Between Sept. 11 and Oct. 4, 2001, the United States was paralyzed by fear: First of terrorism, from the World Trade Center attacks, and then of bioterrorism, because so many government planners believed a biowarfare attack would follow a conventional one. They were right. In this ongoing excerpt from Beating Back the Devil, a history of the CDC’s Epidemic Intelligence Service, a team of young disease detectives fans out across New York City in the wake of Sept. 11, hunting for any signals of a bioterror epidemic and struggling to separate what they see from common illnesses and panicked false alarms. While they search, a victim of bioterror does turn up — but far from New York City, at the other end of the East Coast.
Terrorism, 2001: New York City and Washington, D.C. (Part 3)
On Sept. 30, a newspaper photo editor named Bob Stevens who lived in Lantana, Fla. abruptly came down with a fever and chills. Two days later, he grew so disoriented that his wife took him to the emergency department. Within a few hours, he had a seizure and lapsed into a coma. Doctors thought at first that he had meningitis. They did an X-ray, which showed a peculiar widening of the mediastinum, a vertical space between the lungs that houses the heart, the major blood vessels and nerve trunks, and clusters of lymph nodes. When they tapped his spinal fluid and stained it to look for the organism that was making him sick, they found chains of rod-shaped bacteria that gleamed purple with one of the stains they had used. Very few bacteria possessed that shape and responded in that manner to that particular stain. The lead candidate was Bacillus anthracis, the cause of anthrax disease.
Anthrax was a rare occurrence in humans in the United States. It was also one of the pathogens planners thought would be mostly likely to be used as an agent of bioterrorism.
Dr. Larry Bush, the infectious-disease agent whom the hospital summoned to consult on Stevens’ case, called the director of the Palm Beach County health department. She had the samples rushed to Florida’s state public health lab. They found the same bacteria. A Florida FBI agent drove through the night to deliver a small sample to the CDC. They found the same bacteria as well. By then, it was early on Oct. 4, a Thursday. That afternoon, Health and Human Services Secretary Tommy Thompson stepped in front of the daily briefing of reporters at the White House and announced Stevens’ illness. Thompson suggested that the outdoors-loving Englishman has contracted the disease naturally, perhaps by drinking from a woodland stream in North Carolina where he had been vacationing a week earlier.
Stevens’ case, and Thompson’s guess, were the lead story on every evening news program.
Dr. Kelly Moore, a CDC EIS officer, was still assigned to the Elmhurst emergency room where she had been logging cases, looking for any evidence of bioterrorism after the Trade Center attacks. She watched the news in the ER’s break room along with several of the doctors. One of then looked over at her.
“Natural?” he asked. “I don’t think so.”
Kelly flushed. Clearly he was inviting comment from the CDC representative, but she had none to give. “I don’t know anything,” she said. “This is the first I’m hearing about it.”
The phone rang shortly afterward. It was Marci Layton’s office, with a new assignment: Forget about filling out those pink symptom sheets. Find out if any hospital patients in New York have the same symptoms Stevens does.
The problem was not only that Stevens’ illness was rare. It was that it was extraordinarily rare. Anthrax usually infects cattle and goats. Because the bacteria form hard-shelled spores when exposed to air, anthrax can persist in the environment — for instance, the spot where a sick animal collapses — for a very long time. Anthrax bacteria occasionally cause illnesses in humans, usually people who have had close contact with live animals, butchered ones, or skins or pelts. Most commonly, anthrax is a skin disease that causes a wide lesion with a coal-black crust (“anthracis” comes from the Greek word for coal). Up to one in five cases of cutaneous anthrax, the skin-infecting form, can be fatal. Less frequently, anthrax causes a gastrointestinal illness, from eating meat contaminated with spores or bacteria; gastrointestinal anthrax is fatal about 50 percent of the time, but it occurs mostly in the developing world.
Finally, there was inhalational anthrax, the form of the disease Stevens had developed: a rapidly developing whole-body infection that originates in the lymph nodes linked to the lungs after bacteria are inhaled. Inhalational anthrax is fatal at least 85 percent of the time. Clinically, it follows a predictable pattern: one to four days of fever, fatigue, aches and cough; a brief period of feeling better; then a crash, with sweating, dusky skin and inability to breathe. Once the crash begins, victims die within two days.
There had not been a case of inhalational anthrax in the United States since 1976, and only 18 cases in the entire 20th century. That made Steven’s case a medical mystery. But something else made his illness an occasion for alarm and horror: Military planners had long speculated that, if anthrax were used as a biological weapon, it would be released in a way that would create cases of inhalational disease.
Kelly spent the night calling ERs and ICUs around New York City, searching for patients with the same set of symptoms: rapid onset of fever, neurological diseases, widened mediastinum on X-ray, rod-shaped bacteria that responded positively to Gram stain. By the next morning, she reported with relief that there were no known cases of inhalational anthrax in the five boroughs of New York.
That same day, Bob Stevens died. Simultaneously, though the CDC would not know it for several more days, Steven’s co-worker Ernesto Blanco was also hospitalized with the same symptoms. Blanco was 73, a retiree who had gone back to work as a mail clerk at American Media Inc., the Boca Raton publisher of supermarket tabloids where Stevens worked as well.
News of the Florida cases jolted New York just as the shock of the World Trade Center attacks was beginning to leak away. On Monday, Columbus Day, the FBI called Layton to an emergency, a letter that contained an unidentified white powder. It was a busy day for emergencies. Overnight, a physician had reported an unexplained case of fever and rash that he feared might be smallpox. It was a false alarm, though it took Layton several hours to be sure. She had barely returned to her temporary office when an FBI agent in an unmarked car arrived to pick her up. They roared uptown, blaring a siren. It took the rest of the day for Layton to be sure the letter was a false alarm as well.
It was dark by the time she arrived back at her office. Her cell phone rang, again; it was the FBI, again. They wanted Layton to call a 36-year-old woman named Erin O’Connor, an assistant to NBC News anchor Tom Brokaw. O’Connor had heard the news from Florida. She had researched the disease over the weekend, and she thought she might have anthrax.
O’Connor was not seriously ill in the way Stevens had been ill. Her symptoms were fever and a skin rash, which a doctor had already treated. But like Stevens, she worked in a large media organization and handled mail, and the coincidence made her anxious.
Skin samples were rushed to the New York City lab, and to the CDC. At 3 a.m. on Oct. 12, several CDC scientists and the agency director Jeff Koplan eyed the samples through a microscope. The samples had been subjected to a test developed by CDC pathologists that would turn any anthrax bacteria bright red. O’Connor had been given antibiotics by the doctor she had gone to, but the drugs had not yet reached full effect. Through the eyepiece, the red signal shone like a beacon. O’Connor had cutaneous anthrax.
The health department announced her case a few hours later, once the business day began. By the time Layton returned to her office at 7 p.m., after a long day of setting up the investigation at NBC and talking to other media, she had dozens of phone messages and emails. Among them, there was news of three more anthrax cases, at CBS News, the New York Post, and ABC News, where the 7-month-old child of an assistant to anchor Peter Jennings had become seriously ill after being in the building only 90 minutes.
The anthrax situation was no longer a medical mystery confined to Florida. Once they learned of the New York cases, authorities had to acknowledge: It was an attack.
In midtown Manhattan, Kelly had been packing to leave for Atlanta. At about midnight, a fax slid under her hotel room door.
“Your departure is cancelled,” it read. “Please report to NBC News at 8 a.m. tomorrow.”
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The next morning, health department and CDC employees headed for NBC and the other media companies. At NBC, they sorted the 1,200 employees into groups: the small number of people who worked near O’Connor, who would need to be checked for exposure and given antibiotics; and the much larger group who needed to be informed and reassured. When Kelly arrived, informing became her job.
“They paired us with a crisis counselor, someone who had experience working with people in disasters,” she said later. But on that first day at least, the NBC employees had little interest in crisis counseling. Emotional processing would come later; right now they wanted information, and Kelly had it.
Over and over, she recited the same points: Their co-worker had developed cutaneous anthrax, not the more dangerous inhalational kind. The CDC believed that, to contract a case of inhalational anthrax, it was necessary to inhale thousands of bacterial spores. There was no evidence any of them had been exposed to a source of spores. There was a nasal-swab test that could show whether there had been spores in their environment, but it could not predict who would develop anthrax disease. There was one solid protection against developing anthrax, taking up to 60 days of antibiotics, but the two main antibiotics had a high rate of unpleasant side effects. Unless someone knew they had been exposed, or had definite symptoms — fever, rashes, the beginnings of something that felt like flu — taking the drugs was not recommended.
Over three days, she repeated those messages to almost 300 people. Some listened carefully. Others were half out of their minds with anxiety over symptoms that might have been early-season colds or flu.
“I’ve had a fever on and off for the last two weeks, and a runny nose,” one woman told Kelly halfway through the second day of counseling. “I just want to know: If I had anthrax, would I be dead by now?”
Kelly said Yes, she would.
Later in the day, a group of custodial workers came to consult her. “My wife won’t let me sleep in the bed with her,” one said. “She says I might give her anthrax.”
“Well, sir,” Kelly said, “she’s going to have to come up with a better excuse.”
By the end of the second day, investigators found what they thought was the source of O’Connor’s exposure: a handwritten letter, dated Sept. 18, that had been postmarked in Trenton, NJ, just across the Hudson River. It was almost identical to a letter they had found at the New York Post, addressed to the paper’s editor. That letter was also postmarked Trenton, Sept. 18.
On Oct. 15, in Washington DC, an intern in the Capitol Hill office of Senate Majority Leader Tom Daschle cut open a hand-printed envelope, taped along its edges. It released a puff of white powder. It was postmarked Oct. 9. It had been mailed in Trenton.