the people's role in u.s. national health security: past, present, and future

Special Feature: A Decade in Biosecurity

The People’s Role in U.S. National Health Security:

Past, Present, and Future

Monica Schoch-Spana

Over the past decade, assumptions have been made and unmade about what officials can expect of average people

confronting a bioterrorist attack or other major health incident. The reframing of the public in national discourse and

doctrine from a panic-stricken mob to a band of hearty survivors is a positive development and more realistic in terms of

the empirical record. So, too, is the realization that citizen contributions to national health security encompass not only

individual preparedness and volunteerism but also mutual aid and collective deliberation of the tough choices posed by

health disasters. In projecting what needs to occur over the next 10 years in biosecurity, 2 priority challenges emerge:

retaining the lesson that a public prone to panic, social disorder, and civil unrest is a myth, and building an infrastructure

to bolster the public’s full contributions to health emergency management.

According to the National Health Security Strategy(2009) and its implementation plan (2010) released by

the Department of Health and Human Services (HHS),‘‘informed, empowered individuals and communities’’ un-derpin U.S. resilience to a catastrophic health event.1,2

Echoing the sentiment, President Obama included thistenet in his 2010 National Security Strategy: ‘‘We willemphasize individual and community preparedness andresilience through frequent engagement that provides clearand reliable risk and emergency information to the pub-lic.’’3 In a public address that same year, Department ofHomeland Security (DHS) Secretary Napolitano entreatedthe country ‘‘to build resilience—the ability to get up andcome back stronger if we get hit.’’ She went on to explain,‘‘That doesn’t come from a set of government programs; thatcomes from the heart of the American people.’’4 When un-veiling the nation’s first ever preparedness goal in 2011,Federal Emergency Management Agency (FEMA) Admin-

istrator Fugate argued, ‘‘As we work to build a more preparednation, we must work with the entire community—thepublic and private sectors, faith-based and non-profit orga-nizations, and most importantly the public.’’5

The notion that citizens have a positive and conse-quential role to play in managing public health and otherdisasters seems obvious today, but this was not always so.Neither was the idea that people could be resilient—that is,capable of coping with, rebounding from, and even expe-riencing positive growth as a result of a disaster. Chronicledhere, then, are the diverse ways in which the public’s role ina health emergency has been imagined, taking into accountimportant historic events, policy milestones, and pro-grammatic initiatives over the past 10 years. Neither acomprehensive nor strictly linear history, this broad brushpicture documents the transformation in basic assumptionsabout the citizenry’s ability to cope with a health disaster.Once considered a hindrance to the official response, the

Monica Schoch-Spana, PhD, is a Senior Associate, Center for Biosecurity of UPMC, Baltimore, Maryland.

Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and ScienceVolume 10, Number 1, 2012 ª Mary Ann Liebert, Inc.DOI: 10.1089/bsp.2011.0108

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public is now seen as a critical ally. No small feat, this shiftin collective thinking nonetheless represents only a partialvictory for biosecurity and the country. If the past decadehas been about defining a genuine role for citizens in publichealth emergency management, then the next decade mustbe about fully institutionalizing that role. That is, the samemethodical and material effort to achieve other criti-cal public health preparedness capabilities such as bio-surveillance, medical surge, and medical countermeasuredispensing must be applied to community engagement.

Panicky Mob

‘‘How will the public react to a biological attack?’’ was aquestion underpinning many conversations in the late1990s among U.S. national security, public health, andmedical authorities about the bioterrorist threat and thebest ways for managing its consequences. Responsible forprotecting the population’s health and safety, these pro-fessionals focused principally on the potential for wide-spread psychological and social disturbances brought aboutby a terrorist attack with unconventional weapons.6 As aresult, terrorism-related literature, professional discourse,and response exercises tended to cast the public as emo-tionally vulnerable as well as prone to panic, social disorder,and civil unrest. Rare was the viewpoint that the publiccould play a more productive role in the context of anattack involving weapons of mass destruction (WMD).7

Such thinking had direct parallels to early civil defensewhen programs were explicitly designed to control panic; inthe minds of security planners, the terror that the publicmight experience with an atomic attack was seen to be asproblematic as the destructive weapon itself.8-10

Included with the 1997 articles in the Journal of theAmerican Medical Association on the medical and publichealth aspects of the bioterrorist threat was a thoughtfularticle on the probable psychological impacts.11 Here, as inother period literature, the central concern was maladaptiveresponses by the public.11,12 Among the ‘‘common psy-chosocial responses’’ following an act of bioterrorism citedwere horror, anger, panic, magical thinking about microbesand viruses, fear of contagion, anger at terrorists, scape-goating, paranoia, social isolation, demoralization, and lossof faith in social institutions.11 The authors identified ef-fective risk communication as one possible intervention toprotect against some of these effects. Nonetheless, fullyabsent from their analysis was any discussion of possibleconstructive reactions such as humanitarianism, hopeful-ness, resilience, resourcefulness, and reasoned caution, aswell as the frequency with which these positive reactionsmight occur.6

National meetings convened in the same time framereflected a similar mindset. In a July 2000 HHS and De-partment of Defense (DOD) conference on the behavioraland mental health aspects of bioterrorism, attendees con-

curred that ‘‘[a] swift and effective response by publicofficials to a bioterrorist attack can prevent negative con-sequences (e.g., panic, stigma, scapegoating) and promoteresponsible behavior by citizens (e.g., staying away fromcontaminated areas).’’13(pxiii) They also recommended fur-ther research on mass behaviors, including ‘‘actions andsettings which increase/decrease hysteria, evacuation, riot-ing, and panic.’’13(pxix) In December 2000, the DOD andthe Federal Bureau of Investigation (FBI) convened aworkshop on ‘‘human behavior and WMD crisis/riskcommunication,’’ focusing panels on the followingquestions: ‘‘How can public panic/fear be lessened?’’‘‘How can the public be persuaded to take appropriateaction and to avoid inappropriate actions?’’ ‘‘Whoamong responders and the public are at higher risk ofadverse psychological effects and how can such effects beprevented or mitigated?’’14(ppi-ii)

Commonly woven into the narratives or ‘‘scenarios’’structuring early awareness-raising tabletop exercises wereexpectations of societal breakdown in the context of abioterrorist attack. In Biowar, the first nationally televisedtabletop featured on Nightline in October 1999, a panel ofcity authorities contemplated aloud the response challengesof an anthrax release in a crowded subway system and theresulting outbreak of 65,000 cases.15 The expressed priorityconcern for both the police commissioner and the mayorwas ‘‘panic.’’ The mayor, in fact, pondered the need tobring in federal troops during the crisis, explaining:

I’ve got to stabilize the population because I think . nomatter how much information—there’s widespread panic.There are people that are storming hospitals. There arepeople that are breaking into doctors’ offices. I think nomatter what you say from the mayor’s posture, you’ve stillgot to stabilize the population from a panic point of view.15

The Biowar broadcast featured riot scenes with looted drugstores and other sites that might store antibiotics. In May2000, a $3 million drill known as TOPOFF was held to testthe readiness of top government officials to respond tomultiple unconventional terrorist attacks; mock civil unrestunfolded in one scenario as people, learning of a plagueattack, scrambled to get scarce life-saving antibiotics.16

Rioting, self-serving, panic-stricken mobs, too, were fea-tured in the June 2001 Dark Winter Exercise, in which 12former senior officials simulated National Security Councildeliberations in reaction to a covert smallpox attack and avaccine shortage.17 Among the information ‘‘briefed’’ totabletop participants was a mock news report on violenceerupting at vaccination sites, with one riot in Philadelphialeaving 2 people dead.17

Arguably, by anticipating the adverse reactions of thepublic to bioterrorism, authorities could better considerways to reduce their occurrence and severity.11-14 None-theless, an exclusive focus on negative psychosocial impactspossibly fostered expectations that these constituted the

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78 Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science

population’s prevailing response.6 Scenario typecasting ofcitizens in one-dimensional roles—as mass casualties or aspanicked mobs fleeing stricken areas or obtaining scarcemedical resources through violence—might have preparedpolicymakers and emergency professionals for the ‘‘worst,’’encouraging them to think through every contingency.6

Yet, such plotlines did not likely inspire thoughtful plan-ning for people’s adaptive, pro-social reactions. Instead,they may have helped perpetuate an image of the public asconsumed by antisocial behavior, something refuted byextensive sociological research into natural and technicaldisasters18-20 and by detailed accounts of infectious diseaseoutbreaks.21-23

Able Volunteer

Whatever notions policymakers and emergency profes-sionals may have held about public reactions to hypothet-ical biological and catastrophic terrorist attacks, they wereconfronted with very real events and behaviors in the fall of2001.

Social cohesion rather than social disarray characterizedpublic reactions even before the World Trade Center(WTC) twin towers collapsed. An estimated 17,400 peoplewere in WTC Towers 1 and 2 at the time the attacksoccurred, and more than 14,000 were estimated to havesuccessfully evacuated the buildings.24 The congressionallymandated study of the WTC evacuation indicated thatfully 99% of the occupants below the floors of impactsuccessfully evacuated25—this despite inconsistent in-structions.26 Evacuees most frequently cited assistance fromco-workers, emergency responders, and photo-luminescentmarkings in the stairwell as aiding their departure.25 In-deed, individuals risked their own lives assisting mobility-impaired colleagues.25 Gathering personal items (eg, keys,files), searching for a friend or co-worker, and making surethat others were able to leave were the first actions peoplemost often took before deciding to leave the buildings.26

Creative coping and mutual aid similarly marked col-lective behavior as lower Manhattan residents and com-muters sought refuge from the destruction and the pollutedand suffocating air. Immediately after the attack, membersof the tenants’ association for the Independence Plazahousing complex just north of the WTC towers self-orga-nized to perform a critical public safety function whenmany police had been called away.6 These residents helpedorient and direct the streams of people running away fromthe collapsed structures through the Independence Plazaarea. By 11:00 am, every manner of watercraft (eg, ferries,tour and dinner boats, private pleasure craft, tugs, outboardrunabouts, pilot boats, oil response vessels) had begun toconverge on the shoreline of lower Manhattan—some oftheir own accord, some at the Coast Guard’s request—ready to transport evacuees elsewhere.27 This ad hoc fleetmoved at least 300,000 persons, and perhaps as many as

500,000, without any casualties or accidents in a matter of6 to 7 hours.27 Photo and video documentation of the eventshowed thousands of civilians calmly waiting their turn andhelping one another to climb into waiting craft.27

The catastrophic destruction and loss of life, the broadexposure provided to the tragedy via televised reports, andthe national security implications of a terrorist attack trig-gered immense levels of volunteerism and charitable giv-ing.28 In New York City, those who could converged on thescene of disaster to aid the search-and-rescue efforts and thelonger-term recovery; others did what they could fromafar.6,28,29 On September 11, an estimated 500 potentialblood donors arrived at St. Vincent’s Hospital and MedicalCenter, the trauma facility nearest to Ground Zero, andorganized themselves by blood type using makeshift card-board signs.6,30 In the following weeks, national bloodcollection rates were several times their normal levels, withfirst-time donors accounting for 50% of all contributions,in comparison to the usual 20%.6,31 Two weeks after theattacks, 59% of Americans—and a higher percentage ofNew Yorkers—reported that they had donated or at-tempted to donate blood, made charitable donations, and/or performed extra volunteer work.32

Volunteerism in New York City demonstrated people’sresourcefulness in organizing humanitarian efforts. Unions,churches, tenant associations, professional societies, busi-nesses, and many other non-disaster groups used their ex-isting communication and organizational structures tochannel a collective desire to help.6,28,33 The American RedCross (ARC) and the Salvation Army also activated theirtrained, highly structured disaster volunteer membershipand coordinated with unaffiliated individuals who wantedto help.6 By 2½ weeks after the attacks, the Red Cross hadapproximately 22,000 offers of assistance and had pro-cessed 15,570 volunteers.29 ARC and affiliate groups suchas the Church of the Brethren supported the Disaster As-sistance Service Center, which aided displaced families andworkers; the Family Assistance Center, which offered re-sources to families of the missing and deceased; and theRespite Centers that provided food and resting places forrescue workers at Ground Zero.29

As a result of this national burst of volunteer spirit,President George W. Bush announced in his 2002 State ofthe Union address the creation of the USA FreedomCorps—a vehicle ‘‘to connect Americans with more op-portunities to serve their country and to foster a culture ofcitizenship, responsibility, and service.’’34 Part of this ini-tiative, the Citizen Corps, was launched to facilitate indi-viduals’ contributions to the safety and security of theirhometowns. Citizen Corps Councils—local coordinatingbodies to bring together leaders from government, busi-nesses, nonprofits, advocacy groups, and faith and com-munity organizations—were a new platform to developcommunity emergency plans, encourage volunteerism viafederal partner programs, conduct public outreach andeducation, and offer training and participation in

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exercises.35 Citizen Corps volunteer programs today in-clude the Fire Corps, Volunteers in Police Service (VIPS),USAonWatch-Neighborhood Watch, and the CommunityEmergency Response Team (CERT) and Medical ReserveCorps (MRC) programs.35

The concept of an MRC program—which, as of De-cember 2011, included a national network of 973 units and203,673 volunteers36—originally grew out of the experi-ence of a cadre of medical volunteers responding to theNYC mayor’s request for physicians to help at GroundZero.37 They arrived at the chaotic Stuyvesant TriageCenter (normally a school), organized themselves, and be-gan to triage and treat injured search and rescue workers.From this grew the idea that the city and perhaps the nationcould use trained and prepared volunteers to supplementemergency medical and public health response efforts. Thiscompelling notion, coupled with the realization during thesoon-to-follow anthrax attacks that any large-scale massdispensing/mass vaccination would require volunteers, wasthe impetus for the MRC’s formation.37 Since then, MRCvolunteers—both medically and non-medically trained—have played important roles during disasters includingHurricanes Katrina, Rita, Gustav, and Ike,38 and duringmore routine public health events like immunizationdrives, health fairs, and screenings for high blood pressureand kidney disease.39

Attuned Audience

The pro-social, problem-solving stance of most people inreaction to the WTC and Pentagon attacks belied expec-tations of social mayhem and self-serving behavior in thecontext of catastrophic terrorism. Communication failureson the part of authorities during the response to the soon-to-follow anthrax letter attacks further called into questionthe prevailing notion of the public as a panicky mob. Thatis, the hard-earned lesson from the fall of 2001 that sharingtimely, substantive information with the public is essentialto outbreak containment helped shift thinking of the publicfrom a problem to be managed to a constituency to beserved: anxious people understandably in need of knowl-edge about what the danger is and what to do about it.

Shocked by evidence of vulnerability to attack, alerted tothe possibility of future hostility, and confronted by thedevastation and disruption of terrorism, many peoplewondered following the 9/11 attacks what to expect andwhat they and the government should do about a possiblebioattack.6 Despite the public’s strong appetite for au-thoritative and personally relevant knowledge, however,political and public health officials engaged in a restrainedcommunications campaign at the outset of the anthraxcrisis.40,41 Predicated on the need to avoid panic, this ap-proach unintentionally diminished the credibility of someofficials. The iconic failure, and that which initiated asteady stream of criticism beginning in late September, was

over-reassurance by the Secretary of HHS on governmentreadiness to handle a biological attack, as well as underes-timation of the significance of the first anthrax death.40,41

Other communication missteps during the anthrax re-sponse, which have been detailed and debated elsewhere,included the absence early on in the crisis of highly visiblespokespersons expert in the medical and public healthimplications of the unfolding bioterrorist incident; theinitial void of information for civilians on how to cope withthe threat of additional terrorist attacks; the shifting ofpublic health protocols regarding patient screening andprophylaxis, with insufficient transparency in the reasonswhy; the lack of robust linkages between the public healthsector and private physicians, the experts to whom manypeople turned for protective guidance; and insufficientsensitivity to the complex trust factors arising in publichealth interactions with minority members of the postalworkforce.41-45

As a result, a number of critical analyses and guidebooksfor officials on successful communications with the mediaand the larger public began to emerge in the wake of theanthrax letter attacks. In 2002, the Substance Abuse andMental Health Service Administration released Commu-nicating in a Crisis: Risk Communication Guidelines forPublic Officials.46 That same year, the Centers for DiseaseControl and Prevention (CDC) released Crisis and Emer-gency Risk Communication, the core text of a trainingcourse—now much expanded—for state and local healthpublic information officers, first responders, healthcareprofessionals, and others.47 A robust academic literatureevaluating the communication practices and challenges ofthe anthrax response, as well as proposing ‘‘lessons learned’’and ‘‘best practices’’ for the future, was also established.48,49

Also, in response to the events of 2001, the federalgovernment took swift and strong measures to reinvigoratethe U.S. public health infrastructure by way of the PublicHealth Security and Bioterrorism Preparedness and Re-sponse Act of 2002.50 This act established the system offederal grants to state and local health departments to up-grade their readiness and response capabilities for bio-terrorism and other public health emergencies. In the CDCguidance issued with this funding, ‘‘risk communicationand health information dissemination’’ were singled out as1 of 7 priorities for practitioners.51

Underscoring the health security role of an informedpublic was the nation’s first biodefense strategy, HomelandSecurity Presidential Directive 10: Biodefense for the 21stCentury (HSPD-10).52 Released in April 2004, HSPD-10argued that ‘‘[t]imely communication with the public .can significantly influence the success of response effortsincluding health- and life-sustaining interventions.’’52 Thereauthorizing legislation for the federal preparedness grants(ie, the Pandemic and All Hazards Preparedness Act of2006, or PAHPA) reaffirmed that same role by naming riskcommunication and public preparedness as ‘‘essentialpublic health security capabilities.’’53



Practical investments in improved risk communicationcapability made their mark over the long term. The re-sponse to the 2009 H1N1 influenza pandemic suggested asignificant break from the prevailing communicationpractices during the anthrax scare when guidance on citizenprotective measures was judged late in coming and in-scrutable when it did.54,55 During the pandemic, the U.S.government relied on all manner of media to disseminateeducational materials on preparedness and self-protec-tion.56,57 The GAO found that, according to public surveysand its poll among state officials and professional associa-tions, CDC’s pandemic public communication campaignwas largely considered effective.58

Agency officials attributed this in part to the decision tobe transparent and open with the public about both knownand unknown information.58 Another study revealed that amajority of state and local health departments providedonline information about the H1N1 pandemic within 24hours of the declaration of a public health emergency, withsmaller local health departments being the least successfulin this effort.59 Nonetheless, significant gaps remained inthe ability of public health officials to reach minority seg-ments of the population at risk for increased morbidity andmortality during the pandemic.60,61

Self-Reliant Stockpiler

Another notional public emerging in the aftermath of fall2001 was the self-reliant stockpiler: individuals prepared totake care of themselves and their families by putting to-gether a plan and emergency ‘‘kit’’ and by becoming versedin unconventional threats and self-protective actions.Storing essential goods and being self-sufficient until theprofessionals arrive have long been tenets in the fields ofemergency management and civil defense.8-10 The ex-traordinary events of 2001, however, heightened the per-ceived urgency of this advice, both generally and in thecontext of WMD terrorism. In fact, in the aftermath of the9/11 attacks, all levels of government, but especially thefederal government, were highly criticized for the initialvoid of official guidance on civilian self-protection—a voidthat existed despite government warnings about the po-tential for additional terrorist attacks.54,55,62

Inhibiting some officials from issuing clearer guidanceon terrorism-related personal preparedness and responsemeasures was worry that doing so would instigate publicpanic and undercut the political message that the govern-ment was doing everything it could to protect the coun-try.55,62 One Washington Post reporter, driven by her ownsearch for authoritative guidance and by reader demand,queried contacts at HHS and FEMA about what ‘‘the av-erage citizen should do to prepare.’’55 During her in-vestigation, she asked Anthony Fauci, the director of theNational Institute of Allergy and Infectious Diseases, whohad emerged as a medically authoritative voice during the

anthrax scare, ‘‘Why doesn’t the government tell us more?’’In his reply, he explained, ‘‘There is a delicate balance be-tween the government giving guidance and alarming peopleinto a state of paralytic anxiety.’’55 Such a dilemma—nodoubt seen as genuine by many authorities—nonethelesswas based on unsubstantiated fear, given what is known aboutactual behavior and communication needs in a crisis.18-20

In light of the U.S. government’s perceived reticence tolead the development and delivery of authoritative guidanceon citizen preparedness, others stepped in—many withAlfred P. Sloan Foundation support. In 2002, Senator BillFrist released his own practical guidebook for the public,When Every Moment Counts: What You Need to Know aboutBioterrorism from the Senate’s Only Doctor.63 Sponsored bySloan, RAND carried out a study to develop guidance foraverage citizens to complement terrorism readiness effortsat local and federal levels.64 The final text, released in 2003,Individual Preparedness and Response to Chemical, Radi-ological, Nuclear, and Biological Terrorist Attacks, was ac-companied by a ‘‘quick guide’’ and portable referencecard.64 Another Sloan grantee, the Center for Strategic andInternational Studies, issued strategic recommendations in2003 on ‘‘civil security’’—that is, the ‘‘ability of Americansto recognize danger, limit damage, and recover from ter-rorist attacks,’’ along with a detailed catalogue of personalprotective actions.65

February 2003 marked the launch of ‘‘Ready,’’ a nationalpublic service advertising campaign and website(www.ready.gov), the result of a collaborative effort amongDHS, the Advertising Council, and the Sloan Foundationto ‘‘educate and empower American citizens to prepare forand respond to potential future terrorist attacks.’’66

Ready.gov has since grown in mission, now addressingnatural, technological, and terrorist hazards; advising on thefull disaster cycle including recovery; reaching a broad au-dience across 12 different languages; readying businesses;and providing materials for children. Advance planningand self-reliance are now applied to the whole of civil so-ciety and commercial enterprise. In 2006, the NationalStrategy for Pandemic Influenza: Implementation Planprovided preparedness checklists for individuals, families,businesses, schools, and faith- and community-based or-ganizations.67 In 2008, as a result of 9/11 Commissionfindings, DHS moved to establish common criteria forprivate sector preparedness and a voluntary certificationprogram now known as PS-Prep.68

Since 2001, pollsters, researchers, and emergency pro-fessionals have steadily queried Americans as to whetherthey have taken basic steps to prepare for the unexpected;these professionals also have investigated motivators andbarriers to citizen preparedness.69 Even the dramatic con-sequences of Hurricanes Katrina and Rita, some surveysindicated, were not enough to raise the numbers of pre-pared citizens significantly.70,71 In December 2006, to helpreverse this trend, the Council for Excellence in Govern-ment released the Public Readiness Index and the online

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RQ (Readiness Quotient) Test, developed in collaborationwith DHS, the American Red Cross, and the SloanFoundation.72 With a simple measurement tool, the de-velopers argued, citizens could independently assess theirpreparedness, recognize their accomplishments, and setgoals where more effort was needed.72

Exhortations on individual and family preparedness,nonetheless, have had uneven success. Behavioral expertsnote that many people believe that a disaster will not reallyhappen, and if it does, it will happen to other people.People’s perceptions of ‘‘being safe’’ are reinforced everyday that a disaster does not occur, undercutting any in-centive to prepare.73 Historical evidence suggests, in fact,that experiencing a disaster may be the strongest motivatorfor people to prepare.73 At the same time, federal calls forcitizens to prepare have been met with some skepticism, asindicated by the comedic ridicule directed at DHS Secre-tary Tom Ridge in 2003 for encouraging people to stock upon duct tape and plastic sheeting to seal windows in case ofa biological or chemical attack74 and at HHS SecretaryMike Leavitt in 2006 for advising people to put cans oftuna and powdered milk under their beds to prepare for aninfluenza pandemic.75

Despite some cause for derision, reasonable argumentsstill support the idea of a public equipped to make do on itsown. Becoming more knowledgeable about unconventionalthreats may reduce the shock value of otherwise dread-inducing hazards such as chemical, biological, and radio-logical weapons.11 Family emergency plans target a mean-ingful solution to the worry and uncertainty about thewelfare of loved ones in disasters. Gathering flashlight,crank radio, nonperishable foods, routine medications, andother ‘‘basics’’ is a human-scaled task with real materialvalue, depending on the circumstances.76 Lastly, every self-sufficient individual and household eases the burden ofemergency professionals who have to protect an entirepopulation, allowing them to target resources to those mostin need.77

Policymaking Partner

The initial view of the public in the context of a biologicalattack as, at best, getting in the way of the professionals and,at worst, constituting a secondary disaster, was in keepingwith much of the thinking in the history of North Amer-ican civil defense as a quasimilitary activity. As such, theorganizational emphasis had been on a chain of commandamong authorized personnel and on centralized decisionmaking and communications.78,79 Disaster planning, byand large, was seen as something done for, not with thecommunity.79-81

At the same time, the risk communication model pro-moted in the wake of the anthrax scare was reminiscent of acommand-and-control approach. How state and localhealth agencies spent their preparedness grants suggested an

understanding of the public as a passive receptor for di-rectives issued by knowing officials and channeled by massmedia. Surveys of health departments indicated that thepreparedness grants early on had supported the hiring ofpublic information officers to interface with journalists andthe training of designated spokespersons in risk commu-nication.82-84 As one public health preparedness observernoted, however, much still remained to be done in terms ofbuilding direct, long-term relationships with the public,businesses, and faith-based organizations.85

The concept of the public as policymaking partner grewalongside and in many respects in reaction to the idea of thepublic as merely the recipient of government directions.The Working Group on ‘‘Governance Dilemmas’’ in Bio-terrorism Response, convened by the Johns HopkinsCenter for Civilian Biodefense Studies in 2003 with Sloanand DHS support, encouraged authorities to support thepublic’s own active role in remedying a health emergencyand to situate public communications within a broaderunderstanding of the societal dilemmas that could be an-ticipated with bioattacks, based on past epidemics.86

Among the group’s charge to governors, mayors, and healthofficers was ‘‘. approaching the public as a capable ally,not a problem that needs managing; keeping responsetransparent through open channels with the media and acommunity’s other trusted sources; prioritizing voluntarycompliance among the many over coercion of the few;advancing equity in access to emergency resources; [and]sharing difficult decisions when they arise. .’’86(p36)

Similarly, in 2004, the New York Academy of Medi-cine’s Redefining Readiness study argued that emergencyplanners had been focusing a great deal on public educationand risk communication but not sufficiently listening to thepublic about its own concerns, priorities, and potentialbarriers to acting on government instructions.87 Studyfindings suggested that current planning assumptions aboutpublic reactions to a smallpox outbreak or dirty bomb ex-plosion did not reflect people’s experiences and perspectivesand that greater inclusion of the American public in ter-rorism preparedness plans was necessary.87 The initiativedeveloped community demonstration projects as well as asuite of practical tools through which residents couldcontribute their essential knowledge to emergency pre-paredness efforts.88

Public inclusion and community-based collaboration inemergency planning efforts, too, were the goals of theReady, Willing, and Able Act (HR 3565), federal legisla-tion introduced by mental health advocate Rep. Patrick J.Kennedy (D-RI) in July 2005 and then again as HR 1891in April 2007.89,90 Drafted and promoted with the supportof staffer Michael Barnett, a psychiatrist, the act laid out theempirical evidence for public resilience in disasters as well asstrategic plans for ‘‘the American public to have a direct andinfluential role in developing and reviewing communitydisaster preparedness, response, recovery, and mitigationplans. .’’89 Unfortunately, the bill did not advance far.



The devastating impacts of Hurricanes Katrina and Ritain 2005 underscored the importance of assuring the socialacceptance and practical feasibility of emergency plans toprotect the population, especially groups proven to be morevulnerable in disasters. For instance, the highway-basedevacuation plan for New Orleans was, on the one hand,considered a major success in that more people were able toleave the city in a shorter time than was thought possible.91

On the other, many people in low-mobility groups werestranded—namely, the poor, the socially isolated, and thefrail; those with no car, no money for gas to fuel a car, or nolicense or insurance to rent a car; those who were worriedabout losing a job if they left town; those who were notpoised to receive and interpret warnings; and those whowere elderly or frail or who had to care for an elderly or frailperson.91,92

Having witnessed the shocking and broad effects ofHurricane Katrina, public health professionals took actionsthey hoped would prevent the disproportionate impact offuture disasters. Public Health Seattle and King County(WA), for example, established the Vulnerable PopulationsAction Team (VPAT) in 2006 to work collaboratively withcommunity-based organizations that serve vulnerablepopulations to ensure the continuity of this safety net inemergencies, to exchange emergency information withhard-to-reach populations, and to advocate on behalf ofvulnerable groups for greater consideration in emergencypreparedness.93

In 2006, at the federal level, health policy staff in SenatorLieberman’s (I-CT) office prepared the draft bill, the PublicHealth Emergency Preparedness Community EngagementAct, ‘‘to improve public involvement in preparedness forand response to bioterrorism and other public healthemergencies and disasters.’’ Among the bill’s objectives wasdisbursing community engagement practices and traininggrants that would help strengthen state and local disasterplanning for special needs populations. While the bill wasnever introduced, the analytic and advocacy efforts behindit led to a successful amendment to PAHPA creating theOffice of At-Risk Individuals under the new HHS AssistantSecretary for Preparedness and Response. This office wascharged with advising public health agencies on the needsof at-risk individuals in federal, state, and local prepared-ness and response strategies.94

In the wake of Katrina, public health officials alsostepped up efforts to address the enhanced risk of certainsubgroups to the effects of a potential pandemic influenza,the national planning for which was already under way. In2007, with support from CDC, the Association for Stateand Territorial Health Officials began developing modelguidance on the protection of vulnerable populations in apandemic, relying on input from public engagementmeetings with members of at-risk populations and theirservice providers and with national organizations workingwith at-risk populations.95 A top planning recommenda-tion was ‘‘collaboration with and engagement of at-risk

populations’’—that is, ensuring that ‘‘at-risk individualsshape the pandemic influenza planning and policies thataffect their lives.’’95(pp3-4)

Pandemic flu planning, in contrast to early bioterrorismresponse planning, was marked by strong arguments forproviding members of the public with the opportunity toweigh in on key preparedness policy decisions—in partic-ular, those with a strong ethical component.96-98 Colla-borative problem solving on federal health policy in thepandemic flu context was piloted in the form of publicdeliberations among citizens at-large and national stake-holders in 2005 about the best, early use of limited vac-cine99 and in 2006 about the economic and social tradeoffsassociated with community mitigation measures.100 Selectstate and local jurisdictions also conducted their own publicengagement exercises,101,102 some funded with federalpreparedness funds explicitly set aside to implementpromising practices for involving the public in the policy-making process.103

Resilient Survivor

Though perhaps not yet conventional wisdom among allpractitioners and policymakers, the idea that the U.S.public plays an essential role in disaster and epidemics andhas a rightful claim on the direction of emergency plans hasstill managed to crowd out earlier assumptions of the publicas panicky, selfish, disorderly, and potentially violent. Infact, key federal documents on emergency preparedness,response, and recovery policy increasingly have embracedthe notion of community resilience, the capacity of peo-ple to adapt to and ‘‘bounce back’’ after a major disrup-tive or destructive event. A burgeoning literature onresilience104-107 is making its way into policymaking circles,now eager to enlist individuals, civil society, and privateindustry in the larger societal effort to reduce disaster-related losses. (Nonetheless, some adherents to the panicmyth may continue to hold out, especially when doing soserves institutional interests.108,109)

Released in October of 2007, Homeland Security Pre-sidential Directive 21: National Strategy for Public Healthand Medical Preparedness (HSPD-21) identified commu-nity resilience as one of the ‘‘four most critical componentsof public health and medical preparedness,’’ alongsidebiosurveillance, countermeasure distribution, and masscasualty care.110 Community resilience was 1 of the 2 topgoals in the 2009 National Health Security Strategy,1 theimplementation plan for which saw strength in:

� Community members, including at-risk groups, who areknowledgeable about health threats, what to do, andwhere to seek out help;

� Faith-based organizations, private businesses, and NGOswith community ties that are integrated into emergencyplanning; and

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� Social networks that are adept at disseminating risk in-formation and aiding community members in responseand recovery.2

In March 2011, the CDC issued Public Health Prepared-ness Capabilities: National Standards for State and LocalPlanning to aid state and local health departments whenforming strategic plans, setting priorities, and measuringprogress.111 At least 4 of the 15 capabilities related to cit-izen and civil society contributions, with ‘‘communitypreparedness’’ (a named ‘‘community resilience’’ capability)presenting the most robust agenda. Among the steps tostrengthen this capability, state and local planners wereadvised to: (1) convene coalitions that include business aswell as community- and faith-based partners; (2) incorpo-rate community input into emergency operations plans andinto problem-solving sessions; (3) provide occasions forvolunteers to participate in safety efforts year round and tohelp maintain health services during an incident; and (4)identify community leaders who can serve as trustedspokespersons to deliver public health messages.

Conclusion: What’s Next?

Over the past decade, assumptions have been made andunmade about what officials can expect of average peopleconfronting a bioterrorist attack or other major health in-cident. The reframing of the public in national discourseand doctrine from a panic-stricken mob to a band of heartysurvivors is a positive development and more realistic interms of the empirical record. So, too, is the realization thatcitizen contributions to national health security encompassnot only individual preparedness and volunteerism but alsomutual aid and collective deliberation of the tough choicesposed by health disasters. In projecting what needs to occurover the next 10 years in biosecurity, 2 priority challengesemerge: retaining the lesson that a public prone to panic,social disorder, and civil unrest is a myth, and building aninfrastructure to bolster the public’s full contributions tohealth emergency management.

Though present doctrine supports the idea of commu-nity resilience to a health emergency, the potential stillexists for the strong return of thinking about people as anunstable menace to suppress. In spite of accumulated evi-dence to the contrary, belief in mass panic and socialbreakdown in disasters and epidemics lingers in the U.S.,fueled in part by Hollywood blockbusters and distortednews reports on disaster behaviors.112,113 The latest incar-nation of such imagery exists in Contagion, a heavily viewed2011 film that has been lauded by some health authoritiesas having a strong scientific base.114 While the depictions ofviral mutation and epidemiology may ring true, the societalresponse does not. Such exaggerations of mayhem and vi-olence are problematic not simply because they are erro-neous, but because belief in them has the potential to

influence individual, organizational, and government re-sponses.112 Coercive forms of epidemic management be-come defensible when people are defined as a problem tocontrol, rather than an ally in caring for the sick and pre-venting the spread of disease.115,116

If, as the National Health Security Strategy sets forth,community resilience is 1 of the country’s 2 top healthsecurity goals, then we need to recommit to strengtheningthe public health infrastructure, this time with an emphasison hiring, training, and assigning sufficient staff to partnerwith the public in emergency preparedness, response, andrecovery. No other public health preparedness capability—whether biosurveillance, medical countermeasure dispens-ing, or medical surge—is treated as if it were an organicprocess that will somehow happen on its own.117 TheMarch 2011 Public Health Preparedness Capabilitiesguidance charts a good path forward. Yet, enough dedicatedpeople—with leadership’s support—are still needed todevelop an engagement strategy, cultivate relationshipswith community- and faith-based groups, conduct broadpublic outreach and communication, mobilize volunteers,and involve the public in preparedness policymaking. Nowthat a consensus has seemingly emerged around whatconstitutes a genuine role for citizens in a public healthemergency, the country must move forward in expandingthe institutional base to realize this vision.

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Manuscript received December 20, 2011;accepted for publication February 24, 2012.

Address correspondence to:Monica Schoch-Spana, PhD

Senior AssociateCenter for Biosecurity of UPMC

621 East Pratt St., Ste. 210Baltimore, MD 21202

E-mail: [email protected]

