1. Mass traumas, health, and health “need” Sandro Galea, MD, DrPH Local Public Health Planning for Mental Health Emergency Response Ellen J. Clement, MSW, MPH

2. Mass traumas, health, and health “need” Sandro Galea, MD, DrPH University of Michigan School of Public Health Disaster Research Education and Mentoring Center sgalea@umich.edu

3. Eight observations about the health consequences of mass trauma 1. After mass traumas most people are just fine 2. But, there are a substantial number people who are not fine, and those people may have a range of health problems, both physical and psychological 3. Mental and physical health “go together” after these events 4. Illness due to mass trauma exposure may persist for several years 5. There are some groups who are particularly vulnerable to illness after mass traumas 6. After very big disasters, nearly everyone is exposed to stressful events that may contribute to illness 7. The media matters for health after these events, in many ways 8. Understanding “need” for services requires a full understanding of the factors (beyond pathology) that “cause” need

4. Eight observations about the health consequences of mass trauma 1. After mass traumas most people are just fine 2. But, there are a substantial number people who are not fine, and those people may have a range of health problems, both physical and psychological 3. Mental and physical health “go together” after these events 4. Illness due to mass trauma exposure may persist for several years 5. There are some groups who are particularly vulnerable to illness after mass traumas 6. After very big disasters, nearly everyone is exposed to stressful events that may contribute to illness 7. The media matters for health after these events, in many ways 8. Understanding “need” for services requires a full understanding of the factors (beyond pathology) that “cause” need

5. Health consequences of mass traumas

6. Long-term pathology and disability Short-term pathology Acute disorders Non-specific symptoms and minor injuries Behavior change, concerns Resilience Health consequences of mass traumas

7. Long-term pathology and disability Short-term pathology Acute disorders Non-specific symptoms and minor injuries Behavior change, concerns Resilience Health consequences of mass traumas Severity of health consequences

8. Eight observations about the health consequences of mass trauma 1. After mass traumas most people are just fine 2. But, there are a substantial number people who are not fine, and those people may have a range of health problems, both physical and psychological 3. Mental and physical health “go together” after these events 4. Illness due to mass trauma exposure may persist for several years 5. There are some groups who are particularly vulnerable to illness after mass traumas 6. After very big disasters, nearly everyone is exposed to stressful events that may contribute to illness 7. The media matters for health after these events, in many ways 8. Understanding “need” for services requires a full understanding of the factors (beyond pathology) that “cause” need

9. Mallonee S, Shariat S, Stennies G, Waxweiler R, Hogan D, Jordan F. Physical injuries and fatalities resulting from the Oklahoma City bombing. JAMA. 1996;276(5):382-387.

10. Madrid IsraelGulf Coast New York, Madrid, Israel, and the Gulf Coast

11. Madrid IsraelGulf Coast New York, Madrid, Israel, and the Gulf Coast

12. Eight observations about the health consequences of mass trauma 1. After mass traumas most people are just fine 2. But, there are a substantial number people who are not fine, and those people may have a range of health problems, both physical and psychological 3. Mental and physical health “go together” after these events 4. Illness due to mass trauma exposure may persist for several years 5. There are some groups who are particularly vulnerable to illness after mass traumas 6. After very big disasters, nearly everyone is exposed to stressful events that may contribute to illness 7. The media matters for health after these events, in many ways 8. Understanding “need” for services requires a full understanding of the factors (beyond pathology) that “cause” need

13. An example...mental health and asthma Asthma symptoms Emergency room visits Unscheduled physician visits 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 2003;65(6):993-996.

14. Eight observations about the health consequences of mass trauma 1. After mass traumas most people are just fine 2. But, there are a substantial number people who are not fine, and those people may have a range of health problems, both physical and psychological 3. Mental and physical health “go together” after these events 4. Illness due to mass trauma exposure may persist for several years 5. There are some groups who are particularly vulnerable to illness after mass traumas 6. After very big disasters, nearly everyone is exposed to stressful events that may contribute to illness 7. The media matters for health after these events, in many ways 8. Understanding “need” for services requires a full understanding of the factors (beyond pathology) that “cause” need

15. Prevalence of September 11 th -related PTSD among residents of Manhattan living south of 110th street

16. Eight observations about the health consequences of mass trauma 1. After mass traumas most people are just fine 2. But, there are a substantial number people who are not fine, and those people may have a range of health problems, both physical and psychological 3. Mental and physical health “go together” after these events 4. Illness due to mass trauma exposure may persist for several years 5. There are some groups who are particularly vulnerable to illness after mass traumas 6. After very big disasters, nearly everyone is exposed to stressful events that may contribute to illness 7. The media matters for health after these events, in many ways 8. Understanding “need” for services requires a full understanding of the factors (beyond pathology) that “cause” need

17. Persons affected by mass traumas

18. Killed and Injured Rescuers Family of killed/injured Persons in proximity Families of rescuers General population Persons affected by mass traumas

19. Killed and Injured Rescuers Family of killed/injured Persons in proximity Families of rescuers General population Risk of pathology Persons affected by mass traumas

20. Prevalence of PTSD related to traumatic exposures among Israeli Jews and Palestinians

21. Eight observations about the health consequences of mass trauma 1. After mass traumas most people are just fine 2. But, there are a substantial number people who are not fine, and those people may have a range of health problems, both physical and psychological 3. Mental and physical health “go together” after these events 4. Illness due to mass trauma exposure may persist for several years 5. There are some groups who are particularly vulnerable to illness after mass traumas 6. After very big disasters, nearly everyone is exposed to stressful events that may contribute to illness 7. The media matters for health after these events, in many ways 8. Understanding “need” for services requires a full understanding of the factors (beyond pathology) that “cause” need

22. 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. 2006;84(12):930-939

23. 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. 2006;84(12):930-939

24. Eight observations about the health consequences of mass trauma 1. After mass traumas most people are just fine 2. But, there are a substantial number people who are not fine, and those people may have a range of health problems, both physical and psychological 3. Mental and physical health “go together” after these events 4. Illness due to mass trauma exposure may persist for several years 5. There are some groups who are particularly vulnerable to illness after mass traumas 6. After very big disasters, nearly everyone is exposed to stressful events that may contribute to illness 7. The media matters for health after these events, in many ways 8. Understanding “need” for services requires a full understanding of the factors (beyond pathology) that “cause” need

26. Available information and rational behavior after a disaster

27. Is frequent viewing of disaster images associated with higher likelihood of having mental illness? Images seen in the seven days after September 11 p<0.05 Ahern J, Galea S, Resnick H, Kilpatrick D, Bucuvalas M, Gold J, Vlahov D. Television images and psychological symptoms after the September 11 terrorist attacks. Psychiatry 2002;65(4):289-300.

28. Eight observations about the health consequences of mass trauma 1. After mass traumas most people are just fine 2. But, there are a substantial number people who are not fine, and those people may have a range of health problems, both physical and psychological 3. Mental and physical health “go together” after these events 4. Illness due to mass trauma exposure may persist for several years 5. There are some groups who are particularly vulnerable to illness after mass traumas 6. After very big disasters, nearly everyone is exposed to stressful events that may contribute to illness 7. The media matters for health after these events, in many ways 8. Understanding “need” for services requires a full understanding of the factors (beyond pathology) that “cause” need

29. Prevalence of mental illness, use of services, and perceived service need after Hurricane Katrina

30. Barriers to service use among persons reporting no need for services after Hurricane Katrina Need Enabling Predisposing

31. Barriers to service use among persons reporting no need for services after Hurricane Katrina Need Enabling Predisposing

32. Barriers to service use among persons reporting no need for services after Hurricane Katrina Need Enabling Predisposing

33. Barriers to service use among persons reporting no need for services after Hurricane Katrina Need Enabling Predisposing

34. The truth, perceived, and actual need Illness Service use Truth Assessment Perceived need Service use

35. The truth, perceived, and actual need Service use Truth Perceived need Service use unmet need? Illness Assessment

36. The truth, perceived, and actual need Service use Truth Perceived need Service use unmet need? Illness Assessment

37. Eight observations about the health consequences of mass trauma 1. After mass traumas most people are just fine 2. But, there are a substantial number people who are not fine, and those people may have a range of health problems, both physical and psychological 3. Mental and physical health “go together” after these events 4. Illness due to mass trauma exposure may persist for several years 5. There are some groups who are particularly vulnerable to illness after mass traumas 6. After very big disasters, nearly everyone is exposed to stressful events that may contribute to illness 7. The media matters for health after these events, in many ways 8. Understanding “need” for services requires a full understanding of the factors (beyond pathology) that “cause” need

38. Local Public Health Planning for Mental Health Emergency Response Ellen J. Clement, MSW, MPH Health Officer Washtenaw County Public Health Department http://publichealth.ewashtenaw.org clemente@ewashtenaw.org

40. Gaps in mental health response infrastructure: Coordination of agencies and services Training and supervision Public communication and dissemination of information Financing Knowledge and evidence based services Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy. IOM, 2003.

41. Public Health’s role in emergencies includes restoring the psychological and social functioning; reducing adverse mental health outcomes and speeding recovery.

42. Local mental health population planning and assessment capacity is limited or nonexistent.

43. Critical to bring disaster mental health planning to the forefront in local communities emergency response.

44. Establish community relationships for effective mental health emergency response

45. Define and develop the capacity for roles needed to deliver comprehensive mental health emergency response.

46. Effective communication to the public during emergencies is an important mental health prevention strategy.