Organizational Responses to Two Biological Weapons Events

Jeanne Guillemin MIT Security Studies Program

Thomas Schelling, Foreward to R. Wohlstetter Pearl Harbor. Warning and Decision, 1962.

Surprise, when it happens to a government, is likely to be a complicated, diffuse, bureaucratic thing…The danger is not that we shall read the signals and indicators with too little skill; the danger is in a poverty of expectations—a routine obsession with a few dangers that may be familiar rather than likely.

The 1979 Sverdlovsk Anthrax Epidemic

March 1980-The US accuses the Soviet Union of violating the 1972 Biological Weapons Convention

September 1988-Soviet public health officials give the US State Department a report describing an anthrax epidemic in Sverdlovsk caused by a breakdown in government meat inspection

June 1992-US academic team travels to Sverdlovsk (Ekaterinburg) to investigate cause of epidemic

Establishing Valid Cases

• KGB list of 64 victims’ names and addresses• Interviews with families/neighbors of 56 victims• Cemetery data • Autopsy tissue data• Hospital records (5 survivors)• Local hospital and factory clinic lists• Veterinary documents/animal deaths

Anna KominaCeramics factoryworker, age 54;resident of affected district

Date of onset of symptoms: April 4,1979Date of death: April 10

1993.Interior of pipe shop of abandoned ceramics factory. Large, third-story windows on left face northwest.

1993. Gate of Compound 19 military base,Ekaterinburg. Soldier is allowing truck to enter.

Sverdlovsk, c.1985Red dots=NighttimeLocations of victims. Addresses obtained fromKGB and other lists. Southern cluster is in Chkalovsky rayon. Arrows=homes off map.

Chkalovsky District Only(note inset of entire city)

Irregular white lines showCompounds 19 and 32.

White rectangle indicatesceramics factory.

Red dots=daytime locations of62 victims, including11 survivors.

Six villages southeast ofSverdlovsk where 1979 epizootic occurred. Public health measuresApril through May. Interviews conducted atF, Abramovo, confirmedVeterinary documents.

Ask No Questions: Soviet Public Health Response, Sverdlovsk 1979

• Urban: quick lab diagnosis, screening at clinic level, central hospital ID intensive care, pediatric unit, emergency ambulance transport, autopsy team; 4000 “volunteers” for screening, home disinfection, and distribution of antibiotics; Moscow clinical team on site, vaccine campaign for 50,000; buildings washed, fliers and radio.

• Rural: roadblocks, carcasses burnt, enforced human vaccinations, animal sheds destroyed, 3-week village quarantine.

Diagnosis 9 days postApril 2 exposure

Total 21 deaths

Moscow doctorsApril 12 arrival.Total 25 deaths

17 victims die with nohospital care

City clean-up begun.30,000 vaccinated. April 16,Total 42 deaths

Last recorded deathMay 16.Total 66 valid cases11 survivors

Sverdlovsk Research Findings

• Accidental military aerosol emission on April 2 caused 1979 anthrax epidemic that killed an estimated 68 people

• First evidence of prolonged incubation in human inhalational anthrax (max. 43 days)

• Virulence of anthrax 50 kilometers from source established by animal deaths

• No children or young people apparently affected by anthrax aerosol

• Dose response: as few as 9 spores per individual calculated (Science 1994 and ASA Newsletter 1999, 2001)

2001 US Postal Anthrax Attacks

• Multiple locations: New York, Florida, New Jersey, Washington, DC, Connecticut

• Delayed diagnosis (cutaneous and inhalational) New York and New Jersey

• Delayed diagnosis (inhalational) New Jersey and Washington, DC

• Mystery cases: New York (Oct.25) and Connecticut (Nov.14)

First Known Letters-NBC and NY Post, 9/18/01 Postmark

Onset/Age/Sex Date/DX Outcome

September 22 (NY Post)/31/F October 19/C Alive

September 25 (NBC)/38/F October 12 /C Alive

September 26 (USPS-NJ)/39/M October 18/C? Alive

September 28 (AMI)/73M October 15/I Alive

September 28 (USPS-NJ)/45/F October 18/C Alive

September 29 (ABC)/6mos/M October 15/C Alive

September 30 (AMI)/63/M October 4/I Dead (Oct.5)

October 1 (CBS)/27/F October 18/C Alive

Second Known Letters (Daschle and Leahy)October 9, 2001

Onset/Age/Sex Date/DX Outcome

October 14 (USPS-NJ)/35/M October 19/C Alive October 14 (USPS-NJ)/56/F October 28/I Alive October 15 (USPS-NJ)/43/F October 29/I Alive October 16 (USPS-DC)/56/M October 21/I Alive  October 16 (USPS-DC)/55/M October 23/I Dead October 16 (USPS-DC)/47/M October 26/I Dead October 17 (USPS-NJ)/51/F October 29/C Alive October 19 (NY Post)/34/M October 22/C Alive October 22 (FedMail)/59/M October 25/I Alive  October 23 (NY Post)/38/M October 28/C Alive

Evidence of Envelope Leakage and Anthrax Dispersal/Chronicle of Events

October 12 NY cutaneous case and ? of unopened letter

October 15 (Monday) Daschle letter dispersion underestimated

October 16 (Tuesday) “err on the side of caution” at Hart, antibiotics distributed; House offices buildings close

October 17 (Wednesday) Anthrax at Dirksen SOB; Senate buildings closed

October 18 (Thursday) NJ cutaneous case; Brentwood environmental tests positive

October 19 (Friday) NJ exposure and cutaneous case cause shutdown; Mr. Richmond diagnosed with inhalational anthrax at night.

October 20 (Saturday) 2nd Brentwood worker hospitalized

October 21 (Sunday) Richmond test results; Mr. Morris dies. Brentwood closed in afternoon and antibiotics made available

October 22 (Monday) Mr. Curseen dies; Gov. Ridge press conference

Anthrax as a Disease: The Public Health Model

Consequence: CDC focuses on (outdoor) soil contamination as cause of index case

Consequence: CDC misses DRES report.Consequence: CDC relies on low-risk exposure

model for industrial settingConsequence: Post Office fails to warn workersConsequence: erroneous dose response “threshold” Consequence: institutional memory loss when US

veteran anthrax experts left out

Anthrax as a Weapon: Federal Crime and Terrorism Models

• Consequence: FBI shuts Florida and New York sites as crime scenes (CDC excluded)

• Consequence: Classified DRES and Patrick Reports on dispersal not forwarded to CDC

• Consequence: US BW veterans left out• Consequence: confused public communication

concerning risk of anthrax material (strain, source, and weaponized dispersal) and perpetrator

Conclusions

1.Weapon models and public health models should inform each other

2. Government secrecy obstructs public health response and delays diagnosis

3. Public trust is lost without credible and complete risk information