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LETTER |
D. A. Henderson is with the Johns Hopkins Center for Civilian Biodefense Studies, Baltimore, Md.
Correspondence: Requests for reprints should be sent to D. A. Henderson, MD, MPH, Johns Hopkins Center for Civilian Biodefense Studies, The Johns Hopkins University, 111 Market Place, Suite 850, Baltimore, MD 21202 (e-mail: dahzero{at}aol.com).
I was astonished to learn from Fee and Brown's article on preemptive biopreparedness1 that beginning in the 1950s, Dr Alex Langmuir's stress on biopreparedness efforts fed the Cold War climate, narrowed the scope of public health activities, and failed to achieve sustained benefits for public health programs across the country. They point out that as "funding for biological warfare research was increasing . . . funds for local health departments were cut sharply. Jobs in public health departments went unfilled for long periods" and "enrollments in schools of public health declined."1(p725) To suggest that this sorry state of affairs was, in some manner, attributable to Langmuir's biopreparedness efforts taxes credulity. I would remind Fee and Brown that during these same years, the number of telephone poles increased sharply, but I wouldn't suggest that this, in some manner, served to precipitate the demise of public health.
It is fact that during the 1940s and 1950s, there was little Public Health Service money spent on biological weapons programs or research and little activity devoted to it. I joined Langmuir's Epidemic Intelligence Service (EIS) in 1955. Of the 50 or so EIS officers at that time, there was exactly 1 who worked part-time in the evaluation of a new anthrax vaccine among workers in goat-hair processing plants. Virtually all others were working either at the Centers for Disease Control or in state health departments endeavoring to bolster infectious disease reporting and control or participating in studies of the new polio vaccine. During the 4-week orientation training, there was only a 1-hour lecture on biological weapons, and that was dropped a year later. Note that the annual cadre of EIS officers was substantially smaller than the number of new enrollees in just 1 school of public health. They were, in fact, an inconsequential fragment of the total available public health manpower.
Certainly, the status and strength of public health waned after World War II as a result of many different factors. Of significant importance were developments in biomedicine and society that dramatically changed the health environment. New vaccines and antibiotics, along with improved housing and sanitation, altered the infectious disease burden and this, along with improved drugs and surgery, shifted the focus toward curative medicine. It is also fact that faculties of schools of public health became increasingly preoccupied with academia and less with the practice of public health, a factor that undoubtedly contributed to a less vocal and articulate public health presence.
Amidst all of this, there was a notable beacon, and that was Alex Langmuir, one of a diminishing number of passionate advocates and public health practitioners. As Fee and Brown note, Langmuir defined and stressed the principle of surveillance—a concept and approach whose importance is now widely recognized internationally but was unknown as such in the 1950s.2 He believed that it was important to establish effective international, national, and local reporting systems to monitor and analyze, on a continuing basis, the epidemiologic patterns of infectious diseases so that strategies and resources could best be applied in a timely manner to prevent and control disease. Today, we accept this as an obvious precept of good public health management. Then, it was a new and different concept. By 1968, it was considered to be of sufficient importance to warrant asking Langmuir to lead special technical discussions on the subject at the World Health Assembly.3
By 1961, Alex had started a surveillance program for leukemia (the first of its kind) and, a few years later, a program to monitor family planning data.4 It was noted then that Alex's EIS officer was the only public health service officer engaged in family planning. So much for allegations of his narrow focus. However, I am pleased that Fee and Brown believe that "[n]either Langmuir nor the biological warfare establishment can be held responsible for all that was lost to public health in the late 1940s and early 1950s" [emphasis added].1(p725)
Should we be concerned about bioterrorism today? From Fee and Brown's superficial explication of the threat, it might well appear that the concerns are only déjà vu. Regrettably, however, the world has changed, making the prospects for use of such weapons far more likely than ever before. Many of these reasons have been reviewed elsewhere.5 Curiously, however, Fee and Brown's article makes no mention of the most serious development of all. With the Biological Weapons Convention, which came into force in 1972, essentially all countries agreed to cease research on biological weapons and to destroy existing stocks of material. One notable exception was the former Soviet Union, which undertook to develop a greatly expanded research and production capacity. That enterprise eventually involved some 60 000 people and 50 laboratories.6
The science of biological weapons was advanced significantly in the former Soviet Union, but at a price. Included in that price were some 100 fatalities in Sverdlovsk when anthrax spores were accidentally released into the environment from a bioweapons production center. Many of the Russian scientists have now dispersed to other countries, bearing with them expertise and, undoubtedly, some of the special strains they developed. At least 10 countries are now engaged in developing and producing biological weapons. What with the growing power of biotechnology, one has to anticipate that this technology, like all others before it, will eventually be misused.
Meanwhile, as we review the nation's capability to respond to a medical or public health catastrophe, whatever its source, we discover a tattered, seriously underfunded public health infrastructure and a medical care system that is taxed today by even a small outbreak of influenza, that is suffering severe shortages of health care personnel, and that regularly experiences shortages of the most common antibiotics. Were a new strain of influenza to explode in pandemic form—were 100 acutely ill persons to appear over a 1- or 2-day period in any emergency room—present systems would be overwhelmed. This, unfortunately, is fact. With the ability of organisms to move readily and rapidly around the world, we can no longer count on living in a fortress home protected from naturally occurring or manmade threats by the Atlantic and Pacific oceans.
Drs Fee and Brown, we are living now in the 21st century, and it is a different world than in 1950. Worries over biological preparedness may appear to be of little relevance to you, but to those of us concerned with the health of our own and the world's population, they are anything but.
Accepted for publication August 17, 2001.
References
1. Fee E, Brown TM. Preemptive biopreparedness: can we learn anything from history? Am J Public Health.2001;91:721–726.[Abstract]
2. Langmuir AD. Evolution of the concept of surveillance in the United States. Proc R Soc Med.1971;64:681–689.[Medline]
3. National and Global Surveillance of Communicable Disease. Report of the Technical Discussions at the Twenty-First World Health Assembly. Geneva, Switzerland: World Health Organization; May 1968. Technical Discussions of the 21st Assembly, Working Paper 5.
4. Ethridge EW. Sentinel for Health: A History of the Centers for Disease Control. Berkeley: University of California Press; 1992.
5.
Henderson DA. The looming threat of bioterrorism. Science.1999;283:1279–1282.
6. Alibek K. Biohazard. New York, NY: Random House; 1998.
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