JAMA THEME ISSUE                     ---! cl

Editorial

Editorials represent the opintons of the authors and THE JOURNAL and not those of the American Medical Association,

Infectious Disease and Biological Weapons

Prophylaxis and Mitigation

The topic of biological warfare (BW) was last covered system-
atically by JAMA, as part of a discourse on weapons of mass
destruction, in August 1989.`3 That year marked the bicenten-
nials of the French Revolution and the start of the American
presidency. By year's end, 1989 also marked the collapse of the
Soviet Empire, and with that the end of the cold war. The Bio-
logical Weapons Convention (BWC) had been in place since
1972; nevertheless, compliance on the part of great states, no-
-

tably Russia, with that convention was the centerpiece anxiety
in 1989. United States national policy was likewise concen-
trated on the defense of our troops in tactical combat settings.

Medical interests, notably symbolized by the World Health
Organization's pleas4 had played a sign&ant role in the diplo-
matic priority given to the BWC, and then to concern for its
enforcement. Since 1989, the Persian GulfWar, the escalation of
terrorism, and a recrudescence of many infections have added
new dimensions to concerns for the malicious incitement of dis-
ease. Iraq was proven to have developed and militarized a rep-

ertoire of BW agents, notably anthrax spores." Terrorists
achieved new levels of violence in New York, Oklahoma City,
and Tokyo-and operated on ever more incomprehensible and
unpredictable rationales. Having deployed chemical weapons
in Tokyo and dabbled in SW, terrorists would soon be attempt-
ing to deploy BW on an increasing scale. It is not difficult to find
recipes for home-brew botulinurn toxin on the World Wide Web;
terrorists justify this with the proposition that every citizen
should have the parity of power with government. Meanwhile,
the growth of biotechnology has great promise for new modes
of diagnosis and therapy, but if left unchecked, advances in
biotechnology will allow for even more troublesome microbio-
logical agents of destruction.

This theme issue of JAMA then touches on a set of timely
concerns that unite'national security and public health, con-
cerns that cry out for well-articulated convergence of the hu-
man community worldwide. Various articles in this issue touch
on the historical,6 diplomatic,78 and legal background"; on mo-

   JAMA. August 6. 1997-Vol 278. No. 5
I

Commentaries/Editorial 435


dalities of diagnosis and management"`~**; and on case studies
ofsmall-scale BW attacks that have already been perpetrated,
though amateurish in design and ending with limited malefac-
tion.`Z,`Y The needs and interests of physicians have been up-
permost in the selection of articles to publish from among
many excellent submissions for this issue. The medical com-
munity does indeed have a primary role in institutionalizing
the prohibition of BW as a global commandment, as well as in
mitigating the harm from infractions. How else can BW be
described than as the absolute perversion of medical science?

The problematics of invoking humanitarian regulation of
means of warfare are well understood."*15 Resort to warfare is
tied to the use of any means necessary for the survival of the
state, including organized violence. It is mainly the peacetime
behavior of states that can be regulated by international law,
and this has evolved toward greater coherence and impact in
an interdependent global economy. Even in the thrall of vio-
lent combat, states will also be deterred when there is a firm
international resolve: Iraq did not, after all, use its massive
stockpiles of anthrax.5 Physicians can help drive home the
understanding that the habitual practice of BW would be ru-
inous, underminin g personal security and civil order far more
grievously than any other weapon likely to get in the hands of
disgruntled individuals or rogue states. One sine qua non for
the elimination of BW is its utter delegitimation; in the lan-
guage of the Geneva Protocol of 1925, it must be "justly con-
demned by the general opinion of the civilized world."1G

As a matter of international law, any debate has already been
settled by the wide adoption of the 1972 BWC. The abnegation
of biological weapons is approaching the status of a norm of
international behavior, going beyond a mere contract for mutual
compliance. When an international consensus can be achieved
and sustained, as happened after Iraq's invasion of Kuwait, se-
vere sanctions can be imposed by the international community.
The task is to build that moral consensusl' and give it sustain-
ability and priority over more transient aspects of perceived
national interest, like commercial advantage or access to re-
sources. We are happily less burdened by the choosing up of
sides of the cold war and the strange bedfellows that process
engendered. There is much to answer for in the nonchalance
exhibited by most of the world when Iraq used chemical weap
ons in its wars against Iran and its own Kurd dissidents.`*

Scrupulous adherence to the BWC on our own side, coming
to the bar with clean hands, is of course an absolute prereq-
uisite to the moral platform of BW prohibition. There is no
more powerful instrument for that credibility than factually
competent self-inspection.

. . . physicians in every country should insist on being
empowered to scrutinize suspicious occurrences and fa-
cilities and to investigate outbreaks.

   With regard to infectious disease and microbiologic agents,
.   physicians in every country should insist on being empowered
  Y, to scrutinize suspicious occurrences and facilities and to inves-
  tigate outbreaks. I do not suggest that every physician be man-
  ,{ dated to snoop into every commercial orgovernmental facility,
    '
! but every physician should be free to ask for evidence of the
   kind ofintermediating oversight that will provide assurance of
' !eti.timacv. Such machineili already governs the arotection of

research subjects and of environmentai safety. Knowledge
that Russian physicians were freely and actively engaging
their own government and military on the disposition of cold
war-era BW facilities would be far more reassuring than any
formal system of verification by transnational inspection (and
its absence correspondingly alarming). Revival of trust will be
further promoted by initiatives for joint cooperative research
and public health programs, particularly in infectious disease,
some of which are beginning to be emplaced.

Finally, physicians will be in the front line for remediation in
the wake of BW attack. They should be alert to any constel-
lation of disease that might be the harbinger of new outbreaks.
This issue of THE JOURNAL includes an invaluable primerlo on
the most likely exotic agents, otherwise hardly expected to be
within the ken of most physicians. In the United States, indi-
vidual clinicians would of course funnel their reports to local
and state public health offices, and in turn to the national Cen-
ters for Disease Control and Prevention (Emergency Re-
sponse Coordination Group, telephone [`7'70] 488-7100).

Besides their personal contribution, physicians are in the
best position to assess the readiness of local health services,
police, and firefighter first-responders to deal with health
emergencies. This is the safne apparatus needed to deal with
natural disease outbreaks-recall Legionellaand Escherichia
coli 015i:H7 of recent vintage. The local responders also need
to be trained in exercises entailing support from the Public
Health Service and, if need be, military personnel. Several
articles in this issue point to recent progress, and a long way
still to go, in the coordination of resources among a host of US
governmental agencies-federal, state, and local."~" In view
of the rapid dispersal of people via jet aircraft, that coordina-
tion needs to be extended to a global venue, and this scarcely
e.xists at all at the present time.

Joshua Lederberg, PhD *

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