9/11: Mental Health in the Wake of Terrorist Attacks ; Are We Ready? Public Health since 9/11

www.ucpress.edu

Rating: ****

Terrorism's primary target has always been the psyche, not the body. Destruction of life and property is simply its vehicle for inflicting broader, long lasting harm to the mental health of populations. The 11 September 2001 terror attacks in the United States were no exception to this centuries old principle. However, their nature and scope were without precedent on American soil, and have exerted a singular impact on the research and practice of disaster mental health. The influence of the attacks on this nascent field receives worthy treatment in 9 /11: Mental Health in the Wake of Terrorist Attacks, which attempts to document and critically examine the wide ranging mental health response.

In the book, leading researchers offer candid, behind the scenes insights into their own efforts in conducting mental health studies in the wake of 9/11. Vividly described profiles of large scale mental health interventions after 9/11, such as New York City's project liberty and the Pentagon's operation solace, offer remarkable examples of ingenuity and collaboration and contain heartbreaking stories of trauma and loss. To their credit, the editors offer constructive critiques of these post-9/11 programmes for their lack of embedded research methodology and evaluative rigor, and their book cogently argues for greater use of evidence based mental health interventions after mass trauma. Refreshingly, the book's contributors freely—and vigorously – critique each other's chapters (one contributor refers to another's perspective as “dangerously naïve,” for example). Such exchanges reflect the growing pains of disaster mental health, a rapidly developing field that appears to lack consensus on relevant exposures, outcome variables, research methodology, evaluation design, and implementation practices.

In this spirit of open feedback, it is worth noting that ethical considerations in post 9/11 disaster mental health research merit more coherent, dedicated discussion than they receive in this volume. While the book's emphasis is understandably New York City focused, it inadequately addresses the unique post-9/11 mental health response challenges of smaller communities with fewer resources. Many of its chapters redundantly open with the same research data presented in a nearly identical context.

However, these modest shortcomings do not reduce the book's overall relevance to our understanding of community level mental health response challenges in the wake of terrorism and other disasters. It offers an important contribution to the disaster mental health literature.

Five years on from the terror attacks and a second book also documents how it affected and altered health services, this time from the perspective of public health.

Are We Ready? Public Health Since 9/11 considers how 9/11 and an ensuing series of anthrax laced letters shoved the American public health system on to centre stage in a new role as first responder. Health department workers now stood shoulder to shoulder with law enforcement personnel, as “incident command” and “Category A agents” permanently joined the public health lexicon. Unprecedented federal funding for bioterrorism preparedness also raised new questions about the primary roles that the public health infrastructure can—or should—have.

These tensions of institutional identity are at the core of David Rosner's and Gerald Markowitz's “contemporary history” on the part terrorism has played in redefining the boundaries of public health in the United States. Their extensive interviews with public health leaders at the local, state, and federal levels yield an insightful story of shifting priorities and challenges in the days, months, and years since September 2001. The book is divided into three chapters, each covering a separate jurisdictional level and a distinct interview time frame: New York City public health officials in the immediate aftermath of 9/11 and anthrax, state health department leaders within two years of the attacks, and federal public health officials three years after the attacks. The resulting narrative is rich in unflinching detail. It includes local public health heroism, risk communication failures, state budget shortfalls for public health, and a controversial national smallpox vaccination campaign in 2003. Woven throughout are fundamental philosophical questions about the “militarization” of public health in the years since 9/11 and the value of “dual use” applications for bioterrorism funding.

The authors allow readers to generate their own conclusions in response to the question their book's title poses; this decision is laudable. My criticisms rest primarily in the book's missed opportunities in exploring the challenges faced by local health departments. The authors' exclusive use of New York City's perspective on local public health in the immediate aftermath of 9/11 and anthrax, while critically relevant, is too limited in time and space. Given the maxim that “all disasters are local,” their treatment would have benefited greatly from a variety of local health department perspectives throughout the United States, not just in the immediate aftermath but in the months to years following 9/11 and the ensuing anthrax attacks. A more diverse set of public health workforce perspectives than just those of senior management would have enhanced the book's value as a contemporary history.

As the authors acknowledge in their preface, they completed this book before Hurricane Katrina, a transformative event for disaster preparedness in the United States. While this is an obvious gap, the book none the less provides an instructive look at a critical and redefining chapter for the American public health system.