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Harvard Public Health Review/Summer 2002

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Since September 11

The Harvard school of Public Health, where the scourges of malaria, tuberculosis, and AIDS still draw the intense efforts of its dedicated researchers, has shouldered a new responsibility in the wake of Sept. 11: helping to protect the public from the threat of humanitarian disaster arising from terrorist activity. "We have to act on the understanding that public health is a critical element of public safety and now an important pillar of national security," said Margaret Hamburg, vice president for biological programs at the Nuclear Threat Initiative, an organization working against the spread of weapons of mass destruction. She spoke during a special Dean's Seminar on the public health response to bioterrorism held at the School in October (archived at www.hsph.harvard.edu/bioterrorism/ symposium).

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.

Managing Disasters

Jennifer Leaning, professor of international health and director of the Program on Humanitarian Crises and Human Rights at the François-Xavier Bagnoud Center for Health and Human Rights, is a longtime expert in humanitarian disasters stemming from civil unrest in places ranging from Kosovo to Afghanistan. She has since felt her academic life shifted by the events at home.

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.

Communicating Risk

Invited by the us office of Homeland Security, the School's Center for Risk Analysis addressed the issue of public fears and lectured senior communications officials from a wide range of federal agencies on risk communication in the fight against terrorism. "When people are afraid, they often make choices that can make them feel safer, but which actually raise their risk, like driving instead of flying, or buying guns," says David Ropeik, one of the co-directors of the School's Risk Communication Challenge Continuing Education course, who delivered the lecture in Washington, D.C. "Helping people keep their fear in perspective through effective risk communication should be a vital part of any campaign to protect public health."

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."

Polling Public Fears

Following the recent anthrax incidents, Robert Blendon, professor of health policy and political analysis, and his colleagues embarked on a polling project of value to government officials and particularly the CDC, which asked the American public how the terrorist attacks had changed attitudes and habits. The poll, funded by a grant from the Robert Wood Johnson Foundation, found that Americans were not panicking about anthrax "but most are starting to take some sensible precautions," Blendon reported. "Many are being more careful with their mail and maintaining emergency supplies of food, water, or clothing, an action people often take to prepare for possible emergencies."
More dramatically, the poll found that, for a majority of the public, no national figure emerged as a source of reliable information during a national outbreak of disease caused by bioterrorism. Americans indicated they were more likely to trust public health officials and physicians than appointees who do not have such backgrounds.

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.

Advising the Government

Andrew Spielman, Donald Milton, Jack Spengler, and other environmental and infectious disease experts have briefed staff at the US Depart-ment of Transportation's (DOT) John A. Volpe Center in Cambridge, Mass., lecturing on biological issues that could help strengthen the center's thinking about bioterrorism. The Volpe Center performs transportation and logistics research for the federal government with an emphasis on devising safer and more efficient systems from the airport to the highway. DOT staff, explains Spielman, "will be the point people when something happens. As soon as a discovery is made that there is an infectious agent, they will have to shut down the transportation system or limit it to a degree."

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."

Harnessing the power of numbers

Statistics can serve as a powerful tool in terrorism surveillance. Marcello Pagano, professor of statistical computing in the Department of Biostatistics, is working with Kenneth Mandl, research director of the Division of Emergency Medicine at Children's Hospital Boston, to develop methods for quickly detecting clusters of disease in order to identify outbreaks. Using these methods, Mandl has established a surveillance system, currently in use at two Boston hospitals, which automatically collects and analyzes emergency department data. Such a system could have been useful last fall, when people exposed to anthrax showed flu-like symptoms, masking the nature of the attack.

In the surveillance system, visits to emergency departments serve as detection sentinels for emerging health threats. The system does not follow patients individually but instead tracks the number of visits and symptoms, which are then compared to eight years of historical data on expected admissions for that time of year and day of the week. The system also includes information about patient location and, using methods derived from Pagano's statistical work on spatial clustering, can detect groups of patients from localized geographic regions with similar syndromes. Mandl, working with the Massa-chusetts Department of Public Health, hopes eventually to integrate detailed, automated data from 11 different hospitals in the region. Data from children's admissions may be especially timely because parents are generally quicker to bring children in for treatment than deal with their own health problems.

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."

Testing readiness

The school is also pursuing a collaboration with Lincoln Laboratory at MIT to create a project that will evaluate the preparedness for a biological attack of a major metropolitan area like Boston and identify strategies to improve protection. In the past, Kimberly Thompson, assistant professor of risk analysis and decision science, and Harriet Burge, associate professor of environmental microbiology, have worked with Lincoln Lab researchers on microbial risks. They now hope to bring together faculty to leverage the School's depth and breadth in the public health arena to help bridge the divide between the military and public health aspects of biodefense. Thompson emphasizes that "risk analysis plays a critical role in helping us create and implement a health surveillance and biodefense system that will serve the dual functions of protecting us from biological attacks and from the large toll of infectious disease." Burge, who serves on two National Academy of Sciences committees related to biodefense, will work with Thompson on developing a matrix to help frame the decisions that must be made rapidly by civil defense and health authorities in the event of an attack.

Affecting students

The post-Sept. 11 US is presenting new hurdles for some students at the School, according to Leaning. "I have students who are trying to find jobs," she says, "and they're suddenly encountering enormous visa hurdles and difficulties finding employment in American academic and engineering circles. It's much harder for anyone from Asia--defined broadly from, say, the Philippines to the Middle East. This is all anecdotal but of sufficient volume to make me concerned about civil liberties issues and immigration law."

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.

Changing attitudes

in a school of highly individualized departments, there seems to be after Sept. 11, "a greater willingness to collaborate," notes Leaning. "My course on bioterrorism came together fast. People are more generous about their time. You see it in the halls, a greater readiness to talk about the general good, and the overall social and political dilemmas we face, than in years past. People are more willing to share what their personal feelings are around major world trends. In that regard it's been positive. My sense is, this is what happens when a country is gravely at risk, which I think we still are."

Robin Herman

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