The Anthrax Letters: The Attacks That Shocked America (3 page)

Besides bioagents as military weapons of war, biological terrorism has become more worrisome. The 1995 release of sarin in the Tokyo subway by the Aum Shinrikyo cult was particularly alarming. In that case the weapon was a
chemical
nerve agent that killed 12 people and injured more than a thousand. But the attack suggested that the same, or worse, could be done with a
biological
agent. So by the beginning of the 21st century, bioweapons were understood to be a growing threat. Then came September 11. After the jetliners crashed into the World Trade Center and the Pentagon, terrorism became the subject overshadowing all other issues. Residents of South Florida were acutely aware that several of the suicide hijackers had lived among them and taken flying lessons nearby. Anxiety there as elsewhere was about further hijackings and other forms of terror, though the possibility of bioterrorism received no special attention.

For Larry Bush on October 2, the bioconnection was immediate. He turned to the woman who had prepared the Stevens specimens: “Kandy, did you see his cerebrospinal fluid? Did you look at that Gram stain?” Kandy Thompson, a medical technologist since 1975, had worked at JFK for 6 years. She had previously run a microbiology laboratory at another hospital, and Bush knew she could offer an experienced impression. She looked again through the microscope and said: “The spinal fluid looks milky, pussy, bloody. I don’t know—large rods, a bacillus, maybe clostridium.” Neither she, the emergency room doctors, nor anyone else who had attended Robert Stevens imagined the kind of thought that had leaped to Larry Bush’s mind: “They’re large. Really. You know, it could be anthrax,” he said. Her pleasant smile melted: “Oh my God. Don’t say that.” “Look, in my mind this
is
anthrax until proven otherwise. But we don’t know yet, so don’t say anything to anyone.”

Kandy was so frozen by the thought that for days she refused to talk about it. Even her family didn’t find out about her involvement until the news became public. She calls the experience “exciting and scary, like nothing else in my life before.” And, “I hope I never see anything like it again.”

Physicians are largely unfamiliar with many of the germs likely to be adapted as biological weapons. The
variola
virus, which causes smallpox, killed hundreds of millions of people in past centuries. But by the mid-20th century, vaccinations against the disease had markedly reduced the numbers. The last recorded case in the United States was in 1949. A global vaccination program by the World Health Organization to eradicate smallpox from the earth was declared successful in 1980. Thus, few doctors practicing today, especially in the United States, have ever seen a case of smallpox.

Plague is equally obscure. Caused by the bacterium
Yersinia pestis
, outbreaks in the past wiped out huge populations. In the Middle Ages a plague epidemic killed one-third of Europe’s population in just four years, 1346 to 1350. The disease became less fearsome after the development of penicillin and other antibiotics in the mid-20th century, since they offer protection if administered soon after exposure. In the United States, beyond a few locations mainly in the Southwest, where an infected rodent occasionally transmits the bacterium to a human, today’s physicians have never treated a case. Timely diagnosis thus is less likely.

Still, in the cases of smallpox and plague, historical experience provides a bank of knowledge. Symptoms, treatment, and methods of prevention are well established. None of this is true for anthrax, which in recent centuries has never been widespread among humans. In the United States only 18 cases of anthrax from inhaled spores were recorded in the 20th century. Dr. Bush’s early suspicions therefore seem all the more remarkable. Despite the increased publicity about bioterrorism, the cold fact is that the use of biological agents for hostile purposes has been rare. The only known large-scale incident in the United States was in 1984, when the Rajneesh cult in Oregon poisoned restaurant salad bars with s
almonella
bacteria. At least 750 people became ill, but none died. As far as we know, anthrax had never been used in this country for hostile purposes—never deliberately to infect or kill anyone. Dr. Bush was running against the grain of history and experience.

Anthrax spores normally lie beneath the surface of the soil. Grazing animals, like sheep, goats, or cattle, may become infected by ingesting or breathing in the bacteria. Human anthrax infections almost always arise from contact with such an infected animal or its wool, hair, or hide. Cutaneous anthrax, which occurs if spores enter through cuts or other skin openings, is largely treatable with antibiotics. But if the spores are inhaled, they are far more likely to be deadly. Unless antibiotics are administered soon after exposure, recovery is uncertain. Moreover, 90 percent of
untreated
victims of inhalation anthrax die.

In spore form, anthrax bacteria are tough and durable. Potentially dangerous anthrax spores have been found in locations where infected cattle carcasses were buried 140 years earlier. After lying dormant for decades, certain conditions can transform spores into active, germinating organisms. Paradoxically, one such condition occurs if a spore is engulfed by a macrophage, one of the body’s natural defense cells that ordinarily destroy such foreign bodies. Thus, the very cell that usually protects a person from an invading microorganism may transport and activate an anthrax spore into a germinating organism that reproduces and releases deadly toxin. It is the durability and lethal power of the spore that make anthrax an attractive biological weapon. Dr. Bush’s presumption that someone had been deliberately infected with anthrax took matters across a divide with immense and frightening implications.

Soon after Bush settled on the possibility of anthrax, he had a sample of the bacteria delivered to Anne Beall, the head medical technologist at Integrated Regional Laboratories in Fort Lauderdale, Florida. The lab, which is used by several hospitals in the area, performs tests in addition to those done in the hospitals. One test determines the germs’ motility—whether they are capable of spontaneous movement. Motility can be observed through the microscope or sometimes through the spread of growth in a culture medium. Another test involves the action of the bacteria on red blood cells. When placed in a medium containing red cells, certain bacteria destroy the cells, a process called hemolysis. Completing these assessments takes time, maybe 6 to 12 hours, because quantities of bacteria must first be grown and then applied to the tests.

The regional lab received the sample at about 9 a.m. Bush called over to the lab: “Here’s the deal, Anne. I think this could be anthrax. We’ve got to do these tests now so that we can see if we should move ahead with this.” Beall began setting up the tests immediately. By early afternoon she had results. The bacteria were nonmotile and nonhemolytic.
Bacillus anthracis
is nonmotile and nonhemolytic. “You know what?” he told her, “these tests don’t fit with the other bacilli I thought could be alternative choices. This is really looking quite like anthrax.”

Bush then called the state laboratory in Jacksonville and shared his suspicions with the head microbiology technician, Philip Lee, who was also Florida’s biological defense technical coordinator. “Phil, we’re going to overnight the organism to you. What can you do up there that will give us fast results?” Thanks to the national Centers for Disease Control and Prevention, Lee’s lab was well positioned to identify the organism. Based in Atlanta, the CDC is the lead federal agency charged with protecting the health and safety of the American public. Part of the U.S. Department of Health and Human Services, its activities range from monitoring disease outbreaks to providing citizens with health information, from developing vaccination programs to performing advanced laboratory testing to identify microorganisms. In 1999 the CDC established the bioterrorism preparedness and response program to help state laboratories adopt uniform testing methods for suspected bioagents. Dubbed the “laboratory response network,” by 2001 about 80 labs around the country were participating.

Not only was the Florida state laboratory in Jacksonville part of the network, but Lee himself had taken courses at the CDC on how to test for suspected bioweapons, including anthrax. “We’ll be doing three tests,” he told Bush. “What we’ll be looking at is capsular staining, a polysaccharide test of the cell wall, and something called a gamma phage test.”

The first test, capsular staining, identifies whether the bacillus has a capsule, a thick outer coating. The capsule exists only when the organism is in vegetative form, not in spore form. In its vegetative form the organism reproduces and releases toxin, whereas in spore form it remains dormant and durable for an indefinite period. Through chemical and temperature manipulation in the lab, anthrax bacteria can be induced into either spore or vegetative form. The capsular test by itself is not conclusive for anthrax because some other bacilli are also encased in capsules.

The second test, the polysaccharide test, is performed on the cell wall of the organism when it is in spore form. The wall contains a specific sugar, a polysaccharide that is peculiar to anthrax and a few other bacillus species. As with the first test, a positive result does not mean confirmation. But if both the capsule and the polysaccharide tests are positive, the bug is almost certainly anthrax.

The third test, the gamma phage test, is based on the fact that certain viruses, called phages, can enter and infect bacteria. Among a group of them known as gamma phages, one type can uniquely infect anthrax bacteria. Once inside the bacteria, the phages rapidly reproduce and cause the bacterial cell to split open. The test involves introducing these gamma phages into a population of bacteria. If the bacteria break open, or lyse, they are virtually certain to be anthrax.

By Tuesday evening the specimens were en route to Jacksonville, though Lee would not receive them until noon the next day. Before speaking with Lee, Bush had placed another important call. Around 2:30 he rang up Jean Malecki, the Palm Beach County health director, but she was not in her office. JFK Medical Center is in the county’s jurisdiction, and she and Bush had a close working relationship. Ironically, on that day, Dr. Malecki was attending a conference that she had organized on chemical and biological terrorism. Eighty physicians and other healthcare professionals were learning about what to do in case of a bioweapons attack. Half an hour after Bush called, Malecki’s assistant handed her a list of messages, including the one from Dr. Bush. She stepped out of the conference hall to a phone in a nearby office and dialed his number:

“Hi Larry. What’s up?”

“Jean, just a minute—I’m going to close my door. Are you by yourself?”

“Yes. OK, I’m closing my door, too.”

“Look, I’ve got this guy here, and his clinical course is unusual.” Bush summarized what he had found with Bob Stevens and then said, “I think he could have anthrax.”

“No. You really think so?”

“I can’t prove it, and there is no reason to believe it’s based on anything he’s been exposed to, but otherwise it sure seems to fit. So yeah, I think he may well.”

Dr. Malecki, a tall woman with flowing red curls, has presided over local responses to hurricanes, tornadoes, food poisoning, West Nile fever, and Legionnaire’s disease. She joined the county health department in 1983 and became its director in 1991. Malecki revels in her work, which, she announces with pride, is to oversee the largest health department in the state. She emphasizes the difference between her work and that of state and federal public health agencies:

Jean Malecki and Larry Bush were a perfect match for the needs of the moment. Both were quick to assert their convictions and challenge conventional thinking. They discussed which organisms, besides anthrax, might be causing Bob Stevens’s symptoms. They mapped a course of action pending results from the Jacksonville lab. Above all, they agreed to keep the matter quiet, though Malecki said she would call the state epidemiologist at the Department of Health in Tallahassee, Steven Wiersma. Wiersma, she was sure, would notify the CDC. But they worried that premature leaks might cause panic among the hospital staff and patients.