SirsThe article by Susser and Susser (2002;31:71920) opens up a much needed debate on the aftermath of September 11. They ask What is an epidemiologist to do?
The apparent narrowness of the immediate public health response to the acute phase of this pandemic, as noted in their paper, is easy to understand, given the terrible nature of the event of 9/11 and concerns relating to subsequent threats. However, it is clear (at least from this side of the world) that the almost 3000 innocent victims of that day constituted only the first epidemic wave. The most obvious other direct victims (not yet acknowledged or solemnly commemorated by the world community) included the estimated 5000 innocent civilians who died in the subsequent bombing of Afghanistan. Beyond this, people around the world have suffered major social impacts: heightened mutual suspicions, travel restrictions, flagrant human rights violations, and political opportunism. The Sussers are right: terrorism is ... an assault on the mental state of a population. The resulting global situation is one of widespread social pathology. There is yet great potential for the pandemic to become still larger, with innocent people in other countries becoming potentially directly affected. For example, if Iraq is attacked (as the paradigm enlarges from terrorists to include tyrants), this could lead to secondary impacts throughout the Muslim world, which (comprising a fifth of mankind) cannot fail but risk global catastrophe through various ramifications. The issue is far too important to be left to leaders of particular political factions, generals, or even presidents, elected or otherwise, but should be of concern to all people.
Just as we accept violence as a public health problem, so too should terrorism be viewed, with a legitimate need for scientific research from a number of fields, including epidemiology and allied health sciences. The paradigm of prevention is relevant, from primary prevention dealing with the underlying causal factors, to secondary prevention through the identification of risk situations so as to intervene appropriately before actions get out of control, to tertiary prevention which relates to the undesirable impacts at all levels in society. Beyond the immediate victims, we have a responsibility to examine more closely and speak out for the underlying injustices which lie at the roots, or alternatively to tease out the misperceptions or false communications, and not simply restrict ourselves to the oversimplified paradigms of our politicians. By and large, it is lack of enlightened leadership over many years which has brought us to this point.
There is a great risk of such effort being confined to official government agencies, whose links to national policies or defence-related funding create an inescapable bias towards official priorities (e.g. national security), if this leads us to ignore the need to study root causes. Epidemiology itself derives from a search for causes, and its pursuit is not likely to advance if the scope of inquiry is so limited. There is a need to define and classify terrorism in a scientifically objective manner and study it in all its dimensions, including national and international forms, state terrorism, and over-reactions to perceived threats (which could be a greater hazard in some instances than terrorism itself).
In closing, my view is that the emphasis on defence against terrorism is misplaced if this does not include equal or greater attention to examining root causes with a view to determining how to reduce these forms of psychopathology (on all sides), thereby contributing to solutions consistent with global equity, health and human rights. There is a good case for developing a comprehensive epidemiology of terrorism, to encompass all relevant features from its impacts to its root causes, in response to this major new pandemic of the 21st century, thereby improving public and political comprehension concerning its origins, and ultimately to contribute to potential long term solutions.
SirsOur commentary called for epidemiologists to open a debate, in the aftermath of September 11, to identify the resulting opportunities and dangers for our profession, and shape a response.
Dr Whites thoughtful letter answers this call. He underscores the risks of confining public health efforts to government agencies, and proposes reframing the debate over terrorism in broader terms, with global equity, health, and human rights as the guiding principles. We agree; in fact, he extends and clarifies our argument. We hope others will present either similar or opposing views in a similarly lucid way.
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