Capitol hill staff workers' experiences of bioterrorism: qualitative findings from focus groups.

Abstract

Little systematic information is available on mental health issues related to bioterrorism. Five focus groups were conducted with Capitol Hill office staff (n = 28 total participants) to learn about their experience of the anthrax incident on October 15, 2001. More than 2,000 verbal passages were coded into categories and themes by using qualitative analysis software. Issues emerging from the discussions included difficulties utilizing customary social supports, concerns over potential long-term dangers created by efforts to eradicate the anthrax, and nonadherence to antianthrax medication regimens. Nonadherence to antibiotic prophylaxis is of immediate concern for response to future bioterrorist events as well as infectious disease epidemics. Other topics that warrant attention are social support and mental health interventions.

Full text

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Journal of Traumatic Stress, Vol. 18, No. 1, February 2005, pp. 79–88 (C ?2005)
Capitol Hill Staff Workers’ Experiences of Bioterrorism:
Qualitative Findings From Focus Groups
Carol S. North,1,6David E. Pollio,1,2Betty Pfefferbaum,3Deborah Megivern,2
Meena Vythilingam,4Elizabeth Terry Westerhaus,1
Gregory J. Martin,5and Barry A. Hong1
Little systematic information is available on mental health issues related to bioterrorism. Five focus
groups were conducted with Capitol Hill office staff (n = 28 total participants) to learn about their
experience of the anthrax incident on October 15, 2001. More than 2,000 verbal passages were
coded into categories and themes by using qualitative analysis software. Issues emerging from the
discussions included difficulties utilizing customary social supports, concerns over potential long-
term dangers created by efforts to eradicate the anthrax, and nonadherence to antianthrax medication
regimens. Nonadherence to antibiotic prophylaxis is of immediate concern for response to future
bioterrorist events as well as infectious disease epidemics. Other topics that warrant attention are
social support and mental health interventions.
Qualitativeresearch withfocusgroupshasbeenused
to explore varied topics in depth, such as health attitudes,
beliefs, and behaviors, including medication adherence
among low-income urban African Americans who have
chronic asthma (Freedman, Norfleet, Feldman, & Apter,
2003), differences in physicians’ and patients’ opinions
on medical error disclosure procedures (Gallagher, Wa-
terman, Ebers, Fraser, & Levinson, 2003), and promo-
tion of human immunodeficiency virus (HIV) testing,
1DepartmentofPsychiatry,SchoolofMedicine,WashingtonUniversity,
St. Louis, Missouri.
2George Warren Brown School of Social Work, Washington University,
St. Louis, Missouri.
3Department of Psychiatry and Behavioral Sciences, The University of
Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.
4The National Institute of Mental Health, Bethesda, Maryland.
5Department of Medicine, The Uniformed Services University,
Bethesda, Maryland.
6To whom correspondence should be addressed at Department of
Psychiatry, Washington University School of Medicine, 660 S. Eu-
clid Avenue, Campus Box 8134, St. Louis, Missouri 63110; e-mail:
NorthC@psychiatry.wustl.edu.
counseling, and sex education programs in an undevel-
oped country (Castle, 2003). Novel and unexpected find-
ings have sometimes emerged from this exploratory re-
search: For example, many highly educated people in
the latter study expressed disbelief about the existence
of acquired immunodeficiency syndrome (AIDS) (Castle,
2003). Focus groups also provide a relatively straight-
forward means of obtaining preliminary data for new in-
vestigationsofpoorlyunderstoodtopicssuchasbioterror-
ism,aboutwhichlittlesystematicinformationiscurrently
available to guide interventions.
Few pertinent systematic data pertaining to men-
tal health effects of bioterrorism are available; however,
previous literature has identified characteristics for in-
vestigation, including risk communication, management
of misattributed somatic symptoms, and the role of so-
cial support (Covello, Peters, Wojteki, & Hyde, 2001;
Holloway, Norwood, Fullerton, Engel, & Ursano, 1997;
Kawana,Ishimatsu,&Kanda,2001;Norwood,Holloway,
& Ursano, 2001). Relevance to these deliberate acts
may be found in studies of disasters, including toxic
contaminant spills, industrial accidents, and infectious
79
C ?2005 International Society for Traumatic Stress Studies • Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jts.20006

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80North, Pollio, Pfefferbaum, Megivern, Vythilingam, Westerhaus, Martin, and Hong
epidemics, which share uncertainties about personal ex-
posure, boundaries of the exposure, and duration of
risk. Anticipated psychological and social repercussions
may include potential for mass “psychogenic” or “so-
ciogenic” illness in multitudes of unexposed individ-
uals who have medically unexplained symptoms who
may seek access to and overwhelm the medical care
system (Alexander & Fedoruk, 1986; Amin, Hamdi, &
Eapen, 1997; Bartholomew & Wessely, 2002; Pastel,
2001;Schoch-Spana,2000).Systematicallyobservedout-
comes that followed toxic exposure to dioxin contamina-
tion, however, included neither somatoform symptoms
(Smith, Robins, Przybeck, Goldring, & Solomon, 1986)
nor posttraumatic stress disorder (Robins, et al, 1986).
In the fall of 2001, anthrax-filled letters were mailed
through the U.S. Postal Service to several sites, including
Capitol Hill, killing 5 and infecting 12 others (none on
Capitol Hill). On October 15, an office worker in Senate
Majority Leader Tom Daschle’s sixth-floor Hart Building
office opened a letter that contained suspicious powder
later confirmed to be anthrax. The office was closed and
staff workers briefly quarantined. Hundreds of potentially
exposed individuals were tested for anthrax, and antibi-
otic prophylaxis (ciprofloxacin) was provided (Hsu et al.,
2002). Buildings across Capitol Hill were subjected to
decontamination procedures.
A recent comprehensive study of 16 individuals
who were infected by anthrax during the attacks in the
fall of 2001 identified indications of persistent medically
unexplained health problems, psychological symptoms,
and poor life adjustment (Reissman et al., 2004). A report
(currently in press) of focus groups, which studied 36
Brentwood postal workers and 7 Capitol Hill workers
more than 1 year after the anthrax exposures, describes
concerns about demographic inequality in their medical
treatment (Blanchard et al., in press). The current report
describes results of focus groups of Capitol Hill staff that
inquired about their attitudes, beliefs, and postexposure
behaviors to explore the themes identified, identify
appropriate concerns for mental health interventions, and
inform future studies.
Method
Fivefocusgroupsoffourtoeightmemberseachwere
conducted between January 14 and February 1, 2002, ap-
proximately 3 months after the Capitol Hill anthrax inci-
dent (4 months after the September 11 terrorist attacks).
The 28 study participants constituted a convenience sam-
ple of staff recruited by word of mouth from six offices,
ranging from the highly exposed Hart offices to offices in
separate, unexposed buildings and remote sites, including
twoHouseoffices.Approvalfortheresearchwasobtained
fromtheWashingtonUniversitySchoolofMedicineInsti-
tutional Review Board. A federal Certificate of Confiden-
tiality was obtained for further protection of participants’
privacy. Participating congressional offices provided ap-
proval for the conduct of this study in their offices. Indi-
vidual participation was voluntary and written informed
consent provided.
The sample was 61% female and 96% Caucasian.
Mean age (SD) was 28.3 (7.1), 77% were single, and 32%
had advanced degrees.
The two facilitators (CSN, DEP) conducting these
groupshadpreviousexperienceinnondirectiveinterview-
ing techniques or training in conducting of groups. Group
discussions of approximately 60 to 90 minutes were au-
diotaped. The groups began with an opening instruction
by one of the facilitators explaining the purpose of the fo-
cusgroup(tolearnabouttheirissuesrelatedtotheCapitol
Hill experience with anthrax). Because the anthrax letters
werepartofaseriesofunsettlingnationaleventsthatorig-
inatedwiththeSeptember11terroristattacks,participants
were invited to begin by describing their experiences of
both events. A protocol of primary questions developed
for this study included the following:
(1) HowdidyoulearnoftheanthraxonCapitolHill,
and how did you react?
(2) How has your behavior or your life changed
since then?
(3) How did you react when you first learned of the
September 11 terrorist attacks?
Thereafter, group facilitators avoided further direc-
tion.Questionssuchas“Canyoutellusalittlemoreabout
that?” or “What else happened?” were interjected only as
needed to stimulate discussion from prior statements to
prevent inserting new topics. Thus, the groups provided
distinct content without direct bias or structure imposed
by facilitators.
Data Analysis
Qualitative methods used NVivo software to orga-
nize and interpret data from transcriptions of audiotapes
of the focus group by labeling passages of text with codes
identifying specified content. The text of the five focus
groups was reviewed for recurring themes, and “nodes”
(codes) were created for nine thematic categories identi-
fied: context of 9/11 and anthrax incidents, personal ex-
posure, personal safety, emotional reactions, psychiatric

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Bioterrorism Focus Groups 81
symptoms, social support, social disruptions, authorities’
response, and medical response. Two independent raters
reviewed 2,162 passages, tagging passages that identified
thethemeswithoneormoreoftheninenodes.NVivotabu-
latedthenumberofitemscodedintoeachcategory,allow-
ing assignment of relative frequencies of response types.
Kappa measures of interrater reliability on items included
in the nine categories ranged from .83 to .88 (calculated
on nonnegatively scored response pairs only), statistics
all within the excellent range of reliability (Fleiss, 1981).
Differences in ratings were subsequently discussed by the
team and resolved by agreement.
Results
This report presents findings regarding the context
and perceptions of individuals’ experiences relating to
eight categories (context, exposure, personal safety, med-
ical procedures, disruptions, emotional reactions, psychi-
atricsymptoms,andsocialcontext)thatconstitute77%of
the responses coded from these groups. Authorities’ re-
actions (23% of responses) are detailed in a forthcoming
report (North et al., in press). Category item frequencies
in this report ranged from 17% (personal safety) to 4%
(symptoms).
Context of Anthrax and September 11
During the September 11 terrorist attacks, the cog-
nizance of Capitol Hill workers of their status as a terror-
ist target provided potential candidacy for posttraumatic
emotional consequences. Anthrax attacks in the follow-
ing month added layers of concern to this backdrop. The
concern was relative, however: A worker from a directly
exposed office explained, “September 11 was horrible, it
was awful and I will never forget it, but it did not hit me
the way October 15 did.”
InthepenumbraoftheSeptember11terroristattacks,
CapitolHillstaffersponderedtheirworkplacesafety.They
sensedthattheCapitolBuilding,ratherthanthesurround-
ing Senate and House offices where they worked, was the
intendedtargetoftheattacks.“Itcouldhaveeasilybeenus.
Perhaps, if the plane hadn’t gone down in Pennsylvania.”
Comments of participants from the Senate side of Capitol
Hill seemed to reflect more upset and preoccupation with
theanthraxexperience,whereasthosefromtheHouseside
indicated more concern about the September 11 attacks.
A House worker stated, “It seems easier to accept anthrax
than the September 11 [attacks].”
The September 11 attacks may have primed the
Capitol Hill population to react vigorously to the next
event.
The only time I was ever really frightened and my heart
started pounding was [during a false alarm] a few days
after September 11th. I was in the Capitol and the guards
just started yelling, “Everybody get out! Everybody get
out!” and there was this big evacuation of the building . . .
this was like a mad dash by everyone to the door.
Choice of footwear was a new concern in the
post-9/11 workplace: “I definitely make a point since
September 11th not to wear shoes to work that I can’t
run very fast in.”
In comparing the anthrax experience with 9/11, per-
ceptions of the two events sometimes blurred together,
as if reflecting a single event. “In my mind it seems so
hard sometimes to separate September 11 [from] the an-
thrax.... Ican’tgetthetimelinerightinmymind,because
it all folds into one big mess.” This relationship was cap-
tured in new terminology, for example, “bioterrorism at-
tacks.” One focus group participant described the Capitol
Hill experience as “the Ground Zero of anthrax.” Famil-
iar quotations found novel applications in discussions of
thebioterrorismexperience:“‘Youarelivinghistory’—as
scary as it is, the first bioterrorism attack on the United
States.”
Contrasts between 9/11 and the anthrax attack on
CapitolHillwerealsoconsidered:“It’salotdifferentwith
anthrax than it is with September 11th... . On the Hill,
we didn’t know anyone who died from anthrax or that
was really affected; while September 11th, we all saw the
devastation.”
After the debut of anthrax in Florida and New York
City news stations, a vivid expectancy arose: “We kind of
knewsomethingelsewasprobablygoingtohappen.”“We
had just discussed that it was probably only time before
they targeted someone on the Hill.”
Anticipation of the next terrorist event kindled anx-
iety: “I really don’t have any idea of what it could be;
I just feel like something is going to happen again. I
feel like it’s inevitable.” “People who want to hurt the
government or cause mass terror, they’ve seen how easy
it can be.... I mean, good grief, look at those freaks
who’ve been sending [hoax] letters.... There are people
out there who are going to realize that you don’t even
have to kill a lot of people.” These worries generalized to
a variety of potential catastrophes: “I worry more about
stuff that they can’t protect you against, like car bombs,
or chemical attacks.” “I’ve always personally been much
more concerned about [terrorism] committed against this

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82North, Pollio, Pfefferbaum, Megivern, Vythilingam, Westerhaus, Martin, and Hong
building by more conventional means than anthrax... .
It’s much easier for your common garden-variety lunatic
to blow up a pickup truck, a panel truck outside of our
building ... or a car bomb, or someone just runs in with
a bomb.” “Maybe the difference between September 11
andtheanthraxisweweren’texpectingSeptember11... .
After the anthrax came, we knew something else was go-
ing to happen so you’re kind of expecting it. September
11 was out of nowhere.”
Perceptions of Exposure
The perceptions of exposure category describes peo-
ple’s ability to perceive and accept the dangers of the
anthrax attacks they experienced. Participants’ emotional
responses varied across the evolving time frame of events
described. Initially, the reality of the anthrax letter was
hard to accept, and denial was prominent. “I think I was
feelingcompletedenialthatsomethinglikethatwasgoing
to happen to us. That was my first instinct. I went through
the ‘No, this isn’t real, it’s not going to be real, it’s going
to be fine, we are all going to be fine,’ and ... deep down
I knew this was bad.” Incidents of false alarms, threats, or
hoaxes occur regularly on Capitol Hill. Comments sug-
gestedtheymayhavehadvariouseffects,sensitizingsome
peopletodangeryetreinforcingcomplacency amongoth-
ers.Oneworkerstatedthatover8yearsofemploymenton
CapitolHill,“I’veopenedalotoflettersandtalkedtoalot
ofpeoplewhowerereallymean,butafterawhile,youstop
taking them seriously because you get threat after threat
after nasty letter and nothing ever happens.... Probably
we took it all way less seriously than we should have.”
Another participant identified the September 11 terrorist
attacks as helping him realize the anthrax incident was
probably not a hoax.
Participants in the focus groups indicated that the
gravity of the anthrax exposure sank in only gradually.
“It wasn’t until maybe the next day that everything was
quarantined and they told us, ‘You have to come ... and
get a nasal swab.’ That’s when we [realized] .. . ‘Oh,
my gosh, wow, we actually have to get tested for this.’
You know, that’s huge.” Early concerns over the poten-
tial danger evolved with continuous unfolding of new
events. “I started to get a little bit more concerned. We
got nose swabs, and then on Wednesday the news came
out .. . Daschle and Feingold staffers had tested positive;
it was the [close proximity of the] Feingold staffers that
panickedme.”Anotherworkersaid,“Ihadtobetoldthree
times that my [nasal swab] test [for anthrax] came back
positive.” It wasn’t until 2 days later that a 7:00 A.M. tele-
phone call with the news “Your name was one that came
back positive” convinced the worker to take the incident
seriously.Manyworkersdidnotappreciateatthetimethat
the nasal swab test result was not an indicator of infec-
tion for any individual, but rather an epidemiologic tool
for defining boundaries of anthrax contamination levels.
“When our office ... tested negative, I think that’s when
all of us kind of breathed somewhat of a collective sigh of
relief.”
Uncertainty about exposure complicated efforts to
establish personal temporal and spatial boundaries to the
danger. “OK, I am not as safe as I thought; I am kind of
back and forth on it, I am safe, I’m not safe.” Participants
described difficulty interpreting and attributing physical
sensations,astheworstimaginablescenariosplayedoutin
life-and-deathstrugglesagainstdisease,blendingfearand
fact.“Ifyouhavethesniffles,that’sacold,butifyoudon’t,
that’s possibly ... anthrax.... ‘Is this normal? How do
I feel?”’ “Oh my God, I am going to die of anthrax and
it’s horrible.” Common physical sensations and bodily
changes were misconstrued as anthrax infection: “I was
allergic to the holder for my badge and I got a rash....
I [thought], ‘A rash! Maybe I was exposed to anthrax.’ I
had already gone through a whole rationalization: There
is no way I could have been exposed.”
Disruption
Disruptions to usual work activities during weeks to
monthsofdisplacementfromSenateHartBuildingoffices
weredescribedasamajorsourceofpersonalhardshipand
emotional burden. “For a week and a half, except for the
essentials, we were completely, completely interrupted.”
The uncertainty of how long the work shutdown would
continue further increased the distress: “It was a day-to-
day status. You couldn’t make plans . . . but because you
werewaitingeachdaywithexpectationsthatitmightopen
the next day, it was a constant mind tease.”
Resuming business, entire offices were forced to
conduct their work in other locations, doubling up with
other offices, sometimes with rivals. “We started shar-
ing offices ... took over the conference table in the other
room.... People had to be creative with coming up with
waystocontinuetogetworkdone,soyouhadtogetalong
with the people you were with.” “Trying to move major
piecesoflegislation”proceededwithoutU.S.mailservice,
without access to any paperwork including filed docu-
ments and address files, and often without personal com-
puters,telephones,oremail.“We’vegottennomail ... no
FedEx deliveries, no courier deliveries, no UPS deliveries
still to this day.... It brought the place to its knees and
it’s still having an impact now.” “I wasn’t jealous [that

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Bioterrorism Focus Groups 83
I didn’t have a work space]; I was mad. I was watching
everybody work like we had never left the building; I was
mad. I’m like, how can you people pretend that nothing
ever happened?” Workplace disruption displaced the an-
thrax as a major source of distress: “Now it’s really not
the anthrax anymore; it’s not the bombing anymore; it’s
none of that; it’s that I am not in my office.”
Perceptions of the effects of the anthrax incident on
workplace stress appeared to differ by exposure. Com-
ments from the House side of Capitol Hill suggested that
closure of the buildings was taken more in stride. “To be
brutally honest, anthrax then came almost as a relief....
I almost needed time to just get away from everything.”
Safety Issues
Safety was a prime personal consideration after the
appearanceoftheanthraxletter.Safetyconcernsextended
notjusttotheanthraxitself,butalsotohealtheffectsofthe
remedies used to control the anthrax, including chemicals
for its cleanup and irradiation of mail handled by the
workers.
They never applied [these chemicals] within an office en-
vironment, they never used it on anthrax before, and I am
much more concerned about the cure than I am about the
disease in this instance. What impact is that going to have
on a building that has no open ventilation, and everything
is recirculated; and what impact is that going to have on
breathing in these fumes constantly from a carpet that’s
completely been treated with chlorine dioxide, walls, fur-
niture?
The period of concern did not end with the current
period. “You just wonder ... 30 years from now am I
going to get cancer because I was exposed to irradiated
mail for however long?”
The irradiation of mail affected the paper in ways
that bothered workers.
Now the mail is . .. sent to Ohio. Then they bring it back
here and it’s sorted again and brought to us and it smells
funny... . It’s all stuck together... . That almost freaked
me out more than the actual anthrax.... This stuff is
grotesque; I don’t want to touch it.... Sometimes it’s still
sticky and I am still opening it and the letter is wet.... It
sticks together like a stamp you can’t open up.
Confronting uncertain risks, people resorted to mea-
sures such as cleaning their computer keyboards with al-
cohol swabs and donning gloves and masks to handle
irradiated mail. They pondered the wisdom of continued
exposure to danger working on Capitol Hill and living in
Washington, weighing the satisfaction of their job against
the risk. “At what point [do] you draw the line and say,
‘I’m going to quit my job because I don’t feel safe?”’
Workers could not always agree on the level of danger.
Uponbeingtoldbyacoworker,“Oh,stopstressingout....
You’rejustobsessingaboutthis,”onestaffworkerreplied,
“I am not obsessing; this is dangerous!”
Medical Procedures
Before antibiotics and vaccinations were adminis-
tered, nasal swab testing was conducted widely. Some
described the nasal swab procedure for anthrax testing—
typically a relatively innocuous process—as unpleasant
and uncomfortable: “They hit two nerves on each side of
your nose ... I was actually sick that night. I felt like I
hadabadcold,fever.”“Itwasjustawful.Iwouldneverdo
it again, because I was miserable for the entire evening. It
felt like my head was just drained and my eyes were wa-
tered.... I just kept thinking about the test and how much
it battered me.” One individual described “an incredibly
long swab inserted all the way up the nasal passages that
brings tears to the eyes—I had no idea my nasal passages
went back so far.” The implements were called “brain
swabs.”
Completing the medical protocols on hundreds of
people in a short time created occasional awkward mo-
ments.Theworkersrecalledreceivingtheirantibioticpre-
scriptionsingroups.Assembledtogether,theywereasked
what medications they were taking, to prevent potential
antibiotic drug interactions. Workers learned surprising
personal information about colleagues who disclosed use
ofcertainmedicationssuchasbirthcontrolpills,antiretro-
viral agents, chemotherapy, Viagra, or psychotropics.
Despite known dangers including death caused by
infection with anthrax, adherence to a 2- or 3-month reg-
imen of twice-a-day antibiotic administration was not as
simple as imagined. When a physician admonished one
of the workers that she would need to take the medication
faithfully even though it would be easy to forget doses,
she thought, “Forget! Are you kidding me? How would
I forget?” But she did forget: “The first couple of days
you have to take it on time. I took it 15 minutes late—
oh, no! And after a while, [it was] like, ‘Yeah whatever,
it kind of makes me sick; oh, I don’t think I’ll take it.”’
Succinctly stated by another: “These are not fun antibi-
otics.” Workers described media reports they thought they
had heard warning people not to take antibiotics for more
than 3 days lest they “become immune” to them (clearly
incorrect information and advice). A worker who heard

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84North, Pollio, Pfefferbaum, Megivern, Vythilingam, Westerhaus, Martin, and Hong
one of these reports admitted, “I took it for I don’t even
think 3 days, to be honest with you.” Another said, “I
don’t even think I took it for 3 days; I think I took it for
2.” Another worker explained:
I haven’t been taking it as regularly as I should, and in my
head that’s OK, because I’ll save some for when we finally
go back to the Hart [Building].... I know how antibiotics
work; that’s bad . .. I don’t take it because I’m sick of
taking it and I don’t remind myself to take it as often. I’ve
beentiredofit.AndIhatetakingit.Butthen,whenIforget
to take it, I don’t beat myself up about it as much as I did
the first 60 days because I am really OK now, but I am just
taking it in case.
The public seemed to have a fascination with
ciprofloxacin. One participant observed: “Cipro became
the status drug of D.C.... It replaced Ecstasy.... If
you were taking Cipro . .. it meant you must have been
some place really cool.” People they met were drawn to
their experience. “People would ask me, ‘Oh, you are
taking Cipro?’ and it was like a novelty or you are a
celebrity. They were definitely excited.... ‘Can I see the
Cipro?’ .. . It was the hit drug of November 2001.”
Emotional Responses
Initial emotional responses reflected various forms
of disbelief. The anthrax incident felt “like a mind game,”
a hoax or a joke or part of a scenario being enacted for
a disaster training drill. “I remember thinking, it can’t be
happening. My first reaction was complete denial, like
they are overreacting or somebody is screwing around
with us.”
As disbelief gave way to the reality of exposure to
anthrax, immediate emotional reactions included an array
of feelings, from fear (“terrified,” “nervous,” “fearful,”
“it was disturbing,” “freaking out”) to anger (“angry,”
“livid).”
Symptoms
Symptoms received surprisingly little mention rela-
tive to the amount of other material covered in the groups.
One worker described new onset of upper gastrointestinal
symptoms and exacerbation of previous problems with
headaches after the anthrax incident. After a thorough
evaluationinvolvingseveralmedicaltests,herdoctorcon-
cluded, “Well, I think it’s stress.”
One worker described concentration difficulties:
“There were days when people just couldn’t work. They
couldn’t focus.” Arousal and intrusive recollection were
directly observed by the focus group facilitators in one of
the study’s groups, when the discussion was diverted to
attend to some noises outside the window. The group de-
scribed it as a “whooshing sound” and pondered whether
it was an airplane. This discussion prompted one partici-
pant to mention sounds of sirens along with airplanes as
upsetting reminders of 9/11.
Avoidance and denial received more extensive de-
scriptions. “For the 3 first days of the anthrax thing I
stopped reading the newspaper, I just zoned out, I was
in denial.” “I didn’t want anything to do with politics,
or ... anything to do with Washington. I just wanted to
forget about it for a while.” Their denial extended to be-
haviors involving decisions to cooperate with the medical
response. “I didn’t know if I had [anthrax]; I didn’t want
to get tested ’cause I was believing that I didn’t have [it].”
Avoidance even extended beyond the workplace to other
parts of people’s lives. “I stay at home a lot more now.
I used to be the kind of person who would fill up every
night of my schedule.”
Early psychological interventions to help workers
cope with their feelings about the anthrax incident in the
workplacereceivedmixedreviews.Somecommentswere
quite critical. “The Employment Assistance Office set up
grouptherapysessions ... mostofthesepeoplehavebeen
to a couple of those. I didn’t think of those as very pro-
ductive at all.” “The way [this] psychologist approached
it, it was, ‘So, tell us about your feelings’ or . .. ‘That’s
normal,’ every time we said [anything] ... ‘That’s nor-
mal.’ Don’t just tell me that what I’m feeling is OK. Tell
me why I’m feeling what I’m feeling.” Others were more
positive. “We went to a really good one that talked about
coping skills.” Some felt their own emotional support of
one another was more helpful. “We all talked [to each
other] about what we are doing to get by, but in a lot of
ways we were getting therapy from each other... . So,
yeah, there’s psychologists out there who are experts on
trauma, but we are experts on this trauma.”
Social Support
Workers reported receiving extensive emotional and
social support from one another in the wake of the an-
thrax exposure. Participants explained that offices well
known for their cohesiveness even before the event found
theirsupportsystemshad“intensifiedtremendously.”Un-
pleasant business such as standing in lines for anthrax
testing fostered opportunities for interpersonal support.
“Waiting to be tested ... [I] made friends with everyone
else around.... I could go to any of those offices [of

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Bioterrorism Focus Groups85
people] we were in [line] with and say, ‘You remember
me.. ..”’ They considered their support of one another as
therapeutic:“Ineededtobebackoutherewithpeoplewho
had gone through it, so we had our own support group.”
You would think we would want to run as far away
from each other as you can get, but ... everybody under-
stood.. .. If you needed somebody to talk to, there was
somebody there and if you needed to not talk there was
somebodywhowouldhelpyoufindsomethingelsetotalk
about.
Within the Capitol Hill community, however, not ev-
eryonewasasourceofsocialsupport.Theparticipantsex-
plained, “You have to figure out who among your friends
youcanshareinformationwith,”toguardagainstpersonal
information’s leaking to the media.
Although “sometimes it was just too much and I
needed to talk to someone else,” participants indicated
that social support was not as readily found outside work.
They felt their friends and family “just don’t understand
and they don’t care and I can’t relate to them.” “I needed
to be around people that had gone through it.... My
friends ... don’t really talk about it.” One worker said
her sibling would not allow her to talk about anthrax
“because I am unpleasant conversation.” Another said,
“My boyfriend didn’t deal with this well so we are no
longer dating.” Families did not provide the social sup-
port people usually expect of them: “I feel like I can’t dis-
close challenges at work as much with family and close
friends because ... there’s no reason to concern others
when ... they can’t do much about it.”
Families’ needs for reassurance from the workers
created more social liability than support from family
members. One worker “had 14 messages from [my hus-
band] trying to find me to figure out if I was OK.”
I had hysterical messages from my mother.. .. My
dad called; my boyfriend called; my friends called;
and they couldn’t find me and they were watching the
news. And then Tuesday morning, I am in the meet-
ing... and it breaks on CNN that 23 people.. . tested
[positive] . .. and my mother called, and my father called
and my boyfriend called and like, I used 1700 minutes on
my cell phone. . .. The media was very difficult for me.
One worker’s mother had asked, “Are you sure you
want to risk your life for this job? ... Maybe you should
justleavethereandgodosomethingelse.”Anothermother
made the worker promise never to go into the Hart Build-
ingagain.Workersfoundthemselvesreassuringtheirfam-
ily rather than the reverse: “[I was] trying to weigh out
information[thatwouldbe]easierforthemtohear,what’s
going to make them feel better, and trying to weigh that
with the fact [that] I don’t want to talk about it anymore.”
Theapparentprevalenceofthissituationisreflectedinone
worker’s summary of it: “Almost everybody had some-
body in their family who was making them miserable.”
In social situations, workers encountered celebrity
status as anthrax victims, such as the worker who was in-
troducedas“theanthraxbridesmaid”atawedding.“They
introduced me at the rehearsal dinner as ‘My friend [—];
she has anthrax’ .. . like it’s part of your identity now.”
This was not the kind of celebrity status one might wel-
come: “Yeah, I wanted to be famous, but not this way. Not
like this.”
Discussion
Context of the Findings
These focus groups provided a glimpse into Capitol
Hill workers’ experience of the October 15, 2001, an-
thrax exposures. Emerging topics of medical response,
personal safety issues, and social context are consistent
with the earlier literature’s suggestions of the importance
of risk communication and social support in bioterrorism
and with findings from relevant nonbioterrorism research
(Lamar & Malakooti, 2003; Norris & Kaniasty, 1996;
Patel & Zed, 2002). Concerns emphasized by exposed
postal workers (Blanchard et al., 2004) and infected vic-
timsoftheanthraxattacks(Reissmanetal.,2004)inother
studies—equality of medical care, persistent medically
unexplained health problems, psychological symptoms,
and life adjustment problems—were not prominent in the
Capitol Hill focus groups. The relative underemphasis
of psychological symptoms and medically unexplained
symptoms in the Capitol Hill study matches findings of
published studies of dioxin contamination (Robins et al.,
1986; Smith et al., 1986).
The amount of legislation successfully enacted dur-
ing the postanthrax period on Capitol Hill is an indicator
of thwarted terrorist effect (Congressional Management
Foundation, 2001). Despite the disruption, workers said
they pulled together and refused to allow derailment of
their work, a testament to the resilience of this popula-
tion. The 9/11 attacks a month earlier may have had both
sensitizing and habituating effects in people’s response to
traumaandinthecontext ofother stressorsinindividuals’
lives.
Safety and Medical Concerns
A concern identified by the focus groups was the
unresolved issue of possible continuing danger in the

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86 North, Pollio, Pfefferbaum, Megivern, Vythilingam, Westerhaus, Martin, and Hong
perceptionsoftheworkers.Althoughriskofanthraxexpo-
sure passed within days for most, and within 4 months for
thehighest-exposuregroups,longer-termworrieslingered
about potentially harmful effects of the irradiation of
mail and chemicals used to clean up the contamination—
consequences of the interventions, not the infectious ex-
posure itself.
Admission of nonadherence to antianthrax antibiotic
prophylaxis in this setting is of immediate concern for
response to future bioterrorist incidents and epidemics.
Despite these intelligent and well-informed individuals’
appreciation of the importance of medication, their ac-
tions seemed inconsistent with their knowledge. Incon-
sistent recommendations by authorities and conflicting
messages in the media in the weeks that followed the ex-
posures, combined with the passage of time when no one
on Capitol Hill became ill, may have contributed to com-
placency in the workers and perceptions that medical au-
thorities’ application of antibiotics was overly broad and
excessively cautious. In circumstances of extended (60-
to 90-day) antibiotic prophylaxis for potentially exposed
groups, medication adherence may have less in common
with familiar 7- to 14-day antibiotic courses for acute in-
fections in the community that produce dramatic relief
than with chronic medication maintenance among people
who do not feel ill without medication. In the long-term
treatment of hypertension, for example, antihypertensive
medication side effects function as a potent disincentive,
contributing to nonadherence (Menzin et al., 2004). Fur-
ther investigation into treatment adherence and risk com-
munication in the context of bioterrorism is crucial.
In focus group comments, early psychological inter-
ventionsdidnotreceiveparticularlyhighapprovalratings.
Whereas some people felt that techniques such as relax-
ation were helpful, others wanted them better tailored to
their needs. Even though their feelings were identified
as “normal” for people in the context of extreme stress,
these feelings were not normal in their usual experience,
and therefore simple reassurance about the normality of
their feelings was inadequate.
Social Support
Facilitation of postdisaster recovery involves restor-
ing effective social roles and returning people to their
usual sources of social support (Norwood et al., 2001).
However,socialsupportisamultifacetedphenomenonin-
volving complex systems, as Norris and Kaniasty (1996)
noted in their social support deterioration model devel-
oped by using longitudinal data on hurricane victims.
Disaster exposure, received and perceived support (which
may differ), and psychological distress in this model are
interrelated and may in turn be confounded with extra-
neous variables such as preexisting individual character-
istics. Consistent with this model, combined effects of
anthrax exposure, the stigma of victimization, and na-
tional media attention may have conspired to weaken the
primary support system of family and close friends out-
sidework.TheCapitolHillworkers’usualsocialsupports
ironically sometimes added to, rather than reducing, their
distress (or were perceived to do so). The support they
could not find elsewhere they provided to one another, in-
voking Lindy and Grace’s (1985) concept of the “trauma
membrane,” which isolates survivors in a self-contained
unit of social support. The social support of exposed in-
dividuals for one another identified in these discussions
should not be overlooked as a valuable source of strength
to complement formal mental health interventions.
Study Limitations and Future Directions
This study was limited by the small sample size and
volunteer nature of its selection of participants, who rep-
resented only a small portion of the workers on Capitol
Hill. The participants may not be fully representative of
Capitol Hill workers; their experience may not generalize
to other groups; and the findings here cannot necessarily
be considered to be representative of the general thoughts
and emotions of workers on Capitol Hill or other popula-
tions such as the Brentwood postal workers. This sample
was young, highly educated, high-functioning, well in-
formed, and resourceful. Volunteering to participate in
the study in itself may reflect willingness or eagerness to
discuss personal reactions, characteristics that might not
be shared by nonparticipants, some of whom might be
more symptomatic and avoidant than the participants, or,
alternatively, less concerned about or upset by the experi-
ence.
The findings may be limited by participants’ con-
cerns about confidentiality, despite measures taken to re-
assure them that their privacy would be protected. With
oneexception,thegroupswereconductedinclosedrooms
within governmental offices (one group was conducted in
a private room in a nearby hotel). Four of the five groups
were composed of members from a single office; the fifth
group comprised individuals from different offices. Al-
though members may have been reluctant to discuss per-
sonal topics in the presence of professional colleagues,
who may have included supervisors, they may also have
beenmorecomfortableinthepresenceoftheircolleagues,
from whom they had received social support in the wake
of the anthrax incident. Individual anecdotal comments

Page 9

Bioterrorism Focus Groups87
by members indicated that both processes may have been
operative.
Most comments from the focus groups about the
management of the anthrax incident were negative. This
response should not be taken to indicate general negativ-
ityin theoverall perceptions of staff workers.Because the
focus group study was not designed to generate represen-
tative data on opinions about medical and safety issues
but rather to learn about issues the workers faced, the
concerns elicited reflected generally negative content, in
part as a result of instructions to the focus groups to dis-
cusstheirspecific“issuesandconcerns”abouttheanthrax
experience.
Further studies seeking more representative samples
and providing more systematic data with greater depth
are needed to confirm, refocus, and expand the findings
of the current study. Primary considerations of additional
study should include assessment of more diverse sam-
ples; examination of psychiatric diagnosis; consideration
of longer-term, slowly emerging effects of bioterrorist
incidents; investigation of determinants of treatment ad-
herence; and exploration of social support mechanisms.
Summary
These focus groups who described Capitol Hill staff
workers’ experience of the anthrax incident on October
15, 2001, indicated several concerns, including medical
and personal safety issues and social context. Psycho-
logical and medically unexplained symptoms were not
emphasized. Nonadherence to antianthrax antibiotic pro-
phylaxis is of immediate concern for bioterrorism and
infectious disease epidemics.
Acknowledgments
This research was supported by National Institute of
MentalHealthGrantMH40025toDr.NorthandbyAward
MIPT106-113-2000-020 of the Oklahoma City National
MemorialInstituteforthePreventionofTerrorism(MIPT)
and the Office for Domestic Preparedness, U.S. Depart-
ment of Homeland Security, to Dr. Pfefferbaum. Points
of view in this document are those of the authors and do
not necessarily represent the official position of NIMH,
MIPT, or the U.S. Department of Homeland Security.
TheauthorsgratefullyacknowledgetheassistanceofPam
Lokken; Laura Petrou; Rear Admiral John F. Eisold, The
Attending Physician to Congress, United States Capitol;
the participants in this study and Capitol Hill offices in-
volved.
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