Laurie Garrett is a senior fellow for global health at the Council on Foreign Relations. A Pulitzer-prize winning author, her most recent book is I Heard the Sirens Scream: How Americans Responded to the 9/11 and Anthrax Attacks.
Many Americans don’t place public health in the same arena as national security. What is the connection?
It’s sort of hard to believe that anyone would not see the connections after 9/11 and anthrax. That’s a pretty open and shut case, and we’ve had now two pandemics of influenza in recent years, the most recent one was 2009 H1-N1, and we saw that the world could not make a sufficient vaccine in anything close to the amount of time in which we needed it. And there was clamoring among nations who was going to get the medicines, who was going to get the vaccines, who was going to make it, who was going to charge what for it, and in the end no one was happy in how we preformed in the H1-N1 flu pandemic. But in a larger sense, the relationships between national security and global health are multitudes complex. To begin with, the most blunt way to put it is, as long as it is the case that children are dying of measles in Palestine; let’s say the West Bank and no child contracts measles in Israel, as long as it is the case that has happened recently, somebody trying to carry out polio vaccination is targeted for assassination by the Taliban on the grounds that the CIA is contaminating vaccines or carrying out fake vaccine campaigns — as we in fact did to ensnare Osama Bin Laden — so imperiling 350,000 Pakistani children, that tells you that whether we see the links or not the rest of the world does. And in the case of HIV/AIDS its very obvious that as the pandemic swelled it was taking a huge toll on the militaries of key countries and on the economies of key countries and had we not been able to develop treatment and get it out there, so that people are able to continue to work and raise their children, we would now be seeing real carnage particularly in southern Africa.
Where do biological threats rank in terms of the United States’ national security priorities?
Well as far as I can tell, the old fashion establishment of national security still thinks that the world is all about nation-state conflicts. So climate change doesn’t rank high, energy scarcity doesn’t rank high, resource generally, global health issues, even financial management after 2008 still ranks far below the sort of old fashion country verses country conflict issues. That’s changing, but it’s changing slowly, and I think there are a number of reasons for that. It’s very hard for the old establishment of National Security to get out of their comfort zone which is a direct link to military force. Well, military force isn’t going to do you much good in the case of an influenza pandemic, or a repeat of anthrax. In fact our military forces did very poorly in the face of the anthrax threat and similarly, you’re not going to bring military forces to bear, to deal with climate change. And so the problem we have with defining our threat in the world and understanding how to deal with it, is that we have this cumbersome old security apparition that’s very tightly knit with classic military force that predates WWII and imagines a world of Westphalia conflicts. Here we are today in something very different, where all of the major threats that society faces are, in fact, supranational not just transnational; they are above the concept of national borders and any national solutions. The real frustration is that no one country can solve the problem, no one country can take care of climate change, no one country can take care of resource scarcity or a pandemic, or the widespread counterfeit and fraudulent manufactured pharmaceuticals that are killing people all over the world. These all require a kind of global governance that does not now exist, and that is actually strongly resisted by many countries who see it as an intrusion into their space. And here in the United States when you start talking about global governance, a lot of the security establishment look at it like, “You children, you silly things. I, the big bad America, can take care of everything. We have such a massive military.” Well, show me how the military takes care of a pandemic.
What were the lessons from the post September 11th anthrax attack?
I find it shocking that we’ve never really as a nation examined that history, we had the fantastic 9/11 commission which did a very good job of figuring out how and why we missed the threat of al-Qaeda and why the World Trade Centers collapsed; but we’ve never really done a serious look of the whole anthrax episode, and never looked at them as a continuum. From the point of view of how the population experienced these events, it was a continuum; there was no moment to catch your breath between the tremendous shock, fear, and grief that was produced by 9/11, not just for people who lived right by Ground Zero in New York City, but for the whole world. Barely had one caught ones breath when suddenly, “What? Somebody at a newspaper in Florida has anthrax?” and this all began to unfold very quickly and so you had this sense of tension and anger in the population that was never well addressed. It’s a remarkable arc of what occurred because immediately after 9/11, you had a sense that most of the world was united behind America, and a sense of outrage — almost everybody was an honorary New Yorker overnight — there was not only a sense of solidarity with those that had been attacked and outrage against the attackers, but also a tremendous sense of whatever my country calls upon me to do in this moment, I shall do.
And in Washington and in New York you, you saw tremendous acts of kindness and sacrifice from common citizens reaching out to help one and other, tens of thousands of volunteers lined up. It went around the block several times, lined up at the Jacob Javits Center; construction workers, demolition experts, search and rescue, from all over the world said, “How can we help?” By the time you get half way out into anthrax, that whole physic has changed and we went from, “We are united and we shall sacrifice” to “How come nobody can give us a straight answer, what’s going on here? How come every piece of anthrax is wrong? How come our government can’t solve this? Who the heck is doing this to us?” And because there was no uniform analysis from government or from the scientific community about precisely what the threat was, how dangerous a given spore of anthrax may be to human health, and how people were getting infected, everybody had to make up their own mind. So, you had this sort of individualistic threat assessment, and what that lead to was a sort of disillusion of that moment of unity that had come right after 9/11. So, you went from the American people, but I would argue most of the world was in a state of very united and concerted feel and resolution, to every man, woman and child for themselves. Responses ran the gamut from people who literally did not open their mail for a month and were terrified and would not let their children by any sort of powder and that sort of thing, to people who said, “It’s nothing, it’s all…there is nothing to worry about.” I think there are a couple of very specific take home messages.
There are a couple of very specific and I think important take home messages that have never really been carefully been assessed in terms of imagining the next possible event. The first one is that people need to feel they are of use, when a mass tragedy occurs, there are basically two kinds of people. There is the person who says, “Oh my goodness where are my children? Let’s find a safe place and huddle down” and there is the person who says, “How can I help? Let me out there.” And after 9/11 we had an absolute deluge of people who wanted to be of use and the state had no way to absorb them. At one point President Bush called upon his newly created Office of Homeland Security, before it was a department, and said, “I’m asking the American people to come forward and help this great nation.” And the nation was deluged with phone calls and no one knew what to do with a single one of these people.
Even on a local level, you saw that here in New York City, you’d look down at the Brooklyn Bridge and there were hundreds of people almost immediately with water bottles and eye-drops and bandages; whatever they could do. People want to be of use, and government cannot be patronizing and assume that the average citizen is incapable of wise decision making; leave it to the military, leave it to the police. That is not only a terrible waste of talent and energy, but it also turns out that it contributes to post-dramatic stress, because when people feel helpless and their desire to contribute is rebuffed, fear sets in. I think huge mistakes were made, if you look at how New York was treated and Washington DC after 9/11 to 7/7 in London, night and day. There was virtually no post-dramatic stress seen in the citizenry in London, and the difference was that here the attitude in New York; we had heroes and then we had the rest of us. The hero was defined as someone who was a victim and died, or as a firefighter or police officer or rescue worker, someone in an actual uniform paid by the state. But the rest of us were what? Losers out on the street on the side walk, who knows? By making this abrupt way of separating the heroes from the rest of the population, a sense of helplessness set in the general population, and whatever fearfulness that was contributing to post-dramatic stress was not considered legitimate. In fact the health authorities did not set up any kind of hotline or any way that people who were traumatized could contact authorities until well down the road; whereas in London practically the day after the 7/7 dust had settled, they started having bill boards and phone messages and television messages all over greater London saying if you have a friend or a family member or a co-worker showing any of these symptoms, call this number immediately. The intervention was imitate, and it worked.
Another big take home lesion is hubris. You know, not only did we think we had everything under control and think it wasn’t possible for al-Qaeda to hijack three jets and turn them into missiles; but we also thought we know everything about biology. So, there can’t possibly be any surprise about anthrax, should it happen we would know immediately what to do; isn’t it treatable with ciprofloxacin and so on; wouldn’t it take 10,000 spores or more to produce a viable infection and on and on and on. Every single one of the alleged facts about anthrax turned out to be completely wrong, and the scientific community and the public health community had mud of their faces. We also thought we knew how to manage an outbreak situation, and in fact we had no clue. The fact that the senators and the senate buildings took priority over the postal workers that had delivered the mail to the senate offices was so striking and such an enormous mistake. And on top of it all. the perception of it was really brutal because all of the postal workers that were lethally infected were African American and the vast majority of postal workers on the eastern seaboard are African American, so it was perceived that some white guy on Capitol Hill gets infected and you’re all over the place going crazy, but a poor working stiff who happens to have dark skin gets infected and where is the concern?
There were many, many other things that came through, that to this day the actual “who done it” on anthrax is an open question. And though the FBI has officially closed the investigation and has said that Bruce Ivans was responsible and that he was a lone-wolf sole culprit, very few people accept that; when I say few people I mean intelligence people, fellow scientists, and police here in New York that were behind the investigation. It’s just logistically almost inconceivable that one person could have pulled it off, and in this case that he could have been physically checked into his lab in the Baltimore area when supposedly he was hand delivering these letters into a mailbox in New Jersey. I think that there is a tremendous amount of very powerful circumstantial evidence pointing to al-Qaeda, that the very same operatives that were leading the hijacking of the jets were also possibly the culprits responsible for the anthrax mailings, and as the evidence mounts and we see more and more of it, it becomes a very persuasive case. Certainly the quality of evidence against Bruce Ivans is no better than the quality of the evidence indicating that it was an al-Qaeda attack.
And just a couple of other quick things that come through. When a major catastrophic event occurs, there is a tendency to focus on the piece of it that is blatantly National Security and shove the rest to the side; even to indicate that there is almost something not patriotic about raising it, almost to the point where admitting you might have post-dramatic stress as a mere member of the public. So, we now know from the very instant that jet fuel caught fire on the North Tower we had a public health event. Of course, it was a homicide event, killing more than 2,000 people right there but it was also a catastrophic public health event in that the plume that was produced from the collapse of the World Trade Centers to the ongoing burn that lasted for four months was extremely toxic. Just recently, high court in New York and then the Federal Courts ruled that cancer is a certifiable outcome of exposure to that plume. We now see a mounting desk full of more and more people are added to the list of victims of the World Trade Center attack, I don’t think we will know for quite a long time how radically human health was affected by that plume; but it didn’t help that governments response was, whenever the people of New York City said, “I can’t breath at night, the smell is so horrible, I’m coughing up blood on my pillow,” the response was, “Shut up, we’ve certified it, it’s safe, there is no legitimacy to your complaints.” And again, this undermines the credibility of government in a time of crisis, and also illustrates that this tendency to focus in on one threat and not see the larger picture can be a great disservice to your people.
In terms of what did we do in result of these events — massive expenditure, billions and billions of dollars expended to deal with bio-terrorism preparedness, most of it went to buying the small-pox vaccine — why? We have absolutely no evidence that any foreign group of any kind possessed small-pox viruses with intent to use as a weapon. And yet, because of a certain set of coincidental experiences that occurred just before 9/11 that involved Vice President Cheney, there was a real fixation on small pox. I think we can now see that it is very difficult for leaders to make a wise and careful threat assessment when they feel personally at risk for acquiring disease. There’s something very visceral, it’s in our very DNA to be afraid of viruses, bacteria, of illness. There was a critical moment in the White House when President Bush went to Beijing to meet with Putin and Hu Jintao to work out a joint anti-terrorism statement. While he was a way he was in secure video communications with Dick Chaney and the rest of the White House staff, and there was a moment when Dick Chaney and Condoleezza Rice came on the video and said that “Mr. President, it’s been an honor to serve with you. We will not be alive tomorrow and most of the White House will not be with us tomorrow. We have been informed by the FBI that we have all been exposed to botchulinum toxin.” Indeed, the botchulinum detectors had gone off in the White House. Chaney was absolutely convinced he was going to die. It turned out to be a false reading.
I don’t think people make clear decisions when their mind is wrapped around the notion that they have just been exposed to botchulinum, so next it’ll be small pox, and its going to be that. I think it’s very hard to think clearly especially if you’re not trained in biology and you don’t understand these organisms and you don’t understand how to protect yourself.
Do you think any lessons have been learned post 9/11?
Au contraire. We have spent an absolutely astonishing amount of money in preparedness and really have very few things to show for it. There was a crazy typical “technology will solve everything” response, and money from congress flowed into pots to be doled out to the pharmaceutical industry and the research labs to come up with all these cures for X, Y, and Z; microbes and detection devices that can be put in the subways and the airports and all that. It’s all garbage. There is nothing significantly different from our preparedness today compared to the eve of 9/11 except that at the grassroots level we are losing our talent. So in many ways we are less prepared. We spend a lot of money through Homeland Security, through the Department of Health and Human Services and so on training first responders at the local level in every community in America; every city, town, county, you name it, police public health workers, physicians; every kind of person you can think of that’s involved in city government all the way up through the Federal Tire, and we train them and spend a huge amount of money doing it. Now we are watching all these services unravel in a budget crisis, at every single one of these municipalities, these states and so on, and most of the memory of these exercises and drills is disappearing. And I can guarantee you, that if the Mayor of “fill in the blank” opened up a letter and all of the sudden white powder poured all over her there would be no more competence in the response today.
What is your biggest fear in terms of a biological threat?
Well, I think all of us worry about a 1918 style influenza, just because we have so many more people and we are so much more globalized. The assumption that if you had an organism that viral, that the death toll would be enormous, that it would be several hundred million people. And I worry about the organisms that are out stripping out drugs; we now have a microbe — well it’s not even an microbe, it’s a plasmid — that surfaced in New Deli about a year ago and therefore is named NDM-1, New Deli 1, and this is a mutation which can go into almost any bacteria and make the bacteria completely drug resistant so you can get a strep infection, and I don’t care how much antibiotics you take, the strep could kill you. I have this terrible sense that our toolkit is diminishing and time is running out. We desperately need far more tools to fight the microbes that we have.
We recently had a real wake-up call, because two labs working independently made a man-made form of bird flu that could transmit between mammals. This is the flu that we’ve been watching with great concern, it’s called H5-N1 and its basically a 100% killer for chickens, super deadly for a broad range of bird species; rarely transmits to humans, but when it does well over half the humans die of it. But it’s not human to human transmitting so we don’t get a human pandemic out of it. But everybody is watching this thing carefully. Well, two different labs have made a man-made version of it and this has prompted great concern in a few different things. Number one: what’s going on in the labs, should anybody have done such a thing? Number two: is this giving us some meaningful warning that showed us the virus could do it? Fewer then five very tiny mutational changes are necessary. Well the good news is its shaken a lot of the trees.
It’s got people in national security, in public health, in basic science, all scratching their heads and saying, “Wow, we’ve been getting a little complacent again; maybe we need to wake up and pay attention.” As far as our elections go, it’s interesting that — of course, we and global health are humble, we know that our issues will never be key issues that decide any election — but there is a big difference between the two candidates in the United States on foreign assistance and global health rite large. Barack Obama has carried out some pretty large reconstruction of the whole foreign affairs and foreign policy establishment in the U.S. government and put global health really way up on top, giving it a position that it had never really enjoyed until President George Bush created the HIV/AIDS program, that’s good news. The bad news on the other side of the partisan divide is that Mitt Romney has never said a word about foreign assistance at all of any kind, he’s never said a word about any global health programs, he’s never uttered the word AIDS, never said HIV out loud — at least it’s never been recorded — and depending on who he picks as vice president we could be walking into a situation where all this global health apparatus and bio-terrorism preparedness apparatus is just so much collateral damage in a budget restriction.