The School has been designated by the Centers for Disease Control and Prevention (CDC) as a National Center for Public Health Preparedness, charged with providing bioterrorism defense training to public health practitioners at many levels, including students, public health workers, local and state health officers and staff, and health care providers. The preparedness effort, led by principal investigator Deborah Prothrow-Stith and Leonard Marcus of the School's Division of Public Health Practice, is based on a successful campaign to train public health workers in violence prevention. Indeed, many across the School felt an immediate impulse to lend their skills to national defense after Sept. 11 but in fact much of their work was already relevant to the cause in a number of discrete areas.
After initially diving into student psychological needs and disaster response at the University level, where she chairs the Harvard University Student Health Consulting Board, Leaning found herself in January on a mission to Afghanistan with Physicians for Human Rights inspecting Afghan prisons where Taliban fighters were held. The group documented appalling health conditions and returned to the US to brief Washington officials and the press on the situation.
Returning to the School, she quickly pulled together a short course on bioterrorism for the "C period" in February, co-taught with Jonathan Burstein, an emergency department physician and assistant professor at Harvard Medical School, who is also director of disaster medicine at Beth Israel Deaconess Medical Center. Faculty colleagues jumped to participate, including Andrew Spielman, Richard Pollack, Sam Telford, Thomas Bossert, Donald Milton, and Jack Spengler, as well as Anita Barry, director of communicable disease control in the Boston Public Health Service, and Richard Platt, professor of ambulatory care and prevention at Harvard Medical School. In addition to topics such as disaster planning, Leaning and her students examined the psychological and legal dimensions of terrorist attacks such as "problems of warning" and "deploying public health in a more muscular legal mode to protect health--ordering populations to evacuate or into quarantine," she says. Leaning explains that an early warning of a bioterrorism incident would be of little use if populations haven't been adequately prepared to understand and accept relocation.
The talk included a description of the concept of "mental modeling," a scientific approach developed at Carnegie Mellon University to identify which risk communication messages will work best. The lecture also described the literature on risk perception, research that has identified the psychological roots of how people subconsciously "decide" what to be afraid of and how afraid to be. "Understanding why people are afraid allows the communicator to respect those fears and speak in terms that are relevant to the audience, increasing the likelihood that the message will be received, not rejected," notes Ropeik.
"The Risk Communication Challenge is particularly relevant and useful to the nation at this point in time," says the Center's Acting Director George Gray. "We wanted to help and thought that this outreach might be valuable. We were honored to have a chance to make a contribution."
In a late spring poll, Blendon probed the public's knowledge of smallpox and feelings about preventive vaccination. Funded by the Robert Wood Johnson Foundation, the survey found that, as federal government advisory committees debated the need for voluntary smallpox vaccination, three in five Americans said they would get vaccinated even though no smallpox cases had been reported. More than three-fourths said they would get vaccinated if cases of smallpox were reported in their own community.
The recent epidemic of foot and mouth disease among livestock in England demonstrated the crucial role of transit, notes Spielman. "If they had stopped movement of potentially affected animals early enough, there would have been a substantial savings. Human movement is how any release will find its way into the more general population." Nearly four million animals in the UK were destroyed as a result of the epidemic at the cost of anywhere from £800 million to £2.4 billion to the farming industry alone. It is estimated that the number of cases could have been halved if a ban on livestock movements had been introduced just days earlier.
Volpe Center researchers heard from School faculty about four threat types: airborne non-communicable threats such as anthrax, tularemia, and viral hemorrhagic fevers; airborne communicable threats such as smallpox, plague, and bioengineered influenza; vector-borne threats (i.e., by mosquitoes and rodents) such as encephalitis viruses, typhus, and yellow fever; and agro-terrorism such as foot and mouth disease, anthrax, and potato blight. School researchers have had recent, local experience investigating eastern equine encephalitis outbreaks in western Massachusetts and tularemia among gardeners on Martha's Vineyard, which was eventually traced to rabbits there.
Milton and colleagues are modeling modes of transmission--considering different space and time factors--for biological agents. Wind patterns in cities, for example, would make it difficult for a bio- logical agent to be effective in an open-air release. But closed spaces in buildings and transport systems can be exploited. Fortunately, the Department of Environmental Health was already deeply committed to the study of indoor air quality, detection devices for contaminants, novel "air hygiene" techniques, and creating more effective ventilation systems--in response to the growing asthma epidemic in this country. Asthma will remain the main target of researchers such as Milton, even while they study transmission models for bioterrorism.
Another part of the Volpe Center assignment challenges researchers at the School to imagine the most dire scenarios of how a lethal attack might unfold. "They're looking to us as out-of-the-box thinkers," says Leaning, a member of the delegation that briefed the center. "We have to run public health in reverse--going from what could be the worst ways of affecting populations through perturbations and perverse distortions of the transportation system. They rely on our expertise of what 'awful' is, and then we go upstream to say how could you create it in the smartest way."
the power of numbers
This work represents an important advance in using clinical information in real time, establishing new statistical methods to understand this information, and creating links between hospitals and public health authorities--a welcome change. Surveillance systems for public health have never received much financial support but may have more cachet in the post-Sept. 11 era, Pagano observes. "Surveillance is sort of like insurance," he says. "You don't realize how valuable it is until you have the misfortune of having to use it. Look at places that don't have surveillance--you have horrible outbreaks, and you have no idea what's happening."
Students are also anxious about relocating after graduation into areas of the US, "where there may not be that much reception to people from Asia or the Middle East," Leaning says. "There is a vast swath of the world from where we have students and colleagues coming that is currently under very heavy and, I think, uneducated scrutiny in this country, and we as an educational institution are going to have to pay attention to this." On May 7, 2002, the Bush administration unveiled new regulations requiring screening by a special panel of intelligence and law enforcement representatives of visa applications from foreign students who want to do advanced work in sensitive subjects and technologies taught only at American universities or laboratories.
Yet, typically, HSPH students have responded constructively to a post-Sept. 11 world. They quickly organized fundraising efforts to aid survivors and families of victims. They have also launched research efforts around the attacks. Ashok Nimgade, a student in occupational health, worked with the National Institute for Occupational Safety and Health on a study evaluating physical and mental health problems of office workers near "ground zero" of the World Trade Center attacks. And K.A. Kelly McQueen has become one of the first two recipients of a new Nuclear Threat Initiative/AAAS fellowship in global security. She will spend the next year in Washington, D.C., where she intends to investigate how factors such as poverty, disease, and oppression might contribute to terrorism.
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