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Immediate responses to the attacks -
Bioterrorism and the new security -
Communication, protection and mitigation -
We can not be everywhere -
"No-regrets" measures -
War -
Conclusion -
Acknowledgement -
References -
Authors' details
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More articles on Social issues
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Boston, 18 September
Seven days ago, I heard on National Public Radio's 9 AM news that planes had just struck the towers of the World Trade Center. We had only recently arrived in the United States via Honolulu, so I thought of Pearl Harbor. In the week since, many others have recalled the attack of 7 December 1941, living on — in the definitive diction of Franklin Roosevelt preserved in newsreels — as "the day of infamy". |
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The Oxford Dictionary defines "infamy" as the "reputation
earned by an extreme, publicly known evil act; public reproach, shame
or disgrace". It adds a legal consequence — the loss of rights of a
citizen after being convicted of certain crimes. What are the
implications of this new infamy for security and public health in the
present and near future?
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From one of the doomed jets, passengers had told their families by
mobile phone that they would die fighting. So there was
communication, but not enough time for intervention by the US Air
Force. Yet, there was calm appraisal of the disaster at ground level.
US Secretary of Health and Human Services Thompson ordered the
activation of the National Disaster Medical Assistance Teams and
Disaster Mortuary Operation Response Teams.
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the true places never are."
Herman Melville | |
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Heroism took many forms, such as the deaths of fire fighters and police
officers during their efforts to save others, and the detailed
attention paid to the logistics of rescue efforts by Mayor Giuliani of
New York. The disaster immediately promoted a sense of unity among the
survivors, those who came to help them, and other people across the
United States and many other parts of the world.
As people donated blood or money or time in the week following the
attacks, compassion became almost competitive. Advertisers in the
New York Times vied to "outdo" each other with expressions of
sympathy, solidarity and nationalism. Fundraising scams were also
reported.
The counterterrorist inquiry started immediately, involving
thousands of FBI agents and support staff — probably the most
intensive investigation of this kind ever conducted in the United
States. Osama bin Laden was soon named as the prime suspect.
Just as soon, retaliation was on President Bush's agenda, gaining the
support of all but one representative in Congress. The feared
reprisal attacks and harassment of Arab-Americans in New York and
elsewhere began to occur, but perhaps to a lesser extent than was
expected.
Local environmental investigations were largely unrevealing. The
high temperature of the fires that razed the towers of the World Trade
Center could have converted the refrigerant freon to phosgene, a
highly poisonous gas, but this was not found. Stray sources of
radiation among the rubble, another potential hazard, were also not
detected. Days of black smoke, much thicker than the air pollution
caused by industry, caused some respiratory distress, while many
rescue workers, at least in the early urgency of the disaster, failed
to wear safety masks, and so may have been exposed to asbestos. (Later,
engineers wondered whether the towers would have stood for longer if
the ban on use of asbestos had come in after, rather than during,
construction of the Center.)
Trauma takes its toll, but most of us will be able to put these events
into a corner of our lives. A few will experience post-traumatic
stress disorder, so, in New York, the world capital of psychotherapy,
a surge in that industry may be expected. The trauma, physical and
psychological, was exhaustively documented, and there were
countless analyses of the way forward.
How should the medical community respond to the death and destruction
caused by terrorism? Can we move from the infamy of 11 September to
constructive action for human health worldwide?
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As a result of the events of 11 September, far stricter guidelines for
airports are now in place in the United States. Doubt had been
expressed on many previous occasions about the effectiveness of
security checks, partly because security is typically run by
contractors working for the airlines. This outsourcing of security
functions carries a risk that has been widely recognised as
intolerable: security and surveillance must be strengthened. This
may include more attention to a small proportion of passengers in a
"high-suspicion" category, as well as measures that will be applied
to the entire travelling public.
Some types of security, previously considered unacceptable for
reasons of privacy protection, practicality, or expense, will
emerge, at least in New York.1 In highly vulnerable and
densely populated areas of the city, such as Times Square, options
include the widespread use of surveillance cameras, connected to
computers with software for face recognition. There will be more
police and security officers, with dogs to detect explosives in
suspicious bags or packages. Buildings will be reinforced, while
heating, ventilation and air-conditioning systems will be secured
to prevent the introduction of chemical or biological agents.
Traffic and parking will be restricted.
The possibility of biological warfare is the chief health concern in
plans for the management of catastrophic terrorism. After the events
of 11 September, the Centers for Disease Control and Prevention
mounted special surveillance programs at New York healthcare
facilities for unusual skin lesions that might be indicative of
anthrax, plague or smallpox. (Later events showed that this
localised approach was not enough.) The establishment of disaster
surveillance is not new, following widespread concern about
bioterrorism in the 1990s, but how far and how fast should we pursue
safety measures?
Ideally, the public health approach would focus on prevention of
contamination episodes, but terrorism specialists warn that mass
screening methods to detect the carriage of chemical or biological
agents are not yet available. That leaves the collection and review of
information about possible sources, the prevention of acquisition
of hazardous material, and the early detection of cases and outbreaks
of disease as the principal counterterrorism measures.
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Governments should know where and why scientific equipment (such as
that required for microbiology) is used, to reduce the chances of
mischief. Public health authorities, including all healthcare
facilities, require clear channels of communication with the police
and other security agencies. Compliance with the Biological Weapons
and Chemical Conventions should be verified worldwide.
In Australia, security should be improved at the many places that
could be raided by terrorists to obtain biological
weapons.2 Existing public health
infrastructure (including electronic information systems) should
be upgraded, probably without requiring a new bureaucracy, for case
and epidemic surveillance. All other aspects of the healthcare
system should be reviewed now from the point of view of security.
Education and training in the medical aspects of bioterrorism should
be a priority. This has started with the development, in 1999, of a
training program by the Australian Medical Disaster Coordination
Group. Security issues surrounding the 2000 Sydney Olympic Games
have also increased our awareness of bioterrorism. However, no
country can yet claim to be well prepared.
The Clinton administration's campaign to build civil defences
against terrorism included the stockpiling of drugs and vaccines.
(For example, 40 million doses of smallpox vaccine were to be prepared
by 2004.3) The adequacy of these
measures is under urgent review.
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The hijacked planes departed from Boston, Dulles and Newark
airports, with the mayhem occurring in New York and Washington DC.
Soon after the attacks, investigators, following any
available leads, searched businesses and homes in New Jersey,
Massachusetts, Florida and other states. Follow-up investigations
spread to countries where Osama bin Laden's allies in the
jihad are known: Egypt, Saudi Arabia, Yemen, Somalia,
Eritrea, Afghanistan and Pakistan (to name but a few). As the list gets
longer, the likelihood of finding the "true place" (in Melville's
phrase) — the base of the terrorists or the trace to their next attack
— gets smaller.
How far will technology allow the improved tracing of terrorists —
or, in the public health sphere, the mapping of diseases and their risk
factors? Modern mapping techniques, enhanced by
computer-generated imaging, can provide highly sophisticated
representations of the distribution of people or diseases. Yet maps
yield only partial truths, as Melville suggested. Comprehensive
security and public health measures simply can not be implemented
everywhere.
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The technical difficulties of trying to root out terrorists or
pinpoint the sources of all disease outbreaks make it essential to
work on other fronts, to make more effort with responses that would be
worthwhile regardless of whether or not terrorism was involved. Such
"no-regrets" measures would have much in common with policies aimed
at reducing the health burden caused by degradation of the global
environment. For example, climate change threatens the livelihoods
of people in poor countries; yet, in rich countries, governments do
little to curb the environmentally harmful behaviours (such as the
widespread use of private cars and sports utility vehicles) that
contribute to global warming. This is but one reflection of the
environmental injustice between rich and poor nations. Such
inequalities have in turn fuelled a suicidal terrorist anger towards
Western success and the hegemony of the United States in particular.
The Hippocratic ideal requires that the medical community promote a
positive program with a focus on the fundamental causes of terrorism,
including such environmental concerns.
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War is not the answer to the atrocities of 11 September. "Infamy" seems
a fair description, but otherwise the analogy with the attack on Pearl
Harbor fails. The identity of the "enemy" was rapidly declared by
President Bush, but the retalictory action has not been properly
targeted. The population of Afghanistan is not the enemy: most have
been oppressed by the Taliban, not in league with it. Afghanistan
needs support, not indiscriminate bombing. Bringing the terrorists
to justice is the only acceptable form of retaliation. There may be a
role for military intervention, but there must be at least as much
digging in the civilian trenches to create peace.
"The enemy of my enemy is my friend" is an inadequate basis for
allegiance in a renewed "war" on terrorism; it will only serve to
enlarge a war of hate. ("Wanted dead or alive" was an even more
inflammatory phrase, but probably just a Wild West lapse of
concentration from President Bush.) Instead of war, international
unity, with genuinely shared strategic interests, must be
developed. Stronger US support for the United Nations should be a good
start.
The term "war" is best avoided, even as a metaphor. In the medical
arena, as elsewhere, "wars" are rarely won. Consider what has still to
be achieved, 30 years after President Nixon's declaration of a "war
against cancer". The "wars" on drugs and tobacco will also drag on
throughout the new century.
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Building global cooperative strategies to counteract catastrophic
terrorism may take decades. The public health system must play its
part in the scale-up of disease surveillance systems now, while
recognising that we can not be everywhere. Medicine and healthcare
represent a locus of vulnerability that should be covered. Removing
the causes of terrorism — including an extremism that arises from
poverty, hate and envy — will be harder. And increasing our
information and security without unjust reductions in the freedom of
some populations may be harder still.4
We can not predict the time or place of the next strike, but it will
happen. We must prepare. Public health surveillance must now have a
global network, promoting not only the peaceful purpose of
epidemiology, but also the warning, prevention and deterrence of
bioterrorism.
The epidemiologist classifies health problems according to time,
place and person. I have argued here that the place for modern
surveillance — not only of terrorism, but also of the risk factors and
occurrence of disease — must be expanded, and now is the time. As for
the people, government health authorities are necessary but not
sufficient: "they" cannot do something about everything. We are all
responsible.
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Postscript, 29 October
Bioterrorism in the United States is now a fact: anthrax has been transmitted by mail. After criticism of the failure of intelligence services to prevent the hijackings on 11 September, blame is now cast on health authorities for underestimating the danger to postal workers.5 Will anyone now take bets against the re-introduction of smallpox? Vaccine production has been accelerated.
War is also now a fact, but that does not make it right. Our response to this new infamy of terrorism requires, as the Oxford Dictionary noted, a criminal conviction. There has not yet been one. Unilateral declarations of war have been illegal since the adoption of the United Nations Charter in 1945, except under very limited conditions that constitute self-defence.6 The attack on Afghanistan by the United States has exceeded the legitimate use of force. Objections to this war derive not only from the hope for the sustainable, international rule of law, but also from the effect of retaliation, likely to increase the authority of Osama bin Laden and his supporters in some places. Will the US government — now working with the advertising agencies of Madison Avenue on ways to improve the US image abroad — consider that?
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Many of the facts recorded above derive from media reports, mainly
National Public Radio (WBUR Boston) and the New York Times,
September 12-18.
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- Barstow D. Envisioning an expensive future in the brave new world of
Fortress New York. New York Times 2001; 16 September: A16.
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Robertson AG. Bioterrorism and Australia: where to from here?
Aust Mil Med 1999; 8: 18-23.
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Broad WJ, Petersen M. Nation's civil defense could prove to be
inadequate against a germ or toxic attack. New York Times
2001; 23 September: B12.
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Ignatieff M. Paying for security with liberty. Financial
Times 2001; 12 September: 14.
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Miller J, Stolberg SG. Anthrax: US officials acknowledge
underestimating mail risks. New York Times 2001; 25 October:
A1.
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Charter of the United Nations, 1945. Articles 2(4) and 51.
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Department of Population and International Health, Harvard School
of Public Health, Boston, MA, USA.
Charles Guest, PhD, FAFPHM, Visiting Scholar.
Reprints will not be available from the author.
Correspondence: Dr C
Guest, Department of Population and International Health, Harvard
School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
cguestAThsph.harvard.edu
©MJA 2001
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