Reality Check

During the past two weeks, as the terrorism-alert logo on America's television screens switched to orange, I began receiving the same worried phone calls from my patients that I had received during the fall of 2001. They told me they were not sleeping, thinking constantly about bombs or rushing to buy emergency supplies. In the months after September 11, they had desperately sought gas masks and Cipro; now, they told me, they were buying duct tape and plastic sheeting.

In response, I've given my patients the same advice I dispensed back in 2001: Focus on things besides terrorism and continue your normal daily activities. "If you don't want your children to panic, don't panic yourselves," I tell them. "We've been through this before. In the era of the Cold War we had to get used to emergency-response systems, air-raid drills and hiding under desks. And we did."

One might also keep in mind the example of Israel, where people are able to live normal lives despite frequent suicide bombings and constant military conflict. Statistically, a walk to the supermarket in Israel is still far more likely to be uneventful than unsafe. As a result, in Israel and in other societies whose citizens have lived with similar uncertainties, people become desensitized to the chance of terrorism with time; the threat gradually starts to seem both less real and less imminent, and thus more in keeping with the statistical probability of terrorism actually taking place.

I have told my patients to expect to be irritable or angry. Such anxiety can come in different forms -- including a racing heart, shortness of breath, chest pain or indigestion. I've encouraged patients to call me so that I can reassure them or, if necessary, prescribe a sedative to help them get through the night or weather periods of excessive worry.

Mostly I've spoken in terms of risks and probabilities. These are prime tools of the medical trade: to place things in perspective, to assess risk in a levelheaded manner, to rationally weigh the chances of a certain disease occurring. I understand that patients feel more vulnerable since 9-11 -- and that terrorism alerts only exacerbate such feelings of vulnerability -- but the fact is that even as perceived risks to our country are growing, actual risk to individual citizens remains quite low. Americans may be harboring any number of nightmare scenarios involving biological or chemical weapons. But there are good reasons why we shouldn't be worrying too much about these threats.

Anthrax, for instance, is not contagious, and technology is being developed to neutralize its spores. A small deployment of anthrax is the most we should fear -- and as they were in fall of 2001, containment and decontamination should be effective tactics in limiting the loss of life from any such attack. The hoarding of perishable antibiotics without a prescription is not only fruitless, it is also expensive. Doctors ought to be discouraging this habit; ditto for the anthrax vaccine, which can cause flu-like symptoms and does not prevent anthrax, but only lessens its severity.

Smallpox is another risk that keeps some Americans awake at night. But because the disease is only communicable from person to person, it can be contained by quarantining victims and vaccinating others after it appears. Even among those unfortunate few who would be infected, the death toll would still be less than 10 percent. And even weaponized smallpox could be kept contained. As far as smallpox vaccinations, though the live-virus vaccine has well documented side effects -- including the spread of a related virus, brain swelling and skin conditions -- there is no need to fear it. If necessary, this vaccine and others would prove relatively safe for use on a wide scale. Right now, however, it is not necessary to vaccinate anyone besides first responders.

The bubonic plague requires fleas to be spread, and public-health measures would be able to limit the disease's reach relatively easily should it be used in a terrorist attack. The last time the bubonic plague was deployed as a weapon -- in China during World War II -- the Chinese public-health system did not contain it particularly effectively. Today, the American public-health system would.

The threat we face from chemical terrorist attacks has been similarly exaggerated. Nerve gas is very difficult to produce and to distribute; moreover, it dissipates rapidly. As for sarin gas, when it was released in the Tokyo subway system in 1995, a lot more fear than gas ended up being spread. (Only a dozen people actually died in Japan during that attack.) VX gas is more deadly because it stays around longer and can stick to your skin, enter your pores and block all your nerves -- but it would be just about impossible for clouds of VX gas to blow through the streets. A delivery system that could expose a massive number of citizens to nerve gas without the gas being destroyed by heat or dissipated by wind simply doesn't exist. Duct tape and plastic sheets? To protect us from what? How is a terrorist going to bring VX gas to my door?

We need to see such risks in just these kinds of terms in order to combat them psychologically. We need to understand that our fear causes us to mythologize these weapons, which have already taken on enlarged significance in our collective imagination because some have been used in the past for evil purposes. But fear of these diseases and chemicals far outweighs their actual risk to us. Here in the United States, an unsexy virus not much associated with evil or terrorism -- influenza -- claims between 10,000 and 20,000 lives per year; smallpox hasn't taken a life since the 1970s.

So why are alerts taken so seriously if the potential for terrorists to use biological or chemical weapons on a large scale is so small? First of all, we are about to fight a war, and though it will be fought on the other side of the globe, people may be personalizing and localizing their general sense of the vulnerability of U.S. soldiers and U.S. interests. Many have wondered whether a war in the Persian Gulf could trigger the use of weapons of mass destruction on our soil, either by a proxy for the Iraqi regime or al-Qaeda terrorists. Unfortunately the "preparations" for such an attack -- unlikely though it may be -- create a great deal of anxiety. And the cold truth is that holding a gas mask or a roll of duct tape or a box of Cipro in your hands should not provide reassurance to a rational person. "When do I use this tape or this gas mask?" my patients ask me. The answer is that in the one-in-a-billion chance they would ever need it, they probably wouldn't have the time or know-how to employ it.

In any event, it would be difficult to deploy weapons of mass destruction on a broad scale within our borders. As a result, in all likelihood, the most we have to fear on this side of the ocean are conventional terrorist attacks. But meanwhile we are left to imagine -- erroneously -- something far worse.

Our elected officials understandably don't want to be criticized for not having warned us should an unconventional terrorist attack take place. Only five people died from anthrax exposure during the scare following September 11. Yet many subsequently criticized the FBI, the Centers for Disease Control and Prevention, and other agencies for a lack of preparation and cooperation. So this time around, President Bush and his administration have opted to panic the country in advance. But they would do well to remember that for 50 years Americans lived with daily threats far scarier -- if perhaps more predictable -- than those we face today. As I remind my patients, we got used to them then. And we will now.

Marc Siegel is an associate professor of medicine at New York University.

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