It was still early when Larry Bush reached the gurney in the emergency room of JFK Medical Center in Atlantis, Florida, part of a strip of towns that stretches from Miami to West Palm Beach. Bush was the hospital’s chief of staff and an infectious diseases physician, on his way to a regular morning meeting, but some ER physicians had asked that he drop by. A 63-year-old man named Bob Stevens had been brought in about 2:30 am with a roaring fever. Now he was comatose and plugged into a ventilator, with his frightened wife by his side.
The wife told Bush their story. As he recalled it later, she said they lived a few miles away, closer to the ocean. Her husband worked in Boca Raton for a company that published supermarket tabloids, but they had been out of state for a week, visiting their daughter. He had started to feel ill the day before on the long drive home, and had gone to bed as soon as they arrived. He had woken her up in the middle of the night, wandering around the house, confused.
Fever, confusion, rapid collapse: That sounded to Bush like meningitis, an infection in membranes around the spinal cord and brain that can be caused by several organisms. He headed to the hospital’s lab to check test results, and found himself staring down a microscope at one he had not expected to see: strings of bright-purple rod-shaped bacilli, threaded end to end like train cars on a track.
Bush recognized the arrangement, but he couldn’t make sense of it. Infections with the organism he was looking at are so rare that they had occurred in the United States fewer than 20 times in a century, and only among people in a narrow range of occupations—cattle ranchers and drum-makers, not photo editors in a Florida suburb.
“If this is anthrax,” he said to himself, “it’s bioterrorism until proven otherwise.”
That was October 2, 2001. It took two days for Bush’s suspicions to be confirmed. When his diagnosis was announced at a press conference on October 4—20 years ago today—it launched the most complex and concentrated public health response in US history to that point, rivaled only today by the effort to respond to Covid.
You could not open a laptop or turn on the news three weeks ago without being reminded of the 20th anniversary of the World Trade Center attacks of September 11, 2001. Compared to that honored memory, the anthrax-letter attacks—the first fatal bioterror attack on US soil—are barely remembered, though in the days following Bush’s announcement they killed five people, sickened another 17, sent 30,000 people to doctors, put 10,000 of them on preventive antibiotics, and convulsed Capitol Hill and the New York media world.
But people who were involved in the response then, including Bush—who continues to work as an infectious disease specialist at the medical center where Stevens later died—say the anthrax attacks presented hard lessons that could have helped the Covid response if they had been remembered. “What went well was our ability to recognize it right away, and report it,” says Bush, who is now also an affiliate professor at the medical schools of Florida Atlantic University and the University of Miami. “But we are not better prepared now than we were then.”
A brief recap, though with something as complicated as the anthrax attacks it’s difficult to be brief: Stevens was not the first case; he was only the first to be diagnosed. The anthrax had been sent through the mail that September and October. All the victims had some contact with spore-laced letters that were sent to offices in Congress and the media, or were exposed after the letters spread spores into mail-processing equipment and contaminated other mail, workplaces, and homes.
The massive investigation that spun off from Stevens’ diagnosis eventually discovered that he was the ninth person infected, though everyone exposed before him developed only lesions from getting the organism on their skin. His case was fatal because he had inhaled it.
The perpetrators at first were believed to be foreign terrorists; two of the World Trade Center attackers had taken flying lessons in the same part of Florida. In 2008, the Federal Bureau of Investigation linked the attacks to a scientist working at the US Army Medical Research Institute of Infectious Diseases, the federal government’s bioterror-defense lab. That scientist, Bruce Ivins, died by suicide as the FBI was investigating him. In 2011, an independent review by the National Research Council concluded the case against him was not proved.
But in the autumn of 2001, the response to anthrax swamped public health. Tens of thousands of Capitol Hill, TV network, and postal workers had to be checked for unrecognized exposure. Random citizens terrified by unexplained spills of anything powdery clogged phone lines. The Centers for Disease Control and Prevention later estimated that it put more than 2,000 agency personnel on the response. The CDC-supported Laboratory Response Network analyzed more than 125,000 samples taken from possible patients. The National Pharmaceutical Stockpile, established three years earlier, delivered 3.75 million doses of antibiotics to health departments in the locations—Florida, and also New York, New Jersey, Connecticut, and Washington, DC—where people were believed to be at risk.
Twenty years later, those public health workers are stunned all this has almost vanished from collective memory. “I mentioned this to a probably 25-year-old recently, and his response was, ‘What was that?’” says Ali S. Khan, a physician and dean of the College of Public Health at the University of Nebraska Medical Center, who was part of the CDC’s Washington investigative team in 2001.
Federal reassessment of the nation’s vulnerability to bioterror following the attacks sent a lot of money flowing out to states, and Khan’s university was one beneficiary: It now houses the National Quarantine Center, where anyone potentially exposed to a rare disease can be checked out—including the first Americans repatriated from Wuhan last year. “We’re much better prepared for a bioterror attack now, 20 years later,” Khan says. “But we still remain woefully unprepared. I know that’s a dichotomy, but this pandemic is proof. We don’t have the public health practitioners and the information systems that we need.”
The anthrax attacks were a harbinger of public health challenges to come. In 2001, the US had been spared major epidemics for years. The first cases of AIDS had been recognized in 1981, but the first versions of the multi-drug cocktails that would make HIV a survivable disease debuted in 1996. The H5N1 avian flu that leaped to humans in Hong Kong in 1997, sickening 18 people and killing six, did not surge out of Asia because authorities slaughtered more than 1 million chickens to deny the virus a host.
But after anthrax, other disease crises showed the US how it might be at risk. H5N1 leapfrogged out of China in 2004. Then H1N1 avian flu sparked a worldwide epidemic—fortunately, of mild disease—in 2009. Ebola surged in West Africa in 2014, killing 11,325 people there—one of whom, before his death, flew to the US and infected two nurses, both of whom survived. In 2015, Zika virus moved into the Americas, infecting several million people and causing thousands of cases of birth defects. Yet after each crisis, the US failed to learn the after-anthrax lesson that public health needs sustained investment—in adequate staff, digital surveillance and abundant lab capacity—to handle the unpredictable.
“Public health funding has always followed the pattern of, ‘Out of sight, out of mind,’” says Thomas Frieden, a physician, former CDC director and CEO of the nonprofit Resolve to Save Lives. “You get big infusions of money, but you really can’t build capacity effectively with one-time dollars.”
As much as public health didn’t learn a lesson about funding, it also didn’t learn lessons about communicating. A good portion of the stress on the system was caused by members of the public not understanding whether they were at risk of anthrax exposure. “In New York, we received two letters and had eight cases and one death,” says Sandra Mullin, who was communications director for the city’s health department in 2001 and handled its twice-daily press conferences. “But we had 1,700 people on antibiotics and 3,000 ‘powder events.’ It was really a psychological terrorism event, more than one that created impact in terms of illness and death.”
Mullin, who is now senior vice president at the global health nonprofit Vital Strategies, says one lesson of the New York anthrax experience was that politicians tended to soft-pedal bad news, rather than “directly and frankly and bluntly” delivering information that residents needed. That same mistake was made at the start of the Covid pandemic, she points out—especially by the Trump White House, which perpetually insisted that the virus was going to disappear. “We haven’t quite mastered how to trust that people can bear bad news,” she says, “and bear uncertainty, and bear the truth about the risks they might be facing.”
This leaning isn’t unique to politicians. Confusion about what’s the best message for the public to hear has been threaded through the Covid response. Tensions over mask-wearing might not have been so acute if everyone in the US had been told to wear them right from the start, instead of that masks would not be helpful—and people might not resist wearing them now if they hadn’t been told in the spring that they could take them off. And it’s likely to have been dizzying for the public to see health officials disagree; as recently as two weeks ago, federal agencies and their advisory committees split over backing the White House’s call for broad access to Covid booster shots—a back and forth that ended with the CDC director endorsing wider approval than her committee did.
People who worked in public health in 2001 recall the shock of learning how patchy health communication was. Medical care was just starting to move health records into digital form, encouraged by the passage of the Health Insurance Portability and Accountability Act, or HIPAA, five years earlier. But systems weren’t interoperable (and many still are not now). That made it impossible to automate alerts about worrisome symptoms, leaving public health reliant on astute clinicians such as Bush. At the state level, some health departments discovered they did not possess email addresses for doctors in their jurisdictions, and had to rely on faxes to communicate.
Twenty years later, public health is still struggling to get access to data that could help officials respond. That was evident during the early days of Covid, when the civilian-run Covid Tracking Project assembled a corps of volunteers to assemble case count and testing data faster than the CDC could publish it, when the Department of Health and Human Services took responsibility for Covid hospital data away from the CDC, and when HHS’s own data diverged from that of the states sending information to it.
The experience of this pandemic made clear to investigators how much remains to be done to create rapid, sensitive systems for gathering information. “A public health system is only as strong as its weakest link,” says Rima Khabbaz, a physician who directs the CDC’s National Center for Emerging and Zoonotic Infectious Diseases, and was part of its Washington deployment in 2001. “We need to modernize systems for surveillance and laboratory exchange of information. Travelers’ health, border issues, migrant populations, there is lots of work to do.”
If there is a single lesson that could echo down the years from the anthrax attacks and response, it is that looking back—something that is built into public health systems, which tend to analyze outbreaks and trends after they occur—is insufficient for future protection.
“We have this cycle of complacency, and then panic, and then complacency again,” says Lawrence O. Gostin, who directs the O’Neill Institute for National and Global Health Law at Georgetown University. “We haven’t learned the lessons of anthrax and Ebola and influenza and Zika. We just keep having one crisis after another, and we react, and we never prepare.”
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