Leading During Times of Trouble: A Roundtable Discussion of Recent Terror Events

Biosecur Bioterror. 2003;1(2) 


In February 2003, a panel was convened as part of an invitational summit on leadership during bioterrorism, titled "The Public as an Asset, Not a Problem."1 The goal of this meeting was to synthesize for government and public health authorities some essential principles of leadership that encourage the public's constructive collaboration in confronting a bioterrorist attack, based on frontline experiences with recent terrorism events and other relevant crises.2 More than 160 people attended, representing senior operational decision-makers in public health and safety–including bioterrorism coordinators from 35 state and local health agencies–as well as thought leaders in medicine, public health, nursing, hospital administration, and disaster relief.

The roundtable discussion, focusing on how to lead a community during times of trouble, was moderated by Dr. Tara O'Toole, Director of the Johns Hopkins Center for Civilian Biodefense Strategies and Coeditor-in-Chief of Biosecurity and Bioterrorism. The other participants were seasoned political and public health leaders, and representative constituents, who had had to confront a recent terrorizing event, including the Washington, DC-area sniper shootings, the anthrax letter attacks, the World Trade Center attacks (2001, 1993), and the Oklahoma City bombing:

Georges Benjamin, MD, was trained in internal medicine and was a practicing emergency medicine physician. He was formerly the Commissioner of Health for the District of Columbia and the Commissioner of Health for the State of Maryland (1995-2002), and he is currently Executive Director of the American Public Health Association.

Edward Clarke has had a distinguished career in law enforcement, including community policing. He is Director of School Safety and Security, Montgomery County (Maryland) Public Schools, a position he held during the sniper attacks of 2002.

Tom Day is Vice President of Engineering, U.S. Postal Service, which employs more than 750,000 people. He and his staff managed the postal system response to the anthrax attacks of 2001.

Margaret Hamburg, MD, was formerly Assistant Secretary of Health and Human Services, where she set up the CDC bioterrorism program, and New York City Health Commissioner, a position she held during the first World Trade Center bombing in 1993. She is currently Vice President for the Nuclear Threat Initiative program in biological weapons and bioterrorism.

Ronald J. Norick is a three-term Mayor of Oklahoma City (1987-1998). He was mayor during the 1995 bombing of the Murrah Federal Building and later convened a committee to create the Oklahoma City National Memorial. He is now a prominent social and business leader in Oklahoma City.

Sally Quinn is an author and a reporter for The Washington Post. During the anthrax crisis, Ms. Quinn wrote an article about the need for officials to provide the public with better information about how they should protect themselves from the anthrax threat.

Ivan C. A. Walks, MD, is former Chief Health Officer for Washington, DC, and he led the public health response in DC during the anthrax attacks of 2001. He is now CEO of Ivan Walks and Associates, a consulting firm dedicated to proactive health security, with a focus on the specific opportunities and challenges facing urban communities.

Peter Sandman, PhD, is one of the world's preeminent risk communicators. He has helped public officials and others negotiate a wide range of controversial crises in the course of his career. He is now advising the New York Department of Health on bioterrorism preparedness and communication. He is also a Professor of Environmental and Community Medicine at Rutgers University.

Dr. O'Toole: We're going to ask our panel members, all of whom have been leaders in different contexts and in different crises, to share with us their recollections, their insights, and the lessons from their own experiences, and from observations of other leaders through the course of challenging crises.

Dr. Walks, I want to ask you, as someone who was in the confusing firestorm of the immediate aftermath of the anthrax attacks, how you managed to maintain your credibility in the course of ever-shifting information. At one point, for example, we believed that postal workers who hadn't been exposed to open envelopes were safe from anthrax, and we found that that was wrong only after the tragic deaths of two postal workers from Brentwood. How do you go with the flow, with facts changing as quickly as they were during the anthrax attacks, and still be a leader?

Dr. Walks: You start by remembering who you are, and where you come from. My mother always told me, if you honestly tell people what you don't know, they'll believe you when you come back to tell them what you do know. And that one pearl stayed with me throughout all of the shifting facts.

The other thing that, again, goes back to my own community and my own neighborhood is that it's very difficult to come to someone and say, "Trust me." Trust is garnered through experience with consistent behavior, so if you behave the same way, people begin to trust that that is how you will behave. And you can build credibility that way.

With respect to what happened during the anthrax attacks: people were very concerned, they felt they were being treated unfairly, they felt that people were just flat out lying. I find that during a time like that, it helps if you can use examples. For instance, when people asked, "Dr. Walks, how do you know that the post office people didn't know that there was [anthrax contamination]?" The answer was, "The Postmaster General had a press conference in the back Brentwood work area. Do you think that if he knew it was dangerous, he would have gone back there?" That kind of anecdote helps to break through, because no matter how technical you try to talk to people, people want to know about real life experiences. They want a real story, and then they want someone who will come and stand in front of them when they know everything–and when they don't know everything–but always be honest.

Dr. O'Toole: Ed Clarke, you were also in the midst of a very complicated and scary set of events with the sniper attacks of last fall. You had to balance a lot of different stakeholder groups and maintain their trust, including the parents of all of Montgomery's school kids, many of whom were anxious about the decision to reopen the schools two days after the first attack. What do you have to say about maintaining trust in stakeholder communities?

Mr. Clarke: It's about getting out accurate, timely, and factual information, and not being afraid to stand up and say we don't have all the facts at this time, but we're working very, very hard to get you the most accurate information, to provide the senior level decision-makers, the superintendent of the schools with good recommendations. What should we do? Should we open on time? Should we delay our openings? What information do we share? How do we coordinate that information with the lead agency that is charged with investigating these homicides in Montgomery County and outside Montgomery County (Chief of Police Moose)? It's important to have those relationships and be able to get information back and forth so the senior decision-makers can give good information to a variety of stakeholders.

Dr. O'Toole: Did the fact that you had been a cop play an important role in your ability to be a player in that decision?

Mr. Clarke: Absolutely. I think that was a critical role for me to play, having come from the county police department that was leading the investigation, just removed two years from retirement. In my role, we were now a consumer of public safety services, so it's important to have those relationships.

I was dispatched to the police command post. Ironically, the day of the first shooting in Montgomery County, the very first homicide, the police department was also burying one of their own officers who had died unexpectedly. I was at the service and the chief called me directly on the cell phone; there was a rumor circulating that the superintendent might be considering school early dismissal. The chief said, "Ed, here's what I need you to do. Please get with the superintendent, inform him that everything is okay, and we'll share information." So that relationship and the confidence that the chief had in me to go directly to the superintendent as sort of a broker were valuable and important.

Dr. O'Toole: Tom Day, you also were in a very difficult position during the anthrax attacks. You had many different stakeholders that you had to answer to. Your bosses in the postal service, CDC, and Dr. Watts' department were also giving you information. You had to deal with the union leadership, as well as the rank and file. What was that like?

Mr. Day: The leadership really came right from the top. Importantly, Postmaster General Jack Potter came up through the ranks of the postal service. He's a career employee and spent much of his career working to improve labor relations. From the very onset of the problem, we had daily meetings with our unions and management associations so that they had the latest information. But obviously, this was a daunting task. We have 750,000 employees to communicate with. They're spread out amongst 38,000 locations, so getting a clear, consistent message out to them is not an easy logistical task in and of itself. And then we service the entire U.S. population–the 280 million-plus consumers who see us six days a week–so it's not an easy thing to do. But clearly, communicating to them, getting them accurate information was essential.

Dr. O'Toole: So I'm hearing communication, communication, communication here.

Mr. Day: I think the key is not just talking. It's letting people know what you know, but also being honest with what you don't know. I think the defining moment for Jack Potter came in a meeting I was involved in. From the original event on October 15th, and then the deaths of Mr. Curseen and Mr. Morris on the 21stand 22nd, obviously, the whole situation progressed rapidly. The question arose is the mail safe? We discussed that in a meeting, and there were those pushing that we ought to say it's safe because there was a huge potential for financial problems. The postal service in general (that's the whole mailing industry) represents 8 percent of the gross domestic product. It's a large industry and employs 9 million people. But the reality was we couldn't really say the mail was safe. In a defining moment, he very publicly admitted that, no, we cannot say that at this time. So you've got to be honest.

Dr. O'Toole: Georges, you and Ivan Walks have an interesting story about the difficulty leaders sometimes have getting good information during a crisis. Can you tell us about your late night tryst with Dr. Walks, beginning with the anthrax event?

Dr. Benjamin: Well, it was a very interesting dynamic in that the world was centered around Washington, DC, and Maryland and Virginia were pretty much considered outliers, which meant that we were not in the information flow initially at all. So one night, I decided to insert myself into the information flow and met Ivan on the corner outside his house. We sat in his kitchen all night, and we talked about communication and ways in which we could improve communications. And ultimately, one of the things that happened was we met with the CDC and got liaisons in place between Virginia and Maryland. A lot of communication was going on at the lower levels between staff, but there was not a lot of communication at the upper levels. And when we had a governor, or mayor, or the White House on the phone wanting to get answers, they understood we were part of the process, but the infrastructure did not, and so we had to create that on the fly.

Dr. O'Toole: So what's the sound byte there to leaders in the midst of a crisis where it's murky what's going on?

Dr. Benjamin: I think it is this: Don't just sit there and accept it. Go find the information that you need and create the opportunities to solve your problems.

Dr. O'Toole: Dr. Hamburg, you've had many interesting crisis experiences in your life, one of which was mentioned earlier today. It involved the outbreak of plague in Surat, India, when you were New York City Commissioner of Health. Could you tell us a little bit about what went through your mind, and what you did, and how you dealt with all of the uncertainties and the implications of decisions in that kind of crisis?

Dr. Hamburg: We got a call about the seriousness of this plague outbreak in India, and the fact that we needed to be aware that there was going to be a lot of travel potentially between the Indian community, which is quite large in New York City, and India because there was a major Indian festival going on in New York City. When we looked into it, there were 36 flights a day that either came directly into Kennedy Airport or had a brief stopover. So we began thinking about how you would deal with imported cases of plague, and proactively set up a program to try to address how we would screen patients, screen potential—

Dr. O'Toole: How much warning did you get? I mean, what kind of preparatory time was involved to set up the programs?

Dr. Hamburg: This wasn't an acute crisis. There was an outbreak going on in India. It was actually poorly defined, but seemed quite a bit worse. It clearly was causing major disruptions. When I realized that this was something we didn't seriously think about, and that we didn't necessarily have the capacity to deal with proper isolation and management of a lot of cases of importing plague, I thought it might be good to brief Mayor Giuliani about the preparations that we were putting in place. We identified triage hospitals and worked with CDC to develop a screening approach at Kennedy Airport for individuals coming off of airplanes who might be symptomatic, and we put out bulletins to all frontline health care providers about what to look for and who to call if they saw a certain set of symptoms.

Initially, I got a very brusque response that the mayor really didn't need to be briefed about plague in India. He could read it in the New York Times. But then I called back and left a message: Was he aware that there were 36 flights per day that came directly into New York City, or with a brief stopover? Then he personally got on the phone and said, "Should we close Kennedy Airport?"

Dr. O'Toole: Knowing how to get colleagues' and bosses' attention is definitely one of the key skills of leadership. I noticed that in the conversations earlier today, there's the sense that information flows quickly, naturally. That's not usually the case in my experience. Does anybody have a really good worst nightmare story of having to deal with a boss who didn't get it, or a colleague who was fighting turf battles when the ship was going down, and what you do in that situation?

Dr. Walks: I can tell one. The person who didn't get it was me, and the person who came up and told me I didn't get it was Bob Malson, head of the D.C. Hospital Association. When you're in the government you think what you're doing is very important, and you've got your colleagues, and you're moving right ahead. Bob called and said, "Ivan, I don't know what the hell you're doing, because I don't know, and there's no communication set up with the outside community." It was one of the critical junctures that helped all of us during the anthrax attacks. With Bob's leadership, we set up a routine, 10 a.m. conference call every day that got all of the folks from Maryland, Virginia, the military health system, the hospitals, primary care folks, and the health department all on one call to share information. I was the one who didn't get it, but I had good friends who were able to call and say, "You're not getting it. You need to do it this way."

Dr. O'Toole: Georges, at one point in the anthrax response, there was a moment when the District of Columbia, Virginia, and Maryland were about to issue contradictory prophylaxis guidelines. It was nipped in the bud, and things were coordinated, but can you say a little bit about how that happened, and how it got fixed, and what you did afterwards?

Dr. Benjamin: The fundamental issue was, when do you stop antibiotics? We had different recommendations from the federal government and the local jurisdictions. It all revolved around the debate about what trace anthrax was. The testing was qualitative, not quantitative, so nobody knew what "trace" meant.

Dr. O'Toole: I still don't know what it means, actually.

Dr. Benjamin: Ivan and I were very uncomfortable taking people off antibiotics whom we had put on antibiotics until that facility had been cleared. And there was a discussion of a federal recommendation to take people off the antibiotics. Ultimately, we came to near agreement. We still had varying recommendations out there, but they were much more narrow when we were all done. I think actually our recommendation was very similar to what New Jersey ultimately did, but it was based on this belief that you couldn't get sick unless you had 8,000 spores, and we all know ultimately that turned out not to be true.

I think that the take-home message was that it is okay to disagree, because what we ultimately decided was that we would disagree on the narrow clinical question, but that we would explain it so that we all understood the rationale for doing it differently. That was a very, very tricky communications message. I happen to believe that we were right in the end, and we saw that in Connecticut and other places where people apparently got sick from very, very low doses of anthrax.

Dr. Sandman: I want to reinforce that, because it's a point that hasn't come up all day, and I think it's an enormously important point–that when mommy and daddy disagree the kids really can take it. What the kids can't take is if mommy and daddy hate each other. That's another story, but two authorities like CDC and the health department that are respectful of each other's opinions, each of which is capable of explaining its own opinion and the other's opinion and why they reached somewhat different conclusions, does not leave the public in the lurch. It leaves the public understanding that there is a dilemma here, that the answer isn't obvious, and that honorable people who are working well together reached somewhat different conclusions. I know my clients are terrified that if they don't speak with one voice, the kids will go crazy. I think it's a false fear, and the kids can take it.

Dr. Hamburg: I basically agree about open discussions, but I think it puts an additional burden on leaders to really speak to the public and explain the issues so that people don't come away with only the sense of confusion, that even the experts can't tell me what to do. I think that in the anthrax incident, there was an unfortunate episode around the use of the vaccine that I think didn't reflect well ultimately on public health leadership. The data were inadequate, and it was confusing as to whether or not vaccine should be used with people who had been exposed, and/or potentially exposed, and had gone on antibiotics. There were several standing recommendations that said, yes, they should be, but it hadn't really been broached until the very end of the treatment period, the 60 days of antibiotic therapy. And then there was a lot of discussion about the pros and the cons, and the inadequacy of the data, and the problems with the monkey models that had been used, and so on.

Finally, the recommendation that formally came out was that the data were too confusing, so discuss it with your personal physician and make your own decision. I think that was very unhelpful. I was struck by it at the time, and I was on a panel a few weeks ago with Leroy Richmond, the postal worker who had inhalation anthrax and did pull through. And he said, you know, I was looking for leadership, and I really felt let down. The data may be confusing, but don't tell me to talk about it with someone who knows even less.

Dr. Sandman: People do feel let down when they're not told precisely what the answer is. But leadership means letting them down gently, if you don't know precisely what the answer is.

Dr. Hamburg: But giving them as many tools as you can in order to make a good decision. I think it's right that if there isn't an answer that's clear, you don't give it. But I think you have to realize then you have an additional burden of responsibility to take the time to educate the public, explain the information, and make sure that there are resources in their community that are well educated about it as well, that they can turn to.

Dr. Sandman: I agree. And they should understand that you're not saying we hate each other but that we can't agree. What you're saying is, we agree it's a difficult decision, and one of us came down on one side of that difficult decision, and another of us came down on the other side.

There's a spectacular example right now with smallpox vaccination, where lots of people think ACIP was right and many fewer people should be vaccinated than the President decided, and lots of people think that Vice President Cheney was right and we should vaccinate humongously more people. And that difference of opinion depends mostly not on what you think are the side-effects of the vaccine, but on what you think is the probability of a smallpox attack. Now as we reach out to healthcare workers and give them pretty much exactly the same situation–that is, you can get the vaccine if you want it. You don't have to take it if you don't want it. It's voluntary. It's up to you–the task is, I think, to explain to them why some people think it's a good idea and some people think it's a bad idea.

Dr. Walks: I don't like that, because what typically winds up happening is that you have people making individual decisions that fall out along resource lines. We saw this with anthrax. We see it with health literacy differences, primarily folks who understand what you're talking about when you're trying to explain it. And we saw things move out along racial lines, and it's very, very dangerous during a public health crisis to have behavior fall out along racial, religious, ethnic, or age lines.

Public health is really very simple during a time of crisis. It's shelter in place; it's line up for the vaccine. It can't be, you decide what you want to do. With anthrax maybe, okay. If you don't take it, you die. But with something contagious, you don't take it, many others may die. So I think that leadership is going through all of those gyrations about who's right. But then there needs to be a clear leadership recommendation–not an order, but a clear recommendation that fits everybody in this risk group.

Dr. O'Toole: Sally Quinn, you wrote a very widely noted article in the midst of the anthrax response, saying in effect that you weren't hearing coherent advice from public officials, and you called many of them personally to ask what you should do to protect yourself and your family. What do you think about this exchange?

Ms. Quinn: Well, actually there are two pieces. One of them, which was for the op-ed page, was extremely provocative. I had watched Tommy Thompson on 60 Minutes where he had said, "We're prepared," and it just drove me crazy because I knew that we were not prepared. We weren't getting any kind of advice from the government at all on what to do. Should people have gas masks? Should people have Cipro? The gas mask stores were sold out. So I did a piece about that.

And then I did a follow-up piece for Outlook on whether the government actually was prepared, and I called everybody: Homeland Security, the White House, the Pentagon, and FEMA, and Bob Malson [head of the DC Hospital Association] is the only one who gave me any decent information. He actually had figured out how to at least create some sort of communication in the city among the health care facilities and the police and all of that.

But I think the thing that's important for all of us to realize today is that what we're all talking about here on this panel are things that happened that we were not expecting. And now one of the reasons that we're all here today is that we are expecting the unthinkable. It's not unthinkable any more. It's possible; it might even be probable, particularly if we go to war in Iraq.

I now feel even more strongly that the government should inform us–just give people the basic idea of how to protect themselves. There is a view, and it has been reiterated over and over and over on the panel today: information, information, information. We can take it, and people are less likely to panic, the more information they have. What I found was that nobody wanted to give out information, because they were afraid to say, well, you should have a mask, an N-95. I carry it with me at all times, it cost a dollar. Or if you want to put bottled water in your house, or have extra money, or flashlights or batteries, it seems to me that that's basic.

Even in California when they have earthquakes, or in the Midwest when they have hurricanes, they give you that basic information. People say, oh well, it's on the website; you can look it up. But I think we need to have somebody, particularly in places that are target cities like Washington, DC, there should be guidelines. There should be neighborhood organizations. The government should come out and say, "This is unlikely but we're going to be in a war. We had air raid shelters during World War II. We need to be prepared. The citizens need to be prepared."

After I did my last piece, Senator Bill Frist called me up and said, "You know, I was so horrified to see what you had written. All these people in the government not having any answers at all, and I might even write a book about it." He did, and one of the things he did was to include a list of things that everybody should have in their house: a radio with batteries, extra water, cash, medicine, and that kind of thing. I just don't see why, particularly now, we can't be given guidelines by the government as to what to do in case there's some sort of attack.

Dr. O'Toole: Mayor Norick, you actually lived through the unthinkable, in a city that was not a target city. All of the commentaries I read on the Murrah Federal Building bombing noted with great admiration how forthcoming spokespersons were in the immediate aftermath of the bombing about what was going on, and what to do, and so on.

What, in your mind, was valuable in terms of preparedness for that catastrophe? Or what would you do differently now if you were told, God forbid, that such a thing were about to happen in a city? What would you advise other mayors about preparedness?

Mayor Norick: Well, it wasn't in my operations manual to begin with, so, obviously, I don't think anybody expected it. In what I'm going to call the Heartland, which includes everybody that doesn't live on the coasts, we figure that anything that's going to happen is probably going to happen on the coast and it's not going to happen to us. So I think that is what shook the nation up more than anything–that it happened right flat in the middle of the country.

Our city was very fortunate in that the bombing was April 19, 1995. In the summer of 1994, our city staff came to Washington to a FEMA EMI [Emergency Management Institute] to learn about how to deal with disasters. And, of course, at the time that our people were in Washington, they were thinking of disasters like tornadoes or maybe even an airplane crash at the airport, or something like that–but mainly acts of Nature. When the Murrah Building bombing occurred, the police officers and the fire department that were on the scene knew very, very quickly that it was a bombing and not a natural disaster–like a natural gas line–by the crater and what was going on.

I've heard today over and over about communication, which is absolutely true. And I heard what everybody said: If you don't know, tell them you don't know. You just can't believe how well that sits with the public.

I had some advantage in that I'd been in office for eight years; I'd been through three elections; and, without wanting to sound like I'm bragging, I was very popular and was very well respected not only by the people of Oklahoma City but also by the press. I had always shot very straight with the press and with the people, so they felt that whatever I told them about this particular incident was no different than what I'd been telling them for eight years previously.

Governor Keating had been in office three months, so he was at quite a bit of a disadvantage compared to me at that time. We worked very well together, but it all got down to communication. We didn't know who was the cause or what was the cause. We knew what it was pretty quickly, and we relayed that that day. We didn't hide it. We came out in a very organized fashion. I'd have to say we were fortunate that we had had planning on disasters a year before, and that obviously had to have a great impact on the way our community reacted.

Dr. O'Toole: There's been a lot of mention today about the public's not being an undifferentiated mass. Ivan talked about different levels of health literacy in the population. We've also heard a lot about children being a special population. Ed, you had to deal with a lot of very anxious parents in the course of the sniper shootings. Is there anything you or others would like to say about what leaders should consider when particularly vulnerable populations, especially children, are imperiled?

Mr. Clarke: I think it's critical in a couple of areas. You cannot wait until the day of an emergency or crisis to develop relationships and partnerships, nor can you wait to be trained up. That has to be done in advance. I think you have to have an established relationship as a building principal or a teacher. You need to know your parent groups, and you need to know that in the event of an emergency or crisis, they're coming to your schools.

As we saw on September 11th, and in some of the sniper days, parents were coming to retrieve their school-children, their loved ones, and that was a natural reaction. But I think it's how we plan for that event, how we communicate it, and the superintendent needed to reassure parents that children were safe during that horrific ordeal.

It's also important to have good preparedness drills and training of employees. In Montgomery County Public Schools, we have what we call a Code Blue status, which is an enhanced level of safety and security. We may, depending on the situation, secure the exterior doors. When we developed that concept, we never envisioned that we would be in a prolonged state of Code Blue for 22 days.

So, it's getting that information out and being supportive of parents, and also of the teachers that are in that building, because they are parents, too. It's how you reach out to the parents, and how they have confidence that you have a safe facility for children.

Dr. O'Toole: Let's talk about the end and the aftermath of crises. Tom, you recently were on television because of scares that there was trace anthrax contamination found in the Federal Reserve Building. Would you make a few comments about how you handled that, and what it means to have these kinds of scares following in the wake of a real crisis, such as we had last fall?

Mr. Day: In the case of anthrax, and really any biological threat that might come through the mail, the reality is that we faced the attack in September/October of 2001, but we've had incidents throughout, and some very public ones like the one at the Federal Reserve. It's just as important that you communicate that, even as this one ultimately turned out to be negative. It was not an anthrax event, but the level of anxiety quickly rises. Our employees are very concerned, and we learned a great deal from the attack of 2001, so based on that knowledge, it prompts us to respond that much more quickly. We did some precautionary testing to assure ourselves that we didn't have a risk.

It was interesting to watch the media. It was a slow news day, and we got a lot of coverage over about a 24- to 36-hour period. The media kind of went both ways on me. I had to handle all the interviews, and there were some, when it ultimately turned out to be negative, who said, well, why did you put us through this? And on the other hand, the question on the other extreme was, why were you so slow to react?

But we understood there was a reason to be concerned, and we wanted to get the information out there quickly. We went the extra step of personally briefing our employees at the facility that potentially was at risk, but ultimately was not.

As we found, it's not something that goes away. There's still a heightened sense of awareness, particularly in our workforce. To give you the statistics–and this is probably a little bit dated–but in the year that followed the anthrax attack, we had 17,000 incidents that closed facilities for four hours or longer. The overwhelming majority of that was in the first three to four months after the initial attack. But you've got to treat it like it's real. You've got to deal with it. You've got people getting anxious just from the fact that they went through what ultimately turned out to be a negative event.

Dr. O'Toole: Ron, you're still dealing with the aftermath of the 1995 bombing. Is that right?

Mayor Norick: Yes, we are still having cases of mental health problems, and it's been eight years. There are still police officers, firemen, rescue workers, individuals [who are having mental health problems]. The human mind is a funny thing. It doesn't know exactly when it's going to break, but it'll break. One of the speakers this morning talked about New York, that they had had more problems in mental health in the year after 9/11. Well, I'm here to tell you it'll be a lot longer than just the year after; it'll be years after.

We are still rebuilding the area. Although the cameras focused on the Murrah Building, we had 300 buildings damaged in Oklahoma City, and we had over 100 buildings that were completely torn down. They were not the size of the World Trade Center, but they were buildings nevertheless. The final part of the rebuilding is the federal campus that's now being built about two blocks north of the Murrah Building, which will rehouse a number of those agencies that are going to come back into the downtown area.

Ms. Quinn: In regard to the mental health reaction, there is the kind of anxiety that people have every day, particularly in Washington and New York, about the possibility of an attack. There was an article written by Bart Gellman in The Washington Post right before Christmas where he was talking about the possibility of attack, and saying that the terrorists are going to finish off what they didn't accomplish the first time, and the plane that crashed in Pennsylvania was headed toward the White House, and they're going to kill the White House next time. And this was said by someone who was a terrorism expert, who works right next to the White House, "I'm scared to go to work every day. I don't want to be on that street."

It shows itself in every way. It's like it's one level below the conversation. I have friends who are high-powered journalists, and they woke up one morning. There was this horrible explosion; and they were terrified. They grabbed the baby. They went down to the basement. They were just absolutely panicked, and they thought that there had been a terrorist attack. It was thunder.

I have friends who carry iodine with them every day, and friends who carry Atropine with them every day to give themselves a shot in case there's some kind of attack. I know people who have gotten motorbikes so that they can get out of town quickly, and they don't talk about it. Women will talk about it, but the men won't. The men seem to be in denial, but the women will talk about it. But it's there all the time.

It seems to me that instead of having this kind of underlying sense of anxiety and terror, that people would feel a lot safer if there were some guidelines, any guidelines, so that there wouldn't be this sort of psychological atmosphere.

Dr. O'Toole: On that note, and given that everyone in this room is faced with trying to lead during very powerless and uncertain times, let me offer the panel parting shots or pearls of wisdom that you might want to offer. Does anybody have any?

Mayor Norick: To somewhat agree and disagree with what Ms. Quinn said, if we as a country are going to crawl under a rock, then in essence the terrorists have won. I know that we need to protect ourselves, and we need to do everything that we can. I told the people in my community eight years ago, we didn't know who had done it, why, or anything else. And like Mayor Giuliani, I wasn't in a bomb shelter somewhere. I was out there on the street. That's where I needed to be. If I was in harm's way, so be it. That was just the way it was going to have to be. I understand what you're saying, but I think we can get to the point that we can overreact. We do need some guidance. I won't disagree with that at all, but to go around and put fear either into our hearts or fear in the hearts of our children, I just think that means that we've waved the white flag and given up, and I'm just not ready to do that.

Dr. Sandman: Somebody commented earlier today that fear is appropriate. Terror isn't; apathy isn't; denial, which is not the same as apathy, isn't; but fear is. In terms of our task, which is to think about leadership, it seems to me one of the things leaders need to do is model being fearful and bearing it. A fearless leader is no help at all, because I'm fearful, and if the leader is fearless, I can't follow there. I can't go there, but a leader who is fearful and bears it, and makes decisions nonetheless, and is not freaking out, and there's sort of a routinization of that fear–that's where we need to go as a society, and that's where our leaders have to take us.

Ms. Quinn: That's exactly what I'm talking about. It's important to be realistic, and to be realistic you have to be truthful, and you have to be prepared. And that makes people feel less panicked and less fearful.

Dr. Walks: I think one of the other things that helps people to feel less panicked and less afraid is routine. It's like Tom was talking about: 17,000 things you respond to, and you close the building each time. There's something about routine that helps you to build trust, and helps people to feel a little bit more secure. We live in a very, very diverse America, and we keep hearing these messages as if all of America looks the same way, has the same education level, and, most importantly, has the same history of dealing with leaders. In many communities we've had some very bad experiences with the person who shows up and says, "Hi, I'm from the government and I'm here to help."

If you don't keep that in mind, and you don't treat every scare as if you're going to do the same thing, the same suits come on, same folks show up, close the building for hours, do the whole thing, then the trust that you need during a crisis when people will trust you to tell them what the real risk is–that will be lost.

I think we've had some recent examples of that not happening, and we've seen the fallout break out across communities, across neighborhoods, across racial lines. My biggest concern is that during a time of crisis, we'll see that again. And we'll have an unnecessary loss of life, because when we're there giving that real good advice, using all the great risk communication skills, the history of the people we're talking to will prevent them from doing what they should do, and we'll have an unneeded loss of life. That's the thing that I spend my time concerned about.

Mr. Day: I'll go to my engineering side. Some of it is technology, and there are moves afoot to do things. When the person shows up in the emergency room with advanced symptoms, be it anthrax or any other biopathogen, we're well into the crisis, and the mask isn't going to help then. It's already happened. So the investment in technology that gives us some warning that an event has taken place is critical, because then we can spend a lot of time warning the public. But the reality is, we're not going to know it until people start getting sick and dying. And at that point, the mask and the gloves and all the rest of it are just a placebo. They're not going to do a thing for you. So there is a technology side to this that we need to advance. If we have this threat that is going to be with us for the foreseeable future, we need to have systems that let us know as early as possible.

Dr. O'Toole: Thank you. Well, it remains to thank our panelists for your generosity with your time and your insights. It gives us a lot to think about in the days ahead.

1This conference was supported under award #2000-DT-CX-K002 from the Memorial Institute for the Prevention of Terrorism (MIPT) and the Office of Justice Programs, National Institute of Justice, U.S. Department of Justice, and award #2000-10-7 from The Alfred P. Sloan Foundation. Points of view expressed during the course of this meeting were those of the individual speakers and do not necessarily represent the official position of MIPT, the U.S. Department of Justice, or The Alfred P. Sloan Foundation.
2Transcribed and audiotaped proceedings of the entire meeting are available online at http://www.hopkins-biodefense.org/pages/events/peoplesrole/main.html


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