| Home > Events > The Public as an Asset, Not a Problem > Ann E. Norwood Anticipated Psychological Impact of Bioterrorism Transcript [Listen to this talk] [View the slides] DR. URSANO: Our first speaker is Dr. Ann Norwood, and is a wonderful friend and colleague. She's a member of my faculty at the university. She's also the Associate Chair of the Department of Psychiatry. Ann is one of the leading speakers in the area of bioterrorism at almost any meeting that you go to. She is presently the Chair of the American Psychiatric Association's Committee on Disaster Psychiatry, and she's going to speak this morning on anticipated psychological impact of bioterrorism. DR. NORWOOD: Good morning. First, as Monica said, Dr. Ursano is a stellar thinker in this area, but I also want to just underscore this part, and the Associate Chair part. He's also the smartest man I know, so moving on, I first want to thank Monica Schoch-Spana for her scholarship and leadership in this area, and also to commend the Center for Civilian Biodefense Strategies for their good sense in hiring her very early on. This morning again the emphasis is why do we care about psychological impact? I just want to focus for a moment on this word, "terror" embedded in bioterrorism, and that's really the reason we're speaking this morning. Today, I'll be discussing factors that make bioterrorism so frightening. I'll also discuss psychological responses, and I'll present a couple of examples of outbreaks. The one take-home point I really want to make is that our goal as leaders, as health care providers and so forth, is to prevent ideally or convert terror to a realistic fear in the wake of these sorts of events. First, I want to also acknowledge my collaborators, Dr. Ursano, and also in the audience Dr. DeMartino. There are a number of reasons that I think psychological responses are important to our understanding. In the first place, they affect our physiological responses, and that can directly impact health care seeking behaviors, which I'll allude to later on this talk. Also, overwhelming emotions can disrupt realistic problem solving, and we're going to hear more about panic. I rather liked yesterday's definition that was offered at lunch time; is that, panic really is when people do what we don't want them to do, and don't do what we want them to do. The last, and I think this really is the cornerstone. As a psychiatrist, of course, I'm interested in how people do long term as well as acutely. But in the immediate aftermath of a bioterrorist attack, we're really focused on behaviors, whether people do things that are adaptive or mal-adaptive, and that's at both an individual and a group level. Why is bioterrorism so scary? Well, first of all, the agents are invisible and odorless. They tap into very deep rooted fears of being invaded and destroyed by an invisible force. There's a delayed onset between exposure and illness, which produces tremendous anxiety and uncertainty in those fearing they may have been infected. Because most biological weapons produce diseases that are rarely seen in American medical practice, there is limited medical knowledge about diagnosis, treatment and outcome. And as you saw with the Anthrax, these agents may behave differently than we anticipated based on prior experience in terms of their ability to infectivity, and ability to be aerosolized and so forth. Because of this uncertainty, physicians and patients really are in the same boat. And another thing to emphasize is this will be relatively new. We did have the Anthrax experience, but as we've see over a variety of things; for example, the introduction of machine guns in war, the use of gas for the first time, the novel use of something is terror-producing. The idea of taking something familiar like an airplane and crashing it into the World Trade Center and the Pentagon causing so much destruction, again is novel and, therefore, more frightening. The other thing is grotesqueness. The agents like Smallpox are very disfiguring, and you just show a picture of someone with Smallpox, that does a pretty good job right there of establishing fear and terror. Other aspects that are important to our understanding, is there is a potential for a high number of casualties, although again as we saw with Anthrax, even with relatively few fatalities, as awful as those were, the amount of disruption, and economic and psychological toll that they took was very remarkable, so that they may or may not be weapons of mass destruction, but they certainly can be weapons of mass disruption. Again, there may be limited availability of treatments. You can recall as we started to worry about Smallpox, the amount of vaccine that was available. That was a topic very much on our minds. Uncertainty about the effectiveness of treatment. Again, we have new medicines, new procedures since we've dealt with these infectious diseases in the past, so it's kind of a new ball game. Also, the wild card of potentially genetically altering things. If there's contagion involved in something like Smallpox then that ups the fear ante quite a bit. And again, biological casualties could be widely dispersed in this era of rapid transportation. Again, biological agents generally are poorly understood outside of limited professional groups, and there can be uncertainty there, as well. And the way that scientists tend to like to learn the truth, if you will, is to argue with one another, and that tends not to be terribly reassuring in the event of a bioterrorist attack, as you saw with the Anthrax. And again, I've added the scientific uncertainty. It's hard to give advice when you really don't know what's going to happen. Okay. And this is to point out the real dilemmas for those of us who will be dealing with risk communication, and especially with the media since they'll be our primary mode of getting information out to that public. Events will be viewed as uncontrollable, dreaded, catastrophic. Again, with something like Smallpox, it may produce a third casualties and deaths. These are things we found out in other sort of events similar to bioterrorism. Additional stressors. First of all, you have to look at the context. Is this going to be an isolated event or is it in the case of a metropolitan area like Washington and New York, in a set of ongoing threat, and the expectation of the other shoe dropping, which makes a big difference in psychological stressors. Other things that happen, again depending on the scope of that disruption of your natural support system, loss of job, relocation, the hassle of working with insurance and government agencies, as wonderful as they may be, it takes a fair amount of energy to navigate that. The other point I wanted to make is that in a bioterrorist attack, even if it's one attack, there are a series of events that you have to anticipate. There is, first of all, discovering that it happened and figuring out where the exposure took place. There is also then the issue of evacuating buildings, the issue of treatment. You recall all the psychological ramifications of introducing an investigational drug like a vaccine, or the discrepancy between one group, the postal workers get one set of antibiotics, and those on the Hill getting another. And then the decision to go back into buildings, how safe is safe? So there's a whole -- even within one attack, there are a series of events embedded in that that will have psychological consequences. This is just to show us that the psychological toll, this was from a national poll, that in the aftermath of 9/11, 71 percent of the representative sample of the nation felt depressed, difficulty concentrating, trouble sleeping. I suspect the recent tragedy with the shuttle you'll also see a fair amount of sadness, if that's being studied. Psychological responses. This is just a partial list, and again, there's that sense of horror, fear, anger and paranoia. And I want to point these out because that can lead to rumors and scapegoating. Rumors can be very -- have powerful consequences of their own. For example, in the Surat Plague outbreak there was a rumor that Pakistan had deliberately introduced the agent from the Soviet Union as a weapon of bioterror. And again, with two nuclear armed countries, that creates a bit of heartburn. Sadness, grief. Again, we tend to overlook the positive outcomes of responding to a tragedy. Altruism. Again, I had mentioned uncertainty, terror. Again we do see resilience. Numbing and withdrawal is a problem, as is a feeling of helplessness, so that anything that helps empower people with a sense of there's something they can do is generally helpful.
Okay. To speak a little bit about the Surat Plague outbreak again, this was not bioterrorism. It was a natural outbreak. It resulted in 58 deaths. It was antibiotics susceptible, so in other words if you caught it, it was effectively treated. But I just want to -- again we'll hear more about panic and behavior, but the doctors took off too in this event, so we are not immune from fear and terror. And this points to the fact that I think again that panic is sort of in the eye of the beholder, and it may not be so silly to stock up on a treatment if you think that you might need it and there might be a shortage. Maybe not desirable from a management point of view. And again, there are social and economic consequences, a ban on flights from India. Of course, a lot of people didn't feel like traveling over there. And just to show the international, things aren't local any more. The CDC Plague Hotline received over 2,500 calls during that time period. Another thing that our concern is, is that there'll be a tremendous health care seeking behaviors that again could be distributed throughout the country, or indeed the world, for people fearing they've been exposed to something. If we look at best case scenarios, there's an identifiable event like the Tokyo sarin attack where the scud missiles, where they thought there might be something going on during the first Gulf War. It produced immediate symptoms so there is not that uncertainty. You know something has happened. The agent is identified rapidly so you know what you're dealing with. Ideally, there's some warnings so you're kind of primed and ready to go, and it's a small event. And under those best circumstances, I've chosen to call these behavioral rather than psychological casualties. What I mean by this is that people take themselves to a health care provider or a hospital to get checked out because they're worried that they might have whatever it is. Now why do people do that? Well, some of the signs of physiological arousal when we're exposed to fear are quite ubiquitous and quite, you know, wide-ranging. And you can imagine if you start to feel these kinds of things that that might just reinforce your concern and fear that you have been infected with something, so that there is a real true physiological response that can play into this health seeking behavior and fear. So again, this misattribution of the normal symptoms of, if you will, fight, flight or freeze, to be something of a serious illness. And if there are rumors and false information, again to underscore points that have been made, it's important to be honest and fast in getting the information out. And also, to monitor for rumors and address them. And there's a certain amount of hypersuggestibility right after something that kind of stuns us. And again, the take home point is that risk communication will be a critical factor in determining outcome to one of these events. Just wanted to show another national sample by London. Again, I think people were relatively -- put things into pretty good context overall following -- in the immediate aftermath of the Anthrax. I have a few more slides on that, but you can see like most people thought it was more likely they'd get the flu. Moving to things that are behaviors, again, which I think is really where the money lies. Thirty-seven percent used precautions opening the mail, about a quarter of people had stocked up on emergency supplies, looked for information. And this again is what I want to show, is really less than 5 percent purchased something or started taking -- I think it was less than 1 percent that actually took antibiotics, even though some had purchased it. And this is just to show that other things around here, again in a climate of expected continuous threat, the terrorists, sniper incidents really generated more terror in this particular region than the Anthrax did. And I think understanding the reasons for that would be important as we try to predict and manage responses to. And again, looking at behaviors, almost 44 percent changed their outdoor activities in this region. Thirty-six percent use a different gas station. And again, I think rather than seeing this as necessarily panic, you might also see that this is reasonable strategy perhaps to avoid being shot, even though there was a very small risk of doing so. And with that, I think I will close with the final remarks, that I think it's very important that we understand the psychological and social consequences of these attacks so that we can mitigate against them. And that risk communication and honesty, and trusting in the public will be the cornerstone of those activities. Thank you. DR. URSANO: Thank you, Ann. You know the last time I had the opportunity to introduce Ann, my wife was in the audience, and Ann also made that comment about being the smartest man she'd ever met. I went home that night and I said to Diane, my wife, who's a social worker, isn't that wonderful what she said? And Diane said, "Bob", she said you're the smartest man." Just to make sure you all are out there and staying with us. [return to top] |
