Dr. Kaplan, what is your BSL-4 capability?

In the wake of the 9/11 terrorist attacks on our country, by the following Tuesday anthrax spores were discovered in letters mailed to members of the media and United States senate. Subsequently, additional cases were discovered and the United States Postal Service had cases of infected employees as well. According to the FBI web site, the ensuing investigation by the FBI and its partners – code named “Amerithrax”, has been one of the largest and most complex in the history of law enforcement. Their efforts involved more than 10,000 witness interviews on six different continents, the execution of 80 searches, and the recovery of more than 6000 items of potential evidence during the course of the investigation. The case involved the issuance of more than 5750 grand jury subpoenas and the collection of 5730 environmental samples from 60 site locations. Dr. Bruce Ivans, a scientist who worked at the United States Army Fort Detrick Biomedical Research Laboratory took his own life prior to when charges could be brought before him.

My fellow residents and I, some of whom were now stationed overseas, had taken our pathology board exams approximately three months prior to the events of 9/11. I was a new attending at Walter Reed Army Medical Center when the news broke that an airplane had hit the World Trade Center in New York. Certainly no one had prepared for that, nor had we significantly prepared for any bioterrorism. In the course of my military medical training, there were short courses and seminars on bioterrorism, and more specifically biodefense. Tularemia, the plague, food poisoning, and other not so uncommon infectious diseases were discussed. If there were any, no real plans to address any of these bioterrorism threats were ever discussed, in my recollection. What would really happen if tularemia, the plague or a virulent strain of smallpox was released on Washington, D.C., New York City, or other metropolitan areas?

In addition to surgical pathology, I carried the title of “Medical Director, Microbiology”. I had some interest in microbiology but certainly had no specific fellowship training in microbiology and at that point had about three months experience actually being the medical director of any laboratory. In the wake of the anthrax attacks, rapid and accurate testing was required to quickly isolate, identify, treat, and prevent further infection. These terms have been discussed numerous times over the past several weeks. The military and government apparatus was determined to find the cause, to find the source and eliminate the threat. Rapid testing of any copycat crimes as well as potentially lethal anthrax spores were paramount to restore operations within the congress, the United States Postal Service, and eliminate not only public health risk but public health fear.

Early on in addressing the situation, conference calls were held between experts at CDC, NIH, For Detrick, the Pentagon, DOD, the Army Surgeon General, and others. I was invited on those calls as the Medical Director of Microbiology. There was no playbook for this and I was by many years, in my estimation, the most junior and least experienced person on any of these calls. Fortunately, I had a very well-trained, qualified, full bird colonel as the Technical Director of Microbiology. He also served in his official capacity as consultant to the Army Surgeon General for microbiology issues and as part of the larger microbiology community within many infectious disease societies, working groups, and task forces. Therefore, he managed much of the day to day, including appropriate handling of suspected samples to rule out anthrax. New standard operating procedures were created and safety protocols put in place. Everyone recognized we did not have the testing apparatus to do this. In fact, at that time, very few labs would have. During one call, a husky voice from the speaker asked me, “Dr. Kaplan, what is your BSL-4 capability?”

This may have been an official from the Pentagon, CDC, NIH, Fort Detrick, or other components of the military-federal public health apparatus. In that moment, I did not know what BSL-4 stood for.

I simply replied, “Sir, what is BSL-4?”

The truth of the matter is that I certainly wasn’t trained for this, nor were those who trained ahead of me. While we talked about bioterrorism and biodefense, the actual plans, personnel, equipment, and testing apparatus that would need to be done were not, in my mind, factually advanced to the “front of the line”. In truth, probably three BSL-4 laboratories existed in the United States at that time including Fort Detrick in Maryland, CDC in Atlanta, and somewhere in the western United States.

To my knowledge, based on research for this post, there appeared to be at last now 15 BSL-4 level laboratories that can process everything from Bacillus anthracis to SARS, tularemia and Yersinia. Of course, the decision was quickly made to test samples regionally between the known capable BSL-4 laboratories and our world became one of simply appropriate transport with chain of custody to do so.

I’ve thought a lot about those days and weeks nearly 20 years ago and how in some ways we may have learned some lessons that have been brought forward, others have clearly not been addressed to handle a pandemic. Our ability to rapidly mobilize resources has been shown, but with a novel entity such as what we are dealing with now, our ability to test and treat is hampered. The testing apparatus required for an unknown agent, much like it would be for a biological agent, which fortunately is not encountered very often, has not been put in place in this country or many others.

While I didn’t learn how to culture Bacillus anthracis in the laboratory and learn what reactions it would case in a 13-tube setup, I did learn a lot about leadership and being a leader. At the end of the day, you have to do what you can with what you have. You have to be sure to ask the right questions of the right people and verify the answers as best you can. You have to work together with all of your resources and provide a calm and resolute nature. You have to rely on those you know, know more than you.

I hope when we can see our way clear again, and the recent health crisis is further understood, with widespread testing, treatment, and vaccination, we will take these lessons forward for the next crisis. I would hope that the states and federal government would be able to stockpile equipment, gowns, medicines, and mobile hospital units to be deployed rapidly in good working condition with appropriate controls, standards, policies, and procedures. However, despite the billions and billions, and trillions and trillions that have gone into containing and trying to eliminate the threat, I am concerned very little will be put into preparing for the next.