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18 Dec 2002

Source: Editorial. The Lancet 358(9290), October 20, 2001. 

Two years ago DA Henderson, director of the Johns Hopkins Center for Civilian Biodefense Studies, wrote in The Lancet's end-of-year supplement about anthrax and smallpox as "weapons of the future". He concluded that "to counter these weapons will require a most unwelcome diversion of resources and concern, but we ignore them at our peril". Henderson, who has recently been appointed chairman of an advisory council on bioterrorism by the US Secretary of Health and Human Services, Tommy Thompson, has been tirelessly campaigning for a more transparent and a more efficient public-health system to be prepared for such future threats. But few politicians in the world were prepared to admit the real possibility of bioterrorism attacks, despite knowing about Russia's massive Biopreparat programme chillingly described in Laurie Garret's book Betrayal of Trust. This complacent attitude was to change after Sep 11, 2001.

Then on Oct 5, Robert Stevens, a photo editor at a supermarket tabloid published by American Media Inc. in Boca Raton, Florida, died from inhalational anthrax, alarm bells started ringing. And yet, the initial reaction was -- as seen so often in recent months--one of false reassurance. On the day the diagnosis was confirmed, Tommy Thompson announced that this case appeared to be an isolated instance and that Mr Stevens might have contracted the disease while drinking from a stream. A very improbable explanation for the inhalational form of anthrax.

The US public-health response to this case was reasonably quick, not least because of the rapid recognition by Larry Bush, an infectious diseases specialist at the JFK Medical Center in Atlantis, where Stevens was admitted. But despite this case of vigilant surveillance the ensuing coordination, and above all the communication with the public, left much to be desired. As The Lancet goes to press, seven more people have been diagnosed as contaminated in Florida, one person employed by the National Broadcasting Corporation in New York has contracted cutaneous anthrax and three people involved in the investigation have been contaminated. A substance sent to a Microsoft subsidiary in Reno, Nevada, and -- in the latest of such attacks -- to the offices of US Senate majority leader Tom Daschle in Washington, has been confirmed to contain anthrax spores with no clear indication yet about the origins. Across America, many European countries, and Australia, numerous discoveries of suspicious substances, usually false alarms, are threatening to overwhelm ill-prepared national institutions. In the USA, a jittery public is flocking to accident and emergency departments demanding prophylactic antibiotics. And this is by no means even close to the scenario in which anthrax spores are dispersed by aerosol devices inside Grand Central station, as envisaged in a role play by Pentagon officials in 1999.

Only after these events did the UK chief medical officer, despite the UK being as likely a target as the USA after strikes on Afghanistan, step out into the limelight and give reassurances that Britain was well prepared to respond to any chemical or biological attack. Given that general practitioners were sent letters only late last week with information about anthrax and that the Public Health Laboratory Services issued provisional guidelines "for action in the event of a deliberate [anthrax] release" on its website on Oct 11, this seems a hasty and overconfident statement.

Public health in the pre-antibiotic era, when many infectious diseases were life-threatening and when surviving infancy was a formidable accomplishment, was very different. 21st-century public health has become complacent, ill-focused, and overly bureaucratic. The spontaneous emergence of new infections such as HIV and variant Creutzfeldt-Jakob disease should have served as warning shots already.

Appropriate reactions to such deliberate attacks, but also to any other emerging epidemic, by a well-organised and well-functioning public-health system requires preparedness at all times on all levels. Primary-care physicians and accident and emergency personnel need to be trained appropriately and updated at regular intervals. Public-health officials need to have well-coordinated plans of action that are widely known and transparent. And policy makers need to include such threats to the health of their nation in strategic planning. At present, there are widespread shortcomings at all levels in all countries.

The Lancet