Since the autumn of 2001, our nation has experienced a heightened sense of vulnerability. As a nation, we have demonstrated that resilience is a part of our national character. However, as individuals many of us are still struggling to be certain that we are doing all we can to prepare ourselves and our communities for the possibility of future assaults. Are we building our response capabilities to limit the negative physical and psychological effects of terrorism on our children?
Children and adolescents are not small adults - a statement well known to anyone involved in the care of children. This is critical when preparing to treat children affected by all forms of terrorism, whether domestic or abroad. They have unique physiological, psychological, and developmental needs that will impact not only preparation for, but also treatment of and recovery from, such events. (These unique pediatric vulnerabilities are summarized in Table 1.) The American Academy of Pediatrics (AAP) has identified 5 forms of terrorism that we should be prepared for: thermomechanical, biologic, chemical, radiation-related, and psychological.1
Appropriate preparation should anticipate how events would affect children, families, and communities. All disasters are first and foremost community events with secondary ramifications on our larger society. The preparation for and mitigation of disasters is thus an element of community medicine. Community response plans need to link providers, public health resources, government agencies, and individuals in disaster preparedness as outlined in the article by Bradley et al. earlier in this series (32:2:86-94). Pediatric health professionals should be empowered to become advocates for children in disasters in the local community as well as on a national level. Knowledge about terrorism is the first step toward preparedness. In this three- volume series we have attempted to provide the reader with a basic understanding of a wide range of terrorismrelated issues, including community and federal response plans as well as the medical management of the main forms of terrorism: thermo-mechanical, biologic, chemical, radiation-related, and psychological. In particular, these articles have detailed the unique impact on the child as a victim.
Where do we go from here? How do we translate this knowledge into actions that will make our communities better prepared in particular to help children in disasters?
BECOMING AN ADVOCATE FOR CHILDREN'S ISSUES
How does one become an effective advocate? Early steps could include making an assessment of deficits in response capability at the local health care facility, city, county, state, or federal level (see Pediatric Assessment sidebar, page 000). An example might be determining if your community emergency department is properly equipped and trained for management of child victims should a chemical or industrial chemical disaster occur. However, assessment should not be limited to identifying deficits that may exist but must also include creating partnerships and relationships among assets that the community may already have in place to respond to events and solve problems. This method has been termed asset-based community development2 and applies to disaster preparedness as it does to other community issues.
Factors Unique to Pediatric Victims*
The assets considered must include governmental and nongovernmental first responders, hospitals and clinics, schools and daycare facilities, and mental and medical health providers as well as a multitude of community-based service providers and organizations. Parents and families are also important partners in advocating for appropriate preparation to care for children should an event occur. In addition to assuring political interest in addressing deficits and building collaboration between assets, it is the parents who will ensure that solutions are delivered in a child and family focused way.
The type of intervention your advocacy efforts are directed toward (local, state, federal, global) is determined by the specific goal you set for yourself or your community. In the example above, your goal is to make sure your community emergency department is properly equipped and trained for management of child victims should a chemical or industrial chemical disaster occur. The level of advocacy might initially be local, through hospital committees, but would likely eventually extend from that committee to engage local emergency medical response and governmental officials to bridge the gap between prehospital and hospital care of potential child victims.
There are advocacy issues that extend beyond the capacity of local authorities to resolve (Table 2). Issues such as the availability of child-appropriate doses of autoinjector nerve agent antidotes in the United States (the product is currently manufactured in the United States but not approved by the Food and Drug Administration, and thereby not licensed for use in the United States). Engagement of large professional and advocacy organizations like the AAP in such issues may be the most effective way to bring about necessary legislative events. The AAP Task Force on Terrorism has developed chapter contacts. These volunteers, already active in AAP chapter activities, become point persons to assess the inclusion of child-specific issues in state-level and regional-level terrorism preparedness plans as they are developed and as the influx of federal funds reaches states. Early experiences of these contacts suggests that pediatric issues are under-represented at state and regional planning meetings. They also found that even without content expertise in terrorism, their participation as experts in child health issues has been welcomed.
Many pediatric health professionals who would like to get involved hold back because they do not feel that they have sufficient expertise to contribute to debates. But if you care for children - as a physician, nurse practitioner, or nurse - you are a pediatric medical expert.
What you already know about children, and can anticipate about the impact of terrorism on children, is what policy makers and planners need to hear. Many others in a multitude of disciplines who care for children (psychologists, teachers, parents, social workers) can join pediatric health professionals as experts in their field regarding caring for children. Collaborative leadership skills consolidate expertise and strengthen response to prevention, preparation, and recovery on behalf of children in regard to terrorism. It is an unfortunate truth that if we, as child advocates, are not at the table to provide insight into the unique issues of child victims in terrorist events, they are not likely to be considered.
Terrorism is an issue of potent emotional content that can easily lead rational individuals down a path of fear and panic. Irrational behavior can be fueled by sensationalized media coverage and commercial opportunists that aim at our more primitive instincts. There are still many uncertainties about the appropriate preparation for management of terrorist events. The potential benefits of potassium iodide administration following certain types of radiation exposure were detailed by Clifton Yu in the March issue of this series (32(3): 169-176). Further explicit recommendations are soon to be published by the AAP. However, neither of these documents clearly outlines the best method for communities to plan for or conduct mass distribution of potassium iodide should it be needed. Should stockpiles of potassium iodide be kept at home or in schools, or both? There has been recent media attention on the Internet market for purchasing personal protective equipment, such as gas masks, for individuals in case their community suffers a chemical attack.
Before, During, and After a Terrorist Incident*
As a result of imminent fear of attack with a chemical or biologic agent-laden missile, Israel distributed 4 million personal protection kits that included gas masks between October and December 1990. The distribution was accompanied by training on appropriate use of the equipment on television and in newspapers, as well as hands-on training for school-aged children. Although Israel suffered 18 separate missile attacks during the 47-day war, none were proven to contain biologic or chemical agents. Among individuals, ranging from 9 months of age to the elderly, there were 119 fatalities who suffocated, suffered cardiac arrest, myocardial infarction, or other injury as a result of using these masks.3 It is perhaps wise for us to remember that in Israel during the Gulf War, mortality associated with cardiorespiratory complications and sudden death related to mask use, anxiety, and confinement to sealed rooms exceeded trauma mortality caused by the missile attacks.
Military professionals and other professional first responders, whose work requires donning of this equipment, undergo extensive and repetitive training in the maintenance and use of this equipment. Personal protective gear is only worn in the context of high-risk settings like decontamination of casualties after a known event, or on the battlefield where use of effectively weaponized chemical agents on a concentration of troops is anticipated.
The information about the delivery and dispersion, vapor characteristics, and physical effects of chemical agents presented in articles in this issue should make it clear that charcoal suits and gas masks are likely of limited usefulness for families in most domestic scenarios in the United States and perhaps more likely to result in harm. As we proceed with preventive health and public policy decisions, a careful analysis of risks, benefits, and feasibility should be undertaken in order to assure that the most good is achieved. As we proceed as professionals in our role as caregiver to patients, advisor to parents or schools, or advocate attempting to shape effective policy decisions, it is critical that we act not on our fears and anxieties, but rather on legitimate information and by using the critical analysis and decision-making skills that are part of our profession.
How Can I Immediately Help Families and Children?
Creation of the Office of Homeland Security indicates that our government plans to take an active role in our preparation and response to terrorism. But the response should not be limited to federal, state, or other agencies and institutions. As pediatric health professionals, in addition to becoming advocates for child-related issues, we can have an immediate impact by incorporating what we understand about terrorism into our daily practices. We can assist families in preparing for events by discussing terrorism-related issues as part of our anticipatory guidance. Examples include soliciting concerns and assessing the coping skills of parents and children as local and world events occur, as well as advising families to consider home disaster kits that would support the family equally well in the event of a natural or manmade disaster. In fact, most families are at greater risk of suffering from a local natural disaster such as a flood or severe storm than from a terrorist attack. We can advise families to have a family communication and reunification plan and be available as advisors to schools, daycare facilities, and other organizations that routinely house children. It is imperative that each pediatric health professional consider the role he or she can play in reducing the vulnerability of our children and families to all disaster events. It is clear that three points bear repeating from the information we have on children's developmental and psychological response to terror: (1) answer questions as concisely and precisely as possible; (2) reassure children that parents (or other caring adults) are all right and doing what they can to protect them; and (3) limit exposure to television viewing.
General Pediatric Terrorism Advocacy Issues
We hope that this series provided the background knowledge to facilitate pediatric health professionals in becoming more effectively engaged in disaster and terrorism preparedness and response. Every community in our nation needs to assess its real world vulnerability to the forms of terrorist threats. If there were ever a problem that required broad community input it is planning a community response to terrorism - prevention, planning, or recovery after an event. We can incorporate what we know about terrorism and its effects into our current practice and anticipatory guidance. We must help others recognize that many physiological, psychological, developmental, and specific cognitive aspects of childhood make children uniquely vulnerable to terrorism.
We should educate families about appropriate response plans that are not driven by fear and panic. We must advocate to develop, drill, and use appropriate prehospital and hospital response plans that take into account children, families, and communities (Table 3). We must ensure that the knowledge and skills of pediatric providers are included in the governmental policy making process, whether at the local institutional, community, state, or national level. Those who care for children must be at the table as decisions are made, because the actions taken will affect our children and our children's children.
1 . AAP Task Force on Terrorism. Available at: www.aap.org/terrorism. Accessed March 10, 2003.
2. Kretzmann J, McKnight J. Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community's Assets. The Asset-Based Community Development Institute. Northwestern University. Chicago, 111: ACTA Publications; 1993.
3. Rivkind A. Emergency preparedness and response in Israel during the Gulf War. Ann Emerg Med. 1997;30(4):513-521.
Factors Unique to Pediatric Victims*
Before, During, and After a Terrorist Incident*
General Pediatric Terrorism Advocacy Issues