Recent tragic events in New Zealand and Sri Lanka provide a devastating reminder of the global threat of terrorism from all extremes. For over a decade, the UK government has rated the threat level from international terrorism as severe or critical, and opinion polls reflect high levels of public concern. Although criminal justice agencies work to suppress terrorist activities; there have been with 46 fatalities in five years.  However, such figures tell us little about how living with the continuous threat of terrorism affects population wellbeing or how both the threat of terrorism, and state programmes to control it, have an impact on prejudices between communities or sympathies for such violence. Beneath immediate activities to foil terrorists, are we successfully reducing or stoking vulnerability to violent extremism? Drawing on lessons from youth, knife, and gang violence, a new report calls for a broader approach to tackle violent extremism which embraces early interventions, reduces risk, and enhances protective factors at both individual and societal levels.  Such an approach requires urgent engagement from health systems. 
Around one in ten people in the UK have been the victim of or know someone who has been the victim of violent extremism.  The population impact of such exposure is poorly studied, but mental health impacts include over a third of victims experiencing some form of Post Traumatic Stress Disorder.  Those affected may adversely change their lifestyles; increasing health harming behaviours (e.g. alcohol and smoking).  Moreover, the inflammatory and contagious nature of terrorist activity means others change their attitudes; interrupting positive trends in feelings towards immigrants.  Equally, official responses may be interpreted as prejudice against some communities (e.g. Islamic) or deemed inadequate by others (e.g. right-wing activists).  For those that are already vulnerable (e.g. with mental health issues) responses to violent extremism may trigger lone actor atrocities.
Understanding risk and protective factors for violent extremism remains a work in progress. However, vulnerability can result from childhood trauma and social isolation creating cognitive openings to extremist ideologies.  Individuals with access to resilience-promoting assets (e.g. positive roles models) may navigate such openings without developing propensities for extremism. Early development of poor mental health represents a related pathway into vulnerability.  Individuals struggling to achieve a sense of identity are more attracted to and more easily exploited by extremist groups; especially when such groups provide a missing sense of purpose and offer power, influence and escape from poverty.  Feelings of prejudice reinforced by inequity and discrimination lead to higher levels of aggression and negative health and well-being outcomes.  Some individuals have many of these risk factors concurrently and there are surprising similarities between these risks for violent extremism and those for gang violence.
Many of these risks can be moderated through adapting broader public health approaches. Evidence is slowly emerging for peace promoting programmes based on multicultural awareness and human rights.  However, interventions must recognise the underlying socioeconomic, cultural, and legislative determinants of wellbeing, adopt a life course approach that addresses early years and consider how to build positively on individual, family, and community assets. Communities need support to offer safe and nurturing childhoods followed by opportunities for integration and progression in adolescence. Continued hardship in early years needs balancing with assets for resilience—developing problem solving or decision-making skills and exploring concepts like personal identity and belonging. Exemplars focused on violent extremism are emerging but opportunities to borrow from other areas of public health are underexploited.
Critically, health systems can do more to deliver non–threatening solutions to issues previously seen as criminal issues. Well-established local and national dialogues on reducing inequalities should incorporate counter violent extremism objectives. Activities to tackle childhood adversity including prevention initiatives, building resilience and providing trauma informed services are needed to tackle all types of violence with additional consideration being given to trauma experienced before arriving in the UK in the case of violent extremism. Actions to protect and improve community and individual mental health must consider their role in reducing vulnerability to extremist narratives and the emergence of lone actors. The underlying epidemiology of violent extremism also needs urgent attention. Better models of risk and protective factors could move professional and public understanding to a more defined, less prejudiced picture of where terrorist threats reside. Equally, all interventions need to be evaluated to understand their impact, not just on those already at risk, but on the wider communities in which risks develop. Ultimately, success must be judged on reductions in both violent events and community support for any such violence. Currently, this intelligence is noticeably unavailable.
The serious violence strategy for England and Wales adopts a public health approach to break cycles of violence. Such approaches are desperately needed to turn a tide of gang, drug, and knife related brutalities. While there are unique aspects to violent extremism, in many respects its proponents are members of their own gangs and their religious or political extremism can be an addictive incentive to violence comparable to any drug. If we do not address the socio-economic, disempowerment and isolational links to all types of violence, including violent extremism, the wellbeing of all communities will ultimately pay the price.
Mark A. Bellis, director, Policy and International Health,WHO Collaborating Centre on Investment in Health and Well-being, Public Health Wales
Katie Hardcastle, senior public health researcher, policy and International Health, WHO Collaborating Centre on Investment in Health and Well-being, Public Health Wales
John Middleton, President of the Faculty of Public Health
Competing interests: None declared
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