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To the Editor: The review¹ of our book by Drs Wilde and Johnson misrepresents the science and history of biological warfare (BW) during the Korean War era. They fail to cite studies and original sources that might have changed their conclusions about "experiments that do not seem logical, based on the level of knowledge that existed in 1950 as well as today."

Wilde and Johnson dismiss as "anecdotal" our evidence from Chinese and North Korean medical sources by claiming that (1) Chinese medical science was backward, and no one with appropriate training evaluated the evidence; (2) the scientific information was vague or incorrect; (3) BW using insects as vectors is fanciful, as insects cannot survive air drops; (4) the outbreaks were of endemic diseases that probably occurred naturally.

The first claim is simply wrong. The Chinese medical scientists involved had affiliations with at least 30 major European and US educational institutions. Others graduated from Peking Union Medical College, affiliated with the Rockefeller Institute and praised by the most famous US epidemiologist of the day, Hans Zinsser.

Second, Wilde and Johnson say the medical reports are unconvincing. However, close reading reveals scientific rigor and restraint. For instance, from suspect air drops they identified the reservoir of scrub typhus, the vole Microtus, and its trombiculoid mite vector. Unable to culture its agent, Rickettsia tsutsugamuchi, nor identify cases of scrub typhus, they refrained from claiming a scrub typhus BW attack. They also reported suspect air drops containing Collembola (springtails) although these were not known disease vectors. A 1957 US Army report described unusually widespread R tsutsugamuchi infection in multiple mite and rodent species during the war in the battlefield area. This paper revealed that Collembola was used in Army laboratories for the mass culture of trombiculoid mites.

Third, Wilde and Johnson discount air-dropped munitions, citing their unpublished experiments with an automobile and a butterfly net. It is documented that Japanese BW scientists successfully experimented with air-dropped insects. We described a document in which G. B. Reed, head of the Canadian biological weapons research laboratory and an expert on insect vectors, informed his government that, "The dropping of insects from the air is entirely feasible," and the Chinese and North Korean evidence credible. It is on the record that the closely coordinated Canadian and US programs developed insect vectors and air-drop munitions during WWII, through the Korean War era and after. By the early 1950s the US Civil Defense Agency was producing training films warning of insect-vector BW.

Finally, every infectious-disease outbreak must be considered in terms of its specific epidemiology. Wilde and Johnson dispute our claims by citing a heterogeneous group of diseases that naturally occur in "Asia" over "decades." Contemporary records detail anomalous outbreaks of disease and specific circumstances.

Wilde and Johnson ignore a wealth of valid medical evidence, supporting nonmedical data, and other corroborating documentation indicating that there were ample means, motive, and opportunity for the United States to explore biological warfare in China and Korea.

Stephen Endicott, PhD; Edward Hagerman, PhD
York University
Toronto, Ontario

1. Wilde H, reviewer, Johnson RN, reviewer. Review of: Endicott S, Hagerman E. The United States and Biological Warfare: Secrets From the Early Cold War and Korea. JAMA. 1999;282:1877-1878. FREE FULL TEXT

To the Editor: In their book, Drs Endicott and Hagerman contend that the United States used biological weapons during the Korean conflict.¹ In their review of that book Drs Wilde and Johnson's skepticism is understandable, but they imply that the medical evidence is vague, that it was collected by unqualified scientists, and that it cannot pass epidemiological examination.² None of these criticisms is valid.

Wilde and Johnson fail to mention 5 cases of inhalation anthrax presented prominently in the book. These cases occurred in northern China within a 30-day period, were without occupational exposure, and occurred following overflights of US aircraft. The cases were diagnosed by physicians with appropriate training at postmortem examination with histologic and bacteriologic confirmation.

A recent Consensus Statement entitled "Anthrax as a Biological Weapon"³ indicates that in the absence of an identifiable occupational exposure even a single case of inhalation anthrax should cause alarm regarding possible biological weapon use. Had 5 similar cases occurred during the Gulf War, or should they occur today, they would be taken very seriously.

It appears unlikely that these reports were fabricated as propaganda. Pathology literature in 1952 described human pulmonary anthrax as bronchopneumonia, often with a bronchial "malignant pustule." Meningitis was sometimes described if septicemia developed. Biological weapon laboratories have reported animal models of inhalation anthrax causing generalized sepsis, but without bronchial, pneumonic, gastrointestinal, or meningeal pathology.⁴ The Chinese autopsy series follows neither of these models, instead reporting hemorrhagic mediastinitis and lymphadenitis and/or hemorrhagic meningitis. These findings were only later recognized as pathognomonic for inhalation anthrax. Moreover, 3 Chinese cases showed gastrointestinal mucosal hemorrhages, and 1 a focal necrotizing anthrax pneumonitis, ancillary findings strikingly concordant with the definitive 1979 Sverdlovsk outbreak.⁵ Furthermore, the theory of an artificial "construction" of an epidemic from preexisting sporadic cases seems unlikely: the Chinese government claim that there were no autopsy cases of systemic anthrax in their institutional files is corroborated by a prerevolutionary publication.⁶

The Chinese experienced and documented a nonoccupational epidemic of inhalation anthrax in 1952. Current epidemiological understanding supports this contention. Only occupational or biological weapon–related inhalation anthrax epidemics have been described.

These findings are profoundly troubling. The question of the true source of the 1952 epidemic should motivate the thoughtful physician to examine this controversy with sober and honest scrutiny.

Martin Furmanski, MD
Newport Beach, Calif

1. Endicott S, Hagerman E. The United States and Biological Warfare: Secrets From the Early Cold War and Korea. Bloomington: Indiana University Press; 1998. 2. Wilde H, reviewer, Johnson R, reviewer. Review of Endicott S, Hagerman E. The United States and Biological Warfare: Secrets From the Early Cold War and Korea. JAMA. 1999;282:1877-1878. FREE FULL TEXT 3. Inglesby T, Henderson DA, Bartless JG, et al. Anthrax as a biological weapon: medical and public health management. JAMA. 1999;281:1735-1745. FREE FULL TEXT 4. Young GA, Zeele MR, Lincoln RE, et al. Respiratory pathogenicity of Bacillus anthracis spores. J Infect Dis. 1946;79:233-246. WEB OF SCIENCE 5. Abramova FA, Grinberg LM, Yampolskaya OV, Walker DH. Pathology of inhalational anthrax in 42 cases from the Sverdlovsk outbreak of 1979. Proc Natl Acad Sci U S A. 1993;90:2291-2294. FREE FULL TEXT 6. Ling C-C, Chen Y-S. Bacillus anthracis meningitis. Chin Med J (Engl). 1948;66:431-434.

In Reply: Drs Endicott and Hagerman asserted that US and Canadian forces used biological weapons during the Korean War causing outbreaks of such diverse diseases as bacterial meningitis; scrub-, murine-, and tick-borne typhus; dengue fever; encephalitis; cholera; smallpox; plague; hemorrhagic fever; dysentery; and typhoid on the battlefield and in mainland China.¹ All of these infections had been reported from the area decades prior to the war.^2-5 Five isolated cases of respiratory anthrax were described from different localities, occurring some 250 miles apart in northern China during the Korean War.¹

Human and animal cases of anthrax are still seen worldwide including in North America.⁶ Nonoccupational inhalation anthrax is very rare but is not unknown. It is difficult to believe that spore containing munitions would leave only 1 person dead at 1 site. An anthrax-infected animal carcass can contaminate an environment for years. Spores can spread by wind or be inhaled by a dutiful son digging up his father's bones for proper burial elsewhere.^{1, 6}

The authors failed to discuss the dismal academic environment in China during that period. Institutes had powerful political monitors and dissidents were forced to submit to humiliating public confessions or worse. Korea and China had endured civil war, an oppressive occupation, famine, and all kinds of human rights abuses. One would expect a near total breakdown of public health. If North Korea and China did not report cases of encephalitis, cholera, and plague in the years prior to 1952, it is likely that the Chinese public health authorities of these countries had other priorities.

Endicott and Hagerman accused the US Army's 406 Laboratory at Tokyo of being actively engaged in offensive biological warfare research and having continued Japanese "studies" from the infamous Manchurian Unit 731.¹ This is untrue. The mission of the 406 Laboratory during and after the Korean War was to act as a reference laboratory for military hospitals and to do research in epidemiology, virology, and microbiology. It was an open facility and teeming with Japanese and other postdoctoral students. The staff made significant contributions by working out such problems as "what happens to the Japanese encephalitis virus during the winter when it virtually disappeared in Japan and Korea."¹ They also worked with malaria, Korean hemorrhagic fever, leptospirosis, hepatitis, dengue, venereal diseases, enteric fevers, and rabies.

The US, British, Canadian, Russian, and other governments have admitted to defensive and offensive biological warfare research since World War I. It is impossible to completely refute all allegations that experiments with microbes and vectors were carried out during the Korean conflict. However, any effort must start with careful examination of the sources of accusations. Endicott and Hagerman failed to present convincing evidence and relied on Chinese government propaganda materials and hearsay. Only the release of Allied engagement reports or the voluntary appearance of an actual perpetrator might settle this emotional issue.

Henry Wilde, MD
Queen Saovabha Memorial Institute and Chulalongkorn University
Bangkok, Thailand

1. Endicott S, Hagerman E. The United States and Biological Warfare: Secrets From the Early Cold War and Korea. Bloomington: Indiana University Press; 1998. 2. Gubler DJ. The global pandemic of dengue/dengue hemorrhagic fever: current status and prospects for the future. Ann Acad Med Singapore. 1998;27:227-234. PUBMED 3. Fan MY, Walker DH, Yu SR, et al. Epidemiology and ecology of rickettsial diseases in the People's Republic of China. Rev Infect Dis. 1987;9:824-840. 4. Smorodintsev AA, Chudakov VG, Churilov AV. Haemorrhagic Nephroso-Nephritis. London, England: Pergamon; 1959. 5. Hugh-Jones M. 1996-97 Global Anthrax Report. J Appl Microbiol. 1999;87:189-191. FULL TEXT | PUBMED 6. Turnbull PC, Lindeque PM, LeRoux J, et al. Airborn movement of anthrax spores from carcass sites in the Etosha National Park, Namibia. J Appl Microbiol. 1998;84:667-676. FULL TEXT | PUBMED

Letters Section Editors: Stephen J. Lurie, MD, PhD, Contributing Editor; Phil B. Fontanarosa, MD, Deputy Editor.

JAMA. 2000;284:561.

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