Preparing for the Psychological Consequences of Terrorism

Lewis R. Goldfrank, MD Professor and Chair, Emergency Medicine New York University School of Medicine Director, Emergency Medicine Bellevue Hospital/NYU Hospitals/VA Medical Center Medical Director, New York City Poison Center
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July 12, 2006

Omaha, Nebraska

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Living in a Fearful World Societal Concerns

Tuberculosis HIV/AIDS War Snipers Anthrax Serial Rapist West Nile Virus SARS
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The New York Times OP-ED Wednesday, April 30, 2003

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Living in a Fearful World

Societal Concerns
Psychological Injury
Physical Injury

Sociocultural Injury

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Worst Case Scenarios?

March 17, 2003 Should President Bush have said terrorists could kill hundreds of thousands of innocent people in the country and wreck destruction of a kind never before seen on this earth.
Terrorists evoke horror. How likely is an unprecedented catastrophe? Why dwell on worst case scenarios?
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Worst Case Scenarios

The probability of a terrorist attack in the USA is high but the risk to any one person is quite low. These scenarios distort the proportional likelihood Responsible risk assessment avoids this strategy
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What is Risk?
Wide Spread Anxiety
Toxic threats: industrial chemicals and pesticides. Vehicles and smoke stacks fouling the air. Dental fillings, aluminum pots, electromagnetic fields. Terrorism: Biological Warfare.
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Definitions
Hazard is a potential harm Hazards are sometimes confused with risk A risk is the probability that the potential danger of a hazard will be realized If a person is not exposed to a hazard, however dangerous, there is no risk
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Types of Hazards
Chemical Physical Biological Radiological Cultural
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Risk/Hazard Assessment
Example:
A fire is a hazard but the risks vary tremendously Next door? Down the block? Or mile away next to a pesticide plant?
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 Laboratory scientist studying properties Manufacturer defending against liability A worker who believes she became ill from exposure A consultant charged with cleanup A family concerned that the water is too polluted to drink A public health official attempting to counsel the 26 community.

Chesapeake Bay

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Experts believe that societal risks have never been less. Individuals believe that they face more risks than ever before and the risks will be greater in the future.
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Self Assessment Test

1. Industrial explosion releases toxic chemicals 2. Radioactive radon gas released from the soil seeps into homes 3. Deposits of buried hazardous wastes 4. Pollution of air in home and office
1.Medium-Low, 2.High, 3.Medium-Low, 4.High29

What is the difference between Risk and Uncertainty?

Risk can be calculated: the probability of winning the lottery, Uncertainty arises when the odds of success or failure are incalculable: weighing the economic and political consequences of war
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If you remember the Werner Heisenberg Uncertainty Principle (1926) uncertainty is unavoidably introduced into the measured qualities by the measurement itself. Preparedness: The more we study possibilities the more uncertain we become. The better prepared we become.
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Differences Between Individuals and Experts Experts:

use probability and populations.

Odds of harm occurring to a % of a population and the severity of damage

Goal of the expert: to protect the greatest number of

people the greatest amount of time

Individuals: analyze the consequences of an event

occurring independent of its likelihood

Goal of an individual:

is to be protected at all times

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Characteristics of Hazard Assessment

Low Risk
Voluntary (not wearing seat belts) Familiar (second hand smoke) Natural (radon) Controllable (personal habit) Not Dreaded (one causing emphysema) Diffuse in Time (kills 500 over year)

High Risk
Involuntary (a nearby garbage dump) Unfamiliar (food irradiation) Artificial (X-ray) Uncontrollable (natural disaster) Dreaded (causes cancer) Focused in Time (kills 500 per decade but all at once)
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Slovic P: Perception of risk. Science 1987;236:280.

Preventive Health
Risk Factors
Age, Sex, Family History Workplace, Education Home/Community Tobacco, Diet, Alcohol/Substance use Stress, Social Support Sexual Practice

Modifiable
No Partially

Yes

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ACCIDENTS aRe Not raNdom eVents

THey are PreDictABle

thEy CAN BE PreVENTed

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Citizen Preparedness for Terrorism Deal with our anxiety. We wont die in a terrorist attack but we will watch on CNN and must explain to children Routinization and understanding of terror prevents paralysis by fear. This strips terrorists of their power.
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There are no dumb questions!

Confidence Perseverance Caring Teamwork Common sense Problem solving
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That which ought to be the most noble and the most becoming to those who are really educated, release from perturbation, release from fearfreedom. We must not believe the many, who say that only free people ought to be educated, but we should rather believe the philosophers, who say that only the educated are free. Epictetus: The Discourses
Roman Philosopher and Former Slave Discourses (101AD)
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Tyrants and autocrats have always understood that literacy, learning, books and newspapers are potentially dangerous.
1671: British Royal Governor of Colony of Virginia I thank God there are no free schools nor printing; and I hope we shall not have (them) these (next) hundred years; for learning has brought disobedience, and heresy, and sects into the world, and printing has divulged them and libels against the best government.
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If Washington Irvings character Rip Van Winkle were to return to New York City from his 100 year slumber in the Catskills investigating our TV, radio, movies, newspapers, magazines, comics and many books he might conclude that we focus solely on sex, murder, rape, superstition and consumerism.
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Tabloids, TV Talk Shows, Movies

Pseudoscience/Superstitions
Astrology Big Foot Loch Nessie UFOs Ghosts ESP Unlucky number 13 Witches

Aliens

Extraterrestrials

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Dumbing Down of America Decay in the content of the influential media Lowest common denominator programs
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The Six OClock News

The thirty second sound bites Rarely Science Progress in medicine and technology When did the president last say something intelligent about science?
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We Must Transform the Role of the Newspapers, Television, Internet

No matter how sincere, no matter how deeply felt, facts are truly more comforting than fantasy. A fundamental understanding of the findings and methods of science must be available on the grandest scale.... It is insufficient to produce a small highly competent group of professionals.
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It is not the function of our government to keep the citizen from falling into error; it is the function of the citizen to keep the government from falling into error.
US Supreme Court Justice Robert H. Johnson 1950

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The science of the future must be comprehensible to the leaders and the people
Biology: The genome, evolution Chemistry: Nerve agents, carcinogens Physics: The planets, nuclear energy
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Science alerts us to the perils introduced by our world altering technologies. Science teaches us about the deepest issues of origins, natures and fates of our species, of life, of our planet and universe. The gift of science may be to know where, when and who we are.
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The rate of change in science is responsible for confusion and lack of faith
 No longer true  Partially true  Difficult to understand  Social revolution; disquieting to those who cant keep up
Carl Sagan, The Demon Haunted World: Science as a Candle in the 48 Dark. Ballantine Books 1996.

Science
Experimental results Data Observations Measurements Possible explanations
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Humans may desire absolute certainty; They may pretend to have achieved it. Throughout history the goal of science is to achieve improved understanding.

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Science
Independent analysis: controlled experiments Could this logic be distorted? Is there a deficit in approach/reasoning? Substantial debate from all perspectives Dont depend on Authority; no anecdotes Quantify Simplify strength of evidence
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Avoidable human dilemmas are caused not so much by stupidity as much as by ignorance, particularly ignorance about ourselves. The attraction of pseudoscience and superstition are great dangers. Science like democracy is an imperfect instrument, but they are the best weapons against ignorance and injustice. The whole idea of the democratic application of skepticism is that everyone should have the essential tools to effectively and constructively evaluate claims to knowledge.
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As children tremble and fear everything in the blind darkness, so we in the light sometimes fear what is no more to be feared than the things children in the dark hold in terror.
Lucretius, On the Nature of Things. 60BC
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Education
Start early Universal high quality Public health and public policy Science will increase understanding True risk assessment Understand complex world Personal responsibility Continue for a lifetime
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Living In a Fearful World

Societal Concerns

Psychological
Physical casualty

Casualty

Psychological

Education

Physical

Sociocultural

Sociocultural Casualty

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 Public and private  Outpatient/hospital

Medical care system

 Mental health system

 Production  Prevention  Promotion  Surveillance

Public health system

Emergency response system

 Emergency Medical Services  Police/fire  Water/electric  Communication

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Systems responsible for the publics health. SOURCE: Ursano (2002)

MMRS Goals
Unique response plans. Integrated immediate response structures. Local and regional support network. Integrate regional response systems into the planning process. Integrate local mass casualty plans. Collaboration of city planning agencies Initiate hospital NBC planning. Primary care and public health collaboration. Develop appropriate medical treatment protocols.
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Preparedness: Emphasis and Concerns

Most Federal, State and Local agencies have little experience collaborating. Develop real time seamless channels of inter and intra agency coordination and cooperation Establish preparedness planning with honest intra agency and inter agency criticism Achieve unity of purpose evaluate areas of potential, bureaucratic dysfunction. Share expertise and capabilities no unit is an island
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Preparedness
Empowers local communities Permits Community flexibility Depends on rigorous continuing education and improvement Depends on shared responsibilities of governmental and nongovernmental agencies
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Successful Preparedness Plan

Know your area
y y y y

Potential targets Mass transit Large public spaces Landmarks

Know your enemy Potential toxins

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Know your resources

Emergency response
y Containment y Diagnostics y Decontamination y Treatment y Transport

Hospitals Antidotes
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Defining Psychological Consequences

e.g., Insomnia, Sense of Vulnerability

Distress Responses

Behavioral Changes
e.g., PTSD, Major Depression

Psychiatric Illness

e.g., Change in Travel Patterns, Smoking, Alcohol Consumption

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Unintentional vs Intentional Events

In 2001 World death toll terrorism 4000 vs accidents (car crashes) 40,000 in USA Concentrate on
Seat belts Air bags Brakes Helmets Car seats Drinking Driver Age etc.
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Haddon Matrix
Factors
Human (Host) Pre-event Drivers education Car (Vehicle/Vector) Building of cars with crumple zones and airbags Speeding without Seatbelt (Environment) Guard rails and divided highways

Event

Use of seat belts

Activation of anti-lock Witness contact emergency breaks and medical services deployment of airbags Use of emergency equipment to rescue victims Damaged car Emergency care and rehabilitation Damage to property and/or other cars
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Post-event

First aid

End Result

Injured passengers

Cases
 Inhalational (11)
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deaths (5)

 Cutaneous (11)  Treatment

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10,000s
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 Psychological!

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Public Health Strategy

Factors
Phases Preevent Affected Individuals Terrorism and and Populations Injurious Agent* Physical Psychological Sociocultural Event Physical Psychological Sociocultural Postevent Physical Psychological Sociocultural Desired End Results
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Physical and Social Environment Physical Psychological Sociocultural Physical Psychological Sociocultural Physical Psychological Sociocultural

Physical Psychological Sociocultural Physical Psychological Sociocultural Physical Psychological Sociocultural

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Integrate all emergency preparedness functions into public health structure and policy so that each days activities generate practical training experiences for emergency responses.

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Use the Web!

www.gnyha.org www.bt.cdc.gov/ www.hopkins-biodefense.org/
Latest update on outbreaks Information on bio/chem/radiation agents For physicians For patients (also in Spanish) Commonly asked questions/answers Emergency contact numbers (212POISONS)

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1.800.222.1222

The success in preparing for naturally occurring or human initiated disasters will be severely impaired by excessive emphasis on financial considerations and a limited emphasis on public health. The current assault of accountants and the lack of collaboration and competence among emergency preparedness personnel are more powerful forces than the bioterrorists.
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Focus on:
Belief in Incident Command Ending Insularity and Reluctance or Inability to Share
Disaster personnel Policy makers Emergency managers First responders Public health works Physicians Researchers

Ending Distrust and Territoriality Creating a New Leadership

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Ignorance more frequently begets confidence then does knowledge: it is those who know little, and not those who know much, who so positively assert that this or that problem will never be solved by science.

Charles Darwin, Introduction, The Descent of Man, 1871.

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Nonetheless, he knew that the tale he had to tell could not be one of a final victory. It could be only the record of what had had to be done, and what assuredly would have to be done again in the never ending fight against terror and its relentless onslaughts, despite their personal afflictions, by all who, while unable to be saints but refusing to bow down to pestilences, strive their utmost to be healers.
Albert Camus The Plague
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