The Magazine of the Pan American Health Organization: Volume 6 No. 2 - 2002By Daniel Epstein
The televised images of Sept. 11, 2001, were deeply shocking: jetliners crashing into skyscrapers, desperate office workers leaping to certain death, and stunned, ash-covered survivors stumbling about in a daze.
When terrorists demolished New York's tallest buildings and crashed into the Pentagon in closely timed suicide attacks that day, they killed some 3,500 people. In the following weeks, deadly anthrax spores mailed to politicians and media figures killed five, but induced fear of bioterrorism among millions throughout the United States and even abroad.
These attacks caused an immediate rise in stress levels and mental problems, according to mental health experts. But they have also brought a reassessment of the role and importance of the public health sector, prompting calls for new international efforts to strengthen the United States' and other countries' capacities to respond.
"We must maximize our collective resources and expertise to improve our health security-nationally, regionally, and globally," said U.S. Secretary of Health and Human Services Tommy G. Thompson during a ministerial meeting on international health security in Ottawa in early November.
The events that added up to the worst terrorist strike in history-and their rapid sequence-stunned the world. They started at 8:45 that morning, when an American Airlines jet slammed into the North Tower of the World Trade Center. Most people thought it was a freak accident until 18 minutes later, when a second jetliner crashed into the South Tower, creating a huge explosion. Shortly afterward, a passenger jet crashed into the Pentagon, while a fourth hijacked plane, possibly intended to hit the White House or the Capitol, was forced down in rural Pennsylvania by passengers who overpowered their hijackers.
In less than two hours, both 110-story towers in New York had collapsed, burying thousands of office workers and rescue personnel under tons of debris. All of southern Manhattan was evacuated, federal workers were sent home, schools were shut down, and U.S. airspace was closed for the first time ever, stranding thousands of travelers both in the United States and overseas.
The impact of what was probably the most traumatic day in U.S. history was further magnified by the endlessly repeated media coverage of planes crashing into buildings, buildings collapsing into piles of smoldering ruins, fire fighters and police weeping as they fought the flames and searched for survivors, and relatives desperately searching for their loved ones, clutching heart-rending fliers with photos and personal descriptions.
"It's not surprising that people would have trouble dealing with these events as real," says Dr. Andrew Baum, professor of psychiatry at the University of Pittsburgh. "We have seen events like these in movies or in other countries, mostly in unreal contexts. This is such a horrific event that people need to distance themselves from it to process it."
Dr. Baum, who studies long-term consequences of trauma on the mental health of disaster victims and rescue workers, says that events like those of Sept. 11 "challenge many of the assumptions that we make as part of our basic daily lives, and until those assumptions can be repaired, people find themselves having some difficulty."
Terrorist attacks-like armed conflict and other catastrophes-invariably strain people's abilities to cope, understand, and respond, says Dr. José Miguel Caldas de Almeida, coordinator of the Pan American Health Organization's Program on Mental Health. Most people exposed to events such as the Sept. 11 attacks-even as remote observers-will be affected, he says, with varying degrees of impact on their health and psychosocial functioning.
Many people find themselves haunted by the scenes they viewed in television news coverage. This mental replay of events is explained by what experts call "attention bias," or the tendency of threatening images to rivet human attention even after danger has passed.
"The reason people can't easily shift their attention back to their normal routines is that threatening images hold our attention much longer than nonthreatening ones," says Professor Elaine Fox of the University of Essex in England, author of a study of attention bias published in the December issue of the Journal of Experimental Psychology.
This may be a function of the way the brain handles such images, according to Dr. Nancy Smyth, a trauma expert and professor at the University of Buffalo in New York. "There's a mounting body of evidence that our brains don't process traumatic images into long-term memories in the same way that ordinary events are processed," she says. "Different parts of the brain seem to be involved in processing and storing threatening sensory data and more conventional experiences. In fact, it may be that some traumatic images are never completely processed in the usual fashion." People who found themselves glued to the television, viewing the images over and over again, may experience even greater difficulty assimilating them, she says, "as will people who perceive a personal connection between their lives and the traumatic event they have seen images of."
The weekend following the terrorist attacks, nine of 10 American adults showed clinical signs of stress, according to a Rand Corporation study published in the Nov. 15 issue of the New England Journal of Medicine. Forty-four percent of those surveyed reported at least one symptom of substantial stress, such as being extremely upset when something reminded them of the tragedy, having trouble sleeping, or having unwarranted outbursts of anger.
"People reacted as if they were personally attacked," says Dr. Mark Schuster, who headed the study. "The stress was felt across all groups, all ages and all regions. Naturally, the stress was more intense the closer one was to the scenes of the World Trade Center and Pentagon, but even people who lived in places where there aren't tall buildings were experiencing substantial stress levels."
Speaking at a mental health summit in New York two months after the attack, Secretary Thompson said, "The anguish that accompanied Sept. 11th is going to stay with some people for a long time." He added that emergency workers responding to crises can show signs of psychological distress up to three years after a tragic event.
Yet if fear of additional conventional terrorist attacks is long-lasting, the fear of attacks using biological, chemical, or even nuclear weapons is arguably more intense.
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.
State health officials were quickly overwhelmed by a high demand for anthrax testing, as thousands of hoax anthrax incidents were reported. The Senate office building where anthrax was found remained closed for weeks, and postal facilities were shut down for decontamination. In November, a fourth anthrax-laced letter addressed to another senator was found in a search of quarantined mail.
"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."
The ultimate nightmare of some health experts is a terrorist release of smallpox, a scourge that killed 3 million to 4 million people every year before it was eradicated more than two decades ago. If released in an international airport, for instance, the virus could infect people who would not show symptoms for days. Because the virus spreads through face-to-face contact, they in turn could infect many more people worldwide, initiating a full-blown outbreak of smallpox that would become an international health emergency.
There is no approved treatment for smallpox, and about a third of those affected by it die, although a vaccine administered even several days after infection can reduce its effects substantially. However, there is not enough vaccine in the world today for those who might be infected in a widespread attack. As a result, the United States and Canada are working to stockpile enough vaccine for their own populations, while countries in Latin America and the Caribbean, with support from PAHO, are exploring renewed vaccine production.
The eradication of smallpox in 1980, culminating a 12-year global effort led by the World Health Organization (WHO), is widely considered one of humanity's greatest achievements, marking the first time a disease was wiped off the face of the earth. But no one is certain who still has the deadly virus, apart from the two declared stocks in the United States and Russia. Former Soviet scientists say Russia continued biological weapons research after smallpox was eradicated, producing the virus at least into the 1990s. Some officials fear that scientists who worked on that effort might have sold the virus to terrorists or rogue nations.
Ironically, the successful eradication of smallpox is what led to its potential use as a weapon; because vaccination ceased some 25 years ago, many-if not most-people today are susceptible to the virus (experts disagree on how immune those who were vaccinated still are). Some fear that the disease could spread rapidly.
How realistic is the smallpox threat? No one really knows. But Dr. D.A. Henderson, the physician who led the global smallpox eradication effort from 1966 to 1977, was concerned enough that he began warning about just such a threat in the early 1990s. A former dean of the Johns Hopkins University School of Public Health and currently an adviser to PAHO, Dr. Henderson founded and directed the Johns Hopkins Center for Civilian Biodefense Studies to carry out research on bioterrorism.
On Nov. 1, seven weeks and two days after the events of Sept. 11, Dr. Henderson was named to head a new Office of Public Health Preparedness for the U.S. Department of Health and Human Services. One of a select and tight-knit group of doctors who worked to rid the world of smallpox, Dr. Henderson says that more than anything, he would like to persuade the countries of the world to come together to condemn the use of germs as weapons.
"We've got to put the genie back in the bottle," he told The New York Times in November. The eradication program was an international effort, he points out, and other nations wanted the virus destroyed. "We had countries around the world saying, 'Why are Big Brother United States and Big Brother Russia keeping the virus?'" Clearly, there was a danger that the virus could escape, as it did in a laboratory in England in 1978, infecting a medical photographer. Moreover, he adds, by destroying its stocks, the United States could make possession of it a crime.
Dr. David Heymann, who worked in the smallpox eradication effort under Dr. Henderson and is now executive director for communicable diseases at WHO in Geneva, notes that in the event of a terrorist attack with smallpox, "the industrialized countries are, and will be, much better equipped to contain it than are developing countries." He adds, "It's not clear that we could muster up any will to do another eradication program. I think it would be hard to sell because if you do eradicate it again, you're in the same vulnerable situation we are in now."
After the disease was eradicated, governments agreed to keep stocks of the live virus in two secure laboratories, one at the Centers for Disease Control in Atlanta and one in Siberia, Russia. WHO and others advocated complete destruction of the remaining stocks of the virus, but that position was contested by some U.S. scientists. In 1999, U.S. President Bill Clinton declared the smallpox stocks should be retained while more research was conducted. On Nov. 15, the Bush administration also decided that the remaining smallpox stocks should be retained, until new vaccines and treatments for the disease are developed-a process that is likely to take years.
Terrorism experts generally agree that the risk of using a weapon that could kill their own people would not deter some radical groups, especially those that are motivated by religious fervor. Mr. Michael Swetnam, chairman of the Potomac Institute for Policy Studies in Arlington, Va., says the possibility of a smallpox attack should be taken seriously. But he adds that other weapons, such as a conventional bomb, a chemical agent, or a different type of biological agent, are more likely to be used for the simple reason that smallpox is hard to get. Still, exaggerating the risk of a smallpox attack might not be a bad thing, Mr. Swetnam says. "If we blow it out of proportion and we make sure we stockpile enough vaccine for everybody, then there's no incentive for them to use it. It will cost us a lot of money, but it's buying insurance."
For public health officials, the time to start buying insurance is now, and not just against smallpox. "The threat of bioterrorism is now a reality," Dr. Mohammad N. Akhter, executive director of the American Public Health Association, said in October. "Public health departments nationwide are not fully prepared to handle these growing bioterrorist attacks."
Dr. Henderson agrees, noting that U.S. hospitals have little extra capacity, and health departments cannot keep up even with routine disease outbreaks. In October, U.S. health secretary Tommy Thompson asked the U.S. Senate for new funds to bolster the public health sector's ability to respond to bioterrorism. Newly appointed U.S. Director of Homeland Security Tom Ridge has said he plans to request billions of additional dollars for the sector in 2002.
Health officials from around the world are also expressing concern. In mid-November, the U.S. Centers for Disease Control and Prevention reported that it had received requests for lab tests and bioterrorism information from 66 countries concerned about anthrax outbreaks. That concern is already being translated into international action and calls for greater cooperation and collaboration among countries that consider themselves potential targets.
PAHO, which has 35 Member Countries, convened its emergency task force in October to discuss bioterrorism preparedness in the Americas. The organization is placing new emphasis on chemical warfare, radiological emergencies, and other bioterrorism topics in its training activities, with courses that got under way in December. In addition, PAHO is working with its Member Countries to upgrade health sector expertise to handle potential emergencies resulting from terrorism. Measures include better disease surveillance, laboratory improvements, and improved crisis management planning, information dissemination, and response capacity.
At the G-7 health security meeting in Ottawa (see "Call for Global Action"), representatives of eight countries and the European Union declared that the Sept. 11 attacks "changed the focus of governments. It has centered our attention on how we assess risks, how we prepare for any eventuality, and how we respond more effectively to public health secu-rity crises. It has added urgency and determination to further strengthen our plans, networks, and protocols in collaboration with other countries as well as international organizations."
Beefing up the international capacity to respond to bioterrorism does not require starting from scratch. WHO's Global Outbreak Alert and Response Network, which incorporates bodies such as the United States' CDC, is an international mechanism already in place that can help countries coordinate efforts at rapid detection and response.
Moreover, says Dr. Claude de Ville, chief of PAHO's Emergency Preparedness and Disaster Relief Coordination Program, most concerned countries already have domestic systems in place for responding to natural and man-made disasters, and for surveillance of emerging and re-emerging infectious diseases. These systems also provide some preparation for dealing with bioterrorism.
For example, hospital capacity would likely be a concern in any bioterrorism attack, but "emergency plans in Latin American countries include procedures to make beds available during emergencies," observes Dr. de Ville. He and other experts agree that hospitals are likely to be the front lines in the event of a bioterrorist attack. The first biological damages would become apparent as the affected population sought emergency room services to treat illness. Hospitals, and particularly emergency room personnel, would have to deal with the consequences. Therefore, they "must be included early in the planning for these situations," says Dr. de Ville.
Another area of concern raised by a potential bioterrorist attack is the possibility of public panic and concomitant damages beyond the disease itself. This makes public information a key part of the response. "Governments must provide complete and accurate information to prevent panic," bioterrorism experts concluded at the PAHO meeting in October.
In general, improving preparedness of the health sector to respond to bioterrorism will be best done by strengthening everyday health capacity, says Dr. de Ville. An improved capacity to detect and respond to all types of epidemics, as well as any chemical or radiological emergency, is the soundest approach and will have the long-term benefit of strengthening health systems overall.
"The key is strengthening public health infrastructure," agrees Dr. Henderson, who holds out hope that smallpox will never again pose a threat to the world's health systems.
No one can know if there will be more terrorist attacks, or what the long-term consequences of Sept. 11 and its aftermath will be. But if there is any silver lining in the cloud of apprehension, experts say, it is a newfound respect-backed up with additional funding and support-for the field of public health.
Anthrax does not spread from person to person but can be made into a powder that is easily dispersed. To prevent serious illness or death, cases must be detected as early as possible. Emergency room personnel must be trained and alert; public health staff must be knowledgeable about the disease; and a network of laboratories must be competent to identify infectious agents.
The best response to anthrax exposure is prophylaxis with antibiotics for 60 days following contact. Anthrax is sensitive to a wide array of antibiotics in addition to Ciprofloxacin; penicillin and doxycycline are recommended. Although a good vaccine is not currently available, research to develop one has been stepped up.
The number of individuals susceptible to smallpox infection today is larger than ever, given that immunization stopped more than a quarter-century ago, and very few people have natural immunity. Although smallpox is more difficult to release, its hazard potential is much greater than that of anthrax. Because it is highly contagious, smallpox would become an immediate international problem. Countries that in the past had the capacity to produce a vaccine against the disease are no longer able to do so, and regaining that capacity would require training and revision of production procedures. The United States has decided to restart the production of smallpox vaccine using the traditional New York City Board of Health strain of vaccinia virus. U.S. government scientists are also conducting studies to see if any existing antiviral drugs would work against smallpox.
Senior public health officials from eight countries and the European Union met in Ottawa in early November to map out a plan for improving global health security in the face of potential bioterrorism. The officials, including ministers and secretaries of health, discussed ways of coordinating preparedness and response to acts of biological, chemical, and radio-nuclear terrorism. Their final declaration called for concerted global action to confront bioterrorism through stepped-up collaboration among governments and with international organizations such as the World Health Organization (WHO). "Terrorism, particularly bioterrorism, is an international issue," the ministers declared in their Ottawa Plan for Improving Health Security.
The countries agreed to:
Canada agreed to take the lead in establishing networks among the countries' public health sectors to facilitate sharing of best practices and to coordinate the development of additional proposals for ministerial consideration. Other countries attending the conference were France, Germany, Italy, Japan, Mexico, the United Kingdom, and the United States, along with officials from PAHO and WHO.
In late October, the Pan American Health Organization (PAHO) gathered experts on bioterrorism and emergency response from throughout the Ameri-cas to discuss coordinated efforts to deal with potential biological, chemical, or radiological attacks by terrorists.
PAHO Director Dr. George Alleyne told participants that his organization already has considerable capacity to detect and contain the spread of disease and to deal with disasters. But he added, "Countries of the region must now prepare to respond to the challenge posed by bioterrorism."
In their report, issued at the meeting's conclusion, the experts defined biological weapons as "devices used intentionally to cause disease or death through dissemination of microorganisms or toxins in food and water, by insect vectors or by aerosol." Potential targets, they observed, "include humans, food crops and livestock." Any infectious disease outbreak involving biological weapons would present "major challenges to already fragile national health systems," the experts said.
Noting that the recent incidents of terrorism have "created a sense of urgency," they recommended that countries start now to expand their existing disaster preparedness capabilities to cover possible biological, chemical, or radiological attacks. Such capabilities should include early detection of man-made infections, quick diagnosis, and effective response.
The group also asked PAHO and its Member Countries to "explore the potential for production of smallpox vaccine, including updates of good manufacturing practices for production." They noted that several countries, including Argentina, Brazil, Colombia, and Mexico, have appropriate manufacturing capabilities.
The group issued two sets of recommendations, the first for increasing national preparedness and the second for revamping PAHO's technical cooperation activities in light of bioterrorist threats.
Their report emphasized that the response to bioterrorism should be international: "Given the global econ-omy, an outbreak anywhere in the world may be considered a threat to virtually all nations."