The implications of terrorism for public health.

Abstract

The true historical significance of any event can only be assessed 50 years after it has happened but the view that ‘things will never be the same after September 11th’ now seems to be widely accepted. While some Europeans have lived with the threat of terrorism for many years, in regions such as Northern Ireland or the Basque country, the events in the US have added new dimensions in their scale (up to 5,000 deaths in a single day) and nature (the invisible threat from anthrax). Policies in many different sectors have implications for health; the policy responses to terrorism are no exception. And they may be much greater than we might imagine. In any major incident, such as the attack on the World Trade Towers, the public health services will inevitably be present, often in the background, ensuring that facilities for treatment are co-ordinated and residual threats to health, such as environmental contamination, are dealt with. However, unlike terrorism waged with conventional weapons, bioterrorism places the public health services on the front line. The nature of bioterrorism is such that, in the absence of an admission by those responsible, it is likely to go undetected unless an effective surveillance system is in place. Unfortunately, even in western Europe, there are many gaps.1 Recently it has been argued that the weakened state of the American public health service leaves it increasingly vulnerable to such threats.2 Although the initial public health response to the anthrax incidents in Florida and New York city was exemplary,3 it was a close run thing. If the use of anthrax been more widespread or if it had not taken place against the highly visible background of the air attacks, would the response been as rapid? Bioterrorism is also unusual in its ability to cause mass panic. Just how the public responds to the threat of exposure to an invisible, inexplicable, and potentially lethal hazard is increasingly recognised4 and the scale of this response places a large burden on already stretched public health services. Episodes of bioterrorism are highly newsworthy but they are also extremely rare. However other threats from biological or chemical contamination are common and recent events serve to highlight just why it is important to maintain a strong, effective public health infrastructure with the capacity to respond to unpredictable surges in demand. But the consequences of September 11th are much greater, although their impact may be difficult to predict. Thus, the reduction in global economic performance will have major implications for millions, creating unemployment, impeding the prospects for economic development, and reducing the value of pensions. Given the link between wealth and health, and the need to generate revenues to fund public services such as health and education, this is likely to have important, if not easily detectable, consequences for health, especially in the developing world that is highly dependent on inward investment. On the other hand, not all investment is beneficial, such as the establishment of cigarette plants, and a reduction in air travel would bring benefits from reduced pollution and, in particular, stratospheric ozone depletion. The impact on human rights is likely to be especially great. The role of Islamic fundamentalist groups in the air attacks, although apparently not in the spread of anthrax, which seems more likely to have domestic origins, risks exacerbating already worrisome levels of hostility to migrants. Inevitably this will make it more difficult to respond to their already substantial health needs. And as has happened so often in the past, the spectre of an external threat is being used by some politicians to justify policies that overturn long-established norms of human rights. On the other hand, the removal of the Taleban regime will allow Afghan women at least a semblance of freedom, although the difficulties they still face should not be underestimated. Other consequences are even more uncertain. As policies come up for renewal, the insurance industry is looking for ways to divest itself of risk against terrorist attack, while at the same time increasing premiums. This has led some commentators to argue that high-rise buildings may effectively become uninsurable. One lesson of September 11th is the vulnerability of many of the symbols of modern society. Will this stimulate people to seek new, smallscale and less vulnerable solutions? Will the sense of shared risk lead to a new sense of community spirit? Already there are many anecdotal reports of high-flying executives reassessing what is most important in their lives. Other people have been provoked, often for the first time, to look to the reasons underlying these attacks, at the global inequalities from which fundamentalism emerges. The future is always uncertain. But whatever happens, it is clear that September 11th and its aftermath will have EUROPEAN JOURNAL OF PUBLIC HEALTH 2002; 12: 1–2