Since the 11 September and 15 October 2001 attacks on the U.S. homeland, Americans have faced a new era of security threats from asymmetric warfare and terrorism. As a result, defense of the nation is changing dramatically. In particular, the role of the U.S. health system—both military and civilian—in response to the use of microbes as weapons must become a "defensive weapon system," a role unlike anything the system has been expected to play in the past.
The Persian Gulf war demonstrated that conventional military forces cannot prevail against the U.S. military. As a result, our adversaries have embarked on a search for ways to terrify U.S. citizens, destabilize our government, and diminish U.S. political and economic influence. Over the past decades, we have watched them undertake ever more desperate and asymmetrical measures to strike the United States—from the capture of American hostages in Tehran, to the bombing of the Marine Barracks in Beirut, the 1993 bombing of the World Trade Center, the attack on the USS Cole (DDG-67), and finally the events of fall 2001.
One question these latest attacks left for us to answer is, Which of them should we consider the most successful, the 11 September assault with airplanes, or the 15 October attack with germs? The immediate and long-term consequences of these attacks are dramatically different and presage very different futures for U.S. conflicts.
The first of those futures began on the morning of 11 September 2001, when al Qaeda terrorists hijacked four U.S. airliners and flew them into the Twin Towers of the World Trade Center and the Pentagon. Nearly 3,000 people died. The people of the United States responded with a righteous fury that has not been seen since the attacks on Pearl Harbor.
The first salvo occurred even before the terrorists had finished their work. When passengers aboard United Airlines Flight 93 learned the intention of their hijackers, they fought back, preventing another deadly attack—even at the cost of their own lives. Those brave men and women offered a preview of the national response: the combined might of the U.S. Army, Navy, Air Force, and Marine Corps invaded Afghanistan and, within weeks, destroyed the base responsible for these atrocities. Surviving al Qaeda and Taliban fighters fled and were driven into caves. As the United States opened its global war on terrorism, the President announced a new era of foreign policy—one dedicated to eliminating terrorism from the face of the earth.
Contrast that response to the events following the anthrax letter attack on Senator Tom Daschle's Capitol Hill office on 15 October 2001. The specter of biological warfare terrified citizens in a way conventional attacks might never accomplish. Congress shut down, and Washington streets were clogged with hazardous materials teams and fire trucks, responding to calls from citizens and businesses to investigate suspicious mail.
The airline attacks enraged us. The anthrax attacks terrified us. A passenger plane as a deadly missile was a call to arms. The U.S. mail as a biological weapon was a call to fear. Before this event, the jury was out as to whether biological weapons could be effective terrorist tools. Experts debated their practical limitations as well as expected societal responses. But without actual attacks in modern times, the discussions were academic. Until now.
Biological weapons are relatively inexpensive, effective even with a primitive delivery system, and terrorize out of proportion to the actual impact of an attack. And every terrorist and enemy of the United States now knows it. A new genie is out of its bottle, and it does not take much imagination to predict we will see more of that genie in the future.
So, the face of war has changed again. We must now learn how to defend against biological weapons. Our homeland is a battle space in this era of asymmetric and unconventional warfare, and the citizens of our nation must be defended.
Defense against biological weapons requires a biological defensive weapon system (DWS)—a new concept. Military medicine historically has been considered an element of combat service support. Medics respond to illness and injury. Civilian medical care in the United States also has been seen largely as the response to illness or injury—with much less focus on prevention. But when a germ is used as a weapon, the equation changes. The health-care system must become a defensive shield.
A DWS against biological weapons is a defense in depth. It includes global surveillance of disease and syndromic patterns, detectors to warn, detectors to treat, vaccine mitigation of susceptibility in at-risk populations, and finally, trained and capable health-care providers. An integrated defense designed to deter, prevent, mitigate damage, and respond rapidly is the "shield" that will blunt future attacks.
Navy medical professionals and Navy Medicine have not been caught off guard by this emerging threat. Long-standing research-and-development programs for biological warfare defense already have paid off in the global war on terrorism. Emergency responders used prototype rapid biological detectors to determine if Capitol Hill buildings were safe for occupancy. Recent technological advances permit us to do the same on the battlefield. Military vaccine research promises "agile vaccines" to protect safely and effectively against a previously unimaginable range of biological threats. The Navy Bureau of Medicine and Surgery established the Navy Medicine Office of Homeland security in 2001, and that organization has made great strides in reducing vulnerabilities through healthcare provider training, strengthened emergency planning, and institutional vulnerability assessments of Navy health-care facilities around the world. But more needs to be done. Military medicine can—and must—continue to join with other organizations and national leaders. Each element of the U.S. health system has a role to play.
The Defense Department works closely with the civilian sector during events resulting in mass casualties. The Federal Emergency Management Agency, Department of Health and Human Services, Department of Veterans Affairs, National Disaster Medical System, state and local governments, academic institutions, and professional associations such as the American Medical Association, American Nurses Association, and American Public Health Association, and many others have their own roles and responsibilities in this fight.
Our success as a nation and a people will depend on our ability to recognize the nature of the danger facing us and to counter it. The U.S. health-care system, in particular the military medical departments, will play an unprecedented new role in national defense and national security. The threat is clear. The preferred future is clear. The time to act is now.
Admiral Cowan is Surgeon General, U.S. Navy. He assumed the assignment one month prior to the 11 September 2001 attacks on the United States.