Lewis Goldfrank presentation

Lewis Goldfrank presentation - Transcript

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

July 12 2006

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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

Warfare Toxic threats industrial chemicals and pesticides Vehicles and smoke stacks fouling the air Dental fillings aluminum pots electromagnetic fields Terrorism 21 Biological

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

Chesapeake Bay

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 26

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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 29

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 32

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

Slovic P Perception of risk Science 1987 236 280

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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 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 38

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 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 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 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 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
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

Systems responsible for the public s health SOURCE Ursano 2002

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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 58

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 59

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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Defining Psychological Consequences

e g Insomnia Sense of Vulnerability

Distress Responses

Behavioral Changes
e g PTSD Major Depression

Psychiatric Illness 65

e g Change in Travel Patterns Smoking Alcohol Consumption

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 Driver s 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 Emergency care and rehabilitation Damage to property and or other cars

Post event

First aid

End Result

Injured passengers Damaged car

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Cases
Inhalational 11


deaths 5

Cutaneous 11 Treatment


10 000s
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Psychological

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Public Health Strategy
Factors
Phases Pre event Affected Individuals Terrorism and and Populations Injurious Agent Physical Psychological Sociocultural Event Physical Psychological Sociocultural Post event Physical Psychological Sociocultural Desired End Results Physical Psychological Sociocultural Physical Psychological Sociocultural Physical Psychological Sociocultural Physical and Social Environment 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 day s 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 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 85

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
Alb e rt Cam us The Plag ue 88

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