Milbank Quarterly

s of other articles in this issue Subscriptions, sample copies, and back issues Emotional and Behavioral Consequences of Bioterrorism: Planning a Public Health Response BRADLEY D. STEIN, TERRI L. TANIELIAN, DAVID P. EISENMAN, DONNA J. KEYSER, M. AUDREY BURNAM, and HAROLD A. PINCUS RAND Corporation; University of Southern California; University of California, Los Angeles; University of Pittsburgh Millions of dollars have been spent improving the public health system’s bioterrorism response capabilities. Yet relatively little attention has been paid to precisely how the public will respond to bioterrorism and how emotional and behavioral responses might complicate an otherwise successful response. This article synthesizes the available evidence about the likely emotional and behavioral consequences of bioterrorism to suggest what decision makers can do now to improve that response. It examines the emotional and behavioral impact of previous “bioterrorism-like” events and summarizes interviews with experts who have responded to such events or conducted research on the effects of communitywide disasters. The article concludes by reflecting on the evidence and experts’ perspectives to suggest actions to be taken now and future policy and research priorities. he importance of preparing our nation to counter and respond effectively to terrorist threats has been evident since the attacks of September 11, 2001. Of particular concern is the possibility of terrorist attacks involving chemical, biological, radiological, or nuclear weapons (CBRN) (Gilmore Commission 2002). Organized terrorist groups (such as al-Qaeda) have tried to obtain or develop CBRN weapons and have publicly proclaimed that they consider obtaining them to be a religious duty (Lumpkin 2001), but they have not yet demonstrated the capability to effectively acquire, create, or use them. Nonetheless, CBRN weapons remain a substantial concern because of their potential to cause widespread death and destruction. Biological terrorism is likely to differ from conventional terrorism, such as a bombing or hijacking, on a number of dimensions, as illustrated in Table 1. Given these differences, we might also expect differences in the emotional and behavioral impact of bioterrorism compared with that of other types of terrorist events. For example, the unfamiliarity of biological weapons, the uncertainty in determining whether an attack has occurred and the scope of that attack, and the possibility of contagion and of being an unknowing victim of the attack may heighten the level of fear and anxiety associated with a bioterrorist attack (Alexander and Klein 2003; Demartino 2002; Holloway et al. 1997). But precisely how the public will respond to a bioterrorist event is unclear. Some people are concerned that the demand for health care services by the “worried well”— individuals without an organic etiology of their symptoms (Bartholomew and Wessely 2002)—will overwhelm health resources, even in the event of a very small bioterrorist attack. Based on prior terrorist events such as the sarin gas attacks in Tokyo in 1995, the U.S. Department of Defense estimates that an attack from a CBRN weapon would produce five psychological casualties for every one physical casualty (Warwick 2001); other estimates of the ratio of psychological casualties to physical casualties range from 4 to 1 to as high as 50 to 1 (Demartino 2002). Some experts recommend planning for widespread public panic, whereas others believe that such expectations are misguided (Glass and Schoch-Spana 2002; Pastel 2001; Schoch-Spana 2000). We do not understand under what circumstances people’s emotional reactions will differ. These emotional reactions can range from common distress responses such as fear and anxiety to full-blown psychiatric disorders (Institute of Medicine 2003). Nor can we now confidently predict how individuals’ behavioral reactions to a bioterrorist attack (e.g., seeking health care services) may complicate planned public health responses.