How to Lead During Bioattacks with the Public

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How to Lead During Bioattacks with the Publics
Trust and HelpA Manual for Mayors,
Governors,and Top Health Officials

• UPMC CENTER FOR BIOSECURITY

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Presentation Overview
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Purpose Anticipate and Avert Governing Trouble
Spots that Arise during Epidemics

• Set forth strategic goals that distinguish
  effective, compassionate leadership in epidemics
• Illustrate circumstances posed by bioattacks that
  further complicate response to the health crisis
• Identify dilemmas of governing that commonly
  arise during epidemics natural or
  deliberate
• Recommend principles and actions for averting
  and/or remedying such predicaments

Presentation Overview
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Working Group on Governance Dilemmas in
Bioterrorism Response

• Convened by UPMC Biosecurity Center staff, Feb
  2003 to Feb 2004
• Thirty members including seasoned political and
  public health decision-makers
• Consensus statement Biosecurity Bioterrorism
  20042(1)25-40
• Experience, professional judgment evidence
  obtained by literature review

Presentation Overview
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What defines leadershipduring an epidemic
orbiological attack?
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Dynamic Collaboration with the Public Essential
Means to Strategic Aims

• Swifter resolution of immediate health crisis
• Enhanced social and economic resilience of
  affected communities
• Continuity of fundamental democratic values and
  processes

Successful Leadership Strategic Goals
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Strategic Goals

• Limit death and suffering through proper
  preventive, curative, and supportive care
• Defend civil liberties by using least restrictive
  interventions to control spread of disease
• Preserve economic stability, managing impact on
  victims and hard-hit locales
• Discourage scapegoating and stigmatization
• Bolster ability of individuals and groups to
  rebound from traumatic events

Successful Leadership Strategic Goals
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Why do biological attackspresent special
challengesand high-stakes decisionsfor leaders?
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Epidemics Are Complex Phenomena due to Unfolding
Biology and Competing Social Aims

• Troubling to consider leaders and the public
  may deny problem or intervene too quickly without
  regard to negative effects.
• People need to make sense of random and
  terrifying events, but epidemics elude quick and
  easy explanation.
• Mysterious diseases can trigger impulse to
  isolate oneself and blame others, or to care for
  victims without regard to ones own safety.

Bioattacks Unique Challenges
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Modern Conditions Disperse Impacts More Quickly,
Make Some People More Vulnerable

• Global, round-the-clock news reports cause fear
  and dread and in places far from immediate harm.
• Todays transportation moves people quickly
  across vast distances, potentially accelerating
  spread of disease.
• Epidemics have broad, indirect financial impacts
  due to close ties among global, national, and
  local economies.
• Poverty, lack of insurance, and distrust of
  healthcare system make those most vulnerable
  during outbreaks the least able to protect
  themselves.
• Personnel shortages and lean budgets limit
  response capabilities of U.S. hospitals and
  health agencies.

Bioattacks Unique Challenges
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Case Study SARS 2003

• gt4,000 cases (1/2 total global count) traceable
  to chance encounter by handful of international
  travelers with virus at four-star Hong Kong
  hotel among the guests was an infected doctor
  who had treated patients in Guangdong Province,
  where the outbreak first emerged.
• When the global SARS outbreak peaked, some New
  Yorkers transposed news reports on conditions in
  hard-hit cities like Hong Kong to their hometown,
  where impact was negligible.

Bioattacks Unique Challenges
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Calculated Attack Further Magnifies the
Consequences of an Epidemic

• Attackers motivations and tactics attacks on
  multiple cities or over a prolonged period
  heighten an epidemics uncertainties.
• Scapegoating will be more severe than in natural
  outbreaks as people demand to know, Who did
  this?!
• If a disease is weaponized or infects people
  through an unusual route (such as the mail), it
  may be harder to detect and treat.

Bioattacks Unique Challenges
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Case Study Anthrax 2001

• Frustration and confusion arose from lack of
  immediate answers to basic, factual questions.
  Who did this? How many letters were involved?
• Health authorities and clinicians had to make
  critical decisions based on partial science What
  is best treatment? Who should receive antibiotics
  and for how long? Which mailrooms should be
  closed and surveyed?
• Apparent gaps in the governments response
  fostered more uncertainty Were officials
  withholding information about the attack? Was
  treatment for postal workers and Capitol Hill
  employees really different, and why?

Bioattacks Unique Challenges
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What leadership dilemmasmay arise in a
deliberate epidemic, and how mightthey be
averted?
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Conflicts of Interest, Priority, and Purpose that
Commonly Emerge during Epidemics

• Balancing imperatives of disease control with
• Individual liberty
• Economic stability
• Protection against victim stigmatization

Epidemics Recurring Dilemmas
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Stopping Disease that Spreads Person-to-Person
while Upholding Individual Freedoms

• Make bioterrorism plans public before crisis
  occurs a well-informed population is more likely
  to follow advice.
• Sketch out the big picture make concrete the
  fact that personal actions can affect the safety
  of others.
• Provide goods and services that help people
  comply with health orders.
• Use disease controls that respect autonomy and
  self-determination Public cooperation limits
  illness and death resistance does not.
• Restrict civil liberties, if necessary, only in a
  transparent and equitable way.

Epidemics Recurring Dilemmas
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Case Study Smallpox 1894

• Facing a citywide outbreak, Milwaukee health
  authorities forcibly removed infected individuals
  to isolation hospitals, selectively using this
  technique among impoverished immigrants and not
  the well-off.
• Perceived to be discriminatory and authoritarian,
  these measures caused month-long riots and
  ultimately abetted the spread of smallpox.
• Outbreak Impact 1,079 cases, 244 deaths

Epidemics Recurring Dilemmas
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Case Study Smallpox 1947

• NYC officials effectively quelled outbreak by
  implementing a voluntary mass vaccination
  campaign that was universally applied, carrying
  out an elaborate public relations campaign, and
  involving grassroots organizations.
• Outbreak impact 12 cases, 2 deaths

Epidemics Recurring Dilemmas
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Protecting the Economy while Using Disease
Controls that Disrupt Commerce

• Be mindful of the goal of long-term financial
  recovery when controlling disease do not react
  based solely on the desire to avert short-term
  economic loss.
• Recognize public trust as precious capital that
  grows the economyif people see their health as
  your top priority, confidence in your efforts to
  safeguard the economy will follow.
• Account for the less visible and more scattered
  monetary impacts when making epidemic control
  decisions (e.g., costs of victims healthcare,
  economic toll of stigma).

Epidemics Recurring Dilemmas
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Case Study Tylenol 1982

• 7 Chicago-area residents died after taking
  Extra-Strength Tylenol capsules laced with
  cyanide.
• JJ executives halted manufacture, withdrew
  product worldwide, and offered customers refund
  or replacement.
• 100 million in inventory was destroyed market
  share dropped 87 experts predicted the brands
  demise.
• JJ reintroduced Tylenol products with
  tamper-resistant packaging, with robust
  advertising campaign.
• Responding to the companys civic-minded
  behavior, consumer confidence rebounded, quickly
  returning market share to pre-crisis levels.

Epidemics Recurring Dilemmas
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Restoring Social Bonds when People Feel at the
Mercy of a Mysterious Disease or Attacker

• Express empathy for peoples fears about getting
  sick from others help people gauge personal risk
  accurately.
• Explain to community-at-large the social costs of
  avoiding people out of fear, rather than out of
  actual danger.
• Give frequent updates on the criminal
  investigation counsel people not to lash out
  against others.
• Spotlight community projects aimed at bringing
  people together across social divisions
  sensitized by the crisis.
• Direct law enforcement to deal appropriately with
  hate crimes in the event prevention fails.
• Coordinate humanitarian relief effort, with extra
  focus on assisting the most vulnerable.

Epidemics Recurring Dilemmas
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Case Study Anthrax 2001

• Employees of American Media, Inc., the site of
  the first inhalational anthrax case, were doubly
  victimized.
• Physically threatened by potential exposure to
  anthrax, they sometimes found themselves shunned
  by other community members.
• Long-time physicians refused to care for them
  schools turned away their children and those
  moonlighting as housekeepers were not allowed
  into homes to clean.

Epidemics Recurring Dilemmas
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What situations splinterthe social trust
necessaryto cope with health crises,and how
might theybe defused?
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Alienation between Leaders and Public, and among
Community Members Themselves

• Breaches in social trust are a common predicament
  during outbreaks and are likely to arise during a
  bioattack.
• Often propelled by
• Pre-existing social and economic fault lines
• Preconceived notions about the government, the
  public, and the media

Social Trust Building Reserves
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Unproductive Fear, Denial, or Skepticism by the
Public when Leaders Give Crisis Updates

• Share what you know. Creative coping is the norm
  panic is the exception.
• Hold press briefings early and often to reach the
  public.
• Confirm that health agencies and medical
  facilities can handle onslaught of questions from
  concerned people.
• Convey facts clearly and quickly so that people
  have peace of mind or so that they seek out care,
  if need be.
• View rumors as a normal sign of the need to make
  sense of vague or disturbing events. Refine your
  outreach efforts the current ones may not be
  working.

Social Trust Building Reserves
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Earning public confidence in leaders plans for
effective use of scarce resources

• Account for income disparities in planning
  anticipate the need for free or low-cost
  prevention and treatment.
• Make planning transparent so that the public sees
  that access to life-saving resources is based on
  medical need and not on wealth or favored status.
  
• Be open about eligibility criteria for goods and
  services, especially when tough choices arise
  unexpectedly.
• Show thorough preparations to protect vulnerable
  populations like children and the frail elderly,
  thus bolstering everyones sense of security.

Social Trust Building Reserves
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Case Study Healthcare Access

• Given routine differentials healthcare access and
  a prevalent belief that inequity will prevail
  during a bioattack, leaders are in the
  unfortunate position of having to prove
  otherwise.
• One of every seven Americans lacks health
  insurance, with minorities overrepresented.
• 72 of respondents to a Dec. 2002 national poll
  said they believed that if it were not possible
  to vaccinate everyone quickly during a smallpox
  outbreak in their community, wealthy and
  influential people would get the vaccine first.

Social Trust Building Reserves
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Maintaining Credibility when Leaders Have to
Decide before All the Facts Are in

• Advise the community at the outset if crisis
  conditions are evolving or could be prolonged.
• Offer more detail rather than less, even when the
  unknowns outnumber what is known.
• Resist the urge to reassure for reassurance sake
  alone.
• Be frank about any uncertainty regarding facts
  describe plans to fill in knowledge gaps.
• Vary your means of reaching the public. Mix
  high-tech outreach with contact through
  grassroots leaders.

Social Trust Building Reserves
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Case Study Anthrax 2001

• Secretary of Healths definitive reassurances
  that Bob Stevenss inhalational anthrax was an
  isolated case and that there is no terrorism
  came before all the facts were in.
• Created the impression that the government was
  not forthcoming about the extent of the problem,
  especially when more cases of infection and
  anthrax-laden letters turned up.

Social Trust Building Reserves
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Conclusion
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Leadership Conscious Pursuit of Shared
Responsibility for the Publics Health

• Approach the public as a capable ally
• Keep planning and response transparent
• Prioritize voluntary compliance among the many
  above coercion of the few
• Advance equity in access to emergency resources
• Share difficult decisions when they arise
• Call for solidarity and compassion while
  shielding and aiding the ostracized

Conclusion
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Acknowledgements
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Veteran Politicaland Public Health Leaders

• Georges Benjamin, MD, FACP, Exec Director,
  American Public Health Association Marylands
  Commissioner of Health during 01 anthrax attacks
• William Bicknell, MD, MPH, Professor and Chairman
  Emeritus of International Health at Boston
  University, School of Public Health former
  Commissioner of Health for Massachusetts
• Neal L. Cohen, MD, Executive Director, AMDeC
  Center on Bioterrorism former Commissioner of
  Health for New York City during 99 West Nile
  Virus outbreak, 01 World Trade Center bombing,
  and 01 anthrax attacks
• Aaron Greenfield, JD, Executive Director,
  Maryland Business Council former Special City
  Solicitor Homeland Security Advisor, Baltimore
  City Mayors Office
• Margaret A. Hamburg, MD, Vice President,
  Biological Programs, Nuclear Threat Initiative
  former Assistant Secretary for Planning
  Evaluation, Department of Health and Human
  Services
• Jean Malecki, MD, MPH, FACPM, Director, Palm
  Beach County Health Department led investigation
  team of first inhalational anthrax case in 2001
• Tara O'Toole, MD, MPH, Director, UPMC Center for
  Biosecurity former Director, Johns Hopkins
  Civilian Biodefense Center former Assistant
  Secretary of Energy for Environment, Safety and
  Health

Working Group
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Medical, Public Health,and Disaster Experts

• Kenneth D. Bloem, MPH, former top executive at
  Georgetown, Stanford, Chicago, and Boston
  University Medical Centers
• Brian W. Flynn, EdD, Associate Director, Center
  for the Study of Traumatic Stress, Uniformed
  Services University former Rear
  Admiral/Assistant Surgeon General, U.S. Public
  Health Service
• Thomas V. Inglesby, MD, Deputy Director, UPMC
  Center for Biosecurity former Deputy Director,
  Johns Hopkins Civilian Biodefense Center
  Infectious Disease Clinician, Johns Hopkins
  Hospital
• Linda Morris, BSN, RN, Director, Community Health
  Youth, Greater Kansas City American Red Cross
  (GKC-ARC) former Community Health Nurse Manager,
  GKC-ARC
• Ann E. Norwood, MD, COL MC, USA, Associate
  Professor Associate Chair, Department of
  Psychiatry, Uniformed Services University
• Monica Schoch-Spana, PhD, Chair Senior Fellow,
  UPMC Center for Biosecurity former Senior
  Fellow, Johns Hopkins Civilian Biodefense Center
• Kathleen Tierney, PhD, Director, Natural Hazards
  Research and Applications Center Professor of
  Sociology, University of Colorado at Boulder

Working Group
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Community Leadersand Special Population Advocates

• Naomi Baden, JD, MS, Facilitator, mediator,
  negotiator specializing in inter- and
  intra-organizational decision-making processes
• Marion J. Balsam, MD, FAAP, Diplomate, American
  Board of Pediatrics Member, American Academy of
  Pediatrics Task Force on Terrorism retired Rear
  Admiral of Medical Corps of the U.S. Navy
• Emira Habiby-Browne, MA, Founder Executive
  Director, Arab-American Family Support Center,
  New York City
• Robert G. Kaplan, Founding Director, Commission
  of Intergroup Relations Community Concerns at
  the Jewish Community Relations Council of NY
  Public Health/Faith Based Community Institute of
  CDC and Emory Univ.
• Myrna Lewis, PhD, Assistant Clinical Professor,
  Community Preventive Medicine, NYC Mount Sinai
  School of Medicine United Nations NGO Committees
  on Aging and Women NYC Mental Health Disaster
  Team
• Onora Lien, Research Analyst, UPMC Center for
  Biosecurity Doctoral Candidate in Sociology,
  Johns Hopkins University
• Shirley G. Mitchell, PhD, President, Board of
  Directors, Phyllis Wheatley YWCA, Washington, DC

Working Group
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News Media, Public Affairs,and Risk
Communications Experts

• Thom Berry, Director, Media Relations, South
  Carolina Dept of Health and Environmental
  Control Pres., National Public Health
  Information Coalition
• John Burke, MA, JD, President, Strategic
  Communications Inc. Advisor to clients including
  Union Carbide, Pfizer, Merck, and Johnson
  Johnson
• Joan Deppa, PhD, Associate Professor, S.I.
  Newhouse School of Communications, Syracuse
  University former UPI editor reporter
• Darren Irby, Vice President of External Affairs,
  American Red Cross
• Richard Knox, Health Science Correspondent,
  National Public Radio
• Sandra Mullin, MSW, Director of Communications
  for NYC Health Department during 99 West Nile
  Virus outbreak, 01 World Trade Center attacks,
  01 anthrax attacks, and 03 SARS outbreak
• Barbara Reynolds, MA, Crisis Emergency Risk
  Communication Specialist, CDC managed public
  communications during 01 anthrax attacks
• Peter Sandman, PhD, Risk Communications
  Specialist advisor to NYC health department and
  CDC on bioterrorism, preparedness, and
  communication
• Mary E. Walsh, National Security Producer, CBS
  News, assigned to Pentagon

Working Group
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• Support
• Award MIPT-2002J-A-019 from the Oklahoma City
  Memorial Institute for the Prevention of
  Terrorism (MIPT) and the Office for Domestic
  Preparedness, Department of Homeland Security,
  and Award 2000-10-7 from The Alfred P. Sloan
  Foundation.
• Disclaimer
• Points of view in this presentation are those of
  the working group and do not necessarily
  represent the official position of MIPT, the U.S.
  Department of Homeland Security, or the Sloan
  Foundation.

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Project Team

• Monica Schoch-Spana, Principal Investigator
• Bruce Campbell, Financial Administrator
• Molly DEsopo, Production Coordinator
• Jackie Fox, Senior Science Writer
• Tim Holmes, Web Design Specialist
• Onora Lien, Research Analyst
• Scott Sugiuchi, Graphic Designer

Working Group
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This presentation, additional materials, and
resources are available online at

• www.upmc-biosecurity.org/pages/resources/leadershi
  p.html