THE WORRIED WELL: STRATEGIES FOR 

INSTALLATION COMMANDERS 

Fran Pilch 

INTRODUCTION 

How do you use mitigation strategies, including education of 

personnel, to decrease the number of the worried-well? What are 

the best media/public affairs strategies or responses to a BW 

incident? (INSS Abstract) 

The question concerning the most effective strategies that 

should be employed by base commanders to mitigate problems 

involving the worried well in the event of a biological weapons 

attack is important and critical. The anthrax crisis, following on the 

heels of the devastating terrorist attacks of September 11, 2001, 

drew attention to the very real possibility of the use of biological 

weapons by terrorist or criminal elements seeking to disrupt society. 

The discovery of attempts to produce lethal amounts of ricin in 

London in 2002 added to these fears. The fact that not all of the 

biological agents developed in the former Soviet Union are 

accounted for also presents great cause for concern; added to this 

concern is the fear that scientists who once worked in the Soviet 

biological weapons program may be vulnerable to exploitation and 

co-option. Considering the very weak inspection framework of the 

Biological Weapons Convention, it is difficult, if not impossible, to 

determine the extent to which additional states are pursuing active 

biological weapons development.1

Given the very real possibility of a biological weapons (BW) 

incident in the future, it is prudent for base commanders to consider 

appropriate responses to this threat. The problem of the “worried 
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2

well” has been increasingly recognized by all levels of government, 

scholars, and specific emergency response teams. In a crisis 

situation involving intentional disease outbreaks, any contingency 

plan has to consider the effect on resources of those who think they 

are sick, but who realistically are not medically at risk for a specific 

disease. In addition, there are huge mental health components to 

any terrorism event that must be understood and appreciated, 

including post-traumatic stress disorder, somatic presentations of 

psychological distress, and intensification of formerly identified 

medical and psychological ailments. 

Questions concerning appropriate responses to the problem of 

the worried well have been addressed in this research project 

through multiple approaches: reports summarizing BW simulations 

and exercises have been examined and scholarship on the worried 

well has been consulted. However, it became apparent that the 

problem of the worried well, as it affects strategies of base 

commanders, could not be looked at in isolation. Issues involving 

quarantines, media relations, surge capacities of hospitals and 

emergency facilities are closely connected to the problem of the 

worried well. Any strategy being developed by a base commander 

has to include thinking about a broad range of issues. Above all, no 

military installation can operate in complete isolation from the 

community that surrounds it; most are deeply connected and 

interrelated with local communities. 

The larger question for the base commander concerns his need 

to keep the base operational so that it can fulfill its mission in times 

of crisis. An additional and critical concern for the base 

commander concerns the short- and long-term physical and mental 

health of his personnel and their dependents. These questions 
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3

cannot be addressed in isolation from the community in which the 

base is located. Therefore, any strategy to plan for a BW crisis must 

include familiarity and planned interaction with the community 

surrounding the military installation. Additionally, any strategy 

concerning appropriate responses to a BW incident must also 

address the problem of the worried well. 

After an initial evaluation of the mental health components of 

terrorism, particularly the use of BW, through a survey of reports, 

journals, symposia, and other literature, the author conducted 

interviews with numerous “stakeholders” in the city of Colorado 

Springs, including local and county officials, members of 

emergency response units, physicians’ groups, and experts on 

mental health. The objective of these interviews was to obtain one 

snapshot of perceptions on local relationships with the military 

installations in the area. Although El Paso County may not be 

entirely representative of communities in which other bases are 

situated, it does represent an area where four military installations 

are located (US Air Force Academy, Peterson Air Force Base, Fort 

Carson, and Schriever Air Force Base). Important insights into the 

interrelationships between military bases and local communities 

were gained; specific concerns of actors within the community were 

highlighted that are undoubtedly appropriate beyond this specific 

geographic area. 

Each section of this report is organized as follows: under the 

general heading of an important facet or concern involving a 

potential BW event, expertise is reviewed to explain the concept or 

to elucidate elements of the concept that might not be readily 

understood. Insights from the local interviews are then shared, 

when relevant to the general concept or issue under discussion. 
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4

Finally, based upon all pertinent information, including interview 

material, recommendations to installation commanders are 

highlighted in bold type. 

THE BIOLOGICAL WEAPONS THREAT 

The three basic groups of biological agents which are most 

likely to be used as biological weapons are bacteria, viruses, and 

toxins. Each one of these groups has different implications for 

disease, lethality, and treatment. Bacteria often produce diseases 

that respond to treatment with antibiotics. Viruses require living 

cells in which to reproduce, and they produce diseases that do not 

respond to antibiotics. However, antiviral drugs are sometimes 

effective. Toxins are poisonous substances found in and extracted 

from living organisms (plants, animals, or microorganisms). Some 

toxins can be treated with specific antitoxins and others can be 

treated with specific drugs. 

The CDC has developed a list of potential biological agents, 

and divided them into categories. Category A agents can be easily 

disseminated or transmitted person-to-person, can cause high 

mortality, might cause panic and social disruption, and require 

special action for health preparedness. Category A agents include 

smallpox, anthrax, plague, botulism, tularemia, filoviruses such as 

Ebola Hemorrhagic Fever, and arenaviruses such as Lassa Fever. 

The second highest priority agents, according to the CDC, are 

moderately easy to disseminate, cause moderate morbidity and low 

mortality, and require specific enhancements of CDC’s diagnostic 

capacity and enhanced disease surveillance. They include Q fever, 

brucellosis, glanders, and ricin. A subset of List B agents includes 

salmonella. Category C agents include emerging pathogens that 

could be engineered in the future and include Hantaviruses, tick-
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borne viruses, and multi-drug-resistant tuberculosis. List C agents 

require ongoing research to improve detection, diagnosis, treatment, 

and prevention.2

Some experts believe that the major biological threats are 

anthrax, ricin, or contamination of food/water. In these cases, 

person-to-person transmission is not a concern (they are noncontagious). However, in the case of anthrax, persistent 

contamination is a problem. So although quarantine is not 

necessary, people must be prevented from entering an area that is 

potentially contaminated. The above threats are considered to be 

high-probability, low consequence agents. Smallpox and plague are 

identified as the most likely agents that cause contagious diseases, 

and could potentially precipitate an “epidemic.” If these agents 

were used, infection control would become a paramount issue. The 

deliberate reintroduction of smallpox is particularly frightening. In 

a society that has not been immunized, each person infected with 

smallpox could conceivably infect between 10 and 20 others. With 

a transmission rate of 20, the first 50 victims of a disease could 

hypothetically infect 1000 others, who could infect 20,000 more. 

Within a very short period of time, over 160 million persons could 

become involved.3

 Timely interventions, however, can reduce these 

numbers dramatically. 

Biological agents could be dispersed in various ways. It would 

be possible, though technically difficult, for an agent to be dispersed 

into the air as an aerosol, forming a mist or cloud that could 

potentially travel for miles. Inhaling this might cause disease in 

animals or humans. Others are spread by insects and animals, such 

as fleas and mosquitoes. Spreading disease through livestock is 

referred to as agroterrorism. Food and water present fairly 
Pilch—The Worried Well 

6

accessible targets, and could be contaminated with biological 

agents. 

In the case of the anthrax crisis of 2001, anthrax spores 

formulated as white powder were mailed to individuals in the 

government and media. Postal sorting machines and opening of 

letters facilitated the dispersal of the spores, which resulted in 

several deaths and widespread fear of contamination of postal 

facilities and government offices. Finally, some infectious agents 

are spread through person-to-person contact. Smallpox, plague, and 

the Lassa viruses fall into this category. 

Dr. Raymond Zilinskas, of the Center for Non-Proliferation 

Studies at the Monterey Institute, has noted that “it is highly 

probable that biological attacks by terrorists or criminals utilizing 

food borne and water borne pathogens or toxic chemicals will occur 

in the next five years.”4

 He notes that these attacks are likely to 

cause casualties ranging in number from a few to hundreds, and 

gives as an example past attacks, including the contamination of 10 

salad bars by the Rajneeshee cult in Oregon in 1984, causing illness 

to 751 people.5

 He believes that the probability of airborne attacks 

with pathogens in the next five years is low, due to technical 

difficulties of effective aerosol dispersal. He notes, however, that 

biological and toxin weapons are likely to become more attractive 

to criminals and terrorists in the future, because the number of 

persons possessing expertise in microbiology and the biosciences 

will increase, and some might be willing to sell or apply their 

expertise for anti-societal purposes. The lack of sophistication 

necessary to develop and deliver certain pathogens and toxins and 

the ability to hide them also makes the possibility of the use of these 

agents more likely.6
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The very nature of biological weapons has implications for 

public reaction to a terrorist event in which they are employed, for 

“(t)he invisibility of biological agents and the insidious nature of 

bioterrorist events makes them especially frightening.”7

 

Additionally, a BW event may not be readily detected and is 

unlikely to be viewed as finite in time and space. These 

characteristics suggest that a crisis involving BW has enormous 

potential for producing extreme stress and anxiety in the public. 

Insights from Interviews 

According to psychologist Dr. Charles Benight, from a stress 

perspective, a BW attack presents three huge problems—it is 

viewed as unpredictable, ambiguous, and uncontrollable. To reduce 

the stress of such an event, therefore, you need to address all three 

of those elements. To address unpredictability, you can engage the 

public in planning and preparedness. To address ambiguity, you 

need rapid and effective detection systems and clear algorithms for 

clinical responses, with clear risk communication to the public. To 

address uncontrollability, you need to put into place medically 

sound plans to limit the risk to the public and control an outbreak. 

He notes that once a crisis occurs, a person’s thought process 

becomes narrowly focused, and rationality may be impaired. 

Therefore, the earlier that information can reach the public in a 

crisis, the better, from the standpoint of stress management.8

THE WORRIED WELL 

Experts have long recognized the gravity of problems 

associated with the “worried well.” Although we have few 

instances of intentional use of BW from which to increase our 

understanding of the worried well phenomenon, we can look at the 
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impact of other terrorist events, natural disease outbreaks, and 

virtual simulations to give us insights. 

In 1995, the Japanese cult, Aum Shinrikyo, released sarin gas 

into the Tokyo subway system. This catastrophe led to 12 deaths; 

5,500 presented at Tokyo hospitals. Of these, about 1,000 were 

casualties related to the attack.9

 Unexposed persons flooded 

emergency rooms in Tokyo after the attack; the number of those 

presenting to health professionals with complaints of post-exposure 

symptoms exceeded the number who required medical treatment 

caused by exposure by a ratio of 4:1.10

The “worried well” can be divided into three major categories. 

The first are those who experience symptoms of the disease in 

question, or generalized symptoms, but who do not have the 

disease. These individuals may not have been exposed in any real 

way, and yet they are genuinely convinced that they are ill. This 

group would include those who experience physiological symptoms 

as a consequence of heightened fear, alertness, or feelings of 

helplessness. The second group consists of those who are anxious 

about potentially being or becoming infected, but are not 

experiencing physical symptoms. In these cases, there may or may 

not be a rational basis for their anxiety. These may seek health care 

partly as a preventive measure or due to their uncertainty as to risk. 

The third category consists of those who experience psychological 

distress during or after a traumatic event, such as chronic anxiety, 

depression, fatigue, and despair. These categories may overlap, but 

all represent unique problems that must be addressed in planning 

undertaken by disaster response teams and health facilities. 

The idea of mass psychogenic illness has been noted for 

hundreds of years. Outbreaks of this nature often start with an 
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environmental “trigger,” which can be a “bad smell, a suspiciouslooking substance or something else that makes people in a group 

believe they have been exposed to a germ or a poison.”11 In mass 

psychogenic illness, people feel sick, but physical exams show 

normal results, and experts cannot detect a rational cause of the 

sickness (for example, a poison). Yet people who are involved in 

outbreaks of this kind have real, and not imagined, symptoms. 

They may feel dizzy or experience headaches, but these may have 

been induced by stress or anxiety. 

Reports on the psychological consequences of the terrorist 

attacks on 9/11 are still emerging. They all point to the huge mental 

and emotional health component of a disaster such as 9/11. 

Physiological manifestations of psychological distress are common, 

often stemming from “living with a heightened state of alertness 

and harboring a fear of the unknown....”12 It is estimated that about 

half of individuals will cope well with even extreme trauma and 

threat; these hardy persons will “roll with the punches.” Another 

30% are likely to feel somewhat anxious or depressed for a period 

of time, but will return to normal levels of psychological health. 

However, “about 18% are vulnerable to persistently engaging in 

behaviors most Americans only briefly if ever considered or 

engaged in post-September 11; avoiding airplanes and other public 

transportation; steering clear of tall buildings, national landmarks, 

tunnels, and bridges; stockpiling food, water, and Cipro 

(ciprofloxacin hydrochloride); purchasing gas masks; discarding 

their mail unopened; and/or retreating into their homes in an attempt 

to assert personal control over the uncontrollable and assuage fears 

of the unpredictable. It is this type of person, experiencing 
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unrelenting fear and hyperarousal, who, often silently, may develop 

multiple serious health consequences.”13

Therefore, the problem of health consequences following a 

terrorist attack is far more complicated than the immediate surge of 

persons who have been exposed to agents or diseases, those who 

worry that they may be infected, or those who are impacted 

emotionally by the catastrophe. The mental health consequences 

with concomitant implications for health-threatening behaviors and 

stress reactive disease, may be long term and extremely significant. 

A study in the Journal of the American Medical Association noted 

that 17% of the US population outside of NYC reported symptoms 

of September 11-related posttraumatic stress, two months after the 

attacks.14 Indeed, the psychological casualties from a WMD 

incident is expected to greatly exceed the number of physical 

casualties. The figure may be as large as a 5:1 ratio for planning 

purposes.

15

Three to five days after the 9/11 attacks, 90% of those surveyed 

nationally experienced at least one moderate symptom of stress, and 

44% reported experiencing a substantial symptom.16 Based on this, 

one might expect to find increases in incidence and severity of 

conditions and diseases that are affected by psychological distress—

coronary artery disease, diabetes mellitus, peptic ulcer disease, 

hypertension, upper respiratory tract infections, asthma, psoriasis, 

autoimmune disease, Graves disease, and others. In addition, when 

under stress, people tend to engage in behaviors that may 

additionally impair their health, such as increased use of alcohol, 

drugs, tobacco, and overeating. People may “forgo healthenhancing activities such as following medical regimens, getting 
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exercise, obtaining adequate sleep, and pursuing hobbies and other 

relaxing activities.”17

Surveys conducted on persons exposed to terrorist incidents in 

Israel and in Oklahoma City confirm these relationships. Persons at 

high risk for stress-related somatic disorders were not necessarily 

those in closest physical proximity to the event, nor were the effects 

of a terrorist event short-lived. A study conducted one and one half 

to three years after the Murrah Federal Building bombing showed 

that “up to one third of survivors reported worsening of preexisting 

medical conditions;” other studies have shown that more than a year 

after the event, high rates of psychological distress, use of alcohol 

and tobacco, and PTSD symptoms persist.18 Studies in Israel 

regarding the first Gulf War show that more people were killed 

from problems stemming from anxiety than from war, such as the 

misuse of gas masks and medicines.19

Studies of the psychosocial effects of radiation accidents are 

also illuminating. Common stress reactions to such an incident are 

compounded and complicated by the fact that “exposure to invisible 

contaminant has also been shown to produce a chronic state of 

alarm.”20 Interestingly, research on a radiological accident in Brazil 

found that people who had been exposed to radiation and others 

who had not been exposed but were concerned about potential 

exposure, showed similar psychological behavioral and 

cardiovascular-neuroendocrine effects. The effects of a radiation 

accident have been shown to extend far beyond the immediate area 

of impact. 

Certain populations appear to be especially at risk for adverse 

psychological consequences. These include those with previous 

high levels of “neuroticism,” (trait anxiety), children, females 
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between the ages of 40 and 60 years, and those with previous 

histories of psychiatric disorders. Emergency workers and mothers 

with small children may also be at special risk.21 Health care 

workers need to be aware that patients presenting with symptoms 

without medical explanations still need to take patients’ concerns 

seriously, without trivializing the very real distress the patient may 

be experiencing. 

In the anthrax crisis, five people died, all from inhalation 

anthrax, from October 5 to November 21, 2001. Seventeen others 

became ill by inhalation or cutaneous anthrax. Decontamination of 

several post office buildings, the headquarters of American Media, 

Inc., in Boca Raton, and government office buildings in Washington 

DC is in some cases, ongoing. Technically, the huge number of 

persons who called fire departments around the United States, with 

concerns about white powdery substances in the mail, would not be 

considered the “worried well.” However, it has been estimated that 

there were over 200,000 such calls around the country. 

The anthrax-related events in 2001 led numerous individuals to 

self-medicate, purchase protective masks, and even forego opening 

their mail. Federal health agencies reported that 32,000 Americans 

took antibiotics because of concerns raised by the anthrax mailing. 

A poll taken by the Harvard School of Public Health indicated that 

25% of those surveyed were very or somewhat worried that they 

might become infected with anthrax. Of these, almost 15% said that 

they had taken one or more extreme measures, such as the purchase 

of a firearm or stockpiling antibiotics.22 

The problem of the worried well is real and serious. Studies of 

the anthrax crisis and other natural disease outbreaks demonstrate 

that there are serious mental health issues in any disaster scenario. 
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Insights from Interviews 

During the anthrax crisis of September and October 2001, every 

credible call in Colorado Springs was investigated by a crisis team 

from the Fire Department. In all, over 300 calls were answered in 

this community alone. This placed enormous stress on emergency 

personnel. However, as one county official said, “In many ways, 

the anthrax crisis was the best thing that ever happened to us. We 

had to develop effective communication and learn how to handle an 

emergency of this nature. Before, we were totally unprepared. 

Now we are much better prepared.”23

Recommendations for Base Commanders 

Base commanders should familiarize themselves with the 

short and long term mental health consequences of disasters, 

including the phenomenon of the worried well. These potential 

consequences warrant serious concern. 

DETECTION SYSTEMS 

Public Health preparedness has been a focal point for the 

CDC’s strategic response plan regarding BW. Unless a disease 

outbreak is detected accurately and in a timely manner, accurate 

information to the public and assessment of risk and response will 

be delayed, with potentially dangerous consequences for the 

community. Training of health workers to recognize and accurately 

diagnose symptoms that might be related to intentional disease 

outbreaks and educating them on appropriate responses to such 

illnesses have been high priority items. Computer systems designed 

to detect and track disease outbreaks also have been a primary 

focus. 

The quick and authoritative determination that a BW event has 

occurred is not dissimilar to efforts to track frequency and severity 

of natural disease outbreaks. Clusters of patients presenting with 
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uncommon symptoms or unusual distributions of outbreaks can be 

picked up in a variety of ways; all involve data entry or some other 

form of communication comprising pertinent evidence from 

laboratories, hospitals, physicians, veterinarians, and even billing 

entities. Surveillance systems to compile and review data of this 

nature have been rapidly developed. However, they are only as 

useful as the data that goes into them. 

In August 2003, a legislative audit of the Colorado Electronic 

Disease Reporting Systems (CEDRS), which was developed in 

1999 to link hospitals and health departments in Colorado to track 

outbreaks of diseases such as SARS and West Nile, found that the 

system was significantly underutilized. Among the specific 

criticisms was that the CEDRS database was not updated on a 

regular basis, and in some cases there could be a substantial lag in 

time between an outbreak incident, collection of the data, and 

dissemination to parties. Only 41 of 70 hospitals used CEDRS at all 

in 2002, and some significant information about the diseases were 

missing from the data—for example, the locality in which the 

victim was exposed to the disease.24

The Department of Defense Global Emerging Infections 

System (DoD-GEIS) has developed a system for early detection of 

infectious disease outbreaks at military treatment facilities. This 

system, called ESSENCE, for Electronic Surveillance System for 

the Early Notification of Community-based Epidemics, relies 

primarily on data collected during patient visits, rather than after 

diagnoses or laboratory work, thereby greatly lessening the time lag 

between collection of data and detection of syndromes. The system 

plots data on a graph and sorts it by symptoms, age group, zip code 

and other factors. It has been praised as very useful in identifying 
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unusual clusters of illness, even before they are noticed on the 

ground. For example, in 2002 the network caught an outbreak of 

diarrhea at a Marine facility before doctors there were even aware 

of it. Since the September 11th attacks, it has been expanded, and 

now includes data from 121 Army, 110 Navy, 80 Air Force, and 2 

Coast Guard installations. It has historical data, against which 

current data is compared, dating back three years.25

The Global Outbreak Alert and Response Network links many 

informational and diagnostic networks around the world. This 

World Health Organization initiative includes information from the 

191 member countries. It checks for reports and rumors of any 

outbreak of infectious disease, either naturally occurring or 

deliberate. Each report is checked by a team of WHO specialists. 

This network has picked up and verified outbreaks of Ebola in 

Uganda and yellow fever in Cote d’Ivoire.26

Accurate detection/diagnoses are critical to an effective BW 

response. As indicated earlier, each agent requires a different 

response from health care workers. Some illnesses will require 

quarantine/isolation; others will not require quarantine, but will 

necessitate decontamination closures. Health workers will take 

different precautions in different disease scenarios. Therefore, 

communication between military and civilian physicians, the CDC, 

and state/county/local departments of health is absolutely essential 

to the success of a BW emergency response. 

There are many prototypes of “clinical pathways” for the most 

likely bioterrorist events. For example, Stanford University has 

developed a series on bioterrorism that includes a “Clinic Anthrax 

Phone Call Pathway/”Worried Well” Pathway.27 It calls for 

distinguishing between symptomatic and asymptomatic patients, 
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exposure assessments, and clinical consequences. These kinds of 

diagnostic aids would be very helpful in a mass outbreak. 

Recommendations for Base Commanders 

The Base Commander should ensure that the early 

detection systems on his/her installation are being fully utilized. 

He/she should foster good communication between the health 

professional leadership on his base with their counterparts in 

the community, and in particular state, county, and local health 

departments. 

SURGE CAPABILITIES 

A biological weapons (BW) attack has the potential for putting 

a severe strain on many kinds of resources, including health care 

personnel, volunteers, disaster treatment facilities, contact tracers, 

law enforcement, medical supplies, and equipment. Addressing the 

problems associated with an overwhelming patient surge has been 

recognized as a critical feature of any contingency plan. A press 

release from the Department of Homeland Security noted that 

“(m)any of our health care systems are not adequately prepared for 

a large-scale attack.”28 According to DHS, the lack of surge 

capabilities and isolation facilities in the event of escalating 

numbers of victims, and antiquated and inadequate information 

systems that knit together hospital emergency rooms and health 

officials, scarcity of mutual aid compacts among health institutions, 

and infrequent training for health care providers in the handling of 

bioterrorism victims are all problems that need to be addressed. 

Evaluations of the SARS outbreak in Singapore noted that 

“(w)ith the ... SARS outbreak, the local hospital system is being 

stretched to its limits by a not-too-lethal bug which has claimed 28 

lives from the 205 cases to date.”29 The TOPOFF exercise, the first 

full-scale simulated test of the public health system in a terrorist 

attack using BW (May 2000), demonstrated that probably no 
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hospital could deal with more than 100 contagious patients at a 

time. The worried well represents considerable additional stress on 

the capacity of the health system to treat the sick. 

Alternate sites for triage, treatment, and possibly isolation need 

to be inventoried. Problems associated with the requisitioning of 

hotels, schools, vacant housing, and other suitable sites should be 

considered prior to the actual necessity to use them, for it is 

probable that in a BW crisis, they will be needed. Additionally, 

routes and modes of transportation to these sites must be considered 

in order to minimize contamination in the broader area. 

Even more critical than facilities, is the availability of health 

care workers—doctors, nurses, laboratory technicians, ambulance 

drivers, etc. Fear of exposure may influence some to limit their 

work time at exactly the moment that patient surges are placing 

additional stress on the health care system. Mass vaccinations and 

distribution of preventive drugs may require enlisting law 

enforcement personnel, members of the armed forces, pharmacists, 

veterinarians, and civilian volunteers to assist. 

Insights from Interviews 

Even though plans have been developed to share resources, 

perhaps utilizing base clinics and hospitals, some local actors feel 

that in the event of a BW terrorist incident a base will lock down, 

and that the burden of caring for military personnel, their 

dependents, and retirees who are off base in the community will fall 

solely upon the locality.30 

Recommendations for Base Commanders 

1. The Base Commander should anticipate the surge of 

patients that will be associated with most BW attacks. 

2. The Base Commander should inventory both the 

personnel and facilities on his installation. Management, 
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Coordination, and Resource-Sharing Plans may exist, but may 

not be widely understood or disseminated. He/she should 

consider the implications for the community in the event that 

the base locks down. 

TRIAGE 

Most state and local contingency plans recognize the need for a 

triage system that distinguishes between the acutely ill, the possibly 

ill, and the worried well. Guidelines established by the CDC and 

incorporated into disaster response plans indicate the need for this, 

but are often developed in a relatively simplistic way. For example, 

the Georgia Division of Public Health has developed a bullet plan 

for dealing with a BW crisis that enumerates the need to develop a 

questionnaire that can be used to rapidly collect victim 

identification and background information, including where they 

have been recently. Although it is important to have such 

questionnaires readily available in the event of an emergency, the 

bullet plan emphasizes the need to “send the worried well home,” 

and send the acutely ill to appropriate medical facilities, and 

conduct an initial outreach by sectors in the community. This might 

involve door-to-door sector surveys, during which medical 

information is provided, with a full community outreach follow-on 

that includes citizen home help mobilization and potential noninfected patient relocations.31

It is true that if the worried well were to swamp emergency care 

facilities, they actually might contribute to the spread of a 

bioterrorist epidemic, as they are much more likely to become 

infected with a pathogen at the health facility than at home. 

Therefore, it is essential for any strategic plan to be able to divert 

this population quickly, with the help of diagnostic kits (that need to 

be readily available), to alternate facilities, and ultimately to safe 
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locations. “Public health officials could use nurse call centers, mass 

communications media, or both to convey to the public the need to 

remain calm and to limit use of urgent health care facilities to truly 

urgent cases.”32

However, most experts agree that it is not necessarily 

appropriate to send the worried well home immediately. Some 

prevention of adverse psychological effects will occur at the point 

of an individual’s encounter with health workers in the triage 

system, which definitely should include a strong mental health 

component. One of the most important recommendations of experts 

is to provide “safe holding areas” where those with acute 

psychological responses to a crisis can be observed while removed 

from the intensity surrounding the facilities where truly ill patients 

are being treated. It is clear that implementing a positive mental 

health strategy will require the assistance of community mental 

health workers, social workers, pastoral care, and other volunteers, 

so that emergency and primary care health professionals are free to 

devote their attention to the critically ill.33

The importance of the appropriate response to the worried well 

during triage cannot be overemphasized. “First responders, premedical care personnel, and mental health treatment providers must 

be prepared to provide some level of treatment for individuals with 

acute (and most often transient) emotional and behavioral 

disorganization or other symptoms.”34 The creation of a location 

where symptoms can be observed and monitored, or a holding 

environment, “favors social and psychological recovery.”35

The Modular Emergency Medical System (MEMS) has been 

developed to deal with triage in the event of a large-scale biological 

weapons attack. It seeks to address shortfalls in hospital space, 
Pilch—The Worried Well 

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equipment, and medical personnel. In short, while area hospitals 

form their own internal emergency medical command centers, acute 

care centers would be established close to area hospitals for the 

acutely ill who exceed hospital capacity, and neighborhood 

emergency help centers (NEHCs) would provide the main point of 

entry into the emergency medical system for BW patients and 

worried well, and would distribute medical prophylaxis 

medications. Community outreach would link home-bound patients 

to the NEHC. A citizen home care effort would augment NEHCs. 

“Thus, during catastrophic medical emergencies such as large scale 

bioterrorist attacks, area hospital, clinics, and private medical 

doctors would forego their normal autonomy and begin functioning 

as an integrated system.”36 

Recommendations for Base Commanders 

1. Base Medical Contingency Plans should include a strong 

mental health component. After initial triage, which should 

include diagnostic kits and questionnaires to discriminate 

between patients, the worried well or those suffering other 

mental/emotional trauma should be diverted to holding facilities 

where their progress can be monitored. Triage facilities, acute 

care facilities, and holding facilities should be predetermined, 

and their status should be inventoried on a regular basis. The 

MEMS Plan presents a useful model for triage that includes 

appropriate attention to mental health issues. 

2. The need for competent personnel to address mental 

health issues in a BW crisis should be anticipated. Available 

personnel who can be activated should be inventoried and 

contact information readily accessible. 

ENGAGING THE PUBLIC: INFORMATION AND 

EDUCATION 

Information during a crisis is absolutely critical to the response 

of the public. “Better than any medication that we know, 

information treats anxiety during crisis.”37 Without access to 
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21

complete and honest information, rumors may fester, and mistrust in 

authority may grow. 

The nature of the threat should be determined as early and as 

accurately as possible. The threshold for information sharing with 

the public should be “the earlier the better,” and as soon as there is 

reasonable scientific verification of the evidence. Uncertainty is 

preferable to silence, as long as it is stated within the framework of 

an “all-out attempt” to ascertain the facts. 

Conflicting reports by government officials about the nature of 

an attack, persistent dangers of the attack itself, previous indications 

of a terrorist event, and risks related to proximity to an attack can 

lead to increased anxiety and a decrease in public trust. Therefore, 

every attempt should be made to share information between 

stakeholders to achieve consensus. However, delays in 

communicating to the public breed fear and rumors. Citizens need 

to believe they are being kept fully informed. Public information 

and rumor control are extremely important components of 

emergency response. Hotlines, information to the media, press 

conferences, and self-help fact sheets are all tools for information 

dissemination. Timely and accurate dissemination of information is 

critical, and media participation is essential. 

Reports following the anthrax crisis are instructive. Neal L. 

Cohen, M.D., Commissioner of New York City’s Department of 

Health, 1998-2002, said of his “lessons learned”: “Always err on 

the side of letting the public know as much as possible.”38 He adds 

from his experience that “we did not see our job at NYCDOH as 

reassuring people. Our job was only to provide information. The 

public makes pretty good decisions when given information.”39
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22

On working with the media, Dr. Cohen notes that “the media 

are too savvy and too committed to ‘catching’ you. That is their 

job—you cannot blame them.”40 Therefore, communication must 

be a top priority. Honesty is imperative—for if you are dishonest 

up front, the media will not trust you later. 

Some of the problems involved in crisis management can be 

mitigated by engaging the public in self-help preparedness 

measures. Mental health experts advocate the empowerment of the 

public through the creation of emergency plans. These plans might 

include establishing a network listing the routine whereabouts of 

friends and family, contact phone numbers and e-mails, choosing a 

leader, selecting a meeting point, stocking emergency supplies, and 

inviting experts on terrorism to speak to civic and church groups.41

The development of a planned response is important for the 

mitigation of “a community’s sense of helplessness.... Doing so 

(Planning) also increases the community’s capacity to provide 

social support to victims. Because poor planning or failed 

execution would increase the risk for feeling helpless or 

overwhelmed, there is a pressing need to practice continually and to 

evaluate the effectiveness of the planned actions.”42

During a crisis, a public information plan should inform the 

public, help the public interpret the attack, and include measures 

they can carry out to protect themselves and their loved ones.43 “It 

is critical that the information provided be truthful, even if it is bad 

news. Information regarding distribution of medications or 

vaccinations must be delivered in a manner that does not increase 

panic when inevitable shortages are recognized.”44 Clearly, 

understanding the nature of the pathogen and its effects is vital to an 

educated public response. Precise risk communication information 
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23

will ease the burden of the second group of worried well, who will 

visit emergency rooms and triage centers primarily as a preventive 

measure. “Clear, consistent, accessible, reliable, and redundant 

information (received from trusted sources) will diminish public 

uncertainty about the cause of symptoms that might otherwise 

prompt persons to seek unnecessary treatment.”45

Analysis of the medical and public health response to the 

anthrax crisis of 2001 has illuminated the very real challenges of 

information dissemination and risk communication in the midst of 

an ongoing crisis where there is scientific uncertainty. The CDC 

changed guidance on protocols, there was a lack of trust in CDC 

recommendations, and the different recommendations on remedies 

on the part of the CDC and the Congressional physicians caused 

equity to be questioned and confusion to prevail. The CDC website 

crashed twice during the crisis due to heavy use and lack of 

redundancy.46

Studies of the anthrax crisis have also found that public health 

officials lacked prepared materials or detailed public 

communication plans. Dealing with media demands became 

extremely time-consuming and difficult. There was tension among 

elected officials and health practitioners “trying to reach consensus 

about how much information should be released to the press.”47 

The media reported great difficulty obtaining reliable information, 

and complained that public health officials were unresponsive. 

Only very late in the game were daily telephone press briefings 

instituted. Without information from public health officials, 

reporters “had to assemble pieces of the anthrax puzzle from a 

variety of what they hoped would be credible sources.”48 One of 

the major conclusions of these studies is that public health 
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24

emergencies require media-savvy spokespersons who will provide 

accurate and comprehensive information to the public. Even though 

individuals resorted to self-help measures that were unwarranted 

during the anthrax crisis of 2001, and in spite of the challenges of 

communicating with the media, it should be noted that there was no 

general panic. 

Risk communication has been the focus of debate for those 

attempting to establish best practice guidelines for future crises. 

The consensus seems to be that “(p)ast public health emergencies, 

notably those involving environmental crises, have yielded many 

well-tested lessons about how health risk information can reliably 

be communicated. The essence of these lessons is that authorities 

should tell the truth as they know it, when they know it; they should 

be forthright about what is not known; and they should explain what 

is being done to improve understanding of the situation and manage 

the problem.”49

Experience with natural disasters and disease outbreaks clearly 

indicates that public reaction can be effective and adaptive, if 

appropriate education of and communication with the public takes 

place. A recent influential article on the importance of the 

engagement of the public in responses to emergencies names five 

guidelines for integrating the public into bioterrorism response 

planning: 1) treat the public as a capable ally, 2) enlist civic 

organizations in public health activities, 3) anticipate the need for 

home-based patient care and infection control, 4) invest in public 

outreach and communication strategies, and 5) ensure that planning 

reflects the values and priorities of affected populations.50

While censorship undermines public trust, partnership between 

the media and the emergency response network should be 
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25

encouraged. A clear framework for cooperation should already 

have been established in contingency planning, and within this 

framework, the media should be encouraged to contribute to selfrestraint when necessary to avoid public panic. We know that 

repetitive images of horror, such as those continually shown in the 

September 11 crisis, have serious consequences for mental health. 

Sensationalist images have an effect on children and those who are 

psychologically at risk. It is important to educate the media, before 

as well as during a crisis, to enlist their support in informing, but not 

unnecessarily terrorizing, the public. 

Insights from Interviews 

The El Paso County Emergency Action Teams expressed the 

view that Public Information Officer Training is extremely 

important. “We need the media to help, not incite panic.” They 

noted that it is a good idea to bring the media into the preparedness 

process, and have a “heart to heart” with representatives of major 

media outlets in the community.51 They noted the importance of a 

common message, and thought that the military should be part of a 

Crisis Communications Network. A “common language” is critical, 

and the importance of simple direct messages with a minimum of 

acronyms cannot be overstated. 

Stephen Dubay, Director of Emergency Management in 

Colorado Springs noted an incident at a conference on emergency 

response in Los Angeles. When response managers talked about a 

“partnership with the media,” members of a media panel, including 

representatives from national television, radio and print media 

protested that they may not view themselves as partners. They 

perceive of their role as the Fourth Estate, and have a watchdog 

obligation.”52 In spite of the sometimes adversarial or skeptical 
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26

posture that the media may feel their role should be, their inclusion 

in preparedness is seen by the El Paso County community to be 

critical. 

One of the problems local administrators noted regarding 

working with media involved the rapid turnover of personnel in a 

mid-size market such as Colorado Springs, where journalists and 

TV personnel aspire to move into larger markets. Because of the 

transient nature of personnel in media, the establishment of routine 

communication networks is difficult and connections need to be 

continually updated. 

In addition to media outlets, emergency managers have other 

ways of communicating with the public—including reverse 911 

networks, national weather service radio, the internet, and other 

alert systems. Military installations in this area are linked to the 

Office of Emergency Management with 24-hour contact numbers. 

Dr. Larry Schaad recalled the importance of information in an 

incident in which a 14-month old died of septicemic plague on the 

USAFA installation. The Academy received calls from all over the 

country from parents concerned about the health risks to cadets. 

Correct information concerning the nature of this kind of plague 

was extremely important in calming the anxieties of parents, and 

informing them correctly as to the risk to their children. 

The Department of Defense has altered its philosophy regarding 

its role in the dissemination of information and communications 

with the public in general following the TOPOFF 2 exercise in May 

2003, in which international, national, state, and local cooperation 

was tested. Prior to the exercise, DOD generally deferred to Federal 

agencies in communications with the public. The importance of 

public confidence in all levels and departments of government is 
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27

now recognized, and DOD has taken on a more active role in 

communications. This represents a partnering role with other 

agencies and a significant change in emphasis.53

Recommendations to Base Commanders 

1. Information dissemination to the public should be timely, 

accurate, and straightforward. It should include plans that can 

be actualized. 

2. Points of contact for public affairs personnel with the 

media and local police/fire departments/hospitals/government 

officials should be pre-established. 

3. Military Installations should be connected with Crisis 

Communications Networks in surrounding communities. 

4. The threshold for dissemination of information to the 

public should be “as soon as possible.” The Base Commander 

should rely on the positive potential of the public to understand 

and react responsibly to knowledge and information, as long as 

that message is clear, timely, and includes practical information 

(actionable information is highly desirable). He/she should 

avoid the tendency to withhold disturbing information from the 

public or to conduct emergency responses in secrecy. 

5. The Base Commander needs to have pre-established, 

continually updated links to the main media outlets both on 

his/her installation and in the community at large. 

6. The Base Commander needs to update contact 

information for these contacts continually. 

7. The Base Commander should continually foster trust 

and good relations with the media, so that when there is a crisis, 

a partnership already exists. 

8. Public Information Personnel need training in how to 

communicate in crisis situations. This training should be 

accomplished in cooperative efforts with community emergency 

response teams. 

9. There should be a pre-determination of who will be the 

primary/secondary spokesperson for the military installation. 
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28

ADDITIONAL INSIGHT INTO RISK COMMUNICATION 

A Rift Valley fever simulation conducted in 2003 strongly 

indicated the enormous importance of clear messages to the public. 

Interestingly, the most confused and fearful group of respondents in 

this exercise were the journalists themselves. The study concluded 

that in the event of an actual crisis, the media may not be able to 

serve the best interests of the public effectively.54 In addition, 

respondents were wary of sole source information. Responses 

concerning the most trusted purveyors of information varied, but 

often included the President, physicians, and local government 

officials. The exercise concluded that “bioterrorism training should 

include information management for risk communicators and public 

affairs officers who have the responsibility of providing timely and 

accurate information to dispel the ‘fog’ of rumors and 

misinformation present during the aftermath of an intentional 

disease outbreak. Journalists and other media specialists should 

participate actively in scenarios and other similar exercises to gain 

insight into the complexity of information management in a 

bioterrorism-related crisis.”55

The West Nile virus outbreak and spread also provides an 

excellent laboratory for analysis of public information and 

education campaigns. The NYC Mayor’s office established an 

emergency hotline, operated by the Mayor’s Office of Emergency 

Management, staffed by the NYC Department of Health, to answer 

questions about the illness, pesticides (especially the mosquito 

spraying undertaken by the government), and the use by citizens of 

insect repellents. The hotline, operating during September and 

October, received over 150,000 calls. Peak calling periods revolved 

around spraying schedules and media attention.56
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29

Citizens need to have the knowledge necessary for informed 

decision-making about risks to themselves and to their families. 

This implies the need for governments/leaders to rapidly gather and 

analyze facts, develop clear, understandable and actionable advice, 

truthfully provide continuous information to the media, and help 

people understand their options. 

In several of the simulations, questions were raised about 

secrecy. To some leaders, withholding information from the public 

may appear to be a logical course of action to “minimize panic.” 

However, most experts and studies clearly agree that honesty and 

the provision of maximum amounts of information are essential to 

an appropriate public response. “In emergencies, law enforcement 

personnel are accustomed to ordering—not explaining. So the 

biggest challenge is to involve the general public as participants in 

the development of norms and procedures for worst-case scenarios. 

This will require specialists unlearning familiar behaviors that 

thwart communication. The threshold requirement is for clear, 

understandable, and candid discussion of the risks, the objective, the 

problems, the options, and the underlying values at stake—before a 

response is required.”57

Insights from Interviews 

The El Paso County Emergency Team noted that in a BW 

emergency, hotlines set up by the health department through special 

software systems would be staffed primarily by nurses. A central 

line would be called, and the caller would be “farmed” to a bank of 

phones. Nurses, or other respondents, will be given assistance to 

develop standardized, consistent responses to common queries.58
Pilch—The Worried Well 

30

Recommendations to Base Commanders 

1. The military installation should be able to initiate 

hotlines rapidly, manned by competent personnel with clear 

guidance on correct information. 

2. A plan to notify media and base personnel of hotline 

numbers should be in place. Hotlines should be open 24 hours 

a day during an immediate crisis. 

3. A variety of ways to contact base personnel, including 

alert systems, recall rosters, and internet addresses should be 

predeveloped for use in a crisis. 

LESSONS LEARNED: NATURAL DISEASE OUTBREAKS 

Natural disease outbreaks and natural disasters have the 

potential to seriously disrupt base operations. A BW event would 

probably be even more complicated in terms of its effect on the 

mission of any particular base. Such an event may manifest itself 

slowly, over time, and may have continuing, persistent medical 

effects that involve not only military personnel, but also their 

families, and civilian base personnel. The locus of the outbreak 

may be difficult to determine; it may be either on base or off base in 

the community where many military families live. As opposed to 

injury inflicted by an explosion or the disruption of a chemical 

attack, a BW event cannot necessarily be contained to one 

geographical area. In the event of an infectious disease, contacts 

may have been expanded from exposed individuals before the event 

is completely understood. Standard sensory cues such as location, 

beginning, and end of the event, are not available. 

Natural disease outbreaks have tested the reporting and 

surveillance networks already in place in the United States. The 

West Nile virus outbreak has been an especially important real-time 

crisis, and it has led to greater awareness of the strengths and 

weaknesses of our public health actors and the response of the 
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31

public to health emergencies. The initial outbreak in New York 

required health professionals—including infectious disease 

specialists and veterinarian pathologists—to observe disease 

clusters, report them to public health officials, and engage local 

health care providers, the media, and government personnel in 

educating the public and fostering community support for an 

appropriate response.59 

The public response to West Nile Virus in New York City 

clearly indicated the enormous importance of educating and 

communicating with the public. NYC officials, including the 

mayor, the office of emergency management, and the health 

commissioner, were available on a daily basis to meet with the press 

and answer their questions. “In addition, New York’s health and 

emergency management officials made significant efforts to educate 

a multicultural, polyglot city in the need for mosquito control, by 

providing multilingual educational brochures.”60

The Air Force has developed a surveillance system called the 

Air Force Reportable Events Surveillance System. Suspected cases 

of an infectious disease such as SARS are reported through that 

system, and then to appropriate local and state health departments. 

Each disease requires different health protocols for providers. The 

CDC is considered to be the primary source of information on 

diseases, epidemics, and details of transmission and precautions. 

In 2003, 12 people at Dyess Air Force Base in Abilene, Texas, 

were isolated for possible SARS infection. Although all of the 

initial tests on the 12 had come back negative for the virus, each 

remained in isolation for 10 days after the last symptom had 

disappeared, according to the CDC guidelines. This incident 

demonstrated the need for close communication and working 
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32

relationships between bases and local communities. “Despite the 

circumstances, this was a great opportunity for us to test our 

procedures and lines of communication for dealing with an event 

like this,” noted Dr. (Col) Schuyler Geller, the 7th Medical Group 

commander. He noted the cooperation of officials in Abilene and 

the local hospitals.61

SIMULATIONS AND EXERCISES 

Simulations and exercises provide important insights into 

community preparedness for a BW event. Much federal money has 

gone into these exercises, which attempt to discern gaps in 

communication structures, potential logistical problems, and 

inconsistencies in decision-making frameworks. 

TOPOFF was the first exercise of national dimensions.62 It 

consisted of three mock events that took place during May 2000: a 

chemical attack in Portsmouth, NH, a radiological attack in 

Washington DC, and a bioweapons attack in Denver CO. The 

exercise included FEMA, the FBI, the CDC, and multiple 

state/county/local response teams. In the Denver portion of 

TOPOFF, plague was the agent, released in an aerosol on May 17. 

By May 20, 500 persons at area hospitals presented with cough and 

fever, the CDC had confirmed plague, and CDC staff had been sent 

to Denver. Upon declaring a public health emergency, the 

Governor restricted metro-Denver travel. By May 22, state borders 

had been closed and face masks advised, and by May 23, there were 

4000 cases and 1000 probable deaths. 

The lessons of TOPOFF were startling—great uncertainty as to 

proper roles and decision-making in a crisis; questions arose as to 

who had legal and moral authority; there was no clear-cut system 

for triaging scarce resources; actors were inefficient, indecisive, and 
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33

decisions were frequently reversed; calls overlapped and callers 

groped for contact information, as they had never worked with one 

another before; people felt overwhelmed and expressed a sense of 

hopelessness; and communication was very inefficient (much time 

was spent exchanging phone, pager and fax numbers!). Another 

conclusion from TOPOFF was that local health facilities were 

totally unable to provide the care necessary during a serious surge in 

patient population. One of the conclusions was that attention had to 

be paid to determining pre-designated sites for the worried well, 

who indeed swamped hospitals. 

The implications of the exercise for a real crisis were 

staggering—and led to many changes and processes that had not 

been in place prior to TOPOFF. One of the most important 

conclusions of the exercise was that critical first responders needed 

to stay healthy while managing a disaster, and in order to maintain 

their commitment to work, they had to be assured of the safety of 

their families. This has direct implications for military personnel; 

concern for families will be paramount in their minds. 

In 2001, the Johns Hopkins Center for Civilian Biodefense 

Strategies in collaboration with other similar groups, held a senior 

level exercise entitled “Dark Winter,” that simulated a smallpox 

attack on the United States. With a fatality rate estimated at 30% 

and no effective medical treatment, this disfiguring disease presents 

a very disturbing threat. The tabletop exercise, in which senior 

participants were presented with a rapidly changing scenario, was 

conducted over a two week span. One of the problems with an 

infectious disease such as smallpox is that by the time the disease is 

recognized, it will already have spread to the next generation of 

cases. 
Pilch—The Worried Well 

34

The conclusions reached after an analysis of the response of the 

senior decision-makers reaffirmed those reached in other 

exercises—“the challenges of distinguishing the sick from the well 

and rationing scarce resources, combined with shortages of health 

care staff, who were themselves worried about becoming infected or 

bringing infection home to their families, imposed a huge burden on 

the health care system.”63 

For example, a simulation in 2003 conducted by the CDC 

featured an intentional outbreak of Rift Valley fever in the southern 

part of the United States. Video and news reports about the 

fictional nine-day crisis were released to selected first-responders, 

families, and journalists, and their responses tabulated. The 

simulation determined that even though federal health authorities 

served as primary sources of information and direction, all groups 

demanded more complete information from and expressed more 

trust in local sources of information. There was also considerable 

confusion in the community over disease management, the need for 

vaccines, and necessary environmental measures. 

Operation Determined Promise, a national exercise designed to 

gauge and improve the cooperation between the military and local, 

state, and federal responders, was conducted in August, 2003, north 

of Las Vegas. In this exercise, local fire departments worked with 

members of the National Guard’s WMD civil support team to test 

for pathogens in a “laboratory.” These kinds of exercises are timeconsuming and labor intensive, but invaluable in what they can 

demonstrate about response preparedness. 

Insights from Interviews 

In September 2003, important actors in emergency management 

on the county and local level in El Paso County participated in an 
Pilch—The Worried Well

35

exercise in which an outbreak of Q Fever was simulated. The 

exercise pointed to significant improvements in networks of 

communication between essential partners, including the 

involvement of the physicians’ response group, DR HELP. Because 

the many actors have worked together in planning and exercises, 

they know each others’ names, numbers, and e-mail addresses, and 

they have an idea of the prioritization of who should be called, 

when, and under what circumstances. 

The exercise was extremely useful in that it exposed several 

loose ends in emergency preparedness—among those were 

questions concerning agreements with facilities (such as schools) as 

to their use as auxiliary medical locations and decision-making 

authority as to when to activate Disaster Medical Aid Centers 

(DMAC).64

Recommendations to Base Commanders 

1. Exercises and simulations are labor and time intensive. 

However they can provide extremely useful insights into 

weaknesses in emergency preparedness. 

2. Base emergency response teams should participate as 

often as possible in community simulations and exercises. 

3. Base emergency response teams should be an integral 

part of “hotwashes” concerning these simulations. 

EMERGENCY RESPONSE TO INFECTIOUS DISEASE: 

QUARANTINE 

As has been previously noted, the use of different biological 

agents requires different responses. In some cases, as in anthrax, 

there is no person-to-person transmission. In other cases, there is 

limited risk of widespread person-to-person transmission. Only a 

small number present such a great risk of serious illness and death 

that widespread confinement of large groups of people, in large 

geographic areas, would become necessary. In most cases, serious 
Pilch—The Worried Well 

36

consideration must be given to incubation periods of disease and 

how long it might be necessary to contain populations before the 

threat of transmission is past.65 Biological threats such as smallpox 

require stringent containment procedures, including quarantine.66

In the Rift Valley fever simulation, reacting to rumors of 

quarantine, not to an official quarantine announcement, 59% of 

media and 75 % of residents said that they would comply and not 

try to leave. Also, six% of residents and 13% of spouses said they 

would try to leave regardless of the consequences.67 

The TOPOFF exercise involving a simulated bioterrorism 

attack in Denver provided great insight into problems of 

containment of disease. When the Governor’s Emergency 

Epidemic Response Committee, in consultation with the CDC, 

discussed closing Colorado state borders and the Denver 

International Airport, not all committee members agreed that 

borders should be closed. Several asked how the city planned to 

feed four million people. Another containment measure considered 

was to have healthy people go to “holding tanks” while the sevenday incubation period of plague passed. Civil unrest broke out 

(notionally) in the simulation, as people were not allowed to shop, 

and food supplies dwindled due to the fact that trucks were not 

allowed into the state. Gridlock occurred, and there was serious 

civil disruption. One observer noted, “They told 1 million people to 

stay in their homes. How would we have enforced this?”68

If quarantine were to be mandated in a BW crisis, arrangements 

would have to be in place for monitoring of those who are 

quarantined. Web cams have been suggested, and even electronic 

bracelets, such as those utilized by our correctional system. The 

idea of quarantine has legal and law enforcement implications. 
Pilch—The Worried Well

37

Logistically, if it were to involve a wide area, it is highly 

problematic. 

EMERGENCY RESPONSE TO INFECTIOUS DISEASES OR 

OTHER BW CRISES: SHIELDING 

The goal of both quarantine and shielding is to limit the spread 

of infectious disease, breaking the cycle of the disease, and 

preventing further infections. Although quarantine may be 

necessary in some cases, it is clear that it presents a problem both in 

terms of its enforcement, its logistics, and the limitations it imposes 

on civil liberties. For example, it became clear after the TOPOFF 

exercise in Denver that violations of mandatory quarantine would 

have been rampant, and that if more extensive limitations on 

personal freedom had been imposed, there would have been limited 

enforcement capacity. The initial overwhelming tendency in a 

terrorized population may be to flee the immediate area that is 

viewed as a threat. In some crises, the flight response may be 

appropriate. However, in the event of a BW crisis, flight might be 

an inappropriate response. It imposes burdens on the infrastructure 

and would increase the possibility of secondary outbreaks of an 

infectious disease. Recent work in the area of disease control in the 

event of a BW attack has proposed a new concept, that of shielding, 

that may provide a far better strategy than quarantine.69 

The shielding strategy focuses on self-imposed measures, 

remaining close to home, and support of the needs of the family and 

community as they remain in place. The essential features of this 

idea are that people will be given maximum amounts of information 

and urged to remain at home for a few days or a few weeks at most, 

for the good of the whole. Thus the epidemic is contained or 

minimized. Shielding is considered to be a much better option than 

quarantine in that it enlists the support of the individual and family, 
Pilch—The Worried Well 

38

keeps them in locations that are familiar to them, constitutes a 

positive action for them and engages them before an incident, 

maintains more functions of society, and ensures the continuity of 

some of the most important features of our way of life, including 

self-reliance in conjunction with community support, liberty, and 

security.70

Shielding maximizes the opportunity for the individual to be 

part of a plan, and to be treated as a responsible adult who can be 

counted on to function effectively in the event of a crisis. The very 

idea of planning to remain in one’s home and community “will 

serve as a positive mental health purpose during and following an 

incident.”71

We have learned that coping with crisis works better when we 

are in stable, rather than unstable, environments. “Stable 

environments offer security because they have an existing 

infrastructure of support. Knowing where we will sleep, eat, and 

receive information is always beneficial...anxiety increases in 

unstable environments where we lack a sense of control and 

ownership even over basic decisions involving food, water, and 

hygiene...familiar environments decrease anxiety.”72

Shielding is rooted in the “consensual ethic of a social 

compact,” as opposed to the coercive nature of a mass quarantine.73 

It can be instituted as a precaution, even before an emergency is 

declared. This would ease traffic flows and facilitate delivery of 

essential personnel and products to where they might be needed. 

However, it does not imply that government activities will be less 

important. Those who stay at home have to rely upon safe and 

reliable delivery of supplies and health care when necessary. 
Pilch—The Worried Well

39

Insights from Interviews 

Models have been run on the courses of infectious diseases. If 

a case of smallpox were to present, an aggressive contact tracing 

initiative would be undertaken. People at risk would probably be 

vaccinated, and under the shielding concept, a “ring” of those at risk 

would be asked to stay home. This model suggests that the disease 

would burn itself out in 53 days.74 Lt Col Donald Thompson has 

developed models pertaining to different diseases and the impact on 

the spread of those diseases with various levels of containment or 

shielding.75

When asked for their response to the idea of shielding, the El 

Paso Emergency Response Team noted the reluctance of people to 

stay home, even in blizzard conditions. They acknowledged that a 

mandatory quarantine presents a logistical nightmare, but stressed 

that education and home access to health care, information, and 

food would be essential components of shielding. They anticipated 

that retirees would be most amenable to shielding, and that many 

others would have to be specifically directed as to when it was 

important to stay home from work, and when it was not. The 

support of businesses would have to enlisted, and economic impact 

on all parties addressed. Many heads of households would perceive 

that they could not afford to stay home from work. Additionally, 

not many families have adequate provisions to stay at home for any 

length of time. Therefore, in order for shielding to work, the public 

would have to be confident that their primary needs for food and 

health advice/service would be met at home, and would not 

necessitate their leaving home to go to the store, etc.76

Stephen Dubay noted the importance of Community 

Emergency Response Training (CERT), which includes the idea of 
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40

a “72-hour kit,” that is an emergency supply of basic food and 

health needs for a family. This idea originated in Japan in 

earthquake response, and was imported to Los Angeles. FEMA and 

the Federal Government have endorsed this idea for “all hazards 

preparedness.”77

The great advantage of shielding, according to Stephen Prior, is 

that it is a voluntary response and utilizes existing support systems. 

He notes that being prepared builds “psychic resilience.” People 

need to know the risks involved to themselves and their families, 

and what they can do to decrease those risks. Therefore, you need 

to build knowledge in the public. He adds that building public 

resiliency in this manner may in itself decrease the risk of attack. 

He noted the difference in response to SARS in Canada and in 

Hong Kong. In Canada, a voluntary system featuring extensive 

amounts of public education and home visits by doctors when called 

for, worked extremely well. In Hong Kong and Singapore, 

mandatory quarantines in large residential areas were instituted. 

Before law enforcement could get there to enforce the quarantine, 

50% of the population had fled. If shielding were to be used in the 

United States, for example in the event of a smallpox outbreak, you 

would have to find ways for homes to be visited by health care 

professionals when necessary, and for every home to have absolute 

access to information. In this smallpox example, potentially 

infected persons would be asked to take their temperature twice a 

day. If a person runs a temperature of more than 100 degrees in two 

incidents, he would be isolated. People need to understand that if 

they are outside an eight-foot radius of an infected person, there is 

no risk of infection. Each kind of outbreak would necessitate 
Pilch—The Worried Well

41

different educational content for the public. He stressed that it is 

knowledge, and not just information, that the public requires!78 

Recommendations for Base Commanders 

1. The concept of shielding and its positive relationship to 

the mental health of the public should be understood. 

2. Whenever possible, shielding should be utilized in 

preference to quarantine. 

3. The public needs to understand the specific ‘best 

practices’ corresponding to the specific BW event, in order to 

make informed decisions. 

4. Military personnel will be very concerned about the 

safety of their families. The stability of the home environment 

is preferable to flight during BW crises, and adds a dimension 

of personal empowerment that will help diminish anxiety. 

5. Shielding within home environments necessitates support 

of those environments with medical assistance, food supplies, 

and unhampered access to information. 

PREPAREDNESS AND MENTAL HEALTH MANAGEMENT 

Terrorist attacks have far-reaching psychological consequences. 

Mental health consequences may be immediate or delayed, and may 

have longstanding ramifications for individuals, families, and the 

community. Addressing these psychological effects begins with 

preparedness and public engagement in their own planning for 

potential BW events. This mitigates a community’s sense of 

helplessness and increases the community’s understanding of its 

support role in the event of an attack. This, of course, implies the 

need to practice continually. 

There are some tools available for the education of the public 

on bioterrorism. The new Office of Homeland Security, for 

example, has a brochure that can be downloaded from its site, called 

“Preparing Makes Sense: Get Ready Now.” However, the 

information in many of these brochures is broadly formulated and 
Pilch—The Worried Well 

42

may not address the information needs of the public adequately. 

For example, the “Get Ready Now” brochure attempts to inform the 

public that biological attacks may not be immediately obvious, that 

some agents do not cause contagious diseases while others do, and 

that one should not automatically assume he/she should go to a 

hospital emergency room or that any illness is the result of the 

biological attack.79 Most military bases have some brochures or 

internet training available on how to respond to a BW attack. These 

may be helpful and correct, but insufficient to truly educate the 

public. 

Preparation deceases anxiety. The idea that individuals and 

families can be engaged in taking steps to increase their 

understanding of and preparation for a disaster is empowering, and 

in itself, fosters better mental health in a community. Helping 

others is also therapeutic in times of crisis. Community support 

networks may become activated, including churches, civic groups, 

and even homeowners’ associations. With proper direction, they 

can be extremely helpful in community support functions. 

Recommendations for Base Commanders 

1. Educational seminars for the public on bioterrorism 

should be developed and instituted, and given at regular 

intervals to base personnel, who tend to transition frequently. 

2. Base personnel should be encouraged to have a basic 

minimum of provisions within their homes. 

3. Information on specific potential biological agents and 

appropriate citizen response in the event of the deliberate use of 

that agent should be disseminated to the public to enhance 

knowledge and preparedness. To facilitate this, the base 

readiness team, especially medical contingency teams, should 

have current fact sheets on hand or should be aware of exactly 

how to access very specific information on illnesses and agents. 

The CDC remains the main source of expertise; however, 
Pilch—The Worried Well

43

communication routes should be established with state, county, 

and local health authorities. 

4. The military installation should NOT rely on 

computerized lessons/exercises or website information on BW 

threats. Although these are better than no education at all, 

there are better educational methods for preparedness 

available. Websites should be up and running, and may be 

useful in a crisis. However, it is unlikely that the public will 

access them in the absence of a specific crisis or some kind of 

preparedness exercise that calls their attention to the web 

resource. 

COMPLEX RELATIONSHIPS BETWEEN LEVELS OF 

GOVERNMENT AND OTHER ACTORS 

Clinicians will be essential actors in both the detection and 

response phases of a BW attack. Recognition of diseases will be 

assisted by surveillance mechanisms, but alert physicians are 

equally, if not more, important. Frontline clinicians are also very 

important in dealing with the worried well. In the anthrax crisis, 

they “faced a challenge that often was even more difficult than 

diagnosing anthrax—excluding the diagnosis among the many 

worried patients with concerns about potential exposure among 

those who sought care for rashes or illnesses suggestive of the 

diagnosis. In the absence of algorithms or rapid diagnostic tests, 

their clinical judgment helped reassure patients and avert the 

distraction that initiating unneeded response efforts would have 

otherwise entailed.”80

Effective community response teams will comprise local 

government officials, emergency management officials, public 

health authorities, health care organizations, police, fire, public 

works, emergency medical services, local industry leaders, and 

other key participants. The wider response will involve state public 

health departments and federal agencies, notably the Department of 

Homeland Security, the CDC, and the Department of Health and 
Pilch—The Worried Well 

44

Human Services, among others. This labyrinth of agencies and 

organizations that will be drawn into any crisis situation requires a 

well-thought out communications plan, that is continually updated. 

Exercises and simulations provide important means to test 

communications networks, and to uncover “holes” in the decisionmaking structure. 

Insights from Interviews

A scenario of a bioterrorism event might unfold as follows:81 

an incident increase in a disease or illness would probably be 

detected by a surveillance system such as CEDRS. The State 

Department of Health and pertinent county health department would 

be notified. Local emergency team directors would become 

involved, as would the FBI. There would be an initial notification 

of primary stakeholders, and an Emergency Operations Center 

would be activated. This operations center would include 

representatives from approximately 40-50 agencies. It would serve 

as a center for the gathering and dissemination of information. The 

local director of the Office of Emergency Management would report 

to the military installations, and would ask for information on the 

military installation response (such as potential lockdowns). A 

Crisis Communications Center would become activated, in 

conjunction with the EOC. 

An essential component of the emergency response system in 

Colorado Springs is the Metropolitan Medical Response System 

(MMRS). Even prior to September 11, the Federal Government had 

identified the need for communities to prepare for mass 

emergencies, including natural disasters, epidemics, and terrorist 

incidents. Federal assistance was targeted at first to larger urban 

areas, such as New York, Los Angeles, Chicago, and Washington, 
Pilch—The Worried Well

45

DC. Colorado Springs was identified for the second round of 

funding.82 The MMRS is part of the National Disaster Medical 

System, which is managed by the Department of Health and Human 

Services. The strategic national stockpile of medicines, cached in 

secret locations around the country, also falls under their purview. 

Needed medicines can be rapidly deployed to critical areas under 

this program. 

Military assets can be called upon in the event of an emergency. 

For example, Ft. Carson can provide assets to the local community 

even without permission from the Secretary of Defense and the 

Department of Defense in an immediate emergency (Military 

Assistance to Civil Authorities, MACA). The Governor of 

Colorado can activate the National Guard as well. Colorado 

Springs is in the 8th Federal Region; each Federal Region retains 

civil support teams that can assist the local community. 

In El Paso County, a Multi-Agency Terrorism Task Force 

meets monthly, and constitutes the framework for the EOC. 

Although counterparts from local military installations do 

participate in some of these groups and exercises, some feel there 

has been a decline in joint planning. However, most feel that there 

is excellent communication between military installations and 

Colorado Springs teams. The one possible weakness in cooperation 

identified was in resource-sharing. One community leader noted 

that he suspected that most emergency personnel in the community 

and on the bases probably don’t even know that a resource-sharing 

plan exists; if they do know that, they might not know where it is or 

if it still applies. 

Another pertinent observation was that continuity in planning 

and in maintaining lines of communication is hindered by the 
Pilch—The Worried Well 

46

frequent change in base commanders and other military personnel. 

It was recommended that a position on coordination with the 

community for emergency preparedness be created on installations, 

and that it be filled by a civilian who might have a longer tenure.83 

If there were to be such a position, such as a deputy commander, 

there would be much greater institutional memory and continuity. 

Every person on the medical contingency team at a military 

installation should know his counterpart in the community. 

When asked the question “What do you worry about most in 

terms of a BW event,” the Director of the Colorado Springs Office 

of Emergency Management echoed the sentiments of county 

officials. “I worry that the initial episode will be chaotic, and that 

we will have difficulty getting everyone on the same page. I worry 

about getting the situation organized and getting correct, and not 

incorrect, information to the public. I worry about panic.”84

The City of Colorado Springs has a very active group called DR 

HELP (Disaster Response for Health in El Paso County Task Force 

and Medical Reserve Corps (MRC), created on the initiative of the 

El Paso County Medical Society. It serves as the planning body and 

lead organization to recruit and train volunteer health professionals 

to serve as the MRC of El Paso County and southern Colorado. It is 

designed to integrate health care professionals into disaster planning 

for the community. In the event of a crisis, it serves as the resource 

that will assist in activating health care personnel and DMACs. 

When they are overwhelmed and need to divert, hospitals would 

communicate with the El Paso Department of Health and DR 

HELP. DR HELP will be instrumental in credentialing health care 

workers and in setting up and manning primary and secondary 

DMACs, such as schools and long-term care facilities.85 The report 
Pilch—The Worried Well

47

outlining the role that DR HELP plays in emergency preparedness 

says that “(w)e will bring a greater predictability to volunteer 

resource capability and will be able to demonstrate that we will 

strengthen medical response and can reach “surge” capacity in our 

area. The challenge is to find financial resources in order to 

credential and then further educate and train health professionals.”86

Recommendations for Base Commanders 

1. Base Commanders should establish a position to be filled 

by a civilian to coordinate with local communities on emergency 

preparedness. This would provide historical memory for the 

base commander and would address the problem of continuity 

that confronts emergency planners in the community when 

communicating with the base. 

2. Base Commanders need to know about community 

initiatives, like DR HELP, that may become very important in 

an actual crisis, but may not be readily apparent when looking 

at agency/government networks. Participating in these kinds of 

groups is very advantageous and will enhance a coordinated 

approach to a BW event. 

PREPAREDNESS: MILITARY INSTALLATIONS AND 

LOCAL COMMUNITIES 

It is clear that “(d)etection, diagnosis and mitigation of illness 

and injury caused by biological and chemical terrorism is a process 

that involves numerous partners and activities. Meeting this 

challenge will require special emergency preparedness in all cities 

and states.”87 It is also understood that effects of the use of 

weapons of mass destruction are not limited by geographical 

boundaries, fences, or gates. “If an attack involves terrorism or 

weapons of mass destruction, it doesn’t stop at a fence line. 

Chemical and biological weapons don’t discriminate.”88

As the time period between terrorist crises lengthens, there is a 

tendency to lose focus and intensity. “We must recognize the 

possibility that a determined terrorist organization may not be 
Pilch—The Worried Well 

48

deterred, may evade detection, and may succeed in releasing an 

aerosol of a virulent bacterium, virus, or toxin in a susceptible target 

area such as an airport or stadium. Our current capability to 

effectively respond to such a scenario and minimize the impact is 

far less than needed. The US Armed Forces and the Department of 

Defense have the greatest capability in biologic defense, but the 

responsibility for dealing with the threat of biologic weapon use by 

a terrorist falls on multiple federal, state, and municipal agencies 

and the civilian health care community. Most of the organizations 

are inadequately prepared to deal effectively with the problem.”89 

As previously stressed, “(r)obust systems must be in place for 

dissemination of information during and following the attack. 

Resilience of these systems must be well tested in advance.”90

In responding to a BW attack, the federal government will play 

an important role. However, local communities will almost 

certainly play a far more important and immediate role as people’s 

needs are addressed. They can react quickly to an event, and have 

connections with essential groups and organizations within the 

community that may become activated to play vital support roles. 

Insights from Interviews 

Lt Col Donald Thompson stressed that commanders need to 

fully understand that “bases are not islands.”91 Their personnel live 

in surrounding communities, and children, spouses, workers and 

supplies pass through their gates daily. In the case of the US Air 

Force Academy, for example, there is no longer ambulance service 

on USAFA, but rather a contract with AMR. Fire Departments 

have mutual aid agreements. There are agreements as to the use of 

medical personnel and facilities by the civilian community, but 
Pilch—The Worried Well

49

these agreements may not be relevant in the event of a base 

lockdown.92 

In a BW crisis, bases may be called upon to assist local 

communities in multiple ways; for example, contingency plans 

specify hospitals and clinics on bases that may be needed to 

augment community health facilities. Conversely, local community 

resources are likely to be utilized heavily by base personnel living 

off the base. Local emergency response teams urge that base 

commanders fully coordinate emergency response plans with those 

of the local community in which the base is located. 

Lt Col Thompson noted that contact tracing in the event of an 

intentional infectious disease outbreak will be a critical step in 

controlling the spread of the disease. Because bases and 

communities are so intertwined, contact tracing will require 

extensive cooperation. This will require additional effort and 

resources on the part of base health personnel and community 

personnel.93

The El Paso County Emergency Task Force asked the question 

as to whether, if a quarantine were imposed upon the county or 

portions of the county, a base commander could override that 

decision. One hundred percent of the personnel who work at 

Schreiver AFB, live off base. Clear directives as to decisionmaking authority between state/county/local authorities and base 

commanders need to be established. 

Another example of the importance of communication between 

the military installation and local health authorities was illustrated 

when 10,000 Ft. Carson personnel were vaccinated for smallpox. 

Up to six of those in contact with those vaccinated, not the soldiers 

themselves, had adverse reactions, and some presented at Memorial 
Pilch—The Worried Well 

50

Hospital. There was a lapse in communication between the military 

installation and the County Department of Public Health about these 

adverse reactions.94

The El Paso County Emergency Team continually noted the 

importance of continuity, practicing together, coordination, and 

communication between military installations and their local 

communities. One noted that the MAT, which consists of 60-80 

people and includes military members, is “the best thing our 

community has going for us!”95 This forum provides a regular 

venue for planning and communication between many facets of the 

community, and it includes representation from military 

installations. 

Stephen Dubay, when asked what he would want base 

commanders to know, answered that he would stress the concept of 

military installations partnering with local communities and 

fostering good relationships with civilian counterparts. Building 

trust between leadership of the two entities is critical in a situation 

where a threat does not respect artificial boundaries. He also noted 

the importance of military families having a discussion about their 

family strategies in the event of a crisis, particularly if they are “torn 

apart.” The base commander needs to understand the importance to 

his personnel of the safety of their families.96

Recommendations for Base Commanders 

1. The nature of the interdependence between the military 

installation and the community needs to be understood, as it is 

different in each situation. 

2. The base commander should seek representation on the 

major emergency response forums and teams in the community. 

3. A multitude of agencies and organizations have stakes in 

emergency preparedness. Understanding this complicated and 

complex network of emergency response is extremely difficult, 
Pilch—The Worried Well

51

and cannot be adequately accomplished in the climate of an 

actual crisis. Therefore, a flow-chart of this network should be 

developed and maintained before any crisis takes place. 

STRATEGIES FOR ENGAGING THE PUBLIC 

Although we know that the worried well will be a part of public 

response to a BW incident, we also know that the American people 

have great capacity to react with courage, compassion, and a sense 

of community responsibility during a disaster. However, 

preparedness and planning are essential to such a constructive 

response. Panic need not occur, nor should it be assumed by 

leadership that it automatically will occur. 

However, we also know that people will ignore risk to get to 

their families in times of crises. If families are together, anxiety is 

reduced. The family unit is of primary importance in times of 

crisis. In addition, if people have a plan ahead of time, they do 

better. Panic behavior occurs where choices are limited, such as 

trampling in stadiums or in fires, where exits are few.97

The public can be engaged in many constructive ways to 

address a bioterrorist threat. Giving the public a positive role to 

play, assisting them with self-help measures, helping them 

understand the crisis, the government response, and the plan for 

recovery, making use of trusted local spokespersons and civic 

organizations to disseminate important information, treating the 

media with respect, and engaging the public in frank discussions 

about problems where civil liberties and disease control collide 

(such as containment and quarantine), will pay enormous dividends 

in public cooperation. Panic is “rare and preventable.”98 

True panic responses (for example, where people are trampled 

in attempts to escape burning buildings) occur when a crowd 

perceives no means of escape from a dangerous situation. Many 
Pilch—The Worried Well 

52

studies of catastrophes, however, show that the response of the 

public can be one of “resourcefulness, civility, and mutual aid.”99 

In fact, many experts suggest that “(t)he myths of irrational and 

antisocial behaviour in disaster are not just erroneous—they hamper 

the effectiveness of emergency planning by misdirecting the 

allocation of resources and the dissemination of information. For 

example, expectations of citizen “panic,” often become the 

justification for giving the public incomplete information about an 

environmental threat or withholding information altogether.”100

In a fascinating comparison between a smallpox outbreak in 

Milwaukee in 1894 and another in New York in 1947, the public 

response to government strategies is markedly different. In 1894, 

the outbreak precipitated urban rioting that lasted for one month. In 

New York, where one man brought smallpox back from Mexico, a 

large voluntary mass vaccination program was undertaken. The 

Health Department relied on case tracing, voluntary vaccination, 

and daily press conferences. People felt they were being kept 

informed, and even President Truman came to visit New York, after 

being publicly vaccinated. Lots of volunteer workers helped, as did 

other civic groups. “Public compliance was incredibly high.”101

Public reaction to a crisis is greatly shaped by their perception 

of the competence and trustworthiness of government. Experts on 

the shielding concept note that “(i)t is the opinion of the authors that 

the public response will in part be conditioned by local perceptions 

of the federal government and the trust, or otherwise, in the state 

and local authorities.”102 Engendering trust and confidence needs to 

be given extremely high priority by public officials. 
Pilch—The Worried Well

53

Recommendations to Base Commanders 

1. Do not expect a panic response from the public. Treat 

the public as equal and intelligent partners in the crisis. Expect 

cooperation and positive civic response. 

2. Try to continually build trust and confidence in 

government, by aggressively seeking and disseminating the 

truth and letting the public know your efforts on their behalf. 

LEADERSHIP 

What leadership styles have been shown to be effective in a 

disaster scenario? The importance of leadership during a crisis 

cannot be overemphasized. The trusted leader relates to the public 

with empathy, candor, and courage. He/she is visible and draws on 

reservoirs of public confidence that have been well-established in 

the past. The leader is decisive but not arrogant, confident but not 

falsely optimistic. The leader communicates both what he/she 

knows and what he/she does not know, and assures the public that 

the crisis is being addressed competently. Messages are simple, 

direct, and straightforward; leaders treat the public as intelligent, 

cooperative adults. 

Recently, the Director of the Center for Disease Control was 

asked about her vision of leadership, if a BW event were to occur: 

Q: “As director [of the CDC], you are going to be the focal 

point in a crisis. How will you reach out to Americans? How will 

you quell panic?” 

A: “I don’t have a mature answer to that. It’s something that 

I’m practicing; it’s something that I’m getting training in. I think 

that Mayor Giuliani is a role model of effective communications 

during a crisis. What I observed about his communication was that 

he was consistently there with news. He read the news, he told the 

truth, he said what he knew when he knew it, and he told people 

what he didn’t know and what they were doing about it. He also 
Pilch—The Worried Well 

54

communicated a very strong message of empathy that came across 

as sincere and heartfelt.”103

Additional observations by insiders on Mayor Giuliani’s 

leadership style are, “He embraced that role of being a leader with 

confidence, but not with arrogance. His credibility for that role was 

strengthened by the fact that he was everywhere. He was seen, he 

was very visible.... Another element of his leadership was the 

credibility of his public statements. No doubt there is a great 

temptation for government leaders to put out reassuring and 

comforting statements to the public, but those very same reassuring 

statements can badly damage credibility with a loss of trust when 

the statements are found to be inaccurate or less than an honest 

assessment of their safety.”104

In Dark Winter, the smallpox simulation conducted in 2001, it 

was noted that “(t)he individual actions of US citizens will be 

critical to ending the spread of contagious disease; leaders must 

gain the trust and sustained cooperation of the American people.”105 

To gain cooperation of the public, there must be a perception of 

fairness, and a sense that emergency measures are taken for the 

good of the whole. 

Insights from Interviews 

To facilitate cooperation and an appropriate public response 

during times of great insecurity or crisis, trust in government, 

leadership, and public institutions is essential. This cannot be 

developed overnight; it has to be nurtured continually, so that when 

a crisis erupts, a reservoir of trust and confidence already exists.106 

Recommendations for Base Commanders 

1. Be visible! In times of crisis, people need to see their 

leaders. 
Pilch—The Worried Well

55

2. Be visible before a crisis. During a BW event, 

information from trusted leaders will be absolutely critical. If 

they know who you are, they will look to you for guidance and 

trust what you say. 

3. Emotional support to your personnel in a crisis is as 

important as the more obvious duties you will need to 

coordinate. 

4. Recognize the validity and importance of mental health 

issues. Don’t allow them to be ignored; weigh in against 

stigmatization of those who suffer psychologically during a 

crisis. 

5. Recognize the importance of families to base personnel. 

Military personnel will only be able to function effectively if 

they have confidence that their families are safe. 

6. Be decisive, but not arrogant. Be open and honest with 

your personnel. Treat them as part of the solution to any crisis. 

Enlist their support and cooperation. Don’t be afraid to be 

human. 

CONCLUSION 

The problem of the worried well and mental health 

consequences in the event of a BW crisis deserves serious attention. 

However, it cannot be addressed adequately simply in terms of 

health facility capacity and patient surges or emergency 

preparedness. Understanding how populations might react in an 

actual crisis is important. Populations will worry about their health 

and may present with or without symptoms of various kinds when 

they become aware of an attack. Many will experience heightened 

fear and anxiety, and this will lead to health consequences. Shortand long-term mental health will be implicated for many. 

The question of how base commanders and other base 

leadership should respond to mitigate these effects cannot be looked 

at in a vacuum. Because the threat will undoubtedly not be limited 

to the base exclusive of the surrounding community or vice versa, 

the answer to an effective mental health response has to be looked 
Pilch—The Worried Well 

56

at within the context of the relationship of the military installation to 

the community in emergency preparedness. 

Perceptions of community leaders in El Paso County show that 

cooperation and coordination with bases is highly desirable. 

Cooperation has increased since September 11, but there are still 

some areas where it could be improved. Because communication 

and information are such critical components of emergency 

response, coordinated messages and open lines of communication 

need to be assured. 

Psychological distress and the anxiety of the worried well is 

most effectively addressed through early, straightforward, and 

simple communications from trusted spokespersons. Guidance on 

options and education on risk are essential. The public needs, and 

should be trusted with, knowledge of the incident and its potential 

impact on themselves and their families. They should be supplied 

with plans that can be actualized. Preparedness on the part of the 

public should be encouraged; messages that empower individuals 

and families, and assist them in intelligent planning, will mitigate 

negative psychological consequences. Leadership and 

communication skills become paramount in a crisis, and attention 

should be paid to training in these skills prior to a crisis. Finally, 

networks and cooperation between local communities and military 

installations are essential components of an effective response to a 

crisis. 

While acutely ill patients have to be prioritized in the event of a 

BW attack, attention must also be paid to the worried well and 

others affected psychologically. Long after the immediate crisis is 

over or an infectious disease runs its course, a community/base will 

experience mental health consequences. “How do we reconstruct a 
Pilch—The Worried Well

57

belief in justice and safety in the wake of a mass terrorist attack? 

Without attention to mental health, i.e. the ‘psychological side of 

terrorism,’ we run the risk of rebuilding a nation without a spirit, 

without vitality, without a sense of humanity.”107 The manner in 

which the issue of the worried well and psychologically traumatized 

is handled during a BW attack matters; it will have significant 

implications for the long-term mental health of our nation. 

NOTES 

 

1

 Experts on bioterrorism are increasingly calling for more 

sophisticated threat assessment and risk management techniques. The 

central question is whether it is possible to do objective assessments of 

the risk of bioterrorism that would include identifying a hierarchy of 

bioterrorist threats, intents and goals of groups, technical capabilities of 

groups/individuals, attributes of pathogens or toxins of utility to 

terrorists, and range of possible targets. Associated with each threat are 

potential outcomes, and cost consequences. See Raymond Zilinskas 

(Rapporteur), “Bioterrorism Threat Assessment and Risk Management 

Workshop: Final Report and Commentary,” Presented to the US 

Department of Energy, June 24, 2003 (Monterey: Monterey Institute of 

International Studies, 2003). 

2

 “Biological and Chemical Terrorism: Strategic Plan for Preparedness 

and Response,” Recommendations of the CDC Strategic Planning 

Workgroup. Available on-line at http://www.cdc.gov/mmwr/preview/ 

mmwrhtml/rr4904a1.htm, 16 and 17. 

3

 Apatow, Stephen, “Weapons of Mass Destruction, Nonproliferation 

and International Security.” Available on-line at 

http://www.humanitarian.net, October 15, 2002. 

4

 Zilinskas, Raymond A., “Combating Terrorism: Assessing the Threat 

of Bio Terrorism,” Statement before the US House of Representatives 

Committee on Government Reform, Subcommittee on National 

Security, Veterans Affairs, and International Relations, October 20, 

1999. Available on-line at http://chem-bio.com/resource.1999/ 

zilinskas102099.html. 

5

 Zilinskas, “Combatting Terrorism.” 

6

 Zilinskas, “Combatting Terrorism.” 

7

 Benedek, David M., Holloway, Harry, and Becker, Steven M, 

“Emergency Mental Health Management in Bioterrorism Events,” 
Pilch—The Worried Well 

58

 

Emergency Medicine Clinics of North America, Volume 20 (2002): 

394. 

8

 Charles C. Benight, PhD, Associate Professor of Psychology and 

Director of UCCS Trauma Center, interview, September 25, 2003. 

9

 Croddy, Eric, et al, “Chemical and Biological Terrorism: A Unique 

Threat,” in Disaster Nursing and Emergency Preparedness for 

Chemical, Biological, and Radiological Terrorism, Veenema, Tener 

Goodwin, editors (New York: Springer Publishing Company, 2003), 

15. 

10 Benedek, Holloway, and Becker, “Emergency Mental Health 

Management in Bioterrorism Events,” 403. 

11 “Mass Psychogenic Illness,” Information from primary care 

organization, available on-line at http://www.familydoctor.org/ 

handouts/648.html. 

12 “Unforeseen Consequences of Terrorism,” Commentary, Archives of 

Internal Medicine, Volume 162 (September 9, 2002): 1809. 

13 “Unforeseen Consequences of Terrorism.” 

14 Silver, R.C., Holman, E.A., McIntosh, D.N., Poulin, M, Gil-Rivas, 

V., “Nationwide Longitudinal Study of the Psychological Responses to 

September 11,” Journal of the American Medical Association, Volume 

288, Number 10, 1235-1244. 

15 Becker, Steven M., “Are the Psychosocial Aspects of Weapons of 

Mass Destruction Incidents Addressed in the Federal Response Plan: 

Summary of an Expert Panel,” Military Medicine, Volume 166, Suppl. 

2:66 (2001): 66. 

16 Becker, “Are the Psychosocial Aspects of Weapons of Mass 

Destruction Incidents Addressed in the Federal Response Plan,” 1810. 

17 Becker, “Are the Psychosocial Aspects of Weapons of Mass 

Destruction Incidents Addressed in the Federal Response Plan,” 1810. 

18 Benight, C.C., Freyaldenhoven, R.W., Hughes, J., Ruiz, J.M., 

Zoschke, T.A., and Lovallo, W.R., “Coping Self-Efficiency and 

Psychological Distress Following the Oklahoma City Bombing,” 

Journal of Applied Social Psychology, Number 30 (2000): 1331-1344. 

19 Charles C. Benight, PhD, Interview, September 25, 2003. 

20 Becker, Stephen, “Psychosocial Effects of Radiation Accidents,” 

Medical Management of Radiation Accidents 2nd Ed. (New York: CRC 

Press, 2001), 521. 
Pilch—The Worried Well

59

 

21 Becker, “Psychosocial Effects of Radiation Accidents.” These 

groups were identified as being especially at risk in studies on radiation 

accidents. 

22Croddy, Eric et al, “Chemical and Biological Terrorism: A Unique 

Threat,” 6. 

23 Arnie Lavelett, Commander Emergency Services Division, El Paso 

County Sheriff’s Office; Larry Schaad, DVM, MPH, Chief, Health 

Systems Development, El Paso County Department of Health and 

Environment; Jim Mesite, Emergency Program Manager El Paso 

County Sheriff’s Office; and Jim Reid, Assistant Fire Marshall, 

Emergency Services Division, El Paso County Sheriff’s Office—Group 

Roundtable Interview, September 25, 2003. 

24 Colorado Springs Gazette, August 19, 2003, Metro 1 and 2. 

25 http://www.geis.ha.osd.mil/GEIS/Surveillance Activities/ESSENCE/ 

ESSENCE.asp. 6/3/2003. 

26 http://www.sho.int.csr/delibepidemics/faqbioagents/en/, 9/11/2003. 

27 “Anthrax Clinical Pathways for Clinics” (Updated 01/09/02), 

Stanford University Medical Center. 

28 “Defending against Biological Terrorism,” US Department of 

Homeland Security Press Release, February 5, 2002. Available on-line 

at http://www.dhs.gov/dhspublic/display?theme=34&content=63. 

29 Ho, Andy, “What If Bio-terrorists Strike in Singapore?” The Straits 

Times, May 29, 2003. Available on-line at http://straitstimes.asia1. 

com.sg/columnist/0,1886,56-189377,00.html. 

30 Arnie Lavelett et al, Group Roundtable Interview, September 25, 

2003. 

31 Georgia Division of Public Health, Bioterrorism Slide Show, “Care 

of Sick and Worried Well.” Available on-line at http://www.ph.dhr. 

state.ga.us/programs/emerprep/bioterrorism.shtml. 

32 “Bioterrorism and the ‘Worried Well,’” Science and Technology 

Perspective, 1st Quarter 2003. 

33 Benedek, Holloway, and Becker, “Emergency Mental Health 

Management in Bioterrorism Events,” 394-5. 

34 Benedek, Holloway, and Becker, “Emergency Mental Health 

Management in Bioterrorism Events,” 395. 

35 Benedek, Holloway, and Becker, “Emergency Mental Health 

Management in Bioterrorism Events,” 395. 
Pilch—The Worried Well 

60

 

36“Improving Local and State Agency Response to Terrorist Incidents 

Involving Biological Weapons,” Prepared in response to the NunnLugar-Domenici Domestic Preparedness Program by the Department of 

Defense, September 12, 2000. Available on-line at 

http://www2.sbccom.army.mil/hld/downloads.bwirp/bwirp_interimplanning_guide.pdf. 

37 Saathoff, Gregory and Everly, George, “Psychological Challenges of 

Bioterror: Containing Contagion,” International Journal of Emergency 

Mental Health, Volume 4, Number 4 (Fall 2002): 249. 

38 Neal L. Cohen, MD, NYC Commissioner of Department of Public 

Health, 1998-2002. Speech, May 30, 2002. Reported on-line at 

http://www.ben.edu/semp/archives/biots/biot05.pdf. 

39 Cohen Speech. 

40 Cohen Speech. 

41 Reynolds-Cane, Dianne, “Educating Patients and the ‘Worried 

Well,’” Michigan State Medical Society, Thursday May 29, 2003. 

Available on-line at http://www.msms.org/peml/bdfs/ 

ramifications5.html. 

42 Benedek, Holloway, and Becker, “Emergency Mental Health 

Management in Bioterrorism Events,” 395. 

43 Benedek, Holloway, and Becker, “Emergency Mental Health 

Management in Bioterrorism Events,” 402. Loved ones may include 

friends, children, and pets! 

44 Benedek, Holloway, and Becker, “Emergency Mental Health 

Management in Bioterrorism Events,” 402. 

45 Benedek, Holloway, and Becker, “Emergency Mental Health 

Management in Bioterrorism Events,” 405 

46 Gursky, Elin; Inglesby, Thomas V.; and O’Toole, Tara, “Anthrax 

2001: Observations on the Medical and Public Health Response,” 

Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and 

Science, Volume 1, Number 2 (2003): 105. 

47 Gursky, Inglesby, and O’Toole, “Anthrax 2001,” 105. 

48 Gursky, Inglesby, and O’Toole, “Anthrax 2001,” 106. 

49 Gursky, Inglesby, and O’Toole, “Anthrax 2001,” 109. 

50 Glass, Thomas and Schoch-Spana, Monica, “Bioterrorism and the 

People: How to Vaccinate a City against Panic,” Clinical Infectious 

Diseases, Volume 34, Number 2 (January 15, 2002): 217. 
Pilch—The Worried Well

61

 

51 Lavelett, et al, Group Roundtable Interview, September 25, 2003. 

52 Stephen Dubay, City of Colorado Springs, Director Office of 

Emergency Management, interview, September 23, 2003. 

53 Lt Col Donald Thompson, Office of the Surgeon General, 

Northcomm, interview, September 15, 2003. 

54 DiGiovanni, C., Jr; Reynolds, B.; Harwell, R.; Stonecipher, E. B.; 

and Burkle, F. M., “Community Reaction to Bioterrorism: Prospective 

Study of Simulated Outbreak,” Emerging Infectious Disease (June 

2003): 6. Available on-line at http://www.cdc.gov/ncidod/EID/ 

vol9no6/02-0769.htm. 

55 DiGiovanni, et al, “Community Reaction to Bioterrorism,” 7. 

56 Schock-Spana, Monica, “A West Nile Virus Post-Mortem,” 

Biodefense Quarterly, Volume 1, Number 3 (December 1999). 

57 Saathoff, Gregory and Everly, George, “Psychological Challenges of 

Bioterror: Containing Contagion,” International Journal of Emergency 

Mental Health, Volume 4, Number 4 (Fall 2002): 255. 

58 Lavelett, et al, Group Roundtable Interview, September 25, 2003. 

59 For an excellent study of the implications of the West Nile virus 

crisis for an intentional disease outbreak, see Schock-Spana, “A West 

Nile Virus Post-Mortem.” 

60 Schoch-Spana, “A West Nile Virus Post-Mortem,” 5. 

61 http://www.af.mil/stories/story_print.asp?storyID=123005340. 

62 “The Role of Communities in Bioterrorism Response and Recovery,” 

Illinois Department of Public Health. Available on-line at 

http://www.app.idph/state.il/us/phfi/pdfs/mrichards.pdf. 

63 O’Toole, Tara; Mair, Michael; and Inglesby, Thomas V., “Shining 

Light on ‘Dark Winter,’” Clinical Infectious Diseases, Volume 34 

(2002): 982. 

64 Lavelett, et al, Group Roundtable Interview, September 25, 2003. 

65Barbera, Joseph; Macintyre, Anthony; Gostin, Larry; Inglesby, Tom; 

O’Toole, Tara; DeAtley, Craig; Tonat, Kevin; and Layton, Marci, 

“Large-Scale Quarantine Following Biological Terrorism in the United 

States,” Journal of the American Medical Association, Volume 286 , 

Number 21 (December 5, 2001): 6. 

66 Croddy, et al, “Chemical and Biological Terrorism,” 1. 
Pilch—The Worried Well 

62

 

67 DiGiovanni, C. Jr.; Reynolds, B.; Harwell, R.; Stonecipher, E. B.; 

and Burkle, F. M., “Community Reaction to Bioterrorism: Prospective 

Study of Simulated Outbreak,” Emerging Infectious Disease. Serial 

On-line, June 2003, 4. Available at http://www.cdc.gov/ncidod/EID/ 

vol9no6/02-0769.htm. 

68 Inglesby, Thomas V.; Grossman Rita; and O’Toole, Tara, “A Plague 

on Your City: Observations from TOPOFF,” Clinical Infectious 

Diseases, Volume 32 (2001): 442. 

69 The Critical Incident Analysis Group at the University of Virginia 

School of Medicine is credited with advancing this concept. See for 

example, “Critical Incident Analysis Group, Fourth Annual 

Conference, April 2-3, 2001,” Public Responsibility and Mass 

Destruction: Facing the Threat of Bioterrorism (Charlottesville: 

University of Virginia, 2001). See also Prior, Stephen D.; Ford, 

Rowan; and Saathoff, Gregory, “Foundations of Shielding,” 

International Journal of Emergency Mental Health, Volume 4, Number 

4 (Fall 2002): 235-238. 

70 Prior, Ford, and Saathoff, “Foundations of Shielding,” 237. 

71 Prior, Ford, and Saathoff, “Foundations of Shielding,” 237. 

72 Saathoff, Gregory and Everly, George, “Psychological Challenges of 

Bioterror: Containing Contagion,” International Journal of Emergency 

Mental Health, Volume 4, Number 4 (Fall 2002): 249. 

73 Spaulding, Suzanne E.; Bonnie, Richard L.; and Bernheim, Ruth 

Gaare, “Legal Framework for Shielding,” International Journal of 

Emergency Mental Health, Volume 4, Number 4 (Fall 2002): 261. 

74 Lt Col Donald Thompson, interview, September 15, 2003. 

75 Thompson, Donald F., “Bioterrorism: USNORTHCOM 

Preparedness and Response,” Unpublished Briefing, 2003. 

76 Lavelett, et al, Group Roundtable Interview, September 25, 2003. 

77 Stephen Dubay, interview, September 23, 2003. 

78 Telephone Interview, Stephen Prior, September 19, 2003. 

79 “Preparing Makes Sense: Get Ready Now,” Department of 

Homeland Security brochure available at http://www.ready.gov. 

80 Gerberding, Julie Louise; Hughes, James; and Koplan, Jeffrey, 

“Bioterrorism Preparedness and Response,” Journal of the American 

Medical Association, Volume 287, Number 7 (February 20, 2002): 

898. 
Pilch—The Worried Well

63

 

81 Steven Dubay, interview, September 23, 2003 and group interview, 

El Paso County Emergency Response Team, September 25, 2003. 

82 Steven Dubay, interview, September 23, 2003. 

83 Lavelett et al, Group Roundtable Interview, September 25, 2003. 

84 Lavelett et al, Group Roundtable Interview, September 25, 2003. 

85 DR HELP (Disaster Response for Health in El Paso County), 

monthly meeting, September 23, 2003. 

86 Brochure outlining DR HELP’s purpose and participants, who 

include the American Red Cross, Colorado Nurses Association, 

Memorial Hospital, TriCare Central Region, and the US Air Force 

Academy, among others. 

87 “Biological and Chemical Terrorism: Strategic Plan for Preparedness 

and Response,” Recommendations of the CDC Strategic Planning 

Workgroup. Available on-line at http://www.cdc.gov/mmwr/preview/ 

mmwrhtml/rr4904a1.htm. 

88 Maj Gen John Doesburg, quoted from his speech at a bioterrorism 

conference of military, state, and local officials from across the nation. 

Reported on-line through the Global Security Newswire, 

http://www.nti.org/d_newswire/issues/2002/2/13/3s.html. 

89 Russell, Philip K., “Biologic Terrorism—Responding to the Threat,” 

Emerging Infectious Diseases, Volume 3, Number 2 (April-June 1997): 

1. Available on-line at http://www.cdc.gov/ncidod/EID/vol3no3/ 

russell.htm. 

90 Benedek, Holloway, and Becker, “Emergency Mental Health 

Management in Bioterrorism Events,” 402. 

91 Lt Col Donald Thompson, interview, Sept. 15, 2003. 

92 Maj Mike Bailes, interview, September 26, 2003. 

93 Maj Mike Bailes, interview, September 26, 2003. 

94 Lavelett et al, Group Roundtable Interview, September 25, 2003. 

95 Lavelett et al, Group Roundtable Interview, September 25, 2003. 

96 Stephen Dubay, interview, September 23, 2003. 

97 Charles C. Benight, PhD, interview, September 25, 2003. 

98 Glass and Schoch-Spana, “Bioterrorism and the People,” 218. 

99 Glass and Schoch-Spana, “Bioterrorism and the People,” 218. 
Pilch—The Worried Well 

64

 

100 Perry, Ronald W. and Lindell, Michael K., “Understanding Citizen 

Response to Disasters with Implications for Terrorism,” Journal of 

Contingencies and Crisis Management, Volume 11, Issue 2 (June 

2003): 50. 

101 Leavitt, Judith W., “Public Resistance or Cooperation? Historical 

Experiences with Smallpox,” The Public as an Asset, Not a Problem: 

A Summit on Leadership During Bioterrorism, Johns Hopkins Center 

for Civilian Biodefense Strategies. On-line at http://www.hopkinsbiodefense.org/pages.events/peoplesrole/panel/panel_trans.html. 

102 Prior, Ford, and Saathoff, “Foundations of Shielding,” 237. 

103 Drexler, Madeline, “An Interview with CDC Director Julie 

Gerberding,” Biosecurity and Bioterrorism: Biodefense Strategy, 

Practice, and Science, Volume 1, Number 1 (2003): 17-18. 

104 Cohen, Neal L., “Leadership’s Role in Helping New Yorkers Prevail 

after 9/11,” The Public as an Asset, Not a Problem: A Summit on 

Leadership During Bioterrorism, Johns Hopkins Center for Civilian 

Biodefense Strategies. On-line at http://www.hopkins-biodefense.org/

pages.events/peoplesrole/panel/panel_trans.html. 

105 O’Toole, Tara; Mair, Michael; and Inglesby, Thomas V., “Shining 

Light on ‘Dark Winter,’” Clinical Infectious Diseases, Volume 34 

(2002): 982. 

106 The importance of trust in leadership and government was 

mentioned in every interview, and emphasized by Lt Col Donald 

Thompson, Dr Stephen Prior, and Dr Charles Benight. 

107 Saathoff and Everly, “Psychological Challenges of Bioterror,” 251. 

INTERVIEWS CONDUCTED 

Richard F. Pilch, MD, Scientist in Residence, Center for NonProliferation Studies, Monterey, CA, May 28-June 4, 2003. 

Lt Col Donald Thompson, Office of the Surgeon General, Northern 

Command, Sept. 15, 2003. 

Stephen Prior, Potomac Institute for Policy Studies, Critical Incidents 

Analysis Group, telephone interview, Sept. 19, 2003. 

Stephen Dubay, Director Office of Emergency Management, Fire 

Department, City of Colorado Springs, September 23, 2003. 

Charles C. Benight, PhD, Associate Professor of Psychology and 

Director of UCCS Trauma Center, September 25, 2003. 
Pilch—The Worried Well

65

 

DR HELP (Disaster Response for Health in El Paso County), observed 

monthly meeting, September 23, 2003. 

Arnie Lavelett, Commander Emergency Services Division, El Paso 

County Sheriff’s Office; Larry Schaad, DVM, MPH, Chief, Health 

Systems Development, El Paso County Department of Health and 

Environment; Jim Mesite, Emergency Program Manager El Paso 

County Sheriff’s Office; and Jim Reid, Assistant Fire Marshall, 

Emergency Services Division, El Paso County Sheriff’s Office—Group 

Roundtable Interview, September 25, 2003. 

Maj Mike Bailes, USAF Academy Medical Readiness and Plans, 

September 26, 2003. 

Sandra Knight, PhD, President of the Mental Health Association of the 

Pikes Peak Region, October 3, 3002. 

WORKS REFERENCED 

Journal Articles, Commentaries, Edited Volumes, Books 

Barbera, Joseph, Macintyre, Anthony, Gostin, Larry, Inglesby, Tom, 

O’Toole, Tara, DeAtley, Craig, Tonat, Kevin, and Layton, Marci, 

“Large-Scale Quarantine Following Biological Terrorism in the United 

States,” Journal of the American Medical Association, Volume 286 , 

Number 21 (December 5, 2001): 2711-2717. 

Barkun, Michael, “Community Shielding and the Political System,” 

International Journal of Emergency Mental Health, Volume 4, Number 

4 (Fall 2002): 265-270. 

Becker, Steven M., “Psychosocial Effects of Radiation Accidents.” 

Becker, Steven M. et al, “Bioterrorism and the Emergency Physician: 

On the Front Lines,” Emergency Medicine Practice, Volume 4, 

Number 7 (July 2002). 

Becker, Steven M., “Meeting the Threat of Weapons of Mass 

Destruction Terrorism: Toward a Broader Conception of Consequence 

Management,” Military Medicine, Volume 166, Suppl. 2:13 (2001). 

Becker, Steven M., “Are the Psychosocial Aspects of Weapons of Mass 

Destruction Incidents Addressed in the Federal Response Plan: 

Summary of an Expert Panel,” Military Medicine, Volume 166, Suppl. 

2:66 (2001). 

“Management in Bioterrorism Events,” Emergency Medicine Clinics of 

North America, Benedek, David M., Holloway, Harry, and Becker, 

Steven M., Emergency Mental Health Volume 20 (2002): 393-407. 
Pilch—The Worried Well 

66

 

Benight, C.C., Freyaldenhoven, R.W., Hughes, J., Ruiz, J.M., Zoschke, 

T.A., and Lovallo, W.R., “Coping Self-Efficiency and Psychological 

Distress Following the Oklahoma City Bombing,” Journal of Applied 

Social Psychology, Number 30 (2000): 1331-1344. 

Brown, Bertram S., and Prior, Stephen D., “Public Health and Public 

Trust: The Defining Dyad for the 21st Century,” International Journal 

of Emergency Mental Health, Volume 4, Number 4 (Fall 2002): 239-

244. 

Casani, Julie, Matuszak, Diane, and Benjamin, Georges., “Under Siege: 

One State’s Perspective of the Anthrax Events of October/November 

2001,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, 

and Science, Volume 1, Number 1 (2003): 43-45. 

Cohen, Neal L., “The New York City Experience,” Speech on May 30, 

2002. Available on-line at http://www.ben.edu/semp/archives/biots/ 

biot05.pdf. 

Critical Incident Analysis Group, What is to be Done? Emerging 

Perspectives on Public Responses to Bioterrorism, (Charlottesville: 

University of Virginia School of Medicine, 2002). 

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Democracy (Charlottesville: University of Virginia, 2001). 

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2001, Public Responsibility and Mass Destruction: Facing the Threat 

of Bioterrorism (Charlottesville: University of Virginia, 2001). 

Croddy, Eric et al, “Chemical and Biological Terrorism: A Unique 

Threat,” Disaster Nursing and Emergency Preparedness for Chemical, 

Biological, and Radiological Terrorism, Veenema, Tener Goodwin, 

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Darling, Robert G., et al, Emergency Medicine Clinics of North 

America: Bioterrorism (Philadelphia: Saunders, 2002). 

DiGiovanni, C. Jr, Reynolds, B, Harwell, R, Stonecipher, E. B., and 

Burkle, F. M., “Community Reaction to Bioterrorism: Prospective 

Study of Simulated Outbreak.” Emerging Infectious Disease, Serial 

On-line, June 2003. Available at 

http://www.cdc.gov/ncidod/EID/vol9no6/02-0769.htm. 

Drexler, Madeline, “An Interview with CDC Director Julie 

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Practice, and Science, Volume 1, Number 1, 2003, 15-18. 

Everly, George S., “Responding to Bioterrorism and Psychological 

Toxicity: An Introduction to the Concept of Shielding,” International 
Pilch—The Worried Well

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Journal of Emergency Mental Health, Volume 4, Number 4 (Fall 

2002): 231-234. 

Gerberding, Julie Louise, Hughes, James, Koplan, Jeffrey, 

“Bioterrorism Preparedness and Response,” Journal of the American 

Medical Association, Volume 287, Number 7 (February 20, 2002): 

898-900. 

Glass, Thomas and Schoch-Spana, Monica, “Bioterrorism and the 

People: How to Vaccinate a City against Panic,” Clinical Infectious 

Diseases, Volume 34, Number 2 (January 15, 2002). 

Gursky, Elin, Inglesby, Thomas V., and O’Toole, Tara, “Anthrax 2001: 

Observations on the Medical and Public Health Response,” Biosecurity 

and Bioterrorism: Biodefense Strategy, Practice, and Science, Volume 

1, Number 2 (2003): 97-109. 

Hughes, James M. and Gerberding, Julie Louise’, “Anthrax 

Bioterrorism: Lessons Learned and Future Directions,” Emerging 

Infectious Diseases, Volume 8, Number 10 (October 2002). Available 

on-line at http://www.cdc.gov/ncidod/EID/vol8no10/02-0466.htm. 

Inglesby, Thomas V., Grossman Rita, and O’Toole, Tara, “A Plague on 

Your City: Observations from TOPOFF,” Clinical Infectious Diseases, 

Volume 32 (2001): 436-445. 

Kwik, Gigi, “So What Can We Learn About Epidemics after 

Recovering from SARS?” Biodefense Quarterly, Volume 5, Number 2 

(Autumn 2003): 1 and 9. 

Monaghan, Karen, “SARS: Down but Still a Threat,” ICA 2003-09. 

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Nuzzo, Jennifer and Schoch-Spana, Monica, “Parity for Mental Health 

in Public Health Preparedness,” Biodefense Quarterly, Volume 5, 

Number 2 (Autumn 2003), 3 and 10. 

O’Toole, Tara, “Bioterrorism Response: Proposed Planning 

Assumptions and Actions.” USNORTHCOM Briefing, April 18, 2003. 

O’Toole, Tara, Mair, Michael, and Inglesby, Thomas V., “Shining 

Light on ‘Dark Winter,’” Clinical Infectious Diseases, Volume 34 

(2002): 972-983 

Perry, Ronald W. and Lindell, Michael K., “Understanding Citizen 

Response to Disasters with Implications for Terrorism,” Journal of 

Contingencies and Crisis Management, Volume 11, Issue 2 (June 

2003). 
Pilch—The Worried Well 

68

 

Pilch, Richard F., “Smallpox: Threat, Vaccine, and U.S. Policy,” VI 

Part Series available on-line at http://cns.miis.edu/pubs/week/pdf/ 

smallpox.pdf. 

Prior, Stephen D., “Appendix: Smallpox Outbreak: Critical Incident 

Management,” International Journal of Emergency Mental Health, 

Volume 4, Number 4 (Fall 2002): 277-280. 

Prior, Stephen D., “The Implementation of Shielding,” International 

Journal of Emergency Mental Health, Volume 4, Number 4, (Fall 

2002): 271-278. 

Prior, Stephen D., Ford, Rowan, and Saathoff, Gregory., “Foundations 

of Shielding,” International Journal of Emergency Mental Health, 

Volume 4, Number 4 (Fall 2002, 235-238. 

Reynolds-Cane, Dianne L., “Educating Patients and the ‘Worried 

Well,’” Michigan State Medical Society. Available on-line at 

http://www.msms.org/peml/bdfs/ramifications5.html. 

Roberts, Brad and Moodie, Michael, “Biological Weapons: Toward a 

Threat Reduction Strategy,” Defense Horizons, Number 15 (July 2002). 

Rowan, Ford, “Public Participation and Risk Communication,” 

International Journal of Emergency Mental Health, Volume 4, Number 

4 (Fall 2002): 253-258. 

Russell, Philip K., “Biologic Terrorism—Responding to the Threat,” 

Emerging Infectious Diseases. Volume 3, Number 2. Available on-line 

at http://www.cdc.gov/ncidod/EID/vol3no2/russell.htm. 

Saathoff, Gregory and Everly, George, “Psychological Challenges of 

Bioterror: Containing Contagion,” International Journal of Emergency 

Mental Health, Volume 4, Number 4 (Fall 2002): 245-253. 

Schock-Spana, Monica, “A West Nile Virus Post-Mortem,” Biodefense 

Quarterly, Volume 1, Number 3 (December 1999). 

Silver, R.C., Holman, E.A., McIntosh, D.N., Poulin, M, Gil-Rivas, V., 

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288, Number 10, 1235-1244. 

Spaulding, Suzanne E., Bonnie, Richard L., and Bernheim, Ruth Gaare, 

“Legal Framework for Shielding,” International Journal of Emergency 

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Thompson, Donald F., “Bioterrorism: USNORTHCOM Preparedness 

and Response.” Unpublished Briefing, 2003. 
Pilch—The Worried Well

69

 

Tyler, Patrick, “Germ War, a Current World Threat, Is a Remembered 

Nightmare in China,” New York Times, February 4, 1997, A6. 

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162 (September 9, 2002): 1809-1813. 

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Reports and Symposia 

“Basic Metropolitan Medical Response System Plan for the Colorado 

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Department of Health and Human Services, 12 April 2002. 

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Response,” Recommendations of the CDC Strategic Planning 

Workgroup. Available on-line at http://www.cdc.gov/mmwr.preview/ 

mmwrhtml/rr49041l.htm. 

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Sick and Worried Well.” Available on-line at 

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Illinois Department of Public Health Bioterrorism Leadership Team, 

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mrichards.pdf. 

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Pilch—The Worried Well 

70

 

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March 2003. 

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Websites: Information on Biological Weapons Threat 

Agency for Healthcare Research and Quality, Department of Health 

and Human Services, Bioterrorism Planning and Response, on-line 

resources at http://ahcpr.gov. 

Center for Disaster Preparedness, University of Alabama, on-line 

resources at http://bioterrorism.uab.edu. 

Center for Disease Control on-line resources available at 

http://www.cdc.gov. For specific information on bioterrorism, see 

http://www.bt.cdc.gov. 

Center for Non-Proliferation Studies, Monterey Institute of 

International Affairs, on-line resources at http://cns.miis.edu. 

Center for the Study of Bioterrorism, St. Louis University, on-line 

resources available at http://www.bioterrorism.slu.edu. See also their 

emerging infectious diseases website, available through their 

homepage. 

Department of Homeland Security, on-line resources at 

http://ready.gov. 
Pilch—The Worried Well

71

 

Georgia Department of Public Health. “Guidelines for Biologic 

Disaster Planning in Hospitals.” Available on-line at 

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Humanitarian Resource Institute, resources available on-line at 

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Health Affairs Information Website for the U.S. Department of 

Defense, http://www.ha.osd.mil

World Health Organization, Communicable Disease Surveillance and 

Response, Preparedness for Deliberate Epidemics, resources available 

on-line at http://www.who.int/csr/delibepidemics/sac/en/index.html. 
Pilch—The Worried Well 

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