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PUBLIC HEALTH PREPAREDNESS

dangers lurk in unanswered quandaries and in disconnects among a hectic
potpourri of activity. And to repeat a constant refrain: worldwide, prepared-
ness measures are dismally ill-prepared to meet even limited expectations.


PREPAREDNESS VS. COMPLICATION “ THE FALSE DEBATE

Preparedness measures operate differently than the complication mea-
sures earlier discussed. Complication measures focus on the perpetrator:
there should be thorny obstacles to his attempts to carry out his malevo-
lent plans, and law enforcers should have optimal tools to interdict him.
Preparedness measures focus on the victims: we want to reduce their expo-
sure and limit harm. Complication measures are primarily the concern of
law enforcement; preparedness measures are primarily the concern of
medical and health care communities.
Ideally, preparedness, resistance, and complication measures should
be mutually reinforcing. Vaccinations and rapid response preparations
can diminish some pathogens™ utility for bioviolence, which would force
perpetrators to choose other agents that might be harder to deploy or
covertly prepare; law enforcers would be able to concentrate on fewer
attack varieties. After an attack, preparedness measures can abet coordi-
nation between health care providers and law enforcers to mitigate harm
and maintain order.
Yet, some public health proponents, focusing on natural diseases™ real
horrors, argue that scarce resources should be devoted exclusively to dis-
tributing medicines and to installing early warning surveillance. Resources
should not be diverted to strengthening law enforcement efforts to stop
bio-offenders. In this argument, the alternatives are zero-sum “ a dollar
spent for police is a dollar less for public health. This would be an unwise
trade-off because the risks of bioviolence are lower than the risks of nat-
ural disease, especially in developing regions. After all, bioviolence™s his-
torical toll is negligible, but natural disease kills millions yearly, and many
casualties could be avoided with even a modicum of resources. Says the
Commission on Macroeconomics and Health: for additional annual health
outlays of $57 billion by 2007 and $94 billion by 2015, approximately 330
million disability-adjusted life years (DALYs “ one disability-adjusted year
is de¬ned as the loss of one year of healthy life to disease) could be saved
for every eight million deaths prevented, generating economic bene¬ts of
$186 billion per year as of 2015.1
If bioviolence occurs, continues the argument, enhanced public health
capacities would be useful; even if bioviolence never happens, these
162 BIOVIOLENCE: PREVENTING BIOLOGICAL TERROR AND CRIME

capacities will bene¬cially mitigate natural disease outbreaks. In sharp
contrast, law enforcement measures to impede, disable, or interdict biovi-
olence preparations will have no signi¬cant impact against natural epi-
demics and therefore will have scant value if bioviolence threats never
materialize. Unlike public health measures that are worthwhile for multi-
ple purposes, denial and interdiction measures can never be completely
effective. They would likely produce bloated legal bureaucracies that
deprive on-the-ground public health providers of what they need to save
lives now and tomorrow regardless whether bioviolence ever occurs.
No one should disagree that global disease ¬ghting capabilities must
be improved, whether against disease that is natural or human-in¬‚icted.
Here is a dual-use opportunity. Devoting resources to strengthen medi-
cal response and health interventions will save lives from the inevitable
onslaught of natural disease and, if bioviolence happens, such prepared-
ness will limit the damage. In the face of dreadful emerging disease threats,
there is every reason to promote preparedness measures “ if the rationale
for increasing public health budgets is portrayed as preparedness against
bioviolence, so be it.
There is yet another argument for preparedness measures: they do not
entail profound changes in international law and governance. Complica-
tion measures require global harmonization of laws, bureaucratic struc-
tures, and police capabilities; compliance mechanisms must be emplaced.
If those structures and mechanisms are inconsistent, bio-offenders can
exploit the weakest link. Preparedness measures, by contrast, can be ben-
e¬cial at the national or local level. A community that chooses to protect
itself from disease by investing more resources in public health will realize
bene¬ts even if other communities make different choices. Globalization
of preparedness measures is hardly irrelevant, but compared to complica-
tion measures there is much less need to substantially recon¬gure gover-
nance systems.
It is not surprising, therefore, that the U.S. government views biovi-
olence as a subset of disease threats generally, eliciting consistent dis-
ease surveillance and response efforts. By so characterizing bioviolence
threats, U.S. policy devotes billions to drug development and local pre-
paredness while sidestepping international legal commitments to harmo-
nize standards for denying access to lethal pathogens or to enhance global
law enforcement. From the Bush administration™s perspective, there is a
convenient convergence of policy agendas that call for strengthening the
domestic population™s preparedness yet eschew diplomacy to strengthen
international law and institutions.
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PUBLIC HEALTH PREPAREDNESS

Yet, can preparedness measures, even if substantially upgraded, keep
us safe from human malevolence? The argument against looking at biovi-
olence as predominantly a problem of disease containment is that inten-
tionally in¬‚icted disease differs from natural disease precisely because the
bio-offender has strategic agility. The attacker can choose where to pierce
society™s preparedness, even pierce it repeatedly. Government of¬cials per-
sistently assert that they can predict risks and adequately protect us, but
it is preposterously na¨ve to suppose that a bio-offender will cooperate by
±
choosing a disease that is readily responsive to medical counter-measures
and attack where public health is prepared to respond. In connection
with bioviolence, the attacker holds the advantage because it is easier and
cheaper to create new ways to commit an attack than to develop and ¬eld
defenses.2
Certainly, preparedness measures have value. There are effective vac-
cines for some diseases that are easily spread and devastating; of course
we should stockpile such vaccines for rapid distribution. For example,
there should be smallpox vaccine aplenty. Smallpox would be an imper-
iling bioviolence threat against unvaccinated populations but will cause
only limited harm to a vaccinated population. Precluding a smallpox pan-
demic by preparing to mitigate vulnerability makes obvious sense.
If there were only a few bioviolence agents and effective immunities or
antidotes against each of them, then preparedness measures might suf-
¬ce. But there are innumerable bioviolence threats; full-spectrum immu-
nization against many of them would likely kill the people we are trying
to protect. Moreover, emerging bioscience increasingly enables scientists
to bioengineer around even the best defenses, opening vast risks of mis-
use with ever easier ways to target victims. Given the range of available
agents, the agent-speci¬c nature of most defenses, the long time needed
to develop new vaccines, and how easily an attacker can achieve surprise,
protecting large populations against numerous threat agents is a daunt-
ingly expensive undertaking that might readily be eluded. Simply stated,
preparedness measures have substantial bene¬ts, but without compre-
hensive denial and interdiction policies they are a Maginot Line: unre-
liable for containing the suffering, loss, and ensuing panic ignited by a
well-designed bioattack.
It is imperative to view complication measures and preparedness mea-
sures as complementary “ each makes the other stronger. Asserting that
resource allocation choices are zero-sum perpetuates a false debate that
distracts pursuits of bene¬cial synergies and makes adversaries out of
potential partners. It is possible and productive to sustain two parallel
164 BIOVIOLENCE: PREVENTING BIOLOGICAL TERROR AND CRIME

agendas simultaneously. The vital question, therefore, is how to impel
systems for integrating promotion of public health with making bioscience
more secure and strengthening law enforcement.
The remaining sections of this chapter discuss how to harden targets
so that conducting attacks is more dif¬cult, how to encourage prompt and
effective medical response measures, and how to maintain social order in
the face of a bioattack.


HARDENING TARGETS

Bioviolence attacks (other than agroviolence) will likely take place in con-
¬ned spaces: buildings, airplanes, subways, or sports arenas. Making it
harder to penetrate these targets is therefore a preparedness priority. Of
course, enhancing building security generally “ positioning trained guards
and security cameras at entry points and in front of sensitive areas “ is use-
ful whether the threat is explosives, chemicals, or something else. This sec-
tion, however, focuses on two types of measures that are uniquely appro-
priate for preventing bioviolence. First, there are ways to make it harder to
circulate pathogens through air (and less so, water). Entry points for cir-
culation systems can be locked and guarded; ¬lters can collect pathogens.
Second, sensors for identifying undue concentrations of pathogens can
enable rapid and accurate response. Sensors cannot stop an attack from
happening, but they might help mitigate its consequences.
Unfortunately, all these guards, ¬lters, and sensors are porous. There
are essentially an in¬nite number of targets, but which targets should be
protected? Major transportation hubs including airports and central train
stations likely top the list, followed by parliaments, major entertainment
venues, and large (and symbolically signi¬cant) of¬ce towers. Yet, as most
targets will not be adequately protected, it must be asked whether pro-
tecting any target makes sense. If an offender can pass one building and
immediately go to another, protecting the ¬rst but not the second is a strat-
egy of questionable value. Hardening targets is an excellent proposition
in theory, but doing it worldwide is daunting. Even a very selective list of
high-priority sites would number in the thousands.
Moreover, while some pedestrian devices make obvious sense (e.g.,
putting locks on access points to air ¬ltration systems), more cutting-edge
technologies should be met with a healthy dose of skepticism. Much money
is being spent on sensors, but like vaccines they tend to be pathogen-
speci¬c and evadable. As to all these technologies, dif¬cult questions arise:
are the bene¬ts worth the costs? If so, how can those bene¬ts be fairly
distributed worldwide?
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PUBLIC HEALTH PREPAREDNESS


Protecting Air Circulation Systems
Air ¬lters can be installed in heating, ventilation, and air-conditioning
(HVAC) mechanisms to capture and remove aerosolized agents, but it is
not easy or cheap to retro¬t facilities. Moreover, various ¬lters work differ-
ently against many potential agents. Depending on the agent and how it is
weaponized, it might be too small to be caught within a ¬lter. Most effective
are HEPA (high-ef¬ciency particulate air) ¬lters that provide ef¬ciencies
greater than 99.99 percent for their particulate size range.3 Yet, because
of the wide range of buildings and HVAC systems, no single off-the-shelf
¬lter can be installed in all buildings to protect against all agents. Some
system components have multiple and ¬‚exible applications, but they work
best if custom designed for a speci¬c building.4 Filters used in con¬ned
spaces could have great utility especially in high-pro¬le targets such as
parliament buildings. However, ¬ltering air in open areas such as airports
would be extremely costly, and it is uncertain if they would protect against
various attack agents. Moreover, determining which ¬lters to use and how
to use them might differ due to regional variations in building construction
or climate conditions.
There are recent reports that air ¬ltration technology is improving.5
Globally viewed, however, it would be overwhelming to retro¬t airports,
train stations, government buildings and entertainment venues with effec-
tive air ¬lters and maintain them to work at high ef¬ciency. All these con-
siderations do not negate the value of using air ¬ltration systems in prime
sites or suggest that the technology is defective (see Box 7-1 for guidelines
on installing air circulation ¬lters). Over time, new construction codes
can be envisioned that would incorporate these systems. For the fore-
seeable future, however, it is questionable whether the high cost of ¬lter
research and development has bene¬ts that are comparable to traditional
law enforcement interdiction techniques and medical response measures.


Protecting Water Supplies
Widespread bioattacks against water supplies are more dif¬cult to do suc-
cessfully than aerosol attacks. An attack would have to be well-planned
to put enough agent into water supplies and circumvent ¬ltration sys-
tems in order to sicken large populations. Some experts assert, however,
that even in the United States there are serious weaknesses in protect-
ing water distribution systems from a bioattack; better security measures
such as installing cameras, sensors, or guards are necessary.6 Moreover,
water-quality testing methods for detecting intentional contamination,
166 BIOVIOLENCE: PREVENTING BIOLOGICAL TERROR AND CRIME


BOX 7-1. CON S I DERATION S FOR I N STALLATION OF AI R CI RCU LATION
FI LTERS

The National Institute for Occupational Safety and Health (NIOSH) has identi¬ed the
following “important questions” concerning installation of ¬ltration systems:
r How are the ¬lters held in place and sealed? Do the ¬lter frames provide for an
airtight, leakproof seal?
r What types of air contaminants are of concern? Are the air contaminants particulate,
gaseous, or both? How toxic are they?
r How might the agents enter the building? Are they likely to be released internally
or externally, and how can various release scenarios best be addressed?
r What is needed? Are ¬lters or sorbents needed to provide protection in an acci-
dental or intentional release or from a potential terrorist attack using CBR agents?
r How clean does the air need to be for the occupants, and how much can be spent
to achieve that desired level of air cleanliness? What are the total costs and bene¬ts
associated with the various levels of ¬ltration?
r What are the current system capacities (fans, space for ¬lters, etc.) and what is
desired? What are the minimum air¬‚ow needs for the building?
r Who will maintain these systems and what are their capabilities?

SOURCE: Guidance for Protecting Building Environments from Airborne Chemical, Biological, and
Radiological Attacks, NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH (April 2003).



although improving throughout developed nations, would probably fail
to detect a bioattack until changes in disease trends and illness patterns
are noticed. Far more severe consequences can be expected if pathogens
are disseminated through water systems in developing areas where over-
crowded populations rely on water that is inadequately cleansed of
microbes. Even without the threat of bioviolence, there is a compelling
case for improving drinking water supplies worldwide. The vulnerabil-
ity of sizeable populations to bioviolence via water contamination only
heightens the urgency of this priority.


Sensors
Accurate sensors, especially in enclosed spaces, could be helpful if inserted
into air circulation systems. Sensors could detect the presence of inten-
tionally disseminated agents before they are widely inhaled. Such devices
are being developed for airplanes to enable early detection of pathogens;
in that case, the plane could land and passengers given immediate
medical treatment. In of¬ce buildings or subways, evacuation alarms
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PUBLIC HEALTH PREPAREDNESS

could be sounded. High-intensity, pulsated Advanced UV Source (AUVS)
sensors are being developed that rapidly sense and then destroy biological
agents. They can be placed in air ducts to eliminate biological agents or
be used to purify water, but they are expensive.7

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