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Stigma and Barriers to Care in Terrorism & Public Health Emergencies 45
and disaster and emergency behavioral health in particular. I want us to think about
the issues of stigma as it pertains to our field and about what we do, but we should
not equate that with the stigma that individuals feel. They are not comparable. Those
of us who choose to be in this field choose to be in this field. People do not choose
to have a mental illness. The magnitude of problems for individuals should not be
trivialized in any way.
I want to talk particularly about disaster and emergency behavioral health as
a subset of our field, particularly about how it interacts and intersects with health
and medical and emergency management issues. If I were to redo my slides based on
my thinking today, I would probably add a couple of more pieces about the need to
consider stigma and barrier issues with primary victims and survivors and also with
workers and helpers, because while I think there is overlap, there are also some separate
issues. As we move away from the more traditional areas of health and into behavioral
health and then into disaster and emergency behavioral health, there is increased marginalization,
misunderstanding about what we can and cannot do, and myths about
our profession along with stigma. The irony is that if you get into a major public health
disaster, some of this may shift. When we talk about emergency management, we again
have the same problems of marginalization and stigma.
I worked with the Federal Emergency Management Agency (FEMA) over the years.
The health component is not really central to their operation and they sometimes
do not know how to handle it. Once you get into the health and medical emergency
support function, they do not know what to do with the mental health component.
There are increasing issues of stigma and marginalization that happen as you move
away from the core. In a public health emergency, emergency management may not be
at the center; rather, public health and medicine will be central. When the shoe is on
the other foot, we need to be careful that we do not trivialize the emergency management
function. It may be just as important to get vaccines in place and out to people,
or whatever kind of medical interventions are appropriate.
We also want to make sure that we have people who understand human behavior
and who understand the importance of social functions and community continuity.
We need to make sure that the food supply is maintained if there are blockages of
borders and that the guy who fills the ATM machine gets there. These functions may
be just as important as getting people inoculated or immunized. For those of us who
choose to be in this field, if we are going to escape with our egos intact we need to
share some delusions. One of those delusions is that emergency management always
values what we do in this field. That has not always been my experience when I get
out in the field in disasters.
The other delusion is that I am always a full-blown part of the team. Many
times when I have been out working on disasters, I felt like a lonely cat in the presence
of a row of dogs, the emergency managers. In 2004 I was invited to be part of a CDC
process to develop an operations manual for what to do in the first 48 hours of an
event that had public health consequences. The process used computer-based decision
making. Everyone in the room had a computer, you were asked a question, you typed in
your response, and it appeared on a big screen in front of the room. It was anonymous
so people were more candid. There were only two of us in this group of about 60
people who had a behavioral health background. Because of my bias I kept injecting
comments about behavioral health because I feel it has a role in everything.
Apparently that view was not shared. A public health official said, “I understand
and empathize with your concerns about mental health and public health emergencies.