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Stigma and Barriers to Care in Terrorism & Public Health Emergencies 49 different than the civilian system, and both are very complex. The overall assumption that you can equate the overall reduction of burden of disability in a society with a reduction in caseness is based on two ideas being confused. You can prevent caseness and not change disability at all. The example was offered earlier about fixing cars. That is a good example of a situation where you do not change caseness but you lower disability by making better cars. Another classic example would be that you can treat diarrhea, but it would be better to fix the water by putting chlorine in it. That is the way to lower disability. We ought to distinguish in these response systems between ways of lowering the prevalence and incidence of disability as opposed to lowering the incidence and prevalence of caseness. This is important because they are very different systems and they require very different kinds of interventions, which may or may not be related. DR. BRITT: Something worth highlighting is the difference between the stigma and barriers to care of getting treatment following disasters versus military combat duty in terms of the context of traumatic exposure. A soldier who is exposed to high levels of combat is accruing these experiences as part of his or her job. In terms of encouraging treatment-seeking versus focusing on resiliency and not needing treatment, when you have soldiers who are exposed to the highest levels of combat reporting elevated symptoms, there is really a majority who are reporting symptoms. I wonder whether an emphasis on resiliency might be detrimental to that segment of the population getting treatment. DR. URSANO: I noticed the progression of ideas is appropriate to the collegial sense that we are all in this together to do some tussling. That is the usual progress of such a conference that is headed in the right trajectory. It was said somewhere that this is a military meeting. This is not a military meeting. It has to be funded by DoD funds, but remember our topic is war, disaster, and terrorism. As many others have pointed out, we are attending to the public health model, not just the treatment model. Think about the different tools and the different targets that are present in those two models. All of that is to say there is a reason why this conference is called stigma and barriers to care—because we really do think stigma is just one of the buckets under barriers to care. We chose care and not health care because the questions of dealing with distressed populations involve issues such as increased motor vehicle accidents or people deciding to not shop, which can impair the economy and become a national security issue. That is why this is the forum on health and national security because it is important to address the entire range of populations from distressed, mild disorder, moderate disorder, to severe disorder. There are people with problems caused by the trauma itself, along with those who have emergent mental health problems and who take the opportunity of the trauma event to come in for care. We need a public health model and a treatment model to address the questions of stigma and barriers to care across the whole population. We have now begun to reveal the complexity of this problem. We want to inform and keep track of this complexity. If you are still in your bucket of being a disaster person or a military person or a terrorism person, it is time to jump out. This is where it begins to be important to think across those frames, because if we do not, there will be national security, continuity of operations, and continuity of government problems for us in the future. Whether the issue is 9/11, suicides in the military, or Katrina, there are substantial issues of getting people to care. Health care is one aspect of care, not all aspects of care, or of sustained national security. As many others have pointed out, we are attending to the public health model, not just the treatment model.
50 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
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FORUM ON HEALTH AND NATIONAL SECURI
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From the Conference Series: FORUM O
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9 Day 1 Discussion ................
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ii Bruce G. Link, Ph.D. Professor,
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iv Alisha H. Creel, Ph.D. Assistant
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Center for the Study of Traumatic S
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