In a message dated 12/6/2008 10:23:38 A.M. Pacific Standard Time, edo_mcgowan@hotmail.com writes:
The following was drawn from a series of original scenarios developed in 1991 as the US ventured into the Gulf. I had
just come back from duty with the Foreign Service where this type of game theory was an ongoing process. I became
part of a team looking at impacts. Our group was composed of NATO planners, Air Force command staff, former
Soviet planners and Soviet physicians as well as local health officers. I rewrote it and submitted it for review a decade


Toxicology and medical hydrogeology,
Santa Barbara.
Corresponding author edo_mcgowan@hotmail.com

    The methods used in terrorism had, until September 11th, generally been limited to
    small efforts by poorly trained radical groups. Prior to that date in September, reporting
    of such events lead one to acknowledge the possibility of an attack, but because of t
    he limited past destruction, little credence was given to a major threat. America had not
    been burdened with invasions by foreign powers. Consequently the public was naïve—
    “it always happens over there, never here” In the past the public attention with respect to
    terrorist acts, while the news was fresh, was one more of curiosity and awe. It was felt
    that US citizens had become more isolationist in their interests. That such events could
    be much larger and substantially more destructive seemed not to have been seriously
    entertained by the public. In reality, as we have now seen, it was WHEN a major event
    would occur rather than IF such might occur. Current and long-standing U.S. foreign
    policy merely exacerbates the situation.

There have been several model studies of an attack on the U.S. The results of the recent events as well as the
TOPOFF and Dark Winter exercises, which were mocks of terrorist attacks have demonstrated that much needs yet
to be done.

At least two questions arise from the recent disasters in New York and Washington, D.C. What might we have done to
avoid this and why was it done? Several medical journals have commented upon the topic of terrorism and
determined that there is a need amongst the medical profession to consider such events. Preparedness, however,
must include the public and local public officials and education must be at the top of the list.
The question of the moment is then how to reach the public. Books and media information treating foreign policy or
international relations attract few. Books or programs on politics are of interest only to the extent that personalities
rather than issues are discussed [1]. We, however, may be able to assist since the public and our patients are one
and the same.
Beside the events of September 11, you may have noted the reporting of several recent mock terrorist disaster
exercises that have been conducted by local agencies across the US. Many of these exercises were a combined
effort by hospital emergency programs and local fire or police departments. For the most part, these exercises
focused on the biological aspect only. Others considered only the release of a chemical weapon, or the single
release of a radioactive weapon. While this narrow focus is to some extent useful, it may tend to give a false sense of
security. In fact, these exercises may have been designed specifically to provide a sense of security. One may wish to
bring to mind the old “Duck and Cover” exercises during the early nuclear arms race of the last century.

This paper treats both chemical and biological terrorism. Sponsored terrorism is an attractive alternative to more
expensive wars of aggression [2]. For many nation-states, WMDs are far cheaper than ICBMs, and these weapons
can easily circumvent the US strategic defense systems [3]. Would nations under attack from the US and its partners
be deterred by an accelerated series of strikes? England during WWII as well as more recently, nations such as Iraq,
Afghanistan under Russian attack, Somalia, and North Vietnam have demonstrated considerable strengthening of
resolve under increasingly escalated attack. William Cohen has previously noted that accelerated deterrence may be
of little use in situations where leaders are insensitive to their people’s welfare [4].

A combination of both biological and chemical agents, rather than a single agent is felt to present a more realistic
picture of the future. The underlying scenario for Los Angeles was originally developed in the early 1990s to
demonstrate the vulnerability of large metropolitan centers. In some aspects, little has changed over the ensuing
decade. The committee upon which this duty fell, of which the corresponding author was a member, was composed of
former NATO, DOD, and Foreign Service Officers and planners, public health planners, and former Soviet staff MDs.

Several approaches were modeled. The most effective demonstrated that the best results would entail use of multiple
modes of delivery with both biological(s) and chemical(s).

What follows is felt to be a realistic scenario and is put forth to give clinicians and public health planners some feel for
the extent of difficulty that may be faced. It is hoped that through this paper, a dialogue may be opened to discuss
where we might fit into such a situation. Since many of us are working within fairly sophisticated environments, what
would we do if those tools and support bases suddenly disappeared?

In the original 1990 analysis, it was felt that the more radical groups, those less well funded and sporadic, would not
likely have the capacity discussed below. That thought, as we now know, no longer prevails. The effort depicted
below would require the planning capacity and backing from a well-organized hostile group or government. As
mentioned, these scenarios were developed in mid 1990, and with Iraq in mind as the United States and others
began to progress toward the war in the Middle East desert.

Congress has reported on several nations that have consistently been considered as posing a potential threat for
ballistic missiles—Russia, China, North Korea, Iran and Iraq. Other nation-states are also on the State Department’s
list and yet still others, while potentially posing a threat, are not listed for political reasons [i]. What has been less well
stated is the potential for state sponsored WMD terrorism. Current U.S. Foreign Policy and posturing seems to again
bring this picture into sharper focus. Consequently the players envisioned in terrorist events, though few, would be
well funded, highly skilled and trained, and well placed considerably in advance.

Los Angeles was chosen as a typical large US city. It has several weaknesses. Each major city will have certain
weaknesses that can play to the advantage of a well-planned terrorist operation. It has been noted that there are
about 12 major centers within the U.S, upon which this nation depends. Los Angeles has been previously mentioned
as a potential point of attack. It has been reported that one of China’s high officials quipped in a thinly veiled threat,
that for the US to step in for the defense of Taiwan, Los Angeles might be considered. “America will not sacrifice Los
Angeles to protect Taiwan [ii].” Further, it has been said that weak nations need not follow the rules established by
the strong [5].

LA has no local water supply of any consequence. It is also bound by its mass such that streets and roadways are
insufficient in the case of a major disaster. It additionally, in the early 1990s, along with most US cities, had poorly
planned emergency contingency plans. The GAO, in a report released in 1997, updated this appraisal. The GAO
stated that there was a lack of adequate coordination [iii]. The TOPOFF and Dark Winter exercises have confirmed

Many of the strategic centers and vital processes necessary to LA’s survival are easily available and part of the
public record. Finally, the local weather, as will be seen, plays into the hands of terrorists. The Los Angeles area is
composed of a series of stagnant and non-circulating air sheds in which there is creation of its well known SMOG.
This process is created by an inversion that would tend to concentrate aerially applied materials. These contributing
factors will be discussed below momentarily.

Several micro-organisms or their toxins can be used for biological weapons (see Tables 2 and 3). The bacteria and
some biologicals are easily acquired and can be mass produced. As a point of illustration, American militants, the
Minnesota Patriotic Council, have demonstrated this through their work with ricin. Viral agents require considerably
greater skill and care in both manufacture and handling. Nonetheless, several of the State Department listed nation-
states are assumed to have the capacity. Additionally, there are stocks of Soviet manufactured smallpox that are
presumed to be missing.

Criteria for selection of biologicals are listed in Table 1. For this model, anthrax and cholera were selected as
probable biologicals for aerial application.
Botulinum toxin (to be discussed momentarily) was selected for
contamination of the city’s drinking water system.
The 1990 team and current authors also considered the
introduction of a psychopharmacologic agent, e.g. LSD, as a method of disrupting emergency operations.

Additionally, in classic warfare, the capture of foreign soil was often a driving force. Today, in contrast, this end may
not be considered. It may not be necessary to capture lands---merely making them uninhabitable may be the ultimate
goal. From an economic perspective, it is important to remember the testing done by the British on one of the islands
off the UK. This island was used as a test site for
anthrax during WWII. It remained contaminated for at least 50 years
and was quarantined during that time. It may still be considered dangerous to set foot there. Thus the ramifications of
anthrax are considerable. Major portions of a city would remain contaminated for decades. The businesses, homes
and representative tax base would be lost. There is poor insurance coverage for such events.

Table 1. Desirable attributes for biological agents

  • Ease of production, transport, and storage

  • Ease of dissemination

  • Difficult diagnoses during initial cases

  • High initial mortality, lingering and debilitating sequelae

  • Potential for high person-to-person transmission

  • Necessitates high level of surveillance and effort to counter act

  • Ability to cause confusion, disorder, panic, and socioeconomic disruption

Anthrax would start to show symptoms in 3 to 5 days [iv] and cholera in 2 to 3 days [v]. A confounder from Table 2
might also be included. The delivery of anthrax and cholera might relate to inversion weather conditions with a mild
onshore breeze. This would require obtaining data for modeling the basin’s air movements, and again such data are
available through public information. Inversions are typical of the Los Angeles basin. The delivery would be aerially
applied, part with rotary wing as these craft are allowed to fly much lower. The material would be applied at night
(obviating detection of a particle plume as well as any destruction by sunlight) with runs through the valley as well as
parallel to the coast. There is considerable light aircraft traffic in the Los Angeles area such that there would unlikely
be any question. The aircraft would then be flown out of the area and abandoned, probably ditched at sea to
eliminate evidence and the pilots picked up by boat. The application pods would be dropped prior to the ditching to
reduce contamination of the pilots. Pilots would be previously vaccinated, wear special protective equipment, and
following the disposal of such would receive decontamination.

Much has been said about the use of cropdusters for the application of materials. This may be naïve thinking. These
aircraft are slow, easily identified, and built to carry large dilute loads. The application pods for biologicals need be no
larger than a carry on suitcase, and thus would be easily fitted within any light aircraft.

Before all this, however, there would be the rental of several strategically placed vacant homes or warehouses. Each
such structure would be selected for the following requirements: (1) attached garage or internal enclosed area, (2)
equipped with laundry facility outlets or similar plumbing facilities, and (3) the houses or buildings would be sited up
gradient along water mains servicing major emergency centers—hospitals, police stations, fire stations, military
installations, power plants, port control, airports, sewer plants, etc. The network of water delivery systems is public

It was felt that, for assault on the water supply, a mixture of biological and chemical agents would be most effective.
Nonetheless, biologicals alone could be used. The most effective chemicals were considered to be fast acting
organophosphates (OPs) that would cause rapid enzyme ageing as well as being highly lipophilic materials. The latter
requirement would see rapidly absorption into the adipoise tissue, where it would remain after the fast acting OPs had
been treated. Thus upon coming back out of the adipoise tissues there would be a second cholinergic crisis [vi]. This
would tie up more emergency support personnel and there would also be more adverse sequelae. This would only
add to the psychological effect. An additionally consideration is the potential for mixing carbamates (CB) as
confounders for the OPs. The rationales and mechanisms will be discussed in more detail below. Additionally one
might expect the use botulinum toxin as the symptoms mimic the anti cholinesterase effects of the chemicals.

There are approximately 3 dozen OPs in current avenues of commerce that are considered highly toxic
(see table 4 below).

From available agricultural supplies, there would be the purchase of a large number of 55 gallon barrels of organo
phosphate (OP) pesticide as well as large supplies of carbamates and possibly paraquat. This would require
considerable pre planning and obtaining a license in some agricultural pursuit so these materials could be obtained.
The examinations for such licensing are not difficult to pass and once obtained, these materials are in regular
commerce. They can also be purchased in Mexico and trans-shipped to a central warehouse for later disbursement.
The tightening of record keeping since the early 1990s would render such purchases more difficult but not
impossible. Thus a choice between chemical and biological would depend on commercial availability of supplies of the

The OPs would be the first choice based on lethality and early presenting symptoms. At least two would be chosen:
one having a fast action, such as a parathion and the second a highly lipid soluble material. The latter, once
absorbed, will seek body adipose tissue storage and only after a number of days will the second cholinergic crisis
appear. Thus the initial crisis from the fast acting material will be treated and the patient released. The patient then
experiences the slow release of the second material. If the bond between the OP and cholinesterase is not quickly
broken by pharmacological intervention, the bond ages and becomes irreversible. The window of opportunity for this
varies with the material. Soman, considered unavailable, ages the enzyme in a matter of minutes. This is why this
military chemical weapon is so deadly. In most agricultural equivalents, the ageing requires about six hours and up to
24 hours. Additionally, if carbamates are chosen, there is some question in the use of 2PAM to reverse and
reactivate the enzyme. Early work suggested that the use of 2PAM in carbamate poisonings actually exacerbated the
condition. Such has been demonstrated for carbaryl [vii]. This was thought to occur from a locking up the enzyme in
carbamate poisonings.

Parathion not only kills, usually by cardiopulmonary arrest, but survivors often have serious permanent neurological
and cognitive damage. Oxygen and assisted ventilation are necessary (cf. paraquat below). Parathion also
permanently contaminates zinc; hence large segments of the water delivery system would remain contaminated. It
should be noted here that one of the primary treatments for poisoning is decontamination. The gut can be washed
and the skin can be decontaminated with water. If the water system is already compromised by contamination, then
this is no longer a viable option. If the water system it self is also contaminated, then this also plays into the hands of
the terrorists.

The pulmonary symptoms of acute paraquat poisoning may be confused with anthrax, hence this chemical agent may
not be treated. The ability of paraquat to destroy organs is well known by its ability to cause mass apoptosis. There
are few if any antidotes for paraquat poisoning. Additionally, the usual emergency room procedure of giving
supplemental oxygen is highly contraindicated in paraquat poisonings [viii]. Oxygen in such cases greatly
exacerbates the effect of the poison, [cf organophosphates] driving the level of apoptosis in the lung to considerably
higher levels. The long term sequelae and morbidity in survivors of paraquat poisoning are serious

The operation:

In each rented home or building, one can enter the garage, close the door, and unload cargo once inside with
complete privacy. Human behaviour also enters into the equation. People in American metropolitan centers almost
never speak to or interact with neighbors. Thus, there is an added behavioral protection to clandestine operations.
Night deliveries are also common in the industrial areas.

There are few cities with back flow devices installed on the water meters, all these can be also overcome. Thus with
the aid of a high-pressure pump, for example a Jacuzzi, one attachés the pump to the cold laundry outlet or internal
pluming. A manifold is then attached to the 55 gallon barrels, other mixtures (botulinum), and thence to the pump.
The pump is turned on by a timer, same device that runs sprinklers in most yards—easy to install and cheap at any
nursery supply. The Jacuzzi thus overcomes the local water pressure and back pumps the highly concentrated
material into the main water delivery system. From here highly concentrated solutions are carried to targets. It should
be seen from this that merely protecting reservoirs may be missing a major delivery source.

On day three or five, following the aerial application of the biological(s)—as the first symptoms are arriving at medical
centers—at about 4:00 in the morning, the pumps go on. This pumps the pesticide and/or the botulinum toxin into the
water system in time for meal preparations, breakfast, and shower. Again the timing of flow and volume can be
approximated from data in the public record showing, pipe size, pressure and estimated distance to target. The
placements and concentration will also contaminate the emergency centers, rendering them and their staff non-
effective. The morning news will spread the panic and the city’s streets will become impacted on top of any commuter
traffic coming in from outside. Because of the panic and clogged streets, emergency crews may not be able to

As we saw from New York, there was mass confusion. In New York, however, the area of damage was limited to a
relatively small portion of the city. In our scenario, vast areas are affected.

Additionally, it is doubtful that a sufficiency of supplies would exist. Since the CDC maintains stockpiles of antidotes
for such events, their delivery would require staging and trans-shipment. Would the arrival be too late for many? How
much do local hospitals keep on hand? The answers seem to be crucial to the questions.

For the survivors, the long-term sequelae are often serious and their outcomes bleak. The morbidity would be high in
both mental and physical symptoms. There are significant dangers to pregnancies and there would thus be much
reproductive wastage as well as serious physical and mental birth defects. Assuming the use of a highly
communicable pathogen, there would be the added issue of the early infected, but not clinically apparent, leaving the
area and thus spreading the disease to a much wider area. Tracking the number of such persons would be seen as a
major task. The TOPOFF exercise in Denver demonstrated that the spread of plague was far reaching. It was picked
up in several adjacent states as well as in foreign lands as those leaving the area took it with them.

For the current paper’s purposes, the terrorist team that has set this Los Angeles attack in place would number about
12. They would have left before the application of anthrax or other aerially applied pathogen. An international flight
would have them safe at home within 18 hours of their departure, well before the majority of the event took place.

In addition to this they would probably leave large timed charges to (1) destroy major water delivery systems such as
the siphons bringing water over the mountains into the Los Angeles area, and (2) destroy the principal sewer mains
leading to the principal sewer plants. This latter explosive device could be introduced into the sewer considerably
above the site and floated to the intended site. Again these networks and man-hole cover sites are public record.
Loss of sanitation would only enhance the spread of disease, especially a disease that is enteric. Additional
considerations would be the destruction of major power services and their supply links. Many of the high-tension lines
come through very remote areas and are thus easy targets. With no water and limited power, emergency response
would be drastically crippled.

An added twist in this is the insurance issue. Many insurance policies have disclaimers for acts of war, declared or
undeclared. In the event of a nuclear release, there is an absolute disclaimer. Thus depending on the situation and
level of contamination, many may find that their insurance is worthless.

TABLE 2: Bacterial Agents         

TABLE 3. Viral Agent

Of the viral agents, stockpiles of smallpox were held by some of the nations during the Cold War. Although these
were to be destroyed, there were unaccountable disappearances. There are now considerable numbers of people
who were borne after the announced world–wide eradication. These are a naïve population and there may not be
enough vaccine to now cover this at-risk population.

Organophosphates and Problems with Treatment

The medical treatment of chemical WMDs requires, in the addition to adequate preparation, the use of technology,
procedures, drugs and antidotes. None of the medical procedures are risk free. Of the antidotes, many are also
toxins [ix]. Gastric lavage, which has its own risks, is essentially ineffective after about an hour. In many ingested
liquids, the bulk will have left the stomach and moved into the gut within 15 to 30 minutes. Additionally, the airway will
need protection. Many will already be in seizures. Assistance with pulmonary ventilation will be required, but there
may be insufficient supplies or personnel. Most of the effective measures are dependent on technology that is
typically in short supply. For example hemodialysis or hemoperfusion may be indicated for the occasional single
suicide but would be difficult to consider for a mass poisoning.

Significant ingestion of organophosphates or carbamates, as well as arsenicals will produce profuse diarrhea. On the
other hand diquat or paraquat will cause the gut to spasm and seize. As a consequence charcoal, which is often
combined with a cathartic, may actually exacerbate the condition. Activated charcoal is also contraindicated in
unprotected airways [x].

In the complex milieu of managing human poisonings, there is rarely time for the precise comparisons of alternatives
and differential diagnoses. Thus in a mass attack, clinical management decisions will become an unfortunate and
ugly triage. Many will watch their fellows die and those in the throws of death will be bypassed, some only to watch in
their last moments, as others are saved.

Organophosphates (OPs):

These materials act by phosphorylating the enzyme acetylcholinesterase (AchE) at nerve endings. Without the
enzyme, the neurotransmitter acetylcholine is not removed and the nerves continue to fire. This over activates some
systems and exhausts others. The entire organism is thus thrown into chaos. Death usually results from cardio-
respiratory collapse. In addition to the acute cholinergic crisis, there are long term sequelae such as dementia,
weakness or paralysis as well as deformities in utero.

Commercially, there are about thirty OPs of particular concern (see Table 4 ). These have LD 50s under 50 mg/Kg.
But these data are based on rat studies. The metabolic weight of the human in dose per kilogram is about 1/8th that
of the rat. Thus while considered as highly toxic on a rat basis, some of these materials are ultra toxic to humans.

Some OPs such as parathion or diazinon are highly toxic and lipophilic. This thus affords terrorists with an added
advantage. Fat storage allows for a second and delayed toxicity as the materials are released later, after an initial
cholinergic crisis. This then ties up more support. In addition to the two just mentioned, other OPs have delayed
release, e.g., demeton-methyl or dichlorofenthion. In addition to the single toxic assault, combinations are more
effective in sequestering or tying up the liver enzymes necessary to the body’s defense. This potentiation causes one
necessary liver enzyme to inhibit another critical enzyme. As time passes, the complexing bond between the enzymes
and the poison begins to harden or “age”. This occurs as one of the alkyl groups from the phosphorylated adduct is
lost, leading to the aging process. Reactivation with antidotes after this aging becomes progressively difficult, if not
impossible. This is why some of the military equivalents are designed for almost immediate aging and are
consequently so deadly.

Most OPs in commerce will age after 6 hours and up to 24 hours. Thus the old saying that “time is of the essence” is
well to remember here. Unfortunately, in a mass poisoning with thousands affected, time will run out before help can
be reached for many.

Also please remember that decontamination with water is near the top of the list for immediate treatment. Although
one of the first effective and necessary treatments, if the water supply is lost, this option is lost. If the water supply is
also contaminated with toxic chemicals this option becomes another weapon for the terrorist.

Table 4: Commercially available organophosphates with rat LD 50 less than 50 mg/kg [ source: EPA pub 735-R098-
003, Recognition and Management of Pesticide Poisonings. Mar 1999:35.]

Chemical name          Common Trade Name
Azinphos-methyl             Guthion

Bomyl                             Swat

Carbophenothion          Trithion

Chlormephos                Dotan

Chlorthiophos             Celathion

Coumaphos                Co-Ral

Cyanofenphos             Surecide

Demeton                      Systox

Dialifor                        Torak

Dicrorophos                Bidrin

Dimefos                       Pestox

Dioxathion                   Delnav

Disulfoton                 Disyston

Ethyl paathion           Parathion

Fanphur                     Famfos

Fenamiphos                Nemacur

Fenophosphon            Agritox

Fensulfothion             Dasinit

Fonofos                    Dyfonate

Fosthietan               Nen-A-Tak

Isofenphos                  Amaze

Methamidophos              Monitor

Methidathion              Supracide

Methyl parathion         Penncap-M

Mevinphos                Phosdrin

Mipafox                          Pestox

Monocrotophos              Azodrin

Phorate                       Thimet

Phosfolan                  Cyolane

Phosphamidon           Dimecron

Propyl thiopyrophosphate          Aspon

Schradan                            OPMA

Sulfotep                    Thiotepp

Tetraethyl pyrophosphate           TEPP

Local Counter Terrorist Preparation:

In many instances, the military has prepared its members. This effort has not been duplicated within the civilian ranks
[xi]. The effects of current US foreign policy for potentiating aggression are currently under discussion in some circles
[xii]. To reduce risks from an internal perspective, however, there must be enhanced capacity to rapidly detect and
react to attacks. This will require coordination amongst formerly disparate jurisdictions. Such coordination must also
include mechanisms for the rapid and accurate communication of data. Many of the potential biological and chemical
agents will cause illnesses that are rarely encountered in medicine as practiced in the United States. Accordingly, a
major education effort will be required for diagnostic laboratories, health care professionals, and public health
officials who will be on the front lines. Each major area must also stock pile a sufficiency of supplies. This will require
funding. A sufficiency of funding must be made available. Disbursement of this funding should be coordinated by a
transparent oversight committee [xiii]. Finally, there is a need to educate the public. There may, however, be a
reluctance to carry out such education, especially considering the potential negative effect on current politics and
foreign policy from a more educated public.


It would appear, if one accepts the above scenario, that many US cities are at risk. A high ranking member of the
Soviet GRU, the army’s counterpart to the KGB indicated that large cashes of both biological and chemical agents
had been previously pre-positioned for use in US cities [xiv]. Additionally, David Kay of the UN weapons inspection
team indicated that the potential use of pre-positioned WMDs was highly likely [xv]. The consequences are often so
overwhelming that many local jurisdictions and their support systems as well as their decision makers are moribund.
Because of the complexity and sheer magnitude of the issues, there is often a reluctance to squarely face such
events; although over time much could be accomplished.

It appears that each political subpart, Federal, State, County, City or Special District, while recognizing some aspect
of the problem, and presumably its seriousness, awaits action by another. Solutions will continue to be both driven
and hindered by short-term economic or political considerations. Additionally, often these various subparts are based
on narrowly defined and disjointed academic, professional, or discipline oriented subsystems. The treatment of the
process by dividing it into its various subparts, while seemingly providing answers may in fact increase abstraction.
Further, bureaucratic politics for bureaucratic convenience often relates to mere sub-segments, and to change this
meets with increasing resistance as the status quo is threatened. This division into subsystems precludes an ability to
grasp the broader spectrum of alternatives necessary to functional solutions.

Management to be comprehensive must be based, in part, on long-term planning. Planning is, however, by its nature
proscriptive and, when combined with regulatory functions, faces resistance to internal change. It also is subject to
clientele capture, thus rendering planning retrogressive and prone to failure. There will be a tendency for the
creation of “new” agencies in response to public outcry. This is seen as the political “quick fix”.

As the complexity of this “fix” increases, the non-technical policy maker is still left with the responsibility for
establishing a highly technical process. Many policy makers, however, are at a minimum, uncomfortable in technical
arenas. The attempt then is to cram the issue of a scientific problem and its answer into an area of typical political
compromise. As such, there will be an increased inability to engage in meaningful planning.

When, however, a conceptual plan starts to shift into a regulatory phase, it shifts from prescriptive to proscriptive.
There is an increasing concern with the circumscription of permissible conducts. Thus when government, through its
decision makers, is responsive to the electorate and reacts to the short-term demand horizons, it cannot plan. Policy
thus may be the residual of a series of missed opportunities.

Thus, rather than merely having emergency room and medical staff and other responders go through drills, the entire
system needs a thorough re-evaluation.

1 Green A Will Publishing Survive? Book Review: Los Angeles Times, Sunday, February 25, 2001

2 Laqueur W. Postmodern Terrorism. Foreign Affairs. 1996, Oct;75(5):34.

3 National Intelligence Council. Foreign Missile Developments and Ballistic Missile Threat to the United States
Through 2015. September 1999.

4 Cohen W. Rogue States Cannot Hope to Blackmail America or Her Allies. London Times, March 1, 2000.

5 Pomfret J. China Ponders New Rules of “unrestricted War.” Washington Post, August 8, 1999.

i US Congress. Office of Technology Assessment. Proliferation of Weapons of Mass Destruction: Assessing the Risk.
Washington, DC:. USGPO, August 1993.

ii Prager, K. China: Waking up to the Next Superpower. Time Magazine; March 25, 1966.

iii GAO. Combating Terrorism: Spending on Governmental Programs Requires better Management and Coordination.
GAO/NSIAD-98-39; December 1, 1997.

iv Joklik WK, Willett HP, and Amos DB, eds., Zinsser Microbiology, 5th Ed. Appelton-Century-Croft, Norwakl, Conn;
1984:673-76. Cotran RS, Kumar V, and Collins T, eds., Robbins Pathologic Basis of Disease. WB Saunders,
Philadelphia, PA;1999:344. Dutz W. Anthrax. In Braude AI, Davis CE, and Fierer J, eds,. Infectious Diseases and
Medical Microbiology, 2nd Ed. WB Saunders. Philadelphia, PA;1986:1514-18.

v Joklik WK, Willett HP, and Amos DB, eds., Zinsser Microbiology, 5th Ed. Appelton-Century-Croft, Norwakl, Conn;
1984:626-27. Cotran RS, Kumar V, and Collins T, eds., Robbins Pathologic Basis of Disease. WB Saunders,
Philadelphia, PA;1999:356-8. Wallace CK. Cholera. In Braude AI, Davis CE, and Fierer J, eds,. Infectious Diseases
and Medical Microbiology, 2nd Ed. WB Saunders. Philadelphia, PA;1986:911-14.

vi Reigart RJ and Roberts JR. Recognition and Management of Pesticide Poisonings, 5th Ed. EPA pub 735-R-98-003.
USEPA. USGPO, Washington, DC.: 1999:34-54. Klaassen CD, Amdur MO, and Doull J, eds. Casarett and Doull’s
Toxicology: The Basic Science of Poisons, 5th Ed. McGraw-Hill; New York, NY, 1996:656-67.

vii OpCit. Recognition and Management of Pesticide Poisonings @ p. 41.

viii OpCit. Recognition and Management of Pesticide Poisonings @ p.11.

ix OpCit. Recognition and Management of Pesticide Poisonings @ p. 2.

x OpCit. Recognition and Management of Pesticide Poisonings. @ p. 13.

xi See notes 1 and 3 supra.

xii Quillen C. State-sponsored WMD Terrorism: A Growing Threat? The Terrorism Research Center. 2000 (word
search via GOOGLE).

xiii See note #3 supra.

xiv Lunev S. Through the Eyes of the Enemy. Washington, DC.: Regency Publishing 1998.

xv Macko S. The WDM/Terrorist Threat From Iraq. ERRI Daily Intellegence Report. February 10, 1998, Vol 4-041.
Easily spread
Bacillus anthracis
edema producing, complex, lethal
Bordetella pertussis
whooping cough   
lethal, dermonecrosis
Clostridium botulinum  
lethal neurotoxin       
Cl. tetani   
lethal neurotoxin          
Vibrio cholerae    
lethal, enterotoxin   
Shigella shiga   
shiga toxin, enterotoxin, lethal  
Yersinin pestis  
Ebola hemorrhagic fever   
Marburg  hemorrhagic fever    
Lassa fever      
Argentine hemorrhagic fever