The Effects of Fighting the War on Terrorism upon Public Safety, Public Health, and Other Emergency Response Professionals
By George S. Everly, Jr, PhD & Cherie Castellano, MA, LPC
The Journal of Counterterrororism & Homeland Security International
Copyright 2007 Counterterrorism Inc.
This article was written by: George S. Everly, Jr, PhD of The Johns Hopkins Bloomberg School of Public Health, Center for Public Health Preparedness; and Department of Psychiatry The Johns Hopkins University School of Medicine AND Cherie Castellano, MA, LPC of The University of Medicine & Dentistry of New Jersey University Behavioral HealthCare
World War IV continues.
In their book entitled Psychological Counterterrorism and World War IV (Everly & Castellano, 2005), the authors contend that the war on terrorism is the fourth world war. They further contend that this war will last years, if not generations. It will be a war of attrition. It will be a war where many battles may be won, but the war itself could be lost.
When considering wars of attrition, Korea and Vietnam, of course come to mind.
By 1952 in Korea, military forces of the United States were losing the war. They were not losing militarily, they were simply losing because they were not winning militarily. A costly stalemate has been reached. The war was costly in terms of financial expenditure as well as human lives lost. The war was very unpopular with the American public. Political forces pushed for a cessation of the conflict that had cost 50,000 American lives. America was tired of war. On July 27, 1953 a peace treaty was signed. Korea was divided. In the war fought in Vietnam, the United States military prevailed in every major military conflict, except for the siege of Saigon. Yet, the overall war was lost. It was lost because the North Vietnamese successfully fought a strategic war of attrition...a war designed to tire and wear out the strategic sources of American power...the American people. They were successful. A similar strategic plan for war appears to be currently employed by Muslim jihadists in Iraq. It appears to be working, as recent elections in the United States would attest. A dramatic shift in political power came about as American voters appeared to issue a vote of no confidence in the manner in which the war in Iraq was being pursued. As in the cases of Korea and Vietnam, has the will of the American public once again been eroded?
It is one thing to speak of the will and perseverance of the American people. It is another to speak of the will, perseverance, and response capability of those who will have to respond if and when another terrorist attack is successfully completed on American soil.
It will be the job of public safety, public health, and other emergency response professionals to respond to such an attack. In this paper, we raise two important questions:
1) Are public safety, public health, and other emergency response professionals ready to respond? Has the constant vigilance and sustained state of readiness that characterizes this war on terrorism adversely affected them so as to lower their potential response capability?
2) What would the effects of terrorist attacks using weapons of mass destruction be upon public safety, public health, and other emergency response professionals?
The War Continues
In a report published in November of 2006, British MI5 chief Dame Eliza Manningham-Buller warned that young British Muslims were being trained in terrorism. She noted that MI5 was aware of up to 30 terrorism plots. Manningham-Buller also recalled the results of a recent opinion poll that showed over 100,000 UK citizens consider the July bomb attacks in London as justified. She estimated that the number of UK-based terror sympathizers had grown by 80 percent over the past ten months. Future attacks could likely “include the use of chemicals, bacteriological agents, radioactive materials and even nuclear technology” Dame Manningham-Buller warned.
On the five-year anniversary of the worst terrorist attack in the United States, President Bush said the war against terrorism is “the calling of our generation.”
President Bush went on to say, “America did not ask for this war, and every American wishes it were over...The war is not over - and it will not be over until either we or the extremists emerge victorious.”
It has been reported in the American media that Islamic jihadists may view the November United States election results as another form of victory in their war to rid the Middle East of Western imperialism. Over 50% of American voters indicated that the war in Iraq was a key election issue. The vote of “no confidence” may have inadvertently fueled the resolve of the insurgents and other terrorists that wage the terror-based war of attrition.
1. Are public safety, public health, and other emergency response professionals ready to respond? Has the constant vigilance and sustained state of readiness that characterizes this war on terrorism adversely affected them so as to lower their potential response capability?
“By failing to prepare you are preparing to fail.”
-- Ben Franklin
“The nation’s mental health, public health, medical, ...systems currently are not able to meet the psychological needs that result from terrorism.” This statement is from the National Institute of Medicine’s 2003 report on the psychological consequences of terrorism. However, on-going program development and training by 1) FEMA’s Emergency Management Institute, 2) the CDC/ASPH Centers for Public Health Preparedness (such as the Center at Johns Hopkins University Bloomberg School of Public Health), as well as, 3) the noted TOPOFF exercises, are directed at remedying that situation.
Great strides are being made in understanding surge in the wake of terrorism and natural disaster. Innovative programs such as “psychological first aid’” and crisis leadership are being instituted to improve preparedness in the field.
The cornerstone of national performance-based exercises is the Top Officials (TOPOFF), biennial exercise series. TOPOFF included a functional exercise in 2000 (TOPOFF I) and a full-scale exercise in 2003 (TOPOFF II). With TOPOFF III exercise occurring in 2005. One of the authors (CC) participated as a “player” in TOPOFF III in New Jersey. TOPOFF III underscored the importance of pre-incident planning as well as the importance of crisis leadership.
Inherent in any preparation involving terrorism must be establishing adequate surge capacity. Currently, most medical systems are not prepared to handle the patient surge from a terrorist attack, especially if it involved biologic weapons.
We must build a homeland defense and a public health infrastructure that can identify, mitigate, or control any weapons of mass destruction used by our enemies to attack America. We must do the same in terms of handling the casualties associated with the successful attack. According to the US Surgeon General “This won’t be easy. But it is possible. And we’re doing it. President Bush has asked us to develop vaccines to fight anthrax and other deadly diseases, and to help states and communities train and equip our heroic police, emergency medical responders, and firefighters.”
If as a country we are doing all these things, we are moving towards developing surge capacity in our already overburdened hospitals. The funding for public health preparedness in the recent years is the largest one-time investment in our nation’s public health system. Through this additional funding the federal government will partner with state and local governments and research laboratories across the nation to strengthen our response network and expand the availability of vaccines and drugs, while protecting our food supply and enhancing research.
Regarding the notion of constant vigilance being a strain on first response personnel, initial unpublished data seem to suggest that it is indeed taking a toll on the psychological well-being of first responders.
Addressing the mental health needs of the public safety and public health workforce seems critical as we face a future of increased and unprecedented risk for terrorism, as well as the certainty of natural disasters. Relational experts bring much needed skills to disaster preparedness and disaster response work. A systemic perspective affords the opportunity to help couples and families appreciate how external events impinge on family relationships and functioning. It also affords the capacity to consult with organizations about policies and practices that will enhance their staff’s abilities to be effective caregivers for the public, their co-workers, and their families both during and after a disaster.
Helping first responders necessitates our paying attention to the larger systems as well as to the families in which these professionals are embedded. These systems can affect the openness of first responders to acknowledge mental health and substance abuse problems, reach out for help when needed, and refer colleagues.
Disaster response work is rewarding but difficult. We must acknowledge the impact of secondary trauma exposure and reflect on the impact that these experiences have. We can grant ourselves permission to cry, sit in awe of the resilience of those we try to help, and be ever mindful of the power of hope and the strength of the human spirit. Like those we seek to help, we must stretch to find the strength for the journey.
2. The Effects of Terrorism upon First Response Personnel
So, what are the effects of terrorism likely to be upon public health and first responders? We believe these personnel to be more resilient than the general public, but that does not mean they are immune to the psychological distress that is associated with being exposed to trauma and disaster. Some limited research has been conducted in an effort to document the effects of trauma and disaster upon public health and safety personnel.
In the Fall of 1991, what has been called the deadliest shooting in U.S. history occurred in Kileen, Texas (North et al, 2002c). North and her colleagues (North, et al., 2002c) followed the longitudinal course of this event from a psychiatric perspective. The rates of PTSD, major depression, and panic at the 6-8 week baseline for a sample of 136 were 28.8%, 10.3%, and 2.3%, respectively. At the one year follow-up (n=124), those rates were 17.7%, 4.9%, and 2.4%, respectively. There were no cases of delayed onset PTSD. Overall recovery from PTSD at the 3 year assessment was about 50%.
In the Fall of 1996 (4.5 years after the Iraqi withdrawal from Kuwait) a random survey of 2,387 Kuwati firefighters was conducted in an effort to assess the prevalence of posttraumatic stress disorder (Al-Naser & Everly, 1999). The survey yielded 108 male respondents. Using the Impact of Events Scale to assess probable posttraumatic stress disorder, 18.5% of the sample endorsed symptoms consistent with PTSD, there was no difference in prevalence rate between those firefighters who were in Kuwait during the Iraqi invasion and those firefighters who were not in Kuwait during the invasion.
In an assessment of emergency workers conducted 34 months after terrorist attack in Oklahoma City, North, Tivis, et al. (2002a) used the Diagnostic Interview Schedule to retrospectively assess probable posttraumatic stress disorder subsequent to the Oklahoma City bombing. The prevalence of probable posttraumatic stress disorder was found to be 13% in this male population compared to a prevalence of 23% found in a sample of male primary victims. About 16% of firefighters received professional intervention for mental health issues (North, et al, 2002c).
Fullerton et al. (2004) compared disaster workers exposed to an airport disaster to disaster workers who were matched on socioeconomic status, geography and urban or rural location, but not exposed to such a disaster. The rate of PTSD was 13% amongst the exposed group at 13 months after the airport disaster. Early dissociative symptoms, acute stress disorder and depression were also predictive of later PTSD at 13 months, and among the exposed disaster workers, assisting survivors was associated with greater odds of PTSD.
After the September 11, 2001, attacks on the World Trade Center (WTC), a comprehensive screening program of 1,138 rescue and recovery workers and volunteers was conducted by the Mount Sinai School of Medicine during July 16--December 31, 2002 (CDC, 2004). On the basis of standardized screening questionnaires, 51% of participants met threshold criteria for a clinical mental health evaluation. Approximately 20% of participants reported symptoms consistent with posttraumatic stress disorder (PTSD), 13% indicating impairment in addition to their symptoms. Of the 1,138 participants, only 3% reported accessing mental health services before participating in the screening.
Although limited, we see that exists some research on the vulnerability of public health and safety personnel to the psychological distress associated with trauma and mass disaster. Evidence suggests that first response personnel are indeed more resilient than the general public. Nevertheless, they are not immune to primary and secondary traumatization.
Summary
“People only see what they are prepared to see.”
-- Ralph Waldo Emerson
The reality of this is that today, there will be no special forces elite unit immediately available from the federal government to contain a biological or chemical attack.
Instead, local EMS, police and fire units will be the first to respond. In the case of bioterrorism, hospital personnel will be on the frontlines as the first point of contact for casualties, as we saw for anthrax. Local health professionals will need to be prepared to determine quickly if the event is a terrorist attack, or another type of threat. *
We have seen that we are making progress in preparedness, but more effort is needed. On-going program development and training by 1) FEMA’s Emergency Management Institute, 2) the CDC/ASPH Centers for Public Health Preparedness (such as the Center at Johns Hopkins University Bloomberg School of Public Health), as well as, 3) the noted TOPOFF exercises, are directed at building a stronger response infrastructure. On the foundation of such an infrastructure greater stress resistance and resilience will emerge.
On a personal note, I (Castellano) participated as a “player” in TOPOFF III in New Jersey and found myself experiencing a myriad of emotions. It had not occurred to me prior to the exercise how a mass bioterrorism event could unravel my sense of control and preparedness. So many unknowns, despite my experience responding to 9/11/01 I was preoccupied with the “What if’s?” What would my choice be in terms of my family? Would I rush to them or consider contamination as a threat and isolate myself? Where would my husband be and how would I communicate with him? Suddenly after the exercise my family preparedness plan in an “all hazards” model was essential to complete. We did that, but have not “practiced” our own drills. The reason is fear, anxiety, and concern over the impact of our preparedness efforts on our children. They should not grow up afraid yet we owe it to them to protect them as comprehensively as possible. At the end of TOP OFF III a reporter approached me for an interview but did not print the most profound thought I shared after the exercise. “Cherish each day” was my comment simply as I got in my car to go home.
REFERENCES
Al-Naser, F., & Everly, G. (1999). Prevalence of posttraumatic stress disorder among Kuwaiti firefighters. International Journal of Emergency Mental Health, 1, 99-101.
Carmona, R.H. (2003). United States Surgeon General U.S. Department of Health and Human Services, Nashville Surgical Society,Tuesday, October 7, 2003,"Prevention and Preparedness: Medical Reserve Corps Serving America”
Fullerton, C.S., Ursano, R. J., & Wang, L. (2004). Acute stress disorder, posttraumatic stress disorder and depression in disaster or rescue workers. American Journal of Psychiatry, 161, 1370-1376.
North, C.S., McCutcheon, V., Spitznagel, E.L., & Smith, E.S. (2002c). Three-Year Follow-up of Survivors of a Mass Shooting Episode. Journal of Urban Health, 79, 383-391.
North, C. S., Nixon, S., Shariat, S., Malonee, S., McMillen, J.C., Spitznagel, K.P. & Smith, E. (1999). Psychiatric disorders among survivors of the Oklahoma City bombing. Journal of the American Medical Association, 282, 755-762.
North, C. S., Tivis, L., McMillen, J.C., Pfefferbaum, B., Spitznagel, E.L., Cox, J., Nixon, S., Bunch, K.P. & Smith, E. (2002a). Psychiatric disorders in rescue workers after the Oklahoma City bombing. American Journal of Psychiatry, 159, 857-859.
North, C. S., Tivis, L., McMillen, J.C., Pfefferbaum, B., Cox, J., Spitznagel, E.L., Nixon, S., Bunch, K.P., Schorr, J. & Smith, E. (2002b). Coping, functioning, and adjustment of rescue workers after the Oklahoma City bombing. Journal of Traumatic Stress, 15, 171-175.