated disease tracking system linked to hospitals, clinics, and public health facilities. Perhaps the more relevant question is whether we have the political will. On a positive note, the World Health Organization International Health Regulations that establish requirements for global disease reporting by 2012 represent an important step in global biosurveillance. Just as advances in biotechnology allow for the proliferation of increasingly danger- ous dual-use capabilities, they also provide a greater capacity to develop new age treatments and prophylaxes. In the future, developing technologies such as DNA engineering and combinatorial chemistry combined with emerg- U.S. Marine Corps (Leslie Palmer)
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ing technology such as nanotechnology will Nes o t over 4,000 atmospheric monitoring stations nation- provide new opportunities for fighting naturally wide for the detection of atmospheric pollutants. occurring disease as well as bioterror attacks. 1 Commission on the Prevention of WMD Pro- Under the auspices of Project BioWatch, atmo- spheric samples in numerous cities are monitored The importance of casualty care and liferation and Terrorism, World at Risk: The Report of around the clock for select agents. Filters from community resilience cannot be overstated. the Commission on the Prevention of WMD Prolifera- the sampling apparatus are analyzed by the CDC A bioterror attack will likely result in a mass tion and Terrorism (New York: Vintage, 2008), xv. 2 David A. Lake, “Rational Extremism: Under- network for numerous biological threat agents. If casualty situation with large numbers of standing Terrorism in the Twenty-First Century,” any such agents were detected, mechanisms and affected individuals and worried well con- Dialog-IO (Spring 2002), 1–29. protocols are in place for DHS, EPA, and CDC to verging on hospitals, clinics, and treatment 3 Bruce Hoffman, Inside Terrorism (New York: reach crucial public health decisions rapidly, and facilities. The ability to rapidly assess and Columbia University Press, 2006), 3–40. promulgate a uniform course of action for local treat, instill public confidence, and commu- 4 See “Statistics on Terrorism” at