Radiological Terrorism and Public HealthLecture 1: Terrorism, Public Health

Steffan Puwal, PhD

Source Text: Terrorism and Public Health: A Balanced Approach to StrengtheningSystems and Protecting People

Terrorism• Terrorism is defined as “the politically

motivated use of violence or the threat of violence, especially against civilians, with the intent to instill fear.”*▫Terrorism is a crime.▫Terrorism is also a mental health term. Note the

use of the terms “intent” and “fear”.▫This course will focus on the science of a

particular terrorist weapon: the Radiological Dispersion Device, or “dirty bomb”; we will not discuss the psychology of terrorism.

*source: Levy & Sidel, Terrorism and Public Health

Terrorism

Terrorism

Conventional Terrorism Bioterroris

m

Radiological/Nuclear Terrorism

Chemical Terroris

m

Terrorism

•Bioterrorism is defined as the use of, or threat to use, biological weapons to commit acts of terrorism.▫Because the response model is so similar,

and because public health professionals are involved in all three, the use of chemical, biological, and radiological weapons are often grouped under the heading of “bioterrorism”

▫Acts of nuclear terrorism are rarely called bioterrorism

Terrorism•Prevention is Key

▫The best defense in public health is one that reduces casualties to the greatest extent possible

▫But, of course, you can guarantee no casualties by preventing the terrorist attack in the first place

•Conventional terrorism, as its name suggests, is the most likely scenario for a terrorist attack▫Before the 1990s, public concern about terrorism

often focused on the use of small arms and light weapons, explosives, or incendiaries

Conventional Terrorism• Oklahoma City Bombing

▫ April 19, 1995▫ Alfred P. Murrah Federal Building▫ 168 fatalities, approx. 680 injured▫ Damaged or destroyed

324 buildings in a 16 block radius▫ FBI Investigation: Code name OKBOMB

Suspect: Timothy McVeigh Motivation: Mistakenly believed this was the building from

which the ATF operation in Waco Texas was ordered in 1993 Weapon: ANFO (Ammonium Nitrate/Fuel Oil) bomb- 50 lbs.

of ammonium nitrate fertilizer, 210 liters liquid nitromethane, Torex explosive

Conventional Terrorism

•Oklahoma City Bombing▫ABC News report on the day of the

Oklahoma City bombing▫Stable URL:

http://abcnews.go.com/Archives/video/oklahoma-city-bombing-1995-9851736

▫All URLs referenced in this class last accessed in 2011

Oklahoma City Bombing4:26 duration

Public Health• If you do a Google search, Public Health is

defined as the science and art of preventing disease, prolonging life, and promoting health through the organized efforts of public and private organizations▫This includes research, administration of medical

care to populations, and education/training programs for both patients and medical responders/health professionals

▫This course, therefore, is part of a public health response/prevention model: education of scientific professionals in this field

Public Health

•Our course will focus on the science of radiological and nuclear weapons and scenarios likely to be associated with a terrorist attack.

•We will specifically focus on the physics of these agents and their health effects.

•The information we cover will logically suggest a response, which we will cover toward the end of the course.

Public Health (Prevention)• Primary Prevention – attempts to prevent

disease or injury from occurring in the first place. (e.g. non-proliferation treaties, advocating destruction of remaining smallpox stockpiles)

• Secondary Prevention – attempts to identify and control the spread of disease/health effects at an early stage. (e.g. surveillance programs to recognize signs of anthrax in the population, monitoring air samples for radioactive isotopes, distributing stable iodine tablets after the event, etc.)

Public Health (Prevention)

•Tertiary Prevention – attempts to aid in recovery after the fact (e.g. treating bombing injuries to prevent death of that patient)

In order of effectiveness: Primary prevention is most effective, secondary prevention is next most effective, and tertiary prevention is the third most effective

Public Health and Terrorism•The role of health scientists and health

professionals in dealing with terrorism includes:1. Responding to health consequences of terrorist

act and threatsa. Diagnosing and reporting: The front line of

public health is early warning. In 2001 a Florida man, Robert Stevens, was exposed to anthrax trough the mail at work. After an initial diagnosis of meningitis, an infectious disease specialist, Dr. Larry Bush, suspected anthrax. This was the first diagnosis in the anthrax terror attacks of 2001

Public Health and Terrorismb. Providing preventive measures: Into the 2001 antrax attacks, people working in congress were given the antibiotic Ciprofloxacin as a preventive measure (or prophylactic). Unfortunately, no one considered it necessary to give this antibiotic to postal workers handling the letters. It was thought the anthrax spores could not escape the envelope.

Public Health and Terrorismc. Preventing secondary spread: Educational measures

tell the community how to properly respond. In the anthrax attacks, people were told to immediately report white powder in envelopes, open mail away from your face, and the post office began irradiating mail to kill the spores.

d. Assisting law enforcement with the investigation: This includes educating law enforcement professionals about the means of production of the weapon, and providing forensic analysis. In the anthrax attacks it was determined that the strain used was common in research (the Ames strain). Beyond that, officials have not disclosed any additional signatures in the weapon.

Public Health and Terrorisme. Discouraging inappropriate responses: In the wake of the 2011 Japanese nuclear disaster some in the USA began buying stable iodine tablets. This, in spite of the fact that absorbed doses are far too low in the US, medical problems from excessive iodine consumption are possible, and stockpiling is not effective as these tablets have a finite shelf life

Public Health and Terrorism2. Developing improved preparedness for future

terrorist acts/threats.The conventional wisdom is that even a small

probability event is likely to happen, given enough time.a. Educating the public and other health professionals: this course is a prime example. Radiological weapons are often confused in the public with nuclear weapons. Fear and irrational response can hamper the efforts of first responders. Education before the event is, therefore, a crucial component of the response.

Public Health and Terrorismb. Participate in preparedness planning/training exercises: theory is one thing. Repeated practice should make the proper first response second nature.c. Evaluation of preparedness programs: Feedback and constant improvement are key components to preparedness. By evaluating drills, one discovers weaknesses and suggests improved methods.

3. Taking actions to help prevent terrorist actse.g. advocate arms control treaties, address underlying motivation for terrorism, reduce access to agents

4. Promote a balance between preparedness/response and civil liberties

Public Health and Terrorism

Respond to Health

Consequences of Terrorist Event

Develop Improved Terrorist

Response Model

Act to Prevent Future Terrorist

Attack

Promote a Balance Between Preparedness & Civil Liberties

Diagnose & ReportPreventive measuresHalt further spreadAssist law enforcementDiscourage inappropriate responses

Preparedness ExercisesEvaluation & Re-evaluationEducational Programs

Terrorism

•In the late 1990s, perceptions about terrorism began to shift as:▫It became apparent, with the defection of

key scientists, that the Soviet Union had a massive biological weapons program

▫Terrorist groups like the Aum Shinrikyo and Rajneeshee cults demonstrated a capacity to use biochemical weapons

▫The scale of attacks by international terrorist groups like al Qaeda continued to escalate

Terrorism• Small arms and explosives remain the most likely

weapons for use in a terrorist attack and coping with this threat remains a significant challenge for law enforcement

• Less likely, though a significant concern, are agents referred to as Weapons of Mass Destruction. These are agents that have the capacity to cause mass casualties through non-conventional means.▫The agents themselves are often referred to as

Nuclear, Biological and Chemical - NBC Agents, a term that includes radiological weapons (sometimes NBCR)

Weapons of Mass Destruction

?

BiologicalWeapons

ChemicalWeapons

NuclearWeapons

RadiologicalWeapons

Weapons of Mass Destruction• Biological Weapons

▫Biological weapons are living organisms (usually micro-organisms) or their toxic products used intentionally to cause illness or death in humans, animals, or plants.

▫Examples of Agents: Anthrax, Plague, Smallpox, Botulinum toxin (a toxin produced by the bacterium Clostridium botulinum)

▫Examples of Use: The 2001 Anthrax Attacks by Mail (USA)

Videos Stable URL:http://abcnews.go.com/Archives/video/oct-18-2001-anthrax-scare-cbs-9316958http://www.charlierose.com/view/interview/2428

2001 Anthrax Attacks 9:59 duration

Biological Attack

•2001 Anthrax Attacks by U.S. Mail▫September 18, 2001 – Late October, 2001▫U.S. East Coast▫17 infected, 5 fatalities▫FBI Investigation: code name

AMERITHRAX Persons of Interest: Bruce Ivins (USAMRIID

Researcher with mental health issues who committed suicide July 29, 2008 just prior to charges being filed)

Biological Attack

•FBI Investigation (Continued)▫Targets: ABC News, CBS News, NBC News,

New York Post, National Enquirer, Sun (tabloid), Sen. Tom Daschle, Sen. Patrick Leahy

▫Weapon: Letter mailings of the bacterium Bacillus anthracis

▫No formal charges filed to dateVideo Stable URL:http://abcnews.go.com/Archives/video/oct-15-2001-anthrax-scare-abc-senate-9316877

2001 Anthrax Attacks 21:02 duration

Weapons of Mass Destruction

•Chemical Weapons▫A chemical weapon is “any chemical which,

through its chemical effect on living processes, may cause death, temporary loss of performance, or permanent injury to people or animals

▫Examples of Agents: VX Nerve Agent, Sarin, Chlorine Gas

▫Examples of Use: WWI in Europe, The 1995 Sarin Gas Subway Attack (Tokyo, Japan)

Chemical Attack• Sarin Gas Subway Attack

▫March 20, 1995▫Tokyo (Japan) Subway System▫13 fatalities, approx. 6252 injured (984 permanent

eye injury)▫Investigation:

Carried out by Aum Shinrikyo doomsday cult by Ikuyo Hayashi – A medical doctor and heart specialist Kenichi Hirose – A physicist with a postgraduate degree Toru Toyoda – A physics doctoral student Masato Yokoyama – An engineering physicist Yasuo Hayashi – A computer Scientist

Chemical Attack

•Sarin Gas Subway Attack▫Aum Shinrikyo (“religion of universal

truth”, today known as Aleph) seeks to bring about the end of the world through the use of WMDs Known to have traveled to Africa seeking

samples of Ebola▫Target: Tokyo Metro, 3 separate lines with

3 separate bombs▫Weapon: Sarin Gas (also known as GB) an

organophosphate, [(CH3)3CHO]CH3P(O)F

Chemical Attack

•Sarin Gas Subway Attack▫As a nerve agent/organophosphate it

attacks the nervous system inhibiting the enzyme family cholinesterase

▫cholinesterase catalyzes the breakdown of acetylcholine (a neurotransmitter) so the neuron can return to a resting state after activation/signal transmission

Video Stable URL:http://abcnews.go.com/Archives/video/march-20-1995-gas-attack-tokyo-subway-9719213

Tokyo Subway Sarin Attack 3:59 duration

WMDs vs. Conventional Terrorism

•What’s the takeaway?Oklahoma City 1995: 168 fatalities 680 injuredAnthrax 2001: 5 fatalities 17 infectedSarin 1995 Japan: 13 fatalities 6252

Injured

▫Conventional doesn’t always mean less deadly▫Conversely, non-conventional doesn’t always

mean more deadly▫The chief effect of (N)BCR agents is often the

fear they can inspire in the target population

Weapons of Mass Destruction• Nuclear Weapons

▫A nuclear weapon suddenly releases vast quantities of energy by splitting the nuclei of atoms (fission) and/or by fusing the nuclei of atoms (fusion)

▫Fortunately no examples of terrorist use so far▫Dr. Abdul Qadeer Khan (known as AQ Khan), a

nuclear scientist and engineer, facilitated the proliferation of nuclear weapons to rogue regimes, including Iran, Iraq, Libya, and North Korea His operations essentially were a one-stop-shop for

the technical expertise and included tech support operations

Weapons of Mass Destruction

•Nuclear Weapons▫AQ Khan (Continued)

In 2001 the Pakistani ISI (Intelligence Service) arrested 2 scientists who worked with Khan and had close ties to the Afghan Taliban

▫Operations such as Khan’s mean that, while a nuclear scenario is not likely, it should not be disregarded completely

Weapons of Mass Destruction• Radiological Weapons

▫Radiological weapons/attacks are truly weapons/attacks in the sense that they are designed to injure.

▫The initial deaths associated with the attack are the main casualties; subsequent cancer-related deaths associated with exposure are usually minimal

▫For this reason, the radiological scenario is sometimes called a “Weapon of Mass Disruption”. Fear, rather than death, will be the biggest problem in these scenarios.

Radiological Scenario

RDDIn

Transit

Nuclear

Facility

Nuclear Device

Terrorism

Conventional Terrorism Bioterroris

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Radiological/Nuclear Terrorism

Chemical Terrorism

Radiological Scenarios• Radiological Dispersal Device (RDD), also known as

a “Dirty Bomb” is the most likely radiological scenario. A medical or industrial isotope, is obtained and combined with a conventional explosive; the explosive is the main source of injury, with cancer-fatalities years later

• An attack on spent fuel in transit designed to detonate in place (or to obtain material for an RDD later) is the next most likely scenario. Transporting material to a central repository such as Yucca Mountain in Nevada creates opportunities for attack in transit▫ less likely than an RDD because of security for the transit

Radiological Scenarios•A direct attack on a nuclear facility which

seizes the control room and initiates a core meltdown is the next most likely scenario; the law enforcement role here is unique, but the health community response is no different than an unintentional nuclear accident▫the public health response model does distinguish

the two by insisting on preparedness exercises that include preparing for malicious intent

▫considered not as likely as an RDD because terrorists must have control room expertise

Radiological Scenarios• By far the least likely scenario is the detonation

of a stolen or manufactured nuclear device. Detonation includes initiation of a fission/fusion reaction, or conventional explosive dispersal with the bomb core (Uranium or Plutonium)▫Considered least likely because of the expense in

producing a nuclear device and security associated with existing weapons stockpiles

▫Nuclear forensics can narrow down the source of the device and policies such as Mutual Assured Destruction (MAD) discourage state actors

Summary

•This class will focus on radiation, radiation health effects, likely isotopes for an RDD, and nuclear power incidents

•We will make minor reference to nuclear weapons

•The public health response model tackles Weapons of Mass Destruction in general; for this reason we will also discuss biological and chemical agents

Summary• Suggestions for Additional Reading

▫ An account of the Soviet germ warfare program is given by one of its directors in Biohazard by Ken Alibek (with Stephen Handelman), Dell Publishing (Random House), 1999 (ISBN 0-385-33496-6).

▫ An account of a research career with USAMRIID is given in Virus Hunter by C.J. Peters (with Mark Olshaker), Anchor Books (Random House), 1998 (ISBN 0-385-48558-1).

▫ An account of a research career with the CDC is given in Level 4: Virus Hunters of the CDC by Joseph B. McCormick and Susan Fisher-Hoch, Barnes & Noble Books, 1996 (ISBN 0-7607-1208-5 or paperback ISBN 0-7607-1211-5).

Summary• Suggestions for Additional Reading

▫A somewhat discredited account (includes significant references to a post 2001 Iraqi bioweapons program) is given in Germs: Biological Weapons and America’s Secret War by Judith Miller, Stephen Engelberg, and William Broad, Touchstone Books (Simon and Schuster), 2002 (ISBN 0-684-87158-0 or paperback ISBN 0-684-87159-9). This text includes an accurate description of the Aum Shinrikyo cult’s use of sarin in Tokyo and the Rajneeshee cult’s use of salmonella in Oregon

Summary• Suggestions for Additional Reading

▫An account of the U.S. anthrax attacks of 2001 and the smallpox eradication program is given in The Demon in the Freezer by Richard Preston, Random House, 2002 (ISBN 978-0375508561).

▫An account of an outbreak of the Reston strain of Ebola in the United States is given in The Hot Zone by Richard Preston, Anchor Books (Random House), 1995 (ISBN 978-0385479561).

▫A good undergraduate nuclear physics textbook is Introductory Nuclear Physics by Kenneth S. Krane (Wiley & Sons), 1988 (ISBN 0-471805533).

Summary• Suggestions for Additional Reading

▫A good dosimetry textbook is Introduction to Radiological Physics and Radiation Dosimetry by Frank Attix (Wiley), 2004 (ISBN 0-471-01146-0).

▫An appropriate text for medical uses of radiation may be Principles and Practice of Nuclear Medicine, 2 ed. by Paul J. Early and D. Bruce Sodee (Mosby), 1995 (ISBN 0-8016-2577-7). An alternative text is Intermediate Physics for Medicine and Biology by Russel Hobbie and Bradley Roth, Springer, 2007 (ISBN 978-1441921673).

Summary

•Suggestions for Additional Reading▫A significant portion of this lecture is based

on Terrorism and Public Health: A Balanced Approach to Strengthening Systems and Protecting People, by Barry Levy and Victor Sidel

Summary• Because of the regular media references to the

attacks of September 11, 2001, references to those attacks will be kept to a minimum in this course. Some suggested sources of original material on these attacks include:

• An interview with national security professionals that aired on PBS on September 11, 2001▫http://www.charlierose.com/view/interview/2955

• A digital archive of news footage as aired September 11-13, 2001▫http://www.archive.org/details/sept_11_tv_archive

Summary• Popular fiction plays a role in public perceptions

of nuclear and radiological disasters. Some particularly popular movies include▫The China Syndrome▫Dr. Strangelove▫Fail-Safe▫Thirteen Days (based on RFK’s memoirs of the

same name)▫The Day After (not to be confused with The Day

After Tomorrow)▫Contagion▫Outbreak

Review Questions

1. Compare and contrast biological, chemical, radiological, and nuclear terrorist acts with conventional attacks.

2. List at least 4 specific examples of▫Radiological weapons (isotopes)▫Biological weapons (viruses, bacteria,

prions)▫Chemical weapons

Review Questions

3. Discuss potential mechanisms for primary prevention, secondary prevention, and tertiary prevention of a radiological terrorist attack.

4. Discuss potential mechanisms for primary prevention, secondary prevention, and tertiary prevention of an anthrax attack. (You may use the 2001 anthrax attacks as a model.)

Review Questions

5. Discuss the 5 ways we covered in class by which the public health community responds to a terrorist attack.

6. How does this class fit into the public health model for preparedness and response to a terrorist attack.

Review Questions7. Why is a radiological terrorist attack often

termed a “weapon of mass disruption”?

8. List the five likely scenarios for a nuclear/radiological terrorist attack. Which is generally accepted as the least likely, and why?

9. Compare and contrast a radiological terrorist attack with a nuclear terrorist attack.▫Be sure to include which is more likely.