Needed: A Comprehensive Medical Intelligence Picture

Acts of bioterrorism, diseases for which there are no treatments (or that have become resistant to treatments that have been effective in the past but are less effective today), and the spread of diseases with catastrophic consequences – e.g., a pandemic flu – are all part of today’s response environment.  First responders, health professionals, and security personnel need much better medical intelligence about these and other health issues to complete their operational pictures and be able to save lives.  

The term medical intelligence, which originated in the Department of Defense, refers to the type of intelligence related to foreign medical, bio-scientific, and environmental information that could have a significant impact upon military planning and operations overseas.  However, medical intelligence as a major subject area has in recent years become a civilian priority as well, and has grown to emphasize other matters – including domestic public health and healthcare delivery data, a determination of how diseases might affect foreign dignitaries who contract such diseases, and studies of how different agents that negatively affect health might be intentionally or accidentally introduced into the local population.

Today, the process for generating medical intelligence should and usually does involve taking all of the different types of information regarding and affecting the health and security of people in a particular region, and analyzing it. Carrying out this process presents a variety of challenges, including the difficulties involved in dealing with often vastly different types of data; the assignment of responsibility – to organizations that by law are allowed to have access to such information – for generating the information needed to develop an accurate and complete domestic medical intelligence picture; and finding and/or training analysts who possess both intelligence and public health analytic skills. Once generated, this accumulation of medical intelligence has to be actionable, practical, and distributed to those who might have a legitimate need for it – the police officer on the beat, for example, the hospital nurse, the political decision maker, and in many if not all cases, the everyday citizen.  

A Grim Realization, and Unwarranted Assumptions

For many years, members of the intelligence community – including, among others, personnel assigned to the Armed Forces Medical Intelligence Center, the Central Intelligence Agency (CIA), and the State Department’s Bureau of Intelligence and Research – collected and analyzed medical and other health-related information, usually concentrating on: (a) illnesses that were affecting foreign dignitaries; and (b) the disease burden in countries in which the United States expected to deploy troops and/or intelligence personnel.

The grim realization that certain other countries were still producing biological weapons added new and more demanding collection requirements to those intelligence agencies (the CIA again, and all of the military intelligence agencies) directly responsible for programs and situations involving weapons of mass destruction (WMDs), regardless of the type of agent weaponized.  One difficulty with this obvious and seemingly prudent approach was that, without significant changes in the backgrounds and perspectives of the analysts responsible for addressing these new requirements, the procedures of the past continued to be followed. Another difficulty was that, in those days, the biological threat was considered to be more or less a variant of the chemical threat, a gratuitous assumption that led in turn to the unrealistic and in many ways misleading “ChemBio” approach.

When the chemical and biological threats were finally split into two separate entities, a temporary paralysis of sorts spread through the nation’s intelligence, law-enforcement, and first-responder communities. This was understandable in view of the fact that the threat posed by chemical agents conveniently shares a number of characteristics with the threat caused by most explosives – and the latter is a threat the U.S. intelligence community already understood quite well. For that reason alone, the threat posed by chemical weapons seemed relatively familiar. Further complicating the picture was the fact that the delivery of chemical weapons was thought to be localized, and in many situations the effects of chemicals are so quick that decontamination and clean-up are the most common and sometimes only response possible.  

But the biological threat was almost completely different, in several ways – and those differences were and are intimidating.  The general consensus in the intelligence community was that the biological threat was too great, too complicated, and too far outside any particular agency’s jurisdiction to be dealt with effectively. For those and other reasons, the modus operandi followed by most agencies was to respond to an event involving biological weapons in the same way they would respond to a chemical event.

Forging New Partnerships

Increasing evidence soon indicated, however, that both biological terrorism and biological warfare were rapidly becoming real and present dangers, and it was in that context that information about the very different types of dangers posed by microorganisms and chemicals began to be accumulated and distributed more broadly. The intelligence organizations that were most successful in overcoming their previous paralysis in dealing with the biological threat did so by developing, reestablishing, and strengthening partnerships with other organizations with which they previously had little or no contact. In relatively short order, intelligence specialists were working with the agricultural community, for example, law-enforcement agencies were working with public health authorities, and other ad hoc partnerships of a similar nature were in various stages of formation. However, the more information these communities exchanged, the more evident it became that medical intelligence, particularly in domestic matters, was sorely lacking.  

To the extent that medical intelligence is currently available, members of the federal, state, territorial, tribal, and local governments, as well as the military, can obtain that intelligence directly from the Armed Forces Medical Intelligence Center ( One problem here, though, is that the center’s medical intelligence is focused primarily on threats and situations outside of the United States itself, and is understandably oriented toward troop deployments overseas.

Fortunately, an abundance of other relevant information is available from public health agencies that have broad mandates to address naturally caused and intentionally distributed diseases – e.g., the U.S. Centers for Disease Control and Prevention, and the World Health Organization. However, the fact remains that no one organization currently has all of the information needed by responders and incident commanders to generate the actionable medical intelligence required to plan adequately, prior to an actual mass-casualty event or incident, for the response actions likely to be needed.  

Pointed Questions, Unusual Events

The generation of the much more comprehensive medical intelligence now needed is based on three prerequisites: (1) bringing together all of the organizations that have any relevant input to the overall medical intelligence enterprise; (2) training analysts to do what many have never been trained to do (namely, be lateral thinkers, be able to operate simultaneously in two or more different worlds, understand and be able to speak different organizational languages, and see trends, patterns, relationships, and connections where no one else can see them); and (3) making medical intelligence activities more than just a federal responsibility.  

Non-federal organizations can join the collective effort rather easily. For example, local, tribal, territorial, and state law-enforcement organizations can work with public health agencies to find out: (a) what the disease burden is in their jurisdictions; and (b) how those diseases can and do affect their own personnel as they respond to disturbances and crime.  For those same organizations, for example, knowing that antibiotic-resistant tuberculosis exists is one thing – but knowing that it co-exists with crime in the highest crime areas is another, and affects how police and other responders handle themselves in those neighborhoods.  

The next step should be to track abnormal health events in various localities, then pose questions, such as the following, to a disparate but knowledgeable group of representatives: Why is it that a problem with whooping cough has suddenly developed here, and only here, in this county?  Why is it that there suddenly seems to be a problem with E. coli at this particular restaurant chain?  Does it mean anything of significance is happening when birds suddenly fall out of the sky in just one city?  

The posing of such questions to a group of intelligent people coming from very different backgrounds will prove informative in itself, and will generate not only a number of possible answers but also some follow-up requirements. Beyond that step, purposeful but more comprehensive data collection and analysis could be undertaken, as could assuming that unusual events lacking reasonable explanations are probably the result of biological terrorism or warfare – in which case analysis and operations should be conducted accordingly.  

The Credibility of Smaller Sociopolitical Units

It would not necessarily cost millions of dollars to obtain and analyze such data.  States, territories, tribes, and localities already have in their files much of the data that ultimately would be needed. A credible case could be made, in fact, that the smaller the sociopolitical unit, the more information about that unit is likely to be available without asking for federal assistance. It may well be that as requirements for and the understanding of medical intelligence both continue to develop, state intelligence fusion centers and similar operational headquarters find that they are ideally suited to meeting the bulk of the nation’s overall medical-intelligence requirements.  

To summarize: A much more detailed, and comprehensive, medical intelligence picture is required before a successful response can be mounted to any event that affects the health of a major segment of the population. However, U.S. federal agencies have not yet determined how best to meet the requirement to develop, analyze, disseminate, and use the huge amounts of intelligence data required. Moreover, some of the sources of information necessary for analysis – and, eventually, the production of medical intelligence – are available only at the state and lower levels, or in the private sector.

In short, the truly comprehensive medical intelligence picture needed can be achieved only with the supportive input from, and leadership provided by, a broad spectrum of non-federal entities. 

Asha M. George

Asha M. George, DrPH, is the executive director of the Bipartisan Commission on Biodefense. She is a public health security professional whose research and programmatic emphasis has been practical, academic, and political. She served in the U.S. House of Representatives as a senior professional staffer and subcommittee staff director at the House Committee on Homeland Security in the 110th and 111th Congress. She has worked for a variety of organizations, including government contractors, foundations, and non-profits. As a contractor, she supported and worked with all federal departments, especially the Department of Homeland Security and the Department of Health and Human Services. She also served on active duty in the U.S. Army as a military intelligence officer and as a paratrooper. She is a decorated Desert Storm Veteran. She holds a Bachelor of Arts in Natural Sciences from Johns Hopkins University, a Master of Science in Public Health from the University of North Carolina at Chapel Hill, and a Doctorate in Public Health from the University of Hawaii at Manoa. She is also a graduate of the Harvard University National Preparedness Leadership Initiative.



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