Carnegie Reporter, Vol. 1, No. 4 | Preventing “Dark Winter”— The Public Health System’s Role in Strengthening National Security, page 3 (low bandwidth)

Dr. Akhter's prediction that it would take a week or so before anyone recognized a biowarfare epidemic proved all too true in several recent war games exercises, among them Operation TopOff and Dark Winter, which involved experienced physicians, public health experts and government officials.

Operation TopOff, in May 2000, included top officials of the government (hence the name). Aspects of the exercise were staged with real people simulating plague symptoms. Other parts were calculated on paper, such as shipments of medications and equipment.

In the Operation TopOff scenario, airborne release of plague at the Denver Performing Arts Center was not detected until three days later when people began seeking medical care and some were dying. The state public health laboratory and the CDC quickly confirmed plague, probably much faster than would happen in the real world. Hospitals called in extra staff, who began wearing masks. Already there were shortages of ventilators and antibiotics and by the end of the first day, 783 cases of plague had been confirmed and 123 people had died. Travel in and out of the Denver metropolitan area was restricted. The public was told about the outbreak: Seek care if you feel ill, but otherwise stay home.

By the end of the second day, hospitals were running out of antibiotics and ventilators. Emergency supplies were flown in, but there were difficulties moving supplies from the airport to the hospitals that needed them. At day's end, 1,800 cases of plague had been reported in other states, England, and Japan and 389 had died.

By day three, medical care in Denver was shutting down and the CDC advised closing Colorado's borders, while Colorado officials worried about getting food and medical supplies into the state. Operation TopOff ended on day four, with an estimated 3,700 cases of plague and 950 deaths, but without an end to the epidemic.

Dark Winter was a war games exercise carried out in June 2001. Former senior government officials, journalists and experts in the field played familiar roles in mock meetings of the National Security Council. While a Middle East crisis developed involving a rogue state that might have bioterror weapons, 20 confirmed cases of smallpox showed up in Oklahoma and there were suspected cases in two other states.

A week later, there were 2,000 cases in 15 states and isolated cases in Canada, Mexico and the U.K. Vaccine supplies were running low, the healthcare system was overwhelmed, and there was social unrest. International and some state borders were closed. There was sporadic violence against minorities of Arab descent. Officials had to make hard decisions: How could the government meet homeland security needs and contain the disease while maintaining international commitments? What about quarantine, travel restriction, civil rights infringements? Who should be vaccinated, given limited supplies?

By the third week, there were 16,000 cases in 25 states with 1,000 deaths and cases in ten other countries. It was predicted that smallpox would infect as many as 300,000 victims and kill one-third of them. No new vaccine supplies would be available for a month and the national economy was suffering from food shortages and restriction of travel.

The exercise stopped there. Obviously, the epidemic would not have. Former Senator Sam Nunn, who is currently the co-chairman of the Nuclear Threat Initiative and a member of the board of trustees of Carnegie Corporation of New York-and who also played the role of the U.S. president in the Dark Winter exercise-later gave testimony about the experience to a congressional committee. "Our lack of preparedness," he told the representatives, "is a real emergency." He added, "It is not necessary to overstate the threat to make the point that it is real [and] it is dangerous."

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