RAND has been instrumental in developing a line of research regarding terrorism. This collection of issue papers extends that research. Although the issue papers focus on California, the lessons are drawn from experience in various parts of the United States and from other countries, and they clearly have national implications.
Each issue paper focuses on a different policy aspect. Three focus on the economy, including the effects of September 11 on the travel and tourism industry in California, on the U. In both these regards, research will continue to play a vital role in shaping the development of appropriate long-term policy responses.
The issue paper was a product of the RAND Corporation from to that contained early data analysis, an informed perspective on a topic, or a discussion of research directions, not necessarily based on published research. The issue paper was meant to be a vehicle for quick dissemination intended to stimulate discussion in a policy community. Overexposure to combustion byproducts among firefighters has been well documented in the literature. Risk assessment i. Several factors limit our knowledge: monitoring equipment to measure possible contaminants was understandably not in place on September 11th, 12 the dispersion of contaminants was not uniform, 13 the continuing fires made the environment highly unstable, and experts do not agree about appropriate sampling methodology and evaluation criteria.
Still, tens of thousands of indoor and outdoor air and dust, leachate, and water samples were collected in the months following the attack and analyzed for more than 70 contaminants, including asbestos, lead, chromium, mercury, and other metals; polychlorinated biphenyls PCBs ; dioxins; and several other organic compounds. This highly alkaline material, which can cause upper respiratory irritation, contained high concentrations of sulfate, calcium carbonate, and bicarbonate, as well as several metals.
Overall, these levels have been highest at Ground Zero and have dissipated with time and distance from the site. Several months after the attacks, most government agencies and environmental professionals agreed that outdoor air quality in Lower Manhattan was similar to that of other parts of the city. The available evidence suggests that the most heavily exposed people were recovery workers, including emergency responders and construction workers at Ground Zero.
In addition to chemical exposures, they faced significant safety hazards from working in an unstable physical environment, as well as psychological trauma from losing coworkers and viewing and handling human remains. Fortunately, during the first 6 months of the recovery effort, there was not a single fatality, and injury rates were below national averages.
Symptoms persisted for some at least 5 months after the cessation of exposure. Outside of Ground Zero, thousands of building cleanup workers were exposed to dust particles. In medical evaluations of workers mostly non—English speaking, nonunionized, temporary workers , conducted in a mobile van located near the former WTC, major symptoms were found to be upper airway irritation and other nonspecific symptoms including insomnia, headaches, and dizziness.
None had health insurance or access to regular medical care. Nearby residents were also affected. Six weeks after September 11th, the DOH conducted a survey of Lower Manhattan residents and found that about half were experiencing symptoms. By definition, terrorism is an assault on the mental health and well-being of the public. Its goals are to create panic, fear, and anxiety.
The attacks on the WTC affected the mental health of New Yorkers in 3 ways: it created psychological distress for millions, exacerbated or precipitated mental disorders among some smaller groups, and threatened social cohesion, one of the foundations for mental health, in a variety of ways.
Within a few days of the attack, the DMH identified 3 priorities. First, it provided crisis intervention to bereaved families, survivors, workers at Ground Zero, and the general public. LifeNet, a mental health hotline sponsored by the DMH, provided telephone counseling in 5 languages; the average number of calls to the hotline doubled in the days after the attack.
Family Assistance Centers were established to provide counseling and to assist people in searching hospitals for loved ones, filing death certificates, and collecting DNA samples. Second, the agency worked with other providers to develop a long-range plan to provide mental health services to those affected by the attack.
A consortium of agencies created Project Liberty; by March , this project had located new support services at 68 agencies and sites. The attack affected the mental health of millions of New Yorkers in the following months. Less than a third of respondents had received supportive counseling, and many residents were unaware of or did not have access to mental health services.
A telephone survey of adults from a random sample of households in Lower Manhattan in October and November found that 7. Subsequent studies show that while the prevalence of symptoms declined over time, at least some symptoms persisted more than 3 months after the attack, 34 and that vulnerable populations such as drug users experienced unique effects. No systematic data are available yet on the impact of the attack on social cohesion or division, but newspaper accounts suggest that assaults on Arab Americans increased after September 11th.
Within minutes of the attack, hospitals in Lower Manhattan prepared to receive victims. Within hours of the attack, thousands of people began to congregate in local hospitals, looking for family members or friends, seeking safety, or offering to volunteer; hospitals were thus forced to develop crowd management strategies. GNYHA also established a patient locator service to help people find family members. In the following weeks, the disaster affected hospital finances. Hospital admissions declined, leading to lost revenues, and the proportion of uninsured patients increased.
To assist victims of the disaster and to minimize disruption due to lost government functions, New York State established Disaster Relief Medicaid, designed to provide 4 months of Medicaid benefits to eligible low-income New Yorkers. By January 31, , almost New York City residents enrolled in this program.
After completing a 1-page form attesting to their income, applicants were given Medicaid coverage, usually on the same day—a dramatic reduction in the time usually required to determine eligibility. While the impact on smaller community-based health and social service providers has not been studied systematically, testimony by providers at several public meetings held in New York City in the 6 months following the attack suggested the following: higher levels of stress among staff and clients, disruptions in client entitlements such as Medicaid and welfare due to some government offices being shut down, disruption in agency funding, and cutbacks in public funding due to budget deficits in New York City and New York State.
Providers in these agencies reported that their ability to provide safety net services to their clients was compromised by these factors. In the aftermath of September 11th, public and nonprofit organizations, health providers, and ordinary citizens responded with courage and professionalism. Their actions saved lives, helped New Yorkers to cope with fear and grief, and helped the city to restore key functions.
They are summarized here, not to criticize any specific agency or individual but to guide future action. First, the structure of government hampered its response to the crisis. The events of September 11th highlighted gaps in the environmental regulatory framework e. Even where regulations existed regarding asbestos, for example , none had been construed with a WTC scenario in mind, and controversy thus arose over jurisdiction and applicability. In some instances, this led to long delays in clear criteria regarding guidance, action, and clearance e.
Moreover, no prior mechanism existed for resolving conflicts—especially in the early days—between, for example, law enforcement and public health agendas e. Second, although agencies reported that disaster exercises had helped them to respond more effectively, the attacks illuminated gaps in emergency planning and disaster preparedness. The scope of the attack was unanticipated. No plan, however, can anticipate all possibilities, demonstrating the importance of maintaining a robust infrastructure that has reserve capacities beyond routine functioning.
Third, the events emphasized the importance of strengthening surveillance systems for environmental and health conditions, and they have led to post hoc efforts to identify, screen, 45 and track affected persons. The attack also demonstrated the importance of mental health surveillance in order to guide development of appropriate and timely services and prevention education.
Fourth, communications emerged as a critical issue. Public health authorities had to communicate with other government agencies, with health care providers, and with the public. Communications needs changed over time. The disaster highlighted the necessity of redundant communication systems—not only multiple locations but also multiple forms of communication cellular and regular telephones, radio, fax, Internet.
While many agencies quickly set up ways to transmit information to the public, they had more trouble listening to community concerns. Early 2-way communication can help to reduce distrust and maintain credibility. Fifth, the attacks emphasized the importance of linking the public health system to health and mental health services. In the last few decades, New York City, like other jurisdictions, has separated public health and health care systems.
When surveillance systems identified health problems, it was sometimes difficult to link people to the services they needed—for example, the occupational problems of immigrant cleanup workers or the mental health problems of uninsured Lower Manhattan residents. Disaster Relief Medicaid was a creative partial response to this problem and demonstrated that government can cut red tape to meet emergent needs. In the longer run, the lack of a national health plan and the limitations of current mental health parity laws compromise the ability to respond to either disasters or routine health needs.
Sixth, the response to the WTC attack suggested new approaches to the education and training of public health professionals and toward public health research. Recently, the CDC and other federal agencies have expanded training for a public health response to terrorism. On the research side, public agencies and researchers have generally collaborated well to identify specific problems and devise solutions.
Once again, however, the lack of coordination and leadership has made it difficult to select priorities or to ensure common instruments that will allow researchers to share data or compare findings. One exception is an effort by officials and investigators at the New York State Department of Mental Health and Columbia University to develop a unified research agenda.
Finally, the response to September 11th demonstrated the importance of finding a balance between responding to crisis and maintaining other vital public health functions. While the city stood to gain millions of federal dollars for strengthening its public health capacity to respond to terrorism, some public health experts feared that these new resources were too narrowly targeted.
One of the most striking lessons from the WTC attack was the extent to which it demanded routine health functions: safeguarding air quality, protecting workers, ensuring food safety, controlling pests, funding and providing the physical and mental health services that relieve acute distress, and offering credible health information.
While the WTC attack has left indelible marks on the well-being of New York, its most powerful lesson for the health community may be how much the city depends on functioning public health and health care systems. This article is based on their observations as well as our review of media coverage and available published and on-line reports on the health impact of the September 11th events. These individuals, along with the thousands of staff in their organizations, have continued to work tirelessly to protect the health of New Yorkers during and after the WTC attacks, and we acknowledge their extraordinary efforts.
We also thank Salwa Nassar for assistance in preparation of the manuscript and 2 anonymous reviewers for their helpful suggestions. The opinions expressed in this article represent the point of view of the authors and not necessarily the organizations sponsoring The Public Health Impact of September 11th conference or the speakers.
Both authors conceptualized the framework for the article and cowrote the introduction and the section on implications for the public health and health care infrastructures. Klitzman researched and wrote the section on environmental and occupational health. Freudenberg researched and wrote the introduction and the section on health care and social services. National Center for Biotechnology Information , U.
Am J Public Health. Find articles by Susan Klitzman. Find articles by Nicholas Freudenberg. Author information Article notes Copyright and License information Disclaimer. Accepted November 10, This article has been cited by other articles in PMC. Open in a separate window. Notes Both authors conceptualized the framework for the article and cowrote the introduction and the section on implications for the public health and health care infrastructures.
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Bart Hobijn Department of Economics. Buch Deutsche BundesbankFrankfurt. James J. WestEdward Whitehouse. Michael Hanemann Department of Economics. Carl Shapiro Walter A. SauerLuc Savard. Under the FCC's rules, wireless providers are subject to increasingly Public Safety Answering Points or PSAPS with meaningful, accurate location information so that local emergency responders can be dispatched quickly to help wireless callers. KlorEdward S. Caroline Freund Peter G.Selected reports · Collective behavior in the September 11, evacuation of the World Trade Center · The emergency response operations · Final report of the. Academic Papers. The following articles are peer-reviewed journal papers that address issues surrounding the day of 9/11/ from a critical perspective. This collection of issue papers illustrates that there is work to be done to improve our understanding of terrorism's longer-term effects.