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Living Terrors: What America Needs to Know to Survive the Coming Bioterrorist Catastrophe

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Living Terrors is a book that should be read by all Americans. The
book is written by Michael T. Osterholm, Ph.D. and science journalist
John Schwartz. It is based largely on Dr. Osterholm's experience as
an epidemiologist, his expertise in biological weapons, and his
efforts to educate the public on the threats of bioterrorism. He
illustrates several points about the unique aspects of this threat by
beginning chapters with fictional vignettes about hypothetical
bioterrorists. The emphasis is on the general anonymity of the
perpetrators, ready availability of biological agents, and the
difficulty tracking the terrorist. He uses the subsequent chapters to
argue that the bacteria and viruses are readily available and the
technology for dispersing easily learned. He discusses estimates of
potential loss of life and economic damage from a bioterrorist
attack.

The second half of the book describes a hypothetical
smallpox attack on the city of Chicago. Most Americans over the age
of thirty have some recollection of smallpox vaccinations they
received as a child. The wild form of smallpox was eradicated in 1977
and the World Health Organization recommended discontinuing
vaccinations against it in 1980. The only remaining smallpox was in
laboratories in the United States and the Soviet Union. The authors
present evidence here that other countries have this agent and that
the combination of high infectivity, high lethality, and low immunity
make it lethal if dispersed by a terrorist.

Living Terrors also
focuses on systems and logistics that need to be addressed. Both
antibiotics and immunizations are effective in specific situations,
but there are currently not enough doses to have much of an impact in
the event of an attack. Civil defense preparedness is also lacking.
The type of response needed for a chemical weapons release is compared
with biological weapons. Early identification of the infectious
disease is critical since many of the diseases appear to be similar to
upper respiratory infections. Quarantine and respiratory isolation of
individuals affected with smallpox is also the best initial
intervention to prevent subsequent waves of infection. The more
specific issue of containing patients in negative air pressure rooms
is contrasted with the fact that there are only 60 such rooms in the
state of Minnesota's 144 hospitals.

The associated public health
issues of decreased bed capacity and physician time to devote to these
issues are discussed. One of Dr. Osterholm's recommendations involves
increasing the "slack" in the system. He points out that
for smaller disasters, such as plane crashes, the current systems are
deficient and these deficiencies would be greatly amplified in a
bioterrorist attack. Many physicians have never seen a case of small
pox or anthrax and would benefit from the appropriate training.
Appropriate training programs exist, but don't target local health
systems.

The legal responses by both local officials and federal
officials as well as law enforcement are discussed. Large epidemics
are inherently disruptive to public health and law enforcement
systems. The authors point out how the different perspectives of law
enforcement and medicine (preserve the crime scene vs. do whatever is
medically necessary) can lead to non-productive and at times
embarrassing conflicts during public health emergencies. They also
discuss the current legal landscape as it applies to a large epidemic,
referencing the work of legal scholar Terry P. O'Brien. Several
problems with the current the policies about the government response
to a terrorist event are described.

Dr. Osterholm ends the book
with an "eight point plan" to improve readiness in the case
of a bioterrorism attack. He encourages a realistic appraisal of the
current situation and concrete steps to improve readiness both within
the government and the medical community. This book is a compelling
read from a number of perspectives. At the level of government's
ability to address difficult problems, we find that very little seems
to be going on. Funds are targeted for the wrong purposes and local
officials seem to be waiting for federal guidance that never comes.
On another level we are introduced to terrorists that act unilaterally
and with no provocation. A situation where a random act of aggression
can become a biological catastrophe seems plausible. As a
psychiatrist, I am interested in the thinking behind terrorism
specifically what would cause a person to murder large numbers of
people. The book does not explore the consciousness of terrorists
except to suggest that there are no common threads. We are left with
the problem that it is impossible to predict the person capable of
this rare, but devastating behavior.

I liked the layout of this
book. It is written to maintain the interest of the casual reader,
but also includes fairly detailed footnotes. Those footnotes cover
official documents, scholarly references, and articles in the press.
I have an interest in bioterrorism and found that the references were
more comprehensive and relevant than those I had been able to find in
the medical literature. The authors have done a service in outlining
the scope and nature of the current problem. It is up to the rest of
us to make sure something gets done about it.

George Dawson, MD

It arrived late on a Thursday evening. Like the rest of the world, I had much to do over the coming weekend. I would get to it when I had time. Unfortunately, I made the mistake of picking up Living Terrors late that night and scanning the cover jacket. The next thing I knew, I was finishing the second chapter. What was I thinking? By 6 a.m. Sunday morning, I had completed the book and began to consider what I could say to emphasize its critical message. I had yet to get to my weekend chores.

First, a disclaimer. While at a national meeting on infectious diseases in the fall of 1998, almost solely out of curiosity, I decided to listen to a presentation on "Bioterrorism" by Dr. Osterholm. I was familiar with him from a distance - he was a well known expert in food borne illnesses and the like, while at the Minnesota Department of Public Health. Like a child being told by his older sibling that there is no Santa Claus, what I heard that day I desperately wanted not to be true, but in my heart, like that child, I knew it was, and I could not go back. Since that time, I have become more and more interested in bioterrorism (defined as the intentional use of biologic agents or their products for the purpose of producing disease among humans, animals or plants) while at the same time convinced that Dr. Osterholm's concerns are right on the mark. It was with this bias that I eagerly awaited publication of his book.

As one who grew up during the Cold War, I remember all too well the fears of nuclear war - the civil defense drills and the scenes on black and white television of a simulated nuclear blast with instructions to "take cover". These fears were magnified many fold as I grew older, married, had children and began to slightly understand the true implications of it all. I vaguely recall also of hearing of biologic or germ warfare, but these terms had no real meaning to me at the time.

As the Cold War wound down, the Berlin Wall fell, and disarmament began, one could almost hear a collective sigh of relief......until THIS! Michael Osterholm and John Schwartz shock us back to the reality that the war is not over and the bad guys are still out there. They argue convincingly only that the rules have changed, the enemy is more elusive, and an attack, this time in the form of a lethal and quite possibly contagious agent, when (not if) it comes, will be devastating. Depending on the circumstances, the biologic agent chosen, the method of delivery, and the degree of contagiousness, tens, hundreds, or even thousands may die and an untold number left standing will be paralyzed with fear as they wait to see if they, too, will fall victum. Like a Steven King novel, as you read this book, the hair on the back of your neck will begin to rise and your palms will begin to sweat. But this is no novel, and their concerns are not fiction.

Living Terrors does not lose you in the science; rather, the far bigger fears of the authors are dramatically emphasized in a series of all too plausible hypothetical scenarios involving bacteria, viruses or their toxic products that begin each chapter. Each is described in terms that anyone can understand, followed by an indepth analysis that is superbly researched, albeit with conclusions that, by their nature, are conjectural.

I read each chapter carefully and deliberately, seeking flaws in the author's scenarios and subsequent arguments so that as an infectious disease physician I could offer my own personal perspective competently, and, to hopefully find cracks in their fears. Unfortunately, as I've deliberated these concerns, and as I completed Living Terrors, I found myself only more convinced that they are not alarmists and they are not crazy. Rather, they are right on target. If anything, I believe their analysis, e.g. the relatively successful control of a hypothetical epidemic of smallpox in Milwaukee once it had virtually wiped out Chicago (Chapter 7, Mitigated Disaster), is rather optimistic.

Consider also the ethical and legal dilemmas of withholding antibiotics that will be in short supply from a patient who has symptoms of anthrax, and who in all likelihood will die (>80% mortality once symptoms develop), so that they may be saved for others who may not even have been exposed, (the so-called "worried well"). What about the dead? Who would be willing to go near them? Would they be left where they fell? Where would they be taken and who would take them there? What would be done with them? Mass burials? Mass cremation? One can readily imagine what the media would do with this.

The authors have a challenging task of writing for several different audiences - the front line physicians who will be the first to see these patients, then to care for them; the politicians and governmental leaders who control the money, give direction, and provide leadership and who will have to explain to all how such a disaster could possibly take place on U.S. soil; and finally, the public whose support is desperatelly needed to get the attention of the politicians and public officials. Unfortunately, most, as yet, have absolutely no clue!

Living Terrors is about getting your attention, and it does so completely. It will (or should) scare the hell out of you. It will (or should) make you think, and perhaps even follow some of the authors' suggestions as to what can be done to attempt to dodge the impending cataclysm. Read this book and pay very close attention. We must all understand that as you read this, somewhere out there, in all likelihood, is a misguided individual, group or country that is contemplating such an attack within our own borders. It will not be pretty. Finally, hug your kids and pray that Michael Osterholm and John Schwartz are wrong.

G. Blackburn, D.O., Section of Infectious Diseases, Botsford Hospital, Farmington Hills, Mi

I'm part of the problem! I'm one of those individuals that Mike Osterholm talks about in this very important book. Unfortunately he is right on target. The federal response, of which I'm supposed to be a part of, remains disorganized and lacking leadership. In my small way, I thought I could help change that as part of the public health leadership within the great governmental bureaucracy. In fact, I read Living Terrors hoping to convince myself that Dr. Osterholm was wrong. However, as I watch the political paralysis occurring around the election results and the continued stalemate, even within the Administration, I'm not optimistic. We can't get influenza vaccine to the general population this year, how are we ever going to respond to an unplanned crisis of the likes of a bioterrorism event? Even the recent passage of the Frist/Kennedy legislation to improve the public health infrastructure (and response to bioterrorism) gives me concern. In that legislation much of the control of funds to support bioterrorism response will still be under the control of the Depts of Defense and Justice; not HHS, the public health/medical research arm of the federal system. The above comments are really just setting the table to say, if you really care about our future and the potential of what bioterrorism can and will do to our country, you should take to heart what Dr. Osterholm has said. I know my coworkers who have read the book all wish our bosses and their bosses would read it and take it to heart. I'm afraid that is not going to happen on this watch and I'm not optmistic it will happen on the next one, regardless of who is President. If we are to get our act together, it will have to come from the people...who in turn get their local, state and federal elected officials to REALLY understand the issues and respond accordingly. Dr Osterholm's book should be the their Bible. It's the best we've got.

This book should be read by every public health, medical and emergency response professional throughout the world. In addition, it would sure be helpful if the media, government officials and military experts also took a crack at it. We might finally have a chance at coming up with a rational and practical response to this likely diaster. Dr. Osterholm is out there...some would say he has crossed the line with hype. Unfortunately, as an infectious disease physician, I have followed his work for the past 20 years and he has challenged us on numerous occassions with predictions that have all come true. I hope he is wrong (but I really don't think so), but if he is not, his book contains the only rational discussion of the issue of bioterrorism in print today and without a doubt the only plan for what we must do to prepare ourselves. Finally, its a book the makes sense to average citizen. I had to fight my teenage son all weekend for the only copy in our house.

From William Clinton to anti-terrorism czar Richard Clarke to the bioterrorism mavens at USAMMRID and Johns Hopkins University-- the prediction is as unanimous as it is chilling. There will be a biological attack by terrorists --on U.S. soil-- within the next five to ten years.

And when it does, it will doubtless follow one or another of the scenarios detailed in Living Terrors. I've spent the past six hours reading it cover-to-cover, and it is an outstanding book-- the kind of thing that ought to be required reading at all levels of government and the general public. It is that rare combination of solid research and excellent writing to which all non-fiction should aspire.

I've extensively researched biological terrorism for a novel on the subject-- from Richard Preston to Ken Alibek to the works of Don Henderson of Johns Hopkins, and more. Living Terrors stands among the best of them. Frankly, since starting research on the subject back in November 1999, I've been shocked and appalled at just how vulnerable the world is --and remains-- to biological terrorism. Dr. Osterholm and Mr. Schwartz detail this onrushing catastrophe in a manner that is cautionary without sensationalism-- providing information that, when the inevitable microbe attack occurs, could nonetheless save American lives.

Buy --and read-- Living Terrors. And for your own sake, take this issue seriously, today.

As a first responder (fire fighter / paramedic) and as a paramedic that works in a hospital ER, I found this book to open my eyes on the events that could effect all of our lives. This book is a MUST read for our community leaders and policy makers. Anybody that thinks that Bioterrorist will not strike at our home have not read this book, or live in the stone age. This book drives the point home, and needs to be read by Doctors, and Goverment Officals.

It is a very quick read, and easily understood by the target readers.

In writing Living Terrors-What America Needs to Know to Survive the Coming Bioterrorist Catastrophe Dr Michael T. Osterholm and John Schwartz have constructed a sobering guide to one of the more horrific potentials of the international terrorist threat: biological murder. Tightly structured and tersely written, this book is a functional layperson's guide to the topic of Bioterrorism and some of its most insidious weapons: anthrax, botulism and smallpox. Once the reader is introduced to these potential modern plagues they are then shown what effects the introduction of them into the general public might produce. Unfortunately it is these same scenarios which weaken the important message that the book is meant to convey.

While the bulk of the book is written in a straightforward style; listing thevarious viruses, their affect upon humans and their physicalproperties; Living Terrors is interspersed with passages which, with "What If?" scenarios, seek to describe the likely outcome ofthe introduction of bacterial agents into the general population. The problem with these "instructive scenarios" is that unlike the rest of the book, they're written in the breathless, simplistic style of the works of Tom Clancy (whose works, regrettably, are referenced in the text). These scenarios, while instructive can'thelp but detract from the weight of the message behind the book; they seem unnecessarily trite and alarmist; lending an air of sensationalism to what otherwise is a fairly scholarly approach.

The reader must however forgive the authors for their use of their somewhat forced literary device, for within the text it becomes clear that Dr Osterholm has long tried the path of cautious, reasoned argument and has failed. Among the topics discussed, Living Terrors also recounts Dr Osterholm's many attempts to goad the American Government into action in creating a comprehensive response protocol to Bioterrorist events. As recounted in the book, the response, and the result has been less than heartening. Given this it is perhaps understandable that Osterholm has taken the lower road and sensationalised his message in order to reach a wider audience - a perhaps necessary evil considering that it is a topic which has direct implications for everybody.

Bioterrorism is a real and considerable threat. The technology and the will are (as the book argues) present,and the political conditions right. In the past I have attended conferences on this very same subject and watched as influential government officials shrugged their shoulders and offered embarrassed smiles when questioned about this subject. Perhaps we need a more strident approach to bring this topic to the fore of the national discussion. Living Terrors-What America Needs to Know to Survive the Coming Bioterrorist Catastrophe , a self proclaimed "manifesto" might be just what is needed. Even if it is somewhat alarmist and the authors fall into hyperbole when they claim it "lays out a prescription for survival-for our nation, and for us all" this book is an important one.

Dr. Michael Osterholm, chief epidemiologist for the Minnesota Department of Health and nationally-known authority on bioterrorism, has (with journalist John Schwartz, his co-author) put together the literary equivalent of a good, PBS-class documentary or an especially good lecture on bioterrorism. Well-crafted and easy to follow, "Living Terrors" is a very useful introduction for the more educated layman to this suddenly very relevant topic.

If you're up to assimilating the information Mike Osterholm lays out in this book, it's a rewarding experience, very much like attending a highly condensed lecture series in a very short time (if you're a reasonably fast reader). Osterholm's style engages the reader's attention and very effectively communicates the severity of the hazards with which we are now much more familiar with than we ever wanted to be. By the way, Dr. Osterholm didn't rush to print after the tragedy of September 11th but had written and published this book not very long after Richard Preston's bioterrorism novel "The Cobra Event" and "The Hot Zone," Preston's previous bestselling documentary on the near-disastrous introduction of a mutant strain of the Ebola virus to the outskirts of Washington DC touched off a spate of novels and documentaries on the topics of emerging diseases, exotic epidemiology and bioterrorism.

I can recommend "Living Terrors" as a solid, sometimes mildly hackneyed, yet engaging introduction to the topic of biological warfare and bioterrorism. Although America now already knows what a bioterror offensive is, Dr. Osterholm's book continues to serve as an in-depth introduction to this topic for anyone who wishes a better understanding of what is happening in the United States.

The average American can readily grasp this book's fairly complex subject matter -- helpful to those of us who aren't familiar with the world of bioterrorists. Tho' some of the writing is redundant, it is great, informative reading, though frightening. Author suggests that citizens can best take action by pushing for their local, state, and federal government to increase their preparations for bioterrorism. I would have had no interest in this subject before Sept. 11, but now it is incredibly pertinent.

The good doctor's book was truly an eye opener for me. I found his 8 step plan invaluable as a mother with 3 children. I would recommend this book to anyone and everyone who values the sanctity of freedom from terrorism. I've been reading about biological warfare for years, and I find it fascinating. Also read "Requiem" by K.M. Bourgeois and "The Eleventh Plague" by John S. Marr M.D. and John Baldwin