After an Attack

Responses to a catastrophic bioterror attack are likely to greatly amplify or substantially mitigate the attack’s consequences. No less significant, if our post-attack responses fail, we are likely to encourage future attacks by demonstrating their efficacy in spreading terror.

Citizen preparedness is a key variable in our response, but while the United States has made substantial investments in professional preparation, only rhetorical attention has been paid to preparing the broader public. Using aerosol anthrax and smallpox attacks as primary examples, this paper demonstrates that our present preparations are likely to fail when measured against the six most fundamental citizen expectations. It advocates five research and development investments that would enhance citizen preparation.

The Likely Failure to Meet the Most Fundamental Citizen Expectations
We anticipate that if a substantial aerosol anthrax or smallpox attack were to occur in an American city, most members of the public would reasonably expect six fundamental kinds of support from the government. However, at present we believe local, state, and federal officials would fail to provide this support. Phrased as expectations from indi¬vidual citizens, the requested support and likely responses would be:

1. Instruct and equip me to protect myself as much as possible immediately and in the event of future attacks. Advice about modes of protection (the value of masks, modes of decontamination, means of infection control, etc.) is for the most part designed for professionals in hospitals rather than laypeople in everyday environments. It is remarkably rudimentary, without a sound scientific basis, and without consensus. After a bioterrorist attack, citizens would receive little or no advice, and the advice they receive will likely be conflicting, often incorrect, and would probably amplify their anger at the government’s failure to prepare.

2. Tell me whether I and/or those I love have been infected by this attack. Our health care system cannot diagnose smallpox early enough for the most efficacious treatment and our anthrax diagnostic capabilities would be overwhelmed in the wake of a catastrophic attack. Jurisdictions across the United States lack a mechanism for informing individuals about the whereabouts and status of their loved ones in the aftermath of an attack, as made clear by the confusion in the initial 24 to 48 hours after the September 11, 2001, collapse of the World Trade Center and experience after Hurricane Katrina in 2005.

3. If I cannot be reasonably assured that I was not infected, operate a system that will fairly, safely, and expeditiously provide me and others at risk with whatever drugs or vaccines will protect us. Policymakers have taken significant steps to accumulate supplies of some critical drugs and vaccines. But present distribution mechanisms are not likely to be fast, fair, or credibly safe. They are especially vulnerable to further terrorist attack and inadequately prepared to cope with likely transportation, staffing, and psychological obstacles.

4. Provide health care to those who require it. Emergency room and hospital bed capacities plan to “surge” to approximately 20 percent beyond capacity. We estimate that the require¬ment will be on the order of 1,000 percent of present capacity. Beyond this number, estimates of the number of “worried well”—those who mistakenly fear they have been infected—are both huge and hugely variable. Little effective attention has been given as to how to minimize that number and cope with the triage problems it presents.

5. Prevent more attacks of this kind so that I can be assured the worst is over. A bioterrorist who can attack once will likely have the ability to reload and attack again and again. The United States has improved forensic capabilities that will facilitate long-term criminal investigation, but has not developed quick reaction and interdiction tools to prevent follow-on attacks. The inability to prevent follow-on attacks will have even more debilitating effects on capabilities, confidence, and morale than the initial attack.

6. Speedily establish conditions and provide information that will permit me and my family to safely return to ordinary daily activities. While resuming normal activities soon after bioterror attacks risks illness, delays in resumption entail great costs. The United States has dramatically underinvested in decontamination research and development, lacks standards and a strategy for mass decontamination, and capabilities are so rudimentary that the best analysis of the subject concludes that after an aerosol anthrax attack on Manhattan, effective decontamination would take decades or even centuries.

Recommendations for Research and Development
A program of technological and social science research, development, and testing is required to meet citizen needs, empower laypeople to care for themselves and their loved ones, and adjust their expectations. We suggest allocating three percent of the current Department of Homeland Security research and development budget of $1.2 billion, i.e. $36 million, for initial development of a program based on our recommendations. We would spend this money on five priorities:

1. Research, development, and testing to develop and evaluate different methods of self-protection and self-decontamination by laypeople. To the extent warranted, this program would result in more specific and well-grounded messages of advice to be distributed in advance and most especially to be immediately disseminated after authorities become aware of an attack. It may also lead to stockpiling, distribution, surge-production capabilities, and building code innovations.

2. An aggressive program to develop advice and support systems that would facilitate home care and protection of home caregivers from infection in the event of broad-scale aerosol biological attack. Because we anticipate that the demand for hospital care will greatly outstrip its supply, home care will play a vital role. Moreover, home care can be effective, particularly since for many of those exposed to biological agents the care required will be palliative. Home care can be enormously enhanced if systems are developed in advance to provide caregivers with information that allows them to minimize risks of transmission of infectious agents and maximize quality of care.

3. Determine ways to supply individuals with the medical goods and basic supplies of daily life that they will need for self-care at home, or for ongoing sequestration in the case of a contagious disease. Neither price nor a first come, first served system will be an appropriate rationing mechanism. The vulnerability, logistical difficulties, and psychological resistance to central distribution points suggest that alternate mechanisms are required, including outreach systems that support people in their homes and efforts to flood the system so that supplies can be obtained in multiple ways from multiple places.

4. Create means for rapid diagnosis outside of hospitals to reduce demands from the worried well and enable hospitals to focus on treatment. Effective diagnosis outside the hospital setting is enormously difficult, but also enormously important to targeting treatment for those who require it, reducing the burden of the “worried well” on hospitals, and improving the psychological wellbeing of the population after an attack.

5. Supplement traditional “hub-and-spoke” communication from centralized government with complementary social network systems. The research program suggested here will be of practical use only if its findings can be credibly disseminated to the public at a time of great stress. Traditional hub-and-spoke communication from government authorities to citizens has a vital role to play, but sole reliance on it ignores the deeply ingrained human tendency to double-check information with trusted members of social networks. Social and peer-to-peer networks and trusted points of contact can complement existing information distribution capabilities. For example, peer-to-peer users could identify in advance those authorized to receive notice in the event of an injury, illness, or emergency. Experience of past catastrophes suggests that local and personal contacts can dramatically reinforce or undermine centralized government communication.