Emotional and Behavioral Consequences of Bioterrorism ... · Emotional and Behavioral Consequences...
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Emotional and Behavioral Consequences of Bioterrorism: Planning a Public Health Response BRADLEY D. STEIN, TERRI L. TANIELIAN, DAVID P. EISENMAN, DONNA J. KEYSER, M. AUDREY BURNAM, and HAROLD A. PINCUS RAND Corporation; University of Southern California; University of California, Los Angeles; University of Pittsburgh Millions of dollars have been spent improving the public health system’s bioter- rorism response capabilities. Yet relatively little attention has been paid to precisely how the public will respond to bioterrorism and how emotional and behavioral responses might complicate an otherwise successful response. This article synthesizes the available evidence about the likely emotional and be- havioral consequences of bioterrorism to suggest what decision makers can do now to improve that response. It examines the emotional and behavioral impact of previous “bioterrorism-like” events and summarizes interviews with experts who have responded to such events or conducted research on the effects of com- munitywide disasters. The article concludes by reflecting on the evidence and experts’ perspectives to suggest actions to be taken now and future policy and research priorities. T he importance of preparing our nation to counter and respond effectively to terrorist threats has been ev- ident since the attacks of September 11, 2001. Of particular concern is the possibility of terrorist attacks involving chemical, bio- logical, radiological, or nuclear weapons (CBRN) (Gilmore Commission 2002). Organized terrorist groups (such as al-Qaeda) have tried to ob- tain or develop CBRN weapons and have publicly proclaimed that they Address correspondence to: Bradley D. Stein, RAND, 1700 Main Street, Santa Monica, CA 90407-2138 (e-mail: [email protected]). The Milbank Quarterly, Vol. 82, No. 3, 2004 (pp. 413–55) c 2004 Milbank Memorial Fund. Published by Blackwell Publishing. 413
Transcript of Emotional and Behavioral Consequences of Bioterrorism ... · Emotional and Behavioral Consequences...
Emotional and Behavioral Consequencesof Bioterrorism: Planning a PublicHealth Response
BRADLEY D. STEIN, TERRI L . TANIELIAN,DAVID P. E ISENMAN, DONNA J . KEYSER,M. AUDREY BURNAM, and HAROLD A. PINCUS
RAND Corporation; University of Southern California;University of California, Los Angeles; University of Pittsburgh
Millions of dollars have been spent improving the public health system’s bioter-rorism response capabilities. Yet relatively little attention has been paid toprecisely how the public will respond to bioterrorism and how emotional andbehavioral responses might complicate an otherwise successful response. Thisarticle synthesizes the available evidence about the likely emotional and be-havioral consequences of bioterrorism to suggest what decision makers can donow to improve that response. It examines the emotional and behavioral impactof previous “bioterrorism-like” events and summarizes interviews with expertswho have responded to such events or conducted research on the effects of com-munitywide disasters. The article concludes by reflecting on the evidence andexperts’ perspectives to suggest actions to be taken now and future policy andresearch priorities.
The importance of preparing our nation tocounter and respond effectively to terrorist threats has been ev-ident since the attacks of September 11, 2001. Of particular
concern is the possibility of terrorist attacks involving chemical, bio-logical, radiological, or nuclear weapons (CBRN) (Gilmore Commission2002). Organized terrorist groups (such as al-Qaeda) have tried to ob-tain or develop CBRN weapons and have publicly proclaimed that they
Address correspondence to: Bradley D. Stein, RAND, 1700 Main Street, SantaMonica, CA 90407-2138 (e-mail: [email protected]).
The Milbank Quarterly, Vol. 82, No. 3, 2004 (pp. 413–55)c© 2004 Milbank Memorial Fund. Published by Blackwell Publishing.
413
414 Bradley D. Stein et al.
consider obtaining them to be a religious duty (Lumpkin 2001), but theyhave not yet demonstrated the capability to effectively acquire, create,or use them. Nonetheless, CBRN weapons remain a substantial concernbecause of their potential to cause widespread death and destruction.
Terrorism using biological weapons is of particular concern becausesmall quantities of biological agents can kill or seriously injure largenumbers of people. However, even if there are few casualties, theseweapons can have serious and extensive psychological, economic, andpolitical consequences (Gilmore Commission 2002). Recognizing thethreat posed by bioterrorism, the federal government has allocated morethan $4 billion to states and communities to improve the public healthresponse to a bioterrorist attack (Gilmore Commission 2002).
Biological terrorism is likely to differ from conventional terrorism,such as a bombing or hijacking, on a number of dimensions, as illustratedin Table 1. Given these differences, we might also expect differences inthe emotional and behavioral impact of bioterrorism compared withthat of other types of terrorist events. For example, the unfamiliarity ofbiological weapons, the uncertainty in determining whether an attackhas occurred and the scope of that attack, and the possibility of contagionand of being an unknowing victim of the attack may heighten the levelof fear and anxiety associated with a bioterrorist attack (Alexander andKlein 2003; Demartino 2002; Holloway et al. 1997).
But precisely how the public will respond to a bioterrorist event is un-clear. Some people are concerned that the demand for health care servicesby the “worried well”—individuals without an organic etiology of theirsymptoms (Bartholomew and Wessely 2002)—will overwhelm healthresources, even in the event of a very small bioterrorist attack. Basedon prior terrorist events such as the sarin gas attacks in Tokyo in 1995,the U.S. Department of Defense estimates that an attack from a CBRNweapon would produce five psychological casualties for every one physi-cal casualty (Warwick 2001); other estimates of the ratio of psychologicalcasualties to physical casualties range from 4 to 1 to as high as 50 to 1(Demartino 2002). Some experts recommend planning for widespreadpublic panic, whereas others believe that such expectations are misguided(Glass and Schoch-Spana 2002; Pastel 2001; Schoch-Spana 2000). We donot understand under what circumstances people’s emotional reactionswill differ. These emotional reactions can range from common distressresponses such as fear and anxiety to full-blown psychiatric disorders(Institute of Medicine 2003). Nor can we now confidently predict how
Emotional and Behavioral Consequences of Bioterrorism 415
TABLE 1Differences between Bioterrorism and Other Forms of Terrorism
Other FormsBioterrorism of Terrorisma
Speed at which attackresults in effect
Delayed and/orprolonged
Immediate
Site of attack Unknownb SpecificKnowledge of attack
boundaries or scopeScope or boundaries
unknownUsually well understood
Distribution ofaffected patients
Geographicallydispersed, particularlyin event of human-to-human transmission ofdisease
Usually in aconcentrated area
First responders Physicians, nurses,public health officials
Police, fire, EMS
Decontamination ofvictims andenvironment
Geographically dispersed Confined environment
Isolation/quarantine Required fortransmittable diseases
Not usually necessary
Medical interventions Antibiotics, vaccines Trauma, first aid,antidotes
aOther forms of terrorism include the use of explosives or other kinetic events, as well as chemical,radiological, and nuclear terrorism.bUnless authorities are informed about the site of the attack.
individuals’ behavioral reactions to a bioterrorist attack (e.g., seekinghealth care services) may complicate planned public health responses.
This article synthesizes the available evidence about the psychologicalconsequences associated with a bioterrorist event to suggest steps thatdecision makers can take now to improve their response and to iden-tify the research questions that must be addressed to better prepare thenation to cope with such events. We begin by examining a range ofpsychological consequences of previous bioterrorist-like events for var-ious populations. We categorized these psychological consequences asemotional consequences and behavioral consequences. Emotional conse-quences include clinical psychiatric disorders like posttraumatic stressdisorder (PTSD), in which individuals display the full constellation of
416 Bradley D. Stein et al.
symptoms and impairment required by clinicians to make a diagnosis.Emotional consequences also include less severe generalized distress andanxiety as well as symptoms of psychiatric disorders that may not meetclinical diagnostic criteria. Behavioral consequences cover such actionsas seeking medical services; increasing one’s use of tobacco, alcohol, orillicit drugs; avoiding an area; or evacuating a community. Next, wesummarize our interviews with experts who have conducted research oncommunitywide trauma and disaster victims or have designed and imple-mented psychological response strategies for such events. We concludeby reflecting on the evidence and the experts’ perspectives to suggestactions to be taken now and to recommend future research and policypriorities.
Methods
We conducted a literature and Web site review from November 2001 toJuly 2002 to collect information about the psychological consequencesof communitywide trauma from manmade, technological, or other ter-rorist disasters or incidents, such as large-scale terrorist events (e.g., theWorld Trade Center bombing, 1993; the Oklahoma City federal build-ing bombing, 1995; and the September 11 attacks on the Pentagonand the World Trade Center, 2001). We also looked for informa-tion about feared and actual chemical attacks (e.g., Israel SCUD mis-sile, 1994; Tokyo sarin gas, 1995). The intentional nature of many ofthese events is comparable to bioterrorism, although many are differ-ent in other respects, such as uncertainty of exposure, as highlighted inTable 1. Our key word search terms included psychological consequences oftrauma, terrorism, bioterrorism, biological warfare, and disasters. We also listrelevant references that have come to our attention since the originalreview.
We searched for studies of known events with one or more of theaspects of bioterrorism identified in Table 1 that were not associatedwith terrorism, such as outbreaks of infectious disease (e.g., the severeacute respiratory syndrome [SARS] epidemic in 2003 and the earlydays of HIV/AIDS) and industrial events (e.g., the nuclear meltdownat Three Mile Island, Pennsylvania, in 1979). These events differ frombioterrorism in that they were unintentional, but they are better ana-logues of bioterrorism in regard to their uncertainty of exposure than are
Emotional and Behavioral Consequences of Bioterrorism 417
many communitywide disasters. Our team members also read articlesand books from conference proceedings and reference lists. We reviewedthe titles and abstracts of all relevant sources for articles, book chapters,and reports.
To complement the literature review, we interviewed (1) expertswith clinical and research experience assessing and responding to theemotional and behavioral consequences of terrorism and disasters and(2) senior policy and operational decision makers with expertise and ex-perience in devising and implementing disaster and terrorism responseplans and strategies. We found the interviewees through the literature(e.g., if they had published widely on the topic) or on the basis of theirposition (e.g., if they were in a position charged with responding to adisaster). The RAND Human Subject Protection Committee reviewedand approved all our study procedures.
These semistructured interviews were designed to explore the chal-lenges of managing emotional and behavioral issues resulting frombioterrorism and to examine how these might differ systematically fromthose of other types of terrorist events. We also asked about additionalresources, tools, and strategies that might be needed at local and statelevels to prepare for and respond adequately to bioterrorism.
We asked those interviewees with clinical and research experience tocomment on (1) whether the psychological effects of bioterrorism mightdiffer from the effects of other terrorist events, and what these differencesmight be; (2) to what extent the available data and earlier studies mightallow experts to predict the emotional and behavioral consequences of abioterrorist attack; (3) whether they believed the emotional or behavioralconsequences of a bioterrorist attack might be different for populationsnot in close geographic proximity to the attack and what these differencesmight be; (4) whether preparedness strategies for bioterrorism needed tobe different from strategies for other traumatic or terrorist events and,if so, how; and (5) what the most important advice they could give tosenior operational decision makers would be regarding the capacities,preparation, acute response, and long-term response for managing thepsychological aspects of bioterrorism.
We asked senior policy and operational decision makers to discuss(1) the current status of federal, state, and local plans to address theemotional and behavioral effects of terrorism; (2) any critical gaps inbioterrorism preparedness; (3) differences between the responses to ter-rorism and those to bioterrorism; and (4) the information that they would
418 Bradley D. Stein et al.
need to respond adequately to bioterrorism, as well as the informationmost needed by the public.
Results
Literature Review
Our literature review yielded little empirical information about the emo-tional and behavioral consequences of bioterrorism. We found no em-pirical studies examining the emotional and behavioral consequencesof actual bioterrorism events for directly exposed individuals, and fewempirical studies of the emotional and behavioral consequences of bioter-rorism for other populations.
Given the lack of terrorism-specific empirical data, we then looked atempirical studies of other events to help us understand and predict theemotional and behavioral consequences of bioterrorism. We organizedour findings according to the different populations commonly identifiedin the trauma field (Norris 2001):
• Direct victims, who have suffered an injury, trauma, or other de-structive result from an event (Frederick 1987).
• The general public, whose exposure to an event is most commonlythrough the media—TV, radio, newspapers, and the Internet—aswell as through conversations with family and friends.
• First responders, such as police, firefighters, or emergency medicaltechnicians, whose occupations require them to respond to the needsof those exposed to a disaster.
• Vulnerable populations, who may be more susceptible to the emo-tional and behavioral consequences of a disaster as a result ofpredisposing personal characteristics, such as children (Flynn andNelson 1998), those with preexisting psychological problems(Kessler et al. 1999; North et al. 1999), and those with physicaldisabilities (Orr and Pitman 1999).
Some characteristics of bioterrorism may influence the compositionof these groups. Uncertainty about exposure to a biological agent andwhether one was directly exposed is likely to increase fear and anxietyamong the general public. Similar to what may happen in some chemical
Emotional and Behavioral Consequences of Bioterrorism 419
events, this uncertainty may occur even in situations with low levels ofexposure and not only in the early phases of an attack but even formonths or years after an attack (Hyams, Murphy, and Wessely 2002).The risk of emotional and behavioral consequences for these individualsmay mirror those of victims for whom exposure is documented. Similarly,the first responders to a bioterrorist event are likely to encompass morethan the traditional emergency response community (fire, emergencymedical service [EMS] personnel, police, search and rescue), to includehospital emergency department personnel, primary care physicians, andothers working in the public health care system (Benedek, Holloway, andBecker 2002). In fact, if a covert release of a biological agent does notimmediately result in symptoms, the traditional first responders may notbe called, and the first responders would be mainly health care workers(Gilmore Commission 1999, 2000, 2001, 2002). In a covert bioterroristattack during which the first indication of the event is the increasedpresentation of affected individuals at health care facilities, health careworkers may initially have the highest morbidity rates, as was observedin health care workers in China and other countries in Asia following theoutbreak of SARS (Centers for Disease Control and Prevention 2003).
Much of the literature we reviewed provides a theoretical or conceptualdiscussion of the psychological consequences of disasters and terrorism,comments on the resources and strategies needed to prepare for theemotional and behavioral consequences of terrorism and disasters, ordescribes the emotional and behavioral sequelae in victim populations,with a heavy emphasis on assessing symptoms of PTSD in various victimpopulations. The assessment of disorders such as PTSD offers usefulinformation for predicting the early and longer-term clinical mentalhealth needs of affected populations. This literature does not, however,offer much information about other emotional and behavioral responsesand their effect on functioning. Such information would be useful forplanning early large-scale intervention strategies and predicting howthe majority of people, who are unlikely to develop clinical psychiatricdisorders such as PTSD, would respond to a bioterrorist event.
The following tables highlight our findings from empirical stud-ies of the major emotional and behavioral consequences for each vic-tim group associated with three types of large-scale trauma: mass vio-lence/conventional terrorism, industrial events/chemical terrorism, andinfectious disease outbreaks. The tables are organized by victim popula-tion and type of event. Table 2 lists examples of studies that examined
420 Bradley D. Stein et al.
emotional and behavioral consequences for direct victims; Tables 3 and4 describe these issues in the general population and first responders,respectively; and Table 5 focuses on two large vulnerable populations,children and individuals with drug and alcohol problems.
Emotional and Behavioral Consequences for Direct Victims. Research ondisasters has found that mass violence is the most psychologically dis-turbing type of disaster. One review suggested that as many as two-thirdsof those directly exposed are psychologically impaired to some degree(Beaton and Murphy 2002). As Table 2 explains, those directly exposedto mass violence and conventional terrorism experience a wide rangeof emotional and behavioral consequences, such as clinical PTSD, post-traumatic stress symptoms that do not meet the criteria for PTSD, otheranxiety disorders, depression, and substance use problems. The docu-mented prevalence of such problems varies widely for different eventsand may be attributed to differences in study methodologies (includingscreening methods and timing), as well as to differences in the popu-lations studied and the traumatic events. Most studies screen victimsto identify symptoms of posttraumatic stress and to determine whetherthe victims meet the criteria for PTSD. The severity of symptoms maynot meet the criteria for some victims at the first screening, but if leftuntreated, these symptoms may become more severe in the followingmonths and thus meet the criteria later.
Technological and industrial events and terrorism using chemicalagents may also be important analogues of a bioterrorist event, but theydiffer from bioterrorism in important ways. Because these events are notintentional, they are likely to generate less fear and anxiety. Terroristattacks using chemical agents do not present the same risk of contagionas many bioterrorist events do. In many cases, individuals in close geo-graphic proximity to the event may also depend on the source of thedisaster for jobs and for economic support of the region. Despite thesedifferences, studies show that even several years after these events, manypeople continue to have emotional distress and physical (e.g., somatic)symptoms unrelated to the amount of exposure.
Reports of the emotional and behavioral reactions by persons affectedby SARS and botulism may also inform expectations for likely reactionsto bioterrorism, including the need for psychosocial interventions torelieve anxiety and depression. Before much is known about a novelinfection, such as SARS or HIV/AIDS, those victims directly exposed andthose thought to be potential vectors may also be stigmatized (Blendon
Emotional and Behavioral Consequences of Bioterrorism 421
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422 Bradley D. Stein et al.
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Emotional and Behavioral Consequences of Bioterrorism 423
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ore
than
1,00
0in
divi
dual
sex
peri
ence
dso
me
degr
eeof
acut
eor
chro
nic
gas
expo
sure
,and
13pe
ople
died
.App
roxi
mat
ely
4,50
0in
divi
dual
sw
hoso
ught
med
ical
serv
ices
but
coul
dno
tbe
dete
rmin
edto
suff
erfr
omne
rve
gas
expo
sure
wer
eco
nsid
ered
psyc
holo
gica
lcas
ualt
ies.
Man
yof
thos
ein
volv
edin
this
atta
cksu
ffer
edso
me
phys
ical
sym
ptom
sor
emot
iona
lre
acti
ons
for
atle
ast
one
year
foll
owin
gth
eat
tack
.
Oku
mur
aet
al.1
998
App
roxi
mat
ely
60%
ofin
divi
dual
sw
hopr
esen
ted
atSt
.Luk
e’s
Inte
rnat
iona
lHos
pita
lfol
low
ing
the
sari
nat
tack
suff
ered
from
post
trau
mat
icst
ress
sym
ptom
sth
atpe
rsis
ted
long
erth
ansi
xm
onth
s.
Ohb
uet
al.1
997
Vic
tim
sof
the
sari
nat
tack
cont
inue
dto
suff
erfr
omph
ysic
alsy
mpt
oms
and
emot
iona
lrea
ctio
nsfi
veye
ars
afte
rth
ete
rror
ist
inci
dent
s,m
ost
com
mon
lyey
epr
oble
ms
and
depr
esse
dm
ood.
Kaw
ana,
Ishi
mat
su,a
ndK
anda
2001
424 Bradley D. Stein et al.T
AB
LE
2—C
onti
nued
Eve
ntD
irec
tV
icti
ms
Sour
ce
Infe
ctio
us
orF
ood
-or
Wat
er-B
orn
eD
isea
seO
utb
reak
sB
otul
ism
outb
reak
inP
eori
a,Il
lino
is,O
ctob
er19
83.
Dur
ing
smal
l-gr
oup
disc
ussi
ons
(int
ende
dfo
rin
form
atio
nsh
arin
g)fo
llow
ing
the
outb
reak
,fam
ily
mem
bers
ofpa
tien
tsex
pres
sed
seve
rale
mot
iona
lrea
ctio
ns,i
nclu
ding
conc
ern,
wor
ry,f
ear,
and
pres
sure
tobe
wit
hth
epa
tien
tat
allt
imes
.Dat
aon
affe
ctiv
ere
spon
ses
wer
ega
ther
edfr
omth
epa
tien
tan
dfa
mil
ym
embe
rsdu
ring
wee
k1
and
wee
k2
ofth
eil
lnes
sou
tbre
ak(b
efor
ean
daf
ter
the
init
iali
nfor
mat
iona
lgro
upm
eeti
ngs
for
fam
ilie
s).
Par
tici
pant
sra
ted,
ona
10-p
oint
scal
e,th
eir
leve
lofa
nxie
ty,f
ear,
help
less
ness
,dep
ress
ion,
and
ange
r.Le
vels
ofan
xiet
y,fe
ar,
help
less
ness
,and
depr
essi
onde
crea
sed
over
the
two-
wee
kpe
riod
for
fam
ily
mem
bers
.Lev
els
ofan
ger
rem
aine
dth
esa
me
inbo
thpa
tien
tsan
dfa
mil
ym
embe
rs.F
orpa
tien
ts,w
hile
leve
lsof
anxi
ety,
fear
,and
help
less
ness
decr
ease
dov
erth
etw
ow
eeks
,the
leve
lof
self
-rep
orte
dde
pres
sion
sign
ific
antl
yin
crea
sed.
Coh
enan
dA
nder
son
1986
SAR
Sou
tbre
akin
Toro
nto,
Mar
ch–A
pril
2003
.P
atie
nts
depr
ived
offa
mil
yvi
sits
expe
rien
ced
inso
mni
a,an
xiet
y,an
din
terp
erso
nalf
rict
ion
wit
hst
aff.
Pha
rmac
olog
ical
and
beha
vior
alin
terv
enti
ons
totr
eat
inso
mni
aw
ere
used
exte
nsiv
ely.
Mau
nder
etal
.200
3
Bio
logi
calT
erro
rism
Susp
ecte
dan
thra
xpa
ckag
ein
Sout
hW
ales
,13
peop
leex
pose
d,O
ctob
er20
02.
Usi
ngth
eH
ospi
talA
nxie
tyan
dD
epre
ssio
n(H
AD
)sca
leon
ew
eek
foll
owin
gth
eev
ent,
the
auth
ors
docu
men
ted
anxi
ety
(HA
Dan
xiet
ysc
ore>
10)i
n45
%of
thos
eex
pose
d.A
nxie
tysc
ore
was
sign
ific
antl
yhi
gher
inpe
rson
sex
pose
dto
the
hoax
anth
rax
pack
age
com
pare
dw
ith
unex
pose
dm
atch
edco
ntro
ls.D
epre
ssio
nsc
ores
wer
eno
tdi
ffer
ent
betw
een
the
grou
ps.
Mas
onan
dLy
ons
2003
Emotional and Behavioral Consequences of Bioterrorism 425
and Donelan 1988; Gostin, Bayer, and Fairchild 2003), which in turnmay intensify the emotional consequences of the disorder.
To date, there have been few bioterrorist events, and no empiricallybased articles documenting the emotional and behavioral reactions ofdirect victims of bioterrorist events, including the populations exposedand treated during the anthrax attacks in the fall of 2001 in the UnitedStates. One study did report on emotional reactions following a hoaxevent in South Wales and found that individuals had significantly moresymptoms of anxiety immediately following the hoax (Mason and Lyons2003).
Emotional and Behavioral Consequences for the General Population. Table 3shows how large catastrophic events, similar to a bioterrorist event, affectthe general population.
Before September 11, 2001, the only study of how intentional massviolence or conventional terrorism affected the public examined the ef-fects of the bombing of the federal building in Oklahoma City in April1995. It documented posttraumatic stress symptoms among residentswho did not hear, see, or feel the explosion.
Studies conducted in the immediate aftermath of the September 11terrorist attacks discovered a range of emotional and behavioral reactions,both in the cities where the attacks occurred and across the country.Subsequent surveys found a decrease in the prevalence of more severeemotional distress reactions in the general public (Silver et al. 2002;Stein et al. 2004) but also noted changes in health-related behaviors, suchas a persistent increase in the use of cigarettes, alcohol, and marijuanain New York (Vlahov et al. 2004) and an increase in missed doses andsuboptimal doses of antiretroviral therapies in HIV-positive men in NewYork City (Halkitis et al. 2003).
Several studies have followed community members in surroundingareas after industrial events (e.g., unintentional releases of hazardouschemical or radioactive substances) and could be helpful in understand-ing the emotional and behavioral consequences for persons geographi-cally distant from an event. These studies found that at the time of anevent, many individuals may be fearful, anxious, and present for screen-ing related to the noxious agent. In at least one event (e.g., the Chernobylnuclear disaster in the Soviet Union in 1986), the emotional impact maypersist for years, manifested as a higher rate of depression and mooddisorders (Havenaar et al. 1997).
426 Bradley D. Stein et al.
TA
BL
E3
Psy
chol
ogic
alC
onse
quen
ces
ofE
vent
sM
easu
red
inth
eG
ener
alP
opul
atio
n
Type
ofE
vent
Gen
eral
Pop
ulat
ion
Sour
ce
Inte
nti
onal
Mas
sV
iole
nce
/Con
ven
tion
alT
erro
rism
Bom
bing
ofM
urra
hFe
dera
lB
uild
ing,
Okl
ahom
aC
ity,
Apr
il19
95.
Eig
htpe
rcen
tof
Okl
ahom
aC
ity
resi
dent
sin
terv
iew
edsi
xm
onth
saf
ter
the
bom
bing
who
did
not
hear
,see
,or
feel
the
expl
osio
nre
port
edem
otio
nals
ympt
oms
cons
iste
ntw
ith
post
trau
mat
icst
ress
diso
rder
(PT
SD).
Spra
ng19
99
Terr
oris
tat
tack
son
Wor
ldTr
ade
Cen
ter
(WT
C)a
ndP
enta
gon,
Sept
embe
r20
01.
Fort
y-fo
urpe
rcen
tof
nati
onal
sam
ple
repo
rted
expe
rien
cing
subs
tant
iale
mot
iona
lstr
ess
thre
eto
five
days
foll
owin
gth
eat
tack
s.In
divi
dual
sex
peri
enci
ngsu
bsta
ntia
lem
otio
nals
tres
sen
gage
din
copi
ngst
rate
gies
(e.g
.,ta
lkin
gto
othe
rs,t
urni
ngto
reli
gion
,che
ckin
gon
fam
ily
mem
bers
and
frie
nds)
mor
eof
ten
than
did
thos
ew
itho
utsu
chre
acti
ons.
Schu
ster
etal
.200
1
One
totw
om
onth
saf
ter
the
atta
cks,
esti
mat
esof
prob
able
PT
SDin
area
scl
ose
toth
eat
tack
rang
edfr
om3%
(for
the
Was
hing
ton,
D.C
.,m
etro
area
)to
11%
(for
the
NY
Cm
etro
area
).E
stim
ate
ofpr
obab
leP
TSD
inre
stof
coun
try
was
4%.
Schl
enge
ret
al.2
002
One
totw
om
onth
sfo
llow
ing
the
atta
cks,
8%of
Man
hatt
anre
side
nts
repo
rted
sym
ptom
sco
nsis
tent
wit
hP
TSD
and
10%
cons
iste
ntw
ith
depr
essi
on.A
mon
gM
anha
ttan
resi
dent
sin
clos
est
geog
raph
icpr
oxim
ity
(sou
thof
Can
alSt
reet
near
the
WT
C),
the
prev
alen
cew
asas
high
as20
%.
Gal
eaet
al.2
002
Seve
ntee
npe
rcen
tof
the
U.S
.pop
ulat
ion
outs
ide
New
Yor
kC
ity
had
post
trau
mat
icst
ress
sym
ptom
stw
om
onth
saf
ter
the
atta
ck;6
%at
six
mon
ths.
Pri
orde
pres
sion
oran
xiet
yw
asas
soci
ated
wit
hhi
gher
leve
lsof
post
trau
mat
icst
ress
sym
ptom
s.
Silv
eret
al.2
002
Emotional and Behavioral Consequences of Bioterrorism 427
Fiv
eto
eigh
tw
eeks
afte
rth
eat
tack
s,in
crea
sed
use
ofci
gare
ttes
,al
coho
l,an
dm
arij
uana
was
foun
dam
ong
New
Yor
kC
ity
resi
dent
sli
ving
clos
est
toth
eaf
fect
edar
eaan
dw
asas
soci
ated
wit
hhi
gher
prev
alen
ceof
curr
ent
PT
SDor
curr
ent
depr
essi
on.
Vla
hov
etal
.200
2
Thr
eeto
six
mon
ths
afte
rth
eat
tack
s,18
%of
1,00
9in
divi
dual
sin
terv
iew
edin
Man
hatt
anha
dsy
mpt
oms
seve
reen
ough
topu
tth
emat
risk
for
PT
SD.O
nly
27%
ofth
ese
indi
vidu
als
wer
ere
ceiv
ing
coun
seli
ngor
psyc
hiat
ric
trea
tmen
t.
DeL
isie
tal
.200
3
One
toth
ree
mon
ths
foll
owin
gth
eat
tack
s,th
eth
ree
stat
esin
clos
est
prox
imit
yto
the
WT
C(N
.Y.,
N.J
.,an
dC
onn.
)add
eda
terr
oris
mm
odul
eto
thei
ron
goin
gB
ehav
iora
lRis
kFa
ctor
sSu
rvei
llan
ceSy
stem
.In
this
surv
eyof
noni
nsti
tuti
onal
ized
U.S
.ad
ults
,the
yfo
und
that
3%re
port
edbe
ing
dire
ctvi
ctim
sof
the
atta
ck(7
%ha
dre
lati
ves
and
14%
had
frie
nds
who
wer
evi
ctim
s),a
nd75
%re
port
edha
ving
prob
lem
sth
atth
eyat
trib
uted
toth
eat
tack
.
Cen
ters
for
Dis
ease
Con
trol
and
Pre
vent
ion
2002
Ind
ust
rial
Eve
nts
/Ch
emic
alT
erro
rism
Uni
nten
tion
alre
leas
eof
radi
atio
nat
Thr
eeM
ile
Isla
nd,P
enns
ylva
nia,
Mar
ch19
79.
Mor
ein
divi
dual
sin
the
surr
ound
ing
com
mun
ity
evac
uate
dth
anw
ere
actu
ally
advi
sed
todo
so.
Hou
ts,C
lear
y,an
dH
u19
88A
lmos
t18
mon
ths
afte
rth
eev
ent,
chro
nic
stre
sssy
ndro
mes
,an
xiet
y,so
mat
icco
mpl
aint
s,fe
elin
gsof
alie
nati
on,a
ndph
ysio
logi
calm
arke
rsof
stre
ssw
ere
high
erin
the
surr
ound
ing
com
mun
ity
than
inco
mpa
riso
nco
mm
unit
ies.
Bau
m,F
lem
ing,
and
Sing
er19
83;B
aum
,G
atch
el,a
ndSc
haef
fer
1983
428 Bradley D. Stein et al.
TA
BL
E3—
Con
tinu
ed
Type
ofE
vent
Gen
eral
Pop
ulat
ion
Sour
ce
Che
rnob
ylnu
clea
rpo
wer
plan
tdi
sast
er,S
ovie
tU
nion
,Apr
il–M
ay19
86.
Ina
smal
lstu
dyof
the
long
-ter
mef
fect
sof
the
Che
rnob
yldi
sast
er,h
ighe
rra
tes
ofm
ood
diso
rder
wer
efo
und
inlo
cal
resi
dent
ste
nye
ars
afte
rth
enu
clea
rca
tast
roph
e;m
othe
rsw
ith
chil
dren
unde
rth
eag
eof
18ha
dth
ehi
ghes
tle
vels
ofps
ycho
path
olog
y.C
hild
ren
inth
eaf
fect
edar
eaha
dhi
gher
rate
sof
thyr
oid
canc
er,w
hich
may
have
cont
ribu
ted
toth
em
othe
rs’
psyc
hopa
thol
ogy.
Thi
sst
udy
high
ligh
ted
the
long
-ter
mem
otio
nalc
onse
quen
ces
asso
ciat
edw
ith
ara
diol
ogic
aldi
sast
erth
atpr
oduc
edm
ajor
heal
thco
nseq
uenc
esfo
rth
ein
divi
dual
sex
pose
d.
Hav
enaa
ret
al.1
997
Rad
iolo
gica
linc
iden
tin
Goi
ania
,Bra
zil,
Sept
embe
r19
87.
Onl
y25
0pe
rson
sw
ere
actu
ally
expo
sed
toth
era
dioa
ctiv
esu
bsta
nce:
125,
000
peop
le(1
3%of
popu
lati
on)r
eque
sted
scre
enin
g.F
ive
thou
sand
(8%
)oft
hefi
rst
60,0
00se
ekin
gm
edic
alca
rew
hen
the
inci
dent
beca
me
publ
icha
dph
ysic
alsy
mpt
oms
that
mim
icke
dac
tual
sym
ptom
sof
expo
sure
.
Col
lins
and
Ban
deri
ade
Car
valh
o19
93
Uni
nten
tion
alre
leas
eof
19,0
00ga
llon
sof
met
amso
dium
,nor
ther
nC
alif
orni
a,Ju
ly19
91.
Res
iden
tsli
ving
near
anun
inte
ntio
nalr
elea
seof
19,0
00ga
llon
sof
met
amso
dium
,ato
xic
pest
icid
e,ex
peri
ence
dsi
gnif
ican
tem
otio
nala
ndph
ysic
alco
mpl
icat
ions
thre
eto
four
mon
ths
afte
rth
eev
ent.
The
yha
dm
ore
depr
essi
on,a
nxie
ty,a
ndad
vers
ehe
alth
sym
ptom
sth
andi
dm
atch
edco
ntro
lsub
ject
s.
Bow
ler
etal
.199
4
SCU
Dm
issi
leat
tack
sin
Isra
eldu
ring
Gul
fWar
,19
92.
At
the
tim
eof
the
atta
cks,
773
civi
lian
sw
ere
take
nto
12di
ffer
ent
hosp
ital
s:43
%w
ere
iden
tifi
edas
“psy
chol
ogic
alca
sual
ties
,”an
d27
%ha
dm
ista
kenl
yus
edth
ean
tido
tefo
rch
emic
alex
posu
re.
Ble
ich
etal
.199
2
Emotional and Behavioral Consequences of Bioterrorism 429
Dur
ing
the
peri
odof
the
atta
cks,
a25
0%in
crea
sew
asre
port
edin
the
risk
ofcl
inic
alde
pres
sion
amon
gth
eIs
rael
ipop
ulat
ion.
Lom
ranz
etal
.199
4
Sari
nga
sat
tack
inTo
kyo
subw
ay,M
arch
1995
.M
ore
than
4,50
0in
divi
dual
sfr
omth
eTo
kyo
popu
lati
onw
ere
labe
led
“psy
chol
ogic
alca
sual
ties
”be
caus
eth
eypr
esen
ted
wit
hph
ysic
alsy
mpt
oms
unre
late
dto
dire
ctex
posu
reto
the
sari
nga
s.It
isno
tkn
own
how
man
yw
ere
atth
esu
bway
atth
eti
me
ofth
eat
tack
,how
man
yw
ere
resp
onde
rs,a
ndho
wm
any
wer
ein
gene
ralp
opul
atio
n.
Kaw
ana,
Ishi
mat
su,a
ndK
anda
2001
Bio
logi
calT
erro
rism
Ant
hrax
lett
ers
mai
led
thro
ugh
U.S
.Pos
tal
Serv
ice
inN
ewY
ork,
Dis
tric
tof
Col
umbi
a,N
ewJe
rsey
,and
Flor
ida,
Oct
ober
2001
.
Mor
eth
an30
,000
peop
lew
ere
offe
red
prop
hyla
ctic
anti
biot
ics,
desp
ite
the
rela
tive
lyna
rrow
scop
eof
the
atta
ck.
Ger
berd
ing,
Hug
hes,
and
Kop
lan
2002
Two
mon
ths
foll
owin
gth
efi
rst
conf
irm
edca
se,m
ore
than
75%
ofA
mer
ican
ssu
rvey
edbe
liev
edth
eyw
ould
surv
ive
ifth
eyco
ntra
cted
inha
lati
onal
anth
rax.
Ble
ndon
etal
.200
1
Less
than
25%
ofA
mer
ican
ssu
rvey
edw
ithi
ntw
oto
four
wee
ksof
the
anth
rax
atta
cks
repo
rted
taki
ngem
erge
ncy
prec
auti
ons
beca
use
ofco
ncer
nsof
biot
erro
rism
;the
rew
asno
diff
eren
cebe
twee
nar
eas
wit
han
dw
itho
utan
thra
xca
ses.
Less
than
10%
ofA
mer
ican
sre
port
edav
oidi
ngpu
blic
even
tsow
ing
toco
ncer
nsof
biot
erro
rism
;the
rew
asno
diff
eren
cebe
twee
nar
eas
wit
han
dw
itho
utan
thra
xca
ses.
Ble
ndon
etal
.200
1
The
rew
asno
larg
e-sc
ale
incr
ease
inth
ede
man
don
the
heal
thca
resy
stem
foll
owin
gth
ean
thra
xat
tack
s.“H
is/h
erow
ndo
ctor
”w
asvi
ewed
asm
ost
trus
twor
thy
sour
ceof
reli
able
info
rmat
ion
inth
eev
ent
ofbi
oter
rori
smin
aco
mm
unit
y.
Ble
ndon
etal
.200
1
430 Bradley D. Stein et al.
TA
BL
E3—
Con
tinu
ed
Type
ofE
vent
Gen
eral
Pop
ulat
ion
Sour
ce
Inth
em
onth
foll
owin
gth
efi
rst
repo
rted
anth
rax
case
,the
rew
asa
wid
espr
ead
incr
ease
ofpr
escr
ipti
ons
for
cipr
oflo
xaci
n(4
0%in
crea
se)a
nddo
xycy
clin
e(3
0%in
crea
se)c
ompa
red
wit
hth
esa
me
tim
ea
year
earl
ier,
mor
eth
anw
asw
arra
nted
base
don
conf
irm
edor
susp
ecte
dan
thra
xex
posu
real
one.
Shaf
fer
etal
.200
3
Infe
ctio
us
orF
ood
-or
Wat
er-B
orn
eD
isea
seO
utb
reak
sP
lagu
eou
tbre
akin
Sura
t,In
dia,
wit
h53
deat
hs,1
67co
nfir
med
case
s,an
dm
ore
than
5,00
0su
spec
ted
case
s,Ja
nuar
y19
94.
Mas
sex
odus
wit
h60
0,00
0fl
eein
gth
ear
ea.I
nves
tiga
tors
beli
eve
that
muc
hof
this
beha
vior
isli
kely
asso
ciat
edw
ith
wid
espr
ead
anxi
ety
abou
tin
fect
ion,
low
conf
iden
cein
the
heal
thca
resy
stem
’sab
ilit
yto
effe
ctiv
ely
trea
tan
dm
anag
eth
eou
tbre
ak,
and
peop
le’s
beli
efth
atth
eyco
uld
esca
peth
eil
lnes
s.
Ram
alin
gasw
ami2
001
E.c
olio
utbr
eak
inW
alke
rton
,Ont
ario
,sev
ende
aths
,2,3
00il
l,M
ay20
00.
Fort
y-fi
vepe
rcen
tof
3,90
8W
alke
rton
area
resi
dent
sw
hopa
rtic
ipat
edin
ahe
alth
asse
ssm
ent
foll
ow-u
pst
udy
repo
rted
heal
thco
ncer
nsco
nduc
ted
afte
rth
eou
tbre
ak.M
ost
com
mon
conc
erns
repo
rted
incl
uded
stre
ss,h
eada
che,
and
fati
gue.
Wal
kert
onH
ealt
hSt
udy,
pers
onal
com
mun
icat
ion,
Dec
embe
r17
,200
2A
necd
otal
repo
rts
ofan
xiet
yan
dde
pres
sion
inth
ew
eeks
and
mon
ths
foll
owin
gth
eou
tbre
akw
ere
note
din
the
form
alin
quir
yfr
omth
isou
tbre
ak.
O’C
onno
r20
02
Emotional and Behavioral Consequences of Bioterrorism 431
SAR
Sou
tbre
akin
Sing
apor
e,20
02/2
003.
Dur
ing
the
firs
tth
ree
mon
ths
ofth
eSA
RS
outb
reak
,3%
ofSi
ngap
ore
resi
dent
sre
port
edhi
ghle
vels
ofan
xiet
y;42
%re
port
edm
oder
ate
leve
lsof
anxi
ety.
Anx
iety
was
unre
late
dto
perc
eive
dli
keli
hood
ofco
ntra
ctin
gSA
RS.
Indi
vidu
als
wit
hhi
ghor
mod
erat
ele
vels
ofan
xiet
y,w
omen
,and
thos
eov
er35
year
sol
dw
ere
mor
eli
kely
than
othe
rsto
take
prev
enti
vem
easu
res.
Qua
han
dH
in-P
eng
2004
SAR
Sou
tbre
akin
Hon
gK
ong,
2003
.T
hirt
een
perc
ent
ofH
ong
Kon
gre
side
nts
surv
eyed
duri
ngth
eSA
RS
outb
reak
wer
equ
ite
orve
ryan
xiou
sab
out
SAR
S.A
nxie
tyan
dpe
rcep
tion
ofri
skfr
omSA
RS
was
asso
ciat
edw
ith
prec
auti
onar
ym
easu
res
agai
nst
SAR
Sbu
tw
asun
rela
ted
tore
cent
use
ofhe
alth
serv
ices
.
Leun
get
al.2
003
SAR
Sou
tbre
akin
Toro
nto,
2003
.N
inet
y-se
ven
perc
ent
ofTo
ront
ore
side
nts
and
93%
ofU
.S.
resi
dent
ssu
rvey
eddu
ring
the
SAR
Sou
tbre
akre
port
edth
eyw
ould
agre
eto
bequ
aran
tine
dif
expo
sed
toSA
RS.
Twen
ty-f
our
perc
ent
ofTo
ront
ore
side
nts
who
wer
equ
aran
tine
dor
had
afa
mil
ym
embe
ror
frie
ndqu
aran
tine
dfo
rSA
RS
repo
rted
itw
asa
maj
orpr
oble
m;5
1%sa
idit
was
am
inor
prob
lem
.Em
otio
nald
iffi
cult
yfr
ombe
ing
conf
ined
was
the
mos
tco
mm
onm
ajor
prob
lem
.
Ble
ndon
etal
.200
4
432 Bradley D. Stein et al.
Several studies examined the impact on the general population of theSARS outbreak in 2003. These studies found higher levels of anxietyin much of the general population. This anxiety was often related tothe increased use of precautionary measures against SARS but was notassociated with a greater use of health services (Blendon et al. 2004;Leung et al. 2003; Quah and Hin-Peng 2004).
Until the anthrax attacks, our nation had not yet experienced a deadlybioterrorist event. Several years ago, some salad bars in Oregon wereintentionally poisoned in order to influence a local election, but no em-pirical data were collected on the emotional and behavioral consequencesof this event. At the time of our literature review, no studies had beenpublished that assessed the emotional reactions of those people exposedto anthrax in the fall of 2001. Reports of the public health response andsurveys of attitudes toward and opinions about the anthrax attacks andthe risk of bioterrorism are informative, however. Despite the relativelynarrow scope of the attack, more than 30,000 individuals were offeredprophylactic antibiotics by public health officials (Gerberding, Hughes,and Koplan 2002), and many more appear to have sought antibiotics ontheir own (Shaffer et al. 2003). But the majority of Americans reportedthat they did not take emergency precautions or visit their doctor, withno difference in behavior in those living in areas either with or withoutanthrax cases (Blendon et al. 2001).
Emotional and Behavioral Consequences for First Responders. Firstresponders—those who respond to disasters and terrorist events and carefor both survivors and those lost—must enter dangerous environmentswhere their own health and well-being may be harmed and where theymay witness mass carnage and destruction. A fair amount of literaturediscusses the emotional repercussions of such experiences in the first re-sponder communities, traditionally thought of as police, fire, and EMSpersonnel, particularly in those who responded to the Oklahoma Citybombing and the World Trade Center attacks (Table 4). These studiessuggest that the experience of responding to these events placed theseindividuals at a significantly higher risk for symptoms of PTSD.
The emotional and behavioral reactions of health care workers re-sponding to the SARS epidemic were examined in medical personnel inHong Kong and Toronto. Their emotional distress was higher than thatof the general population, and while most continued to care for theirpatients, a number of hospital staff were reported to have refused work
Emotional and Behavioral Consequences of Bioterrorism 433
TA
BL
E4
Psy
chol
ogic
alC
onse
quen
ces
ofE
vent
sM
easu
red
inF
irst
Res
pond
ers
Type
ofE
vent
Fir
stR
espo
nder
sSo
urce
Inte
nti
onal
Mas
sV
iole
nce
/Con
ven
tion
alT
erro
rism
Bom
bing
ofM
urra
hFe
dera
lB
uild
ing,
Okl
ahom
aC
ity,
Apr
il19
95.
Thi
rtee
npe
rcen
tof
181
mal
efi
refi
ghte
rsan
dre
scue
wor
kers
who
resp
onde
dto
the
bom
bing
met
crit
eria
for
PT
SDth
ree
year
sfo
llow
ing
the
disa
ster
.Hig
hra
tes
ofal
coho
ldis
orde
rs(2
4%fo
llow
ing
disa
ster
;47%
life
tim
epr
eval
ence
)wer
eob
serv
edin
mal
efi
refi
ghte
rsan
dre
scue
wor
kers
who
resp
onde
dto
the
bom
bing
,but
virt
uall
yno
new
case
soc
curr
edaf
ter
the
bom
bing
.
Nor
th,T
ivis
,et
al.2
002
Terr
oris
tat
tack
son
Wor
ldTr
ade
Cen
ter
and
Pen
tago
n,Se
ptem
ber
2001
.
Inre
port
sdi
scus
sing
the
men
talh
ealt
hre
spon
seto
the
Pen
tago
nat
tack
s,au
thor
sci
ted
anec
dota
lrep
orts
ofth
eem
otio
nal
cons
eque
nces
ofre
cove
ring
bodi
es,p
ulli
ngvi
ctim
sfr
omth
esc
ene,
and
goin
gth
roug
hth
eru
bble
and
rem
ains
.The
auth
ors
also
note
dth
atw
orke
rsre
port
edsl
eepi
ngdi
ffic
ulty
,str
ess,
and
anxi
ety
duri
ngth
eir
mis
sion
asw
ella
sin
the
afte
rmat
h.A
ltho
ugh
thes
esy
mpt
oms
wer
eno
tcl
inic
ally
asse
ssed
and
empi
rica
lly
docu
men
ted,
they
wer
ew
idel
yci
ted
inre
port
san
dar
ticl
es.
Rit
chie
and
Hog
e20
02
Ina
men
talh
ealt
hne
eds
asse
ssm
ent
for
New
Yor
kSt
ate
cond
ucte
don
em
onth
foll
owin
gth
eat
tack
s,re
sear
cher
ses
tim
ated
that
appr
oxim
atel
y24
%of
resc
uew
orke
rsw
ould
mee
tcr
iter
iafo
rP
TSD
and
requ
ire
trea
tmen
t.
Her
man
,Fel
ton,
and
Suss
er20
02
434 Bradley D. Stein et al.
TA
BL
E4—
Con
tinu
ed
Type
ofE
vent
Fir
stR
espo
nder
sSo
urce
Infe
ctio
us
orF
ood
-or
Wat
er-B
orn
eD
isea
seO
utb
reak
sH
IV/A
IDS,
Los
Ang
eles
,19
85.
Man
yph
ysic
ians
repo
rted
conc
erns
abou
tco
ntag
ion
was
ade
terr
ent
totr
eati
ngpa
tien
tsw
ith
AID
San
dth
atm
ore
know
ledg
ean
dex
peri
ence
rega
rdin
gA
IDS
wou
ldli
kely
incr
ease
the
num
ber
ofph
ysic
ians
wil
ling
toca
refo
rA
IDS
pati
ents
.
Ric
hard
son
etal
.198
7
HIV
/AID
S,C
hica
go,1
987.
Nea
rly
90%
ofth
enu
rses
and
mor
eth
anha
lfof
the
phys
icia
nssu
rvey
edre
port
edw
orri
esab
out
trea
ting
pers
ons
wit
hA
IDS.
Seve
nty-
two
perc
ent
ofnu
rses
and
57%
ofph
ysic
ians
wor
ried
abou
tth
eir
own
heal
th;5
6%of
nurs
esan
d41
%of
phys
icia
nsw
orri
edab
out
bein
gin
fect
edby
trea
ting
thes
epa
tien
ts;a
nd37
%of
nurs
esan
d25
%of
phys
icia
nsw
orri
edab
out
infe
ctin
gth
eir
fam
ilie
s.N
urse
sw
ere
also
less
like
lyth
anph
ysic
ians
orso
cial
wor
kers
tore
port
alw
ays
bein
gco
mfo
rtab
leta
lkin
gw
ith
AID
Spa
tien
ts.
Dw
orki
n,A
lbre
cht,
and
Coo
ksey
1991
SAR
Sou
tbre
akin
Toro
nto,
2003
.O
nem
onth
foll
owin
gth
efi
rst
SAR
Sca
se,r
etro
spec
tive
anal
yses
indi
cate
dth
atth
epr
omin
ent
reac
tion
sam
ong
hosp
ital
staf
fw
ere
fear
,anx
iety
,ang
er,f
rust
rati
on,f
atig
ue,i
nsom
nia,
irri
tabi
lity
,and
decr
ease
dap
peti
te.A
nxie
tyw
orse
ned
whe
nis
olat
ion
proc
edur
esch
ange
d,st
affe
nter
edqu
aran
tine
/tr
eatm
ent,
staf
fdev
elop
edfe
vers
,or
staf
fwer
ead
mit
ted
wit
han
uncl
ear
sour
ceof
infe
ctio
n.M
any
staf
fwer
eco
nfli
cted
betw
een
thei
rpr
ofes
sion
alre
spon
sibi
lity
ashe
alth
care
prov
ider
san
dfe
elin
gfe
arfu
land
guil
tyab
out
pote
ntia
lly
tran
smit
ting
illn
ess
toth
eir
love
don
es.N
urse
son
the
SAR
Sun
itdi
dno
tre
fuse
wor
k
Mau
nder
etal
.200
3
Emotional and Behavioral Consequences of Bioterrorism 435
assi
gnm
ents
,but
som
epr
ofes
sion
alan
dno
npro
fess
iona
lsta
ffon
gene
ralm
edic
alfl
oors
refu
sed
toca
refo
rpa
tien
tsw
ith
SAR
S.Tw
enty
-nin
epe
rcen
tof
resp
onde
nts
ina
hosp
ital
surv
eydu
ring
the
SAR
Sou
tbre
akex
peri
ence
dem
otio
nald
istr
ess,
mor
eth
ando
uble
that
seen
ina
gene
ralp
opul
atio
nsu
rvey
.Nur
ses
and
alli
edhe
alth
care
prof
essi
onal
sha
dsi
gnif
ican
tly
grea
ter
emot
iona
ldis
tres
sth
andi
ddo
ctor
san
dst
affn
otw
orki
ngin
pati
ent
care
.Par
t-ti
me
empl
oyee
sw
ere
also
mor
eli
kely
toha
vesi
gnif
ican
tem
otio
nald
istr
ess.
Nic
kell
etal
.200
4
SAR
Sou
tbre
akin
Hon
gK
ong,
2003
.Si
xtee
npe
rcen
tof
fam
ily
phys
icia
nssu
rvey
eddu
ring
and
imm
edia
tely
afte
rth
eSA
RS
outb
reak
repo
rted
spen
ding
less
tim
ew
ith
pati
ents
;7%
avoi
ded
phys
ical
exam
inat
ions
.P
hysi
cian
sin
priv
ate
clin
ics
wer
em
ore
like
lyth
anth
ose
inpu
blic
clin
ics
toqu
aran
tine
them
selv
esfo
ra
ten-
day
peri
odaf
ter
cont
acti
nga
SAR
Spa
tien
t(5
8%ve
rsus
31%
).P
hysi
cian
sin
priv
ate
clin
ics
wer
ele
ssli
kely
than
thos
ein
publ
iccl
inic
sto
repo
rtst
ayin
gaw
ayfr
omho
me
topr
otec
tth
eir
fam
ily
(5%
vers
us19
%).
Won
get
al.2
004
Ind
ust
rial
Eve
nts
/Ch
emic
alT
erro
rism
Sari
nga
sat
tack
inTo
kyo
subw
ay,M
arch
1995
.Se
cond
ary
cont
amin
atio
nw
asfo
und
in10
%of
fire
figh
ters
and
emer
genc
ym
edic
alse
rvic
ew
orke
rs,a
nd20
%of
hosp
ital
staf
fbe
caus
eof
lack
ofde
cont
amin
atio
npr
oced
ures
.
Oku
mur
aet
al.1
998
Eig
hty-
seve
nha
zard
ous
mat
eria
lsin
cide
nts
inW
ashi
ngto
nSt
ate,
Dec
embe
r19
97–O
ctob
er19
99.
Som
atiz
atio
nw
asth
eon
lyps
ycho
logi
cals
core
stat
isti
call
yel
evat
edab
ove
the
norm
ativ
epo
pula
tion
wit
hin
40da
ysof
expo
sure
;pr
ior
trea
tmen
tfo
ra
psyc
holo
gica
lcon
diti
onw
asas
soci
ated
wit
han
incr
ease
dri
skof
som
atiz
atio
n.
Kov
alch
ick
etal
.200
2
436 Bradley D. Stein et al.
assignments, and a few family physicians avoided physically examiningpatients or stayed away from home to protect their family (Maunder et al.2003; Nickell et al. 2004; Wong et al. 2004). Many of the emotionaland behavioral reactions and fears of contagion reported by health careworkers in response to SARS are similar to those documented more thana decade ago in the early phases of the HIV/AIDS epidemic (Dworkin,Albrecht, and Cooksey 1991; Gallop et al. 1992; Richardson et al. 1987;Searle 1987; Treiber, Shaw, and Malcolm 1987).
Less has been written about first responders, emergency workers, andhealth care professionals responding to industrial events or chemicalexposures, but what is available indicates that these groups are at riskfor secondary contamination as well as primary contamination and arealso at a higher risk of emotional distress.
Emotional and Behavioral Consequences for Vulnerable Populations. Manystudies have identified factors that put individuals at risk for more seriousemotional and behavioral consequences following a disaster; fewer studieshave specifically examined the emotional and behavioral impact of massviolence and terrorism in vulnerable populations. Table 5 focuses on twoparticularly vulnerable populations: children and those with a history ofpsychiatric disorders or psychological problems.
Studies of children suggest that they may warrant special attentionand may be at greater risk than adults are of developing emotional dis-tress and other adverse behavioral consequences of terrorism. The data onindividuals with current and previous psychiatric disorders are mixed.Many studies found that individuals with a previous psychiatric illnesswere more likely to develop posttraumatic stress symptoms. However,studies that specifically looked at persons who currently had clinical dis-orders (substance abuse, PTSD, etc.) had differing results regarding howthe disaster affected health care service use, increase in illness severity,or return to substance use.
General Lessons from the Literature Review. The studies just summarizeddefined the populations of interest in slightly different ways and useddifferent methods to assess emotional and behavioral reactions. There-fore, comparisons across studies must be made with care. Nevertheless,our literature review of the emotional and behavioral consequences ofearlier terrorist events, communitywide disasters, and potentially anal-ogous events offered several lessons that can help us prepare for futurebioterrorist events.
Emotional and Behavioral Consequences of Bioterrorism 437
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Emotional and Behavioral Consequences of Bioterrorism 439
• A broad range of emotional and behavioral reactions are likely afteran event.
• Widespread emotional reactions such as fear and anxiety are themost common. Less common is the development of clinical disor-ders such as PTSD. Many reports, however, do not clearly differen-tiate the level of emotional reactions (e.g., clinical levels of PTSDversus subclinical levels of symptoms of posttraumatic stress versusmore general anxiety), thereby making a comparison of the studiesdifficult.
• Events in which the perceived threat is greater than the tangi-ble exposure (e.g., biological events, radiological exposure, manychemical events) are likely to stimulate more sustained emotionaland behavioral consequences.
• When the perceived threat is greater than the tangible exposure,a relatively large number of people in the nearby population maychange their behavior with respect to seeking medical care. Thiseffect should not be equated with panic. Rather, these people oftenpresent with physical (e.g., somatic) complaints or for screening.Little empirical research, however, has systematically examined therelationship between emotional reactions and behavioral reactionsafter such events.
Observations from the Experts
The experts we interviewed generally agreed on the important differencesbetween bioterrorism and other events, but they offered a variety ofopinions about what these differences implied for planning and research.
Several interviewees noted that the plans and preparation for bioter-rorism must go well beyond what is currently in place for other typesof communitywide disasters. For example, uncertainty about exposuremeans that individuals across broad geographic areas are likely to per-ceive themselves as being at risk following a bioterrorist event, even ifall confirmed cases are confined to a single state or geographic region.Accordingly, a response plan should extend beyond those areas in whichthere have been documented infections. Commenting on the experienceof the anthrax attacks, one expert observed that a bioterrorist attackanywhere in the country would require public health officials in all 50states to activate some components (e.g., heightened surveillance) of theirresponse plan. As was noted, “A new model [will be needed] for respond-ing in a situation with cross-jurisdictional issues.”
440 Bradley D. Stein et al.
All the experts agreed that effective communication will be criticalto addressing the public’s fear and anxiety in the event of a bioterror-ist attack and reducing the likelihood that unaffected individuals willflood the public health triage system. Several experts emphasized theimportance of local risk communication strategies to complement theinformation likely to be provided by national authorities. As one in-terviewee remarked, “National messages just aren’t very personal.” Butseveral experts maintained that we lacked empirical data to modify thecommunication strategies necessary for bioterrorism. According to oneexpert, “We really don’t understand the psychological context in whichwe are delivering our messages, nor whether they are really addressingthe needs of the community. We need to better understand [it] so wecan modify our messages and target our outreach.”
Another interviewee added, “Communities are not made up of ho-mogenous groups. In order to respond effectively, we must strive to un-derstand how different subgroups will respond differently.” Accordingto several others, “We need a new model of how to deliver mental healthsupport and services for bioterrorism.” Many felt that organizations likeschools, churches, employee assistance programs, and employers whoalready have relationships with large and specific segments of the com-munity would be an important part of such a response. Such organiza-tions can help educate the public, offering basic knowledge of biologicalagents and likely public health response plans and thereby enhancingthe public’s understanding and preparedness. These organizations arealso well positioned to give information and support to individuals withparticular concerns or needs, thus greatly increasing the effectiveness ofthe overall response. But several interviewees observed that “we probablyneed organized efforts to train ministers, teachers, and others about theirpotential roles in psychological management” after a bioterrorist attack.An additional benefit of a broad-based community response noted byseveral experts is that it would concentrate more on individual and com-munity resiliency and less on emotional reactions and clinical psychiatricdisorders.
Many interviewees pointed out that while we have effective treatmentfor individuals with PTSD from a variety of traumatic events, we cur-rently know little about what helps those traumatized by mass violence,in which many in a community are traumatized by a single event. Manyechoed the consensus panel of the National Institute of Mental Health(NIMH), which called for a larger base of evidence regarding effective
Emotional and Behavioral Consequences of Bioterrorism 441
early interventions for specific populations across different settings. Theinterviewees also recognized the importance of determining how to treateffectively those persons who do develop psychiatric disorders, such asPTSD and major depression, as a result of bioterrorism. However, theexperts also felt that relatively few would develop psychiatric disorderssuch as PTSD and major depression solely as a result of a bioterroristattack and suggested that efforts to improve services to such individualsshould not distract policymakers from the more global issues of man-aging changes in behavior (e.g., staying home, becoming hypervigilant,demanding more health care information, avoiding community involve-ment) that could be associated with bioterrorism. Several experts alsonoted that bioterrorism presents the additional challenge of devisingplans to support health care workers, first responders, and others im-portant to an effective public health response to a bioterrorist event, aresponse that is likely to be characterized by greater uncertainty aboutthe level of risk for longer periods than in most other disasters.
Discussion
As highlighted in our review of the literature and interviews with experts,policymakers making bioterrorism prevention and response plans facemany critical gaps in knowledge, such as the following:
1. What are the range and severity of the expected emotional andbehavioral consequences?
2. To what extent will these emotional and behavioral consequencesaffect the public health response?
3. How can our preparation and response to bioterrorism capitalizeon and enhance the effectiveness of natural supports in our society?
4. What aspects of risk communication are most useful for and ap-propriate to a response to bioterrorism?
5. What interventions should be used to reduce the emotional andbehavioral consequences of a bioterrorism event?
The Uncertain Nature of the Threat
The increased psychological effect that results from uncertain exposureto an invisible agent has previously been recognized (Holloway et al.
442 Bradley D. Stein et al.
1997). Many experts noted that this uncertainty requires the modifica-tion of many existing disaster response plans. These concerns also weresupported by our literature review, which found high rates of emotionaldistress and behavioral changes stemming from those events that in-cluded uncertainty about exposure. Furthermore, in a bioterrorist event,the lag between exposure and the development of symptoms may exacer-bate this uncertainty. Inaccurate knowledge about the organism involvedmay also hamper response plans and should be addressed by public healtheducation programs. For example, for months after the anthrax attacks,many Americans were still not sure whether anthrax was contagious,despite media announcements that it was not (Blendon et al. 2002; LisaMeredith, personal communication, February 13, 2003). The public andthe health care community should be given basic knowledge of the or-ganisms likely to be used in a bioterrorist event and the planned publichealth response (Ferguson et al. 2003). Such efforts would remove someof the uncertainty among the public and first responders and wouldbegin to define some of the risk/benefit issues with regard to a response.
One component of response plans about which we know very little ishow the behavior of those responsible for coordinating and conductingan effective public health response would be affected by uncertaintyabout exposure. Not only could these persons be at risk as a result oftheir professional activities, but in a number of scenarios their familiesalso might be at risk. The actions of the first responders and healthcare professionals cannot be taken for granted. One survey of physiciansreported that more than half would not be willing to put themselves atrisk of contracting a deadly illness in order to save the lives of others inthe event of a bioterrorist attack (Alexander and Wynla 2003), and fewerthan half of emergency department physicians surveyed were willing toget the smallpox vaccine (Kwon et al. 2003). Such attitudes and behaviorson the part of health care professionals are not unique to bioterrorismand were expressed during both the SARS outbreak of 2003 and theearly years of the HIV/AIDS epidemic.
Providing rapid and accurate information to the public in the eventof a bioterrorist event is, therefore, critical to reducing uncertainty (U.S.Department of Health and Human Services 2002) and should be joinedby the efforts of local, state, and federal governments to enhance surveil-lance for a bioterrorist attack and increase lab capacity to rapidly identifya bioterrorist agent. By its very nature, however, bioterrorism will al-ways carry with it a high level of uncertainty, particularly during the early
Emotional and Behavioral Consequences of Bioterrorism 443
stages of an attack. Accordingly, response and mitigation plans must bedesigned with this inherent uncertainty in mind. Robust strategies areneeded to address the needs of communities that are unsure of their levelof risk and recognize that this uncertainty may also affect the behaviorof first responders and health care professionals.
Currently, however, we have little empirical information about howuncertainty regarding the threat or level of risk affects an individual’semotional and behavioral reaction. Studies of those persons exposed toanthrax will increase our understanding of these reactions related tobioterrorism. In addition, we should study events that, while not bioter-rorism, are sufficiently similar that they can help us understand thepublic’s emotional and behavioral reactions when facing an event withan unknown level of risk. Recent examples include the spread of WestNile virus and the SARS infection, as well as the HIV/AIDS epidemic(Nicholas, Tredoux, and Daniels 1994). In such cases, in which exposureto the threat is not apparent, how do people determine their own riskof exposure (and that of their families), and how does this perceived riskaffect behavior of the general public, first responders, and health careworkers?
The Role of Natural Support Systems
In the past, planners and policymakers were often able to assume thatthe duration of the actual disaster would be relatively brief. Therefore,their plans to address the psychological impact of disasters often re-lied on the deployment of mental health professionals after the event. Abioterrorist attack, however, may require the public to shelter-in-placefor an extended period or to observe social distance practice and contactmanagement (e.g., isolation, quarantine, and other restrictions on move-ment) in order to control the risk of contagion, thus needing emotionaland behavioral supports during the event and perhaps complicating thedeployment of mental health professionals.
One way to address these issues is to include natural support systems,such as schools, family physicians, and clergy and other faith-based orga-nizations, in communitywide emotional and behavioral response prepa-ration and planning. These natural supports are often not formally in-tegrated into a community’s disaster response plan, even though theirimportance in helping individuals deal with disasters and other trau-matic events has been widely demonstrated (Schuster et al. 2001; Silver
444 Bradley D. Stein et al.
et al. 2002; Stein et al. 2004). Support systems also provide a naturalavenue through which to educate the public as part of preparing for andresponding to a bioterrorist event.
The extent to which people can draw on natural support systems overtime is limited (Pennebaker and Harber 1993), and little is known abouthow more formal mental health response systems will function underconditions of continuing and uncertain risk. We therefore should lookat how people use the natural emotional supports in their community tohelp them cope over time when a threat does not pass quickly (e.g., SARS;the Washington, D.C., snipers; West Nile virus). There is little doubtthat the support of family, friends, the clergy, and others to whom peoplenaturally turn will be vital after a bioterrorist event. Policymakers andplanners will be able to make better-informed decisions about the bestuse of such resources in preparing for and responding to a bioterroristevent by examining the following issues:
• How should schools, faith-based organizations, and the health caresystem prepare for such events, particularly with respect to educat-ing the public and first responders?
• How should schools, faith-based organizations, and the health caresystem mitigate and manage the emotional and behavioral issuesassociated with such events?
• How can we best use natural support systems to provide emotionalsupport following a bioterrorist event?
• How can the educational materials commonly distributed by pro-fessional organizations and experts to help people cope be moreuseful during these more sustained events, or how can they beimproved?
The Role of Risk Communication
Numerous efforts are now under way to help local, state, and nationalpublic officials refine their risk communication strategies, particularlythose involving the media (U.S. Department of Health and HumanServices 2002). These efforts are based on well-developed theories andtheir application after events such as exposure to industrial hazardsand contaminated drinking supplies (Commission on Risk Perceptionand Communication 1989; Fischhoff 1995; Johnson and Slovic 1995;Rowan 1994; Sandman 1991, 1993). The applicability of such events to
Emotional and Behavioral Consequences of Bioterrorism 445
bioterrorism, however, may be limited because of bioterrorism’s inten-tional nature and the relative unfamiliarity of both the public and medicalcommunity with the likely agents.
It is important to understand how risk communication strategies canbest address sociocultural differences. As was apparent in the aftermathof both the anthrax attacks and the smallpox inoculation efforts, differ-ent groups in our society have very different life experiences and beliefsthrough which they view official communications regarding bioterror-ism and related health behaviors. The collaborative and multigroup ap-proach that the Institute of Medicine recommends is essential to a publichealth approach to these issues (Institute of Medicine 2003). Better un-derstanding these issues must be a priority, especially considering theimportance of risk communication to mediating, mitigating, or promul-gating emotional and behavioral responses in the event of a bioterroristattack, and given the reality that an effective public health response willlikely require communitywide action.
Events other than bioterrorism, in which the certainty about the levelof risk to a community is not known, may provide an opportunity toevaluate the impact of different risk communication strategies. Collabo-ration among researchers, decision makers, and funding agencies beforesuch an event would allow the development of a research design thatcould be used to test the effectiveness of different risk communicationstrategies. This planning would allow an investigation to be fielded quiterapidly, thus beginning to build an evidence base on which future riskcommunication strategies could be built.
Knowing When, Where, and How to Intervenein the Event of a Bioterrorism Attack
The NIMH’s consensus report on early intervention after mass trauma ac-knowledges that the current evidence from randomized, well-controlledtrials cannot definitively confirm or refute the effectiveness of such earlyinterventions. But even this limited evidence does permit several con-clusions: (1) any early intervention should consider the hierarchy of avictim’s needs, including safety, food, and shelter; and (2) the importantelements of early intervention activities are an assessment of needs, thedissemination of information and the education of directly affected in-dividuals and the general public, and the facilitation of natural supportnetworks (National Institute of Mental Health 2002).
446 Bradley D. Stein et al.
We do have effective treatments for adults and children with clini-cal disorders such as PTSD and depression that commonly occur aftertrauma. Several experts underscored the importance of ensuring that in-dividuals with such disorders have access to these evidence-based treat-ments in both traditional mental health treatment settings and otherless traditional settings, such as primary care for adults and schoolsfor children. Few studies, however, have examined the effectiveness ofsuch interventions delivered in such settings (Stein et al. 2003). Treat-ing these disorders after a bioterrorist event may also be complicatedby reminders of the trauma, as well as the continuing stress associ-ated with the possibility of future attacks and any related economicdisruption.
Additional research on the emotional and behavioral consequences ofterrorism and terrorist-like events will also lead to the continued devel-opment and evaluation of interventions. We still need to understand howinterventions and response strategies might differ according to the typeof event or agent (chemical versus biological, etc.). We need to knowwhether different populations would require different types of interven-tions, how interventions should be modified to be culturally relevantand responsive to local conditions, and whether these interventions needto change over time to meet different demands. In addition, we mustdetermine to what extent interventions are appropriate and effective inthe different settings (e.g., primary care clinics, schools) in which theyare likely to be delivered.
Conclusion
Faced with continued threats from weapons of mass destruction andmounting concerns about bioterrorism, our nation urgently needs toconsider how best to meet the challenges associated with managing theemotional and behavioral consequences of these acts of violence. If theanthrax attacks and the sniper attacks in Washington, D.C., taught usanything, it is that events like bioterrorism, in which the level of risk isuncertain for a prolonged period, create emotional distress responses andbehavioral changes in far more individuals than are physically at risk.Substantial efforts and funding are still needed to understand and preparefor the emotional and behavioral consequences likely to be associatedwith bioterrorism. At the same time, many of those efforts directed
Emotional and Behavioral Consequences of Bioterrorism 447
at improving our response to bioterrorism will allow us to be betterprepared to face a range of current public health problems.
We already know about the emotional and behavioral effects of terror-ism and of nonterrorist events that contain some of the components ofbioterrorism. Our preparations and response planning must draw from allthese sources. But only by examining how people respond to such eventsand by learning how these responses can be modified by community-wide responses can we develop evidence-based assumptions about howpeople within and across communities will react to bioterrorist events.This new knowledge will be essential to improving our response strate-gies, including the use of natural support systems, risk communicationtechniques, and effective treatment interventions.
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Acknowledgments: We are indebted to Jaceyln Cobb and Jennifer Green for theirresearch assistance; Mary Vaiana and Kenneth Shine for their comments on themanuscript; Alaida Rodriguez, Shannon A. Thomas, Stephanie D. Thompson,and Summer Haven for their assistance in preparing the manuscript; and tothose individuals who shared their expertise in our interviews. Support for thisstudy was provided by the RAND Corporation, the NIMH (K23/MH00990),and the Centers for Disease Control and Prevention (U48/CCU915773).
