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As the swine flu quickly circled the earth this past summer, the Obama administration shifted from the rhetoric of “hope” to a genuine effort to “cope” with the real dangers of bioterrorism

The Obama administration has been re-thinking the War on Terror from its start. Issue-by-issue, step-by-step, it’s been re-examining each piece of the complex mosaic that defines America’s post-9/11 strategic environment, from Iraq to missile defense. And so it came as no surprise that the administration has now turned its attention to the nefarious threat of bioterrorism – convening its first meeting of bioterrorism experts at the White House Conference Center on August 13th to partake in a round-table discussion co-chaired by National Security Council (NSC) senior director for WMD terrorism Laura Holgate.

One participant at this summer’s White House meeting on bioterrorism was Brian D. Finlay, a Senior Associate at the Washington, D.C.-based Henry L. Stimson Center, who found few concrete take-aways from this first meeting on bioterrorism, but explained to me that “when you get 40 experts on bioterrorism in a room, you’re going to hear 50 different opinions on how to address the threat – this is testament to the complexity of meeting this challenge.” And “because the White House discussion was designed to be one-way,” Finlay added “we don’t yet have a sense as to where the administration is going at this point.” While it’s “clear that the administration is in the midst of a top-down review of the U.S. government’s bioterrorism strategy,” he finds “there is much less clarity on what the path forward might look like.”

Finlay observes that “not only has the President not spoken out as vociferously on this subject, which necessarily depresses its priority within the bureaucracy, but early indications of the administration’s commitment based upon the FY2010 budget request are less than promising.” For biological threat reduction programs, Finlay notes “the President’s request is $33.4 million below the FY2009 appropriated level.” Finlay recalls in December 2008 a “bi-partisan Congressional Commission declared a 50% or greater chance of a terrorist attack involving a nuclear or biological weapon. Shockingly, these odds represented the probability of an attack over the next five years. In light of these findings, the President’s reductions to bio-threat activities at the Department of Defense are a distressing indication of flagging commitment to preventing bioterrorism.”

Finlay believes “there are two critical steps” the administration should pursue going forward: the first is to “develop tighter partnerships with the biotech and pharmaceutical sector,” and the second is to “break down the barriers within government between the public health agencies and the national security agencies.” An encouraging indicator of the government’s commitment to bioterror prevention is its new FDA Commissioner, Margaret Hamburg, “a brilliant choice by the White House” who during the Clinton administration “led the U.S. government’s efforts to build a biodefense plan,” and who after leaving government “led a non-profit effort that sought innovative public-private responses to the same.” She thus has the “capacity to bridge the unnecessary and dangerous divide between the public health and national security communities in Washington,” but “the question will be how much time and effort she is able to dedicate to this important effort.”

One of the greatest difficulties in developing a response to bioterrorism is determining whether an outbreak of a pathogen is an act of terror or just an unfortunate natural event. I spoke with Dr. Anne Clunan, editor and co-author of the 2008 Stanford University Press book on bioterrorism, Terrorism, War, or Disease? Unraveling the Use of Biological Weapons. Clunan, who is a professor at the U.S. Naval Postgraduate School in Monterey, California, explained her book “is about how can governments determine whether the appearance of a biological or toxin agent was deliberate or naturally-occurring, and if deliberate, how to credibly establish who was responsible. This question is the ‘attribution problem’ – how do we know who is responsible for a suspicious outbreak of disease?” She explains the attribution problem has three parts: The first is “identification of which bio agent is responsible for the illness that appears.” The second is “characterization of that outbreak as intentional or unintentional.” And the third is “attribution: if the outbreak is the result of intentional introduction of a bio-agent, who is to blame for that introduction?”

Clunan believes “that managing biological warfare attribution and other problems arising from nontraditional threats requires shifts in how governments acquire and use information. The first shift requires changing the understanding of information, from intelligence, as something to be kept secret in order to gain relative advantage over an adversary, to information, as a resource to improve government management of and response to threats. In other words, governments must move from ‘need-to-know’ limitations on intelligence sharing to a ‘need-to-share’ paradigm of information sharing.” This in turn requires the “development of networks for information sharing,” and “addressing the challenges of establishing trust among members of such networks and between networks and the public.”

Such networks “include health and medical professionals and other first responders, epidemiologists, entomologists, toxicologists, animal and public health experts” – agencies such as the CDC, the World Health Organization (WHO), and the World Organization for Animal Health (OIE), as well as “biotechnologists in industry and academia, law enforcement officials, military personnel, and policymakers.” Clunan notes there are “a lot of efforts to collect and in some cases, share, information that are underway” and that “governments have made recent efforts to improve technical and technological capacity to aid in biological warfare detection, including early detection and warning systems. For example, in 2003 the United States adopted a nationwide system of sensors to detect pathogens in 31 U.S. cities, called the BioWatch program.” As well, the U.S. Centers for Disease Control and Prevention (CDC) “actively promote the wider adoption of U.S. technical standards to increase international interoperability of information systems that address biological warfare information needs,” and CDC’s Epi-X program “was developed to help public-health professionals nationwide share preliminary health surveillance information.” In the private sector, Clunan notes “the Google foundation is supporting surveillance of flu outbreaks with its Flu Trends website.”

Additional efforts are taking place at the global level, such as the WHO’s Global Outbreak Alert and Response Network (GOARN), and – in conjunction Health Canada – its open-source Global Public Intelligence Network. And in 2006, the OIE, the UN Food and Agriculture Organization (FAO), and the WHO “jointly created the Global Early Warning and Response System (GLEWS).” Clunan adds that “many countries have also adopted ‘syndromic surveillance’ for early detection of both biological terrorism incidents and newly emerging diseases, such as SARS and avian influenza. The U.S. has BioSense and National Biosurveillance Integration System (NBIS); the UK has the NHS Direct Syndromic Surveillance Project.” Clunan observed that “globalization tremendously increases the consequences of the intentional or unintentional spread of pathogens and toxins. With SARS, we saw the transmission of the disease from China to 6 countries in 24 hours, and to 28 over 5 months. Swine flu this year spread to over 141 countries in just 3 months. Similar results could occur with intentionally introduced diseases that were highly contagious.” Clunan added that “a key consequence of bioterrorism is not only illness and death, and this is the other way in which globalization enters into the risks associated with a bio-attack. Globalization has increased every country’s exposure and dependence on foreign commerce. A bio-attack or a disease outbreak in one country will have tremendous economic costs to that country and to those that do business with it and travel to it.”

I also spoke with Dr. Laurie A. Garrett, Senior Fellow for Global Health at the New York-based Council on Foreign Relations, and the Pulitzer Prize-winning author of the best-selling books The Coming Plague: Newly Emerging Diseases in a World Out of Balance and Betrayal of Trust: The Collapse of Global Public Health. Garrett also noted the challenges inherent in globalization, and explained that a key lesson of the global spread of swine flu was that “globalization of risk, as well as economics and benefits, has occurred.” She finds the response by governments to the H1N1 pandemic indicates “the world community is still in early, even primitive, stages of maturation in global governance. When pushed by a real threat, countries still retreat to old-fashioned nation-state ‘solutions’ that are based on the false promise of controlling microbes along human national borderlines. We still have a very long way to go, as a world community.” She recalls how “following 9/11 and the anthrax mailings, significant amounts of money poured into public health and bioterrorism-related drug development in the U.S. and some European and Asian societies. It was slanted toward anti-terrorism. After SARS, more money poured in, slanted towards surveillance and international transparency. After Katrina, still more money was directed in the U.S. towards a homeland security model. Following the spread of H5N1 flu attention and funds shifted toward control of that bird virus. And now the world is reacting to H1N1.” As she explains, “Each of these ‘moments’ has infused cash and attention to an element of public health, in one country or another. Still missing is a systematic and strategic approach to global public health infrastructure. The key missing element is personnel.”

Garrett observes that “overall, the Obama Administration is seeking a more nuanced approach to all forms of terrorism than Bush’s ‘War on Terrorism.’ This affects everything from nuclear proliferation to the war in Afghanistan. My sense is it is still evolving.” Her advice to the administration as its policy continues to evolve is to “seek evidence, and base policy on empirical realities. That would be very refreshing.” While many people worry about the risks of terror, she believes the greater threat is from a naturally evolving plague, and notes that “nothing beats the threat of virulent pandemic flu, e.g., a reassortment of H5N1 and H1N1.” But she believes we can reduce the risk, whether from a virulent pandemic flu or a malicious act of biological terror, through more “surveillance and rapid diagnostics.” As she elaborates: “We need far more sophisticated RT-PCR (reverse transcription polymerase chain reaction) going on, affordably and on a mass basis, not just in U.S. but all over world. Right now RT-PCR for unknown and mass-platform organisms is still too costly and difficult for developing country routine use. Worse, insurance companies are not reimbursing their cost in U.S. hospitals. This needs to get fixed. Frankly, if the U.S. insurance piece gets fixed, massive use in our hospital system will pull cheap, easy technologies out of the pipeline, taking care of the developing country side of the problem.”

Clunan also has some advice for the Obama administration as it begins to build its bioterrorism response: “The bumper-sticker version would read: ‘Discourage use and deny effect.’ Or ‘make health, not war.’ The bottom line for policymakers is to focus on consequence mitigation – on measures to prevent, resist and withstand the impact of a bio attack. Instead of deterring a potential attacker by threat of physical punishment, the best defense is to have a robust public health and first responder system in place to protect your population from harm, which discourages attacks, and if one comes, significantly mitigates the health effects and any public panic.” She adds that “robust national and transnational networking, information exchange, standard setting and collaboration among first responders, health workers, the biotech industry, academics, and non-proliferation, intelligence and law enforcement officials is critical for successful mitigation and attribution.” Clunan believes “we also need to strengthen international laws and norms against biological warfare and to discourage and de-legitimate the development and use of biological and toxin weapons,” and “to develop international standards for monitoring the development, movement, and use of agents with the potential for warfare uses.”

By taking these actions, Clunan presents us with a comforting solution to the question raised by her bioterrorism book’s title: Terrorism, War, or Disease? With a diligent effort to prevent or reduce the consequences of bioterrorism, we just might be able to add a fourth choice to consider: None of the above.