Among the underappreciated aspects of war is the emotional and psychological trauma it creates. In Israel that's been significant. A sampling in 2003 found 9.4% of adults had current PTSD diagnoses.1 Ten months into the Second Intifada (2000-05), another found the rate at 27% in directly exposed communities, and 21.4% even in communities that weren't directly exposed.2 In Sderot, a 2009 study concluded that 45% of children under 6 were suffering PTSD.3
A steady backdrop of rockets and sirens and explosions can leave people jumpy. The 2006 Lebanon War produced more than 5,600 casualties and more than 2,700 stress reactions. Operation Cast Lead yielded 2,600 hurt and 1,800 stress reactions. During that period, the city of Ashkelon took 46 missiles in three weeks, and more than 300 called the city mental health line for assistance.
And so anxiety reactions become the problem of the healthcare system. Hospital staffs distinguish the traumatized from those with physical injury and offer treatment pathways for them. Ambulance crews differentially diagnose anxiety sufferers and help get them to the right resources, which include community mental health centers that work in collaboration with hospitals and reinforce them in emergencies. Knitting these resources into the fabric of the emergency response improves their accessibility to people and ultimately the population's resilience in times of conflict.
The U.S. Perspective
It's not that the U.S. neglects the civilian mental health aspects of large disasters. We muster resources for rattled residents after big events like 9/11 and incidents with heavy emotional baggage, like school shootings. And it's true that, absent the kind of incessant civilian attacks Israel endures, we may not need as much day-to-day acute reaction capacity across our communities. But consider a few things. One, a population unused to big events can't be expected to handle one calmly.
"Our communities are not prepared for the types of incidents Israeli citizens are concerned with on a daily basis," says Hick. "So when any tragedy comes to our community, there's a big psychological impact I think we've not done enough to address."
Two, it's from our communities' day-to-day mental health capacity that crisis capacity will be drawn. If there's not enough personnel and infrastructure for the trials of daily living, what's going to happen in extraordinary circumstances?
"We don't have enough psychological and psychiatric care for our country as it is," says Heilicser. "At any given time, I have four psych patients restrained in my ED waiting for beds we don't have. How would we handle thousands of people? A dirty bomb's not going to kill anybody, but it's gonna make everyone nuts. How would we handle that? I don't think we've made those provisions."
If the Israeli system has, it's by necessity--"They're always restarting the healing process," observes Schmider. "Go through it today, get bombed tonight, start over again tomorrow." Our context is much different. But recall the baseline truth of disaster planning: Awful things will eventually befall even the quietest backwoods burgs. Ask the folks down in Joplin or Tuscaloosa.
"Having some local resources where you can send people or who can help you triage folks makes sense," says Robinson. "I just don't know many communities in our country that have the resources to do that."
1. Bleich A, Gelkopf M, Solomon Z. Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. JAMA 290(5): 612–20, Aug 2003.
2. Shalev AY, Tuval R, Frenkiel-Fishman S, Hadar H, Eth S. Psychological responses to continuous terror: A study of two communities in Israel. Am J Psych 163, 667–73, Apr 2006.
3. Or MY. Study: Half of Sderot's Toddlers Suffering from PTSD. ynetnews.com, June 30, 2009.