One of my colleagues who ran a large research program once said that his daily mission was to “keep the wheels on the ‘bus’ from falling off while driving ninety miles an hour down the highway.” On many days as a division chief, I felt the same way—like I held my finger in the dyke just long enough for another place to spring a leak.
I didn’t have time to gloat over my recent success because one day after the Winkenwerder brief, another crisis developed. On a Thursday afternoon, April 18, 2002, around 5:00 p.m., the acting institute commander, stepped into my office and closed the door.
“How’s it going?” the colonel said.
My suspicion meter jumped immediately because he rarely walked down to my wing of the building. Something was up, and it probably wasn’t good.
Dressed in his army green “class B” uniform with wire-frame glasses accenting his square face, the colonel had something of an academic air. He sat down on the beat-up white love seat next to my desk and tried to make small talk.
I decided to make it easier for him to get to the point. “So what’s going on?” I asked.
My instincts were spot on. The colonel leaned forward on the edge of the love seat. As he described the situation, I felt the white cinder block walls in my office closing in. The more I heard, the more claustrophobic I felt.
Although we were only seven months out from 9/11 and the anthrax letter attacks, the institute still ran high-volume operations in the Special Pathogens Lab, testing thousands of samples from the FBI for anthrax. The lab work was conducted in the BSL-3 lab suite called B3. Because of the high-op tempo, work had spilled out to other parts of the institute. One of the Bacteriology Division scientists became concerned about potential anthrax contamination in his office because some lab colleagues had borrowed his desk and left the area a mess. Dr. Bruce Ivins, one of the nation’s leading experts on anthrax, took swab samples around his office for anthrax testing. This was highly irregular without first informing a supervisor, but his paranoia was apparently not unfounded: BINGO. Some of the samples came up “hot” (positive) for anthrax spores.
The colonel didn’t know the extent of contamination yet. A lab team had been assembled rapidly and planned to work through the night collecting and testing samples taken from throughout the institute to verify whether the positive samples thus far were the real thing and not some other harmless organism.
“I wanted to give you a heads up to start planning your response in case more samples come up hot,” the colonel told me. “Thanks, I appreciate it,” I said. “Keep it ‘close hold’ for now,” he advised, with the exception that I could confer with other doctors in my division.
Before leaving, he requested my presence at a meeting of the key decision makers at eight o’clock the next morning in the headquarters, when we would review the results from the overnight sampling and come up with a plan.
“Wonderful,” I said sarcastically. “I can’t wait.”
“Another chance to excel!” the colonel said flippantly as he left my office.
I had a significantly different opinion. There was no way to sugarcoat this. It was a freaking disaster! I started asking myself key questions and running scenarios as my mind went into overdrive. Where else was the contamination? Who was at risk? What kind of risk did they face? How can we determine that? Was anyone already sick? Who should receive antibiotics? Do I need to treat all six hundred employees or a targeted group? Who else needs to know?
Most people had already left for the day. I didn’t think I knew enough yet to alarm my fellow Division of Medicine physicians, but I immediately hustled down the hall to Scott Stanek’s office. Scott, who owned the Slammer space, ran the Operational Medicine Division and was a seasoned public health physician with an even keel and a quiet, thoughtful demeanor. He frequently served as my sounding board, and vice versa, because I trusted his opinion. Scott also had several physicians working for him who could back my team up if a stampede of panicked employees overwhelmed us.
I brought Scott up to speed, and we discussed the potential implications. He agreed with me. It was too early to make any decisions until we had more information from the overnight sampling, but we needed to prepare to spin up operations quickly.
That night at home, as usual, I didn’t tell my wife about this latest crisis. I preferred to keep similar issues to myself until they became public. My natural tendency is to internalize stress, while trying to project an external calm demeanor. Consequently, the tension burns in my gut like a bed of hot embers. I tossed and turned the whole night wrestling with several “worst case” scenarios and how to respond. At a minimum some workers in the Bacteriology Division could be at risk, but my biggest fear was that spores had gone airborne through the ventilation system. That could put everyone in the institute at risk, and I might have to give antibiotics to over six hundred workers. Even if only a few employees were exposed, we might have to give antibiotics to many more because we couldn’t risk missing anyone. The health and safety of everyone in the institute was on the line, and possibly by extension any family members through contaminated clothing or shoes, although that was much less likely. It might be hard to prove a lack of risk, though.
This could be a huge public relations disaster—one more opportunity to make the front-page headlines of the Washington Post. Containment labs have earned that designation for a reason—they are supposed to contain the pathogens. Agents aren’t supposed to break out of the lab, like Clint Eastwood in Escape from Alcatraz. I wondered, “How did this escape?” and I walked through the possibilities in my head.
Researchers enter the BSL-3 lab through the “cold” side locker room, where they shed their street clothes and don scrubs. Then they move through a passageway to cross over to the “hot” side. The direction of the airflow moves from the exterior hallway down the main suite corridor and into individual labs. Upon exiting, researchers remove their scrubs and “shower out” before returning to the locker room.
Pathogens have only a couple of ways to escape the containment laboratory. Someone could sneak them out deliberately, but he or she would need to hide them, possibly where the “sun don’t shine,” while stripped naked and showering out. A pathogen could hitch a ride on the person’s skin or in his or her hair, if the person didn’t wash up thoroughly. If he or she became infected in the lab, once ill, the person might infect others outside the lab.
Airlocks are used to move large equipment in or out of each containment suite. If the standard decontamination procedure failed, a pathogen could stow away on contaminated equipment.
Each suite of labs has a “dunk tank,” about the size of a two-drawer filing cabinet, filled with a decontamination solution. It sits in the laboratory wall with openings inside and outside the lab that are separated by a central baffle. If someone wants to “dunk out” a sample to outside the lab, he or she seals it inside two layers of plastic, decontaminates the outer surface, and then submerges it in the solution under the baffle. Someone in the hallway outside the lab then accesses the dunk tank and takes the sample elsewhere for testing or for storage.
Each lab suite also has a “pass-box” about the size of a breadbox, embedded and sealed into the lab walls, with openings on both sides, for moving small objects, such as lab notebooks or individual papers, in or out of the laboratory safely. An ultraviolet (UV) light inside the box turns on to kill any live organisms.
I welcomed the next morning’s sunrise and an end to my torture of uncertainty. At least I hoped to learn enough details to develop an action plan after the morning’s meeting.
When I arrived at my office, I noticed a small, red, circular sticky tab on my doorknob with a number on it. Someone had swabbed my door overnight to test for anthrax. It was a sobering moment. Prior to this I had not considered my own risk of exposure and illness.
As I made my way to the headquarters for the 8:00 a.m. meeting, I noticed numerous similar numbered tabs attached to door handles, walls, machinery, and other locations along the hallways.
By this time I had become all too familiar with the commander’s office in the headquarters. His large oval conference table that seated twelve or so people dominated the room. A map of the world, symbolic of USAMRIID’s global reach, covered the center of the table and was protected by a large glass plate. Several covers from medical journals showing colorful photographs of pathogens taken by USAMRIID scientists were arrayed at the head of the table where the commander usually sat.
I joined about ten of the senior institute leaders around the conference table. The commander phoned in from Chicago, where he was lecturing, and our commanding general’s chief of staff dialed in from his office on the other side of Fort Detrick.
The deputy commander rolled out a large floor plan of the institute on the table, and he pointed out the locations of the sample testing conducted overnight, and the positive and negative results known thus far. We didn’t have all the results yet, but the team had taken over eight hundred swab samples throughout the institute on April 18 and 19.
As I heard the testing results, I felt relieved to learn that the contamination appeared to be more confined than I had anticipated. Only three locations came up hot for anthrax. The bulk of contamination was centered around the B3 lab pass-box, with over two hundred spores, so that appeared to be a potential source for the spores escaping the lab. Bruce’s office and the B3 locker room had only three or fewer colonies of anthrax. None of the other sampling sites in the building came up hot.
Even if some spores had gotten into the air around the pass-box, the directional air flow in that area of the building would confine their spread and clear them from the air quickly. A large airborne breach was unlikely.
The meeting lasted about an hour, at which time the acting commander announced that he would hold a town hall meeting with the entire institute in the main auditorium—at 10:00 a.m. The featured speakers would include himself, the deputy commander; the chief of Safety; and Lieutenant Colonel Kortepeter, chief of Medicine.
What?! I almost coughed up my breakfast! I had only forty minutes to prepare something intelligent to reassure the entire institute.
Having dealt with other volatile issues before, I knew that employees with any concern would come see us in the Medical Division clinic. So I had to prepare my division personnel— and fast. My mind raced to come up with solutions as I rushed back to the medical ward and called my medical staff together.1 I wanted to ensure that they agreed with my risk assessment that we had a focused area of contamination and, therefore, a limited number of employees at risk. The entire institute did not need to take antibiotics. However, to prepare for a likely deluge of worried workers, we would cancel the usual clinic activities. All agreed with my assessment.
After we met, I had only a couple of minutes left to organize my thoughts. I jotted down some key messages and bullet points on a yellow legal pad, then headed to the auditorium.
Over the course of two town hall meetings, the entire institute of over six hundred workers packed into our main auditorium with standing room only. The acting commander spoke first, followed by the deputy commander, who reviewed what had happened. The chief of Safety came up next and stated that there was no recognized breach of laboratory safety. I was next.
I took a deep breath and approached the podium.
“As chief of the Medical Division,” I said, while trying to steady my voice and hide my shaking legs, “the safety of the workforce is my highest priority. I believe the risk to personnel from the contamination to be low for several reasons: we have not had any reports of illness among the workforce; the contamination appears to be localized in a remote hallway that few people enter; if there had been any aerosolization of spores, the directional airflow in the building would reduce any risk of exposures; and most of the people who work in or near the contaminated area would have been vaccinated already against anthrax.”
We had no way of knowing how long the contamination had been there, but as far as we could tell at the time, no one had been infected thus far. We had that in our favor.
As I concluded, I said “We specifically want to see anyone who worked in the contaminated hallway or who worked in suite B3, but any other concerned individuals should feel free to come see us.” Anyone could make an appointment, and we would start seeing workers at 1:00 p.m.
When the town hall meetings ended, I was pleased that the workforce seemed reassured, and I didn’t hear any grumblings. When I returned to my office, I asked my chief nurse to draft a one-page assessment form that we could place in a worker’s medical record that would document (1) where the person worked; (2) whether he or she had entered the contaminated hallway; (3) whether the person had received anthrax vaccination; and (4) whether he or she had been ill. This would help us divide those with bona fide risk from the worried well.
At 1:00 p.m., as a flood of workers arrived in our clinic, we learned quickly the limits of our risk communication. Many workers were confused about which section of the building had come up hot, but once we showed them the building floor plan, we alleviated a lot of fear. Some weren’t too worried for themselves, but family members had nagged them to get checked. Many just wanted us to swab their noses to test for anthrax for their peace of mind—just to be sure.
News travels fast around the Washington DC Beltway. The command realized that shortly before we discovered the contamination, an entourage of Senate staffers had visited the institute for a “dog and pony show” and tour. Not surprisingly, once they learned about the contamination, the staffers were upset and called to ask about their risk. The deputy commander called me up to the headquarters around 3:30 p.m. on Friday and gave me another “opportunity to excel.”
He told me to drive down to Washington DC to brief the senator and explain the situation. He pulled out a map of the institute and drew on it the exact route the group had taken during their tour and the locations of contamination, so I could show the senator. I asked if I could bring Scott Stanek as my “wing man” and to take notes, because I knew I would be an easy punching bag. The deputy commander refused, so I went alone. Before leaving I touched base with the senator’s medical advisor, a navy commander, then I rushed off on a fifty-mile drive south on Interstate 270 toward Washington. On the way I repeated nervously my upcoming dialogue of reassurance for the senator and her staff.
I crossed the Arlington Bridge into DC around 4:30 p.m. and slammed into a wall of traffic. A running competition had concluded around that time near the Capitol Mall. It took me an hour to move one block. As the clock ticked toward the end of the workday, I had repeated conversations on my cell phone with the senator’s medical advisor. After sitting in traffic for over an hour, she finally told me she had brought the senator up to speed, everyone was reassured, and I was off the hook. Even though it all felt like a wild goose chase, I breathed a sigh of relief and gradually crept my way back out of DC.
From Friday afternoon through Saturday, we saw eighty-eight workers and took fifty-seven nasal swabs for anthrax. We placed nine on antibiotic prophylaxis with doxycycline initially (ciprofloxacin had been depleted across the country), but we discontinued it after seventy-two hours because we reassessed the risk to be low. All swab tests came back negative for anthrax.
The institute put out a press release. The army has an adage that “bad news doesn’t improve with age.” If we hadn’t made the incident public, someone would have leaked it anyway.
The national news reports varied in their support and criticism. In one article a sympathetic CDC colleague noted, “If it can happen to USAMRIID, it can happen to anyone.” An academic anthrax expert had a different view, saying the event was “highly embarrassing,” and “evidence of a lack of leadership.”2
Despite the negative press, at this point, things were looking up. We had not seen any illness among the workforce, and we had managed the onslaught of concerned workers. Unfortunately, almost on cue something jumped up and bit us in the ass. The institute contracted with a company for laundry services that employed handicapped individuals. We had inadvertently left the laundry company out of the information chain. Because we found contamination in the B3 lab locker room, it was conceivable that some spores might have hitched a ride out of the building on contaminated laundry. Regardless how unlikely this might be, we had to jump on it.
As soon as he returned from Chicago, the USAMRIID commander held a meeting early Saturday morning for an update with the key institute leaders as well as our commanding general. Things were generally under control, although we were just beginning to deal with the laundry situation. The general pulled in a team from the army’s environmental center to test the laundry facility for anthrax.
During the meeting I happened to look out the window and was surprised to see an unexpected visitor rounding the sidewalk—our local congressman, Roscoe Bartlett.
A few moments later, he interrupted our meeting in the commander’s office. I had met Congressman Bartlett on a couple of occasions, and he usually has a folksy, farm-boy manner. Not today. Fort Detrick fell within his district, and he had read our press release. He launched into a tirade, accusing us of creating a firestorm over nothing.
“If you took soil samples around Frederick County, you would probably find anthrax everywhere,” he complained. “I probably have some on my boots.”
The commander spent the next half hour calmly and painstakingly explaining the situation and our response.
To prove his point, before leaving, the congressman reached into his pocket and pulled out a clear glass jar, the size of a prescription bottle, filled with a dark brown substance. “I brought some dirt from my farm,” he said as he set the bottle on the end of the conference table. “I want you to test this for anthrax.”3
The commander reluctantly agreed to do so.
Shortly thereafter the commander concluded the meeting, saying he would order a formal “15–6” army investigation into possible wrongdoing in how the building contamination occurred and why a single researcher took it upon himself to do sampling of his office. 15–6 investigations are never fun. Usually some poor sucker, a military officer or government civilian external to the situation, gets appointed as the investigating officer. A colonel from our sister institute, the Walter Reed Army Institute of Research, was directed to investigate. He called me and many others to provide sworn testimony for his report.
Unfortunately, the building contamination occurred near simultaneously with another event, which did little to reassure the public of our competence. About ten days earlier, an anthrax researcher and technician had come to our clinic because they worried about a possible exposure to anthrax.4 We routinely evaluated anyone who had a mishap in the containment laboratories. Most were minor.
Not this one.
Scientists who work on anthrax occasionally grow organisms to test them in the lab. The scientists injected some bacteria into a liquid broth and then incubated the solution overnight in two-liter flasks that swirled to mix in air for optimal growth. According to the standard procedure, one of the scientists screwed the lids on tight and then loosened them back a quarter turn to allow air exchange. He then taped a paper towel and gauze over the lid. The next morning he opened the flasks inside a biosafety hood and removed the paper towels and gauze. When he discarded the gauze and towels in the garbage next to him just outside the hood, the scientist noted some dried liquid on the paper towels, the neck of the flasks, and the screw tops. Somehow, some of the broth had spilled out over the top of the flasks, like a bubbling volcano, and dripped down the necks.
He was worried—and for good reason.
An air curtain flows continuously down across the front of a biosafety hood to protect the lab worker from the organisms inside. However, when the researcher pulled the paper towels and gauze out of the hood through the air curtain, it could have provided the energy source to spray anthrax spores into the air—like putting talcum powder in front of a fan. Neither of the scientists wore respiratory protection at the time, since they would have been vaccinated.
Each containment lab suite is divided into a series of labs off a central corridor, which function like individual vacuum “containers.” Within minutes any contamination in the air would be sucked up and filtered safely out of the air. No one in the neighboring rooms had any risk, but the two scientists with the anthrax flasks stood at ground zero. They could have inhaled any spores floating in the air and developed the “queen mother” of the anthrax infections: inhalational anthrax.
When Ellen Boudreau, my clinic chief physician, evaluated the two scientists, she was worried. Large exposures to a pathogen can overwhelm the protection from any vaccine. She started them on the antibiotic ciprofloxacin as a preventive measure, just in case. She also swabbed their noses to test for anthrax spores. Whenever treatment was prescribed for a possible lab exposure, we sent a summary to the army’s safety headquarters. This occasionally led to increased scrutiny from the media or the army chain of command, including at times, orders for the institute to conduct a “safety stand down.”
In this situation the proximity in time with the hallway contamination hurt us. Media reports sounded as if the two lab workers had been exposed to anthrax because of the building contamination. That was wrong. They were two separate incidents.5 The anthrax in the lab exposure carried a resistance marker to distinguish it from other strains.
These two events occurred while we had been running 24/7 operations in our Special Pathogens Lab for months to assess thousands of FBI samples, letters sent to Senators Daschle and Leahy, and samples from the contaminated Hart Senate office building. Sadly, at its finest hour, as USAMRIID supported the national anthrax response effort, the institute commander had to stand in front of the workforce in the Fort Detrick gym to reassure everyone that “USAMRIID is safe.” Somehow it didn’t seem right, but as that same commander once told me after another disaster, “It is what it is.” We dealt with it and marched forward the best we could.
The local town of Frederick, Maryland, has a love-hate relationship with Fort Detrick. Fort Detrick is the largest local employer, but the local paper frequently criticizes the base for events like this one. Although we tried to be proactive to maintain good relations, the institute commander still had to do a mea culpa to the Frederick mayor during a press conference.
When the FBI later named a former USAMRIID researcher, Dr. Steven Hatfill, as a “person of interest” in their investigation of the anthrax letter attacks, suspicion that the perpetrator of the attacks might have come from within USAMRIID cast another shadow over the institute’s efforts, making the institute “radioactive.” After the anthrax letter attacks quieted down, we were chagrined that President Bush flew down to Atlanta to congratulate the CDC for its efforts. We never saw him, even though we were an hour up the road from the White House. After several months the army surgeon general paid us a visit, but it was too little too late. The entire institute staff assembled in the Fort Detrick gym for over an hour waiting for his entourage to arrive. He spent most of his time at the Fort Detrick headquarters and then did a short appearance for a few words before departing quickly. The deputy commander from our higher headquarters handed out the congratulatory certificates, instead, to all the “unsung heroes” who had assisted with the diagnostics response effort.
In 2008 the press covered the army’s official 15–6 investigation when the 361-page report was released through a Freedom of Information Act request.6 Some of the conclusions focused on adherence and documentation of safety procedures supervision. Recommendations included the need for better reporting procedures for biological mishaps, improved written precautions for lab procedures, regular retraining, and lab inspections.
One key conclusion the report could not make was the source of the contamination. It suggested the possibility of inadequate decontamination of containers brought out of lab suite B-3 or from the opening of evidentiary material from the FBI there, such as the letters and other items contaminated with powdered anthrax. Jeff Adamovicz, deputy chief of Bacteriology, who had come up with a technique months earlier to quantitate the spore concentrations in the anthrax letters, had expressed concern about the risk of contamination in the hallway months earlier. Those concerns may now have been realized, but ironically he felt the brunt of the blame. The hallway contamination led to finger-pointing between the different divisions in USAMRIID that worked on anthrax and supported the investigation—who was at fault?
This event was only the beginning of more challenges to come. Dr. Bruce Ivins, the anthrax expert who did the unauthorized testing in his office, justified doing so because one of his contract technicians worried about potential exposure to powdered spores from the letters. Ivins noted that his desk had been covered in dirt and dust by others temporarily using his office. He had done some earlier testing of his desk back in December 2001 and found growth consistent with anthrax. At the time Dr. Ivins decontaminated areas around his desk but did nothing further to confirm the results, nor did he notify his superiors. His boss, the Bacteriology Division chief, was reprimanded because of it, but colleague and bacteriologist Hank Heine argued that “Bruce was completely within his rights to do that, because it was a safety situation. If he suspected there was contamination, he was right to get down there with some swabs and figure out what was going on.”
Jeff Adamovicz said that years later, when the FBI would focus its attention on Bruce Ivins as the possible anthrax letter perpetrator, it would use his taking of swab samples in his office against him, asserting, “He’s covering up the evidence of malfeasance.” On the contrary, Jeff believes “it could’ve also been that in fact what he [Bruce] claimed was actually correct . . . but that never really got resolved.”
In 2002 the FBI investigation was still in its infancy, but it would dog the institute for years to come.
The nose sample from one of the two scientists exposed in the lab came back positive, confirming our worst fears that anthrax spores in the fluid that had trickled out of the neck of the two-liter flasks had gone airborne. Ellen Boudreau had made the right judgment call to start the scientists on antibiotics.
To our relief, though, everything in the laundry facility came up clean. I had a follow-up phone call with the manager there, who was satisfied with our response.
We tested the soil sample from the congressman’s farm. The result: negative for anthrax.
The hallway contamination experience pulled me into the leadership cadre of the institute more effectively than any prior experience, because our quick response seeing the workforce in the Medical Division was critical to quelling what could have been a much bigger disaster. Although it came the hard way, I could also add risk communication to my new set of skills.
At this point for me, anthrax went into the rearview mirror. I had to shift my focus back to vaccinating the forces because the pendulum had swung toward war with Iraq, focused on Saddam Hussein’s biological weapons caches. Smallpox was at the heart of those concerns.