BIOTERROR Praeger Security International Advisory Board Board Cochairs Loch K. Johnson, Regents Professor of Public and International Affairs, School of Public and International Affairs, University of Georgia (U.S.A.) Paul Wilkinson, Professor of International Relations and Chairman of the Advisory Board, Centre for the Study of Terrorism and Political Violence, University of St. Andrews (U.K.) Members Anthony H. Cordesman, Arleigh A. Burke Chair in Strategy, Center for Strategic and International Studies (U.S.A.) Ther´ ese` Delpech, Director of Strategic Affairs, Atomic Energy Commission, and Senior Research Fellow, CERI (Foundation Nationale des Sciences Politiques), Paris (France) Sir Michael Howard, former Chichele Professor of the History of War and Regis Professor of Modern History, Oxford University, and Robert A. Lovett Professor of Military and Naval History, Yale University (U.K.) Lieutenant General Claudia J. Kennedy, USA (Ret.), former Deputy Chief of Staff for Intelligence, Department of the Army (U.S.A.) Paul M. Kennedy, J. Richardson Dilworth Professor of History and Director, International Security Studies, Yale University (U.S.A.) Robert J. O’Neill, former Chichele Professor of the History of War, All Souls College, Oxford University (Australia) Shibley Telhami, Anwar Sadat Chair for Peace and Development, Department of Government and Politics, University of Maryland (U.S.A.) Fareed Zakaria, Editor, Newsweek International (U.S.A.) BIOTERROR Anthrax, Influenza, and the Future of Public Health Security R. William Johnstone James Dutton, Imprint Adviser PRAEGER SECURITY INTERNATIONAL r Westport, Connecticut London Library of Congress Cataloging-in-Publication Data Johnstone, R. William, 1953– Bioterror : anthrax, influenza, and the future of public health security / R. William Johnstone. p. ; cm. Includes bibliographical references and index. ISBN 978–0–275–99326–9 (alk. paper) 1. Bioterrorism—United States. 2. Anthrax—United States. I. Title. [DNLM: 1. Bioterrorism—United States. 2. Anthrax—United States. 3. Disease Outbreaks—United States. 4. Public Health Administration—United States. 5. Public Policy—United States. WA 295 J73b 2008] HV6433.35.J64 2008 363.32530973—dc22 2008020105 British Library Cataloguing in Publication Data is available. Copyright C 2008 by R. William Johnstone All rights reserved. No portion of this book may be reproduced, by any process or technique, without the express written consent of the publisher. Library of Congress Catalog Card Number: 2008020105 ISBN-13: 978–0–275–99326–9 First published in 2008 Praeger Security International, 88 Post Road West, Westport, CT 06881 An imprint of Greenwood Publishing Group, Inc. www.praeger.com Printed in the United States of America The paper used in this book complies with the Permanent Paper Standard issued by the National Information Standards Organization (Z39.48–1984). 10987654321 CONTENTS Illustrations vii Preface ix 1. The Anthrax Attacks of September/October 2001 1 2. Threats and Risks 20 3. The Pre-9/01 Public Health System 39 4. Response to the Anthrax Attacks: Criminal Investigation 63 5. The Public Health Response to the Anthrax Attacks 80 6. Public Policy Response to Bioterrorism, SARS, and Avian Flu 105 7. Current Status of Public Health Security 131 8. Conclusion 165 Notes 177 Index 211 This page intentionally left blank ILLUSTRATIONS TABLES 1.1. Summary of Confirmed and Suspected Cases of Anthrax from Bioterrorist Attack, Fall 2001 18 2.1. Major Potential Infectious Disease Threats 26 2.2. Major Potential Biological Weapons Threats 32 3.1. U.S. Public Health Expenditures, 1960–2000 (in $ millions) 62 4.1. Timeline of USAMRIID Information Disclosure, Fall 2001 78 6.1. Status of National Strategy for Pandemic Influenza Implementation Plan, December 2006 116 6.2. Federal Preparedness Grades, 2005 120 6.3. U.S. Public Health Expenditures, 2001–2006 (in $ billions) 124 6.4. Public Health Security Budget, Selected Programs, FY 2001–2008 (in $ millions) 127 7.1. Post-2001 Key Homeland Security and Public Health Security Plans 137 7.2. FY2008 Appropriations for Selected HHS Programs (in $ millions) 161 FIGURES 3.1. Death Rate from Influenza, Pneumonia, and Tuberculosis in United States, 1900–1980 46 viii ILLUSTRATIONS 6.1. Federal Spending on Bioterrorism and Pandemic Flu, Departments of Health and Human Services and Homeland Security, FY 2001–2008 (in $ billions) 125 PREFACE On the morning of September 11, 2001, I was working as the legislative director for U.S. Senator Max Cleland (D-GA) in the Dirksen Senate Office Building in Washington, DC when four planes were hijacked by foreign terrorists. After the crashes of the aircraft into the World Trade Center in New York and the nearby Pentagon, I helped evacuate the Senator’s office. In the days and weeks that followed the shock of those events, our office, like most of Capitol Hill, focused on responding to them. A little over a month later, on October 15, 2001, the Capitol and na- tion were hit by another attack, this one involving the opening of a letter containing anthrax spores in the Hart Senate Office Building suite of U.S. Senator Tom Daschle (D-SD) that was only about a hundred yards away through an open passageway from my own room. Along with many other Senate workers, a few members of Senator Cleland’s staff (not including me), who were thought to have possibly been exposed, were tested and put on ciprofloxacin, which was the preferred treatment for inhalational anthrax. The Hart Building was closed on October 17. As the seriousness of the situation and the extent of the contamination became better under- stood (including the discovery that the mailroom in the Dirksen basement had traces of anthrax), the Dirksen Building was shuttered on October 20, 2001 and our staff had to “telecommute” from our widely dispersed homes. Although none of the Cleland staff members tested positive, and none of the few dozen Senate workers who were found to have been exposed subsequently developed an infection, and though the Dirksen Building was opened several weeks later (with the Hart Building following in January x Preface 2002), the physical disruption was real and the psychological impact was palpable. Subsequently, I had the privilege of serving on the staff of the National Commission on Terrorist Attacks Upon the United States (the 9/11 Commis- sion), and thus had the opportunity to participate in that effort to understand and explain the September 11 hijackings, while making recommendations designed to prevent a reoccurrence. There was no such body created to perform an authoritative and compre- hensive examination of the anthrax attacks and to help produce public and congressional consensus behind appropriate policy responses. The genesis of this work was, thus, the notion to attempt to create, on a much humbler scale, a 9/11 Commission-like look at the anthrax crisis, including con- sideration of the attacks themselves, the evolution and performance of the defenses against them, and suggestions for policy improvements to reduce the probability of future such attacks. Lacking the resources of the 9/11 Commission, it was clear that some choices were going to have to be made in narrowing the scope somewhat to allow for the desired comprehensiveness in treatment of the chosen subjects. Therefore, though many other relevant topics presented themselves (includ- ing, among the defensive entities involved in some way in the anthrax case, the intelligence community and the Environmental Protection Agency), a de- cision was made to focus primarily on the public health system, which was the most directly implicated in the response. In providing a more thorough view of the anthrax attacks themselves, it was also determined that a limited look at the criminal investigation conducted by law enforcement agencies would be included. Having decided to center on the public health system, however, it quickly became apparent that limiting my survey to anthrax alone would not al- low for a true assessment of that system, which was, and is, faced with a large number of ongoing challenges, including one—the threat of pandemic influenza—that has emerged since 2001 as perhaps an even greater concern than bioterrorism in the eyes of many in the public health community, the administration, the Congress, and the general public. In the end, the de- termination was made to broaden this study to include pandemic flu, in addition to anthrax and other biological weapons threats. And since the notion of infection is central to most of those threats, the more general topic of infectious disease control was also added. The primary point of analysis in the present work is at the policy level rather than on the medical side, so that, for instance, much more attention is given to the legislative and administrative authorization and funding of pub- lic health policies and programs than to the clinical descriptions of diseases and treatments. The goal herein was to assess the capability of the public health system to address the anthrax attacks and the ongoing challenges of bioterrorism Preface xi and naturally occurring pandemics, to offer some suggestions for remedying major deficiencies, and to do so in a manner that is accessible to policy makers, public health officials, and the interested public. Extensive endnotes are provided to help direct readers seeking more information on specific topics to additional sources. This page intentionally left blank CHAPTER 1 The Anthrax Attacks of September/October 2001 Though significantly less