On 24 June 1763, Captain Ecuyer, acting on the orders of Sir Jeffery Amherst, commander of British military forces in North America, issued two blankets and a handkerchief from the Fort Pitt smallpox hospital to Native Americans who lived nearby.

An entry in his journal indicated that he hoped the distribution of these items would "have the desired effect.” The desired effect in this case was not the warmth and comfort of these indigenous groups, but rather the aim of his commanding officer to use smallpox as a biological weapon against the local tribes who had virtually no natural immunity or previous exposure to the virus. The plan worked: over the next few months, some 100,000 people in the Ohio River valley—Shawnee, Delaware, Mingo, and others—died from the disease.

The captain's use of a biologic agent as a weapon was neither novel nor specific to North America. During the 14th century siege of Kaffa, a seaport on the Black Sea on Russia's Crimean peninsula, the attacking Tartar force experienced an outbreak of plague. Being good soldiers and masters of turning misfortune into fortune and benefit, the Tartars took to launching the disease-ridden bodies of their comrades over the walls of the fortress in an effort to infect the troops within. An outbreak of plague followed as the Tartars retreated. Intentional contamination of water sources during the Napoleonic wars was as common an event as the use of pungi sticks (sharpened bamboo poles covered with feces) during the Vietnam War in the 1960s.

Unfortunately, humans have been adept at weaponizing both naturally occurring and artificially created biologic toxins for years. These efforts can be as sophisticated as those very recently undertaken by Iraq to weaponize anthrax and botulism, or as simple and exquisitely effective as the darts and arrows dipped in curare and other plant- and animal-derived toxins that have been used for centuries in the jungles of South America to poison and disable enemies.

The use of biological agents as weapons of terror is real and growing. These weapons have the potential to devastate populations, cripple economies, destroy infrastructures of local and regional governments, and create precisely the kind of panic and fear the agents of terror are hoping for. On television screens across the United States, people watched in horror as the New York World Trade Center and Oklahoma City Murrah Federal Building tragedies unfolded in recent years, acutely aware of the potential for large-scale disaster that weapons, placed in the hands of the misguided, disgruntled, and disenfranchised, can cause. Yet the terror resulting from the use of a biologic agent is greater still, given the fact that there may well be no "event” or explosion that warns citizens of its release. These dangers, can, and most probably will be, silent and subtle when used.

For four decades, the world worried and debated the concerns and dangers posed by nuclear weapons, and the United States and other superpowers focused much of their energy on making sure they were protected and capable of responding to an attack from an enemy using these weapons. Submarine launching platforms, airborne early warning and delivery, along with land-based missile systems provided a "triad” of protection that was never breached.

But when it comes to biological terrorism the front line of defense for every nation is quite simply its nation's public health system. According to Dr. Donna E. Shalala, U.S. Secretary of Health and Human Services, "With bioterrorism, the public health and medical communities stand directly on the front lines. How well we respond to a threat or attack will depend on the preparedness of our public health and medical communities." Yet, she says, "This is a fight we cannot win by ourselves," adding that the most effective response is to "forge new working partnerships across the board."

Therefore, the U.S. Government is spending billions of dollars to address this issue at virtually every level. Law enforcement, military, National Guard, fire departments, emergency services, environmental departments, public health agencies, and others are being urged to work together to create plans and systems within their communities to deal with these threats, which, according to reports of the Federal Bureau of Investigation, have increased significantly and included some 140 anthrax false alarms in 1998 alone. Of course, no agency or department in any community can afford to take these threats lightly and many view each such threat as an opportunity to practice and rehearse the effectiveness of response procedures.

A theme that consistently has run through all of the programs in countries and communities that have dealt with these threats has been the absolute need for a solid public health infrastructure. Without exception, public health officials, elected leaders, and military and emergency officials point to the importance of building a good, strong, public health structure at the local level to both recognize and begin to deal with threats. Many elected and appointed experts seem to have concluded along with their public health colleagues that success in this arena will come about through a combination of factors: (1) strong relationships at the federal, state, and local level; (2) tools for prevention and treatment, including an effective epidemiological surveillance network to enable public health authorities to quickly recognize potential threats and communicate the dangers and possible solutions; (3) improved and enhanced laboratories in both the public and private sectors so that these diseases can be identified with precision and the proper vaccines and other types of treatment can be developed, stockpiled, and delivered; and (4) the knowledge of threats, so that health care practitioners at all levels can work together to triage, assess, treat, educate, and deliver needed services and information when the moment for decisive action presents itself.

Of course, there are those both in and out of government who question whether the level of concern and expenditure matches the threat. Yet Dr. Margaret A. Hamburg, who served as New York City Health Commissioner at the time of the World Trade Center bombing and currently is Assistant Secretary for Planning and Evaluation at the U.S. Department of Health and Human Services, says: "I have no doubts that the threat of terrorism within our borders is real," noting that even though sarin isn't a biological pathogen, "when the sarin attack occurred in the Tokyo subway system, it was hard not to imagine what such an event would have meant in the New York subway system."

How widespread are the knowledge and expertise among individuals and organizations to create and carry out effective acts of bioterrorism? Consider the case of a small commune of followers of an Indian guru in Oregon in 1984, who displayed an extraordinary amount of creativity in their efforts to impact the local city council elections. The commune members visited local restaurants over a number of evenings prior to election night and secretly poisoned the salad bars with a salmonella agent, making 751 people sick with vomiting and diarrhea. They did not win the election, but it took a year for public health and law enforcement officials to determine exactly what had happened and who was responsible for the attack.

Instances like these prove that the pathogens need not be exotic and remote in origin to be effective or have impact. Both public health officials and battlefield commanders who specialize in the use of biological toxins openly admit that they worry as much about a commonplace agent used with skill and determination as they do about more exotic and esoteric chemical creations. In some past wars, as many soldiers have died from influenza, bacterial diseases, malaria, shigella, cholera, and other foodborne, waterborne, and vector-borne diseases as from actual battle.

Since the 1972 ratification of the Convention on the Prohibition, Development, Production, and Stockpiling of Biological and Toxic Weapons and on Their Destruction, more than 100 nations have agreed that these weapons would not be a part of their arsenals. Yet there is significant evidence that a number of the treaty's signatories continue to stockpile the weapons and are even working to improve their effectiveness and deployment. In 1992, Russian President Boris Yeltsin publicly admitted that an accidental anthrax release in 1979 had sickened and killed people and livestock in the area around a military biological production facility near Sverdlovsk. Additionally, there is no question that Iraq's Saddam Husseim ordered the use of chemical and biological agents on his own citizens of Kurdish descent following the Gulf War. Both of these incidents demonstrate that individual, organizational, and the state-sponsored use of biological threats must be considered in the evaluation or "mix” when public health is confronted with highly unusual disease threats.

Both distant and recent history is littered with case studies of persons and groups who, having possessed the will, have found a way to deliver their personalized message of terror or destruction. In the early 1960s, the airline industry did not seriously envision that a realistic threat to the safety of its passengers existed. Yet today at airports around the globe, travelers are required to pass through metal detectors, past bomb-sniffing dogs, and await their luggage as a machine scans it for the presence of explosive materials.

Increasingly, partners in the international public health community have come to realize they must marshal all possible resources and assets at their disposal and share information and their concerns with others. The development of epidemiological and laboratory systems that can share information has been an important tool in these efforts. Almost daily, success stories emerge highlighting effective collaborations between in-tergovernmental agencies and international organizations. Even former Cold War enemies have come together on a number of projects. One such effort is a partnership between hospitals in New Mexico and Russia in which health professionals are sharing information on hepatitis C. Many policymakers and politicians now are coming to realize what doctors long have understood: disease is apolitical, knows no borders, respects no boundaries, and honors no treaties.

It is incumbent on public health and political authorities everywhere to "step up to the plate” on this issue. The time has come to think about the unthinkable and consider how and where the resources will be acquired to protect our citizens. Pragmatic ways must be discovered to share, distribute, and quickly provide vital information, expertise, and messages of prevention and protection to our communities. Local authorities need to focus on detection capability, laboratory capacity, and communication systems and to seek out the vaccines, treatments, and protective materials and systems for our public health partners who will—without choice—be on the front line of these emergency situations.

Planning should be ongoing and constantly updated. Systems should be in place that support the good public health infrastructure that will greatly aid public health professionals in dealing with these crises. Governmental and private concerns should seek out collaborations and other opportunities for cooperation. New partnerships with media outlets, and educational, business, and community support groups can contribute greatly to our ability to quickly reach those potentially at risk. Primary prevention should be combined with realistic training so that community public health workers or law enforcement officials won't spend the precious first few hours of a crisis trying to figure out who exactly is in charge.

Most importantly, the public health field must come to grips with this issue. At all levels of the public health system, health workers need to hone and improve their skills and awareness of these threats. We need to create an environment in which epidemiologists can operate with the appropriate tools and skills and take advantage of the innate scientific expertise and curiosity that bring them to this profession. At the same time, everyone can benefit by asking questions about what others are doing and learning from their experiences.

The lessons of the past and the avenues for global collaboration in the future are becoming clearer. "An act of bioterrorism cannot be contained by any national border or barrier,” U.S. health secretary Dr. Donna E. Shalala has said. "When it comes to microbes, we are not protected, in the words of Indian poet Tagore, 'by narrow domestic walls.' Since these organisms recognize no boundaries, in our battle against them, neither can we. Because we share a common future, we must share a common resolve."

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Robert J. Howard is Special Assistant for Media Affairs at the U.S. Centers for Disease Control and Prevention in Atlanta, Georgia.