An aerosol mist laden with deadly microbes filters through the air and is inhaled by an unsuspecting population in a U.S. city under attack by unknown terrorists. Their destructive intent--a secret for weeks as the germs incubate--is revealed only after the first casualties arrive at hospital emergency departments. Disaster officials move to contain the disease; but the system is soon overwhelmed, not only by people who are really sick, but also by thousands of healthy individuals whose growing anxiety yields false symptoms of illness. Public health and government relief efforts sag under the strain, and fearful crowds begin to react in ways that threaten the social fabric.
This scenario is so real, so potentially devastating, that the federal government will spend $11 billion this year alone to combat terrorism, whether biological, chemical or nuclear. In all, some 40 government agencies will play a role, and there are at least three bills pending in the U.S. Congress that aim to better organize the agencies that must respond to an attack by foreign or domestic foes.
The hallmark of terror, by definition, is that it can disable an opponent by undermining confidence in its institutions. According to one government report, terrorism is, "The unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives." Yet despite the psychological component at its core and the enormous dedication of resources devoted to meet the threat, mental health experts say that more must be done to meet the behavioral issues that arise following an attack.
Robert J. Ursano, M.D., professor and chair of the department of psychiatry at Uniformed Services University of the Health Sciences in Bethesda, Md., told Psychiatric Times that the mental health component is presently dramatically underfunded and underrecognized. "If you don't deal with the mental health issues," he said, "you won't have to worry about the other issues because the system will be overloaded [with mental health issues]."
Ursano, who is also the former chair and a current member of the American Psychiatric Association's committee on psychiatric dimensions of disaster, said that one of the reasons mental health does not receive the emphasis it deserves is the sheer magnitude of integrating a large number of government agencies. Some of the billions spent, he said, are often duplicative and not well-organized.
Not atypically, mental health issues are also marginalized to an extent. "I think people see it as a secondary line of concern, and they don't appreciate the reality of how individuals in communities will respond in such settings," Ursano said. "They get targeted toward the infectious agent without thinking about the complexity of the responses people will have. It's not to say that one shouldn't be dealing with how to identify infectious agents better [or] how to develop treatments for them--those are certainly of great concern--but if you don't address the mental health and psychological issues, all of that may go for naught."
In many respects, the psychological responses and need for psychiatric intervention in the case of a bioterrorist attack are similar to those in natural or other man-made disasters, but there are reasons that the biological weapons of mass destruction--smallpox, anthrax, botulism and plague--possess a unique character, Ursano said. For instance, there is a likelihood that the health care system will be flooded by people who exhibit "multiple unexplained physical symptoms." The prospect of an invisible destructive agent activates emotions that are difficult to manage, particularly when people organize in disruptive ways because they feel their safety needs are not being addressed by public officials.
Despite the specialized attention to behavioral responses required by a biological weapons attack, federal budget officials have yet to fund the work necessary to prepare, psychologist Brian W. Flynn, Ed.D., told PT. Flynn is the emergency coordinator for the Substance Abuse and Mental Health Services Administration (SAMHSA) and a rear admiral and assistant surgeon general in the U.S. Public Health Service.
"Over the past four years we have been completely unsuccessful in getting any funding from outside the agency with respect to bioterrorism," Flynn said. "Each year we propose a bioterrorism budget, and we have been completely unsuccessful. We've gotten very good support from HHS [U.S. Department of Health and Human Services], but it has been zeroed out each time at the Office of Management and Budget."
That failure means that important work is left undone. "We feel that we have to build a new field," Flynn said. "There is a need for the development of knowledge and development of models and protocols that simply don't exist. The interface between behavioral health and emergency health in a bioterrorism incident is going to be much greater than we typically see in natural disasters. Emergency room personnel aren't trained to make differential diagnoses; they don't have models; they don't have tools; so we need to build and test those tools and train those people. We also must get much more deeply into risk communication, which we see as having a very significant behavioral health component."
"It's a very real concern that we don't have much experience with bioterrorism," Carol Sue North, M.D., professor of psychiatry at Washington University School of Medicine in St. Louis, told PT. North, who has studied the psychiatric consequences for victims of disasters, added, "I'm a data person and I like to have data to [substantiate] what we would expect and what kind of things we might recommend The thing is, there aren't any data, because there haven't been many such incidents, otherwise we wouldn't be talking about worrying about it."
Under the circumstances, North said, the best that can be done is to extrapolate from research conducted following disasters of other sorts. "There are specific psychiatric diseases that will arise, and we know how to treat those no matter what form they come in," North explained. "If they get to us, we know how to treat them. The problem is psychiatric problems may flood the rest of the system. For example, somatizing or phobic people coming in and, thinking they've been exposed, demanding prophylaxis for the probable exposure. There's also the issue of coordination of efforts so that psychiatrists can come in and do what they're good at, and so the right people get to the doctors."
Responsibilities still need to be delineated, North said, especially when it comes to managing what could be large groups of people and the emotional tides that will flow through them. "A lot of what happens looks psychiatric but may not be per se psychiatric," she said. "A lot of people who get excited and come in and bollix up the system maybe aren't psychiatrically ill and are simply scared."
While there are things officials can do to help calm the masses, it is still not particularly clear as yet who bears the primary responsibility for assuring these things get done, North told PT. "The way it stands is maybe that hasn't been figured out."
According to the second annual report issued late last year by the federally funded Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction, there is still much to do, including developing a coordinated national approach. Particularly with respect to bioterrorism, "The key issues are insufficient education and training in terrorism-related subjects, minimum capabilities in surge capacity and in treatment facilities, clear standards and protocols for laboratories and other activities, and vaccine programs," the panel members wrote. "A robust public health infrastructure is necessary to ensure an effective response to terrorist attacks, especially those involving biologic agents."
In May, President George W. Bush assigned Vice President Dick Cheney the task of overseeing the national effort of dealing with weapons of mass destruction. In addition, an Office of National Preparedness, under the jurisdiction of the Federal Emergency Management Agency, will "serve as the focal point for the coordination and implementation of preparedness and consequence management programs for dealing with the threat of weapons of mass destruction," director Joe M. Allbaugh said in a statement to congressional committee members.
"It's good to have some senior leadership addressing the topic of how these multiple organizations are going to relate to each other, which is one of the issues in any type of disaster, but even more so in the area of bioterrorism," Ursano said. He is hoping that the new emphasis will result in considering mental health consequences.
"There have been a lot of activities about training first responders, and 120 cities have been identified and training efforts have taken place in those cities," Ursano explained. "So for the last several years there have been substantial amounts of funds, but in those settings mental health frequently gets overlooked--more than overlooked, it gets specifically zeroed out."
A 319-page study published last October by the Henry L. Stimson Center, a nonprofit think tank in Washington, D.C., agreed that wasteful government spending substituted "pork" for "preparedness" and that "throwing money at the problem is a costly substitute for effective government." Among the report's findings, it urged, "To prevent hospitals from collapsing during an infectious disease outbreak, cities should have workable plans to care for the unaffected and the mildly or moderately ill, including the establishment of field care centers where medical exams could be conducted, prophylactic drugs dispensed, and counseling provided, as appropriate."
Richard C.W. Hall, M.D., a private practice forensic psychiatrist in Maitland, Fla., and clinical professor of psychiatry at University of Florida College of Medicine, has consulted with various federal agencies since the Oklahoma City bombing, after which public interest in psychiatric casualties increased. In the wake of a biological weapon attack, how people will react will depend on the facts of any given situation, but patterns do emerge.
"The issues are usually not ones we think of," Hall told PT. "If a city has 200,000 bodies to dispose of in a week, the normal morgue system doesn't work you need some way to incinerate the bodies. If you have a contaminated water supply or you have to put troops in a city to cordon off areas that may be infected, then you've got an issue of whether people are trapped and if they can get out of an infected area. Will soldiers fire on civilians? Will civilians break curfew? Will parents try to reunite with their children? All those kinds of things come up."
Meanwhile, he said, the population will likely divide into thirds. "The initial reaction is disbelief, and then about a third of the people panic and they start consuming resources," Hall said. "About a third of the population is numb but compliant, they do what they're told to do and follow orders. And about a third of the population wants to take charge and, if they don't get a chance to do it, then they get oppositional and they start to form an opposition group."
As a result, Hall said it is important that preparedness programs include components that offset these effects. At the onset, high quality communications are needed for all types of reactions. The third of the population that wants to get involved and do something positive needs to know what they can do; the other third that is numb but compliant needs clear directions; and the rest of the population needs very structured systems. All of these issues must be addressed in any disaster plan.
Spencer Eth, M.D., vice chancellor and clinical director of the department of psychiatry at Saint Vincents Hospital and Medical Center in New York City and professor of psychiatry at New York Medical College, said that mass hysteria is a likely outcome of a biological weapon attack, but dealing with it will be complicated because of the number of real victims. In a real terrorist attack, "you're also going to have real people who have been injured and traumatized and all sorts of psychiatric issues to deal with other than the generally self-limiting mass hysteria. But the problem with the mass hysteria is that people do very dumb things when panicking."
While planning is important, there are limits. "Once it starts, you're kind of hanging along for the ride," Eth said. There are limits to how much anyone will be able to control the multi-faceted consequences of a bioterrorist attack, agreed Ursano. "I don't think one controls them. One tries to anticipate, one tries to prepare and one tries to have the resources available to meet the needs. And, in doing that, one can decrease the level of disruption, the degree of fear and, hopefully, the loss of life."