Terrorism response plans will not protect many Americans, new study finds.

What would you do if you found out that some people in your community had become sick with smallpox after having been exposed to the virus in a terrorist attack at a major airport? What if terrorists exploded a dirty bomb a mile away, when you were at work and your children were at school?

Existing terrorism response plans don't account for how people would behave in these situations, according to a study by the Center for the Advancement of Collaborative Strategies in Health at the New York Academy of Medicine. Current plans have been created "top-down," telling people what to do in the event of an attack without considering all of the risks and concerns that drive people's actions, the investigators found.

The study found that only two-fifths of respondents would follow instructions to go to a public vaccination site in a smallpox outbreak and only three-fifths would stay inside an undamaged building other than their home after a dirty-bomb explosion. "It's not that the rest of the people want to be uncooperative," said lead investigator Roz Lasker, M.D., director of the center and of the academy's Division of Public Health. "The problem is that current plans unwittingly put them in extremely difficult decision-making predicaments."

Although current plans will put many people unnecessarily at risk, immediate actions can be taken to dramatically increase their effectiveness, said Lasker. "If planners listened to and learned from the public, they could protect many more people."

Called Redefining Readiness: Terrorism Planning Through the Eyes of the Public and funded by the W.K. Kellogg Foundation, the year-long study involved in-depth conversations with government and private-sector planners, 14 group discussions with diverse community residents around the country, and a telephone survey of 2,545 randomly selected adults in the continental United States.

The study shows that during a smallpox outbreak, three-fifths of the population would be seriously worried about the vaccine--that's twice as many people as would be seriously worried about catching smallpox. Vaccine worries would keep many people away from the vaccination site.

"The public's concern about the smallpox vaccine is well founded," said co-investigator Alonzo Plough, Ph.D., director of public health in Seattle and King County, Washington. Over 50 million people in this country have conditions like eczema, pregnancy, or immune system problems that put them at risk for severe complications from the vaccine, either from being vaccinated themselves or from coming in contact with someone who has recently been vaccinated.

The study also shows that two-thirds of the American people would try to avoid being with other people they don't know in a smallpox outbreak. This behavior puts people in a terrible predicament, because they can't simultaneously isolate themselves and go to a public vaccination site. Two-fifths of the population would be afraid of catching smallpox from other people at the site, the study found. One-fifth would be afraid of coming in contact with someone who shouldn't be exposed to recently vaccinated people.

In the event of a dirty-bomb explosion, the study shows that people would want to know that they and their loved ones would be safe and cared for in whatever building they happen to be at the time of an explosion. Three-quarters of the people who said they would not fully cooperate with instructions to stay inside a building after a dirty-bomb explosion would do so if one of the following conditions were met:

1. they could communicate with people they care about or

2. they were sure that they and their loved ones were in places that had prepared in advance for this kind of situation.

But three-fifths of Americans know only a little or nothing at all about how people would actually be cared for in such places.

Such problems can be avoided by adopting the model plans proposed in the study, said co-investigator Otis Johnson, mayor of Savannah, Georgia: "These model plans reduce the conflicting worries and trade-offs that people face."

The study's proposed smallpox plans include specific strategies that protect both the people who are at risk of contracting smallpox and the many people who are at risk of developing serious complications from the vaccine. The study's dirty-bomb response calls for the development of safe-haven plans in the broad array of places where people are likely to be when an attack occurs: work sites, shops, malls, schools, day care centers, and entertainment facilities. That means preparing to keep the people inside fed and safe during the crisis.

Putting people in specific and realistic crisis scenarios is an effective tool for engaging the public. Through upcoming demonstration projects, the Center for the Advancement of Collaborative Strategies in Health will provide planners with the information they need to put this kind of public engagement into practice. Fortunately, the study documents that over a third of the American people have a strong personal interest in participating in community and organizational planning.

The study report is online at www.cacsh.org/eptpp.html.