Recently, a package was delivered to the Hawai'i State Laboratory by the fire department's hazardous materials team. It had been picked up from a woman who called 911 because it contained white powder. Inside the package was infant formula, diapers, and a plastic bottle labeled Johnson's Baby Powder. The return address was the same as her mother-in-law's in California. She just had a baby. Despite all the signs that it was a care package, she refused to touch it. Perhaps she knew something about her mother-in-law that we didn't.

More likely, she was just scared.

This was just one of more than 400 packages and letters received by the state Department of Health's laboratory and tested for anthrax over the past few months. People have purchased gas masks, asked for antibiotics, and many called our mental health centers. They are scared. It's rare to turn on CNN for more than a few minutes without hearing a new warning about some poorly defined threat.

Fox News even linked Hawai'i's dengue outbreak to possible bioterrorism.

News anchors and their guests speak about "rogue nations," some ominous stockpile of weapons, global terrorist networks, and the funds available to fanatical or deranged individuals; and above all, allegations about the lack of preparedness in the face of what is described as looming threats of massive casualties among an essentially unprotected citizenry.

It's not all talk. Billions of dollars — some of it specified in congressional appropriations and much more hidden in military and counterintelligence budgets — have been allocated over the past few years to pay for antiterrorism programs ranging from those focused on screening immigrants and foreign students to stockpiling antibiotics and other supplies.

Despite this investment, our infrastructure is woefully inadequate to deal with a major attack.

Everyone is talking today about being prepared. But what does preparedness mean? Consider tourists visiting Hawai'i. Even in Hawai'i we may experience snow in some places — for example on the top of Haleakala, Mauna Kea or Mauna Loa. From this, one can imagine a hypothetical snowstorm. Then conduct a poll of travelers to Hawai'i to determine if any of them have packed down-filled parkas and snowshoes. From this survey, you might determine the state of preparedness for a snowstorm.

A more reasonable conclusion might be that travelers coming to Hawai'i are best prepared by leaving their parkas and snowshoes at home and bringing sunscreen.

Preparedness does not make sense without an estimate of risk.

These and other issues might be best discussed in response to a series of questions:

Warnings about "bioterrorist" attacks often cite recent instances of the use of biological or chemical agents. There are only a few over the past two decades, but they have been dramatic. In 1984, an Oregon cult contaminated salad bars with a biological agent, salmonella. Hundreds of people became ill, but there were no fatalities. Then there were two attacks using sarin gas, a chemical warfare agent, in Japan by the Aum Shinrikyo cult. One was in Matsumoto, Japan, in 1994. The cult again gassed people in a Tokyo subway in 1995. Thousands of people went to the hospital and 11 died.

By almost any standard, Aum Shinrikyo was a terrorist nightmare — a cult flush with money and technical skills led by a con-man guru with an apocalyptic vision and no qualms about killing. As it turns out, it wasn't that easy to manufacture chemical or biological weapons. Aum Shinrikyo could not even get past step one, failing to isolate for replication a lethal strain of Clostridium botulinum from more than 675 existing variants.

Although the cult attempted on numerous occasions to disseminate both anthrax and botulinum toxin, the cult's bioweapons program was a flop from start to finish.

Almost every article and book warning of unpreparedness cites these incidents, then invokes an alarming, dramatic, and entirely hypothetical scenario that it could have been much worse. Until Sept. 11, there was general agreement that the probability of a biological or chemical attack was low. Now, with at least five deaths from anthrax associated with handling contaminated mail, experts are reassessing the risks of biological attack.

The Soviet lesson

The risk is obviously real — but it is still not clear what the magnitude of the risk may be.

To address the growing threat of "germ warfare," a Biological Weapons Convention was called in 1972. Essentially, all countries agreed to cease research on the development of biological weapons except for defensive purposes and destroy their existing stocks of material. Under the guise of defense and in secret, the former Soviet Union continued to develop a greatly expanded research and production program in direct violation of the treaty. That enterprise eventually employed, conservatively, more than 10,000 people at 50 laboratories and produced large quantities of nerve gas and tons of biological agents to be used in biological or chemical warfare.

The science of biological weapons was advanced significantly in the former Soviet Union, but at a price. Included in that price were some 100 fatalities in Sverdlovsk when anthrax spores were accidentally released into the environment from a bioweapons production center. Many of the Russian scientists involved have now dispersed to other countries bearing with them expertise and, possibly, smallpox and the most virulent and infectious bio-agents they developed.

Bioweapons proliferating

Today, at least 10 countries are engaged in developing and producing biological weapons. Given this situation, one must anticipate that this technology will eventually get into the hands of terrorists.

The federal government took the risk seriously and began in earnest to prepare for terrorist attacks involving weapons of mass destruction under President Clinton. In 1995, Clinton's Decision Directive 39 triggered preparatory actions among many federal agencies. Congress enacted the Defense Against Weapons of Mass Destruction Act of 1996, requiring the development of a Domestic Preparedness Program, including efforts to improve capabilities of local emergency response agencies.

President Clinton was fascinated with the advances in biology and concerned about how they might be applied. His concern, undoubtedly arose in part from the collapse of the Soviet Union, which left tens of thousands of scientists with expertise on the manufacture of biological agents unemployed and looking for work.

I am sure he also viewed the dangers of biological weapons in the context of terrorist incidents that marked his presidency.

Clinton was a voracious reader on the subject and nothing influenced him more than "The Cobra Event," a novel by Richard Preston published in 1998. The book depicted a mad scientist's determination to thin the world's population by infecting New York City with a designer pathogen. By combining smallpox and an insect virus that destroys nerves, the scientist invented "brainpox," an ideal doomsday organism that spread quickly and melted the brain.

The book opens with a 17-year-old girl heading off to her private high school in upper Manhattan. She had a bad cold. By art class, her teeth were chattering and her nose was gushing. Disoriented, she found herself seized by convulsions and, bizarrely, biting her own mouth. She collapses, her body lashing back and forth, her face twitching uncontrollably. With classmates and a teacher standing by helplessly, she died a violent death, her spine cracking under the strain of her contracting muscles. The psychopath behind the killings also eventually fell victim to the organism he had created, a twist in the plot to make biological weapons seem less attractive to most potential terrorists (not necessarily those intent on a suicide mission).

Clinton was impressed by the book's grim narrative and apparent authenticity. More than one hundred experts — physicians, scientists, intelligence analysts, and others — had been consulted by Preston in writing the book. After reading it, Clinton began asking his friends, Cabinet members, and legislators if they had read the book. When he asked John Hamre, the deputy secretary of defense, if the scenario was plausible, Hamre had not read the book.

"But, I'll have one hundred colonels reading the book at dawn," he promised.

Two days later, he announced that the scenario was theoretically plausible.

I describe this scenario in some detail because it is accounts like this that have shaped national policy on the subject, not scientific data or detailed intelligence information.

What is the real risk?

There are dozens of agents that may be used and an incredible number of ways individuals could be exposed. Indeed, the variations are infinite and should supply ideas for novels for years to come. Nevertheless, scientists have attempted to rank the list of agents that are likely to be involved, at least qualitatively. Those agents that top the list include smallpox, anthrax, and plague.

Depending on whom you are talking to, the ranking of these substances varies but nobody can quantify the risks.

The current bestseller, "Germs: Biological Weapons and America's Secret War" (by Judith Miller, Stephen Engelberg, and William Broad), provides a detailed account of discussions that have occurred over the past decade on risks. In one account, Defense Secretary Cohen, in an attempt to quantify the risk for ABC News, held a five-pound bag of sugar over his head. He challenged his audience to imagine that the five-pound bag of sugar was actually anthrax.

The normally loquacious Sam Donaldson and political analyst Cokie Roberts were momentarily stunned into silence. If Saddam Hussein spread this amount of anthrax over a city the size of Washington, D.C., "it would destroy at least half the population of that city," said Cohen.

"One breath," he continued, "and you are likely to face death within five days." Still worse was VX, a potent nerve agent that Iraq had also developed.

If properly dispersed through aerosols, VX could kill "millions," he said.

Iraq, he said, had made four tons of VX and at least 2,100 gallons of anthrax. Hoisting his bag even higher, he repeated the number. Roberts, tired of being upstaged by a bag of sugar, interrupted to ask: "Would the secretary please put that bag of sugar down?"

Thus began the great sugar debate. Some military experts and scientists were outraged by Cohen's performance.

Yes, a five-pound bag of anthrax spores could theoretically kill half of Washington's population — or about 300,000 people — but only if atmospheric conditions for such an attack were perfect, the germs very potent and the dispersal highly efficient.

Some experts privately complained that Cohen had presented a worst-case casualty estimate to terrify Americans and, possibly, influence Congress to earmark money for combating bioterrorism.

He did — and he got the attention he felt was needed.

It would be unrealistic to expect that hospitals could adequately prepare for a terrorist attack involving anthrax and causing 30,000 deaths — much less 300,000. The reality is the trend toward managed care and other cost-cutting measures have reduced the number of vacant beds and inventory of supplies to the point where most large hospitals would struggle with taking care of 50 victims or less.

Events of Sept. 11 have changed attitudes toward emergency preparedness. Hospitals in Hawai'i are now scrambling to put together plans and obtain equipment and supplies. The Queen's Medical Center has recently begun construction of a state-of-the-art decontamination unit. In the face of ever-shrinking profit margins and losses, the challenges of maintaining an adequate supply of antibiotics with limited shelf life and sufficient staff to treat a large number of victims is enormous.

A few years ago, the U.S. Centers for Disease Control and Prevention decided to address the shortage of medication and antibiotics to treat casualties of a bioterrorism incident by establishing eight national repositories known as the National Pharmaceutical Stockpiles. The stockpile contains enough antibiotics, vaccines and medical supplies to effectively manage the initial stages of an event.

Front-line resources lacking

If we were to have an event, a "12-hour push package" would be deployed that can treat up to 6,000 victims and up to 800,000 people prophylactically. This would be followed by a "Vendor Managed Inventory," which will be shipped to Hawai'i within 48-72 hours and is "tailored" to treat the casualties after it is determined what agent is responsible. However, even with all these resources, there would be a lack of emergency ambulance services and front-line practitioners to respond to such an attack — and the system has never been fully tested.

No matter how much we would like the federal government to come to our aid, the truth is that we are critically dependent on the availability of resources at the local level, and additional resources are required locally to be truly effective.

Are the "preparedness" efforts now proposed or actually under way proportional to the hazard?

Since Sept. 11, we now know of 22 cases of anthrax (including the five individuals who died) from contaminated mail. The potential for widespread illness and death is obviously present but, even under the worst-case scenarios, would be small in comparison to the morbidity and mortality associated with preventable health conditions.

In the United States alone, there are estimated to be more than 75 million cases of food-borne illness each year resulting in more than 300,000 hospitalizations and 5,000 deaths. In addition, approximately 60,000 chemical spills, leaks and explosions result in more than 300 deaths annually. It is estimated that more than 30,000 people will die from complications from influenza this year.

It is certain that one toxic agent inhaled deep into their lungs will kill over 400,000 people this year — cigarette smoke.

In Hawai'i alone, 1,200 people die each year from tobacco-related illness. It may be of interest that, since Sept. 11, it can be estimated that more than 250 people in our state have died from exposure to cigarette smoke.

Today, our nation is practically paralyzed with fear because of five deaths from anthrax. As some would say: Go figure.

Given the limited amount of money we have to throw at any problem, we need to set priorities. Obviously, we need to set priorities in the expenditure of public funds at both the state and federal level. Funds allocated for bioterrorism are small compared to the military budgets of the United States. However, it is highly unlikely that a significant amount of money is going to be shifted from our military to public health programs.

Within public health and safety programs, we must set priorities.

Benefits of preparedness

The federal programs for preparedness will result in significant residual benefits for public health, with increases in money for infectious-disease surveillance, personnel training, information systems and equipment, and research on infectious agents. Regardless of the focus, this will allow public health agencies to more effectively deal with unintentional food-borne illness and chemical incidents and new, emerging infectious diseases, such as dengue fever.

A partnering of public health departments with military medical experts in "coordinating" preparation for bioterrorism is likely.

The Epidemiology Intelligence Service of the Centers for Disease Control was organized in the 1950s in response to our country's then-perceived vulnerability to biological warfare attack during the Cold War. Today, many modern emergency medical practices, antibiotics and vaccines have resulted from military-based research. And, the Epidemiology Intelligence Service is still training dozens of EIS Officers each year to respond to everyday outbreaks of infectious disease.

Schools of public health across the country may see a rich new source of income for the additional courses on disease surveillance and control. Schools of medicine will need to train physicians in the recognition and management of smallpox, anthrax, and other infectious diseases that heretofore were extremely rare and not a focus of their training. We will also need to train nurses, paramedics, emergency medical service staff and other health professions in how to deal with a terrorism event.

There will be opportunities for research on biological and chemical hazards for those schools that are ready, willing, and able to conduct this research.

After years of budget-cutting and neglect, most public health professionals consider this an unprecedented opportunity to, as some would put it, "grow public health infrastructure." Certainly, better communications, more training for public health personnel should have broad applicability for other, perhaps more pressing, public health issues.

But, again, choices will need to be made.

Limited expertise and facilities turned toward one set of problems can be, and is often, diverted from others. For example, a refocus on research related to anthrax, a disease that is not of any real threat to most individuals outside of its presumptive use as biological weapons, may divert resources away from identifying means of preventing and treating AIDS, hepatitis, and other diseases that affect a large segment of the population in Hawai'i and elsewhere across the country.

The road to bioterrorism preparedness is paved with good intentions, but, if we're not careful in how we allocate money, going down that road may be a significant detour from improving public health in Hawai'i and the nation as a whole.

I recall — and some of you may also remember in the 1960s — another episode of fear and a frenzy of "preparedness," the false promise of nuclear defense against the real consequences of nuclear attack during the Cuban Missile Crisis: shelters, duck-and-cover exercises at schools, and my parents stockpiling food and medicine. We were told then by federal officials that "with enough shovels," most of us would survive.

Eventually, clear-headed thinking prevailed and convincingly refuted these exaggerations. No amount of digging was going to save us from a nuclear holocaust. Certain parallels with the current debate over preparedness for biological and chemical attack are obvious.

We can anticipate that in the near future, much of our nation's energy and public health resources will be channeled to addressing real and perceived threats associated with infectious agents and chemical exposures. Yet any public health professional will agree that the country's leading causes of morbidity and mortality are heart disease, cancer and diabetes, problems primarily associated with poor diet, lack of physical activity, and smoking. We can't forget that these are the major risks if we really want to save lives.

So, are we ready?

It depends on what happens. We do have a plan to respond to small-scale incidents. We responded quickly and, in my opinion, appropriately to the Sept. 11 incident by setting up surveillance of hospitals and laboratories for unusual patterns of illnesses and in providing mental health support to those who were severely affected. However, the health care system has never been tested by a large event.

Without better quantifying the risks and knowing what we are preparing for, it is impossible to know if we are ready.

Will resources becoming available to counter the threat of bioterrorism or any other "threat of the day" hinder public health? Are they out of proportion to the seriousness of the threat? Will this focus drain resources from other public health programs? Will present funding trends and policies skew the system of health promotion and protection toward a few exotic threats rather than the sources of existing social inequalities in health?

Some say yes to all these questions.

The debate on some of these policy issues will continue. However, it is important to note that it will occur in a radically changed national political context. Thousands of people will die this year from influenza and tens of thousands more from smoking cigarettes. Poor nutrition and the lack of physical activity will cause hundreds of thousands more people to die from heart disease and cancer.

There is nothing hypothetical about these threats to public health, and they may be far more immediate and consequential than the risk of bioterrorism. With limited resources, we need to establish priorities with care and a vision toward the future.

I cannot say, of course, what the future will bring, but there is no question in my mind that the events of Sept. 11 have brought unprecedented opportunity to improve the public health system in Hawai'i.