Anthrax Anxiety

A firefighter (left) assists an FBI agent investigating the offices of American Media, in Boca Raton, Fla., where a photo editor became the first victim of bioterrorism using anthrax. Two other employees tested positive for exposure. (Photo ©AFP/Rhona Wise)

Dr. Itzhak Levav, a psychiatrist who formerly headed PAHO's mental health program and is now an adviser to Israel's Ministry of Health, says, "The potential of a biological terrorist attack to cause fear is much greater. It's closer to the unknown, random, without reason." In contrast, a bomb or other conventional attack has a local, more lim-ited effect, he notes.

A resident of Jerusalem, Dr. Levav knows fear as a daily companion, given the relatively frequent bombs and suicide attacks in Israel. "A citizen who knows there is danger is naturally afraid," he says. "He withdraws, goes out less, and has a permanent feeling of apprehension." He adds, "You learn to live with it. If I get on a bus I look at everyone, I'm conscious of the fact that there could be danger. I'm alert and wary of anything unusual."

People in Israel received government-issued gas masks and prepared sealed rooms in their homes during the Gulf War in 1991, when Iraq launched a series of Scud missiles at Israel. The missiles turned out to have conventional explosive warheads, but that did not lessen the fear, says Levav. Being in "a hypervigilant mode, constantly scanning the environment" can cause depression, tension, and stress, he notes. "This is increasingly the case in the United States as well."

Fears of new terrorist attacks using biological agents intensified with the anthrax scare that began last October, when a photo editor at a tabloid newspaper in Boca Raton, Fla., died of the inhaled form of the disease. The U.S. Centers for Disease Control and Prevention (CDC) described its own response: "The CDC initiated an epidemiologic investigation and public health surveillance to identify how infection with Bacillus anthracis occurred and to identify other infections. An environmental investigation identified one sample taken from the victim's workplace (American Media Inc.) as positive for anthrax. B. anthracis also was identified in one nasal sample from another worker in the same building, which suggests exposure."

Subsequently, anthrax-laced letters were received in the office of a U.S. senator, a network anchorman, a New York newspaper, and other places, starting a spate of anthrax infections that killed five people, infected 18 others, put 30,000 Americans on antibiotics, and instilled fear in millions of others.

"We're getting dangerously close to being at capacity," said Dr. Georges Benjamin, director of the State of Maryland Department of Health and Mental Hygiene and president of the Association of State and Territorial Health Officials. "When you take epidemiologists off their work to do this epidemic, that means if another epidemic occurred, we would not have been able to handle it."

The need to reshuffle resources to deal with bioterrorism concerns, often at the expense of other public health work, highlights a lack of funding that has been eroding the nation's public health infrastructure for decades, says Dr. Benjamin. Even though relatively few people have been infected by anthrax, the work associated with the response has been difficult to manage. "Think about it," he says. "Three letters and a relatively small amount of anthrax-and billions of dollars of loss."

At the Maryland state health department, Dr. Benjamin says, employees have fallen behind in entering computer data and monitoring other diseases. "If we miss a disease because that data didn't go in or we couldn't track it, that's a worst case," he notes. "It shows we need to fix the public health infrastructure now."

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