Dual Use or PoorIn their Viewpoint in the July/August 2000 issue of Public Health Reports, M. R. Fraser and D. L. Brown express concerns about the risk of bioterrorism and the adequacy of bioterrorism preparedness.1 They are not alone.

Bioterrorism appears regularly on public health conference agendas, government advisories, and lists of health care challenges. The US federal budget for fiscal year 2000 allocated more than $10 billion to counter terrorism, including more than $1.5 billion specifically for bioterrorism.2 Enormous attention in the media as well as medical and health journals reflects, and perhaps amplifies, widespread concern. But is this concern justified?

Fraser and Brown list a number of potential threats to public health: food inadvertently contaminated with hepatitis A virus; a large outbreak of influenza; water pollution caused by floods; “the willful contamination of food products with Salmonella*; and a “terrorist’s release of aerosolized Bacillus anthracis (anthrax) in a city center.”1 This list mixes fact and fiction and requires closer attention. Virus contamination, flu outbreaks, and water pollution are three of many public health problems that actually occur in the US every year and claim hundreds or even thousands of lives. In contrast, willful Salmonella contamination is not a common problem. Rather, mention of this potential threat is a veiled reference to the only documented bioterrorist episode ever to take place in the US—a solitary incident in Oregon in 1984 that caused 751 mild illnesses and no deaths.3 Inclusion of an anthrax incident is even more misleading since it is totally fictional. No such incidents have occurred, and the likelihood of one occurring is remote. Militarized anthrax spores are so difficult to manufacture that only a handful of countries with large military-industrial establishments (including the US and the former Soviet Union) have ever developed the capacity. It is highly unlikely that military establishments with any hypothetical stockpiles would share these with terrorist organizations outside their control. Anthrax spores are difficult and dangerous to handle, and would-be users may be more likely to hurt themselves than others.4 Despite numerous fictional scenarios, hoaxes, and false scare stories about anthrax being readily available through the Internet, the fact remains that there has never been a confirmed use of anthrax spores, anywhere, by anyone, in a military or terrorist attack.

Proponents of bioterrorism preparedness must rely on fictional scenarios since real cases of terrorism using biological or chemical agents have been so exceedingly rare. In addition to the aforementioned Oregon incident involving a biological agent, there have been only two recent documented episodes of terrorism using a chemical agent—both carried out by the Aum Shinrikyo cult in Japan using sarin nerve gas in 1994-1995, resulting in a total of 19 fatalities.5
Can three incidents in almost 20 years with a total of 19 deaths constitute a major threat to public health? Compare those numbers to the real challenges our health system faces. In the United States alone, an estimated 76 million illnesses from foodborne disease occur each year, resulting in 325,000 hospitalizations and 5,000 deaths.6 Each year in the US there are approximately 60,000 chemical spills, leaks, and explosions, of which about 8,000 are considered “serious,” resulting in about 300-400 deaths.7 Despite these staggering numbers, neither foodborne disease nor chemical spills has received a fraction of the publicity and attention given to bioterrorism.

Fraser and Brown argue that funding bioterrorism preparedness programs “…should allow for the development of a dual-use response infrastructure that improves the capacity of local public health agencies to respond to all hazards…!’1 They further state that “using bioterrorism initiatives to build the  capacity of local public health systems is an efficient and effective use of limited public health resources.