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How to Lead during Bioattacks

Case Studies

The following case studies are examples of responses to recent crises.

2003, Fearing SARS, New Yorkers Avoid Chinatown

Despite the fact that the number of potential SARS cases in New York City was few during the 2003 outbreak, fear of the disease kept many people away from the usually bustling Chinatown neighborhood. Acting on the presumption that Chinatown residents and merchants traveled back and forth frequently to Asia and therefore posed a greater risk for transmitting SARS, New York City residents and tourists avoided Chinatown in an effort to protect themselves. Local businesses felt the impact; in late April 2003, nearly 2 months after the disease was first identified in Asia, 84% of surveyed Chinatown businesses reported a drop in business because of the SARS crisis. Many proprietors reported drops of 30% or more. Restaurants, grocers and the garment industry suffered, but travel agencies were the hardest hit -- some nearly went out of business.

Reference: Asian American Business Development Council. "Double Impact: Chinatown Businesses Still  Struggling from the Impact of September 11th only to be Hit Again with the SARS Crisis." April 28, 2003. Accessed online 4/29/03.

1976, Swine Flu Vaccination Campaign Too Much, Too Soon

In 1976 a new, potentially serious flu virus emerged. To avoid the staggering numbers of casualties experienced during the 1918 pandemic (550,000 in the U.S.), health authorities swiftly launched a national immunization campaign. However, the pandemic never materialized, and the flu shots were subsequently blamed for a wave of Guillain-Barré syndrome cases. These factors overshadowed public health efforts and negatively affected people's attitudes about vaccine safety.

Reference: Kolata G. Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It. New York: Farrar, Strauss & Giroux; 1999.

1918, Spanish Influenza Grips the Globe

In 1918 and 1919, the world faced the "Spanish Lady," a particularly severe strain of flu that killed 550,000 in the U.S. alone. To control the spread of disease, Baltimore, Maryland health officials cut retail business hours. This seemed like a sound decision from a public health perspective, but the measure angered hourly retail workers. They needed the income to buy extra heating fuel, which they felt was vital to their and their families' well-being in the midst of an epidemic.

Reference: Schoch-Spana M. Psychosocial consequences of a catastrophic outbreak of disease: lessons from the 1918 pandemic influenza. In Bioterrorism: Psychological and Public Health Interventions, Ursano R, Fullerton C, Norwood A, eds. Cambridge University Press, 2004.

2003, Information about SARS Elusive

The 2003 SARS epidemic was prolonged and unfolded gradually. The first known SARS cases emerged in mid-November 2002 in China's Guangdong Province. Four months later, China formally reported the outbreak to the World Health Organization (WHO), by which time at least 305 cases and 5 deaths had occurred. The disease made its way to Hanoi, Hong Kong, Singapore, and Toronto—where health officials and practitioners faced the urgent need to halt the outbreak, despite a dearth of clinical and epidemiological data. What's causing this illness? How is it spread? Who has been exposed and should be isolated? Why are so many health care workers getting sick? What is the best therapy? Scientists working non-stop as part of a global network took 4 weeks to identify a novel corona virus as the causative agent and another month to describe the mode of transmission. Many uncertainties about SARS still remain, including whether the virus may resurface in a more virulent form.

Reference: World Health Organization (WHO) Communicable Disease Surveillance and Response.Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons for the Immediate Future. 20 May 2003; Geneva: WHO.

2001, Anthrax Evades Easy Answers

During the 2001 anthrax attacks, the public and decision-makers alike were frustrated by the lack of immediate answers to basic, factual questions. Who did this? How many letters were involved? Who came in contact with the letters? Health authorities and clinicians had to make critical decisions without having complete scientific knowledge. What is the best treatment? Who should receive preventive antibiotics and for how long? How many anthrax spores cause sickness? Which mailrooms should be closed and surveyed? Apparent inconsistencies and gaps in the government's response fostered more uncertainty. Were officials withholding information about the severity of the attack? Was treatment for postal workers really different from that offered to Capitol Hill employees and, if so, why?

References: (1) Toole, T. Congressional testimony, terrorism through the mail: Protecting postal workers and the public (part II). U.S. Senate Committee on Government Affairs, Subcommittee on International Security, Proliferation and Federal Services. (2) Inglesby TV. Congressional testimony, the state of public health preparedness for terrorism involving weapons of mass destruction -- a six month report card. U.S. Senate Committee on Governmental Affairs.

2003, SARS Victims Shunned Globally

The uncertainties presented by the new disease, SARS, have had lasting impacts on recovered patients. They, their families and neighbors, doctors and nurses, formerly quarantined contacts, and residents of affected cities have been shunned globally. Of Hong Kong residents polled in July 2003, 51.3% expressed fear of former SARS patients. In a survey conducted in March 2003, nearly a year after SARS struck, 20% of respondents reported that they avoid contact with recovered SARS patients.

References: (1) Bradsher K. Now the SARS emotional toll. The New York Times 2003; June 4:A-16. (2) Pomfret J. A Beijing address is now a stigma, not a benefit. Washington Post 2003; May 16:A-14. (3) Maunder R, Hunter J, Vincent L, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. Canadian Medical Association Journal 2003; 168(10):1245-1251.

2003, Fearing SARS, People Avoid Chinese-Americans

Tourists in New York City avoided Chinatown during the SARS outbreak based on the presumption that Asian Americans frequently travel back and forth to Asia and, therefore, posed a SARS threat. Compounding the problem was that the "public face" of the epidemic—i.e., the images featured in round-the-clock news reports—was that of Asians wearing protective masks. Asian-Americans were branded as "outsiders," a category of person long blamed as the origin of disease.

References: (1) Hubler S, Pierson D, Goldman JJ. A fever pitch of fear; misconceptions about SARS are driving away business at Chinatowns across the country. Los Angeles Times.2003; May 4: part 1, page 1. (2) King NB, Immigration, race, and geographies of difference in the tuberculosis pandemic. In Gandy M & Zumla A, eds., Return of the White Plague: Global Poverty and the New Tuberculosis. London: Verso, 2003. (3) Kraut AM. Silent Travellers: Germs, Genes, and the "Immigrant Menace." Baltimore, MD: Johns Hopkins University Press, 1995.

2001, Muslim Americans Face Hate Crimes in Wake of September 11

During times of crisis, people understandably want to protect themselves and to feel in control of their circumstances. A common way of coping with uncertainty is to blame others. Individuals and groups who are blamed, however, often belong to racial, ethnic, or social groups for which there are other preexisting prejudices. In the aftermath of September 11, the Council on American-Islamic Relations reported rising anti-Muslim sentiment in the U.S.: "religious and ethnic features of Muslim life or Muslim religious and political views [are] set apart from what is considered normal and acceptable." According to FBI statistics, anti-Muslim crimes increased seventeenfold during 2001.

References: (1) Council on American-Islamic Relations. The Status of Muslim Civil Rights in the United States, 2002. Washington, DC, 2002. (2) Human Rights Watch. "We are not the enemy": hate crimes against Arabs, Muslims, and those perceived to be Arab or Muslim after September 11. United States 2002; 14(6[G]):3.

2003, New Yorkers Perceive SARS to Be Local Outbreak

SARS had a negligible impact on New York City during the 2003 global outbreak. Nevertheless, at the peak of the global SARS outbreak, the NYC Department of Health and Mental Hygiene discovered that some anxious residents were transposing what they were reading and seeing about Hong Kong and other disease epicenters to conditions in New York City, where the impact had been minimal. That is, the crisis elsewhere became the baseline for what was perceived to be happening locally.

Reference: Roberts, S. Communicating with the public about public health preparedness. DIMACS Working Group on Modeling Social Responses to Bioterrorism involving Infectious Agents. New Brunswick, NJ: Rutgers University; May 29, 2003.

2001, Far from Anthrax Attacks, People Anxious

Although anthrax exposure was limited to a few East Coast cities, the effects of the attacks were felt in distant locations. Events were broadcast around the clock, and the deluge of information caused anxiety for people who were nowhere near the epicenter. A woman from Seattle recalled, "I was on vacation in Mexico when all of this happened, and everybody was glued to the television set watching CNN in the bar at the resort...And they finally made a decision to turn off the people could enjoy their vacation." Nonstop, live news coverage of unfolding events had made the "distant" problem of anthrax a local concern.

Reference: Schoch-Spana M, Young R, Lien O. The People Talk Back: Communication Needs during the 2001 Anthrax Attack and Hypothetical Smallpox Attack 2003. Unpublished Manuscript.

2003, SARS Spread Facilitated by Global Travel

More than 4,000 SARS cases (half the total global count) can be traced to a chance encounter with the virus by a handful of international travelers staying at a four-star Hong Kong hotel; one of the guests on the ninth floor was a doctor who had become infected while treating patients in Guangdong Province, where the outbreak first emerged.

Reference: Nakashima E. SARS signals missed in Hong Kong; physician's visit may have led to most known cases. Washington Post May 20, 2003: A01.

2001, The High Costs of the Anthrax Attacks

In addition to the obvious human toll, there were serious economic consequences caused by the anthrax attacks of 2001. The temporary closure of mail facilities and an overall decrease in the use of mail services resulted in financial losses for the U.S. Postal Service; decontaminating and renovating facilities that had received anthrax letters cost millions in taxpayer dollars. The costs for decontaminating and renovating the Brentwood postal facility, which was closed on October 21, 2001, and remained so for more than 2 years, totaled approximately $130 million. Decontaminating the Hart Senate Office Building cost $27 million.

References: (1) Nakashima E. SARS signals missed in Hong Kong; physician's visit may have led to most known cases. Washington Post May 20, 2003: A01. (2) Capitol Hill Anthrax Incident: EPA's Cleanup Was Successful: Opportunities Exist to Enhance Contract Oversight. GAO Report GAO-03-686 June 2003.

2001, Economic Repercussions of Foot and Mouth Disease

Financial losses from an epidemic can be dramatic and glaring. To control the 2001 foot-and-mouth disease outbreak in the United Kingdom, 1/8 of all farm animals—8 million animals across 9,677 farms—were slaughtered. By June 2001, 7,800 farmers and farm workers had lost their jobs; revenues for feed producers, rural businesses, and tourist enterprises plummeted. If there were a comparable FMD outbreak in the U.S., it is estimated that losses would be $14 billion—a 9.5% drop in farm income including lost export markets, curtailed domestic demand due to consumer concerns, and infected animal removal.

References: (1) Brown P. Foot and mouth epidemic officially overGuardian Unlimited; 29 December 2001. Accessed 29 July 2003. (2) Paarlberg PL, Lee JG Lee, Seitzinger AH. Potential revenue impact of an outbreak of foot-and-mouth disease in the United States. Journal of the American Veterinary Medical Association 2002; 220(7):988-992.

1986, Mad Cow Disease Devastates British Beef Industry

Driving the U.K. government's handling of the "mad cow" (bovine spongiform encephalopathy, or BSE) outbreak that emerged in 1986 was the desire to limit immediate costs and protect the beef industry. Operating on this principle and the belief that BSE posed little risk to humans, despite uncertain science, government leaders did not intervene early, allowing BSE to remain in the cattle population thus contributing to greater human exposure. To avert public concern about food safety and its economic impact, British leaders repeatedly dismissed BSE as a human threat. By safeguarding the cattle industry while underplaying human health risk, the government created conditions for enhanced spread of disease, diminished public trust in government management of the problem, and, paradoxically, a shrinking domestic demand for beef (e.g., down 37% from 1987 to 1995).

Reference:  Lanska DJ. 1998. The Mad Cow Problem in the UK: Risk perceptions, risk management, and health policy development. J Public Health Policy. 19(2): 160-83.

Social and Economic Disparities Influence Public Responses to Bioattacks

Social and economic disparities can influence attitudes and behavior following a bioterrorist attack. Distrust of the healthcare system and lack of insurance influence people's decisions about whether to follow health recommendations or seek medical care. These attitudes are not without merit. One in every 7 Americans lacks health insurance, with minorities over-represented. Moreover, past events—such as experimentation on slaves and the Tuskegee syphilis study—and today's findings that race/ethnicity can adversely affect the standard of care received have led many African-Americans to distrust medical and public health institutions. Language barriers, cultural misunderstandings, and fear of deportation among undocumented immigrants cause other populations to regard the medical system with suspicion. These factors render these populations more vulnerable to the effects of an outbreak.

References: (1) Wynia MK, Gostin L. The bioterrorist threat and access to health care. Science 2002; 296:1613. (2) U.S. Census, Health insurance coverage: 2001. September 2002. (3) Betancourt JR, Green AR, Carrillo JE at al. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports 2003; 118:293-118. (4) Betancourt JR, Green AR, Carrillo JE at al. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports 2003; 118:293-118. (5) Gamble VN. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health 1997; 87(11):1773-1778. (6) Canlas LG. Issues of health care mistrust in East Harlem. Mt Sinai Journal of Medicine1999; 66(4):257-58

1995, Chicago Heat Wave Singles Out the Poor and the Isolated

Between July 13 and July 20, Chicago experienced a record-breaking heat wave that claimed the lives of more than 700 people. Most victims were low-income elderly people who lived alone, were isolated from friends and family, and were left abandoned for days before being discovered. Seventy-three percent of the victims were age 65 or older, and the majority were African-American. The deaths were not caused by extreme temperatures alone; existing social conditions common to urban areas compounded the effects of the heat. A substantial number of seniors live alone in unsafe, decrepit, low-income housing in neighborhoods that have been abandoned by businesses, service providers, and many residents. These conditions create a culture of isolation and fear that discourages seniors from trusting neighbors or even leaving their homes. Thus, seniors were particularly vulnerable because of the fact that they are largely homebound, with no one checking in on them and nowhere to turn for help.

Reference: Klinenberg, Eric. (2002). Heat Wave: A Social Autopsy of Disaster in Chicago. Chicago: University of Chicago Press.

Hospitals Unprepared for Epidemic Control

The nation's hospital response capacity and public health infrastructure have been compromised by decades of neglect. Although attention is now being focused on bolstering response capacity, the nation still faces serious issues:

  • High vacancies exist for all U.S. hospital staff including nurses, imaging technicians, and pharmacists. More than three-fourths of urban emergency departments operate "at" or "over" capacity. In other words, too few professionals exist to staff these critical positions within hospitals across the country. The demands that would be placed on hospitals during a large-scale or prolonged epidemic would be grave.
  • Only 2 states (FL, IL) are now prepared to deploy adequate personnel to break down the Strategic National Stockpile of drugs, antidotes, and medical supplies once it arrives.
  • Few trained disaster mental health professionals, a weak infrastructure for implementing broad mental health protections, little knowledge on effective treatment, and scarce funds for long-term mental health care inhibit U.S. response to terrorism's psychological effects.

References: (1) American Hospital Association. Cracks in the foundation: averting a crisis in America's hospitals. Washington, DC: AHA, August 2002. (2) Trust for America's Health. Ready or Not?: Protecting the Public's Health in the Age of Bioterrorism. Washington, DC, December 2003; 7. (3) Institute of Medicine. Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy. Washington, DC: National Academies Press; 2003.

Blaming "Outsiders" for Causing Disease

Individuals and groups of different national origin or ethnic or religious background have long been singled out as the source of disease. For example, the early sixteenth century, diverse people have attributed syphilis outbreaks to everyone but themselves. Syphilis has been called "morbus gallicus" (the French pox) in Italy; "le mal de Naples" (the disease of Naples) in France; the "Polish disease" in Russia; the "Russian disease" in Siberia; the "Portuguese disease" in India and Japan; the "Castilian disease" in Portugal; and the "British disease" in Tahiti. Scapegoating may be more pronounced in the context of bioterrorism when an epidemic has been deliberately unleashed.

References: (1)King NB, Immigration, race, and geographies of difference in the tuberculosis pandemic. In Gandy M & Zumla A, eds., Return of the White Plague: Global Poverty and the New Tuberculosis. London: Verso, 2003. (2) Kraut AM. Silent Travelers: Germs, Genes, and the "Immigrant Menace." Baltimore, MD: Johns Hopkins University Press, 1995. (3) Porter R. The Greatest Benefit to Mankind. New York: WW Norton & Co., 1997, p. 166. (4) Peek LA. Community isolation and group solidarity: examining the Muslim student experience after September 11th. In Monday JL, ed., Beyond September 11: An Account of Post-Disaster Research. Special Publication #39. Boulder, CO: Institute of Behavioral Science, University of Colorado, 2003, p.81-102.

2001, Letters Laced with Anthrax

In October 2001, the U.S. was on edge following the discovery of several letters containing anthrax. People who worked in facilities that received letters containing anthrax were sometimes stigmatized within their communities. Some employees of American Media, Inc., the site of the first anthrax case, were doubly victimized. Physically affected by their potential exposure to anthrax, they were also socially stigmatized by physicians who refused to care for them, schools that turned away their children, and employers of second jobs who refused to let them work: Some American Media employees who moonlighted as housekeepers were not allowed into homes to clean.

Reference: Malecki J. Health Commissioner, Plam Beach County, FL. Personal communication.

2001, Anthrax Letters Give New Meaning to "Handle with Care"

During the anthrax attacks of 2001, the routine activity of opening the mail became a source of worry for many Americans. In a U.S. poll conducted in November 2001, 24% of those surveyed reported that they were very worried or somewhat worried about contracting anthrax by opening the mail. Thirty-two percent reported handling the mail with precautions—including washing hands after handling mail, wearing gloves to open envelopes, or avoiding opening mail entirely.

Reference: Blendon RJ, Benson JM, DesRoches CM, et al. The impact of anthrax attacks on the American public. Medscape General Medicine 17 April 2002; 4(2). Accessed 30 July 2003.

2001, Treatment Protocols for Anthrax Revised in Wake of Letter Attacks

Until the 2001 attacks, clinical knowledge about inhalation anthrax was based primarily on 16 historical cases of naturally occurring anthrax among goat mill and tannery workers. The 2001 anthrax letter attacks challenged prior assumptions and raised many new questions as to the physiological and environmental effects of a weaponized form of anthrax. For example, prior to the anthrax letter attacks, it was generally believed that anthrax victims with high toxicity levels would not respond well to antibiotic treatment and would die. However, the 2001 experience demonstrated otherwise, when a majority of patients recovered with antibiotics and aggressive treatment. Before the 2001 attacks, Ciprofloxacin had been recommended as the sole antibiotic treatment for inhalation anthrax; however, case evidence in 2001 led the CDC to revise recommendations and advocate the use of Doxycycline as well. Additionally, prior to the letter attacks, it had not been recognized that "weapons grade" anthrax spores could leak out of the edges of envelopes or through the pores of envelopes, thereby potentially exposing the envelope's handler; nor did scientists understand how factors such as machine processing or air flow in a building would affect the dispersal of spores. While it was once believed that it might require thousands of spores to make a person ill, evidence from the New York City and Connecticut victims suggests that this assumption could be false—it may only require 1 to 3 spores.

References: (1) Casani, Julie, Diane Matuszak and Georges Benjamin. 2003. "Under Siege: One State's Perspective of the Anthrax Events of October/November 2001" Biosecurity and Bioterrorism 1(1): 43-45. (2) Inglesby, TV. et al. 2002. "Anthrax as a Biological Weapon, 2002: Updated Recommendations for Management" JAMA 287(17).

Laundry List for Bioterrorism Response Planners

The scope and magnitude of a bioterrorist attack is limited only by the imagination of a perpetrator and his/her technical ability to pull it off. A particularly challenging element of bioterrorism planning is that there is a wide range of scenarios to consider:

  • Threats or scares, such as the increasingly frequent anthrax "hoaxes"
  • Assassination of individuals—such as the ricin poisoning of Bulgarian defector Georgi Markov
  • Discrete, nonlethal attacks—such as the 1984 Rajneesh contamination of salad bars, when hundreds became ill
  • Incidents that produce few cases and deaths but that are still profoundly disruptive—such as the anthrax letter attacks
  • Localized lethal outbreaks, comparable to the accidental 1979 anthrax release from Soviet bioweapons facility
  • Campaign of mass casualty attacks in different cities, at different times—such as featured in the Dark Winter exercise
  • Lethal pandemic (or global outbreak) through an unchecked reintroduction of smallpox.

References: (1) Cole LA. Bioterrorism threats: Learning from inappropriate responses. J Public Health Manag Pract 2000;6:8-18. (2) Franz DR, Jaax NK. Ricin toxin. In: Sidell FR, Takafuji ET, Franz DR, eds. Textbook of Military Medicine: Medical aspects of chemical and biological warfare.Washington, DC: Office of the Surgeon General; 1997:631-42. (3) Torok TJ, Tauxe RV, Wise RP, et al. A large community outbreak of salomnellosis caused by intentional contamination of restaurant salad bars. J Am Med Assoc. 1997;278(5):389-95. (4) Meselsohn M, Guillemin J, Hugh-Jones, M, et al. The Sverdlosk anthrax outbreak of 1979. Science. 1994; 266:1202-8. (5) O'Toole T, Mair M, Inglesby TV. Shining Light on Dark Winter. CID. 2002;34(7):972-83.

2001, Mayor Leads Mourning New Yorkers

Mayor Rudolph Giuliani modeled effective leadership and communication after the September 11 attacks. When asked a few hours after the attacks how many people were anticipated dead, and when the exact number of victims was still unknown, he responded, "More than any of us can bear, ultimately". At a time when people were feeling misery, this response displayed empathy and compassion without downplaying the severity of the tragedy. He was forthcoming even when he did not have all of the information or answers to all of the questions. He understood that people needed to be kept up to date on what was happening, so he held regular press conferences to provide status updates, and shared any new information on the response to the attacks.

References: (1) ''It's 'more' than any of us can bear.' 26 September 2001. Accessed 10/13/03. (2) Giuliani, Rudolph. (2002) Leadership. New York: Mirimax.

2001, EPA Reassures Ground Zero Residents that Air Is Safe

Following the collapse of the Twin Towers, air quality became an issue of prime concern for the residents of lower Manhattan. However, the Environmental Protection Agency, at the urging of the White House, deleted cautionary statements and added reassuring ones in early press reports about the air quality in lower Manhattan. By declaring the air outside Ground Zero as "safe," based on inadequate data and analysis and in the face of New Yorkers' own experiences of difficult breathing, the EPA undermined its own credibility, not only on this sensitive issue, but perhaps on future ones as well.

Reference: Office of Inspector General. EPA's response to the World Trade Center collapse: Challenges, successes, and areas for improvement. Report No. 2003-P-00012. Washington, DC: U.S. Department of Environmental Protection; August 21, 2003.

Polled Americans Expect Discrimination during Smallpox Outbreak

Seventy-two percent of respondents to a 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. Nearly half (43%) thought that the elderly would experience discrimination, and one-fourth (22%) believed that African-Americans would experience discrimination. Decision-makers can account for income disparities in contingency plans by setting up vaccination clinics in locations accessible to people without transportation and by informing the public about plans to make free or low-cost emergency treatment or prophylaxis available. To ensure that potentially marginalized constituents understand that their interests will be protected in a health emergency, officials should engage with them in non-crisis times, ideally through health programs that address specific needs of these populations.

Reference: Blendon RJ, DesRoches CM, Benson JM, et al. The public and the smallpox threat. N Engl J Med 2003; 348(5).

2001, New York City Health Officials Earn Public Trust

In the earliest hours following the first diagnosis of inhalation anthrax in New York City, local officials understood that timely and candid communication with the public would be essential to managing the crisis successfully. Confirmation of the anthrax case was received in late evening, around 10:00 pm, but many questions were still unanswered—including how the victim contracted anthrax and whether anyone else was ill. Despite the late hour, leaders were forthcoming about what they knew and what they did not yet know. The mayor and his top health officials convened the first press conference at approximately 11:30 that night, and they provided a public hotline so community members could have access to information about anthrax and unfolding events. Convening this press conference at the onset of the incident helped set the tone for how the emergency would be handled: Leaders would be the ones to provide information to community members. Moreover, getting the word out at the earliest point in the crisis helped minimize the chance for speculation and the spread of misinformation the following day.

Reference: Mullin, Sandra. (2003). "New York City's Communication Trials by Fire, from West Nile to SARS." Biosecurity and Bioterrorism 1(4): 267-272.

2003, Chinese Leaders Withhold SARS Information from Villagers

As SARS spread across China, government officials withheld information from villagers on the theory that, as one bureaucrat reported to the news media, "They just won't understand." But when residents learned their villages might be used to quarantine outsiders who had possibly been exposed to SARS, they rioted against government preparation of quarantine centers and set up makeshift roadblocks to keep out nonresidents.

Reference: Beech H. The quarantine blues: with suspected SARS patients getting dumped in their backyards, China's villagers rebelTime Asia Magazine 19 May 2003: 161(19). Accessed 15 December 2003



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