Safe at Home: A Family Survival Guide

Americans have suddenly had to come face-to-face with the now very real threat of the use of biological and chemical agents against them and their loved ones. The risk is small, tiny in fact. But there is risk, and unfortunately, as recent times have so vividly illustrated, it is increasing.

Everywhere I've gone in recent months, people have asked me what they can do to protect themselves and their loved ones from the threat of bioterrorism. They want to know how to cope effectively with the stress and anxiety it can cause.

Our family has been affected by the events of last fall. Every family has. My wife, Karyn, and I have three boys: Bryan, who is fourteen years old; Jonathan, sixteen; and Harrison, eighteen. They watched me live through the frightening uncertainty of the anthrax exposure on Capitol Hill, and I’ve done my best to address their concerns about the events surrounding September 11 and the anthrax-laced letter that was mailed to my colleague Senator Daschle.

At their school events, I receive many questions from concerned parents regarding what they should tell their children and how they can help them live without fear. My purpose here is to answer as many of those questions as I can, as specifically and practically as I can.

In this chapter, I won't deal with the government's preparation and response. I'll cover that thoroughly in the final chapter. In the chapters that follow, I'll answer the pertinent questions about the main, specific bioterrorism threats that we face, such as anthrax and smallpox.

Here, our focus is simply on what families need to know and do to be as prepared as they can be for this threat our nation faces. Just to be clear, there is a huge difference between being prepared and living in fear. One of the most perceptive things I read in the aftermath of the anthrax attacks last fall was written by columnist Jonathan Alter in Newsweek. Recounting his experiences working in the New York offices of NBC when an anthrax-tainted letter was delivered there, Alter wrote, "Anthrax is not contagious, but fear is."

Precisely. There is no reason for paralysis in our everyday lives, and clearly no cause for panic. But there is good reason for every American, young and old, to know much more about what in these times might confront them. Bioterrorism personalizes terror like no other type of terrorism. But there are steps each of us can take to reduce our vulnerabilities and thereby restore our sense of security and safety.

What is bioterrorism?

Bioterrorism is the intentional release of potentially deadly bacteria, viruses, or toxins into the air, food, or water supply.

Ounce for ounce, biological agents such as anthrax and smallpox are among the most lethal weapons of mass destruction known. Inhalation of a millionth of a gram of anthrax may be deadly. In 1993, the Office of Technology Assessment estimated that under certain atmospheric conditions dispersion by airplane of 220 pounds of anthrax spores over Washington, D.C., could result in up to three million deaths.

That's a worst-case scenario. But even on a much smaller scale, a bioterrorist attack could be designed to instill fear in our people.

"As I see it, the goal of bioterrorism is not as much to do mortal harm as it is to disrupt our way of life and make us clearly aware of our vulnerability," says Larry Bush, M.D., infectious disease specialist at the John F. Kennedy Medical Centerin Atlantis, Florida. “Though recent events have proven this successful, we will now be both intellectually and emotionally better prepared."

Bioterrorism is certainly not a new phenomenon. Biological weapons are as old as mankind, going back to Hannibal, who won a naval battle in 190 b.c. by firing earthen vessels full of poisonous snakes into his enemy’s flagship. Recent use of bioweapons has only exposed and affirmed our nation’s and other countries’ vulnerability to these agents.

The mailing of anthrax-laced letters to U.S. Senate offices and media outlets last fall infected eighteen people and killed five. Tens of thousands more who were exposed to the potentially lethal biological agent were initially treated with antibiotics, and even though the attacks were confined to the East Coast, the impact could be felt across our land.

But this wasn't the first time our nation was subjected to bioterrorism. In rural Oregon in the 1980s, members of a religious commune, in a plot to make large segments of the population too sick to vote, sprinkled salmonella on the salad bars of several restaurants in the county. Over 750 people became ill.

And in 1995 the Aum Shinrikyo “Supreme Truth” cult staged an attack with the chemical agent Sarin in the Tokyo subway system. The attack killed twelve people and injured five thousand. The cult also was working with bioweapons, including anthrax and botulinum toxin.

Can we expect more bioterror events in the wake of the anthrax-letter attack?

It is no longer a question of if but when and where and how.

Just as many of us never imagined that American commercial airliners would be converted into weapons of mass destruction, it is perhaps beyond the grasp of many that the weapons of choice in the first war of the twenty-first century may be tularemia, smallpox, and anthrax. But this should come as no surprise.

The threats from biological and chemical agents are real. Terrorist groups have the resources and the motivation to use germ warfare. Well before the September 11 attacks, Osama bin Laden publicly stated that it was his religious duty to acquire weapons of mass destruction, including biological and chemical weapons. And when our troops went through hideouts abandoned by bin Laden's terrorist network, Al Qaeda, they reportedly found evidence of efforts to develop biological and chemical weapons.

For years, we assumed that no nation or group—even terrorists—would use biological weapons because of the universal condemnation their use would surely bring from all corners of the world. Sadly, we know better now.

If anything, bioterrorism is likely to be embraced by terrorist organizations for several reasons. As we have seen, they often are driven by fanatical religious beliefs and deep-rooted ethnic struggles. There clearly is no limit to the level of violence and death they find acceptable in support of their twisted goals.

In addition, rapid advances in the technology needed to deliver biological agents have made the weaponization of germs much easier. And, with the fall of the Soviet Union, the expertise of thousands of scientists knowledgeable in germ warfare may be available to the highest bidder.

There are other advantages for terrorists in using a biological agent over other methods of attack. It is very difficult to trace a bioagent back to its source. In general, neither sophisticated knowledge nor significant resources are required to launch a bioterrorist attack, and the materials are relatively easy to acquire. It has been estimated that a substantial biological arsenal could be developed in a fifteen-foot-square room with just $10,000 of equipment.

Biological weapons pose considerable security challenges that are different from those of standard terrorist devices. They are not detected by methods used for explosives and firearms, such as metal detectors and x-ray devices. They are invisible. The first indication of an attack is the development of symptoms by those exposed. Yet, victims of a covert bioterrorist attack do not necessarily develop symptoms immediately upon exposure to the bioagent. Symptoms may occur days later, long after the bioweapon is dispersed.

As a result, people who are exposed will most likely arrive in emergency rooms, physician offices, and urgent-care centers or clinics with symptoms that mimic the common cold or flu. In all likelihood, physicians and other health care providers will not attribute these symptoms to a bioweapon. If the bioagent is communicable, such as smallpox, many more people—including health care workers—may be infected before doctors know what they're dealing with.

When the nation is put on “high alert,” what specific actions should I take?

After the September 11 attacks, the federal government issued several notices placing law enforcement agencies and the military on “high alert” when credible information of possible terrorist attacks had been compiled by intelligence sources. At the same time, general alerts were issued to the public.

The alerts are a way for the federal government to let citizens know that the military and law enforcement agencies are increasing their vigilance and that citizens should, too. I know people feel frustrated because they don't know exactly what to do. It can be stressful for them and their families.

Frankly, our government is in a tough spot on this one. If we receive what we believe is credible information regarding a possible terrorist attack—even if key details such as when and where are missing—shouldn't the government let the people know? President Bush believes we should, and I agree.

But is there really anything you can do to help? Absolutely. First and foremost, you can be the eyes and ears of our law enforcement agencies. You know your communities better than anyone else. You know when something looks out of place, whether it's a package left on the subway or someone acting in an unusual or suspicious manner in your neighborhood.

Being more vigilant empowers you to be part of our war to rid the world of the evil of terrorism. Be more conscious of what's going on around you. Report any suspicious activity or behavior to local authorities. But vigilance alone is not enough. You should take additional steps now to plan and prepare for how your family will respond if there is a bioterrorist or some other form of attack.

When I'm in public, what should I look for?

Terrorists tend to choose highly visible targets where large numbers of people gather. These would include large cities, international airports, subway systems, resorts, historic landmarks, and major sporting and entertainment events.

It's not that people should avoid these places. In fact, it's important that we not give in to fear by allowing the terrorists to change the way we live. Instead, whenever you're in one of these situations, just be a little more aware of your surroundings.

Learn where the emergency exits and staircases are. Plan ahead how you would get out quickly in an emergency.

If you're traveling, take note of any conspicuous or unusual behavior. Don't accept packages from strangers, and never leave your luggage unattended.

What should I do if I find myself in the middle of a scene that might involve biological or chemical materials?

Don’t panic! Yes, every situation is different, but there are general steps that will minimize risk to you and your loved ones. And these apply both to biological and chemical events:

1. If you’re outside, evaluate the suspected area from a position upwind, cover all exposed skin surfaces, and protect your respiratory system as much as possible, perhaps using a handkerchief to cover your mouth and nose.

2. If the incident is inside, leave immediately and try to avoid the contaminated area on your way out. Keep windows and unused doors closed. Turn off the ventilation system (air-conditioning or heat). If you are inside and the event is outside, stay inside. Turn off the ventilation system and seal windows and doors with plastic tape.

3. Call 911 and report the following:

• Your name and phone number
• Date and time of event
• Distance from the incident or point of impact
• Reason for the report (for example, people becoming sick, a vapor cloud, dead or sick 
  animals or birds, unusual odors, dead or discolored vegetation)
• Location of the incident
• Description of the terrain (for example, flat, hills, river)
• Weather
• Odor (for example, none, sweet, fruity, pepper, garlic, rotten eggs)
• Visible emission (for example, none, smoke, haze)
• Symptoms (for example, none, dizziness, runny nose, choking, tightness in chest, blurred vision, fever, difficulty breathing, stinging of skin, welts/blisters, headaches, nausea and vomiting) and time they appeared
• Explosion (for example, none, air, ground, structure, underground) and location

4. Once clear of the suspected contaminated area, remove all external clothing and leave it outside. Proceed directly (within minutes) to a shower and thoroughly wash with soap and water, scrubbing aggressively to cover every part of your body with at least ten scrubbing motions. Irrigate your eyes with water.

What kind of plan do I need for my family?

Every family should have a disaster plan. If yours doesn’t, start discussing a plan tonight at the dinner table. Even without the threat of bioterrorism, this is a sound idea. The current world situation only reinforces the need for preparedness. We're not talking about bomb shelters here or the pre-Y2K hysteria to which some fell prey. The things you should do to safeguard your family in case of a bioterrorist attack are basically the same as what you would do for any natural disaster.

Your plan should cover three essential elements, according to the American Red Cross:

Communication:

• How will you communicate with family members if there is a bioterrorist attack or some other disaster?
• Destination: Where will your family go if there is an attack?
• Supplies: What supplies should you have on hand in case you need to "shelter at home"
  for a while?

What kind of communications plan do I need?

Choose one person who lives out of state to be your family's contact in case of emergency. Why? In a disaster, it's often easier to call long distance than to make a local call. Everyone in your family should know the phone number.

Also, choose a family meeting place outside your neighborhood in case you can't go home. Again, everyone in your family should know the address and phone number.

In addition, you should have a backup out-of-state contact and a backup meeting place, just for insurance. And be sure to discuss your plan routinely with family members so that it becomes second nature. That will help prevent panic if disaster does strike.

Where should my family go if there's a bioterrorist attack?

That obviously will depend on how close the attack occurs to your home. The most likely scenario appears to be that emergency officials would urge people to shelter at home in the event of a bioterrorist attack. So designate a “safe room” in your home, one with a telephone and radio. Choose an interior room without windows, if possible. Don't use the basement, however, because—in a chemical attack—heavier chemical vapors would tend to sink to the lowest place in a house. Gather your family in the safe room and listen to the news for further instructions.

If officials order an evacuation, make sure everyone in your family knows in advance how to get outside from every room in the house. Where possible, devise two escape routes from every room, in case one is blocked.

What about disaster supply kits? What supplies should I have in case of a bioterror attack?

Disaster supply kits are just what they imply: a collection of basic supplies that are readily available in the event there is a “worst-case scenario” that requires you and your family to become fully self-sufficient for several days. In the case of bioterrorism, this might occur because stores are closed and other social services interrupted. The disaster kit for bioterrorism is not very different from that required for other types of emergencies.

Pack essential supplies in an easy-to-carry container such as a large, covered trash can, a duffel bag, or a camping backpack. Store this disaster supply kit where it can be easily reached, and make sure every family member knows where it is. That way, you can grab it quickly whether you have to remain inside or evacuate.

Your disaster supply kit should include the following items:

• Water. Store in plastic containers such as large soft-drink bottles. Have at least a
  three-day supply, figuring on one gallon a day for each person. Change the water in your kit at least every six months.
• Canned food. At least a three-day supply. Good items include canned meats, fruits, and vegetables; juices, milk, and soups; high-energy snacks such as peanut butter, jelly, crackers, “power bars,” and trail mix; candy and cookies; instant coffee and tea bags; and any special foods for infants, the elderly, or those on special diets. Avoid salty items, though, as they will make you drink more water. Write the date on the food items and change foods at least every six months. Be sure to check expiration dates on labels.  An easy way to remember to update your water and food supplies is to change items at the beginning and end of daylight savings time, when you also change the batteries in smoke detectors.
• Nonelectric can opener
• Cell phone
• Change of clothing. One extra set of clothes and footwear for each member of the family
• Goggles. One pair for each member of the family, to protect the eyes. Swimmer’s
  goggles are fine.
• Respirators for each family member. These are filtered fiber masks and only cost about
  $1 each. Look for ones with N95 certification. (I'll explain what that means in just a bit.)
• Roll of plastic tape, such as package-sealing tape (to seal windows, if necessary)
• Flashlight with extra batteries
• Portable radio with extra batteries
• Portable heater
• Thermal blankets or sleeping bags. One for each member of the family
• Extra car keys, credit card, and cash
• Extra pair of eyeglasses
• Special items for infants or elderly or disabled family members
• First aid kit, including:
• A ten-day supply of your family's prescription medications
• Painkillers, such as ibuprofen, acetaminophen, or aspirin
• Antihistamines, if family members have allergies
• Mild laxative
• Antidiarrhea medication, such as Pepto Bismol, Kaopectate, or Imodium AD
• Broad-spectrum antibiotics for possible respiratory, intestinal, or urinary tract infections. Now, this may be confusing because elsewhere I say you should not stockpile Cipro, that antibiotics to combat a bioterrorist agent will be made available by public health officials, and that there are serious risks associated with misuse and overuse of antibiotics both in terms of side effects and emergence of bacteria resistant to all treatment. The antibiotics that you might appropriately have in a disaster kit are not for preventing or treating the bioterrorist agent but rather for the short-term treatment of unrelated infections, such as pneumonia or urinary tract infections. Your doctor will prescribe these if you are very clear that you are aware of the dangers of unnecessarily using antibiotics and that these are specifically for a disaster supply kit.

If you have pets, include the following items in your supply kit:

• Identification collar and rabies tag
• Carrier or cage
• Leash
• Medications
• Newspapers, litter, trash bags for waste
• Two-week supply of food and water
• Veterinary records (necessary if your pet has to go to a shelter)

There are all kinds of different masks on the market. Which offers the best protection for my family?

The best bet, I believe, is a simple mask with a filter that covers your mouth and nose and can block extremely tiny particles. The technical term for this kind of mask, manufactured by 3M as well as other companies, is a “respirator.” Look for one with the rating of N95. I'll explain what that means in a minute.

There are generally three categories of masks: ones that enclose the entire head (“full-face”), ones that cover the mouth and nose (“half-face”), or the simple disposable masks where the mask itself serves as a filter.

If fitted correctly—and this is harder than it sounds—respirators can reduce exposure to anthrax bacteria and other harmful agents. It is very difficult, however, to achieve a perfect fit with these simple masks. It takes about fifteen minutes to adjust the mask to fit your face the right way. So just owning one, without a proper fitting, may provide a false sense of security.

Now, about the rating. Filters are tested by the National Institute for Occupational Safety and Health (NIOSH). The rating reflects how efficiently the filter blocks tiny microscopic test particles of 0.3 microns in diameter. A filter with a 95 rating filters out at least 95 percent of the particles in a test. A filter with a 100 rating filters out 99.7 percent of the particles.

Filters are also classified into one of three categories: N, P, or R. N means the filter was tested with sodium chloride particles. P signifies that the filter is impenetrable by oils. R signifies that a filter is resistant to oils.

So you need to understand that N95 masks only reduce exposure to particles, they don't eliminate it entirely. Since at this point we still don't know exactly how many anthrax spores, for example, it takes to infect a person, there's no guarantee that wearing a mask would offer complete protection—even if it screens out 95 percent of the particles.

The majority of filters you’ll hear about are N95, P100, or N100. All N95 through P100 masks should be fit tested. The Occupational Safety and Health Administration (OSHA) does not require fit testing for disposable N95 masks if they are worn voluntarily. You should be aware that any facial hair where the mask meets the skin greatly reduces the efficiency of the mask.

A more expensive option is the rubbery half-face mask that has filters protruding on the sides. It's called an “elastomeric respirator,” in industry terms. Elastomeric masks have replaceable filters that screw on and off, and the synthetic material of the mask can be disinfected with cleaning material. The P100 elastomeric mask does the best job of protecting against biological agents.

How much do these masks cost, and where do I get them?

Prices for masks vary. Disposable N95 respirators are about $1 each. N100 disposables are around $5. Disposable respirators are available at most hardware or paint stores.

Available at Home Depot or industrial-supply stores, elastomeric masks are about $20 each, and filters can be purchased for $5 and up, depending on the efficiency of the filter. All NIOSH-approved filters are marked as such on the box, the filter itself, or in the instructions—look for the NIOSH approval.

The less expensive but widely marketed "dust and nuisance" masks are not NIOSH approved and are essentially ineffective for biological agents. But they are useful for visible dust.

The top three respirator manufacturers are 3M, Moldex, and MSA.

Are these filtered masks useful for chemical agents as well?

None of the industrial masks mentioned above are effective against chemical agents. Chemicals are effectively filtered by using activated-carbon filters that are treated with impregnate. Different filters are typically made for specific chemicals. However, some manufacturers make carbon filters that protect against several different chemicals.

Military-type gas masks that protect against chemicals are not rated by NIOSH for use because they physically restrict breathing and could harm the general public. Highly sophisticated “supplied-air” respirators that deliver their own self-contained clean air are effective for most chemical exposures. However, no respirator is capable of preventing all airborne contaminants from entering the wearer’s breathing zone. A mask is ineffective against contaminants that can penetrate exposed skin, such as sulfur mustard gas.

Within a year, NIOSH and the U.S. Department of Defense will for the first time come up with specific approval standards for protection against chemical and biological weapons.        

Do simple fiber masks offer protection against biological and chemical agents?

Fiber masks without filters are simple masks that cover the mouth and nose, similar to those you see surgeons wearing on television. The main purpose of these simple masks is to keep out dust and other particles that may fill the air in disasters such as the World Trade Center attack. Fiber masks without filters will not be very useful in a biological or chemical attack because the mesh of fiber masks is not small enough to keep out the very tiny biological or chemical agents. Only gas masks and other specialized industrial masks will work in such situations, and even they would have to be worn at the time of the attack.They would have to be worn at the time of the attack, and sinTo some degree. They may reduce the odds of inhaling some biological agents in particle form, and they could help prevent the spread of infectious diseases such as smallpox. [I need some expert help here -- any thoughts??)  But in order to help, you would have to know that an attack was under way and have the mask with you. Putting it on after you were exposed would be too late.  Putting a mask on after you were exposed would be too late.

Therefore, I recommend that you include in your disaster supply kit an N95 NIOSH-rated mask for each of your family members. Without a personalized fitting, however, this mask offers only limited protection against biological agents—better than a simple fiber nonfiltered mask, but not as complete as industrial-grade respirators.

Should I buy a “gas mask?"

The interest in gas masks when faced with the threat of biological or chemical attack is certainly understandable, especially when you learn that so many of the biological agents are so deadly when they are inhaled into the lungs.

True industrial-grade gas masks can protect against biological as well as chemical agents. A sophisticated, powered, air-purifying respirator with high-efficiency particulate air (HEPA) filters, when properly fitted, can reduce inhalation exposures by 98 percent.

But—and this is a very important point—this kind of mask is effective only if you are wearing it at the time of the attack.

If there is a biological or chemical attack, one thing is virtually certain: It will come without warning. And that's really the key issue here, in terms of the practical question about buying a gas mask. Unless you have enough advance warning to get the mask, put the right filter in, and make sure it's fitted properly, it won't do you any good.

And the odds of that happening are slim. In an urban setting such as New York, sheltering in your safe room and immediately turning off the ventilation system (heat or air conditioner) is likely to be more useful than a gas mask.

How can I decontaminate an area suspected of being hit by a biological or chemical attack?

Although your natural reaction might be to immediately decontaminate an area, check with your local public health authority first, because you may be putting yourself at risk by further exposure to the offending agent during the cleanup. Moreover, you may lose important information and evidence that could be useful to a law enforcement investigation.

For suspected biological and chemical decontamination, the contaminated areas can be washed with a 0.5 percent sodium hypochlorite solution, allowing a contact time of ten to fifteen minutes. To make a 0.5 percent sodium hypochlorite solution, take one part household bleach, such as Clorox, and ten parts water. Keep this solution away from your eyes.

If biological or chemical contamination is suspected on fabric, clothing, or equipment, you can decontaminate with undiluted household bleach. Leave it on for thirty minutes before discarding or using the item.

The September 11 attack was the most terrifying event of my life. How can I deal with the stress and anxiety I feel living on high alert?

First, realize that you're not alone! A nationwide study showed that nine out of ten Americans showed some clinical sign of stress the week after the September 11 terrorist attacks. And almost half of all adults reported at least one substantial symptom of stress, such as having difficulty sleeping or uncalled-for outbursts of anger.

And we can learn much from others around the world. Citizens in Israel and Northern Ireland have been living under the threat of terrorism of years. They have experienced the terror but have accommodated and adapted and been able to regain normalcy in their lives.

We know from research that while the effects of a disaster such as the terrorist attacks typically lessen with time, they can linger for years and may resurface from time to time.

So what are the signs that you're continuing to feel stress over the terrorist threat?

Reactions may be physical or emotional. Among the physical symptoms are backaches, headaches, stomachaches, diarrhea, nausea, and shortness of breath.

Emotional symptoms include shock, disbelief, fear, grief, anxiety, disorientation, hyperaltertness, being easily startled, nightmares, crying, anger, irritability, detachment, numbness, feelings of betrayal, survivor guilt, isolation, depression, inability to concentrate or carry on normal activities, a sense of loss of control, revival of past traumatic memories, apathy, and decreased ability to feel joy.

If you're experiencing any of these signs, know two things: You're not alone. And there are simple steps you can take to feel better. Here's what mental health experts recommend to relieve stress and anxiety:

• Talk with others. This is a time to draw closer to those you love and trust, not push them away. And chances are they're feeling many of the same things as you. Just giving voice to what you're feeling inside can lessen stress.
•  Keep the faith. For many of us, faith was a source of comfort and strength in the wake of the unspeakable horror we witnessed. As a medical doctor, I know the healing power of prayer. In these difficult times, prayer can help ease anxiety and bring us together. This is a time to draw strength from the traditions of your church, synagogue, mosque, or temple. Knowing that God is just and that he is in control offers great comfort when we feel so powerless.
• Embrace your daily routines. It's important for all of us to go about our lives as normally as possible. If you're feeling like your life is spinning out of control, the simple, productive daily routines—whether it's taking a walk, listening to an audio book on your commute to work, or shuttling the kids to soccer practice and music lessons—offer calming reassurance that life does go on. In particular, make a point of doing the things you do well. Whether it's baking cookies, playing basketball with your daughter, doing a crossword puzzle, crocheting a scarf—whatever, it doesn't matter. The idea is to feel once again that sense of being in control and excelling at something.
• Take a news break. Television news can become seductive. It's important for all of us to be informed. But with twenty-four cable news networks, the Internet, and a huge assortment of newspapers and newsmagazines, it's easy to feel overwhelmed by too much information. And this can heighten your anxiety. In the week after the September 11 attacks, adults and children watched on average an hour more of television a day, and those who watched the most TV news coverage exhibited the most signs of stress. Again, this isn't to say that watching the news, reading the newspaper, listening to the radio, or checking out your favorite news sites on the Web is harmful in any way. It's a matter of being selective about how much news you get. If your news habits are feeding your anxiety, it's time to cut back.
• Show your colors. We saw a rebirth of overt, good old-fashioned patriotism after September 11. And that is a magnificent and healthy reaction. The greatest thing about the American people is our indomitable spirit. The outpouring of generosity and caring this country witnessed after the September 11 attacks made me so proud of this nation that I love. Seeing yourself as part of this great land is more important now than ever before. If you're feeling isolated or not in control, small acts can help. Wear a flag lapel pin. Our family put up a large permanent flagpole in our yard so we could fly the American flag daily. Send a donation to a local charity. Get involved in your community's preparedness plan. Do what you can to support your country during these trying times.
• Join a group. A sense of community, of belonging to something larger than yourself, goes a long way in overcoming feelings of isolation. Shared interests can help you expand your network of friends. So join a book group, take a modern dance class, sign up to take a foreign language—again, whatever interests you, whatever you've always wanted to do.

One of the encouraging signs from the nationwide study on post–September 11 stress is how many Americans turned to these coping strategies to deal with the anxiety they felt. According to the study, which was done by the Rand Corporation and the University of California at Los Angeles, 98 percent of those responding to the survey said they talked with others to help themselves cope; 90 percent said they turned to religion; 60 percent said they participated in group activities; and 36 percent said they made donations to relief funds.

Also, make sure you take proper care of yourself. Here are some other ways that mental health experts say you can relieve stress and anxiety:

• Exercise regularly. During stressful times, exercise often is the first thing to go. You may not feel like you have the time or energy to exercise. But that’s precisely when you need it the most. Exercise can actually boost your energy and give you a greater sense of control. Going to the gym is terrific, but there are lots of other ways to fit exercise into your hectic life. Start small. Walk with a coworker, friend, or family member at lunchtime. Take family hikes or bike rides on weekends. The key is to make exercise part of your routine. Just avoid exercising within three hours of bedtime, so it doesn’t interfere with needed sleep.
• Eat well. Healthy eating is another of the first things to go during stressful times, usually for the same basic reasons as exercise: lack of time and energy. But just like exercise, eating regular meals with health foods is a great stress buster. Make sure you eat five to nine servings of fruits and vegetables daily, and avoid too much caffeine, sugar, or alcohol.
• Get a good night’s rest. Tempting as they might be, turning to alcohol or relying too much on prescription or over-the-counter sleep aids can have a negative effect on your ability to get restful sleep. If you are having trouble sleeping, eliminate caffeine from your diet, talk or write about your concerns and worries before you try to sleep, and avoid late-night news or other activities that get you agitated. Take a warm bath, and, yes, drinking warm milk does help some people sleep.

One last note: Everyone copes with tragedy in different ways. There is no one right way. So be willing to experiment and find out what works for you. Recognize that it may take time before the stress and anxiety you feel subside. That's perfectly normal.

How long will I feel this way?

People are often surprised that reactions to trauma last longer than they expect. Resilient as we are, it may take weeks, months, or, in some cases, years to regain equilibrium. Traumatic experiences often remain vivid forever. Most of us will always be able to say where we were when we first learned of the terrorist attacks and the events that followed.

Some people will work things out with the help and support of family, friends, and colleagues. But these days, many are finding that they or their children have a number of stress reactions that won’t go away or that interfere with work, school, home life, or leisure activities. Talking to a mental health trauma specialist can help. The key is to reach out—ask for help, support, understanding, and opportunities to talk.

Are children at greater risk for certain types of bioterrorism than adults?

They may be, and this is an area to which we need to devote a lot more research. Certainly for chemical weapons, this is true. Nerve agents, including Sarin—which I discuss in chapter 9—are denser than water, so they concentrate closer to the ground, in the breathing zone of a child.

Children breathe faster than adults, which would potentially place them at greater risk for inhalational agents. They are more likely to have minor cuts and scrapes, which could make it easier for germs to enter the body. For their body weight, children have a greater skin surface than adults, which could expose them more to blister agents, such as mustard gas. In addition, many of the potential bioterror agents cause vomiting and diarrhea, which can quickly lead to dehydration and shock in children.

To further complicate matters, the vaccines and antibiotics to fight these biological agents have generally not been studied as well in children as they have been in adults. The anthrax vaccine, for instance, has never been licensed for persons under eighteen.

But we in government are working to change this. Age-related research is critical. As new antibiotics and vaccines are approved, we must make sure that dosages and side effects are carefully studied in children as well as adults. As we work to improve our public health system's ability to respond to bioterrorism, we must do a better job of addressing the specific needs of children and make sure they're fully accounted for in all local and state planning as well as in the research for appropriate treatments.

How can we better prepare our children to cope with a major attack without making them afraid?

This is probably the question I've heard most from parents in recent months. We all want to do whatever we can to make sure our children are safe. But we certainly don't want them to have to live in constant fear. So how do we allow our children to lead normal, happy lives while being aware of, and prepared for, potential bioterrorist threats? That's a tough question. But it can be done.

A lot of the specific answers depend on the age of the child, and I'll deal with those differences in just a bit. But there are certain things that apply to all children.

First and foremost, spend more time with your children. Reassure them that you love them and will do everything in your power to keep them safe. You can’t just think it. You’ve got to verbalize it and express it openly. How you do this will depend on how old your child is, although hugs and kisses are universally understood, from toddlers to teenagers.

Remember, like it or not, they'll take their cue from you. We all know that children are a lot more perceptive than we often give them credit for. They will pick up on any fear and anxiety you feel. So be mindful of what you say and do in front of your children.

If you're feeling overwhelmed by anxiety, anger, or grief, that's probably not the best time to talk with your children. But there's no reason to try to hide it, either. Just tell them right up front that you are feeling upset right now, so it's not a good time to talk. Let them know that you do want to talk to them, though, and that you will in a while, once you feel calmer. This lets children know that these feelings, as overwhelming as they may seem at the time, will pass and that adults can handle them. That can be very reassuring.

Just make sure that you really do talk with them later. It's important that parents don't become so wrapped up in their own feelings that they ignore their children's needs.

Also, regardless of how old your children are, listen before you talk. The only way you'll know what's really bothering your children is to let them tell you. Resist the temptation to lecture or tell them everything you think they need to know. Ask them what they've heard from friends, teachers, on the TV, or on the Internet.

Ask them what questions they have, and answer them as best you can in a direct and straightforward manner, with limited detail. Too much information can be overwhelming, especially for younger children. Often, they'll have only a couple of simple questions. That's fine.

Just keep in mind that your children may not always tell you in so many words that they're scared or worried. Those feelings may come through in their expressions, the way they play, or even by angry outbursts. Watch for dramatic changes in your children's behavior or mood, and if those changes persist, consider seeing a mental health professional.

One other thing to keep an eye on is your children's TV-viewing habits. Now, given the quality of television programming these days, that's good advice anyway for parents. But it's especially true when the airwaves are filled with around-the-clock news of terrorism or war.

If the news is on, watch it with them so you can talk about it and answer any questions they have. And limit their viewing if it seems excessive or if it appears to be increasing their stress and anxiety levels. Though it’s harder to monitor, also discourage excessive surfing on the Web in search of terrorism reports.

During these uncertain times, one of the most important things you can do for your children is to maintain family routines and traditions. Celebrate holidays and birthdays with all the joy you can muster. Make sure your children eat a balanced diet and get enough sleep. And be sure to carry on the regular activities that have always been part of your lives, whether its sports, music lessons, religious services, or scouting.

How can I help my kindergarten and elementary-school children?

 Young children will hear information about bioterrorism from all kinds of sources—schoolmates, teachers, parents of friends, TV, even snippets of conversations overheard in a store. At this age, they are almost certainly going to misunderstand some of the information and have trouble separating exaggerations and rumors from fact.

They may think terrorists are in their school or believe that something bad happened that didn't. The main thing you need is patience and a willingness to listen. Find out what they've heard, and help them sort through what's real and what's not in a calm, gentle manner.

You may have to reassure them many times about the safety of your family and their school. Tell them the president and many other good people—firefighters, police, military personnel, and medical workers—are working hard to keep us all safe. They may ask you the same questions over and over, which every parent knows can be frustrating. Again, be patient. They may just need to hear the answers several times before they fully understand and accept them.

Children, particularly preadolescent children, may reenact traumatic events as they play (repeatedly wrecking planes and buildings, for example). Such play is often a way for children to attempt to master events that make them feel threatened and helpless.

Reenactments—no matter how uncomfortable for adults—should be encouraged. Young children can often express their feelings and thoughts more fully through play activities than through talking. It may be helpful to provide a special time to paint, draw, or write about the events.

They may also ask what you consider shocking questions seemingly out of the blue. Remember, they're trying to process very confusing and frightening information, and there's no telling when something might pop into their mind. So try to respond in a calm, reassuring way, answering their questions simply and directly. It's important for them to know they can talk with you anytime.

Don't be surprised if you see some regression in young children, including whining, bed-wetting, or needing more help with getting dressed and eating. Be patient and understanding.

And as part of your nightly routine, be sure to tuck them safely into bed and tell them you love them. Sleeping difficulties, especially nightmares, are common. Talk through nightmares with your children, and reassure them about their safety.

How can I help my middle-school children?

To children at this age, the grown-up world can seem scary enough. You may see more aggression in some children, as they try to cover up fears and insecurity with tough talk. And you may see more emotion in others, as they cry and seek reassurance.

Just as this is a time for adults to spend more time with one another, it's important for adolescents to spend more time with their closest friends. Encourage this, even if it means you have to play taxi driver a little more often.

Some middle-school students find it helpful to keep a journal or express what they're feeling through drawing. If they want to share these with you, great. But don't force them to.

It's also possible that middle-school children may talk more about death and dying. Or they may ask questions that include gruesome details or focus on death. This is natural, as they try to comprehend what's happening in the world. Respond calmly. If these comments become persistent, seek professional help.

The main thing parents of middle-school children need to do is be willing to listen. Understand that, on any given day, you may be the last person your child wants to talk to. It's nothing personal. Think back to when you were their age. How much did you talk to your parents?

But your children will know if you're really interested in what's on their mind. Create a warm, understanding environment for them to share when they're ready.

How can I help my high-school children?

Take time to discuss the numerous physical and emotional signs of stress I talked about earlier. This will not only help them understand their own reactions to events but also will teach them important life skills they will need as they prepare to enter the adult world.

Don't talk down to them or try to shelter them from what's going on. They want, and deserve, straight talk from you. For many, the events of September 11 and the months that followed will be forever fixed in their memories.

Without downplaying the tragedy of all those who died, be sure to emphasize the way our country pulled together in a common cause. Talk about all of the people who sacrificed to help others and make a difference.

One of the dangers is that, just as teenagers are about to enter the adult world, it can appear to be a frightening and uninviting place. We can't allow them to grow disillusioned. We owe them a better, brighter future. Talk with them about how world leaders could help reduce hate and violence, and encourage them to get involved in school, religious, or civic organizations.

Many high-school students are searching for, or have only just begun to formulate their own ideas about, what they should believe in. They may have idealistic concepts of right versus wrong, peace versus war, etc.

You may not think so, but as a parent you have a great deal of influence over how your children’s beliefs develop. Discuss current events with them, allowing them to raise their own questions about what is right or wrong. As you begin to better understand some of the values your children have started to develop, you will be better able to help guide them..