Image: A mailbox from which the attacker posted Anthrax laced letters in 2001, displayed at the US Postal Museum in Washington, D.C. Photo taken by Bradley Trefz, Copyright 2014.

[Author’s Note: Aside from some light editing and the addition of two sentences, one in the introduction and one in the conclusion, the following post is published here as I wrote it in late 2013 for a research project. It was not published previously. I have highlighted several portions of critical interest (in italics below) as they relate to the ongoing COVID-19/SARS-COV-2 pandemic, without further comment. They are the same problems and issues observed in 2001. Failure to learn history dooms one to repeat the mistakes of the past.]

Introduction

The 2001 anthrax attacks in the United States, dubbed Amerithrax by the FBI, generated widespread media coverage, public fear and anxiety, and a confused response at the federal level. Academic literature examining the attacks focused on various elements of the response to include scientific aspects, the FBI investigation, and the federal response. Yet, the most significant impact of the Anthrax letters was not in the Hart office building or the offices of NBC. The greatest impact of the attack was widespread: the Amerithrax attack produced thousands of “white powder” calls in communities across the country. From rural communities to major metropolitan areas, no population escaped the widespread public worry and strain on emergency services that resulted. Thinly stretched emergency services and hazardous materials teams struggled to keep pace with a backlog of calls. Adding to the confusion was the emergence of hoax “white powder” attacks, which continue up to the present day, two decades after the Amerithrax attacks. Amidst widespread public worry, the confused and conflicting information coming from media, different departments of the federal government, and state and local officials, led to different protocols to deal with the problem, many ad hoc. Since the attacks, many of those protocols became Standard Operating Procedure (SOP) across the nation. While the volume of powder calls eventually diminished, the problem did not as hoax attacks continue. Further, many of the problems noted in 2001 returned in exaggerated form during the response to the COVID-19/SARS-COV-2 pandemic.

The literature mostly ignored many aspects of the Amerithrax attack. Lessons learned, SOPs, and procedures regarding “white powder response” continue to vary from jurisdiction to jurisdiction. The problems presented by the Amerithrax attack still exist. The white powder problem was a manifestation of what emergency services call “the worried well.” The Amerithrax attack produced a nationwide outbreak of the problem, the first on such a geographic scale. The phenomenon spread worldwide as hoaxes and powder scares multiplied. In addition to communities across the United States, the French parliament, the U.S. Embassies in Berlin and Athens, the National Parliament in Canberra, Australia, postal depots in the United Kingdom, and Spain’s largest newspaper all shut down due to false alarms and hoax mailings (Garrett, “Ten Years Ago” 2011). Multiple factors contributed to the white powder phenomenon and different methods developed to address it. The Amerithrax attack represented a new and novel form of the worried well problem, one that could reappear in the event of a similar dispersed attack or a biological outbreak. This paper explores the phenomenon of the worried well, the way some U.S. communities responded to the problem, the disaster research into the anthrax attacks, and the ways that community planners can incorporate lessons learned from the Amerithrax attack into their planning for biological threats.

The Amerithrax Attacks

The events of September 11, 2001, were still front and center in American media and society when stories began to circulate about the first known pulmonary anthrax case seen in the United States in decades. Fears of follow on terrorist attacks dominated the media and crept into official statements (Garrett, Sirens 2011:163). Concerns about the threat of bioterrorism and chemical weapons after 9-11 sparked increased interest in everything from radiation meters to antibiotics. Gas masks and Ciprofloxacin (Cipro) for sale on the internet appeared within days of the 9-11 attacks. At official levels, the Director for the Centers for Disease Control (CDC) in Atlanta was participating in a daily conference call chaired by Health and Human Services (HHS) Secretary Tommy Thompson. During these calls, federal officials discussed intelligence about biothreats and preparedness (Garrett, Sirens 2011:163-164).

Meanwhile, Robert Stevens and his wife were vacationing in North Carolina. Stevens was a 63-year-old photo editor at the American Media Incorporated (AMI) corporate offices in Boca Raton, Florida. When he began feeling ill, the couple cut their trip short and returned to Florida. Stevens checked into the JFK Medical Center in West Palm Beach, Florida, early in the morning on October 2, 2013. Initially diagnosed with a severe case of pneumonia, Stevens suffered a seizure, slipped into unconsciousness, and required a ventilator to keep him alive.

Days before, while Stevens was cutting his trip short, a postal worker from the Trenton, New Jersey United States Postal Service (USPS) sorting center was visiting her doctor to inquire about a lesion on her arm. Just days earlier, Richard Morgano, a janitor at the same Trenton facility, visited his doctor seeking aid for a growing black lesion on his arm. A report had also come into the FBI office in Manhattan, operating from temporary offices in a parking garage. Twenty-four hours earlier, someone from the NBC News offices had called to report a threatening letter containing a strange powder. Two agents visited the office, examined the letter, and interviewed some of the staff who handled it. The agents took the letter back to their office and stuck it in a desk drawer.

Another AMI employee, Ernesto Blanco, became sick, while Tom Brokaw’s assistant and a child of an NBC News Producer who visited the NBC offices for a birthday celebration also sought medical attention for lesions. Across town, an assistant to CBS anchor Dan Rather, also noticed a lesion, though she initially ignored it. Another media employee at the New York Post developed a similar lesion on one of her fingers. By the time Robert Stevens checked into the hospital, at least seven individuals in the U.S. had signs and symptoms of either inhalational or cutaneous anthrax infections.

All of those affected sought treatment by the time Blanco and Stevens entered South Florida hospitals. Doctors failed to perform diagnostics or take samples and did not conduct any out of the ordinary tests or analysis. Recognition of anthrax did not occur until Dr. Larry Bush, a physician at the West Palm Beach hospital, noted rod-shaped bacterium in a sample of Stevens’ blood on October 3. Bush previously attended training in bioterrorism preparedness and recalling that training, immediately suspected anthrax. He called the Palm Beach County Health Department and reported his findings. Bush then sent samples to a laboratory in Fort Lauderdale and overnighted pathology samples to Florida State University for analysis by Phillip Lee, one of the few microbiologists in the country trained by the Centers for Disease Control (CDC) in bioterrorism laboratory forensics (Garret, “Ten Years Ago” 2011).

The next day Lee made an initial confirmation of anthrax and contacted the CDC. By October 4, the story went public when Secretary Thompson delivered a press conference from the White House. Officials in Washington, Florida, and Atlanta were insistent that the Stevens case was isolated and did not point to terrorism. By Friday, October 10, the story had changed dramatically (Robinson and Newstetter 2003). Television sets tuned to twenty-four-hour news reports showing images of the still smoking ground zero in New York City were everywhere, so too were reports about anthrax and bioterrorism. The media coverage was incessant. It did not take long for speculation to link the 9-11 hijackers, who had spent time in South Florida, to the anthrax attacks, with no evidence to support those claims. Public health officials, the federal government, the Centers for Disease Control (CDC), and the Federal Bureau of Investigation (FBI) struggle to deal with the situation. Contradictory statements from “experts” and officials flooded the airwaves.

Throughout October and November 2001, worried calls to emergency services flooded into emergency services reporting white powders everywhere. By October 19, the worldwide reports of powder scares and the ongoing reports related to the AMI facility and New York letters pushed the New York Stock Exchange down to levels not seen since 9-11. The city of Atlanta burned through $15 million in lab analysis costs in two weeks. Philadelphia spends $60 million in the same period (Garrett “Ten Years Ago” 2011). The USPS went into near paralysis with conflicts emerging between the postal workers union and the government over vaccination protocols and antibiotic treatments. Screening efforts through the sorting centers stall significant parts of the postal system. Many Americans worried about opening their mailbox, scared by news media reports to beware of unexpected mail reported Publisher’s Clearing House entry forms as suspicious because they were “unexpected.” Companies and government offices published emergency mail handling guidelines and purchased screening devices and x-ray machines. Kool-Aid, talcum powder, sugar, coffee creamer, even white scuffs on luggage resulted in exhausted fire and police bagging “suspicious” substances while sweating inside their Tyvek suits and protective masks. Workplaces, schools, and the United States Postal Service faced severe disruptions, adding to the economic impacts produced by the attacks on the Pentagon and the World Trade Center. Across the country, community emergency services were overwhelmed while state and local governments struggled to find ways to relieve the pressure.

Eventually, the call volume reduced, procedures put in place, and the media coverage died down. By 2002, the story had moved on to the investigation into the attacks and the investigation’s numerous problems. As the focus shifted, many of the ad hoc procedures implemented during the crisis of October and November 2001 became standard in jurisdictions across the country. These procedures continue as communities deal with the considerable number of powder hoaxes that have flourished since 2001. Since 2001, there have been several minor incidents involving ricin, but nothing has produced effects like those of the anthrax attack.

When it was all over, the attack made 22 people ill, five of whom died. An additional 10,000 to 32,000 individuals received medical advice for suspected exposure, recommending courses of antibiotics and anthrax vaccinations (Stone 2007). Few of the individuals who received such advice had positive tests (or any tests) for exposure. The actual incidence of exposure was significantly lower than the number of those considered “at-risk,” which made up the majority of those told to seek treatment. There is no accurate measure of how many individuals self-medicated or sought independent medical treatment. However, according to a contemporary poll by ABC News and the Washington Post, five percent of Americans spoke to their health care provider about anthrax, and two percent purchased antibiotics. Gallup found similar numbers reporting three percent of Americans attempted to obtain an antibiotic prescription (Stone 2007).

 While that two to five percent represents a sizeable population (between 7 and 17 million people), the number of calls to emergency services for white powder was the more significant problem, mainly because they overwhelmed the capacity of emergency responders. In one week, nine states reported to the CDC they received 2,817 bioterrorism calls. This number is deceptively low. Between October 13 and 19, 2001, Anne Arundel County, Maryland, between Washington, D.C. and Baltimore, responded to at least 170 incidents, including a white scuff mark on a piece of luggage at Baltimore-Washington International Airport (Barnhardt 2001). Neighboring counties reported similar numbers. Media reports suggest similar patterns across the country and into Canada (Waite 2002; Dillon 2001; Ottawa Sun 2005). Compounding the problem was the proliferation of hoax letters, which have continued to the present day (Stone 2007; Bhattacharjee 2012).

This worldwide reaction was unlike anything ever seen by emergency services or government. Several key factors drove the widespread fear, a manifestation of the problem emergency services refer to as “the worried well.” Worried well are not a new phenomenon, especially concerning chemical, biological, or radiological incidents. The worried well are individuals who seek medical care during a chemical, biological, radiological, or nuclear incident for whom the primary reason for seeking medical care is to assuage fear. These individuals show no visible signs or symptoms of injury or exposure and may be geographically far from the incident and well outside its impact zone. In past incidents, the ratio of casualties to worried well was as much as 1 to 10.[1]  In the case of the Anthrax attacks, the medical system saw some manifestation of worried well, mostly from those seeking Cipro prescription. 

In one of the few works to examine the worried well problem, the author excluded the anthrax attack since worried well did not seek medical attention in significant numbers in 2001 (Stone 2007). Yet, the Anthrax attacks were different in that worried well sought reassurance of their safety from police and fire services. Many emergency management officials in Texas recounted dealing with inquiries about where to seek “mail screening.”[2] Cornstarch, used as a “slip agent” in newspaper printing, resulted in numerous calls to emergency management (Oreskovic 2001). Reassurance, in this case, came from sample gathering, basic decontamination, and laboratory analysis proved extraordinarily expensive. Yet, even now, no complete accounting exists of the effects on emergency management produced by the Anthrax attacks.

Risk Communication

Literature instead has focused on the numerous communication problems at the federal, state, and local level, media coverage, and the Amerithrax investigation and its numerous scientific and investigatory problems. On the communications front, the primary account is that of Vicki S. Freimuth, who managed the CDC’s communication activities during the anthrax attacks. Freimuth published an academic article in 2009 on the “self-organization of communication,” examining the specific communication challenges brought on by the attack and the way her agency reorganized its communications to deal with them. She described their actions within the framework of chaos theory (Freimuth 2009). She identified five primary challenges:

• Communicating uncertainty,

• Selecting credible spokespersons,

• Collaborating with other organizations,

• Satisfying a competitive 24/7 media,

• Speed [of the response].

In particular, she noted a tendency, especially among politicians, to emphasize reassurance and demonstrate control over the situation. This, she argued, compounded the situation. She noted the Federal Emergency Response Plan then in force “placed the White House and Cabinet secretaries in charge of all communication with the public and the press” (Freimuth 2009). Because chemical, biological, radiological, and nuclear incidents are technical subjects demanding a degree of scientific and technical literacy and knowledge, cabinet-level communications staffs and their political bosses, both of whom lacked technical expertise, suffered from a credibility problem. Freimuth singles out several statements by HHS Secretary Tommy Thompson as damaging government credibility as the attack unfolded. Her boss at the CDC, then director Jeffrey Koplan echoed the communication problem Freimuth identifies:

During the anthrax crisis as in no other, it became obvious that public communication had become in some sense fully as important as – if not even more important than – the line duties of senior decision makers. If this lesson was not totally clear during those harrowing October days, it has become indelibly apparent in subsequent “crises” involving mass preemptive vaccination for smallpox, West Nile Virus outbreaks, and the recent eruption of SARS (Freimuth 2009).

These problems are much cited and played out both internally and externally as different agencies of the government pursued different communications strategies. The internal divisions between USPS management and unionized labor became prominent on television screens and led to a groundbreaking union contract that applied OSHA guidelines to the USPS. The demands of the modern news cycle also played a role. Over the six weeks between the Stevens case in Florida and the last known incident of exposure and testing, the CDC dealt with 7,700 press calls, issued 44 press statements, and conducted 306 broadcast interviews. By comparison, their normal workload is approximately 20,000 calls a year (Freimuth 2009).

 Freimuth points to the communications problems that can influence worried well responses among the public, but she was not alone in examining the communications problems presented by the Anthrax attacks. Susan Robinson and Wendy Newstetter conducted a more wide-ranging examination of the CDC communications response through interviews with all the communications staff. One of their key findings was the importance of communicating uncertainty, which ran counter to the scientific culture at CDC (Robinson and Newstetter 2003). Liana Blas Winett and Regina G. Lawrence discovered a similar issue in their research on media coverage of the attacks, finding that variations in the political context in coverage rested in part on the unwillingness of key public health sources to articulate certain claims in the heat of the crisis (Winett and Lawrence 2005). Lee Clarke, Caron Chess, Rachel Holmes, and Karen M. O’Neill evaluated the premise of speaking with “one voice” within the context of the anthrax attacks (Clarke, et al. 2006). They found that different audiences required different messaging. This problem reappeared in research that looked at the problem from a multiethnic viewpoint (SteelFisher, et al. 2012).

One of the few articles examining a localized communication response was that of Christopher Clarke and Caron Chess, looking at the communications response of a major university to the anthrax attacks (Clarke and Chess 2006). They found that many of the problems found on the federal level reappeared within the university organizational structure. They also noted the challenge of maintaining a steady flow of information to multiple audiences absent concrete facts.

G. James Rubin, Alexander Chowdhury, and Richard Amlot conducted a broader review of the literature addressing communications about chemical, biological, radiological, and nuclear (CBRN) terrorism identified thirty-three relevant studies on the subject (Rubin, Chowdhury, and Amlot 2012). These included those previously mentioned. Interestingly, none of them specifically addressed the issue of the worried well.

What these studies do suggest is that the credibility of government risk communication is a crucial factor in producing effects like those observed in the anthrax attacks. Likewise, while officials may not need to speak with “one voice,” they must communicate consistent messages. Competing information sources and a media lacking information with which to fill its twenty-four-hour news broadcasts will fill any void and create further confusion and misunderstanding among the public.

Public Health Responses

Surprisingly, the literature covering the response of public health organizations to the Anthrax attack is less wide ranging than that addressing communications. In part, this may be because of the sheer complexity of the topic. Several common issues emerge, however. First, the role of the CDC in relation to state health officials was problematic. State officials had differing expectations of the CDC role, and the CDC had no authority to mandate specific actions (Gursky, Inglesby, and O’Toole 2003). This led to a multitude of messages, which resulted in media comparisons between differing guidance. Politicians at the federal level were also critical of some state actions. These studies also highlight risk communication, as well as information dissemination to hospitals and medical professionals. Information from the CDC might reach local public health officials but did not necessarily reach those expected to act on it. In part, this was due to uncertainty at the top. The CDC’s reluctance to release guidance without scientific certainty led to public health and medical professionals operating in a vacuum and developing their own guidelines (Gursky, Inglesby, and O’Toole 2003).

A related issue found in public health literature is the lack of compliance among those prescribed prophylaxis for anthrax exposure (Stone 2007). Two studies, one looking at Senate office building workers, the other at workers in a USPS facility, both of which had exposures resulting in casualties, found about sixty percent complied with medical treatment instructions (Stone 2007). Another study found numbers that suggested the number of individuals seeking antibiotic treatment might have been higher than that suggested in public polling. That small sample study found that sixty-six percent of emergency physicians in Pennsylvania that responded to the survey reported requests from patients for antibiotics during the period of the anthrax attacks, though only twenty-five percent of those prescribed them (M’ikanatha, et al. 2005).       

One of the few studies to examine the worried well problem specifically, looked for ways to reduce the impact of what the researchers called “low-risk patients” in a bioterrorism incident (Rubin and Dickmann 2010). In their examination of the anthrax attacks, they suggested that the increase in antibiotic prescriptions during the attacks indicated stockpiling. More apropos to this examination, they found that information seeking increased dramatically during the attacks. The CDC website saw a one hundred percent increase in traffic, and incoming calls overwhelmed public hotlines established to field calls from the public about anthrax. One location received more than 25,000 calls in just two weeks (Rubin and Dickmann 2010).

Responses 

Local response to the flood of white powder calls in the wake of the anthrax attacks led to widely divergent and ad hoc methods to screen calls. Scripts for 911 operators saw use in some jurisdictions, with accompanying decision trees designed to weed out the worried well and those looking for “screening” of their mail. In one jurisdiction known, fire officials began informing callers that they would destroy their mail as part of any analysis, which quickly eliminated a large number of calls, many self-terminating their emergency service contact.[3] More problematic was the proliferation of test kits, bioassays, and other devices designed to detect biological agents. Federal guidance later discouraged their use, but many of these tests remained available and in use long after the Amerithrax attacks ended. These tests were problematic as they only offered a presumptive diagnosis and then only for specific agents, assuming they worked at all. Both federally supplied and commercially available bioassay tickets in 2001 suffered from several false negative/false positive problems. Many of these were design flaws or issues related to storage and use. The commercial market also saw an increase in fraudulent devices and claims regarding the ability of some testing products.

During one response in October 2001 that the author of this article participated in, responders to a white powder call used a federally supplied bioassay ticket to assess a sample gathered from boxes in a container arriving in the United States from Pakistan. The bioassay ticket, which resembles a pregnancy test, typically show lines indicating a negative or positive result. The first test turned the entire assay window bright red. A second test produced comparable results. Further investigation revealed the federally sponsored laboratory providing the tickets, never tested the tickets against environmental contaminants and common toxic substances, only the targeted biological agents, meaning that while the tickets had a relatively low false-negative problem, they suffered severe false positive issues. Additional sampling and investigation revealed the white powder residue was residue from a common insecticide that interfered with the bioassay.

Such bio-assay tickets could indicate something was anthrax, under optimum conditions. However, their false positive rate and malfunction in the presence of other contaminants made them ill-suited for fieldwork. Likewise, a negative on a bioassay for anthrax did not mean that the substance was not ricin or something equally toxic. Because of these issues, the standard procedure was to send multiple samples to a lab, even where using bioassays. The bioassays served as a preliminary tool to reassure victims or provide law enforcement with an initial assessment.  Whether the tickets were used or not, the sampling generated a more significant issue. Lack of screening in responses meant that a high volume of samples, many of dubious nature, overwhelmed state labs.

Further, lab testing got expensive, very quick. Initially, state and contract labs were unable to deal with the sheer volume of samples. Their procedures were also not always up to par. In one incident in New York, an over-exuberant police officer contaminated an entire lab with anthrax spores (Garret, Sirens 2011).

Internet searching of state and federal emergency management and public health websites found several widely variable guidelines for dealing with unknown or questionable substances, letters, or packages. The official unclassified federal guidance coordinated and jointly published by the Federal Bureau of Investigation, the Department of Homeland Security, and Health and Human Services/CDC dates from November 2004. It addresses the issue of biological tests in the field directly:

Field safety screening should be limited to ruling out explosive devices, radiological materials, corrosive materials, and volatile organic compounds. Currently, there are no definitive field tests for identifying biological agents. Additional field-testing can mislead response efforts by providing incorrect or incomplete results, and destroy limited materials critical for definitive laboratory testing required to facilitate any appropriate public health and law enforcement response (FBI, et al. 2004).

The post-Amerithrax federal guidance, targeted to responders, runs to six pages and incorporates elements of guidance provided by the International Association of Fire Chiefs. It focuses on evaluating threat levels and determining the next level of response, if necessary. On the other end of the spectrum, the Caltech University guidelines date from November 2001 and only occupy a single page. These targeted individual students and employees and their response to any perceived chemical or biological threat. At their most basic, these guidelines tell the reader to “keep calm” and “call security.” In fact, those are steps one and three specifically, step two instructs individuals to “not open the letter or package” (Caltech 2001).

The North Carolina Suspicious Substance Response Guidelines published by the North Carolina Division of Public Health are the most detailed of any examined and the most recent, dated August of 2012. The guidelines target public health, emergency responders, and law enforcement. The guidelines dealing with threat assessment and response are six pages long. They include another ten pages in attachments that detail sampling instructions and forms for submitting samples to state labs for testing. These attachments suggest that the state has prepackaged sample kits available to their responders. The guidelines differ in their guidance on the use of a bioassay device (also called a handheld assay or HHA).

Note: The U.S. Centers for Disease Control and Prevention (CDC) and the N.C. Division of Public Health do not recommend the use of handheld assays (HHAs) for the detection of biological agents. If first responders choose to utilize HHAs, the results they provide should not be used as the only means of determining threat credibility (North Carolina 2012).

The Wisconsin Division of Public Health Guidelines date from March 2011 and incorporate state-level assets into a flow chart diagram, the only one to present the guidelines as a decision matrix instead of pure text. These guidelines are a joint protocol produced by the Division of Public Health, the Wisconsin State Laboratory of Hygiene, FBI, US Postal Inspection Service (USPIS), Capitol Police, Wisconsin Emergency Management, and the 54th Civil Support Team-Weapons of Mass Destruction (CST-WMD) of the Wisconsin National Guard. This protocol adopts a different standard for biological agent screening, noting the capabilities of certain response agencies.

NO biologic field testing will be done UNLESS performed by the USPIS inspector, CST, or with an FBI agent present (Wisconsin 2011).

The oldest guidelines found in searching public websites were those of the Oregon Department of Administrative Services. These dated October 15, 2001, the height of the anthrax attacks. Their preface notes they are not mandatory and are for managing internal mail processes. They are the only guidelines that include instructions for employees to bag or cover suspicious mail or packages in plastic, something not recommended in later guidance since such action could disturb and distribute spores (Oregon 2001).

As can be seen from this brief examination, protocols vary widely and are often suggestions only for their intended audience, not requirements. Federal guidelines appear incorporated into post-attack guidance, but in different ways depending on the jurisdiction. Those examined for this article are also primarily state-level guidelines that suggest a similar variation and differentiation between state and local guidelines.

Worried Well and the Panic Issue

Panic in a disaster is rare, a finding supported by research. The founder of modern disaster studies, Quarantelli, even suggested in 2002, “…the concept of panic within collective behavior in sociology may disappear as a technical term in the future” (Clarke and Chess 2008). Recent research suggests that while panic may be rare, it can still drive decision-making and relationships in disaster response and planning. There is also research examining the idea that while the “public” may not panic in a mass sense, individuals do, and some of those individuals are in leadership positions. Clarke and Chess explore the research and definitions in detail, but for this examination, several of their observations are important, specifically as it relates to “elites.” Clarke and Chess adopt an alternate definition of panic from Quarantelli that is more inclusive to include the idea of moral panic. They also note that while few individuals in the public panic, decision makers can and do. Clarke and Chess call these decision makers “elites.” They observe, “Elites sometimes fear panic, elites can cause panic, and elites can themselves panic.” They examine the fear of panic in the context of the Three Mile Island disaster. The examination of elites panicking themselves makes use of several individual leader reactions during Hurricane Katrina. Essential for this discussion is their examination of “elites can cause panic” in relation to the 2001 anthrax attacks [and the pandemic response of 2020!]

Here, Clarke and Chess argue many of the manifestations of worried well discussed that produced the responses that overwhelmed many emergency services, were produced by elite communication problems. This observation clearly links to the previously discussed communications research, but they make several observations not noted elsewhere. There is debate about the public response to the anthrax attacks, and whether it was panic in the traditional sense. Clarke and Chess state only that the hoarding of Cipro and other actions, like the numerous calls to emergency services and other examples, showed that instead of forming an altruistic community in response to a disaster (the usual response) people were distancing themselves in a self-protective mode. They note the public pleas for individuals not to hoard Cipro, which other studies suggest elements of the public ignored. These, and other examples, they claim, might lead to a reasonable conclusion “that people were panicking over the possibility of exposure to B. anthracis [anthrax]” (Clark and Chess 2008). They blame this panic on communications from the “elite.”  Clark and Chess also make a note of a different and more severe example. In 1894, a smallpox outbreak in Milwaukee led to an extended period of rioting in some places. Immigrant residents refused vaccination, which led to authorities responding with force. In that historical event, the residents were more afraid of the vaccine than the disease, and the authorities/elites were more afraid of the residents.

While there can be some room for argument over whether to term the behavior of individuals during the Amerithrax attacks as panic, many actions by elites, responders, and the public were, at the minimum, over-reactions to the situation. Social science calls this “disproportionate concern.” Fear drove public reactions and did lead to breakdowns in social bonds, in some cases. The research seems to agree universally that the actions and communications from leadership were a contributing factor to those breakdowns. Whether that rises to the level of panic or not is more a matter of defining the term than assessing the facts. People were worried, and that worry led them to seek remedy via both the medical community and emergency services, depending on how they perceived the threat.

Conclusion

Since 2001, there has been no attempt in disaster research to evaluate the 2001 anthrax attacks and their effects on emergency services fully. The only extant work that attempts to capture the broad range of responses to the attacks is a deeply personalized account by the Pulitzer winning journalist Laurie Garrett. Her day-by-day account, I Heard the Sirens Scream is the only semi-complete account, and that looked at the response in the broadest possible sense with a focus on Garrett’s deeply personal narrative, which she has since turned into a niche to market herself as a quasi expert on biological threats. Her account, while covering much ground, mixes personal events and observations from the time with official actions and incidents in emotive prose. It is not an academic study. Nor, does one exist.

This broad outline examined the current research about the anthrax attacks. It is possible to draw several conclusions from this research. Specifically:

• Communication failures on the part of key leaders during the anthrax attacks contributed to public fear.

• This fear manifested itself in two ways:

  • The hoarding and use of antibiotics by people who did not need them

  • A spike in calls to emergency services regarding suspicious mail and powders, which were mostly low risk/low threat inquiries from worried citizens.

• Additionally, and concurrent with the attack, hoaxes emerged that fueled public fears.

• These fears died down over time as the real attack ended, but hoaxes continued.

•  In some jurisdictions, ad hoc procedures and guidelines published amidst the attacks were never revisited or updated in the two decades that followed.

• Guidelines and procedures for dealing with suspicious mail, packages, or substances continue to vary widely by jurisdiction

The research also suggests the following recommendations:

• Jurisdictions should revisit and update their guidelines and procedures if they have not done so since 2001, and those procedures should be in accordance with federal guidelines.

• The flowchart model of the Wisconsin Division of Health is a “best practice” and is the easiest and quickest to comprehend and understand, of guidance examined during this research project.

• Planning for bioterrorism and dispersed threats must account for manifestations of public fear and address them through communication strategies that incorporate lessons learned from 2001.

• Fear driven reactions by worried well eventually subside and are short term, but expensive issues, if the threat decrease or the government improves its risk communication allowing the public to put more proper bounds on the scope of the threat.

The general lack of disaster research on the issue of the worried well and the anthrax attacks, suggests this is an area ripe for additional research. The worried well phenomenon is not new in CBRN events. Research suggests that the inordinate focus on questions of “panic” and definitions of the term in most research studies examining the issue fail to capture the nuance and particularity of this problem. Fear drives actions by the public during CBRN events, and those actions can quickly overwhelm emergency services and medical systems. What the anthrax attacks provide is a unique opportunity to explore the differentiation in response. Previous events with significant manifestations of worried well were chemical and radiological. The anthrax attacks provided an opportunity to compare the response and the problem of the worried well between a chemical, radiological, and biological attack. They also suggest that biological attacks (and pandemic response) might work differently from chemical and radiological events in their broader effects.

Related to these differences, and a contributing factor unexplored in the research was the lag between incidence and detection. Multiple individuals sought medical attention for anthrax exposure before Robert Stevens’ death. This went undetected. It represents a serious failure of the CDC surveillance system (Bush and Perez 2011). It also suggests that individuals on the front line of medicine remain critical to detecting biothreats. As Dr. Bush, the clinician at JFK hospital who first diagnosed anthrax noted later, had he not taken the time and possessed the knowledge he did, it might have been longer before anyone noticed the nation was under attack (Bush and Perez 2011). This detection lag time remains unexplored in the literature examined for this study. Further, the public health response to the threat in the early days also contributed to the public’s reaction, well beyond the problems with communication strategies. That suggests that the ability to conduct early detection feeds directly into the public response to any risk communication regarding the threat.

Finally, the context of the anthrax attacks is an important consideration. The events of 9-11 happened right before the anthrax attacks. That certainly elevated the level of fear and apprehension in the American public, but also the world’s population. Likewise, the numerous problems of the Amerithrax investigation played a role.[4] Yet these factors may only have enhanced already inherent effects. The worried well issues presented by the anthrax attacks were more complex than those observed in other events. They deserve further study.

Works Cited

Barnhardt, Laurie. 2001. “Responding to worried residents,” Baltimore Sun, October 19, http://articles.baltimoresun.com/2001-10-19/news/0110190287_1_suspicious-packages-anthrax-powder (October 31, 2013).

Bhattacharjee, Yudhijit. 2012. “The Curse of the White Powder: How fake bioterrorism attacks became a real problem,” Slate.com, January 30, http://www.slate.com/articles/health_and_science/science/2012/01/white_powder_hoaxes_a_trend_in_fake_terrorism_.html (December 6, 2013).

Bush, Larry M. and Maria T. Perez. 2012. “The Anthrax Attacks 10 Years Later,” Annals of Internal Medicine 156:41-44.

CalTech University. 2001. “How to Handle Suspicious Packages, Letters or Substances and Other Biological or Chemical Threats,” November 11. https://safety.caltech.edu/documents/86-suspicious_packages.pdf (October 31, 2013).

Clarke, Christopher and Caron Chess. 2006. “False Alarms, Real Challenges – One University’s Communication Response to the 2001 Anthrax Crisis,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 4 (1): 74-83.

Clarke, Lee and Caron Chess. 2008. “Elites and Panic: More to Fear than Fear Itself,” Social Forces 87 (December): 993-1014.

Clarke, Lee, Caron Chess, Rachel Holmes, and Karen M. O’Neill. 2006. “Speaking with One Voice: Risk Communication Lessons from the U.S. Anthrax Attacks,” Journal of Contingencies and Crisis Management 14 (3): 160-169.

Dillon, Sam. 2001. “In Houston, Much Ado About Powder,” The New York Times, October 17, http://www.nytimes.com/2001/10/18/us/in-houston-much-ado-about-powder.html (November 12, 2013).

Federal Bureau of Investigation, Department of Homeland Security, Health and Human Services, and the Centers for Disease Control. 2004. “Guidance on Initial Responses to a Suspicious Letter / Container With a Potential Biological Threat.” November 2. http://emergency.cdc.gov/planning/pdf/suspicious-package-biothreat.pdf (October 31, 2013).

Freimuth, Vicki S. 2006. “Order out of Chaos: The Self-Organization of Communication Following the Anthrax Attacks,” Health Communication, 20 (2): 141-148.

Garrett, Laurie. 2011. I Heard the Sirens Scream: How Americans Responded to the 9/11 and Anthrax Attacks. Seattle: Amazon Digital Services.

____. 2011. “Ten Years Ago Today the Anthrax Nightmare Unfolded, and Globalized,” Council on Foreign Relations, October 5, http://www.cfr.orfg/publi-health-threats-andpandemics-ten-years-ago-today-anthrax-nightmare-unfolded-globalized/p26111 (December 4, 2013).

Gursky, Elin, Thomas V. Infglesby, and Tara O’Toole. 2003. “Anthrax 2001: Observations on the Medical and Public Health Response,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 1 (2): 97-110

M’ikantha, Nkuchia M., Kathleen G. Julian, Allen R. Kunselman, Robert C. Aber, James T. Rankin, and Ebbing Lautenbach. 2005. “Patients’ request for and emergency physicians’ prescription of antimicrobial prophylaxis for anthrax during the 2001 bioterrorism-related outbreak,” BMC Public Health, January 5, http://www.biomedcentral.com/1471-2458/5/2 (November 22, 2013).

North Carolina Division of Public Health, Public Health Preparedness & Response Branch. 2012. “North Carolina Suspicious Substance Response Guidelines (SSRG) For Public Health, Emergency Responders and Law Enforcement.” August. http://epi.publichealth.nc.gov/phpr/docs/protocolguideandattach.pdf (October 31, 2013).

Oregon Department of Administrative Services. 2001. “GUIDELINES: Strange / Suspicious Mail or Parcels,” October 15. http://www.oregon.gov/DAS/docs/guidelines-procedures.pdf (October 31, 2013).

Oreskovic, Jessica Branson. 2001. “White powder in my morning paper,” Salon.com, October 18, http://salon.com/2001/10/18/white_powder/print (December 2, 2013).

Ottawa Sun. 2005. “Hazardous Materials Team,” Ottawa Sun Online, September 16.

Robinson, Susan J. and Wendy C. Newstetter. 2003. “Uncertain Science and Certain Deadlines: CDC Response to the Media During the Anthrax Attacks of 2001,” Journal of Health Communications 8: 17-34.

Rubin, James G. and Petra Dickmann. 2010. “How to Reduce the Impact of ‘Low-Risk Patients’ Following a Bioterrorist Incident: Lessons From SARS, Anthrax, and Pneumonic Plague,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 8 (1): 37-43.

Rubin, James G., Alexander K. Chowdhury, and Richard Amlot. 2012. “How to Communicate with the Public About Chemical, Biological, Radiological, or Nuclear Terrorism: A Systematic Review of the Literature,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 10 (4):383-395.

SteelFisher, Gillian K., Robert J. Blendon, Amanda S. Brule, Eran N. Ben-Porath, Laura J. Ross, and Bret M. Atkins. 2012. “Public Response to an Anthrax Attack: A Multiethnic Perspective,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 10 (4): 401- 411.

Stone, Fred P. 2007. “The ‘Worried Well’ Response to CBRN Events: Analysis and Solutions” The Counterproliferation Papers, Future Warfare Series No. 40. Maxwell AFB: USAF Counterproliferation Center, Air University.

Waite, Matthew. 2002. “Powder hoaxes sap county’s resources,” St. Petersburg Times, January 19, http://www.sptimes.com/2002/1/19/news_pf/Pasco/Powder_hoaxes_sap_cou.shtml (October 31, 2013).

Winett, Liana Blas and Regina G. Lawrence. 2005. “The Rest of the Story: Public Health, the News, and the 2001 Anthrax Attacks,” The Harvard International Journal of Press/Politics 10 (3): 3-25.

Wisconsin Division of Public Health. 2011. “Unknown Substance/Package/Letter Protocol” March 2. http://www.dhs.wisconsin.gov/preparedness/pdfs/ wiprotocol.pdf (October 31, 2013).

NOTES:

[1] This was the ratio observed in the Tokyo Aum Shinrikyo Sarin attacks in 1995. 

[2] The author participated in the anthrax response in Texas and worked with numerous jurisdictions in October and November 2001 dealing with white powder scares. The title of this paper “White Powder Rodeo,” comes from the nickname given the events by members of the author’s team.

[3] The author of this article, a state level CBRN responder with the 6th CST-WMD during the Amerithrax attacks, received this information from a local jurisdiction during the attack while advising jurisdictions on their response.

[4] The FBI paid a multi-million-dollar settlement to Dr. Steven Hatfill, a scientist the FBI publicly and falsely accused of the attacks (similar to the settlement paid to Richard Jewel for similar false accusations in the 1996 Olympic bombing). The Amerithrax investigation never charged anyone with the attacks. In 2006, following a change of leadership, the investigation shifted its focus to Dr. Bruce Ivins, a researcher at Fort Detrick’s U.S. Army Medical Research Institute of Infectious Diseases (USAMRID). Ivins had been part of the investigation from the beginning and conducted tests on some of the samples gathered in the attacks. As investigators began to close in on Ivins in 2008, Ivins committed suicide. In 2010, nine years after it began, the Department of Justice closed the case, controversially declaring Ivins the sole perpetrator.