by Steven Crimando
In Part I of this article, the point was made that CBRN events (with the E for explosives purposefully left out of this discussion) were unlike other types of disasters in the psychosocial impact. Due to the prolong and ongoing threat of long-term health problems, exposure to CBRN agents is more likely to result in a chronic stress reaction, rather than the acute stress reactions typically associated with natural and man-made disasters, including acts of conventional terrorism using high-yield explosives.
Pandemic influenza may share other psychodynamics with CBRN hazards. Both scenarios are potentially “silent disasters” or “invisible threats”. One cannot see, hear, feel or taste the presence of many chemical, biological or radiological agents. Likewise, during the asymptomatic phase of the illness, one might be a carrier of the disease or exposed to others who are not yet aware they are sick. As a general state, people are typically more afraid of what they don’t know, than what they do. “Uncertainty in illness” is a universal source of anxiety, across ages and cultures.
In Part I of this article it was mentioned that unlike other forms of disaster, health emergencies do not have “bookends.” This means that it would be difficult to know exactly when the event began, when it ended, and exactly who was in the impact zone. Most natural and technological disasters are confined to a limited area, making mutual aid from surround communities possible. The possibility that thousands or tens of thousands of communities might be experiencing the pandemic simultaneously, combined with restricted movement, leads to a potentially overwhelming scenario in which the opportunity mutual aid is greatly diminished.
The expectation that the pandemic will occur in wave also greatly compounds the emotional and behavioral impact of the event. Stress research has clearly established that we, as humans, are better suited to cope with short-term, acute stress, rather than long-term, chronic stress. The results of prolonged stress exposure on individuals and communities can erode both physical and mental health, as well as the overall social fabric. A prolonged emergency occurring in waves is a worst case scenario from the stand point of psychological stress.
The psychosocial affects are much greater in number and in complexity than can be fully addressed in this article. They are in many ways like that great mass of an iceberg that remains below the surface. The emotional consequences of a pandemic may in fact be as great or greater than the medical consequences, and represent a significant challenge to emergency management professionals, health care workers and first responders who will be mobilized during a prolong health crisis. The cascading financial impact on markets, businesses and households can only further exacerbate the emotional impact of a pandemic. As mentioned, there are myriad factors related to pandemic influenza that may stimulate intense emotional and behavioral reactions that in turn may represent great challenges to the overall response and recovery from the event.
There are no established predictive models for the behavioral and emotional response to pandemic influenza
Although the emotional and behavioral consequences of unconventional terrorism is a relatively new area of academic inquiry, much is known that can help emergency management professionals and first responders predict and prepare of the short- and long term reactions of both individuals and communities. The same can not be said of pandemic influenza.
A comprehensive review of the literature yields no empirical studies addressing the behavioral or emotional consequences of a pandemic. The concepts used today to discuss mental health and human behavior was not in existence during the last great pandemic. The concept of a diagnosable traumatic stress disorder did not fully come into the literature until after the Viet Nam war. The bottom-line is that there are no existing models for the emotional and behavioral response that may grip the public during a long emergency, such as a global disease outbreak occurring in successive waves. What is called for is an entirely new paradigm for anticipating the human response to such a threat that may truly inform planners and responders in a way facilitates the best-possible response to the worst case scenario.
Leaders and policymakers must consider the following questions:
What are the range and severity of the expected emotional and behavioral consequences?
To what extent will these emotional and behavioral consequences affect the public health response?
What strategies and techniques should be used to reduce the emotional and behavioral consequences of a pandemic influenza?
No pandemic influenza plan can be considered complete until the emotional and behavioral dynamics have been integrated into the weave of the overall mitigation effort. The psychosocial impact on the general public, healthcare workers, emergency responders, and other groups cannot be ignore. Failure to anticipate the human factor in such a complex emergency is an invitation for disaster.
The concepts discussed in this article are considered evidence-informed assumptions about the risk of pandemic and the likely emotional and behavioral responses to such an event. There have been no detailed studies, no clinical trials or longitudinal outcome data. During the last great pandemic of 1918 very little was documented about the emotional and behavioral response of the public, so much was what is discussed here is extrapolated from other data sets sharing similar threat elements as a pandemic. Having made the appropriate and obligatory disclaimers, there are some very foreseeable emotional and behavioral responses to pandemic influenza that emergency managers and first responders must factor into their response and recovery strategies. Those foreseeable responses are the focus of this article.
Emotional and Behavioral Responses
For the sake of clarity, it is important to understand the distinction between emotional responses to disasters and other traumatic events. In this context the emotional response refers to what is typically thought of as “mental health” issues. For example, the numbers of those with either diagnosable and sub diagnosable depression, anxiety, posttraumatic stress, other mental health problems are likely to skyrocket following a 12 plus month health crisis that results in a tremendous loss of life, disruption of personal, professional, and social functioning.
It is also foreseeable that those in the population who already have some sort of pre-existing mental health problem may experience an exacerbation of their condition due increased stress, separation from caregivers and supportive programs, as well as disruption in psychiatric medications. These sorts of new or restimulated mental health problems are considered the emotional responses to a pandemic or other health emergency.
Behavioral responses are those reactions such as panic, hoarding medications or supplies, non-compliance with vaccination or quarantine orders, and so on. They are not the signs or symptoms of a mental illness, but rather significant behavioral alterations that may cause further harm, to the individual, the community or to the larger society.
One landmark study highlights the fact that emergency management professionals often fail to properly predict human behavior in crisis conditions. If you have not yet read the “Redefining Readiness: Terrorism Planning through the Eyes of the Public” study, it is a must for all first responders and emergency managers. You can find the study online.
In a nut shell, Dr. Roz Lasker and her colleagues sampled a significant number of U.S. citizens via random phone dialing to inquire how they would behave in two different emergency scenarios. The first was a dirty bomb detonation; the second was a smallpox outbreak.
In the first scenario about ¼ of all respondents said that regardless of what they were told by officials about sheltering-in-place or other life safety precautions, they would not stay put. Those individuals were willing to risk contamination and the problems of trying to travel during movement restrictions to get home to loved ones. In the smallpox scenario, roughly 2/5 of those surveyed said they would not get vaccinated even if mass vaccinations were ordered.
This sort of behavior can serious complicate the emergency and public health response to the emergencies at hand, and point to the fact that it should not be assumed that people will necessarily follow official directions.
In summary, the emotional and behavioral response, while closely linked in many instances, are not the same things. First responders and emergency management officials would do well to understand the difference and to factor both into response and recovery plans.
Understanding Panic
There are multitudes of potential emotional and behavioral responses that can occur in isolation or in combination with each other. For the sake of this brief article, the focus will be narrow but if reader interest dictates, others can be discussed in later issues. A natural place to begin this discussion is with the foreseeable risk of panic.
The potential for panic during pandemic influenza cannot be underestimated. Panic can seriously inhibit the public health response to the disease and further complicate an already extremely complex emergency. Every emergency manager and first responder should have a working knowledge of panic and its implications. Panic is not simply intense fear in an individual. Rather, panic is a group phenomenon, characterized by intense fear and driven by overwhelming survival impulse. To understand panic, one must understand economics. Economics is not confined to financial markets. By definition, economics is the allocation of scarce resources.
It is likely that the following economics may apply during pandemic influenza:
Demand for health care services will overwhelm current capacity;
Critical medical equipment will also be in high demand and low supply;
There is a likelihood of price gouging and the development of a “black market” for essential goods. Vaccines, antiviral medications, hospital beds, and later perhaps basic necessities will be in tremendous demand;
Other important goods, such as food, water, and power may be short supply, as may critical medicines like insulin, heart drugs, and other prescription medications; this includes masks, gloves, antibacterial soaps, and other protective gear. Panic is related to the perception of a limited opportunity for escape, a high-risk of being injured or killed, or that help and supplies will only be available to the very first people who seek it. Panicked individuals think only of their own needs and survival. In most disasters, there is a strong “neighbor-helping-neighbor” response, whereas, when there is panic, it is more likely to become a “neighbor-competes-with-neighbor” response as people scramble to get essential medicines or supplies. Panic also contributes to irrational fighting and fleeing, not the typical fight or flights reaction common in most disaster scenarios.
When, in the wake of Hurricane Katrina, high level officials stated that they did not foresee the lawlessness in New Orleans, it clearly indicates that they had not thoroughly through the potential catastrophe with any real depth. When the news media focused attention on looters or those shooting at incoming helicopters and supply trucks, many scratched their heads and asked why? Panic is illogical, irrational and dangerous. It is borne out of competition to survive.
The inadequacy of the current stockpile of vaccine, and the prolong nature of vaccine production once a novel strain is isolated, as well as the paucity of the antiviral supply will naturally and predictably fuel panic. Panic in turn can trigger all manner of seemingly senseless and counter productive behavior. It is not that the panicked individual or group is making a bad decision; rather they are not making a decision at all. They are on auto-pilot, caught up in a powerful “group-think” that steers them toward hypercompetitive survival behavior.
One model of economics often discussed with relation to this sort of crisis is “game theory.” Game Theory assumes as degree of cooperation between plays all interested in the best case outcome. Such a model may apply to other disasters when there is a degree of community cohesion, but does not apply in emergencies in which panic is a factor. This instead is a form of “Non-cooperative Game Theory” in which the player think only of their own needs, and essentially, all bets are off. Panic is one of the primary factors that negate predictive models of human behavior in a potential pandemic scenario.
Foreseeable Emotional Responses
Following most natural disasters the rate of posttraumatic stress disorder (PTSD) in the exposed population is usually in the 11-15% range. This is an elevation above the baseline rate of 8% in the general population. PTSD will be a concern in the pandemic and post-pandemic phases, but rates depression, anxiety, complicated grief and other mental health conditions will also be greatly elevated. This may occur during at a time when access to mental health care and medications may be greatly diminished.
There is a significant number of individuals in any community who struggle day-by-day with serious and persistent mental illnesses, such as schizophrenia and bi-polar disorder (manic depression). Those individuals deprived of their medications and support systems are likely to decompensate and begin to experience a resurgence of psychotic symptoms, such as hallucinations and delusions. The same interruption in medications and treatment for those afflicted with severe depression or anxiety may exacerbate these conditions and result in increases in suicidal and/or homicidal thoughts and acts.
During the SARS outbreak, the inability of families to see their loved ones in hospital, or to say, “good-bye” if they were dying, greatly complicated the grief and bereavement process. Inability to quickly get bodies back for funerals and other rituals also added to the angst of many surviving family members. The manner in which corpses may be handled en masse during a pandemic may also add insult to injury for many, especially if bodies are where housed due to shortages in caskets, burial plots or availability of crematory services.
Individual with addictions to various substances, such as alcohol, cocaine or heroin will soon see the supply of those commodities dry up as travel becomes limited and goods cannot move as easily from supplier to customer. In the instance of substance abuse dependency, acute withdrawal symptoms will create medical emergencies in many individuals and also contribute to increases in criminal activity and other social problems.
In Conclusion
There are myriad emotional and behavioral responses to a pandemic that will greatly impact upon all aspects of emergency management, public health and first responder activities. The affects of fear, anxiety and prolonged stress on healthcare and hospital workers, as well as others on the frontlines of this crisis must be anticipated and integrated into all phases of pandemic planning. While much is not known about the exact psychosocial consequences of pandemic influenza, there is enough known from our global experience with other disasters, CBRNE terrorism, SARS, HIV/AIDS and other serious threats to extrapolate and inform the planning process. Pandemic plans that do not fully incorporate the emotional and behavioral consequences of the crisis are deficient and risky. Now is the time to reach out to those in your academic, medical and behavioral health care communities to seek input and advice about the unique characteristic of your region’s emotional and behavioral risks and resources. This is not a facet of planning that can in anyway be ignored.
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Steven M. Crimando, MA, BCETS, is a noted author, consultant and trainer to governmental agencies, NGOs and multinational corporations. He is the Managing Director of Extreme Behavioral Risk Management (“XBRM”), a consultancy focused on the human factor in disaster recovery, business continuity and homeland security. XBRM is a division of ALLSector Technology Group, Inc., a New York based full service technology consulting company offering systems integration, managed services and applications development and implementation. ALLSector Technology Group, Inc. is a subsidiary of the F∙E∙G∙S Health and Human Services System, one of the nation’s largest and most diversified not for profit organizations.
