Questions Linger / Unknown dominates probe a year after deadly anthrax mailings

First of two parts

It came into the building in a letter. Somewhere along the way, Ernesto

Blanco, an American Media company mail room clerk, handled it. The letter was

opened near a stack of reams of paper for the 68,000-square-foot building's

copy machines. Eventually, photo editor Robert Stevens held the envelope,

unwittingly sprinkling its contents onto his computer keyboard.

It spread all over the three-story Boca Raton, Fla., office building as

those reams of paper were inserted into copy machines that shuffled the pages

about. Or so the Federal Bureau of Investigation would conclude a year later.

It was there, but nobody could have imagined its presence at the time. And

nobody would, until Stevens was taking his final breaths and Blanco was lying

in an intensive care unit, fighting for his life.

Anthrax.

On Oct. 4, 2001, the world learned that Stevens was dying of acute

inhalational anthrax disease, and with his death the following day a chain of

events unfolded that would permanently imprint the word "bioterrorism" into the

consciousness of Americans. It would shake up the country's public health

system as nothing ever had. And it would test the resolves of thousands of

health workers, the largest group of whom would be scouring the nation's

capital and New York City in search of clues and answers.

A year later, those dogged disease detectives have scaled many obstacles,

but still face a long list of unsolved mysteries. How two of the five anthrax

victims - including Bronx resident Kathy Nguyen - contracted the disease

remains unknown. The FBI still is searching for the culprit or group

responsible for the deadly mailings.

And officials at the federal and local levels still are struggling to

reshape America's public health system, trying to mend the enormous holes in

the nation's safety net that were revealed last fall. What became clear in the

past year is the extent to which the public health system was overwhelmed by

just seven known anthrax-laced envelopes.

On Oct. 2, 2001, Stevens, 63, was admitted to a West Palm Beach, Fla.,

hospital. He was in a terrible state. The American Media photo editor had been

on a fishing vacation with his wife, traveling about the South, when he came

down with what he thought was the flu, in North Carolina. That was five days

earlier, during which time his condition had worsened considerably. By Oct. 2,

Stevens was nauseated and making little sense. He had no idea where he was,

what year it was, or who was the president of the United States. Blood tests

revealed a war was under way, with millions of white blood cells doing battle

with some unknown invader.

While the nearby Jacksonville, Fla., public health laboratory tried to

identify that mysterious invader in Stevens' blood, the hospital put him on

massive doses of antibiotics. But the anthrax bacteria had long since made

their way into Stevens' spinal cord and brain, triggering meningitis. As he lay

in intensive care, the bacteria released three powerful toxins into his blood.

It would be months before scientists, spurred by the urgency of the anthrax

crisis, would study how these toxins kill. One way, they learned, was by

disabling Stevens' immune system, allowing the other two to wreak havoc inside

cells all over Stevens' body.

Months later, scientists and clinicians would realize that giving

antibiotics to patients as far gone as Stevens only worsens matters, as the

drugs kill some anthrax bacteria, which break open, releasing their deadly

toxins. The sudden toxic surge flooded Stevens' brain, causing a grand mal

epileptic seizure. Were it not for a machine that pumped oxygen into his

airways, Stevens would have died immediately.

By Oct. 3, the toxins began killing cells in Stevens' heart. He suffered a

heart attack and then went into a coma. He never regained consciousness.

Months earlier, the federal Centers for Disease Control and Prevention in

Atlanta had begun a poorly funded effort to upgrade the nation's public health

laboratories in hopes of improving local capacity to diagnose rare infections,

such as anthrax. A tiny cadre within the CDC, the Army and a handful of other

institutions had long feared the potential use of biological weapons and was

appalled to learn that most American health labs couldn't run reliable tests

for a long list of likely germ weapons.

The gold standard for such lab work was set by CDC lab chiefs Richard Meyer

and Tanja Popovic, who had trained several dozen local laboratory staffers

before the Sept. 11 terrorist attacks. Yet nationwide, fewer than 100 health

laboratories - out of thousands - had completed laboratory response network

training and equipment upgrades, Meyer said.

Fortunately, one such trainee was Phillip Lee of Jacksonville, the man who

grew anthrax from Robert Stevens' blood samples. Lee used the special stains

and fluids Popovic had taught him would reveal the presence of anthrax in a

fluid sample.

Peering through a microscope at a thousand-fold magnification, he saw

Stevens' cerebrospinal fluid swarming with long thin rods, stained a deep

purple, and lined up end to end to form chains - classic attributes of anthrax

bacilli. When he called Popovic on Oct. 3 to tell her what he found, the CDC

scientist knew the result was solid - America had anthrax on its hands.

The world's top DNA-PCR (DNA fingerprinting) lab and anthrax diagnostics

facility is a two-tiered facility at the CDC. Meyer ran the first tier - a

section that conducted the primary screenings of samples, processing them both

for anthrax DNA and as legally certified criminal evidence.

In a higher-security building, Popovic directed the lab that confirmed

infection by growing living anthrax bacilli from a sample. Fortunately,

Popovic's lab was housed in a brand-new building, completed just weeks before

Sept. 11. A few months before, the dangerous work would have been performed in

a World War II-era facility in which contamination could not have been easily

prevented. By the time she received the fateful call from Jacksonville, Popovic

and her tiny staff were working in a state-of-the-art facility, housed under

security so strict that its innermost core could be entered only by a handful

of people.

Meyer's DNA analysis could give a tentative answer within an hour or two,

but Popovic's confirmation couldn't come any faster than the rate at which

anthrax grows - at least seven hours.

Back in Florida on Oct. 3, Lee's anthrax diagnosis was more a matter of

puzzlement than anything else. Nobody then could anticipate the national chain

of events that would unfold shortly. Lee didn't know that another patient -

mail clerk Blanco - also was suffering from anthrax, or that the Florida cases

were part of a bioterrorism event that had already led to skin infections in

New York newsrooms - infections that wouldn't be properly diagnosed for several

more days.

On Thursday night, Oct. 4, the CDC's chief of meningitis and special

pathogens, Dr. Brad Perkins, had just nestled in for his daughter's piano

recital when his cell phone rang. The CDC caller told Perkins that a Florida

man was hospitalized with inhalational anthrax. Fourteen hours later, Perkins

was in Florida leading a CDC investigation to determine how Stevens got

infected with a remarkably rare microbe. His first stop was the hospital where

Stevens remained unconscious and was running a fever of 104 degrees.

"He was intubated, critically ill, unable to speak," Perkins recalled. "But

I did not expect him to die that day. And actually the family was very hopeful

that he was going to survive."

In Washington, Health and Human Services Secretary Tommy Thompson

officially had announced the ailing Stevens' anthrax case to a nation whose

nerves were still very much on edge from the Sept. 11 attacks. He said of

Stevens' infection that it "appears that this is just an isolated case" and

"there's no evidence of terrorism."

Proceeding on a scientific mission, Perkins took his team to the American

Media building, where Stevens had worked for The Sun supermarket tabloid. As

they met with editors who knew Stevens, the phone rang. It was the hospital,

informing American Media that the photo editor had just died of anthrax

poisoning.

"That was a fairly dramatic moment because we were sitting in a room with

people who had known him," Perkins said. "This was a universally loved guy.

Everyone was just in utter disbelief."

Stevens' Oct. 5 death brought grim urgency to a CDC investigation that

spanned four states through which he had recently traveled. And it brought the

world's media, numerous state and federal agencies and the White House into the

picture.

Thompson once again faced the media, saying the anthrax case was probably

of natural origin, based on something Stevens picked up from drinking from a

South Carolina stream. Anthrax is not a water-borne organism, however, and the

secretary's comment would haunt his department, undermining its credibility for

months.

Thompson, a former governor with no scientific or medical training, issued

orders that all information to the public and media come from his office,

barring government scientists and health experts from providing expert advice

or information.

In Florida, meanwhile, Perkins' job was to stay focused on leading a solid,

scientific investigation. He and his small staff meticulously scoured Stevens'

home and office, as well as the American Media mail room, swabbing for anthrax

spores.

In Atlanta, the CDC was eager to have autopsy results on Stevens, but

nobody in Florida wanted to perform the procedure. Pathologist Sherif Zaki, the

CDC's top medical examiner, flew to West Palm Beach on Saturday, Oct. 6, and

headed straight for the morgue. He found the staff of the medical examiner's

office understandably frightened, Zaki said, but willing to assist once he had

explained safety procedures.

When they opened Stevens' chest, Zaki recalled, the team found "evidence of

anthrax in literally every organ we touched," especially the man's

disease-fighting lymph nodes. Those were so saturated with the toxins that they

actually disintegrated as Zaki's probes touched them.

The next day, Perkins got word from the CDC's anthrax laboratory that swabs

collected from Stevens' computer keyboard and the mail room tested positive

for Bacillus anthracis. That finding triggered the FBI's criminal

investigation. He also got CDC laboratory confirmation that there was a second

case of the disease - in someone who worked in the same building as Stevens -

and learned about Ernesto Blanco, fighting for his life in another hospital.

At that point, Perkins said, he decided to place thousands of American

Media employees and recent visitors on ciprofloxacin antibiotics as a

precaution. In coming days television footage of long lines of anxious

Floridians queued up to get nasal swabs and pills would spark public anxiety

and a demand for antibiotics. Within two weeks the nation's entire supply of

ciprofloxacin would be sold out, with none available for treatment of genuine,

and often serious, ailments for which it is normally used, such as children's

ear infections.

In Atlanta, the CDC was deluged with calls asking who should be given

antibiotics. In what doses? What are the symptoms of anthrax? Is the powder in

my Alaska office a hoax or the real thing? The agency was in danger of being

overwhelmed. And because of the directives from Thompson, most of the queries

had to go unanswered.

"We needed information," John Auerbach, executive director of the Boston

Board of Health, said recently. "Every kind of government report that we needed

was delayed. We were getting information from journalists, for God's sake, not

the CDC. There simply wasn't a good, accurate, timely internal communication

system."

"We made a decision at CDC that the people who needed information in order

to effectively respond should be our priority," Dr. Julie Gerberding recalled.

Last fall she was the deputy director of the CDC's National Center for

Infectious Diseases. Ten months later, her boss, Dr. Jeffrey Koplan, would be

forced to resign and Gerberding would be named CDC director. Few could get

information from the CDC for days, Gerberding would later concede, not even

America's physicians, most municipal health directors or even members of

Congress.

With the exception of New York City, where then-Mayor Rudolph Giuliani

personally handled all public announcements related to terrorism, the nation's

public health messengers were late in communicating. Public health officials

learned that their communications systems - computers, phones, faxes, video

systems - were woefully out of date. Their ranks of skilled speakers and

information officers were thin, and their ability to control panic minimal. A

year later, the CDC has built the Health Alert Network, reaching every public

health department, no matter how small or remote, in America. But that was a

mere skeleton last October.

"As events wore on, it became clear the CDC needed to be the primary source

of scientific information," Gerberding said in an interview months later. "But

once it was obvious to all that we needed to take the lead, we were in a

reactive mode. And we are still catching up."

Within hours of the collapse of the World Trade Center, Dr. Kevin Yeskey,

director of the CDC's Bioterrorism Response Program, had issued an alert to

health departments nationwide "calling for enhanced surveillance, meaning,

'Please be vigilant for anything that might be suggestive of a bioterrorism

event,'" Yeskey said. As word of the Florida case spread, health providers and

public health officials all over America started remembering that alert, and

anxiously sought information from Atlanta.

"I said, 'Let's set up an Ops [Operations] Center here,'" Yeskey recalled.

He sat down with a sheet of paper and drew a pyramid, with CDC director Koplan

at the top and Infectious Diseases Director Dr. James Hughes and Gerberding

just below. He drew a military-style chain-of-command map that connected Koplan

to the field investigators then dispersed over the states tracing Stevens'

movements and suspected additional anthrax cases.

Yeskey, a former military officer, marched into Gerberding's office, his

chart in hand, and said, "We need a Special Ops Center. This is what it would

look like. Field A responds to command leader A here in Atlanta, and Field B

... "

Gerberding stared at the piece of paper and thought it was a crazy idea.

Slightly amused, she listened as Yeskey spun a web of desks and phones and

chains of command. But under prior bioterrorism preparedness guidelines, she

knew some sort of operational center was necessary, so she gave Yeskey the

green light to implement what, in the back of her mind, remained a whacky

concept.

Within 24 hours, Yeskey's team had transformed the CDC's auditorium into a

command center, with portable walls erected according to the chart he had

mapped out. In each space were CDC officers, drawn from their normal duties to

handle emergency coordination. One desk was Florida. One desk soon would be New

York City. As events unfolded, Washington, D.C., and other hot spots around

the country got desks, staffed 24 hours a day by high-ranking CDC scientists

whose job was to coordinate all the information and logistics in a given field

location.

At another desk was a medical team that did nothing but answer questions

from physicians. If doctors called in with suspected anthrax cases, that team

had a list of questions and symptoms to walk the person through, aimed at

winnowing out cases that obviously were not anthrax.

By mid-October, the Ops Center was a noisy beehive, coordinating activities

all over the world - indeed, a global liaison desk was added. Never in the

history of the CDC had such a system been used. Of course, Hughes said, "Never

in the history of the CDC have we dealt on so many fronts at the same time,"

even during serious epidemics.

A year later, the CDC is building a multimillion-dollar Special Ops center

in Atlanta, and encouraging local health departments all across America to

erect mini-versions of such communications and command centers. Looking back on

October 2001, health officials shake their heads in wonder that Yeskey's

primitive pyramid had somehow gotten them through the chaos of the anthrax

crisis.

TUESDAY, in Discovery:

A New York Diagnosis

Deadly Sequence

Sept. 18, 2001: Two letters, later found to contain anthrax spores, are

postmarked at the main post office outside Trenton in Hamilton Township, N.J.

Postal inspectors later said the letters could have started at any of 46 mail

facilities before reaching the main post office.

Sept. 19 or 20: One of the letters, addressed to Tom Brokaw, arrives at NBC

News in Manhattan. Employee opens it, finds brown granular substance

inside, and dumps much of it into the garbage.

Oct. 2: Bob Stevens, 63, a photo editor at The Sun, a supermarket tabloid owned

by American Media Inc., enters Florida hospital critically ill, vomiting and

delirious.

Oct. 4: Stevens diagnosed with the inhalation form of anthrax. Lab tests find

bacteria in blood and spinal fluid. CDC lab, using DNA test, confirms bacteria

identity.

Oct. 5: Stevens dies.

Oct. 6-7: Anthrax spores found on Stevens' computer keyboard at Sun office.

Ernesto Blanco, 73, mailroom clerk at American Media, enters hospital for

treatment of pneumonia.

Oct. 12: Authorities in New York announce an NBC News employee contracted the

skin form of anthrax. It was believed to be the first confirmed case of anthrax

in the city's history.

Oct. 13: Letter opened by NBC employee Sept. 19 or 20 tests positive for

anthrax.

Oct. 15: Tests confirm Blanco has the inhaled form of anthrax. Second letter

bearing Trenton postmark opened by employee of Senate Majority Leader Tom

Daschle; letter, containing white powdery substance, tests positive for anthrax

in initial field tests and more sophisticated tests at Fort Detrick, Md. FBI

says letter delivered to American Media likely was incinerated with rest of

company's trash before investigation began.

Oct. 21: An employee at the Brentwood postal center in Washington, D.C., dies

hours after

Oct. 31: Two days after being diagnosed with inhalation anthrax, Kathy Nguyen,

a Manhattan hospital worker, dies.

Nov. 17: Anthrax-laced letter addressed to Sen. Patrick Leahy (D-Vt.) is

discovered in barrels of quarantined mail from the U.S. Capitol.

Nov. 21: Ottilie Lundgren, of Connecticut, dies of inhalation anthrax.

Dec. 6: Government scientists open the Leahy letter. It appears to have been

sent by the same person who mailed the letter to Daschle.

June 25, 2002: Dr. Steven Hatfill, 48, a former employee of an Army research

institute in Fort Detrick, Md., allows the FBI to search his Maryland

apartment. FBI says Hatfill is on a short list of "persons of interest'' in the

anthrax case, but not a suspect.

July: Hatfill is hired by the National Center for Biomedical Research and

Training at Louisiana State University.

Aug. 11: After more searches of his property, Hatfill and his attorney hold a

news conference in Alexandria, Va., professing Hatfill's innocence and saying

he is a "fall guy'' for the FBI's inability to solve the nearly year-old case.

Sept. 3: Hatfill is fired after the university receives an e-mail message from

the Justice Department directing it to "cease and desist'' from using Hatfill

on "all Department of Justice-funded programs.''