Abstract
The fear and disruption caused by the 2001 anthrax attacks understandably led Americans to seek enhanced biodefenses. However, the path followed since those attacks has left the country inadequately prepared to face further risks from biological attacks. Why has security against these threats been only partially achieved? This article suggests that our responses over the past decade can be sorted into 4 levels in order of increasing difficulty. First, we rapidly appropriated funds, augmented personnel, and mandated reorganization of agencies. Though not easy to accomplish, these steps were easily conceptualized and, whatever their imperfections, could rather assuredly be achieved. A second level was more demanding, but also quite achievable. It involved the amplification of ongoing efforts. These efforts sometimes suffered as they scaled up, but, though they were qualified by delays and uncertainties, we can point to real achievements at this level. A third level was more difficult: It required evolving new strategies to deal with this largely unprecedented problem. In this regard, we have so far had only glimmers of possibility. At a fourth level, our performance and our prospects are worse still. At this level, our problems stem from resistances inherent in our country's cultural and political framework. This article identifies some of these problems and suggests, regrettably, that they are not likely to be resolved until change is catalyzed by further, and more dramatically traumatic, attacks or natural disasters. If this situational assessment is correct, what remedial strategies should we pursue? The article distinguishes 3 strategic approaches: an evolutionary one in which the U.S. continues advancing along its present path; a radical approach that attempts to address the fourth-level issues; and a third approach that prepares for punctuated evolution. This third approach accepts the improbability of level 4 change either by gradual evolution or by radical argument, but asserts that it is possible to lay the conceptual groundwork now for the radical changes that will be possible, even demanded, after a catastrophic incident. This approach, neglected at present, would be a valuable addition to our present efforts.
Calls for this approach were predictable because the traumas of 9/11 catalyzed our energies and demonstrated the magnitude of modern killing that could be achieved by nonstate actors. The aviation attacks that day are reckoned to have killed some 3,000 people—more Americans than had died in any single event (military, terrorist, or natural) on American soil since the Galveston Hurricane of 1900. The anthrax letter attacks that killed 5 people paled in comparison, but they demonstrated that modern biology could be conscripted to modern killing and that we had few means of detecting and mitigating, much less thwarting, this mode of attack. The first function of government is to provide security. It was natural then that Congress and the President, reflecting the American public, demanded it.
Why then has security against these threats been only very partially achieved? I think that our problems and our progress can usefully be thought of at 4 levels. The deeper we descend through these levels, the greater our difficulties. The first level requires coming to grips with demanding, but relatively straightforward, tasks of funding, augmenting of personnel, and reorganization. The second involves amplifying efforts that are familiar and generally well understood. This is harder, but not too hard. Over the past decade we have been pretty good at it. The third is much more difficult: While operating within the political and cultural framework that now exists, it is to initiate new strategies—not simply to invigorate or expand preexisting approaches. Our achievement at this level should be valued, but our progress is at risk as the catalyzing impact of the anthrax letter attacks wanes and as budgets are cut.
Unfortunately, there is a fourth level that is still more difficult. At this level serious preparation for bioterrorism requires fundamental changes in our cultural and political framework. On these problems we have made little if any progress. I will argue that only the catalyst of a crisis is likely to be sufficient to stimulate the requisite action. Sadly, at this level we are not likely to make further progress until after a major, perhaps catastrophic, attack.
The First Level: Reorganizing and Adding Resources
The first, and perhaps most American, reaction to any problem is to throw money at it. The second is to reorganize. These things can be done rapidly and rather easily, they can be pointed to as demonstrations that those allocating the resources care about the issue, and these “initiatives” can be achieved (albeit not always desirably) without much technical understanding or resolution of substantive issues. Thus, for better and for worse, we have spent some $60 billion on bioterrorism issues over the past decade, 1 formed a Department of Homeland Security (DHS), established a Director of National Intelligence, created a Department of Defense Combatant Command (“Northern Command”) and an Assistant Secretary of Defense for Homeland Security, established a National Biodefense Analysis and Countermeasures Center (NBACC) overseen by DHS, created a Biological Advanced Research and Development Authority (BARDA) as a part of the Department of Health and Human Services (HHS), established a National Biodefense Science Board (NBSB) to advise the Secretary of HHS, and on and on.
Very valuably, under these rubrics, and probably to a greater extent within preexisting organizations (the CIA, the FBI, the Centers for Disease Control and Prevention [CDC], the National Institute of Allergy and Infectious Diseases [NIAID], DARPA, the military services, etc), we have greatly increased the number of experts who focus on biological terrorism and biological warfare. Moreover, though imperfectly, these experts have achieved a measure of consensus and community: Many more people understand these issues and are working to resolve them than in 2001. 2 They are critical assets in reaching stages 2 through 4. And they will be critical assets in future crises.
The Second Level: Adapting and Expanding Preexisting Resources
In January 2003, President George W. Bush used his State of the Union address to announce the development of Biowatch. This was a system intended to alert us to aerosol biological attacks by taking air samples at multiple intervals every day in major cities and routinely analyzing these samples to see if they contained pathogens (smallpox, anthrax, etc) identified as threats. One of the more remarkable achievements of this decade was that a group of bureaucrats and contractors made good on this promise, though most were surprised by and unprepared for the announcement.
In order rapidly to fulfill the President's promise, they understandably turned to what they had in hand. The best in hand was a system developed by Lawrence Livermore and Los Alamos National Laboratories to help defend the 2002 Salt Lake City Olympics. Within a year they met the challenge of scaling this jerry-rigged novelty that had operated for only a few weeks into a standardized system operating round the clock in dozens of cities, with millions of samples. Some gaping deficiencies in the system will be described below. Here it suffices, however, to note that, remarkably, at a budget of $90 million per year, Biowatch provides a likelihood of recognition of urban aerosol attack by the identified pathogens, and it has done this without generating false alarms that would be discrediting and immensely disruptive.
Similarly, over the years since the anthrax letters, officials at BARDA, within other parts of HHS, in the Department of Defense, and elsewhere have ordered and stockpiled drugs and vaccines whose safety and efficacy were already FDA approved. Of particular importance, a National Pharmaceutical Stockpile formed under President Clinton was expanded into a “Strategic National Stockpile” of supplies of antibiotics, vaccines, and other drugs. Under the joint management of the CDC and DHS, expenditures rose from some $20 million per year to some $400 million per year, yielding a stockpile that is substantially larger and more accessible than in 2001.
In parallel with this, existing institutional plans and capabilities were dusted off, emphasized, and exercised, so that major metropolitan areas have better plans for emergency personnel (“first responder”) mobilization, drug distribution, and public communication than previously; clinicians and a supporting laboratory network have a greater likelihood of recognizing biological attacks; hospitals have a greater capacity to treat victims of these attacks; and intelligence, military, and policing agencies have a better chance of recognizing threats and attacks.
The Third Level: New Initiatives
Unfortunately, the adoption and adaptation of preexisting initiatives cannot make this enterprise successful. If we stay at levels 1 and 2, we are doomed to insecurity and, if major attacks occur, catastrophe. This is both because what we had off the shelf was spotty and inadequate and because the proliferation and pace of change of biotechnologies renders the old inadequate to cope with the new. Thus, for all its achievement, Biowatch only samples for identified traditional airborne pathogens. It does not alert us to pathogens transmitted in other ways, pathogens in places where the detectors are not established, or to pathogens different from those it had been programmed to detect. The rise of synthetic biology, the dissemination of sequencers and synthesizers, and the multiplication of those who can use them lead many to conclude that a system that will be useful for the years ahead must detect threatening pathogens that have not been previously identified, and it must do so across a broader spectrum of environments.
Beyond this, an adequate detection system needs to do more things than Biowatch can accomplish. At best Biowatch sounds an alarm. It provides little or no information as to the hour of an attack, its size, its character (other than the species of the pathogen), its concentration, its predominant locale, and so on. A satisfactory detection system must not only alarm, it must provide substantial situational awareness. Some of us can see the outlines of such a system: 3 It would regularly survey human beings instead of aerosol samples, drawing from a base population of emergency room patients, or police or firemen as they come off shifts; it would detect indicative changes in blood or mucus and correlate aberrations with GPS data from cell phones or (in the case of police and firemen) official vehicles so as to permit us to deduce the time and locale at which infection probably occurred.
However, this transition in thinking is challenging to effect. DHS is now investing some $25 million per year into the evolution of a Generation III Biowatch system, but at most the effort will simply make Biowatch faster, more accurate, and a bit broader in the pathogens it surveys. Incremental stage 2 improvement is the natural course, but to be more secure we must get to stage 3. And unfortunately, stage 2 progress often preempts stage 3 possibilities. Particularly as funding environments become more austere, existing programs of record absorb all the resources, existing bureaucracies protect established projects, and new concepts are smothered or starved.
The same observation can be made about our work on vaccines and drugs. We have been able to expand supplies of what we have, but as biological prowess proliferates, we will be unable to confine our requirements to a predictable limited list. DARPA, the Venter Institute, and others have shown methods that may enable us to produce vaccines and drugs much more rapidly than at present (in DARPA's case, 1 to 3 million units of a vaccine within 12 weeks from the appearance of a new virus 4 ). This is immensely useful against naturally occurring pathogens as well as against manmade threats. However, we have a long way to go from proof of concept to managing the policies, capital investments, scaling technologies, and regulatory requirements that are needed for transition to widespread use of these approaches. Sufficiently powerful champions for these efforts have not emerged.
We have an object lesson that demonstrates that new initiatives can be brought to fruition. Detection of the sources of the anthrax letters required a new technology formed from cooperation between experts operating in different institutions both in the federal government and in academia. Under the leadership of the FBI, concepts of what has come to be called “microbial forensics” have been developed and contribute to insights into the genetic markers of biological weapons that contribute to deterrence and detection. The field has developed intellectual capital, acknowledged experts, and institutional homes (notably at the new National Bioforensic Analysis Center, a part of DHS's National Biodefense Analysis and Countermeasures Center).
In sum, not surprisingly, new things can be accomplished when the institutional actors are committed to progress, but this is much harder than resourcing, reorganizing, or incrementally improving the old. Moreover, the new is engaged in an uneven competition with the old, where the established programs have established patrons. The consequences of bioterrorism are too complex and widespread to permit preparation just by doing the old things. New approaches and achievements are necessary. Accomplishing these requires more consistent focus, will, and achievement than we have so far manifested.
The Fourth Level: Fundamental Rethinking
We can, if we achieve near our capabilities, even reach the third level of preparation. Unfortunately, there are yet deeper challenges at level 4. Challenges at this level require not merely embracing the new, but going back and retracing our steps to dismantle cultural and institutional barriers that are deeply embedded in our system. The experience of the past decade indicates that we do not now have the will to do this. Our national history suggests that decisions of this kind require the catalyst of crisis.
Our emergency planning well illustrates this. The response to the anthrax letters a decade ago was a case study in ad hoc achievement. An unusually capable National Security Council staff member saw the need for many agencies (the CDC, the FBI, the Postal Service, etc) that did not normally work together to fashion a coherent response to the unfolding attacks. She convened daily conference calls of federal, state, and local agency representatives, eventually reaching attendance of scores of participants, many of whom had never met one another. The result was a rough coordination capable of coping with a slowly unfolding crisis (the letters arrived over a period of weeks) that then abruptly and inexplicably, but for no reason apparently related to defensive efforts, stopped.
In the decade that ensued, the organization of emergency response has been a priority. Federal entities have been created and first responders have been designated and trained in states and municipalities—initiatives described above. Numerous exercises from TOPOFF (Top Officials) on down have addressed biological attack scenarios. A Federal Response Plan in place in 2001 was replaced by a National Defense Plan in 2004, and that in turn evolved into a National Response Framework promulgated at the start of 2008. A National Incident Management System (NIMS) provides a structure for operational coordination.
Underneath all this effort, however, core issues remain unresolved. Foremost among these is the appropriate role of federal authorities as compared with municipal and state authorities after a biological attack. Our federal system clearly allocates authority for external security to the President and his federal executive branch subordinates (principally through the Secretary of Defense and the Director of National Intelligence). No such clarity exists with respect to transnational threats that ripen into attacks inside the United States. Responses to domestic biological attacks would be particularly complicated, because the required health and environmental measures as well as local policing are squarely in the domains of state and local authorities.
Amidst a patchwork of authorities, our existing systems are built on a premise of local control after a biological attack. This premise is deeply embedded in our federal system. Unfortunately, it is unrealistic. Mayors and other local authorities do not have the expertise, training, or support systems to permit them to fulfill this role under postattack conditions that will be extremely complicated and stressful. Moreover, biological attacks cannot be presumed to be contained within a single jurisdiction. Wind can carry aerosols a hundred kilometers or more; contaminated products, vehicles, and commuters can spread pathogens throughout regions and then the nation; infected individuals may not be recognized before they are widely dispersed. If local officials preside, inconsistent responses can be expected, and these will breed confusion. One aim of terrorism—to reduce faith in the power of our government to protect us—will be amplified, rather than diminished, by our responses.
Our planning does not address this. Rather, it is built on premises of “cooperation” and “coordination,” where the federal government acts in support of local authorities. Some may object that this is not so harmful because in reality the federal government will take over, as it de facto did, for example, after Hurricane Katrina. But this process of saying one thing but intending another is costly. It impedes real planning and thrusts us back into the ad hoc mode of the original anthrax attacks. Moreover, in the event, it creates delay, confusion, and dissension as we saw after Katrina. Katrina was child's play compared to a catastrophic biological attack, much less a series of attacks. Our plans and our lines of command need to be much clearer.
However, our federalist presumptions are so deeply embedded that no leader is likely to come to grips with this issue before a crisis compels us to do so. The problem is compounded by a second, though not so deeply embedded, level 4 issue. That is the need for decisive allocation of command authority among our federal officials. A panoply of statutes, directives, and plans makes the Secretary of the Department of Homeland Security responsible for “coordination” of federal resources. It does not give him or her directive power. That focus and clarity would force a reconfiguration of power relationships among our major bureaucracies. Neither our Presidents and Congress, nor our cabinet members, are willing to wrestle this issue to resolution without the catalyst of catastrophic failure. Unfortunately, as a result, our ship with many captains is not likely to do well under catastrophic conditions.
As a third example of work that apparently can't get done until after it is first needed, I note the spasmodic efforts that have been made at preparing American citizens by educating them about bioterrorism. Even after 9/11 and the anthrax letters, the concept of catastrophic attack remains foreign to American experience, and the American public remains distracted by many much more immediate concerns. The experience of the past decade forces me to conclude that, however well conceived, messages about preparation are unlikely to penetrate the noise of the day-to-day.
Conclusion
How should we respond if, as I have argued, our present path leaves us less robust than we should be in the face of a catastrophic risk? There are, I think, 3 strategic approaches. I will call the first “evolutionary,” the second “radical,” and the third “preparation for punctuated evolution.” None are satisfying alone. Taken together they have their vulnerabilities and faults, but they are compatible and I think offer meaningful improvement.
The evolutionary strategy proceeds as we have been. The inadequacies of this approach do not render it irrelevant. Working at levels 1, 2, and 3, it is valuable, for example, to build pools of experts and stockpiles of drugs, to develop detection systems (however imperfect), and to improve our forensic and other capabilities. But as I have described, this strategy is inadequate. Because it doesn't grapple with level 4 issues, it leaves us dangerously exposed to failure. It simply means that at best we will make that failure less catastrophic.
The second approach would seek a more radical result (though its means are not radical). It would redouble our efforts to catalyze the will to address level 4 issues. This requires education of our leadership and the broader public through soundly premised and realistic exercises, credible analyses of technological risk, and careful intelligence assessment of terrorist and hostile nations' intentions and capabilities to use biological weapons.
I am not optimistic about our success in pursuing this strategy. The experience of the last decade indicates that cultural resistance to fundamental change is too deeply embedded to give way until a crisis catalyzes a tidal wave for change. But this strategy should be pursued. It may be more successful than I expect. And even if it has too little power to catalyze a response by itself, it may raise consciousness of the risk and thereby lower resistance to fundamental change so that we respond more vigorously if, for example, a credible attack is botched or a successful attack occurs abroad.
Between these 2 courses lies a third strategy. To label it, I have borrowed the biologists' concept of “punctuated evolution.” 5 Its premise is that, while in the normal course change is only incremental and evolutionary, an exogenous jolt may create the conditions for radical change. With this scenario in mind, this strategy aims to develop now the conceptual infrastructure for what the American public and its leaders will demand later when their consciousness is raised by crisis. It seeks, in other words, to prepare for punctuated evolution. Or to adopt a metaphor from a more familiar context, if we cannot get our cooks to now prepare a meal, let's at least stock the cupboard so when they are hungry they will have something to cook.
Three examples may illustrate the approach. First, this strategy would assume that we are unlikely in advance of a biological attack to make headway in educating the American public about how best to respond to that attack. But while accepting this limitation, this strategy would invest in improving our capabilities by now conducting research and making decisions about what postattack messages we would want to make available. For example, should movement be encouraged or discouraged? Should citizens be encouraged to vacuum and close or open windows? It will be objected that CDC and others have identified key questions to be addressed in public messages and that advice on recommendations will depend on the precise nature of the pathogen, its patterns and quantities of distribution, and the like. But these facts are not only unknown now—they are likely to be unknown at the time an attack is first recognized, at which point we will need to give advice in a state of ignorance. We ought to have at least a standby template, based on research.
Our standby systems should also include the clear designation of leading experts across a range of relevant disciplines and their integration into teams, so that in the event of a biological attack, relevant senior policymakers would at least know whom to call and they would know each other. Some will assert that memoranda of understanding, exercises, and presidential directives have achieved this—and indeed they have at the working level in many jurisdictions. But real questions in a real crisis—What is the likelihood of reaerosolization? How are food and water supplied in contaminated areas?—will provoke disorganized searches for the best expertise in and outside of government. The designation, organization, and training of experts is a long-lead-time effort that can be undertaken at little cost before an attack makes the need imperative.
Similarly, we can plan better for relationships between authorities, even while accepting that the central premises of federalism and cabinet authority now impede efficient responses. An important step would be to move beyond the generalities of our one-size-fits-all national planning to negotiate a template for federal-local interaction in rich detail with one locality. At least then we would have a model to start from. Beyond this, true preparation would now assess contingent plans and legal authorities in the event this model failed.
Leaders are often praised for the way they respond to crisis. But exceptional leaders respond before a crisis: Their insights and energies form the agenda and the initiatives that affect the shape of things to come. We cannot respond instantly and effectively to bioterrorism. Too many of the things we need take too much preparation. It is the task of leadership to make these investments and develop these tools before they are needed. We are not now sufficiently succeeding by this standard. These strategies suggest paths to improvement. They will not leave us as well protected as we should be, or even as we could be, but they can better position us if the next decade brings attacks that are more frequent and more damaging than the last one.