Forensic Epidemiology: When is an illness also a crime?

On November 1, 2006, a previously healthy 43-year-old male named Alexander Litvenenko presented to a London medical facility complaining of a sudden GI illness. Initially there was no thought of a connection between Litvenenko’s illness and his previous job with the KGB or his current criticism of Vladimir Putin. Rather, the illness was thought to be simply a form of food poisoning from a sushi meal earlier that day. Only after the man became gravely ill with hematemesis, hematochezia, and failure of his bone marrow was the possibility of radiation exposure considered.

Only after Mr. Litvenenko lost his hair were his claims of assassination heeded. Eventually, Polonium 210 was found in Litvenenko’s urine. He died three weeks after his initial presentation. British authorities investigated. On January 26, 2007 (87 days after the attack), a tea pot from the Millennium Hotel was discovered that was not only highly contaminated with Polonium-210 but was also in continuous use. Prior to detection, multiple airlines, hotel and medical personnel, and an unknown number of the public were exposed due to the delay in recognition. The alleged perpetrator, Mr. Alexi Lugovoi, remains at large in Russia.

Americans need to change the way we use information to improve homeland security in an age of terrorism. There are approximately 17 active Islamic terrorist groups and 751 active domestic hate groups operating in the United States, each with its own agenda and methods, which may include bioterrorism. To recognize a bioterrorism event early, medical, public health, and law enforcement information must be shared more efficiently than has been the case in the past.

Forensic Epidemiology is a new discipline that combines medical, public health and  law enforcement information to create situational awareness of illness that could indicate a natural event, an accident, a crime, or a national security matter. The threat of chemical, radiological, and biological agents may create ill victims in which recognition and response must happen simultaneously for lives to be saved and contamination limited. Information collection, analysis, decision-support, needed medications, mitigation strategies, and rapid surge capacity must be rapidly and accurately implemented for the event to be recognized and the victims saved.  Forensic Epidemiology differs from standard epidemiology in that it includes law enforcement information on terrorist subjects, goals, capabilities, and likely venues of attack in its analysis of illness patterns. Forensic epidemiology analysis may produce law enforcement actions, investigations, or result in criminal charges; which must be done with both speed and accuracy to serve the needs of national security organizations. Emergency Medical Services and emergency departments will be the first to see these victims and therefore have the first opportunity to detect disease patterns that correspond to deliberate attacks and therefore are vital components of the national strategy for counter-terrorism. Failures at this level can have far-reaching consequences.

As the Litvenenko case demonstrates, there are several unique challenges to accomplishing forensic epidemiology analysis, some structural and some operational. Structural challenges include the fact that over 90% of healthcare in the US is delivered by private businesses who are largely uneducated about the presentations of chemical, radiological, and biological terrorism. Over this system lies another highly irregular system of municipal, county, state, and federal public health authorities, each with different capabilities and interest in terrorism investigations. Each level possess information on terrorist group characteristics, but there exist very little process guidance to regulate the combined analysis of protected health and classified law enforcement information. Without a forensic epidemiology partnership, both health practitioners and law enforcement personnel are blinded from each other’s information.

There are also many operational challenges in sharing and analyzing such information. These can be summed up as issues of “threshold” and of “responsibility and authority”. Threshold problems deal with the initial recognition and reporting of an event. Individual practitioner limitations, lack of awareness, and lack of confidence to report a questionable event, create these barriers. In the absence of an overt threat like white powder and a threatening letter, illness patterns that may constitute a “terrorist attack” are unclear to most medical, public health, and law enforcement personnel.

Once an event has been reported, proper authorities must establish clear lines of responsibility and authority under which an investigation may be conducted. Historically, this process takes weeks to months. If the Litvenenko case had occurred in a major US city, it would have involved municipal and state health departments; the US Dept of Energy and Federal Bureau of Investigation; along with various state and local Hazardous Materials Teams, law enforcement organizations, and medical practitioners. Legal statutes governing forensic epidemiology investigations are equally variable and are found at various levels of government within the US system of federalism.

Emergency physicians are mostly concerned with recognition and reporting, therefore forensic epidemiology methodologies must be local and familiar, not federal. Emergency physicians are placed not only on the “front line” of detection, we are also the secondary victims should a hazardous event go unrecognized. It is vital that forensic epidemiology structures be developed and maintained.