Living Terrors: What America Needs to Know to Survive the Coming Bioterrorist Catastrophe

by Michael T. Osterholm, John Schwartz, 2000

Living Terrors is a book that should be read by all Americans. The book is written by Michael T. Osterholm, Ph.D. and science journalist John Schwartz. It is based largely on Dr. Osterholm's experience as an epidemiologist, his expertise in biological weapons, and his efforts to educate the public on the threats of bioterrorism. He illustrates several points about the unique aspects of this threat by beginning chapters with fictional vignettes about hypothetical bioterrorists. The emphasis is on the general anonymity of the perpetrators, ready availability of biological agents, and the difficulty tracking the terrorist. He uses the subsequent chapters to argue that the bacteria and viruses are readily available and the technology for dispersing easily learned. He discusses estimates of potential loss of life and economic damage from a bioterrorist attack.

The second half of the book describes a hypothetical smallpox attack on the city of Chicago. Most Americans over the age of thirty have some recollection of smallpox vaccinations they received as a child. The wild form of smallpox was eradicated in 1977 and the World Health Organization recommended discontinuing vaccinations against it in 1980. The only remaining smallpox was in laboratories in the United States and the Soviet Union. The authors present evidence here that other countries have this agent and that the combination of high infectivity, high lethality, and low immunity make it lethal if dispersed by a terrorist.

Living Terrors also focuses on systems and logistics that need to be addressed. Both antibiotics and immunizations are effective in specific situations, but there are currently not enough doses to have much of an impact in the event of an attack. Civil defense preparedness is also lacking. The type of response needed for a chemical weapons release is compared with biological weapons. Early identification of the infectious disease is critical since many of the diseases appear to be similar to upper respiratory infections. Quarantine and respiratory isolation of individuals affected with smallpox is also the best initial intervention to prevent subsequent waves of infection. The more specific issue of containing patients in negative air pressure rooms is contrasted with the fact that there are only 60 such rooms in the state of Minnesota's 144 hospitals.

The associated public health issues of decreased bed capacity and physician time to devote to these issues are discussed. One of Dr. Osterholm's recommendations involves increasing the "slack" in the system. He points out that for smaller disasters, such as plane crashes, the current systems are deficient and these deficiencies would be greatly amplified in a bioterrorist attack. Many physicians have never seen a case of small pox or anthrax and would benefit from the appropriate training. Appropriate training programs exist, but don't target local health systems.

The legal responses by both local officials and federal officials as well as law enforcement are discussed. Large epidemics are inherently disruptive to public health and law enforcement systems. The authors point out how the different perspectives of law enforcement and medicine (preserve the crime scene vs. do whatever is medically necessary) can lead to non-productive and at times embarrassing conflicts during public health emergencies. They also discuss the current legal landscape as it applies to a large epidemic, referencing the work of legal scholar Terry P. O'Brien. Several problems with the current the policies about the government response to a terrorist event are described.

Dr. Osterholm ends the book with an "eight point plan" to improve readiness in the case of a bioterrorism attack. He encourages a realistic appraisal of the current situation and concrete steps to improve readiness both within the government and the medical community. This book is a compelling read from a number of perspectives. At the level of government's ability to address difficult problems, we find that very little seems to be going on. Funds are targeted for the wrong purposes and local officials seem to be waiting for federal guidance that never comes. On another level we are introduced to terrorists that act unilaterally and with no provocation. A situation where a random act of aggression can become a biological catastrophe seems plausible. As a psychiatrist, I am interested in the thinking behind terrorism specifically what would cause a person to murder large numbers of people. The book does not explore the consciousness of terrorists except to suggest that there are no common threads. We are left with the problem that it is impossible to predict the person capable of this rare, but devastating behavior.

I liked the layout of this book. It is written to maintain the interest of the casual reader, but also includes fairly detailed footnotes. Those footnotes cover official documents, scholarly references, and articles in the press. I have an interest in bioterrorism and found that the references were more comprehensive and relevant than those I had been able to find in the medical literature. The authors have done a service in outlining the scope and nature of the current problem. It is up to the rest of us to make sure something gets done about it.