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Biopreparedness and Public Health
NATO Science for Peace and Security Series
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Series A: Chemistry and Biology

Biopreparedness and Public Health
Exploring Synergies

edited by

Iris Hunger
Carl Friedrich von Weizsäcker Centre for Science and Peace Research
University of Hamburg, Hamburg, Germany

Vladan Radosavljevic
Military Academy, University of Defence, Belgrade, Serbia

Goran Belojevic
Institute of Hygiene and Medical Ecology, Faculty of Medicine
University of Belgrade, Serbia

and

Lisa D. Rotz
Centers for Disease Control and Prevention, Atlanta, Georgia, USA

Published in Cooperation with NATO Emerging Security Challenges Division

Results from the NATO Advanced Research Workshop on
Exploring Synergies between Bioterrorism Preparedness and General Public
Health Measures
Belgrade, Serbia
15–17 November, 2010

Library of Congress Control Number: 2012944988

ISBN 978-94-007-5299-3 (PB)

ISBN 978-94-007-5272-6 (HB)
ISBN 978-94-007-5273-3 (e-book)
DOI 10.1007/978-94-007-5273-3

Published by Springer,
P.O. Box 17, 3300 AA Dordrecht, The Netherlands

www.springer.com

Printed on acid-free paper

All Rights Reserved

© Springer Science+Business Media Dordrecht 2013
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Preface

The threat from the terrorist use of pathogens has been a major security concern in
recent years, particularly after the anthrax letter attacks in the USA in 2001. This
threat of intentional outbreaks of diseases stands side by side with the constantly
changing natural threat from diseases, epidemics, and pandemics, as illustrated in
recent years by the H1N1 influenza pandemic, the SARS outbreak, and the H5N1
avian influenza event. While naturally occurring diseases – both newly emerging
and well-known ones – claim the life and health of many people year after year,
bioterrorism events have so far had a very limited health impact.
Protection, prevention, and response measures for natural disease outbreaks
and for bioterrorism events differ greatly between countries. At the national level
these aspects all too often are handled by different actors with different approaches
under different funding arrangements. In many states, resources and political
attention are so stretched that the bioterrorism threat is not dealt with at all. While
natural and deliberate outbreaks of disease differ in a number of ways – e.g., the
types of diseases involved, risk communications, or the legal follow-up – in many
areas the differences are likely to be small, in particular those involving non-
disease-specific public health detection and response activities. Finding these
areas of overlap, identifying the differences and the gaps in preparedness mea-
sures, and thereby contributing to streamlining response measures so as to enable
them to protect public health from all three types of biological threats – natural,
accidental, deliberate – is an urgent need for countries worldwide, and in particu-
lar for countries whose public health systems are already overburdened by natural
disease response.
To address the issue, 34 experts from 17 European countries, including Turkey,
as well as the USA, Israel, the World Health Organization, and the European
Centre for Disease Prevention and Control gathered for a NATO-sponsored
Advanced Research Workshop entitled “Exploring synergies between bioterrorism

v
vi Preface

preparedness and general public health measures” in the Serbian Academy

of Sciences and Arts (SANU) in Belgrade, Serbia, during 15–17 November 2010.
In addition to the 34 workshop participants, the first half-day of the workshop, with
introductory and more general presentations, drew a number of local experts,
illustrating the interest in the issues under discussion. Most notably, the workshop
participants welcomed Zoran Jeftic, State Secretary from the Serbian Ministry of
Defence, and Lee Litzenberger, Deputy Head of Mission of the US Embassy in
Belgrade, who addressed the gathering during the opening ceremony.
The workshop focused on Southeastern Europe, a region where some of the
diseases caused by agents of bioterrorism concern, such as tularemia or certain
types of hemorrhagic fevers, are endemic. This region also regularly experiences
natural outbreaks of other diseases whose causative agents also have relevance as
potential bioweapons risk agents. The workshop was not only an opportunity to
learn from local experiences in fighting these diseases, but also a unique occasion
for regional and global networking.
The workshop addressed the current level of threat from naturally occurring
infectious diseases and the current bioterrorism threat, the response and prepared-
ness efforts in different countries of Southeastern Europe, France, Germany,
Israel, Poland, the United States, the European Union, and globally. From these
empirical data, commonalities, differences, and gaps among states’ efforts and
between general public health measures and biopreparedness were extracted and
discussed. Lessons were derived on where bioterrorism preparedness and response
measures at the moment and in the future can benefit other areas of public health
and vice versa.
To capture the information that was exchanged during the workshop and
further explore synergies for public health preparedness, selected workshop
participants were asked to write detailed case studies on the relationship between
biopreparedness efforts and other public health measures in their countries or
their international organizations, which – together with a number of chapters on
more general bio-threat related topics – are assembled in this international
scientific monograph.
The thanks of the editors of this volume go to NATO’s Science for Peace and
Security Programme for funding the original workshop, to the Serbian Academy of
Sciences and Arts (SANU) – and in particular to Academician Prof. Ljubisav Rakic –
for hosting the workshop in Belgrade, and to two external reviewers who contri-
buted valuable comments during the preparation of this book – Brig. Gen. (ret) Mario
Stefano Peragallo, MD, Consultant in Preventive Medicine and Hygiene, Italian
Army Medical Research Center, Rome (Italy), and Brig. Gen. (ret) Ioannis Galatas,
MD, Consultant in Allergy and Clinical Immunology, Medical/Hospital CBRNE
Planner, and Senior Asymmetric Threats Analyst, Athens (Greece).
Preface vii

Last but not least, the editors thank the participants and guests at the workshop,
and all the authors of this book who were willing to give part of their limited time
and share their experiences to make further advancements on the route towards a
world free from the threat of deliberate disease.

December 2011 Atlanta, Belgrade and Hamburg

Iris Hunger Goran Belojevic

University of Hamburg University of Belgrade
Hamburg, Germany Belgrade, Serbia

Vladan Radosavljevic Lisa Rotz

Military Academy, University of Defence Centers for Disease Control and Prevention
Belgrade, Serbia Atlanta, USA
Contents

1 Introduction ............................................................................................. 1
Iris Hunger
2 The Current Bioweapons Threat ........................................................... 7
Jonathan B. Tucker
3 A New Method of Differentiation Between
a Biological Attack and Other Epidemics............................................. 17
Vladan Radosavljevic
4 The Difference in Responding to Natural
and Unnatural Outbreaks ...................................................................... 33
Amesh A. Adalja
5 Managing Acute Public Health Events: A World Health
Organization Perspective........................................................................ 39
Catherine Smallwood, Andrew Smith, Nicolas Isla,
and Maurizio Barbeschi
6 Public Health in South-Eastern Europe – Exploring Synergies ......... 45
Dorit Nitzan Kaluski and Maria Ruseva
7 Health Security and Disease Detection in the European Union.......... 55
Massimo Ciotti
8 Case Study – Bulgaria ............................................................................ 75
Raynichka Mihaylova-Garnizova and Kamen Plochev
9 Case Study – France ............................................................................... 91
Elisande Nexon
10 Case Study – Germany ........................................................................... 107
Christine Uhlenhaut, Lars Schaade, and Ernst-Jürgen Finke
11 Case Study – Greece ............................................................................... 121
Nikolaos V. Zaras

ix
x Contents

12 Case Study – Israel.................................................................................. 131

Adini Bruria, Manfred S. Green, and Daniel Laor
13 Case Study – Italy ................................................................................... 147
Francesco Urbano and Maria Rita Gismondo
14 Case Study – Poland ............................................................................... 161
Anna Bielecka and Janusz Kocik
15 Case Study – Romania ............................................................................ 173
Alexandru Rafila and Daniela Pitigoi
16 Case Study – Serbia ................................................................................ 187
Goran Belojevic
17 Case Study – Turkey ............................................................................... 197
Gurkan Mert
18 Case Study – United States of America................................................. 209
Lisa D. Rotz and Marcelle Layton
19 Concluding Remarks .............................................................................. 221
Iris Hunger, Lisa D. Rotz, Goran Belojevic,
and Vladan Radosavljevic
Chapter 1
Introduction

Iris Hunger

Abstract Health and security have become intertwined in recent years. While this
has been welcomed by many experts because it led to an increase in funding for
selected public health activities, others worry that this development will distract
from sustaining and improving basic public health services. The challenge, in
particular in low- and mid-income countries, is to improve the public health system
as a whole and simultaneously provide an appropriate level of awareness and response
capability for the low-likelihood, but high-consequence event of a bioterrorist attack.

1.1 Connecting Health and Security

For a long time, public health was an issue which security experts did not care
about. Over the last decade, this has changed. Epidemics, gaps in disease surveil-
lance, and lack of public health intervention capacities are increasingly perceived as
a threat to national security, regional stability and international peace. Starting in the
late 1990s, health has more and more been conceived as a security issue.
This re-conceptualization of health as a security issue started in a number of think
tanks that described infectious diseases – in particular the HIV/AIDS pandemic – as
a threat to peace and security. Promoting health globally, it was postulated, is not
just a matter of “doing good”, but also a critical aspect of foreign policy and national
security [6–8]. Already in April 2000, U.S. President Bill Clinton announced that
AIDS would be treated as a threat to U.S. national security. And in July 2000, the

I. Hunger (*)
Research Group for Biological Arms Control, Carl Friedrich von Weizsäcker
Centre for Science and Peace Research, University of Hamburg,
Beim Schlump 83, 20144 Hamburg, Germany
e-mail: [email protected]

I. Hunger et al. (eds.), Biopreparedness and Public Health: Exploring Synergies, 1

NATO Science for Peace and Security Series A: Chemistry and Biology,
DOI 10.1007/978-94-007-5273-3_1, © Springer Science+Business Media Dordrecht 2013
2 I. Hunger

United Nations Security Council passed Resolution 1308, which declared that action
was necessary before the AIDS pandemic could further threaten world stability
([10]: 30).
The World Health Organization (WHO) initially rejected a formal relationship
between health and security. There was the fear that neutral health work could
be misused for political goals. It was not before 2007, that “global public health
security”entered the vocabulary of WHO [13].
Meanwhile, arms control and non-proliferation experts dealing with biological
weapons issues increasingly turned their attention away from verifying compliance
with the global bioweapons ban and towards countering bioterrorism and securing
public health. During the past decade, disease surveillance has been one of the few
issues that states parties to the 1972 Biological Weapons Convention have been
discussing during their annual consultations in Geneva [1].
There is a question in many experts’ minds to what degree security and health
can be and should (or should not) be connected and how best to link the two. For
many it is a positive development that public health – local and global – is receiving
attention from the security community, because that attention has led to substantial
additional funding. Money for health is always a good thing, independent of source
and motivation, the argument goes. But there is also some uneasiness about the fact
that health has been turned into a security issue in the last 10 years. There is concern
that global health is transformed from a humanitarian issue into an issue of national
interest, which could lead to shaping the international health agenda more narrowly
around the diseases that are of security concern to Western donor countries [4].
WHO noted in one of its recent annual reports that primary public health care (such
as the nurse visiting a village once a month) does not get the attention needed for
sustainable health improvements [14].

1.2 The Mismatch Between Public Health

and Biodefence Funding

The threat from the terrorist use of diseases has received much attention in recent
years, particularly after the anthrax letter attacks in the USA in 2001. This threat of
intentionally-caused outbreaks of diseases has joined the long-existing and constantly
changing natural threat from diseases, epidemics, and pandemics. While the disease
burden from naturally occurring diseases continues to be heavy, bioterrorism –
fortunately – has remained a largely hypothetical threat.
Looking at the resources available to counter both threats, a glaring mismatch is
evident between the number of death and illness from natural disease outbreaks
compared to the ones caused by bioterrorism on the one hand, and the funding available
to prepare for such events on the other. Illustrative examples are listed in Table 1.1.
While the impact of naturally occurring infectious diseases is to a certain degree
foreseeable and a lot of experience with preventing, limiting, countering, responding
to, and recovering from natural disease outbreaks exists, bioterrorism events have
1 Introduction 3

Table 1.1 Illustrative quotes and numbers on the mismatch between disease burden and funding
of countermeasure development from natural public health threats and bioterrorism
Disease burden Countermeasure development
Estimated 1.7 million people “Funding for [tuberculosis] control continues to increase and will
died from tuberculosis in reach almost US$5 billion in 2011. … Compared with the
2009 [15] funding requirements estimated in the Global Plan [to Stop
TB], the funding gap is approximately US$ 1 billion in 2011.
Given the scale-up of interventions set out in the plan, this
could increase to US$3 billion by 2015 without intensified
efforts to mobilize more resources” [15]
Estimated 781,000 people “International funding for malaria control has risen steeply in the
died from malaria in past decade. Disbursements reached their highest ever levels
2009 [16] in 2009 at US$ 1.5 billion, but new commitments for malaria
control appear to have stagnated in 2010, at US$ 1.8 billion.…
The amounts committed to malaria, while substantial, still fall
short of the resources required for malaria control, estimated
at more than US$ 6 billion for the year 2010” [16]
Estimated 1.8 million people “A total of US$ 15.9 billion was available for the AIDS response
died from AIDS-related in 2009, US$10 billion short of what is needed in 2010” [12]
illnesses in 2009 [12]
Five people have been killed Biodefence spending in the United States has grown from USD
in bioterrorist attacks 0.6 billion in 2001 to USD 8.1 billion in 2005. USD 6.5
since 1900 [9, 11] billion were budgeted for 2011 [3]
Biodefence and biosecurity activities and funding have increased
in many – mostly Western – countries around the world. [3, 5]
Cooperative projects on biosecurity are funded in a number of
non-Western states. (See, for example, [2].)

been so rare that knowledge is largely hypothetical. Undoubtedly, bioterrorist

attacks have the potential to be unexpected mass casualty events. How likely such
events are, how exactly they would look like, and how best to respond remains
very much debated. The uncertainty associated with the bioterrorism threat makes
public health preparedness planning for such events practically and politically very
difficult.

1.3 Aim and Structure of This Book

In a world of limited financial resources states can ill afford to create parallel structures
for preventing and preparing for natural disease events and for human-made,
deliberately caused disease outbreaks. While there are obviously a number of differ-
ences between natural and deliberate outbreaks of disease – e.g. the types of diseases
involved, the extent of decontamination necessary, or the legal follow-up – there
also are large areas where differences are likely to be small, in particular in the areas
of detection (e.g. through disease surveillance) and non-disease-specific public
health responses. After all, in both cases one deals with a disease outbreak.
4 I. Hunger

At the moment, preparedness for natural disease outbreaks and bioterrorism

preparedness are all too often dealt with by different actors with different approaches
under different funding arrangements. Describing and comparing the existing
relationships between measures to protect public health in general and measures to
prepare for the unlikely but potentially catastrophic event of a bioterrorism attack,
and drawing lessons for optimizing this relationship is the aim of this book.
The book focuses on countries in southeastern Europe, a region where some of
the diseases caused by agents of bioterrorism concern are endemic, such as tularemia
or Crimean Congo hemorrhagic fever. This region suffers regularly from natural
outbreaks of bioweapons-relevant diseases. To allow a broader comparative analysis,
case studies on a number of countries from outside this region are also included.
The book is divided in two parts. In the first part, the scene is set. Jonathan Tucker,
a policy analyst on chemical and biological security issues, Washington, DC (USA),
assesses the current bioweapons threat. Vladan Radosavljevic from the Military
Academy, University of Defence, Belgrade (Serbia), offers a framework for differen-
tiating between a biological attack and other epidemics. The differences in responding
to natural and unnatural disease outbreaks are analysed by Amesh Adalja from the
Center for Biosecurity, University of Pittsburgh Medical Center, Baltimore (USA).
The following three chapters address selected public health issues from a supra-
national perspective. Catherine Smallwood and colleagues from Health Security
and Environment, World Health Organization, Geneva (Switzerland) offer WHO’s
perspective on managing acute public health events. Dorit Nitzan Kaluski, WHO
Country Office Serbia, Belgrade (Serbia), and Maria Ruseva, WHO Regional Office
for Europe, Copenhagen (Denmark), describe the recent reforms of public health
systems in countries in the South-eastern Europe Health Network. And Massimo
Ciotti, European Centre for Disease Prevention and Control, Stockholm (Sweden),
portrays health security and disease detection efforts in the European Union.
The second part of the book contains case studies on individual countries with a
focus on countries from southeastern Europe. Authors of the country studies were
asked to address the following questions:

• What are the main public health threats (in terms of infectious diseases) in your
country? How important does your country perceive bioterrorism as a potential
threat?
• How is preparedness and response to health emergencies organized in your
country? How does preparedness and response to a bioterrorism event differ in
your country from preparedness and response to other health emergencies?
• What role does the military, in contrast to civilian agencies, play in preparedness
and response to natural and human-made health emergencies?

The country case studies cover:

• Bulgaria, authored by Raynichka Mihaylova-Garnizova and Kamen Plochev,
Military Medical Academy, Clinic of Infectious Diseases, Sofia (Bulgaria);
• France, authored by Elisande Nexon, Fondation pour la recherche stratégique,
Paris (France);
1 Introduction 5

• Germany, authored by Christine Uhlenhaut and Lars Schaade, Robert Koch

Institute, Berlin (Germany), and Ernst-Jürgen Finke, scientific consultant in
medical biological defence, Munich (Germany);
• Greece, authored by Nikolaos Zaras, Special Joint CBRN Company, Hellenic
Army, Athens (Greece);
• Israel, authored by Adini Bruria and Daniel Laor, Emergency and Disaster
Management Division, Ministry of Health, Tel Aviv (Israel), and Manfred Green,
School of Public Health, University of Haifa, Haifa (Israel);
• Italy, authored by Francesco Urbano, Italian Army Logistic Branch, Medical
Department, Rome (Italy), and Maria Rita Gismondo, Faculty of Medicine and
Surgery, “Luigi Sacco” University Hospital, Milan (Italy);
• Poland, authored by Anna Bielecka and Janusz Kocik, Military Institute of
Hygiene and Epidemiology, Department of Epidemiology, Warsaw (Poland);
• Romania, authored by Alexandru Rafila and Daniela Pitigoi, University of
Medicine and Pharmacy “Carol Davila” and National Institute for Infectious
Diseases “Prof. Dr. Matei Bals”, Bucharest (Romania);
• Serbia, authored by Goran Belojevic, Institute of Hygiene and Medical Ecology,
Faculty of Medicine, University of Belgrade, Belgrade (Serbia);
• Turkey, authored by Gurkan Mert, Gulhane Military Medical Academy, Ankara
(Turkey); and
• USA, authored by Lisa Rotz, Centers for Disease Control and Prevention (CDC),
Atlanta, GA (USA), and Marcelle Layton, New York City Department of Health
and Mental Hygiene, New York, NY (USA).
In their concluding remarks, the editors provide a summary and comparison of
public health preparedness efforts for natural and unnatural disease outbreaks in the
countries covered by the case studies, and offer recommendations on the relation-
ship between biopreparedness and wider public health.

The editors were very sorry to learn about the death of Jonathan Tucker during
the preparation of the book manuscript. Jonathan Tucker died unexpectedly in
July 2011. He was an internationally esteemed expert on chemical and biological
weapons, arms control and non-proliferation, on security aspects of biotechnolo-
gies, on dangerous infectious diseases, and on unconventional terrorism. He
worked at the interface of science and policy in very different institutions includ-
ing the US Congressional Office of Technology Assessment, the US Arms
Control and Disarmament Agency, the Center for Non-Proliferation Studies, and
the Federation of American Scientists. Jonathan Tucker was highly respected for
his balanced, careful research, and enormous productivity. The world is a safer
place because of his work. His many friends and colleagues around the world
feel his loss sorely.
6 I. Hunger

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BWM%202011%20WEB.pdf. Accessed 21 Dec 2011
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Health Programme working paper no.1. The Nuffield Trust. London. http://www.nuffieldtrust.
org.uk/sites/files/nuffield/publication/health-foreign-policy-and-security-apr03.pdf. Accessed
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The American University. http://books.google.de/books?id=WuLE5jBS0esC&printsec = front
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Sep 2011
11. Tucker JB, Sands A (1999) An unlikely threat. Bull At Sci 55(4):46–52
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documents/20101123_GlobalReport_full_en.pdf. Accessed 24 Sep 2011
13. WHO (2007) The world health report 2007. A safer future: global public health security in the
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Chapter 2
The Current Bioweapons Threat

Jonathan B. Tucker†

Abstract According to unclassified U.S. government sources, states of biological

weapons (BW) proliferation concern include China, Iran, North Korea, Russia, and
Syria. Assessing the BW threat is challenging, however, because illicit development
and production can be concealed at dual-use industrial sites such as vaccine plants,
and only tens of kilograms of an agent like dried anthrax spores can be militarily
significant. The lack of unambiguous technical signatures of BW-related activity
means that most estimates of foreign capabilities draw heavily on human intelligence
sources, yet spies and defectors are notoriously unreliable. A key factor driving BW
proliferation is the perceived military utility of biological weapons, which may
include strategic deterrence, asymmetric warfare, or covert operations. Globalization
of the biotechnology industry has expanded trade in dual-use materials and produc-
tion equipment, increasing the risks of diversion and misuse for BW purposes. With
the advent of flexible biological manufacturing systems, it has also become possible
for countries to acquire a “latent” capacity for BW production during a crisis or war.
Since the 2001 anthrax letter attacks, sub-state actors have become a prominent
part of the threat matrix, but terrorist acquisition and use of BW requires both
the motivation to use disease as a weapon and the technical capability to do so, a
combination that is quite rare. At present the threat of mass-casualty BW attacks
emanates primarily from nation-states, while terrorist use of biological weapons
will likely remain limited in scale and impact. Nevertheless, the emergence of new
biotechnologies with a potential for misuse could result in more damaging incidents
of bioterrorism in the future.

The editors mourn the loss of Dr. Jonathan B. Tucker, who died unexpectedly during the preparation
of this book.
J.B. Tucker† (Deceased)

I. Hunger et al. (eds.), Biopreparedness and Public Health: Exploring Synergies, 7

NATO Science for Peace and Security Series A: Chemistry and Biology,
DOI 10.1007/978-94-007-5273-3_2, © Springer Science+Business Media Dordrecht 2013
8 J.B. Tucker

2.1 Introduction

A starting point for assessing the current threat of biological weapons (BW) is the
unclassified arms control compliance report prepared periodically by the U.S. State
Department, most recently in July 2010, although it does not cover all countries of
proliferation concern. The section of the report addressing compliance with the
1972 Biological and Toxin Weapons Convention (BWC) suggests that Iran, North
Korea, and Syria (a signatory state) may have active BW programmes and that
China and Russia have been less than forthcoming about their past offensive activities
[16, pp. 10–26].
Because the BWC lacks any formal multilateral verification mechanisms, these
assessments are based on U.S. national intelligence capabilities. The 2010 State
Department report uses extremely hedged language, however, suggesting the
high level of uncertainty that surrounds the BWC compliance of several countries.
The entry on Iran, for example, reads: “Available information indicates that Iran has
remained engaged in dual-use BW-related activities. The United States notes
that Iran may not have ended activities prohibited by the BWC, although available
information does not conclusively indicate that Iran is currently conducting activities
prohibited by the Convention” [16, p. 16].
This uncertainty stems from the fact that monitoring clandestine BW programmes
is a challenging task for several reasons. First, BW development and production
capabilities can be concealed at ostensibly legitimate industrial sites, such as vaccine
plants or facilities for the production of single-cell protein or biopesticide. Second,
the equipment and know-how needed for the manufacture of BW agents is entirely
dual-use, although technologies for weaponization and delivery are more specialized.
Third, because only tens of kilograms of an agent such as dried anthrax spores can
be militarily significant, even small-scale production facilities are relevant from a
security standpoint. Fourth, proliferant states often use deception and denial
techniques to conceal their BW-related activities, as was demonstrated by the cat-
and-mouse game played by Iraq and United Nations biological weapons inspectors
after the 1991 Persian Gulf War. Finally, since the terrorist attacks in the United
States on September 11, 2001, and the subsequent mailing of letters contaminated
with anthrax bacterial spores, the biodefence programmes of several countries have
expanded dramatically, providing a potential cover for offensive BW development.
Because of the difficulty of monitoring clandestine BW programmes, several
countries have violated the BWC in the past with impunity, including the Soviet
Union, apartheid South Africa, and Saddam Hussein’s Iraq. From the 1970s through
the early 1990s, Moscow conducted a vast, top-secret biological warfare programme
that was partially concealed inside a pharmaceutical development and production
complex known as Biopreparat. The full scale and scope of this effort were not
detected by Western intelligence agencies at the time and were only revealed after the
defection of high-level Biopreparat officials in the late 1980s and early 1990s [1].
The lack of clear technical signatures of biological weapons development and
production means that most current estimates of foreign BW capabilities draw heavily
2 The Current Bioweapons Threat 9

on human sources. Unfortunately, spies and defectors are notoriously unreliable.

Before the 2003 Iraq War, for example, the CIA was seriously misled by an Iraqi
source code-named “Curveball,” who claimed that after the UN weapons inspectors
the country in December 1998, the regime of Saddam Hussein had reconstituted
its BW programme by deploying mobile biological production facilities. The CIA
unwisely placed credence in this uncorroborated source, who later turned out to
have fabricated his story out of whole cloth [4]. In sum, for the reasons noted above,
publicly available lists of countries suspected of possessing or seeking biological
weapons should be viewed as little more than educated guesses.

2.2 Perceived Military Utility

An important factor affecting the state-level BW threat is the perceived military utility
of biological weapons. Most of the microbial pathogens that states have developed
in the past as BW agents are zoonotic bacteria and viruses that infect humans as well
as animals but are not transmissible from person to person; examples include the
causative agents of anthrax, tularemia, Q fever, and Venezuelan equine encephalitis.
Such non-contagious agents are best suited for targeted military use because only
troops directly exposed to the agent cloud would be affected. During the Cold War,
however, the Soviet Union developed two contagious agents (the smallpox virus and
the plague bacterium) as strategic biological weapons for attacks on U.S. cities.
Soviet military planners apparently assumed that the delivery of these agents against
distant targets in the United States would trigger local epidemics that would not
spread widely enough to boomerang against the Soviet population [1].
Because microbial BW agents have an asymptomatic incubation period lasting
days or even weeks after infection before they produce incapacitating symptoms,
they have little tactical utility on the battlefield. Instead, paramilitary or special-
operations forces might employ biological weapons for non-time-sensitive
operations, such as attacking troop reinforcements or command-and-control centers
deep behind enemy lines or targeting dug-in troops or insurgents in remote areas
or mountain redoubts. Anti-crop or anti-livestock agents might also be used for
covert sabotage attacks in order to undermine the agricultural economy of an adver-
sary nation.
Some countries that are currently assessed to possess a BW capability appear to
view it as a means of holding a potential adversary’s populated urban centers at risk
for deterrence purposes. Syrian President Bashar al-Assad, for example, once
suggested obliquely in an interview that his country was justified in acquiring
biological and chemical weapons as a means of balancing Israel’s undeclared
nuclear weapons capability. “We are a country which is [partly] occupied and from
time to time we are exposed to Israeli aggression,” Assad said. “It is natural for us
to look for means to defend ourselves. It is not difficult to get most of these weapons
anywhere in the world and they can be obtained at any time” [2].
10 J.B. Tucker

Acquiring a BW capability may also be attractive to militarily weak states as

an asymmetrical means of deterring or countering conventional attack by a much
stronger military power. Before the 1991 Persian Gulf War, for example, Iraqi leader
Saddam Hussein ordered the crash production of a stockpile of biological weapons,
including aerial bombs and missile warheads filled with anthrax spores, botulinum
toxin, and aflatoxin. Saddam viewed this BW capability as an “ace in the hole” to
secure his regime from the internal and external opponents seeking to topple him
from power. Although it is not clear how a secret weapons programme could serve
as an effective deterrent against the United States and Israel, Saddam may have
counted on the rumors before the Gulf War that he possessed biological weapons [9].
After Iraq’s military defeat, Saddam ordered the unilateral destruction of
the biological weapons stocks so they would not be found by UN inspectors. At the
same time, however, he continued to maintain ambiguity about whether or not
the weapons still existed in order to deter Iran as well as his domestic enemies, the
Shiites and the Kurds. The CIA’s Iraq Survey Group, which searched in vain for
Iraq’s suspected weapons of mass destruction in the aftermath of the 2003 Iraq War,
concluded that Saddam had bluffed about possessing biological and chemical weap-
ons because he felt vulnerable without them [7].

2.3 Impact of Economic Globalization

In recent decades, economic globalization has affected the dynamics of BW prolif-

eration. Several developing countries, including China, Cuba, India, Malaysia, and
Singapore, have invested heavily in industrial microbiology as a vehicle for
economic development. The global spread of the biotechnology industry has
complicated the task of regulating the international trade in items of biological
production equipment, such as fermenters and spray-driers, increasing the risk of
their diversion and misuse for bioweapons production. Despite the existence of the
Australia Group, an informal forum of more than 40 countries that harmonize their
national export controls on dual-use materials and equipment relevant to chemical
and biological weapons, suppliers in countries that do not participate in the Australia
Group (such as China, Cuba, India, and Russia) have sold dual-use items to countries
of BW proliferation concern.
Another troubling development is what has been called “latent” or “virtual” BW
proliferation. With the advent of flexible biological manufacturing systems that can
switch rapidly from one product to another in response to shifts in market demand,
dedicated factories are no longer required for the production of BW agents. Instead,
it has become possible for countries to acquire and maintain a standby mobilization
capacity for biological weapons production at dual-use facilities without overtly
violating the BWC. A would-be cheater could perform the research, development,
and testing for an offensive BW programme in secret and then maintain a latent
production capacity in distributed form at several locations until a political decision
was made to break out of the BWC and acquire a weapons stockpile. At that time,
2 The Current Bioweapons Threat 11

key items of dual-use equipment, and the technical teams needed to operate them,
could be brought together to initiate a BW production campaign. The short period—
measured in weeks—required to manufacture a militarily significant stockpile might
prevent an adversary from bolstering its medical defenses in a timely manner.
Mobilization programmes at dual-use biological facilities are very hard to detect,
even with intrusive on-site inspections such as those conducted by the UN weapons
inspectors in Iraq. Accordingly, evidence that a state has acquired a breakout BW
production capability would depend on intelligence about the intentions of the
country’s leaders. The high-placed human sources needed to collect such information,
however, are difficult to recruit. Latent proliferation also poses a major challenge
for biological arms control. Because the BWC compliance of a dual-use production
facility is largely a matter of intent, a state party would violate the treaty only
when it started to produce biological agents “of types and in quantities that have no
justification for prophylactic, protective or other peaceful purposes.” Given the
difficulty of monitoring illicit production, it is far from certain that such a violation
would be detected.

2.4 Non-state Actors

Since the mailing in autumn 2001 of letters contaminated with anthrax bacterial
spores, killing five people in the United States and infecting 17 others, non-state
actors have become a prominent part of the BW threat matrix. Compared to states,
terrorist organizations are hard to deter and thus have fewer constraints on the use
of biological weapons, although their technical capabilities tend to be significantly
lower.
To acquire a BW capability, a terrorist group must be motivated to employ
infectious disease as a weapon and must also possess the necessary technical
resources. On the motivational side, only a small number of terrorist organizations
have sought biological weapons in the past, for several reasons. First, terrorist
groups tend to be conservative in their choice of weapons and tactics, innovating
only when forced to do so, and they typically select materials and delivery systems
that are readily available and have predictable effects, such as high explosives.
Second, politically motivated terrorist organizations (such as the Irish Republican
Army) have not pursued biological weapons because their use would be perceived
as disproportionate and illegitimate, alienating the group’s supporters and potential
recruits and provoking a severe crackdown by government authorities. Third, the
uncertainties associated with the effective use of biological agents are considerable,
raising doubts in the minds of the potential perpetrators about whether or not a
planned attack will be successful [10].
The types of terrorist organizations most likely to pursue biological weapons are
those with an extreme religious or ideological worldview, such as apocalyptic cults,
white supremacists, and jihadist organizations. Such groups are more inclined than
more traditional, politically motivated terrorist organizations to inflict indiscriminate
12 J.B. Tucker

casualties and to pursue risky, innovative tactics. Al-Qaeda, for example, launched
a BW programme code-named Al Zabadi (the Arabic word for “yogurt”) in May 1999
with an initial investment of a few thousand dollars. At training camps in Afghanistan,
Al-Qaeda operatives established makeshift labs where they experimented with the
plant toxin ricin (suitable for assassination purposes) and attempted unsuccessfully
on at least two occasions to acquire a virulent strain of anthrax [13].
Beyond the motivation to acquire and use biological weapons, would-be bioterror-
ists must possess the specialized know-how and financial resources needed to acquire,
weaponize, and deliver highly infectious and lethal agents. Popular accounts in the
news media generally underestimate the technical hurdles involved in acquiring
biological weapons and delivering them effectively. To develop an anthrax weapon,
for example, would-be bioterrorists would have to obtain and cultivate a virulent strain
of the bacterium, induce it to sporulate, process the spores into a liquid slurry or a dry
powder, formulate the agent with stabilizing chemicals, and fill it into a specialized
sprayer device that can disseminate the spores as a fine-particle aerosol, infecting
those exposed through the lungs. Outdoor releases of BW agents would also have to
timed to take advantage of favorable wind, weather, and atmospheric conditions.
The combination of motivation and technical capabilities required for successful
bioterrorism is quite rare. Since 1945, only about a half-dozen terrorist groups
have tried to acquire and use biological weapons, and none of them has mastered
the complex set of knowledge, skills, and know-how needed to produce and deliver
BW agents effectively on a large scale. All known bioterrorist attacks to date have
involved standard bacterial or toxin agents (e.g., anthrax spores or ricin) and crude
methods of delivery such as the contamination of food, beverages, or unchlorinated
water supplies. In 1984, for example, the Rajneeshee cult in Oregon used cultures
of salmonella bacteria to taint restaurant salad bars in the town of The Dalles.
The attack sickened 751 people, some seriously, but caused no fatalities [3].
In the past, terrorists have faced significant technical problems when attempting
to move beyond crude biological weapons, suitable for assassination or food con-
tamination, to more advanced aerosol-delivered agents capable of causing mass
casualties. During the early 1990s, for example, the Japanese doomsday cult Aum
Shinrikyo prepared a liquid slurry of anthrax spores and dispersed it repeatedly
in aerosol form from the roof of a building in Tokyo, but the attacks did not kill
or harm anyone. The reason for this failure was that the group had inadvertently
acquired, produced, and released a harmless strain of the anthrax bacterium that is
used as a veterinary vaccine [8].
Since the U.S.-led invasion of Afghanistan in 2001, Al-Qaeda has become a
decentralized global network made up of largely autonomous affiliates in various
countries, such as Algeria, Indonesia, and Yemen. These groups appear to lack the
expertise and resources needed to organize and carry out a major bioterrorist attack.
Although numerous jihadi websites and terrorist manuals provide recipes for
producing BW agents such as ricin, they often contain technical errors or yield only
crude preparations.
These observations suggest that at least for the near future, the threat of mass-
casualty BW attacks will continue to emanate primarily from nation-states. Terrorist
2 The Current Bioweapons Threat 13

attacks with biological weapons, while considerably more likely than state use, will
probably remain limited in scale and impact. Nevertheless, a wild card exists that
could potentially transform the nature of the BW threat: the potential exploitation of
recent advances in the life sciences and biotechnology for hostile purposes.

2.5 Impact of Emerging Biotechnologies

The past few decades have seen a “revolution” in the life sciences that offers great
benefits for human health and agriculture but also has potential BW applications.
One example is the growing convergence of biological and chemical production
technologies [15]. Pharmaceutical companies now use genetically engineered
bacteria and yeast to manufacture complex natural products of medicinal interest
that are difficult or costly to extract from plant or animal sources. For example, the
antimalarial drug artemisinin is currently purified from the sweet wormwood plant.
In an attempt to increase the supply of the drug and lower its cost, scientists at the
University of California, Berkeley, have used a technique known as “metabolic
engineering.” They isolated the set of genes coding for enzymes in the biosynthetic
pathway of artemisinin from the sweet wormwood plant and inserted them into
yeast cells, with the aim of producing an immediate precursor of the drug in large
fermentation tanks [11]. In theory, a similar process might be used to mass-produce
toxic natural substances such as saxitoxin, a potent paralytic poison made by marine
algae that cause harmful blooms known as “red tides.” Although at present it is
impractical to extract large quantities of saxitoxin from shellfish contaminated by a
red tide, metabolic engineering might conceivably be used to mass-produce the
toxin for BW purposes.
Also of growing interest to the pharmaceutical industry are bioregulators, natural
body chemicals that play a key role in many physiological processes, such as the
regulation of temperature, blood pressure, immunity, and brain function. Although
these biochemicals are essential for life at extremely low concentrations, they can
be toxic at higher doses or when their molecular structure is modified. Neuropeptides,
a class of bioregulators in the central nervous system, are known to affect cognition
and emotion. These compounds might therefore be developed into a new class
of potent incapacitating agents with potential applications in law enforcement,
counterinsurgency, and counterterrorist operations. If such biochemical agents
prove to be tactically useful, countries might well be motivated to acquire and weap-
onize them, a development that would seriously undermine the biological and
chemical disarmament regimes [14].
Advanced DNA synthesis techniques have also made it possible to reconstitute
entire microbial genomes by strictly chemical means, a feat that has been accom-
plished to date for poliovirus, the 1918 Spanish influenza virus, a SARS-like coro-
navirus, and a small bacterium [6]. In the future, whole-genome synthesis techniques
will make it possible to construct any pathogenic virus for which an accurate genetic
sequence has been determined, including the smallpox virus, which was eradicated
14 J.B. Tucker

from nature in the late 1970s by a global vaccination campaign under the auspices
of the World Health Organization (WHO). Because smallpox eradication led
countries around the world to stop vaccinating their civilian populations against the
disease in the early 1980s, the human population has since become increasingly
vulnerable to the deliberate use of smallpox as a biological weapon. Although
the known stocks of the smallpox virus are currently held at two WHO-approved
repositories in the United States and Russia, the CIA reportedly believes that undeclared
cashes of the virus may exist in countries of BW proliferation concern, including
Russia, Iran, and North Korea [5].
The worldwide diffusion of advanced biotechnologies such as gene synthesis
may increase the risk of their misuse for harmful purposes. In principle, terrorists
with the necessary scientific training could order fragments of DNA from several
commercial suppliers and assemble them into a deadly virus, circumventing the
physical access controls on “select agents” of bioterrorism concern. While genome-
synthesis technology could be used to recreate known viruses in the laboratory,
the design and construction of artificial pathogens more deadly than those that exist
in nature will remain unlikely. To create such novel agents, it would be necessary
to assemble complexes of genes that work in unison to infect the host and block
the human immune response—a task far beyond the current state of the art.
Those individuals who are potentially most capable of harnessing advanced
biotechnologies for harmful purposes are life scientists working in academic,
industrial, or government labs. Although scientists tend to be highly rational people,
the fact that Aum Shinrikyo was able to recruit university-trained biologists and
chemists for its unconventional weapons programmes suggests that some brilliant
but alienated scientists may be vulnerable to a charismatic leader who provides a
false sense of spiritual meaning and community.
The 2001 anthrax letter attacks in the United States have also increased concerns
about the so-called “insider” threat. In August 2008, after a 7-year investigation, the
Federal Bureau of Investigation (FBI) concluded that the sole perpetrator of the
anthrax letter attacks had been Dr. Bruce E. Ivins, a respected microbiologist
and developer of anthrax vaccines who had worked for decades at the U.S. Army’s
premier biodefence laboratory at Fort Detrick in Maryland. Because Ivins committed
suicide shortly before he was to be indicted, the evidence against him was never tested
in court. Nevertheless, the Ivins case has called attention to the risk that scientists
working in national biodefence programmes could be motivated by personal grievance
or ideology to carry out biological attacks. Ironically, because the 2001 anthrax
letters attacks resulted in a huge expansion of U.S. government biodefence research,
today more than 14,000 scientists are authorized to handle “select agents” of bioter-
rorism concern.
Growing numbers of researchers are also pursuing fields with clear dual-use
potential, such as synthetic biology and nanotechnology. The International Genetically
Engineered Machines (iGEM) competition, held each year at MIT, attracts student
teams from around the world who present research projects involving the manipulation
of advanced genetic components and technologies. When the iGEM competition
began in 2003, it was limited to a few teams from U.S. universities, but it has since
2 The Current Bioweapons Threat 15

gone global: in 2010, 118 teams from 26 countries participated [17]. Because any
large group of people is likely to include some individuals with psychopathic
tendencies, the expanding pool of scientists with dual-use knowledge has increased
the statistical risk that powerful biotechnologies such as whole-genome synthesis
could be misused for harmful purposes.
An important variable in assessing the risk of high-tech bioterrorism is the set of
skills and resources needed to acquire and deliver dangerous pathogens effectively.
Kathleen Vogel of Cornell University contends that in addition to “explicit knowl-
edge,” such as recipes for producing and processing biological agents, would-be
bioterrorists would require a great deal of “tacit knowledge” that cannot be written
down but must be acquired through hands-on experience in the lab [18]. In addition,
the fact that much of the know-how needed to weaponize biological agents remains
classified would limit the ability of terrorists lacking specialized training and hands-
on experience to prepare mass-casualty attacks.
Other scholars disagree, however, arguing that synthetic genomics and other
advanced biotechnologies are subject to a process of “deskilling,” or a reduction
over time in the level of tacit knowledge required for their use [12]. Genetic
engineering techniques that a decade ago could be performed only in cutting-edge
laboratories are now available in the form of kits, processes, reagents, and services
that can be utilized by individuals with only basic laboratory training. At least
potentially, terrorists might also be able to recruit or coerce scientists with prior
experience in a state-level BW programme. Given these factors, the risk of high-
tech terrorism, while currently low, warrants continued vigilance.
In conclusion, the current bioweapons threat emanates primarily from a few
countries of proliferation concern, such as China, Russia, North Korea, and Syria,
as well as a small minority of terrorist organizations that are both motivated to
acquire and use biological weapons and are technically capable of doing so. At least
for the near term, bioterrorist attacks are likely to remain small-scale and to involve
standard agents and crude methods of delivery. If, however, terrorist groups manage
to move up the technical learning curve, the destructive power of biological attacks
could increase significantly.

References

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cal weapons program in the world—told from inside by the man who ran it. Random House,
New York
2. Brogan B (2006) We won’t scrap WMD stockpile unless Israel does, says Assad, The Telegraph
(London), 6 January 2004
3. Carus WS (2000) The Rajneeshees. In: Tucker JB (ed) Toxic terror: assessing terrorist use of
chemical and biological weapons. MIT Press, Cambridge, pp 115–137
4. Drogin B (2007) Curveball: spies, lies, and the con man who caused a war. Random House,
New York
5. Gellman B (2002) 4 Nations thought to possess smallpox: Iraq, N. Korea Named, Two Officials
Say, Washington Post, 5 November 2002, p A1
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content-detail.html. Accessed 20 Sep 2012
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