Minimizing Casualties in Biological and Chemical Threats (War and Terrorism)

Shabtai Noy, Ph.D

Senior Clinical and School Psychologist

12 Kubovy St., Jerusalem, 96757, Israel

Phone: 972-2-6416111

Fax: 972-2-6416173

Email: <Shabtai_Noy@huji.ac.il>

Abstract

The most effective means of defending against biological or chemical warfare, whether in war or as a The Threat

Since the beginning of the 21^st Century, the world has been under continual intimidation by extremist states and terrorists, threatening to use unconventional weapons of mass destruction against civilians. A primary concern relates to biological or chemical threats as part of a war, or by means of terrorism. According to military intelligence sources, until the war in Iraq, 2003, the main threat in Israel was the risk of missiles carrying biological or chemical materials being launched from Iraq during a war. After the war is over, the risk may change to missiles coming from Syria. The primary danger in Western countries is the dispersal by terrorists of biological, chemical or radiological materials through a variety of possible means.

During the 1991 Gulf War, the civilian population in Israel was under the threat of unconventional war from Iraq, but instead suffered only missiles with conventional warheads. The public has not yet experienced a full-blown biological or chemical attack; the novelty in the prospect of such threat and the unknown factors involved raise considerable fear and much irrational anxiety.

The U.S. has experienced the biological terror of anthrax, and Japan, Iran and Kurdish villages in Iraq have experienced chemical terror. But despite the cumulative experience, there is no sense of security, and the means of defending oneself against the risks involved are not fully comprehended by the public.

The main danger embedded in biological warfare is the risk of a large number of casualties, associated with missiles or aircraft. However, in addition to the potential for a vast amount of physical and psychological casualties, there is also a great likelihood that a pervasive sense of helplessness, rage, and mistrust will proliferate in the entire population that may persist for years to come. Should a very large number of casualties occur, as in the case in which people are surprised or ill prepared for the attack, the medical system may be unable to handle the mass casualties, and the number of fatalities may rise further. The public may then feel abandoned by the leadership, and may act against the ruling party or against democracy altogether. History has shown that mistrust coupled with rage may prompt riots, general discontent, and anarchy (1, 2, 3, 4, 5). In extreme situations, the sense of helplessness and perceived need for a strong alternative leadership could even bring down the social structure and the democratic system (3-7).

In a non-conventional terrorist attack, the number of physical casualties is expected to be rather low, and they may appear gradually, as in the anthrax fright in the U.S.A. In terror, the main damage is attained via proliferation of fear and disturbance to normal life (8-16).

The threat of biological or chemical attack in time of war

A missile carrying certain chemical or biological agents can contaminate an estimated area within a radius of 500 meters, which can be somewhat elongated in the direction of the wind. If the unconventional agent is dispersed in a densely populated area, and if the people are not sheltered by protective gear and remain outside of their homes during that time period, there is immediately a substantial risk for many thousands of physical casualties, including a high mortality rate. The unprotected population may inhale the unconventional agent, enabling it to be readily absorbed in the blood stream, causing paralysis in the body if the agent is a nerve gas, or sometimes, rapid development of an illness can occur with certain biological agents.

Moreover, there may be many additional injuries and devastation in the form of psychological casualties in those who did not inhale the agent but perceived themselves as having been exposed, and consequently were overwhelmed by anxiety. The number of psychological casualties may amount to a ratio of 10 to 500 casualties per each physical casualty, as, for example, the radiological accident in Goiania, Brazil (17). In the immediate situation after an impact, many of the psychic casualties may present themselves as classical cases of acute anxiety reaction, or false injection of Atrophine[1]. Many more are expected to mimic reactions to the agent, without real exposure (3, 7-10).

The vast numbers of immediate casualties, actual exposures to the agent and psychic reactions, may clog the medical system and render it impotent in its ability to provide effective treatment. This circumstance may augment the rate of fatalities and affect social unrest.

In contrast, if at the time a missile strikes, the population has been educated, prepared, informed, sheltered, and uses personal protective gear, the number of casualties would be significantly reduced, and the social sequelae will be significantly reduced as well.

Many of those with psychological casualties may suffer for an extended period, if not indefinitely, as a result of traumatic sequelae such as posttraumatic stress disorder (PTSD), dissociative disorders, panic attacks, phobias, and somatic and somatoform disorders (7-8, 12-16, 18). The societal impact of these consequences is far reaching and can include financial, emotional, relational, employment, medical and legal implications.

Much has been said previously about the vast number of casualties that may be expected in an unconventional war (12-14, 16-17, 19). However, not enough emphasis has been placed on the fact that the number of casualties can be significantly reduced if the leadership sets forth a prevention program, and the population complies with the instructions and prepares itself to be protected in the time of a strike. Because of the potential risks stated above, it is critical to plan a prevention program well in advance of such a strike, which will help to ensure, that as many people as possible are sheltered, if a biological or a chemical attack occurs. Being proactive, prepared and informed is one of the best approaches in order to limit the number of casualties. Such prevention programs can be effective only if they involve active participation of the public (1-6, 9, 11, 18).

The Threat of Terrorism vs. The Threat of War

While the threat of war is intensive but may be time-limited, terror may be sporadic and prolonged, with no clear demarcation of start and end points. As a result, while the expected number of casualties from a terrorist attack is not high, the prolonged effect of the uncertainty of when, where or how an attack will occur can result in disturbance to normal functioning and psychic life, leading to the development of an on-going and pervasive state of generalized anxiety and disruption of life.

During a war, there typically is a warning that a missile has fallen, and therefore the medical system is immediately alerted in order to begin proper triage and treatment. In a terrorist incident, awareness that an attack has occurred may only be known after casualties have already arrived in hospital emergency rooms and been diagnosed properly. Therefore, the frontline of detection of biological or chemical terrorism is within the medical system and epidemiological services. Alertness and up-to-date knowledge by the medical team and systematic epidemiological surveys are critical to minimizing casualties resulting from terrorism. However, even in a terrorist act, a well-informed public can help the medical system by calling their attention to particular events, and by coming promptly for medical examination. Moreover, the leadership must cope with the pervasive anxiety by proper information and explanation to the public, which may minimize the irrational fear and provide tools for survival.

The Expected Typical Human Behavior in Time of Disaster

There is a commonly held expectation that public reaction to a disaster is typified by generalized panic. This modern legend is decidedly rejected by experts in mass-casualty disasters. Experience shows that even in the most catastrophic events, the majority of people are inclined from the onset to behave in a rational, adaptive way, in accordance with their previous knowledge and understanding of the situation (1-9, 18, 20-23).

When a threat to safety is familiar, and when an informed, effective way of coping is known, there is a greater likelihood that the population will act reasonably and adaptively. But even when a threat is unfamiliar, the prevalent mode of action is not panic. When there has been no prior information about actual aspects of the threat and no previous knowledge of appropriate methods or preferred ways of coping, the risk for maladaptive response is much higher. In the case of biological or chemical warfare, an example of a maladaptive reaction is to refrain from using the protective gear. Public surveys in Israel during the period of the 1991 Gulf War showed that approximately 30% of the population did not utilize their protective gear, even in the areas most severely hit by missiles (22). In the 1993 threat, almost 100% of the population did not keep their protective gear nearby to prepare for a potential strike. This could have resulted in substantial and preventable casualties, and fatalities.

Essentially, mass panic is not to be expected in the case of an unconventional threat Rather, the crucial danger that the leadership must concern itself with is a lack of appropriate preventive activities due to insufficient preparedness, which would not bode well for providing or maintaining health or ensuring public safety.

Example 1: The atomic bombing of Hiroshima was, no doubt, one of the greatest man made disasters. The public reaction at that time was not characterized by irrational panic. Instead, many people streamed from the periphery to the epicenter of the disaster in order to save lives, clear roads, bring water, etc. Order, and clear goals characterized their behavior, despite the devastating disaster. However, because there was no awareness of the danger of radiation, there was no adaptive behavior to prevent this risk, and many of the rescue workers and the general population suffered radiation exposure.

Example 2: Thousands of people were trapped and perished in the World Trade Center on September 11, 2001 when the towers collapsed. However, approximately 40,000 men and women were able to escape from the burning hell, because they utilized previously learned and rehearsed methods and procedures of escaping from buildings. Media reports indicated that there was limited panic, and instead, there was an orderly evacuation aided by the police and fire departments.

Biological warfare introduces a novel threat, and one for which appropriate preventive coping strategies are not known by a significant percentage of the population, even including the professionals. The unknowns greatly increase collective and individual anxiety levels, and can include as well some irrational components. But the main hazard is not the current level of anxiety, although that, in itself, can over time take a severe toll on mental and physical health.  One of the most serious aspects of the threat of non-conventional warfare may be the high risk that the population is not responding in a way that is conducive for survival, resulting in unnecessarily increased exposure to the biological or chemical agent, without deployment of preventive measures. This behavior contains the potential for catastrophic suffering and casualties throughout the population.

The need to prevent this risk requires an early education program directed to the public, informing individuals, groups and communities at large about the nature of the threat and the preferred strategies for coping with it. Such education and dissemination of information should be initiated and mapped out by the political and military leadership, as well as by local and community leaders, school principals, teachers, and parents. It is crucial to also incorporate plans for communication and/or translation of the information to people with special needs, such as the elderly, children, the disabled, new immigrants, minorities, foreign workers, and so on.

The Natural Process of Coping with External Threat

The natural process of coping has three stages: the Stage of Alert, when an awareness of a threat exists, the Stage of Impact, when the threats materializes, and the Post-Traumatic Stage, after the termination of the impact (10, 22-24).

The Stage of Alert

The Stage of Alert involves awareness, alertness and preparation, including cognitive evaluation of the threat and identification and assessment of available and needed resources (21). This assessment also includes gaining understanding of the essence of the risk, as well as any existing relevant information about needed resources.  Evaluation of inner resources involves identifying and developing effective personal coping strategies; assessment of external resources refers to being aware of available community and national resources, and identifying appropriate preparedness measures and an exploration of sources of social support. Trust in the leadership may be tested as well during this period. This cognitive evaluation is vital in the process of developing effective coping mechanisms for dealing with stress. For the sake of maintaining mental health and social stability, this stage is not to be skipped. (More on this stage in the chapter titled “The Traumatic Process: Conceptualization and Treatment” in this book.)

Table 1: The Process of Coping with External Threat

Once it has been determined that knowledge and resources are sufficient, the next step is to develop a defensive plan. However, when the threat and its effects are assessed as larger than the available resources, there is already risk for the development of a sense of helplessness and psychic trauma, or alternatively, total denial of the threat. 

It is imperative to utilize this first stage prior to the occurrence of a strike. When it has become clear that a risk exists, plans for national prevention programs and strategies for coping with the threat need to be developed. Citizens must be informed of their own roles and responsibilities in developing effective personal coping strategies, so they are better prepared to deal with the adversity they might face, and thus increase their chances of survival. It is widely noted that adequate prevention programs at the first or “Stage of Alert” enhance coping behavior in the second stage, or “Stage of Impact“ (2-8, 20, 23).

The Need to Process New Information

Risk communication, i.e., communicating information to the population about the threat and ways of coping with it, is vital when facing a potential national peril. In biological and chemical warfare, such crucial information may be previously unknown and may be frightening. When new information is presented that has the potential of changing existing beliefs, practices and attribution for safety, there is a need for enough time to process, digest and assimilate this information and to modify previously held beliefs (1-2, 11, 15, 19).

Such new information can also initially result in resistance, confusion, emotional reactions, and thus, limited immediate absorption of new concepts. Therefore, gradual presentation over time is advised, coupled with repetition of the information and its rationale. This approach allows for gradual cognitive evaluation and integration of the risk and resources, which is an imperative component in the process of preparing to face a threat. Lack of adequate time for processing and assimilation of the new information and practices may result in rejection of the information, thus leading to subsequent inappropriate behavior and maladaptive responses (lack of protection) in the Stage of Impact. The Stage of Alert is vital and must be used for learning about the threat, and planning effective ways and means of coping when adversity strikes.

The 1991 Gulf War in Israel may serve as an example of bad preparation. While the leadership planned the military protection meticulously, it did not place much value on informing the public and explaining the novel protective steps that were required. The leadership considered it sufficient to give short directives. Trust in the leadership was assumed, rather than earned. Consequently, according to surveys conducted by the military, about 30% of the people in the severely hit areas did not use their protective gear (22). If the threat of biological attack had materialized, there would have been a high number of casualties.

It may be concluded that prevention failed in the 1991 Gulf War in Israel because of the lack of advanced dissemination of information and guidance to the population. If biological or chemical missiles had fallen in Israel, vast number of casualties would not have been prevented, due to a lack of public compliance. Furthermore, the long-term effects of how that war was handled have resulted in mistrust of the leadership, as well as a perception that the leadership does not take seriously the safety of the population.

In the 2003 war in Iraq, when Israel was threatened again, the leadership was busy tranquilizing the population, fearing panic more than the non-conventional threat. The population felt mistrust in the leadership already from the previous experience. Therefore, the population as a whole did not follow the instructions given by the military leadership. They did not trust the directive and were not alert enough to plan for their defense. If an actual attack had materialized, the number of casualties may have been as large as in the WTC in New York.

Consequently, preventive efforts in Israel in the future must take into account this low baseline level of trust, and work up from this point to develop and improve the sense of security and trust throughout.

Stage of Impact

The second stage, or Stage of Impact, may be sudden and brief, allowing only for brief orders with no explanation. In the Stage of Impact, there is insufficient time for assimilation. Therefore, if there is no time for processing the new information at the outset (in the Stage of Alert), then there is a high risk that the population will not be adequately prepared and will thus respond in a maladaptive way when adversity strikes.  The lack of adaptive behavior very likely would then render the population unprotected and undefended when exposed to the biological or chemical agent. Lack of protection may give rise to a high prevalence of physical and psychological casualties. (More on this stage in the chapter titled “The Traumatic Process: Conceptualization and Treatment” in this book.)

The Post-Traumatic Stage

See discussion of this stage in the chapter titled “The Traumatic Process: Conceptualization and Treatment” in this book.

The Need for Trust in the Leadership

Trust in the leadership is an important condition in time of peace, but then, its absence is not traumatic. In the time of a national emergency such as occurs in a period of waiting for or fearing that an unconventional threat is going to materialize, trust in the leadership is crucial for survival and for a sense of safety. It becomes a necessary condition for mental health, and maintenance of order. Because individual persons generally do not possess the ability to help themselves during a large-scale threat, the absence of trust in the leadership renders them helpless and unprotected, states that have been identified as precursors to the development of psychic trauma and social unrest (23).

Despite being so imperative, though, trust is not created or maintained automatically. It has to be cultivated and fostered over time, starting with a prevention program in the Stage of Alert and maintained until and possibly through the post-traumatic stage. Trust can be established, or at least encouraged in part, by the act of an ongoing dialogue with the public, transmitting accurate and orderly information, and informing about the threat and methods of responding or coping. This can be a first step in establishing the conviction that the leadership cares and knows what it is doing.  This also can provide the individual citizen with the tools and knowledge necessary for ultimate survival. Accurate information also helps to empower the public, giving people a greater sense of control over their lives and fate (1-2, 11, 18).

It is important to realize that permitting a lack of authoritative information about the threat may draw out alternative perceptions or misinformation. Self appointed “experts” are likely to fill in the gap, using the mass media to relay inaccurate or unreliable information and criticism of the leadership, which then may increase the sense of demoralization, confusion, distrust and helplessness. When the leadership is the first to display clear information, even bad news, it provides accurate direction for preventive coping, and the opinions of the critics that follow may remain marginal. But when outspoken critics are heard first, there is a risk that the voice of the leadership may be perceived as unreliable. Leading rather than reacting is an essential ingredient in risk communication (1, 3-5).

To summarize, a reliable leadership is one that prepares for adversities ahead of their occurrences. When trust in the leadership falters, public coping may diminish. Therefore, increased physical and psychological casualties can be expected. 

Prevention Program Against Biological and Chemical Warfare

Implementation of a prevention program, far in advance of a strike, is both necessary and the best protective program against non-conventional warfare. A prevention program relies on the premise that the public is rational and acts adaptively, and should take an active role in protecting itself and the community (1-3, 6, 9, 11, 18). Such a program includes four ingredients: 1. early mobilization of the medical system for prompt diagnosis and treatment, including preparation of an adequate supply of medication; 2. early recruitment of the detection service (police, emergency services, military home command, epidemiological centers, and special laboratories); 3. early preparation of specific instructions to the population for the time of the strike; 4. a process of slow dissemination of broad information and guidance to the population.

This paper emphasizes the last component, because without it, the entire prevention program is ineffective. The success of any prevention program, geared towards minimizing casualties of a biological or chemical strike, is dependent upon several factors: the cooperation and active participation of the population at large, the learning and implementation of subsequent adaptive behaviors, and adherence to the guidance of the leadership, i.e., utilization of protective gear and being in sheltered areas at the time of the strike (2-6, 9-10, 18). In a non-conventional warfare, planning by the leadership is futile if it does not mobilize the active participation of the public. If the public is to react to the threat in an adaptive way, thus increasing the chance of survival and maintenance of order, people must understand what the situation is all about, and what they can and must do in order to survive. Without this comprehensive understanding, it is not likely that the public will behave adaptively (3-5).

Vital as it is, in time of national threat, trust in a national or local leadership is not automatic, and may be more difficult to establish in times of crisis. Trust is something that is earned and maintained by the actions of the leadership, by its efforts to guide the public, and to secure its understanding and active participation. Education of the public and provision of information about the nature of the threat and effective strategies for survival, in an ongoing dialogue, can help lead the population to a sense of personal and group safety, as well as to trust in the leadership (1-5, 11).

The Public Needs to be Alerted, Not Pacified

One may ask what are the factors that deter leadership from disseminating important information and guidance to the general public.  One key factor is the fear of instigating panic. Many political leaders are worried that displaying bad news to the public not only may spread panic, but also negative feelings toward the leader(s). Accordingly, leaders are inclined to pacify the public. This stance is short sighted.

As stated previously, studies show that panic is not the most likely response in the face of threats (2-8, 11, 23). If adequate resources or information are available, the public can be expected to behave rationally and adaptively. Tranquilizing the public may appear to act favorably in the short run only. But in the long run, pacification of the public impedes planning of prevention programs, and thus may eventually cause a high prevalence of trauma and pervasive mistrust and rage, once the impending threat materializes.

Pacifying fear by denying or ignoring it may cause long-lasting harm. Reduction of anxiety, when anxiety is a reasonable response to a legitimate threat fosters denial and impedes the individual from planning effective coping strategies. Anxiety is the “alert siren”, signaling when something is wrong. Its role is to elicit alertness and mobilize energies to plan for survival. It is analogous to the flashing red light in one’s car, or to pain in the body. It alerts the person that something is wrong and needs fixing. It is not to one’s advantage to shut off the siren without addressing its cause. Instead, reason dictates that one would act to solve the underlying problem signaled by the siren. Acting primarily to reduce anxiety without addressing the cause may be iatrogenic. It may expose people to the sudden, unexpected threat, without adequate preparation. This situation may result in mass physical casualties due to exposure to the threat, as well as to subsequent mass psychological casualties, prolonged illness and social unrest.

Frightening information may rightfully raise the level of anxiety in the population, in the short run. However, giving appropriate information and guidance to insure that proper steps are taken for survival tends to channel that anxiety in the right direction, i.e., developing and implementing effective coping mechanisms and reasoned response.

The principal goal of a primary prevention program is not focused on reducing anxiety. Its aim is to reduce future helplessness and casualties, and this is achieved by channeling anxiety into active coping.

How to Conduct the Risk Communication with the Public

Risk communication is a dialogue between the leadership and the public in a time of crisis, when there is a dire need to make important decisions under stress (1-2, 11). The approach to the public should be in a gradual manner, with many repetitions and explanations for each step. It is advisable to utilize experts in the various fields related to the biological and chemical threats, and their treatment and prevention. These experts are expected to gradually expose the public to the threat and foster understanding of its fundamental nature.

It is vital to address subsections of the population in their own language. This is meant not just for foreigners, but also for children, the elderly, and the handicapped. Intermediate level leaders, such as parents, teachers, school counselors and psychologists, can carry out this translation of information.

In countries with a free press, the general public is allowed to voice their opinions. In a time of national stress, many self appointed experts may express their ideas and counteract the clarity of the leadership directives and guidance. This will be especially marked if the leadership failed to guide the public to begin with. When widely known authorities in the field represent the leadership and speak about the threat and the defensive actions needed to combat it, there is a chance that the number of critics is reduced, and their relative weight is minimized. It is imperative that the leadership gives information first, before the critics discuss it. Information given after the critics have voiced their opinions stands the risk of being considered less trustworthy (1, 3-5, 11). 

However, negative information should not be withheld, as this may result in mistrust. This information can be communicated together with the plans to counter these events. There is no need to pacify the public. It must be correctly informed about the threat and the protective steps, so that every individual feels a participant in the prevention plan.

In the Stage of Impact, the same elements should be continued as in the Stage of Alert. However, the direction is geared more to what to do at that moment, instead of planning for the future. Also, it is imperative that in this stage, empathy is displayed to the public suffering (1). 

The Essence of the Communication to the Public

The following is the essence of the messages that should be disseminated.

Messages in the Stage of Alert

1. Explanation of the nature of biological warfare and its danger, minimizing irrational aspects. It is suggested that the speaker be a well-known medical authority. The message is to be delivered in simple language, without technical terms. This repeated exposition might be accompanied by simple videos. It should be emphasized that physical damage to humans occurs primarily when inhaling the agent.
2. The medical system is familiar with all the known chemical and biological agents, and has adequate means for treating each.
3. The Ministry of Health and the military have already gathered supplies and initiated methods of organization (details according to event).
4. The protective means against chemical warfare, i.e., masks, protective uniform, sealed space, are very effective in safeguarding against exposure to the biological agent.
5. The protective mask has to be tested for leakage each time it is worn (instructions how to do it).
6. Compliance with the directives given by the leadership will save lives.
7. Instructions about the usage of masks and the establishment of sealed spaces.

For anthrax, additional messages may be given:

8. Anthrax is not a contagious disease. It is not transmitted from one person to another.
9. There is antibiotic treatment, which if administered within 24 hours of exposure, prevents mortality.
10. It is important for survival and safety to remain within the sealed place until ordered to leave. This order will be given when the area is free of danger.
11. Because people will be asked to stay in their homes in the contaminated area, medications will be distributed to the homes by well-protected soldiers. In the periphery, people will be notified of the posts to go to for obtaining medications.

For small pox, the following messages are essential:

12. Small pox is a contagious disease.
13. The chance of small pox being used in biological warfare is very slim.
14. The reason for talking about this agent and initiating preparation is the lack of effective medical treatment, and its contagious nature. 
15. Small pox can be prevented only by immunization, and avoiding contact with those who have been exposed.
16. Many states have already started to accumulate vaccine for immunization.
17. Health professionals and military personnel are already being vaccinated against small pox in order to collect serum (VIG), which may minimize side effects when mass vaccination is called for.
18. In Israel, the policy is to start wide scale vaccination only after a first case is detected. However, the political leadership may decide to start vaccination earlier. 

Messages in the Stage of Impact

1. Repetition of the information and explanations given at the Stage of Alert.
2. Specific instructions for actions (which were prepared beforehand) focusing on specifically hit areas, and defining their borders.
3. Instructions about the need to stay at home or in other sealed places, with explanation of its contribution to survival.
4. Instructions about the usage of the protective gear and the way to test for leakage.
5. Instructions about the specific ways of getting medications (whether brought to one’s home in the contaminated area, or where one should go to obtain medications outside of this area), with explanation of the logic of the distribution system and the risks involved in not following leadership directives.
6. Instructions about where to go for help in cases of medical crisis.

Conclusions

In contrast to the popular myth that information may cause panic at the time of a threat, it is clear today that panic is unlikely, and that information and guidance may actually minimize the number of physical and psychological casualties, and prevent the spread of mistrust and social unrest. Dissemination of information about a potential threat and directions for acquiring or developing effective coping tools are essential ingredients in any prevention program, and specifically, in the face of non-conventional warfare.

A concerned leadership must start an early dialogue with the public so that the general population will understand the nature of the peril and the necessary protective responses. The goal is to make the public an active participant in the prevention program.

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[1] Atrophine is the medication provided together with the NBC masque to serve as a first aid in an event of exposure to nerve agent chemical.