Importance of Mental Health in Management of Chemical and Biological Casualties

By Madeline Roty, Biodefense MS Student

In March 2020, I was supposed to attend the Medical Management of Chemical and Biological Casualties (MMCBC) course sponsored by the United States Army Medical Research Institute of Infectious Diseases (USAMRIID) and the United States Army Medical Research Institute of Chemical Defense (USAMRICD). These plans were foiled by the COVID-19 pandemic which forced the Army to pause its in-residence courses: it would be rather ironic if an outbreak of COVID-19 occurred at a course on how to manage biological casualties. Fortunately, USAMRIID and USAMRICD were able to adapt the training and transition to a virtual format which I attended in October 2020. 

Though we were not able to don and doff personal protective equipment (PPE), simulate atropine injections to treat a nerve agent attack, or engage in other hands-on opportunities, being in a virtual setting did not reduce our access to some of the world’s leading experts on chemical and biological threats. An incredible amount of information was covered in six surprisingly short days. The first three days focused on chemical threats, and the remaining three days focused on biological threats. Topics included the history of chemical and biological warfare, specific chemical agents and pathogens, treatments, decontamination, triage, epidemiology, and even care for military working dogs. Case studies and patient scenarios allowed us to put our knowledge to the test by making presumptive diagnoses, triaging and prioritizing our patients for decontamination and evacuation, and determining how we would treat the presenting patient. My background is nursing, which made understanding some of the content easier, but in my four years of nursing school, we only scratched the surface of the content delivered in these six days. I now have the knowledge to go into the field and confidently assess a victim of a mustard gas attack or identify patients presenting with symptoms of inhalational anthrax. Much of the information covered in the biological portion of the training was familiar to me from my biodefense courses at George Mason, but it was a great opportunity to apply my knowledge and to learn more about the Department of Defense’s role in biodefense. 

One of my favorite lessons was given by Dr. Ross Pastel on the “Psychological Effects of Biowarfare.” I have a particular interest in the psychological effects of disease outbreaks on health care workers, so I was thrilled to see that the Department of Defense includes behavioral health in its educational courses and planning for biological events. The most important points that Dr. Pastel expounded on were the difference between risk and the perception of risk, the expectation of psychological casualties during chemical and biological events, and the acknowledgment that the psychological effects of hazardous conditions are real.

For experts, risk is “simply” calculated by multiplying the hazard by the amount of exposure to it and its consequences. For the layperson, risk is more subjective; it is the product of the hazard and the person’s perception of the hazard. Perception can be influenced by factors like uncertainty of exposure to the hazard, limited knowledge, experience, and controllability of the hazard. Why is this distinction important? Perception of risk contributes to a person’s psychological reaction, even if the perceived risk is greater than the actual risk. Even in the absence of a true threat, the perception of a threat can still exist and result in psychological casualties.

During World War II, the proportion of combat stress casualties to wounded in action was about 1:4. Data from the 1991 Persian Gulf War, during which troops feared potential exposure to chemical agents from smoke plumes following the destruction of Iraqi sites, showed that the proportion of combat stress casualties to wounded in action was 3:1. (In reality, only a small percentage of concerned troops were actually confirmed to have been exposed to chemical agents. The known exposure was accidental and resulted from the post-war demolition of Iraqi chemical rockets.) This extreme inversion suggests that more psychological casualties should be expected during a chemical or biological attack than from a traditional attack. Similar findings have been found beyond the battlefield. Health care workers have reported that they were more unwilling to report to work during a biological threat, like the SARS pandemic, than to any other disasters, like snow storms or mass casualty events. Characteristics of biological weapons, like the invisibility of the agent and lack of experience with these threats, increases the perception of risk and contributes to the higher number of acute psychological effects.  

When thinking about planning for catastrophes, including chemical or biological attacks, many discuss the “worried well.” Worried well is an inaccurate term that diminishes the genuine psychological impact chemical and biological attacks can have, preserving the stigma associated with mental health diagnoses and treatment. Psychological symptoms are real, and they can be painful. Furthermore, symptoms of anxiety and fear can manifest with the vague, similar symptomology of some biological or chemical agents including nausea, dizziness, and difficulty breathing. While most psychological effects are acute, long-term effects can include burn-out and job change, alcohol and drug misuse, family disturbances, domestic violence, and chronic medical issues including depression and PTSD.

This lesson is particularly important in light of the ongoing COVID-19 pandemic. Health care workers are overworked, understaffed, and stressed. Exposure to the media covering pandemic news is constant, which could increase incidents of post-traumatic stress symptomology. It is important to note that experiencing symptomatology is not the same as having the disorder, but it is still painful and unhealthy. As we try to respond to the pandemic by taking actions to protect and/or improve the physical health of patients, workers, and the public, mental health cannot be neglected.

MMCBC was an amazing experience that I would recommend to anyone interested in the fields of chemical and biological weapons. While I hope I never have to use my new knowledge, I am very glad to have it. The instructors and staff deserve a big thank you for making this course possible during these unconventional times. I am particularly appreciative of Dr. Pastel for bringing much-needed attention to the importance of mental health and acknowledging that psychological effects following exposure to hazardous conditions are real and need to be addressed, not dismissed.

Madeline Roty is working towards her Master’s in Biodefense at George Mason University. She became a registered nurse after graduating from the University of Michigan School of Nursing in 2019. Her interests include public and nursing education about mass casualty events and the role of culture on decision-making.

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