If you ask the question, "What does public health have to do with response to and recovery from the Boston Marathon bombing and to terrorism in general?", my answer is "everything."
The immediate response to the April 15 blast injuries by both bystanders and medical teams was truly impressive: efficient, effective and professional, with lives and limbs saved. The ability to provide that response, and to have the facilities, people and processes to enable it, was public health at its finest. But to achieve the durable social resilience required to withstand not just this attack, but future terrorist attacks and other assaults on our collective sense of "social-order," something more sustained and comprehensive will be required.
At its core, terrorism is the deliberate attempt to disrupt the social order for political reasons, typically with planned attacks on people, facilities or both. The damage inflicted is direct and indirect, injuring or killing innocent civilians and destroying civic infrastructure, but also instilling fear, anxiety and unrest that leads to societal destabilization and increased vulnerability to further assault.
Social resilience is the capacity for a society to withstand shocks and pressures of various sorts and to maintain the so-called "social order," a set of assessments, assumptions and expectations around which individuals and communities organize their affairs. Since terrorism is, in many ways, fundamentally an attack on "social order," social resilience can be viewed as a measure of a society's ability to withstand that attack.
Public health is a set of activities committed to improving the health of the public, health being defined in the World Health Organization's 1948 Constitutional Preamble as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." Within this broad interpretation, the opportunity to link public health to improved social resilience is not yet on our collective radar. It should be.
The time has come for appreciating and investing in the public health programs that invigorate and optimize the societal mechanisms that allow us to absorb high-stress impact, flexing with blows but not shattering. And not just for withstanding the shock of terrorism but to surviving other challenges to the way we "think about things" and "imagine the future," including weather disasters, ten years of war in Iraq and Afghanistan and prolonged economic downturns and unemployment.
Americans have long prided themselves on their resilience. The dominant social narrative, that all Americans who work hard and honestly can achieve the future they want, underscores this. Yet many have pointed out that the mental parchment this narrative is written on is yellowing with age and fraying at the edges. We are an increasingly lonely, fearful and alienated country, with an uncertain view about the future and whether we can fit into it in a way that satisfies us. From a social resilience perspective, that leaves us vulnerable. Certainly, some of this American narrative reconstruction needs to be addressed within a political and economic agenda, but I believe that the public health agenda, taken in its most powerful and broad interpretation is also critical.
But if so, how do we get started? How do we best examine the public health factors that underpin our ability to maintain and expand social resilience? Physical health and its preservation and enhancement may be straightforward to address but what about the more elusive constructs of mental health and social health? We know from population health studies, especially among socio-economically vulnerable groups, that generalized anxiety, depression and fearfulness are on the rise and that growing alienation, isolation and loneliness have driven up suicide rates. Whatever this portends for social resilience, it's not likely to be a pretty story, and leaves us vulnerable to the growing threat of terror attacks as well as other "social-order" disruptions.
The good news is that there is much that we do know about public health's interventional capabilities, and how to begin to address these questions. We know for instance that effective community-based outreach programs that promote physical, mental and social well being can be made available, evaluated, improved and maintained. In addition to traditional programs that provide basic social services to the most vulnerable, expanded approaches to community-based mental health and social health that are "person-centered" and employ a portfolio of high-engagement modalities show great promise. Whether its children being asked to make collages that portray the things they value most, or a group of older adults at a senior center, recalling and sharing meaningful and personal experiences, new modalities are emerging that amplify and sustain our ability to achieve balance and resilience.
These programs are already present and well accepted in many settings. They instill positive changes to people's attitudes and beliefs as well as to their confidence levels and sense of control and empowerment. Above all, they give individuals -- especially those most susceptible to anxiety, fear, alienation and isolation -- the tools and skills needed to maintain a sense of belonging, meaning and purpose in their lives. What's missing is a shared public health oriented vision that could articulate the importance of these programs, fortify them with additional resources and expand access. Otherwise, since chains break at their weakest link, we risk falling short in achieving the resilience that provides the sense of safety and security sought by all of us.
I am confident that public health programming, done wisely and well, can strengthen all the links of the chain, offering to every American vitality and increased social connectedness. These programs have a place not just in community centers and health clinics, but in schools, workplaces, places of worship, and even in our daily engagements with each other. They will assist us in withstanding terrorism and other disruptions, and allow us to thrive. And going forward, will demonstrate that a commitment to public health is an essential part of the foundation that a new American narrative of resilience can be built on.