Mitigating the consequences of disasters and terrorism

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Mitigating the consequences of disasters and
terrorism

• Sandro Galea, MD, DrPH
• University of Michigan School of Public Health
• sgalea_at_umich.edu

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Hurricane Katrina in the Gulf of Mexico
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Mississippi and Louisiana. Area of disaster
declaration September 11, 2005
http//www.gismaps.fema.gov/2005graphics/dr1604/de
c_1604.pdf
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equivalent in size to the UK
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Loma Prieta, CA 1989
Marmara Region, Turkey 1999
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The overarching questions

• What determines the population health
  consequences of mass trauma?
• How can we mitigate the population health
  consequences of mass trauma?

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sightlines
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Latino
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Prevalence of September 11-related PTSD among
residents of Manhattan living south of 110th
street
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Prevalence of September 11-related PTSD among
residents of Manhattan living south of 110th
street
?
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Latent trajectories of depressive symptoms
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Latent trajectories of depressive symptoms
Ongoing traumas
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Causes and causes of causes
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Causes and causes of causes
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The aftermath of the March 11, 2004 terrorist
attacks in Madrid, Spain
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Stressful life experiences after Hurricane
Katrina
Kessler R, Galea S, Jones RT, Parker HA and the
Hurricane Katrina Community Advisory Group.
Mental illness and suicidality after Hurricane
Katrina. Bulletin of the World Health
Organization. 200684(12)930-939
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Practical problems after Hurricane Katrina
Kessler R, Galea S, Jones RT, Parker HA and the
Hurricane Katrina Community Advisory Group.
Mental illness and suicidality after Hurricane
Katrina. Bulletin of the World Health
Organization. 200684(12)930-939
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Prevalence of PTSD related to traumatic exposures
among Israeli Jews and Palestinians during the Al
Aqsa Intifada
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Explaining higher likelihood of PTSD among
Palestinians vs Jews
Increased likelihood of PTSD among Palestinians
39 reduction
OR1.9 (1.2-3.2)
Model 1 Unadjusted Model 2 Adjusted for sex,
age, income, education, religiosity Model 3
Adjusted for above direct exposure, threat from
conflict Model 4 Adjusted for aboveeconomic
loss, psychosocial loss, traumatic growth, social
support
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Causes and causes of causes
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Post-hoc analysis showing prevalence of
post-hurricane PTSD and MD diagnoses by 5-HTTLPR
genotype, level of social support, and level of
hurricane exposure in adults exposed to 2004
Florida Hurricanes
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Causes and causes of causes
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Median household income, New York City
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Two neighborhoods in New York City Upper West
Side and the South Bronx
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Two neighborhoods in New York City Upper West
Side and the South Bronx
SOUTH BRONX Median income 16,000 Per capita
income 8,856 below poverty level 45.7
unemployed 23.5 lt high school education
56.8 buildings deteriorating 10.3 Assaults
per 1,000 residents 7.2
UPPER WEST SIDE Median income 64,125 Per capita
income 62,987 below poverty level 10.9
unemployed 5.1 lt high school education
10.5 buildings deteriorating 2.7 Assaults
per 1,000 residents 1.6
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Two neighborhoods in New York City Upper West
Side and the South Bronx
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Relative odds of incident depression in
multilevel adjusted models
AOR2.19 95 CI1.04-4.59
Galea S, Ahern J, Nandi A, Tracy M, Beard J,
Vlahov D. Urban neighborhood socioeconomic status
and incidence of depression Evidence from a
population-based cohort study. Annals of
Epidemiology. 200717(3)171-179.
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Can we put all this together?
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The universe of agents
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Agent population is representative of the US
population
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Neighborhoods
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Neighborhoods
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Summarizing relations between levels
Friend
Friend
Agent
Household
Friend
Neighborhood
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Primary trauma at time 10
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Primary trauma at time 10
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Primary trauma and incident PTSD at time 10
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PTSD at time 11
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Trajectory of trauma and PTSD in one model run
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Diffuse mass trauma affecting 25 of the
population
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Diffuse mass trauma affecting 75 of the
population
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Mass trauma occurring in the center of the
environment
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Mass trauma with income loss
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Mass trauma with income loss and potential
relocation
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Mass trauma with income loss and potential
relocation
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Trajectory of PTSD incidence
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Trajectory of PTSD incidence
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Trajectory of PTSD incidence
Feedback/Adaptation
Future PTSD
PTSD
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Trajectory of PTSD incidence
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Trajectory of PTSD incidence
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Trajectory of PTSD incidence
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Trajectory of PTSD incidence
Feedback/Adaptation
Future PTSD
PTSD
Consequences of mass trauma
Future trauma
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Comparable patterns in available longitudinal data
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Comparable patterns in available longitudinal data
Yzermans CJ, Donker GA, Dirkzwager AJE, Soeteman
RJH, ten Veen PMH. Health problems of victims
before and after disasters a longitudinal study
in general practice. International Journal of
Epidemiology. 200534820-826.
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Secondary trauma across models
No mass trauma
Mass trauma, no consequences
Mass trauma, income loss, relocation
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Secondary trauma across models
Feedback/Adaptation
Social networks
Secondary trauma
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Cumulative PTSD across models
No mass trauma
Mass trauma, no consequences
Mass trauma, income loss
Mass trauma, income loss, relocation
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Cumulative PTSD across models
No mass trauma
Mass trauma, no consequences
Mass trauma, income loss
Mass trauma, income loss, relocation
Feedback/Adaptation
Social networks
Secondary trauma
Social support
PTSD
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Where are we going with this?
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Mallonee S, Shariat S, Stennies G, Waxweiler R,
Hogan D, Jordan F. Physical injuries and
fatalities resulting from the Oklahoma City
bombing. JAMA. 1996276(5)382-387.
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Available information and rational behavior after
a disaster
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Fear after the September 11, 2001 terrorist
attacks
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Mental health and asthma
Fagan J, Galea S, Ahern J, Bonner S, Vlahov D.
Relationship of self-reported reported asthma
severity and urgent health care utilization to
psychological sequelae of the September 11
terrorist attacks on the World Trade Center among
New York City area residents. Psychosomatic
Medicine 200365(6)993-996.
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Prevalence of mental illness, use of services,
and perceived service need after Hurricane Katrina
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Prevalence of mental illness, use of services,
and perceived service need after Hurricane Katrina
Why?
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Barriers to service use among persons reporting
no need for services after Hurricane Katrina
Need Enabling
Predisposing
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Barriers to service use among persons reporting
no need for services after Hurricane Katrina

Need Enabling
Predisposing
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Conceptual next steps

• Incorporate determination of other mental
  illness, of physical health, and of behavior in
  the complex dynamic model
• Better parameterization of influence of treatment
• Understand the role of different barriers to and
  efficacy of treatment

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Funding and contributors

• Funding NIH grants MH66081, MH66391, DA13146-S2,
  and DA017642
• Contributors Ron Acierno, Jennifer Ahern,
  Connie Best, Joseph Boscarino, Michael Bucuvalas,
  Gerry Fairbrother, Alan Fleischman, Joel Gold,
  Dean Kilpatrick, Tom Matte, Betty Pfefferbaum,
  Heidi Resnick, Kenneth Ruggiero, Jennifer Stuber,
  Ezra Susser, Melissa Tracy, David Vlahov
• Funding Robert Wood Johnson Foundation
• Contributors John Cowan, George Kaplan, Sheng
  Li, Melissa Tracy
• Funding NIH grants MH070884-01A2, MH078152,
  DA017642-S1, Federal Emergency Management Agency
  and the Assistant Secretary for Planning and
  Evaluation, Department of Health and Human
  Services
• Contributors Chris Brewin, Scott Coffey, Russell
  T Jones, Rachel Kaul, Ronald C Kessler, Daniel
  King, Lynda King, Linda Ligenza, Nicole Lurie,
  Fran Norris, Richard Powers, Dori Reissman, Julie
  Schumacher, Theresa Smith, Anthony H Speier,
  Benjamin Springgate, Robert Ursano, Simon Wessely
• Funding NIH grants MH070552, MH05220, DA15105,
  MH 070627
• Contributors Ron Acierno, John Boyle, Joel
  Gelernter, Karestan C Koenen, Kenneth Ruggiero,
  Heidi Resnick, John Roitzsch