After the devastating attacks on the World Trade Center and the Pentagon, government officials are beginning to imagine something even worse – a chemical or biological attack that could kill thousands, if not millions. How a large city would react to a bioterrorism attack became a key concern for governments and health experts after the Aum Shinrikyo Sarin nerve gas attack on Tokyo?s underground system in March 1995. The attack killed 12, and made thousands of people ill.

?Many experts believe that it is no longer a matter of ?if? but ?when? such an attack will occur,? said James Hughes, director of Health and Human Services Department National Center for Infectious Diseases, in a recent public testimony before Congress.

The most likely scenario would be a combined attack, according to Tim Brown of ?For a terrorist the type of weapon doesn?t really matter. What matters is causing the greatest number of casualties,? he says. ?A scenario could be, for instance, a suicide bombing in the subway, combined at the same time with the release of anthrax or a deadly virus, which are invisible. The problem is that emergency and rescue personnel are not trained to recognize what?s going on. They would flock to the scene.?

Despite plans to combat germ warfare, some experts remain skeptical of our ability to cope. ?We are not prepared at the national level,? warns Michael Osterholm, director of the center for infectious research and policy at the University of Minnesota. ?We need more resources – disease surveillance and rapid response in case of a catastrophic epidemic outbreak.?

A study of 200 hospitals published in the American Journal of Public Health in May shows only one hospital in five has emergency plans to cope with a biological or chemical attack. Less than a third have sufficient antidotes to respond to a nerve gas attack. And only one in 10 has mobile respiratory equipment available for doctors treating the injured. ?The first line of defense would be to prevent terrorists getting into the country,? Brown says. ?The psychological effect of such an attack would be a widespread panic, far beyond the area where it took place.?

The sarin gas attack in Tokyo did not take many victims, but it woke up U.S. authorities. When a hoax canister marked ?nerve gas? was discovered in a cellar in the New York borough of Queens in 1997, it inspired New York Mayor Rudy Giuliani to put together an emergency plan in case of such an attack. The emergency plan subsequently put in place by is considered by Steve Macko, risk analyst at the Emergency Response and Research Institute in Chicago (ERRI), to be the most advanced in the country.

Very few details of the plan, which is designed to improve the readiness of emergency rescue teams, ensure a swift response to attack and protect civilians, have been made public. It includes equipping 12 vehicles with equipment to prevent the spread of a chemical or germ attack, as well as several hundred handheld detectors, some as small as a matchbox, containing antibodies capable of indicating the presence of infectious bacteria within 10 minutes. City authorities have negotiated access to regional hospitals in case of emergency, as well as made a deal with pharmaceutical companies to provide huge quantities of vaccines and antidotes. And some 4,000 New York police officers, firemen and health workers have been given quasi-military training on how to cope with an assault of this nature.

?The likelihood is high enough that we have to be prepared,? says Philip Russell, professor emeritus at Johns Hopkins University. ?Terrorists tend to shift their strategies and their tactics. As we develop defenses, they seek new ways. So it?s quite probable that sometime in the future somebody will try a biological attack of one sort or another. We do have to be prepared for the worst scenario – for a smallpox release that would trigger a global pandemic. We are not prepared today. Our smallpox vaccine [stock] has not been restored.?

Tests done by the Army in St. Louis and elsewhere in the Midwest in the 1950s proved how easily biological weapons can spread across large areas. ?There are so many variables that play an enormous role in how a biological weapon is delivered,? says Bruce Clements, associate director of the Center for the Study of Bioterrorism & Emerging Infections at St. Louis University. Clements and other experts have studied the factors that determine where a biological agent can go and whether it will be dangerous when it gets there. Among the variables are a range of weather conditions, the type of agent, how much is released and exposure to sunlight.

During the Cold War, the Army secretly sprayed test particles on the ground and in the air as part of a biological weapons research program. Details of the experiments were revealed in documents declassified in the mid-1990s. The aim was to track the ways biological weapons disperse.

The researchers used zinc cadmium sulfide particles, because they are about the same size and weight as biological agents. They are also fluorescent and can be easily traced. In one group of tests, the Army in 1953 sprayed 35 clouds of zinc cadmium sulfide particles from street corners in St. Louis and tracked the clouds over two 25-square-block areas.

Army officials made up a cover story to win city approval of the tests by claiming they were intended to see if smoke screens could protect the city from Soviet bomber attacks. Similar tests were conducted in Minneapolis, Corpus Christi, Texas, and Winnipeg, Manitoba, Canada.

In another round of tests, in 1957 and 1958, the Army released the particles from an airplane flying across the Midwest. Collecting instruments on the ground at 175 weather stations in 39 states helped trace where the particles landed. In some cases, the particles were detected more than 1,000 miles from the release point.

Among the discoveries provided by the tests was that random flights over a target area would disperse small particles widely. The Army says the particles were harmless. But some scientists warned them at the time that the tests presented a potential health hazard.

The are several kinds of biological weapons that terrorists would be expected to use. Anthrax is one of the main ones. It?s a livestock disease caused by bacteria that form spores that can live in the soil for decades. In a biological weapons attack, anthrax would most likely be spread as a cloud of spores. Such a cloud inhaled by a city?s residents would create widespread flu-like symptoms, killing 80 percent of those infected within one or two days after their symptoms appear. Anthrax is not spread from person to person and is not effective when dissolved in water, so it would not be used to pollute a water supply. The disease has not been seen in humans in the United States in 20 years, so even one case would indicate that we had been attacked. Treatment with antibiotics must begin before the flu-like symptoms begin. Anthrax vaccine is currently available only to the military and there is an extremely limited supply.

Smallpox is another possible weapon. The world has been free of this disease since 1978, but some strains are still kept in laboratories. The former Soviet Union reportedly stockpiled large amounts of the virus for use in weapons. The virus is easily spread from person to person. An aerosol release of smallpox infecting only 50 people could unleash an epidemic killing 30 percent of those infected with the painful, disfiguring disease. Smallpox may take up to two weeks to appear in infected people. The disease starts as a rash resembling chicken pox. There is no known treatment for smallpox. Vaccinations in the United States ceased almost 30 years ago, and people who were vaccinated then may no longer be immune to the virus. The United States has limited stores of the vaccine, and efforts are now under way to develop new vaccines.

A third possibility is plague, which caused the Black Death epidemics that killed large populations of Europeans in the 14th century. A few cases of bubonic plague still show up in the southwestern United States, and in countries such as India, every year. A biological terror attack would probably involve the pneumonic form of plague and could kill up to 60 percent of those infected. If 100 pounds of Black Death bacteria was released over a city of 5 million, about 150,000 people would contract the disease. More than 35,000 of those would probably die. The Soviet Union produced massive quantities of the bacteria for weapons use. After exposure, victims begin to show symptoms of severe respiratory and gastrointestinal problems. The disease can spread from person to person.

The first sign of a biological attack might be rather mild. People would start showing up at doctors? offices or hospital emergency rooms with runny noses, teary eyes, headaches and fevers. Only the sheer number of these patients, not the severity of the initial symptoms, would suggest that something unusual is going on. Over a period of days these flu-like symptoms would turn into worse problems, such as bleeding, internal and external lesions, and labored breathing. This would provide the first proof of an attack on a civilian population with biological weapons.

?In a worst-case scenario, a biological attack could be considered the most horrible of all in terms of a hostile effort against a population,? says Leonard Cole of Rutgers University in Newark, New Jersey, author of The 11th Plague: The Politics of Biological and Chemical Warfare. ?And that?s because, at least theoretically, every person who becomes infected, if it is with a certain kind of micro-organism, himself becomes a biological weapon who can infect others, and you get kind of a domino effect.?

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