   |  | | What we're still learning from 9/11 | By Mike Magee, MD
Recently I addressed the need for positive leadership in our society, and specifically in creating the potential for a unified approach to reforming our health care system. I referenced a commencement address that I had given at St. Thomas Aquinas College which, in part, addressed the corrosive impact of fear post 9/11.1 My belief is that our nation continues to suffer the impact of that event, and that in order to recover, we must deliberately direct ourselves toward positive challenges which we might accomplish together.
I said at the time of the address in 2004,
"Why am I so concerned that we are living in fear? I am concerned for a number of reasons. First, fear is currency for negative leaders. In an environment overwhelmed with fear, negative leaders find fertile ground for their divisive messages, and once in control, fan those fears to advance their goals. Second, fear has distinct mental health implications. Third, fear accumulates. My studies reveal that vulnerable populations already subject to discrimination or abuse including African Americans, Hispanics, and women have the highest levels of persistent fear in New York City 31 months post- 9/11. The fourth reason for my concern is that fear is fundamentally regressive in that it blocks imagination, innovation, and risk taking. In short, it robs us of our dreams and hopes for a bright future."1
"According to Dr. Paul Slovic, expert in risk management and Professor of Psychology at the University of Oregon, "Fear is a natural human response to the perception of risk. Fear and risk are complex. Risk is socially constructed. Risk assessment is inherently subjective and represents a blending of science and judgment with important psychological, social, cultural, and political factors."2
The studies I referred to above were conducted at 12 months and 31 months after 9/11 on random citizens of the five boroughs of New York City, and revealed a community that was recovering nicely on the surface, but one also that harbored significant anquish and mental disruption just below the surface.3 In assessing the results back in 2004, I said, "In general, the city is stable, peaceful, and recovering, at least economically. The crime rate has declined steadily every year for the past 15 years - five percent this year and ten percent over the last two years - while domestic tourism is up five percent.4 Yet the survey in April 2004, 31 months after 9/11, finds that over half of New Yorkers fear they or their families will be the victims of a terrorist attack. More than one-third feel less safe than they did two years ago. More than one-fifth have seriously considered relocating out of New York City since 9/11 and nearly one-half experienced a flashback to 9/11 during the energy blackout in August 2003."3,4
The research clearly demonstrated that fear, absent the ability to contribute in a significant way, creates loss of control, anxiety and despair. While 73 percent of New Yorkers saw themselves as more vigilant, careful and alert, fewer than one in five at the time of this study thought they could identify a terrorist in their midst. Less than half found color-coded alerts to be helpful. Residents and workers on Manhattan island said they were more conscious that Manhattan was an island than they were on 9/11. Their fears included being trapped, being crowded and congested, being exposed, and lacking information.5,6
Fear was and remains now, with events in Iraq and elsewhere, an ever-present companion for many Americans. This is not a theoretical concern but quite tangible in day to day life for many. Take, for example, New Yorkers in 2004: More than half of riders at the time feared an attack during their daily commute on the train and ferry; more than one-third feared an attack on the bus.3 Fear in transit is a large problem in terms of scale. There are, on average, some 8 million passengers using the New York system each weekday.6
Fear disproportionately affects women, blacks and Hispanics. In the 2004 New York study, five percent more women than men worried that they would become the victims of terrorism. Six percent more women than men felt less safe than they did in 2002, and eleven percent more women than men felt more at risk for terrorism on the train. Hispanics were 12 percent more likely than whites, and 10 percent more likely than blacks, to worry that they would become victims of terrorism. While about four in ten Hispanics felt less safe than in 2002, only about three in ten whites felt that way. And while concern for safety on the train was present in about six in ten Hispanics and blacks, it was present in only 46 percent of whites.3
This pervasive level of fear, overrepresented in minorities and women, has significant corrosive effects on stable, peaceful, civil societies over the long term. Certainly the experience of 9/11 and the associated trauma and fear resulted in highly visible fallout for the city, for the nation, and citizens around the world. The changes in physical landscape in New York City were more immediately recognizable than were the mental effects. A study of New Yorkers published in the New England Journal of Medicine one year after the event revealed that post-traumatic stress disorder was present in 20 percent of the population below Canal Street and 7.5 percent of the population below 110th Street.7 The survey in April 2004, 31 months post-9/11, found that 35 percent of New Yorkers reported suffering anxiety, depression, or mental illness as a result of 9/11, and 35 percent continued to think about 9/11 "every day or almost every day."3 Now four years later, the country continues to absorb physical and mentally injured service people returning from wars in Iraq and Afganistan which were initially justified in part based on the events of 9/11.
A fear burden on this level has broad societal implications beyond personal health. It undermines worker productivity, safety and security and the level and tone of civic dialogue as a segment of leaders play to the fear of citizens in pursuit of related or unrelated goals.8
Fear management needs to be a major priority in our schools of public health, and public servants need to be especially careful about using fear as currency for short-term objectives. Guidance can be drawn from a wide range of disciplines, including public health, psychology, sociology, philosophy, political science, and medicine. We know a fair amount about what makes an individual feel at risk. Uncertainty in the form of non-observable, new, unknown, delayed or increasing threats, and dread of catastrophic, fatal, random, involuntary, and uncontrollable events trigger fear.8
This list helps explain the nation's current reality - living at home in peace, but living in fear as well.3,9 We all need to better appreciate that serving real short-term needs for homeland security might inadvertently be undermining and further complicating our long-term needs to assist the recovery of those injured in the Iraq and Afganistan and to assure the continued growth of a stable, peaceful, civil and democratic society.
For Health Commentary, I'm Mike Magee.
References
1. Magee M. Islands of Common Stewardship. St. Thomas Aquinas Convocation. 2004.
2. Slovic P. Assessing and communicating risk and benefits. The Pfizer Journal. 2001; 4(5):13.
3. Magee M. Fear in NYC Post 9/11. Yankelovich Research. 2004
4. Health Preparedness and the Blackout of 2003. Health Politics. Accessed April 30, 2004.
5. Partnership for New York City. Monthly Overview. March 2004.
6. The MTA Network. Accessed April 30, 2004.
7. Galea S. Psychological sequelae of the September 11 terrorist attacks in New York City. NEJM.2002;346:982-987.
8. Slovic P. Perception of Risk. Science. 1987;236:280-285.
9. NYC official government website. New York Is Nation's Leading Crime Fighter. Accessed April 30, 2004.
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