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How to Lead during Bioattacks

Executive Summary

This interactive manual is the executive summary of the Working Group consensus statement. By outlining key points and providing supporting case studies of responses to real-life crises, the manual is designed to advise leaders of four specific issues that should be considered in bioterrorism and epidemic response planning. Specifically:

define iconWhat defines "leadership" during an epidemic or biological attack?

Five strategic goals help distinguish successful leadership during an epidemic or bioattack in 21st century America. An informed and involved public, along with guidance and material support from respected leaders, can help achieve these aims:

  • Limit death and suffering through proper preventive, curative, and supportive care; tend to the greater vulnerability of children, the frail elderly, and the physically compromised.
  • Defend civil liberties by using the least restrictive interventions to contain an infectious agent that causes communicable disease.
  • Preserve economic stability, managing the financial blow to victims as well as the near- and long-term losses of hard-hit industries, cities, and neighborhoods.
  • Discourage scapegoating, hate crimes, and the stigmatization of specific people or places as "contaminated" or unhealthy.
  • Bolster the ability of individuals and the larger community to rebound from unpredictable and traumatic events; provide mental health support to those who need it.

challenge icon Why do bioattacks present special challenges and high-stakes decisions for leaders?

A deliberate epidemic poses compounded, unfamiliar dangers in today's setting. Most elected U.S. officials, health authorities, and the public have no direct experience with large outbreaks, nor do they know the best ways to control them. Even less familiar is the premeditated use of disease as a weapon.

Epidemics are complicated events due to their biology, but also because they provoke fear, contradictory impulses, and competing social aims:

  • An epidemic's outcomes: Suffering, death, lost livelihood and commerce—are troubling to consider. Leaders and the public may deny that a problem exists, or intervene too quickly without regard to the negative effects of their actions.
  • People need to make sense of random and terrifying events, but epidemics elude quick and easy explanation. The nature of a disease, a population's vitality, and the responsiveness of health institutions affect how an epidemic unfolds.
  • A mysterious disease can trigger the human reflex to isolate oneself and blame others for the tragedy or, in deep contrast, to care for victims without regard to one's own safety.

Features of modern society can speed up and disperse an epidemic's negative impact and make some people more vulnerable than others:

  • Global media and around-the-clock news reports cause anxiety and dread in people, even those who are in places far from immediate danger.
  • Today's transportation systems move people quickly across vast distances, potentially accelerating the spread of disease.
  • Epidemics have broad, indirect financial impacts due to close ties among global, national, and local economies.
  • Poverty, lack of health insurance, and distrust of the healthcare system mean that those who are most vulnerable during disease outbreaks are least able to protect themselves.
  • Personnel shortages and lean budgets limit the emergency response capabilities of U.S. hospitals and state and local public health agencies; they are spread thin on a "normal" day.

A calculated attack further magnifies the consequences of an epidemic:

  • An attacker's motivations and tactics—for example, attacks on multiple cities, over a prolonged period, or on random victims—heighten an epidemic's uncertainties.
  • Scapegoating will be more severe in the case of bioterrorism than in natural outbreaks as people demand to know, "Who did this?!"
  • If a disease is weaponized or infects people through an unusual route (such as the mail), it may be harder to detect and treat. What is known about natural outbreaks of the same disease may not apply.
  • The wide range of scenarios—scares, discrete non-lethal attacks, a campaign of mass casualty attacks—makes planning for every contingency impossible.

dilemmas icon What leadership dilemmas may arise in a deliberate epidemic, and how might they be averted?

An epidemic exerts immense political and social pressure for decisive, visible action—more so in the case of a bioattack. Apparent and sometimes genuine conflicts among strategic goals can arise in this charged setting. The most common dilemmas facing past leaders have been balancing disease control imperatives with those of individual liberty, economic stability, and preventing stigma.

Stopping disease that spreads person-to-person while upholding individual freedoms

  • Make bioterrorism response plans public before a crisis occurs; a well-informed population is more likely to cooperate with advice for reducing the spread of disease.
  • Sketch out the "big picture"; make concrete the fact that personal actions can affect the safety of others—for example, remind people that staying home from work or keeping children out of school when they are ill protects others from getting sick.
  • Use disease controls that respect ideals of autonomy, self-determination, and equality—public cooperation limits illness and death; public resistance does not.
  • Provide goods and services that help people comply with health orders—for example, set up vaccination clinics in locations accessible to people without cars.
  • Restrict civil liberties, if necessary, only in a transparent and equitable way.

Protecting the economy while using disease controls that disrupt commerce

  • Be mindful of the goal of long-term financial recovery when controlling disease; do not react based solely on the desire to avert short-term economic loss.
  • Recognize public trust as precious "capital" that grows the economy—for example, if people see their health as your top priority, confidence in your efforts to safeguard the economy will follow.
  • Account for the less visible and more scattered monetary impacts when making epidemic control decisions (e.g., costs of victims' healthcare; economic toll of stigma).

Restoring social bonds when people feel at the mercy of a mysterious disease or attacker

  • Express empathy for people's fears about getting sick from others; follow up with meaningful medical details that allow people to gauge personal risk accurately.
  • Demonstrate compassion toward victims of disease; explain to the community-at-large the social costs of avoiding people out of fear, rather than out of actual danger.
  • Provide frequent updates on the criminal investigation; counsel people not to lash out against others who "look like" presumed perpetrators.
  • Spotlight community projects aimed at bringing people together across social divisions sensitized by the crisis -- for example, ethnic and religious affiliations in the case of 9/11.
  • Direct law enforcement to deal appropriately with hate crimes in the event prevention fails.
  • Coordinate volunteers, relief groups, and civic organizations in humanitarian response, with extra focus on assisting the most vulnerable—for example, children, the frail elderly, and disabled people of all ages.

splinter icon What situations splinter the social trust necessary to cope with health crises, and how might they be defused?

Breaches of social trust are a common predicament for leaders during outbreaks and are likely to arise during a bioattack. Social and economic fault lines as well as preconceived notions about "the government," "the public," and "the media" can alienate leaders and the public, and community members from one another.

Preventing unproductive fear, denial, or skepticism on the part of the public when delivering crisis updates:

  • Share what you know. Do not withhold information because you think people will panic. Creative coping is the norm; panic is the exception.
  • Hold press briefings early and often to reach the public. Answering questions is not a distraction from managing the crisis; it is managing the crisis.
  • Confirm that local health agencies and medical facilities are prepared to handle an onslaught of questions from concerned individuals, in person and by phone.
  • Convey basic health facts clearly and quickly so that people have peace of mind that they are safe or so that they seek out care, if need be; similarly, brief healthcare and emergency workers so they have a realistic understanding about job safety.
  • View rumors as a normal sign of people's need to make sense of vague or disturbing events. Refine your outreach efforts; the current ones may not be working.

Earning confidence in the use of scarce resources despite existing social and economic gaps:

  • Account for income disparities in response plans; anticipate the need for free or low-cost prevention and treatment.
  • Make planning transparent so that the public sees that access to life-saving resources is based on medical need and not on wealth or favored status.
  • Be open about eligibility criteria for goods and services, especially when tough choices arise unexpectedly—for example, which botulism attack victims will receive the limited antitoxin that exists.
  • Show thorough preparations to protect vulnerable populations like children and the frail elderly, thus bolstering everyone's sense of security.

Maintaining credibility when decisions must be made before all the facts are in:

  • Advise the community at the outset if crisis conditions are evolving or could be prolonged.
  • Offer more detail rather than less, even when the unknowns outnumber what is known; resist the urge to reassure for reassurance sake alone.
  • Be frank about any uncertainty regarding "facts"; describe plans to fill in knowledge gaps.
  • Vary your means of reaching the public. Mix high-tech outreach (internet, cable, network, print, radio, cell phone, automated hotlines) with contact through grassroots leaders.

Agility, Endurance, and Recovery through Collaboration

Dynamic, cooperative effort among leaders and residents of a model city helps resolve the immediate health crisis, hasten long-term recovery, and promote the ability to weather future adversity.

event sphere graphic


blue Leaders and decision makerssuch as the mayor, health commissioner, emergency manager, and police and fire chiefs: Ideally discern the "big picture" and tailor their advice and actions accordingly.
gray Intermediates: "Connecting" people on a regular basis in everyday settings, such as workplaces, schools, neighborhoods, and places of worship, and providing information that is passed along by trusted sources, such as family, friends, grassroots leaders, and journalists. 
brown Public-at-large: Members of the public have only a diffuse impact if individual efforts are not harnessed to one another and if people judge their actions only from their own point of view. At the same time, their broad reach provides a potential safety net for dispersed, vulnerable populations, such as children and non-institutionalized disabled people. 
teal Solution
white Context: The city is not self-contained. For example, commuters move between home and work; leaders interact with their counterparts in neighboring jurisdictions; federal authorities lend their support.

Modeling an Actual City

Representative statistics taken from a mid-sized Northeastern U.S. city demonstrate the relative numbers and influence of leaders, intermediaries, and the public.

  • Leaders: Mayor, Mayor's Cabinet, City Council - 49
  • Intermediaries: 
    • Schools - 558
    • Religious Organizations - 675
    • Community Organizations - 854
    • News Outlets (print, radio, broadcast) - 39
  • Public-at-Large:
    • Total Population - 651,154
    • Children 19 Years and Younger - 183,207
    • Non-institutionalized Disabled - 162,044
  • Context:
    • Counties and States within 90 Miles - 26
    • Daily Commuters - 229,526


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