Recommendation: While human mortality and the magnitude and duration of morbidity should remain the primary focus of DHS bioterrorism risk analysis, DHS should incorporate other measures of societal loss, including the magnitude and duration of first- and second-order economic loss and environmental and agricultural effects.

Some direct impacts of bioterrorist attacks are relatively easy to quantify because they are easy to measure in dollars: insured losses to homes, businesses, and industry; bridge and highway repairs; equipment replacement or repairs; crop loss; and so on. The costs of other direct impacts and many indirect impacts are less easy to determine and quantify—for example, psychological distress and family instability.

Cost-benefit analysis (CBA) has been proposed as a way of combining direct and indirect effects of alternative programs. If one undertakes CBA, it is necessary to monetize each of the direct and indirect impacts to provide a common metric for ranking the risks of different bioagents. Monetization means assigning values in dollars. Mortality and morbidity (including psychological distress) could be monetized by setting 1 DALY or 1 QALY equal to the “value of a statistical life-year” or to 1 year of income (typically on the order of $50,000). The value of environmental impacts is measured in terms of willingness to pay by using contingent valuation techniques and has been a source of debate by economists over the years.

The total social cost of a bioterrorist attack can be estimated by combining direct and indirect economic costs with the monetization of mortality, morbidity, and environmental costs. Some critics of CBA are unwilling to attach monetary values to life, environmental impacts, or other non-economic consequences from different events. One then has to use other methods of analysis such as cost-effectiveness analysis or multigoal analysis.¹⁰

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