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In the late twentieth century and the early twenty-first century, two seminal events occurred relating to the likelihood of a natural outbreak of a new deadly global pandemic with large numbers of victims on the one hand, and the possibility of a biological terrorist event with similar results on the other. The first event was an avian influenza virus that appeared in a many countries around the world and resulted in the death of much poultry. The second event was the wave of anthrax envelopes in the US shortly after the September 11 terrorist attacks. A few people were killed in this episode; most of all, it aroused panic and anxiety concerning the destructive potential in the hands of terrorists.

These two events were a turning point in the attitude of the US and other countries on preparation for and prevention and handling of epidemics – both those occurring naturally and those liable to result from deliberate hostile activity. Furthermore, it became clear that preparations for the two phenomena must be joined. Other than the cause for the outbreak of the disease, the elements in both cases are similar or even identical. Most national planning, from research and development to operational preparations, must therefore be combined and coordinated.

Avian influenza is not passed from one person to another. The rate of infection among humans was therefore very low and there were few fatalities, but the virus did cause serious economic damage in many countries. More than anything else, however, this event constituted a warning of what actions were necessary in the event of a virus that is passed quickly from one person to another, where results could be much more serious. Particularly alarming is the possibility of a mutation – a genetic change – in the avian flu virus that would make it infectious among humans. The fear was that such a virus would spread rapidly around the world and that because the global population would have no natural immunity to the new virus, it would cause serious morbidity. As a result, all the developed countries, led by the US and the World Health Organization (WHO), announced both national and global programs in preparation for a possible pandemic – a deadly worldwide epidemic of a new strain of avian influenza. The US even classified a possible pandemic as a first-level danger to national security. These programs included the preparation of laboratory detection and identification systems, programs for epidemiological tracking and monitoring, storing inventories of drugs, and preparations for development and production of a suitable vaccine.

The recent outbreak of swine influenza gave credence to the anxiety about the appearance of a new unknown strain, and proved once again that nature does not always fulfill the expectations of the experts and scientists. Despite the predictions of a new and deadly strain of avian influenza, what actually appeared was a new strain originating in swine influenza. This virus usually causes infection only among pigs. It appears that the genetic content of the virus has changed, and now includes segments of human influenza. It is therefore capable of infecting humans and moving from one person to another through the respiratory passages. Yet as a result of the many years of enhanced preparation for a pandemic originating in avian influenza, ready shelf plans, guidelines, and procedures already existed in most developed countries and at the global level. All that had to be done was to update these preparations and put them into operation, together with prepared and well-drilled medical set-ups and inventories of drugs for a large portion of the population.

The extent and force of the epidemic are still unclear, and anxiety about more severe second and third waves exists (as occurred with the Spanish influenza in 1918-20). At this stage, however, it appears that outside of the country of origin (Mexico), where the mortality rate is significant, the disease is equivalent to the familiar seasonal influenza, being neither serious nor fatal.

The fact that a severe infectious event is very hard to control reduces the risk that a properly run country will use it as a means of biological warfare. Extremist terrorist organizations, however, would likely not stop short of adopting such measures as a kind of doomsday weapon. It is easy to see that if an extremist terrorist organization gets its hands on a classic pandemic virus such as smallpox, for example, and spreads it deliberately in a small area, a high mortality rate would result.

The rapid development of the methods of molecular biology and innovative DNA technologies have already made it possible to produce deadly disease elements in a laboratory from simple and readily available building blocks. For example, strains of polio, which cause infantile paralysis, and the Spanish influenza virus, which killed tens of millions of people around the world in 1918-20, have recently been produced in a laboratory. There is no doubt that the smallpox virus can also be produced in a laboratory using well-known and available technologies.

A country that confronts the outbreak of a disease well and is properly prepared to provide a solution for diseases and viruses caused naturally by disease generators, such as microbes and viruses, will also be ready to deal with a case of deliberate biological attack. The comprehensive national and global responses should rest on the following principal elements: detection and identification of the type of element in a laboratory, epidemiological tracking and monitoring of the spread of the disease, control of the transit and movement of people, vaccination and treatment with medication, and hospitalization.

The current instance of swine influenza, although it has thus far proved to be relatively mild, constitutes an excellent live drill at both the global level (led by the WHO) and the national level for evaluating procedures, training, exercises, drawing conclusions, and learning lessons about preparation for and handling more severe and deadlier epidemics, whether natural or caused by terrorist elements. So far – though this judgment may be premature – it seems that the level of readiness and the measures taken at the global level and in most countries were appropriate, although it is possible that there was a slight tendency towards excessive caution, perhaps due to certain failures in handling previous events such as avian influenza and SARS, and in view of the lesson learned from much previous epidemics, such as Spanish influenza. There is no doubt that the high degree of global awareness and preparation, due to concern about a pandemic caused by a deadly strain of avian influenza, was responsible for these results. The same can be said about Israel’s preparations and handling of the event, led by the Ministry of Health. The current case has also proved that where infectious diseases are concerned, especially trans-border epidemics, international cooperation, both at times of calm, and certainly when events occur, is very important.

Although the likelihood of an epidemic or pandemic, whether natural or deliberately caused, is usually not great, a significant biological event is liable to have destructive effects with far-reaching consequences in injury to the population and at the socioeconomic level. The potential damage to security and national resilience is enormous, and therefore this is the parameter for judging the rate of readiness and the extent of resources that the state must invest in meeting this challenge.