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Biological and chemical warfare date to biblical times. The Old Testament describes a series of plagues, some involving biologic agents, that convinced the Pharaoh to let the Jews escape slavery in Egypt, and Judges 9:45 has a reference to the use of salt to destroy crops (1). As early as 300 BC, Persian, Greek, and Roman literature discussed using animal and human cadavers to contaminate drinking water. In the middle ages, Tatar troops catapulted plague victims over their enemy's city walls (1–3). Aerosolized weapons appeared in the in the mid-seventeenth century, when a Polish infantryman suggested creating hollowed bombs filled with rabid dog saliva and other materials that could cause disease (1,3). In 1763, bioterrorism arrived in the New World, when British troops supplied smallpox contaminated blankets to Indian tribes during the French and Indian War (1–3).

Historically, most planning for an emergency response to terrorism has focused on overt attacks such as bombings and attacks using chemicals. Chemical events are also likely to be overt because inhalation or skin/mucous membrane absorption of chemicals produces effects that are usually immediate and obvious. For obvious reasons, explosive and chemical attacks elicit an immediate response by law enforcement, fire and Emergency Medical Services personnel. In comparison to chemicals and explosives, the impact of biologic agents is more likely to be covert and delayed. As the recent anthrax events demonstrated, biologic agents do not have an immediate impact due to the interval between exposure and the onset of illness (the incubation period) (1). Consequently, the most likely responders to future biologic attacks will be family physicians and other primary health care providers. For example, after an intentional, covert release of Variola virus, some infected patients would arrive at their doctors' offices and local emergency rooms 1–2 weeks later. Other infected people may have traveled, and they would probably show up at emergency rooms distant from their homes. Their symptoms would appear at first to be an ordinary viral infection, including fever, back pain, headache, and nausea. As the disease progressed, many physicians would not recognize the characteristic early stage papular rash of smallpox.

Chemical terrorism, the use of chemicals to cause human casualties or environmental destruction for political purposes, is as least as ancient as the Bible. Judges 9:45 describes the use of salt to poison soil used to grow crops (1). During the Peloponnesian War, in 429 BC, troops used smoke from lighted coals and sulfur to injure civilians barricaded in forts (2). In modern times, World War I featured the use of chemical weapons, specifically chlorine, phosgene, and mustard gas, in causing over 1 million injuries and deaths to soldiers and civilians (1). Perhaps the most horrific use of chemical weapons was the Nazi use of Zyclon B to kill over 6 million Jews and other civilian victims during the holocaust in Europe. More recently, in 1995, the cult Aum Shinrikyo used Sarin gas in attacking Tokyo subway passengers.

Radiological terrorism is the use of radioactive material to cause human casualties, environmental destruction and maximum disruption, panic and fear (1) in the general population for political purposes. Since the atomic bombing of Hiroshima in 1945, with 150,000 casualties and 75,000 fatalities (2), people have feared nuclear explosives more than any other weapons of mass destruction, because of the ability of these weapons to cause immediate devastation and trauma, and because radiation, undetected by human senses, can cause ongoing morbidity and mortality, including cancer, years after exposure (3).

The intentional use or threatened use of biological, chemical and radiological agents has proven effective in coercing and intimidating populations. One review of available literature on biological, chemical and radiological terrorism identified several terrorist aims (1):

In October 2001, when the first anthrax patients sought medical care, none of them had a history suggesting exposure to anthrax. Given the rarity of anthrax, many other causes more likely explained their early, nonspecific symptoms. The diversity of anthrax victims, which included an infant, revealed that biological terrorism could affect anyone, regardless of age, gender, health status, occupation, or socioeconomic status (1). The anthrax events also taught us that alert clinicians who recognize a potential terrorist-caused illness, obtain the appropriate laboratory tests, and notify public health officials, play a critical role in protecting their communities as well as their individual patients (1). Early warnings to local health officials, who work closely with law enforcement, can be successful in preventing additional casualties.