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Thomas A. Glass, Ph.D. DR. INGLESBY: Our first speaker this morning will be Dr. Thomas Glass. He's an Assistant Professor on the faculty of epidemiology at the Johns Hopkins School of Public Health, who is a social scientist and epidemiologist with special expertise in public response to disasters. His former faculty position over much of the past decade was at the Texas A&M University, Hazard Reduction and Recovery Center. He was a principal investigator on an extensive National Science Foundation funded study of public response to 10 mass casualties disasters. He has held faculty positions at Harvard, Yale, and now Johns Hopkins. His talk is entitled "Understanding Public Response to Disasters." He will discuss from analyses of prior disasters, what can be stated about the public response to disasters now. How should expectations of public response influence our planning efforts? Dr. Glass?
DR. GLASS: Thank you, Tom. I'm very glad to be here. I suspect that I am actually the least distinguished speaker at this conference, but I am an academic. And as Dr. Falkenrath observed yesterday, this gives me some license, as an outside observer, to bring a different perspective to the table. So, in essence, we are now moving from Tom's talk about exercises and the world of "what if" to the "where the rubber meets the road." And I'm going to talk to you briefly about what can be learned from the study of actual technological or natural disasters, with the eye to what can be learned for preparation for potential biological weapons release. These conclusions are necessarily speculative and subject to the limitations of these data. First of all, a quick overview. I want to do three things in this talk. One is to describe in broad terms the results of a comparative study of 10 natural and technological disasters that we undertook at Texas A&M University some years ago. I'll try to condense these to the most relevant important facts, and I'm going to tell stories rather than give you data, because I think they are often more compelling. Secondly, I'd like to draw out the implications of this reasoning for bioterrorism research. And, third, just to state up front the essence or theme of my remarks, and that is that there is -- despite the temptation to think about preparation for biological weapons release, solely in professionalized terms, it would be a terrible mistake to ignore or underestimate the role of the public. And, in fact, I think there has been a relative lack of attention to what it is -- what role the public plays in all of this during the context of our discussions, with some notable examples. In fact, I'd argue what the public does, what the lay public does, both individually and collectively, will make the greatest difference in the ultimate outcome. We did this study between 1984 and '94, and it was funded by the National Science Foundation. It was really one of the first studies done in this way. We sought to study 10 events comparatively. We had a quick response team, including an engineer to look at the built environment. We had social scientists and epidemiologists, survey researchers, and our idea was to look multi-dimensionarily at the various response processes in mass casualty events, to try to get a sense of what the general patterns are. The goal was to conduct this multi-disciplinary study to try to learn about pre-hospital care, hospital-based care, characteristics of buildings and structures and what difference that made, and the role of victim response. And this was a rather unique study of its time. In fact, very few people have actually empirically, at least university-based researchers, have actually looked empirically at response to mass casualty events. Here you can see the events we studied. They include both large and small events, natural and technological events, and what I would call single-site versus multi-site events -- a distinction that I will come back to later. In the far right-hand column you see a summary of the casualty figures. In all of the events we studied, the common refrain from all of those studies, from an epidemiologic point of view, was it's a miracle that more people weren't killed. The World Trade Center, six people killed. Loma Prieta earthquake, 62 killed. Hurricane Andrew, 34 killed. I can still remember the day that I drove down into the Homestead area and witnessed the degree of devastation of the built environment there, the residential communities, and I found myself absolutely astonished, given the numbers of people that we estimate to have been in Homestead that night, that there were only 34 casualties. The common story behind each of these events is that victims respond to these events resourcefully and collectively in a way that mitigates disaster, in ways that surprise people. And I'll talk more about this in a minute. Now to the five main lessons that I think we learned in the context of this study. Disaster planning doesn't always go as planned. Disasters are not chaotic, but things don't usually go as planned. Formal response systems tend to break down. Communication systems notoriously fail. Plans are not implemented in the expected way. Dr. Rubin's remarks yesterday about hospitals not functioning within the system is something we saw over and over and over. Now, this is not always a bad thing. When we do top-down planning, we tend to set up overly rigid planning frameworks, and sometimes it's better that hospitals and individual EMS personnel, etcetera, freelance, because sometimes that emergent flexibility is something that is very, very useful. There is a tendency to plan for the wrong things. In most disaster drills, particularly in hospital community -- community hospitals, we tend to prepare for heavy trauma, lots of heavy trauma. That's what we expect. That's what we plan for. In our experience, the vast majority of injuries after disasters are minor. Disasters tend to be, for the most part, primary care events. There were more people at Hurricane Andrew injured in cleanup than during the actual event itself. While all hospitals and emergency systems, EMS systems, conduct disaster drills, they don't usually include the externalities to make real disasters challenging. So drills are done -- rarely done when the staff isn't expecting them, or at night, or during bad weather, or when vital personnel are on vacation. Drills rarely are designed to include communications failures, and I think this is one recommendation that comes out of our study is that you need to prepare for communication failures, because they are almost ubiquitous. And drills don't take advantage of the fact that the hospital infrastructure and the personnel are often directly impacted by the event itself. Drills tend to be mandatory for nursing staff and house officers, but I'm not speaking here of Top Off and the high visibility drills. But in exercises in smaller places, the senior medical staff tend not to go. And as a result, the disaster event occurs, and the typical convergence on the hospital -- here come the psychiatrists and all of the various other personnel who hear about the disaster and converge on the hospital. And the medical director of the facility takes command in the ER, but has not been to the exercises, doesn't know the procedures, and things get rather mixed up at that level. An example of this is the crash of USAIR Flight 405 at LaGuardia Airport, March 1992. In that event, they had done a disaster drill of a similar event, exactly in the same location that the plane skidded off the runway one year earlier. However, in the drill, there was no traffic because people weren't flooding to the airport upon news of the air crash, and so the -- in fact, on the day of the event, the incident commander was not -- it took him two and a half hours to get to the airport because of traffic. They hadn't anticipated that. The actual event occurred at nighttime, so when the first responders got to the plane they tried to radio back to the MS commanders, but they couldn't tell them where on the runway exactly the plane was, because it was dark and they had always drilled during the day.
So it's a reminder of the idea that exercises need to think about externalities, and that there will always be limits to what can be learned from these exercises. Lesson number two -- victims respond with collective resourcefulness. Mistrust of the public's ability to participate effectively in EMS response is widespread. Disaster planning has tended to emphasize centralized high-tech DMAT, USAR, and other kinds of highly professionalized groups. The result of this tendency is that professionals treat the public as an unwanted nuisance, as part of the problem. I call this the yellow tape effect. In other words, EMS personnel tend to try to establish a kind of physical and psychological perimeter around an event demarcated by that famous yellow tape. And this event is supposed to be a fence keeping the public out. Now, this is overall a useful and functional strategy in a typical emergency, but in a disaster, when by definition the resources and capacities of local formal EMS responders are insufficient to handle the needs of the problem, then this yellow tape phenomenon becomes a tremendous difficulty, because what it does is it relegates the public and the lay bystander to a secondary role. Overall, the evidence suggested victims tend to respond effectively and creatively. What we saw over and over in disasters was that victims formed spontaneous groups that have roles and rules and leaders and a division of labor. This is the phenomenon of collective -- emergent collective behavior talked about extensively in the literature on the social science side. And this makes it possible for ordinary citizens to do extraordinary things. An example, in the sewer explosions in Guadalajara, Mexico, which was a tremendously violent, nasty explosion leveling 5,000 homes, citizens formed search and rescue teams that performed in amazing ways. They used automobile jacks to lift rubble. They used garden hoses to get air into void spaces where people were trapped. And, of course, the majority of people rescued in that event were rescued by ordinary folks and not by the military, the Red Cross, the Green Cross, etcetera. Incidentally, there was a high degree of cooperation there between civilians and formal EMS responders, something that would not have been likely to occur in the United States. Number three -- and, of course, this is potentially something we could disagree about. But, in fact, the literature shows -- and our study shows -- that panic is relatively rare. There's a lot of talk about panic, and there's a general assumption that the public would panic in a bioterrorism event. My question is: where do the data come from to support that? In the events that we studied, we were amazed to interview victims and health care workers who commented repeatedly on the absence of panic, complaining, or irrational behavior. Many emergency department workers said, "Gee, I wish things worked this smoothly all the time." Most people talked about an eerie feeling of calm that came over people during life and death moments. Panic happens in disaster movies, but typically not in real disasters for reasons that probably are based in evolution. What we witnessed is ordinary citizens are amazingly capable of avoiding deadly harm. One exception to this rule about panic is the case in which strangers are entrapped in a fire. The classic example of this is the Coconut Grove Night Club fire in Boston, which, interestingly, happened in 1942 on this very date. In that event, 491 people were killed. So knowing that, the one event that we've studied that we figured there would be a lot of panic was the World Trade Center bombing. There were thousands of people stuck in these vertical columns, these stairwells. They were dark. They were filled with smoke. There was no lighting. There was no sound. We figured this was a recipe for panic. If we were going to see panic anywhere, we would undoubtedly see it here. It took people hours and hours to get out of these buildings because they were stuck in this vertical column of victims trying to get out.
We did observations and we did a random sample of 415 people who were in those stairwells, and we found by their reports, as well as other data, that panic was actually quite rare. And, in general, people said that there was relatively little panic, and that people were generally cooperative and friendly. And, of course, we reasoned that the -- we decided that the reason for this is that people entered these stairwells in kind of strata, a people who knew one another, because they entered the stairwells in their workgroups. And this is one of the lessons that we came away with, was that personal -- preexisting personal knowledge of one another, being in a situation with people you know, inoculates against panic and dysfunctional behavior. Now, the question of whether there would be panic after a bioterrorism event is a very complicated question, and I don't claim to know the answer. I will say two comments about that, though. Number one, the historical record on the 1918 pandemic in general does not bear out projections of panic. Number two, whether or not groups or individuals panic may have a lot more to do with what we, the professional community, do in the way of preparing and providing information to the public than any inherent tendency within the public. So I think in general our tendency is to withhold information too long for fear that it will cause panic when, in fact, it's the absence of information that is most likely to cause panic. This is a very complicated issue, and I'm not trying to oversimplify it. But that's, in general, a place to start. Lesson number four -- the majority of lives will be saved by the public. In disasters, we talk about the -- we used to talk about the golden 24 hours with respect to earthquake preparation in particular. I suspect -- in our findings, the most people who died died very, very quickly. And the result is those who were going to be saved were injured in a more minor way, and the vast majority of people who were injured and rescued were injured by bystanders and not formal EMS providers. Now, again, I'm talking here about earthquakes, hurricanes, etcetera, where the EMS system gets very disruptive. And I'm talking about multi-site incidents. The dominant pattern is that EMS professionals tend to arrive late to multi-site events, due to disruptions, communication, traffic, and other kinds of problems. An example of this -- the Nimitz Freeway, the Loma Prieta quake. We studied that event quite extensively. The EMS response was slow. They were getting 911 calls by the thousands. 911 is not set up for disasters. It's very difficult to prioritize when you have literally thousands of calls coming in simultaneously, saying, how do you triage the incoming calls, from a 911 perspective, during a disaster?
There were about 150 people on the Nimitz Freeway. It was -- despite the fact that it was publicized on TV during the World Series, about 50 people were killed instantly, or relatively quickly, about 50 people walked away from -- on their own power, and about 50 were rescued. Of those 50 who were rescued, 49 were rescued by lay bystanders, workers who were working in an industrial facility below the Nimitz Freeway, who did amazing things like they made backboards out of road signs, and did these rather amazing things. And then they waited several hours for EMS to finally arrive in that situation. You may remember that one person who was excavated by EMS. It was widely televised by CNN. But, of course, by the time they got there the majority of people had been rescued. Lesson number five -- other social factors to be considered. Trust -- where do -- people will go where they trust health care facilities, especially in a disaster situation. The truth is that we tend to assume that people are going to go to the VAs or these tertiary care hospitals, when indeed people tend to trust local hospitals more.
Rumors will fill the information gap. Sometimes these rumors are conspiratorial, and sometimes they are very destructive. And whether or not these rumors are destructive will have as much to do with how and when and from whom we release information. The press problem has been remarked upon a couple of times. One theme is the characteristics of social relationships, preexisting social relationships, tend to be very important and ought to be considered. Quickly, implications for bioterrorism -- and I'll just run through these relatively quickly. I know time is short. First of all, victims will self-transfer and self-triage. There will be no perimeter, for the most part, for an event of this type. The boundaries of the event will be permeable. People will come to the hospital on their own. And, of course, what will happen is what happens in all disasters of this type, is that the emergency rooms tend to fill up with the least severely injured in the initial stages, because it takes the more severely injured people longer to get there. So we need to plan for this. Number two, we need to anticipate that emergent systems will arise. And we need to plan for what people are going to do rather than what they are supposed to do. And if this is the mantra that we learn from our study, I would say that's it. Hospitals will be heavily stressed. If you look at the numbers, if we have numbers presented yesterday, if we have 100,000 casualties and 300,000 -- I'm sorry, 3,000 hospital beds, you do the numbers. What we're going to have to do is develop -- and I think there is a strain or a thread of denial that runs in our thinking.
If there's a massive event, it's not simply going to be a matter of moving people to other hospitals, and it's not going to be a matter of developing clinic relationships. Home care and other kinds of models, as occurred in 1918, are going to have to be seriously considered. The public response will shape the extent of the epidemic through patterns of evacuation, self-help, collective action, and rumoring. Finally, so how do we involve the public? The idea here is that I believe in all our conversations at this conference about partnerships, I've heard very few people say we ought to make partnerships with the public, with the general public. How do we do that? Well, public service announcements. Why not? We need a public communications strategy. We need a strategy for what it is we're going to do if an event occurs and we need to notify the public. And that's going to have to be very clearly thought about. That is going to be one of the most crucial features of response to this kind of thing. Excuse the alliteration -- pocket-sized PPEs for the public. This is something that I haven't heard anybody talk about. We need to decentralize the capacity for response. We need to work with civic organizations, churches, neighborhoods, corporations. These are the organizations people trust. This is where people live and reside, and these organizations can be mobilized as a kind of infrastructure of a scaffolding around which the public can participate. Publicly, we need to collaborate with the media. The hero in Hurricane Andrew was a radio announcer on an AM talk show who everyone listened to in Homestead. And this guy rather amazingly told people to get into their bathtub and put their mattress on their head. This guy saved more lives than anybody. We went to -- we interviewed many, many victims, and we went to many, many homes where the entire home was destroyed, and there was a bathtub and a mattress over it. And the people spent time during that hurricane with their little AM radio, with radios, listening to this guy who talked them through this. So as much as we talk about the press being a potential difficulty, we need to also see them as potential allies. And, finally, we need to train EMS workers to cut the yellow tape in a disaster, and to be trained to work with the public and not see them in some sort of adversarial kind of function. Thank you very much.
(Applause.)
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