Galea et al. Respond

We would like to thank Myers for her interest in our work. Two issues are raised; we would like to tackle each in turn. First, we are in complete agreement on the need for cross-cultural validation for any measure used to assess mental health. While definitive validation is particularly challenging in contexts like Liberia, where psychiatrists or psychologists who may provide “gold standard assessments” are essentially nonexistent, we conducted both focus groups to help us better understand the local setting and subsequent cognitive interviewing to adapt the Harvard Trauma Questionnaire (HTQ) to the Liberian context. Space limitations precluded us summarizing this process in more detail in our article. Second, the issue about event-specific attribution of posttraumatic stress disorder (PTSD) symptoms is also important. Several authors have published approaches that link PTSD measures to sentinel events.1 We did not do so in this context, primarily to minimize respondent burden. However, our findings of a geospatial pattern showing concordance between PTSD symptoms and the documented path of conflict in Liberia stand irrespective of linkage to specific symptoms. As we noted in our article, this observation likely suggests direct exposure to the conflict of decades past as well as to more recent traumatic events that might be more likely in areas previously rendered more vulnerable by experiences of conflict. Although we do not here present a model outlining these hypothesized relations, we have previously published models that suggest how features of the social environment may influence the risk of adverse consequences of trauma2; these models are applicable to the findings in our recently published study. Ultimately what is of central importance in this article is the dramatic geospatial congruence of PTSD with the patterns of war nearly two decades earlier. This finding suggests that the consequences of war are long-lasting and that the causal pathways between war and adverse health are likely complex. Future research can certainly fruitfully work to disentangle these pathways. In the short term, relief efforts may be guided by historical patterns to identify areas that are particularly vulnerable to poor population health in postconflict countries like Liberia.