Aftermath: The Psychological Toll of Terror

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On September 11, 2001, Sandro Galea was at his office at the New York Academy of Medicine, at the corner of Fifth Avenue and 103rd Street.

At 8:45 that morning, a plane flew into the north tower of the World Trade Center. Eighteen minutes later a second plane flew into the south tower. Galea went outside and could see smoke in the distance. A physician and medical epidemiologist, he headed for the nearest hospital, Mt. Sinai, to volunteer his services. Once there he sat and waited along with many other volunteers. They watched the immediate aftermath of the crashes on television and continued to wait for the injured. None came.

The reality was that the number of physically injured people was small. But Galea, who studies the mental and physical consequences of disasters and mass trauma, knew the behavioral and mental health sequelae would likely be enormous. Research had long confirmed that factors such as loss of life, property damage, and financial challenges after a disaster all negatively impact psychological health. Given the scale of what had happened in New York that morning, the potential mental health consequences were huge, as was the possible impact on public health in general.

And, in fact, months later, when Galea and other researchers set out to ascertain the prevalence and scope of the mental health consequences in New York City after the September 11th attacks, they found significant increases in both depression and post-traumatic stress disorder (PTSD)—twice the baseline values.

You never think a disaster is going to happen to you, Galea says, but statistics show that there is a major disaster about once a day somewhere in the world, and United States statistics show that about ten percent of the population will experience a disaster, either directly or indirectly, at some point in their lives, most commonly a natural disaster. “The thing is, disasters are not going away,” says Galea, an associate professor at the University of Michigan School of Public Health, where he is an affiliate of the Center for Social Epidemiology and Population Health. “So we have to find out how to mitigate their consequences.”

The long-term aftermath of disasters goes far beyond the destruction of property, businesses, and vital economic infrastructures. As we come to terms with the devastation of natural disasters like Hurricane Katrina and man-made disasters like September 11th, it is increasingly clear to the public health community that a significant portion of the population will suffer from mentalhealth disorders after these critical incidents. We already know that untreated mental illnesses like depression can exacerbate other chronic illnesses such as heart disease, and that psychopathology can be associated with risky behaviors like smoking and drug abuse. Further research is vital to better identify interventions that might improve the health of populations after disasters.

Sandro Galea is particularly interested in measuring the psychological consequences of disasters, including PTSD and depression, and in mapping the impact of disease and distress and planning for that impact. As co-director of the Disaster Research Education and Mentoring Center (DREM), a collaboration between the University of Michigan and the Medical University of South Carolina (where researchers have long done work on post-disaster health), Galea is striving to improve the quality and utility of disaster mental health research so that victims of disasters are better understood and served.

Funded by the National Institutes of Health, the DREM center harnesses the expertise of researchers who are already examining the impact of disasters in order to recognize both individual and community needs and ultimately improve disaster preparedness. “One of the most overlooked areas in our national preparedness planning has been the mental health implications of disasters,” says Matthew Boulton, associate dean for practice at SPH, who oversees the Michigan Center for Public Health Preparedness. “Sandro Galea’s research has done much to increase our collective recognition of the importance of addressing this critical pubic health issue.”


Galea remembers well his own training as an emergency physician, when a colleague remarked that ER doctors start off thinking it’s all about trauma and random events and disease. Then later, toward the end of their training, these same doctors realize it’s all fundamentally about mental health.

“It’s ironic”, says Galea, “that mental health tends to be marginalized in public health when, in fact, it is probably more central to the health of the public than any other aspect of health. Mental diseases remain stigmatized in ways that other diseases are not. Nobody would dare blame a cancer patient for having cancer, but somehow it’s okay to think that way when it comes to mental health,” he points out. “We are missing an important determinant of cardiovascular health, for example, if one does not recognize that if you are depressed or suffering from PTSD, you are less likely to recover from heart disease.”

Galea’s interest in disaster stems from a larger interest in understanding the consequences of trauma. This makes sense, given his early professional career. Born and raised on the tiny island of Malta, Galea, who speaks rapid English with a slight accent, knew from a very young age that he wanted to be a doctor. “As long as I can remember, I have wanted to practice the kind of medicine that is broad and all-encompassing, where I could deal with whatever people needed,” he says.

He trained initially as both an emergency physician and a family medicine doctor but soon discovered that the fundamental determinants of ill health were beyond the purview of the primary care physician. “As a clinician, I felt I was just plugging holes in the dam,” he remembers. “I wanted to contribute in a way that would lead to changing the causes of poor health in the first place.”

So he returned to school for training in public health and epidemiology. He earned his MPH from Harvard in 2000 and his doctorate from Columbia in 2003, and since then has forged a prolific career illuminating the ways in which mental health impacts public health in general.

At 35, Galea has lived and worked all over the world, from the tiny northern Canadian town of Geraldton to New York City and the dangerous Mudug region of Somalia where, as a physician with Medecins Sans Frontieres (Doctors Without Borders), he was accompanied at all times by armed guards and witnessed his fair share of trauma, including a shooting in a local market. He learned firsthand what it feels like to be in a position of weakness surrounded by potential danger. “The Somalia experience was both grounding for me—that is, remembering what we fundamentally are talking about when we consider the factors that influence the health of populations—and also instrumental in guiding me to public health as a career choice,” he says.

Last year, Galea published over 30 peer-reviewed articles. Many of these demonstrate epidemiological evidence of the behavioral consequences of disasters, risk factors for depression after disaster, alcohol and substance abuse post-disaster, as well as the behavioral consequences of terrorism and the epidemiology of PTSD after disasters.

Frank Ochberg, the former mental health director for the state of Michigan and editor of the first treatment text on PTSD, is grateful for the body of research Galea provides to the mental health community. “Galea is able to gather statistics about how many people are affected by a disaster. He understands the concepts of PTSD and depression, and he’s gifted at portraying this information to those who are not academics or physicians,” Ochberg says. “This matters, because we still have to sell PTSD to mental health professionals and the general public and all those people who are skeptical about normal people being vulnerable to very debilitating emotional events. Anything that proves that PTSD is real, that otherwise healthy, strong and courageous people can get these symptoms, is important. These people need our understanding, not our contempt.”


On March 11, 2004, ten bombs exploded on four commuter trains in Madrid, Spain, injuring over 1,800 people and killing almost 200. As they had two years earlier in New York, Galea and his research team set out to measure the extent of PTSD and depression in the surviving population.

When people are exposed to a traumatic stressor such as an act of terrorism—or rape, robbery, murder, or military combat—they may be at risk for PTSD, a condition first defined as a mental health disorder in 1980. The diagnosis (the only diagnosis specific to trauma) is given only when PTSD symptoms persist a month or more after a given event.

Before the diagnosis of PTSD, rape-trauma syndrome and the psychological symptoms among incest survivors and battered women were well- documented, as was battle fatigue in soldiers and a growing body of research on the psycho logical impact of disasters. “It took an alliance of leaders in the field to define the common core of a disabling and profound reaction to trauma that lingers and haunts,” says Ochberg, who served on the committee that developed the diagnostic criteria for PTSD in DSM III-R, the 1987 edition of the Diagnostic and Statistical Manual of Mental Disorders.

Typically, PTSD symptoms have three stages. In the first stage, patients remember what they do not want to remember. These intrusive memories can be confusing because they feel intense, almost as though one is reliving the trauma. In the second stage, instead of a flooding of intrusive memories, patients experience simply a loss of feeling, a kind of numbness. The third stage of PTSD involves the nervous system; patients become very anxious and nervous, with a heightened adrenaline rate and symptoms such as jumpiness, difficulty sleeping, hypervigilance, and irritability.

Brian Martis, medical director of the PTSD clinic at the Ann Arbor VA Health System, says it is essential to get an accurate assessment of the extent and severity of PTSD in high-risk populations. “PTSD is a serious public heath problem and when unrecognized and/or untreated is associated with a high cost to a person, his or her family, and the community,” he says. “An effective way to make this information meaningful is to apply the approach used with other public health problems such as breast cancer or depression—that is, to be able to educate, screen, prevent and treat people at the primary care level.”

Galea and his colleagues found that for a significant number of Madrid resi dents surveyed for PTSD after the Madrid train bombings, this meant coping with an onslaught of distressing symptoms. But the prevalence of PTSD was lower in Madrid after the March 11th bombings than in New York after September 11th, a fact that may be explained by the difference in magnitude between the two attacks as well as by the number of people exposed to each attack. Twenty percent of New York City residents said they saw the planes strike the World Trade Center towers, compared to just 6.7 percent of Madrid residents who reported having seen some aspect of the commuter-train bombings.

The prevalence of depression in both cities was comparable, however. Although there is much overlap between PTSD and depression, depression differs from PTSD in that it affects people’s moods rather than their memory and fear systems. Galea points out that the heightened prevalence of psychopathology after both the September 11th attacks and the Madrid train bombings will be associated with morbidity that extends beyond the short-term aftermath of the attacks.

He points to another vital phenomenon that occurs after disasters: changes in human behavior. His research in this area, published in the American Journal of Epidemiology (2002), and the results of a second measurement published in the American Journal of Public Health (2004), demonstrate an increased use of cigarettes , alcohol, and marijuana among residents of Manhattan after September 11th.

Nearly 60 percent of respondents, for example, reported at least one symptom of PTSD soon after September 11th, and 7.5 percent reported symptoms that warrant a probable PTSD diagnosis. While the relationship between substance use and psychopathology is very complex, these findings are critical because of the ways in which substance use can increase psychopathology as well as interfere with attempts to resolve the psychological effects of the initial trauma. And with in- creased substance use there is the known risk for other health and societal problems.

If a disaster such as September 11th or March 11th—or, more recently, Hurri-cane Katrina, the effects of which Galea is studying—results in changes in how people behave with respect to their health and other dimensions of their lives, this might well lead to profound differences in the health of populations.


Another critical determinant of increased psychopathology after a disaster is the community response to the disaster itself. Social support is also crucial to the long-term impact of disasters. Peri-event emotional reactions—that is, how one reacts during an actual trauma—are also important predictors of mental health after trauma. People who panic, for example, are at a greater risk for developing later psychopathology. This is true whether a disaster is man-made or natural.

Galea is expecting to see spikes in the prevalence of both depression and PTSD after Hurricane Katrina, particularly since so many residents were displaced and separated from the profoundly therapeutic effects of communities and social support systems. He emphasizes the critical need for solid social networks and a comprehensive federal, state and community response that includes tangible social and material supports in order to decrease poor health outcomes after a disaster.

Many of Katrina’s victims are especially vulnerable because of pre-existing conditions such as poverty or because they have been exposed to previous storms. Galea has looked at citizens of Israel who have been exposed to repeat terrorist attacks, and he’s assessed the mental consequences of Hurricanes Jeanne, Ivan, Charley, and Frances in Florida in 2004. His findings suggest that those who are exposed to repeat events are even more likely to experience psychopathology than those exposed to fewer such events.

He’s not pessimistic about society learning to recognize mental health as a mainstream disorder. But it’s a very slow process. “At least in New York City,” he points out, “people are more aware of the potential for psychological morbidity after 9/11 and aware of the services available to them.” But Galea’s goal is to have that acceptance transcend the circumstance and permeate how we think about mental health in general. He is profoundly committed to building bridges with other practitioners and researchers as well as government and nongovernment agencies in order to improve disaster response and preparedness.

Much of the burden of response and preparedness will fall on primary-care physicians, because, as Galea points out, there is good data that shows that half the patients who go to their primary care doctor have an underlying mental health reason for the visit. If disasters like Sept- ember 11th and Katrina trigger an increase of patients suffering from mental health disorders, it is vital to better equip primary care physicians to screen routinely for mental health disorders after a disaster. Psychiatrists and social workers will also play pivotal roles.


The notion that mass traumas and traumatic experiences shape our health and behaviors is not at all new. The history of human conflict is long and deep with consequences that can torture our psyches and plague our dreams. There is a much richer literary and artistic tradition, for example, of thinking and writing about the consequences of human conflict and events such as wars and disasters than there is of thinking and writing about the consequences of heart attack. Galea points out that Homer described Odysseus’ nightmares and aversions after the Trojan War, and we see now that they are symptoms consistent with PTSD.

And yet it is only recently that science is finally quantifying what has been evident in the arts for centuries.

“The reason there is so much written about the consequences of conflict and disaster is that we are dealing with a universal phenomenon,” Galea says.

A single disaster—a terrorist attack, a large-scale incident can affect thousands, even millions, of people. Although Galea is primarily interested in the impact of disaster and trauma, he is hopeful that his work will lead to interventions to help reduce that impact. Recently he took part in a study on the efficacy of internet-based interventions for mental health and substance-abuse problems in the wake of mass violence and other disasters.

“I hope that my work will both explain what we may find after disasters and highlight how we can mitigate some of these consequences,” he says.

As history reminds us, disasters are inevitable. But what’s not inevitable is their aftermath—and that’s what Sandro Galea wants to change.

Billie Ochberg, a writer who lives and works in Ann Arbor, contributed to this article. Ochberg holds an MSW from Case Western Reserve University and is the daughter of Frank Ochberg, who is mentioned in this story.

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