Robert M. Gould

The Pitfalls of Bioterrorism Preparedness: the Anthrax and Smallpox Experiences

Bioterrorism preparedness programs have contributed to death, illness, and waste of public health resources without evidence of benefit. Several deaths and many serious illnesses have resulted from the smallpox vaccination program; yet there is no clear evidence that a threat of smallpox exposure ever existed. The anthrax spores released in 2001 have been linked to secret US military laboratories-the resultant illnesses and deaths might not have occurred if those laboratories were not in operation. The present expansion of bioterrorism preparedness programs will continue to squander health resources, increase the dangers of accidental or purposeful release of dangerous pathogens, and further undermine efforts to enforce international treaties to ban biological and chemical weapons. The public health community should acknowledge the substantial harm that bioterrorism preparedness has already caused and develop mechanisms to increase our public health resources and to allocate them to address the worlds real health needs.

COHEN ET AL. RESPOND TO RUMM

We have never been “dismissive” of the potential threats posed by biological, chemical, or nuclear weapons. On the contrary, we have worked over many years to prevent the use of these weapons by nation states (usually termed “war”) or by individuals or groups (often termed “terrorism”). As we stated in our commentary, “war, poverty, environmental degradation, and misallocation of resources are the greatest root causes of worldwide mortality and morbidity, as well as ultimately being the underlying causes of terrorism itself.” It is our view that a “war on terrorism” is a dysfunctional way to prevent terrorism and the use of these weapons. With regard to “terrorism preparedness,“ our evidence that current funding is an “empty promise” is given in our commentary. We cited reports that state and local funding cuts and unfunded federal mandates like the smallpox campaign have undercut or outweighed increases in federal spending,1,2 and others have expressed concern about this.3 Centralized data have not been collected, but local reports are consistent. For example, a Virginia health district director reported that 2 new positions were created with federal funds but the mandated activities required the effort of at least 4 full-time employees, so that resources had to be diverted from school health, communicable disease, and environmental health programs (S. Allan, MD, JD, MPH, oral communication, October 18, 2004). A study of California public health programs reported “substantial evidence that reassignments of staff to accomplish preparedness functions, as well as cuts to public health budgets at a county level that have resulted from the current fiscal pressures are compromising other public health functions. Multiple examples of retrenchments in essential programs (such as sexually transmitted disease and tuberculosis contact tracing or teen pregnancy prevention programs) were provided during key informant interviews.”4(p7) Furthermore, some bioterrorism preparedness programs may do more harm than good. The proliferation of laboratories studying bioterrorism agents such as anthrax increases the risk of accidental releases5 as well as deliberate releases, such as the 2001 dissemination of militarized anthrax spores linked to US military research.6 Bioterrorism preparedness programs have turned public health priorities upside down. Huge resources were expended to produce and distribute smallpox vaccine and conduct the failed campaign to inoculate 500 000 health workers without evidence of imminent risk of exposure to a disease eradicated from the ecosphere more than 20 years ago.7 Contrast this with the most recent shortage of influenza vaccine. The government was oblivious to warnings of the impending crisis8 despite serious problems in 3 of the previous 4 flu seasons.9 The lack of attention to and resources for public education about flu and for manufacturing and distribution of the vaccine represented public health negligence in the face of an estimated 36 000 flu-related deaths in the United States every year. Rumm suggests that bioterrorism programs can be adapted to address critical public health needs. Instead, let’s get our priorities straight and address the issues that cause the preponderance of morbidity and mortality in the United States and the world: endemic and epidemic disease, environmental and industrial hazards, and lack of clean water, nutrition, housing, sanitation and preventive medicine. A public health system equipped for these major challenges will be able to handle the unlikely event of a major bioterrorism incident.

GOULD ET AL. RESPOND TO AMADIO

We certainly share Amadio’s view that public health has been underfunded for decades. We believe this situation is attributable in part to our nation’s propensity for prioritizing colossal military budgets over vital domestic and global public and environmental health programs. Consider, for example, the possibilities denied public health by the United States’ expenditure of approximately

SIDEL ET AL. RESPOND

5.5 trillion (in constant 1996 dollars) for nuclear weapons programs from 1940 through the late 1990s.1 We also agree that bioterrorism preparedness funding “is some of the first real new money that has come to public health in many years.” However, the impact of such appropriations, useful though they may be for limited improvements in communications and disease surveillance capacity, has been often constrained by strict restriction of their use to bioterrorism preparedness programs. These restrictions have left public health without adequate resources to meet fundamental needs. At the same time, public health has been stretched to the breaking point by ill-considered, dangerous programs such as the smallpox vaccination campaign, conducted in a climate of widespread state and local funding cuts.2 Reports heard at the 2004 annual meeting of the American Public Health Association3 and communications we have received from grassroots public health practitioners since our article appeared support this view. The reality of the current crisis in public health underscores the deficiencies of a bioterrorism-oriented public health model, compared with a model oriented toward prophylaxis and primary prevention of all forms of emerging and reemerging infectious diseases. The latter model could provide surge capacity to deal with new challenges4; for example, it could ensure an adequate annual supply of influenza vaccine. Improved communication among public health and other agencies is useful, but we must strictly avoid breaches of privacy based on mere suspicion of bioterrorism.5 A full evaluation of bioterrorism preparedness programs must weigh the putative benefits against the risks and adverse impacts of these programs, which Amadio does not mention. We would hope that any program oriented toward prevention of all potential biological threats would be comprehensive in scope and would address as a public health priority the potential threats posed by new developments in the biological sciences.6 A strong demand by public health leaders for development of the strongest and most stringent inspection and verification protocols for the Biological Weapons Convention, safeguards now spurned by the US government, would be a welcome change from the silence on this issue currently emanating from the Centers for Disease Control and Prevention. In this vein, all putative biodefense research programs must be made transparent and all potentially offensive programs halted as a bulwark against setting off a biological arms race that will seriously challenge any attempts at secondary or tertiary prevention.7,8 Thoughtful anticipation of future threats predicted to arise from global climate change9 should challenge us to move beyond heightened surveillance and vector eradication programs of the sort employed against West Nile virus to prevention strategies linked to the promotion of sustainable and renewable sources of energy.10

Bioterrorism initiatives: public health in reverse?

We are grateful to Dowling and Lipton for their letter and to the Journal for providing an opportunity to continue this important discussion. Dowling and Lipton provide additional data that underscore the absurdly distorted priorities of bioterrorism preparedness spending relative to spending for real public health needs in the United States. Outside the United States, the United Nations has estimated that about US

Good intentions and the road to bioterrorism preparedness.

10 billion invested annually in safe water supplies could reduce by one third the 4 billion annual cases of diarrhea that result in 2.2 million deaths.1 Bioterrorism preparedness spending thus diverts resources not only from US public health needs but also from urgent international public health work. In addition, overstated concern with bioterrorism has led to a climate of fear that is inimical to public health and that incites constraints on civil rights and human rights. The Model State Emergency Health Powers Act, elements of which had been adopted by states, and the USA Patriot Act and the Homeland Security Act, which have been adopted by the US Congress, are examples of such constraints.2,3 The potential for misuse and abuse of emergency powers is great in a climate in which even a rumor of a bioterrorist threat can evoke panic.4 The overall climate of fear to which an exaggerated fear of bioterrorism contributes has led to domestic and foreign policies that are antihealth, such as the disastrous “preemptive” war in Iraq that has killed and injured many military personnel and civilians and has diverted funds from health, education, and social services. The now discredited campaign for the war on Iraq followed a well-known pattern. Nazi leader Herman Goering, interviewed during the Nuremberg Trial in 1945, said, “The people can always be brought to the bidding of the leaders. That is easy. All you have to do is to tell them they are being attacked, and denounce the pacifists for lack of patriotism and exposing the country to danger. It works the same in any country.”5(pp278–279) While it may be hard to convince the people of the United States that fears of bioterrorism are being overstated for political reasons and that the health of the people of the United States and the world requires action for peace and justice and the denunciation of war, this is nonetheless an urgent priority for public health workers.6