Resilience of Cities to Terrorist and other Threats: Learning from 9/11 and further Research Issues

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All statistical analyses were performed using SPSS version Respondents felt very much 5. Gender, place of living and working, age, religiousness and media exposure were associated with a high level of threat. There was also a significant difference in threat level as a function of religious affiliation, with larger proportions of Muslims perceiving the highest threat Table 2. Firstly, respondents with high levels of perceived threat reported lower subjective wellbeing. Among respondents with high levels of perceived threat, Almost three-quarters Secondly, respondents with high levels of perceived threat also reported substantially more mental health problems mean score on PHQ-4 scale: 7.

Of the people perceiving a high threat, Thirdly, physical health problems also occurred more often in this group of respondents mean score on PHQ scale: 9. Almost one in five Three-quarters All of the subjective health problems were more frequent in the group with high levels of perceived threat. The most frequently reported problems were mental health problems anxiety and depressive symptoms , lack of energy and sleeping problems. However, the subjective health problems that differentiated most markedly between those with high and low perceived threat were fainting spells 3.

We then examined the unique contribution of perceived threat to subjective health outcomes, beyond the role of three confounders, using hierarchical multiple regressions. The latter included age, gender and place of residence Brussels, elsewhere. Age and gender reflected background information known to affect health outcomes. Place of residence reflected an objective estimate of proximity and exposure to the terrorist attacks and this was also significantly related to subjective wellbeing and both health outcomes. The most prevalent health problems were mental health problems, but the most pronounced differences between people with low versus high levels of perceived threat were physical health problems.

A main finding is that three-quarters of the people in this study who self-identified as feeling much or very much threatened in the week following the terrorist attacks in Brussels felt bad and reported moderate to severe levels of mental or physical health problems Kroenke et al. Some subgroups reported more negative effects: people working or living in the region of the attacks, women and religious people, especially Muslims.


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Some symptoms, such as fainting spells and chest pain, were more prevalent in the respondents who experienced high levels of threat. Perceived threat was significantly associated with wellbeing as well as mental and physical health, even after statistically controlling for the effects of age, gender and place of residence.

As far as we know, this is the first study exploring self-reported subjective health problems shortly after one of the more recent terrorist attacks in Europe and especially on the role of feeling threatened. By collecting the data shortly after the attacks, recall bias was limited. By using a self-selected online sample, we were able to recruit a large number of respondents who were willing to provide us a thorough insight into how they felt and what they experienced after these tragic attacks.

An obvious limitation of this study is that the sample was not representative. We must be very prudent about generalizing the results.

Ten Years After 9/11 — Risk Management in the Era of the Unthinkable

Women and highly educated persons are more highly represented than in the population, for example. It is also unclear whether people who worried most were overrepresented among our respondents. Furthermore, people with less access to or with fewer skills in using the Internet were probably underrepresented. Another limitation is that the reported symptoms were based entirely on self-assessment and that we had no baseline pre-stressor measurement.

The cross-sectional design does not enable conclusions about the directionality of observed associations or about cause and effect and neither can we make statements about the evolution of health problems. PHQ measures are often used for research but, to our knowledge, there is limited or no research on the usefulness and validity of the PHQ-4 and PHQ shortly after terrorist attacks.

Although the risk of being directly affected by a terrorist attack might be very low, our findings show that the perceived threat is a major factor associated with how people react to such traumatic events. The most prevalent problems reported by people who felt highly threatened were anxiety and stress-related mental health problems, lack of energy and sleeping problems. These problems were also found in studies conducted after other terroristic attacks. However, the most pronounced differences were related to some less prevalent but more alarming health problems: fainting spells, chest pain and shortness of breath.

This poses the question of whether such health problems might be related to a rise in myocardial infarctions shortly after terroristic attacks in high-risk individuals, as reported in other studies Goldberg et al. The finding that women are more prone to threat and its effect is well known Schuster et al. People working or living in the region of the attacks felt more threatened, which is in line with most other studies Hansen et al. However, some studies only found a weak association between perceived threat and level of exposure Bleich et al.

The finding that middle-aged people feel more threatened than other age groups is consistent with a study by Chen et al. A possible explanation might be that feelings of threat in this age group may be extended to their close significant others. Muslims reported the highest levels of threat. Although they were only a very small subgroup in our study, this finding is in line with other studies after terrorist attacks Rubin et al.

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Studies in Israel showed that populations associated with the offenders do not suffer less than the populations that are the explicit target of terrorists Bleich et al. An alternative explanation might be that these people felt more vulnerable because of their limited income or because of threat from the terrorist attacks and from being mistakenly affiliated with its origin Rubin et al. People who spend a lot of time viewing information about the terrorist threat reported significantly higher levels of perceived threat.

Fighting Terrorism: The Democracy Advantage | Journal of Democracy

We cannot derive from our data whether people who felt threatened sought out more information or whether the opposite was true: people felt more threatened because of seeing more information about the attacks. Our findings suggest that terrorist attacks do not only result in victims directly affected by the explosions but that many others may experience subjective health problems.

After all, this is one of the main aims of terrorism. It can be therefore hypothesized that the months preceding the attacks, during which Belgium was in a state of highest alert after the attacks in Paris in November , could already have primed a negative impact on the population. Our study reports on subjective health specifically one week after the attacks and cannot make predictions about how this will evolve in the future. However, a study by Stein et al. In a longitudinal study among police responders enrolled in the World Trade Center Health Registry, the prevalence of PTSD doubled between — and —, suggesting that certain responses may even worsen with time Bowler et al.

Three-quarters of the people who felt threatened reported at least a moderate level of mental or physical health problems. Longitudinal studies are needed to investigate if these subjective health problems will abate spontaneously or persevere and might require treatment by a professional caregiver. Self-administrated scales have been suggested as an efficient method for stratifying people into screen-positive and screen-negative groups, and might therefore be helpful by allowing clinicians to prioritize their limited time in favour of a smaller group with high scores Kroenke et al.

However, no systematic attempts have been made to identify populations at risk early after the attacks Gruebner et al. This is especially useful because other studies have shown that a substantial number of people with high levels of symptoms do not seek professional care, and thus might develop problems that remain under the radar Chang et al.

It has also been shown that self-reported symptoms are highly associated with clinician-rated somatoform disorder symptom counts and that high scores are strongly associated with worsening function, increased disability days and health care utilization Kroenke et al. Especially for people with pre-existing problems, the terrorist threat might be a trigger causing severe problems such as major depression Neria et al. The finding that certain populations are particularly vulnerable and that they may present typical health problems is also a reason to be prepared for providing adequate care tailored to the high-risk groups Neria et al.

Syndromic surveillance might be a useful measure for early detection at population level and to monitor the effects of terrorist attacks over time Vandentorren et al. In addition, prevention strategies are needed that should be applied to all at risk, including those not yet showing PTSD symptoms shortly after the traumatic events. Furthermore, not only survivors of terrorist attacks and their relatives are confronted with major stressors.

Regime Types and Terrorism: The Scholarship

Pre-hospital responders and health care services workers in general are professionally exposed to traumatic events. This is also the case for those providing psychosocial support to survivors and other people affected. Here too, the psychological problems are often underestimated Bowler et al.

Further research is needed to check if physical health problems, such as fainting spells and chest pain, may be engendered by terroristic attacks in people who felt threatened. Longitudinal research is also needed to address the evolution of terrorism-related health problems and to shed light on cause—effect relationships, the role of religion and other factors, and the best ways to deal with future terrorist threats, should they happen. The most prevalent symptoms were mental health problems but the most pronounced differences between people with low versus high levels of perceived threat were physical health problems.

National Center for Biotechnology Information , U. Journal List Eur J Psychotraumatol v. Eur J Psychotraumatol. Published online Aug Author information Article notes Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Background Terrorist attacks are fundamentally different from other catastrophes Stein et al. Methods 2. Design, participants and measures We conducted a cross-sectional study using a web survey among a self-selected sample one week after the terrorist attacks in Belgium on 22 March Results 3.

Table 1. Open in a separate window. Factors associated with feeling threatened Gender, place of living and working, age, religiousness and media exposure were associated with a high level of threat. Association between feeling threatened and subjective health Firstly, respondents with high levels of perceived threat reported lower subjective wellbeing.


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Table 2. Level of feeling threatened according to characteristics of respondents. Table 3. Association between feeling threatened and subjective health. Table 4. Differences in subjective health according to the level of perceived threat. Table 5. Association of perceived threat with subjective wellbeing, mental and physical health problems We then examined the unique contribution of perceived threat to subjective health outcomes, beyond the role of three confounders, using hierarchical multiple regressions.

Disclosure statement No potential conflict of interest was reported by the authors. References Benjamins M. Self-reported health and adult mortality risk: An analysis of cause-specific mortality. Bioethics , 13 3—4 , — New York , on the other hand, swiftly dismissed the threats as a hoax. The tough-talking chief of police, William Bratton, suggested the sender had indulged in too many episodes of Homeland.

Post-Paris, the sense of unease is pervasive. There are dozens of warnings a day. Law enforcement agencies are bogged down. And the probability of actual attacks seems to be growing. Which means that, pranksters or not, terrorists are inflicting real costs , both in terms of life and money, on our cities — which is of course the point. In other words, our increasingly panicky reaction to terror threats mean you can inflict a degree of damage on a city at the click of a mouse.