The imaginary patients started stumbling into emergency rooms in Munich and Frankfurt, then Istanbul and Los Angeles, and within hours after the start of a war game yesterday, Western intelligence agencies concluded that there had been a choreographed attack on numerous cities by terrorists wielding smallpox pathogens.
By mid-afternoon, health experts realized that millions of people worldwide would soon die agonizing deaths. World leaders -- or at least people posing as them -- who were assembled at a mock Washington summit yesterday interrupted each other and waved their arms as they debated potential real-life choices. Perhaps the most important: Would wealthy nations that possess smallpox vaccine share it with their unprepared neighbors?
The exercise, called Atlantic Storm, featured former secretary of state Madeleine K. Albright as the U.S. president and eight current or former high-ranking officials of America's European allies -- such as Britain, France and Germany -- role-playing as the prime ministers of their respective countries.
In the war-game scenario, they were gathered for a routine Washington summit to discuss problems such as the global response to the South Asian tsunami when word emerged of a rampaging virus outbreak. An al Qaeda offshoot had constructed the pathogens in an Austrian brewery and had released them at a dozen sites.
Within hours of the first victims being diagnosed with smallpox, riots developed on the Polish border with Germany, whose border guards barred entry to nearly everyone. The Germans had enough vaccine to protect all their citizens, while the Poles had enough for only 5 percent of theirs.
This real-life distinction between the nations with sufficient smallpox vaccines and those with far too little was a key element of the day's events. In reality, the United States, Britain, France, Germany, the Netherlands, the Czech Republic, Israel and Singapore can vaccinate 100 percent of their residents, while Canada and Japan, for example, have enough vaccine for about 20 percent of theirs, and Turkey for just 1 percent.
"The United States is feeling unappreciated now" because of world condemnation of its invasion of Iraq, Albright said in her role as the president, reflecting on the political pressures on her to protect people in this country before sending spare doses overseas. "A lot of Americans are saying, 'Why cooperate with them, anyway?' " she said.
"This is creating horrible pressures among and within nations," said Jan Eliasson, the Swedish ambassador in Washington, who acted as his country's prime minister.
Turkey -- which in the war game had suffered an attack at the bazaar in Istanbul -- was urgently requesting vaccine for all its 70 million residents.
Throughout the day, France's prime minister -- played by former French health minister Bernard Kouchner, a physician -- continually told the summit members that they were moving much too slowly in reaching consensus on policy matters. "This is the emergency period," he said at one point. "We must not lose one hour."
The players seemed disoriented on a number of key policy questions that, in the event of a real attack, would require speedy worldwide decision-making and action. One was the question of whether it is safe to dilute smallpox vaccines by 5 to 1 to stretch limited supplies. U.S. government scientists said it was, but the Europeans disagreed.
Perhaps the starkest lesson of the war game -- which was sponsored by Johns Hopkins University and the University of Pittsburgh, among other organizations -- was that there is no playbook anywhere to guide international leaders on how to divide up the few extra doses of vaccine, or even who would make such decisions. By the end of the day, the participants agreed that the World Health Organization, a United Nations affiliate, should handle the job, but Albright said that, as a U.S. president pressured by constituencies that mistrust the United Nations, she agreed to that only reluctantly.
Throughout the exercise, the leaders begged each other not to take the dangerous step of closing borders, which they knew would create panic and destroy the world economy. But within hours, Germany and the Netherlands had done so.
A simulated newscast at the day's end described the state of the world two months after the attack, in terms bioterrorism experts said were realistic -- 45,000 Americans dead, millions dying worldwide, the global economy at a standstill and ethnic fighting in many nations.
"It was a shock how little prepared many countries were," said former Dutch interior minister Klaas de Vries, who played the role of his country's prime minister.
"The scenario we posited is very conservative," said Tara O'Toole, a Pittsburgh bioterrorism expert who helped organize the event. "The age of biological weapons is not science fiction; it's here."