Hospital Management of Blast Event Casualties: We Aren’t Prepared

By Maddie Roty, Biodefense MS Student

At the end of January 2021, I attended a virtual session of the Hospital Management of Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) Incidents course offered by United States Army Medical Research Institute of Chemical Defense (USAMRICD), the United States Army Medical Research Institute of Infectious Disease (USAMRIID), and the Armed Forces Radiobiology Research Institute (AFRRI). This five-day course expanded on the Medical Management of Chemical and Biological Casualties Course, which I attended in October 2020, to include a wider array of casualties from weapons of mass destruction (WMD). This course was also of greater relevance to me as a registered nurse because it focused not on military field management, but also on civilian hospital preparedness for managing mass casualties. The course consisted of a series of lectures regarding incident command, assessment, triage, and treatment of WMD casualties. Each day focused on a different threat, with the final day featuring a tabletop exercise to apply our new knowledge. The chemical and biological sessions were largely a review from MCBC and covered material I was already familiar with through my coursework as a master’s student in the Biodefense program at the Schar School of Policy and Government, so while the review was appreciated, the most captivating sessions for me were about conventional bombings and blast effects.

Blast events, meaning explosions caused by bombs, are a surprisingly common occurrence in the United States. In 2019 alone, there were 715 explosion events, including 251 bombings, not including failed or foiled incidents. It was unnerving to learn that a survey of seven U.S. cities conducted after the 2004 Madrid train bombings, which caused 191 deaths and 1,800 injuries, found that none of these cities had the capacity to respond to a mass casualty event of this magnitude. As we progressed through the lectures, gaps in preparedness for treatment of casualties from an explosive event became obvious to me compared to what I had learned in nursing school.

A blast creates three blast zones – the epicenter, the secondary perimeter, and the periphery. These zones are important for hospital management because different injuries can be anticipated depending on which zone the patient was in at the time of the event. There are the expected trauma injuries that are obvious to even an untrained eye. Of particular interest for me were primary blast injuries, which are caused by blast waves and affect air and fluid-filled organs such as the lungs, ears, and parts of the gastrointestinal tract. These types of injuries are internal and can have a delayed onset or non-obvious symptoms. I did not learn about these types of injuries in nursing school. We also did not learn that ruptured eardrums (tympanic membrane ruptures) and bruising in the pharynx (pharyngeal petechiae) are associated with greater morbidity in bomb victims or that we should assess for blocked blood vessels (air embolisms) or collapsed lungs (pneumothoraces), even in the absence of symptoms, as these are common consequences of blast waves.

I thought this knowledge gap might be remedied during on-the-job training, so I contacted a friend who works in an emergency department as a nurse. She told me they did not receive specific training for blast events, but they were taught to assess for trauma in mass casualty events. It was stressed repeatedly during this course that blast events are not like other mass casualty events, as they may or may not result in obvious signs of trauma. I would anticipate that if a significant blast event occurred in the United States, many critically ill patients would not receive timely or appropriate care simply due to lack of knowledge about the effects of these events.

I am very grateful to have had the opportunity to receive this education from some of the world’s leading experts in the field. The COVID-19 pandemic has, hopefully, elucidated the necessity of hospital preparedness, even for CBRNE events that seem unlikely but could happen anywhere at any time. Increasing training, education, planning, collaboration, and funding for management of casualties caused by bombings and other blast events should be a priority for health care systems. This is not just a health issue; it is a matter of national security. 

Understanding the Challenges of Hospital Preparedness for CBRNE Incidents

By Marisa Tuszl, Biodefense MS Student

My interest in how well prepared hospitals are to respond to a chemical, biological, radiological, nuclear, or explosive (CBRNE) attack was sparked last fall after I took two different, but equally fascinating courses, on the topic. In October, I attended the US Army’s Medical Management of Chemical and Biological Casualties (MCBC) course and during the fall semester I took a course on building healthcare system resilience with Dr. Saskia Popescu who teaches in the Biodefense program at the Schar School of Policy and Government at George Mason University. While the Army course focused on the threats posed by chemical and biological weapons and managing military casualties in the field caused by these weapons, Dr. Popescu’s course focused on the readiness of civilian hospitals to respond to a range of hazards. My curiosity about the intersection of CBRN weapons and hospital preparedness led me to take Hospital Management of Chemical, Biological, Radiological, Nuclear, or Explosive (HM-CBRNE) Incidents course offered by the United States Army Medical Research Institute of Chemical Defense (USAMRICD) and United States Army Medical Research Institute of Infectious Diseases (USAMRIID). The week-long, virtual HM-CBRNE course presented an opportunity to improve my understanding of how hospitals can manage these types of incidents, the Federal programs and protocols that are in place to provide assistance, and the most common challenges confronting hospital preparedness.

The first day of the course provided a foundation regarding the Federal guidelines for responding to a CBRN incident, such as the National Response Framework (NRF) and National Incident Management System (NIMS), and the response systems in place within healthcare facilities, such as the Hospital Incident Command System (HICS). The subsequent days were focused on the different types of CBRNE threats covered by the course, how the nature of these different threats affected planning, decontamination, triage, and response efforts, and the overall role of the different incident command and management systems in planning and response. Altogether, the buildup of information was designed to prepare us for a capstone exercise at the end of the week in which we utilized a traditional HICS to handle an unknown event in real-time.

The capstone exercise was my favorite part of this course because everyone in our group held a specific role in the HICS organizational chart and we had to work together to triage incoming patients to determine whether they were routine patients, required emergency care, or were victims of the incident and required special medical attention. In addition, the proctors threw curveballs at us during the exercise which required each team to work together to come up with solutions to these new problems. In my role as the Situation Unit Leader, I had to keep track of the patients and available beds in the emergency department to ensure a smooth distribution of patients throughout the hospital and mitigate any surge capacities, if possible, during the incident. Though this was a virtual exercise, it revealed several real issues that hospitals can face as they attempt to handle an unknown public health emergency, such as communicating with other hospitals to ensure that each has adequate resources, making sure that memorandums of understanding (MOUs) are in place before an incident, having a location for families to be directed to avoid confusion and traffic at the hospital, having capabilities to decontaminate patients, and turning over beds in an efficient manner to prevent overfilled emergency departments. The capstone exercise displayed how important it is for localities to have emergency planning committees and perform hazard vulnerability analyses to determine what threats are the most probable for them. The after-action session also allowed the two teams that participated in the capstone exercise to discuss the similarities and differences in their planning and response techniques to the same event. Thus, we were able to learn how others handled the event and gained insight into additional complicating factors such as the possibility of multiple threats or emergencies occurring concurrently and the difficulties in utilizing volunteers and external partners during a major incident.

All in all, the HM-CBRNE program supplied me with an invaluable educational experience for learning about the “ins-and-outs” of hospital emergency management. This course was beneficial in providing myself and the other participants with the tools to identify potential CBRNE incidents and the protocols to respond accordingly. As with the MCBC course, USAMRIID and USAMRICD did a great job in utilizing a virtual platform to provide practical information on hospital preparedness to an array of participants.

The Challenge of Triage for CBRNE and Mass Casualty Incidents

By Deborah W Cohen, Biodefense Graduate Certificate Program

Imagine you have travelled across the country to attend a professional conference. While attending a presentation, the session is suddenly interrupted by news that other attendees are falling ill from a chlorine leak at the conference center’s pool. There are sounds of sirens and chaos outside. The presenter asks everyone to stay calm. They resume their presentation, but about an hour later a handful of individuals in the room begin to fall ill. As you being to wonder if this is connected to the incident outside at the pool, you suddenly become incapacitated and fall off your chair. The last thing you see is first responders wearing hazmat gear entering the room. 

This was the initial stage of the scenario for the Tabletop Capstone Exercise on the last day of the U.S. Army’s Hospital Management (HM) – Chemical, Biological, Radiological, Nuclear, and Explosives (CBRNE) Incidents training course held in late January 2021. I was assigned to the RED HOSPITAL response team which was comprised of military and civilian members. As the scenario unfolded, we organized a response utilizing the doctrine, tools, and planning concepts of the Hospital Incident Management System (HIMS) taught during the first four days of the course. 

Many kinds of emergency incidents happen in our communities. The scenario to which we responded could have been caused by a “conventional” emergency or a terrorist attack involving a chemical agent and a biological agent. The nature of the attack would be determined through an investigation using evidence collected during and after the response. The disaster response, however, must start immediately and be premised on the National Incident Management System (NIMS) guided by the National Response Framework (NRF). The NRF is the national emergency management doctrine formulated by the Office of the Assistant Secretary of Preparedness and Response (ASPR) in the Department of Health and Human Services. The NIMS provides federal support to state and local incident managers and is designed to be scalable, flexible, and adaptable to all types of incidents. 

This emergency management system was put in place by Homeland Security Presidential Directive 5 in 2003 which sought to “enhance the ability of the United States to manage domestic incidents by establishing a single, comprehensive national incident management system.” The guiding principles of the NIMS are the template for local Incident Command Systems (ICS). By way of background on nomenclature, Incident Management Systems (IMS) are more comprehensive in scope than Incident Command Systems (ICS).  IMS also deal with the longer term direct and indirect effects of an event in a community. ICS can be thought of as aa component of IMS dealing more narrowly with specific urgent actions of getting an incident under control.  However, ICS and IMS are designed to be compatible with each other. The ICS operates on the principle of “unity of effort” which provides the multiple organizations responding to an incident a way to coordinate and focus their efforts efficiently by setting aside overlaps and competition across authorities and jurisdictions.Local hospitals are required to prepare for and respond to disasters using the Hospital Incident Command System (HICS) in compliance with NIMS. One of the ways that HICS improves emergency planning, response and recovery is by clearly designating who is responsible for different roles across the response command organization such as incident command, security, medical technology, personnel, finance, supply, logistics, public information, liaison services, and transport.  Since compliance with NIMS is a condition for any healthcare facility to receive Federal assistance, the adoption of ICS by first responders and HICS by healthcare organizations enables government and non-government entities to respond cooperatively to an incident.

The week of training provided by the HM-CBRNE course covered the properties of each of the CBRNE threats and their respective hospital management protocols. These threat-response relationships were further illustrated by incident scenarios. In these scenarios, triage was, for me, the main component that best characterized the realities of emergencies.  In contrast to the Medical Management of Chemical and Biological Casualties (MCBC) Course that I attended last year, which focused on battlefield triage, this course also included lessons on triage in a  civilian community setting.

We learned about three types of triage systems that hospitals use for trauma casualties that are not specifically designed for CBRNE incidents: (1) field triage conducted at the scene of an incident to match available resources with patients; (2) inter-hospital sorting for the transfer of more seriously injured patients to higher level care facilities; and (3) mass-casualty sorting and prioritizing during a disaster. There is also a reverse triage system to sort hospital patients for discharge. These triage systems support the creation and utilization of surge capacity by hospitals to deal with mass casualty incidents, which resonates today with the challenges posed by the COVID-19 pandemic.  Triage of casualties caused by a CBRNE incident can be complicated by the unique effects of these weapons as well as by pre-existing conditions among patients and the impact of psychological trauma. 

The U.S. Army uses three types of “sorting” systems for triage: medical treatment, decontamination, and evacuation. For medical treatment, there are four categories of triage: Immediate, Delayed, Minimal, and Expectant (IDME). In medical triage, Immediate cases require intervention within a few minutes using the ABCDDs: Airway, Breathing, Circulation, Decontamination, and Drugs. In CBRNE events, immediate intervention can also use the (MARs)2 system:  Mask, attention to issues of Massive hemorrhage, Airway, Antidotes,Respirations, and Rapid removal of contaminants. Delayed cases can tolerate a short postponement of medical attention. Minimal patients are those with minor, stable, or resolving injuries that can tolerate a longer delay in treatment.  Expectant patients will not survive without the use of scarce resources that could otherwise be used for possible survivors.  For a civilian community setting, triage of CBRNE casualties will be handled differently.  Four different triage systems for CBRNE casualties, each with their own advantages and limitations, have been developed: (1) Rapid Assessment of Mentation and Pulse (RAMP); (2) Sort Assess Life-saving Treatments Treatment and/or Transport (SALT); (3) Simple Triage and Rapid Treatment (SMART); and (4) Simple Triage and Rapid Treatment (START).

A second triage system developed by the military is for decontamination and it depends on the type of agent and exposure involved. It is typically conducted concurrent with medical triage. For decontamination, the sorting categories are Immediate, Operational, and Thorough. The Assistant Secretary for Preparedness and Response (ASPR) and its partners have developed a protocol for decontamination triage based on a tool called the Primary Response Incident Scene Management (PRISM).

The third triage system is for evacuation which includes Urgent, Priority, and Routine (UPR) sorting categories.  Triage for evacuation is based on the determinations of medical triage and time factors. Patients who can be matched with available treatment and are most likely to survive and recover will be evacuated. Patients in the Urgent category are those who need treatment within two hours. Priority triage is for those who need treatment within four hours. Routine triage patients can wait for up to 24 hours for treatment. The Routine group of evacuees will also include terminal patients.

Col. (ret.) James M. Madsen, MD, the Army presenter, explained that while all triage methods are based on on-the-scene determinations of urgency, survivability, and resource availability, mass-casualty and CBRNE triage is different from other kinds of triage in several ways. For triage of victims of a CBRNE incident, the speed of operation is even more critical, personal protective equipment (PPE) is always needed due to the risk of contamination, verbal communication is difficult, hands-on exams may not be possible, and first responders are sorting simultaneously for medical treatment, decontamination, and evacuation. CBRNE triage schemes are very challenging as they must quickly account for the clinical implications of the specific CBRNE agent to which the victims have been exposed. For instance, the length of the latent period before symptoms manifest, the risk of secondary contamination, and the existence of specific antidotes varies among different chemical warfare agents. The most important message about triage for mass casualties and CBRNE incidents is that while there are many methods under development, there is no consensus about the best option to employ in every case. It was sobering to learn that current triage methods are not adequate for the complex situations, conditions, and circumstances that characterize the evolving landscape of CBRNE and terrorism events.

Intersection of Mental Health and Hospital Management for CBRNE Incident Response

By Sally Huang, Biodefense PhD Student

In January 2021, I attended the Hospital Management—Chemical, Biological, Radiological, Nuclear, Explosives (HM-CBRNE) course organized by the United States Army Medical Research Institute of Chemical Defense (USAMRICD), the United States Army Medical Research Institute of Infectious Diseases (USAMRIID), and Armed Forces Radiobiology Research Institute (AFRRI). Seeing how the COVID-19 pandemic has overwhelmed hospitals nationwide, I was interested in learning how healthcare workers and first responders respond to CBRNE scenarios. With the Army offering the course virtually to substitute for what would normally be an in-person course, the HM-CBRNE course was a great opportunity for me to gain a first-hand look at hospital management operations and protocols as well as improve my understanding of CBRNE casualty symptoms. The course covered a variety of topics through informative lectures by subject matter experts, interactive seminar discussions, and a tabletop exercise and it provided a very useful complement to my education in the Biodefense Graduate Program at the Schar School of Policy and Government.

Though it was unfortunate that we could not be in the classroom to interact with the seasoned professionals who served as instructors, their vivid descriptions of various facilities and CBRNE equipment helped us learn how to navigate the frenzied scene at a hospital in the wake of a mass casualty incident. The virtual setting also did not inhibit our ability to communicate with the instructors or cooperate with other students. Setting aside reticent mannerisms that would have been apparent in the classroom, the virtual platform instead allowed us to more freely type or vocally express our opinions and questions. After the first day of acquainting ourselves with the platform and with each other, the following four days consisted of constant dialogue in the chat hub. It was particularly heartening to be part of a cohort who openly shared their personal and professional experiences with the rest of the class to create a more dynamic and memorable learning experience.

As hospital management is not regularly part of mainstream academic curriculum, the opportunity to familiarize myself with hospital protocols was a valuable experience. The course introduced me to essential federal disaster response frameworks, such as the National Incident Management System (NIMS), National Response Framework (NRF), and Occupational Safety and Health Administration (OSHA) best practices that help ensure that CBRNE response and recovery operations are carried out safely and effectively. Without knowing that these protocols exist, one may be forgiven for thinking that federal responses to such events are spur-of-the-moment occurrences. Through the HM-CBRNE course, I learned about the six critical areas vital to guiding interagency coordination for an all-hazards response effort: communication strategies, resources and assets, safety and security, staff responsibilities, utility management, and patient support activities. As important as it is to actively respond, learning the fundamentals in hospital logistics, planning, finances, and operations is equally important in order to optimize mass casualty CBRNE response.

I was especially glad to see the incorporation of mental health in the HM-CBRNE course. While healthcare providers may first scan for physical symptoms to indicate what kind of CBRNE agent is involved, it is equally important to recognize the telltale psychological signs that affect mental and behavioral health, increase mass panic, and cause the “worried-well” phenomenon. There is historical evidence of psychological effects from battlefield experience and, although mental health awareness has increased over recent years, we cannot dismiss the occurrence of psychological impacts during CBRNE events. Scorn and stigma remain highly correlated with mental health conditions, which can negatively impact the way that hospitals receive and treat patients. As a result, the HM-CBRNE course effectively highlighted how considerations of psychological symptoms can be integrated into casualty management to pave the way for more holistic, well-informed medical decisions.

This importance of mental health is particularly relevant as the COVID-19 lockdown and quarantine dominates our daily lives. From overworked and overstressed healthcare workers, individuals whose feelings of isolation compound preexisting mental health issues, and family members who have to simultaneously juggle professional and personal responsibilities, it is clear that the extent of a person’s limits is being tested like never before. Thus, it is important that we continue efforts to improve mental health awareness and actions beyond a case-by-case approach.

The HM-CBRNE course was an informative and distinct experience that any individual interested in mass casualty and CBRNE management would benefit from. The instructors and staff worked diligently to help make a challenging and complex area seem less scary. This week-long course, filled with high-quality lectures and interactive activities, demonstrated the Army’s deep commitment to providing civilian and military participants with functional hospital management knowledge about how to address CBRNE incidents. This was an amazing and instructive experience that provided me with an inside look at how the United States prepares for and responds to unconventional weapons and incidents.

Book Review – The “Red Line” That Wasn’t

By Chris Quillen, Biodefense PhD Student

Syrian President Bashar al-Assad’s use of chemical weapons (CW) against his own people is the greatest challenge the Chemical Weapons Convention has ever faced. This breach of the taboo against CW use sparked numerous national and international investigations to determine the details of exactly what happened and who had done it. These investigations, in turn, were severely complicated by numerous factors. Investigators had to deal with (1) the dangers of operating during a complex civil war, (2) multiple belligerents using CWs on the battlefield (both the Syrian government and the Islamic State of Iraq and Syria or ISIS), and (3) the Syrian government’s repeated denials and counter-accusations of any CW use. Syria’s dubious position was backed by Vladimir Putin’s Russia in the public debate and, most importantly, at the United Nations Security Council, which provided Assad significant protection from international sanction. The global opposition to Syria’s use of CWs was widespread, but was led by the United States primarily under Barack Obama and also Donald Trump. The debate about what happened in Syria—and especially about how the world reacted to it—will undoubtedly rage for years to come. Joby Warrick’s Red Line: The Unraveling of Syria and America’s Race to Destroy the Most Dangerous Arsenal in the World is a useful addition to this debate, but the definitive book on the use of chemical weapons in the Syrian civil war remains to be written. 

A Washington Post reporter since 1996, Warrick offers a compelling, character-driven narrative with interesting new insights and impressive detail on key aspects of the story. His focus on individual actors, however, offers both strengths and weaknesses. Warrick should be commended for telling the compelling stories of (1) everyday Syrians risking their lives to get the evidence of Assad’s CW use to the world, (2) international inspectors from the United Nations (UN) and the Organisation for the Prohibition of Chemical Weapons (OPCW) overcoming amazing odds to gather the proof, and (3) American bureaucrats courageously and creatively destroying the part of Syria’s CW turned over by the Assad government. These individual stories are invaluable and offer useful guidance for similar efforts to document and destroy CW in the future. However, the focus on the individual often obscures the broader strategic context and limits the perspective of the book. At its best, this approach presents unique historical insights, but, at its worst, it runs the risk of allowing each individual perspective to overwhelm the big picture. As the saying goes, “Every person is the hero of their own story.” While many true heroes can be found in the pages of Warrick’s book, the temptation to put one’s own spin on history is evident and ultimately detracts from the larger message.

Warrick covers numerous sides to the story through his characters, but focuses primarily on the US angle, the most accessible to him. The life-threatening challenges inside of Syria are largely viewed through the eyes of refugees who later escaped the war in their homeland. ISIS’s efforts to develop and use sulfur mustard and the coalition efforts to destroy it are told through a largely unrepentant ISIS detainee who worked in the sulfur program.. The political battles at the UN are recounted from various diplomats and bureaucrats. 

The bulk of the book, however, addresses the US response to Syria’s use of chemical weapons. The title of the book makes this focus clear, but also reveals the two competing narratives of the story. The main title “Red Line” is taken from President Obama’s August 2012 statement in which he implied the US military would take action if Syria used chemical weapons: “We have been very clear to the Assad regime that a red line for us is we start seeing a whole bunch of chemical weapons moving around or being utilized. That would change my calculus.” The fact that no such military action followed Syria’s repeated confirmed use of CWs remains one of the more controversial aspects of the Obama administration’s record. Eric Sterner has argued the lack of a response destroyed America’s credibility on the issue such that later explicit threats to use force after Assad continued to use CWs were ineffective. For his part, Obama acknowledges that his credibility was on the line after his previous statements, but defends his decision not to act as being in “America’s interest.” Warrick largely defends Obama’s decision citing the lack of Congressional and public support for US military action, but these justifications seem to come too late. The fact is Obama issued a red line and failed to follow through. As a result, the taboo against CW use was severely weakened. 

The second part of Warrick’s story is captured in the subtitle “America’s Race to Destroy the Most Dangerous Arsenal in the World.” While legitimate debate can be had about whether Syria’s chemical weapons constituted “the most dangerous arsenal in the world,” the successful effort to destroy the bulk of Assad’s chemical weapons is undoubtedly a victory to be celebrated and Warrick should be commended for his work in capturing this account. Warrick’s inside stories about the development of the hydrolysis systems that were used to break down Syria’s CWs and the subsequent destruction that took place at sea onboard the Cape Ray are fascinating tales that need to be told.         

In the final analysis, the juxtaposition of the failure of Obama to enforce his own “red line” and the success of the effort to destroy most of Syria’s CW carried out by his administration is striking. The credibility of US government statements, however, is not the real issue here. The failure of the taboo against CW use—and the failure of the international community to enforce that taboo in any meaningful way—is the real story and the real tragedy. The fact is Bashar al-Assad used chemical weapons extensively against his own people, but he remains in power in Damascus, weakened but unapologetic. Assad claims to have given up his entire chemical arsenal, but he still retains (and still uses) his chemical weapons to this day, fewer in number but every bit as deadly. For a world that claimed to learn its lesson after Saddam Hussein’s extensive use of chemical weapons in the 1980s, these failures are egregious and heartbreaking. So much for that “red line.”

Procuring PPE through Innovation, Evaluation, and Coordination: A Strategy for True Cooperative Procurement

By Dr. Nathan Myers, Advisor to the Continuity of Supply Initiative

As this is being written, vaccines to protect against COVID-19 are being distributed all over the United States and around the world. If the vaccine proves to be the decisive tool for ending the pandemic, it will be the result of innovation, scientific research, collaboration, and coordination in regard to creating, distributing, and dispensing the vaccine. We must never lose sight of the fact, however, that vaccines have become so vital because of critical failures in other areas of the medical and public health systems. The same elements that allowed for the rapid development of vaccines in this pandemic must be applied in other areas to make vaccines less critical for the next major public health emergency. One such area is procurement of personal protective equipment (PPE).

A article by Jessica Gold reports on Center for Disease Control and Prevention (CDC) statistics indicating that 287,010 healthcare workers have been infected with the novel coronavirus with 953 providers succumbing to the illness. The article attributes these deaths, in large part, to inadequate protection, including a shortage of adequate PPE. The article notes that some personnel lacked access to N-95 masks and were forced to create their own makeshift protection. A BMJ study by Liu and colleagues found that 420 healthcare providers who were reassigned to work with COVID-19 positive patients in Wuhan, China did not contract the disease after being provided with proper PPE and the training to use it correctly. The article cites studies indicating that masks, gloves, eye protection, and gowns, if available and used correctly, can provide adequate protection against the virus. The article advises that national leaders must facilitate the ability of healthcare workers to abide by safety guidelines to protect themselves through ensuring a durable supply of PPE.

That is why groups, like the Continuity of Supply Initiative, are working to develop improved models for true cooperative procurement that will leverage innovation in procurement practices, evaluation research, as well as collaboration and coordination among suppliers and providers to create a more efficient, effective, and resilient system for the continued procurement of PPE during a major emergency. Access to PPE has been a major challenge to the US response to COVID-19 since the beginning. When PPE was available, the pricing could prove prohibitive for some healthcare institutions. The Continuity of Supply Initiative (CoSI) is working to create a framework for a master agreement between suppliers and healthcare providers in which PPE would remain available at reasonable prices during normal circumstances and across a range of emergency situations. To be resilient and effective, the true cooperative procurement advocated by CoSI must result in sufficient market clout to incentivize and assure a continuous supply in all circumstances. That same sufficient market clout and the willingness on the part of the group or coalition to pay reasonably higher prices in non-routine circumstances motivate competitors to craft, commit to (in their proposals and contracts), and honor creative, nontraditional supply solutions. 

Organizations like the National Association of County and City Health Officials (NACCHO) recognized in a 2013 report the benefits of cooperative purchasing for public health organizations. They noted “piggy-backing” as being the most useful in an emergency, because organizations could join existing contracts and save time by not having to negotiate their own arrangements. Through the use of true cooperative procurement, CoSI seeks to remove the need for piggy-backing by creating efficient, effective, and resilient systems during normal times that can flex to meet the challenges of emergencies. A 2014 article by Rego, Claro, and de Sousa notes that improvement of purchasing strategies in the healthcare field usually involves increased centralization facilitated by information sharing using current communication technologies. Costs are reduced through order consolidation. In their view, this makes horizontal cooperation between healthcare institutions to reduce cost and pool supply chain knowledge a reasonable approach. Rego, Claro, and de Sousa go on to cite sources regarding the advantages of cooperative purchasing at the supply chain level, which include more favorable terms with suppliers, reduced purchasing efforts, development of purchasing expertise, better informed selection and standardization, and improved ability to respond to emergency situations. The one disadvantage noted at the supply chain level was coordination costs when the size of the cooperative increases.  

Healthcare institutions as well as state and local governments found themselves in fierce competition for limited resources when the pandemic hit. Healthcare institutions had been placing themselves in a precarious situation for years by relying on “just in time” purchasing and a thinly stretched, international supply chain to meet their needs. Rather than trying to address the situation to allow for more effective and equitable distribution, the federal government sought to outbid those entities to which they should have been offering aid. Some suppliers opted to provide PPE to the highest bidder rather than honoring contracts, leaving institutions at the mercy of unscrupulous profiteers who provided substandard material at hugely inflated prices. Hospital systems, public health organizations, and governments at all levels, as well as suppliers of PPE, must recognize that it is in the interest of everyone that a stable and resilient procurement system is in place to prevent the disruption seen during COVID-19 in the future.

During the pandemic, some state governors formed procurement coalitions to leverage the combined purchasing power of their states to obtain better pricing for equipment as well as better performance in the provision of goods. States also shared unneeded resources with states more heavily impacted by COVID-19. As chair of the National Governors Association, Governor Andrew Cuomo of New York is in a position to advance the idea of creating a national procurement coalition. Such proposals speak to the need to extensively review and revise the legal framework and resourcing of healthcare procurement agencies that hindered the COVID-19 response. It should be emphasized that CoSI is not proposing a “one-size-fits-all” approach to procurement, but rather a model for a master agreement that different regions, states, and localities can modify to meet their particular needs.

Nevertheless, a true cooperative procurement agreement will require considerable work on the part of the lead procurement agency in regard to procurement planning, proposal evaluation, and contract administration. While group purchasing will be used, each individual healthcare provider must be held responsible for upholding their part of the agreement. As previously noted, innovative scientific research, as well as collaboration and coordination, will be just as vital in regard to improving procurement as it has been in developing, distributing, and dispensing a vaccine.

For one, procurement agencies can employ surveillance techniques and use data collected by a variety of stakeholders to identify signals or trends indicating that a greater supply of PPE will be needed. Additionally, program evaluation techniques can be employed to evaluate supplier performance in a range of circumstances, as well as the degree to which the procurement system works after an emergency event. Healthcare institutions must collaborate to determine the metrics by which suppliers’ performance will be evaluated, as well as coordinate to effectively administer contracts and make sure that individual institutions are meeting their commitments.

One of the many important lessons from the COVID-19 pandemic is that the American healthcare system cannot afford to rely on procurement systems that function well during routine operations, but are not designed to facilitate adequate supplies at a reasonable cost during a public health emergency. That is why the Continuity of Supply Initiative is working to design and promote procurement master agreements that will facilitate true cooperative procurement in which suppliers and purchasers will honor the terms of the agreement in routine and emergency situations, while the market leverage created by institutions banding together will allow supplies to be purchased at the best price. In order for the system to be sustainable, (1) both suppliers and healthcare providers will need to maintain consistent vigilance for emergencies, (2) supplier performance needs to be evaluated using evidence-based techniques and consistent metrics, and (3) healthcare institutions must regularly coordinate on the administration of the contract.

It is important to honor the memories of the healthcare providers lost during the COVID-19 pandemic. Part of that will be reforming the healthcare system in the US to make sure that supplies of PPE will be adequate when the next emergency occurs.  The Continuity of Supply Initiative will continue to promote the concept of true cooperative procurement as an efficient, effective, and resilient way to achieve that goal.

Pandora Report: 12.18.2020

As the holidays approach, we encourage mask-wearing, social distancing, and the holiday gathering guidelines of the CDC. 2020 has been the year of zoombombing, social distancing, and doomscrolling. On a happy note, 2020 is also the year that wild polio was eradicated in Africa and a major leap in HIV treatment research was made. To end the year on an interesting note, Filippa Lentzos shares her expertise about bioweapons.

The Pandora Report wishes everyone a happy holiday and New Year! We will see y’all in 2021!

Good Riddance, 2020!

In just two weeks, we will be bidding adieu to 2020 as the New Year begins. In 2021, Joe Biden will take office as president and the rollout of COVID-19 vaccines will expand, hopefully turning the tide of the pandemic. TIME released a list of terms that embodies 2020, which includes antiracist, blursday, covidiot, defund, doomscroll, Karen, on mute, quarantini, social distancing, superspreader, and zoombombing.

The Johns Hopkins Bloomberg School of Health highlighted 2020’s top global health moments, many of which, but not all, have been unfavorable. The WHO-UNICEF-Lancet Commission produced a report that emphasized the dangers ahead for children – climate change, migrating populations, conflict, inequality, and predatory commercial practices – that threaten their health and their futures. Of course, in March, the COVID-19 pandemic was declared by the World Health Organization, and a subsequent severe health worker shortage – including 5.9 million nurses – was revealed. Adding insult to injury, the Trump Administration announced that the US will withdraw from the WHO, a move that many global health leaders deem reckless. During the pandemic, the murder of George Floyd in Minneapolis, Minnesota, “sparked outrage, anguish, and a newfound urgency among Americans and American organizations to face the generations of systemic oppression and trauma Black Americans have endured.” The pandemic’s disproportionate effects on people of color and women helped put race and gender in the international spotlight.

Switching gears, in 2020, the Democratic Republic of the Congo (DRC) is better managing Ebola, even enjoying a temporary end to cases. Despite a reappearance of Ebola cases in the DRC, as of November, the country is again case-free. After four years without a case, Africa was certified as wild polio-free as a result of vaccination campaigns, pressure from the international community, and determined health workers. A welcome announcement in September shared that the HIV Prevention Trials Network study stopped their trial early because results were so effective. The trials include over 3,000 women at risk for acquiring HIV across seven countries in sub-Saharan Africa and have found that a single shot given every two months could be more effective at preventing HIV in women than a daily pill.

Despite the achievements of 2020, this year has been largely defined by SARS-CoV-2, the lackluster pandemic response of the US, and systemic prejudice. In short, 2020 has accurately been dubbed a dumpster fire.

Playing Politics in a Pandemic

Speaking of dumpster fires, more information has emerged regarding President Trump’s mishandling of the response to the pandemic. This week, Representative James E. Clyburn, Chairman of the Select Subcommittee on the Coronavirus Crisis, sent a memorandum to Members of the Select Subcommittee referring to new documents acquired in the investigation of political interference by senior Trump Administration appointees in the work of career officials at the Centers for Disease Control and Prevention (CDC). These documents revealed that officials at the Department of Health and Human Services (HHS) “repeatedly discussed pursuing a ‘herd immunity’ strategy and were aware that Administration policies were causing an increase in virus cases—but tried to hide the true danger of the virus and blame career scientists for the Administration’s failures.” Specifically, the memorandum explains evidence that Senior Advisor Paul Alexander, a Trump Administration appointee at HHS, privately planned with other Administration officials to follow a “herd immunity” strategy that advocated infecting “infants, kids, teens, young people, young adults, middle aged with no conditions etc. have zero to little risk….so we use them to develop herd…we want them infected.”

Accelerated Advances in Biotech and the Bioweapons Threat

Yong-Bee Lim, a Biodefense PhD candidate, published a short piece, “Accelerated Advances in Biotech and the Bioweapons Threat,” with the Council on Strategic Risks (CSR). In 2018, the National Academies of Sciences, Engineering, and Medicine (NASEM) released a report highlighting how “nefarious actors may use technical advances in delivering genetic information like messenger RNA (mRNA) to generate a new class of biological weapons: weapons that modify human cell protein expression.” Given that two of the leading COVID-19 vaccines – one by Pfizer with BioNTech and another by Moderna – are mRNA-based, it is no surprise that mRNA has recently received heightened attention. Lim notes that these two vaccine candidates speak to the remarkable advances in biotechnology and the life sciences since 2018, a mere two years ago. National security experts must realize that biotechnology moves quickly and we must readily adapt to the swiftly-changing circumstances around us, or we will miss critical opportunities to avert the emergence and use of novel bioweapons.

Lim will soon be a Fellow for the Nolan Center on Strategic Weapons at the Council on Strategic Risks, working on the Making Biological Weapons Obsolete project. This program emerges as countries such as North Korea, Syria, and Russia are weakening norms against WMDs by increasing the use and testing of chemical weapons and nuclear weapon capabilities. Given the current and emerging technological advances as well as the current geopolitical climate, biological weapons are a ripe target for a new WMD. As a Fellow, Lim will conduct research, help develop an actionable vision of a world where bioweapons are obsolete, and build bridges and engage with stakeholders.

Moderna’s COVID-19 Vaccine Gets the Thumbs Up for VRBPAC

On 17 December, the Vaccines and Related Biological Products Advisory Committee (VRBPAC) convened to discuss and provide recommendations on whether the benefits of the mRNA-1273 COVID-19 Vaccine outweigh its risks for use in individuals 18 years of age and older. The VRBPAC voted 20-0 with one abstention to support mRNA-1273. This endorsement all but guarantees that the vaccine will receive emergency use authorization from the Food and Drug Administration. The Moderna vaccine will be approved for use in adults only.


The Biomedical Advanced Research and Development Authority (BARDA) hosts a helpful website, MedicalCountermeasures.Gov, which facilitates communication between federal government agencies and public stakeholders to enhance the Nation’s public health preparedness. The site offers information and resources on the coronavirus response, federal initiatives, approvals from the Food and Drug Administration (FDA), emergency use authorizations (EUAs) from the FDA, stockpiles, and more.

The Strategic and Geo-Economic Implications of the COVID-19 Pandemic

The International Institute for Strategic Studies (IISS) published the Manama Dialogue 2020 Special Publication, which explores the regional and global implications of the pandemic, including essays on Gulf defense economics, global and great-power politics, the Gulf states’ development models, strategy and geo-economics. The pandemic will have enduring effects on geopolitics as international suspicion rises and trust wanes. The pandemic hit at a time when US-China relations were deteriorating during a trade war. Additionally, the US and China are battling for dominance in the technological space. The report asserts that economic power, sanctions and regulatory innovations will “evolve to be part of the strategic arsenal of other states.” At the same time, violent transnational actors are increasingly at work outside the scope of modern international law. These actors have exploited the “spaces between the law, and the state system has not responded by rendering their activities illegal.” Many elements of international law are also in need of review, including cyberspace, space, agreements governing asylum and refugees, and the regulation of private military companies and their activities. Read the report here.

The Coronavirus at 1: A Year into the Pandemic, What Scientists Know About How It Spreads, Infects, and Sickens

STAT outlined a portrait of SARS-CoV-2 based on what scientists learned about the virus as it infected the world and sabotaged economies, societies, and health systems. SARS-CoV-2 is an RNA virus with spike proteins that latch onto a receptor, called ACE2, on human cells. This latching allows the virus to enter the cell, take over the host’s cellular machinery, and churn out copies of itself that can burst out of the cell and seek out new cells to infect. SARS-CoV-2 can interrupt the desired immune response and cloak itself in ways that generate a harmful immune response. COVID-19 is the illness created by a SARS-CoV-2 infection. COVID-19 is characterized by respiratory issues, fever, headache, fatigue, and body aches as well as other, stranger symptoms such as a loss of smell and taste. Viruses evolve, and SARS-CoV-2 is no exception. One mutation of the spike protein, referred to as D614G, seems to have rendered the virus more transmissible, but it does not seem to have had an impact on the severity of illness. Learn more about the novel coronavirus here.

The Latest from Lentzos

Dr. Filippa Lentzos, a mixed methods social scientist researching biological threats, recently published two articles about bioweapons: “How to Protect the World from Ultra-Targeted Biological Weapons” and “How Russia Worked to Undermine UN Bioweapons Investigations.” The former article points out that as genomic technologies develop and converge with artificial intelligence, machine learning, automation, affective computing, and robotics, increasingly refined records of biometrics, emotions, and behaviors will be captured and analyzed. These data will enable game-changing developments that will significantly impact how we view health and treat disease, but also how we consider our place on the biological continuum. Further, these developments will radically transform the dual-use nature of biological research, medicine, and healthcare, producing the possibility of novel bioweapons that target specific groups of people or individuals. New governance structures that draw on individuals and groups with cross-sectoral expertise are required to manage the fast and broad technological advances already underway. The latter article focuses on Russia’s efforts to thwart investigations into allegations of chemical or biological weapons use. In fact, Russia has managed to garner aligning votes from China, India, Iran, Syria and Venezuela, who all voted against investigations into the sarin attacks in Ghouta, Syria. In October, Russia introduced a resolution to the General Assembly for updating procedures related to the secretary-general’s investigative mandate; however, beneath the surface of the resolution, it was apparent that the motive was to weaken the ability of the secretary-general to investigative chemical and biological weapons use. Russia’s underhanded proposal to give more power to the Security Council over chemical and biological weapons investigations is a signal that Russia, and the nations that supported the Russian resolution, fear the possibility that an independent impartial process might be beyond their control and veto.

Five Questions on New Data from China-WHO Showing 124 Confirmed Coronavirus Patients in December 2019

Dr. Daniel Lucey poses five key questions regarding the 124 COVID-19 cases from December 2019:

  1. Who are these 124 cases, and how many were linked to the Seafood Market and other specific locations in Wuhan?
  2. Where were the 5/124 cases who were not from Wuhan?
  3. What is the timeline for the day-by-day illness onset for each patient?
  4. How many “isolated” cases are known from before December even if no “unusual clusters” were reported?
  5. How many, if any, additional cases (more than 124) are known in December, and before December (back at least to Nov. 17, 2019 as reported by Josephine Ma, in the South China Morning Post March 13, based on “Government records”)?

On 24 January, there were 40 reported confirmed cases in December 2019, but days later, on 29 January, that number increased to 46. By 17 February, the reports claimed 100 cases. Finally, the count is now up to 124 confirmed cases. Why does this figure keep rising?

US Nuclear Warhead Modernization and “New” Nuclear Weapons

Rebecca Hersman, director of the Project on Nuclear Issues (PONI) at the Center for Strategic and International Studies (CSIS), and Joseph Rodgers, program manager of PONI, published a CSIS brief about US nuclear warhead modernization.  These briefs are based on a series of “deep dive” workshops convened by PONI that bring together next generation technical, operational, and policy experts from across the nuclear community to debate and discuss these nuclear challenges. The majority of workshop participants recognized the need for modernization programs for US and UK nuclear-warheads. Most also agreed that these modernization projects pose considerable fiscal and geopolitical challenges. Such challenges include how to maintain political support, fund modernization work with lengthy acquisition time horizons, compete with the nuclear modernization programs of adversaries, and adequately address nonproliferation challenges. Additionally, participants agreed that the tight coupling of the US and UK nuclear programs demands “greater consistency among policy statements regarding these programs and greater appreciation of the required timeframes for modernization in both countries.” To tackle these obstacles, the nuclear community must develop effective and informed expertise on warhead modernization and cultivate a common understanding of the benefits and risks associated with various warhead modernization approaches.

Crisis Standards of Care: Lessons from NYC Hospitals’ COVID-19 Experience

Last month, the Center for Health Security at Johns Hopkins University released a report, Crisis Standards of Care: Lessons from New York City Hospitals’ COVID-19 Experience. New York City experienced an unprecedented surge of COVID-19 patients from April to June 2020, which was characterized by the extraordinary use of critical care resources and high case fatality ratios. During this surge period, hospitals were overwhelmed and conventional standards of care could not be maintained, forcing hospitals and healthcare workers to adjust their methods of care in order to help the greatest number of patients. The report is the output of a forum convened to allow critical care physicians from a number of hospitals across New York City to frankly discuss their experiences with implementation of crisis standards of care (CSC). The following six major themes arose from the forum:

  • Pre-pandemic CSC planning did not necessarily align with the realities and clinical needs of the pandemic as it unfolded
  • The COVID-19 surge response was effective, but often chaotic
  • Interhospital collaboration was an effective adaptive response
  • Situational awareness, especially related to information about patient load and resource availability, was a challenge for many clinicians
  • Multiple CSC challenges had to be overcome, especially around decision-making for triage or allocation of life-sustaining care
  • Healthcare workers were profoundly psychologically affected by dealing with CSC issues amid the surge

Read the report here.

Pandora Report: 12.4.2020

The ball is rolling for COVID-19 vaccines with two very promising candidates in the pipeline. The pandemic continues to surge, bringing with it continued opportunities for exploitation by malign actors – extremists and hackers. A recently released research paper explores the ethical and legal implications related to the use of performance-enhancing drugs by the military. This fall, four students from the Biodefense Graduate Program attended a virtual version of the Medical Management of Chemical and Biological Casualties Course held by US Army Medical Research Institute of Infectious Diseases and the US Army Medical Research Institute of Chemical Defense. Read about their experiences and takeaways!  

Medical Management of Chemical and Biological Casualties Course

The Medical Management of Chemical and Biological Casualties (MMCBC) Course is the premier chemical and biological defense training offered by the US Army. It is a six-day, two-part course offered jointly by the US Army Medical Research Institute of Infectious Diseases (USAMRIID) at Fort Detrick and the US Army Medical Research Institute of Chemical Defense (USAMRICD) at Aberdeen Proving Ground, both in Maryland. MMCBC covers topics such as the history and current threat of chemical and biological weapons, the characteristics of chemical and biological threat agents, the pathophysiology and treatment of agent exposure, and the principles of field management of chemical and biological casualties. On October 18-23, 2020, four students from the Biodefense Graduate Program at the Schar School of Policy and Government at George Mason University attended a virtual version of the course: Deborah Cohen, Madeline Roty, Marisa Tuszl, and Ishaan Sandhu. You can read about their experiences and takeaways from the MMCBC course here.

COVID-19 Vaccine Update

This week, the United Kingdom granted emergency approval to a COVID-19 mRNA vaccine developed by Pfizer and BioNTech, a German biotechnology company. In the US, the Food and Drug Administration (FDA) will consider granting the same vaccine candidate regulatory approval next week. Pfizer and BioNTech applied for emergency authorization of their coronavirus vaccine in mid-November, following the release of data showing it to be “remarkably effective.” Shortly after, Moderna announced that its candidate was showing “similarly spectacular results.”

HyungJung Kim, a PhD candidate in Biodefense, recently published a new article with the Bulletin of the Atomic Scientists about emergency use authorizations (EUA) for new vaccines. The Food and Drug Administration (FDA) is responsible for issuing such authorizations for medical countermeasures, including vaccines, therapeutic drugs, diagnostic tests, and other medical devices. Initially, the emergency use policy was exclusively aimed at the threat posed by weapons of mass destruction (chemical, biological, radiological, and nuclear weapons), but the scope was expanded to include all hazards to public health. Since the start of the COVID-19 pandemic, the FDA has issued more than 250 emergency use authorizations for antiviral drugs, diagnostic kits, ventilators, and other medical equipment. Though the EUA could provide a vaccine relatively quickly, there are also significant disadvantages to using the emergency use authorization as the legal basis for approving a COVID-19 vaccine for widespread use. Read Kim’s analysis of the pros and cons of an EUA for COVID-19 vaccines here.

AMR Awareness

World Antimicrobial Awareness Week was 18-24 November, and it was celebrated with the slogan, “Antimicrobials: handle with care.” Antimicrobial resistance (AMR) is the characteristic in which microorganisms – viruses, bacteria, and fungi – change over time and exposure in ways that that render antimicrobial medicines futile against them. Globally, about 700,000 people die from these infections annually. The combination of growing resistance across microbes to multiple therapeutics with the lagging creation of new drugs has made AMR a global issue. In the US, there are over 2.8 million antibiotic-resistant infections and 35,000 deaths each year. PEW interviewed Erin Duffy, a chemist with more than 20 years of experience in drug discovery and current Chief of R&D at CARB-X, about the urgent need for innovations to combat superbugs. Duffy pointed out that there is a critical need for economic incentives to “slow the exodus of companies from antibiotic development and stimulate development of urgently needed drugs.” She warns that we are taking antimicrobials for granted and that we may end up in a situation without safe and effective drugs.

The American Society for Microbiology (ASM) shared some good news in regard to AMR. Researchers in Montréal, Canada found that 28% of 324 unique methicillin-susceptible S. aureus (MSSA) isolates from bloodstream infections were also susceptible to penicillin, a marked occurrence given that penicillin resistant strains have persisted for several decades. There have been improvements in antibiotic subscribing: a group of epidemiologists, physicians, and public health experts from the Centers for Disease Control and Prevention (CDC) reported that fluoroquinolone (ciprofloxacin and levofloxacin) prescription rates decreased by 30% between 2011 and 2018.

Cyberattacks Targeting Health Care Must Stop

Tom Burt, Corporate Vice President of Microsoft’s Customer Security and Trust (CST) team, asserts that COVID-19 and the growing use of the internet by malign actors to disrupt society are the two issues that will shape the history of our era. This year, three nation-state actors have carried out cyberattacks targeting seven companies directly involved in vaccine and treatment research for COVID-19. The targets included premier pharmaceutical companies and vaccine researchers in Canada, France, India, South Korea, and the United States, and the attackers originated from Russia and North Korea. Sadly, these are not the first occurrences of cyberattacks targeting the health care sector. In COVID-19, there have been ransomware attacks on hospitals and healthcare organizations across the United States. The Paris Call for Trust and Security in Cyberspace is an invitation to all cyberspace actors to work together and encourage States to cooperate with the private sector, the research world, and civil society. The Paris Call includes organizations like Merck working on vaccines, top hospitals like Hospital Metropolitano in Ecuador, and government health institutes like Poland’s National Institute of Public Health. The Oxford Process, a 136-strong group of the world’s top international law experts, issued a statement emphasizing that international law protects medical facilities at all times. Microsoft announced in April that it would make AccountGuard, a threat notification service, available to health care and human rights organizations working on COVID-19. Burt implores world leaders to “unite around the security of our healthcare institutions and enforce the law against cyberattacks targeting those who endeavor to help us all.”

Stopping the Spread: Pandemics, Warning, and the IC

The National Security Institute at George Mason University’s Antonin Scalia Law School released a new law and policy paper, Stopping the Spread: Pandemics, Warning, and the IC. The paper summarizes the Intelligence Community’s (IC) focus on the national security threat posed by infectious diseases; argues that the IC, with its unique collection and analytic capabilities, can help the public health community with threat monitoring and containment efforts; and proposes actionable recommendations to enhance the US ability to detect global pathogenic outbreaks in order to implement effective mitigation measures. The recommendations include enhancing IC intelligence collection to improve early detection and forewarning of pathogenic outbreaks, increasing information sharing between the IC and Centers for Disease Control and Prevention (CDC), and improving warning mechanisms to assist pandemic preparedness and response. Read the paper here.

‘It will change everything’: DeepMind’s AI Makes Gigantic Leap in Solving Protein Structures

An artificial intelligence (AI) network developed by Google AI offshoot DeepMind is able to accurately determine the 3D shape of some proteins based on their amino-acid sequences, a giant step toward solving one of biology’s biggest challenges. The specific program, AlphaFold, outperformed 100 other teams in the Critical Assessment of Structure Prediction (CASP), a biennial protein-structure prediction challenge. Proteins are the building blocks of life, and their functions are largely determined by the 3D shape. For proteins, “structure is function.” Unraveling a protein’s structure enables a better understanding of how it works, thereby allowing better understanding of how to affect it, control it, or modify it. AlphaFold may enable the use of lower quality and easier-to-collect experimental data to determine a structure. Janet Thornton, a structural biologist at the European Molecular Biology Laboratory-European Bioinformatics Institute, hopes that the approach could “help to illuminate the function of the thousands of unsolved proteins in the human genome, and make sense of disease-causing gene variations that differ between people.”

COVID Outbreaks in the World’s Largest Office Building

The Pentagon moved to a higher health protection level last week (now at Bravo Plus), cutting its maximum occupancy to 40% and bumping up the number of temperature checks on personnel. The building has been below 50% occupancy for the last several months and meetings are regularly conducted by phone or virtually. Brig. Gen. Anthony Tata, the temporary Pentagon policy chief, tested positive for the coronavirus last week as well, though the decision to heighten the protection level was made beforehand. The Pentagon is struggling to contain the virus as new daily cases reach a record 1,300 and another outbreak occurs aboard a Navy ship. The expected surge associated with Thanksgiving celebrations contributed to the decision to up the protection level. A DOD dashboard shows that more than 73,000 coronavirus cases have been confirmed among members of the military with tens of thousands more recorded among DOD family members, contractors, and civilian personnel.

Exploiting the Pandemic

The United Nations Interregional Crime and Justice Research Institute (UNICRI) found that criminals and violent extremists are exploiting the pandemic to expand their networks, undermine trust in government, and weaponize the virus. UNICRI detected an exponential increase in the malicious use of social media to reinforce extremist narratives, ramp up recruitment, and expand territorial control. Social media incitement is a common method of exploitation to “inspire terrorism.” The European External Action Service (EEAS) report provides a snapshot overview of the current trends and insights into disinformation activities related to the coronavirus pandemic. According to the latest analysis, online misinformation and disinformation related to COVID-19 decreased and shifted focus towards vaccines; however, their spread and reach remain troublingly high. EEAS expects the pandemic to continue providing plenty of opportunities for the spread of misinformation and disinformation, especially for actors like China and Russia, who are maximizing on the effect of “vaccine diplomacy” in their campaigns. Sarah Jacobs Gamberini, a Policy Fellow in the Center for the Study of Weapons of Mass Destruction at the National Defense University, expounds on Russia’s weaponization of social media through disinformation campaigns. According to Gamberini, Russia is “drilling deeper into the preexisting fault lines of American society,” especially in regard to the pandemic and recent election. Specifically, Russia is turning the best features of the US – diversity, pluralism, and democracy – into weaknesses ripe for exploitation. Russia is using social media as its weapon by identifying a contentious issue and employing bots and trolls on various platforms to spread divisive rhetoric and amplify debates falsities. Then, it takes advantage of the divisions created by disinformation to augment discord in the US and undermine its institutions.

Pharmacological Performance Enhancement and the Military

Chatham House, a world-leading policy institute based in London, published a research paper, Pharmacological Performance Enhancement and the Military: Exploring an Ethical and Legal Framework for Supersoldiers, which explores the ethical and legal implications related to the use of performance-enhancing drugs (PEDs) by the military. This topic is often overshadowed by concerns regarding side effects and safety. In the armed forces, PEDs could be employed to improve soldier strength, mental capacity, recovery, and resistance to fatigue and trauma; however, the effects of these drugs on the human nature of soldiers remains largely undetermined. This paper avows that administering such drugs in a conflict scenario requires a different cost-to-benefit calibration and it identifies three scenarios in which pharmacological interventions would be ethically permissible: (1) in life or death situations; (2) in situations with strategically exceptional mission requirements; and (3) within restorative limits. Beyond these scenarios, the output does not support the routine use of performance-enhancing drugs in the armed forces. Further, given that the military does not exist in isolation from civil society, attitudes regarding such use of drugs will ultimately be determined by societal opinion. Read the research paper here.

Apocalypse How with Dr. Koblentz

On 7 December, Dr. Gregory Koblentz, Director of the Biodefense Graduate Program, will be featured on the final episode of a BBC radio documentary talking about synthetic biology and smallpox. The documentary series, Apocalypse How, explores the threats beyond COVID-19 that the world may soon face. Such existential threats to humanity include an electromagnetic pulse bomb, a worldwide decline in pollinating insects, and an engineered deadly pathogen. Tune in here.

The Wuhan Files

Leaked documents from the Hubei Provincial Center for Disease Control and Prevention show that China mishandled the early days of the COVID-19 pandemic. Among the 117 leaked pages, an internal and confidential document states a total of 5,918 newly detected cases on 10 February, which is more than double the official public number of confirmed cases. These files belie the Chinese government’s resolute rejection of accusations it deliberately concealed information related to the novel coronavirus. The documents span the period October 2019 to April 2020 and reveal the inflexibility of the Chinese healthcare system and the critical gaps in their preparedness. An October audit states that a “huge gap in staff and operating funds at the [Hubei] provincial CDC has seriously affected the normal performance of public health functions.” Another page says, “the rapid identification and detection of unexplained pathogens is obviously insufficient…the information infrastructure is poor, [Provincial] CDC and medical institution data are still not open to each other, infectious disease surveillance and early warning capacity is not sensitive and accurate.” In December 2019, there were reports of surges in influenzas cases. A spike in influenza and the emergence of SARS-CoV-2 are not linked to the documents, but the data about flu-like outbreaks in several cities in Hubei province will likely be of interest to those researching the origins of the disease. Speaking of the origins of the virus, there are two efforts to determine how it hopped into humans. The World Health Organization (WHO) published the rules of engagement for a multinational team of researchers to investigate the origins of SARS-CoV-2. Recently, a commission created by The Lancet and headed by Jeffrey Sachs, announced the formation of a task force of 12 experts from nine countries who will also look into the how the novel coronavirus leaped species. The goal is not to uncover patient zero, but to “elucidate the ecosystem—physical, but also viral—in which the spillover happened and ask what could make it likely to happen again.” Both teams are faced with solving a very complex problem, compounded by the possibility that the trail to the pandemic’s origin may have gone cold.     

Who Votes with Russia at the OPCW?

Russian has attempted to prevent the Organization for the Prohibition of Chemical Weapons (OPCW) from holding it and other states accountable for their use of chemical weapons prohibited under the 1993 Chemical Weapons Convention (CWC). Specifically, Russia seeks to prevent the OPCW from investigating its use of a military-grade chemical nerve agent, Novichok, to poison enemies of the state, along with the al-Assad regime’s use of chemical weapons against civilians in Syria. The OPCW’s voting process, which uses open ballots and requires a two-thirds majority, has allowed the organization to function more effectively than a number of other international bodies. To counter Russia’s obstruction, the US will have to preserve and widen the coalition of OPCW member states committed to holding violators accountable. Andrea Stricker, a research fellow at the Foundation for Defense of Democracies, recommends that the United States leverage its positive relations with many countries that frequently abstain to broaden the coalition of member states committed to upholding the integrity of the CWC and the OPCW.

COVID-19 Interferes with CWC and BTWC Meeting Schedules

Dr. Jean Pascal Zanders, an independent researcher/consultant on disarmament and security based in France, highlighted the interference of COVID-19 on the meeting schedules for the Chemical Weapons Convention (CWC) and Biological and Toxin Weapons Convention (BTWC). The Organisation for the Prohibition of Chemical Weapons (OPCW) just held the 25th session of the Conference of the States Parties (CSP) on 30 November and 1 December and will reconvene for the remainder of its work by the end of April 2021. The 2021 programme and budget is the most significant agenda item for the first part of the CSP, and the programme and budget proposal are expected to be voted against by Russia and Syria, among others. These nations object to the financing of the Investigation and Identification Team, which was established in 2018 to determine the culprits of the chemical weapon attacks in Syria. For the BTWC, the Meetings of Experts (MXs) have been rescheduled for April 2021, the latest postponement among many. This may result in further delay of the Review Conference.

Pandora Report: 11.13.2020

The Pandora Report thanks veterans of the US military for their service! As the country awaits Biden’s presidency, a number of concerns arise regarding the remainder of the Trump administration as we continue to battle the COVID-19 pandemic. Biden has already named 13 health experts to his COVID-19 Transition Advisory Board. Join the Biodefense Graduate Program for a distinguished panel of international experts in a discussion about how to restore the taboo against the use of chemical weapons and how the Organization for the Prohibition of Chemical Weapons (OPCW) can prevent the further misuse of chemistry.

Friday the 13th

Jason Voorhees, the fictitious killer in the “Friday the 13th” slasher movies and comic series, is the star of a new advertising campaign aimed at encouraging mask-wearing to prevent the spread of SARS-CoV-2. In it, he points out that even though masks may be scary, “not wearing one can be deadly.” Watch Jason’s PSA here.  

Upcoming Event – The Resurgent Chemical Weapons Threat: Current Challenges to the Chemical Weapons Convention (CWC)

The Biodefense Graduate Program is sponsoring an event, The Resurgent Chemical Weapons Threat: Current Challenges to the Chemical Weapon Convention, in preparation for the 25th Session of the Conference of the States Parties on 30 November – 4 December, 2020. The chemical weapons nonproliferation regime is at a crossroads. Chemical weapons have made a comeback with deadly nerve agents being used by Russia, Syria, and North Korea against perceived “enemies of the state.” A new generation of chemical weapons that incapacitate, instead of kill, their victims are also under development. At their next annual meeting, members of the 1993 Chemical Weapons Convention (CWC), which bans the development, production, and use of chemical weapons, will confront this resurgence in the chemical weapons threat. Please join a distinguished panel of international experts in a discussion about how to restore the taboo against the use of chemical weapons and how the Organization for the Prohibition of Chemical Weapons (OPCW) can prevent the further misuse of chemistry.

Dr. Stefano Costanzi is an Associate Professor of Chemistry at American University in Washington DC. Dr. Malcolm Dando is a Leverhulme Trust Emeritus Fellow in the Department of Peace Studies at the University of Bradford in the UK. Dr. Jean Pascal Zanders is an independent researcher/consultant on disarmament and security based in France. The event will be moderated by Dr. Gregory D. Koblentz, Associate Professor and Director of the Biodefense Graduate Program at the Schar School of Policy and Government at George Mason University. The event will be held as a live webinar on 17 November from Noon to 1:30 EST. Register at

Biden Names 13 Health Experts To COVID-19 Transition Advisory Board

As infections continue to surge, president-elect Joe Biden has named 13 health experts to his Transition COVID-19 Advisory Board. The board will be co-chaired by three people: Dr. David Kessler of the University of California, San Francisco and former Food and Drug Administration Commissioner; Vivek Murthy, former Surgeon General; and Dr. Marcella Nunez-Smith, an associate professor of medicine and epidemiology at Yale University. In a statement on Monday, Biden said, “The advisory board will help shape my approach to managing the surge in reported infections; ensuring vaccines are safe, effective, and distributed efficiently, equitably, and free; and protecting at-risk populations.” Biden acknowledged that the ongoing pandemic is one of the greatest challenges that his administration must tackle, and he has committed to being “informed by science and by experts.” The board will also include Dr. Rick Bright, former director of the Biomedical Advanced Research and Development Authority (BARDA); Luciana Borio, a biodefense and disease specialist who has worked for the National Security Council; and Eric Goosby, the UN Special Envoy on Tuberculosis and former United States Global AIDS Coordinator.

Counties with Worst Virus Surges Overwhelmingly Voted Trump

An analysis conducted by the Associated Press (AP) found that nearly all (93%) of the 376 counties with the highest number of new cases per capita went for Trump in the recent election. Most were rural counties in Montana, South Dakota, North Dakota, Nebraska, Kansas, Iowa and Wisconsin. Lower rates of adherence to mandates for mask-wearing and social distancing tend to be seen in rural areas. Given this trend, state health officials are pausing to contemplate how to reframe their messaging to improve compliance in communities resisting the public health measures for COVID-19. According to AP VoteCast, 36% of Trump voters described the pandemic as completely or mostly under control, and 47% said it was somewhat under control. In contrast, 82% of Biden voters said the pandemic is not at all under control.

‘It’s going to be very, very scary’: Before Biden Takes Office, a Precarious 10 Weeks for Escalating COVID-19 Crisis

Dr. Saskia Popescu, a Term Assistant Professor for the Biodefense Graduate Program, shared her worries that the Trump administration will assume a scorched-earth approach in response to losing the election to Joe Biden. She says, “it’s going to be very, very scary.” A number of public health experts fear for the crisis that the election results may incite: a transition period of skyrocketing COVID-19 cases and deaths. Election week saw record high numbers of cases, even as Trump downplayed the pandemic. Though it is not the convention to publicly challenge the outgoing president on basic matters of governance until the president-elect’s inauguration, Biden’s health care advisers are already reaching out to mayors and governors. Biden’s team is also already planning for a transition of power at health agencies like the Centers for Disease Control (CDC) and Prevention and the Food and Drug Administration (FDA). But until Inauguration Day, Biden lacks the formal power to institute mask mandates, affect the manufacture of protective equipment for medical workers, or impact COVID-19 testing. Until then, Biden and his incoming administration are taking a public-facing role to encourage caution and compliance with public health guidelines.

America’s Poised for a 180-Degree Turn on Climate Change with a Biden Victory

The incoming Biden administration aims to shift the US away from fossil fuels and expand protections for public lands, but these efforts will face serious opposition from the Senate GOP. Biden is expected to “restore dozens of environmental safeguards President Trump abolished and launch the boldest climate change plan of any president in history.” Despite the anticipated pushback from Senate Republicans and conservative attorneys general, Biden plans to make a 180-degree turn on climate change and conservation policy in the US. Indeed, he identified climate change as one of his top presidential priorities, and plans to “restrict oil and gas drilling on public lands and waters; ratchet up federal mileage standards for cars and SUVs; block pipelines that transport fossil fuels across the country; provide federal incentives to develop renewable power; and mobilize other nations to make deeper cuts in their own carbon emissions.”

Upcoming Event – Outreach 2.0: Emerging Technologies and Effective Outreach Practices

The Strategic Trade Research Institute (STRI) is hosting an event, “Outreach 2.0: Emerging Technologies and Effective Outreach Practices,” sponsored by the United Nations Office for Disarmament Affairs (UNODA). The event will feature discussion on emerging technology outreach challenges as well as outreach tools and good practices to raise awareness among private sector stakeholders in industry, research, and academia. The speakers, Scott Jones and Andrea Viski of STRI, will present an advanced outreach model – Outreach 2.0 – built on input from international stakeholders from the public and private sectors. Andrea Viski is also an Adjunct Professor in the Schar School’s Master’s in International Commerce and Policy program. During the event, the speakers will introduce Outreach 2.0 and conduct an exchange with three renowned discussants: Todd Perry of the US Department of State; Katherine Wyslocky of Public Safety Canada; and Kevin Cuddy of IBM. Sign up here.

Lessons from the Roosevelt: A Call for Improving the US Navy’s Preparedness for Biological Threats

Lt. Cmdr. Brian L. Pike, leader of the Navy unit that detected the first cases of COVID-19 onboard the USS Theodore Roosevelt, and Dr. Gregory D. Koblentz, Director of the Biodefense Graduate Program, published a commentary in War on the Rocks about important lessons to be learned from the outbreak of COVID-19 aboard USS Theodore Roosevelt. In late March, SARS-CoV-2 snuck aboard USS Theodore Roosevelt to infect its sailors. Kasper et al. assesses the COVID-19 outbreak on the aircraft carrier, finding that SARS-CoV-2 spread quickly among the crew. Given the confined work environment of Navy ships, an outbreak is devastating to the crew and operations. Indeed, on the Teddy Roosevelt, 25% of the crew was ultimately infected, one sailor died, and the ship was forced out of operation for 10 weeks. Pike and Koblentz recommend mitigating the fleet’s vulnerabilities to biological threats of the future and enhancing the Navy’s shipboard capabilities. If an infectious disease cannot be contained and managed, then the advantages of early detection are lost. The authors encourage a comprehensive review of the Navy’s response procedures as an important step for ensuring that it is prepared to mitigate future biological threats.

North Korea and Biological Weapons: Assessing the Evidence

North Korea’s announcement that it is working on a COVID-19 vaccine has revived attention on Pyongyang’s ostensible biological weapons (BW) program. The Stimson Center released a report, North Korea and Biological Weapons: Assessing the Evidence, which reviews the public statements from the United states and South Korea regarding the suspected program. These two nations have the greatest security interests on the Korean Peninsula. The report also examines the policy responses adopted by the two governments and whether those actions have been consistent with concerns that North Korea has an advanced BW program. Five themes emerge from this review: (1) the US government uses several terms to discuss the possibility of BWs that are highly ambiguous; (2) there is a high degree of uncertainty regarding the specifics of North Korea’s suspected BW program; (3) public assessments between the US and South Korea are inconsistent; (4) some assessments into the North Korean BW issue between government agencies have been contradictory; and (5) the US government possesses fragmented insight into North Korea’s BW capabilities and intentions.

73rd World Health Assembly

The 73rd Session of the World Health Assembly (WHA), the decision-making body of the World Health Organization (WHO), is ongoing in a virtual format. Unsurprisingly, one of the major topics of the WHA is charting the course for the COVID-19 response and setting global health priorities. Many nations and cities have successfully prevented and controlled transmission of SARS-CoV-2 with comprehensive and evidence-based approaches. Other nations and areas are still struggling to achieve the same results, but the WHO maintains that we can beat COVID-19 with science, solutions, and solidarity. The WHA is also covering the critical health goals that cannot be allowed to backslide amidst the COVID-19 pandemic. Given that health is foundational to social, economic, and political stability, session will discuss a 10-year plan for addressing neglected tropical diseases, as well as efforts to address meningitis, epilepsy and other neurological disorders, maternal infant and young child nutrition, digital health, and the WHO Global Code of Practice on the International Recruitment of Health Personnel.

Last week, an oversight panel called for reforms to the WHO that encompasses “predictable and flexible funding and setting up a multi-tiered system to warn countries earlier about disease outbreaks before they escalate.” A “significant discrepancy between member states’ financial contributions and their expectations” of WHO’s Emergency Programme was found, raising concerns. In regard to declaring a public health emergency of international concern (PHEIC), COVID-19 raised concerns that the one-level system is inadequate, with experts recommending a graded system with clear criteria.

The CDC Chief Lost His Way During COVID-19. Now His Agency Is in the Balance.

Former acting director of the Centers for Disease Control and Prevention Dr. Richard Besser said, “The integrity of the agency has been compromised. That falls to the director of CDC.” In a letter sent in September, Dr. William Foege, a former CDC director, encouraged Dr. Robert Redfield, the current director of the CDC, to orchestrate his own firing. Records show that Redfield pressured local health officers to grant favors to politicians and businesses and he allowed political appointees outside of the CDC to draft and publish information on the agency’s website, regardless of the objections from his top scientists and without technical review. USA TODAY interviewed dozens of current and former colleagues of Redfield; interviewees included his supporters and critics. One of the interviewed officials stated that agency employees felt like they had no choice but to publish the school reopening guidelines in August, which were revised by the White House. CDC staff has largely lost respect for their leader and recent CDC employee surveys show that morale has fallen severely. CDC employees indicated that they view the White House Coronavirus Task Force as a “black box, where the agency’s guidance goes in one way and mysteriously comes out another.” In fact, Redfield is typically in the meetings held by the task force, but without his deputies or subject matter experts. The ongoing crisis at the CDC occurring parallel to the pandemic is eroding trust as the outputs of the agency are increasingly questioned.

Mobility Network Models of COVID-19 Explain Inequities and Inform Reopening

A new article in Nature uses mobility network models to simulate the spread of SARS-CoV-2 to explain inequities and inform reopening activities. The authors introduce a metapopulation Susceptible-Exposed-Infective-Recovered (SEIR) epidemiological model to simulate the spread of SARS-CoV-2 in 10 of the largest US metropolitan statistical areas. Using cell phone data, the mobility networks map the hourly movements of 98 million people from neighborhoods to points of interests like restaurants and religious facilities. Using these integrated networks, this research shows that a relatively simple SEIR model is able to accurately fit the trajectory of real cases. Their model predicts that a small minority of points of interest served as “superspreader” sites, accounting for a majority of infections. This finding supports the notion of restricting maximum occupancy at these types of sites is more effective than uniformly reducing mobility. Their model also accurately predicts higher rates of infection within disadvantaged racial and socioeconomic groups based on differences in mobility. The authors found that members of disadvantaged groups have not been able to reduce mobility as significantly and that the points of interest they visit tend to be more crowded, thus higher risk.

AAAS Kavli Science Journalism Awards

This year, the Kavli Science Journalism Award administered by the American Association for the Advancement of Science (AAAS) celebrates its 75th year! Since 1945, the AAAS Kavli Science Journalism Awards have honored professional journalists for distinguished reporting on the sciences, engineering, and mathematics. The 2020 AAAS Kavli Science Journalism Award winners include six submissions featuring notable explanatory and investigative reporting on the COVID-19 pandemic. Lauren Weber, Laura Ungar, Hannah Recht, Anna Maria Barry-Jester and Michelle R. Smith from Kaiser Health News and The Associated Press won the Gold Award for Science Reporting – Large Outlet with “Hollowed-Out Public Health System Faces More Cuts Amid Virus.” Sarah Kaplan from The Washington Post won the Silver Award for “The Storm Inside.” Ed Yong from The Atlantic won the Gold Award for Science Reporting – In Depth with “How the Pandemic Will End,” “Why the Coronavirus Is So Confusing,” and “America’s Patchwork Pandemic Is Fraying Even Further.” Joss Fong, Áron Filkey and Joey Sendaydiego from Vox won the Silver Award for Video Spot News/Feature Reporting with “How Covid-19 can be more and less deadly than we knew.”  Wendy Zukerman, Rose Rimler, Meryl Horn, Michelle Dang and Blythe Terrell of the Science Vs podcast from Gimlet Media won the Gold Award for Audio with “Coronavirus: Will Chloroquine Save Us,” “Coronavirus: Was It Made In a Lab,” and “Coronavirus: How Many Silent Spreaders Are There?” Yunanto Utomo, Gregorius Jovinto, Bayu Adi Prakoso, Anggara Kusumaatmaja and Haman Hama from (Indonesia) won the Silver Award for Children’s Science News with “Virion: A Tale of Coronavirus for Old School Comic Fans,” “Virion: A Tale of Coronavirus for Old School Comic Fans – Part 2,” and “Virion: An Interactive Quest to Find Covid-19 Vaccine.”

Diana Davis Spencer Foundation Scholarship

The Schar School of Policy and Government is pleased to offer $250,000 in scholarships, made possible by the Diana Davis Spencer Foundation Scholarship, to eligible master’s students admitted to a security studies-related program for the Spring 2021 semester. Students in the Master’s in Biodefense program are eligible. The mission of the Diana Davis Spencer Foundation is to “promote national security, entrepreneurship, and enhance quality of life by supporting education and global understanding.” These scholarships are intended to support future national security professionals and leaders. “The Diana Davis Spencer Foundation gift makes it possible for many students to attend our high-ranked security studies programs and prepare for careers in intelligence and security policy,” said Schar School Dean Mark J. Rozell. “We are grateful for this new partnership that will advance our shared goal of educating and training future policy professionals in these fields.” Distinguished Visiting Professor and former Director of the CIA and NSA Michael V. Hayden touted the gift:

“There has never been a time when the national security threats facing our nation have been as diverse. The Schar School is growing to meet those challenges, be they from peer rivals, persistent terrorist threats, or the consequences of technological developments. This scholarship fund will enhance the Schar School’s already stellar reputation in attracting a strong and diverse pool of graduate student candidates who will serve as our next generation of hands-on, solutions-driven national security leaders.”

Applications are due by 15 November 2020. To apply, click here.

Driven to Extremes: Vehicle Ramming as a Terrorist Tactic

By Stevie Kiesel, Biodefense PhD Student

On Halloween 2017, a horrific terrorist attack took place in New York City. Sayfullo Saipov, a 29-year-old man inspired by the Islamic State, drove a rented pickup truck down a crowded bike path along the Hudson River. After crashing into a school bus, he got out of the truck and began chasing after pedestrians with two guns – later determined to be a paintball gun and a pellet gun. This attack killed 8 and wounded 11, the deadliest terrorist attack in New York City since September 11. Vehicle ramming attacks are brutal, effective, and hard to anticipate or defend against.

In this article, the term “vehicle ramming attacks” (hereafter, VRAs) encompasses any terrorist attack that utilizes the kinetic force of a vehicle to strike its target. This excludes vehicle-borne explosive devices. Some data sets use a broader definition of “vehicle” than I will use here. For example, the University of Maryland Global Terrorism Database considers the September 11th attacks an example of a VRA because the kinetic force of an airplane was used against several targets. This article examines attacks with land vehicles, such as cars, trucks, tractors, and buses, in order to understand how extremists with limited means can still perpetrate a devastating attack with relatively few resources.

The publicly available information from the Global Terrorism Database contains records of VRAs from 1970 through 2018. Because the scope of this analysis is limited to attacks with land vehicles, records that involved planes and helicopters were eliminated, leaving a total of 146 incidents. The charts below show key trends in the number of attacks over time, as well as perpetrators and locations.

VRAs were a relatively rare occurrence from 1970 to 2013. The first spike in VRAs took place in Israel and the West Bank from 2014-2015, followed by a second spike with origins in North America and Western Europe in 2016. The 2014-2015 spike can be attributed to a larger “wave of terror,” where a combination of deteriorating economic conditions and setbacks in Israel-Palestine peace negotiations led to a sharp increase in attacks by Palestinians against Israeli targets. A trend toward unsophisticated tactics and weapons led to a rise in vehicular attacks, perpetrated by individuals motivated by a nationalist struggle.

The second spike captured by the Global Terrorism Database can be attributed mainly to jihadists, particularly those claiming allegiance to the Islamic State. References to vehicle ramming attacks can be found in jihadist sources going back, at least, to 2010, when al-Qaeda in the Arabian Peninsula called on supporters via their magazine Inspireto use this tactic. However, such attacks were sporadic until the Islamic State began losing territory and encouraging its supporters to conduct retaliatory strikes in Western countries. The first attack in this vein was the 2016 attack in Nice, France, which killed 12 and wounded 67. The Islamic State claimed responsibility for this attack and used it as an example for what its followers could achieve. This attack kicked off a wave of similar attacks in countries around the world, including the United States, Sweden, Austria, Spain, the United Kingdom, and Germany.

Several researchers have suggested that vehicle ramming as a tactic has spread like a virus, largely through media and social media networks: “the coverage of VRAs in the media and in online discussion forums on websites has encouraged others, often with wholly different political and religious motives, to engage in VRAs.” This theory may explain why jihadists were responsible for the second spike of VRAs across North America and Western Europe in 2015, and why white supremacists and other far-right extremists in the US have shown increasing interest in the tactic since 2017.

In 2017, white supremacist James Fields drove into a crowd of anti-racism demonstrators in Charlottesville, Virginia, killing one. This incident was a harbinger of vehicle-based violence against protestors in the United States. Ari Weil, a researcher with the University of Chicago’s Project on Security and Threats, has found at least 104 incidents of people driving vehicles into protests in the United States from May 27 (the start of protests against police brutality sparked by George Floyd’s death) through September 5. While all these actions have targeted anti-racism protestors, the motivations of the perpetrators differ from case to case, and more will become known as these cases are investigated and prosecuted. The image below presents a meme that circulated widely across Facebook in favor of these attacks against protestors.

Using a vehicle as a kinetic weapon has several key advantages that will continue to be attractive to violent extremists. First, vehicles are more accessible than numerous other types of weapons – many people own a vehicle or can easily rent one. There is no assembly require, unlike with vehicle-borne explosives, where the bomb must be manufactured and the vehicle may need to be modified. Additionally, no special expertise is required other than the ability to operate the car, and generally the attack can be carried out with little expense. These features make vehicles particularly appealing to lone-actor terrorists, who can easily carry out such an attack on their own. Vehicles are also chosen because they are effective, both in casualties and psychological impact. Several VRAs recorded in the Global Terrorism Database caused double-digit fatalities, and in one case over 100 people were injured. A final attractive aspect of VRAs is that they allow for follow-up attacks. In several cases, after the vehicle was driven into its target, the perpetrator exited the vehicle with another weapon and attacked the crowd.

Defending against VRAs is difficult. Vehicles are highly accessible and used by millions of people every day. Additionally, there are generally very few indicators that someone is planning to commit a VRA. More complex terrorist attacks tend to have multiple points of interception – perpetrators discussing the attacks online, conducting surveillance, or making purchases of suspicious materials. But VRAs are generally conducted by a single person, with little forewarning and little opportunity to interdict the attack. Therefore, risk mitigation tends to focus on hardening security by identifying likely targets and adding barriers and additional security personnel.