Lewis Goldfrank presentation

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Preparing for the Psychological Consequences of Terrorism July 12, 2006 Omaha, Nebraska 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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Living in a Fearful World Societal Concerns Tuberculosis Anthrax HIV/AIDS Serial Rapist War West Nile Virus Snipers SARS

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The New York Times OP-ED Wednesday, April 30, 2003 A27

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Psychological Injury Physical Injury Sociocultural Injury Societal Concerns Living in a Fearful World

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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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 Toxic threats: industrial chemicals and pesticides.  Vehicles and smoke stacks fouling the air.  Dental fillings, aluminum pots, electromagnetic fields.  Terrorism: Biological Warfare. What is Risk? Wide Spread Anxiety

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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 ½ 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 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.High

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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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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 Differences Between Individuals and Experts

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Characteristics of Hazard Assessment Slovic P: Perception of risk. Science 1987;236:280.

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Preventive Health

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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 won’t 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 fear—freedom. 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 Irving’s 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 Ghosts Big Foot ESP Loch Nessie Unlucky number 13 UFOs 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 O‘Clock 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 can’t keep up Carl Sagan, The Demon Haunted World: Science as a Candle in the Dark. Ballantine Books 1996.

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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  Don’t 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 Education Physical casualty Psychological Casualty Sociocultural Casualty Psychological Sociocultural Physical Societal Concerns

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Systems responsible for the public’s health. SOURCE: Ursano (2002) Public and private Outpatient/hospital Mental health system Emergency Medical Services Police/fire Water/electric Communication Production Prevention Promotion Surveillance Medical care system Emergency response system Public health system

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. MMRS Goals

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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  Potential targets  Mass transit  Large public spaces  Landmarks Know your enemy Potential toxins

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Know your resources Emergency response  Containment  Diagnostics  Decontamination  Treatment  Transport Hospitals Antidotes

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e.g., Change in Travel Patterns, Smoking, Alcohol Consumption e.g., Insomnia, Sense of Vulnerability e.g., PTSD, Major Depression Distress Responses Behavioral Changes Psychiatric Illness Defining Psychological Consequences

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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

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Cases Inhalational (11) - deaths (5) Cutaneous (11) Treatment - 10,000s Psychological!

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Public Health Strategy

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

Use the Web!www.gnyha.orgwww.bt.cdc.gov/www.hopkins-biodefense.org/: 

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 (212-POISONS) 1.800.222.1222

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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