Leading During Bioattacks and Epidemics With the Public's Trust and Help

The Working Group on "Governance Dilemmas" in Bioterrorism Response

In This Article


We have learned very little that is new about the disease, but much that is old about ourselves.

Frederick C. Tilney, MD, on the polio epidemic of 1916, New York [1]

The federal government has to have the cooperation from the American people. There is no federal force out there that can require 300,000,000 people to take steps they don't want to take.

Former Senator Sam Nunn, playing the U.S. President in Dark Winter, the June 2001 smallpox bioterrorist exercise [2]

The prospect of "deliberate epidemics" caused by biological attacks on civilians and the well-chronicled vulnerabilities of human society to large-scale disease outbreaks prompted the Working Group to prepare this report. The document's purpose is to assist U.S. decision-makers, including governors, mayors, and health officials, in defining what constitutes effective, compassionate leadership in the context of an epidemic or bioattack, and to suggest some means to achieve it. The article sets forth strategic goals that make governing laudably in an epidemic of infectious disease a distinctive challenge. It illustrates special circumstances posed by biological attacks that further complicate efforts to limit the death, suffering, and disruption accompanying large outbreaks. The report identifies specific dilemmas of governing that commonly arise during epidemics and which decision-makers are likely to confront in the event of a bioattack. Lastly, it recommends principles and actions for preventing and/or resolving the apparent and sometimes genuine conflicts of interest, priority, and purpose that emerge in public health crises.

The Working Group contends that governing successfully during large, fast-moving, lethal epidemics requires a dynamic collaboration among members of a community and the community's leaders. Officials who have realistic expectations about the societal challenges posed by large outbreaks will be better prepared to protect and actively support cooperation and trust between a community and its leaders. In the absence of an engaged public, resolution of the immediate health crisis is rendered far more difficult, and the social and economic resilience of affected communities is diminished. Particularly in the context of bioterrorism, when fear and uncertainty may be significant forces, leaders' abilities to enlist communities in a collaborative effort to care for the sick and prevent the spread of disease could prove pivotal, not only in terms of implementing an adequate response to the health crisis, but in limiting social and economic losses and in preserving fundamental democratic values and processes.