Exercise developed and produced by:

Johns Hopkins Center for Civilian Biodefense Studies

National Memorial Institute for the Prevention of Terrorism

Office of Justice Programs, National Institutes of Justice, U.S. Department of Justice

The Alfred P. Sloan Foundation

Leadership's Role in Helping New Yorkers Prevail after 9/11

Transcript [Listen to this talk] [View the slides]

DR. O'TOOLE: Good evening. Let me add my welcome to Monica's. Neal Cohen, our speaker for this evening, is a lifelong New Yorker. He is a physician who was appointed by Mayor Giuliani to serve as the Commissioner of Health for New York City from 1998 to 2002, a period which encompassed a number of what can only be called amazing public health crises, which included the outbreak of West Nile Virus, a disease that had never previously been seen in the western hemisphere.

He was called upon to deal with the consequences of the attack on the World Trade Center in September, 2001, and then, in short order, with the outbreaks of anthrax that occurred as a result of bioterrorist attacks in New York City.

During the same period, as though that weren't enough, Dr. Cohen also served as New York City's Commissioner of the Department of Mental Health, Mental Retardation and Alcoholism Services.

I can't even say it, much less imagine doing it all at the same time. He advocated successfully to merge both of these departments into a unified Department of Public Health, a plan which was endorsed by New York City voters last November.

Following the events of September 11, Dr. Cohen oversaw the establishment of Project Liberty, an initiative in New York to ensure that all New Yorkers received the support services, counseling and treatments they needed to address the consequences of the 9/11 attacks.

He has been a strong advocate of integrating mental health professionals into community settings and is a long-time advocate of destigmatizing the acceptance of mental health care throughout the nation.

In February of 2002, Dr. Cohen became the Executive Director of the newly created Center on Bioterrorism, which was formed by a consortium of 39 of New York's schools of public health, medicine and academic and research institutions.

The goals of this new center are to lead a partnership with industry, academia, government agencies and the public to improve the understanding of the threats posed by bioweapons and to improve and augment the planning and research required to mitigate those threats.

So without further ado, it's a great pleasure to introduce our dinner speaker, Dr. Cohen.

(Applause)

DR. COHEN: Thank you. I was very pleased to receive this invitation. I had two conversations in the reception time that bear on what I'm going to say tonight.

One is one colleague, who didn't know I was a psychiatrist and was really very surprised, and I have to confess for a number of years I didn't really sort of speak about that very much as I was trying to gain some credibility as the public health leader, although I had a very strong personal commitment to an integrated public health model.

So that really didn't last that long, but I was pleased that the newspapers, the media didn't refer to Dr. Cohen the psychiatrist as the health commissioner.

They more or less accepted that I was. Another colleague told me it's an opportunity for me to be very blunt and candid, and it must be different now that you're outside of government.

So it is. So I certainly hope that I was fairly candid before, but there is a difference being in government and being outside government with respect to when you wake up the next day and who might have heard what you said and what opinion they may have had about what you said.

So I did have a very unique perspective, opportunity and challenge to address both the public mental health and the public health issues that would emerge from 9/11.

I was a psychiatrist who shared a vision that Surgeon General David Satcher had in his Surgeon General reports on mental health and suicidality where he really advocated for the integration of mental health into the mainstream of a public health agenda, something that there was a good case, a great argument for, but certainly, I think, the events of 9/11 and bioterrorism really lend themselves to that vision in a very easy, clearly demonstrable way.

Long before 9/11 I had become very keenly aware of some of the cultural differences in the public health communities and the public mental health communities concerning community and consumer participation and input into agenda-setting.

I regarded myself as a community psychiatrist in community mental health. I was trained in the principles of deinstitutionalization and the era in which the NIMBY syndrome, which stands for Not In My Back Yard, would be the death knell for really excellent community programs that never had the community support, buy-in or participation that it would need to be successful.

From a perspective in public health practice, I think that limited resources and an ongoing erosion of public health infrastructure has brought about probably more recently somewhat wider acceptance of the need to engage with communities and find partners to establish priorities and develop strategies for intervention.

So for me the take-home lesson, looking at the way public health and public mental health has moved along with regard to community engagement, is that so many programs working so good on paper have failed so miserably in their implementation because of a lack of community acceptance and participation, and ultimate success has not occurred.

So for me, looking at the title of the conference, I would paraphrase it and say the public as an asset, or there will be a problem. That has been my experience and I believe that perhaps at the end of the day tomorrow we'll come to appreciate what that might look like going forward for the asset that needs to be derived from bioterrorism preparedness.

I was asked to direct my remarks to leadership and certainly to do that I have to consider those clearly demonstrated leadership qualities of the person who now literally wrote the book on leadership, Mayor Rudolph Giuliani.

In his book, I noticed that he wrote that, "leadership does not simply happen, it can be taught, learned and developed." So the Mayor goes on to describe leadership skills that he practices, writing that he hopes they'll be useful to anyone who has to run something.

So undoubtedly there are lessons to be learned about leadership style and how you can be successful in leadership roles. I think it probably would take us back to the nature versus nurture argument and my assumption is that there are certain individuals who are constitutionally better prepared to assume the role of leader in the moment of crisis, such as 9/11, and that there were qualities about the man, Rudolph Giuliani, that made it possible for him to emerge so naturally, so clearly as a significant leader.

No doubt history will judge him very differently than if his tenure had run out on September 10 than September 11, because he had that moment of opportunity for that leadership to be appreciated and recognized.

I think that an examination of leadership response in New York City to the events of 9/11 would reveal the benefits to the city of having created an Office of Emergency Management, which occurred in the mid-1990s.

For a number of years, there was a lot of media attention that was focused on "the bunker" as they call it, this very complex, multi-million dollar telecommunications facility that was located at the 7 World Trade Center with opportunities for city, state and federal agencies to come together for emergency management planning and response.

We at the Health Department had participated in a number of practices and drills, including biological and chemical attacks and terrorist bombings under an incident command structure that I think was instrumental in making the events of 9/11 and the weeks that followed sort of unfold in a way that would allow me to speak to the successes of the management of 9/11 in New York City.

Interestingly, we were scheduled on September 12 to hold a POD drill, or a point of distribution drill on Pier 92 on the Hudson River, and in that drill there were about 1,000 police and fire recruits who were going to act as civilians who had been exposed to a bioterrorism release event and they were going to be lining up to receive antibiotic prophylaxis.

Four days after, on the Saturday following the Tuesday of 9/11, the city moved its new emergency operations center to that very same pier, which had some preparation in relation to the drill that was going to be carried out the next day.

On the morning of 9/11 -- I'll just sort of quickly walk through this with you -- I actually got the message on my Nextel phone of the first plane hitting the World Trade Center.

I raced down to the towers and I met up with Mayor Giuliani on the street with a number of his senior cabinet officials and we weren't able to -- My expectation of going down there was I wanted to know what was going on, but I expected that we would be going into 7 World Trade Center into the emergency operations center.

I had my expectation of working from the Health Department desk, then, and telephone that would be available to me. But we couldn't get into the building because there were concerns about the structural integrity of the building, and in fact, later that afternoon the entire building collapsed on its own.

So the Mayor needed to find a place to call Washington. He was going to try to find out what was going on. He was going to be asking for air cover, as it turned out, and he needed some opportunity to communicate.

We went into a building on Barclay Street, which is just a block away from the North Tower, and he was able to reach the White House, learned that the Pentagon had also come under attack and secure air cover for the city.

We were positioned there when the first tower collapsed and despite some locked doors and some significant uncertainty about our safety, we were eventually led out through a smoke-filled basement maze out onto the other side of the building, which is facing Church Street, and we moved north away from the towers.

As we moved up Church Street, we started with a people caravan of about 25 of us who were city officials, and the caravan was growing block by block and I remember vividly the Mayor urging very ghostly and ash-caked survivors to go north.

I remember there was sort of a rowdy teenager who obviously was distressed, but he needed to be calmed and the Mayor gave him a very fatherly shushing along the way.

We almost reached Murray Street, which is four blocks north of the World Trade Center, when the second tower collapsed at about 10:30. As we were doing all this and we eventually got to a firehouse, later to a police academy, which are two miles north of the towers, I'll confess that as a physician and as the only physician who was with the Mayor in his senior cabinet, I kept my eyes on him.

I did that both because he was my boss and also because I felt a responsibility to keep an eye on the leader in this moment of crisis. As a physician, to encourage him to keep on his air filter mask, which some of us had been given when we left the building on Barkley Street, to suggest that he stay hydrated as much as possible with bottled water.
I was also feeling a lot of frustration because phone lines were down in lower Manhattan and I wasn't able to get into contact with my health department staff about the mobilization of our emergency response teams, but in fact that was taking place without me because my deputy knew exactly what to do and that proceeded.

The immediate focus that I was going to address was the public health impact and the potential medical emergency that derived from the tragedy. Witnessing the crash, one had high expectations there would be very large numbers of casualties that would have to be treated in the emergency departments, whether we would have enough beds, and whether there would be a surge capacity in the hospital system in New York to be able to absolve all the wounded that we expected we might see, but regrettably, that surge capacity was never really tested.

But interestingly, actually about 10,000 people were seen in emergency departments in the greater metropolitan area: New York, New Jersey and Connecticut, and there were about 450 hospital admissions.

But there were only nine deaths that occurred after September 11 in the next several weeks that were a consequence of the 9/11 events. So there were a lot of walking wounded, but relatively minor injuries that were addressed.

I think one of the lessons learned -- this is just an example of how people were fleeing the scene. But I think a lesson learned here underscores that terrorism will create health impacts that will go well beyond the immediate boundaries of the disastrous event.

People, whenever they can, are going to try to get home and try to return to their home base and then seek care as they need to. So planning for the management of a terrorist event must always be regional in approach, not local, because it's just never going to stay local.

So we went on that day to set up a makeshift emergency operations center at the police academy and later in that week we were at Pier 92 as I mentioned before.

Johnathan Alter wrote in Newsweek of Mayor Giuliani that he inhabited the role of wartime leader with a fine mixture of brisk compassion and a gritty command presence.

My own observation from the critical early hours of the first day was that he really embraced that role of being a leader with confidence, but not with arrogance.

His credibility for that role was strengthened by the fact that he was everywhere. He was seen, he was very visible. He had presence at Ground Zero again and again and again and later at funerals and memorials.

Here's where I'm out of government and my candor -- this is in contrast to some of the leaders, government leaders, who were criticized later for not being so visible and available to the public at a time when that was sorely needed, or some whom were reported to be in unknown locations.

Another element of his leadership was the credibility of his public statements. No doubt there is a great temptation for government leaders to put out reassuring and comforting statements to the public, but those very same reassuring statements can badly damage credibility with a loss of trust when the statements are found to be inaccurate or less than an honest assessment of their safety.

The post-9/11 events, remember, did not give us any opportunity to really assure the public of safety from further harm. We continued to receive messages of potential further attacks by Tom Ridge and by Secretary Rumsfeld, news of Al Qaeda planning to launch its further attacks, the war in Afghanistan, mid-East strife and terrorism.

It sort of worked like this for us, right? One story after another. So it didn't take a rocket scientist or a psychiatrist posing as a Health Commissioner to figure out that we could anticipate the potential for a looming mental health crisis in New York City.

I just want to make one comment about the Mayor's statements. He didn't promise safety. What he actually did was he talked about the steps that had been taken to make the city safer on 9/12 than it had been on 9/10.

So then he talked about the air defense and he spoke about the heightened alert and vigilance for any further act of terror, but he didn't promise us that we would be free from any further risk.

So we had in New York City, with regard to this looming mental health crisis, I had been there since 1996 and in the `90s we had a number of experiences with the management of the psychological sequellae of mass violence and terrorism.

It first started for us in the creation of crisis intervention services when we had what was called the Happyland fire, and this was arson in the South Bronx in 1990 which killed dozens of people, and from that point on we created, within our public mental health program, a crisis intervention network and an ability to respond with a team of staff who were experts in disaster management and trauma.

Then in 1993 we had the World Trade Center bombing, and then later in the `90s we had several airline crashes, TWA Flight 800 and a Swissair crash. In each instance, what we did was to create a site for family members of the victims to come together, to get information, to receive concrete services as they needed it and to receive crisis counseling and support for their bereavement.

The Mayor, familiar with this model, asked that we set up a family assistance center, which was carried out at the New York State Armory, which is 26th Street, which is also about two miles north of the towers.

In those situations, the American Red Cross assumes authority to manage services at a disaster site and the local health department and mental health agency assume authority to mobilize the clinical staff.

We knew the crisis intervention teams and the mobile outreach programs, so we were able to kind of pull together the professional staff that we needed to man and support these family assistance centers.

So in this instance, the acceptance of the finality of the family members' loss was progressing very slowly, because many family members were clinging to the hope that -- offered by reports, that survival under optimal conditions can last up to two weeks.

So that the movement from a rescue to a recovery operation really moved slowly and unevenly. Almost immediately, we saw the proliferation, if you will, of these posters of missing persons which appeared on lampposts and hospital walls and outside the Family Assistance Center with a picture of the family member who was described as lost or missing, and asking for information about them.

It was on the third day that the Mayor asked me to bring in experts on bereavement and trauma to meet with him, because he also became keenly aware, and he was concerned with how best to speak publicly of the tragedy and how to respect the families' process of bereavement with words that might at the same time help the healing of the city.

So from the very beginning, I think what the Mayor did extraordinarily well was to provide a trauma narrative for the city that actually incorporated a vision of recovery.

So he didn't speak in a more narrow, limited way about the attack and about the losses. From the beginning, he introduced the concept of recovery as a part of the narrative in the experience that we were all going through.

So he described in detail, of course, what the city was doing at Ground Zero. He told families that they could assist by bringing in toothbrushes or hairbrushes that would be collected by the Chief Medical Examiner for DNA identification.

He kept clarifying on a daily basis, he had press conferences a couple of times a day, with new information as it came along, but always in the context of looking forward to the next steps in the recovery.

One of the measures he took was to offer families to waive the usual period before a death certificate can be applied for, because in the absence of a legally identified body, it normally would be several years before you could be eligible for a death certificate, and he recognized that the death certificate would allow certain benefits and entitlements to be paid.

Teams of volunteer lawyers were organized and they were at the Family Assistance Center and there was an annex to the Chief Medical Examiner and his staff could waive the waiting period for the certificate.

But we saw in the first three months that -- I can't put a number on it right now, but there was a very, very small number of families who took advantage and applied for the death certificate.

I've heard Mayor Giuliani say more recently that it underscored for him the need to move slowly with his language and with his actions with respect to addressing the finality of the loss that family members were experiencing.

So we also, you know, I know that I had my staff get me the reprints of the articles on the Oklahoma City federal building bombing, and I was trying to get a quick brush-up on what I might be able to expect in New York City with the belief that we should see comparable rates, if not higher rates of PTSD and depression and other health impacts as well.

We began to prioritize by recognizing there's higher risk, medium and perhaps low-risk individuals for these sequellae, so the higher risk people would include the rescue workers and the evacuees from the towers and family members as well as those people living in the immediate area near Ground Zero and children who were going to school in the neighborhood of Ground Zero and nearby.

There were some unique challenges in thinking about how to mobilize the social support networks of families of victims and surviving coworkers.

For example, there were 343 fire fighters who were lost and we sat down with the Fire Department leadership and it was impressed upon just how insular, if you will, the uniformed services are.

They don't quickly trust or welcome outsiders and historically the Fire Department has looked out for its own. So we attempted to adapt a model by which we paired a peer counselor, someone who was a fire fighter, retired fire fighter, someone who had training in counseling services, they had a small team of people like that, with a licensed mental health professional who was well credentialed and trained in disaster mental health and bereavement in order to have this sort of way of gaining more acceptance with the fire fighters.

Some of you may recall that some of the earlier surveys that were done. The New York Academy of Medicine researchers did a telephone survey five to seven weeks after 9/11 and they looked at 1,000 adults living in Manhattan south of 110th Street, and the finding was that about 7.5 percent had symptoms that were compatible with PTSD, including prolonged occurrence of nightmares and difficulty concentrating and sleeplessness.

Another 9.7 percent had symptoms of depression and consistent with the earlier literature, and literature from Oklahoma City, the rates were much higher for people who lived and worked closer to Ground Zero.

So we had rates of 20 percent PTSD and 17 percent with depression. So we recognize that -- and combining the two was about 13, 14 percent. Well, the population of Manhattan being about 900,000 people, that's a lot of folks who now have significant distress symptoms that were going to impact on them very profoundly.

While it's logical to focus on PTSD, and those values are about twice what you would expect at the baseline for an urban population. PTSD, obviously, is most clearly related to the traumatic event and has been associated in the literature with lots of different types of disability, work impairment and health issues and lower quality of life and suicidality and other dysfunction.

But, you know, the reliance on a categorical model of psychiatric disorder means that relatively little attention gets paid to people whose disability and impairment doesn't reach the threshold to give them this diagnosis.

One of the New York researchers at Columbia, Randall Marshall and his group had just published in September, I think in the American Journal of Psychiatry, an article where they did a survey of 9,000 people who were screened on National Anxiety Disorders Screening Day, and they found that what were called sub-threshold PTSD has very significant disability associated with it as well.

As you go on incrementally to one symptom, two symptoms, three, and then the threshold is reached at four symptoms, you get -- from one to three, you have twice as many people who are going to meet the threshold at four, and that these people were found to have much higher levels of suicidality, even when the presence of major depressive disorder was controlled for.

So you have more suicidality, you have impaired work performance among a population that potentially is twice to three times greater than even the PTSD population.

So the impact is like looking at the tip of the iceberg. There's a much larger chunk of the population that has significant distress as well. For the larger population of New Yorkers, we launched a public education campaign.

In large measure, Sandy Mullin, who worked with me, who headed our Public Affairs Bureau, helped to craft that campaign, and we called it the New York Needs Us Strong Project Liberty campaign.

This campaign appears on bus shelters and subways and there are public service announcements. The intention was to normalize the experiences that New Yorkers had to trauma, and to destigmatize the acceptance of professional mental health care if, in fact, that's what they would need.

Interestingly, I think over the course of months, the numbers of calls -- there was a hotline associated with this, a 24-hour, seven-day-a-week hotline -- and the number of calls to the hotline has increased over the course of the first year.

So it really also corresponds to a finding in the Oklahoma City at there were more people in the second year after the bombing who presented themselves for mental health treatment as a consequence of their reactions to the trauma than in the first year.

We've seen more people call and after the one year, 200,000 people have availed themselves of some level of services related to this Project Liberty campaign, from the very least intensive education and outreach to more intensive crisis counseling services.

At the same time, and I spoke with the Academy of Medicine researchers recently, those surveys have been repeated at seven-month interval and then one-year interval, and we're seeing a significant decline in the PTSD-like symptomology.

I believe that at one year it was 1.3 percent, and it's been declined by about 80 percent. So I'd like to think that the data suggests that we're reaching a population that was significantly impacted by the 9/11 tragedy, many of whom delayed seeking professional care for many months, assuming that, you know, it's something that will get worked out, that they'll be able to get beyond, but over time they've become increasingly receptive with the help of a public health campaign such as this to presenting for professional care.

Actually, again, the premise is that rather than this being a clinical program as a public health model, we saw it as an opportunity to normalize and to help reconnect people with the social supports that they had prior to the 9/11 experience.

So this is an example of one of the posters in which the individual, Tony from Queens writes that, "I guess what I'm going to do is to play ball in the neighborhood park, cook for my girlfriend, attend more 12 step meetings so I don't relapse, find other support and check in with my friends more often."

So, you know, these are posters that appear on subways and if you're riding the subway in New York City, you know, we've got your attention for a little bit of time.

So you read that and you're able to digest the opportunity to sort of normalize and think about what you might do to feel better. It also is a great challenge because we're dealing with a public mental health system, at least the one in New York City, that historically, for the past 40 decades, had seen itself as a safety net for public mental health care that would be rendered originally to the deinstitutionalized population and then to the population of the severely mentally ill.

So it's really a sea change for this public mental health department that has now, as of this past year, become integrated into the Department of Health and is now, the agency's called the Department of Health and Mental Hygiene Services, and that vision that Dr. Satcher advocated for hopefully will be launched in New York City.

The danger, the risks that people felt in those communities where you had the mental health community who was fearful that they would be swallowed up by the big fish, in this case the public health community, and the public health community who sort of questioned what they were doing with a mental health agency, what, you know, just where would it fit in.

So that's going to be a lot of work and a great challenge. But the data suggests to me that there is a lesson learned here, and that mental health promotion, whether it's through education or messaging or by mobilizing social networks and the availability of mental health services that are carried out outside of the usual clinic walls, because FEMA required that the services be done in the community as part of an outreach, and they not be done as business as usual in the licensed mental health clinics; that that type of initiative may have had a major role to play in New York City's recovery.

Difficult to say, you know, how much and how far, but the data suggests that the goals of this campaign are being met. I want to speak now, just specifically to our bioterrorism experience.

It was on October 12 that we got the phone call from the CDC, actually it was about 4:00 a.m. when our Assistant Commissioner for Communicable Disease, Marcie Layton, got the call from Atlanta confirming that the diagnosis of anthrax in the skin biopsy that was done on the person who was the assistant to Tom Brokaw at NBC.

Obviously, it set into motion the perception now that we had a new threat and that this could be a national crisis, despite the focus, as it turned out, in the northeast corridor, in Washington and New Jersey and New York.

It's very vivid in my memory, talking again about leadership, that I called Mayor Giuliani shortly after getting that call and I met him in his office at City Hall at 6:00 a.m.

We got the CDC Director, Dr. Jeffrey Copeland, on the telephone and I recall that Dr. Copeland told the Mayor that the tests were compatible with a diagnosis of anthrax.

You know where I'm going with this. So the Mayor sort of intuitively knew that this was a way that a scientist might speak about a diagnosis, but he also might be hedging a bet a little bit, whether it's absolutely what he'd just heard that it was.

I remember that the Mayor shot back at Dr. Copeland, "Doctor, is it anthrax or isn't it?" and, in fact, Jeff Copeland said, "Yes it is, Mr. Mayor." So we were off to the races right at that point.

So he needed to know, and he needed to know in terms that the public would be able to comprehend. It was only a matter of the next several days that we got several reports of cutaneous cases that needed to come under investigation at CBS, at ABC and also at the New York Post.

The Mayor actually went to each of those networks with myself and with other staff and he brought the people in the newsroom together, because these were sent to, you know, it was Dan Rather.

We don't know the exact source, but the expectation with ABC, because there was no letter found, but we brought together the staff in the newsroom to explain what would be done next in terms of the investigation, both from the public health and the criminal justice perspective; that for the epidemiological investigation we would be interviewing and we might be doing nasal swabbing as part of that investigation; that there would be environmental testing and there would be a clinical component as well; that we would be offering antibiotic prophylaxis for those people who were at risk.

Then, you know, we needed to ascertain what that meant and what level of risk was going to lead to our recommendation that people take prophylaxis. In fact, NBC, there were more than 1,000 people who were prophylaxed in the next 24 hours, but as we went along, those numbers came way down and we had just a handful of people at ABC and CBS.

So as we gained a little more experience and a little more confidence in the risk assessment, we were able to target and raise the level of concern only to those individuals whom we thought were in direct contact and at highest risk.

I should add that given my interest in the integrated public health model, I was never prouder of the performance of my public health agencies than I was in managing those crises at the media outlets, because we set up clinics in each of those buildings, and we had medical epidemiologists, nurses and physicians working side-by-side with mental health professionals.

So they were doing swabbing and they were explaining the risks and at the same time we had counseling going on in a very destigmatized environment that made people feel rather comfortable.

People could talk about their anxieties and their concerns without worrying about being labeled. As you know, when the hoax letters started coming in, as well as when America became white powder-phobic, so all the public health laboratories in the months that followed were overwhelmed by the many calls that were made that required hazmat teams to come in and take envelopes, secure them and bring them to the local public health laboratory, we were overwhelmed.

We were overwhelmed by the need for the public to have their fears addressed in as rapid a timeframe as possible. We could sit back and say high priority, low priority, but it seemed like there was no such thing as a low priority specimen for anyone who was concerned about powder that a hazmat team came in and brought to our laboratory.

So that wouldn't fly with them. But we also learned that our public health laboratory infrastructure was very inadequate, and Surgeon General Satcher, to give us an example of leadership, speaking, though, in the last weeks of his tenure, which also speaks to what I said earlier about being outside of government allows candor, he publicly commented on how antiquated, inadequate and that the CDC laboratories constituted a national disgrace.

So obviously the truth needed to be acknowledged by a public health leader of Dr. Satcher's stature, and in this past year we've all seen a great infusion in new federal funding for public health infrastructure, including laboratory expansion and enhancements at CDC as well as at state laboratories.

But we also remain challenged by the reality that there is a historical schism that exists between public health and clinical medicine. One evidence of that is that historically there has been widespread under-reporting of diseases that public health departments are expected to hear about from hospitals and from community physicians.

With West Nile Virus, in the summer of 1999, when we learned about West Nile Virus, that was fortuitously a phone call from a community physician in Queens who had two patients with atypical presentations in their encephalitis, that turned out to be the West Nile Virus.

So that reporting was critical, but in retrospect, we also found out that there were 17 individuals who were sitting in hospital beds at that time who were later understood to have West Nile Virus.

So we weren't hearing about these presentations and new clusters of symptoms that should have raised a red flag for community physicians until we heard from that one community physician.

I think there is a window of opportunity now with the focus and concern with bioterrorism for much greater cooperation between clinical medicine and public health communities, but there's going to be a requirement, even with all the new funding and the new infrastructure that's being created, there's going to have be a buy-in, acceptance and partnership take place between the clinical medicine and the public health communities that just hasn't existed here.

For that to happen, again to the subject of leadership, we're going to have to find leaders in the clinical medicine world as well as the public health world who are going to be willing to step up and advocate for changes in the medical school curriculum and ways to influence the thinking and the practice of the next generation of physicians and other health care professionals for this partnership really to be meaningful.

Lastly, I wanted to comment on one of the strengths, I think, of the response in New York was that we did make a great effort on communication, both to the public and to the clinical medicine community.

Our Assistant Commissioner Marcie Layton was responsible for providing public health alerts. You know, when you look at the top of those e-mails that are submitted electronically and you see 3:00 a.m. and 4:00 a.m. and 5:00 a.m., you know you have a very remarkable person, very dedicated and that's what Dr. Layton is.

She disseminated these e-mails on a huge list that was regional and national, and we continue always to hear that it had a huge value to the public health and the clinical medicine community who was receiving these alerts.

We know that on the national scene, there was inconsistency and the lack of authoritative and reliable voices to communicate the real nature of the threat.

This is a Times piece in which the reporter writes that, "People in the grip of fear want information that holds up, not spin control. Again and again in recent weeks administration officials tried to reassure the public. Again and again the situation proved more serious than the officials had suggested. As a result, public trust has evaporated."

I think that the Mayor in putting information out there as early as possible. I can tell you that he had a strong belief that we needed to get this information out because if we sat back and held information until we had absolute confirmation as to a specific diagnosis, we probably as we were waiting for this substantiation, this confirmation to occur, that the press would hear about it.

That's been the experience, and then we would be getting phone calls and government would then be put into a reactive position and articles would start appearing, and whatever then we said, there would be this decreased credibility in the public's eye.

So there was no textbook experience that we could fall back on as a guide to how to respond. As you know, a number of assumptions that were made about the pathogenicity of the anthrax spores turned out to be wrong.

So nobody thought that the postal workers who were dealing only with sealed envelopes would be at risk and the expectation was that it would take from 8,000 to 10,000 spores of exposure before you might likely lead to inhalational anthrax.

So we were learning the science as we were going along. So the public, I think, is much more likely to be tolerant and accepting of the kinds of errors that can occur in the management of these crises if they feel that you are engaged in really timely communication; giving out the best information that's available to you at any given time.

If they don't get the information in a timely fashion, the public will perceive the government as not protecting them, and then they are more likely to go and find a way to get Cipro and to buy gas masks and in an adaptive way to protect themselves and their own families, which may not be the best public health advice, but it's something that people have a need to do in order to feel that they gain more control and ability to kind of withstand the threat that we're facing.

We, I think in summary, see that it was very valuable to put emphasis on reconnecting individual loss and tragedy to a larger community. Tara said that I am a native New Yorker, and I never experienced New York this way as a small town, you know, where people actually on elevators, usually we don't look at each other and we kind of look up and we wait to be alone, but we actually spoke to each other on elevators, in a very friendly and supportive way.

The spirit of resiliency and rebound was taking place with the influence of a government leader such as the Mayor. So I think one nice example of how we sort of wove our way through this crisis actually appears in a New York Post headline, which -- this is actually a young woman who was the victim of the anthrax letter at the New York Post, so in their style we're giving anthrax back, we're giving the finger to the terrorists.

So, you know, it's a message about the will and courage and the sense that we don't want to be defeated by this. There is a growing body of literature that suggests that social cohesion and social capital can go a long way toward fortifying people against the terrorist's fundamental goal of inflicting psychological trauma and protect people from overall morbidity and mortality.

I'm grateful to the Mayor for embodying the voice of the city and the nation in a period of mourning, and inspiring, with his sense of control and his optimism for our recovery.

I thank you for the opportunity to share those experiences with you. I think this summit on leadership is really an important opportunity for us to really get our hands around and digest what are the priorities going forward that we're going to need to address in order to ensure that we'll have rebound and resiliency when we face and prepare for future threats.

Thank you.

(Applause)

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