On evenings and weekends, one of the USAMRIID physicians had call duty, usually to treat a lab worker with a vaccine reaction or agent exposure. We also answered the USAMRIID 888 hotline for anyone around the world calling about a biowarfare or bioterrorism crisis. Shortly after my arrival in 1998, we experienced a rash of phone calls for bioterrorism hoaxes around the United States, ranging from the serious to the absurd, although sometimes it was hard to tell the difference. A typical call might be about a suspicious powder found on an office carpet that turned out to be sugar. One evening in July 1999, while I attended the Prairie Home Companion show at the Wolf Trap outdoor theater in Virginia, I received a call from a police chief in the Midwest. I excused myself from the show and took the call seated on the grass outside the amphitheater. Someone had found an empty dog cage outside an apartment building and moved it inside the building’s lobby. When the person noticed a note on the cage with the words “This Dog Has Ebola,” he called 911. Emergency crews evacuated and cordoned off the entire building of about 150 apartments, hosed down the area with water, and then called me.
“What should we do with the cage?” they asked. “Just spray it down with bleach,” I said, and everything would be fine. It took time to convince them there was nothing to worry about.
Unfortunately, I missed most of the show.
In the summer of 2001, the commander promoted me to chief of the Medical Division, where I would serve as his lead medical consultant. I accepted the position a bit nervously but embraced the opportunity to build my expertise and gain more leadership experience. I became accustomed to dealing with a new mini-crisis about once a week for things like immunization policy disputes, potential exposures in the lab, or personnel management. Most of these incidents were minor, like a series of tremors before the earthquake.
The big crisis loomed just over the horizon.
Most people remember where they were on September 11, 2001. I had just walked into our regulatory chief’s office when her phone rang. Her husband was on the line and said an airplane had just flown into the World Trade Center. She immediately hung up the phone, and we rushed around the corner to the commander’s office. There we watched the television, aghast as a second plane hit the Trade Center towers and burst into flames.
I rushed down to my office in the medical wing to alert my personnel in time to see TV footage of the Pentagon also in flames. Now, with the military targeted, we felt our own vulnerability. Could USAMRIID be the next target? We learned that the Centers for Disease Control (CDC) had evacuated. Shouldn’t we evacuate too? Instead, Fort Detrick went to THREATCON DELTA: full lockdown. No one could get on or off the base. The military leaders had no idea what they were dealing with, so they wanted all available personnel within reach. The lockdown worked until the evening, when Fort Detrick’s command realized they had no contingency plan to feed the entire base. We were then released.
By the end of September, things had quieted down significantly. Then, one morning in the first week of October, the USAMRIID commander cornered my fellow division chief, Scott Stanek, in his office.1
“Only three people in the building know this,” the commander said before informing him about a case of inhalational anthrax in Florida. “Be prepared. You may get some calls.”
Scott reviewed the call schedule to see who was around in case things got busy. That afternoon I found a report online about the same case and handed Scott a printout. Clearly, more people knew about it by then, but it appeared to be an isolated case. Scott took the printout up to the front office to show the commander.
The newspaper headlines were focused at this time on the United States’ push into Afghanistan and the attempt to rout the Taliban, with domestic concern for imminent terrorist attacks.
A couple of days later, I wasn’t on call on Sunday, October 7, but as I sat in church with my wife and sons, my pager buzzed on my belt. The sermon was winding down, so I excused myself and left the pews to take the call from a land line in the church office. The page came from my colleague, John Ezzell, chief of USAMRIID’s Special Pathogens Lab, and a PhD microbiologist from North Carolina. With his long white hair and full beard and sporting a black leather jacket atop his motorcycle, he could easily pass for Kenny Rogers’s twin.2 We had built rapport over time, and he frequently sought me out for medical questions.
“I need a doc on the phone with me,” John said.
I dialed in and joined John and another USAMRIID microbiologist who were already part-way through a teleconference with the FBI about the Florida anthrax case. John’s lab served as the FBI’s main referral lab to analyze suspicious samples for biothreats. Several others were on the call, including the FBI’s lead physician.
Robert Stevens, a sixty-three-year-old photo editor for the supermarket tabloid the Sun, had become ill in late September and was admitted five days earlier, on October 2, severely ill with shortness of breath and vomiting. He had died on October 5.
Although the FBI investigated the apartments where some of the 9/11 terrorists had stayed, tests for anthrax came up negative. Tommy Thompson, the secretary of HHS, referring to Mr. Stevens, had said, “It appears to be an isolated case.”3 Reports just a couple of days earlier had noted that “Federal officials say they believe the case arose from natural causes and not from an act of terrorism.”4
As I listened to the discussion on the phone, I visualized the effects of anthrax on the body. Unlucky sheep, goats, or cattle ingest anthrax spores in the soil while grazing and get gastrointestinal anthrax. Human victims, like wool sorters, ranchers, and veterinarians working with large mammals usually get cutaneous anthrax from skin abrasions in the presence of the spores. In her quest for survival, Queen Anthrax made two toxins that gave cutaneous anthrax its characteristic features of a jet-black scab (or eschar) and massive surrounding swelling that were easy to recognize, making it treatable and rarely deadly. The black eschar gives anthrax its name, derived from anthrakis, the Greek word for coal.
Inhalational anthrax, on the other hand, is usually a death sentence. Once inside the body, the spores break out of their “shell,” reproduce, and manufacture a protein coat, as effective as chainmail armor, that thwarts the body’s ability to fight the infection. The toxins act like a bomb going off inside a victim’s chest, filling it with bloody lymphatic fluid, crowding out the lungs, and making it harder and harder to breathe. As the bacteria multiply, they shower the blood stream, like metastatic cancer cells. Wherever they “land,” the bacteria reproduce and manufacture toxins that yield tiny explosions of swelling and death wherever they go. Within a few days, the victim succumbs as he suffocates, and his bloodstream fills with massive numbers of Queen Anthrax’s offspring.
On the call I heard for the first time that Stevens’s case was being assessed for public health as well as criminal concerns. No one knew how or where Stevens became infected. There was some discussion about the public health investigation into places he had visited, like Chimney Rock, North Carolina, where a cow had died and whether he might have been exposed to an aerosol from a stream near where he had camped.
The FBI planned to send their experts into the Sun newsroom to investigate and obtain additional environmental samples to test from Stevens’s work area. They were still awaiting results from samples that the CDC had taken in the building two days earlier. The FBI called for advice on what protective gear their agents should don before entering the potentially contaminated building.
As I listened on the phone, the church service ended. The church officers came into the office and were busily counting the weekly offering. When I said the word anthrax, the room fell silent. The church officers stopped their counting and eyed me with alarm.
The FBI was also considering giving antibiotics to the hazardous material personnel entering the building to prevent infection. I recommended against that. It seemed like overkill because during the course of discussion, the FBI had decided to wear fully encapsulating level-A suits, similar to our BSL-4 lab space suits, but mobile and with their own self-contained breathing apparatus. Without a breach of the suit’s protection, there is no direct physical contact with the microbe and no risk of infection, hence no need for antibiotics. My main concern was that, once started without any known exposures, when would they stop antibiotics? I had also dealt with enough adverse reactions to know that antibiotics are not benign. The FBI doc disagreed with me. Everyone entering the building would get antibiotics. What I didn’t know at the time, and which was probably discussed before I got on the phone, was that some FBI and other response personnel had already entered the building without level-A suits, and those individuals could be at risk. Giving them antibiotics until the earlier sampling results came back, then, was reasonable.
Stevens’s case was alarming. As I heard more about the situation, I wondered how his infection had really occurred. Infectious pathogens behave in certain characteristic ways or live in specific parts of the environment. Queen Anthrax is no different. Stevens had none of the risk factors usually linked to rare cases of inhalational anthrax: he didn’t work in a wool mill, he didn’t bang on animal skin drums imported from Africa, and he didn’t work in an anthrax lab.
No. Something didn’t fit.
I teach my students that any case of inhalational anthrax in humans should be considered bioterrorism until proven otherwise because it is hard to get naturally. It takes about eight thousand to ten thousand spores. In the 1950s wool mill workers were tested and found to inhale hundreds of spores routinely, but they rarely became ill. Therefore, it was unlikely that Stevens had inhaled the dosage needed from nature to make him sick while camping.
Anthrax spores don’t just float around in the air. They need energy to stir them up to get them out of the soil and into the air. Even so most of the spores would normally clump together or bind to dirt particles, so they wouldn’t have gotten down deep into Stevens’s lungs. The spores would have had to be concentrated and in a form that Stevens could inhale. This has happened before, but rarely. In the old U.S. biowarfare program, inhalational anthrax caused two of the three accidental work-related fatalities from a bioweapon agent.5
Still in the church office when I hung up the phone, the assistant minister broke the deafening silence and asked me nervously, “Doc, are we gonna be all right?” I didn’t say anything but gave him the thumbs up sign and left, although I didn’t feel completely reassured myself. The story still had too many loose ends.
Robert Stevens probably opened one of three suspicious letters sent a week after the fall of the World Trade Center, but the FBI never recovered the letter. The CDC had been alerted to his case on October 3 and landed in Florida the next day. USAMRIID launched three of its own scientists to assist. News of Stevens’s death escalated through the Florida Health Department, the CDC, and the FBI.
On the same day as the FBI phone call, two other tests would come up positive: a nose swab on a fellow employee who handled the mail and a sample from Stevens’s computer keyboard. Before the end of the day, the FBI would be placed in charge of the investigation. Over seven hundred employees at the American Media Building, where Mr. Stevens worked, would have their noses swabbed and tested for anthrax that week.
Sometimes it’s easy to miss an outbreak early on until it bites us in the ass. Piecing together disparate clues to determine how and why people are getting infected requires curiosity, a healthy “index of suspicion” for something unusual, and sheer luck.
In medicine, there’s a saying: “If you hear hoofbeats, think horses, not zebras.” Common diseases occur commonly. However, on October 7, 2001, we had a stampede of zebras thundering toward us, but we didn’t know it yet.
Two days after the phone call, someone put two more letters in the mail.