Preparation for the Psychological Consequences of Terrorism: A Public Health Strategy: A Report of the Institute of Medicine • In the Wake of Terror: Medicine and Morality in a Time of Crisis

Since September 11, 2001, "the world has changed"—in the mental health field as in society. The changes presented in the two publications reviewed here involve recognition and preparation for various threats; "lessons learned" from September 11 and from prior terrorism; the early federal responses, including the response to the anthrax threat; and emerging public mental health approaches, and ethical controversy about them.

Terrorism is defined in the Institute of Medicine (IOM) report as "the illegal use or threatened use of force or violence; an intent to coerce societies or governments by inducing fear in their populations; typically with ideological and political motives and justifications; an "extrasocietal" element, either "outside" society in the case of domestic terrorism or "foreign" in the case of international terrorism." The types of threats include "all hazard" or chemical-biological-radiological-nuclear-explosive (CBRNE, or "seeburnie") threats.

The IOM report identifies gaps and recommends essential mental health preparations in response to terrorism. Its findings are limited by the disarray of our health care system, the vast bureaucratic and communicative difficulties, the fact that the report was written in mid-2003, and the fact that funding was too limited to enable the report's recommendations to be implemented. Its strengths include practical mental health guidance, the expertise of its authors, the integration of mental health and public health, and the report's comprehensiveness for policy makers.

The report organizes a public health strategy in five parts: "Rationale for a Public Health Response to the Psychological Consequences of Terrorism," "Understanding the Psychological Consequences of Traumatic Events, Terrorism, and Disasters," "Current Infrastructure for Responding to the Psychological Consequences of Terrorism," "Developing Strategies for Minimizing the Psychological Consequences of Terrorism Through Prevention, Intervention, and Health Promotion," and "Conclusions and Recommendations for Effective Prevention and Response."

According to the report, to prevent the psychological consequences of terrorism, the aim is to identify ways in which groups are vulnerable and to seek to reduce this vulnerability—for example, training and education, risk communication, triage, assessment, psychological first aid, and treatment. These and other steps, such as minimizing exposure to the terrorizing agent, would psychologically "immunize" populations, drawing on the known resilience of most people to harden their defenses against the psychological impact. Those who are less resilient are at risk of distress responses and posttraumatic stress disorder, depression, substance abuse, and other psychopathology.

The report concludes with various recommendations that require psychiatric and psychological expertise. First, it is recommended that the U.S. Department of Health and Human Services, including the National Institutes of Health, the Substance Abuse and Mental Health Services Administration, and the Centers for Disease Control and Prevention (CDC), develop evidence-based techniques, training, and education for psychological first aid in the preevent, event, and postevent phases and develop methods of mental health surveillance to apply to interventions. Second, it is recommended that academic centers and professional associations ensure the education and training of health professionals, public officials, and the public safety sector. Third, psychological consequences should be incorporated into planning, preparedness, and response to terrorism by the National Institute of Occupational Safety and Health, the Department of Labor, the Department of Education, private business organizations, the Food and Drug Administration, the Department of Agriculture, the Department of Homeland Security, and the federal, state, and local public health infrastructure. Finally, the report recommends that federal agencies coordinate their research and funding agendas and fund the study of best practices in this area.

In conclusion, the IOM report fulfills its aim to highlight critical issues and to recommend interventions.

In the Wake of Terror: Medicine and Morality in a Time of Crisis contrasts with the IOM report. It is an "anthology on the bioethical implications of terrorism." Its contributions are primarily in three areas: the governmental responses to the events of September 11, the abuses in government research at times of national crisis, and other ways in which governmental authority is abused, sacrificing individual rights and well-being. The book is rich with examples of government abuses, especially the Tuskegee study, the Lynchburg Colony hepatitis study, the CIA's LSD experiments, and the Willowbrook hepatitis study. There are examples resulting in military and civilian injury and death that are major warning signals to those who advocate for experiments or immunizations.

Several authors are very concerned about the law that appears to have triggered this publication—the Model State Emergency Health Powers Act (MSEHPA), developed in 2001 at the Cantigny Conference on State Emergency Health Powers and the Bioterrorism Threat. This conference was sponsored by the CDC, the American Bar Association's standing committee on law and national security, and the National Strategy Forum. The MSEHPA's lead authors, James G. Hodge, Jr., and Lawrence O. Gostin, state: "Particularly during times of emergency, additional restraints of civil liberties are justified by the compelling need to protect public health." They describe public health reform involving changes in states' statutes of planning, coordination, communication, surveillance, and managing property and protecting persons.

George J. Annas, in "Terrorism and Human Rights," severely takes the MSEHPA and its authors to task. He is concerned about excessive governmental responses and is "hopeful that even though the short-term effect of 9/11 was to curtail and compromise human rights and basic bioethics principles," its long-term effect may enhance both worldwide. His contribution seeks to enhance public trust in government and describes how MSEHPA may do the opposite. He and other contributors describe how a careful response to terrorism can both protect individual rights and protect against terrorism. He states that those who initially sponsored the MSEHPA later withdrew as sponsors, including the CDC.

Ronald Bayer and James Colgrove, in "Rights and Dangers: Bioterrorism and the Ideologies of Public Health," delineate problems that the act encountered from both the left and the right regarding its infringements on civil liberties. These authors conclude: "Whatever the ultimate legislative outcome, the debate inspired by the MEHPA illuminated the enduring ideological tensions that informed the world of public health."

James F. Childress addresses triage. In describing criteria for rationing scarce resources, Childress cites Pesik and associates (1), who delineate what should not be considered in triage, such as age, ethnicity, gender, disabilities or deformities, socioeconomic status, drug or alcohol abuse, and aggressive behaviors. He identifies as morally justifiable triage criteria the likelihood of benefit, the effect on improving the quality of life, the duration of the benefit, and the urgency of the need. He highlights the importance of the public's trust and believes that this is more likely if the public participates in setting procedures and criteria for medical utility, social utility, prophylaxis, and treatments.

A key point raised is the danger of losing scarce health care funding in order to respond to terrorism. Eckweiler explains that the "worry is that bioterrorism initiatives and the emergency response planning will limit the scope of public health and divert resources from other more urgent public health endeavors."

Another issue raised is safeguards in conducting research for those "who are injured, their families, those who escaped, direct observers, first responders, rescue workers, and recovery personnel." Finally, Meslin addresses genetic bioterrorism and raises concerns about the directions in which governmental and pharmaceutical company research may be going to defend against it. After indicating that such research should be prohibited, he describes ethical guidelines and policies for such research to limit the directions in which it proceeds.

Together, these books provide brief introductions to health and mental health preparations in response to the threat of terrorism and to ethical controversies along with and pertinent bibliographies. They provide background that will continue to be very useful even as newer psychiatric and mental health publications on these topics appear.

Dr. Stoddard lives in Boston.