The first sign of trouble might be rather mild -- people showing up at doctors' offices or hospital emergency rooms with runny noses, teary eyes, headaches and fevers.

Only the sheer number of these patients, not the severity of the initial symptoms, might suggest that something unusual is afoot.

But the progression of these flu-like symptoms over a period of days into worse problems, such as bleeding, internal and external lesions, and labored breathing, might provide the first proof of the unspeakable: an attack on a civilian population with biological weapons. In such an event, untold thousands of people could suffer agonizing deaths.

That scenario was offered by experts on Monday amid mounting concern after the September 11 attacks on New York and Washington that the United States is poorly prepared to deal with an attack involving disease-causing micro-organisms or lethal chemicals.

"In a worst-case scenario, a biological attack could be considered the most horrible of all in terms of a hostile effort against a population," said Leonard Cole of Rutgers University in Newark, New Jersey, whose books on biological and chemical warfare issues include "The 11th Plague: The Politics of Biological and Chemical Warfare."

Domino Effect

"And that's because, at least theoretically, every person who becomes infected, if it is with a certain kind of micro-organism, himself becomes a biological weapon who can infect others, and you get kind of a domino effect," Cole said.

America is unprepared to handle an attack with a biological weapon harnessing deadly viruses and bacteria or a chemical weapon that ravages the human nervous system, experts said.

For example, the people who may be the first to respond to a biological weapon attack -- the primary-care physicians -- have not been included in any meaningful way in planning efforts, said Michael Osterholm, director of the University of Minnesota's Center for Infectious Disease Research and Policy.

"At this point, we're woefully short in vaccines and antibiotics. The public health infrastructure is but a shell of what it needs to be able to respond. And public health has continued to be overlooked in most of the kinds of funding that have occurred to date in terms of trying to prepare us for terrorism," Osterholm said.

The nightmare scenario for government officials planning responses to unconventional domestic attacks is the introduction of a biological agent such as anthrax, smallpox or a small list of diseases into a densely populated area, perhaps by dumping a mist or powder over a city from a low-flying, slow-moving, small airplane.

"Silent Killers"

Frank Cilluffo of the Center for Strategic and International Studies called biological weapons "silent killers" because it could take days or weeks for symptoms to manifest themselves. An attack could remain unknown for some time unless the perpetrators announced it.

Because no one would know what had happened, many people who had been exposed -- say, to an infectious disease such as smallpox -- might unwittingly spread the virus to many more victims who had initially been spared.

Experts believe the two most likely biological agents would be anthrax -- a deadly bacterial disease spread by spores and generally confined to sheep, cattle, horses, goats and pigs -- and smallpox -- a viral scourge that killed millions of people throughout the centuries until it was declared eradicated worldwide two decades ago.

Anthrax kills about 90% of those it infects but is not spread from person to person. Smallpox kills only about 30% of those it infects but is alarmingly infectious.

The two most likely chemical agents, experts said, would be nerve gases such as sarin or VX, which short-circuit the nervous system, and mustard gas, which causes deadly internal and external blistering.

High Death Tolls

"A well-placed and effective chemical agent could clearly (cause) thousands of deaths," Osterholm said. "A well-placed and effective biological agent could (cause) hundreds of thousands of deaths."

Various government reports document failings in official preparations for domestic attacks with biological or chemical weapons. The US Centers for Disease Control and Prevention, the agency that would be in charge of nailing down the nature of a germ outbreak in the hours and days after an attack, concedes that the public health system right now is unable to detect and respond to a biological attack.

Congressional investigators have reported in the past 2 years that "the US ability to effectively respond to chemical or biological terrorist incidents is compromised by poor management controls and the lack of required items," such as good vaccines and medical supplies.

One report found that government stockpiles included expired medicines. Another found that supplies were being stored at too high a temperature.

"We're unprepared. I'm not going to lie and say that we would handle it well," said Cilluffo of the Strategic and International Studies think tank.

Reuters Washington DC September 18, 2001

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