20 Years Later, Learning from 9/11

Boston University -- SPH Dean Sandro Galea on how the lessons we learned that day might help us prepare to mitigate the

consequences of other large-scale events, COVID in particular September 9, 2021 by Sandro Galea
 
Twenty years ago, at 8:46 am on September 11, 2001, American Airlines Flight 11 crashed into the North Tower of the World Trade Center, followed, 17 minutes later, by United Airlines Flight 175, crashing into the South Tower. Two other hijacked planes, American Airlines Flight 77 and United Airlines Flight 93 were hijacked that same day, crashing respectively into the Pentagon and into a field in Pennsylvania. Nearly 3,000 people died on September 11, 2001, and about 6,000 people were physically injured. The immediate aftermath of the attacks cost at least $10 billion in property damage and about $3 trillion in total costs. The long-term global consequences of the attacks continue to be felt to this day—9/11 resulted in the launch of global wars in Iraq and Afghanistan, with about 500,000 people dying in Iraq and likely a comparable number of deaths in Afghanistan.

I was in New York City on 9/11, just starting my career as an epidemiologist. Along with millions of New Yorkers, I watched with horror as the World Trade Center unthinkably collapsed. Stunned by the obvious destruction, our team quickly became concerned with the potential longer-term mental health consequences of the attacks. Working with colleagues around the country, we designed and conducted a series of studies aimed at documenting the mental health aftermath of the attacks in New York City. The first study, conducted a month after the attacks, was one of the earliest to show that large-scale attacks like 9/11 can affect populations far beyond just those groups who were directly exposed to the events themselves. We estimated that about 7.5 percent of Manhattan residents had post-traumatic stress disorder (PTSD), and 9.7 percent had depression that month, for a total of approximately 67,000 persons with PTSD and 87,000 with depression. This suggested a prevalence of PTSD and depression two to three times higher than what one might have expected at baseline. 

We subsequently studied residents in the entire New York City metropolitan area, finding a substantial burden of PTSD and depression throughout the region. Other work showed that the burden of mental illness subsided over the first six months among most of those affected, even as it persisted in a small but important subgroup who continued to experience mental illness years after the attacks. This was particularly the case among direct witnesses to the attacks.  

Studies by other research groups have documented the full range of the attacks’ long-term health consequences, evincing strong associations between exposure to the attacks and mental illness—including substance abuse and respiratory illness, particularly among rescue and recovery workers. Ongoing studies continue to monitor many of those who were exposed to 9/11, and this long-term work will undoubtedly document more definitively the physical health consequences of the disaster.

At this point, we probably have more research documenting the health consequences of the 9/11 attacks than we have for any other disaster in human history. Several books have since compiled the state of our knowledge about the consequences of disasters, including one I coedited about a decade after 9/11. Before the attacks, the study of trauma and its consequences focused, with few exceptions, on interpersonal trauma affecting individuals. The 9/11 attacks exposed us to an entirely new world, where large-scale disasters had effects that were experienced by hundreds of thousands of people at the same time, affecting the health of entire populations.

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