How to Lead during Bioattacks with the Public's Trust and Help

This interactive manual is the executive summary of the Working Group consensus statement. By outlining key points and providing supporting case studies of responses to real-life crises, the manual is designed to advise leaders of four specific issues that should be considered in bioterrorism and epidemic response planning. Specifically:

• What defines "leadership" during an epidemic or biological attack?
• Why do bioattacks present special challenges and high-stakes decisions for leaders?
• What leadership dilemmas may arise in a deliberate epidemic, and how might they be averted?
• What situations splinter the social trust necessary to cope with health crises, and how might they be diffused?
• Informational Graph: Agility, Endurance, and Recovery Through Collaboration
   

What defines "leadership" during an epidemic or biological attack?

Five strategic goals help distinguish successful leadership during an epidemic or bioattack in 21st century America. An informed and involved public, along with guidance and material support from respected leaders, can help achieve these aims:

• Limit death and suffering through proper preventive, curative, and supportive care; tend to the greater vulnerability of children, the frail elderly, and the physically compromised.
• Defend civil liberties by using the least restrictive interventions to contain an infectious agent that causes communicable disease.
• Preserve economic stability, managing the financial blow to victims as well as the near- and long-term losses of hard-hit industries, cities, and neighborhoods.
• Discourage scapegoating, hate crimes, and the stigmatization of specific people or places as "contaminated" or unhealthy.
• Bolster the ability of individuals and the larger community to rebound from unpredictable and traumatic events; provide mental health support to those who need it.
   

Why do bioattacks present special challenges and high-stakes decisions for leaders?

A deliberate epidemic poses compounded, unfamiliar dangers in today's setting. Most elected U.S. officials, health authorities, and the public have no direct experience with large outbreaks, nor do they know the best ways to control them. Even less familiar is the premeditated use of disease as a weapon.

Epidemics are complicated events due to their biology, but also because they provoke fear, contradictory impulses, and competing social aims:

• An epidemic's outcomes: Suffering, death, lost livelihood and commerce—are troubling to consider. Leaders and the public may deny that a problem exists, or intervene too quickly without regard to the negative effects of their actions.
• People need to make sense of random and terrifying events, but epidemics elude quick and easy explanation. The nature of a disease, a population's vitality, and the responsiveness of health institutions affect how an epidemic unfolds.
• A mysterious disease can trigger the human reflex to isolate oneself and blame others for the tragedy or, in deep contrast, to care for victims without regard to one's own safety.

Features of modern society can speed up and disperse an epidemic's negative impact and make some people more vulnerable than others:

• Global media and around-the-clock news reports cause anxiety and dread in people, even those who are in places far from immediate danger.
• Today's transportation systems move people quickly across vast distances, potentially accelerating the spread of disease.
• Epidemics have broad, indirect financial impacts due to close ties among global, national, and local economies.
• Poverty, lack of health insurance, and distrust of the healthcare system mean that those who are most vulnerable during disease outbreaks are least able to protect themselves.
• Personnel shortages and lean budgets limit the emergency response capabilities of U.S. hospitals and state and local public health agencies; they are spread thin on a "normal" day.

A calculated attack further magnifies the consequences of an epidemic:

• An attacker's motivations and tactics—for example, attacks on multiple cities, over a prolonged period, or on random victims—heighten an epidemic's uncertainties.
• Scapegoating will be more severe in the case of bioterrorism than in natural outbreaks as people demand to know, "Who did this?!"
• If a disease is weaponized or infects people through an unusual route (such as the mail), it may be harder to detect and treat. What is known about natural outbreaks of the same disease may not apply.
• The wide range of scenarios—scares, discrete non-lethal attacks, a campaign of mass casualty attacks—makes planning for every contingency impossible.
   

What leadership dilemmas may arise in a deliberate epidemic, and how might they be averted?

An epidemic exerts immense political and social pressure for decisive, visible action—more so in the case of a bioattack. Apparent and sometimes genuine conflicts among strategic goals can arise in this charged setting. The most common dilemmas facing past leaders have been balancing disease control imperatives with those of individual liberty, economic stability, and preventing stigma.

Stopping disease that spreads person-to-person while upholding individual freedoms

• Make bioterrorism response plans public before a crisis occurs; a well-informed population is more likely to cooperate with advice for reducing the spread of disease.
• Sketch out the "big picture"; make concrete the fact that personal actions can affect the safety of others—for example, remind people that staying home from work or keeping children out of school when they are ill protects others from getting sick.
• Use disease controls that respect ideals of autonomy, self-determination, and equality—public cooperation limits illness and death; public resistance does not.
• Provide goods and services that help people comply with health orders—for example, set up vaccination clinics in locations accessible to people without cars.
• Restrict civil liberties, if necessary, only in a transparent and equitable way.

Protecting the economy while using disease controls that disrupt commerce

• Be mindful of the goal of long-term financial recovery when controlling disease; do not react based solely on the desire to avert short-term economic loss.
• Recognize public trust as precious "capital" that grows the economy—for example, if people see their health as your top priority, confidence in your efforts to safeguard the economy will follow.
• Account for the less visible and more scattered monetary impacts when making epidemic control decisions (e.g., costs of victims' healthcare; economic toll of stigma).

Restoring social bonds when people feel at the mercy of a mysterious disease or attacker

• Express empathy for people's fears about getting sick from others; follow up with meaningful medical details that allow people to gauge personal risk accurately.
• Demonstrate compassion toward victims of disease; explain to the community-at-large the social costs of avoiding people out of fear, rather than out of actual danger.
• Provide frequent updates on the criminal investigation; counsel people not to lash out against others who "look like" presumed perpetrators.
• Spotlight community projects aimed at bringing people together across social divisions sensitized by the crisis -- for example, ethnic and religious affiliations in the case of 9/11.
• Direct law enforcement to deal appropriately with hate crimes in the event prevention fails.
• Coordinate volunteers, relief groups, and civic organizations in humanitarian response, with extra focus on assisting the most vulnerable—for example, children, the frail elderly, and disabled people of all ages.
   

What situations splinter the social trust necessary to cope with health crises, and how might they be defused?

Breaches of social trust are a common predicament for leaders during outbreaks and are likely to arise during a bioattack. Social and economic fault lines as well as preconceived notions about "the government," "the public," and "the media" can alienate leaders and the public, and community members from one another.

Preventing unproductive fear, denial, or skepticism on the part of the public when delivering crisis updates:

• Share what you know. Do not withhold information because you think people will panic. Creative coping is the norm; panic is the exception.
• Hold press briefings early and often to reach the public. Answering questions is not a distraction from managing the crisis; it is managing the crisis.
• Confirm that local health agencies and medical facilities are prepared to handle an onslaught of questions from concerned individuals, in person and by phone.
• Convey basic health facts clearly and quickly so that people have peace of mind that they are safe or so that they seek out care, if need be; similarly, brief healthcare and emergency workers so they have a realistic understanding about job safety.
• View rumors as a normal sign of people's need to make sense of vague or disturbing events. Refine your outreach efforts; the current ones may not be working.

Earning confidence in the use of scarce resources despite existing social and economic gaps:

• Account for income disparities in response plans; anticipate the need for free or low-cost prevention and treatment.
• Make planning transparent so that the public sees that access to life-saving resources is based on medical need and not on wealth or favored status.
• Be open about eligibility criteria for goods and services, especially when tough choices arise unexpectedly—for example, which botulism attack victims will receive the limited antitoxin that exists.
• Show thorough preparations to protect vulnerable populations like children and the frail elderly, thus bolstering everyone's sense of security.

Maintaining credibility when decisions must be made before all the facts are in:

• Advise the community at the outset if crisis conditions are evolving or could be prolonged.
• Offer more detail rather than less, even when the unknowns outnumber what is known; resist the urge to reassure for reassurance sake alone.
• Be frank about any uncertainty regarding "facts"; describe plans to fill in knowledge gaps.
• Vary your means of reaching the public. Mix high-tech outreach (internet, cable, network, print, radio, cell phone, automated hotlines) with contact through grassroots leaders.

Agility, Endurance, and Recovery through Collaboration

Dynamic, cooperative effort among leaders and residents of a model city helps resolve the immediate health crisis, hasten long-term recovery, and promote the ability to weather future adversity.

Legend:

Leaders and decision makers—such as the mayor, health commissioner, emergency manager, and police and fire chiefs: Ideally discern the "big picture" and tailor their advice and actions accordingly.

Intermediates: "Connecting" people on a regular basis in everyday settings, such as workplaces, schools, neighborhoods, and places of worship, and providing information that is passed along by trusted sources, such as family, friends, grassroots leaders, and journalists. 

 Public-at-large: Members of the public have only a diffuse impact if individual efforts are not harnessed to one another and if people judge their actions only from their own point of view. At the same time, their broad reach provides a potential safety net for dispersed, vulnerable populations, such as children and non-institutionalized disabled people. 

 Solution

 Context: The city is not self-contained. For example, commuters move between home and work; leaders interact with their counterparts in neighboring jurisdictions; federal authorities lend their support.

Modeling an Actual City

Representative statistics taken from a mid-sized Northeastern U.S. city demonstrate the relative numbers and influence of leaders, intermediaries, and the public.

• Leaders: Mayor, Mayor's Cabinet, City Council - 49
• Intermediaries: 
  • Schools - 558
  • Religious Organizations - 675
  • Community Organizations - 854
  • News Outlets (print, radio, broadcast) - 39
• Public-at-Large:
  • Total Population - 651,154
  • Children 19 Years and Younger - 183,207
  • Non-institutionalized Disabled - 162,044
• Context:
  • Counties and States within 90 Miles - 26
  • Daily Commuters - 229,526

References

Leaders

• "The Mayor's Cabinet" accessed 2/16/04; "City Council Members" accessed 2/16/04
• Total budgeted positions according to FY2001 budget. "Managing for Success" Baltimore City Personnel Operations and Management Report presented to Mayor Martin O'Malley July 6, 2001 Greater Baltimore Committee.

Intermediaries

• Schools: Combined total of public, private and publicly funded specialty schools. Baltimore City Public School System. "School Profiles 2002-2003" accessed 2/12/04; "Nonpublic Schools Approved By the Maryland State Board of Education" accessed 2/12/04
• Religious Organizations: Includes churches, synagogues, mosques and other religious organizations. Data from Baltimore City GIS 2002. on Baltimore Neighborhood Indicators Alliance website, accessed 2/20/04
• Community Associations: Tenant, neighborhood and neighborhood business associations. "Community Association Directory" accessed 2/12/04
• News Outlets: Includes local newspaper, weekly alternative community papers and city specific magazines:  "Baltimore City Media" accessed 2/17/04; "Baltimore -Media Links" accessed 2/17/04

Public-at-Large:

• Total Population: U.S Census Bureau, Census 2000 "Profile of General Demographic Characteristics: 2000" Table DP-1 Baltimore City, Maryland. www.census.gov
• Children 19 Years and Younger: Based on population 3 years and older enrolled in nursery or pre-school, through high school; not including college or graduate school enrollment. U.S. Census Bureau, Census 2000 "Profile of Selected Social Characteristics: 2000. Table DP-2: Baltimore City, Maryland www.census.gov
• Non-Institutionalized Disabled: Civilian Non-institutionalized population. Defined by U.S. Census as
  • Person 5 years old and over reporting a long-lasting sensory, physical, mental or self-care disability
  • Person 16 years old over and reporting difficulty going outside the home because of a physical, mental, or emotional condition lasting 6 months or more; or
  • Person 16-64 years old reporting difficulty working at a job or business because of physical, mental or emotional condition lasting 6 months or more
• U.S Census Bureau, Census 2000 "Profile of General Demographic Characteristics: 2000" Table DP-1 Baltimore City, Maryland www.census.gov

Context

• Counties and States within 90 Miles: Road Atlas: United States Canada Mexico. 1999. Rand McNally.
• Daily Commuters: Commuting Flows to and from the Baltimore Region, 2000 Baltimore Metropolitan Council accessed 2/16/04

The following case studies are examples of responses to recent crises.

2003, Fearing SARS, New Yorkers Avoid Chinatown

Despite the fact that the number of potential SARS cases in New York City was few during the 2003 outbreak, fear of the disease kept many people away from the usually bustling Chinatown neighborhood. Acting on the presumption that Chinatown residents and merchants traveled back and forth frequently to Asia and therefore posed a greater risk for transmitting SARS, New York City residents and tourists avoided Chinatown in an effort to protect themselves. Local businesses felt the impact; in late April 2003, nearly 2 months after the disease was first identified in Asia, 84% of surveyed Chinatown businesses reported a drop in business because of the SARS crisis. Many proprietors reported drops of 30% or more. Restaurants, grocers and the garment industry suffered, but travel agencies were the hardest hit -- some nearly went out of business.

Reference: Asian American Business Development Council. "Double Impact: Chinatown Businesses Still  Struggling from the Impact of September 11th only to be Hit Again with the SARS Crisis." April 28, 2003. Accessed online 4/29/03.

1976, Swine Flu Vaccination Campaign Too Much, Too Soon

In 1976 a new, potentially serious flu virus emerged. To avoid the staggering numbers of casualties experienced during the 1918 pandemic (550,000 in the U.S.), health authorities swiftly launched a national immunization campaign. However, the pandemic never materialized, and the flu shots were subsequently blamed for a wave of Guillain-Barré syndrome cases. These factors overshadowed public health efforts and negatively affected people's attitudes about vaccine safety.

Reference: Kolata G. Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It. New York: Farrar, Strauss & Giroux; 1999.

1918, Spanish Influenza Grips the Globe

In 1918 and 1919, the world faced the "Spanish Lady," a particularly severe strain of flu that killed 550,000 in the U.S. alone. To control the spread of disease, Baltimore, Maryland health officials cut retail business hours. This seemed like a sound decision from a public health perspective, but the measure angered hourly retail workers. They needed the income to buy extra heating fuel, which they felt was vital to their and their families' well-being in the midst of an epidemic.

Reference: Schoch-Spana M. Psychosocial consequences of a catastrophic outbreak of disease: lessons from the 1918 pandemic influenza. In Bioterrorism: Psychological and Public Health Interventions, Ursano R, Fullerton C, Norwood A, eds. Cambridge University Press, 2004.

2003, Information about SARS Elusive

The 2003 SARS epidemic was prolonged and unfolded gradually. The first known SARS cases emerged in mid-November 2002 in China's Guangdong Province. Four months later, China formally reported the outbreak to the World Health Organization (WHO), by which time at least 305 cases and 5 deaths had occurred. The disease made its way to Hanoi, Hong Kong, Singapore, and Toronto—where health officials and practitioners faced the urgent need to halt the outbreak, despite a dearth of clinical and epidemiological data. What's causing this illness? How is it spread? Who has been exposed and should be isolated? Why are so many health care workers getting sick? What is the best therapy? Scientists working non-stop as part of a global network took 4 weeks to identify a novel corona virus as the causative agent and another month to describe the mode of transmission. Many uncertainties about SARS still remain, including whether the virus may resurface in a more virulent form.

Reference: World Health Organization (WHO) Communicable Disease Surveillance and Response.Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons for the Immediate Future. 20 May 2003; Geneva: WHO.

2001, Anthrax Evades Easy Answers

During the 2001 anthrax attacks, the public and decision-makers alike were frustrated by the lack of immediate answers to basic, factual questions. Who did this? How many letters were involved? Who came in contact with the letters? Health authorities and clinicians had to make critical decisions without having complete scientific knowledge. What is the best treatment? Who should receive preventive antibiotics and for how long? How many anthrax spores cause sickness? Which mailrooms should be closed and surveyed? Apparent inconsistencies and gaps in the government's response fostered more uncertainty. Were officials withholding information about the severity of the attack? Was treatment for postal workers really different from that offered to Capitol Hill employees and, if so, why?

References: (1) Toole, T. Congressional testimony, terrorism through the mail: Protecting postal workers and the public (part II). U.S. Senate Committee on Government Affairs, Subcommittee on International Security, Proliferation and Federal Services. (2) Inglesby TV. Congressional testimony, the state of public health preparedness for terrorism involving weapons of mass destruction -- a six month report card. U.S. Senate Committee on Governmental Affairs.

2003, SARS Victims Shunned Globally

The uncertainties presented by the new disease, SARS, have had lasting impacts on recovered patients. They, their families and neighbors, doctors and nurses, formerly quarantined contacts, and residents of affected cities have been shunned globally. Of Hong Kong residents polled in July 2003, 51.3% expressed fear of former SARS patients. In a survey conducted in March 2003, nearly a year after SARS struck, 20% of respondents reported that they avoid contact with recovered SARS patients.

References: (1) Bradsher K. Now the SARS emotional toll. The New York Times 2003; June 4:A-16. (2) Pomfret J. A Beijing address is now a stigma, not a benefit. Washington Post 2003; May 16:A-14. (3) Maunder R, Hunter J, Vincent L, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. Canadian Medical Association Journal 2003; 168(10):1245-1251.

2003, Fearing SARS, People Avoid Chinese-Americans

Tourists in New York City avoided Chinatown during the SARS outbreak based on the presumption that Asian Americans frequently travel back and forth to Asia and, therefore, posed a SARS threat. Compounding the problem was that the "public face" of the epidemic—i.e., the images featured in round-the-clock news reports—was that of Asians wearing protective masks. Asian-Americans were branded as "outsiders," a category of person long blamed as the origin of disease.

References: (1) Hubler S, Pierson D, Goldman JJ. A fever pitch of fear; misconceptions about SARS are driving away business at Chinatowns across the country. Los Angeles Times.2003; May 4: part 1, page 1. (2) King NB, Immigration, race, and geographies of difference in the tuberculosis pandemic. In Gandy M & Zumla A, eds., Return of the White Plague: Global Poverty and the New Tuberculosis. London: Verso, 2003. (3) Kraut AM. Silent Travellers: Germs, Genes, and the "Immigrant Menace." Baltimore, MD: Johns Hopkins University Press, 1995.

2001, Muslim Americans Face Hate Crimes in Wake of September 11

During times of crisis, people understandably want to protect themselves and to feel in control of their circumstances. A common way of coping with uncertainty is to blame others. Individuals and groups who are blamed, however, often belong to racial, ethnic, or social groups for which there are other preexisting prejudices. In the aftermath of September 11, the Council on American-Islamic Relations reported rising anti-Muslim sentiment in the U.S.: "religious and ethnic features of Muslim life or Muslim religious and political views [are] set apart from what is considered normal and acceptable." According to FBI statistics, anti-Muslim crimes increased seventeenfold during 2001.

References: (1) Council on American-Islamic Relations. The Status of Muslim Civil Rights in the United States, 2002. Washington, DC, 2002. (2) Human Rights Watch. "We are not the enemy": hate crimes against Arabs, Muslims, and those perceived to be Arab or Muslim after September 11. United States 2002; 14(6[G]):3.

2003, New Yorkers Perceive SARS to Be Local Outbreak

SARS had a negligible impact on New York City during the 2003 global outbreak. Nevertheless, at the peak of the global SARS outbreak, the NYC Department of Health and Mental Hygiene discovered that some anxious residents were transposing what they were reading and seeing about Hong Kong and other disease epicenters to conditions in New York City, where the impact had been minimal. That is, the crisis elsewhere became the baseline for what was perceived to be happening locally.

Reference: Roberts, S. Communicating with the public about public health preparedness. DIMACS Working Group on Modeling Social Responses to Bioterrorism involving Infectious Agents. New Brunswick, NJ: Rutgers University; May 29, 2003.

2001, Far from Anthrax Attacks, People Anxious

Although anthrax exposure was limited to a few East Coast cities, the effects of the attacks were felt in distant locations. Events were broadcast around the clock, and the deluge of information caused anxiety for people who were nowhere near the epicenter. A woman from Seattle recalled, "I was on vacation in Mexico when all of this happened, and everybody was glued to the television set watching CNN in the bar at the resort...And they finally made a decision to turn off the TV...so people could enjoy their vacation." Nonstop, live news coverage of unfolding events had made the "distant" problem of anthrax a local concern.

Reference: Schoch-Spana M, Young R, Lien O. The People Talk Back: Communication Needs during the 2001 Anthrax Attack and Hypothetical Smallpox Attack 2003. Unpublished Manuscript.

2003, SARS Spread Facilitated by Global Travel

More than 4,000 SARS cases (half the total global count) can be traced to a chance encounter with the virus by a handful of international travelers staying at a four-star Hong Kong hotel; one of the guests on the ninth floor was a doctor who had become infected while treating patients in Guangdong Province, where the outbreak first emerged.

Reference: Nakashima E. SARS signals missed in Hong Kong; physician's visit may have led to most known cases. Washington Post May 20, 2003: A01.

2001, The High Costs of the Anthrax Attacks

In addition to the obvious human toll, there were serious economic consequences caused by the anthrax attacks of 2001. The temporary closure of mail facilities and an overall decrease in the use of mail services resulted in financial losses for the U.S. Postal Service; decontaminating and renovating facilities that had received anthrax letters cost millions in taxpayer dollars. The costs for decontaminating and renovating the Brentwood postal facility, which was closed on October 21, 2001, and remained so for more than 2 years, totaled approximately $130 million. Decontaminating the Hart Senate Office Building cost $27 million.

References: (1) Nakashima E. SARS signals missed in Hong Kong; physician's visit may have led to most known cases. Washington Post May 20, 2003: A01. (2) Capitol Hill Anthrax Incident: EPA's Cleanup Was Successful: Opportunities Exist to Enhance Contract Oversight. GAO Report GAO-03-686 June 2003.

2001, Economic Repercussions of Foot and Mouth Disease

Financial losses from an epidemic can be dramatic and glaring. To control the 2001 foot-and-mouth disease outbreak in the United Kingdom, 1/8 of all farm animals—8 million animals across 9,677 farms—were slaughtered. By June 2001, 7,800 farmers and farm workers had lost their jobs; revenues for feed producers, rural businesses, and tourist enterprises plummeted. If there were a comparable FMD outbreak in the U.S., it is estimated that losses would be $14 billion—a 9.5% drop in farm income including lost export markets, curtailed domestic demand due to consumer concerns, and infected animal removal.

References: (1) Brown P. Foot and mouth epidemic officially over. Guardian Unlimited; 29 December 2001. Accessed 29 July 2003. (2) Paarlberg PL, Lee JG Lee, Seitzinger AH. Potential revenue impact of an outbreak of foot-and-mouth disease in the United States. Journal of the American Veterinary Medical Association 2002; 220(7):988-992.

1986, Mad Cow Disease Devastates British Beef Industry

Driving the U.K. government's handling of the "mad cow" (bovine spongiform encephalopathy, or BSE) outbreak that emerged in 1986 was the desire to limit immediate costs and protect the beef industry. Operating on this principle and the belief that BSE posed little risk to humans, despite uncertain science, government leaders did not intervene early, allowing BSE to remain in the cattle population thus contributing to greater human exposure. To avert public concern about food safety and its economic impact, British leaders repeatedly dismissed BSE as a human threat. By safeguarding the cattle industry while underplaying human health risk, the government created conditions for enhanced spread of disease, diminished public trust in government management of the problem, and, paradoxically, a shrinking domestic demand for beef (e.g., down 37% from 1987 to 1995).

Reference:  Lanska DJ. 1998. The Mad Cow Problem in the UK: Risk perceptions, risk management, and health policy development. J Public Health Policy. 19(2): 160-83.

Social and Economic Disparities Influence Public Responses to Bioattacks

Social and economic disparities can influence attitudes and behavior following a bioterrorist attack. Distrust of the healthcare system and lack of insurance influence people's decisions about whether to follow health recommendations or seek medical care. These attitudes are not without merit. One in every 7 Americans lacks health insurance, with minorities over-represented. Moreover, past events—such as experimentation on slaves and the Tuskegee syphilis study—and today's findings that race/ethnicity can adversely affect the standard of care received have led many African-Americans to distrust medical and public health institutions. Language barriers, cultural misunderstandings, and fear of deportation among undocumented immigrants cause other populations to regard the medical system with suspicion. These factors render these populations more vulnerable to the effects of an outbreak.

References: (1) Wynia MK, Gostin L. The bioterrorist threat and access to health care. Science 2002; 296:1613. (2) U.S. Census, Health insurance coverage: 2001. September 2002. (3) Betancourt JR, Green AR, Carrillo JE at al. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports 2003; 118:293-118. (4) Betancourt JR, Green AR, Carrillo JE at al. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports 2003; 118:293-118. (5) Gamble VN. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health 1997; 87(11):1773-1778. (6) Canlas LG. Issues of health care mistrust in East Harlem. Mt Sinai Journal of Medicine1999; 66(4):257-58

1995, Chicago Heat Wave Singles Out the Poor and the Isolated

Between July 13 and July 20, Chicago experienced a record-breaking heat wave that claimed the lives of more than 700 people. Most victims were low-income elderly people who lived alone, were isolated from friends and family, and were left abandoned for days before being discovered. Seventy-three percent of the victims were age 65 or older, and the majority were African-American. The deaths were not caused by extreme temperatures alone; existing social conditions common to urban areas compounded the effects of the heat. A substantial number of seniors live alone in unsafe, decrepit, low-income housing in neighborhoods that have been abandoned by businesses, service providers, and many residents. These conditions create a culture of isolation and fear that discourages seniors from trusting neighbors or even leaving their homes. Thus, seniors were particularly vulnerable because of the fact that they are largely homebound, with no one checking in on them and nowhere to turn for help.

Reference: Klinenberg, Eric. (2002). Heat Wave: A Social Autopsy of Disaster in Chicago. Chicago: University of Chicago Press.

Hospitals Unprepared for Epidemic Control

The nation's hospital response capacity and public health infrastructure have been compromised by decades of neglect. Although attention is now being focused on bolstering response capacity, the nation still faces serious issues:

• High vacancies exist for all U.S. hospital staff including nurses, imaging technicians, and pharmacists. More than three-fourths of urban emergency departments operate "at" or "over" capacity. In other words, too few professionals exist to staff these critical positions within hospitals across the country. The demands that would be placed on hospitals during a large-scale or prolonged epidemic would be grave.
• Only 2 states (FL, IL) are now prepared to deploy adequate personnel to break down the Strategic National Stockpile of drugs, antidotes, and medical supplies once it arrives.
• Few trained disaster mental health professionals, a weak infrastructure for implementing broad mental health protections, little knowledge on effective treatment, and scarce funds for long-term mental health care inhibit U.S. response to terrorism's psychological effects.

References: (1) American Hospital Association. Cracks in the foundation: averting a crisis in America's hospitals. Washington, DC: AHA, August 2002. (2) Trust for America's Health. Ready or Not?: Protecting the Public's Health in the Age of Bioterrorism. Washington, DC, December 2003; 7. (3) Institute of Medicine. Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy. Washington, DC: National Academies Press; 2003.

Blaming "Outsiders" for Causing Disease

Individuals and groups of different national origin or ethnic or religious background have long been singled out as the source of disease. For example, the early sixteenth century, diverse people have attributed syphilis outbreaks to everyone but themselves. Syphilis has been called "morbus gallicus" (the French pox) in Italy; "le mal de Naples" (the disease of Naples) in France; the "Polish disease" in Russia; the "Russian disease" in Siberia; the "Portuguese disease" in India and Japan; the "Castilian disease" in Portugal; and the "British disease" in Tahiti. Scapegoating may be more pronounced in the context of bioterrorism when an epidemic has been deliberately unleashed.

References: (1)King NB, Immigration, race, and geographies of difference in the tuberculosis pandemic. In Gandy M & Zumla A, eds., Return of the White Plague: Global Poverty and the New Tuberculosis. London: Verso, 2003. (2) Kraut AM. Silent Travelers: Germs, Genes, and the "Immigrant Menace." Baltimore, MD: Johns Hopkins University Press, 1995. (3) Porter R. The Greatest Benefit to Mankind. New York: WW Norton & Co., 1997, p. 166. (4) Peek LA. Community isolation and group solidarity: examining the Muslim student experience after September 11th. In Monday JL, ed., Beyond September 11: An Account of Post-Disaster Research. Special Publication #39. Boulder, CO: Institute of Behavioral Science, University of Colorado, 2003, p.81-102.

2001, Letters Laced with Anthrax

In October 2001, the U.S. was on edge following the discovery of several letters containing anthrax. People who worked in facilities that received letters containing anthrax were sometimes stigmatized within their communities. Some employees of American Media, Inc., the site of the first anthrax case, were doubly victimized. Physically affected by their potential exposure to anthrax, they were also socially stigmatized by physicians who refused to care for them, schools that turned away their children, and employers of second jobs who refused to let them work: Some American Media employees who moonlighted as housekeepers were not allowed into homes to clean.

Reference: Malecki J. Health Commissioner, Plam Beach County, FL. Personal communication.

2001, Anthrax Letters Give New Meaning to "Handle with Care"

During the anthrax attacks of 2001, the routine activity of opening the mail became a source of worry for many Americans. In a U.S. poll conducted in November 2001, 24% of those surveyed reported that they were very worried or somewhat worried about contracting anthrax by opening the mail. Thirty-two percent reported handling the mail with precautions—including washing hands after handling mail, wearing gloves to open envelopes, or avoiding opening mail entirely.

Reference: Blendon RJ, Benson JM, DesRoches CM, et al. The impact of anthrax attacks on the American public. Medscape General Medicine 17 April 2002; 4(2). Accessed 30 July 2003.

2001, Treatment Protocols for Anthrax Revised in Wake of Letter Attacks

Until the 2001 attacks, clinical knowledge about inhalation anthrax was based primarily on 16 historical cases of naturally occurring anthrax among goat mill and tannery workers. The 2001 anthrax letter attacks challenged prior assumptions and raised many new questions as to the physiological and environmental effects of a weaponized form of anthrax. For example, prior to the anthrax letter attacks, it was generally believed that anthrax victims with high toxicity levels would not respond well to antibiotic treatment and would die. However, the 2001 experience demonstrated otherwise, when a majority of patients recovered with antibiotics and aggressive treatment. Before the 2001 attacks, Ciprofloxacin had been recommended as the sole antibiotic treatment for inhalation anthrax; however, case evidence in 2001 led the CDC to revise recommendations and advocate the use of Doxycycline as well. Additionally, prior to the letter attacks, it had not been recognized that "weapons grade" anthrax spores could leak out of the edges of envelopes or through the pores of envelopes, thereby potentially exposing the envelope's handler; nor did scientists understand how factors such as machine processing or air flow in a building would affect the dispersal of spores. While it was once believed that it might require thousands of spores to make a person ill, evidence from the New York City and Connecticut victims suggests that this assumption could be false—it may only require 1 to 3 spores.

References: (1) Casani, Julie, Diane Matuszak and Georges Benjamin. 2003. "Under Siege: One State's Perspective of the Anthrax Events of October/November 2001" Biosecurity and Bioterrorism 1(1): 43-45. (2) Inglesby, TV. et al. 2002. "Anthrax as a Biological Weapon, 2002: Updated Recommendations for Management" JAMA 287(17).

Laundry List for Bioterrorism Response Planners

The scope and magnitude of a bioterrorist attack is limited only by the imagination of a perpetrator and his/her technical ability to pull it off. A particularly challenging element of bioterrorism planning is that there is a wide range of scenarios to consider:

• Threats or scares, such as the increasingly frequent anthrax "hoaxes"
• Assassination of individuals—such as the ricin poisoning of Bulgarian defector Georgi Markov
• Discrete, nonlethal attacks—such as the 1984 Rajneesh contamination of salad bars, when hundreds became ill
• Incidents that produce few cases and deaths but that are still profoundly disruptive—such as the anthrax letter attacks
• Localized lethal outbreaks, comparable to the accidental 1979 anthrax release from Soviet bioweapons facility
• Campaign of mass casualty attacks in different cities, at different times—such as featured in the Dark Winter exercise
• Lethal pandemic (or global outbreak) through an unchecked reintroduction of smallpox.

References: (1) Cole LA. Bioterrorism threats: Learning from inappropriate responses. J Public Health Manag Pract 2000;6:8-18. (2) Franz DR, Jaax NK. Ricin toxin. In: Sidell FR, Takafuji ET, Franz DR, eds. Textbook of Military Medicine: Medical aspects of chemical and biological warfare.Washington, DC: Office of the Surgeon General; 1997:631-42. (3) Torok TJ, Tauxe RV, Wise RP, et al. A large community outbreak of salomnellosis caused by intentional contamination of restaurant salad bars. J Am Med Assoc. 1997;278(5):389-95. (4) Meselsohn M, Guillemin J, Hugh-Jones, M, et al. The Sverdlosk anthrax outbreak of 1979. Science. 1994; 266:1202-8. (5) O'Toole T, Mair M, Inglesby TV. Shining Light on Dark Winter. CID. 2002;34(7):972-83.

2001, Mayor Leads Mourning New Yorkers

Mayor Rudolph Giuliani modeled effective leadership and communication after the September 11 attacks. When asked a few hours after the attacks how many people were anticipated dead, and when the exact number of victims was still unknown, he responded, "More than any of us can bear, ultimately". At a time when people were feeling misery, this response displayed empathy and compassion without downplaying the severity of the tragedy. He was forthcoming even when he did not have all of the information or answers to all of the questions. He understood that people needed to be kept up to date on what was happening, so he held regular press conferences to provide status updates, and shared any new information on the response to the attacks.

References: (1) ''It's 'more' than any of us can bear.' CBSNEWS.com 26 September 2001. Accessed 10/13/03. (2) Giuliani, Rudolph. (2002) Leadership. New York: Mirimax.

2001, EPA Reassures Ground Zero Residents that Air Is Safe

Following the collapse of the Twin Towers, air quality became an issue of prime concern for the residents of lower Manhattan. However, the Environmental Protection Agency, at the urging of the White House, deleted cautionary statements and added reassuring ones in early press reports about the air quality in lower Manhattan. By declaring the air outside Ground Zero as "safe," based on inadequate data and analysis and in the face of New Yorkers' own experiences of difficult breathing, the EPA undermined its own credibility, not only on this sensitive issue, but perhaps on future ones as well.

Reference: Office of Inspector General. EPA's response to the World Trade Center collapse: Challenges, successes, and areas for improvement. Report No. 2003-P-00012. Washington, DC: U.S. Department of Environmental Protection; August 21, 2003.

Polled Americans Expect Discrimination during Smallpox Outbreak

Seventy-two percent of respondents to a national poll said they believed that if it were not possible to vaccinate everyone quickly during a smallpox outbreak in their community, wealthy and influential people would get the vaccine first. Nearly half (43%) thought that the elderly would experience discrimination, and one-fourth (22%) believed that African-Americans would experience discrimination. Decision-makers can account for income disparities in contingency plans by setting up vaccination clinics in locations accessible to people without transportation and by informing the public about plans to make free or low-cost emergency treatment or prophylaxis available. To ensure that potentially marginalized constituents understand that their interests will be protected in a health emergency, officials should engage with them in non-crisis times, ideally through health programs that address specific needs of these populations.

Reference: Blendon RJ, DesRoches CM, Benson JM, et al. The public and the smallpox threat. N Engl J Med 2003; 348(5).

2001, New York City Health Officials Earn Public Trust

In the earliest hours following the first diagnosis of inhalation anthrax in New York City, local officials understood that timely and candid communication with the public would be essential to managing the crisis successfully. Confirmation of the anthrax case was received in late evening, around 10:00 pm, but many questions were still unanswered—including how the victim contracted anthrax and whether anyone else was ill. Despite the late hour, leaders were forthcoming about what they knew and what they did not yet know. The mayor and his top health officials convened the first press conference at approximately 11:30 that night, and they provided a public hotline so community members could have access to information about anthrax and unfolding events. Convening this press conference at the onset of the incident helped set the tone for how the emergency would be handled: Leaders would be the ones to provide information to community members. Moreover, getting the word out at the earliest point in the crisis helped minimize the chance for speculation and the spread of misinformation the following day.

Reference: Mullin, Sandra. (2003). "New York City's Communication Trials by Fire, from West Nile to SARS." Biosecurity and Bioterrorism 1(4): 267-272.

2003, Chinese Leaders Withhold SARS Information from Villagers

As SARS spread across China, government officials withheld information from villagers on the theory that, as one bureaucrat reported to the news media, "They just won't understand." But when residents learned their villages might be used to quarantine outsiders who had possibly been exposed to SARS, they rioted against government preparation of quarantine centers and set up makeshift roadblocks to keep out nonresidents.

Reference: Beech H. The quarantine blues: with suspected SARS patients getting dumped in their backyards, China's villagers rebel. Time Asia Magazine 19 May 2003: 161(19). Accessed 15 December 2003

The Working Group on 'Governance Dilemmas' in Bioterrorism Response comprised 30 members, among whom there were seasoned decision-makers at local, state, and federal levels of government; public health practitioners who have managed responses to high-profile outbreaks and terrorist attacks; infectious disease specialists; journalists and news editors who have covered government responses to disasters and crises of authority; technical experts in public affairs, risk communication, and disaster psychiatry and sociology; and community organizers and advocates for special populations. The Working Group was the culmination of a larger project focused on articulating best practices and principles for leaders when communicating with the public in the context of response to a biological attack.

Veteran Political and Public Health Leaders

• Georges Benjamin, MD, FACP, Executive Director, American Public Health Association; former Commissioner of Health for Maryland during '01 anthrax attacks
• William Bicknell, MD, MPH, Professor and Chairman Emeritus of International Health at Boston University, School of Public Health; former Commissioner of Health for Massachusetts
• Neal L. Cohen, MD, Executive Director, AMDeC Center on Bioterrorism; former Commissioner of Health for New York City during '99 West Nile Virus outbreak, '01 World Trade Center bombing, and '01 anthrax attacks
• Aaron Greenfield, JD, Executive Director, Maryland Business Council; former Special City Solicitor & Homeland Security Advisor, Baltimore City Mayor's Office
• Margaret A. Hamburg, MD, Vice President, Biological Programs, Nuclear Threat Initiative; former Assistant Secretary for Planning & Evaluation, Department of Health and Human Services; former Commissioner of Health for New York City during '93 World Trade Center bombing
• Jean Malecki, MD, MPH, FACPM, Director, Palm Beach County Health Department; led investigation team of first inhalational anthrax case in 2001
• Tara O'Toole, MD, MPH, CEO & Director, UPMC Center for Biosecurity; former Director, Johns Hopkins Civilian Biodefense Center; former Assistant Secretary of Energy for Environment, Safety and Health

Medical, Public Health, and Disaster Experts

• Kenneth D. Bloem, MPH, Health Management & Policy Consultant; former top executive at Georgetown, Stanford, Chicago, & Boston University Medical Centers; former CEO, Advisory Board Company
• Brian W. Flynn, EdD, Associate Director, Center for the Study of Traumatic Stress & Adjunct Professor of Psychiatry, Uniformed Services University; former Rear Admiral/Assistant Surgeon General, U.S. Public Health Service
• Thomas V. Inglesby, MD, COO & Deputy Director, UPMC Center for Biosecurity; former Deputy Director, Johns Hopkins Civilian Biodefense Center; Infectious Disease Clinician, Johns Hopkins Hospital
• Linda Morris, BSN, RN, Director, Community Health & Youth, Greater Kansas City American Red Cross (GKC-ARC); former Community Health Nurse Manager, GKC-ARC
• Ann E. Norwood, MD, COL MC, USA, Associate Professor & Associate Chair, Department of Psychiatry, Uniformed Services University
• Monica Schoch-Spana, PhD, Chair; Senior Fellow, UPMC Center for Biosecurity; Assistant Professor, University of Pittsburgh School of Medicine; former Senior Fellow, Johns Hopkins Civilian Biodefense Center
• Kathleen Tierney, PhD, Director, Natural Hazards Research and Applications Information Center; Professor of Sociology, University of Colorado, Boulder

Community Leaders and Special Population Advocates

• Naomi Baden, JD, MS, Facilitator, mediator, & negotiator specializing in inter- and intra-organizational decision-making processes
• Marion J. Balsam, MD, FAAP, Diplomate, American Board of Pediatrics; Fellow, American Academy of Pediatrics, Task Force on Terrorism; retired Rear Admiral of Medical Corps of the U.S. Navy
• Emira Habiby-Browne, MA, Founder & Executive Director, Arab-American Family Support Center, New York City
• Robert G. Kaplan, Founding Director, Commission of Intergroup Relations & Community Concerns at the Jewish Community Relations Council of New York; Design Team Member, Public Health/Faith Based Community Institute of CDC and Emory University
• Myrna Lewis, PhD, Assistant Clinical Professor, Community & Preventive Medicine, Mount Sinai School of Medicine, New York City; United Nations NGO Committees on Aging and Women; Member, NYC Mental Health Disaster Team
• Onora Lien, Research Analyst, UPMC Center for Biosecurity; Doctoral Candidate in Sociology, Johns Hopkins University
• Shirley G. Mitchell, PhD, President, Board of Directors, Phyllis Wheatley YWCA, Washington, DC

News Media, Public Affairs, and Risk Communications Experts

• Thom Berry, Director of Media Relations, South Carolina Department of Health and Environmental Control; Former President, National Public Health Information Coalition
• John Burke, MA, JD, President, Strategic Communications Inc.; Crisis Communications Advisor to clients including Union Carbide, Pfizer, Johnson & Johnson, and Merck
• Joan Deppa, PhD, Associate Professor, S.I. Newhouse School of Communications, Syracuse University; former UPI editor & reporter
• Darren Irby, Vice President of External Affairs, American Red Cross Headquarters
• Richard Knox, Health & Science Correspondent, National Public Radio; former medicine & health reporter for Boston Globe
• Sandra Mullin, MSW, Director of Communications & Associate Commissioner for New York City Department of Health during '99 West Nile Virus outbreak, '01 World Trade Center attacks, '01 anthrax attacks, and '03 SARS outbreak
• Barbara Reynolds, MA, Crisis & Emergency Risk Communication Specialist, Centers for Disease Control & Prevention; managed public communications during '01 anthrax attacks
• Peter Sandman, PhD, Risk Communications Specialist; advisor to the New York City Department of Health and the CDC on bioterrorism, preparedness, and communication; creator of the Hazard+Outrage formula for risk communication
• Mary E. Walsh, National Security Producer for CBS News assigned to the Pentago

The following materials and selected resources are complements to the guidelines in "How to Lead during Bioattacks with the Public's Trust and Help: A Manual for Mayors, Governors, and Top Health Officials"

• Printer-friendly version of "How to Lead" Manual (aka Executive Summary): Text-only version for convenient copying and reproduction
• PowerPoint presentation that reviews working group recommendations:  Presentation that users can customize for briefings in their own institutional settings, provided that UPMC Center for Biosecurity markings and citations remain intact
• 2003 National Summit on Leadership during Bioterrorism:  Conference proceedings of "The Public As an Asset, Not a Problem," convened in Washington, DC, February 3-4, 2003. Reviews recent terrorist and public health crises to discern leadership principles for engaging the public in response
• Select Planning and Response Resources: A sampling of resources that address issues (e.g., volunteers, psychological impact, stigma) and groups of people (e.g., children, frail elderly, ethnic minority groups) frequently overlooked in bioterrorism planning and response
   

Planning Resources

Following is a listing of selected resources that address the needs of special populations during a crisis or disaster. The resources listed focus on issues and groups of people frequently overlooked in response plans, including mental health, and the needs of children, elderly, disabled, and ethnic minority groups that are vulnerable to backlash or hate crimes.

Children

• American Academy of Pediatrics: Children, Terrorism and Disasters: Disaster Preparedness to Meet Children's Needs
• Columbia University Mailman School of Public Health: The National Center for Disaster Preparedness, Program for Pediatric Preparedness
• American Red Cross: Children and Disasters

People with Disabilities

• American Red Cross: Special Needs & Concerns: Disaster Preparedness for People with Disabilities

Ethnic Minorities/Hate Crimes

• Council on American-Islamic Relations: Muslim Community Safety Kit

Seniors

• American Red Cross: Special Needs & Concerns: Disaster Preparedness for Seniors by Seniors
• International Longevity Center: Emergency Preparedness for Older People

Mental Health

• American Psychological Association: Briefing Sheet — The Psychological Impact of Terrorism on Vulnerable Populations
• National Mental Health Association: Coping with Disasters

Schools, Workplace and Community

• US Department of Education: Emergency Planning: Office of Safe and Drug-Free Schools
• National Partnership for Workplace Mental Health: Tools and Resources
• Independence Plaza North Tenant Association: Community/Preparedness