Psychological Effects of a Large Scale Disaster

1. Psychological Effects of a Large Scale Disaster Dr. Igor Khripunov Associate Director Center for International Trade and Security University of Georgia 29 January 2008 Athens, GA

2. Definition A major disaster is a catastrophic, high-consequence event that a) overwhelms or threatens to overwhelm local and regional response capability, and b) is caused by natural phenomenon, massive infrastructure failure, industrial accident, or malevolent action. Indicators of capacity overload include the following: inability to adequately manage immediate rescue of survivors significant backlog of victims waiting to get medical care or other essential support inability to protect vital infrastructure or prevent significant property damage signs of uncontrolled societal breakdown and psychological trauma

3. Background In October 1948, a combination of hazardous chemical fumes in an industrial accident killed 25 persons and sickened 43% of the residents in a small town in Pennsylvania. Military personnel observed that some residents not directly exposed exhibited the same physical symptoms as had victims who had been directly exposed. The evidence prompted the military in January 1950 to turn to social scientists and draw up a master plan for the study of psychological effects of disasters (one of the early major projects focused on a series of devastating tornadoes in March 1952).

4. International Dimension In September 2007, the World Health Organization released �The Guidelines on Mental Health and Psychosocial Support in Emergency Settings� clearly stating that protecting and promoting mental health and psychosocial well-being is the responsibility of all humanitarian agencies and people involved and not only the exclusive role of mental health professionals.

5. Are We Prepared to Face Disasters? 13 states do not have adequate plans to distribute vaccines, antidotes, and medical supplies from the National Strategic Stockpile 12 states do not have a disease surveillance system that is compatible with the Centers for Disease Control and Prevention�s system 7 states have not purchased their share of the federal stockpile of antivirals to use during a pandemic flu (Report �Ready or Not? Protecting the Public�s Health from Disease, Disasters, and Bioterrorism,� December 2007)

6. Are We Prepared to Face Disasters? Question: In thinking about preparing yourself for a major disaster, which best represents your preparedness? (Report Commissioned by the National Center for Disaster Preparedness at the Mailman School of Public Health, National Survey, July 2007)

7. Lessons to Be Learned Hurricane Katrina was the worst natural disaster in the U.S. in the past 75 years, affecting a land area the size of England, killing more than 1,000 people, displacing 500,000 people, and causing $100 billion in property damage More than 30% of the New Orleans residents met diagnostic criteria for post-traumatic stress disorder Efficient provision of practical and logistical assistance in future disasters are important not only on humanitarian grounds, but also as a way to minimize the adverse mental effects of disasters leading to substantial human, economic and intellectual losses

9. Disasters and Hazards

10. Nuclear Facilities in the Southeast

11. U.S. Nuclear Facilities

13. Radioactive Waste Total Shipments Through Georgia Highway: 1,267 Truck Casks Rail: 1,383 Rail Casks RT2 - CSXT from Greenwood, SC to Atlanta to Chattanooga, TN: 431 Rail Casks [Brunswick, Robinson, Harris] (2) RE2 - NS from Vogtle NPP to Atlanta to Anniston, AL: 259 Rail Casks

15. Sensitive UGA Facilities School of Pharmacy Chemistry Building Veterinary Medicine Poultry Science Building Biological Sciences Building East Campus Research Labs (Genetics, CCRC, etc�)

17. Natural Events Natural disasters have been associated with an intense � but short-term � impact and have a clearer end point than human-made disasters. People usually perceive them on the basis of their prior knowledge and after living through one event the next is unlikely to cause a serious psychological trauma. Global warming as a contributor to, and multiplier of, natural events has become a strong stressor. Earthquakes occur with virtually no warning limiting the ability of disaster victims to make the psychological adjustment that can facilitate coping and lessening feelings of controllability Tornadoes move on an unpredictable path, devastate houses and structures on their way and make survivor guilt an especially common coping challenge Wildfires often lead to evacuations and loss of property. The sights, sounds and smells of wildfire often generate fear and anxiety

18. Man-Made Unintentional Events Man-made disasters often have an unclear end point, violate expectations of control, and result in distrust of authorities. The perception of threat does not always end with the termination of a human-made accident and there remain lingering chronic stress and fear. Industrial and infrastructure accidents are expected to rise. The American Society of Civil Engineers assessed the condition and capacity of the U.S. public works with an overall grade of D (ASCE�s 2005 Report Card for America�s Infrastructure). According to the same source, the Georgia Department of Transportation has projected a $74 billion shortfall in transportation infrastructure funding over the next 30 years.

19. Man-Made Intentional (Malicious) Events There is no single, universally accepted definition of terrorism. This term is usually used to describe violence that is political, social, religious, or ideological in nature and that is designed to influence an audience beyond the immediate target or victims of the attack One widely quoted definition of terrorism is the one used by the FBI, which describes terrorism as : �the unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.� (U.S. FBI, 28 Code of Federal Regulations, Section O.85)

20. Man-Made Intentional (Malicious) Events The trauma of terrorism differs in several critical ways from traumas caused by disasters and accidents: The impact of terrorism is chronic. Unlike single-incident traumas, the threat of terrorism is not a contained experience with a clear-cut beginning and end. Terrorism can induce a generalized vigilance to the point of paranoia across a community. Terrorism is a shared experience because attacks are most often directed against groups of people rather than individuals. The particular group of people attacked is often chosen based on their highly-visible membership in a larger racial, ethnic, or sociopolitical community.

21. Known Risks and Unknown Risks Prior knowledge and/or experience are important for people to assess unknown risks. Hence, known risks are associated with unknown risks for four different reasons: They are used to characterize the possible severity and consequences of the unknown risks They are applied to show that similar risks have been tolerated and dealt with before Associations serve to indicate that risky events and/or activities can also have benefits Associations illustrate that previous risks have been resolved

22. Known Risks and Unknown Risks

23. Known Risks and Unknown Risks Within 2 months after 9/11 in Manhattan 7.5% increase in PTSD (67,000) 9.7% increase in depression (87,000) Nation-wide 20% of Americans new someone who was missing, hurt, or killed 64% had a shaken sense of safety and security Secondary trauma via TV and other media correlate with PTSD symptoms � 60% witnessed via live TV

24. What Does It Take for the Hazard/Disaster to Become a Psychological Trauma-Causing Event Experiences that involved serious risk of death (DSM-IV) Death of a loved one (DSM-IV) Personal victimization (DSM-IV) Victimization of a loved one (DSM-IV) Physical illness or injury Extreme physical adversity Major property loss Income loss Ongoing housing-related difficulties

25. Probability of Unconventional Terrorism

26. Scenarios of WMD Terrorism

27. Fear of Radiation Exposure Radiation is colorless, odorless and tasteless (real or perceived?) Effect is not immediate, leaving affected people in a stressful state of anticipation and dread Potential impact of exposure on descendants can leave the affected people feeling guilty and depressed Radiophobia can be defined as the irrational belief that any level of ionizing radiation is highly dangerous, if not immediately deadly.

28. Risk Perception: Professionals v. the Public The objective is to achieve a common risk perception built on objective and transparent risk communication, which means an interactive process of exchange of information and opinion among individuals, groups and institutions. Risk and crisis communication is designed to achieve this objective. Some risks are more accepted by the public than others: Voluntary risks are more readily accepted than imposed risks Risks controlled by individuals or a community are treated with less fear and concern than those outside their control Risks caused by human action are less tolerated than risks generated by nature Risks that narrowly target an individual or a small group are more readily accepted than widely-spread and indiscriminate risks

29. Risk Perception: Professionals v. the Public Perception of risk by the public, prior and mostly during the event, is based on such factors as: proximity to the ground zero or substance release perceived magnitude of the consequences ignorance about the nature of the hazard the degree of physical harm that comes to oneself or fellow citizens exposure to grotesque scenes of injury or death suddenness of the event distrust of the institution attempting to manage the hazard

30. Risk Perception: Professionals v. the Public Threat: The probability that a specific area or group of people is targeted in a specific way Vulnerability: The probability that damages occur, in a specific event, on a specific target Preparedness: The probability that damages are prevented, in a specific event, on a specific target Consequences: The expected magnitude of consequences, given a specific event and specific target

31. Effects of Large-Scale Disasters The stress arising from the direct impact and the aftermath of a major event, particularly man-made malicious events can spawn serious physiological and psychological consequences. Traumatic life experience (cumulative stress) may exceed individual�s coping ability, resulting in lasting changes in brain chemistry. Physiological effects of stress: Increased risk of infections as a result of weakened immune system Susceptibility to ulcers Increased chances of blood clot formation and hypertension Onset of diabetes and lupus Chronic pain conditions such as arthritis and rheumatism Nasal allergies such as asthma and skin allergies such as eczema Risk factor for chronic fatigue syndrome (CFS)

32. Psychological Reaction to Large-Scale Disasters

33. Post-Traumatic Stress Disorder PTSD was first recognized as a diagnostic entity in 1980, when it was included in the DSM-III. The symptoms include: psychological numbing, amnesia of certain aspects of the stressful event, inability to experience pleasure, isolation, reduced interest in activities, sleeplessness, agitation. The prevalence of PTSD among: direct victims of disasters 30-40%; rescue workers and first responders 10-20%; general population 5-10% Long-term patterns: A latency period of delayed onset of some symptoms Symptoms may wax and wane Significant psychiatric symptomatology may remain for as long as 14 years There is evidence of recurrence under the impact of similar events (lapsing-relapsing pattern)

34. Vulnerable Groups Several categories of the population are likely to experience more serious psychological effects that others. People belonging to these categories require specialized care in the pre- and post-event stages if they are to avoid long-term, often irreversible consequences. These categories include: Children Pregnant women Older adults People with serious mental illnesses Ethnic groups First responders Primary care providers Social workers and volunteers It would be a challenge to develop and implement any differentiated approach, because the population in American cities changes dramatically during a typical workday. U.S. Census data are readily available but the source can facilitate only the assessment of where the public resides and the demographics of neighborhoods.

35. Vulnerable Groups: Children After the Armenian earthquake of 1988, 95 % of children from a severely exposed city and 26% of children from a moderately exposed city had severe levels of PTSD 18 months after the event Children�s inexperience, their incapacity to assess and respond appropriately to sudden dangers, and slow reaction times render them even more vulnerable than most other groups. Evacuation and separation from family are the most serious stressors for them. In a 2006 study of the American Academy of Pediatrics, half the schools surveyed admitted that parents of their students do not know where their children would be evacuated in the event of a major disaster including terrorism

36. Vulnerable Groups: First Responders After the 1983 bush fires in southeastern Australia, a 50% prevalence of PTSD was observed among firefighters during the first 2 years of follow-up First responders and rescue workers are at a risk of adverse psychological outcomes, largely because of direct, extended exposure to the perils of a disaster. The terms �compassion fatigue� and �vicarious traumatization� describe the gradual psychological and physical decline that can occur when first responders are overloaded with traumatic events , causing their professional management and personal coping strategy to falter. The same is true of members of the armed forces involved in post-event operations. The experience of treating civilian casualties, particularly children, can markedly increase the psychological impact on soldiers

37. Vulnerable Groups: Ethnic Minorities A number of studies found that African-Americans were more likely that European Americans to develop PTSD despite their having fewer experiences of what is traditionally considered trauma. Latinos/Hispanics experience more PTSD than any other ethnic groups. Their psychological response is not only individually-based, but also influenced by poverty and latent racism. Survivors who are illegal immigrants are likely to live under stress for fear of being deported and in the context of poverty, discrimination, and marginalization. Survival instinct in a hostile environment and exposure to chronic community violence influences how an individual responds to a specific, large-scale events.

38. Vulnerable Groups: Athens-Clarke County Population (2006) 111,300 Male 53,000 Female 58,300 School enrollment 50,500 Preschool 1,960 Kindergarten 1,500 Grades 1-12 3,700 Students 35,900 People with disabilities11,300 Non-U.S. citizens 8,100 Age groups 111,300 (total) 20-60 years 66,400 60+ years 11,900 Note: the share of the 60+ age group across Georgia is expected to rise from 13.1% in 2000 to 15.2% in 2010

39. Vulnerable Groups: Students When surveyed in 2006 to identify the top ten impediments to academic performance, eight of them bore some relationship to potential health concerns The number of students diagnosed with depression has been accelerating at an alarming rate. In 2006, their number increased by 56% from 10% in 2000 to 16% in 2005

40. Does the Public Have Enough Trust in the Government?

41. Getting the Public on Board Risk and crisis communication can be defined as a two-way process of information exchange with the public that includes multiple types of information with multiple purposes Gaining public support requires a realistic portrayal of risk that is accurate and draws a fine line between: Hyping the threat to spur people to action and Trivializing the threat to provide them with reassurances Partnership with the public provides a way for the public to translate risk awareness into action and can consist of a range of activities, including developing and practicing contingency plans, such as communication, evacuation and sheltering As an important benefit, risk communication has the potential to build public trust and resilience in times of crisis.

42. Resilience Resilience is usually defined as the ability to handle disruptive changes, characterized as emergencies that can lead to or result in a crisis. Resilience is an interactive product of belief, attitudes, approaches, behaviors, and physiology that helps people fare better during adversity. The aim of building resilience among the public would be to reduce susceptibility to challenges by reducing the probability of the likely effects of a disaster, whatever its nature might be, and responding effectively to such effects as they do occur.

43. Resilience Effective and durable resilience in the face of large-scale disasters must be built on three tiers: organizational for reassuring the public that the federal government has been doing everything possible to support and assist the public, when needed, by protecting critical infrastructure, improving border control, providing state-of the-art first aid means, dispatching appropriate hardware and personnel to disaster-stricken areas, etc.) social for integrating the public in local community planning, providing relevant information, and soliciting public input to make the arrangements as effective and palatable as possible. Social resilience makes society more coherent and cohesive but, above all, more confident in its objectives and values.

44. Resilience personal for building human qualities and traits enabling people to survive (resilient people bend rather than break during stressful conditions, and they return to their previous level of psychological and social functioning following misfortune) strengthening close relationships offering help and support to others involvement in civic, faith-based, or other local groups to gain social support developing an optimistic outlook encouraging the belief that people can cope and are robust

45. Support Pyramid for Mental Health in Emergencies

46. Our Ultimate Objective Mental health is defined as the successful performance of mental functions, resulting in productive activities, fulfilling relationships, the ability to adapt to change, and successfully coping with adversity �A mind is a terrible thing to waste�

47. Select Sources Irwin Redlener, �Americans at Risk: Why We Are Not Prepared for Megadisasters and What We Can Do Now,� (New York: Alfred Knopf, 2006) Leon A. Schein et al, eds., �Psychological Effects of Catastrophic Disasters: Group Approaches to Treatment,� (New York: The Haworth Press, 2006) Tener Goodwin Veenema, ed., �Disaster Nursing and Emergency Preparedness for Chemical, Biological, and Radiological Terrorism and Other Hazards,� (New York: Springer Publishing Company, 2003) Lee Clarke, �Worst Cases: Terror and Catastrophe in the Popular Imagination,� (Chicago: The University of Chicago Press, 2003) George D. Haddow and Jane A Bullock, �Introduction to Emergency Management,� Second Edition (Burlington, MA: Elsevier, 2006) Michael K. Lindell, Carla Prater and Ronald W. Perry, �Introduction to Emergency Management,� (Wiley, 2006) Charles R. Figley, ed., �Trauma and Its Wake,� (New York: Brunner/Mazel, 1985)