On September 30, 2001, Robert Stevens, a sixty-three-year-old photo editor at the supermarket tabloid the Sun, published in Boca Raton, Florida, began feeling ill on the last day of a five-day vacation at his daughter’s home in North Carolina. He was admitted to the John F. Kennedy Medical Center emergency room in Palm Beach County, Florida, on the early morning of October 2. He was disoriented and vomiting, had a high fever, and was unable to speak. Multiple tests conducted over the next two days at the hospital labs, the State of Florida, and the CDC confirmed that he had anthrax, a disease caused by a bacteria called Bacillus anthracis that predominantly infects animals but can cause serious and even fatal disease in humans. Although rare, cases of inhalational anthrax (spores of the bacteria being inhaled and entering the lung) occur sporadically without much public notice. Given the proximity of this event to the 9/11 attacks and the growing concern within the administration and among the general public about the possibility of bioterror attacks on our country by al-Qaeda sleeper cells, bioterror as a possible cause of Mr. Stevens’s illness was on almost everyone’s mind.
What unfolded over the next several months thrust me front and center into an escalating national state of anxiety and crisis. In addition, it brought Secretary Thompson and me closer together as colleagues and friends, an unusual relationship between a cabinet secretary and a director of one of the many institutes within a department of which he was in charge. It was typical of Thompson to pick out a small group of people whom he trusted and make them his go-to team. I, together with a young attorney named Stewart Simonson, one of the inner circle that he brought with him from his Wisconsin governor’s office, became his closest confidants. During this extraordinary period of national crisis, Stewart and I also grew closer, a relationship that has lasted to this day. Stewart, Christine, and I, along with John Gallin, then director of the NIH Clinical Center, and his wife, Elaine, still spend every New Year’s Eve together celebrating with a late-night dinner at my home.
Almost every day for weeks, and even months, a new surprise heightened public anxiety and confusion. The media, with strong encouragement from the White House, turned to me for answers to questions concerning anthrax. This soon became almost all-consuming because, unfortunately, the anthrax issue did not end with Robert Stevens, who died on October 5.
The assumption was that this was an attack by al-Qaeda and there would be more, possibly with other bioterror agents such as smallpox and botulism toxin. This concern was intensified after October 7, 2001, when the United States together with the British invaded Afghanistan in Operation Enduring Freedom to hunt down the 9/11 mastermind, Osama bin Laden, and expel al-Qaeda from the country. The conventional wisdom at HHS and the White House was that al-Qaeda would likely intensify its efforts to attack the United States with biological weapons as payback.
Even though the evolving anthrax situation was causing great uncertainty, the White House began to fear that the next bioterror attack would be with smallpox. The reason for this concern was that smallpox had been declared by the World Health Organization (WHO) to be eradicated in 1980 and most of the world had stopped vaccinating for smallpox years earlier. For example, routine vaccinations for smallpox were halted in the United States in 1972 since the risk of adverse events from the vaccine was judged to be far greater than the risk of contracting smallpox in an era of essentially no naturally occurring smallpox cases. Thus, the majority of people younger than thirty living in the United States and most other countries were now vulnerable to smallpox because they had not been vaccinated. In addition, the supply of smallpox vaccinations in our Strategic National Stockpile contained only fifteen million doses, certainly not enough to address a massive outbreak of this deadly disease. HHS focused on setting up contracts to manufacture the next generation of smallpox vaccines. The question we had to face was whether the United States should preemptively vaccinate the general public in anticipation of a smallpox bioterror attack if and when enough doses became available rather than wait for an attack. To answer that, Tommy Thompson asked me to work with several smallpox experts to develop a plan on how we might best protect ourselves against a potential smallpox attack. Paramount among them was Dr. Donald Ainslie (D.A.) Henderson, a legendary public health figure who had led the WHO’s successful effort to eradicate smallpox from the planet. Our challenge now, besides expanding our smallpox vaccine supplies, was to begin developing an antiviral drug for smallpox. No small task.
The situation with anthrax was quite different. We had been routinely administering our anthrax vaccine to personnel in the U.S. armed forces. In addition, there were several highly effective antibiotics against anthrax, most prominently ciprofloxacin, referred to as Cipro. The effort against anthrax was concentrated on increasing our supplies of vaccine and stockpiling large amounts of Cipro.
These discussions were not merely academic. Virtually every day new cases of anthrax were popping up in New York City, Washington, D.C., and Connecticut, the pattern of which became clear only in retrospect. Utter confusion and even panic prevailed. By the third week of October, there had been nine cases of anthrax with one death from inhalation, two additional serious inhalation anthrax cases, six cutaneous cases, and about forty cases of documented exposures who had not yet shown signs of infection. The exposures were predominantly related to people who might have handled mail because by this time it was becoming evident that the method of attack was sending highly infectious anthrax spores through the postal system. The machines that sorted the mail were demonstrated to push out an invisible puff of spores into the mail rooms, putting postal workers in these facilities at risk. The Senate majority leader, Tom Daschle of South Dakota, and Senator Pat Leahy of Vermont had received anthrax-spiked letters addressed to them, exposing several of their staffers to the spores.
It is amazing what your adrenaline can allow you to do. For a period of several weeks, on a good night I got only four hours of sleep purely because of the demands on my time that inevitably pushed late into the night. When I did get to bed, my mind was running like an engine in overdrive. I often found myself staring at the ceiling playing out what happened during that day and anticipating the events of the next day. It is difficult to describe to young people now who were not yet born or who were too young at the time what it felt like to not know when there would randomly be another attack that could harm or kill. Superimposed on this was the responsibility that Tommy Thompson and White House officials had put on me to oversee the development of countermeasures for anthrax and other potential agents of bioterror. Time was not on our side, to say the least, as more and more cases of anthrax appeared.
My nature has always been to remain calm under very difficult circumstances. I can get animated and annoyed over trivial things like getting caught in a traffic jam, yet, when important issues are at stake, I am totally focused and unemotional. I imagine that this characteristic was fine-tuned during my internship and residency training, where I was always extremely busy taking care of some of the sickest patients in New York City. The on-call schedule imposed on interns and residents at that time was nothing like it is today. For better or worse, we were formally on call every other day, every other night, and every other weekend, and on your on-call day or days (if it was a weekend) you rarely got any sleep. In addition, if your patient was critically ill, you did not leave their bedside until you stabilized them as best as you could. Every once in a while, the intern or resident in your rotation got sick with the flu or some other infection that put them out of action. The solution was that you just continued to be on call without relief. This happened to me a few times during my residency training, and I found myself simultaneously taking care of several critically ill patients with little or no sleep for days in a row. As surprising as that may seem to an outside observer, and I am certain that this does not apply to everyone, I was at my best under those circumstances. The sicker the patients and the more stressful and demanding the challenges, the better I functioned. The stakes were high; failing to rise to the occasion was definitely not an option.
I felt just like that many times during those weeks in October and November 2001. I can remember one day in late October when my basic physiology and emotions slipped temporarily out from under the umbrella of the adrenaline surge. After spending the entire day at HHS and the White House in intense meetings, I returned to my office at the NIH since I also needed to discharge at least some of the duties of my day job as NIAID director. At about 2:30 a.m., I finally left my office to drive home. As I got off the elevator in the lobby of Building 31 and walked the short distance toward my car, suddenly and without warning I broke into tears. It is a good thing that it was the middle of the night because I would have been terribly embarrassed if any of my colleagues had seen that. However, after about a minute and a half, I felt fine, and the brief outburst reminded me that indeed I still could express genuine human emotions despite a job that required that I remain as cold as ice.
On Sunday, October 21, 2001, I appeared on NBC’s Meet the Press, moderated by Tim Russert, to talk about the broad issues of bioterrorism and the U.S. government’s biodefense efforts. After an extended discussion about our preparedness against potential attacks, and as the segment came to a close, Tim had one final question: “Take thirty seconds and tell the country how they should deal with their anxiety about bioterrorism.” My response centered on a message that I would repeat again and again on countless future media appearances in slightly different ways. The gist of my message was that there was reason to be concerned and there would be some understandable anxiety. But we should not push ourselves over the edge to panic. We should productively channel that anxiety and concern into heightened alertness and preparedness. The purpose of the bioterrorist is to instill terror, and we should not aid them in their goal.
As intense fear of the possibility of other imminent bioterror attacks unfolded and the FBI began a yearslong investigation to determine who was perpetrating the attacks, unexplained anthrax cases trickled in. The latest was an employee working in the Brentwood Postal Service Facility in Northeast Washington, D.C. Investigators concluded that the anthrax-afflicted postal worker never directly touched a contaminated letter, but was exposed to aerosolized anthrax spores likely released in that facility when letters to Senators Daschle and Leahy passed through. Along with verified anthrax cases, suspicious powder was identified in various locations that ultimately turned out to be false alarms, contributing to the public anxiety that was swirling around.
Simultaneously with the anthrax scare, we were having high-level discussions at HHS with Secretary Thompson and at the White House with Vice President Dick Cheney and his chief of staff, Lewis “Scooter” Libby, about our lack of preparedness for a massive smallpox bioterror assault on the country. Cheney and Thompson felt that we needed to mount an intense effort to provide in our stockpile a dose of smallpox vaccine for every person in the United States. Even if we were successful in demonstrating that we could effectively dilute the 15 million doses in our stockpile to 75 million doses, we still would fall short of the projected goal. But there was considerable debate as to whether we actually needed as many as 300 million doses or whether a far smaller amount would suffice for an adequate response to a smallpox bioterror attack. I agreed with Dr. Henderson, who felt that something along the lines of 100 million doses would suffice. Nonetheless, Cheney and his team together with Thompson felt strongly that we should expand the stockpile to the maximal amount as quickly as possible.
The state of high anxiety was compounded by constant rumors of impending bioterror attacks. On October 24, I was called to an emergency meeting in Secretary Thompson’s office. Thompson walked into his conference room looking concerned. With the CDC director, Jeffrey Koplan, connected to us by teleconference, Thompson told us that he was hearing that the United States would be hit with a major bioterror attack (agent unknown) within the next seven days. Thompson felt that because smallpox was high on the list for a possible bioterror attack, we should definitely accelerate the replenishment of our smallpox vaccine stockpile. Jeff did not seem particularly engaged or responsive to Thompson’s urgency, bringing into clearer focus a growing and obvious tension between the CDC and the HHS leadership.
This was not solely a peculiarity of Jeff’s. The CDC, established in 1946 to eradicate malaria in the United States, had evolved to address public health and safety more broadly. Employing thousands of talented, hardworking people, it looked upon itself as an elite academic institution whose job was to collect and analyze data for publication in the scientific literature and to take the lead in responding to crises by advising state and local public health officials. In addition, located in Atlanta, it operated somewhat more independently from HHS leadership compared with the close relationship between HHS and the NIH and FDA, all located in the Washington, D.C., area. Thompson wanted much more direct contact with and influence over the activities of the CDC particularly regarding our response to bioterror attacks. I had known Jeff for several years and found him to be a superb public health official with an outstanding track record. This growing undercurrent between CDC and HHS leadership antedated Jeff, having existed beneath the surface for many years. The conflict got worse over the next couple of months, which ultimately led to Koplan’s resignation in February 2002. Thompson was just too strong a personality with a governor’s style of running a program to let the CDC function as it traditionally had. During the closing months of 2001, the CDC official Julie Gerberding, an old friend and physician whom I had known from her years of work on HIV/AIDS when she was at San Francisco General Hospital, assumed a greater role as the voice and face of the CDC in response to real and potential bioterror attacks. Thompson ultimately appointed Julie to succeed Koplan as director of the CDC.
Between October 25 and 28, more cases of inhalational anthrax were recognized, including five more cases in Washington, D.C., among postal workers. People were more and more afraid to open their mail, and some were even stockpiling Cipro. The first anthrax infection in New Jersey was reported in a woman who developed cutaneous anthrax even though she had no direct connection with the postal service. The theory was later proposed that a contaminated letter from the Hamilton Township Post Office in New Jersey went to her home or place of employment. At the time, her case remained a mystery. In addition, the first case in New York City was reported in a sixty-one-year-old woman named Kathy Nguyen who had unexplained inhalational anthrax, also with no connection to the postal system.
There was a growing feeling among the general public and expressed in the press that the government’s response to bioterrorism should be officially led by someone with a scientific background instead of Tommy Thompson and Tom Ridge, the new assistant to the president for homeland security and former governor of Pennsylvania. Both were experienced and talented politicians but had little knowledge and experience in public health. An editorial in The Washington Post by Charles Krauthammer on October 26 underscored this point and strongly suggested that I be made the official spokesperson on the bioweapons war front: “Have him brief the press and the nation. Every day. Same time. The way Gens. Colin Powell and Norman Schwartzkopf [sic] did during the Gulf War.” In fact, a day did not go by where someone in the media was not asking me for an interview, a quote, or a comment.
On October 31, Kathy Nguyen died of inhalational anthrax, putting the country further on edge. The public’s need to understand where we were headed dominated every conversation. I felt it was critically important to tell the public exactly what we knew and what we did not know. The day Kathy Nguyen died, I led a previously scheduled conference on anthrax and bioterrorism at the NIH. This was supposed to be attended almost exclusively by NIH staff including physicians, scientists, and trainees. Historically, it was virtually unheard of for media to attend such conferences. But as I looked out from the podium in the NIH auditorium, I saw that the back of the room was crowded with cameras representing all major networks, cable, and PBS NewsHour.
I gladly assumed the growing responsibility in terms of both becoming a major spokesperson for the federal government and putting together a substantial long-term biodefense research effort. But there were days when these tasks completely consumed me, leaving too little time for my other responsibilities as director of NIAID including leading the NIH HIV/AIDS efforts. To make matters worse, or better, depending on your perspective, the U.S. Congress became increasingly interested and involved in our activities in response to the anthrax attacks. I was asked to brief the Senate Democratic Caucus including Senators Lieberman, Daschle, and Biden on bioterrorism at a lunch meeting at the U.S. Capitol on November 1. In all, there were about thirty Democratic senators present. I told them everything that we knew from a public health and medical standpoint concerning the anthrax situation. Several of them expressed a strong desire that I lead the nation’s biodefense efforts as my full-time job. I said no on the spot.
Even catastrophe provided some light moments. For example, my debut (of sorts) on Saturday Night Live on November 3 had Darrell Hammond playing Attorney General John Ashcroft and Chris Kattan playing me. It spoofed the fact that the Environmental Protection Agency was having a tough time decontaminating the buildings the anthrax letters had passed through. Just when they thought that a building was clean, another, more sensitive test showed that there were still spores present, and it was not clear what the minimal accepted number of spores was for people to safely reoccupy the buildings. Activities in several government buildings had been severely disrupted even though, apart from the Brentwood Post Office, no one had gotten infected inside a government building. There was great frustration among staff and senators who wanted to return to their Senate offices. This was perfect fodder for satire. “Good evening,” Hammond as John Ashcroft said. “These are, indeed, complicated times for a great nation. But tonight, the United States Justice Department simply wishes to say: Get on with your lives. Do whatever you would normally do. Also, in the next three days, there’s probably gonna be a terrorist attack on our country.” Then Hammond said, “Well, there ya go! Look, everyone, please go back to normalcy, live your lives, just relax. And now, here with an update on the vicious, seemingly unstoppable anthrax scourge, from the National Institute of Health, is Dr. Anthony Fauci.” At that point I (Chris Kattan) said, “Thank you. I’d like to reassure the American public by saying this: we have cleaned the State Department, the White House, the Supreme Court, and the Capitol building with state-of-the-art decontamination instruments, and have installed dozens of $20 million irradiation lasers to keep all dangerous substances away from the U.S. government.” In contrast to what we were doing about the federal buildings, when asked what we were doing about decontaminating the post offices, Kattan had me say, “We’ve given each post office some baby wipes and a dust buster.” A reporter then asks, “But what about the contaminated buildings in New York? Are they safe?” Kattan responds, “I don’t know, lady! I haven’t been to New York in weeks! Do you think I’m crazy?”
No sooner did we believe that things were quieting down than another fatal case of anthrax was recognized in late November 2001. Ottilie Lundgren was a ninety-four-year-old woman from Oxford, Connecticut, a rural community thirty miles from Hartford, who developed inhalational anthrax and died on November 21. Careful detective work on the part of the CDC and the FBI suggested that her exposure might have been through a tertiary mail contamination. A letter that might have passed through the Trenton, New Jersey, postal facility along with the letter to Senator Leahy likely got contaminated and subsequently went on to a post office in Connecticut. Lundgren received a letter that at some time was probably physically next to the secondary contaminated letter. The mystery was never solved. Lundgren turned out to be the final anthrax case in this extraordinary saga, which in the end killed five people and sickened an additional seventeen.
It would not be an overstatement to say that the country was close to outright panic. People continued to be afraid to open their mail, and the postal service took to irradiating the mail before delivery to homes and offices. Most people thought al-Qaeda perpetrated these attacks and that additional attacks were sure to come. But I and several of my colleagues in the security and public health sectors had doubts as to whether this attack really was carried out by al-Qaeda. It seemed that if al-Qaeda wanted to perpetrate mass damage and terror, they would have picked a more effective approach than sending out a few letters with a couple of grams of anthrax spores. As I stated in a New York Times interview, the attacks were “high on terror, but low on biomedical impact.”
Furthermore, al-Qaeda had already proven themselves to our dismay to be highly competent in executing terror attacks. There was a certain amateurishness to these letters that contained the anthrax spores. The notes in one set of letters dated “09-11-01” read,
This is next
Take Penacilin now
Death to America
Death to Israel
Allah is great
This did not sound to me like a ruthless al-Qaeda operative. Nor did the note in the second group of letters to Senators Daschle and Leahy also dated “09-11-01,” which read,
You cannot stop us.
We have this anthrax.
You die now.
Are you afraid?
Death to America.
Death to Israel.
Allah is great.
Al-Qaeda’s lack of involvement only became clear after several years of tortuous investigation by the FBI. In April 2007, an intensive investigation focused on Bruce E. Ivins, a civilian employee of the Department of Defense who worked as a microbiologist biodefense researcher and an expert on anthrax at the U.S. Army facility at Fort Detrick, Maryland. In July 2008 the FBI informed Ivins that it was about to press charges against him as the perpetrator of the 2001 anthrax attacks. Soon after, Ivins died by suicide on July 29, 2008, taking an overdose of Tylenol with codeine. Although the FBI was convinced that he was the guilty party, it was never definitively proven that Ivins sent the anthrax letters.
It had been almost seven years since the anthrax attacks in the fall of 2001, bringing to relative closure a frightening chapter in U.S. history.