Six months after the specter of bioterrorism became
reality, the School's Center for Civilian Biodefense Strategies
has staked out a more activist role in national preparedness.
By Brian W. Simpson
As the final speaker at the School's bioterrorism intersession
O'Toole faced a standing-room-only crowd of 150 researchers
and officials from the Pentagon, the Environmental Protection Agency,
state and local health departments, and a host of other government
agencies. They had already been schooled for eight hours in bioterrorism's
sinister challenges: genetically altered biological agents that
promise greater lethality, "dirty" bombs that would disperse
radioactive material, contaminated municipal water supplies, and
For the closing talk that day in mid-January, O'Toole, director
of the School's Center for Civilian Biodefense Strategies, chose
a suitably forbidding topic: the Byzantine complexities of the federal
The stakes couldn't be higher: the health and safety of the nation
and a once-in-a-lifetime chance to rebuild the nation's crumbling
public health infrastructure. As unprecedented amounts of federal
funds surge into the nation's public health system, the key is how
to ensure the money gets to the right people and is used in the
most effective way.
The United States must work quickly to prepare for and hopefully
prevent another round of terrorist attacks that could come in biological,
chemical, or nuclear form. Cities must develop response plans, states
may need to update quarantine laws, surveillance networks must be
established to warn of disease outbreaks, hospitals must be readied
for mass casualties and infectious patients, and physicians must
be able to quickly get reliable information and warnings of new
threats. The to-do list may be endless, but one thing is certain.
Few items can be checked off without one indispensable resource:
"What I was trying to convey [at the intersession course] is
the message that the government is not an opaque and inscrutable
mystery," says O'Toole, MD, MPH '88. "One can figure it
out. One can influence it. [But] you have to understand what the
budget process is. You have to recognize the constraints on the
administration and the Congress. You have to give them what they
need, when they need it, in a package they can understand."
Six months after the fall anthrax attacks, the Center has gone operational.
The willingness to advise government officials and to engage other
public health experts in the federal budgetary process reflects
a more "activist" role for the Center, which emerged last
fall as the national resource on bioterrorism.
Its new name — now the Center for Civilian Biodefense Strategies,
not Studies — underscores the new attitude. "I think what we
wanted to convey was the notion that we are interested in making
things happen, not simply studying what was going on," O'Toole
says. "We are interested in how we can change the world so
that we actually are better prepared for a bioterrorist attack should
it occur and also help thwart it from ever happening.
"It's not enough to do the analysis and publish it. That's
the starting point," O'Toole says.
So in addition to publishing research in top journals such as the
Journal of the American Medical Association and Clinical Infectious
Diseases, and bringing out a new book (a collection in April of
their JAMA papers on biological agents), O'Toole, Tom Inglesby,
MD, deputy director, and others at the Center are meeting with top
administration and other government officials to ensure the best
use of bioterrorism preparedness funds — $2.9 billion in the current
fiscal year, and $5.9 billion proposed for the next.
While it's widely accepted that the nation must "rebuild its
public health infrastructure," the method for achieving this
goal, or even how to define it, is not clear-cut. "We are going
to have to figure out what that means and certainly the School of
Public Health should be deeply engaged in that. Then we're going
to have to make it happen," O'Toole says. This requires a clear
articulation of state and local health department needs, and a sophisticated
understanding of how money flows, what programs are possible at
each level of government, who needs the money most, and how progress
can be measured.
Against all odds, government can act quickly and effectively. Inglesby
points to the decision to build a national reserve of 280 million
doses of smallpox vaccine and the accelerated schedule for developing
a new anthrax vaccine as important immediate steps. But planning
for the long term must also be part of what's considered right now.
"One of the short-term things is creating policy infrastructure
and resources for work done one, three, five, ten years from now,"
Inglesby says. "Science takes a while. But it's literally the
only way out. We need absolutely new technology, and new vaccines
and diagnostics to manage these threats."
O'Toole envisions a national research priority on the scale of the
nation's Apollo moon project that would stake out clear goals for
the biomedical sciences. "In the long term, we ought to learn
enough about the pathological mechanism of disease and the immune
system that we can [quickly] identify, diagnose, and prevent and
treat any kind of engineered bug that anybody wants to throw up
at us," she says. Such research would spin off new knowledge
and tools to deal with drug-resistant tuberculosis, malaria, HIV/AIDS,
and other diseases that already cause half the premature mortality
in the developing world, O'Toole says.
As a related priority, the Center will work with scientists to devise
of self-governance to prevent new science from being used for dark
purposes and resulting in new bioweapons.
In the Center's long-term future, O'Toole sees its continued expansion
to meet the numerous demands. The Center will need more faculty
members and visiting scholars.
Ongoing projects at the Center include writing a history of the
anthrax attacks and the response, developing a national strategic
research and development plan for biodefense, and continuing briefings
to everybody from the vice president to the U.S. Conference of Mayors,
and high-level officials at the departments of Defense, State, and
Health and Human Services (HHS). ("When I try to remember where
I've been talking in the last two months, it all blurs," O'Toole
As the Center moves forward with its agenda, O'Toole and her colleagues
maintain a close link to the Center's former director, D.A.
Henderson, MD, MPH '60, now leading the Office of Public Health
Preparedness at HHS. When HHS staff wanted more information on preparing
for nuclear or radiological attack, O'Toole, a former Department
of Energy official, connected them to the right people in government.
And when Henderson wanted to know what hospital preparedness needs
were, the Center hosted a meeting of hospital and public health
experts with HHS staff. "We knew who to invite," O'Toole
says. "That's the kind of thing the Center can do."
For the Center and the nation, studying bioterrorism in the abstract
is no longer possible. Fast yet methodical preparation across a
range of public health fronts is demanded because tomorrow's bioterrorism
may look very different from last fall's anthrax terrorism. Inglesby
warns: "As we've said before, it was the preface to the story.
It was not the whole story."