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Defending against bioterrorism: Lessons from the 2001 anthrax attacks

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Defending against bioterrorism: Lessons from the 2001 anthrax attacks

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Content DEFENDING AGAINST BIOTERRORI3M: LESSONS FROM TIIE 2001 ANTHRAX ATTACKS By S. Ford Rowan A Dissertation Presented to the FACULTY OF THE SCHOOL OF POLICY, PLANNING AND DEVELOPMENT UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PUBLIC ADMINISTRATION MAY 2004 Copyright 2004 S. Ford Rowan UMI Number: 3140548 INFORMATION TO USERS The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleed-through, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will oe noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. ®> UMI UMI Microform 3140548 Copyright 2004 by ProQuest Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. ProQuest Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor. Ml 48106-1346 ACKNOW LEDGEM ENTS This study would not have been possible without the consistent support of my chair. Dr. Joseph Wholey, who prodded me for years to complete it. I had the " ‘dream team” of a committee: Joe is an expert on evaluation, Dr. Detlof von Winterfeldt is an expert on risk communication and Dr. Jake Barkdoll worked for years in government, including at the US Food and Drug Administration. All, of course, have other accomplishments and experience which shed light on the problems discussed. Others at USC, including Dr. Bob Biller and Ms June Muranaka were very helpful in pushing the study to conclusion. This study stems from a project I was fortunate to work on at the Critical Incident Analysis Group at the University of Virginia. My thanks to the founder of CIAG, Dr. Frank Ochberg, and Dr. Greg Saathoff, Dr. Steve Prior, Dr. Michael Barkun, Ambassador Nat Howell and Dr. Bert Brown for their help. The work o f colleagues at CIAG is foundational for much of the second half of this study, which draws heavily on the report I helped edit. What is to be Done? Emerging Perspectives on Public Responses to Bioterrorism. I also would like to thank my colleagues at Rowan & Blewitt Incorporated, especially Rich Blewitt, who has worked with me for twenty years. TABLE OF CONTENTS Acknowledgements ii List of Figures iv Abstract v Introduction 1 Chapter 1. The Challenge of Risk Communication 17 Chapter 2. Making Sense of the Anthrax Attack 59 Chapter 3. Evaluating the Federal Government Response 85 Chapter 4. Evaluating the Media and Public Response 115 Chapter 5. Findings from the Anthrax Episode 138 Chapter 6. Planning and Coordination to Avoid Errors 155 Chapter 7. Building Credibility in Stressful Times 183 Chapter 8. Improving Communication 219 Chapter 9. Involving the Public 252 Conclusion 292 Bibliography 303 1.1ST OF FIGURHS F Dimensions of Trust 42 2. Flypotheses and Methodologies 68 3. Logie Model of Crisis Communication 79 4. Survey Results: Confidence in Affected/Unaffected 106 5. Survey Results: Reactions to Anthrax Incidents 107 6. Survey Results: Sense of Risk 108 7. Truth Table 141 8. Methodologies and landings 152 9. Crisis Communication Lifecycle 249 10. Findings, Observations, Options 299 IV ABSTRACT Five persons died from anthrax infection in late 2001 shortly after the hijacked airliner attacks on the World Trade Center and the Pentagon. Amid newly apprehended fear of terrorism the federal government endeavored to explain the risks of anthrax exposure, treatment and protection. The objective of this study is evaluate the federal response in the anthrax episode and recognize lessons regarding risk communication. The research design is a qualitative, descriptive case study with an explicit logic model showing the relationship of factors bearing on risk perception. The factors include problems with the messages, including accuracy and uncertainty; problems with the sources of information, including trust and credibility; problems with media amplification of the risk; and problems with public perception of the risks. Data sources included national opinion poll results, focus group research findings, and a content analysis of official statements, news media coverage, and published expert assessment of the handling of the problem. The study found that errors in official messages were associated with public fear, that contradictory information from official sources was associated with loss of credibility, that intense media focus on the risk coupled w'ith initial official failure to provide health information were associated with public fear and that public lack of a clear understanding of what protective steps and role people could take to protect themselves appeared to be associated with public fear. The study discusses how these finding can improve planning and coordination for the future, build credibility, improve the flow of information to the media and involve the public in planning and response activities, community preparation and voluntary action to reduce risks. Key words: anthrax, bioterror, terrorism, risk communication, homeland security. VI 1 Introduction Biotcrrorism - like chemical and radiological warfare - is terrible to consider. As a society we don’t have a lot of recent experience with natural epidemics. Man-made contagions would be risks of a new order. In addition to spreading disease, biological agents would spread fear, possibly causing a contagious chain reaction of social disruption. Fear clouds judgment and can result in horror, paranoia, and panic. A botched response to a terrorist attack might increase casualties and help the terrorists undermine America’s way of life. The 2001 anthrax attack is instructive about how to improve the capability to respond if biological agents are used to attack the U.S. in the future. In September 2001 B anthracis spores were sent via the US postal service to several locations in the US. The letters were addressed to political leaders and news media organizations. There were 22 confirmed or suspected cases of anthrax infection, including 11 cases o f inhalational anthrax (5 persons died) and 11 cutaneous cases. People were sickened who lived or worked in Florida, New York, New Jersey, Delaware, Pennsylvania, Connecticut, Maryland, Virginia and the District o f Columbia. 2 This is a study of America’s first response to an attack using biological agents against multiple targets. It examines the anthrax episode of 2001 and suggests lessons for dealing whh future attacks, particularly if quarantine and other compulsory steps are thought necessary. The study is divided into two parts: a) an evaluation of how the US government, the media and the public responded to the anthrax attacks and an examination of four factors which may have increased public fear, and b) an exploration of specific steps that can be taken for coping with a future attack involving a contagious biological weapon, such as smallpox or plague. The first part includes chapters on (1) a review of relevant research about communicating environmental health risks, (2) a methodology for making sense o f how the risks of anthrax exposure were communicated in 2001 and (3) an evaluation of the federal government’s actions and (4) the impact of communication about anthrax on the public in 2001. The findings (chapter 5) involve four subject areas: • Errors in decisions and messages, • Lack of credibility and trust in sources of information, • News media amplification of risk, • Public estrangement from coping mechanisms, particularly an inability to know what protective steps were appropriate. 3 The second half includes chapters evaluating the complex issues of improving decision-making, strengthening public health in light of the 2001 anthrax attacks (chapter 6), how sources of information need to establish credibility in times of great psychological stress (chapter 7), specific steps on how to improve the information flow via the media to the public (chapter 8) and how to involve the public in preparation for and response during a bioterror attack (chapter 9). These four last chapters attempt to answer the problems identified in the evaluation, particularly: • How to improve coordination for better decision-making and avoidance of errors, • How to improve credibility and inspire trust, • How to improve communication and decrease the media sensationalism, • How to improve public participation and cope with feelings of powerlessness. The concluding chapter reviews findings and discusses how lessons from the anthrax attacks can inform homeland defense planning and improve communication via the mass media in the event o f a future bioterrorist attack. This study has value for public administration because we can leam from the experiences o f 2001 about how to manage the risks of the unexpected, to 4 encourage informed decisions by government agencies and affected individuals, to improve risk communication practices, to improve the functioning of public health agencies, to involve member o f the public in homeland defense activities and to enhance trust in officials tasked with emergency response to terrorist acts. 1. The Anthrax Attack of 2001 The study examines evidence that some o f the things that the federal government did after the anthrax attacks may have increased public fear and been counterproductive in dealing with the threat. Data is evaluated to test this assumption, primarily from a content analysis o f news accounts and government press statements, results of public opinion surveys and qualitative data from focus groups that were conducted during and after the anthrax episode. News accounts were highly critical of the federal government’s handling of some aspects of the anthrax problem, particularly regarding the dangers of handling mail that might have been contaminated with anthrax spores. Surveys revealed widespread public concern about anthrax but not panic. Results from 17 focus groups held around the country indicate that “people were just hungry for information,” as one o f the lead researchers reported (see chapter 5). The study examines four factors in risk communication that may have confounded efforts to inform the public about anthrax. These problems were 5 identified two decades ago (Covello, et al., 1986) and are now familiar to thk se who have to deal with the challenge of environmental risk communication: • Problems with the message, particularly as to accuracy, complexity and uncertainty, • Problems with the sources of communication, particularly lack of institutional trust and credibility, disagreement among sources and use of technical jargon, • Problems with the media, particularly amplification o f risk by dramatizing and sensationalizing the risks, • Problems with the receivers of information — the public - who may have inaccurate perceptions o f risk in general and little understanding of science and medicine. The anthrax episode o f 2001 is investigated in light of these problems to test a set o f related hypotheses: The accuracy hypothesis states that errors in decisions and public statements were associated with public fear o f a newly apprehended risk, anthrax. Once the public suspected that erroneous information had been conveyed, did this have an impact on public fear? 6 The credibility hypothesis states that contradictory statements from official sources were associated with loss of credibility and public trust in the Anthrax attack. Did the official sources act in a credible manner? Did their actions affect public trust? The amplification hypothesis states that news media amplification of risk was associated with increased public fear in the Anthrax attack. Did the dramatic news coverage and government’s initial slowness in providing information create an information vacuum that was filled by unreliable and sensationalistic claims conveyed by television, newspapers, radio, magazines and the internet? The powerlessness hypothesis states that the absence of knowledge by the public of actions that citizens could take to control the risks of anthrax was associated with public fear. Was the public left feeling that there was little that could be done for self-protection against anthrax in the mail? The study also considered a null hypothesis that that the four factors listed above did not relate to the increased public fear. The null hypothesis would have be 7 proven if (a) there had been no measurable increase in public fear, or (b) if widespread death and disease had occurred - rendering moot any theory that placed primary blame on the government for not communicating well and/or that the media hyped the risks. As discussed below, the opinion poll results clearly show an increase in public fear during the period studied. Moreover, only 5 deaths occurred and there was no epidemic of sick persons, indicating that the fear was tied not to a health catastrophe on a grand scale, but to other factors. For these and other reasons the null hypothesis was not confirmed. The results of this study of showed that all four factors were associated with public fear, and that one of these was strongly related with public fear: the lack of credibility of government sources (hypothesis 2). See Findings in chapter 5. The research design is a qualitative, descriptive case study featuring an explicit logic model showing the relationship o f factors bearing on risk perception. The construction of a logic model follows Joseph Whc-’^y’s suggestion that activities, outcomes and assumed causal linkages can be developed and summarized. (Wholey, 1994, pp. 19-27). Unlike a program evaluation, where the logic model is explicitly present before it is tested, the evaluation of risk communication and its impact on public perception of newly apprehended risks provided evidence that resulted in the articulation of a proposed model. The model, described in greater detail on page 79, attempts to show the interaction between information about bioterrorism, particularly data about the unfolding anthrax attack, as filtered through official statements, news accounts and informal discussions in society. The model describes how events like the anthrax attack triggers government decisions which result in official statements. This information is filtered through the news media, which highlights some aspects and ignores others. The news is digested by the public, affecting risk perception. From this process, behaviors emerge. They can include protective acts like seeking antibiotic treatment and improved precautions in handling mail. There is no doubt that causal complexity confounds easy interpretation of the anthrax episode. It was an unprecedented event ion America. While it is difficult to compare this single case with any others, it is not impossible to compare performance in phases of the crisis as it unfolded over a period o f weeks. In fact there are several distinct phases — (a) immediately after the 9/11 airliner attacks through the initial discovery and alarm, (b) the period o f increased concern that included the evacuation o f Congressional offices, (c) the realization that postal workers were at great risk, and (d) the dawning recognition that some mail recipients had died from anthrax who had not handled the letters stuffed with anthrax spores sent by the perpetrator. This tracks the growing recognition first that people who opened letters with spores were at risk, then those who worked in adjacent rooms, then those who 9 processed the mail, and then those who received a letter that had been co mingled with a contaminated envelope. Three types o f data: archival records of government statements, documentation in the form of news accounts, and review of expert commentary were used for triangulation. (Patton, 1999, p. 1192) Their content was analyzed to assess the impact o f different actions at various stages of the anthrax response and to cast light on its relevance to each o f the alternative explanations. The government was attempting to communicate about a newly apprehended risk. It appeared to ignore lessons from several decades of environmental health controversies. Efforts to improve risk communication in recent years moved away from an initial reliance upon scientific experts to calm “unreasonable fears.” The old, ineffectual approach has been described as “DAD - Decide, Announce and Defend.” (Covello, et al., 2001, pp. 382-391) Over the years of environmental controversies it became obvious that public concerns and values needed to be addressed in a non-technical dialogue. Value considerations - including quality of life - are not bound to mortality and morbidity statistics. The National Academy of Sciences stated in 1989 that risk communication is “an interactive process,” involving “multiple messages,” including some “not strictly about risk,” including “opinions” and reactions to legal issues and institutional management. The academy’s recommended approach is to treat 10 people as partners in a dialogue with the leadership of interested groups to ascertain their concerns, fears, ideas and demands and to agree on ways to address these issues. This challenge will be elaborated upon in chapter one. 2. Lessons Learned for Future Homeland Defense Activities The objective o f this study is not simply to categorize the failings of the government during the anthrax attack but to specify how lessons learned might inform planning to respond to future biological attacks. Drawing on recent studies of complex adaptive systems, this study examines the two systemic approaches to defending against terrorism: • The hierarchy of command, control, communication and intelligence for preventing, detecting and mobilizing against attacks, and • the volunteer model of enlisting citizens and resources to respond during and after an attack. The first is like the human nervous system; the second is like the immune system where parts act to cope with invaders without waiting for orders from on high. Together they provide redundancy and robustness. Both approaches are needed to deal with the complexity of bioterrorism. The second approach, a 11 community-based initiative, would address some of the shortcomings identified in the 2001 anthrax attack. That response was primarily a federal one. But some state officials had much greater success in communicating with their local citizens. Much o f the current effort to improve defenses against bioterrorism focuses on federal actions but public health measures like quarantine have traditionally been state and local responsibilities. In addition to strengthening state and local resources, this study evaluates the need for non-compulsory activities at the community and family level. This study examines the implications for public health, mental health, public participation, communication, legal and ethical issues, and political challenges. Although anthrax spores were spread over a wide geographical area (via the mail), the disease is not communicable from person to person. The method of spreading anthrax - via the postal service - was a form of contagion that was unexpected by authorities. Government planning for a biological attack must deal with the threat o f a contagious outbreak either of a known disease - smallpox or plague, for example - or some genetically engineered variation. Added to the uncertainty o f what to prepare fo r is the challenge of psychological, public health, political and legal challenges of the medical 12 emergency that could occur. This study evaluates options for dealing with a biological attack (in addition to isolating ill persons for medical treatment): evacuation, vaccination, quarantine and sheltering in homes. Because of the importance of public participation in the articulation o f values in situations of risk (as demonstrated in the 2001 anthrax episode) two specific actions are discussed. The first is a process by which individuals and communities can become active participants in planning for worst-case events and responding if necessary. The second is a program of sheltering-in-place called community shielding that would be appropriate in most, but not all, instances o f biological attack. (Prior et al, 2002) Neither of these is a magic solution, but both augment the options of evacuation, vaccination, isolation and quarantine that are actively being deliberated. The study discusses problems with each of the options. No single option may save the day, but we must not overlook the courage and strength of individual Americans and their love of their homes, families and communities. One way to mobilize this powerful force is community shielding, an option that has received little attention. In chapter 8 shielding is discussed as an alternative in the event of a biological attack with a contagious agent. Developing such a program could address many of the problems evident in the handling o f the 2001 anthrax attack. While anthrax is not a contagious disease, the widespread fear of its spread to homes via the mail in 2001, makes that 13 episode relevant to a consideration of home-based measures in the event of an attack with a contagious biological agent. While some protective actions seem simple, their full execution in a time of great stress would be quite complex. No plan will work well if it is first unveiled at the onset of an attack with attendant media frenzy. A plan has to be discussed publicly under the watchful eye o f local news media and a consensus built before it needs to be implemented. Experience with natural disasters, technological accidents and medical emergencies shows that people can act constructively and collaboratively during horrible events. The voluntary response to the attacks of 9/11 shows how quickly and bravely Americans will act to adapt to complex new challenges. The immediate response to the terrorist attacks o f 2001 were not organized from one command center but were the autonomous actions of thousands o f citizens. The initial response was a self organizing effort of courageous men and women acting to help rescue the injured, fight fires, care for the sick, recover human remains, console families of victims, and repair damaged lives and property. These are essential and familiar roles. On the other hand, bioterrorism is a newly apprehended risk and there is no widely appreciated script for how to perform in this new contingency. The script needs to be written in each locality, with support from state capitols and Washington. Participatory design of community programs is a form of inoculation, helping people realize that they will not be alone if an attack occurs and that unaffected areas will provide food, medicine and services for distribution by volunteer groups in affected areas. As discussed in chapter 9, public participation can help overcome some of the drawbacks o f mandatory quarantine or any program requiring people to avoid travel. These challenges include: • African-Americans and Hispanics are more prone than whites to give credence to conspiracy theories and rumors about government-sponsored bioweapon research, • Some members of militias, white racist organizations and tax resistance groups distrust the Federal Emergency Management Agency (believing it is trying to impose a dictatorship in the US). • The government has not perfected its methods for communicating about risk and advising citizens of protective medical actions. • Public health experts often are not unanimous in their views on the magnitude of a risk or of the best course to address it. Our system does not encourage consensus. • The news media are more prone to report sensationalistic claims than sober analysis, aggravating public fear. 15 • Fear of legal liability might discourage some businesses and individuals from helping in the aftermath of an attack. • There is no system for authenticating the means of delivering necessities to communities that would assure residents of the safety of the supplies. • In an emergency some people will be spurred to heroic action. But in the absence of clear directions they may make enormous mistakes and contribute to chaos. • There are wide disparities among public health capabilities in various states and localities, raising fairness issues that would be compounded in an emergency. Each of the foregoing problems relates to whether people feel the process is fair and trustworthy. To be successful, planning for community protective responses has to be highly participative - or it will not inspire trust. These factors, lack of trust of sources and perceptions of powerlessness, were found in the first part of this thesis to have exacerbated public fear during the anthrax attack of 2001. Ways to address these challenges are developed in chapters 6-9. Coordination, collaboration, communication and coping mechanisms are discussed. In conclusion, the lessons o f the anthrax attack of 2001 suggest that the government needs to consider a bottom-up community oriented approach rather 16 than the traditional top-down command and control approach. This study attempts to shed light on how this might be implemented. 17 Chapter 1. The Challenge of Risk Communication The potential for a bioterror attack poses new challenges for communicating the risks to the general public and mobilizing resources to respond to an attack. A lot has been learned about risk communication from dealing with environmental and public health controversies. Effective communication is important in coping with crises involving suspected carcinogens, toxic chemicals, radiological wastes, drug use in society and risky sexual behavior. These type o f problems engender strong emotion and better communication has been viewed as a way to deal with such things as fear, frustration, helplessness, outrage, anxiety and distrust (Covello and Sandman, 2001; Sandman, 1989) For more than 25 years research into risk communication has evolved from a purely scientific orientation (quantifying the probabilities of hazards) to one which increasing looks to the cultural and social factors that influence risk perception. Time and again it was realized that quantification of risk takes a backseat to quality of life and other value issues during such crises. Baruch Fischhoff has traced the evolution of environmental risk communication, listing some of the steps that official experts have tried over the years (Fischhoff, 1994): • All we have to do is get the numbers right, 18 • All we have to do is tell them the numbers, • All we have to do is explain what we mean, • All we have to do is show them they’ve accepted similar risks before, • Ah we have to do is show them it’s a good deal for them, • All we have to do is treat them nice, • All we have to do is make them partners. In conclusion Fischhoff states that all of the above need to happen before people will accept advice on how to cope with a newly apprehended risk. If our society does not communicate about the risk of biological, chemical and radiological weapons before another attack one can easily predict that there will be nothing nice about the way things like quarantine are imposed or evacuation attempted in a future episode. There are three ways to define communication: (1) what / say, (2) what they hear, and (3) what we learn. Many people never get past the I-oriented view of communication and consider the impact of their messages on the audience. The decision on what to say is very important, of course, but the focus of communication study ought to be on what the audience hears, remembers and acts upon. Beyond that, communication is two-way street and an important way that individuals - and society - learn. So communication must be considered a 19 plural process. There are always stakeholders. In situations involving risk there are usually multiple stakeholders. Broadly defined, a stakeholder is anyone with a stake in the process and/or the outcome. These can include persons whose health or safety is directly affected, as well as those who perceive a more general, potential threat. There are several purposes for communicating. The list includes: • To inform, • To educate, • To persuade, • To motivate, • To manipulate, • To coerce. For those on the receiving end, we become uneasy as communicators try to coerce us, but there are situations where coercion is appropriate, for example, when evacuating a burning theatre. Consider the thin line between informing someone and urging them to do something in the following hypothetical situations. How far should a government spokesperson go in each case? 1. A railroad accident has resulted in the spill of highly toxic chemicals that are being carried by the wind toward a nearby 20 neighborhood. A clear danger exists. Should the government inform the public of all the risks or just order an evacuation? 2. Two weeks have passed, the railroad accident is cleaned up and wells are pumping out chemicals (including carcinogens) which leaked into the ground. The best technical assessment is that the chemica! contamination did not spread very far and will not affect the health of citizens. Should the government bring in experts to discuss the risk or simply tell people to return to their homes? 3. Two years have passed and trace amounts of carcinogenic chemicals are found in the drinking water which comes from deep aquifers previously thought to be unaffected by the railroad spill. The amounts of toxins are very small. Should the government inform the citizens of the situation? Should the government urge the citizens to drink the water? To stop drinking the water? 4. Five years have passed and environmental activists complain to the media that several children have leukemia and there’s a “cancer cluster” in the neighborhood. They demand that the government force the railroad to buy all the homes and move the residents to safety. Almost all technical experts say the fears are 21 overblown. What should government officials say to the local residents? Obviously the hypothetical scenario does not afford enough detail to make an informed choice of all that should be done in situations 2 through 4. But the hypothetical “facts” outlined above help illustrate the communication choices. When the danger is clear, action is appropriate. Nevertheless, there’s much uncertainty about unfamiliar and newly apprehended risks. To wrap up this hypothetical scenario, here’s an additional question: would the advice differ if the initial railroad spill was not accidental but was caused by terrorists seeking to release deadly chemicals? When people are told of risks they want unambiguous answers to the question, is it safe for me and my family? Educating the public about scientific risk analysis is not what the public wants; it wants to know what should be done about the risk (Powell & Leiss, 1997). Clear and definitive answers are rarely possible. Dealing with uncertainty is difficult but essential. Since fear o f the unknown increases the fearsomeness of risk, how can an official spokesperson address the unknowns without scaring the public unnecessarily? Sometimes there’s a temptation to keep people in the dark about small risks on the theory that ignorance is bliss, the public is apathetic and “let sleeping dogs lie.” The reason 22 this doesn’t work is that the “dogs” may wake up, growl and bite. If an agency or corporation hides information it risks ruining its credibility when the problem is highlighted. The operative word is “when” not “if.” If people suspect a cover-up it can hamper subsequent efforts at public communication. As environmental health problems became more complex and controversial, new insights were learned and skills taught to managers who had to face the public. Most o f these controversies involved government agencies such as the federal Environmental Protection Agency, the U.S. Food and Drug Administration, the Occupational Safety and Health Administration and their counterparts in state and local governments. Other entities concerned about risk include the National Transportation Safety Board, the National Highway Transportation Safety Administration and the Consumer Products Safety Commission, among others. The overwhelming body of research into risk communication has centered on the risks caused by humans, and most of it has been tied to specific technologies or risk events like accidents, or unintended side effects of drugs or medical devices. More attention was paid to man-made risks than to diseases of a natural origin, until the AIDS epidemic spurred efforts to prevent the spread o f that disease. Nevertheless, public health agencies were largely spared the most bruising lessons about risk controversies that their counterparts in environmental agencies were experiencing. The threat of 23 bioterrorism makes it important for public health specialists to understand how risk communication has evolved over several decades of environmental activism. The agencies tasked with safety regulation differentiate between risk assessment, risk management and risk communication. Risk assessment includes four steps: (1) identification of a specific hazard, (2) assessment of the relation between magnitude of exposure and the probability of occurrence of a health effect, (3) determination of the extent o f human exposure under regulatory controls, and (4) characterization of the nature and magnitude of human risk, including aspects of uncertainty. (National Research Council, 1983) In general, risk assessment attempts to quantify the actual risk. The next step in the process is risk management, which attempts to evaluate those risks against broader social and economic values. “At least some o f the controversy surrounding regulatory actions has resulted from a blurring of the distinction between risk assessment policy and risk management policy,” the NRC stated in 1983 (p. 3), The council recommended that scientific findings and policy judgments in risk assessments should be explicitly distinguished from the political, economic and technical considerations that influence the choice of regulatory policy. It is in risk management that the costs and benefits o f policy choices are usually weighed. The problem with risk management is that there 24 are often disagreements about such values. In a democracy the values of scientists, regulators, elected officials, activists, reporters, whomever, are not automatically better than anyone else’s values. Who is to decide exactly what to do to manage risk, how much to spend and how many lives might be saved over what time span? (See for instance, Prato, 1991) Risk communication was initially thought to be the final part of the process, when the public would be informed of the results of the assessment and risk management processes. Nothing so linear has ever worked. Usually decisions get made by decibel level. An EPA Science Advisory Board stated in 1990 that “since public concerns tend to drive national legislation, federal environmental laws are more reflective of public perceptions of risk than of scientific understanding of risk.” (USEPA, 1990, p. 12) Here are some of the problems inherent in communicating with the general public about risks to health: • Scientific studies are complex, jargon-laden and filled with uncertainty. They rarely answer the layperson’s question: “is it safe?” • Scientists and government officials are not in agreement about how to characterize risk, compare risks, rank risks and prioritize regulatory action. 25 • Many risks are improvable and policy preferences and assumptions influence the results in risk assessments (U.S. Department of Energy, 1994). • Risk information is often communicated by advocates in activist groups, industry spokespersons, trial lawyers and politicians who are perceived to have their own agendas and lack credibility with the public. (Burk, 1993) • Businesses with products under attack often respond with defensive public relations, ranging from the inept to the deceitful. (Rowan, 1996) ® Risk information becomes ammunition in the policy debate, in court battles and in the media. • The news media are interested in conflict and sensationalistic stories (Friedman et al, 1986) and errors often appear in news accounts (Singer & Endreny, 1993). Controversies about risk are easy to start and hard to resolve (Foster et al., 1994). • The general public has a high level of scientific illiteracy. Most people have read and watched more science fiction than have read and learned about science. • The public often feels powerless, fearful and outraged upon hearing of a newly disclosed threat to public health and/or the environment. 26 Several aspects of risk communication in general are worth noting. First, it is about values, things that people care about. It is not just about technical measurement of hazards and their probabilities of harm. Psychological, social and cultural explanations have been offered as competing theories to explain risk perception, but Kasperson and collaborators (1988) say that risk events interact with all three of these factors in ways that heighten or attenuate public perception and related risk behavior. Second, risk communication is about the prospect o f loss. People tend to be willing to expend more energy to avoid a loss of something they possess than they would expend to gain a new, equal amount of the same thing. (Kahneman & Tversky, 1984). All things being equal, people fight to keep what they have with more vigor than they display when they are seeking something new. People tend to be more willing to gamble to prevent a direct loss than to take chances to secure a benefit (Lewis, 1990, pp. 37-41). This explains why some threats o f loss seem disproportionately aggravating. When cost/benefit analysis is performed by disinterested outsiders they might ask “what’s the fuss?” But for someone who faces the loss of security, o f neighborhood tranquility and of his sense that his or her children are safe, that potential loss is felt so acutely that it can outrage people and motivate them to protect themselves. 27 Third, risk communication is about relationships. On one level is about how people interact with technology, including hazardous substances and devices. On a deeper level it is about how people interact with other people - including the ones who manage the technologies or regulate them. It is about people with a stake in the outcome of the discussion. Stakeholder interaction and competing values are at the heart of the controversies about risk (von Winterfeldt & Edwards, 1984). Because the issues are laden with values — differing values — even in the best of times communicating about risk is a challenge. Fourth, because risk communication is about values, potential losses and relationships, it almost always is about conflict. Even at its most juvenile level, when children are told they must take their medicine, or look both ways before crossing the street, or not touch the hot stove, there is room for resistance and it is expected. Grown-up scientists and policy-makers are rarely in agreement on how to characterize risk, compare risks, rank risks and prioritize governmental actions (National Research Council, 1994). As the Carnegie Commission stated (1993, p. 118-119) “science rarely takes decision makers more than a small part o f the distance toward a decision. Intuitions and value preferences span the rest of the distance.” If conflict is such a challenge in the absence of an emergency, imagine the difficulty of communicating about risks o f biological agents during an attack! For many people, complex health information is difficult to comprehend in a time o f stress. One way people process risk information has been described by Sandman (1993). People tend to view risks in the context of their ability to control them. Voluntary risks are perceived as less risky than coerced risks. Risks that an individual has direct control over are deemed less risky than uncontrolled ones. Risks that are familiar seem less risky than unfamiliar risks. Risks that are judged to be “fair” are perceived as less risky than unfair ones. Additionally, risks that provide direct benefit seem less risky than ones with no payoff. These factors - familiarity, controllability, voluntariness, fairness, benefit - are about who knows, who decides, who pays and who gets what; in short, about power. Put a different way, things seem very risky when people feel powerless. An important part of risk perception involves people feeling left in the dark, deprived of choice, coerced into accepting uncontrolled risks, getting the short end of the stick. These feelings of political impotence are what drives outrage and leads people to reject the advice of experts and their technocratic assessments. What many people want is not to be told by officials what the scientific risks are, but to force the system to listen to and respond to their concerns. As Hance and his collaborators (1990, p. 9) have stated, “Many people have lived with industries in their communities for years but haven’t demanded zero risk. By and large people insist on zero risk when they feel that 29 they are being treated unfairly or that their concerns are being ignored - in short when they are angry.” Despite suggestions that the United States is becoming a more risk averse society, there is little evidence to suggest that people will always demand zero risk. What people seem to fear the most - exotic chemicals and invisible radiation - may pose a lower risk than the things people do the most - drive, smoke, drink alcohol - that kill hundreds o f thousands of persons each year. (Lewis, 1990). In fact, regulation must balance two opposing forces: the demand for protection and the demand for freedom o f choice, including access to new technologies and products that offer some benefit. This tension between safety regulation and freedom of access is seen most prominently in regulatory action on new drugs proposed for sale in the U.S. Two critics (Urguhart and Heilman, 1984) of the Federal Food and Drug Administration’s process have stated, “If one were to judge the overall value of drug regulation strictly on a body-count basis of lives lost due to regulatory delay as against lives saved due to keeping unduly dangerous drugs from the market, one would have to question seriously whether drug regulation is a very good bargain.” The imperative to make a choice is a crucial part of risk management; this is a not an academic exercise. It has impact. 30 One of the keys to risk communication is to empower people to choose the best alternative to reduce the risk to themselves and their families. This requires a closer examination of the communication process. There are four aspects: (1) issues regarding what is in the messages, (2) the capabilities and credibility of the sources of information, (3) the performance o f the channel of communication, usually the mass media, and (4) the comprehension o f receivers o f information, the general public. This division into four categories follows a review of risk communication literature by Covello, Slovic and von Winterfeldt (1986). They stated that message problems can result from limitations on scientific methods, analyses and assessments, that source problems stem from the communicators’ limitations, that channel problems result from limitations of the media in communicating scientific and technical information and that receiver problems stem from certain characteristics in the public. The following review builds upon this four-fold division of the problematic nature of risk communication. 1. Understanding the importance of messages Each message may contain factual, inferential, value-oriented and symbolic meaning (Lasswell, 1948). While risk analysts have struggled to maintain a clear distinction between facts and values o f risk management (Hammond & 31 Adelman, 1976; National Research Council, 1983), values are reflected in how risks are characterized (Fischhoff, 1994; Crouch & Wilson, 1981). Scientific facts are “socially constructed in part, and ... embody innumerable biases.” (Woodhouse, 1992, p. 18) The data are evaluated in a social, cultural and political context (Shubik, 1991) Assessments reflect political issues (Ansell & Wharton, 1992). Experts and laypersons might agree about the fatalities that a technology causes in an average year, but still differ on how that risk is characterized or defined. For instance, laypersons place greater weight on the potential for catastrophic harm. (Fischhoff, 1994; Slovic et al., 1979, 1984). Some technical information is unwanted by members o f the public. Communications should tell people what they need to know and do. Fischhoff (1994) states that “telling way more than people need to know can be (and be seen as) deliberately unhelpful.” Efforts to model decision-making by patients suggested that only a few of the possible side effects had a practical impact on agreeing to a medical procedure (Merz, et al., 1993). The implication o f this is that people with little knowledge of a subject only want a few critical facts in order to make a decision. They want qualitative information on how a risk “works” and are less interested in a quantification of parameters about the risk (Fischhoff, 1994). 32 Technical, probabilistic models overlook some of the equity issues that are important to the general public (Doderlein, 1983; Kasperson, 1983). Controversy and debate between experts widen the gap between scientific assessment and popular perception, eroding confidence in the decision-making process (Otway & von Winterfeldt, 1982). While technical risk assessment has focused narrowly on the probability o f events and the magnitude o f specific consequences, the public judges risk on such concepts as whether they chose to be exposed to it, whether they can control it, whether it is a newly apprehended problem and whether it has catastrophic potential (Kasperson, et al., 1988). Some sophisticated approaches to message development have evolved. Fischhoff (1994) has created a mental models approach to create influence diagrams to be used to fill knowledge gaps, produce comprehensible messages, reinforce accurate opinions and correct misconceptions of the public. (This model and a more recent one developed by Morgan and his collaborators (x) are described in detail in chapter 2 to aid in evaluating the anthrax episode.) Newly apprehended risks have “signal value” as portending a new problem or the emergence of something that is more serious than previously understood (Kasperson, et al., 1988). The negative imagery can confer stigma, particularly if vivid photographs drive home how bad the situation has become. So the explicit message that is delivered may be quite different from the implicit 33 message that is heard and processed by the public. Kasperson and his colleagues (1988) note how events can be transformed in the messages that are used to describe them. An event or announcement can convey meanings that were unintended by the speaker. Using Kasperson’s approach, adapted to the present case, we could envision the following hypothetical translation into inferred messages: • Event: anthrax illness > Inferred Message: new catastrophic risk has appeared, • Event: News of another case > Inferred Message: Officials cannot control the hazard, • Event: Dispute over how illness transmitted > Inferred Message: Experts do not understand the risk, • Event: Officials state risk is low > Inferred Message: Officials do not care about endangered people, • Event: Disagreement on medical treatment > Inferred Message: Officials are concealing some risks. In this fashion, facts are endowed with meaning when messages are conveyed. The meaning in the inferred messages may or may not accurately reflect reality. In a study of how the West Nile Virus outbreak was handled in New York, Covello and his collaborators (2001) said that messages must be evaluated on various criteria, including: 34 • Which messages are most effective, • Which messages are most respectful of different values and worldviews, • Which messages raise moral or ethical issues, and • Which messages are most respectful of process. To that we could add the criteria of which messages are least likely to be transformed into a fearful supposition and misinterpreted by the general public. This suggests the importance of examining the capabilities of the sources - the transmitters - of risk information. 2. Evaluating the credibility of the sources of information Risk is amplified when official sources of information are slow, contradictory, or appear to be hiding bad news; into this vacuum flow speculation, rumors and fear. (Powell and Leiss, 1997). During the 1980’s there was a great deal of attention in industry and government to training executives to communicate more effectively. For example the Chemical Manufacturers Association commissioned three experts in risk communication to write a manual and design and deliver workshops for plant managers (Covello et al., 1988). One o f the co authors of that manual, Peter Sandman, offered specific advice in 2001 to the Centers for Disease Control and his suggestions are evaluated in the next chapter. 35 Over the years general advice for communicators has included the following recommendations by Covello and Allen which were distributed by the U.S. EPA: • Accept and involve the public as a legitimate partner. • Plan carefully and evaluate your efforts. Begin with clear objectives. Aim specific messages at target groups. • Listen to the public’s concerns. Opinion research and interviews can be used. • Be honest, frank and open; “trust and credibility are your most precious assets.” • Coordinate and collaborate with other credible parties. Communicate with trustworthy sources like scientists, physicians, university professors and local officials. • Meet the needs of the media. • “Speak clearly and with compassion.” The National Research Council has noted that there can be struggle between community relations practitioners and attorneys. The former want to get information out to the public as quickly as possible while the latter almost always prefer giving out as little information as possible to avoid giving critics ammunition to use in litigation. The messages which emerge from this struggle 36 usually involve a compromise between these two perspectives. (NRC, 1989, p. 110). Organizations are advised to carefully prepare for public announcements. Practical communication advice has included such things as being organized before making any comment, including some of the following preparatory activities (Rowan et al., 1991): • Decide upon an objective before making any statement publicly. What does the spokesperson want to accomplish? • Anticipate questions and concerns. Identify categories of concern and ask: what do people want to know? • Decide in advance what messages to deliver. Make sure that there is a message for each category of concern (see above). Messages should be accurate and concise. • Review the subjects that cannot be commented about. Most public relations gaffes involve inadvertent comments that are blurted out without much thought. While stonewalling is a bad idea, speculation, guesses and the revealing of confidential information ought to be avoided. 37 • Select a main message to emphasize in a statement, interview or press release. Carefully chosen and emphatically delivered, this message could become the newspaper quote or the TV “sound bite.” • Consider whether this main message is related positively to the objective in step 1, If not, develop a better message. In the late 1980’s, when the emphasis on communication technique did not produce the results anticipated, the experts examined how the public related to the sources of information and managerial training programs were adjusted to focus on actions that could involve the public in consensus building activities (Rowan et al., 1991). Those in charge of delivering the messages sometimes complain that the public doesn’t get it. The problem, however, may be miscommunication from the source. Studies of risk perception have shown that the public’s fears should not be blamed on irrationality or ignorance, but that many reactions could be attributed to sensitivity to social, psychological and technical attributes of hazards that were not well understood by those making risk assessments and communicating the information to the public. (Slovic, 1993). The failure of risk communication to facilitate policy solutions is attributed by Slovic (1997) to “a failure to appreciate the complex and socially determined nature of the concept risk." This concept is subjective and value-laden, something that some communicators themselves do not seem to understand. How the story is framed is crucial. It is now recognized that people evaluate risk o f such things as surgery much differently if the same prognosis is presented in the form o f mortality rates rather than survival rates (Tversky & Kahneman, 1981) People are more fearful hearing the odds in terms of death than the same odds stated in terms of surviving. An example of this comes from a study by McNeil and collaborators (1982) who asked people to assume they had cancer and to choose between two therapies: radiation or surgery. One group was presented with the probabilities framed in terms of surviving for various lengths after surgery while the second group received probabilities framed in terms of dying after surgery. (The odds were the same: 68% survived for a year and 32% died.) When the odds were framed in terms of surviving surgery, only 18% chose the alternative treatment, radiation. When the identical odds were framed in terms of dying after surgery, 44% chose radiation instead. McNeil’s study showed the same results for physicians as for laypersons. This is of particular relevance to medical practitioners who must discuss alternatives for a variety o f illness, including those spread by bioterror. Because framing is so important, defining risk is an act of power. As Slovic has said (1997) the danger may be real, “but risk is socially constructed.” 39 Because in our democracy it is not possible to exclude the public from having a role in risk management, controversies such as how to dispose of nuclear and chemical wastes regularly occur. Improved risk communication was seen as a way to manage these controversies and make technological choices easier to resolve. The National Academy o f Sciences report on risk communication (National Resource Council, 1989) was a step toward enhancing the flow of information. Slovic (1993) has pointed out that while preventing communication blunders is important, there is little evidence that improved risk communication has reduced the gap between technical risk assessments and popular perception. It has not facilitated decision making on thorny problems like nuclear waste. As Lewis has stated (1990, pp. 245-6) regarding nuclear waste disposal, “The risk is as negligible as it is possible to imagine ... It is embarrassingly easy to solve the technical problems, yet impossible to solve the political ones.” Slovic attributes the shortcomings not to poor communication but to lack of trust in the sources of information. If the risk manager is trusted, communication is relatively simple, but if there is little trust then communication cannot bridge the gap. (Fessenden-Raden, et al, 1987). Slovic says (1993) “trust is more fundamental to conflict resolution than is risk communication.” He notes the following difficulties for those who want to be trusted: • Trust is easier to destroy than create, 40 • Negative events which diminish trust are more noticeable than trust- building efforts, • Trust-destroying events carry greater weight with the public than positive events, • Bad news is seen as more believable than good news, • Distrust, once initiated, reinforces and perpetuates distrust, • Distrust colors interpretations of events, reinforcing prior belief, • Once trust is lost, it may take a long time to regain it. Lack o f trust has been identified as an important factor in divisive environmental health controversies (Bella, 1987; Cvetkovich & Earle, 1992; Flynn & Slovic, 1993). Distrust has so poisoned some policy issues that observers such as Slovic urge more openness and involvement with the public than mere public relations efforts. He suggests power-sharing and public participation in decision-making beyond what has been attempted (Flynn et al, 1992; Kunreuther et al., 1993; Leroy & Nadler, 1993). Lack of trust is a major reason why the public often rejects scientists’ risk assessments (Slovic, 2000). There is an ongoing battle in the pages of Risk Analysis journal about just how important trust is in explaining risk perception. Siegrist, Cvetkovich and Roth have argued (2000) that social trust is a key predictive factor in explaining perceived risk. Sjoberg (2001) has argued that there is only a weak relationship 41 between trust and risk perception. Sjoberg states that people may trust an expert but still reject his or her advice about risk because they may recognize that not enough is really known about the risky technology. The belief in the existence of unknown factors may make general trust less important in risk perception, Sjoberg states. In the same issue of Risk Analysis (2001) Siegrist and Cvetkovich insist that the importance o f trust for risk perception is well established and that the credibility o f the information source is one o f the most important determinants o f effective risk communication. “Risk perception is hard to understand,” as Sjoberg understates (2000, p. 9) and he offers a variety of well reasoned alternatives to explain why people fear some risks, including factors like ideology (we fear what we dislike), immorality (we fear tampering with nature and other moral transgressions) and fear of the unknown. Trust is not dismissed as a contributory factor. It is worth noting that Sjoberg states (2001) that even though he believes general trust is not so important, he concludes that specific trust, relevant to the particular hazard under discussion, is a more powerful construct for explaining risk perception. In sum, the more the source of information is linked to the specific threat, the more likely trust - or the lack of trust - in the expert will influence public perception of the risks the expert is talking about. 42 The effort to sort out the dimensions of trust has led to several schemas. Here is a comparison of several such efforts, by Peters et al (1997), Renn and Levine (x), Kasperson et al. (1988) and Covello (1998). They were summarized in McComas and Trumbo (2001) which is adapted below: Covello: Peters et al.: Renn and Levine: Kasperson et al.: Caring and empathy Knowledge and expertise Competency Commitment to a goal and fiduciary duty Dedication and commitment Openness and honesty Objectivity Competence Competence and expertise Concern and care Fairness Caring Honesty and openness Consistency Predictability Faith in “good will” Figure 1. Dimensions of Trust McComas and Trumbo note that these dimensions are not based on “previous mainstream communications research on source credibility.” It is clear that 43 more research is needed to disentangle the related components of credibility and trust (for a discussion on its relevance to biological warfare, see part II). As the United States increases defenses against bioterrorism (National Research Council, 1999; Lederberg, 1999) the trust that the public has in emergency responders will be crucial in any post-attack response. Such trust should be established in advance and nurtured before any such event. Case studies, such as the chemical industry’s Responsible Care program, show that proactive community outreach is one of the best ways to achieve this goal (Covello et al., 2001; Santos et al., 1996). In environmental controversies citizen advisory panels have been effective in gaining constructive public participation (Lynn and Busenberg, 1995) and might be of utility in coping with the threat of bioterror (Covello et al., 2001). People want to be treated with respect and they want to be leveled with, Fischhoff states (1994): “People fear that those who disrespect them are also disenfranchising them.” One communication skill that is helpful to building trust is listening rather than speaking (See, for instance, Peters et al., 1997). Much of the attention to problem solving in our society looks first at the technical requirements and only later contemplates the socio-political dimensions. The following quotation from Gerald Jacob (1990, p. 164) is about 44 nuclear waste disposal, but everywhere he mentions waste one could substitute the phrase “defense against biological attack”: “Few have appreciated the political requirements necessary to design and implement such a solution. While vast resources have been expended on developing complex and sophisticated technologies, the equally sophisticated political processes and institutions required to develop a credible and legitimate strategy for nuclear- waste management have not been developed. The history o f high-level radioactive waste management describes repeated failure to recognize the need for institutional reform and reconstruction.” Special interest groups have been quite skilled in using the news media to undermine trust in scientific risk assessment. Trust-destroying information is compounded when the adversarial legal system highlights disagreements among experts. “In sum, our social and democratic institutions, admirable as they are in many respects, breed distrust in the risk arena.” (Slovic, 2000, p. xxxv) 3. Understanding the importance of the channel of communication, the mass media It is important to recognize that journalists are always in a hurry. They are competitive. Peer group pressure is intense (reporters consistently compare stories after they appear). Information has to be compressed and oversimplified. 45 The news must be interesting. Some events are trivialized. Most reporters are not specialists in all the fields they cover. The press is dependent upon sources; this makes them subject to manipulation by sources. (Rowan, 1984). Given these pressures it is not surprising that news stories often include inaccurate information; what is more surprising is how often they do hit the mark. The press is more interested in clashes between people than technical issues about which there is a consensus. Part of the problem of dealing with the press stems from four related shortcomings in journalism (Rowan, 1984 pp. 124-129): 1. The first shortcoming is that much news coverage is superficial. That’s because most journalists are generalists and most know a little about a lot of things. Only a few know a lot about a few important things. O f course, these specialists stand out when their expertise is needed. But often it is general assignment reporter who frames the first story about an issue. 2. The second shortcoming is that much news coverage is sensationalistic. O f course some things (like the 9/11 attacks) are sensational. But the endless repetition of pictures o f disaster can be numbing. Media overkill is apparent in major disasters. Most reporters resist the temptation to exaggerate or hype stories, but the temptation is always present in a business that depends upon ratings and circulation for its revenue. 46 3. The third shortcoming is subjectivity, bias, to use a loaded term. Every person is a subjective creature. We are all captives o f our own mindset, worldview, the values imparted by parents, taught by schools, learned with peers, conditioned on the job, watched on TV and the like. Some journalists claim to be objective, but this self-image makes it harder to rise above the assumptions and viewpoints that predominate in American journalism. The bias is best understood not in familiar liberal versus conservative terms, but as an overarching skepticism, a negative attitude about large institutions, leaders and public officials. This skepticism stems not just from the Muckraking tradition but also from the experience of Vietnam, Watergate, Iran-Contra, Whitewater, Monica, Enron, WorldCom, and so on. This skepticism can have profound consequence when reporters are called to cover government statements about risk, safety and disaster. 4. The fourth shortcoming is about standards, or more precisely, the lack of clear and enforceable standards in journalism. Given our First Amendment, reporters are burdened with almost no external checks and balances. Very few professions have such ill-defined ethical guidelines with so few sanctions for violations. This author’s experience — 18 years as reporter and 13 years teaching journalism at Northwestern University - is the basis for a conclusion that most reporters want to do a good, 47 honest job and report fairly what they learn. But the lack of outside accountability makes deviance from this standard possible. The result of these perils — superficiality, sensationalism, subjectivity and lack of standards - is that those who want to communicate via the media are at risk of being misunderstood, taken out o f context, distrusted and - rarely, but sometimes - distorted. Some ideas on how to cope with these problems are offered in chapter 5, suffice to say that the nature of American journalism makes it possible to see exaggerated, dramatic portrayals ahout major issues. Some risks have been greatly amplified by news media coverage. For example, the chemical leak in Bhopal, India, that claimed thousands o f lives, the destruction of the Challenger space shuttle, the nuclear accidents at Three Mile Island and Chernobyl, the Exxon Valdez oil spill, the adulteration of Tylenol capsules with cyanide, the “mad cow” (BSE) controversy in Europe and the United Kingdom, all represent cases that have been amplified in the media. (Slovic, 2000) Affect-laden messages (of dread, catastrophic impact, unfairness, loss of control) stigmatize risks associated with nuclear and chemical technologies. (Peters and Slovic, 1996). News media coverage o f risk makes it more difficult to get a proper perspective on risks (Combs & Slovic, 1979). Risks from dramatic and sensational causes o f death - accidents, homicides, 48 natural disasters - tend to be overstated while non-dramatic causes - asthma, emphysema, diabetes - tend to be underestimated. (Lichtenstein et al., 1978; Morgan et al., 1985). Most people have difficulty grappling with uncertain odds and yearn to know exactly what will happen (Slovic, 1982; Slovic & Lichtenstein, 1983). News organizations understand this yearning and try to be definitive in coverage. This can backfire. Content analysis of media reporting has revealed misinformation and distortion in news portrayals of DNA research, nuclear power, and cancer (Burger, 1984; Combs & Slovic, 1979; Friemuth et al., 1984; Kristiansen, 1983). Some critics have denounced the media for bias. “Decisions based on distorted views of the world resulting from ... bias have resulted in tragically mistaken priorities, death and suffering.” (Cirino, 1971). Problems o f media include complexity, uncertainty, the dependence of reporters upon expert sources, and lack of consensus among experts. The media filter events and messages, ignoring some and intensifying others, amplifying some risks for public consumption. The news media does not act alone in this process, for journalists are dependent upon sources - official, scientific, advocates of various stripes, even the “man on the street.” Variables include volume (how loudly and often is the data transmitted), controversy (is the information disputed?), the amount of dramatization and the symbols that are 49 associated with the information. Kasperson et al. (1988) say that the amplification steps are as follows: • Filtering signals (only a fraction of information is actually processed), • Decoding signals (what is it?), • Processing risk information (making inferences on the basis of heuristics), • Attaching social value to the information to draw implications (what does it mean?), • Interacting with peers to interpret and validate signals, • Formulating behavioral intentions (to take action or to tolerate the risk), • Engaging in actions to accept, ignore or change the risk. No matter how balanced the news coverage, reassuring claims do not have the power of fear-arousing messages (Sorensen, et al., 1987) which are hardly ever effectively refuted. As Alvin Weinberg said it is harder to “unseam” people than to scare them. (Weinberg, 1977) Because the news media tend to give disproportionate attention to dramatic, unusual (rare) risks, it is not surprising that popular estimates o f leading causes of death are related to the amount of media coverage they get (Combs & Slovic, 1979) A controlled study by Johnson and Tversky (1983) found that reading a story about one type of fatal event (leukemia, homicide or fire, depending upon the example) increased the 50 perceived frequencies for all hazards. In other words, bad news arouses negative affect, which has a general influence on perception, beyond the specific risk. Thus media coverage might have a pervasive and subtle effect on overall perceptions of risk (Slovic, 2000) making the world seem very unsafe. Of course, much of what the media report is bad news, which can diminish trust in institutions that are supposed to protect society. (Lichtenberg & MacLean, 1992) An example o f this tendency to focus on bad news was highlighted in 1991 when two articles appeared in the same issue of the Journal of the American Medical Association. Both studies examined the link between radiation exposure and cancer. One (the bad news) showed increased risk o f leukemia in workers at the Oak Ridge National Laboratory. The other (the good news) showed no increased risk of cancer in people living near nuclear facilities. Koren and Klein (1991) reported that subsequent newspaper coverage was much greater for tne bad news study than the good news one. The media are also less interested in science than in conflict, so disagreement between scientists gets more attention than consensus statements. A study o f 146 environment reporters by Sachsman and his colleagues (2002) showed that one-third rarely included risk assessments in their stories. Human interest, government and politics, pollution and nature were more common story angles than risk assessment. Reporters in the Mountain West region put risk assessment and health at the 51 bottom of their list of story angles they pursued. Twenty five percent o f the reporters in New England and 17 percent of those in the Mountain West said they believed that environmental journalists generally have overblown risks and unduly alarmed the public. The study confirms the view that the media are not very interested in science, unless there is scandal or conflict. (Klaidman, 1990) Journalist Victor Cohn has stated (1989, p. 43) that to get a story into the newspaper or on the air a reporter has to “almost overstate” w hat’s at stake. Cohn says, “we have to come as close as we can within the boundaries of truth to a dramatic, compelling statement. A weak statement will go no place.” Political conflict “engulfs, saturates and distorts virtually all environmental discussions,” according to journalism professor Lou Prato (1991, p. 7) Politicians, advocacy groups and litigious attorneys recognize what the media are interested in, know how to play the system and are adept at getting media attention for their causes, which can feed public distrust. (Slovic, 1993). 4. Understanding how the public receives risk information. The psychologist Seymour Epstein (1994, p. 710) has noted that in everyday life “people apprehend reality in two fundamentally different ways, one variously labeled intuitive, automatic, natural, non-verbal, narrative and experimental, and the other analytical, deliberative, verbal and rational.” It would be erroneous to 52 conclude that lay perceptions of risk are all derived from emotion; affective processes interact with reason in all normal thinking. (Slovic, 2000; Damasio, 1994) In general, people are haphazard in accumulating information. People tend to extrapolate from events they learn about; for instance, Johnson and Tversky (1983) found that people who read in the newspaper about a tragic death tended to exaggerate how often such deaths occurred. The tendency for people to increase their frequency estimates for causes of death learned from the news media could be a problem in a bioterror attack as stories about casualties reinforce the notion of widespread terror. Anthropologists use the term “indigenous technical knowledge” when referring to how a non-expert layperson understands how his or her world works (Brokensha et al., 1980). People tend to employ rules of thumb in making decisions and these are susceptible to biases, misconceptions and illusions of validity (Kahneman et ah, 1982). Popular judgments about uncertainty rely on simple cognitive rules o f thumb, which result in error. (Morgan and Henrion, 1990) The picture is not entirely bleak. “One of the miracles of democratic life is the ability of lay people, often with little formal education, to master technical material when sufficiently motivated,” according to Fischhoff (1994). “Unfortuntely for risk managers, the motivation for this self-education often comes from a feeling of having been wronged.” 53 One factor in feeling wronged is coercion. When people feel that they have been forced to assume a risk, outrage is more likely to occur. The distinction between voluntary and involuntary risks has been widely noted (Starr, 1969; Council for Science and Society, 1977; Kinchin, 1978) although Slovic and his collaborators (1980) doubt that involuntariness increases the feelings o f risk as much as perceptions o f inequality and catastrophic potential. Clearly major changes are destabilizing. The terror attacks of 2001 had an impact way beyond the physical damage in New York City, Washington , DC and the field in Pennsylvania where the fourth airplane crashed. These events are perceived as signals o f new threats. In a different context Slovic and collaborators have warned (1980) that “The alarm created by an accident signal is a strong determiner of its social impact and is not necessarily related to the number of people killed.” As mentioned above, there has been much research into the factors that drive risk perception. Slovic (2000) developed a “psychometric paradigm” with a theoretical framework that assumes risk is defined in a subjective manner by individuals who are influenced by cultural, social, institutional and psychological factors. Research into the psychometric paradigm has examined psychophysical scaling techniques and multivariate analysis to represent risk perceptions (Slovic, 2000; von Winterfeldt et al., 1981). Relative small risks 54 can be magnified if they seem to portend broader social impact or potential catastrophic harm in the future (Slovic et al., 1984). A thorough discussion about risk may not calm people’s anxiety if social or ideological concerns predominate. Hidden agendas need to be examined in the open. (Edwards & von Winterfeldt, 1984) Attributes that are not grounded in the actual danger influence the perception o f risk. For instance, stigmatization of certain risks, like nuclear waste, AIDS, or some forms of mental illness, increases the negative perception of those risks. (Slovic, 2000) It has been noted that incidents of stigmatization - including such as the Tylenol contamination and the Alar and BSE scares - illustrate a new form of societal vulnerability. Although people live longer lives in 2002 than a century ago (when the average lifespan was below 50 years) people often feel greatly at risk. “While human health was the primary vulnerable commodity in the past, increasing technical and medical sophistication, combined with hypervigilant monitoring systems to detect incipient problems, make such problems less likely now,” Slovic has stated (2000, p. xxviii). “But the price of this vigilance, based in no small part upon the incredible ability of modem media to ‘spread the word,’ is the impact that this information itself has upon social, political, industrial and economic systems.” Slovic concludes that “we live in a world in which information, acting in concert with the vagaries of human perception and 55 cognition, has reduced our susceptibility to accidents and diseases at the cost of increasing our vulnerability to massive social and economic catastrophes.” For instance, how much of the concern about anthrax is about the risk/benefit of various treatment options versus the outrage that a terrorist might spread disease in America? When people are under stress and greatly concerned because they perceive a significant threat, their ability to process information is severely diminished (National Research Council, 1989; Baron et al., 2000; Fischhoff, 1989). Exposure to negative psychological attributes (for example, risks that seem involuntary, uncontrolled, unfair and dreaded) creates mental noise and interferes with a person’s capacity for rational discourse (Covello et al., 2001; Neuwirth et al., 2000) There have been efforts to quantify qualitative emotions (Starr, 2001) but the outrage is easier to identify than the inputs which cause such turmoil. It affects people differently, particularly when gender is considered. Most studies o f risk perception have shown that white males are less concerned about hazards than women and non-white men; white men tend to perceive risks as smaller. (Finucane et al., 2000; Flynn et al., 1994). Women and non-white men may feel less control over risky activities and, hence, perceive greater risk; risk perceptions seem to be related to individual power over hazardous activities. (Slovic, 2000; Gustafson, 1998) White men tended to 56 trust institutions more than women and men of color (Flynn et al., 1994) reinforcing the idea that since men manage, control and benefit from many o f the risky technologies, therefore they feel less vulnerable than do those who have less power. (Slovic, 2000). This highlights the importance of non technical factors - power, alienation, benefit, feelings o f vulnerability - in risk controversies. To address these political and social factors, improved methods of risk management are using negotiation, mediation, public oversight and citizen involvement (National Research Council, 1996). Public participation can lead to more successful ways to manage risk. (Slovic, 2000). involving citizens in decisions about managing risk has been much studied in the environmental health context (English, 1992; Kunreuther et al., 1993; Renn et al., 1991; Renn et al., 1995). As Slovic stated (1997) involving citizens as legitimate partners is no quick panacea but it may “in the long run, lead to more satisfying and successful ways to manage risk.” Activities which engage stakeholders in dialogue about resolving disputes and building trust are worthwhile efforts aimed at reaching consensus (Morgan et al., 1992). These will be described in detail in Part II of this study. 57 In sum, the research into risk communication shows that no theory has yet answered all the questions about why people perceive risks the way they do. It has offered practical guidance on ways to communicate - or more precisely, mistakes to avoid while communicating. This practical guidance was widely distributed and recognized as valuable prior to 9/11. It was widely known that poor risk communication could cause fear and poor decisions. The anthrax case demonstrated the accuracy of this view. A bioterror attack does not have to cause thousands o f fatalities to have enormous impact on society. The accident at the Three Mile Island nuclear reactor in 1979 caused not a single fatality, but no accident in history has resulted in so large a cost to society in the form of additional regulation, reduced operation o f reactors, opposition to nuclear technology and increase reliance on more expensive energy sources. Other environmental health controversies — the accident at the Union Carbide plant in Bhopal, India; the pollution of Love Canal, New York, and Times Beach, Missouri; the Exxon Valdez oil spill in Alaska - all resulted in major government safeguards that imposed enormous costs on society. They seemed to be signals, portends and harbingers o f looming risks, unfamiliar and disorienting. (Slovic, Lichtenstein, et al., 1984) Of the Bhopal spill (the most deadly of those mentioned) the New Yorker magazine stated (1985) that “the spectacle haunts us because it seems to carry allegorical 58 import, like the whispery omen of a hovering future.” (quoted in Slovic, 2000). Communication about the risks of bioterrorism ought to confront such omens. 59 Chapter 2. Making Sense of the Anthrax Attack The attacks of September 11 were not simply destructive of lives and property; they caused tremendous psychic damage. The psychological trauma was linked to shocking television images of planes slamming into buildings, fire and smoke, people jumping to their deaths from the high rises and the skyscrapers collapsing in a cloud of debris. For the public, the anthrax attack became an extension of the aircraft disasters. Michael Barkun has stated that the “evil too painful to watch was followed by evil that could not be seen,” and was “the more unnerving for its very invisibility.” (Barkin, 2002 a, p. 17-19) The increase in public fear during the anthrax attack is the subject of this study. National telephone polls conducted in the weeks after discovery of the first anthrax cases showed that a quarter of the American public feared they would become ill with anthrax by opening their mail. (Harvard School o f Public Health, 2002). This chapter describes a methodology for understanding and evaluating the federal government’s response to the attack. Background Historically, anthrax has been a disease closely associated with animals or animal products contaminated with bacillus anthracis spores. In the middle of the 19th century, inhalational anthrax related to the manufacture of textiles was 6 0 called “woolsorters’ disease” in England. In the 20th century, improved industrial hygiene practices and restrictions on imported animal products greatly reduced the number of cases. Recent cases are rare. The most noteworthy was the 1979 outbreak in Sverdlovsk in the Soviet Union. It apparently occurred after the aerosol release of b anthracis spores from a military facility where biowarfare materials were manufactured and tested. Before the 2001 anthrax attacks, the last case of inhalational anthrax in the United States occurred in 1976. (Jemigan, et al, 2002) Most national offensive bioweapons research was terminated after ratification of the Biological Weapons Convention in the early 1970s, although some nations - like Iraq - continued producing and weaponizing anthrax. The former Soviet Union is known to have had a large anthrax production program in the 1970s. There have been frequent allegations o f offensive biological weapons programs in a dozen countries. The cult responsible for releasing sarin nerve gas in a Tokyo subway station in 1995, Aum Shinrikyo, released aerosols of anthrax and botulism throughout Tokyo at least eight times, probably without causing illness. In 1970 the World Health Organization estimated that 50 kg of b anthracis released in aerosol form over a city o f 5 million persons would sicken 250,000 and kill 100,000. The U.S. Congressional Office of Technology Assessment in 1993 compared the release of 100 kg o f anthrax spores with the 61 potential lethality o f a hydrogen bomb. (Inglesby, et. al., 2002) In the Anthrax attacks of 2001 anthrax spores were sent in at least five letters to Florida, New York, and Washington, D.C. All the letters were mailed from Trenton, NJ. Twenty-two confirmed or suspected cases of anthrax were reported. The first case came to light after a photo editor who worked for the company that owns the National Enquirer was diagnosed on October 4th. He died about 24 hours later from the inhalation form of anthrax. During the next seven weeks ten more persons were diagnosed with inhalation anthrax and another 11 became ill from skin anthrax. No cases were reported after November 21, 2001, when an elderly woman in Connecticut died o f inhalation anthrax. In total, five persons died. More than 30 thousand persons received antibiotic treatment to prevent illness. Fortunately, prophylactic use of antibiotics halted infection (if started early enough) so there was great urgency to identify those at risk. There is no way to know how many more persons would have contracted anthrax were it not for antibiotics. (Thomas, 2003) The perpetrator was still at large (as o f August 2003) and the exact source o f the anthrax spores used in the attacks has not been disclosed. Methodology The study examines four problematic factors that may have confounded risk 62 communication efforts during the anthrax episode. These problems were identified two decades ago by Covello, Slovic and von Winterfeldt (1986). They are: • Problems with the message, particularly as to accuracy, complexity and uncertainty, • Problems with the sources of communication, particularly lack of institutional trust and credibility, disagreement among sources and use of technical jargon, • Problems with the media, particularly amplification of risk by dramatizing and sensationalizing the risks, • Problems with the receivers of information — the public — which may have inaccurate perceptions of risk in general and little understanding of science and medicine. The anthrax episode of 2001 is investigated in light of these problems to test a set of related hypotheses: • The accuracy hypothesis states that errors in decisions and public statements were associated with public fear of a newly apprehended risk, anthrax. Once the public suspected that erroneous information had been conveyed, did this have an impact on public fear? 63 • The credibility hypothesis states that contradictory statements from official sources were associated with loss of credibility and public trust in the Anthrax attack. Did the official sources act in a credible manner? • The amplification hypothesis states that news media amplification of risk was associated with increased public fear in the Anthrax attack. Did the dramatic news coverage and government’s initial slowness in providing information create an information vacuum that was filled by unreliable and sensationalistic claims conveyed by television, newspapers, radio, magazines and the internet? • The powerlessness hypothesis states that the absence o f knowledge by the public of actions that citizens could take to control the risks o f anthrax was associated with public fear. Was the public left feeling that there was little that could be done for self-protection against anthrax in the mail? The study also considered a null hypothesis that holds that the four factors listed above did not relate to the increased public fear. Clearly the null hypothesis would be proven if (a) there had been no measurable increase in public fear, or (b) if widespread death and disease had occurred - rendering moot any theory that placed primary blame on the government for not communicating well and/or that the media hyped the risks. 64 The research design is a descriptive case study featuring an explicit logic model showing the relationship of factors bearing on risk perception. The construction of a logic model follows Wholey’s suggestion that activities, outcomes and assumed causal linkages can be developed and summarized. (Wholey, 1994, pp. 19-27; Wholey, 1983, pp. 42-3). Unlike a program evaluation, where the logic model is explicitly present before it is tested, the evaluation of risk communication and its impact on public perception of newly apprehended risks provided evidence that resulted in the articulation of a proposed model (see below, p.53). The model — while designed to show “cause-effect-cause-effect- cause-effect patterns” (Yin, 1999, p. 1215) - is primarily descriptive. Yin states that “an invaluable feature o f the case study method is the ability to ‘discover’ while in the process of doing the research.” (p. 1216). He endorses the approach of using rival explanations as a design strategy for case study research and that the “more that plausible rivals are investigated and then rejected, the greater the support for the original hypotheses.” (p. 1217) This approach, Yin states, can substitute for experimental designs. There is no doubt that causal complexity confounds easy interpretation of the anthrax episode. It was an unprecedented event (notwithstanding other biological and chemical attacks in other countries, see below p. x). While it is difficult to compare this single case with any others, it is not impossible to 65 compare performance in phases of the crisis as it unfolded over a period of weeks. In fact there are several distinct phases: (1) the discovery and initial alarm, (2) the evacuation of buildings on Capitol Hill and offices where contaminated mail was opened, (3) the realization that postal workers were at risk by handling unopened mail, and (4) the dawning recognition that some persons had died from anthrax after handling mail that had not been sent by the perpetrator. This study is a meta-analysis consisting of three types of research: a) A content analysis was conducted of more than 200 separate assessments of the decisions, actions and communications during the phases of the anthrax episode. This analysis, conducted by the author, included several types of data: (1) archival records o f statements, press releases and web postings by federal government agencies, including the Centers for Disease Control, the Department o f Health and Human Services, and the Office of Homeland Security, (2) testimony by officials and other experts before Congressional committees, (3) statements in academic publications and postings on established websites including the Center for Civilian Biodefense Strategies, the Chemical and Biological 66 Weapons Non Proliferation Program and the Brookings Institution, (4) news analysis and opinion commentary in major newspapers, magazines and journals. Some 17,205 newspaper and magazine stories were identified about the anthrax attacks. About one-fourth of these stories — ones that appeared in major publications and broadcast networks — were scanned to select those that contained opinions about how well the risks were being addressed. This permitted the comparison o f expert judgment about the performance and impact o f official actions and statements. The reality of intense scrutiny by Congressional committees and the press increases confidence in the validity of the facts that appeared in these documents. Because of the large amount of expert commentary judging the performance of the government in the anthrax episode, and the overwhelming consistency of opinion, the reliability of the evaluation is enhanced. Moreover, a large sample o f news stories - both print and broadcast transcripts - were reviewed to assess how the news media handled the anthrax story b) Several national opinion polls were reviewed. These included studies by Time/CNN/Harris, ABC/Washington Post, Newsweek/Princeton Survey Research Associates, Gallup/CNN/USA Today, Gallup poll, and Associated Press. One series was primarily relied upon for an assessment of how citizens were responding to the anthrax attacks. This study was 67 performed by the Harvard School of Public Health and was sponsored by the Robert Wood Johnson Foundation. The first telephone poll was conducted in November 2001 and involved more than 1,000 respondents nationwide, plus additional polling of about 500 citizens in each of three regions where the anthrax letters were handled at postal offices. The second (follow-up) poll was conducted a year later by the same researchers. These permitted a quantitative assessment o f levels of concern and provided clues as to the cause of increased fear, c) Two separate series of focus group research were reviewed, including: (1) 8 focus group sessions conducted by the National Public Health Leadership Institute with 90 public health officials, and (2) 17 focus group sessions conducted by the Johns Hopkins Center for Biodefense Strategies with persons who were exposed or potentially exposed to anthrax in 2001. This provided qualitative input on how people - both experts and potentially exposed persons - reacted to the episode and felt that the government had performed. The specific relationship of the various methodologies to the hypotheses is described in figure 2. 68 Message Problems Source Problems Channel Problems Receiver Problems General Examples Errors, Complexity Uncertainty Lack of trust and credibility, disagreement Sensationalism and bias, distortion, fail to inform Misperception, inability to act, feel powerless Hypotheses Accuracy: Errors in decisions and statements were associated with public fear of anthrax Credibility: Contradictor y statements from officials were associated with loss of credibility and public trust Amplification: News media amplification of risk was associated with increased public fear of anthrax Powerlessness The absence of public knowledge of steps to control the risks of anthrax was associated with increased public fear Methodology Media content analysis, review of expert opinion Analysis of public opinion survey data Media content analysis and review of expert opinion Focus group research and review of expert opinion Figure 2. Hypotheses and Methodologies A review of the record and analysis of opinion research permits evaluation of the accuracy and credibility of the US government and public fear during the anthrax attack. This combination of qualitative (content analysis) and quantitative (polling) data helps establish if there was an association between government actions/statements and public fear. The media content analysis and focus group research sheds light on how the media performed and how the 69 public responded. They were judged in the context of their own risk communication objectives. Standards for Evaluation The purpose is to evaluate performance in light of best practices for risk communication. These were illuminated in the recommendations in the National Research Council’s 1989 report Improving Risk Communication where the panel endorsed improved procedures, openness, dialogue and “early and sustained interaction” with the public. Such advice has been incorporated in various criteria, including those endorsed by the U.S. Environmental Protection Agency fifteen years ago which the EPA labeled the “Seven Cardinal Rules of Risk Communication.” (Covello and Allen, 1988) They are: • Accept and involve the public as a legitimate partner, • Plan carefully and evaluate efforts, • Listen to the public’s specific concerns, • Be honest, frank and open, • Coordinate and collaborate with other credible sources, • Meet the needs o f the media, • Speak clearly and with compassion. While the EPA does not set standards of risk communication for the entire federal government, it has long experience in dealing with the vexing problem 70 of explaining risk to the public. Moreover, the EPA’s “cardinal rules” are the strategic counterpoints to the tactical “deadly sins” listed by another federal agency, the Agency for Toxic Substances and Disease Registry (ATSDR) which is part o f the CDC. The ATSDR lists the following as the “Ten Deadly Sins of Communication.” • Appearing unprepared, • Handling questions improperly, • Apologizing for yourself or the organization, • Not knowing knowable information, • Unprofessional use of audiovisual aids, • Seeming to be off schedule, • Not involving participants, • Not establishing rapport, • Appearing disorganized, • Providing the wrong content. Although the two lists do not precisely match up, they both emphasize the need for planning and preparation; handling concerns and questions; involvement, participation and rapport; and avoiding things that undermine credibility. While the second list is much more concerned with tactics, it is not inconsistent with the EPA’s broader advice; in fact, the ATSDR lists the EPA’s “cardinal rules” before listing its own “deadly sins” on its portion of the CDC website. 71 Therefore, it is not inappropriate to hold the CDC to the strategic “cardinal rules” for the purposes of evaluating the performance o f that agency and related federal organizations in the anthrax case. The various forms of research — content analysis of statements and commentary, opinion surveys and focus groups - were used for triangulation in developing conclusions. (Patton, 1999, p. 1192) Their content was analyzed to develop a matrix showing the impact of different actions at various stages of the anthrax response, assessed for relevance to each of the alternative hypotheses. Following Ragin’s qualitative comparative analysis format, this “truth table” shows when different acts did or did not have the hypothesized consequence. (Ragin, 1999, p. 1225). Reviewing the anthrax attack as it unfolded and comparing actions/statements in each phase, facilitated an evaluation of each of the rival explanations to assess whether each was strongly confirmed, confirmed, partially confirmed or not confirmed. It permitted assessment of whether some of these factors are more closely related than others to the increase in public fear. Each of the different types of research has strengths and drawbacks. The content analysis did not cover the entire universe of statements about the anthrax attacks, but a large sample provided confidence that no major explanation of 72 what happened was omitted. It enhanced confidence in the factual accuracy of the timeline included in this report. Despite its inclusiveness, it did not assure that any o f the expert judgments were, in fact, accurate. The strength o f the quantitative opinion research is that it was a valid snapshot of public attitudes at the time o f the survey. The margin o f error for the nationwide sample is +/- 3%. The weakness of telephone polls is that they may tell how people feel but they do not always shed light on why people feel the way they do. Qualitative focus research helps to flesh out why people hold the attitudes and beliefs they espouse. It is suggestive but not definitive. Unlike surveys, one cannot extrapolate from focus research that a majority of similar respondents would respond in identical ways if asked the same questions. A meta-analysis has potential drawbacks. The survey and focus group research were not initially designed to test the precise hypotheses listed above. This weakness is partially overcome by virtue of the fact that in each case researchers were attempting to answer closely related questions that prompted this meta analysis: did fear increase? Why did fear increase? Was it related to poor messages? Lack o f trust because officials did not act in a credible manner? News media dramatization of the risks? Public ignorance, inability to take protective steps, feelings o f powerlessness? Was it caused by other factors? While stated differently, the research design was about the same phenomenon. 73 Although the author did not design either of the focus group research projects, I have worked on consulting projects in the past with the lead investigator o f one (Dr. Vincent Covello of the National Public Health Leadership Institute) and made a presentation to the Johns Hopkins Center for Biodefense Strategies prior to design of its focus research project. Such familiarity offers no assurances that the research design would have been duplicated had the author possessed the resources to conduct the focus groups, but it reinforces the belief that these projects were about identical issues. Confidence in the findings was increased by the independence of the researchers and the uniformity o f the results across all three fonns of research. The content analysis, opinion research and focus group research were consistent in their explanations of what happened in the anthrax episode. Logic Model One tool to help evaluate the process of informing the public about anthrax is a logic model showing the linkages between government programs, actions, announcements, the public reached by the communication efforts and outcomes. The logic model follows the template offered by McLaughlin and Jordan (1999) building on examples from Wholey (1983), Rush and Ogbome (1996), Corbeil (1986) and Jordan and Mortensen (1997). Patton (1997) holds that such a description is an “espoused theory of action,” showing how stakeholders 74 perceive the process to work. The logic model includes the following elements: • Resources (or inputs) including human resources, • Activities, including action steps to implement a program, • Outputs, which are the deliverables for stakeholders, • Stakeholders reached by the program or process, • Short-term outcomes of the process, • Intermediate outcomes of the process, particularly through stakeholders, • Long-term outcomes. In the middle of the model are the customers, or stakeholders, those recipients of the program who are reached by the process. Montague (1997, 1994) describes this as the “3 R ’s of performance: resources, people reached and results,” The model helps to identify the key contextual factors that are external to the government’s program for reaching the public, including factors that are not under the control of officials. (McLaughlin and Jordan, 1999) These antecedent or mediating factors influence the delivery of the program (Harrell, et.al., 1996) The external factors include the notion of shared responsibility between government and other entities. (McLauighlin and Jordan, 1999). In this episode the news media shares responsibility for communicating government warnings and advice to the public on the subject of anthrax. While the logic model is usually developed as part o f a team effort to improve a 75 program, it also can be used by an independent observer to perform an analysis through such techniques as document reviews, interviews and focus groups. The logic model is most often designed around programmatic goals to state the positive outcomes that a government agency is trying to accomplish. In this case a logic model is used to explain how a government effort may have had unintended consequences. Specifically, the logic model is designed around hypotheses that efforts to communicate with the public about anthrax did not calm fears but may have inadvertently increased them. While causation cannot be proven from the available evidence, the linkages are important in assessing whether an unintended outcome can be logically connected with the decisions and actions of the government, the coverage of the media and the response of the public. The logic model includes a series o f “if, then” statements along the lines o f “If assumptions about contextual factors remain correct and the program uses these resources with these activities, then it will produce these short-term outcomes for identified customers who will use them, leading to longer term outcomes.” (McLaughlin and Jordan, 1999, p. 10) In this way the logic model results in an iterative procedure, which shows a pattern that can be used to study the impact of official actions. The product is displayed in a diagram that reveals the essence o f the linkages and a plan to measure outcomes. This tells what 76 McLaughlin and Jordan (2003) call a performance story with attributable results. They state (2003, p. 3) that logic models give a more comprehensive view than flow charts, risk analysis and systems analysis and “address the increasing requirements for both outcomes measurement and measurement of how the program is being implemented to allow for improvement.” For purposes of understanding the government response to the anthrax episode, we will look at inputs, processes and results in the form of information, actions and protection. Following Leeuw (2003) we will use a “policy-scientific approach” that generates a “ Ties of propositions or assumptions” about how things work. The propositions are tested through a review o f research, gathering expert opinion and review of documents. In accord with the process outlined by McLaughlin and Jordan (2002) the following steps were taken: (1) identifying factors that might influence performance that are part o f the context in which this was implemented (including press coverage), (2) looking at how changes in the context influence performance, and (3) looking at how possible partnerships along the programmatic boundary will affect the output o f the effort (particularly the government/media “partnership”). In other words, an effort is made to map the linkages between elements in the chain, as McLaughlin and Jordan describe it (2003, p. 12), “ If this, then that - If that, then what?” In the anthrax episode, the if this, then that logic includes: • If medical surveillance reveals cases of suspected bioterrorism, then officials must be notified of the threat, • If officials are notified of a threat, then they must make decisions on protective steps for the public, • If decisions on protective actions are made, then officials must decide how to implement and announce such steps, • If actions and implementation steps are announced, then officials must deal with media inquiries and the impact o f news coverage, • If media coverage occurs then the public will be informed of the risks and actions taken, • If the public is informed of risks and protective measurers, then people will experience emotional reactions (including such things as stress, fear, vigilance, etc.), • If people experience these emotions then they will seek ways to protect themselves and mitigate the risk, • If people seek ways to protect themselves and reduce risk, then they will need clear guidance from trusted sources 011 best actions to take, • If little clear, credible guidance is provided on how to protect against the risk, then people will perceive that they lack control over the risk, • If people perceive they lack control over the risk, they will perceive a greater threat to their own safety and health, 78 • If people perceive a greater threat then they will experience stronger emotions, including increased fear It should be noted that these assumptions are not easily proved. In fact, the evidence in the anthrax case si _gests some association with the linkages described, but the data are not sufficient to prove causation of the sort suggested above. Nevertheless, these “if this, then that” assumptions help to outline the logic that is being investigated and assist in measuring the impacts. By stating the logic explicitly the reader is facilitated in assessing whether it is indeed logical or is, in fact, illogical. Tne logic model suggests a linear sequence when in fact the situation was much more dynamic. To account for the non-linear factors, a “Z” rorm of the logic model is used (Fraser, 2002) to show concurrent or sequential logics where there is shared responsibility for impacts. Thus we are able fo specify the interaction of one important factor (the news media) that is external to the government but crucial to its ability to communicate with the public. By including the news media in the diagram we can study the interactions o f how the public is usually reached by government officials seeking to announce a program, action, or warning. This Z type o f logic model is incorporated in figure 3. Logic Model o f C om munications During Anthrax Attack (S> (“ ) Stakeholders Reached ( Outputs n Short Term Outcomes M interm ediate Outcomes^ Information about initia attacks and risks Media criticism of government Official decisions Actions and Announcem ents Media Official statem ents Ongoing media coverage and criticism o f government actions demand for protection closing buildings and provision of antibiotics protective actions for Congressional sta ff and Postal W orkers ElTons by indiviudals to reduce risk in handling mail Public Reached by Media aoout subsequent events Figure o. i^ogic M ouel o f Communications During Anthrax Attack 80 The anthrax episode suggests a complicated interplay between what people knew generally about bioterrorism before September 2001, the concerns triggered by the terrorist attacks on 9/11, and what they learned mostly via the news media as the anthrax case unfolded. Official actions and statements were conveyed and elaborated upon by the news media, affecting informal discussions in hundreds of thousands of homes, workplaces and community gatherings, and influencing how people assessed official actions and statements and the public’s perception of risk. These had an impact on the behavior of individuals. The actions by individuals put more demands on government, resulted in a variety of coping mechanisms (for example, stockpiling antibiotics) and raised concern about terrorism in general and the perceived risk of bioterrorism. The model diagrams how events trigger governmental decisions which translate into official statements provided by official sources. This information is filtered though the news media which ignore some aspects and highlight others. The news coverage - particularly critical coverage - affects subsequent government actions. The news is digested by the public in light of both its general perception of risk and its specific (informal) assessments of the accuracy and credibility of advice from various sources. Beyond this evaluation, behavioral actions occur. For example, people might decide to stop opening their mail, wear gloves and/or masks while handling mail, or just keep on doing what they have always done with the mail. Likewise, persons who 81 hear about the problem and work in mailrooms might decide they want to take antibiotics as a precaution against getting ill. During the height of the episode it was not clear what individuals could do to protect themselves. To summarize the parts of this evaluation study: 1. Objectives: (a) to test the four hypotheses about accuracy, credibility, amplification and powerlessness and (b) to assess how well federal agencies, particularly the Centers for Disease Control, measured up to their own objectives, as enunciated by the EPA more than a dozen years ago: ® Accept and involve the public as partners, • Plan carefully and evaluate performance, • Listen to the public’s specific concerns, • Be honest, frank and open, • Coordinate with other credible sources, • Meet the needs o f the news media, • Speak clearly and with compassion. 2. Definition of data: (a) contents of archival data of public statements, testimony, news accounts, journal articles and peer judgments, (b) results o f telephone surveys, and (c) results from focus group research. 3. Methodology: meta-analysis of (a) content analysis of statements, (b) 82 opinion survey results, (c) focus group results, and triangulation of results to assess strength of evidence. Utilize a logic model to understand patterns and linkage between government actions and public response. Utilize truth table to understand the chronology of the event. Weigh anecdotal evidence from truth table and chronology to measure CDC performance under the EPA criteria stated above. State what data support or disconfirm each hypotheses and the level o f strength of confirmation, if any. 4. Instrumentation: (a) content analysis performed by author, (b) surveys performed by Harvard School of Public Health, (c) focus groups performed by National Public Health Leadership Institute and Johns Hopkins Center for Civilian Biodefense Strategies. 5. Data collection by the above individuals and institutions. 6. Data processing: As noted above, some o f the data was analyzed by other organizations, and is reviewed in the context o f the logic model. 7. Data analysis: Meta-analysis of materials that were previously analyzed by the institutions noted above and evaluation of material from truth table in light of processes summarized in logic model. Quantitative results (from the surveys) were given great weight in establishing the level of public fear and changes in perceptions among communities. Qualitative results (from the focus groups and content analysis) were 83 given lesser weight, but were very helpful in describing how people responded to such things as the official messages, media coverage and feelings o f lack of control over the newly apprehended risks. By triangulating the data from various sources it was possible to discern if the hypothesis was strongly confirmed, confirmed, partially confirmed or not confirmed. The data were helpful in establishing whether an association was present but were not strong enough to prove causation. 8. Findings, Observations, Options and Recommendations. The results of this study aided in the articulation of options for improvement. Options are discussed to address issues of accuracy, trust, media coverage and public concern. (See part II) 9. Reporting: Preliminary results were discussed with more than 20 participants in the March 2003 conference of the Critical Incident Analysis Group in Charlottesville, Virginia, and suggestions for additional analysis (particularly as to impact of statements after 2001) were incorporated into this study. The overall results of this study were presented at the following conferences (and feedback solicited and suggestions incorporated by the author): • “Leadership during Crisis Situations,” Presentation at the Mobius Forum on Leadership, Values and Spirituality at the Harvard Business School, June 2003. 84 • “Terrorism and the Impact of Public Perception,” Presentation at the Cantigny Conference on the Role of the Military in Securing the Homeland, Chicago, June 2003. • “Lessons from the Anthrax Attack,” Presentation at the American Bar Association Annual Convention, Woikshop on the Role of the Military Inside the United States, sponsored by the Standing Committee on Law and National Security, August 2003. Covello, Slovic and von Winterfeldt (1987) identified four types of risk communication programs, according to their objectives: (Type 1) information and education; (Type 2) behavior change and protective action, (Type 3) disaster warnings and emergency information, and (Type 4) joint problem solving and conflict resolution. The retrospective focus of this study is on the government’s warnings, emergency information and protective actions in affected areas (Types 3 and 2). The prospective part of this study (the final four chapters) addresses the last category of designing a system that will solve problems and resolve disputes in the future. 85 Chapter 3. Evaluating the Federal Government’s Actions This evaluation of the federal government’s performance is based on two sources o f information. First, a content analysis was undertaken of statements issued by government agencies, testimony before Congressional committees and opinions stated by observers in news stories. Second, an evaluation was undertaken o f survey opinion research in the months after the attack. The information gathered presents a critical appraisal o f how the government handled the crisis. Phase 1. Dawning awareness of casualties in media or2anizations. CHRONOLOGY: September 18: Letters postmarked in Trenton, N.J. are sent to the New York Post and NBC News. September 22: New York Post employee, Johanna Hudson, develops a blister on her finger. September 27: New Jersey postal carrier develops a lesion. September 29: US Health and Human Services Secretary Tommy Thompson appears on 60 Minutes and reassures public that the government is prepared to deal with a biological attack. September 30: Photo editor Bob Stevens at the tabloid Sun in Boca Raton starts to feel ill. 8ft October I: CBS news employee Claire Fetcher develops two lesions on face. October 2: Mr. Stevens is admitted to hospital October 4: First public announcement that Mr. Stevens has anthrax. See. Thompson deems it “ an isolated case " with no evidence of terrorism; suggests it could have natural causes. October 5: Mr. Stevens dies. October 7: Offices o f the Sun's publisher in Florida are closed after anthrax found on Mr. Steven’ s keyboard. October 9: Letters postmarked in Trenton are sent to Senate Majority Leader Tom Daschle and Sen. Patrick Leahy. October 12: Public announcement that Erin O 'Connor at NBC News has developed skin anthrax. CDC issues finding on the Florida case in Morbidity and Mortality Weekly Report website (MMWR). (The chronology is adapted from the MMWR website, the New York Times o f December 26, 2001, and the Globe and Mail, March 6, 2002) Before the first diagnosis of an anthrax case the government was trying to reassure the country shocked by the 9/11 attacks. Health and Human Services Secretary Tommy Thompson appeared on CBS’s 60 Minutes on September 29, 2001, and proclaimed that the United States was prepared for biological attacks and urged people not to be concerned. Officials who had worked on preparedness issues at his department, including Margaret Hamburg, recalled 87 being “apprehensive because we knew that simply wasn’t true.” She dismissed his upbeat comments about preparedness as “wishful thinking.” (quoted by Thomas, p. 15) Within a week Thompson’s predictions were shown to be too optimistic. When he disclosed the first case of anthrax on October 4, Secretary Thompson reassured the public that this was an isolated case, that the infection might have occurred naturally by drinking water from a stream and that it was not a case o f terrorism. As he spoke, Dr. Larry M. Bush, the doctor who had diagnosed inhalation anthrax in Robert Stevens, the first victim, knew that Thompson’s statements were all incorrect. The federal government decided that it would centralize all official statements from one spokesperson, a political appointee. Thompson ordered his public health officials to not speak to the media. This decision resulted in the initial exclusion of knowledgeable experts from the airwaves and newspapers - people at CDC, the Federal Food and Drug Administration and the National Institutes of Health. Only later would they be called upon to speak on the technical issues that eluded the more senior, political appointees. With the confusing and contradictory statements from Washington, skepticism grew about the technical advice being provided. The anthrax episode occurred 88 as people were already wary o f technical explanations for risk. As Pat Caplan stated before the anthrax attack, “The faith of a previous generation in the ability of science to provide answers has turned to doubt, partly because scientists themselves are not in agreement, partly because the answers science now gives are much more complex and contingent, and partly because ‘they’ are always changing their mind.” (Caplan, 2000, p.21) This assessment proved right in the anthrax case, where botched explanations from ill-informed spokespersons set the stage for misunderstanding and mistrust. The government was off to a slow start in communicating with the medical community and other public health specialists as well. It was not until October 12 that CDC issued its findings on the first death October 5th on the computerized Morbidity and Mortality Weekly Report website. The former editor of the MMWR, Lawrence Altman, is now a correspondent for the New York Times. He wrote on October 16, 2001 in that newspaper that “the bulletin that doctors and health workers look to for information about communicable diseases, devoted only two paragraphs to the anthrax situation, providing only sketchy details of the first two cases and a description of anthrax symptoms.” Altman added, “As a former editor of the report, I know that it can quickly transmit needed health information. But this time, its current editor, Dr. John W. Ward, said the report was ‘out of the loop.7 ” CDC spokespersons, now freed 89 to comment to the press, seemed to not have access to information about cases in Florida and New York, Altman stated. They issued “puzzling statements” and in response to a query from news reporter Altman, “they asked me to explain the science, saying they did not understand it or had not been informed.” (New York Times, October 16, 2001). Dr. Julie Gerberding, who headed the CDC’s National Center for Infectious Diseases at the time of the anthrax attack (and who would later become director of the CDC) recalled that few persons, including doctors or municipal health officmls, could get information from CDC. (Newsday, October 8, 2002). Phase 2. Congressional mail tested and more cases revealed. CHRONOLOGY: October 13: An unidentified Delaware residents who works at the Bellmawr, N.J., postal facility, develops lesion on hand. October 14: Norma Wallace, a postal worker at Hamilton, N.J., develops nausea. October 15: Letter containing anthrax is opened in Daschle’ s office, spewing cloud of spores. Office is closed. Second worker at the Sun in Florida, Mr. Blanco, is confirmed as suffering inhalation anthrax. O c to b e r 16: H u n dreds o f se n a te sta ffers a re tested; 12 se n a te offices a re closed. P o s ta l worker Patrick Daniel O 'Donnell is hospitalized with red marks on neck, swollen neck and trouble breathing. Four postal workers are ill. October 17: About 30 persons at the U.S. Capitol test positive for exposure to anthrax. 90 The House o f Representatives closes for testing. New York Governor George Patcki's office in Manhattan is evacuated after anthrax is detected. Linda Burch, a bookkeeper at a business in Hamilton, NJ, develops a large pimple on her forehead. When a Senate staff person opened a threatening letter containing a fine powder, it was suspected of being anthrax. Precautions were quickly taken for those who worked in the immediate office and surrounding areas of the building on Capitol Hill. “Perhaps the biggest mistake officials initially made was to underestimate how easily the anthrax might spread,” according to the Christian Science Monitor (November 7, 2001) “Most assumed that anthrax sent through the mail would endanger only the people opening the letters (or, at most, those in the room when the letters were opened.)” The precautions taken at the Congressional offices were timely. But health officials at the CDC were in the dark about research showing that anthrax could spread more easily than they assumed. Canadian researchers had performed a series of experiments involving simulated anthrax letters that demonstrated that finely powdered anthrax spores could release thousands of lethal doses of bacteria within minutes o f being opened. Also, large quantities of the bacteria could leak out o f sealed envelopes even before they were opened. This research had been conducted hi the spring o f 2001 and shared with American military biodefense experts in four meetings, beginning of May 31 and ending on October 17 less than a mile from 01 where the tainted letter to Senator Daschle had been opened two days before. The information was widely shared with the FBI, Secret Service and US Capitol Police. But apparently no one passed the information on to the CDC. After the first anthrax death, one o f the Canadian researchers sent an email to the CDC on October 9th but it was not read for several weeks. CDC finally learned of the study on November 1. Had the consequences o f the research been recognized earlier it might ha’, e prevented additional cases o f illness at postal facilities. To a certain extent the CDC can be forgiven for not communicating what it did not know. The director of the Office of Public Health Preparedness, D. A. Henderson, told the New York Times (January 6, 2002) that “Everything we knew about the disease just did not fit with what was going on.” And Dr. Henderson added, “we were totally baffled.” And he added, “we were just paralyzed.” One step that the public health department took paid off. It began giving antibiotics to those who might have been exposed to anthrax in the news rooms and government offices where the mail had been received. The drug probably saved many people from illness and death. The antibiotic o f choice, the nation was told, was Ciprofloxacin, a brand name drug manufactured by Bayer. As a matter of fact, another drug, much less expensive than “cipro,” was just as good. Doxycyline, “doxy”as it is known, came to be prescribed only well after Tom Brokaw declared on NBC, “Thank God for cipro.” 92 Phase 3. Growing awareness of threat to postal workers. CHRONOLOGY: October 18: Claire Fletcher of CBS News tests positive for skin anthrax. A New Jersey postal worker, Teresa Heller, who developed a lesion on September 27 is diagnosed with skin anthrax (first case o f a postal worker diagnosed with anthrax). Another postal case, Richard Morgano, is suspected as having skin cancer. Tests conducted at Brentwood mail facility in Washington; facility manager reassures employees they are not at risk. October 19: New York Post announces that employee Johanna Jludon has skin anthrax; anthrax-laced letter is found, unopened, near where she worked. New Jersey postal worker Ms. Wallace is hospitalized. Another NJ worker, Mr. O 'Donnell, is diagnosed with skin anthrax. CDC issues second update in MMWR noting that the anthrax cases were n. m-made, not conventional. Washington postal employee, Leroy Richmond, is hospitalized in Virginia with suspicious symptoms. October 20: Tests confirm anthrax spores in mail handling machines at House office building near U.S. Capitol. Washington postal worker, Mr. Richmond, is seriously ill with anthrax (first government public recognition that postal workers are at risk.) October 21: Postal worker Thomas Morris dies o f inhalation anthrax. Another postal worker, Joseph Curseen, goes to hospital complaining o f flu-like symptoms and is sent home. Officials close two postal facilities, including Brentwood, and begin testing thousands of postal employees. 93 October 22: Mr. Curseen is nished to hospital by ambulance and dies of inhalation anthrax. House and Senate reopen. October 23: Anthrax is found on machinery at military base that handles mail for the White House. Tests at White House are negative. Government announces that postal employee, Ms. Wallace, may have anthrax. Thousands o f postal workers in New York begin antibiotic treatment. October 24: U.S. Surgeon General David Satcher states “we were wrong’’ not to respond more aggressively to tainted mail in Washington. New York Post editor Mark Cunningham has a pimple on his forehead; he had handled a box o f un-opened letters. October 25: Employee at State Department mail facility is taken to hospital with anthrax. Postal Sen-’ ice sets up spot checks at facilities around nation. October 26: CDC issues third update in MMWR with case data and educational information on managing anthrax exposure. October 27: Many businesses in East Coast cities begin testing for anthrax in mail rooms. While offices on Capitol Hill were cleared o f Senators, Congressmen and their staff members, the postal workers who processed and delivered the mail were still on the job at the places where the tainted letters had been gone through the postal system. The head of the CDC, Dr. Jeffrey Koplan, told postal workers that they had little to fear because anthrax spores could not escape the sealed envelopes. That was disastrous guidance. Two postal workers died and others 94 were sickened because the risk to postal workers was not recognized earlier. The initial reassurance persisted for days while anthrax spores contaminated postal facilities in Washington and New Jersey CDC was reluctant to tell the US Postal Service to close building. They did not appreciate how anthrax powder could act like an aerosol, floating long distances to infect people. The system for testing for anthrax was greatly overstressed by thousands of samples, many of them hoaxes, which were received at public health laboratories around the country. Lab workers were at their jobs around the clock, processing hoaxes. This delayed finding some of the real contamination. But when the full extent of the contamination was known and the buildings were closed, postal workers were outraged at the second class treatment they felt they had received. Many complained that the federal agency had shown great care for the congressional workers and no concern about the postal workers. Distrust of the CDC was most evident when the government agency suggested that persons who had been exposed to anthrax spores might take a vaccine, just in case all the bacteria had not been killed by the antibiotics. Postal workers at Brentwood in Washington, DC and in the Trenton center overwhelmingly rejected the suggestion. Dr. Michael Richardson, the senior deputy in the DC Health Department conceded on the Lehrer Newshour that the conflicting advice for the postal workers had caused “distrust.” One postal worker, Dana Brisco, 05 became a leader of “Brentwood Exposed” told of antagonism between the management o f the postal service and the rank and file, and how there was no voice of the workers in meetings with CDC. O f all the errors that the government made, none were as egregious as the incorrect and inconsistent advice given the postal workers. CDC and the US Postal Service reassured workers about the safety of the Brentwood and Trenton facilities, about how spores could not escape from sealed envelopes, and initially about how they did not need to take antibiotics. After the Postmaster General held a news conference at the Brentwood facility to declare it safe (October 18) the falsity of the reassurances started to emerge. The news conference, according to Thompson (p. 130) was an example “of the government’s bumbling response.” In a few days the postal authorities who had “unwittingly walked into the ground zero o f the anthrax affair would find themselves taking Cipro to ward off infection.” She concluded that a terrorist with an envelope and 34 cent stamp “had outsmarted the government’s top scientists, its doctors, and the seasoned bureaucrats running a critical part of the nation’s infrastructure.” The slowness in advising postal workers o f the risks contributed to the deaths of two employees with inhalational anthrax. When the government started advising the workers to take antibiotics, they were told to take doxycycline 06 because of its lower cost and reduced side effects, rather than cipro, which had been prescribed for the Congressional staffers. Incensed workers felt that the switch to a cheaper drug - instead of the well publicized cipro - was discriminatory treatment. One postal employee said that they were being used a “guinea pigs” in a government experiment with a “second-class drug.” (Thompson, p. 147) When experts disagree publicly, people ignore their advice. That happened in the Anthrax attack, most of the workers exposed to anthrax rejected the government’s offer of vaccination against anthrax at the end of their antibiotic treatment. (Gormley, p. 3) Phase 4. Dawning recognition of risk to recipients of mail. CHRONOLOGY: October 28: New York hospital worker, Kathy Nguyen, admitted to hospital with symptoms o f anthrax. October 29: Ms. Burch, the bookkeeper in Hamilton, confirmed as having skin anthrax. October 31. Ms. Nguyen dies. November I: Investigators conclude that bacteria that killed Ms. Nguyen are virtually identical to those found in letter to New York news outlets and Senator Daschle. State of New Jersey asks for immediate federal help to test all post offices in the state and to track anthrax path out of'Trenton post office. November 2: CDC issues fourth update in MMWR with a graph o f likely onset times for the 16 confirmed cases and 5 suspected cases, linking them to three anthrax- 97 contaminated letters. Mr. Cunningham of the New York Post diagnosed with skin anthrax. November 9: CDC issues fifth update in MMWR with information about 22 eases and on adverse events that followed mass antibiotic treatment to prevent anthrax. November 16: CDC issues sixth update with guidance on who should receive preventive drug treatment for anthrax. November 21: A 94-year-old retiree, Ottilie Lundgren, dies o f inhalation anthrax in Connecticut. It is speculated that she received a letter that came in contact with other anthrax-tainted mail. November 30: CDC issues seventh update on a 23r d case arising under mysterious circumstances in Connecticut. CDC issues eighth update on adverse events that followed mass treatment o f postal workers who were potentially exposed to anthrax. December 7: CDC issues ninth update in MMWR removing a previously suspected case (reducing the outbreak to 22 probable cases). December 17: White House says it appears likely that the anthrax bacteria had a domestic sources, perhaps a military lab. December 21: Test results from Brentwood mail processing center in Washington presented by CDC in tenth update in MMWR. Eleventh update provides additional information on therapy and vaccination for persons exposed to anthrax spores. April 5. 2002: CDC issues twelfth update in MMWR describing a lab worker in Texas who developed skin anthrax when handling a vial with spores from the anthrax outbreak. June 7 , 2002: CDC issues thirteenth update designating the Texas lab worker as a 98 confirmed case o f skin anthrax. September 6, 2002: CDC issues fourteenth update on medical protection for workers responsible for de-contaminating buildings. Containment was a major problem as it became obvious that people had died from anthrax even though they were neither the targets o f contaminated letters or had handled the envelopes stuffed with anthrax spores. The anthrax attacks of 2001 revealed glaring gaps in the public health and medical systems of the United States. Tara O ’Toole has summarized these deficiencies in the way the anthrax attack was handled. Officials lacked enough information to understand what was happening. HHS Secretary Tommy Thompson issued reassuring statements that were inaccurate. For weeks the public, media and public health workers had difficulty accessing the federal government’s recommendations on anthrax. Existing data was not always correctly interpreted or applied by health officials, the media and the public. For example, it was incorrectly stated that a person needed to inhale 10,000 anthrax spores to become infected. The CDC did not recognize the importance of a Canadian Defense forces study released in September 2001 about how fast and far an anthrax stimulant powder contained in envelopes could spread in a room. There was no process for identifying and dealing with the novel scientific questions that arose. HHS was slow to utilize interdisciplinary expertise to address new issues. The attacks, which sickened 99 less than 2 dozen persons, imposed significant stresses on medical facilities in areas where the attacks occurred. There is little surge capacity in the medical system. It became obvious that few communities had any plans for dealing with the medical care aspects of any large-scale biological attack. The public health departments in cities and states affected by anthrax attacks had to struggle to cope with the demands o f these cases. “Public health has been under funded and understaffed for decades.” And there is little connectivity between the departments. (O ’Toole, p. 104-109) Scientific uncertainty caused confusion at CDC, according to Elin Gursky and her colleagues (2003). They conclude that poor communication among health officials, the media and the public compounded the problem. “The lack of a consistent, credible message emanating from CDC in the early days after the anthrax attack has yet to be fully explained.” (Gursky et al., p. 104) Sen. Bill Frist noted how conflicting messages about risk, who should be taking antibiotics and how the mail ought to be handled led to distrust, confusion and fear, “sometimes bordering on panic.” Frist said that gaps in the public health system became “glaringly apparent.” (Frist, p. x) For example, when the CDC sent an alert on bioterrorism to all state health departments after September 11, the word did not reach local hospital emergency rooms for days or weeks. One- 100 fifth of public health offices did not have e-mail. Disease surveillance and coordination require more modem communications technology. “As we witnessed during the anthrax scare last fall, we must improve and streamline our methods of communicating with the public,” Frist said (p. 164) The government is both the source o f much information that appears in the mass media and the recipient of feedback (from the press) on how well it is communicating with the public. Some 3,400 news items (out of a universe of more than 17,000 items) were reviewed along with all statements issued by the Centers for Disease Control, the Department of Health and Human Services and the White House (including the Office of Homeland Security). From the onset of the anthrax episode, the national news media was critical o f the government’s response. The news media’s performance will be assessed in the next chapter, but it is important to summarize the media’s impact on how the government addressed the anthrax challenge. The federal government’s handling was criticized as “badly coordinated,” (New York Times, Oct. 18, 2001) and stressing the public’s nerves (Time Magazine, Oct. 29, 2001). The National Journal (Nov. 11, 2001) said the public health response amounted to “contagious confusion.” On January 6, 2002, the New York Times criticized the government’s actions as “missteps.” Time Magazine chimed in on January 12, proclaiming it “clumsy handling.” O f course, the news headlines do not prove 101 that the federal government performed as badly as alleged, but scores o f stories in major publications raised doubts about what was being done to protect the public. The repeated criticism had an impact. The news media criticism put additional pressure on the government to come up with answers when health experts were not sure what to recommend. “Public fears and anxiety gripped the country and initially were further fueled by the apparent misinformation provided by both government sources and the so-called medical/scientific experts,” according to a member of the New York City Mayor’s Task Force on Bioterrorism, Philip Tiemo. Certainly the picture that emerged was one of official confusion, compounded by the perception that officials were trying desperately to prove that they were bringing things under control. The errors and inconsistencies include: • Sec. Thompson says the nation is prepared for bioterrorism on Sept. 30. • On Oct 4 Thompson says the first case is likely due to naturally occurring anthrax, • From the beginning reassurances were given about the safety of the mail, • On October 18 Brentwood workers were assured o f workplace safety, 102 • CDC initially believed that anthrax spores could not escape a sealed envelope, • CDC initially advised postal workers to not take antibiotics, • Even after it was learned that one Trenton postal worker had developed an anthrax lesion, workers there and at Brentwood were reassured that they were safe, • Bush Administration initially silenced health experts at CDC, • Conflicting messages about “weaponized” anthrax spores, • Inconsistent information about how many spores were enough to cause infection, • Failure of postal authorities to close contaminated postal facilities quickly, • Incomplete information about the benefits of doxy versus cipro, • Failure to act quickly that caused two deaths of postal workers, • Failure to explain the risks and benefits of post-exposure vaccination. This last item - inadequate information about vaccination - is a sad postscript to the efforts to prevent disease among the postal workers. In mid-December Sec. Thompson decided to make a vaccine available to ten thousand persons who had been taking antibiotics just in case spores were lurking in the bodies of the individuals. The anthrax vaccine had been approved for preventing the disease before exposure to anthrax spores. Now it was being recommended for post 103 exposure, an unapproved use that required patients to sign cons nt forms acknowledging that they understood the risks. This caused a storm of controversy among postal workers, who said they were being asked to enter an experiment. O f those ten thousand eligible, only 130 persons decided to be vaccinated. (Thompson, p. 184) The government’s credibility had hit bottom. Survey Research Resuits The most comprehensive of the surveys was conducted within two months of the disclosure o f the first outbreak o f anthrax. It was conducted by the Harvard School of Public Health and funded by the Robert Wood Johnson Foundation. It found that Americans were not panicking over anthrax but were beginning to take precautions, including handling the mail with care and maintaining emergency supplies of food and water. The poll of more than 1000 persons had a margin of error of +/-3.74%. About one-fourth of persons surveyed were very or somewhat worried that they could contract anthrax from opening mail at work or at home. One in ten (10%) said that they or someone in their household had either talked with a doctor about bioterrorism (5%), obtained a prescription for or purchased antibiotics (4%) or consulted a counselor or health professional about anxiety (3%). Fifty-seven percent of those surveyed in the poll taken in late November/early 104 December 2001 said they had taken at least one new precaution. Thirty-four percent of respondents stated that they had taken special precautions in opening mail and 17% had instructed children not to touch the mail. The most dramatic finding, according to Robert Blendon, who directed the project, was that “no national figure emerged as a source of reliable information” during the anthrax outbreak. Americans were more likely to trust public health officials than political leaders and more likely to trust local officials than national figures. Asked whom they trusted, the respondents gave the following responses: • 48% trusted the director o f the federal CDC, • 44% trusted the US Surgeon General, • 52% trusted their local or state health director, • 33% trusted the director of the FBI, • 53 % trusted their local police chief, • 33% trusted the director of Homeland Security, • 61 % trusted their local fire chief. • 77% trusted their own local doctor. In every case, local and state officials were judged as more trusted than federal officials. One surprise is that the local fire chief more trusted as a source of information about a disease than the federal officials in charge of protecting public health. While fire chiefs were more trusted, it is unlikely they have as 105 much expert knowledge as the head of the CDC or the Surgeon General. Why would federal officials be less trusted than local officials? Why would the family doctor be more trusted than the senior federal authorities charged with protecting public health? One indication o f public dissatisfaction with CDC’s handling o f the crisis can be seen in the responses of persons who lived in areas where mail contaminated with anthrax was handled and/or found, particularly in Washington, D.C. and the Trenton-Princeton area. The Harvard group surveyed 516 adults in the Washington metropolitan area and 509 adults in the Trenton metropolitan area, as well as 504 adults in the West Palm Beach/Boca Raton area, where contaminated letters were discovered. (The margin o f error was +/- 5% for these local subsets). When these results were compared with the national survey, the Harvard researchers found that confidence in CDC was lower among those who felt they had been affected by the anthrax attacks because they, a friend or a family member had been exposed to or tested for anthrax or had their workplace closed because of suspected anthrax. Such “affected” persons were more likely to have lower confidence in the CDC than their neighbors who were not affected or those polled in the national survey, (see figure 4) Persons who were “affected” were much more likely to believe that they would contract anthrax in the next year, (see figure 5). Figure 6 compares the sense of risk 106 nationally to the three areas (including West Palm Beach) as regards anthrax, smallpox and other terrorist threats. One-fourth of the “affected” DC residents thought they or a family member was likely to get anthrax compared with 9% of all adults nationally. Confidence in CDC Nationally and Am ong “Affected” and “Unaffected” DC and Trenton/Princeton Area Residents Q. Have a great deal/quite a lot o f confidence in CDC to provide correct information on how to protect you and your family from anthrax? National: 60 % DC (“affected”): 55% DC (“unaffected”): 62% Trenton/Princeton (“affected”): 51%* Trenton/Princeton (“unaffected”): 65% Q. Have a great deal/quite a lot o f confidence in CDC to assess correctly the danger to workers in a building where anthrax is found? National: 57% DC (“affected”): 52% DC (“unaffected”): 60% Trenton/Princeton (“affected”): 43% Trenton/Princeton (“unaffected”) : 55% * Statistically significant compared to unaffected in same metro area. Source: Harvard School o f Public Health?Robert W ood Johnson Foundation Survey Project on Americans’ Response to Biological Terrorism, Novem ber 29-Decem ber 3, 2001 Figure 4 , _________________________________________________________________ __ 107 Reactions to Anthrax Incidents Nationally and Among “Affected” and “Unaffected DC and Trenton/Princeton Area Residents R. You or an immediate family member very/somewhat likely to contract anthrax in next 12 months? National: 9 % DC (“affected”): 26%* DC (“unaffected”): 15% Trenton/Princeton (“affected”): 35%* Trenton/Princeton (“unaffected”) : 18% R. Currently taking precautions with mail?** National: 32% DC (“affected”): 47%* DC (“unaffected”): 34% Trenton/Princeton (“affected”): 58% Trenton/Princeton (“unaffected”): 54% * Statistically significant compared to unaffected in same metro area. ** Precautions include wearing gloves, completely avoiding opening mail or washing hands after opening mail. Source; Harvard School o f Public Health/Robert Wood Johnson Foundation Survey Project on Am ericans’ Response to Biological Terrorism, November 29-Decem ber 3, 2001 Figure 5___________________________________________________________________________________ 108 Sense o f Risk, Nationally and in Three Metropolitan Areas: W ashington, DC, Trenton/Princeton, NJ, Boca Raton, FL S. Think the following are very/somewhat likely to happen to you or family member, next 12 months; Contracting anthrax? National: 9 % DC area: 17%* T renton/Princeton: 21%* B oca Raton: 14%* Q. Think the following are very/somewhat likely to happen to you or family member, next 12 months: Contracting sm allpox? National: 8% DC area: 8% T renton/Princeton: 13%* B oca Raton: 12%* Q. Think the following are very/somewhat likely to happen to you or family member, next 12 months: Being injured in terrorist act other than anthrax or smallpox? National: 18 % DC area: 24%* T renton/Princeton: 24%* B oca Raton: 20% * Statistically significant compared to national average Source: Harvard School o f Public Health/Robert W ood Johnson Foundation Survey Project on Am ericans’ Response to Biological Terrorism, November 29-Decem ber 3, 2001 Figure 6 109 The late November/early December survey showed that 44% of persons nationwide thought the news media was overstating the threat, 11% thought the media was underestimating it and 40% thought the media portrayed the threat accurately. This compares with 14% who thought the CDC was overestimating the threat, 17% who thought the CDC was underestimating the threat and 60% who thought the CDC portrayed the risk accurately. Although the CDC got higher marks for accuracy than the media, the criticism of CDC may have eroded confidence in that agency. The Harvard researchers examined the presumption that public anxieties, reinforced by media coverage, would lead Americans to overestimate the risk and make heavy demands on the country’s health systems. This did not prove to be the case. But the 10% who did use health services or prescription drugs did place demands on the health system. Even though only 1 in 25 got prescriptions for or purchased antibiotics, this could translate into millions of people nationwide turning to health professionals for help. (Blendon, et al, 2002) The Harvard study said that the research revealed enough underlying anxiety that additional terrorist attacks using a more contagious biological agent “could create considerable short-term demand on the health system ... and this could translate into real pressure on health professionals and public health officials.” 1 10 The study concluded that the “results of public health agencies’ communication efforts about the threat of anthrax and how to deal with it have been mixed,” with 4 in ten persons not having a high level o f confidence in health agency capability to assess the danger to workers in a building where anthrax is found. (Blendon, et al, 2002) The Harvard research team did a follow-up study a year later, polling 1006 adults nationwide between October 8 and December 8, 2002. More than half of respondents (53%) said they were very concerned about the possibility o f a radioactive, toxic or hazardous material attack (30% were somewhat concerned); 43% were very concerned about the possibility o f an anthrax attack (32% somewhat concerned); and 40% were very concerned about a smallpox attack, with 33% somewhat concerned. Half of the public (51%) said they have a great deal of trust in their own doctor, but a lower number (37%) expressed confidence in the head of the CDC. Asked about health risks, 81% thought it was very likely or somewhat likely that they would get the flu within the next year. Thirteen percent thought it likely they would contract anthrax and 12% thought it likely they would contract smallpox. Fifty-one percent said they were concerned that there would be a terrorist attack using smallpox in the next 12 months. O f those surveyed, 89% correctly stated that smallpox is contagious but 30% erroneously said that there had been cases of smallpox in the United 111 States during the past five years. Sixty-one percent said they would choose to be vaccinated against smallpox if the vaccine were available. When these people were reminded of serious side effects, including death from vaccination, about half said they would still want vaccination. These responses to a potential threat from a disease that was declared eradicated several decades ago shows the continuing anxiety about bioterrorism in the year following the anthrax attack. A similar poll a year before (in November 2001) by the Associated Press found that three-fifths of Americans would want smallpox vaccinations if they were available. In sum, these polls plus others that were taken in the months after the anthrax attacks showed anxiety but not panic about bioterrorism. A Gallup Poll in November 2001 found that fear o f bioterrorism topped the list of Americans’ most urgent healthcare concerns, but with only 22% mentioning it as “the most urgent health concern facing the country at this present time.” (Carlson, 2001) The anthrax attack was mishandled even though a consensus statement had been published in the Journal of the American Medical Association in May 1999 on how to handle an outbreak of anthrax. As Saul B. Wilden noted, the article explained the measures to be taken by medical and public health authorities after the use of anthrax against the public. The consensus statement was detailed in 112 its recommendations. “Despite the existence of this authoritative management plan,” Wilden stated, “when confronted with a bioterrorism attack ... effective communication was thwarted and confusion reigned.” He added, “Clues were ignored, pro-active communication and cooperation were lacking, and even the responses since (9/11) have been primarily reactive.” The disparity between the way the US agencies handled anthrax and the response of New York City officials is striking. In New York, Mayor Guiliani refused to accept ambivalent advice and demanded that his health officials tell him what he should do and recommend that others should do. The city had experience with dealing with West Nile Virus in the prior years and had weathered the storm over controversial spraying to kill mosquitoes which carried the virus. Municipal politicians and health officials learned the importance o f communication from handling the West Nile Virus. When anthrax was suspected of causing illness at media centers in New York City, the mayor insisted that health officials provide clear answers, which he immediately communicated in news conferences which were carried live on television and radio. Unlike the parade of little-known federal officials who took turns trying to calm the public, Guiliani took charge in New York, showing again the leadership traits that were much in evidence on 9/11. His open and forthcoming approach was in stark contrast to federal officials who were still trying to 113 reassure Americans to go about their business while warning of potential new attacks. This review has demonstrated inaccuracies in official statements, delay in providing information to medical professionals and the public and flawed advice regarding safety in postal facilities that endangered workers. The Bush Administration and the Department of Health and Human Services initially sought to speak with one voice, which silenced the public health experts in the government who were best equipped to inform the public. The government provided inconsistent information about prophylaxis and contradictory treatment recommendations for Congressional staffers and postal workers. This led to allegations o f unfair treatment of the postal employees. Polling data shows that public fear was greatest in areas with contaminated postal facilities and that postal workers overwhelmingly refused to heed official recommendations to get vaccinated against anthrax. This demonstrates the erosion of trust and the increase of fear. The data suggest that the government fell short of meeting several o f the guidelines in the “Cardinal Rules'” for risk communication. Specifically it had not initially implemented the CDC’s own communication plan (item 2), it had not been frank and open at all times (item 4), initially it had not coordinated with 114 other credible sources (item 5) and it had not always spoken with clarity (item 7). More detail on each o f these points is included in the next chapter and the performance o f the government in dealing with the public and the media are assessed below. 115 Chapter 4. Evaluating the Media and Public Response A media frenzy followed the disclosure of the anthrax cases. A member of the New York City Mayor’s Task Force on Bioterrorism, Philip Tiemo, said that contradictory information confused and angered many people. (Tiemo, p. 3) It is not clear if the coverage was a cause of public fear or a reflection of that emotion, or — most probably - a complicated mix of the two. Some have dubbed the impact of the news media, particularly television, the “CNN effect.” The impact on the public needs to be carefully assessed. The CNN effect may be real, but Peter Feaver argues that “the people who are moved into or out of action by CNN’s coverage are not the American public, but the decision makers.” (Feaver, p. 64) A review o f hundreds of news stories paints a picture of official confusion, as officials tried to prove that they were bringing things under control. The news media, particularly the broadcast and cable networks, highlighted the worst-case scenarios and the unknown risks to the public. Media Performance A media content analysis was conducted of about 3,400 news items (of a total of over 17,000 news stories). (The CDC was mentioned in over 12,000 articles). The vast majority of news coverage was straightforward and offered no critique of how the episode was being handled. All stories that offered an appraisal of 116 performance were reviewed. The media’s performance has to be viewed in a peculiar light: media organizations were the first targets of the bioterrorist attack. Contaminated letters were sent to several news organizations, causing infection at NBC, CBS, ABC, the New York Post and the parent company of the National Enquirer, where one person died. This review of the news coverage revealed scary broadcast commentaries and frightening headlines like the one that appeared in the New York Times on October 16th after a child had become ill after attending a party at ABC headquarters in New York: “Baby Falls 1 1 1 as Scare Widens Across US.” The review showed the following: • dramatic headlines and graphics predominated, • conflicting information was provided about the danger from spores in sealed envelopes, how many had to be inhaled to cause illness, and the risk of handling mail. • conflicting evaluation was offered about whether the spores were “weapon grade,” • conflicting advice was given about which antibiotics were effective and who should be taking medicine as a precaution, • there was commentary that was highly critical o f government handling of the issue, « there was a lack of clear advice on how individuals could minimize their risk from handling the mail. 1 17 • There was commentary on possible “what i f ’ scenarios, including varying threat warnings from official sources. This review is consistent with several other assessments of media coverage. In her separate review of the coverage, Sherry Ricchiardi concluded that the terrorists “appeared to be working on the axiom: if you want to scare the wits out o f America, scare journalists first.” She said that when the “frenzy” started, “factual information was the first casualty.” She stated that a “myriad of contradictions and misinformation emanated from the White House and official channels” and news organizations “were being held hostage by an unfolding drama over which they had no control.” (Ricchiardi, p. 18) Just two weeks passed after the first victim was announced, the national news media became very critical of the government’s response to the anthrax attack o f 2001. Before then a “behind-the-scenes struggle” pitted journalists seeking information against government agencies that held “a near monopoly on information about the attacks,” according to Patricia Thomas (2003, p. 7). Frustrated journalists felt that “usually helpful press officers [in federal agencies] were stonewalling, government scientific experts were not being made available for interviews, and pubic officials were generally failing to make accurate health information available fast enough.” (Thomas, p. 7) The 118 following headlines show the tone of much of the coverage: • “Anthrax Menace Exposes Badly Coordinated Defense” (New York Times, Oct. 18, 2001). • “Homeland Insecurity: Congress Evacuates As New Anthrax Cases Stress the System and Our Nerves” (Time Magazine, Oct. 29, 2001). • “Struggling to Reach a Consensus on Getting Ready for Bioterrorism” (New York Times, Nov. 5, 2001). • “Contagious Confusion: the American Public Health System is Decentralized and Uncoordinated and its Response to Anthrax W asn’t Pretty” (National Journal, Nov. 11, 2001). • “Anthrax Missteps Offer Guide to Fight Next Bioterror Battle” (New York Times, Jan. 6, 2002). • “A Public Mess- The Government’s Clumsy Handling of Anthrax Exposed the Weaknesses of a Public Health System Gone O ff the Rails” (Time Magazine, Jan. 21, 2002). • “Agency with Most Need Didn’t Get Anthrax Data” (Washington Post, Feb 11,2002). In her review of the coverage, Thomas stated (pp. 7-8) there was “an information shortfall [that] left the American people susceptible to panic, vulnerable to hucksters, and confused about how best to safeguard the health of their families.” In her analysis o f the news coverage shortcomings for the 119 Century Foundation, she lays the blame on the government for providing incomplete and erroneous information. She quotes the former director of CDC, Jeffery Koplan, as saying that Secretary Thompson of HHS made it clear from the start of the Bush Administration that his goal was to have “one department” and centralize HHS control over CDC, the National Institutes o f Health and the Food and Drug Administration, especially more control over communications There was tension, Koplan stated, because o f a perception in the Bush Administration that “because CDC is a public health agency, it is an activist institution.” He added, “It was too much of an advocate.” (Thomas, p. 11) After 9/11 the CDC had been told informed that the Federal Emergency Response Plan was in effect, which put the White House and cabinet secretaries in charge of ail communication with the press. CDC stopped dealing with the press on issues of bioterrorism, except at the instruction of HHS. CDC’s associate director for communications, Vicki Freimuth, said that after the initial terrorist attacks CDC was quiet; “we were not doing any interviews here, we were not even doing any response to the press.” (quoted by Thomas, p. 14). After the anthrax cases surfaced, CDC was forwarding calls from reporters to HHS press officers in Washington, who were not well informed on the technical aspects o f the disease. Veteran reporters who covered health issues were frozen out of interviews with CDC experts between October 4 —18, and said that CDC 120 seemed “swamped by high media traffic and uneasy about connecting reporters with sources.” (Thomas, p. 19) M.A.J. McKenna, the science and medicine reporter for the Atlanta Joumal-Constitution since 1997 said this initial period of anthrax coverage was “two solid weeks o f screaming confusion,” according to Thomas (p. 20). Robert Bazell, NBC’s health reporter, said that CDC and the other federal agencies were told not to talk with the media so information could come from one central source. Washington Post health reporter Rich Weiss said the policy was “one department, one voice. But that one voice is busy right now, so please leave a message.” (Thomas, p. 20) Early in the episode the news coverage became very scary. Unlike the factual and reassuring tone of coverage after the 9/11 attacks, news coverage o f anthrax was “overwrought, speculative, alarmist,” and included “embarrassing mistakes in communicating scientific facts,” according to David Murray and his colleagues in their separate analysis of the coverage (2002, p. 199). Information about the availability o f antibiotics was not provided by the media that might have stopped panic buying o f drugs as precautionary measures. The news coverage overemphasized the effectiveness o f Ciproflaxain and ignored the similar effectiveness o f Doxycycline. But it was the CDC that did not fully disseminate the effectiveness o f the latter until a month after the initial illness was confirmed. (Murray et ah, 204) While the news media may have caused 121 confusion and “undue public alarm,” Murray and his colleagues acknowledge that the media “passed on misinformation from poorly informed government officials whose background was political rather than medical.” (p. 200). Some of the most alarming news concerned whether the anthrax spores found in envelopes had been “weaponized” in a very sophisticated manner posing a “nightmarish possibility of a biological attack that could kill millions,” as an editorial in the Dallas Morning News stated (October 15, 2001). The New York Times (on October 17) stated that “high grade anthrax” sent via the mail was evidence that “someone has access to the sort of germ weapons capable of inflicting huge casualties.” Murray and colleagues say that this sort of coverage demonstrated a lack of understanding of science, “a herd instinct that leaves important questions unanswered and even unasked, a tendency to speculate instead of waiting for the facts to come in, a sensationalist sensibility, and an alarmist mentality that focuses on worst-case scenarios.”. Even so, they note that confusion by government officials and lack of coordination between agencies “earned a substantial share of blame for ratcheting up rational fears into irrational responses.” (Murray et ah, p. 212). Inquiries from the news media totaled 2,516 about anthrax and bioterrorism between Oct. 4 and 18, but for most o f the period the CDC had only one person 122 assigned to handle press calls about bioterrorism. She was swamped with hundreds o f calls a day. At the central media office at CDC, no one was officially designated to handle anthrax inquiries for ten days. (Thomas, p. 21) Into this vacuum flowed a lot of speculation. Experts seemed to come out of the woodwork to appear on news broadcasts. As Thomas notes (p. 23) one of the worst was an “expert” who erroneously kept referring to the anthrax bacterium as “the anthrax virus.” It was two weeks into the anthrax episode before HHS realized how poorly the press relations were being handled and CDC was ordered to put 15 media relations professionals and a strong support staff on duty to field press inquiries. But the damage had been done. News organizations had become frustrated with the lack of information from the CDC, and remained critical of the government throughout the episode. On October 18 the CDC escalated its press operations with a video news release o f director Koplan and a televised conference call with Julie Gerberding, acting deputy director o f the National Center for Infectious Diseases. On the same day, Secretary Thompson, Homeland Security director Tom Ridge, FBI Director Robert Mueller and Surgeon General David Satcher held a joined news conference to reassure Americans that everything was under control. (Thomas, p. 25) The situation went from one voice that wasn’t saying much to multiple voices, saying a lot of different things. CDC director Koplan said it was hard 123 “to present a coherent, dynamic communications plan when everybody is a spokesperson.” (Thomas, pp. 28-9) He quickly was dropped off the list, replaced by the Bush Administration’s choice of Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. “Fauci was a natural rudder for a floundering communications effort,” according to Thomas. He instantly became the star spokesperson on anthrax matters, filling the void after October 21. The choice of an NIH official to speak about anthrax was seen as a “slap in the face to CDC.” (Thomas, p. 28) The off and on nature of the communications effort prompted medical and scientific criticism. The presidents of the National Academy of Sciences, National Academy of Engineering and Institute o f Medicine issued a statement of alann on October 29. “We continue to be alarmed by the amount o f inaccurate information being circulated about anthrax, sending scores of confused citizens to take action that may, in fact, be counterproductive.” The statement went on to criticize “self-appointed experts” and internet sites that hawked gas masks and colloidal silver as protections against anthrax. Journalists offered their own self-appraisal of the coverage. Dan Rather of CBS said the story had been “overcovered” and played into the terrorists’ hands by “spreading fear that they hope will result in panic.” (quoted in Ricchiardi, p. 23) 124 Jennifer Harper in the Washington Times (October 18, 2001) called the coverage “all spores, all the time,” and said it was “spooking the public and vexing officials.” Deborah Potter said that initial coverage was beginning to restore credibility to the news profession but “as the days passed, the networks stumbled” and began hyping the story with graphics and self-promotion. (Potter, 2001) A different appraisal came from Bob Meyers of the National Press Foundation, who proclaimed the coverage “fairly impressive” especially in the use of graphics to educate the public. But media analysts Howard Fienberg told the Atlanta Joumal-Constitution the tone of the coverage was “the sky is falling, we’re doomed.” James Naughton, president of the Poynter Institute said the press did “a very good job of calling attention to the dangers of anthrax and less of a good job of dispassionately and calmly putting things in context.” Naughton added that “the experts aren’t very expert yet” about anthrax, (all quoted in Ricchiardi, p. 20) A skeptical press corps highlighted inconsistent statements and contradictory advice from official sources. The news coverage was fed by expert sources who found fault with the government’s efforts to cope with the problem. These concerns were reflected in the judgments that emerged in the news media, in Congressional testimony and in academic journals that focused on the anthrax attack. A sample of such opinion in the news media includes: 125 • The nation’s “health system was underprepared,” according to Newsday (October 17, 2001). • “No one knew. Those words have become the theme of the medical investigation of the anthrax attacks, a refrain of epidemiological regret,” according to Eric Lipton and Kirk Johnson in the New York Times (December 26, 2001). • “If the attacks-by-mail did America any kind of favor, it was to highlight how many weak links there are in the chains that bind these agencies to each other in a crisis,” according to Sydney J. Freedbert, Jr and Marilyn Werber Serafini in National Journal (November 10, 2001). • Procedures for communicating “proved inadequate to reassure a frightened public” and agencies were unprepared for the close collaboration required to respond to the anthrax attacks. Federal health officials were “confused and disorganized,” and no government scientist consistently delivered a clear message, according to Lawrence K. Altman and Gina Kolata in the New York Times (January 6, 2002). • The response to anthrax has “often been inept and failures of communication among agencies ... have been partly to blame.” According to an editorial in Newsday, October 30, 2001. • The anthrax episode “caught the government off guard,” with outdated guidelines for treating anthrax, short supplies of vaccine and no notion 126 that an envelope could be turned into a bioweapon,” according to Steve Sternberg in USA Today (October 10, 2002). • Even in late 2002, “officials have yet to fully remedy the communication problems that plagued the Department [of Health and Human Services] in the anthrax bioterror attack a year ago,” according to Lawrence K. Altman, a physician and reporter for the New York Times (October 8, 2002). The skeptical news reporting was not a lone voice. Many former officials and academic experts were highly critical of the way government officials had performed, particularly in their communication practices. • “Information was being withheld.... A vacuum was formed. What happens with a vacuum is that it often is filled with rumors,” according to Vincent Covello, quoted in the New Scientist (December 15, 2001). • The biodefense plan is “not adequate,” according to Mohammad Akhter, executive director of the American Public Health Association, quoted in the Washington Post (October 22, 2001). • There were communication difficulties with incoming information (to the agencies), problems o f analysis and advice, and problems of outgoing communication (to doctors and the public), according to Thomas Inglesby of the Johns Hopkins University, in testimony before Congress. • “Physicians, public health officials and other healthcare workers now find themselves in a position of trying to re-educate a frightened public,” according to Karen DeSalvo in Medscape General Medicine 4(1), February 8, 2002. • Communication was inadequate and “the lack of an efficient communications network resulted in confusion and delays in disseminating important clinical information,” according to Lew Radonovich in Biodefense Quarterly (Autumn 2002, Volume 4, # 2). • Risk communication in the anthrax attack was “not gratifying.... Little was said about what the average citizen could personally do None of the expertise about risk communication was known to many of our leaders September 11th,” according to Paul Deisler, Jr., writing in Risk Analysis (June 2002, Vol. 22, # 3). • “The effectiveness o f communications to the public and to health professionals about the anthrax terrorism were found wanting,” according to Dr. Kenneth Shine, president of the Institute of Medicine, quoted in a Congressional Hearing of the House Committee on Government Reform, November 29, 2001. • The Center for Disease Control had an “absolutely terrible” response to the anthrax episode, according to Tara O ’Toole, director of the Johns 128 Hopkins Center for Biodefense Strategies, quoted in Global Security Newswire (February 7, 2002). • “The government did not prepare people for the threat, did not assess the threat quickly, gave misleading reassurances to the public, and continually had to rescind statements and policies. The resulting public distrust of government and its inability to handle these threats is just what risk communication experts would predict,” stated Lester Lave in Risk Analysis (June 2002, Vol. 22, # 3) The opinion research by the Harvard School of Public Health shows that 88 percent of those surveyed were closely following news accounts about anthrax. Large majorities had learned a great deal about the disease in a few weeks from the media coverage: • 75% answered correctly that anthrax is not contagious, • 78% knew that inhalational anthrax is more likely to cause death than skin anthrax, • 87% knew that there were medical treatments that are effective for people exposed to the disease. The director o f the survey project, Robert Blendon, said that the accuracy of the public’s understanding exceeded his expectations (quoted in Thomas, p. 36). Another poll by the Pew Research Center for the People and the Press in mid- 129 November found that a majority of Americans thought that the news coverage had been mostly accurate. Asked if the news coverage about anthrax and other terrorist threats had been “accurate for the most part, or have too many mistakes been made?” 58% answered “accurate.” Thirty percent said that too many mistakes were made. O f this latter group that thought mistakes were made, about one-third blamed the journalists for poor reporting and two-thirds blamed “government for giving out misleading information.” (These results are available on the internet at http://people-press.org/reports/print.php3. ) Polling by the Pew Research Center found that people did not want to “shoot the messenger” o f bad news. About three-fours of the respondents in a survey just after the attacks said the coverage frightened them; 92% stated that it saddened them and 45% said that it “tired them out.” Curiously, the survey found that those who were most worried about the possibility of more terrorist attacks had the most positive evaluations of the quality of news coverage. Ninety percent of Americans got their news from television. The Pew survey found that 45% looked to cable news, 30% to network news and 17% to local television news. As the anthrax story unfolded more people turned to print and internet sources for news. Those relying on newspapers tripled during the period (from 11% to 34%). Use of internet news rose from 5% to 13% and was much stronger among the young. (Kohut, 2002) Focus Group Research While focus group research cannot be extrapolated to reflect the thinking of the nation in the manner o f quantitative survey research, it does provide insights into how people react to ideas and statements. Two different research projects are analyzed below. The first, by Covello and colleagues, was prepared for the National Public Health Leadership Institute in March, 2002. There were eight sessions involving a total of 90 public health leaders selected from alumni of CDC’s Leadership Management Institute, the National Public Health Leadership Institute and state and regional public health leadership institutes. The second project, by Monica Schoch-Spana of the Johns Hopkins Center for Civilian Biodefense Strategies, was conducted in six cities with three different groups of persons: emergency responders, civic leaders and persons who were potentially at risk of Anthrax exposure in the fall o f 2001 (Congressional staffers, media employees and US Postal Service employees). Groups of 8 to ten persons were interviewed in 17 different sessions. Between the two projects a total of 25 focus sessions with 225 persons, including persons potentially at risk of exposure to Anthrax. The project for the National Public Health Leadership Institute had the following goals: (1) to determine the communication challenges that public 131 health officials are facing since 9/11, (2) to determine the communication skills, tools and training they perceive they need, and (3) to determine the instructional methods that would be most useful. The process identified the following top challenges: 1. The need to form more extensive community partnerships; 2. The need to clarify the roles and responsibilities of public health leaders in a crisis; 3. The need to acquire more effective risk and crisis communication skills and resources. Covello and his colleagues reported that the emergency response efforts after September 11 were thought to have gone more smoothly where relationships were already established between community organizations. For example, New York City was able to “springboard” its response from its West Nile Virus response network. But where public health agencies did not have “a partner infrastructure” such was very difficult to establish in a time o f crisis. “Several negative consequences were attributed to the deficiencies in partnering and coordination between public health officials and other emergency response agencies after 9/11 and the response to the anthrax cases,” the report stated. “These included the loss of trust in public health agencies, inconsistent information, contradictory information, late information.” Relationships 132 between agencies (including law enforcement and public health) needed to be improved; resources needed to be more equitably distributed around the nation; and information needed to be shared. “Local health officials were often the last to hear important information. They sometimes heard it first from CNN. At a minimum, quick and usable electronic links to information are needed.” The Johns Hopkins project had similar findings. “People were just hungry for information” during the anthrax attack, according to Monica Schoch-Spana. She summarized the findings at a Conference entitled “The Public as an Asset, Not a Problem,” in Washington in February, 2003. These included the following: • It is critical for the public to be given meaningful and practical advice on how to protect themselves and their families. People want to know how anthrax ought to be handled, the actual plan - not just “bits and pieces.” • People are capable of handling uncertain and unsettling news, provided it is given candidly. The government should not treat people as children with “the mommy mode o f command and control.” • Government should not withhold information for fear it will cause hysteria. “Information flow is an antidote to panic, not its cause.” 133 • Officials need to speak to the limits of their knowledge and the public needs to understand that it may take time to get a clear picture o f what is happening. If there’s less information, there is more uncertainty. • During the anthrax episode there was a feeling among affected groups that the folks in charge were making it up on the fly at times. Agencies need to get their act together. • Media coverage is fragmented and “dizzying.” While the news media is absolutely critical in getting information to people, there is too much noise to perceive a clear signal. The media need a template and filter to help convey critical health and safety information. • Spanish language media needed improvement because it lagged the English-speaking media. • Participants underscored the importance of involving civic and community leaders. “It’s those people who we really do need to tap in terms o f building up our capacity to deal with the effects o f bioterrorism.” (Schoch-Spana, 2003) The focus group research points out the great unmet need for actionable advice. People craved infonnation, particularly about what they should do to protect themselves from the risk of exposure to anthrax spores in the mail. That advice was never clearly delivered, leaving many people feeling that they were unable to protect themselves and their families from this new risk. Peter Sandman, who 134 advised the CDC on communication during the anthrax attack, has stated that “one of the most vivid characteristics” o f the public response to terrorism “was a powerful desire to do something,” and protect themselves and their families. “A significant piece of the misery,” Sandman states, “was the absence of something to do.” He concludes that the government should have advocated protective steps — vaccination, stockpiling antibiotics, or ways to clean the mail — that citizens could utilize. “The best risk communication gives people a choice of things to do,” Sandman states; “the act of choosing is itself an assertion of control that binds anxiety, prevents panic, and reduces denial.” His comments were posted on his website, www.psandman.com in December 2001, available for public view after being ignored by CDC. The reality is that CDC was not sure what to do and therefore, could not give clear advice. One health practitioner said, “Things kept changing, CDC kept changing things. Simple swabs [for environmental surface testing] versus dust wipes. Dry swabs versus wet swabs. Yes to nasal swabs. No to nasal swabs.” If the advice to practitioners was unclear, how about laypeople? One official said, “We would ask CDC a question [about antibiotic treatment] and they would tell us “it’s not warranted.’ We would ask why and they would answer, ‘Not sure.’ There was a lack o f trust o f CDC’s knowledge. CDC was making recommendations that they could not initially justify. Later their guidance was 135 disproved. They could not clearly answer questions about the latency of infection or why Cipro versus Doxy.” A CDC official acknowledged that the “greatest challenge was developing and communicating a set of recommendations for the public.” A hospital infectious disease expert said, “The public had better sense than CDC. They [postal workers] saw their co workers getting sick and came for treatment,” One o f the postal workers said “The information [from CDC] changed every day. Nobody knew what was going on.” (all quoted in Gursky et al., p. 103) One quandary is the difficulty of discussing risks in the context o f unknown facts and uncertain prospects. During the anthrax episode the government was accused of “sowing chaos and confusion with their answers and o f revealing unpreparedness and incompetence through their unwillingness to make absolute assertions,” in an article in the Washington Post by David Brown (4 November 2001; page B01) “While there has been some o f all of these things - chaos, confusion, unpreparedness and incompetence - the biggest problem has been something else. These spokesmen, many from the world o f public health, have been trying to express uncertainty and reassurance at the same time.” As Brown notes, it is nearly impossible to combine uncertainty and reassurance. This dilemma is a good reason why reassurance isn’t a viable communications 136 strategy. Candor is, especially when it includes advice on protective actions that individual Americans can take. In an article in the Christian Science Monitor Liz Marlantes articulated her version o f the lessons from the anthrax episode. Lesson 1, Marlantes stated is that containment is a problem. Lesson 2 is that officials assumed too much about how many anthrax spores had to be inhaled to cause illness. Lesson 3 is that antibiotic treatment is effective and the disease is not as deadly as feared IF antibiotics are given promptly. Lesson 4 is about the importance of having a good communication strategy, “which the government conspicuously lacked during the crisis’ early days. Officials seeking to reassure the public often made incorrect statements, projecting an image of confusion.” Lesson 5 is that the number o f hoaxes will skyrocket after an attack. (Christian Science Monitor, November 7, 2001). Officials need to quickly place newly apprehended fear o f imminent harm into the proper context to avoid unwarranted hysteria. (Gots, p. 8) Man-made fears are perceived as more threatening than natural risks (National Research Council, Science and Judgment, p. 263). With bioterrorism one gets a double whammy: man-made leverage of terrible epidemic potential. As President Clinton was quoted as saying, biological weapons are “the gift that keeps on giving.” (Miller, 137 p. 247) The 2001 anthrax events were immediately perceived as both disasters and “acts of war,” in the words of President Bush. The blurring of lines between domestic emergency response and military action is unfamiliar in the United States. And the unprecedented sight of terrorism’s dreadful impact at home created doubt and uncertainty about what might happen next. 138 Chapter 5: Findings from the Anthrax Episode This review has demonstrated inaccuracies in official statements, delay in providing information to medical professionals and the public and flawed advice regarding safety in postal facilities that endangered workers. The Bush Administration and the Department o f Health and Human Services initially sought to speak with one voice, silencing the public health experts in the federal government who were best able to inform the public. Taken together the survey research and focus groups portray inadequate communication between federal public health officials, the media and the public. The surveys demonstrated that local officials were more trusted than national leaders, including public health officials such as the Surgeon General and the Director o f the Centers for Disease Control. In the focus groups public health leaders and those who had been potentially exposed to anthrax stated that coordination was lacking, that various agencies needed to “get their act together.” The media was not clear in transmitting information to the public about anthrax. In response to the initial silence from CDC’s health specialists, the media turned to unofficial, sometimes uninform ed “experts” who spread m isinform ation about the nature o f the disease and best prophylactic treatment. When government health experts were not forthcoming with advice, critical stories in 139 the media began to appear. The government provided inconsistent information about prophylaxis and contradictory treatment recommendations for Congressional staffers and postal workers. This led to allegations of unfair treatment o f the postal employees. Polling data shows that public fear was greatest in areas with contaminated postal facilities and that postal workers overwhelmingly refused to heed official recommendations to get vaccinated against anthrax. The disparity revealed in survey results between areas with postal workers who were exposed to tainted letters and those other areas without contaminated facilities suggests a greater erosion of trust and increase of fear among those most directly affected by the government’s actions and announcements. The public’s lack o f knowledge about precautions and other ways to cope with the risks left people not knowing what to do to protect themselves. According to the focus groups the public wanted actionable information of a practical nature. The survey data show that people became well informed about the disease as more was communicated, but the focus groups demonstrated that people felt they were not given clear advice to deal with the threat from the mail. The evidence is that the public did not have a clear understanding of protective steps and a role people could play to increase their own safety. The data suggest 140 that the fast-paced coverage of dramatic news, sometimes erroneous information, slow provision of technical information and paucity of useful information were associated with public fear, for the reasons stated below. The content analysis revealed many examples of experts who opined on these problems. The communication failures were recognized by many of those who commented after the anthrax episode. As Elin Gursky and her colleagues have noted (2003, p. 109) “There was no evident media strategy within the federal government for several weeks into the crisis.” They added, “The irregular and at times confused interactions between the federal government and the press during the crisis resulted in a loss of government credibility and an increasingly aggressive media frenzy.” Faced with erroneous and conflicting advice from government, filtered through a hyper-critical mass media, the public felt there was little it could do to protect against bioterrorism. The conclusion o f Gursky and her colleagues is but one example of the many commentaries that have stressed the communications failures of 2001. The attached “truth table” compares performance in four categories (messages, source credibility, media, and public receptivity) across the four phases of the anthrax episode described above. 141 First phase To Oct 12 Second phase To Oct 17 Third phase To Oct 27 Fourth phase Post Oct 28 Government Messages False reassurance, Inaccurate facts Inaccurate scientific info Flawed advice for postal workers Mixed messages about threat Government Sources One voice policy silenced federal health experts Lack of clear information, Many rumors Unfair treatment of mail workers Little guidance for public on protective steps Media Dramatic sensational coverage Criticism of government begins Criticism of government communicati ons Criticism o f government decisions Public Attention to news Public becomes aware o f risks Increased fear in postal workers’ communities Increased fear in general public Figure 7. Truth Table Events triggered government decisions, actions, and communications which were delivered to the public primarily through the mass media, which acted as a critical filter. The information was processed in light of the public’s perception of risk and an informal assessment of the accuracy of what was being stated. This influenced public behavior. The opinion surveys demonstrate that p’ ’ c fear increased, especially among those who were close to postal workers, lelt most at risk and most at the mercy o f inconsistent advice from the government. This suggests that the logic model (figure 3) is a fair representation of the communication process during a terrorist attack with a newly apprehended risk. 142 As stated previously the logic model stated a number of “if this, then that” linkages. This logic pattern from p ag e is repeated below along with evidence from the anthrax episode: • If medical surveillance reveals cases of suspected bioterrorism, then officials must be notified of the threat (this happened in a very timely fashion in the anthrax episode), • If officials are notified o f a threat, then they must make decisions on protective steps for the public (decisions varied from rapid in the case of Congressional workers to delayed in the case of postal workers), • If decisions on protective actions are made, then officials must decide how to implement and announce such steps (announcements were prompt after decisions were made), • If actions and implementation steps are announced, then officials must deal with media inquiries and the impact of news coverage (news coverage was around the clock, pervasive and often critical of government sources), • If media coverage occurs then the public will be informed of the risks and actions taken (the opinion surveys showed enormous public recognition of the anthrax events), • If the public is informed uf risks and protective measurers, then people will experience emotional reactions including such things as stress, fear, vigilance, etc. (the surveys showed heightened fear but not panic), • If people experience these emotions then they will seek ways to protect themselves and mitigate the risk (the focus groups showed that people wanted actionable advice), • If people seek ways to protect themselves and reduce risk, then they will need clear guidance from trusted sources on best actions to take (critical media coverage cast doubt on the credibility of official sources particularly when clear advice was not forthcoming), • If little clear, credible guidance is provided on how to protect against the risk, then people will perceive that they lack control over the risk (as evidenced by focus group results), • If people perceive they lack control over the risk, they will perceive a greater threat to their own safety and health (as demonstrated in earlier research by Covello, von Winterfeldt and Slovic (1986) and echoed in focus groups after the anthrax attacks), • If people perceive a greater threat then they will experience stronger emotions, including increased fear (survey results showed heightened fear during the months after the attacks). 144 This logic does not prove causation but does establish how the pattern of events, decisions, announcements, media coverage and public perceptions may be linked. This provides answers posed by the anthrax episode, specifically to four questions: The accuracy hypothesis stated that errors in decisions and public statements were associated with public fear o f a newly apprehended risk, anthrax. Once the public suspected tiiat erroneous information had been conveyed, did this have an impact on public fear? The evidence from the anthrax attack is that inaccuracies did occur, that there was a lack of public information and that flawed advice to postal workers was associated with heightened fear in the most directly affected communities, according to survey results. The first hypothesis is confirmed. Errors in anthrax messages were associated with public fear of a new risk. The credibility hypothesis stated that contradictory statements from official sources were associated with loss of credibility and public trust in the Anthrax attack. Did the official sources act in a credible manner? Did their actions affect public trust? The 145 evidence from the anthrax attack is that the initial use of politicians as spokespersons rather than health experts backfired. Contradictory and inconsistent information on the best drug treatment and the alleged “unfair treatment” of postal workers (compared to Congressional staffers) weakened the credibility of federal officials. The survey results were particularly clear in showing the erosion of public trust in senior federal officials. The second hypothesis is strongly confirmed. Contradictory information and advice affected the credibility o f federal officials. The amplification hypothesis stated that news media amplification of risk was associated with increased public fear in the Anthrax attack. Did the dramatic news coverage and government’s initial slowness in providing information create an information vacuum that was filled by unreliable and sensationalistic claims conveyed by television, newspapers, radio, magazines and the internet? The news coverage o f the anthrax episode was highly dramatic. When federal health officials were slow to answer media questions, less competent “experts” filled the airwaves with speculation and 146 misinformation. The confusion about recommended antibiotic treatment was heightened by the media coverage. The third hypothesis is confirmed. The intense media focus on risk coupled with the initial official failure to provide health information were associated with public fear. The powerlessness hypothesis stated that the absence of knowledge by the public of actions that citizens could take to control the risks o f anthrax was associated with public fear. Was the public left feeling that there was little that could be done for self-protection against anthrax in the mail? The lack of knowledge about anthrax, uncertainty about precautions to take when handling mail, the absence o f public involvement in the response and “not knowing what to do,” is well documented in both sets of focus groups. The focus groups are consistent with much prior research on environmental health risks that established that risks which are involuntary and not controlled by the individual are judged to be riskier than those which are voluntary and controllable. Because one cannot extrapolate from focus groups to the general population, these results are only 147 suggestive. Thus the fourth hypothesis is only partially confirmed. The study also considered a null hypothesis that that none of the four factors listed above related to increased public fear. The null hypothesis would have be proven if (a) there had been no measurable increase in public fear, or (b) if widespread death and disease had occurred - rendering moot any theory that placed primary blame on the government for not communicating well and/or that the media hyped the risks. The opinion poll results clearly show an increase in public fear during the period studied. Moreover, only 5 deaths occurred and there was no epidemic of sick persons, indicating that the fear was tied not to a health catastrophe on a grand scale, but to other factors. A third alternative was also considered, that uncertainty in-and-of-itself was the source of public fear and that government messages and credibility were irrelevant in the face of the unknown risks. This version of the null hypothesis was rejected because the risks of anthrax were not unknown to medical expei ■ > and those aspects which were unclear - such as how anthrax spores could escape from sealed envelopes, best drug to treat those who might have been exposed and how to decontaminate facilities - were exacerbated by official silence, error, inconsistent decisions and contradictory advice. Much of the confusion 148 stemmed from the effort by some spokespersons to warn and reassure simultaneously, ensuring a mixed message. The expert opinion, survey results and focus group findings permit us to evaluate the government’s performance in light of the “Seven Cardinal Rules for Risk Communication.” This meta-analysis was guided by the logic model to understand patterns and linkage between government actions and public response. The evidence was assessed using the truth table to understand the chronology of the event. Anecdotal evidence from the truth table and chronology was weighed to measure CDC performance under the EPA criteria: • Accept and involve the public as partners, • Plan carefully and evaluate performance, • Listen to the public’s specific concerns, • Be honest, frank and open, • Coordinate with other credible sources, • Meet the needs o f the news media, ® Speak clearly and with compassion. 1. The government did not involve the public. It tried to reassure the public. When that failed, it tried to placate the public. When 149 that failed, it confused the public with mixed messages about going about business as usual coupled with warnings of impending threats. 2. The government had planned carefully before the outbreak of anthrax but it did not follow its own plan. It failed to adjust course quickly when its early efforts fell short. 3. The government did listen to the public’s specific concerns but scientific uncertainty prevented addressing the need for the practical information that the public craved. 4. After its initial efforts to downplay the crisis, the government did institute a policy of improved flow o f information. But it was not open during early October, when the flow of information was slow at times. 5. The federal government did not do a good job o f coordinating with state and local public health officials and the medical community in the initial stages o f the episode. 6. The federal government did not meet the insatiable needs o f the news media. It was not prepared for around the clock news coverage. 7. Unfortunately, the federal spokespersons were not able to speak with clarity. That was partly because o f the scientific and technical uncertainty. Statements did express compassion for those who became ill and those who died, but many postal workers were quoted in newspaper articles as saying that the government failed to act compassionately to mitigate their risk. The agency most responsible for the public health response, the Centers for Disease Control, has conducted its own evaluation of “lessons learned.” The CDC summarized those in a “Bioterrorism Preparedness Progress Report” on September 27, 2002. The lessons were called “the 5 C ’s” and are available on the CDC’s website: • Communication - Proactive communication with multiple audiences is essential; • Coordination - Knowing who’s in charge, how a response will be managed, and practice that is a key part o f preparedness; • Consultation - Getting feedback from partners before, during and after an event; • Capacity - Ensuing we have staff and lab capacity to perform essential functions like sample testing; • Competency - Ensuring that we have a well-trained workforce and ways to get technical assistance. 151 The first three “lessons” on the CDC website are directly relevant to this study. The agency recognized the need to improve its communication, coordination and consultation with stakeholders. These lessons for the future are expanded upon in the following four chapters on how the government can improve its messages, its decisions, its communication via the mass media and involve the public in productive ways to counter feelings of lack o f control over risks. In summary, the results of this study indicate that all four factors - (1) errors in official statements, (2) diminished credibility of officials, (3) amplification of the risk by the news media and (4) public lack of control and risk mitigation were associated with public fear. The opinion polling shows that fear was greatest among those who lived near where contaminated mail was handled and one plausible explanation is that official mishandling of postal safety exacerbated the concern. The focus groups showed that people craved clear information about what they could do to reduce risk, and one plausible explanation is that an antidote to fear is to reduce the feelings o f powerlessness. One of the four factors, issues of official credibility (hypothesis 2) as measured in the survey research related most strongly with increased fear of anthrax. The following summarizes the research methodology, evidence and findings: 152 M essage Problems Source Problem s Channel Problem s R eceiver Problems General Exam ples Errors, C om plexity, Uncertainty Lack o f trust and credibility, disagreem ent Sensationalism , bias, distortion, fail to inform M isperception, inability to act, feel pow erless H ypotheses A C C U R A C Y Errors in decisions and statem ents were associated with public fear o f anthrax CRED IBILITY Contradictory statem ents from officials w ere associated with loss o f credibility and public trust AM PLIFICATIO N N ew s m edia am plification o f risk was associated with increased public fear o f anthrax PO W F.RLESSNESS The absence o f public k n ow led ge o f steps to control the risks o f anthrax was associated with increased public fear M ethodology M edia content analysis, review o f expert opinion A nalysis o f public opinion survey data M edia content analysis and review o f expert opinion Focus group research and review o f expert opinion Evidence Inaccuracies, Lack o f info., Flawed ad vice to postal workers, increased fear in postal em ployee com m unities Politicians as spokespersons, expert silence, contradictory info on drugs, “unfair treatment” o f postal workers Dramatic new s, S low flow o f technical inform ation., initial m isinform ation, use o f unofficial sources, confusion about treatment Lack o f know ledge, uncertainty about precautions, absence o f participation in response, “not know ing what to d o” about danger from the LIS mail Findings Errors in anthrax m essages w ere associated with public fear o f a new risk Contradictory info and advice from official sources were associated with loss o f credibility and eroded trust M edia focus on the problem coupled with initial official failure to provide inform ation were associated with public fear Public lack o f clear understanding o f what protective steps and role p eop le could play to protect them selves, appears to be associated with public fear. Conclusion: Hypothesis Confirmed Strongly confirm ed C onfinned Partially confirm ed Figure 8. Methodologies and Findings Over several decades evaluation studies on environmental health issues have shown the effectiveness of good risk communication practices in helping provide the knowledge necessary for informed decision-making about risks, building trust, and engaging stakeholders to resolve disputes. (Covello, 1998). 153 Sadly, the handling of the anthrax attacks of 2001 suggests the need for improved federal agency risk communication. Specifically, the lessons learned include: • There is a need for the government to gather and analyze the facts in an escalating crisis, • There is a need for officials to develop clear, understandable and relevant information for the public, • There is a need to quickly disseminate information from government authorities, • There is a need for government to provide continuous information for the news media to disseminate to the public, • There is a need for a trustworthy source o f advice, • The advice should help people understand both the risks and the best options for their own behavior. It must be actionable. • There is a need for candor, not false reassurance, • Officials must be accountable; they should acknowledge uncertainty, problems and misjudgments. Otherwise, trust is eroded. To address these shortcomings, future efforts will require greater coordination, collaboration, communication and coping. The following chapters suggest ways to implement the lessons learned from the 2001 anthrax attack by (1) better 154 planning and coordination, (2) trust building actions, (3) improved information flow, and (4) involving the public in the process of developing action steps to enhance safety. 155 Chapter 6: Planning and Coordination to Avoid Errors In the preceding chapter the need was suggested for better planning, trust building, communication and public participation. The anthrax attack of 2001 exposed deficiencies in the federal response, specifically with shortcomings in coordination, credibility, communication and involvement of the public to provide greater individual control over risk. What follows are observations and options for remedying the problems discussed in part 1 of this study. Because there is less evidence to support the utility o f these forward-looking ideas, this part of the study is merely suggestive of approaches that might improve a response in a future bioterror attack. Terrorism is a complex problem, involving law enforcement, the military, the public health agencies, local hospitals, local governments, state and federal officials. (Hogan, p. 11) A complex problem requires a complex solution. The anthrax episode triggered a complex response and efforts to understand it - and what to do to improve it - must address this complexity (Gursky et al., 2003) This chapter examines the complex nature o f dealing with terrorism, the impact on the public, the challenge to the public health system and describes an approach designed to offset the deficiencies experienced in the anthrax attack of 2001. Fortunately our society does not have extensive experience with terrorism 156 but we have had a fair share of natural and technological disasters. These have provided lessons about the complexity of dealing with crises. Disasters are significant events, not confined to isolated areas, not of fleeting duration and disruptive to society. (Stallings, p. 128) Disasters involve a crisis in communication within a community and disrupt and dislocate culture and cognition; they can be manifested in a broad range o f events including hurricanes, chemical spills, epidemics and terrorist attacks. (Oliver-Smith, p. 183) It is not sufficient to think of disasters as an outside attack that caused a social system to break down; attention ought to be directed to the internal contributors to problems and the emergent behaviors to respond and adapt to trouble. (Quarantelli, 1998, p. 266) Disasters strike everyone, but the burden may fall disproportionately on those least prepared and least able to respond. “There is a truism that - in disaster - the poor lose their lives while the rich lose their money.” (Smith, K, p. 33) To reduce the impact of a disaster, communities should mitigate damages, prepare for contingencies, involve members of the community in readiness, organize with various agencies, monitor and interpret information and assess risks for life and property. 157 A crisis is disruptive not only o f normal activities but also of psychological health - of the homeostasis, or balance that we seek - which can overwhelm the usual coping mechanisms and induce stress and functional impairment. (Everly, p. 3) These psychological problems are some o f the most bedeviling because they can cause irrational decisions, induce apathy and malaise, cause unwarranted fear and distress and interfere with society’s coping mechanisms. Moreover, the psychological trauma can persist long after the acute stage of the crisis, confounding efforts to return to healthy, normal life. In the anthrax episode o f 2001 some faulty decisions were made and inaccurate information was conveyed. It became clear that little work had been done before the attack to inform the public about the bioterrorist threat, that there were few protocols for educating people about risks and that there had been virtually no involvement of citizens in planning for such a contingency. Democracy needs to maintain the trust of its citizens, according to Frank Ochberg. “We have a collective interest in trust, legitimate trust, trust that is based on knowing facts, knowing options, and believing our leaders are doing what we would do in a reasonable and humane and effective way.” (ClAG, p. 5). Open, participatory contingency planning can facilitate reasonableness, humane action and effectiveness in a crisis. Since decisions in a crisis have to be made very quickly, the more comprehensive the planning, the more enlightened and 158 rapid the decision-making can be. Nudell and Anatokol have sketched out the things that need to be worked on in the planning process (p. 27). These include: • How and who will coordinate organization and policy issues? • Who and what will receive what and how much? • How will contact with the public be managed? • How will communication with the public be handled? • Who will be in charge of what? • What needs to be codified? • What is the chain of command and the extent of authority? • What will be the organizational response? • Who will have access to sensitive data? • Who and how will media relations be handled? • What is the proper role o f outsiders in the response? • What training needs to be done and what drills and exercises are necessary? • What are the requirements for documenting decisions and actions in an emergency? During a crisis the leadership needs to focus on the underlying challenge, not the symptoms. It has to balance following procedures with an ability to innovate, 159 no small requirement when stress interferes with efforts to concentrate and manage. (Nudell and Anatokol, p. 43) Innovation is possible when problems, policy and politics converge. The World Trade Center destruction and the crash at the Pentagon altered public perceptions of terrorism, refocused attention on the problem, challenged policymakers and motivated politicians. (Gormley, p. 7) This triggered a new paradigm for addressing the problem, one that has not solidified around a core of actions as of this writing. The quest for governmental accountability that had become standard in the late Twentieth Century kept the media and the opposition in Congress looking for those who could be blamed for letting down the guard before 9/11. But the new paradigm for dealing with terrorism ought to focus on coordination, not ownership and accountability; of flexibility not hierarchy; of networks not chains o f command; and o f collaboration not coercion. (Adapted from Gormley, pp. 9-11.) We will have to settle for decisions which are not optimal (because of the time and cost involved in finding the best alternative) and be content with those which merely work to satisfy the requirement. (Smith, K, p. 66) This is not to say that organizations won’t need to be prepared for a broad range of problems. In fact, preparation, attention to all phases o f crises - before, during the acute stage and during recovery - as well as consideration o f cultural and organizational factors and stakeholders affected by our actions, are all essential. But a climate of 160 blame or finding excuses should give way to a climate of learning from mistakes. (M itroff and Pearson, pp 11-13) lan Mitroff and his colleagues have listed dozens of rationalizations that cloud judgment and make an organization more prone to crises. Some o f the rationalizations that hinder preparation for and adaptation to challenges include: • Our large size will protect us, • Crises happen to others, • Nothing new has really happened that warrants major changes, • Most crises turn out to be not very threatening, • We can find a technical quick fix for most problems, • Most crises are the fault of a single, bad individual (or group) and we don’t have to fix our managerial culture, • Crisis management is like insurance; we only need to buy so much, • The most important thing is to protect our image through good public relations. Mitroff, who heads the Center for Crisis Management at the University of Southern California, has written extensively on how to consider worst-case scenarios, the criteria for activating a crisis management team, the warning signals of impending problems, containment measures ana post-crisis recovery 161 and evaluation steps. The goal is to “outthink the unthinkable.” (Mitroff et al, pp. 188, 191) Steven Fink, who had first hand experience at Three Mile Island, says that if “you operate in a prodromal, or vigilant, state, you may catch sight of something that needs to be addressed quickly, before it gets out o f control.” (Fink, p. 7) Specific steps for dealing with the threat of terrorism have been outlined by Maniscalco and Denney (p. 256). Some o f the steps include: • Understand the impact o f specific, potential terrorist attacks, • Examine community vulnerability, • Articulate the threat publicly, • Develop appropriate “response algorithms” to manage the impact of an attack, • Train and equip personnel to confront the problem, • Exercise the response plan, • Incorporate mutual aid assets to improve interoperability. People respond well in disasters but organizations do not. Survivors o f a disaster do not passively await help but initiate search and rescue efforts on their own, care for the injured and house those who are unable to go to their own homes. “Although the research literature emphasizes the coping and adaptive behavior of human beings in disasters,” Quarantelli states, “in contrast, much organizational behavior is inefficient and ineffective, if not actually 162 dysfunctional.” (Quarantelli, 1989, pp. 6-7) Persuading organizations to change is difficult. Large-scale organizational change can pose risks to people in the organization, can have unpredictable consequences and can trigger disruptive emotions. A Complex Crisis The reality is that crises happen all the time. Bioterrorism attack aside, we should be prepared for a variety of threats - natural and man-made - which can strike without warning. Such risks are taken personally by those affected and technical information is often incomprehensible except to specialists. (Lowrance, p. 105) A crisis can happen at any time because our systems are more complex, and hence, more vulnerable. They are interconnected, coupled one to another; their scope and size have grown bigger; impacts spread rapidly and are communicated quickly to the public. (Mitroff and Anagnos, p. 22-24) Failure interacts in a system that is tied together, described by Charles Perrow as “interactive complexity.” Being “tightly coupled,” failed parts cannot be isolated, causing spectacular system failures (Perrow, p. 4) “As our technology expands, as our wars multiply, and as we invade more and more of nature, we create systems - organizations and organizations of organizations - that increase the risks,” Perrow states, (p. 3) 163 Existing procedures usually assume stable environments, regular operations and normal conditions with time to consider and implement changes, but threatening events require rapid response. (Comfort, 113-114) We find ourselves in a world of instability, change and disorder. (Kiel, p. 10) In the dynamic environment of a crisis, there is no luxury o f time. A stressful environment, changing data, interdependent impacts and the pressure to act all render it difficult to make sense of what is unfolding. Such “sense making” relies on mental models of effective behavior in familiar conditions that are in short supply during unimaginable events such as 9/11 and the anthrax attacks. (Comfort, p. 114). The primary resource of organizations is information, which is crucial so humans can leam and adapt to new situations (Argyris and Schon). For example passengers and crew on the first flights hijacked on September 11th couldn’t understand the motives of the terrorists and expected a hostage scenario, but passengers on the last of the four airliners - who received news via cell phones o f the fate of the World Trade Center - were able to make sense of what was happening and take action. (Comfort, p. 116). “Without a common understanding of the threat, participants in an emerging system are unable to act,” Louise Comfort warns (p. 121). She says that Flight 93 from Newark on th • * September 11 is an illustration of an emergent adaptive system. As passengers processed the news about the crashes into the World Trade Center, they were able to recognize the threat and mobilize to thwart the hijackers. Although all 164 lives were lost aboard the flight, the passengers’ collective action is clear evidence o f adaptation to a new threat. She calls for developing a system that can cope with terrorist attacks at local, county, state and federal levels, studying the breaking points that are vulnerable to failure, testing for fragility and resilience in organizations, and creating an adaptive self-organizing emergency response system. (Comfort, 122-125) The current disaster response system depends initially on local public health resources with the federal government acting as a last resort. This linear procedure would not fit the dynamic conditions of a bioweapon attack. Because the risk generated in such an attack would be shared broadly, inter-connectivity with other agencies and jurisdictions is essential. The challenge is to become inter-organizational, interdisciplinary and inter-jurisdictional. This will require the capacity to adapt to new information along the lines suggested by research at the Santa Fe Institute. Complex adaptive systems, according to Stuart Kauffman, operate on a continuum between order and chaos. Near the center there is a narrow “edge of chaos” where there is enough order to utilize information and enough flexibility to adapt to changes. In a crisis public health and other agencies will have to adapt quickly to changing demands from the environment. These adaptive changes are manifestations of “self-organization” 165 because the organization takes the initiative to respond, rather than having the response imposed by the new threatening conditions. Much thinking has been done about the irregularities and patterns of irregularities that pervade both the natural and man-made world. It is helpful to sort out the different, recent theoretical approaches (Taylor, p. 13): • Catastrophe theory looks at uncertainty in the world and the abrupt, qualitative changes that occur in sudden disruptions, • Chaos theory investigates unstable aperiodic behavior in dynamic, nonlinear systems, • Complexity theory also looks at discontinuous change and nonlinear dynamics but focuses on the “edge of chaos” between too little and too much order. Far from equilibrium, systems can adapt in non-random ways. These new ways o f thinking about natural and social processes can inform planning for a response to disasters of the sort caused by chemical, biological and radiological weapons. “Falling between order and chaos, the moment of complexity is the point at which self-organizing systems emerge to create new patterns o f coherence and structures of relation,” according to Mark Taylor (p. 24). Stuart Kauffman has stated that “networks in the regime near the edge of 166 chaos - the compromise between order and surprise - appear best able to coordinate complex activities and best able to evolve as well.” (Kauffman, 1995, p. 26) Critical transitions take place at a tipping point where quantitative change rapidly leads to qualitative change. (Taylor, 148) These changes do not yield simpler systems, but one characterized by emergent complexity. Complex problems require complex solutions. As public health, police and homeland defense agencies struggle to establish new ways to prepare for bioterrorism it is important to recognize the crucial nature of the initial procedures being created now in the wake of 9/11. These initial conditions are not crucial because they must be perfect, but because they must be adaptable. The importance of initial conditions in new organizational forms cannot be understated for emergent systems. (Prigogine and Stengers) In order to be ready to adapt to surprises, Comfort says organizations must initially be created which can meet the following four conditions: (Comfort, p. 121): • Articulate messages which are commonly understood through the system, • Generate trust among leaders, agencies and citizens so that direction is accepted, • Ensure resonance between the system and its environment ;o action is possible, 167 • Have sufficient resources to sustain collective action as conditions change. O f course, the edge of chaos is not a pleasant place. The emotional roller coaster can cause vertigo, or nausea. The information glut can create confusion. “Noise”, as Taylor has noted, derives from the Latin “nausea,”(p 100) Amid all the noise it is hard to discern the signals of real threats. Aaron Wildavsky posed the following question: How would government (how would anyone) know which one(s) of an infinity of hypothetical evils will ultimately become manifest? Many, which now appear dangerous, may never turn up at all, or may actually turn out to be harmless. Others may actually be a little dangerous, but the consequences of trying to prevent them may be much worse than letting them run their course. The most likely eventuality by far is that most of the low probability events will not happen, and that whatever does happen will be unexpected, i.e., it will not be among the envisioned possibilities at all. (Wildavsky, p. 91) Wildavsky suggests that rather than try to prepare for all potential threats (which could dissipate our strength) that we should strengthen our general capacity to respond to realized risks. He suggests a two-fold approach: (1) anticipation (preparation) and (2) resiliency. The first identifies and addresses the high vulnerability and high probability threats while the latter strengthens defenses overall. “There may well be catastrophes in store for us 168 that no one knows about or, if known in advance, that no one can prevent,” Wildavsky wrote in 1991. (p. 91) With some adaptation, here are the six ways Wildavsky says organizations can anticipate and better prepare for trouble: • Create a safe environment, • Enhance the environment to strengthen system stability, • Have a variety of resources that are unrelated (not tightly coupled) so if one resources vanishes, others can be accessed, • Avoid overspecialization and be adaptable, • Separate the elements o f the system from one another (avoid closely coupled systems), • Design robust systems to survive sudden change. No matter how well anticipation operates, it unlikely that planning can offset every potential threat. So anticipation is complemented by building strong systems to respond to the unexpected. Here is a summary o f the six ways Wildavsky suggests that organizations can increase resiliency: • Develop feedback mechanisms to avoid negative consequences, • Have more resources available nearby and in real time in case there is a problem, • Utilize multiple kinds of resources to avoid reliance on a single resource, 169 • Have a large number of independent groups because many responses are better than one, • Create surplus (slack) which can buffer the system against new demands, • Create redundancy; redundancy increases reliability. (Pp. 112-119) In addition to defensive measures taken to anticipate, prevent and prepare for terrorist attacks, society should increase its resilience by strengthening the public health system at the local level, by improving communication capabilities, by educating the public about risks and ways to protect themselves and by encouraging public participation in community based activities. This recognizes that the US government will not be able to prevent all terrorist attacks and that a stronger homeland will be able to take the punch. There are many unknowns, o f course. Karl Weick and Kathleen Sutcliffe answer the question, how can we manage the unexpected? with this advice: “By acting more like a high reliability organization.” They say the path to reliability includes the following steps:(Weick and Sutcliffe, pp. 10-17) 1. Be preoccupied with failure, including small failures, in normal times. Treat lapses as warning signals of problems that could have severe consequences. 2. Take deliberate steps to create complete explanations o f complex problems; do not simplify. 170 3. Be sensitive about operations, particularly to spot loopholes in defenses and latent failures. 4. Commit to resilience. The goal is not to avoid all error but to keep errors small and have a system to quickly devise solutions that bypass the failed part and keep the system working. 5. Develop expertise at all levels and listen to experts. As systems become more complex, decisions have to be made in the field. Rigid hierarchies are vulnerable to error. It must be stressed that this is a bottom up, not just a top down endeavor. The increased level of caution needs to extend down to the level of homes, small businesses and local communities. They all need not just plans but enhanced survival capabilities, including alternative plans and escape routes. (Chiles, pp. 7, 282). Confusion and uncertainty are not always harmful. Disorder can trigger growth and adaptation. (Kiel, p. 151) “The turbulence,” Mark Taylor states, “harbors creative possibilities for people and institutions able to adapt quickly, creatively, and effectively.” Rigidity in a rapidly changing environment can drive one “beyond the edge of chaos to destruction.” (Taylor, p 202) In addition to developing psychological body armor and avoiding rigidity, individuals and 171 organizations need to be encouraged to envision new patterns for coping with new threats. These patterns are schematic mental models that compress the regularities o f experience so that it is possible to respond effectively. When new information is processed - for example, news about terrorism - the models respond and sometimes adapt (Taylor, p. 206). Murray Gell-Mann at the Santa Fe Institute states that adaptation involves operation “thorough the cycle of variable schemata, accidental circumstances, phenotypic consequences, and feedback of selection pressures to the competition among schemata.” (Gell- Mann, p. 329) The key to survival is fitness. In turbulence, fitness will be determined by the ability to identify regularities in the environment, recognize patterns (schemata), adjust these models as changes occur, anticipate the impacts of these changes, and process feedback rapidly to adapt and survive. Public Health Challenges The public health system in the United States has not been diagnosed as fit. In 1988 the Institute of Medicine reported that the public health system is “in great disarray,” something Tara O ’Toole of the Johns Hopkins University School of Public Health says has “only gotten worse.” (Ethiel, p. 97) There is not sufficient capacity, there are inequities in the delivery of services and benefits, and agencies arc fragmented and overtaxed with divergent duties. A collaboration between local, state and federal agencies developed the 172 Assessment Protocol for Excellence in Public Health in 1991. It calls for public health agencies to assess their internal capabilities and for a parallel assessment of how the agencies can serve their communities If we face a contagious disease outbreak, O’Toole warns, “You do not want to be figuring out at the last moment whether you should institute a quarantine, or clap somebody into mandatory isolation, or implement an immunization program by force. You really need to think these things through long before you’re in the middle of a disaster.’’ (Ethiel, p. 99). One way public health can avoid the rigidity that hinders adaptation is to foster a grassroots initiative rather than a centralized hierarchy for dealing with challenges. Homeland defense has largely been preoccupied with identifying external threats through intelligence, law enforcement and cooperation with police and military agencies. This top down approach is entirely appropriate in command, control, communication and intelligence operations. But the public health system works differently. This area of need is best served by a federalist model, where states and localities retain flexibility. The two systems, top down versus bottom up, might be compared to the differences between the body’s nervous system and its immune system. The nervous system is a “central nervous system,” while the immune system is self-organized. It moves quickly on its own when an invading agent is identified. Rather than command and 173 control, the immune system mobilizes and adapts. In many respects that is the challenge for public health and for public safety on the local level: to identify a threat, mobilize quickly and respond well before anyone has time to get orders from on high in Washington. Such an approach is consistent with the traditional way that public health has responded to epidemics and drug use. Specifically, some of the features of intervention include: • Sanitation: to eliminate environmental factors that can enable terrorist acts, • Education: to promote public awareness of the situation, potential threats and recommended behaviors in an attack, • Training: to avoid confusion and delay in reacting to terrorism, • Sui veillance: to track trends and monitor for outbreaks of disease, • Prophylaxis: to inhibit terrorists and prevent them from benefiting from their acts, • Acute intervention: to immediately act to counter outbreaks. (De Armond, pp 65-66) These public health steps can augment the law enforcement, intelligence and homeland defense activities. In sum, government agencies need to recognize the 174 potential impact, articulate it to the public, examine the vulnerabilities, develop appropriate response plans, train and equip personnel (including exercises and drills) and incorporate mutual aid assets to enhance cooperation among agencies and communities. (Roberts, 256). All of this requires cooperation with communities and broader public participation for the bottom up component to work. The potential use of biological weapons raises the specter o f hundreds of thousands of casualties in what Michael Osterholm calls “catastrophic terrorism.” Infectious agents cannot be matched as a cost-effective and efficient weapon for terrorists But there are ways to address this potential problem: enhance the public health system, stockpile antibiotics and vaccines, build surge capacity in our hospitals, clear up jurisdictional issues among agencies, encourage more thoughtful news coverage, and inform and involve citizens. (Osterholm and Schwartz, pp. xix, 7, 189-203) Senator Bill Frist says that the success of public health agencies in responding to a bioterrorist attack will depend on rapid communication and better preparation. "The gaps we now see in our public health system are the result of twenty years of benign neglect and underinvestment.” (Frist, 159) As Frist notes, any improvements in public health designed for combating terrorism will serve the 175 important purpose of helping us prepare to handle all sorts o f infections and communicable diseases. In a study before 9/11, the Henry L. Stimson Center reported that those on the front-line were concerned about investing in existing assets that are useful in multiple contingencies over the long-term. This contrasts with Washington’s effort to have an “inside-the-beltway ... spending carnival” during a crisis. The report (Smithson and Levy, 2000) urges emphasis on public health and hospital investment, including: • Training for fire departments to handle decontamination, • Increase isolation wards and surge capacity at hospitals, • Stockpiling drugs, but rotating them so they can be used before they expire, • Increase syndrome surveillance tools nationwide, • Plan non-traditional health care delivery systems for emergency use (such as through fast food restaurants “to administer drive-through prophylaxis”), • Charter a multi-disciplinary commission to draft legislative proposals on such things as evacuation, isolation and quarantine options, • Develop consensus protocols for treating chemical and biological casualties. 176 • Increase spending from the 6% of the unconventional terrorism budget (in ,2000) to strengthen the public health infrastructure. More recently, a report fo» me Institute of Medicine o f the National Academies stated that the nation’s public health system is not ready to defend the population from the threat o f deadly infectious diseases. The co-chair of the 2003 report, Margaret Hamburg, stated that “We must do more to improve our ability to prevent, detect, and control emerging as well as resurging. microbial threats to health.” The report points to the growth of drug-resistant bacteria and viruses that do not respond to once-effective medicines coupled with the decrease in pharmaceutical development of new antibiotics. “It’s conceivable,” Hamburg stated, “that in certain places microbial ‘perfect storms’ could occur - convergences o f several factors - and unlike meteorological perfect storms, the events would not be on the order o f once-in-a-century, but frequent.” (Warner, 2003) The mission of public health has been described as “the promotion of physical and mental health, prevention of disease, injury and disability, and the protection o f the public from environmental hazards” (US Department o f Health and Human Services, 2002) In 1988 the Institute o f Medicine (IOM) report observed that “(D)ifferent communities have different health problems and they 177 have appreciably different political and social organizations and values. So public health systems in these communities vary widely and offer widely differing public health services.” These differences are as much in evidence today as in 1988 and could become areas of contention if the nation is challenged by a bioterrorist incident. (Brown and Prior, 2002) Current plans will not provide uniform responses in communities. Failure to respond adequately could further extend the disparity in health care across the country and might even aid the psychological goals of the terrorist be fragmenting the public and leaders. The 1988 IOM report was valuable in its identification of three “core functions” that public health systems must provide, these include: • Assessment, » Policy development, and ® Assurance Assessment activities are focused on determining the nature and of illness in populations and evaluating health conditions and resources in communities. Such activities are based on scientiltc disease surveillance and epidemiology. Policy activities include the plans, budgets, official guidance, standards, regulations and laws that public health officials use to guide the actions of public and private organizations. Policy development involves elected offcials, 178 appointed decision makers, advocacy groups, the community at large, and - at times - those most affected by the policy decisions. This process frames, debates and addresses community needs and priorities. Assurance activities intervene to prevent the spread of disease through populations, promote healthy conditions, and maintain the quality of medical care to treat disease in individuals. These core functions manage fairly well for traditional public health threats but are not so well suited to the challenges o f bioterrorism or a new, large-scale naturally occurring epidemic. (Brown and Prior, 2002). The traditional approaches need to be upgraded to meet the challenges of the new, more dangerous world. The stakes can be very high. The introduction of a bioengineered contagious disease could wreak havoc on a population with no immunity.. When diseases that were naturally occurring in Europe were first introduced into the Americas they had a catastrophic impact on the health of natives. (McNeill, p. 180) Wave after wave o f smallpox killed as many as 90% of the Indians who became infected, with whites relatively unaffected. (Bray, p. 130) European-borne diseases may have wiped out a majority of the indigenous Indians; certainly this was the impact of colonialism on the Hawaiians, where good record-keeping showed that the population sank in a century from a conservative estimate of 242,000 to only 48,000. (Crosby, p. 176.) In an attack, the government will have to be prepared to deliver postexposure prophylaxis to enormous numbers of persons. Fear must 179 not paralyze the medical and emergency personnel who do the actual delivery o f health care. (Garrett, 528) Americans expect government public health agencies to act to limit death and disability in the population. The federal response is currently the focus of the planning in the wake of the anthrax attacks of 2001. The planning process is a responsibility for health agencies, such as the Centers for Disease Control, and the new Department of Homeland Security. Such epidemics or attacks are so rare they do not seem to justify a brand new, full blown effort and must rely on existing health agencies and health care providers, volunteers and cooperation from the public. The new department has a myriad of duties, but many activities, including public health, law enforcement, intelligence and military activities are housed in other agencies, such as Health and Human Services, the Department o f Justice, the CIA and the Department of Defense. The responsibilities o f emergency responders represent a critical category of public health practice. Their duties can be divided into preparedness and response capabilities — tightly linked and mutually-dependent activities that need to be re-assessed due to the increased threat from bioterrorism. (Salinsky, 2002). The current attention to homeland defense planning focuses on the challenge posed by bioterrorism as one that should mainly be addressed as a federal 180 problem, with solutions devised at the national level. But if the federal response imposes compulsory activities such as quarantine or mandatory vaccination, some members o f the general public may resist such requirements. Past experience in the United States with both quarantine and compulsory vaccination created vigorous resistance by some portions of the population and triggered legal challenges to government actions. Many of the actions became the subject of judicial review, including at the level of the U.S. Supreme Court. Brown and Prior state that the compulsion element of federal public health intervention is “an unappetizing prospect.” The ‘federalizing’ of the public health response to bioterrorism stands in contrast to traditional public health responses that have relied on local interventions and actions by the states. The 1999 figures on public health expenditures provided by the U.S. Department of Health and Human Services show that only 11% of public health funding comes from federal sources; most comes from State and local governments. A plan of action for bioterrorism that begins with significant federal expenditures to impose federal responses (with strings attached) contradicts the traditional practice o f public health. It could engender mistrust among medical practitioners used to a different system. . We are entering a period in which the public is becoming more empowered in self- care and self-management o f healthcare. Consumers of healthcare resources 181 have increased access to medical information that can inform their decisions concerning health choices. Shared medical decision making between the sick consumer and the health practitioner is increasingly the norm. Attempts to impose a solution from a federal source could be viewed as intrusive and encounter resistance. The ultimate goal ought to be to leverage the local capabilities that have been built over the past century to meet the emerging challenges for public health and public trust. Regrettably, a local-centric approach does not seem to figure highly in current federal planning. A review o f the actions after the anthrax attacks o f 2001 demonstrate that efforts to prepare for bioterrorism have a greater focus on federal intervention and federal funding than traditional public health fields. (Brown and Prior, 2002) The federal influence extends from preparedness (prevention and planning) to response (interventions and education) but at present fails to adequately deal with the issue of public trust. Public health emergency preparedness is imperative. The current public health system is very complex, legally and organizationally, and the public health infrastructure differs significantly from state to state and community to community. A standard o f preparedness, based on the threat posed by bioterrorism, ought to be implemented in every community in the country. Achieving this goal, however, would require enormous resources, coordination 182 between a myriad of agencies and leadership at the local and state level as well as in Washington. Involvement and commitment of policymakers at all of these various government levels will determine if such efforts will be successful. 183 Chapter 7: Building Credibility in Stressful Times No other disaster is more capable of undermining public trust than disease caused by a bioterrorist attack. Aside from fatalities that would result from an incident o f bioterrorism there could also be a significant public panic. If the government seems powerless to control the problem, then there could be a legacy of mistrust in the government that might have greater long-term significance than the death toll. For this reason there is a need for the government to engage the public in an interactive dialogue to prepare for the potential consequences of a bioterrorist attack. An attack could sorely test health care systems in affected communities. Hospitals that might be able to help a dozen patients with inhalational anthrax cannot be expected to help thousands of people clamoring for such care. Because o f the scarcity of hospital beds, Kenneth Kipnis has concluded that during a health catastrophe we cannot expect hospitals to be the primary locus of health care. They will be overwhelmed and must divert prospective patients to temporary and peripheral emergency care centers. (Kipnis, 2003). His scenario, “healthcare without hospitals,” envisions following the Israeli example of requiring people in a zone where chemical weapons or germ warfare has been used to shelter in place in their homes, offices and stores. “If a deadly plume is 184 passing over my city, I am at greater risk if I move about, safer if I stay put, especially in a windowless room or closet with the door taped shut ... with food and water for several days, a radio and a telephone,” Kipnis states. Rather than attracting the ill to hospitals, they would be treated at their homes or in temporary locations, including schools, fire stations, hotels or tents set up for the purpose. This would reduce cross contamination and infection if the attack were a biological agent (Kipnis, p. 105) Such a scenario makes it clear that a response to bioterrorism will not only involve health officials but many other government organizations. This likelihood needs to be addressed in any dialogue with the public. It is clear that in preparing for, and responding to, a bioterrorism attack, or other public health emergency, will require the involvement of a wide range of professional disciplines in addition to public health. Defense, intelligence, law enforcement, public safety, and medical resources all have to be brought to bear to minimize the threat o f bioterrorism and, for that matter, other, non-traditional, public health emergencies. In the absence of a plan to which the public has been exposed and on which it has had some input, the involvement of such a diverse range of disciplines can be seen as frightening to sections of the public and deeply resented by yet others. In fact the presence of the ‘Feds’ may invoke a negative reaction that overshadows the initial event - to the terrorist this ‘over 185 reaction’, by either the Government or its people, is as much a success as causing fatalities. Terrorism has as its goal the spread o f fear and creation of mistrust in society’s ability to deal with an attack on the population. The potential for panic that results from a bioterrorist attack should stimulate public health emergency preparedness. (Scharf, 1999) and has resulted in new initiatives for preparedness and response. These developments have led to significant debate about the merit of imposed actions versus voluntary solutions for the protecting public health. (Annas, 2002) The tools being actively considered include improvements in the following: • Recognition (Detection/diagnosis/biosurveillance) • Treatment (Vaccines/antimicrobials) • Infection control, isolation and quarantine. Recognition o f a bioterrorist incident will probably occur through detection o f a discrete event signifying the release o f an pathogenic agent (for example, the presence of white powder in the anthrax letters) or through increased incidence of disease noted by existing disease-surveillance methods. Non-traditional surveillance systems such as monitoring of pharmacy sales of certain medicines or increased absentee rates from schools or businesses are in the development 186 stage. Some prototypes have shown promise in identifying problems. All require surveillance of vast amounts of data collected from widely distributed systems because the bioterrorist attack could occur anywhere in the nation. Since a disease introduced by a terrorist group could be spread by people who are infected but have not yet shown symptoms, after an initial detection the response by health and public safety officials may extend to a large geographic area where the exact boundaries are not defined for a long time after an attack. This creates management and logistical complications welt beyond those of naturally-occurring diseases, where the effects typically will occur in a more predictable manner and in a more confined geographic area, at least initially. (Brown and Prior, 2002) Efforts to Improve Preparedness After the anthrax episode of 2001 the federal government increased efforts to provide medical products to combat a bioterrorist attack and enhance preparedness. (Salinsky, 2002) There has been an increase in the National Pharmaceutical Stockpile and the procurement of smallpox vaccine by the Department o f Health and Human Services. The government has increased funding for basic and t pplied medical research through the National Institutes of Health. In addition to scientific challenges, there are regulatory concerns, including about licensing medicines by the U.S. Food and Drug Administration 187 which have not been tested for treating man-made diseases. The available medical countermeasures for some biological agents are not in routine clinical use. Medical personnel treating victims of an attack may have to use medicines whose safety and efficacy are unproven or supported only by limited scientific data. Special legal authority may be required to use such drugs in an emergency. Beyond legal issues, substantial ethical and moral concerns could arise from the need to treat large numbers of people who are not only endangered by the target disease but may be at risk from the use o f the drugs themselves. (Brown and Prior, 2002) Compounding the problem is the need to move quickly, both to provide medical attention - including drugs that may not have been completely tested - and isolate persons who are sick and/or those who might be contagious. The issues of mandatory vaccination, isolation and quarantine are difficult ones. Mitigating the impact of a bioterrorism event may necessitate isolation or quarantine o f those exposed or potentially exposed to a disease agent. The number of such individuals may be very large and their confinement may be for an extended time, depending on the incubation period for a specific bio-agent. Isolation is the separation and confinement of individuals known or believed to be infected with a contagious disease to prevent them from transmitting disease 188 to others. Quarantine is the compulsory separation and restriction of movement of healthy persons who may have been exposed to a disease to segregate them in specific areas to prevent the spread o f disease. (Barbera et al, 2001) Government agencies may deem it necessary to prohibit all entry or exit from the area ot a disease outbreak. In a widespread outbreak it is conceivable that the US w have to be closed to international travel. While that may seem overblown, consider the recent European efforts to stop the spread of Foot-and-Mo’ tr, Disease. Draconian measures were needed to stop the spread o f the disease. Such steps can induce additional stress in society. Measures of this sort might be ordered at the federal level, imposed by federal decree, and federally funded - even though they rely on local and state implementation. But quarantine has traditionally been a state power. Authorities at both the federal and state levels rarely engage the public they are designed to protect in the planning or implementation process. Quarantine would clearly be an imposition and the obvious coercion could create mistrust in government.. In some sections o f the population there is already mistrust, it is often deep-rooted, and it can provoke opposition. Given the risks of untested treatments, controversial vaccination and the like, the “cure” might cause more psychological and social damage than the disease. Such iisks ought to be evaluated before, not just during, an attack. For such reasons programs that do 189 not include compulsion would be preferable. Approaches that allow for individual initiative and the emergence o f new solutions ought to be encouraged. They should guide the public in individual actions that will be for the collective good of society. It is clear that such contingencies need to be thoroughly discussed and decisions reached op the contours of government action prior to an emergency. Since terrorism presents a complex challenge, good planning and coordination is essential for avoiding the sort o f errors that occurred during the anthrax attacks of 2001. Traditional public health policies and programs that focus on meeting everyday challenges should continue and ought to be supported. New challenges to public health posed by terrorism necessitate new concepts, approaches and programs. Public health is now more than just about the collective health o f the population; it is part o f national security. (Brown and Prior, 2002) When attacked by bioterrorism - or by new and emerging diseases such as AIDS and West Nile Virus - the concerns become a national issue. Man-made diseases spread by deliberate attacks with anthrax or smallpox can infect and destroy public trust. Building trust requires addressing the factors that cause stress and fear among the public. 190 Some new attempts to deal with the public health challenges have been undertaken but a key element in any plan will be reliance on existing public health management. In a study of health priorities that became the ‘Turning Point Program” the researchers noted that “(T)hreats to our public health from natural disasters, infectious disease and pollution are on the rise.” A major goal of Turning Point is to “transform and strengthen the public health system in the United States to make the system more effective, more community-based, and more collaborative.” This approach seeks to engage the public in action to sustain public health through the building o f public trust, individual and collective action, and the development o f a comprehensive defensive strategy for our nation, (www.tumingpointprogram.org') In bioterrorism preparedness, the federal government is necessary although not sufficient to meet our needs as a society. To expect that the federal government will provide immediately for our needs is to engage in wishful thinking. Local communities possess the ability to react quickly to an event, a critical component to the success of an operation. “Biosecurity must be bottom-up,” according to Gigi Kwik and her colleagues at the Johns Hopkins Center for Civilian Biodefense Strategies. (BCwik et al, 2003). 191 Fortunately, man-made disasters such as bioterrorism are very rare. Natural disasters, however, are more common and have been the subject of much research. Studies of natural disasters demonstrate that proper planning and good communication facilitate the capacity to constructively respond to disaster. Panic is rare. (Glass and Schoch-Spana, 2002) Rather than expect social disorganization in a disaster - and the need for draconian command and control - decades of experience with crises shows the resourceful problem solving capabilities o f communities hit by disasters. (Tierney et al, 2001) Research into natural disasters suggests that the population divides into three categories of similar size. (Saathoff, 2001) (1) About one-third of the population is numbed by the experience and is compliant with instructions from officials. (2) One third o f the population is impaired by anxiety, causing them to over-consume medical, governmental and social resources. (3) About one-third tends to respond with action and courage. In natural disasters, only the second group poses serious problems, (Cohen, 1987) Since they are in the minority, their needs can be successfully managed by the third group, which acts and leads in time o f crisis. This group needs to know what to do to help. Bioterror events are different than most natural disasters and these unnatural events require special precautions and planning. Without instructing citizens on their role society is much more vulnerable than in natural disaster. Those who 192 are numb, frantic with anxiety, and even the heroic can all compound the crisis. Those in the first group, who are numb and do what they are told, can only function if they are given correct information a * i instruction. Their survival requires that government enlist the voluntary support of their community in dealing with the crisis. This support is enlisted through accurate and understandable communication. Without an authorized message and trusted messenger, the numb will be adrift, bewildered by conflicting data and advice. The second group, those who become frightened, panic and lack restraint, are the most vulnerable, and require the greatest assistance. In unstable, unfamiliar settings, their needs are great. They are least able to cope with crisis and will draw upon limited resources. Their survival may depend on the active and successful intervention o f their neighbors in the third group who are ready to act to assist, to solve problems and to fight back against terrorists. Those in this third group, who take a leadership role and want to do something positive, paradoxically can contribute to chaos if they are without direction. These people will do something even if it is not the right thing. If they have not received accurate advice and have no clear idea of what they should do, their acts can inadvertently cause trouble. In the absence o f clear signals and frustrated by lack of direction, they can add to disorder. In unfamiliar circumstances their bold acts can become the problem rather than the solution 193 they seek. For example, if they enter an area that has been contaminated by an infectious agent, they can consume limited resources and might become infected with the bio-agent themselves. If they lead their neighbors to evacuate, they may spread the disease with them. Evacuation can widen the epidemic, since fleeing citizens can carry the very infection they are trying to escape. In effect, they could become “unwitting bioterror weapons themselves, carrying contagious diseases,” according to Saathoff. (2002). He states that they can be even more dangerous than suicide bombers, because the lethal diseases can be transmitted and propagated exponentially in a way similar to the infectious child who attends school, transmits a disease to other children, then to parent, then to co-workers, and on and on. When bioterrorism is spread as innocently as childhood infections, the risk is of epidemic proportions. Psychological Factors A successful policy to combat bioterrorism ought to psychologically vaccinate the public to mitigate the anxiety caused by biowar. Fear clouds judgment; panic confounds decisive action, and can lead to individual and collective panic. Physical illness is not the only contagious threat. Infectious agents, emotions and social disorder are all contagious. They can cascade through society like a 104 chain reaction. Contagion compounds crisis. (Saathoff, 2002). Bioterrorism is an unfamiliar, invisible threat with the potential for dreadful consequences. In medicine, contagion refers to transmission of a disease by direct or indirect contact. This is only one part of the problem that fails to capture the psychological dimensions of great public health significance. In bioterrorism, the contagion can corrupt the emotions of many persons very quickly. As discussed in chapter 2, a Rand study found that 90% of the US population had some form o f stress response to the events of September 11. Forty-four percent experienced at least one of five significant stress symptoms such as lost concentration, sleep difficulties, or having disturbing thoughts. (Shuster et al, 2002) This study also demonstrated that people can cope with stress in creative ways, including by talking with friends or family, seeking solace in prayer, or spiritual pursuits. (Saathoff, 2002). Mental health is an integral component of public health. The behavioral responses to a public health emergency can determine the success or failure o f a public health initiative. Disaster can trigger increases in depression, anxiety disorders and suicide rates, complicating the recovery. Mental health planning for terrorism requires engagement of citizens in order to reflect priorities and values of the affected community. (Glass and Schoch-Spana, 2002) In the absence of planning, the psychological toll of a bioterror attack can turn a crisis 105 into a catastrophe. Some individuals are more sensitive to the emotional trauma of a disaster. These include the young, the elderly, mentally ill, and the disabled, as well as paramedics, doctors and other leaders with first-hand responsibility and close contact with the injured and ill. When affected by a bioterorrorism attack, these sensitive individuals can overwhelm community resources, including hospitals, clinics, emergency shelters, schools and churches. (Saathoff, 2002). American society is saturated with stress. Everly and Mitchell (1999, pp 22-23) reviewed research that indicated the following “epidemic” of psychological crisis or trauma: • Ninety percent of adults will be exposed to a traumatic event in their lifetime, • The rate of trauma exposure for children and adolescents is around 40%, • Conditional risk for posttraumatic stress disorder (PTSD) was about 13% for females and 6% for males, • The prevalence of PTSD among a sample of suburban law enforcement officers was 13%, • PTSD among urban firefighters ranged from 15% to 31 %, • Sixty-two percent of clinical healthcare staff reported being exposed to a traumatic stressor at work, 196 • Suicide rates have been seen to increase 62% in the first year after an earthquake, 31 % in the first two years after a hurricane and by almost 14% four years after a flood, • Each year approximately one million Americans become victims of violent ciimes at work, • In 1997 there were 304 acts of international terrorism, one-third o f which were directed against American targets. The country seems to already be awash in stress and trauma, without considering the additional strains that a future terrorist attack could add. Stress would be a predictable reaction to a terrorist attack. The distress itself is most often a reasonable and healthy reaction to a traumatic event. The solution is to have an appropriate behavioral response; most people will recover if they follow plans to respond to a contagious bioterror attack in constructive ways. A dysfunctional behavioral response will compound problems and complicate recovery. When faced with danger humans typically respond with fight, flight or freezing behaviors. (Norwood, 2003) Since freezing is usually unacceptable, attention turns to the fight or flight options. (Selye, 1950) In a bioterror attack, the choice of whether to stay in an affected community to deal with the problem, or flee to presumably safer territory, can determine whether one lives or dies. 197 As Saathoff states (2002), “While it is wise to flee from a house in flames, it is foolish to leave one’s home in the midst of a blizzard. In the first instance, the house is the problem, and in the second instance, it is the solution.” If one stays in a burning house, the original crisis is compounded, just as the choice to leave the safety of a house in a blizzard may be a fatal mistake. The response to a crisis can be as crucial to one’s survival as the initial crisis itself. In a bioterror attack, a decision to stay in one’s own home and fight the problem is usually optimal from a public health and mental health perspective. This not only safeguards individuals and their families and communities, it serves to diminish the spread of illness and psychological contagion. (Saathoff, 2002) Our homes and businesses are familiar havens that serve as refuges of survival during a contagious bioterrorism attack. The predictable impulse to flee from an infected city is the chief problem that society will face after the attack o f a contagious agent because it would spread disease and trigger emotional stress by severing individuals from familiar, reassuring surroundings. The maintenance of familiar ties requires the full participation of local and state officials in times of stress. Local communities possess the ability to react quickly to a terrorist event while federal assistance is likely to be a late arrival. Local first responders would be first on the scene and the Department of Homeland Security would not initially be a factor in coping with the immediate crisis. (Miller, 2003) All the attention 198 on what could happen, when and where, has obscured the question of who is most appropriate to respond to the event. Citizens in affected areas will be challenged to act. The main action will be at the neighborhood, community level. Unfortunately, despite the billions of dollars spent to combat terrorism, very little is invested in citizen involvement or enlightenment. (Taylor, 2000) Since it is virtually impossible to predict where an attack might occur, and the release of a bio-agent is difficult to detect, it is likely that a government response will take time, precious time. With the delay, the perimeter of the contagion would widen, making a coordinated response more difficult. Initially, it may be difficult to differentiate between chemical and biological agents. Communities will have to face problems that are not directly caused by terrorists. These include hoaxes, hysteria, panic and unwarranted flight in the event o f a chemical, biological or radiological attack. Even before the anthrax attacks of 2001 there were numerous hoaxes. In the 1990s mentions of anthrax and sarin episodes increased twenty-fold. (Roberts, 248-249) One o f the great challenges o f dealing with bioterrorism is coping with the worried well who might swamp hospitals demanding care (Frist, 167) In the anthrax episode, thousands were treated with antibiotics but less than two dozen cases o f infection were confirmed. People often overreact to newly apprehended risks. Individuals can react in an alarmist manner to increases in risks even 199 when these increases are rather small, (Viscusi, p. 138) Some people will be tempted to flee even when the best advice is to stay sheltered in one’s own home (Frist, p. 21) Hoaxes are likely to exacerbate the problem. In 2000 the number of hoaxes about chemical and biological agents in the US and Canada totaled 22. In 2001 the publicity about the anthrax attacks inspired a new wave of hoaxes; there were 566 hoaxes recorded in that year. (Dolnik and Pate, 2002) During the Three Mile Island nuclear accident in March 1979, when uncertainty about the radiation risk was very high, the governor of Pennsylvania issued a calm advisory suggesting that pregnant women and young pre-school children living within five miles of the nuclear power plant might want to evacuate while others within a ten-mile radius should consider taking shelter in their homes. Had the advice been followed, about 3,500 persons living near the reactor would have left the immediate area. In reality about 150,000 persons fled the area. On average they traveled 100 miles. For every person advised to evacuate, almost 45 evacuated. (Erikson, pp 139-140; Flynn) The author of this thesis remembers the Three Mile Island episode well; I was a reporter for NBC News and I covered the incident from the second day until the tenth day. The fear in the community was obvious. The best description for it was dread. 200 It is important to note that concern about the nuclear accident generated numerous rumors about serious health problems, such as increased cancer rates and stillborn children. Within two years all of these beliefs had been shown to be unverified or false, but almost one-third o f residents living within five miles of the plant believed them to be true. The rumors were even more likely to be believed by those farther from the site. The public demand for information caused frustrations that were evident more than a year after the accident. Half o f all respondents to a survey were dissatisfied with the information provided by the media during the crisis. (Houts et al, 1988, pp. 78-80) The TMI episode is curious because no order to evacuate was ever issued, even though it was recommended by some staff members at the Nuclear Regulatory Commission. The NRC recommended that individuals within ten miles of the plant remain indoors. Governor Richard Thornburgh only recommended that pregnant women and preschool children within five miles leave the area. In two-thirds of the households within this radius at least one member evacuated. Half of those traveled at least 90 miles and remained away at least five days. Researchers reported that 80% cited “confusing information as a reason for leaving and almost as many reported that they left the area to avoid forced evacuation.”(Houts et al, 1988, p 13) This despite the fact that no evacuation order was actually issued. (Barkun, 2002) 201 The behavior at TMI was quite different than what often occurs ir natural disasters, where residents fail to heed official advisories to evacuate because they believe their own judgment is better than the experts’. (Houts et al, 1988) Local officials and the Federal Emergency Management Agency (FEMA) encourage people to leave the area during hurricanes buv their advice is sometimes disregarded. This often results in individuals staying rather than getting away from the storm. Such noncompliance occurs in areas with lots of hurricanes because people develop regional “disaster cultures” based on memory, tradition, and folk wisdom. (Barkun, 2002) So residents often leave or stay because of their own judgments rather than those of authorities, since they regard their own judgments as solidly grounded on experience. But at TMI the population had no knowledge upon which to base a decision to flee. Like bioterrorism, the risks were newly apprehended. The communal “disaster culture” - for better or worse - has not solidified for bioterrorism. Some will certainly flee any problem, an impulse that might be encouraged by FEMA’s preference for evacuation as a tool in an emergency. The consequences o f biowar are particularly distressing because little is known about them and because the agents are invisible - gases, pathogens, radiation. The absence of independently grounded knowledge makes people more dependent on outside infonnation, and more susceptible to conflicting or 202 inconsistent messages from government officials and technical experts. This may lead to increased vulnerability where the direct impact of the attack is amplified by the anxiety produced by mixed signals about what to do. (Barkun, 2002) The accident at Three Mile Island spurred evacuation planning for other nuclear power plants, including the Shoreham nuclear power plant on Long Island. The author served as a consultant for Suffolk County officials grappling with local opposition over the plant. At one point Suffolk County commissioned a survey asking residents how they would respond to an accident at Shoreham. One question asked what the respondent would do if an accident occurred and everyone living within five miles of the plant were advised to stay indoors. More than 40 percent of the respondents living within a ten mile radius of the reactor answered that they would evacuate the area. In fact, some 25 percent of the entire population of Long Island - including those many miles from Shoreham - said they would flee. If the warning was for only pregnant women and young children to leave, then 55% of the entire population of Long Island planned to evacuate. If a Shoreham accident had occurred and residents acted as they said they would, “utter deadlock” would have awaited them on the roads of the island. (Erikson, p. 145; Johnson and Zeigler) 203 It is clear that the trauma of critical incidents such as Three Mile Island or the 2001 anthrax episode can overwhelm an individual’s usual coping mechanism. (Everly and Mitchell, 1999, p. 11). While such incidents do raise the anxiety level, people’s assessments of the risks do not fluctuate wildly during highly emotional states. (Bouyer et al, 2001) The experience with Three Mile Island and the dread o f nuclear accidents point out the need to take action now before another terrorist attack, to put in place operational capabilities to respond during an attack, to inform people of what is happening and what they should do, and to establish a system to recover after an attack. In each o f these phases - before, during and after an attack - attention must be given to primary issues (pathogenic stressors), secondary issues (acute distress and dysfunctional patterns) and tertiary issues (mental health treatment and rehabilitation). (Everly, pp. 11-14) Recognizing the need to prepare not only for the acute attack, but also for the recovery or consequence management phase, we need to assist individuals to develop what Everly called “psychological body armor” before an attack. (Critical Incident Analysis Group, p. 79). 204 Technology and False Alarms Newly apprehended risks are likely to trigger alarms for problems that do not materialize. After anthrax had contaminated offices and Congressional offices in 2001 many businesses tested their mail rooms for anthrax spores. One large financial institution (a client of the author, so the name will remain confidential) decided to test for anthrax spores at major facilities on the East Coast. No one in the offices had reported symptoms of anthrax but the company was concerned because it had received mail from contaminated postal offices that handled mail during the anthrax attack. On a Friday afternoon in November we received word that one test was positive at an employees’ cafeteria in a building in the heart of Washington, D.C. There was instant concern among senior company executives. Immediate questions had to be answered: • Should the building be evacuated? • Should employees be informed before they left for the weekend? • Should employees be informed over the weekend or on Monday morning? • If so, how should that be handled? • Should employees be advised to start taking antibiotics? • Should the company bring in medical professionals to treat employees? • Should local police be notified? • How about the FBI or CDC or local public health officials? 205 • What should be done about vendors, customers and tenants in the building? • Should the news media be informed? • If so, what should the company say publicly? • Sould the company wait until additional tests were conducted on the suspected substance found in the cafeteria? As it turned out, the company opted for the last choice and the results the next day showed that the initial, alarming finding was a false positive. While a false positive anthrax test may seem trivial, the whole episode produced tremendous angst during Friday’s deliberation. Imagine if it had caused the building to be de-contaminated or - worse yet - if people had become sickened. The best outcomes can inform our worst-case planning. The relief felt that autumn Saturday should not obscure the lesson from the near miss. The hurried debate over what to do on the previous evening showed the importance o f planning ahead. After the anthrax attacks, thousands of business had their facilities tested for anthrax contamination. In the year after the anthrax attacks there were about 17 thousand incidents that closed facilities for at least several hours (Benjamin et al., 2003). Potential worst-case scenarios and the options for dealing with them should be considered before an attack, when less adrenalin is flowing and when ethical and policy considerations can be carefully weighed in designing protocols for dealing with risky contingencies. The failure of that particular 206 financial institute to communicate its testing plan with employees could have caused panic if the erroneous positive findings had been talked up through the grapevine. Imagine if the news media had reported that anthrax was found in a major commercial building visited by hundreds of people every day. What if the facts were much worse and a contagious disease like smallpox were reported in a city like Washington? The federal government has aimed its resources at improving technology to protect the homeland rather than dealing with the human stress factors that could greatly compound problems during an attack. For instance, the government is investing in new detection technology without fully considering exactly how it would be explained to the public. In February the US Department of Health and Human Services and the Centers for Disease Control announced a federal initiative called “BioWatch” which was dubbed a ‘‘ nationwide program to sniff the air for dangerous pathogens.” The ultimate goal, according to the federal government, is to deploy monitoring devices in various cities so that 80% of the population will be covered. Test equipment is being installed in 20 cities. The federal government has earmarked $40 million for FY 2003. The system is based on using special paper filters on existing air-quality monitoring stations that are run by the US Environmental Protection Agency. Each day the filters would be removed and tested in a laboratory using a polymerase chain reaction 207 (PCR) analysis. It is designed to test for pathogens that terrorists are likely to use. HHS said that the program is beneficial because “early detection is the key to getting a jump on a biological incident.” (Center for Infectious Disease Research and Policy, 2003) BioWatch, like a much larger federal initiative, BioShield, is part o f the President’s National Strategy for Combating Terrorism. That strategy calls for “domain awareness,” or effective knowledge and early identification of threats, according to a white house news release. President Bush has called for “a national system of air sensors to detect biological attack,” and “sophisticated devices to confirm a case of anthrax infection almost instantly.” There is some evidence that real-time PCR is an effective tool for detecting anthrax spores in the air. (Makino and Cheun, 2003) A membrane strip-based biosensor has been developed that can identify as little as one viable B. anthracis spore. (Hartley and Baeumner, 2003) Other devices have been tested and found to not work properly, prompting calls for the government to regulate and validate biological detection gear. (Emanuel et al., 2003) Potential technical and organizational problems exist in relying on such sensor devices. Brad Smith and Calvin Chue of Johns Hopkins University advised against citizen use of such devices in late 2001 because “no test is perfect.” 208 E a,./ home-use versions were often inaccurate and citizens lacked training in their use. Even more sophisticated devices can fail to detect pathogens that are present (a so-called, false negative) or can measure a pathogen that really is not present (a false positive). “There are many variables that affect the accuracy o f a test’s outcome,” Smith and Chue state. Therefore, “it is always best to confirm the results of any test with another test that uses a different detection scheme.” False positives and negatives occur frequently with rapid field tests designed for military use, they state. “All results MUST be confirmed with other test methods.” (Smith and Chue, 2001) PCR may be a very rapid technique, but it requires very experienced personnel to utilize properly. Currently there are not many diagnostic laboratories with the trained staff needed to handle a wide-scale testing program. If a positive test result occurs from the PCR method, then Smith and Chue recommend that the “gold-standard” detection method, microbiological culture, be performed to confirm that it is a real finding and not a false positive. Microbiological cultures yield a sample that is applied to a nutrient rich jelly-like slab in a petri dish. Bacteria will grow, forming a visible colony that an experienced microbiologist can analyze to identify the specific species. This can take up to 24 hours before the results are known. This longer time frame is the main reason for trying to develop the rapid PCR sensor methodology, but the need to confirm the PCR 200 results with the microbiological culture method undermines the time saving feature. The benefit of rapid results is lost if the test has to be confirmed by the slower methodology. The PCR system may not be easily utilized for gathering samples for microbiological cultures. The air sampling units use high-speed airflow that could kill most organisms through such things as “shearing forces” and drying. Spore-forming organisms could survive, but other organisms would not, according to a public health laboratory director. (Center for Infectious Disease Research and Policy, 2003) It may be difficult to reliably test and weed out false positives. Another potential challenge for an air sensor system is that it is difficult to anticipate all the potential pathogens that a terrorist group might attempt to use. While some infectious diseases are well known, biotechnology makes it possible to create new genetic variations that would not be recognized by testing equipment. “The ability to introduce foreign genes into animal and plant DNA in a manner that permits the targeted organism to produce new proteins not previously encoded in its genetic material may have future applications for biological warfare,” according to a study by James B. Petro and colleagues (2003, p. 8). This could lead to such things as “transgenic insects,” bees, wasps 210 or mosquitoes. The authors recommend research into “next-generation systems for environmental detection.” Clearly, that generation has not arrived, or at least, the detection capability for genetically modified pathogens is not present. If we move quickly to develop an airborne monitoring system we could be building one that will not be able to identify a major bioengineered threat. Even efforts to detect the old-fashioned threat of anthrax have not persuaded experts that airborne detection is preferable to traditional medical surveillance. In a study o f the anthrax attack o f 2001 L.M. Wein and colleagues endorsed the need for aggressive medical surveillance and treatment with oral antibiotics of all asymptomatic persons potentially exposed to anthrax. But they concluded that “deployment of modestly rapid and sensitive biosensors, while helpful, produce only second-order improvements.” (Wein et al., 2003, p. 4351) One question is whether money ought to be poured into a new technology or used for more traditional medical surveillance programs. Medical surveillance clearly needs to be improved. Reporting of outbreaks is often delayed by clinicians. Ashford and colleagues (2003) studied outbreak investigations and concluded that “the most critical component for bioterrorism outbreak detection and reporting is the frontline healthcare profession and the local health departments.” Such evidence suggests that an investment in enhanced reporting 21 1 of medical cases would be superior to airborne sensors. There is much work to do in this field. A study of the new CDC guidelines for identifying anthrax cases retrospectively looked at the 2001 incidents and concluded that ten out of 11 anthrax patients would not have been identified under the guidelines. The authors of the study recommended revisions to the guidelines (which would have identified 8 of the 11 patients). (Mayer et al., 2003) There is a great need for training clinicians and establishing systems for rapid reporting of medical outbreaks of disease. With resource scarcity, we must ask where the investment should occur: with proven methodologies which identify an outbreak after it has started or with newer sensing devices which may not be as accurate as needed or which might miss potential bioengineered diseases. The evidence on the first actual use of such sensors is helpful in making this determination. PCR air sensors were deployed during the 2002 Winter Olympics in Salt Lake City. Some 15 to 20 monitoring stations were set up and the filters were removed and tested every 4 hours. If the test was positive, another single-strand test was conducted. A second positive result would prompt a confirmatory test to see if there were four different DNA strands. On Feb. 12 there was a positive reading on a single-strand test at an airport monitor. A second test on a single 212 strand was also positive. The airport authorities were alerted that the facility might have to be evacuated. The airport began preparations to evacuate and hazardous-materials teams were suiting up. The alarm was called off when the confirmatory test “showed that the microbe was a cross-reacting organism, a nonpathogenic one with a DNA strand that matched a strand in one of the pathogens being sought,” according to a Utah state official. Although the organism was never identified, the third test result halted the alert before the airport was shut down. Utah officials recommended that the PCR testing process be changed so that the four-strand confirmatory test would be run simultaneously with the second single-strand test. The lab director called the process, “very labor-intensive.” (Center for Infectious Disease Research and Policy, 2003) This raises the question of organizational resources needed to develop not only the test protocols but the emergency management procedures in the event a positive test is confirmed. There ought to be very specific protocols for making decisions on the basis of sensory findings, with detailed plans for communicating these results to the general public. Once news reports state that “anthrax has been detected,” or some other pathogen has been found in the environment, citizens will want to know precisely what they should do to protect themselves. Putting aside the possibility of false alarms which undermine public 213 trust, do we want to invest in a system that may alert people when there is no productive preventive action that they can be advised to take? These managerial, organizational and communication questions need to be addressed before we let an unproven technology be installed. Failure to do so may lead to situations like the one on May 20, 2001, when a false positive from a test in a mailroom at the World Bank in Washington, D.C. triggered the evaluation o f the building. Some 1,200 employees of the World Bank and the International Monetary Fund had to work at home for four days and antibiotics were given to 100 employees before follow up tests showed that the mailroom had not been contaminated after all. (Emanuel et al., 2003) Learning from Disasters and Near Misses “Disaster has been a great teacher, and we can leam many o f its lessons,” Saathoff states. (2002). “Some circumstances decrease anxiety, allowing us to make more rational decisions in crisis. Other settings provoke anxiety, impairing our ability to act rationally.” It is easier to cope with a crisis if one is in a stable rather than an unfamiliar environment. Unfamiliar circumstances, bizarre risks, frightening alarms, government dictates and temporary accommodations can cause people to feel they lack control over basic decisions about hygiene, childcare, and diet. This can increase anxiety and the ability to 214 act rationally can be impaired. Furthermore, emotional recovery from a crisis can also be slowed in an unstable environment. (Abenhaim et al, 1992) If people are unprepared in unfamiliar, unstable circumstances without access to infonnation, anxiety could interfere with the ability to make rational decisions. Forced quarantine and mandatory vaccination plans in such settings can increase stress and provoke unrest. A destabilized environment is a breeding ground for disease and psychological problems. In such circumstances law enforcement officers might be perceived as aggressors. (Annas, 2002) In such fragile settings efforts to inform can instead inflame. Without credible information, rumor can predominate. Such problems can create civil disobedience, economic hardship and neurosis on a large scale. These problems are exacerbated by shock and surprise. Preparation can reduce anxiety by helping individuals mentally rehearse before an attack and to face a crisis with sound information in familiar, stable environments with some continuation of normal routines to assist in the interim. A recent example of the failure of federal authorities in risk communication matters involves the decision by the Bush Administration in December 2002 that smallpox vaccine should be made available to high risk groups such as medical workers. A veteran consultant on risk communication for the Centers for 215 Disease Control and other agencies, Peter Sandman, has noted (2003) that “most public health people are viscerally opposed to the smallpox vaccination program,” and would have preferred the much smaller program recommended by the government’s Advisory Committee on Immunization Practices “or none at all.” Certainly there are great risks in taking the smallpox vaccine and those risks have to be balanced against the risk to society that smallpox could be used as a bioweapon against a non-immunized populace. If most health care workers are made immune to the disease, the Bush Administration believes, an outbreak could be more easily stopped with “ring vaccination” of those others in a hot zone once it became clear the disease had resurfaced. The problem, as Sandman notes, is that it is not hard to assess the risk of vaccination, but it is hard to assess the risk o f smallpox attack, since it has not happened since the disease’s eradication. So the balancing test is between a known risk (vaccination) versus an unknown probability of biowarfare with smallpox. Sandman says healthcare workers are “outraged” about “the bitter enough pill” and having to publicly support the vaccination plan despite the uncertainty and unlikelihood of such an attack. Whether he has assessed the level of emotion precisely or not, the comments of a consultant to the CDC merit attention. His conclusion is that health care workers are not upset because of the intellectual argument over the risks, but are “finding it hard to think objectively about the merits of the case.” We are talking about well educated health professionals here, not couch potatoes 216 who have never thought about smallpox before. The federal government had estimated that thousands of health care professionals and first responders would be vaccinated, but as of August 2003 only a small percentage had been vaccinated. The Boston Globe reported on August 23, 2003, that 60 thousand doses of the expired vaccine had to be destroyed because health care workers refused to be vaccinated. What seems to be happening is that government credibility was low and many felt their autonomy was threatened by a federal edict that they had no role in crafting. The alternative was to decline vaccination. The principle o f autonomy is one o f the most important in bioethics. Provision of medical care focuses on the needs - and decisions - of individual patients. But society encroaches on personal autonomy when it restricts the freedom of those who create a risk to the community. (Beauchamp, 15, 28-36) Debate on where to draw the line between personal autonomy in medical cases and protecting the community from risk can raise legitimate differences o f opinion. (Leviton, p. 119) Public health experts may be uncomfortable with the implications of the idea that governm ent should override individual health choices when such decisions could have an impact on society. The debate until now has been on issues such as the spread of AIDS. It will intensify if 217 mandatory quarantine and/or vaccination are imposed. Advocates o f public health would be “surprised and offended to be called ‘health fascists,’ when their goal is to extend and improve people’s lives,” J. Sullum writes. “But some defenders of the public health movement recognize that its aims are fundamentally collectivist and cannot be reconciled with the American tradition of limited government,” Sullum states (p. 16). The balancing of the ethical positions of increasing good (beneficence), protecting individual rights (autonomy), enhancing equity (justice) and delivering care (efficiency) is no easy matter. These difficult questions must be considered now, when no emergency looms, rather than in the heat of a crisis. The consideration should be a broad one, with participation invited from a wide segment o f society. Such dialogue could strengthen public health and public trust and is consistent with emerging ethical principles of 21st century health care and bioethics. (Childress et al., 2002; Moreno, 2003) It should be recognized that some segments o f the public are suspicious of public health because the profession does not espouse autonomy as loudly as the medical community. This is due to public health’s focus on populations rather than individuals. There are some Americans who think of public health campaigns as patronizing, scolding or playing upon fear. Anti-smoking 218 campaigns in particular have affected the one-fifth of Americans who smoke. When they think of public health, they may be reminded that they can no longer smoke in their offices or in public places - a remarkable change in society that has improved public health but may have potentially alienated a lot of persons who now get to huddle outside buildings in foul weather to get a nicotine fix. They may be forgiven if they aren’t fans of public health campaigns. That may make it harder to appeal to them to respond wisely in a bioterror attack. In sum, American citizens will best defend against a contagious bioterror attack if government acts credibly and encourages citizens to voluntarily participate in protective action in their communities. Citizens should be advised on how to best help their families and neighbors. Those who wish to volunteer to help their neighbors should be advised on productive ways to assist. By discussing difficult ethical choices before being forced to make tough decisions, citizen support can be increased for controversial options and leaders at all levels can maintain the public trust. 219 Chapter 8: Improving Communication Mass media reports instantly involved millions of Americans in the attacks of 9/11 and in the anthrax attacks o f the following months. In the media age, as one observer has noted, “we don’t experience just the calamities in our own lives - we experience the calamities in everyone’s life.” (de Becker, p. 48) Watching the events o f late 2001 was not a spectator sport: people became actively involved in worrying about the new threats to society. As described in chapter three, people were demanding answers about what they should do to minimize the risk of become ill with anthrax. Glued to media reports o f death, destruction and disease, people thought: what should we do? Less than two years later the government had an answer: duct tape. The furor over the government’s advice in 2003 about stocking duct tape and plastic shows how simplistic advice will be viewed as woefully inadequate. Television comedians lampooned the idea. One email circulating on the internet in March 2003 asked “I am writing to (the Department of Homeland Security) for further instructions for protecting my family from possible attack by terrorists. I have my duck taped; now what?” Whatever the merits of using duct tape in a terrorist attack (how much warning would one have to tape up doors 220 and windows?) the advice seemed trivial in the face of the enormous risks that have been portrayed on television and the newspapers. Some of the criticism of the new Department of Homeland Security is off the mark. It does make sense to have tape and plastic sheeting if there is adequate warning of a chemical, radiological or biological attack and one is attempting to shelter in place. There are very good lists of supplies that one should stockpile to be ready for such an emergency. The program is that emphasis on the grocery store list omits attention to the larger, more pressing community needs. A duct tape defense focuses on the tactical, while what is needed is a strategic approach that puts tactical actions in context. What is required is a comprehensive and participatory approach to informing and engaging the public in how they can best act to help themselves before, during and after an attack. This can mitigate fear, panic and mistrust in the event of an attack. This would require a program of preemptive education on the various options, their pros and cons, and how citizens can take steps to prepare. Moreover, the federal government’s advice seems to take for granted that it would tell people what to do, rather than share power in developing plans for coping with unexpected emergencies. It is a myth to assume that people will automatically follow the advice o f their leaders in a crisis. (Clarke, 2003) 221 Moreover, once people make inferences about a risk and develop expectations (mental models) about what caused something (and what to do about it) they are unwilling to change their beliefs even in the face of contradictory evidence. (Cvetkovich et al, 2002) This underlines the importance of framing the issue correctly before an emergency tests public acceptance of a plan and involving citizens to ensure widespread endorsement, vocal support and reinforcement of the consensus advice for coping with the crisis. Without general agreement before and validation in time o f stress, leaders may find that the public is not following. Now, before another terrorist attack, is the best time to think about actions that can build consensus around a defensive program that involves the public in a constructive way. Waiting to unveil a response plan amid another attack and the attendant media frenzy is a recipe for confusion, fear and compounded disaster. Stocking some items may make sense (yes, even duct tape) but before another attack we need to debate, decide, design and describe clearly what citizens ought to do if attacked by terrorists who spread contagious disease. For example, if enemies are able to use smallpox as a weapon our health system will be extraordinarily taxed. Triage may be necessary at hospitals. There will be a great demand for vaccinations. Public health and law enforcement may have to impose restrictions, including quarantine. Health care personnel would be overwhelmed. People will be urged to stay home or quartered in institutions that are not designed for health care. Left to react instinctively, many people would flee urban areas - including areas not infected - to escape from other people and potential infection. Every stranger may look like a disease carrier. As large numbers of city dwellers became refugees there would be few places - and fewer safe places - to house them. One does not have to spin a detailed scenario to see how frightening a mass exodus could become. Even if not one of the fleeing persons were an infectious carrier o f the disease, the melee would present great risks to public health and safety. There is no reason to be resigned to panic if another bioterror attack occurs. As mentioned above, experience with natural disasters, technological crises and disease outbreaks indicate that people can act constructively and collectively in such situations.(Glass and Schoch-Spana, 2002) On 9/11 people responded with courage, compassion and innovative care. There is no reason to assume that mass panic, civil disobedience and social disorder will result in a future large- scale attack. But steps must be taken before such a contingency occurs. The dreadful events of autumn 2001 have spumed new defensive programs. Two aspects need to be incorporated in such planning: (1) how to involve the general public - particularly civic, religious, business and labor leaders - in planning for worst-case scenarios and (2) how to involve journalists who would report on 223 such events. Among the top priorities should be an examination o f the options for public response to an emergency, including evacuation, vaccination, quarantine, isolation and sheltering-in-place and to inform the news media of such options and proposed actions. This is a far more serious approach than the search for sound bites on the evening news. Political leaders and media companies have sunk public discourse to the lowest common denominator, where duct tape is deemed more interesting than a substantive and strategic review of alternatives. The press highlights disagreement and debate. As more people get their news from broadcast outlets, superficial information proliferates. Impediments to solving problems include a growing knowledge gap between citizens and experts and “more important than the knowledge gap is the trust gap,” according to Shubik. (Pp. 8, 25) Some of the experts in risk communication, led by Baruch Fischhoff, maintain that it is important to provide people with accurate mental models (schemata) about risk. (Leviton, p. 54) These social scientists believe that “people process new information within the context of their existing beliefs. If they know nothing about a topic, then a new message will be incomprehensible. If they have erroneous beliefs, then they may misconstrue the message.” (Morgan et al., 1992, p. 2050) This argues for proactive communications to 224 educate citizens before a crisis. There are several specific reasons for communicating with the public: • Provide basic information so citizens can understand risks, • Reduce risks preferably by voluntary action but by government edict if necessary, • Allow citizens to participate in making decisions about responding to hazards, • Empower citizens to protect themselves. (Hadden, p. 17) To which might be added a fifth reason, to warn citizens not to engage in actions that might endanger themselves and others. Uncertainty contributes to the psychological problems and accurate information may be hard to come by during the first, acute stage of the disaster. Almost all commentators on crises say that accurate information must be provided during a crisis, but the facts may be elusive. One evaluation suggested that the initial “facts” in a crisis are mostly false. (Blythe, p. 12) Whether that is true or not, the real patterns can be hard to discern in the early moments of an emergency. We seem to lose control over events, over our own safety. This loss of autonomy, which is highly valued in our society, is very stressful. When we have some control over risks we feel differently than when we are at the mercy of risks we did not choose and do not control. This is especially the case when a risk is newly apprehended. 2 2 5 Failed communication can cause conflict and controversy. Some critics have maintained that risk communication is typically manipulative, which Granger Morgan and his colleagues warn against. They advocate that risk communication should provide accurate technical information, to help people make decisions for themselves, to help people recognize how a risk can be controlled and to create the mental models that are adequate for people to understand the process. (Morgan et al„ 2002, pp. 4-8) There’s growing recognition that good risk communication requires two-way communication. Thomas Burke at the Johns Hopkins School of Hygiene and Public Health has made a number of recommendations about involving the public in environmental issues, of which the following have relevance to the new threat of bioterrorism: (Burke, 89) • Allocate resources to major public health issues, • Expand comparative risk approach to priority setting, • Strengthen the public health basis for decisions, • Emphasize primary prevention, • Recognize and respond to public outrage, • Involve the public throughout the process, • Develop public trust in risk management, 226 • Develop more effective approaches to risk communication, • Develop more consistent approaches to risk assessment, • Coordinate agency risk policies. Because risk management is highly politicized and involves multiple value questions, “negotiation (rather than mere expert decision making) becomes a virtual necessity for ensuring free, informed consent in situations of controversial risk,” according to K.S. Shrader-Frechette (p. 206). Steps to facilitate negotiations include (1) informal meetings before public meetings, (2) a program of public education and (3) creating ways for citizens to be actively involved in the process. (Richardson, p. 140) To scope the problem, it is essential to recognize all the aspects citizens are concerned about, encourage an inclusive program, and create ongoing ways for public participation as a continuing process. These aspects o f providing information, sharing power and participatory monitoring o f activities can build social trust in the process (Richardson p. 145). C onsensus is not alw ays achieved, but “ constructive co n fro n tatio n ” can help overcome confusion, technical disagreement and other misunderstandings. This can limit the distracting effects of complex challenges, reduce the 227 destructiveness o f power contests, and avoid “analysis paralysis.” (Burgess and Burgess, pp 101-109) Of course, this is no cakewalk. Some have pointed to political apathy as hindering citizen involvement in protecting against bioterrorism, but many political theorists, including Rousseau and Mill have argued that we leam to participate by participating. (Pateman, p. 105) There’s also the problem of manufactured consent. Participation has been criticized when it is perceived as ritualistic, manipulative, harmful to those who are supposed to be empowered, and reinforcing the position of the powerful. (Cooke and Kothari, pp. 1-8) Then there’s the problem of subgroups that can’t understand each other. Part of the challenge is to bridge the competing language of management, politics and community activism. Williams and Matheny suggest that an ongoing dialogue is needed to overcome different vocabularies used by those who focus on the managerial, pluralist, or communitarian approaches respectively. The engagement of all these different ways of addressing problems is necessary to negotiate through the disputes that can intensify when antagonists fail to find a common language for understanding controversial choices. (Williams and Matheny, p. 7). What seems crucial is to bring all major groups and interests to the table. 228 Collaboration is particularly important because while bioterrorism may confront the whole nation, it will affect different people quite differently. In short, the risk will not be spread fairly across the land, at least not in specific instances. In the release of a contagious biological weapon, the initial impact will be on a specific area or region. This can lead to inequitable distribution of risk, particularly if the release comes in an urban area and containment is advised. In such a situation there will be predictable concerns about the injustice of advising (or requiring) citizens to remain in infected areas to avoid the spread of disease. Here again, lessons from environmental battles can inform planning for bioterror attacks. The controversy over “environmental justice” has applicability for planning responses to terror episodes. These controversies arose at the grassroots and were fueled by protests from those who lived near petrochemical plants or hazardous waste sites. Because the hazards affect different subgroups in the population, the disputes revolved around values o f fairness, equity, justice and racism. The discussions acknowledged the “underlying subjectiveness” in what constitutes a disparity. (Zimmerman, p. 289) The issue of environmental justice highlights the value-laden nature of discussions about risk. There are a number of theories about what underlies these risk conflicts. First, they may reflect deeper disagreements about ideology and power. Second, they may involve loss of trust by the public in government. 229 Third, they may involve different perceptions and definitions o f what is really at risk. Fourth, they may involve differing intuitions, or unconscious habits of mind. (Margolis, pp. 20-47) While the theoretical puzzle cannot be solved in this thesis, the dueling explanations each have a similar effect: they suggest that technological considerations play a secondary role to how people believe, feel, trust and perceive about the dangers that confront them. Moreover, whichever of the explanations one favors, the practical imperative is clear: risk communication must address these non-technical concerns. The only way to do that is to involve those at risk in a dialogue about the risk. The only practical way to accomplish that is to do it before an attack. Initiating such a dialogue in the middle o f a crisis is too late for it to have much impact. This is particularly true if Howard Margolis is correct that the fourth theory listed above, intuition, is the best explanation of lay perceptions of risk. If that is the case, then it is difficult to overcome a strong intuition by logical argument. Additionally, because intuitive models are largely propelled by unconscious factors, we don’t recognize all our habits that are unreasonable. Habits of thought that can work quite well in normal times can yield blunders in turbulent times. (Margolis, pp. 50-54). We are susceptible to social contagion; when some people are vocal and worried about a high profile risk, it is likely that others will become agitated as well. (Margolis, p. 90). 230 The only way to address these challenges is to move beyond the crude forms of public relations that once characterized risk communication. Society’s efforts to assess, communicate and make decisions about the risks o f bioterrorism depend on seeing the complexity o f these issues and putting them in historical context. (Kirby, 293-294) Granger Morgan and his colleagues say that the first step in communicating about risk is to set priorities. “Communications should focus on the facts that will have the greatest impact on the greatest portion of the audience.” (Morgan et al., 2002, p. 97). Before any communications campaign is launched on the public, an effort is made to fully understand the mental model the public already holds about the risk. The mental model Morgan’s group is seeking to understand and modify is not a formal model but one that includes emotional and non-rational content. They outline the following steps (p. 20): 1. Create an expert model o f the risk and ensure that it is technically accurate. 2. Conduct open-ended interviews eliciting people’s beliefs about the hazard to compare the public mental model with the expert model, 3. Conduct structured interviews to confirm the prevalence of beliefs expressed in step 2, 4. Draft risk communication messages based on a determination of which incorrect beliefs most need addressing and which knowledge gaps require information, 231 5. Evaluate the draft messages with interviews, focus groups and questionnaires to refine messages. One of the crucial questions in dealing with bioterrorism is whether to use fear as a motivator. While bioterror is truly fearsome, as memories of the anthrax attacks fade there may be lessened interest in developing plans for coping with low probability, high consequence risks. Fear has shown to be an effective way to enhance perceived risk and motivate adaptive behavior in many health issues (Stephenson and Witte, p. 88). But using fear to modify behavior has not been endorsed by many practitioners (Covello et al, 1986). Fear appeals are aimed at the dark emotions. They can backfire without a compelling message about effective ways to avoid harm. Stephenson and Witte concede (p. 98) that fear messages such as the American Cancer Society’s warning on skin cancer (“fry now, pay later”) may do more harm than good. Imagine a campaign that warned, “buy duct tape or else.” It might seem irrelevant or overblown. Because of the possibility that people would be turned off by blatant (or off target) appeals to fear and because of the truly fearful nature of bioterrorism, messages that play on people’s fears ought to be avoided. Such appeals are often manipulative and, in some cases, accompany coercive action (as in anti smoking programs) that turn off many people. 232 Fear appeals have been attempted on health subjects because o f the acknowledged difficulty of motivating people to change harmful behaviors. It is likely that the public is generally open to taking preventive, mitigating and rapid response actions in the bioterrorism context. Few bad habits have already been evidenced because this is a newly apprehended risk. So the challenge will be to reinforce an individual’s willingness to take steps to protect him or herself and family members both before and during any attack. The process of strengthening existing attitudes and making them less susceptible to change is called “inoculation.” Communications inoculation is used to encourage young children to avoid smoking and other risky behaviors. (Pfau, p. 100) When inoculation includes a threat component, it involves forewarning against an impending challenge to existing attitudes. The inoculation process involves posing a threat and then adding a refutational presumption. “It should not be confused with the concept o f a threatening message,” Michael Pfau states, “which is characteristic of fear appeals.” (P. 101) It is designed to bolster correct attitudes. The only way to assess the effectiveness of such an approach is to test it in focus groups, one-on-one interviews and in surveys. The stress on testing message by social scientists like Morgan and his colleagues requires a standard by which to measure the effectiveness of the information 233 communicated. William McGuire has suggested the following “output persuasion steps,” (p. 32): • “Tuning in... • Attending to the communication... • Maintaining an interest in it, • Comprehending its contents... • Generating related cognitions, • Acquiring relevant skills... • Agreeing with the communication’s position (attitude change), • Storing this position in memory, • Retrieval of the new position from memory when relevant, • Decision to act on the basis of the retrieved position, • Acting on it, • Post-action cognitive integration of this behavior, • Proselytizing others to behave likewise.” One approach to judge success is to ascertain if “social inoculation” is occurring. Put another way, are the messages being conveyed and the participatory functions being carried out having an impact on preparedness? Do 234 the activities and messages spur productive activities and lay the foundation for appropriate responses in the event o f a crisis? A key audience for such efforts would be the news media. As the main conduit of information to the general public during a crisis, journalists have a special role. Their performance does not always get rave reviews. They are accused of excessive attention to the problem, of fulfilling terrorist hopes for extended coverage o f their point of view, of highlighting conflict among authorities trying to cope with the problem, and o f making the situation seem hopeless. For instance, in hostage situations, the news media repeat the same mistakes in incident after incident, according to Joseph Scanlon, (p. 118-119) Terrorists who want attention can get it on television. Scanlon quotes one hijacker as saying, “television is a whore.” He says the media do the following: • they almost always learn o f the episode, • they not only report it; they devote many hours to coverage, • they focus on the demands and deadlines of the perpetrators, • they call the hostage takers and keep calling as long as calls can get through, • they flock to such events in large numbers, • they report police responses live on the air, • they ask a lot of questions. 235 The press focuses on conflict, which is interesting and newsworthy. This hampers the efforts of those who facilitate consensus building efforts and seek to resolve conflict. The dichotomy between highlighting conflict in the news and resolving conflict in a community leads to tensions. These can be managed if those seeking agreement invite the press to cover their activities, recommend ground rules for participants and reporters, meet with media leaders, understand the news gathering process and conduct briefings on the process. (Kunde, p. 435, 460) People who watch television often feel helpless, a situation that Michael Robinson has called “videomalaise.” He found that people who watched television documentaries were more willing to doubt their own ability to comprehend the issue that was aired; “it appears as if they were actually more likely to depreciate themselves” if they watched TV coverage. (Robinson, p 413) The media often play the common theme of human helplessness in the face of disaster, but people can act if they :no v what to do. As Wilkins has noted, “What is needed is a mediated reality that has as its fundamental goal the building of community, in addition to mere environmental surveillance.” (Wilkins, p. 33) Some of this is to enhance the odds of survival. Basic requirements at the family level include supplies of food, water, communications, transportation, medication, first aid, tools, sanitation materials, 236 cash, and a safe room in the home. (Weintraub, pp. 157-163) Such unglamorous actions are unlikely to command much media attention, but they could offset the numbness and despair that people can feel in the face of tragedy. A real challenge is dealing with skepticism about official announcements. News reporters are skeptical about motives. At Three Mile Island reporters would not accept that inconsistent statements by experts stemmed from confusion rather than some diabolical motive, so journalists searched for a cover-up. (Friedman, P- 67) Risk is amplified when official sources of information are slow, contradictory or appear to be hiding bad news; speculation and rumors fill into the vacuum, (Powell and Leiss, 1997) Communicating about risk is difficult even in non emergencies. Scientists and policy-makers rarely are in agreement on how to characterize risk, compare risks, rank risks and prioritize governmental actions.(National Research Council, 1994) For most people, medical information is so complex it is hard to comprehend in a time of stress. For those officials concerned about security - national, local or corporate - secrecy is usually the default mode. In emergencies law enforcement personnel are used to ordering — not explaining. So the biggest challenge is to explain what is happening to a skeptical press corps and involve the general public as 237 participants in a problem-solving effort. This will require specialists unlearning familiar behaviors that thwart communication. The threshold requirement is for clear, understandable and candid discussion of the risks, the objectives, the problems, the options and the underlying values at stake. Good communication would make it easier to motivate people to make better decisions in time of crisis. People tend to view risks in the context of their ability to control them. Voluntary risks are perceived as less risky than involuntary ones. Risks that an individual has direct control over are deemed less risky than uncontrolled ones. Risks that are familiar seem less risky than unfamiliar perils. Risks that are judged to be “fair” are perceived as less risky than unfair ones and provoke less outrage. (Sandman, 1993) These factors - voluntariness, controllability, familiarity, and fairness -- are about perceptions of power. Put more personally, things seem very risky if I feel that I am powerless. One of the keys to risk communication is to empower people to choose the best alternative to reduce the risk to themselves and their families. Journalists can facilitate that process or they sabotage it with skeptical commentary. Authorities should resist the temptation to try censorship. As Yonah Alexander and Richard Latter have stated (1990) those who have to deal with terrorism 238 usually favor regulating media involvement while the media favor self regulation. Censorship won’t work because it would undercut public trust and increase media skepticism. Any advantage from government control o f the media in the immediate crisis would be forfeit in the aftermath, as suspicions grow about what was being withheld. A better approach would be to create a clear framework for cooperation between authorities and the news media and to encourage self-restraint on the part of the press. The goal is to develop voluntary guidelines to avoid panic and cooperate on ways to provide information in a timely fashion. The second approach is to forget about “spin.” Many public relations tactics - so beloved by politicians - undennine trust. A crisis involving a newly apprehended risk demands that government, health professionals and emergency management personnel deal forthrightly with an anxious public. The conduit - the news media - are an essential part of the process and should be involved before an episode. During an incident, straight talk is essential. The press has always fixated on the unusual. Which means that bad news gets most of the attention. The coverage o f 9/11 demonstrated how focused the media can be on retelling - and showing - frightening and disturbing events. This can have profound consequences to public health and safety in a large-scale 239 attack using biological, chemical or radiological weapons. So it is important to address the four main shortcomings of the media. The first shortcoming is that much news coverage is superficial. That’s because most journalists are generalists. Few specialize and most know a little about a lot of things. Only a few know a lot about a few important things. O f course, these specialists stand out when their expertise is needed. There are two ways to improve knowledge and enhance news coverage: (1) the media should be encouraged to devote resources to covering the new forms of terrorism even when the clamor about 9/11, anthrax and Afghanistan have calmed and (2) professionals in government and related fields ought to undertake to inform reporters about the risks, options and plans. Both before and during an episode officials should tell w hat’s happening. Knowledge and facts are antidotes to superficiality. The second shortcoming is that much news coverage is sensationalistic. O f course, 9/11 was sensational. But the endless repetition of the pictures of the disaster was numbing. We can expect that another attack would ignite ; competitive urges and the attendant media overkill. Most reporters resist the temptation to exaggerate or hype stories, but the temptation is always present in a business that depends upon circulation and ratings for its revenue. Just as facts 240 are antidotes to superficiality, context can temper the urge to sensationalize. Here are two ways to discourage hype: (1) involve the media before any attack so that the newly apprehended risks can be understood in the correct context and (2) during an attack immediately provide qualified spokespersons to act as expert commentators - sources — for news organizations. Journalists are dependent upon sources. If experts endorse the consensus view of how to deal with an emergency it will reduce the amount of airtime given to uninformed, inflammatory punditry. The third shortcoming is that much news reporting suffers from subjectivity. Bias is a nasty word in journalism but every person is a subjective creature. We are all captives of our ovm mind set, the values imparted by parents, taught by schools, learned with peers, conditioned on the job, watched on TV and the like. Some journalists claim to be objective, but this claim makes it harder to rise above the assumptions and viewpoints that predominate in American journalism. The bias is best understood not in the familiar liberal versus conservative terms but as an overarching skepticism, a negative attitude about large institutions, leaders and public officials. At times it lapses into cynicism. Reporters can be forgiven for skepticism. They grew up nurtured in the Muckraking tradition and experiencing the controversy over Vietnam, 241 Watergate, Iran-Contra, Whitewater, Enron, etc. The distrust some reporters feel for the government can have profound consequences in time of emergency. Trust must be earned, of course, and so the recommendation is that government officials invite reporters to participate in planning sessions, drills and exercises before an emergency occurs. They can be involved as both participants and observers who can report on what they have seen. One antidote to distrust is to be forthcoming, open and accessible. The fourth shortcoming with the press concerns standards, or more precisely, the lack of clear standards. Very few professions have such ill-defined ethical guidelines with so few enforcement mechanisms. Most reporters want to do a good honest job and fairly report what they leam; at least that’s my experience as a reporter for 18 years, including at NBC and PBS, plus 13 years teaching part time at Northwestern University’s Medill School of Journalism. Officials need to encourage high standards in journalists by keeping to the very highest standards of honesty themselves in all dealings with reporters. In summary, the ways to cope with the shortcomings of superficiality, sensationalism, subjectivity and standards include educating reporters, informing them quickly, involving them fully, being forthright and honest. Unfortunately, this has not always been the nonn. We can leam much from three 242 decades of efforts to communicate about environmental health risks, particularly about the importance of involving the public and the press as partners in a dialogue. Failure to involve the public in the planning and response could hamper management of an epidemic and increase the risk of social disruption.(Glass and Schoch-Spana, 2002) Failure to deal forthrightly with the news media carries enormous risk in a crisis. Here are some of the recommendations from Peter Sandman, who has consulted for the CDC. He offers this advice for communicators on his website: http: //www .ps andman. com/co 1 . • Do not over-reassure, • Put ‘good news’ in subordinate clauses, • Acknowledge uncertainty, • Share dilemmas with the public, • Give anticipatory guidance, • Acknowledge the sins of the past, • Be contrite or at least regretful, not defensive, • Acknowledge and legitimate people’s fears, • Be gentle about that awful future of bioterrorism, • Surface and legitimate the misery. • Express wishes, 243 • Stop trying to ally panic, • Protect your credibility - and reduce the chances of panic - with candor, • Err on the alarming side, • Give people things to do. • Give people a choice of actions to match their level of concern, • Never use the word “safe” without qualifying it, • Find a non-zero standard for anthrax. Sandman goes further than most communications consultants in urging officials to open up with their wishes, fears and “sins of the past.” The National Public Health Information Coalition (funded by CDC) has more conventional advice. Here are some o f the recommended “Dos and Don’ts” in what is called a “basic survival guide:” • You should never go jnto an interview just to answer a reporter’s questions, • Have your own agenda, • If you cannot answer, you must explain why, • Take the initiative. Make your points in every answer, • Keep answers short and simple, 244 • Use colorful words, analogies, absolutes and cliches to simply and make your points stand out, • Talk in sound bites, • Do say “I don’t know” when you don’t, • Be positive in making your points, • Do remember that compassion and safety are always your first concerns, • Do remain cool no matter how antagonistic the questions, • Don’t speculate, guess or conjecture, • Don’t ever lie to a reporter. If you’ve made a mistake, admit it and shift the focus to what you’re doing to correct the problem or assure that it never happens again. (Hartman, 2001) Here’s the voice o f experience: Former Surgeon General C. Everett Koop told a Congressional Hearing on November 29, 2001 that he would not give the government “high marks” for its handling o f the anthrax situation. He said his rules for communicating threats to the public included the following: • Don’t make statements, especially predictions, that are not based on facts, • Deliver warnings with enough information to prepare and protect without causing panic. • Choose words understandable to a tenth to twelfth grader, 24 5 • Go over the draft again and again so there is no ambiguity. • Make certain that the public understands the difference between an immediate threat versus a long-term outcome and between a fatal and a non-fatal threat. • Inform the public frequently and in increasing depth. • Squelch rumors that are untrue. • Translate science for the non-scientific public. • Never speculate or indulge in opinions. • Keep the press on your side through honesty and forthrightness. Good communication requires more than good technique, of course. It requires clear advice bolstered by cogent reasons. For a future bioterror attack communicators will have to do more than just tell people whether to evacuate or stay in their homes during an emergency. Officials are challenged to address the public perceptions that can interfere with clear judgment in a time of crisis. In addition to safety, people are concerned about fairness, equity and jus fee as well as feelings of helplessness, fear and anger. No communication program will work without addressing these values and emotions. Efforts to promote health require active community involvement and collaboration in the design and implementation o f local health campaigns. (Bracht, p. 323) A key ingredient is collaboration with stakeholders (and everyone has a stake in the outcome of a 246 bioterrorism episode). (Leviton, p. 213) This has been recognized for some time. Covello, von Winterfeldt and Slovic stated in 1986 that communication efforts should include the following: • Involve the public early in decision-making - that is, before assumptions have been made, alternatives narrowed, and key decisions made, and before decision makers have become committed to a particular course of action. • Understand and respect individual interest, jmotions, values, priorities, preferences, and concerns. • Establish elaborate procedural safeguards to ensure that all voice with an interest or stake in the decision can be heard. • Carefully analyze the nature of conflicts and distinguish factual disagreements from deeply rooted ideological conflicts. In the months since the anthrax attack, the CDC has moved to upgrade its communications capability. Its website now includes information on what it would do if a smallpox outbreak were to occur. It has a number of communications programs that are listed. Its communications plan includes detailed advice on how to deal with the media. It includes a “lifecyle” which provides an overview of the communications process. 247 CRISIS COMMUNICATION LIFECYCLE PRECRISIS: Prepare, foster alliances, develop consensus recommendations, test message, evaluate plans INITIAL: Express empathy, provide simple risk explanations, establish credibility, recommend actions, commit to stakeholders MAINTENANCE: Further explain risk by population groups, provide more background, gain support for response, empower risk/benefit decisionmaking, capture feedback for analysis RESOLUTION: Educate a primed public for future crises, examine problems, gain support for policy and resources, promote your organization’s role EVALUATION: Capture lessons learned, develop an event SWOT, improve plan, return to precisis planning Source: www.orau.aov/cdcynerRv/erc (accessed 30 October 2003) Figure 9. 248 CDC has obviously learned from the problems it had when communicating about anthrax in 2001. But more interaction with local groups - not just state and local governments - is necessary. There is a wealth of talent in the private sector and in non-profit groups. Experience dealing with other health issues can inform community planning for homeland defense on the local level. Such an approach incorporates the following key tasks: • Analyze the community’s assets and prior experience with health problems, • Collaborate with community leaders to design a campaign, • Implement the public health campaign with the assistance of community members, • Maintain high levels of volunteer effort during program maintenance, • Communicate accomplishments and continuing needs for campaign durability. (Bracht pp. 323-338) The news media can become an ally for planning activities. In the past the news media have been excluded from most drills involving hypothetical weapons of mass destruction. “Rather than recognizing that the media will play a central role in assisting local, state and federal government in getting information about terrorism to the public, we fear that the media will act irresponsibly and cause 249 mass panic,” according to security expert Jerome Hauer. But “the media are first responders,” according to Pamela Berkowsky, a former assistant to the Secretary o f Defense for civil support, (both quoted in Ethiel, 2002) They should be involved in exercises and training. The media “may be the weakest link” in the infrastructure, but they “sometimes get to the scene first ... are the only ones focused on and able to describe the level of risk to the public,” according to Randy Atkins of the National Academy of Engineering. “’’ They can save lives through the efficient delivery of good information.” (quoted in the Washington Post, January 26, 2003). In a worst case scenario, the media will be called upon to act as filters for information. Dependent upon sources, reporters will turn to government officials for explanation. This would require that officials demonstrate that they care about people, that they are committed to protecting public health and that they have a thoughtful plan for action steps in the event o f an emergency. Good communication is not simply the ability to transmit accurate information about good decisions. It is helpful to connect the dots between messages, sources, channels and receivers of information. The best advice on how to do this comes from Aristotle in his work, On Rhetoric. He said the provider of information, the speaker, had to focus on three things: • Pathos: The audience’s mindset, values and feelings. 2 5 0 • Ethos: The speaker’s character, reputation and espoused values. • Logos: The specific messages to be delivered to the audience. The value orientation of Aristotle’s model (Nehamas, 1992) is clear. Speakers need to connect with their audience by building on those values that they have in common. For example, safety is a core value that most espouse. If a spokesperson shows that he or she cares about safety (connecting with the audience’s pathos) and is committed to enhancing safety (ethos) and has an action plan for improving safety (logos) the connection can be accomplished. This is not a pat formula for persuading people; it is the first step for involving them in decision-making and empowering them to take actions tnat can protect themselves and society. Those who would lead in times of stress should align their messages so they demonstrate their commitment and address the concerns of the public. The alignment o f logos, ethos and pathos is no small challenge in a society with diverse values; it can only be grounded on sharing power with the public, to achieve a common goal, articulated by democratic, participatory consensus-building actions. It is possible to develop robust contingency plans around viable options to protect people. It is not just a job for the exnerts and authorities. To be successful it will require good communication, open dialogue, full participation 251 and honest efforts to find agreement on value-laden issues. But the task will not be simple, as political and legal challenges figure large in any effort to confront the threat of terrorism. 252 Chapter 9. Involving the Public People need to know what to do to protect themselves if faced with the unfamiliar threat of bioterrorism. Most of the top-down government plans for terrorist contingencies have been based on the idea that federal authorities would take charge and issue orders and advisories as needed. This command and control model did not work well during the anthrax episode. An alternative approach would be based on individual and community action, facilitated by (rather than dictated by) federal and state authorities. This bottom-up approach would be based on citizen participation and community action, utilization of citizen groups, encouragement of volunteer efforts, and use of conflict resolution techniques when disagreements arise. And disputes would erupt, of course. Bioterrorism would pose value-laden challenges including dreadful risks, threats to personal autonomy, issues of civil liberties and restrictions on freedom to travel. We can leam how to cope with such future problems by looking at the dispute-riddled efforts to handle environmental challenges. Environmental disputes have led to the creation of new methods for conflict management. The evolution o f ways to deal with environmental conflict can inform decision making on terrorism at the community level. Initially environmental policy was mostly decided in an adversarial context with frequent 253 litigation about pollution issues. But in a “second epoch” as Mazmanian and Kraft have called it (p. 29) participants in these controversies sough a middle ground by developing new forms o f collaboration and participatory action. While suspicions and conflicts have not been eliminated, new forms of alternative dispute resolution have been attempted to move beyond gridlock politics and expensive litigation. In the “third epoch” collaboration is the preferred approach for setting environmental policies, according to Mazmanian and Kraft (p. 30). This parallels a shift away from a top-down, national approach to dealing with all pollution issues. The idea is growing that bottom- up initiatives based on partnership and collaboration fills the void created by failed federal efforts at command and control from Washington. (Rabe, p. 250). “The institutional locus of decision making has been moving toward the state and local level, with substantially greater local determination,” Mazmanian and Kraft conclude, along with the greater emphasis on collaboration and public discourse. (P. 305) This trend is fully in line with the observation of the National Research Council in 1989 that increased risk communication can increase citizen desire to participate in decisions about controlling risks and can lead to greater sharing of power. (National Research Council, 1989,, p. 111). This does not ensure that power struggles will be easier to resolve. On the contrary, the disputes are likely to be messy and protracted. 25 4 In a possible bioterrorist attack people would confront new challenges with no fixed repertoire of skills for perceiving and acting on information. Certainly it would be difficult to process data about compulsory quarantine, mandatory vaccination and other coercive measures. The most easily acceptable options involve the least restrictive means for coping with the emergency. In a health emergency we may not know initially if an infectious disease is naturally occurring or is a man-made problem. The onset may be characterized by ambiguity. It is possible that a bioterror incident will be definitely identifiable from the onset — if a terrorist is discovered just as the pathogens are rele , for instance, or if a group makes a claim of responsibility, or if the disease no longer occurs naturally (for example, smallpox). If none o f these conditions occur, however, the outbreak initially will be indistinguishable from that of a naturally occurring illness. It may only be gradually identified as bioterrorism if evidence is discovered or if the outbreak’s pattern provides circumstantial clues of terrorist origins. While this will not make much difference for medical treatment, it will make a tremendous difference to the victims and potential victims, who will react differently to a crime than to a natural disaster. As Michael Rarkun has stated (2002), earthquakes, hurricanes, and wildfires are no longer viewed as divine punishment for sins or considered caused in some way by their victims. 255 Manmade disasters on the other hand, especially those that are intentional rather than result from accident or negligence - challenge the popular conception of a morally ordered world. We wish to live as social psychologist Melvin Lemer stated (1980), in a “just world” characterized by getting what we deserve instead of random advantages and deprivations. After the first shock, we can expect an effort to extract meaning from the terrible event, so that suffering no longer seems to have been pointless and arbitrary. We saw this phenomenon after 9/11 as the need to psychologically adjust to the tragedy caused some people, particularly non-Americans, to suggest that the attackers had been spurred by American foreign policy, making the victims somehow responsible for their fate. (Barkun, 2002) The implausibility of this repugnant attitude did not reduce its attraction for some. In the United States, the problem of restoring ideas of moral order after 9/11 was addressed by war rhetoric, denunciations of the evil of the enemy, and commentary about the heroism of policemen, firemen, emergency responders and the passengers on flight 93 who aborted the hijackers’ plan to hit another building in Washington. The wall-to-wall media coverage of the 9/11 events also prompted a feeling of victimization throughout the nation, causing stress and prompting calls for revenge. The anthrax attacks, although the death toll was five, generated high levels of anxiety, particularly because it was not known when the problem was 2 5 6 “over.” We were told that the anthrax spores could sit for years undisturbed, like a time bomb, waiting to be inhaled at some distant date. People already upset by the attacks on the World Trade Center and the Pentagon were easily influenced by media reports about bioterror. Urban legends quickly spread, including rumors that no Jews went to work at the World Trade Center on the 9th, that terrorists had rented trucks to plant bombs at shopping centers, and that biological pathogens had been mailed by the “Klingerman Foundation.” (Barkun, 2002) These false stories were spread on the internet with a rapidity that was astounding. The experience of 2001 suggests that in a future attack the problem of rumor must be addressed. Even a government policy of openness and candor could falter if there is widespread belief in falsehoods. The problem o f urban legends is greatest in some subcultures, which are more skeptical about government. For example, African-Americans and Hispanics are much more likely than Caucasians to believe in conspiracy theories. (Goertzel, 1994) African- Americans are more prone to accept stories about government-funded research on germs for the purpose of eradicating non-whites. (Barkun, 2002) Tales linking CIA activities with AIDS are widespread in Black communities. (Turner, 1993) In other words, what some Americans view as valid medical or emergency advice could be rejected by skeptical persons. This argues for 2 5 7 informing leaders in those communities in advance of an emergency in order to hear their concerns and encourage their support in a time of crisis. Such independent validation would be essential to overcome some of the deeply held negative views of white authority. A related malady with a very different set of beliefs predominates among members of militias, racist organizations, tax resistance groups, and other militantly anti-government circles. They argue that the true function of the Federal Emergency Management Agency (now part of the Department of Homeland Security) is not disaster relief but is the implementation o f dictatorial rule. These conspiracy theories allege that FEMA is building concentration camps in remote areas to detain owners of guns and political dissenters upon the imposition o f martial law in the near future. The concentration camp myth, which has circulated for more than 20 years, is an article of faith on the extreme right.(Barkun, 1996) Such sentiments will certainly interfere with acceptance o f any counter-terrorism role assigned to FEMA, especially if it involves evacuation and relocation. The demonization of FEMA on the far right is probably here to stay, but this attitude ought to be considered in formulating bioterrorism contingency plans. (Barkun, 2002) Activities based on the idea that social control is the appropriate response to bioterrorism are likely to cause unintended resistance among some subcultures, and not just those on the right. 258 On the left there is plenty of suspicion of the government, although the demons are in different agencies. The use o f law enforcement and National Guard units to enforce compulsory actions - quarantine, vaccination, removal to relocation camps — would generate resistance and spur claims that civil liberties were being trampled. The militarization of public health could backfire. Disaster relief measures of the type used during floods, forest fires and storms that remove people from their homes would be more unsettling in a bioterror attack where the threat is invisible and the house itself is not at risk of destruction. Other nations have tried to fuse all crisis management functions — both social control and disaster relief - under a single administration to deal with everything from public health to industrial accidents. But this has worked in small nations, like Sweden, where a homogeneous culture lives in political stability (‘t Hart et al, 1998). In the United States, with its diverse culture and federal system, a centralized approach raises more problems than it solves. (Barkun, 2002). Centralization might also prove to be an inferior counter-terrorism policy. Society is better protected by redundancy than by centralization, since duplication allows some units to continue performing even if some others are destroyed. (Terwilliger et al, 2002) Redundancy would permit some semblance of normal life to continue even when communication has been disrupted and central organizations are not 259 functioning. Although states and localities have lost power to Washington in the past century, some services such as health care and law enforcement are still largely non-federal. If we can expect conflict and suspicion in a terrorism attack, the value of building consensus now - before an attack - would become obvious in the face of dread and fear. One example may help demonstrate why society urgently needs to develop a consensus around the best policies and ought to communicate with the public prior to another attack. When a sudden health threat looms healthy people seek advice, treatment and medication. There is a multiplier effect from news of a bioterror attack. For each person exposed to infection there would be many others who would fear they too could become ill and would seek medical care. Consider the anthrax attack of 2001: there were 23 confirmed exposures but over 35,000 persons were considered to be at high risk and received medical intervention. The multiplier effect was x 1500 (for every person actually infected an additional 1500 persons required medical management). Imagine the multiplier effect in a larger scale bioterror attack. Healthy people might demand immediate treatment. There probably would not be sufficient medical and hospital resources to meet the sudden demand. 2 6 0 Ethical Dilemmas The psychological stress of a terrorist crisis coupled with an overtaxed health care infrastructure will create ethical dilemmas of the sort not seen in normal times. Put bluntly, America’s health care system may not be able to help everyone who needs or wants health care, and some sort of triage could be required. (Kipnis, 2003). And in the alternative, to prevent the spread of disease, compulsory steps may be taken to prevent movement of people and vaccinate those who might have been exposed to a pathogen. In either case, the individual loses control over his or her own health and well being. By being denied care or by being forced to undergo some form o f protection (isolation, segregation or vaccination) an individual would be forced to give up some of the autonomy Americans have come to take for granted. Quarantine, for instance, would be a very unfamiliar measure. There has been no large scale quarantine in recent US history, in fact in the past eight decades. (Barbera et al, 2001) As we shall see, antiquated laws often make it difficult to know who has the legal authority to order quarantine. There have been hoaxes that resulted in the detention o f large numbers of people for hours while the alleged biological agent was analyzed. (Senate Government Affairs Permanent Subcommittee on Investigations, 1995; “B’nai B’rith package contained common bacteria,” (Washington Post, April 29, 1997) In some instances people 261 have been exposed longer to pathogens by being cooped up on vessels. (Barbera et al, 2001). There were judicial findings of racial discrimination in quarantine measures in San Francisco’s Chinatown in 1900. A federal court concluded that the quarantine was unconstitutional and that authorities had acted with an “evil eye and an unequal hand” in Jew Ho \ > . Williamson, 103 F 1024 (CCD Cal 1900). There have been violent protests against the imposition of such measures, for example in Muncie, Indiana in 1893. (Eidson, 1990) There were riots in Milwaukee when officials tried to quarantine victims of smallpox around the turn of the last century. Fast forward to today and imagine how citizens would react if a quarantine were imposed suddenly. And how would they take the news that an authoritative article in the Journal o f the American Medical Association in 2001 had advised against large-scale quarantine as a primary public health strategy? (Barbera et al, 2001) Since individual autonomy is an important value in American society, people believe that they are owed certain rights, including freedom. If we define our objectives in terms o f our personal desires we will try to maximize preference satisfaction. These goals of freedom and the pursuit of happiness are quite different than the values of those who emphasize communitarian ideals. If we see ourselves as fundamentally part of an interdependent community, we will seek to maintain and nurture relationships that sustain us and constitute our 2<S2 identity. The notions of rights and duties are not identical for those who emphasize community over individuality. (Sharp, p. 275) Terrorists seek to undermine America’s way of life. The attempt to undercut democracy by showing that the government is unable to protect citizens aims to provoke draconian measures that will compromise civil liberties and trigger unrest. A heavy-handed response that threatens fundamental rights could cause chaos. One of attributes of community participation in anti-terrorism planning is that it can build on democratic strengths. Our system of government is based on the assumption that informed citizens can make decisions about what is best for themselves, their families, their communities, and their country. We can leverage the strengths of a democracy by empowering citizens through education and community decision-making. If a contagious biological agent is loose in society, there is no course of action without risk. There are serious problems with each of the alternatives: • Evacuation can widen an epidemic. If the biological weapon is contagious, fleeing citizens can spread illness, as they become, in effect, individual bioweapons. Unwittingly, this could further the terrorists’ aims. Relocation poses many problems, not the least being the emotional effect on both the refugees and their new hosts who fear infection. • Programs mandating vaccination can result in several bad outcomes: (a) some citizens will get sick and die because of the vaccinations, (b) some citizens will assert legal rights and refuse to be immunized, and (c) during an attack many citizens might mob vaccination centers demanding expedited treatment. It is instructive to note that in the 2001 anthrax attack some 35,000 persons received medical treatment but only 23 cases of anthrax exposure were confirmed. Do we really want mass congregation of citizens demanding vaccination if an infectious disease were loose in the land? • Forced quarantine raises many legal problems, restricts freedom and is authoritarian. In almost every government exercise o f a hypothetical attack, large-scale quarantine is a favored tool o f policymakers in drills. But there are real-life legal impediments to imposing quarantine at the time it may be most needed - at the onset of an epidemic. Not only might valuable time be lost while citizens begin fleeing; when quarantine is ordered, compulsion could undermine public trust in government. It may be necessary to prohibit all exit from a city like Washington, D.C., or close entire states to travelers. Troops will probably be required to enforce such restrictions on movement. • Voluntary initiatives, including programs for sheltering in homes, can meet with resistance by individuals and opposition from affected groups 264 who demand a more proactive government response. Some areas could be disproportionately affected, raising equity issues. Of all of these, the most controversial is quarantine. The legal authority for quarantine is in flux. Public health powers are almost entirely derived from the laws of the states, some of which date from the 1920s. Gene Matthews, General Counsel for the Centers for Disease Control and Prevention, has stated that these laws usually delegate much discretionary authority to public health officers “to take such steps as are necessary to control diseases.” Such broad and, ill- defined authority has generally not been used on a wide scale since the initial attempt to eliminate polio in the US. Therefore, according to Matthews, “[w]e don’t have currently in place the procedures, the mechanisms, the lore, the way of going about doing this job that our professional grandparents would have had.” (American Bar Association, 2000) Additionally, many of these state statutes were enacted before the courts expanded contemporary principles of individual rights and due process. (Gostin et al, 1999) So it is not clear that these laws would withstand judicial scrutiny under current standards. Moreover, there is a disconnect between the legal authority for responding to a public health crisis, which resides mainly at the state level, and the resources required for such a response for a major emergency, which currently are controlled at the federal level. (Bonnie, 2002) 265 Efforts to change state laws by adopting a model code has run into snags in many states, primarily because of concerns about the infringement of individual rights. A model law developed for the Centers for Disease Control and Prevention in 2001 included provisions to update authority to impose and enforce quarantines, vaccinate people, seize and destroy property without compensation, and ration medical supplies, food and fuel in a public health crisis. Supporters say that without such legislation public health authorities will be uncertain about their authority to respond to a public health emergency or impeded by outdated laws (Gostin et al, 2002). However, less than one-third of the states have adopted new statutes empowering governors and health officials to act in a bioterrorism attack. Opponents worry that these new laws, including CDC’s model statute, provide governments with too much power to impose severe restrictions on important freedoms without adequate safeguards against mistake and abuse (Bonnie et al, 2002). Quarantine is particularly problematic. The courts have enunciated constitutional standards by which public health restrictions would be evaluated. Measures that curtail civil liberties, such as quarantine, must be no more restrictive than necessary to protect the public’s health and be applied in a non- discriminatory manner. Moreover, they are subject to judicial review in cases brought by persons affected by such measures. A large-scale quarantine would 266 have a difficult time meeting these standards because public health officials would have to show that the measure is necessary to protect the public’s health. Such a showing requires medical and epidemiological evidence that the public is endangered by an outbreak, that the measures chosen would be effective and are no more restrictive than necessary. Additionally they would have to show that the impact on individual rights is proportional to the threat. (Bonnie et al, 2002) Even if courts defer to the judgment of health officials, their need to respond to a legal challenge and submit to continuing judicial oversight could interfere with swift execution of quarantine. The news coverage of the court review also could increase public doubt about the measure and suspicion about the motives of officials. These legal hurdles, as well as practical and political considerations, could affect the officials’ willingness to impose quarantine at an early stage while public health officials are still gathering information and trying to determine the nature and extent of the health risk. Valuable time may be lost. Thinking things before trouble strikes requires looking at how decisions were made in the midst of an urgent situation, such as the one faced by Canadian officials in the SARS outbreak o f 2003. Useful lessons can be gained from such retrospective study. (Gursky et al, 2003) Such a study has been conducted by a working group at the Joint Center for Bioethics at the University of Toronto under the direction of Peter Singer, which looks at the ethical issues which 2 6 7 surfaced during the SARS outbreak. (Singer et al., 2003) To avoid confusion about which ethical system is being evaluated, it is worth a short digression to establish context. There are a number of ethical theories, including utilitarianism (which looks at consequences), deontology (which seeks to identify duties), and a variety o f approaches based on value orientations. The latter include traditional virtues, values based on relationships, values expressed in actions and precedents in cases (casuistry), and professional principles. (Beauchamp and Walters, 1999) The latter, Principlism, is the current mainstream approach in biomedical ethics. It focuses on four main principles: (1) the autonomy of the individual (to make choices about his or her health care), (2) beneficence (to care for the ill), (3) non-malifasence (“first, do no harm ....”) and (4) justice (in the distribution of care). (Beauchamp and Childress, 2001) For medical practitioners, the patients’ individual autonomy has come to be a primary value in making decisions. This may be completely proper in dealing with individual cases, but it has limitations when considering populations whose health is at risk. Individual autonomy is not a realistic guiding principle in dealing with threats to the community. While autonomy may be a brake on decision-making, it cannot be the driving force in public health. In an unpublished draft (“Public Health Ethics: Mapping the Terrain”) Childress and a 26X number of leaders in bioethics list “general moral considerations” which ought to guide decision-making. These include: benefit, avoiding harm, utility, distributive justice, procedural justice, respecting autonomous choices including “liberty of action,” protecting privacy, keeping commitments, transparency and trust-building. The generality of these concepts and the fact that they are unranked is acknowledged by the authors, who call for balancing them in a publicly accountable manner. (Childress et al, unpublished). One of the co authors of the Childress draft, Nancy Kass, has developed a framework for decision-making in public health. The steps include clarifying goals, assessing efficacy, identifying burdens, minimizing burdens (and identifying alternatives), assessing fairness, and balancing benefits and burdens fairly. (Kass, 2001) These various approaches underline the fact that there is no universal system for making ethical choices in public health but that the field is characterized by weighing various values. This is the approach that was applied by Singer’s team in Toronto to study the SARS outbreak. The study examined the following ethical issues: 1. “When public health trumps civil liberties; the ethic of quarantine, 2. “Naming names, naming communities: privacy of personal information and public need to know, 264 3. “Health care workers’ duty to care and the duty of institutions to support them, 4. “Collateral damage: other victims of SARS, 5. “SARS in a globalized world,” To evaluate these issues the working group discussed ten “key ethical values” including (1) individual liberty, (2) protection o f the public from harm, (3) proportionality, (4) reciprocity, (5) transparency, (6) privacy, (7) protection of communities from undue stigmatization, (8) duty to provide care, (9) equity, and (10) solidarity. (Singer et al, 2003) The Singer working group noted that there were times when protecting public health “trumped” some individual rights (including freedom o f movement). Thousands o f persons were placed in quarantine, often in their own homes. There were instances when personal privacy was “temporarily suspended” when revealing information would protect the public. It noted the need to protect health care professionals to minimize the transmission of disease. It recognized that restrictions on entry to SARS-affccted hospitals resulted in denial of medical care to sick persons, including some with severe illnesses. It acknowledged that “SARS is a wakeup call about global interdependence, and 270 the increasing risk of the emergence and rapid spread of infectious diseases.” (Ibid.) Some o f the “lessons learned” include: • “Under the ethical value of proportionality, authorities have the right to impose quarantine and isolation, but it is preferable, as was the ease in Toronto, to use voluntary measures first. When people are fully informed, and see that they are being treated as fairly as possible, it is likely that voluntarism will prevail in times o f emergency. In fact, most people in Toronto cooperated with restrictions. More coercive measures (such as detention orders or surveillance technology) should be reserved for those cases where non-compliance is documented and potential harm to others is anticipated.” • “Under the ethical value o f reciprocity, people placed in quarantine and isolation should be assisted to overcome the hardships imposed. This will also facilitate compliance.” • “In the SARS emergency, authorities faced hard choices in deciding which medical services to maintain and which to place on hold.... In the case o f an epidemic it is important to control the spread of the disease, but as much attention should be paid to the rights o f the non-infccted persons who need urgent medical care.... There is also a need for transparency, honesty and good communications on health issues.” 271 The report concluded with a call for a “new global health ethic based on solidarity.” It defined solidarity as “feeling that one has common cause with others who are less powerful, wealthy or healthy.” (Singer et al, 2003) Solidarity might be a hard sell, particularly in the individualistic United States. But there is a long tradition o f community-mindedness both in Canada and the United States. If worldwide solidarity is too long a reach, why not encourage people to build community where they live? Is community a value that might inform planning for coping with epidemics - both natural and man-made? Community activities - particularly if undertaken in advance of an emergency - might reduce the necessity for imposing draconian measures like quarantine. The conclusions of the Toronto working group help illuminate some of the issues about compulsory actions (quarantine) and distributive justice in a bioterror emergency. Even in the absence of a man-made disaster, the United States is not prepared for an epidemic. A recent report for the Institute of Medicine of the National Academies stated that the nation’s public health system is not ready to defend the population from the threat of deadly infectious diseases. The co-chair of the 2003 report, Margaret Hamburg, stated that “We must do more to improve our ability to prevent, detect, and control emerging, as well as resurging, microbial threats to health.” The report points to the growth 272 of drug-resistant bacteria and viruses that do not respond to once-effective medicines coupled with the decrease in pharmaceutical development of new antibiotics. “It’s conceivable,” Hamburg stated, “that in certain places microbial ‘perfect storms’ could occur - convergences of several factors - and unlike meteorological perfect storms. A response in the United States that prompted a decision to quarantine large numbers of persons would pose a number o f constitutional issues, including: • the need for officials to show that a real emergency existed, • that the restrictions imposed were necessary, • that they were proportional to the risk, ® that restrictions on individuals were applied in an equal manner, • that people in quarantine are protected from harm and provided adequate care. A mass quarantine measure would have to conform to legal requirements of demonstrable necessity, least rcstrictiveness, and equality; and its implementation could face inevitable delays from judicial scrutiny. The Toronto working group noted the importance of quarantine in coping with SARS. While quarantine may be necessary in a future health emergency, it ought to be a last resort. To decrease the probability o f its imposition, public 273 health authorities ought to seek community-based alternatives based on an ethic of community and public participation. Building on community spirit would be more practical than attempting to develop a world-wide ethic of solidarity, however much merit that might have. The balancing of the ethical positions o f increasing good (beneficence), protecting individual rights (autonomy), enhancing equity (justice) and delivering care (efficiency) is no easy matter. These difficult questions must be considered now, when no emergency looms, rather than in the heat of a crisis. The consideration should be a broad one, with participation invited from a wide segment of society. Such dialogue could strengthen public health and public trust and is consistent with emerging ethical principles of 218 , 1 century health care and bioethics. (Childress et al, 2002; Moreno, 2003) An Alternative: Shielding Voluntary action for self-protection is an appropriate alternative to quarantine. To lessen the probability of the spread o f disease the government recommends that people shelter in their homes if they are advised of a bioterror attack. This shelter-in-place concept has become the foundation of an initiative by the Critical Incident Analysis Group o f the University of Virginia’s Medical School (CIAG). This group has expanded upon sheltering to encompass community- based activities as well as home-focused planning. They call this program 274 “shielding” to differentiate it from simply holing up in one’s home until the all- clear siren sounds. The shielding concept was developed to facilitate the voluntary isolation of contagious persons and fill part o f the role that quarantine has played historically in "sease outbreaks. Moreover, it is designed to minimize compulsion. The goal of both quarantine and shielding is to prevent or mitigate the transmission of a disease from an infected person to those who are not infected. The net effect of both is to break the cycle o f the disease by halting its spread. (Prior et al, 2002). This advice, to shelter in place, is consistent with recommendations from the only medical doctor in the US Senate, Majority Leader Bill Frist. Senator Frist says everyone should prepare a room at home in case of chemica.! or biological attack, to use as a “safe room.” If there’s a bioterrorist attack, Frist says the “most likely scenario appears to be that emergency officials would urge people to shelter at home.... Gather your family in the safe room and listen to the news for further instructions.” (Frist, 29-30) The attraction o f the shielding alternative is that it is a very simple concept embedded in a complex solution, in the event of a chemical, biological or radiological attack, citizens should stay in their homes unless and until they are advised to leave. This should be the default mode: shelter in place until a determination is made that some other alternative - or set of options - is better. Obviously, this won’t work if a chemical attack has resulted in the release of a 2 7 5 deadly gas that threatens the neighborhood, but if the neighborhood is upwind from the gas, people ought to stay in place to leave roads free of extra traffic so the downwind folks can escape and rescue teams can move expeditiously. The key is to shelter in place until instructed to do otherwise because the threat of staying outweighs the risk of travel. Obviously, people do not have to shelter for long if a chemical or radiological agent has affected a distant area or there’s been a release of a biological agent that is not contagious. In the early hours of an attack, we may not know the extent and nature of the attack, so sheltering may be the best, first option, even for people at a distance from the immediately affected region. In the initial phase of a contagious bioterror attack, the immediate goal would be the isolation of those persons who were ill and the quarantine of those who had come in contact with the ill persons, the so-called “known or presumed infectious individuals.” Most other persons without symptoms would not immediately be isolated, but they should be monitored for signs of the onset of disease. Almost immediately, in the secondary phase of a contagious outbreak, the goal would be to have persons whc have had no known contact with infected persons to shelter in place voluntarily. Those who were ill would still be isolated in hospitals and quarantine would be appropriate for those who had been in contact with an ill person. Those who had chosen to shelter would be 276 shielding themselves from contact with possibly infected persons. To protect against development of disease, those who were sheltering should self-monitor for symptoms of illness. In the case of smallpox, this monitoring consists only of taking one’s temperature twice a day. If during the course of a 24 hour period a person has two successive measurements of fever above 101 degrees, then health authorities should be notified so treatment can be commenced. Some of the bioterror diseases - anthrax, botulinum toxin, plague - would require a period o f isolation (or shielding) for seven days. Others -- smallpox, tularemia, and viral hemorrhagic fever — would require between 18 and 28 days. In this extended period, called the tertiary phase, most people who were not exposed would continue in a shielding mode. (Prior et al, 2002) A shielding strategy could maintain the sense o f community and enhance coordination with local and state response teams by activating local leadership. It is designed to counter the tendency of persons to flee a dangerous situation. Shielding would support the social institutions that are the basis of strong community and national security. It is designed to encourage coordination between neighborhood groups and relevant public health, law enforcement and emergency response authorities. Moreover, it would address some of the 277 problems seen in the poor response to the anthrax attack of 2001 and encourage self-reliance and the sort of emergent organization described in chapter 6. After a biological (or chemical, nuclear, or radiological) attack the majority of persons will be unexposed. The main goal of both these individuals and the authorities running the government response will be to keep them from becoming exposed. Shielding would enable persons to remain with families, to self-monitor for indications of exposure, and to sustain some semblance of normal functions as much as possible. If a decision is made to increase community contacts - for example to deliver food and medicine to homes - the risks need to be assessed and the degree of self-monitoring increased to ensure continued freedom from disease exposure. By so doing, shielding would contribute to breaking the disease cycle and reducing the burden on doctors, nurses, hospitals and other responders so they can concentrate on infected, rather than uninfected people. The planning and successful implementation of shielding will give individuals, citizens, families, community groups, and a variety of responders an opportunity to do something productive rather than panic when an incident occurs. Familiar surroundings are welcomed in a time of crisis. People are comforted most when 27R near their families, friends and neighbors. Terrifying television images are countered by familiar settings in homes where healing occurs. In a crisis, the therapeutic value of family and friends cannot be overestimated. The disabled community can be a model for dealing with a contagious bioterrorism crisis, cut off from access to other locations. Disabled persons have demonstrated that they can not merely survive, but can prevail if their environment is well planned. The growth of home nursing and hospice care reflects the value of such arrangements for those who are suffering serious medical illness. The recent increase in home offices and home schooling shows the growing preference for remaining in the comfort of our homes. These normal behaviors will be especially important to mitigate the effects o f a contagious disease. Familiar settings can help people survive emotionally in a terrorist attack. (Saathoff, 2002) Keeping well informed is as important as stable, familiar surroundings. It will be normal to worry about the safety of loved ones whose whereabouts are unknown. Facilitating telephone connections and dissemination of news via the m edia allows people to m ake rational decisions based on facts, not rumor. On the other hand, false information, bad advice and rumors undermine good decision making and public trust. 2 7 9 Shielding in homes is quite different than relocating citizens into temporary emergency shelters. Placing vulnerable citizens into an alien environment with many strangers invites incubation and spread of the infections that they fear. Paradoxically, this would be the way to further the aims o f bioterrorists. The use of hastily erected shelters fails to deal with the emotional needs of citizens. The shielding concept does not assume that people will panic, would involve the public as active participants in the response, would not rely entirely on an overstressed health care system, would enhance the transmission of clear advice and could build trust, all important objectives in preventing panic. (Glass and Schoch-Spana, 2001) Different communities have unique attributes so each community should develop its own authentic approach to respond to a terrorist attack. Suburban dwellers and inner city residents have different needs and preferences that ought to be addressed in varying ways. One shoe does not fit all. Communication resources — such as cable television and internet connections - may be available to some but not all. Delivery systems and ability to store staples differ according to environment, tradition and income. Different cultures in American society possess different strengths and vulnerabilities and the lessons of dealing with racism and sexism ought not be overlooked in designing shielding 28 0 programs. (Willie et al, 1993) Diversity may require different types of assistance in an emergency. The advantage of the shielding option is that people will be in familiar settings, with more control over their lives, than if they are refugees in an unfamiliar and threatening environment. The disadvantage of shielding - as for forced quarantine - is that some people may feel trapped in a “hot zone.” This is a particular concern for inner city residents who may feel that the government’s policy unfairly discriminates against them and is unfair. Imagine reporters interviewing someone in a locked house - through a closed door - and asking how he or she feels being cooped up in an infected area. Community shielding is not a magic cure for bioterrorism. It has drawbacks beyond the possibility that people in an infected area will feel trapped, cut off from healthy people and unfairly left to sicken and die. If inner city areas are cordoned off from the rest of society, many minority citizens could feel powerless and unfairly bearing the weight o f terrorism. Only assurances of massive outside support to affected localities during an emergency will mitigate feelings of unfairness. In effect, community shielding is a form of inoculation, helping people realize that they will not be alone if an attack occurs but that unaffected areas will provide food, medicine and services for distribution by 281 volunteer groups in affected areas. Here are some o f the other drawbacks of shielding that would need to be addressed on a community-by-community basis: • African-Americans and Hispanics are more prone than whites to give credence to conspiracy theories and rumors about government-sponsored bioweapon research, • Some members of militias, white racist organizations and tax resistance groups distrust the Federal Emergency Management Agency (believing it is trying to impose a dictatorship in the US). • The government has not perfected its methods for communicating about risk and advising citizens of protective medical actions. ® Public health experts are not always unanimous in their views on the magnitude of a risk or of the best course to address it. Our system does not speak with one voice with a consensus view. And a phony “manufactured consent” would be inappropriate. • The news media are more prone to report sensationalistic claims than sober analysis, aggravating public fear. • Fear of legal liability might discourage some businesses and individuals from helping in the aftermath of an attack. • There is no system for authenticating the means of delivering necessities to communities that would assure residents of the safety of the supplies. 282 • In an emergency some people will be spumed to heroic action. But in the absence of clear directions they may make enormous mistakes and contribute to chaos. • There are wide disparities among public health capabilities in various states and localities, raising fairness issues that would be compounded in an emergency. Each of the foregoing problems can be summed up with one word: distrust. To be successful community shielding must be a trust-building exercise. The only antidote to predictable reactions of the unfairness of the circumstance is to deal with it in advance - in effect, to inoculate the leadership of major cities and minority communities with information and seek consensus before action is required. . Community leaders can help develop, decide, design and defend plans in their areas in advance of an attack. Only a collaborative and participatory effort will offset the idea that shielding is anything but voluntary. There’s no guarantee that it would work, of course, and critics have noted that there are practical hurdles, especially in providing essential supplies and services in a neighborhood that has been cordoned off. George Annas has questioned whether medical personnel would ever go door-to-door in a hot zone, an attitude countered by Richard Bonnie, who says “We deliver the mail every day — even during snowstorms. We deliver the newspaper. I don’t see why we 283 couldn’t distribute medicines and food.” (both quoted in the Chronicle of Higher Education, March 14, 2003). If people do not trust the system to provide such assistance, there is little chance they will comply for long with requests for voluntary shielding. This fact reinforces the need not just for advance planning but for advance commitment to a voluntary program. When immediate action is required, it is essential that local governmental, civic, religious and community business leaders support the recommended course of action emphatically. If they are willing to tell the news media that the plan is one the community supports, it is more likely to be viewed as a valid approach. In the absence of such agreed upon endorsement, civil disobedience and disorder could result. Much depends on how the news media portrays events as they unfold, so it is essential that journalists be involved in constructive activities before and during an emergency. Shielding is based on the most local institution o f all, the home, which is a small system that performs important functions of housing, feeding, clothing and caring for its family members. By relieving society of these responsibilities, shielding is a distributed network approach to coping with terrorism. Multiple layers of households, neighborhoods, churches and cluhs, towns and cities, states, and the federal government, are unlikely to all fail at once. Shielding 284 invests the smallest unit with the largest opportunity to make a difference in the event o f a catastrophe. It may help offset the temptation of a centralized unit to overreact to a threat. Any system that is developed can be used in ways that are counteiproductivc. There is always the impulse to act in an emergency. “The temptation to do something, for the sake of being seen to be doing something - even something strategically stupid - can be political1 y irresistible,” according to Colin Gray (2002) Shielding relics on the transmission o f accurate, understandable, authoritative information in a time of crisis. In addition to providing credible information, the government needs to consider ways to counter falsehoods and disruptive rumors. This is a major challenge given the speed with which the internet can transmit messages. Authorities tend to dismiss wild stories as so unbelievable that no one would be swayed by them. This attitude, dubbed snobbery by Barkun (2002) “can permit the proliferation of a dangerous undergrowth o f falsehood and half- truth.” He recommends borrowing a page from the civil disorders of the 1960s and 70s where rumors were quickly recognized as potential catalysts for violence. During the urban unrest of that period rumor control centers were activated in many citi \s. Under conditions of potential biotcrrorism, this mechanism might be revived in a more electronically advanced form. 285 The challenge to leadership is to maintain public confidence during a time of anxious uncertainty. Even a well run public information program will be unable to manage all fears. “The more aggressively the state intervenes in the lives of citizens,” Barkun states (2002), “the more intense these doubts and fears will become, a product of a sense of powerlessness.” Even if basic needs are met, the loss of control makes people feel less safe rather than more secure, particularly in a society, which has come to expect democracy and personal freedom. By maintaining a large amount of personal autonomy, as the shielding anticipates, uncertainty is tempered by familiarity. Particularly crucial, however, is the maintenance of traditional protections afforded by the U.S. Constitution. Shielding would be based on consensus rather than the imposition of government authority. Because it’s voluntary, the government is not restricting movement, association, or other freedoms. So it need not meet the demanding legal standards for quarantine. Shielding might be viewed as the constitutionally preferred “less restrictive alternative” for people in an affected area. (Bonnie, et al, 2002). It can be implemented immediately as a precaution, and because it is voluntary it does not have to meet the tests for equal enforcement. Problems are more likely to be worked out at the community level, rather than immediately in court. There will still be fairness 286 issue, however, particularly if urban areas are hardest hit and suburban areas are unaffected. The attraction of shielding is that it is a very simple concept embedded in i complex solution. So it is easy to explain. In the event of a biological attack, citizens should stay in their homes unless and until they are told to leave. This should be the default mode: shelter in place until a determination is made tha some other alternative - or set of options - is better. Obviously, this won’t w o ; k if a chemical attack has resulted in the release o f a deadly gas that threatens the neighborhood, but if the neighborhood is upwind from the gas, people ought to stay in place to leave roads free of extra traffic so the downwind folks can escape and rescue teams can move expeditiously. The key is to shelter in place until instructed to do otherwise because the threat is chemical or radiological or not contagious. Even persons who are homeless or find it difficult to use home-bound technologies are better off in a shielding program because governmental support and medical services are less likely to be overwhelmed by the majority who will be significantly self-sufficient in the security of their own homes. The capabilities created for dealing with man-made diseases would be just as effective if the disease were naturally-occurring. No one likes to consider the 287 possibility of an epidemic, but strengthening community is a way of protecting public health. The shielding concept augments the role that quarantine has played in preventing the spread o f disease, but it may not be sufficient to halt the spread of infection. The goal o f both is to stop the cycle of the disease and prevent its spread from an infected person to those not infected. While voluntary solutions are superior to compulsory ones, a mixture of voluntary and compulsory solutions is better than strictly compulsory ones. Voluntary programs improve the odds that people will trust what government is recommending. Shielding “presents few legal complications, is consistent with current principles of civil liberties, and builds upon democratic precepts,” according to Richard Bonnie and his colleagues (2002). They call quarantine a “constitutional minefield” and say that mandatory approaches to controlling disease raise significant legal issues and restrict fundamental freedoms. As a less authoritarian measure, shielding provides officials with a tool that can be implemented quickly, perhaps resulting in fewer persons being exposed to a disease and reducing the number of persons who might need to be quarantined eventually, if shielding is not sufficient to stop the disease’s spread. 288 Preparedness and response are tightly linked public health activities and shielding ought not be a one-size-fits-all program; in fact, community programs ought to reflect the priorities and values of the affected communities. If shielding is developed as a community tool it will help members o f the community work together - in their own homes and neighborhoods - in the event of a bioterror emergency. While the concept of community shielding is simple, its full execution would be quite complex. The plan won’t work if it is unveiled at the onset of an attack with attendant media frenzy. It has to be discussed publicly under the watchful eye of local news media and a consensus built before it needs to be implemented. Experience with natural disasters, technological accidents and medical emergencies shows that people can act constructively and collaboratively during horrible events. The voluntary response to the attacks of 9/11 shows how quickly and bravely Americans will act to adapt to complex new challenges. The immediate response to the terrorist attacks of 2001 were not organized from one command center but were the autonomous actions of thousands of citizens. The initial response was a self-organizing effort of courageous men and women acting to help rescue the injured, fight fires, care for the sick, recover human remains, console families of victims, and repair damaged lives and property. These are essential and familiar roles. On the 289 other hand, bioterrorism is a newly apprehended risk and there is no widely appreciated script for how to perform in this new contingency. The script needs to be written in each locality, with support from state capitols and Washington. Leadership No program is problem-free. Shielding requires participatory decision-making and consensus is often hard to achieve. Leadership is still an important factor in whether such a program would work. An instructive example o f building community under situations of great stress illuminates the kind of leadership required. During Iraq’s invasion of Kuwait in 1990, personnel at the US embassy in Kuwait City were holed up with American citizens seeking sanctuary from the Iraqis. More than 25 persons were under siege in the embassy for more than 100 days. Ambassador Nat Howell took charge o f the group but had the good sense to encourage community spirit, participation and initiative among the members of the group. As Iraqi troops prevented the delivery of food, water and other supplies, Howell’s group were in a pressure cooker environment. The ordeal - and how they coped - is instructive on how to handle a confined community, the sort of situation that might develop for shorter periods during shielding. The account by Culbertson and Howell, tells of how the strangers developed an 290 “ethos or culture” that sustained them. The individuals’ feeling o f being useful was integral to avoiding anger and feelings of victimization. Here is a summary o f some of the lessons of their long captivity before their release was arranged: • Create areas of autonomy and activity so people do not feel helpless, • Focus on the real cause o f the problem, not our government’s inability to prevent it, • Keep mentally active and communicate with the outside world - particularly with family, • Encourage problem solving, particularly as regards communication, • Expect frustration and irrational criticism o f leaders from people who have lost control over their own fate, • Keep a sense of humor, • Keep people busy in useful activities. Howell said that communication with the outside world was what kept the group mentally healthy. But he noted this frustration: “People who were used to being able to control their lives suddenly had nothing to say about the fate of those close to hem, or for whom they felt responsibility.” (P. 96). In a bioterrorist attack, if people shelter in homes and/or are quarantined in their neighborhoods, we can expect similar frustration. Howell’s lessons are applicable to the challenges we would face. Communities would have to permit autonomy, 291 develop useful activities, maintain communication outside the community and keep active in the variety of ways that Howell described during his confinement. 2 9 2 Conclusion The response to the 2001 anthrax attack was complicated by errors in official statements, poor communication by officials that undercut their own credibility, amplification o f the risks by the news media and by a public perception o f lack of control over the risk of anthrax. All of these, but especially lack of official credibility contributed to the general angst shown in opinion surveys, focus groups and analysis of news coverage. Here is a summary of the findings of this study: The accuracy hypothesis stated that errors in decisions and public statements were associated with public fear of a newly apprehended risk, anthrax. Once the public suspected that erroneous information had been conveyed, did this have an impact on public fear? The evidence from the anthrax attack is that inaccuracies did occur, that there was a lack of public information and that flawed advice to postal workers was associated with heightened fear in the most directly affected communities, according to survey results. The first hypothesis is confirmed. Errors in anthrax messages were associated with public fear of a new risk. 293 The credibility hypothesis stated that contradictory statements from official sources were associated with loss of credibility and public trust in the Anthrax attack. Did the official sources act in a credible manner? Did their actions affect public trust? The evidence from the anthrax attack is that the initial use of politicians as spokespersons rather than health experts backfired. Contradictory and inconsistent information on the best drug treatment and the alleged “unfair treatment” of postal workers (compared to Congressional staffers) weakened the credibility of federal officials. The survey results were particularly clear in showing an erosion of public trust in senior federal officials. The second hypothesis is strongly confirmed. Contradictory information and advice affected the credibility of federal officials. The amplification hypothesis stated that news media amplification of risk was associated with increased public fear in the Anthrax attack. Did the dramatic news coverage and government’s initial slowness in providing information create an information vacuum that was filled by unreliable and sensationalistic claims conveyed by television, newspapers, 294 radio, magazines and the internet? The news coverage of the anthrax episode was highly dramatic. When federal health officials were slow to answer media questions, less competent “experts” filled the airwaves with speculation and misinformation. The confusion about recommended antibiotic treatment was heightened by the media coverage. The third hypothesis is confirmed. The intense media focus on risk coupled with the initial official failure to provide health information were associated with public fear. The powerlessness hypothesis stated hat the absence of knowledge by the public of actions that citizens could take to control the risks o f anthrax was associated with public fear. Was the public left feeling that there was little that could be done for self-protection against anthrax in the mail? The lack of knowledge about anthrax, uncertainty about precautions to take when handling mail, the absence of public involvement in the response and “not knowing what to do,” is well documented in both sets of focus groups. The focus groups are consistent with much prior research on environmental health risks that established that risks which are involuntary and not controlled by the individual are judged to be riskier than those which are 295 voluntary and controllable. Because one cannot extrapolate from focus groups to the general population, these results are only suggestive. Thus the fourth hypothesis is only partially confirmed. The findings included an evaluation o f how federal authorities, particularly the Centers for Disease Control, measured up to the “Seven Cardinal Rules of Risk Communication” which were originally enunciated by the Environmental Protection Agency and have become the guidelines for government risk communication. These include: • Accept and involve the public as partners, • Plan carefully and evaluate performance, • Listen to the public’s specific concerns, • Be honest, frank and open, • Coordinate with other credible sources, • Meet the needs of the news media, • Speak clearly and with compassion. The conclusions include: 1. The government did not involve the public. It tried to reassure the public. When that failed, it tried to placate the public. When that failed, it confused the public with mixed messages about going about business 296 as usual coupled with warnings of impending threats. 2. The government had planned carefully before the outbreak o f anthrax but it did not follow its own plan. It failed to adjust course quickly when its early efforts fell short. 3. The government did listen to the public’s specific concerns but scientific uncertainty prevented addressing the need for the practical information that the public craved. 4. After its initial efforts to downplay the crisis, the government did institute a policy of improved flow of information. But it was not open during early October, when the flow of information was slow at times. 5. The federal government did not do a good job of coordinating with state and local public health officials and the medical community in the initial stages of the episode. 6. The federal government did not meet the nearly insatiable needs o f the news media. It was not prepared for around the clock news coverage 7. Unfortunately, the federal spokespersons were not able to speak with clarity. That was partly because of the scientific and technical uncertainty. Statements did express compassion for those who became ill and those who died, but many postal workers were quoted in newspaper articles as saying that the government failed to act compassionately to mitigate their risk. 297 Some observations - suggested by the research but not empirically proven — are in order: • Problems with decision-making and coordination led to errors in some messages to the public, « Problems with poor organization and communication undermined governmental credibility, • Poor communication by government officials created a vacuum which was filled with media speculation, sensationalism, and criticism of government agencies, • The lack of actionable advice rendered people feeling unable to cope, almost powerless in the face of a newly apprehended risk. These observations prompted the following options for dealing with terrorist emergencies in the future: 1. Improve coordination to manage the complexities of the problem, particularly with a bottom-up rather than a strictly top-down approach, 2. Encourage public officials to understand the psychological impact of their statements and institute more effective organizational efforts to preserve government credibility in time of stress, 3. Improve communication with the media and public, including such steps as the following: 29 8 • Officials should gather and analyze the facts quickly in an escalating crisis, • Officials should develop clear, understandable, actionable advice for the public, • Officials should quickly disseminate information and advice, • Officials should provide a continuous flow of information for the news media to disseminate, • Officials should help people understand both the risks and the best options for their own protection, • Officials must be accountable; they should acknowledge uncertainty, problems and misjudgments. Otherwise trust is eroded. • There is a need for candor, not false reassurance 4. There are opportunities to enhance public participation and improve the response o f individuals and communities during an emergency to offset feelings o f lack of control and powerlessness. The results o f the study are summed up in the matrix on the following page: 299 M essage Problems Source Problem s Channel Problems Receiver Problems General Examples Errors, C om plexity, U ncertainty Lack o f trust and credibility, disagreem ent Sensationalism , bias, distortion, fail to inform M isperception, inability to act, feel pow erless Hypotheses A CCU RA CY Errors in decisions and statem ents were associated with fear o f anthrax CRED IB ILITY Contradictory statem ents from officials w ere associated w ith loss o f credibility and public trust A M PLIFICA TIO N News media am plification o f risk was associated with increased public fear o f anthrax PO W ERLESSN ESS The absence o f public know ledge o f steps to control the risks o f anthrax was associated w ith increased public fear M ethodology M edia content analysis, review o f expert opinion Analysis o f public opinion survey data M edia content analyst' and review o f expert opinion Focus group research and review o f expert opinion Evidence Inaccuracies, Lack o f info,, Flaw ed advice to postal workers, increased fear in postal em ployee com m unities Politicians as spokespersons, expert silence, contradictory info on drugs, "unfair treatm ent" o f postal workers Dramatic new s, Slow flow o f technical info., initial m isinform ation, use o f unofficial sources, confus'on about treatm ent Lack o f know ledge, uncertainty about precautions, absence o f participation in response, "not know ing what to do" about danger from the US mail Findings Errors in official m essages were associated with public fear o f this new risk C ontradictory info and advice from official sources w ere associated w ith loss o f credibility and trust M edia focus on the problem coupled with initial official failure to provide info w ere associated w ith public fear Public lack o f clear understanding o f what protective steps and role people could play to protect them selves, appears to be associated with public fear. Conclusion Hypothesis C onfirm ed Strongly confirm ed Confirm ed Partially confirm ed O bservations for the future Im prove planning and coordination, build robust public health system s for com plex problems Build credibility with bottom up processes, deal with psychological stress, provide clear direction Im prove the flow o f inform ation to media, utilize scientific and m edical experts and com m unicate quickly in an em ergency Involve the public in planning and response to an attack, focus on com m unity preparation, and articulate voluntary actions citizens can take to reduce risks. Figure 10. Findings, O bservations and O ptions 300 While dreadful, the risks of biological warfare can be managed. The anthrax attacks o f 2001 show the way to improvement. Good communication and participatory community planning can make a tremendous difference in how America responds in a bioterror attack. The proposal known as community shielding has the virtue of undermining terrorist aims by strengthening democracy. It empowers individuals through community decision-making. It provides a tool for people to work together to protect each other in the relative security o f their own homes rather than an unfamiliar relocation center. Among the observations from Part II are the following: • Shielding is the least restrictive measure that can be advocated to protect health in a contagious attack, with an emphasis on sheltering-in-place in homes. • Familiar surroundings reduce anxiety, permitting more intelligent actions. • It sustains some form o f stability, pennitting some people to work at home and students to study where they live. • It reduces the probability of legal challenge or civil disobedience to unwelcome enforcement of such things as quarantine orders. • Good planning can facilitate the provision of food, medical supplies and services for distribution in affected communities. 301 • Community action reduces the need for governmental assistance, so agencies can direct their efforts to those with the most need. • It builds on the most sturdy of social units - the family - and can help it perform normal functions in abnormal times. • It permits communities to work together and build bonds under stress. • It gives people something constructive to do and would help them fight back against the terrorist threat at home. Community shielding can undermine terrorist aims by strengthening democracy. Acting to protect one’s own family and neighborhood empowers individuals to become involved in community decisions. It allows people to work together in the relative security of their own homes instead of a crowded relocation center. Shielding is not a simple cure for bioterrorism. As elaborated in the second half of this paper, shielding would have drawbacks. Primary among them is the possibility that people in an infected area will feel trapped in a hot zone, cut off from healthy people and unfairly doomed. If inner city areas are cordoned off from the rest of society, many minority citizens could feel powerless and unfairly bearing the weight of terrorism. This requires a vigorous program to enlist the leadership of inner city and minority communities to help develop, decide, design and defend plans in their areas in advance o f an attack. Only a collaborative and participatory effort will offset the idea that shielding is anything but voluntary. Only assurances of massive outside support to affected 302 localities during an emergency will mitigate feelings of unfairness. If the program is perceived as unworkable, it will not work. The communication shortcomings revealed during the anthrax episode o f 2001 were not simply tactical foul-ups. They stemmed from strategic and organizational problems that need to be addressed before another biological attack. Fortunately there are steps that can be taken to meet most o f the shortcomings exhibited in the 2001 Anthrax attack. But not all lessons have been learned. As of this writing one main lesson that has not been learned is who perpetrated this attack? As months passed without a solution of the crime, it may have emboldened the perpetrator(s) and others to repeat such a dreadful act. 303 References/Bibliography' Abenhaim L, Dab W, and Salmi LR. 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Asset Metadata

Creator Rowan, S. Ford (author)

Core Title Defending against bioterrorism: Lessons from the 2001 anthrax attacks

School School of Policy, Planning and Development

Degree Doctor of Public Administration

Degree Program Public Administration

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, public health,OAI-PMH Harvest,political science, public administration

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Wholey, Joseph (committee chair), Barkdoll, Jake (committee member), Von Winterfeldt, Detlof (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-528351

Unique identifier UC11336039

Identifier 3140548.pdf (filename),usctheses-c16-528351 (legacy record id)

Legacy Identifier 3140548.pdf

Dmrecord 528351

Document Type Dissertation

Rights Rowan, S. Ford

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA