Ideologically Motivated Violence: A Public Health Approach to Prevention

Early on June 12, 2016, an armed man walked into a nightclub in Orlando, Florida, and began shooting. Two minutes into the rampage, he called 9-1-1, pledged allegiance to ISIS, and told the dispatcher, “You have to tell America to stop bombing Syria and Iraq. They are killing a lot of innocent people. What am I to do here when my people are getting killed over there?” He killed 49 people before being shot dead by police. His actions seemed driven by a toxic confluence of social isolation, romantic troubles, access to weapons, bigotry, and, perhaps, mental illness and radical religious beliefs.

Multiple killings in US cities including Orlando; Charleston, South Carolina; Portland, Oregon; San Bernardino, California; Colorado Springs, Colorado; and elsewhere have been driven, at least in part, by ideological extremism. These heinous acts, in concert with other social forces, have prompted large investments by the US Department of Homeland Security, State Department, and law enforcement to understand and prevent ideologically motivated violence (IMV). Dubbed “countering violent extremism” (CVE) under the Obama administration, some programs have included public health experts—bringing expertise derived from partly analogous previous work preventing gang violence, suicide, and domestic abuse—and mental health practitioners with expertise on how to detect and prevent violence among “at-risk” individuals.¹

A PUBLIC HEALTH APPROACH

It is intriguing to consider what counterterrorism programs might look like if IMV were considered to be a public health as well as a law enforcement problem. Terrorism has important population-level health effects, and so do potential responses to the threat of terrorism.^2,3 Could a public health approach to preventing IMV complement or improve current community-based law enforcement approaches? What opportunities for collaboration might arise if public health professionals were to become involved in contemporary CVE programs?

We recently participated in a workshop, “Exploring the Use of Health Approaches in Community-Level Strategies to Countering Violent Extremism and Radicalization,” hosted by the National Academies of Sciences, Engineering, and Medicine’s Forum on Medical and Public Health Preparedness for Disasters and Emergencies. With attendees from law enforcement, intelligence, homeland security, and the public and mental health communities, the group’s rich discussion addressed myriad medical, legal, ethical, and practical issues.⁴ We came away with two lessons that might be particularly helpful in guiding public health professionals, or others, contemplating whether or how to become involved in CVE programs today.

NO CLINICALLY USEFUL RISK FACTOR

First, clinically useful risk factors marking individuals as being on a predictable path toward carrying out an act of IMV do not exist. Despite considerable research, no constellation of factors predicts with acceptable accuracy that a member of the general public (i.e., someone not already a member of an extremist group) will commit IMV. Factors such as being young, male, religious, disagreeing with US foreign policy, or having a history of mental illness or petty crime are simply too common, even in combination, to be of practical value.

Public health practitioners know that for events occurring at very low rates, even a highly sensitive and specific test will generate impossibly large numbers of false-positive results. One speaker at the workshop noted:

As of 2016, the United States population was 323 million, including a presumed 10 000 violent extremists. If there were an extremely powerful hypothetical screening test that could pick up 99 percent of violent extremists when screened, then screening the population would identify 9900 violent extremists (true positives) and miss 100 of them (false negatives). If the hypothetical test also had a 99 percent specificity, then the test would correctly identify more than 320 million people as innocent (true negatives). However, more than 3.2 million people would be incorrectly labeled as being violent extremists despite being innocent, which is an extremely high number of false positives. In statistical terms, the positive predictive value of this very powerful hypothetical screening test is just 0.3056 percent.^4(p93)

Unfortunately, ill-advised attempts to predict which individuals will carry out acts of IMV pose more than merely statistical challenges. Some recently proposed “risk factors” for committing IMV are so general (e.g., country of origin, legal residency status) that pursuing them as a programmatic focus is likely to cause population-level harm. Public health has recognized that stigmatization, and Islamophobia in particular, carry significant health costs.^5,6

FUNDING AND FOCUS

This raises a second lesson from the workshop: CVE programs with conceptual origins in and continued funding by law enforcement and homeland security face particular barriers to success. Namely, some Muslim American communities view such initiatives as law enforcement cloaked in community service.

Because of this perception, the community leaders whose cooperation is needed for these programs to succeed sometimes avoid them, even if they are sympathetic to their aims in private, because public association might erode their community’s trust. For example, during the formative evaluation of a CVE program in Boston, Massachusetts, after visiting 45 organizations and interviewing more than 50 stakeholders, the evaluator reported “98 percent of interviewees stated bluntly that they would not take part in a program with the ‘CVE’ label, because it would risk undermining the trust and relationships they had worked to build with the communities they serve.”^4(p82)

These concerns are understandable. After all, “CVE” has sometimes described programs developed by law enforcement and focused primarily on threats from “radical Islamists,” despite epidemiological data showing that 43% of recent acts of IMV in the United States have come from far-right extremists, 21% from the far left, and 15% from Islamic extremists.^4(p11) And concerns about stigmatization in these programs have undoubtedly been heightened by the recent US political climate, marked by vitriolic rhetoric and Islamophobia, and exacerbated by proposals under consideration by the Trump administration to focus future CVE programs exclusively on “radical Islamic extremism.”⁷

Well-meaning health professionals might hope CVE programs, regardless of how they are funded or focused, can provide resources for disadvantaged individuals and communities. But as trusted community leaders, with knowledge of the damaging effects of social stigmatization and Islamophobia,^5,6 health care and public health professionals should avoid participating in programs that are focused solely on countering extremist violence among Muslims. Although such programs might have political appeal, they are neither evidence-based nor aligned with the reality of the various sources of IMV in the United States today. As a result, at best, such programs will not work; at worst, they could backfire by exacerbating stigmatization and inequities, which may themselves drive violent behavior.

In sum, the threat of IMV in the United States is real and perhaps increasing; it spans the political, religious, and ideological spectrum; and it has serious individual and population-level health effects. It therefore deserves the attention of health care and public health professionals, because we might encounter patients and communities fearful of being targeted by violence, and we might be able to put a useful public health lens on approaches to preventing IMV. But a public health approach to preventing IMV would have to be evidence-based. As such, it would recognize that programs focused on identifying “at-risk” individuals from a single ethnic or religious community can result in stigmatization and be counterproductive, even dangerous. In those instances, our professional responsibility is not merely to avoid becoming involved in such efforts, but also to speak out against misguided programs that will harm the health and well-being of the patients and communities we serve.