Forensic Epidemiology: On the Threshold of Change

“What we need to build on is the ability to integrate and to share information. … We’ve gone from ‘need to know’ to ‘need to share.’” Former CIA and FBI Director William Webster, 15 April 2004.

Judge Webster’s thoughtful observation highlights the need to change how U.S. officials use information to improve homeland security in an age of terrorism. The Federal Bureau of Investigation (FBI) defines terrorism as “the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives [emphasis added].” However, the political and social objectives of terrorist groups are as diverse as the groups themselves, and their individual members.

There are an estimated 17 active Islamic terrorist groups now operating in the United States, according to Steve Emerson at the Investigative Project.  But according to the Southern Poverty Law Center there are more than 750 active domestic “hate groups” throughout the country. Each of these groups has its own agenda, and uses its own methods of attack – some of which include bioterrorism.

Experts in this field agree that, to recognize a bioterrorism event early enough to take meaningful action (either to prevent it or to deal effectively with the aftermath), medical, public-health, and law-enforcement information must be shared more efficiently than has been the case in the past – which is where forensic epidemiology comes in.

Accuracy and Speed Both Needed

Forensic epidemiology is a relatively new discipline that combines medical information, public-health information, and law-enforcement information to develop greater, and more accurate, situational awareness of illnesses that could indicate whether a specific illness is the result of a natural event, an accident, or a crime – in the latter case, it could be caused by terrorists, and that would make it a national-security matter. The threat posed by biological terrorism is so enormous in scope that recognition that a biological incident has occurred and an appropriate response to it must happen almost simultaneously.  Information collection and analysis, distribution of the medications needed, and a rapid surge capacity all are required for a bioterrorism event to be fully and accurately identified and as many victims saved as possible.

The political and social objectives of terrorist groups are as diverse as the groups themselves, and their individual members.

Forensic epidemiology differs from standard epidemiology in that, in its analysis of illness patterns, it includes consideration of law-enforcement information on terrorist subjects, goals, capabilities, and likely venues of attack. That analysis may lead to law-enforcement actions, including investigations, and/or result in criminal charges. But that step comes later. The most important initial priority is that the analysis be completed both quickly and accurately to serve the needs of U.S. national-security organizations.

EMS (emergency medical services) personnel and hospital or clinic emergency rooms usually will be the first to see the victims of a bioterrorism attack, and therefore will have the first opportunity to detect the disease patterns that correspond to such attacks. For that reason alone they must be considered vital components of the national strategy to combat biological terrorism.

Structural and Operational Challenges

There are several unique challenges – some of them structural and some of them operational – to carrying out an accurate forensic-epidemiology analysis. The structural challenges include the fact that over 90 percent of healthcare in the United States is provided by private businesses – many, probably most, of which are financially stressed, and whose professionals usually are not too well informed about the indications of biological terrorism.

Overseeing this system of variable healthcare providers and businesses is a highly complex system of municipal, county, state, and federal public-health agencies, each with different capabilities and responsibilities, and frequently with little experience in the investigation of bioterrorism incidents. Federal, state, and local law-enforcement authorities all possess varying amounts of information on terrorist-group characteristics, and varying degrees of experience and capabilities as well. But the legal statutes in this complex field are not always uniform at all levels of government, and some are very much out of date as well. Moreover, there are very few guidelines to regulate the combined analysis and processing of the health and law-enforcement information already available.

In addition to these structural challenges, there are several operational challenges in combining health-care and law-enforcement information to develop an accurate and actionable forensic epidemiological analysis. Most of these challenges can be categorized either as issues of “threshold” or as issues of “responsibility and authority.”  Problems of the threshold variety include but are not necessarily limited to the educational and awareness limitations of individual practitioners. In the absence of an overt threat such as white powder and/or a threatening letter, most medical, public-health, and law- enforcement personnel will be uncertain about what illness patterns constitute a “biological attack.”

Time-Consuming Complexities

Illness of any type is expected to wax and wane in the United States, but the recognition of biological terrorism is a relatively rare skill. Dealing effectively with a bioterrorism incident, though, is largely dependent on health professionals first overcoming a threshold of recognition before reporting to higher authorities who have been assigned the responsibility for establishing the rules under which an investigation may be conducted.

Historical experience shows that this process will take several weeks, and perhaps months – which is far too long for operational purposes. Some progress is being made to streamline the process, but public-health and law-enforcement authorities are at only the initial stages of being able to rapidly, cooperatively, and accurately assess the biological terrorism threat.  Because there are so many structural differences between jurisdictions at various levels of government, it often is not clear who is responsible for, and has the authority to conduct, a forensic epidemiology investigation. The fact that the legal statutes governing such investigations also vary from one level of government to another causes additional complications.

In short, medical and legal ambiguities are the norm, rather than the exception, in the field of biological terrorism. But there is at least one thing that is clear – namely, that the methodologies by which the problems caused by and/or related to bioterrorism incidents must be locally flexible, legally supported, and implemented in an ethically responsible manner.

Fortunately, a major first step was taken when the CDC (Centers for Disease Control and Prevention) and FBI cooperatively produced a course and reference material on the subject. That course, which is available on the Internet, will clear away some of the confusion that now exists and, it is hoped, lead to additional changes and improvements within the foreseeable future.