CBN Report: Ten Notable Publications of 2007
Center for Biosecurity of UPMC, January 10, 2008

We asked our colleagues at the Center to reflect on what they read in 2007 and suggest those publications that were most memorable, influential, or representative of new ideas or concepts in biosecurity. The resulting list, below, is of those publications that influenced our collective thinking about biosecurity by offering important insights, valuable new information, novel ways of looking at old problems, or simply confirmation that (much) work is left to be done in the years ahead. We offer this list with the hope that it may encourage you to catch up on important readings you may have missed or that it sparks reflection and insight.

Our list at a glance:
1.  Homeland Security Presidential Directive 21 
2.  Biology's Big Bang
3.  Ready or Not? (2007) 
4.  Regional Approaches to Hospital Preparedness  
5.  The U.S. Capitol Bioterrorism Anthrax Exposures
6.  Community Engagement Leadership Tool for Catastrophic Health Events
7.  After an Attack
8.  Our Own Worst Enemy
9.  The Day After
10. Brave New War 

1. Homeland Security Presidential Directive 21: Public Health and Medical Preparedness [The White House]: HSPD-21 set forth a national strategic vision to “enable a level of public health and medical preparedness sufficient to address a range of possible disasters.” This directive acknowledges that the U.S. remains vulnerable to events that threaten the health of large populations, that present public health and medical systems cannot function effectively in catastrophic health situations, that “few if any cities are presently able to meet the objective of dispensing countermeasures to their entire population within 48 hours after the decision to do so,” and that empowered citizens and resilient communities will play a key role in the aftermath of a disaster. The directive also offers strategies for reducing our vulnerability, with a path forward that reflects the professional judgments of many medical, public health, disaster response, and community engagement experts in and out of government. This is an important and commendable development in national biodefense policy. [Available online at: http://www.whitehouse.gov/news/releases/2007/10/20071018-10.html]
     
   
2. Biology’s Big Bang [The Economist, June 14, 2007]: In an editorial and accompanying articles in The Economist, the editors bet that biotechnology will prove to be the distinguishing feature of the 21st century, offering a compelling argument that “what physics was to the 20th century, biology will be to the 21st.” They note that the first patent application for an artificial, synthetic living organism was filed by Craig Venter in 2007 and that many of the big problems facing humanity, such as climate change and the need for alternative sources of fuel, are “susceptible to biological intervention.” This quote from the editorial says it best: “There is in biology at the moment a sense of barely contained expectations reminiscent of the physical sciences at the beginning of the 20th century. It is a feeling of advancing into the unknown, and that where this advance will lead is both exciting and mysterious.” [Available online at: http://www.economist.com/opinion/displaystory.cfm?story_id=9339752]
     
   
3. Ready or Not? Protecting the Public's Health from Disease, Disasters, and Bioterrorism, 2007 [Trust for America’s Health]: This is the fifth edition of TFAH’s annual report on the nation’s public health preparedness. TFAH ranks each state on 10 key indicators and reviews each state’s plans to distribute supplies from the SNS; provide liability protection for healthcare volunteers in emergencies; maintain disease surveillance systems and test for biological agents; and purchase antivirals for use in an influenza pandemic. TFAH gave 35 states and Washington, DC, scores of 8 or higher (out of 10); Illinois, Kentucky, Nebraska, New Jersey, Pennsylvania, Tennessee, and Virginia scored the highest with perfect 10s. States scoring the lowest were Arkansas, Iowa, Mississippi, Nevada, Wisconsin, and Wyoming, all with scores of 6 out of 10. TFAH maintains that while some progress has been made, the “continuing trend of annual cuts in federal funding for state and local preparedness activities” threatens our nation's safety. [Available online at: http://healthyamericans.org/reports/bioterror07/]
     
   
4. Regional Approaches to Hospital Preparedness  [Maldin B, Lam C, Franco C, et al. Biosecur Bioterror 2007;5(1):43-53]: Among the many problems we face in responding to large-scale health emergencies is the lack of coordination among hospitals. We saw this during the Hurricane Katrina disaster, and we see it as the nation attempts to institute plans for coping with disasters such as pandemic influenza, nuclear blasts, and other large-scale catastrophes. We believe that a crucial component of any preparedness effort will be regional coordination among hospitals and other community partners. This article identifies key ingredients and critical challenges for building successful regional partnerships for healthcare preparedness and recommends policy and practical solutions for their creation and sustainability. This analysis is based on interviews with public health and hospital representatives from 13 regions or states across the country. [Available online at: http://www.upmc-biosecurity.org/website/resources/publications/ 2007_orig-articles/2007-04-09-regionalapproacheshospitalprep.html]
     
   
5. The U.S. Capitol Bioterrorism Anthrax Exposures: Clinical Epidemiological and Immunological Characteristics [Doolan DL, Freilich DA, Brice GT, et al. J Infect Dis 2007;195(2):174-184]: In the aftermath of the 2001 anthrax attacks, individuals deemed exposed at the U.S. Capitol received antibiotics and anthrax vaccine. Researchers analyzed the immune responses to Bacillus anthracis of 124 persons present inside and outside an epidemiologically defined exposure zone, based on their proximity to the letter contaminated with anthrax spores in Senator Daschle’s office. Immune responses were seen not only in individuals inside, but also in 4 out of 20 individuals who were outside the Hart Senate Office Building during the letter opening. These individuals remained asymptomatic for inhalational anthrax. This was a beautifully done study with many messages for those responsible for responding to an anthrax attack. Perhaps most importantly, it showed that exposure to spores was more extensive than initially predicted and that in some people the immune system is able to effectively clear low numbers of spores in the absence of medical intervention. [Available online at: http://www.journals.uchicago.edu/doi/pdf/10.1086/510312]
     
   
6. Community Engagement Leadership Tool for Catastrophic Health Events [Schoch-Spana M, Franco C, Nuzzo JB, et al. Biosecur Bioterror 2007;5(1):8-25]: Based on the premise that disasters and epidemics require “the judgments and efforts of large numbers of people, not simply those who serve in an official capacity,” this article presents the Working Group on Community Engagement in Health Emergency Planning’s recommendations for government decision makers on how to make the best use of the civic infrastructure in response to an extreme health event. Community engagement—including two-way communication between citizens and government, joint problem solving, and collaborative action—can “augment officials’ abilities to govern in a crisis, improve application of communally held resources in a disaster or epidemic, and mitigate communitywide losses.” The article used the example of an influenza pandemic to illustrate how community engagement could improve planning, preparedness, response, and recovery. [Available online at: http://www.upmc-biosecurity.org/website/resources/publications/ 2007_orig-articles/2007-04-04-communityengagementleadershiptool.html]
     
   
7. After an Attack: Preparing Citizens for Bioterrorism [Danzig RJ, Kleinfeld R, Bleek PC. Center for a New American Security; June 2007]: The authors report that “while the United States has made substantial investments in professional preparation, only rhetorical attention has been paid to prepar­ing the broader public.” The authors use nominal aerosol anthrax and smallpox attacks in an American city to show that current government preparedness efforts will not measure up to fundamental citizen expectations in the event of such catastrophic events. The expectations they identify as being “fundamental kinds of support that members of the public could reasonably expect from the government” include: advice for people on how to protect themselves from infection; prompt identification of exposed individuals; timely and fair distribution of medical countermeasures; health care for those who need it; prevention of subsequent attacks; and establishment of a safe, decontaminated environment for speedy resumption of normal activities. The authors recommend research, development, and funding priorities that should be adopted to “empower lay people to care for themselves, their loved ones, and adjust their expectations.” [Available online at: http://www.cnas.org/attachments/contentmanagers/141/AfterAnAttack.pdf]
     
   
8. Our Own Worst Enemy: Asking the Right Questions About Security to Protect You, Your Family, and America. [Larsen R. New York: Grand Central Publishing; 2007]: In this book, Randy Larsen, director of the Homeland Security Institute and a consultant to the Center, engages the lay reader in a smart, straightforward, and clear conversation about questions and issues central to homeland security and preparedness. He provides coherent arguments regarding the threats that most concern people who officially worry about these matters. He illustrates some of the ways he believes the government has failed in its thinking, planning, and execution of measures designed to increase homeland security, and he is bi-partisan in his critiques. The last part of the book offers calls to action for the government, organizations, families, and individuals. In the end, the lists of preparations and the calls to action may be what get most people to notice this book, and it’s what calls out from the title, but this book is an important and realistic assessment of the state of U.S. homeland security and why and how we should think about it more effectively. [Publisher’s web page: http://www.hachettebookgroupusa.com/books/34/0446580430/index.html]
     
   
9. The Day After: Action Following a Nuclear Blast in a U.S. City [Carter AB, May MM, Perry WJ. Washington Quarterly Autumn 2007;30(4):19-32.]: A nuclear attack on U.S. soil is widely regarded as the gravest of all threats, and “nonstate terrorist actors such as al Qaeda have pledged to carry out an ‘American Hiroshima’ of a significantly greater magnitude than the attacks perpetrated against the United States on September 11, 2001.” The authors argue that in spite of the success of programs to prevent the threat of nuclear terrorism, the threat persists: proliferation continues; much fissile material is not adequately safeguarded; and the probability of a nuclear attack on U.S. soil has increased over the past 5 years. They posed the following question to a group of leading federal government civilian and military officials, scientists, policy experts, and journalists convened for a meeting: “What will the United States actually do on the day after prevention fails? What preparations are necessary?” Asserting that the federal government must acknowledge that its role has to and will be greater than that of providing support to local responders, the authors call for serious planning and preparation on the part of the government, including education and preparation of the public. Prior to this report, most questions regarding a nuclear attack on U.S. soil were directed at what we should do to prevent it. The clarity with which Carter, May, and Perry make their case is striking. [Available online: http://www.twq.com/07autumn/docs/07autumn_cmp.pdf; see also: "After the Bomb," Carter AB, Perry WJ, May MM. New York Times June 12, 2007]
     
10. Brave New War [Robb J. Hoboken, NJ: John Wiley & Sons; 2007]: Robb, a former U.S. Air Force special operations officer, provides a provocative and compelling view of the future of warfare, terrorism, and global security. The author sees Iraq as the testing-ground for a new generation of warfare, in which nonaligned guerillas target national infrastructure. Economically, guerillas have the advantage: they can use bombs that cost a few thousand dollars to destroy key nodes—telecommunications, transportation, and power networks—in the industrial infrastructure, costing billions of dollars in damage. The convergence of terrorist and criminal organizations has created a new “marketplace of violence” in which the planning, production, and placement of bombs has become a series of separate services, rented out to the highest bidder. He predicts that within 10 years, the exponentially increasing sophistication of computer and biological technologies will empower individuals to threaten the stability of entire nations. The author believes that national security will depend on the development of community resilience and redundancies in essential infrastructure. Perceptive, original, and grimly sober, Robb’s analysis is influencing thinking in the national security community. [Publisher’s web page: http://www.wiley.com/WileyCDA/WileyTitle/productCd-0471780790.html]