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NSC Meeting 2
Information presented to NSC members, 15 December 2002 (6 days into the epidemic). A total of 2000 smallpox cases have been reported in 15 states, with 300 deaths (figures 2 and 3). The epidemic is now international, with isolated cases in Canada, Mexico, and the United Kingdom. Both Canada and Mexico request that the United States provide them with vaccine. All of the cases appear to be related to the 3 initial outbreaks in Oklahoma, Georgia, and Pennsylvania. The public health investigation points to 3 shopping malls as the initial sites of exposure. Only 1.25 million doses of vaccine remain, and public unrest grows as the vaccine supply dwindles. Vaccine distribution efforts vary from state to state, are often chaotic, and lead to violence in some areas. In affected states, the epidemic has overwhelmed the health care systems, and care suffers. The DoD expresses concern about diverting its critical supplies and personnel to the civilian health care system, given the evolving crisis in the Persian Gulf.
Figure 2
Map showing cumulative reported smallpox cases (n = 2000) reported to the National Security Council at meeting 2 (15 December 2002) as part of the Dark Winter simulation exercise.
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Map showing cumulative reported smallpox cases (n = 2000) reported to the National Security Council at meeting 2 (15 December 2002) as part of the Dark Winter simulation exercise.
Map showing cumulative reported smallpox cases (n = 2000) reported to the National Security Council at meeting 2 (15 December 2002) as part of the Dark Winter simulation exercise.
Figure 3
Smallpox cases reported to the National Security Council at meeting 2 (15 December 2002) as part of the Dark Winter simulation exercise.
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Smallpox cases reported to the National Security Council at meeting 2 (15 December 2002) as part of the Dark Winter simulation exercise.
Smallpox cases reported to the National Security Council at meeting 2 (15 December 2002) as part of the Dark Winter simulation exercise.
Several international borders are closed to US trade and travelers. Food shortages emerge in affected states as a result of travel problems and store closings. Sporadic violence has been reported against minorities who appear to be of Arab descent. There are no solid leads regarding who may have perpetrated this attack. The government response to the epidemic has been criticized. The media continues its 24-h news coverage of the crisis. Misinformation regarding the smallpox outbreak begins to appear on the Internet and in the media, including false reports of cures for smallpox. Schools are closed nationwide. Public gatherings are limited in affected states. Some states limit travel and nonessential gatherings. The Department of Health and Human Services establishes a National Information Center. Three US drug companies agree to produce new vaccine at the rate of 6 million doses per month, with first deliveries in 5 weeks. Russia offers to provide 4 million doses of vaccine.
Critical debate issues and decisions. NSC officials confront a growing set of challenges and decisions. Given the shortage of vaccine, how can the spread of smallpox be halted? Should patients with smallpox be confined to facilities dedicated to care for them? Should contacts of patients be forced to remain at home or in dedicated facilities until they are proven to be free of smallpox? Should national travel restrictions be imposed? How can disease containment best be balanced against economic disruption and the protection of civil liberties? To what extent can and should the government infringe upon civil liberties? Under what conditions can those powers be exercised? What federal actions can and should be taken to care for the sick? Should the National Guard be federalized (i.e., put under federal control)? What additional assistance can the federal government provide to the states? Should troops continue to deploy overseas to southwest Asia? What should the President tell the people of the United States? Who orchestrated this attack and why? Is the nation at war?
NSC members make a series of important policy decisions. Members decide to leave control of the National Guard as well as decisions on quarantine and isolation in the hands of state officials. Members decide to pursue a crash production program for new smallpox vaccine, despite unresolved liability issues. They also decide to accept smallpox vaccine offered by Russia, provided it passes safety evaluations. In addition, a statement is produced for the President to deliver in a press conference. In the press conference, the President provides an assessment of the gravity of the situation and discusses the government's response. He appeals to the people of the United States to work together to confront the crisis and to follow the guidance of their elected officials and their public health professionals regarding necessary disease-containment measures.
NSC Meeting 3
Information presented to NSC members, 22 December 2002 (13 days into the epidemic). A total of 16,000 smallpox cases have been reported in 25 states (14,000 within the past 24 h) (figures 4 and 5). One thousand people have died. Ten other countries report cases of smallpox believed to have been caused by international travelers from the United States. It is uncertain whether new smallpox cases have been transmitted by unidentified contacts of initial victims, by contacts who were not vaccinated in time, or by people who received ineffective vaccine, or are due to new smallpox attacks, or some combination of these. Vaccine supplies are depleted, and new vaccine will not be ready for at least 4 weeks. States have restricted nonessential travel. Food shortages are growing in some places, and the national economy is suffering. Residents have fled and are fleeing cities where new cases emerge. Canada and Mexico have closed their borders to the United States. The public demands mandatory isolation of smallpox victims and their contacts, but identifying contacts has become logistically impossible.
Figure 4
Map showing cumulative reported smallpox cases (n = 16,000) reported to the National Security Council at meeting 3 (22 December 2002) as part of the Dark Winter simulation exercise.
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Map showing cumulative reported smallpox cases (n = 16,000) reported to the National Security Council at meeting 3 (22 December 2002) as part of the Dark Winter simulation exercise.
Map showing cumulative reported smallpox cases (n = 16,000) reported to the National Security Council at meeting 3 (22 December 2002) as part of the Dark Winter simulation exercise.
Figure 5
Smallpox cases reported to the National Security Council at meeting 3 (22 December 2002) as part of the Dark Winter simulation exercise.
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Smallpox cases reported to the National Security Council at meeting 3 (22 December 2002) as part of the Dark Winter simulation exercise.
Smallpox cases reported to the National Security Council at meeting 3 (22 December 2002) as part of the Dark Winter simulation exercise.
Although speculative, the predictions are extremely grim: an additional 17,000 cases of smallpox are expected to emerge during the next 12 days, bringing the total number of second-generation cases to 30,000. Of these infected persons, approximately one-third, or 10,000, are expected to die. NSC members are advised that administration of new vaccine combined with isolation measures are likely to stem the expansion of the epidemic. NSC members ask for worst-case projections. They are advised that in worst-case conditions, the third generation of cases could comprise 300,000 new cases of smallpox and lead to 100,000 deaths, and that the fourth generation of cases could conceivably comprise as many as 3,000,000 cases of smallpox and lead to as many as 1,000,000 deaths. It is again emphasized to participants that these numbers are worst-case projections and can be substantially diminished by large-scale and successful vaccination programs and disease-containment procedures (figure 6).
Figure 6
Smallpox epidemic projections, worst-case scenario (in the absence of disease-containment measures or new vaccine delivery), reported to the National Security Council meeting 3 (22 December 2002) as part of the Dark Winter simulation exercise. Gen, generation of cases; K, thousand.
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Smallpox epidemic projections, worst-case scenario (in the absence of disease-containment measures or new vaccine delivery), reported to the National Security Council meeting 3 (22 December 2002) as part of the Dark Winter simulation exercise. Gen, generation of cases; K, thousand.
Smallpox epidemic projections, worst-case scenario (in the absence of disease-containment measures or new vaccine delivery), reported to the National Security Council meeting 3 (22 December 2002) as part of the Dark Winter simulation exercise. Gen, generation of cases; K, thousand.
No solid leads as to who masterminded the attack have emerged. A prominent Iraqi defector claims that Iraq is behind the biological attack. Although the defector cannot offer proof beyond a reasonable doubt, the intelligence community deems his information highly credible. Polls of US citizens show overwhelming support for retribution when the attacker is identified.
The scenario ends when it is announced that the New York Times, the Washington Post, and USA Today have each received an anonymous letter demanding the removal of all US forces from Saudi Arabia and all warships from the Persian Gulf within 1 week. The letters threaten that failure to comply with the demands will result in new smallpox attacks on the US homeland as well as other attacks with anthrax and plague. To prove the veracity of these claims and the seriousness of their threats, each letter contains a genetic fingerprint that matches the fingerprint of the smallpox strain causing the current epidemic, demonstrating that the author of these letters has access to the smallpox strain.
Critical debate issues. With no vaccine remaining and new vaccine not expected for at least 4 weeks, how can the rapidly expanding epidemic be contained? What measures should the federal and state governments take to stop the epidemic, given the scope of the crisis, the lack of remaining vaccine, and rising stakes? Should the United States pull its forces out of the Gulf in response to the anonymous letters? With no conclusive evidence as to who orchestrated the attack, how and should the United States respond? If the United States discovers who is behind the attack, what is the proper response? Would the American people call for response with nuclear weapons?
Lessons of Dark Winter
The authors of this article have drawn a series of lessons from the Dark Winter exercise. These lessons are based on an analysis of comments and decisions made by exercise participants during the exercise, subsequent Congressional testimony by exercise participants, and public interviews given by participants in the months after the exercise [32]. The lessons learned reflect the analysis and conclusions of the authors from the Johns Hopkins Center for Civilian Biodefense Strategies and do not necessarily reflect the views of the exercise participants or collaborating organizations.
In this section, these lessons are listed, each accompanied by a short explanatory note and quotations from participants in the exercise to illustrate it. The Dark Winter event did not permit attribution of comments without permission from individual participants. Where comments are ascribed to a particular person, permission has been obtained.
Leaders are unfamiliar with the character of bioterrorist attacks, available policy options, and their consequences. The senior decision makers in Dark Winter were largely unfamiliar with the sequence of events that would follow a bioterrorist attack. Important decisions and their implications were dependent on public health strategies and possible mechanisms to care for large numbers of sick people—issues that the national security and defense communities have not typically analyzed in the past.
“We are used to thinking about health problems as naturally occurring problems outside the framework of a malicious actor....If you're going against someone who is using a tool that you're not used to having him use—disease—and using it toward—quite rationally and craftily—...an entirely unreasonable and god-awful end—we are in a world we haven't ever really been in before” (James Woolsey).
“This was very revealing to me—that there is something out there that can cause havoc in my state that I know nothing about—and, for that matter, the federal family doesn't know a whole lot [about] either” (Frank Keating).
“My feeling here was the biggest deficiency was, how do I think about this? This is not a standard problem that I'm presented in the national security arena. I know how to think about that, I've been trained to think about that...a certain amount of what I think went [on] around this table was, ‘I don't get it. I'm not in gear in terms of how to think about this problem as a decision-maker.’ So then I get very tentative in terms of what to do” (John White).
“This was unique...[you know] that you're in for a long term problem, and it's going to get worse and worse and worse and worse and worse” (Sam Nunn).
After a bioterrorist attack, leaders' decisions would depend on data and expertise from the medical and public health sectors. In Dark Winter, even after the smallpox attack was recognized, decision makers were confronted with many uncertainties and wanted information that was not immediately available. (In fact, they were given more information on locations and numbers of infected people than would likely be available in reality.)
For example, it was difficult to quickly identify the locations of the original attacks; to immediately predict the likely size of the epidemic on the basis of initial cases; to know how many people were exposed; to find out how many were hospitalized and where; or to keep track of how many had been vaccinated. This lack of information, critical for leaders' situational awareness in Dark Winter, reflects the fact that few systems exist that can provide a rapid flow of the medical and public health information needed in a public health emergency.
“What's the worst case? To make decisions on how much risk to take...whether to use vaccines, whether to isolate people, whether to quarantine people....I've got to know what the worst case is” (Sam Nunn).
“You can't respond and make decisions unless you have the crispest, most current, and the best information. And that's what strikes me as a civil leader...that is...clearly missing” (Frank Keating).
The lack of sufficient vaccine or drugs to prevent the spread of disease severely limited management options. In Dark Winter, smallpox vaccine shortages significantly affected the response available to contain the epidemic, as well as the ability of political leaders to offer reassurance to the American people. The increasing scarcity of smallpox vaccine led to great public anxiety and flight by people desperate to get vaccinated, and it had a significant effect on the decisions taken by political leaders.
“We can't ration....Who do you choose and who do you not choose to get vaccinated?...People are going to go where the vaccine is. And if they know that you're going to provide the vaccine to my people, they'll stay to get vaccinated. I think they'll run if they think the vaccine is somewhere else” (Frank Keating).
“If we had had adequate vaccine supplies...we would have had more strategies to help deal with this thing and help control the epidemic” (Margaret Hamburg).
The US health care system lacks the surge capacity to deal with mass casualties. In Dark Winter, hospital systems across the country were flooded with demands for patient care. The demand was highest in the cities and states directly attacked, but by the time many victims became symptomatic, they were geographically dispersed, with some having traveled far from the original site of attack. The numbers of people flooding into hospitals across the country included people with common illnesses who feared they had smallpox and people who were well but worried. The challenges of distinguishing the sick from the well and rationing scarce resources, combined with shortages of health care staff, who were themselves worried about becoming infected or bringing infection home to their families, imposed a huge burden on the health care system.
“We think an enemy of the United States could attack us with smallpox or with anthrax—whatever—and we really don't prepare for it, we have no vaccines for it—that's astonishing. That's like, for me, in Oklahoma, where we do have tornadoes, to be assiduously studying hurricanes, or not studying tornadoes” (Frank Keating).
“It isn't just [a matter of] buying more vaccine. It's a question of how we integrate these [public health and national security communities] in ways that allow us to deal with various facets of the problem” (James Woolsey).
To end a disease outbreak after a bioterrorist attack, decision makers will require ongoing expert advice from senior public health and medical leaders. The leaders in Dark Winter were confronted with rapidly diminishing supply of smallpox vaccine and an expanding smallpox epidemic. Some members advised the imposition of geographic quarantines around affected areas, but the implications of these measures (e.g., interruption of the normal flow of medicines, food and energy supplies, and other critical needs) were not clearly understood at first. In the end, it is not clear whether such draconian measures would have led to a more effective interruption of disease spread.
“A complete quarantine would isolate people so that they would not be able to be fed, and they would not have medical [care]....So we can't have a complete quarantine. We are, in effect, asking the governors to restrict travel from their states that would be nonessential. We can't slam down the entire society” (Sam Nunn).
Federal and state priorities may be unclear, differ, or conflict; authorities may be uncertain; and constitutional issues may arise. In Dark Winter, tensions rapidly developed between state and federal authorities in several contexts. State leaders wanted control of decisions regarding the imposition of disease-containment measures (e.g., mandatory vs. voluntary isolation and vaccination), the closure of state borders to all traffic and transportation, and when or whether to close airports. Federal officials argued that such issues were best decided on a national basis to ensure consistency and to give the President maximum control of military and public-safety assets. Leaders in states most affected by smallpox wanted immediate access to smallpox vaccine for all citizens of their states, but the federal government had to balance these requests against military and other national priorities. State leaders were opposed to federalizing the National Guard, which they were relying on to support logistical and public supply needs. A number of federal leaders argued that the National Guard should be federalized.
“My fellow governors are not going to permit you to make our states leper colonies. We'll determine the nature and extent of the isolation of our citizens....You're going to say that people can't gather. That's not your [the federal government's] function. That's the function, if it's the function of anybody, of state and local officials” (Frank Keating).
“Mr. President, this question got settled at Appomattox. You need to federalize the National Guard” (George Terwilliger).
“We're going to have absolute chaos if we start having war between the federal government and the state government” (Sam Nunn).
The individual actions of US citizens will be critical to ending the spread of contagious disease; leaders must gain the trust and sustained cooperation of the American people. Dark Winter participants worried that it would not be possible to forcibly impose vaccination or travel restrictions on large groups of the population without their general cooperation. To gain that cooperation, the President and other leaders in Dark Winter recognized the importance of persuading their constituents that there was fairness in the distribution of vaccine and other scarce resources, that the disease-containment measures were for the general good of society, that all possible measures were being taken to prevent the further spread of the disease, and that the government remained firmly in control despite the expanding epidemic.
“The federal government has to have the cooperation from the American people. There is no federal force out there that can require 300,000,000 people to take steps they don't want to take” (Sam Nunn).
Conclusion
In conducting the Dark Winter exercise, the intention was to inform the debate on the threat posed by biological weapons and to provoke a deeper understanding of the numerous challenges that a covert act of bioterrorism with a contagious agent would present to senior level policy makers and elected officials. Since the Dark Winter exercise, the country has endured the horrific events of 11 September, as well as anthrax attacks through the US postal system. Bioterrorism is no longer just the subject of war games and the source of “futuristic and disturbing topics for...[Congressional] committee meetings” ([33], p. 2454). Many of the challenges and difficulties faced by the Dark Winter participants, unfortunately, have been paralleled in the response to the recent anthrax attacks. The Dark Winter exercise offers instructive insights and lessons for those with responsibility for bioterrorism preparedness in the medical, public health, policy, and national security communities and, accordingly, helps shine light on possible paths forward.
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