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

The Working Group on "Governance Dilemmas" in Bioterrorism Response

Introduction

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.

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Points of view in this document are those of the authors and do not necessarily represent the official position of MIPT, the U.S. Department of Homeland Security, or the Sloan Foundation.

Cite this: Leading During Bioattacks and Epidemics With the Public's Trust and Help - Medscape - Mar 01, 2004.

Table 1. Special Circumstances Posed By Deliberate Epidemics That Complicate Decision-Making
Threats or scares, such as the increasingly frequent anthrax "hoaxes"^[96] Assassination of individuals (e.g., ricin poisoning of the Bulgarian defector, Georgi Markov)^[97] Discrete, nonlethal attacks (e.g., 1984 salad bar contamination with hundreds becoming ill)^[98] Few cases and deaths that are still profoundly disruptive (e.g., anthrax-laden letters) Localized lethal outbreak, comparable to the accidental 1979 anthrax release from Soviet bioweapons facility^[99] Campaign of mass casualty attacks in different cities, at different times, as in the Dark Winter tabletop exercise^[2] Lethal pandemic (or global outbreak) through an unchecked reintroduction of smallpox^[2]

Table 2. Recommendations For Handling Potential Conflict Between Strategic Goals in Response to a Deliberate Epidemic
Make bioterrorism response plans public before a crisis occurs; a well-informed population is more likely to cooperate with advice for reducing the spread of disease. Sketch out the "big picture"; make concrete the fact that personal actions can affect the safety of others -- for example, remind people that staying home from work or keeping children out of school when they are ill protects others from getting sick. Use disease controls that respect ideals of autonomy, self-determination, and equality. Public cooperation limits illness and death; public resistance does not. Provide goods and services that help people comply with health orders -- for example, set up vaccination clinics in locations accessible to people without cars. Restrict civil liberties, if necessary, only in a transparent and equitable way.

Table 3. Principles and Actions for Addressing Well-Chronicled Predicaments That Concern "Social Trust"
Share what you know. Do not withhold information because you think people will panic. Creative coping is the norm; panic is the exception. Hold press briefings early and often to reach the public. Answering questions is not a distraction from managing the crisis; it is managing the crisis. Confirm that local health agencies and medical facilities are prepared to handle an onslaught of questions from concerned individuals, in person and by phone. Convey basic health facts clearly and quickly so that people have peace of mind that they are safe or so that they seek out care, if need be. Similarly, brief healthcare and emergency workers so they have a realistic understanding about job safety. View rumors as a normal sign of people's need to make sense of vague or disturbing events. Refine your outreach efforts; the current ones may not be working.

Sidebar: Working Group on "Governance Dilemmas"

The members of the Working Group on "Governance Dilemmas" in Bioterrorism Response are:
Monica Schoch-Spana, PhD, Senior Fellow
Tara O'Toole, MD, MPH, Director
Thomas V. Inglesby, MD, Deputy Director
Onora Lien, Research Analyst, PhD candidate in Sociology
All at the Center for Biosecurity of the University of Pittsburgh Medical Center (UPMC)

Naomi Baden, JD, MS, Professional Facilitator, Mediator

Marion J. Balsam, MD, FAAP, Diplomat, American Board of Pediatrics; Fellow, American Academy of Pediatrics

Georges Benjamin, MD, Executive Director, American Public Health Association

Thom Berry, Director of Media Relations, South Carolina Health Department; President, National Public Health Information Coalition

William Bicknell, MD, MPH, Professor of International Health, Boston University

Kenneth D. Bloem, MPH, Health Management and Policy Consultant

John Burke, MA, JD, President, Strategic Communications Inc.

Neal L. Cohen, MD, Executive Director, Center on Bioterrorism, AMDeC Foundation, Inc.

Joan Deppa, PhD, Associate Professor, S. I. New-house School of Public Communications, Syracuse University

Brian W. Flynn, EdD, Associate Director, Center for the Study of Traumatic Stress; Adjunct Professor of Psychiatry, Uniformed Services University

Aaron J. Greenfield, JD, Executive Director, Maryland Business Council

Emira Habiby-Browne, MA, Executive Director, Arab-American Family Support Center, New York City

Margaret A. Hamburg, MD, Vice President for Biological Programs, Nuclear Threat Initiative

Darren Irby, Vice President of External Affairs, American Red Cross Headquarters

Robert G. Kaplan, Director, Commission of Intergroup Relations and Community Concerns, New York City Jewish Community Relations Council

Richard Knox, Health and Science Correspondent, National Public Radio

Myrna Lewis, PhD, Assistant Clinical Professor, Community and Preventive Medicine, Mt. Sinai School of Medicine, New York City

Jean Malecki, MD, MPH, Director, Palm Beach County Health Department

Shirley G. Mitchell, PhD, President, Board of Directors, Phyllis Wheatley YWCA, Washington, DC

Linda Morris, BSN, RN, Director, Community Health and Youth, Greater Kansas City American Red Cross

Sandra Mullin, MSW, Director of Communications and Associate Commissioner for NYC Department of Health

Ann E. Norwood, MD, COL MC, USA, Associate Professor and Associate Chair, Department of Psychiatry, Uniformed Services University

Barbara Reynolds, MA, Crisis and Emergency Risk Communication Specialist, Centers for Dis-ease Control and Prevention

Peter Sandman, PhD, Risk Communications Specialist

Kathleen Tierney, PhD, Director, Natural Hazards Research and Applications Information Center; Professor of Sociology, University of Colorado, Boulder

Mary E. Walsh, National Security Producer, CBS News

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

Introduction

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References

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Sidebar: Working Group on "Governance Dilemmas"

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