[00:00:00] President George W. Bush Good morning. As all Americans know, recent weeks have brought a second wave of terrorist attacks upon our country, deadly anthrax spores sent through the U.S. Mail. There’s no precedent for this type of biological attack, and I’m proud of the way our law enforcement officers, our health care and postal workers, and the American people are responding in the face of this new threat. At this point in our investigation, we have identified several different letters that contained anthrax spores. Among them were the letters mailed to Senate Majority Leader Tom Daschle on Capitol Hill, NBC News in New York, and the New York Post newspaper. Four Americans have died as a result of these acts of terrorism. At least 13 others have developed forms of anthrax disease, either in the lungs or less severely on the skin.
[00:00:52] Narrator That was a part of a radio address delivered by then-U.S. President George W. Bush on November 3, 2001, in response to the anthrax attacks, when letters containing spores of anthrax were mailed out to several media outlets and two senators, resulting in the deaths of five people. Beginning only one week after the attacks of September 11, 2001, the anthrax attacks were many Americans’ first encounter with bioterrorism, and the potential for pathogens to be used deliberately to harm and compounded an already growing fear of terrorist attacks on U.S. soil. Welcome to Countermeasures. This season, we’re looking back at historic public health outbreaks and bioterrorism events. From the Black Plague to the 2001 anthrax attacks, we’re looking across the span of time to uncover how we have responded to health threats, what we’ve learned, and what we still have to do. On October 4th, 2001, Bob Stevens, an employee at a newspaper in Florida, was hospitalized with inhalation anthrax, passing away the next day. This was the beginning of a sequence of letters that were sent to journalists and politicians containing spores of anthrax-causing bacterium. Dr. Paul Keim is a distinguished professor, geneticist, and microbiologist. During the anthrax attacks, his lab played a critical role in providing the U.S. Military and intelligence community with cutting-edge assays for biological weapons that proved critical to the investigation. Paul first heard about the first Anthrax case while sitting in his office.
[00:02:31] Dr. Paul Keim I was sitting in my office and I got a call from an FBI scientist named Doug Beecher. I mean, this was just in the week or so after 9/11, and so it was a very sobering time for everybody. Yeah, I was used to getting calls from the FBI, so that part wasn’t so startling, but Doug said, we have a case of anthrax in Florida, have you heard of it? I said, no, he said, it is making the news, but it wasn’t obviously the headline news in the wake of 9/11. And he said, you know, we don’t understand it. We don’t understand why this gentleman has gotten anthrax. He lives in Florida. He, he doesn’t have a high risk occupation. He’s not a veterinarian. He works for a publishing house that produces tabloid newspapers like the National Enquirer, and it just doesn’t make any sense to us. And so he was seeking out my opinion as an expert in anthrax and it didn’t make any sense to me either. So no, it was a mystery. We absolutely had no idea why this gentleman had acquired anthrax at that point.
[00:03:36] Narrator For most Americans, the anthrax attacks were their first time hearing about the disease entirely. Anthrax is caused by Bacillus anthracis, a spore-forming bacterium whose spores can lie dormant in soil for decades before germinating, a property that makes it high risk for misuse as a biological weapon. It was Paul’s lab that identified the strain responsible for Bob Stevens’ death as the Ames strain, a variety found exclusively in laboratory settings. That single finding shifted the investigation decisively. This was not a natural case. Someone had done this deliberately.
[00:04:14] Dr. Paul Keim We didn’t really fully appreciate how widespread the Ames strain was in those first few days or weeks after we identified it. There was lots of misinformation. For example, the name itself is named after Ames, Iowa, where there’s a large veterinary laboratory there. And so everybody in the community, except for maybe two people, just assumed that this strain had originated in Ames, Iowa. And that was totally false. It originated from a dead cow in Texas in 1981. The veterinarian who harvested the sample and sent it to the U.S. Army Lab in Maryland used a box that he had received from the Ames, Iowa lab. And when it got to the lab in Maryland, they saw Ames Iowa on the box and just named it the Ames strain. And so that knowledge about where it was and where it came from was very murky at the beginning. We knew it was a laboratory strain. We didn’t know if it existed widely in nature at that point. And so, you know, when I reported that it was the Ames strain to the policymakers and the investigators, pretty much as it went up the ladder all the way to the president of the United States over the next few hours, it got turned from this is probably a laboratory strain that matches the laboratory strain to this is a laboratory strain. And so that uncertainty about what I knew and other investigators knew at the ground level definitely was not communicated up the chain of command to the directors and secretaries of these different agencies. As it turned out, we were right. It was a laboratory strain.
[00:05:58] Narrator Dr. Daniel R. Lucey is an American physician, researcher, clinical professor of medicine of infectious diseases. At the time of the attacks, he was the chief of infectious disease service at the largest hospital in Washington, D.C.
[00:06:12] Dr. Daniel R. Lucey The first time I heard about anthrax as a confirmed infection was October the 2nd, a Tuesday. And I saw it on the news, on CNN, where it said there was a patient somewhere in Southern Florida that had inhalational anthrax and anthrax meningitis. And he unfortunately passed away. But there was a press conference very soon after that by the U.S. Government and a cabinet level official said that the patient in Florida, was not infected with anthrax because of bioterrorism, but because he was quote, an avid outdoorsman, end quote. And he had gotten the anthrax from drinking out of a stream in North Carolina, where he and his wife had driven from their home in Florida up to see their daughter in college in North Carolina. And that alarmed me a lot because there I knew there was no anthrax in any streams in North Carolina. There’s anthrax in the soil between Texas and North Dakota, the old cattle drive trails, but not in the water in North Carolina. So that really worried me a that a lot. And then, of course, in D.C., what was found, to everyone’s great surprise, an alarm, was that there were letters to two U.S. Senators and the letter to Senator Leahy, if I recall correctly, was delivered to his office in the Senate Hart Building on Monday the 15th of October and the white powder was found when the letter was opened and quite a few people were exposed in that room, not the Senator but others, and nasal swabs were performed by the Office of the Attending Physician, the OAP to Congress, which was led by Navy Admiral who I knew and respected a lot, Admiral John Eisold. By Wednesday, the 15th of October, I think it was initially reported 17, but then 15 confirmed nasal swabs from 15 people were growing anthrax spores. So that was very, very alarming.
[00:08:11] Narrator The letters themselves seemed calculated to deceive. Two contained notes reading Death to America, marked with the date 9-11-01, an apparent attempt to implicate a terrorist group in the immediate aftermath of the September 11 attacks. Meanwhile, the spores kept spreading. Postal workers handling the letters at facilities in Hamilton Township, New Jersey, and Brentwood, Washington, D.C. Were exposed without knowing it. Two Brentwood employees, Thomas Morris Jr. and Joseph Kersine died of inhalation anthrax, the most dangerous form of the disease.
[00:08:46] Dr. Paul Keim The most common form of anthrax is cutaneous anthrax, but the most deadly form is inhalational anthrax that you get from breathing in. You know, very similar to how you acquire COVID is how you would acquire a deadly form of pulmonary anthrax. When you breathe the spores in through your nose and they get deep in your lungs, the spores then germinate in your lung and that vegetative growth that comes out of that sporulation then takes over very rapidly. And in an inhalational case you probably only have two or three days of life left before it takes over. It moves from your lungs, it goes systemic throughout your entire body. A little bit that has to do with your dose, whether you get a large dose or a small dose. You know, militaries that developed anthrax spores as a biological weapon, And they worked real hard at making spores that were very small in size that they would get deep into your lungs. They didn’t catch on your nose or your mucous membranes in your nose that they would get deep into your lung where they could germinate. Anthrax actually takes quite a few spores to cause disease, at least in a healthy person. Maybe as many as five or ten thousand spores have to get deep in your lungs.
[00:10:02] Narrator The U.S. and global community were aware of the risk of bioterrorism prior to 2001. In 1975, the Biological and Toxin Weapons Convention entered into force, which prohibits the development, production, and use of biological weapons. However, the anthrax attacks were a significant turning point in global awareness, bringing bioterrorism to the forefront of national security.
[00:10:27] Dr. Daniel R. Lucey During President Clinton’s administration, there was a U.S. National, I think it was called the National Pharmaceutical Stockpile or something like that, which subsequently became renamed as the Strategic National Stockpile. So that was to prepare for, you know, biological or other types of attacks. But it was still very modest I think in size. The other major thing that is worth noting is that at Johns Hopkins, there is a group that, I don’t remember their exact name at the time, but they were focused on logical attack preparedness. And they put out a document in the Journal of the American Medical Association. It was specifically for civilian, not military, but civilian preparation. And subsequently, they produced a number of documents, including one for Anthrax preparedness, one for plague, one for tularemia, and a few other diseases. I knew a number of those people, for example, D.A. Henderson at Johns Hopkins at the time. So I was, you know, reading that information and some of it came from Fort Detrick. The anthrax expert there is Dr. Art Friedlander. They produced a whole issue, a special issue on bio-preparedness in the Journal of American Medical Association. I used that for preparing for the NATO 50th anniversary in 1999, and then the morning of 9/11, I went to the hospital library and got out that issue and compared it with the notes that I have from 1997 and putting together that one page handout. So I would say that I, I’m sort of an outlier. I was an outlier at the time in terms of preparedness, but there were some, you know, in retrospect, sort of warning signs or preparedness, you know signs, but I would that that’s very important. It’s good to have high level distinguished groups of people putting out, you know, guidelines.
[00:12:22] Narrator Paul himself was interviewed by the FBI as they narrowed their focus on the scientific community.
[00:12:28] Dr. Paul Keim They sent in an investigative team and that this happened maybe about a week to two weeks later that came in and started interviewing us, interrogating might be a better word, interrogating us as to where we were when the letters were sent, did we hate the government? Did we hate whoever, you know? And so those types of questions and of course, the people in Flagstaff, Arizona, which is six hours flight from the East coast, we had lots of alibis. Okay, so we were taken off the list. I mean, I don’t think we are ever seriously suspected of doing this, even though we had the Ames strain, but they went through and very thoroughly made sure that we were not of the mind to do it or had the mechanism to go to the East Coast and do it. If it takes six hours to fly, it’s gonna take four days to drive. And so you couldn’t go missing for eight days to get there and back, right? So we were under suspicion, but it was a pretty light touch compared to what happened to people on the East Coast, especially at the U.S. Army Medical Research Laboratory that became the focus later, where the interrogations were very intense. I had friends who were interrogated by the FBI as part of this and said they would never do it again.
[00:13:44] Narrator It wasn’t until 2008 that the FBI announced it had concluded that Bruce Edward Ivins, a biodefense researcher at the U.S. Army Medical Institute for Infectious Diseases, was the sole perpetrator of the attacks. These conclusions have been contested by some. Paul knew Bruce Ivins.
[00:14:02] Dr. Paul Keim The spores weren’t all identical with each other. They had mutations in them. And that repertoire of mutations in the spores that came from the letters was then used to look at all the different laboratory strains that we collected through the subpoena process. And as that process narrowed down the different sources of the Ames strain. The focus became on one particular flask that was at the U.S. Army Research Lab in Maryland called RMR-1029. RMR-1029 was owned, was developed and owned by a scientist named Bruce Ivins. Dr. Ivins was a premier anthrax researcher. He was one of the leading figures in developing new vaccines for testing antibiotics as therapeutics against anthrax. And so he was a part of our community. He and I worked together on a number of different projects, and frankly, I was very surprised when I found out from the FBI that he was the focus of their investigation. As you can imagine, when the FBI investigates things, they compartmentalize the investigation. So my job was to do the DNA analysis. They didn’t tell me who the suspects were. I thought about who might’ve done it. I actually turned in a few of my colleagues, saying, hey, he might’ve done it. Turned out I was wrong. But for the most part, I was focused upon my task. And so I think it was April 2008, I met with the FBI and the Department of Justice and they started showing me emails that I’d exchanged with Bruce Ivins about who might’ve sent the letters about the nature of the spores. And what they were figuring out is if I inadvertently tipped Bruce Ivins off about what we were doing, our ability to identify different sub-variants within the spores. They’re trying to develop a timeline because he had some suspicious activities that appeared like he was trying to cover his tracks and they were trying to match that timeline with my communications with him. And in the process of doing that, of course, they had to tell me that they thought Bruce was the one that had sent the letters and that was a shock. Bruce was a very amiable, very good scientist. I’d worked with him on many different committees and different projects. We communicated on a regular basis. And so while I thought I knew Bruce really well, there was another side of Bruce that I didn’t know. And as it came out later, Bruce had some, had a dark side. You know, he had demons for sure that were haunting him. And something about 9/11 must have triggered that. And so we believe, the FBI believes, and I believe that Bruce sent the letters. I mean, there’s mostly circumstantial evidence, but it’s strong circumstantial evidence that I think would have held up in court if we’d ever gone to court. Of course, Bruce committed suicide a few months after I learned about this and at that point then the investigation really zeroed in. It became a little more public as well. Again, even myself as inside the investigation didn’t know who the suspects were. And so that investigation moved forward. The FBI continued to kind of tie things together for maybe a year after that. And then eventually they closed the case. And sometime after that, they actually destroyed all the evidence. So all those samples, all those spores from the letters, those were incinerated and they’re gone. I actually regret that because we have technology now that would allow us to analyze those mixtures. In much more convincing fashion than we had in 2005, 2006, when we did the analyzes originally. I think we could have, assuming that it really was RMR-1029, we would have nailed that down very, very, in a very dramatic fashion with today’s technologies.
[00:18:04] Narrator Bruce Ivins died by suicide in July, 2008, weeks before he would have been charged. The FBI closed the case shortly after, but the attacks had already exposed something that couldn’t be closed quite so easily. The fragmented state of America’s bio-defense infrastructure. Dr. Asha M. George is the director of the bipartisan commission on bio-defense at the Atlantic Council’s Scowcroft Center for Strategy and Security.
[00:18:33] Dr. Asha M. George It’s true, the anthrax events of 2001 showed how fragmented and really, I don’t want to say siloed, but separate activities were throughout the entire federal government and really also across the private sector. It’s not even an issue of people not talking with each other as much as it was this vast array of responsibilities across all these different offices and agencies and companies. And in the end, it became very, very difficult to coordinate. How do you coordinate when you’re not sure what everybody else is supposed to be doing, number one, and number two, you’re not even sure who all of the everybody else is in the first place. We took a look, the Bipartisan Commission on Biodefense took a look at the anthrax events of 2001 to see which critical infrastructure sectors were involved. And I think it’s 15. Something like that, 15, 16 of the sectors were somehow involved, somehow affected. You have to remember, each one of those critical infrastructure sectors has at least one government agency that’s responsible for dealing with the owners and operators of the critical infrastructure in those sectors. It was vastly complicated, difficult to coordinate, and for a while there, we just had entities, people, things bouncing off of walls trying to get a handle on what was going on back then.
[00:20:06] Narrator The attacks did prompt significant changes in how the U.S. approached biodefense.
[00:20:11] Dr. Daniel R. Lucey I think with regard to changes, because of and temporally related to the anthrax attacks of September and October of 2001, and then fear about smallpox, which fortunately never materialized, I think that there was a sea change, an immense change, in concern about bioterrorism and the threat and preparedness, but also related to war in Iraq. I think it was around March 23rd of 2003 or so that U.S. went into Iraq and there was a lot of concern that there’d be, you know, bioterrorism attacks again. So there was, there was this immense emphasis on preparing much, much better for anthrax, but also plague, smallpox, tularemia. The CDC put out guidelines they call category A bioterrorism agents. And then later category B, there were six category A, broadly speaking. I made up an acronym and produced a color guide for clinicians, everything you needed to know on one page about the six agents. I called it BPAST, P-A-S-T, so it was botulism, Ebola, plague, anthrax, smallpox, and tularemia. And then there was the CDC category B agents, and there were 17 of those. And again, I produced a document that was shared widely and translated into multiple languages.
[00:21:34] Narrator Asha believes that in general, public health officials did a good job of communicating to the public, although there are lessons that could be learned.
[00:21:43] Dr. Asha M. George I don’t think that the quality of information that people were giving out in a cautious manner was too bad. I don’t think that that was bad. I don’t think people were withholding that much. It’s kind of difficult to withhold a lot of information when the attacks were occurring out in the public in the first place. You know, it was kind of hard to hide. It was hard to hide the first letters that went down to those media. Offices in Florida, and then equally hard to hide when the letters started appearing in New York, also with media, etc. At some point, it’s just out there. And then there were the cross-contamination issues with normal citizens. It started out as something that could not be overly controlled in terms of how much information was going out in the first place. That said I think the bigger issue was incorrect information being put out, when it was being put out. It’s one thing to qualify and say, this is the best information we have right now. This is the best we know right now and tell people like it could change. In that case, we had spokespeople out who really didn’t necessarily know what they were talking about, or they were speaking from their level of understanding. The Secretary of Health and Human Services at the time, Tommy Thompson, was talking about anthrax and riverbeds and just providing information that just wasn’t accurate information. That’s not good. I actually don’t blame him. He was speaking from his understanding, but this is why you want somebody who is necessarily an elected official or an appointed official serving as that spokesperson, somebody with the appropriate background to understand the science, the data, the information that they’re getting in the first place, and the ability to communicate and synthesize that information and then communicate it back out to the public. I don’t think that cabinet-level officials are necessarily the best people to do that, and I don’t think Secretary Thompson was back in the day. But I want to be clear. He wasn’t trying to put out bad information. He was putting out information that he thought was correct on the basis of his own understanding.
[00:24:17] Narrator In 2001, sequencing the genome of a single anthrax sample cost half a million dollars and took weeks. Today, that same process costs a fraction of that and can be completed overnight. The science that made the anthrax investigation possible has been revolutionized, and with it, the speed and precision with which we could respond to a similar attack today.
[00:24:42] Dr. Paul Keim You know, we have gone from, you know, the 500,000 dollar genome, that’s what it cost to sequence the genome of a Bacillus Anthracis back in 2002, to, you now, the 10 dollar genome. I don’t know, if the cost of sequencing a genome is so small now, we don’t even think about it. We just sequence hundreds. We got 100 strains that need sequencing, just do it, then. And it doesn’t take weeks and weeks to get it done. We can do it overnight. So the obvious approach to the same problem is to use whole genome sequencing. You still need to develop the big data sets, you know, you need to have those strain collections. And, but because we can sequence every single nucleotide in the genome with great precision, the databases become so much more valuable.
[00:25:32] Dr. Asha M. George So many years had gone by. I don’t think there was a lot of, you know, hysteria and mayhem or upsetedness or even that much concern. It might have been different, I think, if we had got those revelations, like, within a month or two, not years later. You know, that said, there are still questions to this day as to whether Bruce Ivins acted alone to perpetrate these events or you know, whether he was part of a group or whether it was him at all. Certainly there’s evidence to show the anthrax that was used in those letters does seem to have been proven to have come from his laboratory, USAMRIID, the U.S. Army Medical Research Institute for Infectious Diseases. But there are a lot of questions about intent and motive. And why, why didn’t anybody pick up on it? It’s odd enough for people to this day, experts to this day to say they’re just not entirely sure. You know, I personally, if I had been the FBI director at the time, I don’t think I would have closed the case. I don’t that everybody even inside the FBI agrees that the case should have been closed. But at the same time, you know, we talk about spending taxpayer dollars and how long do you let it go? How long do you keep working on it and working on it? Somebody made a call. Somebody made the decision. And we just all sort of said, okay. If it does, it would be interesting to apply today’s science, today’s forensic capabilities, to the material we had from before to see what new information we might be able to get.
[00:27:19] Narrator Asha reflected on the attacks and the level of preparedness we have today, 25 years later.
[00:27:24] Dr. Asha M. George We have better medical countermeasures, we have better diagnostics, we have better surveillance mechanisms, we have better detectors. Some cases, those things have made them made it into the strategic national stockpile for the United States. In some cases, things have improved, but in some cases not. The nation’s BioWatch, you know, biological detection system is terrible. It’s old technology from back in 2003 in response, in part, to the Anthrax events of 2001. They just never improved, never, never over all of these years. So I would say, as is usually the case, when you have a precipitating event, of course, we respond immediately, we want to save lives. People are all focused on what needs to happen. But with the passage of time, with nobody else dying from those events, with the FBI closing the case, et cetera, people move on. There are other threats to deal with and other threats beyond biological threats to be dealt with, and that’s just the nature of it. I think that 25 years later, there’s plenty of work that still needs to be done. And some of the things that we have done need to be maintained and or implemented in the first place. The Bipartisan Commission on Biodefense recommended, for example, a national biodefense strategy. Requirement for that was signed off on by President Obama. It had made its way into the National Defense Authorization Act. So he signed that, but his administration did not produce it in the last year of his administration, what the Trump administration did thereafter, which was great, but then they didn’t use it to help with the COVID-19 situation. And I’m not trying to equate COVID with anthrax, but the point is they just, they didn’t use it. Does the strategy exist? Yes. Are there efforts and things in place? Like some things still left in the strategic national stockpile, some grants still going out for public health preparedness? Yes. Are those things adequate? Have they been fully implemented? Have they been maintained? Do they get the same amount of funding that they did before? The answer is no.
[00:30:00] Narrator Five people died, 17 were sickened, and a public health system that had never faced bioterrorism at this scale was forced to confront its own gaps in real time, in its laboratories, its hospitals, its communication strategies, and its quarters of power. Twenty five years later, those gaps have narrowed. But as the experts we spoke to made clear, the work of public health preparedness is never finished. It requires sustained investment, clear communication, and the political will to keep preparing for threats that most people would rather not think about. Thank you for listening to Countermeasures. If you enjoy the show, please consider leaving us a rating or review. Thank you to our guests for taking the time to share their insights. If you found this episode insightful, please share it with colleagues and friends. And don’t forget to subscribe so you don’t miss future conversations.