Excerpted from Unprepared: Global Health in a Time of Emergency by Andrew Lakoff

Disease as a National Security Issue

In the mid-1990s, a group of advocates for renewed biodefense measures began to argue that the United States was dangerously vulnerable to a biological attack. They hypothesized an association among rogue states, terrorist organizations, and the global proliferation of biological weapons. Reports during the 1990s about secret Soviet and Iraqi bioweapons programs, along with the Aum Shinrikyo subway attack in 1995, lent credibility to calls for new biodefense measures focused on the threat of bioterrorism. On the one hand, according to biodefense advocates, the increasing accessibility of biological knowledge and the proliferation of biological weapons made an attack highly plausible. On the other hand, a lack of investment in biodefense measures and the disrepair of the nation’s public health system meant that the United States was woefully unprepared for such an attack.

Prominent among the early biodefense advocates were scientists such as the epidemiologist Donald A. Henderson, who had directed the World Health Organization’s successful smallpox eradication program, as well as national security specialists such as Richard A. Clarke, counter-terrorism adviser under Presidents George H. W. Bush and Bill Clinton. These experts argued that adequate preparation for a biological attack would require a massive infusion of resources into both biomedical research and public health response capacity. More broadly, they maintained, it would be necessary to incorporate the agencies and institutions of the life sciences and public health into the national security establishment. In 1998, Henderson founded the Johns Hopkins Center for Civilian Biodefense Studies, which became a leading center of knowledge production around the new biological threat.

The chief concern among biodefense experts at this point was the possibility of a bioterrorist attack using smallpox virus. On the one hand, recent revelations from Soviet defector Ken Alibek about a vast Soviet bioweapons program raised the question of whether rogue states or terrorist groups might have smallpox stocks in hand. On the other hand, the U.S. population was highly susceptible to a smallpox attack because routine vaccination had ended in 1972 and existing vaccine supplies were limited. Nobel prize–winning biologist Joshua Lederberg, a prominent advocate for greater attention to biodefense, argued that “the most likely source of supply for possible bioterrorists” came from the “laboratories of a hundred countries from the time that smallpox was a common disease.” At a 1999 meeting of government biodefense experts, participants were unanimous that smallpox was the primary biological threat to address—not because of the probability of an attack but because of the virulence and transmissibility of the virus alongside the vulnerability of the population. “The likelihood of an attack is small,” commented Henderson, “but were it to occur it would be a real catastrophe.”

The CDC initiated several programs in response to the perceived threat of a biological attack. Among these was the establishment of the Office of Bioterrorism Preparedness and Response, which provided $40 million per year in bioterrorism preparedness grants to local public health departments. However, critics argued that these measures were not nearly enough. For instance, Tara O’Toole of the Hopkins Biodefense Center pointed to numerous vulnerabilities within the public health and medical response systems, to the absence of essential medical counter-measures to treat select pathogens, and to political decision-makers’ unfamiliarity with infectious disease control and public health practices.

Because they were describing an unprecedented event, biodefense advocates’ claims about the characteristics of the biological threat typically took the form of the conditional—of what would happen in the event of an attack. Henderson described the scenario of an aerosol release of a biological agent such as anthrax as follows: “No one would know until days or weeks later that anyone had been infected (depending on the microbe). Then patients would begin appearing in emergency rooms and physicians’ offices with symptoms of a strange disease that few physicians had ever seen.” But such imaginative projections did not by themselves transmit to government officials the sense of urgency felt by figures such as Henderson and O’Toole to actually implement policies to mitigate what they saw as the nation’s vulnerability to a biological attack.

The threat of bioterrorism had to compete in a crowded terrain of emerging security concerns, each vying to fill in what Senator Sam Nunn called the “threat blank” left by the end of the Cold War. Prospective national security threats in the late 1990s included nuclear proliferation, asymmetric warfare, “netwar,” the Y2K bug, and rising economic powers such as China. There were at least two impediments to convincing policy-makers of the urgency and severity of the biological threat. First, defense strategists were not accustomed to thinking about disease in terms of national security. “We are used to thinking about health problems as naturally occurring problems outside the framework of a malicious actor,” as James Woolsey put it. With disease as a tool of attack, “we are in a world we haven’t ever really been in before.” And second, many security officials were not yet convinced that the threat was credible: a mass biological attack was an event that had never occurred, and its future likelihood was difficult if not impossible to assess.

A major task for biodefense advocates in this period was, then, to convince government officials of the seriousness of the security threat posed by a bioweapons attack. As part of this effort, advocates developed a scenario-based exercise that could serve as a pedagogical tool for public officials charged with thinking about and anticipating security threats. On June 22–23, 2001, the Hopkins Center for Biodefense, in collaboration with Kupperman’s former think tank, the Center for Strategic and International Studies (CSIS), and the ANSER Institute for Homeland Security, held an exercise called “Dark Winter,” which simulated a large-scale smallpox attack on the United States. According to its designers, the aim of the exercise was “to increase awareness of the scope and character of the threat posed by biological weapons among senior national security experts and to catalyze actions that would improve prevention and response strategies.” In other words, the exercise sought to constitute the possibility of a biological attack as a significant national security threat.

Although the Dark Winter exercise inherited much of its structure from its Cold War era precursors, there was at least one significant difference. As opposed to the RAND political exercises of the 1960s, in Dark Winter there was no red team against which the U.S. leaders played: in the case of a bioterrorist attack, there was no rational adversary whose actions would have to be understood and managed in a crisis situation. Whereas the strategizing enemy had been a central actor in the RAND exercises as well as the CSIS crisis simulations of the 1980s, “Nature” was now the only opponent. The central problem for exercise participants had shifted: from anticipating and managing enemy motivations and intentions in a diplomatic crisis to understanding the nation’s internal vulnerabilities to an undeterrable external threat.

The organizers recruited twelve prominent public figures to serve as role players. These were all “accomplished individual(s) who serve or have served in high level government or military positions,” and included eminent national security authority Sam Nunn, former chairman of the Senate Committee on Armed Services and chairman of the Board of Trustees of CSIS, as the president; former presidential adviser David Gergen as national security adviser; and CSIS veteran James Woolsey as director of the CIA. These individuals were chosen both because of their firsthand knowledge of how officials would likely react to the events in question and because their analyses of the lessons of the experience would likely be credible to a wide range of current officials.

The exercise took place in three segments over two days, depicting a time span of two weeks after the initial biological attack. It was held before an audience of more than a hundred observers, including national security analysts and members of the press. Although the scenario’s designers used historical data on the transmission patterns of actual past smallpox outbreaks to structure the exercise, the point of using such data was not so much to accurately model how such an event would unfold as to create a plausible scenario—and specifically, one that had a poor outcome. A critical question in designing the exercise, for example, was the rate of disease transmission assumed. Historically, the rate of smallpox transmission fluctuates widely in relation to multiple contextual factors. To determine the rate to be assumed in the scenario, the exercise designers analyzed thirty-four European outbreaks of smallpox between 1958 and 1973, choosing the case of a 1972 outbreak in Yugoslavia as their model not because its transmission rate was the most likely but because this rate would yield a cascading crisis.

The designers structured the exercise to direct participants’ attention to certain key issues that had been identified by biodefense specialists in advance: the limited number of vaccine doses that would be available in the wake an attack, the need for information systems to track the spread of the disease, and the lack of existing plans for coordinating emergency response among federal and state officials. To shape how events unfolded over the course of the simulation, as in the RAND political exercises, “controllers played the roles of deputies or special assistants, providing briefings of facts and policy options to participants throughout the meeting as needed.”

The first meeting of the National Security Council laid out the situation for participants. There were reports of an outbreak of smallpox in Oklahoma City, assumed to be the result of a terrorist attack. Initial questions for the council were technical: “With only twelve million doses of vaccine available, what is the best strategy to contain the outbreak? Should there be a national or a state vaccination policy? Is ring vaccination or mass immunization the best policy?” The participants found that they did not have enough information about the scale of the attack to come up with a solution, especially given limited vaccine stocks. This sense of uncertainty about appropriate action had been built into the assumptions of the exercise: there was in fact no possible decision that could avert disaster.

By the second meeting of the National Security Council, the situation looked increasingly grim. “Only 1.25 million doses of vaccine remain, and public unrest grows as the vaccine supply dwindles,” participants were informed. “Vaccine distribution efforts vary from state to state, are often chaotic, and lead to violence in some areas” read the transcript. International borders were closed, leading to trade disruption and food shortages. Simulated twenty-four-hour news coverage, periodically shown as video clips to participants, sharply criticized the government’s response to the outbreak. The news clips included graphic images of dying American small-pox victims.

As vaccine stocks were depleted and crowds fought over remaining doses, advisers broached the prospect of using the National Guard to enforce quarantine. But who had the authority to make such a decision? In one exchange among participants, a National Security Council member argued that the president should federalize the National Guard, as states had begun to seal their borders. “That’s not your function,” objected a governor, defending states’ rights. The attorney general responded, “Mr. President, this question got settled at Appomattox. You need to federalize the National Guard.” The president then interjected: “We’re going to have absolute chaos if we start having war between the federal government and the state government.” Thus, the structured improvisation built into the exercise guided participants to formulate the vulnerabilities presented by the threat of a biological attack.

Meanwhile, civil unrest intensified. “With vaccine in short supply, increasingly anxious crowds mob vaccination clinics,” reported the simulated news program. “Riots around a vaccination site in Philadelphia left two dead. At another vaccination site, angry citizens overwhelmed vaccinators.” By the third meeting, there had been hundreds of smallpox deaths, and the situation was growing still worse as the disease continued to spread. The exercise ended as the disaster escalated: there were no doses of smallpox vaccine remaining, and none were expected for at least four weeks. The Director of CSIS, John Hamre, later narrated the final stage of the exercise: “In the last 48 hours there were 14,000 cases. We now have over 1,000 dead, another 5,000 that we expect to be dead within weeks. There are 200 people who died from the vaccination, because there is a small percentage [of risk], and we have administered 12 million doses. . . . At this stage the medical system is overwhelmed completely.”

Realism and Affect

One of the objectives of the exercise was to give political leaders a feeling of how a biological attack would likely play out and how little prepared they were for such an event. Its circle of influence extended outward through a series of briefings that included a “documentary” video portray-ing the simulated outbreak as it unfolded. Vice President Dick Cheney, Homeland Security Secretary Tom Ridge, and key congressional leaders were among those briefed. At a congressional hearing where the video was to be shown, Hamre warned the committee chairman: “It is not pleasant. Let me also emphasize, sir, this is a simulation. This had frightening qualities of being real, as a matter of fact too real.” After watching the video, the chairman described his reaction: “I felt like I’ve been in the middle of a movie, and maybe that’s why I was anxious. I wanted to know how it turned out. And so I asked my staff how did we finally get a handle on it, you know, 12 million vaccines out, the disease spreading? And the response was we did not get a handle on it.” Again, the dire outcome was built into the exercise design, given the designers’ assumptions about the scale of the attack, the disease transmission rate, and the lack of available vaccine stocks.

In their congressional testimony on the need for improved bioterrorism preparedness, Dark Winter participants reported on their own experience of the exercise. Sam Nunn reflected on the problem of how to enforce quarantine given the absence of effective treatments: “It is a terrible dilemma. Because you know that your vaccine is going to give out, and you know the only other strategy is isolation, but you don’t know who to isolate. That is the horror of this situation.” The event also revealed critical political vulnerabilities. As Hamre testified, “We thought that we were going to be spending our time with the mechanisms of government. We ended up spending our time saying, how do we save democracy in America? Because it is that serious, and it is that big.” Governor Frank Keating of Oklahoma was stunned at the lack of preparedness demonstrated by the exercise: “We think an enemy of the United States could attack us with smallpox or with anthrax . . . and we really don’t prepare for it, we have no vaccines for it—that’s astonishing.” Dark Winter was successful in that it convinced participants and later briefing audiences of the urgent need for advanced planning to be able to effectively govern in the event of a biological emergency.

The exercise imparted detailed knowledge about existing vulnerabilities in response capacity. First, officials did not have real-time “situational awareness” of the various aspects of the crisis while it unfolded: as the exercise designers wrote, “few systems exist that can provide a rapid fl ow of the medical and public health information needed in a public health emergency.” Second, without available stockpiles of medical counter-measures, emergency responders could not properly manage the crisis. And third, the exercise demonstrated the wide gulf between public health and national security expertise: “It isn’t just [a matter of] buying more vaccine,” said Woolsey. “It’s a question of how we integrate these public health and national security communities in ways that allow us to deal with various facets of the problem.”

In their testimony, participants pointed toward policy measures that would address these lacunae. Nunn argued that first responders must be vaccinated against smallpox well in advance of an attack: “Every one of those people you are trying to mobilize is going to have to be vaccinated. You can’t expect them to go in there and expose themselves and their family to smallpox or any other deadly disease without vaccinations.” Hauer, a former New York City emergency manager, spoke of the need to address the problem of rapid vaccine distribution in an urban context: “The logistical infrastructure necessary to vaccinate the people of New York City, Los Angeles, Chicago is just—would be mind-boggling.”

But the broader lesson of Dark Winter was the need to imaginatively enact a future biological attack to be able to adequately plan for it in the present. As Hamre said, “We didn’t have the strategy at the table on how to deal with this, because we have never thought our way through it before, and systematically thinking our way through this kind of a crisis is now going to become a key imperative. It clearly is going to require many more exercises.” And indeed, among the initiatives funded during the rapid increase in federal support for civilian biodefense of the early 2000s was a nationwide program of public health preparedness exercises, designed and run by the RAND Corporation under contract from the CDC.