A Plague on All Your Houses

Last June 2, emergency teams gathered for a closed-door meeting at the Colorado Convention Center and learned that deadly anthrax had been released at a Sixteenth Street Mall food court. The dissemination had been subtle -- 10,000 to 20,000 spores, a microscopic amount, is all that is needed to infect a person -- and apparently no one noticed as a fine dust of spores settled on women's hair and businessmen's fast-food lunches; no one looked up as the dust swept through the exhaust pipes and drifted through downtown. Skateboarders whiffed the poison as they wove in and out of pedestrian traffic. Workers returning from lunch-hour shopping forays walked through anthrax-laden air.

Initially, those infected displayed no symptoms. But within a few days, people across the metro area began calling in sick to work and showing up at doctors' offices. They complained of fever, stuffiness and aches -- unremarkable symptoms shrugged off as the cold or flu. They were told to rest, drink plenty of fluids and take some aspirin, then were sent home.

In many cases, the symptoms were followed by a brief "eclipse," during which the victims began to feel better. Some even went back to work. Soon, however, the victims experienced more severe signs. Some developed dark swellings on their chest and neck. All had trouble breathing.

Area hospitals were overwhelmed. It took days for doctors to realize what they were dealing with -- pulmonary anthrax -- and once they did, they had to acquire massive amounts of penicillin and streptomycin and administer it quickly. Pulmonary anthrax is not infectious, and antibiotics will stop the progress of the disease -- but only if administered before the first symptoms appear. After that, the drugs have little effect.

By the time victims began exhibiting second-stage symptoms, they were the walking dead. Their lungs slowly filled with fluid, gradually cutting off their supply of oxygen. Their skin took on a bluish tint. They choked, convulsed and died.

The outbreak's toll: 1,500 people dead and 10,000 or so affected (including those with psychosomatic illnesses).

It was the job of the emergency workers meeting in Denver to handle the crisis, to figure out who might have been affected, to transport and treat the ill, to arrange for burial of the dead, and to get the word out to the public in such a way as to prevent panic.

It was a daunting task.

It was also completely theoretical, a six-hour tabletop exercise designed to help local agencies learn how to respond to a crisis situation involving a weapon of mass destruction (known bureaucratically as a WMD).

This month -- at this very moment, perhaps -- local and state health-care and emergency workers are participating in a much more vast exercise, a ten-day "no-notice" test of their responses to another hypothetical act of bioterrorism involving a different WMD. A similar scenario will be played out concurrently in Portsmouth, New Hampshire, while federal agencies conduct a third exercise in the Washington, D.C., area. This trio of tests -- the largest mock bioterrorism disaster ever in this country -- involves top officials from at least eleven federal agencies, including the FBI, the CIA, the Environmental Protection Agency and the Department of Defense, a lineup that inspired the overall mission's name: TOPOFF.

Why Denver? Because area officials volunteered for the job, with Arapahoe County Sheriff Pat Sullivan -- also a major proponent of preparing for the nonexistent millennium meltdown late last year -- leading the way. Although the exercise will involve many volunteers, there are certain to be hard costs, too. For starters, actors will be hired to play victims of bioterrorism. But so far the budget, like the test scenario itself, remains top secret.

The probability of Denver being hit by a real, large-scale act of bioterrorism is low, admits Major Chris Petty, deputy commander of a specially trained bioterrorism response group attached to the Colorado National Guard. "But the consequences are so high," he says, "that we have to address it in a reasonable way."

A reasonable and extremely expensive way. This year alone, the federal government has authorized expenditures of $1.4 billion to protect Americans from chemical and biological weapons. (In 2000, the feds will spend a total of $10 billion on terrorism, up $3 billion from 1999.)

Some scientists argue that the United States is over-preparing for bioterrorism, creating a worst-case-scenario response for a hypothetical threat. Weapons experts with the Center for Nonproliferation Studies claim U.S. officials have drastically exaggerated the danger of mass-casualty attacks involving chemical or biological agents -- after all, they point out, over the past hundred years, just one person in this country has died as a result of such an incident.

Even the General Accounting Office entered the debate. In a report published in March 1999, the GAO said that plans developed by the Department of Health and Human Services for "medical consequence management" after a chemical or biological terrorist attack appeared to be "geared toward the worst-possible consequences from a public-health perspective and do not match intelligence agencies' judgments on the more likely biological and chemical agents a terrorist group or individual might use."

And still, the money keeps coming from Congress. "With terrorism certified by the Clinton administration as the foreign menace of the moment, the money comes easily from a compliant Congress," science journalist Daniel S. Greenberg wrote in a March 1999 piece for the Washington Post. "Who dares risk the opprobrium of being wrong?"

Few politicians, certainly, but many epidemiologists offer a convincing argument against directing so much money toward a national defense targeting bioterrorism. If the government is going to commit this amount of funding, they argue, more of the money should go to local health agencies on the front line rather than to the Department of Defense, which is collecting the majority of the funds right now. Because while D.C. experts worry about fictitious foreign terrorists, local officials worry about very real dangers coming from within -- an influenza epidemic, for example, one similar to the 1918 flu that decimated this country as well as others around the world, killing at least ten million people.

"I think most people in our field think it's a matter of when, not if," says Richard Hoffman, state epidemiologist and Colorado's chief medical officer.

The hypothetical scenario employed for TOPOFF is unlikely to involve anything as mundane as the flu; Hoffman is expecting the culprit to be anthrax or the bubonic plague. "I don't know the exact agent that will be involved," he says, "but I anticipate it will be some agent that we might use antibiotics to offer as a preventive therapy."

Given the large number of casualties that could result from biowarfare, Hoffman adds, "it makes sense to prepare." Besides, the exercise will give area doctors and hospitals valuable experience should Colorado ever be hit by another flu pandemic. And 82 years ago, this state was hit hard.

In September 1918, a virulent type of influenza was first noticed among a handful of sailors in Boston. Within weeks, the disease -- a plague, really, 25 times more deadly than any type of influenza before or since -- had swept to the West Coast, infecting a quarter of the country's population. That fall, the flu cut a deadly swath across the country, killing a half-million Americans.

In her 1999 book, Flu, science reporter Gina Kolata describes the horrible deaths wrought by the 1918 flu:

"It may take a few days, it may take a few hours, but there is nothing that can stop the disease's progress. Doctors and nurses have learned to spot the signs. Your face turns a dark brownish purple. You start to cough up blood. You feet turn black. Finally, as the end nears, you frantically gasp for breath. A blood-tinged saliva bubbles out of your mouth. You die -- by drowning, actually -- as your lungs fill with a reddish fluid. And when a doctor does an autopsy, he will observe your lungs lying heavy and sodden in your chest, engorged with a thin bloody liquid, useless, like slabs of liver."

Virtually overnight, the flu turned Denver into a city of "noiseless houses with the shades pulled down," author Katherine Anne Porter, a Denver newspaper reporter in 1918, wrote in her book Pale Horse, Pale Rider. As the disease took hold, public gatherings of all kind were canceled in an attempt to stop the flu's spread. "It's as bad as anything can be," Porter wrote. "All the theaters and nearly all the shops and restaurants are closed, and the streets have been full of funerals all day and ambulances all night."

At the height of the epidemic, the hospitals had no empty rooms, not even any empty beds.

Today, there are 62 acute-care hospitals in Colorado, 13 in the metro area alone; the state has a total of 9,749 hospital beds, 5,151 of them in Denver. But that number wouldn't come close to accommodating the number of victims resulting from a 1918-type flu or a major bioterrorism incident.

Either of those events would "quickly overwhelm the resources of any city," says Stephen Cantrill, associate director of emergency medicine at Denver Heath Medical Center. "You have to get creative. You may have to set up auxiliary hospitals; that becomes a possibility. Obviously, the criteria of who gets hospitalized may change. Clearly, supplies would be overwhelmed.

"Two people to a bed is scary but realistic," he says of a pandemic. "Obviously, we've come a long way in the way we care for patients, but it's a good example of completely overwhelming the available resources. That's why prevention is so important. We've avoided that in a lot of ways through vaccinations for influenza."

But because the flu virus is incredibly adept at mutating, doctors acknowledge the possibility of a new flu emerging that would be impervious to vaccines. "In 1997 it was determined that an entirely new strain occurred in Hong Kong," Hoffman says. "They slaughtered three million chickens to stop the spread. Another strain in 1957 killed 60,000 Americans. In 1968 there was a less deadly strain, but it caused far more illness."

"I think our preparedness would reduce or keep the number of sick and dying people to a minimum," he continues. "We can only try to minimize it."

And if the flu doesn't get us, there's always the prospect of smallpox or plague being used as weapons.

Bubonic plague, once known as "the Black Death," was responsible for halving the population of Europe in the mid-fourteenth century. The disease is already something of a known quantity in Colorado, since between ten and twenty cases of the hantavirus are reported every year in the Four Corners region. The plague has a short incubation period: The bacterium quickly makes its way into the lymphatic system, then migrates to the liver, spleen and brain. Victims first suffer chills, nausea and fever; as the organs hemorrhage and destruct, the skin takes on a dark pall. One in seven cases proves fatal.

But the plague is treatable with antibiotics, and labs in Denver are equipped to test for it. And while some doctors harbor concerns about the possible manufacture of drug-resistant strains of plague, Hoffman points out that there hasn't been a person-to-person spread of the disease in this country since 1924. The killer plague was the pneumonic type, which can be spread through coughing; our Western plague is much more difficult to catch.

Smallpox is a more vicious killer. "It did not, as was typical for most infectious diseases, preferentially attack the most impoverished members of society," Laurie Garrett wrote in her 1994 book The Coming Plague. "In A.D. 165, the Roman Empire was devastated by an epidemic now believed to have been smallpox. The pestilence raged for fifteen years, claiming victims in all social strata in such high numbers that some parts of the Roman Empire lost 25 to 35 percent of their people. It is believed that the virus struck a completely nonimmune population ..."

Over subsequent centuries, smallpox claimed millions of lives. In 1958, the disease was still killing two million people annually; that year, cases were reported in 33 countries.

A worldwide effort was launched to eradicate the disease, with doctors from the U.S. and the U.S.S.R. joining together in the fight. Consultants for the World Health Organization, including the late Gordon Meiklejohn, onetime chairman of the University of Colorado's department of medicine, fought smallpox outbreaks in Africa from 1968 until 1977, when the last known case was reported in Somalia.

In 1980, the WHO declared that the disease had been eradicated and recommended the discontinuation of smallpox immunization programs.

What that means is, if smallpox were reintroduced, few people would be immune. No one has been vaccinated against smallpox for decades, and those who were vaccinated years ago are long overdue for a booster. Even health-care workers are no longer vaccinated. Vaccines are available but in relatively short supply; at present, there are none in Colorado. As a result, Hoffman explains, our population is vulnerable, in much the same way that the Roman Empire represented "virgin soil" for the disease.

Smallpox's dangerous potential as a weapon was driven home in 1992, when Ken Alibek, first deputy chief of a Soviet state pharmaceutical agency, defected to the U.S. In subsequent debriefings, Alibek outlined details of the U.S.S.R.'s decades-long involvement with biological weapons, including experiments with smallpox, plague and anthrax. Only a microscopic amount of the smallpox virus is needed to infect a human; according to Alibek, the Soviets were under orders to stockpile twenty tons of smallpox virus. And soon after the WHO declared that smallpox had been eradicated, the Soviets reaffirmed their commitment to researching it.

After learning this, American scientists who'd urged the destruction of what they had believed was the last vestige of smallpox in this country -- a legal cache kept at the Centers for Disease Control in Atlanta -- began to rethink their position. Eventually, it was decided to keep the stores of the virus for research and to beef up the nation's store of vaccines. (A second lethal cache is kept in Moscow.) The government is now looking to stockpile forty million doses of the vaccine "just to get us started," says CDC spokeswoman Barbara Reynolds. There are currently fewer than seven million doses now available, according to one unofficial estimate.

Even before Alibek spilled the beans, though, this country was growing increasingly concerned about bioterrorism. In December 1989, hundreds of tropical-disease experts gathered for their annual convention; activities this time included a tabletop exercise in which a virulent and deadly epidemic broke out in war-torn Africa. The scenario was designed to reveal gaps in the public-health response system so that those weaknesses might be eliminated. What the experts learned, however, was that the weaknesses were so pervasive that despite their best efforts, the mythical microbe spread around the world.

The Honolulu exercise spurred a handful of studies regarding the country's readiness to fight biowarfare. The solutions recommended by these studies, skeptics noted, tended to fit the agendas of the people who'd conducted them. Some scientists favored worldwide surveillance and a monitoring network of satellites and laboratories that could track reports of emerging diseases and bioweapons; others recommended a combination of public-health and military preparedness. In 1995, a report submitted to the Senate Permanent Subcommittee on Investigations identified seventeen countries believed to possess biological weapons -- Libya, North Korea, South Korea, Iraq, Taiwan, Syria, Israel, Iran, China, Egypt, Vietnam, Laos, Cuba, Bulgaria, India, South Africa and Russia.

But it wasn't until 1998 that President Bill Clinton began pushing for millions to combat what the administration called the "growing threat" of bioterrorism.

"The Clinton administration, as well as many outside analysts, developed their threat assessments and response strategies in an empirical vacuum," responded scientists with the Chemical and Biological Weapons Nonproliferation Project at the Center for Nonproliferation Studies in Monterey, California. "Lacking solid data, they fell back on worst-case scenarios that may be remote from reality...The tendency of U.S. government officials to exaggerate the threat of chemical and biological terrorism has been reinforced by sensational reporting in the press and an obsessive fascination with catastrophic terrorism in Hollywood films, best-selling books and other mainstays of pop culture."

The Center studied 520 global incidents over the past hundred years involving chemical and biological weapons and determined that 123 people had died in such assaults. The sole death in this country that fit the profile occurred in 1973, when members of the Symbionese Liberation Army used cyanide-tipped bullets to kill a California school superintendent.

The TOPOFF exercise won't involve anything as exotic as Patty Hearst and the Symbionese Liberation Army.

One reason the prospect of biological warfare so worries federal officials is that an attack can be carried out surreptitiously. A terrorist could release an aerosolized virus in the heart of Denver and no one would know about it for days -- until it was much too late. If a terrorist sets off a bomb, emergency crews are immediately dispatched. By contrast, says state epidemiologist Hoffman, the response to a bioterrorist event begins when a doctor phones his local health department, bringing to its attention an odd affliction or a cluster of victims reporting the same type of symptoms.

"It starts as a few drops," Hoffman explains, "then becomes more and more of a downpour." The state laboratory tests specimens or sends them on to another lab. Only after the disease is identified can health officials finally begin dealing with the outbreak. Once biowarfare is confirmed, the national plan is to have vaccines on the ground within twelve hours.

A real incident would call for a long-term commitment of personnel and resources; the TOPOFF exercise will consist of a three-pronged attack over ten days. "A real attack would last much longer than that," Hoffman points out.

Still, in order to deal effectively with biowarfare, local, state and federal health authorities must agree in advance on a scenario for dealing with a disaster. "Awareness and an early-warning network" are integral to being prepared, says Denver Health's Stephen Cantrill. "I know there are federal resources I can call on that might be able to assist us. There are caches of antibiotics that might be available, CDC personnel that we can use, DMAT teams [Disaster Medical Assistance Teams], groups of health-care workers that can be activated and sent to a specific locale." The state health department, for instance, might have to stage mock prophylactic clinics in which to vaccinate large numbers of people. (Hoffman notes that the department was forced to set up real vaccination clinics twice over the past few years to deal with outbreaks of meningitis in local schools.)

"Primarily, we will be doing a command-post type exercise," says Dave Sullivan, deputy director of the Denver Office of Emergency Management. "We'll be looking at the whole system, from local and state all the way to the federal level."

In many ways, though, the city may be better prepared than other parts of the country. "The Denver metro area and the state of Colorado have been out front on a lot of this terrorism and anti-terrorism," says Tommy Grier, director of the Colorado Office of Emergency Management. "The Department of Defense came in here in '95 -- their concern was primarily chemical -- saying we need to look at what the capabilities really are. We've had intensive haz-mat training. We've got chlorine and phosgene rolling through Denver every day -- that's some nasty stuff -- and we have to know how to deal with it in the metro area."

Denver emergency staffers, he says, received special training to deal with such major events as the papal visit in 1993, the Summit of the Eight in 1998, the Oklahoma City bombing trial that same year and the Major League All-Star Game. "Because of the Summit, we were the first city to receive the Nunn-Lugar training," Sullivan points out, adding that the Nunn-Luger-Domenici Domestic Preparedness Training was specifically designed to deal with weapons of mass destruction. "Actually, we've been through it twice," Sullivan says. "The fire, police and paramedic academies have all put pieces of that training in their schools."

In addition, the Denver area is home to a RAID (Rapid Assessment and Initial Detection) team, one of only ten in the country. (The federal government is considering the possibility of placing one such team in every state.) Chris Petty is the deputy commander for the 22-member Colorado team, whose territory includes North and South Dakota, Montana, Wyoming, Utah and Colorado. Its sole job is to assist civilian first responders -- police, firefighters, paramedics -- in dealing with the identification of weapons of mass destruction, which include nuclear, biological and/or chemical agents or contaminants, and their effects.

"We are trained to deal with things that are intentionally designed to kill people," says Petty. "Anthrax, nerve agents, chemical agents, those types of things."

The RAID crew is deployed after paramedics and firefighters "roll to the scene and begin to realize that this is not a normal event, either through symptoms, visible evidence or deaths," Petty adds. "They're going to start requesting additional assistance. They may contact the state office of emergency management, and once it gets to that level, they will come to the Adjutant General of the National Guard, and that request comes straight to us, and we hit the road. We're on a short deployment at all times, on alert status, and it keeps us ready to go."

Once on the scene, the RAID team helps determine the type of agent that has been released, using some of the latest technology. "We have a sophisticated communication capability that takes data from the field from a gas chromatograph mass spectrometer (GCMS), and it takes that data or images and starts sending those in real time over a satellite to experts in D.C.," Petty says. The GCMS breaks down chemical components into parts, comparing them with similar known agents.

The test works for nerve agents, but not biological weapons. For identifying viruses, the RAID team has a handheld re-agent ticket, which changes color depending on the type of agent present. "It's like an early pregnancy test for biological weapons," Petty jokes. "We've got all kinds of special toys. The idea is, because this is such a specialized niche on the high end of the threat spectrum, we can't afford to equip every firefighter."

Nonetheless, eighteen Denver paramedics have already received training in responding to chemical weapon attacks, and federal grants have allowed those paramedics, as well as some firefighters, to purchase "Level B" containment suits that include self-contained breathing apparatus and would allow rescue workers to enter a "warm zone," where the threat of biological contamination is less severe. At present, only the RAID team is equipped with Level A germ-proof suits, which allow them to enter a hot zone where biological agents are present and still potent.

"It's hard to second-guess what the bad guys are going to do because there's such a range available to them," Petty says. A bioterrorist weapon could range from what he describes as a "onesy-twosey device," such as Ted Kaczynski's letter bombs, to the release of a biological agent over a big city.

The TOPOFF exercise is all about "fighting some sexy thing," says Art Davidson, an epidemiologist and director of Denver's public-health informatics program. "But it will help us get ready to deal with devastating diseases as well. That's something we hope will come out of it. And maybe not even for severe events, but to help us with a salmonella outbreak, for example.

"Basically, the government has cut back public-health funding over the last decade or so, and the world has moved ahead," Davidson continues. "Every time there's a victory in public health, when we reduce the occurrence of a disease -- TB or AIDS -- it seems like there's a reduction in funding. And some places have paid dearly for that. In the early '90s, New York was hard hit by multi-drug-resistant TB because the program had been dismantled. Then we have to build up the programs again."

On that point, even Surgeon General David Satcher agrees. "We've got to have the basic health infrastructure, even before we start to worry about bioterrorism," he said last year. "We've allowed our public-health infrastructure to deteriorate." If a bioterrorist attack were to occur, he pointed out, there might not be enough epidemiologists capable of detecting an outbreak, much less enough hospital beds and vaccines for the victims.

Preparing for a bioterrorist attack is "one way to bring back some funding to public health," Davidson says. "Getting the public-health infrastructure up to speed is just as important as getting ready for the next anthrax threat. I don't want to make less of a bioterrorism threat, but I'm looking at it with some optimism -- something positive for public health will come out of it."

Petty takes a much dimmer view. He has no doubt that someday, somewhere, someone will deploy a biological weapon. "Man's never made a weapon that he's failed to use, as far as I know," he says.


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