False Alarm: The Truth about the Epidemic of Fear

PREFACE

This book was conceived unexpectedly during a southbound trip on the FDR Drive in New York City on the morning of September 11, 2001. It was a bright, hot morning when I began to notice the multicolored ambulances from all over the city—Columbia Presbyterian, Metropolitan, St. Vincent’s—traveling alongside and passing me, all exiting at Bellevue Hospital.

I volunteered my services to the transforming emergency center at Bellevue that morning, absorbing the rush of human emotion—at once committed to the task and yet frightened. The fact that ultimately there weren’t the survivors to fill our beds did little to stem the fright. People worked to keep their minds off the unfolding disaster, and this, I discovered, was a necessary coping strategy.

As I volunteered my services to the Red Cross and to my patients in the succeeding months, I discovered a newfound vulnerability. I entered the media world and found that each health care topic I discussed in an article or on TV seemed blown out of proportion to the real danger. I seized the chance to learn about each succeeding bug du jour and to try to offer perspective and a salve of reassurance whenever I could.

We all personalized 9/11, and it made us all feel more at risk, whether we were really at risk or not. We grew afraid more easily than before, misinformed by our leaders and provoked by the news media.

Anthrax was the first manifestation in concrete terms of this personalized susceptibility. I was honored to participate in a U.S. Senate investigation into the handling of the anthrax crisis, directed by Senator Chuck Grassley of Iowa. I discovered amidst the CDC and U.S. Postal Service papers and letters to and from the senator a sense of fumbling. Fear out of proportion to the real risks was made worse by a lack of preparedness. Even if you didn’t have a reason to be afraid before, you could see how poorly you would be protected if there really were a reason to fear.

During the health care scares of the next few years, my patients shared their fears with me every day. I have changed their names here in order to protect their privacy, but I would never have been able to conceive of fear in real terms if it weren’t for their willingness to share their concerns and experiences.

I witnessed their fear of SARS, despite the fact that I never saw any evidence that SARS was close to becoming widespread. My office phone rang with anxieties over influenza as it went from being a ho-hum underappreciated killer to the latest rage.

In addition to my patients, I have a great appreciation for my family. Not only did they bear with the many investigations and revisions that constitute this book, but they also served as my subjects. I’ll never forget the time that I came home from a conference on bioterror, where I had discouraged people from gearing up for worst-case scenarios all the time, only to find my wife Luda’s medicine drawer emptied of cold remedies and replaced with Cipro as a precaution against an anthrax attack.

I understood from the outset that our fear mechanism had gone awry, but I didn’t know exactly how. I could study the process by which dangers were manufactured and provoked, but as a medical doctor I also had to study the original fight-or-flight mechanism that was intended to protect us. The place to start was with animals. My patient and friend Sylvain Cappell, a top-flight mathematician at New York University and well connected to the scientific community, was very committed to the notion that my book be as scientifically based and accurate as possible. He helped me arrange interviews with some of the people who helped me articulate the core principles of fear physiology. I am indebted to his friends and colleagues Rachel Yehuda, Joe Ledoux, Chris Jolly, Esther Sabban, and John Mann.

Eric Nelson, senior editor at Wiley and a vegetarian, first heard about this book over eggplant parmigiana at a midtown Italian restaurant. He immediately committed himself to the project with great excitement and has never looked back. I am very grateful for his generative ideas and great forbearance. Nancy Rothschild, P. J. Campbell, Anna Christensen, and Devra K. Nelson at Wiley have brought passion and skill to the project.

Likewise, Joëlle Delbourgo, agent for the book, has been devoted to it throughout the long process of its birth. She was faithful to my fear concept from the moment she first heard it.

Jennifer E. Berman and Jennifer Choi and the NYU School of Medicine public relations team, along with Nadine Woloshin of Rubenstein Associates all offered crucial support.

I am also grateful and privileged in terms of early readers of the manuscript. The views of the great novelist E. L. Doctorow were indispensable, as were those of the consummate sportswriter Ira Berkow. No one read this book more tirelessly and devotedly than my friend Kenneth Blaker. My sister Fran and the film producer Donald Laventhal also offered important suggestions throughout the editorial process. The final stages were aided by the insights of David Goldston, Hugh Gilmore, and Hesh Kestin.

In the end, though, I have the print and television media to thank the most. By allowing me to participate, as a spy as much as a contributor, the news media permitted this book, for the most part, to write itself.

Introduction

THE FEAR EPIDEMIC

There is—was the feeling, oh, gee, we didn’t do enough on 9/11, so let’s make sure we warn everyone.

—Bob Woodward on CNN’s Larry King Live, April 23, 2004

Fear invades our homes like never before, affecting more and more people. Newspaper headlines are apocalyptic warnings. Media obsessions fuel our cycles of worry, which burn out only to be replaced by more alarming cycles.

The passions and routines of everyday life are our primary defenses against this contagious fear. These defenses, however, are being eroded, bombarded by the ongoing doom-and-gloom of the daily news. Twenty-four hours of cable news infiltrates our sleep and may be as damaging to our health as cigarette smoke is to our defenses against cancer.

How did it get to be this way? Fear is looming larger in our lives. Yet no one has tried to integrate what scientists have learned about the physiology of fear with the increased reliance on fear on the part of both the media and the politicians. Of course some fears have their origin in real events, most prominently the attacks of September 11, 2001, but the overall climate of fear is inflated well out of proportion to the reality and is its own core danger to society.

My investigations of fear have shown that it is designed to be protective, that animals use it to sense genuine threats to their survival. At the same time, we humans have the ability to exaggerate fear until it threatens our health.

Under the stress of unremitting fear, we become more susceptible to disease, including heart disease, stroke, and cancer. Once we become sick, our fear grows. In my medical practice I deal with many patients who are so alarmed by their illness that even offering an effective treatment isn’t enough to reassure them. In treating this fear in my patients, and in analyzing health care scares in my newspaper writing and on television, I have tried to uncover the moment of lost perspective when dangers are first distorted.

My investigation of fear started with the discovery that animals respond by instinct and conditioning, while we, with the same essential fear apparatus as they have, feed our fears through verbal communication. A zebra is wise to be afraid of a roaring lion, yet we are not so wise to fear a metaphorical lion that is a thousand miles away from us. As soon as we hear about a danger, however remote, we tend to see it as a personal threat, especially if the danger is exaggerated to begin with.

This pattern of distortion led me directly to the media. How many of us listen to somber-toned newscasters and expect that what we are hearing is valid information? Many of us grew up believing we could find truth in the news. When did the crew-cut, thick-glasses, thin-tie anchorman become today’s harbinger of doom?

For me, realization of the fundamental change in the media occurred at the beginning of May 2004, when I received a phone call from the WNBC-TV doctor, David Marks. He was looking for a sound bite about the new Medicare discount cards, the latest in false comfort.

Marks was a well-dressed young internist with news-anchor features and a kindly face. He had a private practice in Connecticut, and he came to New York two days a week to tape health spots for the TV station.

As we were being powdered and prepped for the interview, I mentioned that I was investigating the epidemic spread of fear.

What role do you think the media play? I asked him.

We’re so guilty of spreading it, he said. I don’t like reporting the overhyped stories that unnecessarily scare people. But these are my assignments. I try to put things in perspective, to do my best to tone things down, but sometimes I wish we weren’t covering these stories at all.

I was looking for just this kind of direct admission from a card-carrying member of the media.

Media people I’ve met are serious and sincere, which doesn’t mean they always see risk in a proper context. Newspapers issue daily corrections but do not routinely acknowledge when threats that are reported don’t materialize.

In studying fear, I have come to believe that it has a tendency to reignite itself. Once a fear fire is extinguished, another one takes its place. There are fear seekers in our society, and these groups are always expanding in number and infecting new members. People are especially susceptible on the coasts, where fear of terrorism is greatest, but there are plenty of worriers in between.

When it comes to the fear epidemic, are we Americans unique? In parts of the world where wars and acts of terrorism have been more commonplace, America has the reputation of being a country with a soft underbelly. In Israel most people manage to live relatively normal lives despite frequent suicide bombings and constant military conflict. This is because statistically, a walk to the supermarket in Israel is still far more likely to be uneventful than unsafe, and the public has come to understand and accept the small level of individual risk. As a result, in Israel and in other societies whose citizens live with similar uncertainties, people become desensitized to the chance of terrorism over time; the threat gradually becomes less immediate, and thus more in keeping with the statistical probability of terrorism actually taking place.

Still, even in Israel the threat of terrorism has had a cumulative effect on health. Desensitization, as I will show throughout this book, is not a cure, and people in Israel live stressful lives. Suicide bombings that occurred there in 2001 have been shown to have an impact on the perceived sense of safety in 2002.

A study that appeared in the journal Psychosomatic Medicine in July 2004 showed that Israeli women who expressed fear of terrorism had twice as high a level of an enzyme that correlates with heart disease, compared with their less fearful compatriots.

It is not necessary to have a psychiatric disorder in order to be made ill by fear. This is the essential distinction between the well-described diagnoses of anxiety and phobia and the new fear disease that can victimize anyone. And superimposing fears on a population that is already riddled with phobias and anxieties can induce paralysis.

Imagine how someone who is afraid of flying felt after being saturated by the media images of September 11. Or someone who loathes insects, when she reads about mosquitoes and West Nile. Or a healthy person, trying to control his cholesterol by diet alone, who is compelled to view ad after ad of smiling athletes who supposedly stay healthy only by taking a certain cholesterol drug.

The symptoms of fear, the maladaptive kind, include an exaggerated sense of vulnerability, fear of a danger that doesn’t exist, or fear out of proportion to the risk. Like any illness, the illness of fear interferes with function. Fear victims are revved up in fight-or-flight mode. Their bodies ask them, how is a person to be protected from an ever-growing threat without being on the alert? Stress hormones—adrenaline, catecholamines, and cortisol—are secreted in excess amounts. These counterregulatory hormones cause the liver to make more sugar and create more and more energy, which builds up without outlet. To this, nervous sedentary people add more stimulants such as coffee, which revs them up further. People don’t eat well, sleep well, or experience sufficient pleasure because they are always on the alert.

Why such an easy path to hysteria? For months I pored through books and articles trying to figure this out. The tiny pecan-shaped organ deep in the center of all animal brains—the amygdala—serves as the central station for processing fear. Once it has been triggered, the amygdala is difficult to deprogram. The higher centers that help you to unlearn fear are weak compared to the hardwiring of the central amygdala.

Beyond our animal instincts, for many of us our Judeo-Christian background makes fear a familiar concept that can easily motivate us. A disapproving God, we learn, is ready to punish us. Postmodern panic may have its origins in the collective memory of biblical scourges.

With fear infecting and reinfecting us, our pill-happy culture looks for treatments rather than cures. Whether this pill is propranolol, Valium, Prozac, or another new brew, we are told that without it, we will be compelled to live in terror. Rather than examine why we are unnecessarily afraid, rather than ripping out this weed of fear by its roots, we attempt to neutralize it with postmodern concoctions.

In addition to pills, we seek the ultimate vaccine. In a study from Israel in May 2004, Jonathan Kipnis gave a chemical cocktail to panicked mice and found that by bolstering their beleaguered neurons, the mice were once again able to perform their usual tasks. The implication of these results—if they prove applicable to humans—is that immunologically engineered vaccines may help to make people impervious to panic. But it is one thing to employ sophisticated technologies to bolster an overworked nerve fiber in a troubled brain, it is another to bottle the latest preventative and market it widely to treat all fear. Instead of learning how to assess risk realistically, we will try to treat fear with the latest in immunology.

Traditional vaccines already provide us with an apparent shield against our fear of illness. In the fall of 2004, many of the people who trampled over each other in line to get a flu shot at a time of sudden shortage were more at risk of exhaustion than of flu. But as with the faraway roar of the lion, the widely held belief that people are at great risk of the flu is a media creation. So too is the perception that a simple inoculation removes that risk.

The public pendulum swings from dependency on a supposed panacea to panic when a vaccine is found to be flawed or is no longer available. The government makes fear a central part of its agenda, trying to weigh in as our protector. In the process of being so protected, we learn about dangers we didn’t know existed. The real danger of being manipulated in this way is to our health.

I learned firsthand of the devastating reach of governmental fear mongering when, at the request of Senator Chuck Grassley, I examined the response to the 2001 anthrax mailings. The Centers for Disease Control (CDC) attached itself to the media megaphone and made us all feel afraid to open our mail. This response was a way of covering up the miscommunication and mishandling of the evidence by all the federal agencies involved.

The anthrax scare established a precedent for public health hysteria that has been racheted up with each new bug du jour, to the point where the public feels threatened by every possible source of contagion. Smallpox extended the hype to a bug that is no longer infecting anyone. SARS was the first panic to involve the worldwide health community and petrify Asia and Canada along with the United States. The flu scare turned an overlooked disease into a sensation overnight.

The government was sometimes a greater danger than the supposed threat. In its haste to protect us from chemical and biological weapons, for example, the government built expensive high-security laboratories to study these potential weapons. But a study published in February 2001 found that of twenty-one known germ attacks, most were conducted not by terrorists but by government researchers-turned-terrorists who had gained access to human pathogens.

And until it becomes an election issue, our leaders practically ignore the risk of nuclear terrorism, where a terrorist smuggling a suitcase onto a plane or boat can get past the porous safety net and cause great harm. As Harvard scholar Graham Allison wrote in his book Nuclear Terrorism, this is one worst-case scenario that we aren’t doing enough to prevent.

As I interviewed people for this book, I found many who were wistful for the good old days. Perhaps our greatest immunity against panic has always come from go-to people in charge of our safety: the policemen, firefighters, and emergency medical technicians. But these comforting presences are being forced to compete with the all-purpose information glut. Tiny bites of data are always within reach via the Internet, the television, and the radio. Many of my patients complain that they don’t know where to go to find answers that don’t frighten them. Our personal narratives are gradually giving way more and more to the discourse of risk and danger.

We believe that strangers are a threat to us, but as Barry Glassner, the author of The Culture of Fear, has pointed out, most crimes involve people known to the victim.

The narratives of this book are drawn from the many patients I know who live in fear and who struggle to cope in the face of growing misinformation. Their stories are juxtaposed here with the true science that eludes them and the societal trends that heighten their anxiety.

Despite the growing fear, there are those who develop hard reflexes to cope with real dangers. Emergency workers are trained to put their own risks in perspective. Firefighters cannot function if they are afraid of being burned or overcome by smoke, and doctors have to put aside their fear of catching a patient’s illness in order to do their jobs. This training requires a concentrated effort.

A social plan for stabilizing public hysteria involves countering false beliefs regarding danger. But fear researchers have determined that seeing fear in practical terms isn’t easy.

In examining fear, I have attempted to find a new social model to explain today’s post-9/11 outbreak. Using my tools as an internist, I have discovered that the disease model for infection and epidemic fits fear the best. Fear is physiological, but today’s fear has become pathological. It spreads via distorted hype to those who may not have been worried in the first place.

We build up a partial immunity to each cycle of fear with the simple passage of time. We become desensitized, and we learn that the threat we have been coached to fear is not likely to occur. But fear is not easily unlearned. Our deep emotions can override our reason at any time.

Groundbreaking animal studies by Dr. Esther Sabban show that once frightened, an animal is more susceptible to the next threat that comes along. Fear memory, like all the powerful emotions deep in our brains, is hard for us to overcome, or outreason.

Fear has become pervasive. In order to eradicate it, we must first understand it from the microscopic level all the way to the larger issues of national defense and public safety. In examining fear, I have attempted to use my understanding of health and disease as a lens to spot the epidemic as it is spreading and infecting more and more people. I begin with the biology, move on to the personal, and then widen my lens to the systemic.

To understand why our society’s hysteria has grown, I’ve found it is important to look at the individual. I’ve tried to determine why a person’s physiology can turn so quickly to pathology.

Part I examines how our fear biology can wear us down rather than protect us. Fear deeply affects individual patients, from physical illness all the way to imagined terrorism. The government, media, and private businesses contribute to the perpetual pressure to be afraid.

Part II takes a look at the phenomena of publicly reported infections and how these scares contribute to a growing climate of panic.

Part III explores the border between religion and superstition, as well as the relationship between hypochondria, anxiety, and common fear. I examine the question of whether unnecessary fear can be eliminated.

In my life, in treating my patients, and in studying fear, I have found that one effective treatment for fear is to replace it with another deep emotion, like caring. If a person develops a passion that takes him beyond a self-absorbing cycle of worry, this passion can be used to breed the antithesis of fear, also known as courage.

My three-year-old daughter, Rebecca, fractured her thigh bone in a fall. For several days after the cast was removed and an X-ray had shown that the bone had healed, she remained afraid to walk on it. Finally, during an exciting time at the beach she stood on the sand and watched the waves come in. By the time fear memory got ready to extend its shadowy tentacles, it was too late—she was already placing weight on the healed leg. Once Rebecca experienced the reward of renewed mobility, she was able to neutralize her fear.

Those with courage or passion may be able to experience the relative safety of our society by standing up to fear arising from exaggerated dangers. If enough people develop courage, this immunized group can slow the spread of fear through their community in the same way that those who have been vaccinated slow the spread of any contagion.

Part I

FIGHT