Disasters and Trauma: What We Have Learned from 9/11 and Hurricane Katrina

1. Disasters and Trauma:What We Have Learned from 9/11 and Hurricane Katrina William E. Schlenger, Ph.D. Abt Associates Inc.

2. Presentation Overview • Brief Overview of Psychological Trauma Basics • Brief Review of Traumatic Exposures and Outcomes of 9/11 • Brief Review of Traumatic Exposures and Outcomes of Hurricane Katrina • Priority issues in Service Delivery in the Aftermath of Disaster

3. Psychological Trauma Basics • Mental health practitioners use the word trauma to refer to “a wide range of intensely stressful experiences that involve exposure to levels of danger and fear that exceed normal capacity to cope” • The basic epidemiology of exposure to a wide variety of potentially traumatic events (PTEs) has been well documented in recent decades

4. Psychological Trauma Basics (cont.) • Majority of U.S. population is exposed to at least one PTE in their lifetime, and many exposed to more than one • Across a broad range of large scale PTEs, most of those exposed experience some distress (e.g., intense fear, anger, sorrow, uncertainty) but do not have any clinically significant mental health sequelae • In the subset that does experience clinically significant reactions, the reactions typically include PTSD and its frequent co-morbidities: depression and the substance use disorders

5. Psychological Trauma Basics (cont.) • PTSD is a specific psychiatric disorder that involves: • Repeated intrusive recollections of the PTE • Avoidance of reminders of the PTE and/or emotional numbing • Symptoms of hyperarousal • Epidemiologic studies suggest that “human made” events (i.e., purposeful or intentional violence or degradation) are more malignant than natural disasters

6. 9/11

7. 9/11 Evidence Base • Findings from 4 major epidemiologic studies published in top-tier journals within 12 months • All used RDD or internet-based methods, and all used screening instruments to assess PTSD

8. 9/11 Exposures • Massive, visually spectacular destruction at the WTC • Major destruction at the Pentagon • Nearly 3,00 Americans killed • Intense media coverage of the events and aftermath (including anniversaries)

9. 9/11 Psychosocial Outcomes • Prevalence of probable PTSD associated with attacks in first 1–2 months in New York 7.5%–11.2% • Prevalence of probable PTSD in New York fell to about 3% at 4 months post and about 1% at 6–9 months post • Prevalence of depression in New York 9.7%–14.2% • More than 10 million Americans reported a relative or close friend killed

10. 9/11: What did we learn? • Although mass disasters can create large numbers of cases of PTSD, the vast majority are self-limiting. • A person does not have to be on-the-scene of a large-scale PTE to be affected by it. • TV coverage may play some role in outcomes.

11. Hurricane Katrina

12. Hurricane Katrina Evidence Base • At present, virtually no empirical data base on specific trauma exposures or psychosocial impact (no peer-reviewed publications) • Primary source of information at present remains the “grey” literature—e.g., articles in newspapers, magazines, and other media outlets

13. Hurricane Katrina Exposures: Overview • Unusually high winds and heavy rain produce extensive flooding, resulting in many deaths and unprecedented property loss (homes, possessions) • Widespread job loss resulting from infrastructure damage • Some interpersonal violence? • Massive relocation, often very far away (e.g., Denver, Salt Lake City, Boston), of people who had “lost everything” • Widespread loss of social and other support systems • Widespread uncertainty about the future

14. Hurricane Katrina Trauma Exposures: Those Who Stayed • The more than 150,000 people who rode out the storm in New Orleans or along the Gulf Coast were exposed to very high winds, torrential rains, and storm surge as high as 30 feet. • In New Orleans, the confluence of these three factors caused breaches in protective levees that produced widespread, unusually rapid flooding. About 80% of New Orleans flooded, with water depths exceeding 20 feet in some areas.

15. Hurricane Katrina Trauma Exposures: Those Who Stayed (cont.) • Violence and looting were documented in New Orleans in the aftermath of the storm, including at the Superdome • More than 1,000 died in New Orleans, others still classified as “missing” • More than $34 billion in property damage across the Gulf coast, including $22 billion in Louisiana

16. Hurricane Katrina Trauma Exposures: Those Who Evacuated in Advance • The late start and slow pace of evacuation was a source of anxiety, irritation, and/or anger for many evacuees. • Some of those who evacuated did not initially go far enough inland to avoid the storm’s effects, and were therefore subjected to many of the storm’s exposures (e.g., high winds, flooding, additional evacuation). • Evacuation did not protect homes and other property left behind, most of which was damaged or destroyed by flooding.

17. Hurricane Katrina Trauma Exposures: Those Who Did Both • Many of those who rode out the storm in New Orleans were evacuated after the storm passed because of the massive infrastructure damage in New Orleans. • A month after the storm hit, more than 800,000 New Orleans residents were still displaced, and they were dispersed widely across the U.S. • The New Orleans school system was decimated (buildings destroyed, teachers evacuated and have not returned). As a result, few children who returned to NO attended school this year • Similarly, estimates suggest that ~20% of children evacuated did not enroll in schools or enrolled but did not attend schools in the areas to which their families relocated

18. Hurricane Katrina Trauma Psychosocial Outcomes • Telephone survey random sample (n=1,510) of those who had contacted Red Cross in the first month after Katrina found that 7% reported being injured during the storm, and 8% reported being a victim of a crime during or immediately after the storm. Half reported being separated from family members for at least one day, and 20% reported losing a pet. • Telephone survey of a random sample selected from list of more than 160,000 Katrina evacuees 7–8 months after the storm found that African-American evacuees were more likely than whites to report that: they had been separated from family members by the storm, that their former homes had been destroyed, and that a relative or close friend died in the storm.

19. Hurricane Katrina Trauma Psychosocial Outcomes (cont.) • Personal interviews conducted in New Orleans by CDC in the second month after the storm with people who had returned found: • 46% of participants reporting that their homes had “very much” damage; • 52% describing their homes as “not safe;” • 67% had no electricity, no gas, telephone service, no garbage removal, and more than half reported no running water and no working toilet; and • 33% reported problems obtaining medical care.

20. What We Know from Studies of Other Disasters • Post-exposure mental health symptom levels are related to sociodemographic characteristics: • Gender (females are more symptomatic) • Age (younger people are more symptomatic) • Prior trauma exposure (more symptomatic) • Prior psychiatric disorder (more symptomatic)

21. What We Know from Studies of Other Disasters (cont.) • Post-exposure mental health symptom levels are related to sociodemographic characteristics: • Socioeconomic status (lower more symptomatic) • Post-exposure social support (lower more symptomatic) • Resource losses (more losses more symptomatic)

22. What Have We Learned from Katrina? • A disaster that includes both widespread psychological trauma and massive infrastructure damage that cannot be quickly repaired or replaced creates challenges that are much more complicated than when infrastructure damage is minimal • Although from the historical perspective such events are rare, it is clear that better preparedness would have reduced substantially the psychosocial impact of Katrina • We will soon begin to see empirical findings of the psychological aftermath. Many expect that Katrina’s impact on adults will be much more extensive than prior hurricanes, and that its impact on the lives of exposed children will prove to be pervasive • Experience with Katrina raises fundamental preparedness questions about our ability to respond to events that, in addition to threatening lives, also create extensive infrastructure damage (e.g., intense hurricanes or earthquakes)

23. High Priority Research Questions • How can we distinguish in the immediate aftermath of a major disaster between those who are at highest risk for developing chronic PTSD versus those whose PTSD will be self-limiting, so that we can triage them appropriately? • In disasters that produce major infrastructure damage, how can we best: • establish the capacity to provide treatment to those who need it (i.e., how do we arrange for an adequate number of providers), and • assure that professional treatment goes to those who most need it (i.e., how do we optimally allocate the treatment resources that are available)?