First published by The Record

The bombings at the Boston marathon Monday were a devastating reminder that the American homeland remains vulnerable to terrorism. Three people were killed, 176 injured, and judging from media coverage millions of Americans feel aggrieved. The country has been deeply shaken in part because the attack was such a surprise. It was especially shocking to those who had come to believe that terrorism was no longer a major concern.

To be sure, law enforcement officials and other emergency responders have maintained an awareness of the terrorism threat. But for many in the general population the heightened concern prompted by the 2001 attack on the World Trade Center had given way to complacency. This was reflected in Gallup polls during the past decade. After 9/11, 85 percent of Americans worried that another terrorist attack could be imminent. Ten years later the worriers had declined to 38 percent. The marathon bombings may reverse the trend.

In fact, about 50 terrorist plots against the United States have been thwarted since 9/11. At least 15 of them had targeted New York City, according to the city’s Police Commissioner Raymond Kelly. Several plots, including the 2010 bombing attempt in Times Square, nearly succeeded. After a street vendor saw smoke coming from a parked car, he alerted the police. An ignited bomb was found in the vehicle, but police were able to disarm it before it could explode. Such close calls evidently had little effect on the public’s declining unease about terrorism.

Even the shooting in 2009 at Fort Hood, Texas, by Major Nidal Malik Hasan, failed to stir a public reaction comparable to that by the Boston marathon attack. Hasan killed 13 and wounded 29. While firing his weapon, he repeatedly shouted Allahu Akbar (“God is Great”). In the previous months he had corresponded by email with Anwar al-Awlaki, then a senior al-Qaida operative in Yemen. Still, the Obama administration considers Hasan’s attack not an act of terrorism but only of “workplace violence.”

Words that describe an action may frame how others view and react to it. Thus the Fort Hood shootings like other mass shootings, as at the Newtown, Conn., elementary school, are attributed to deranged individuals. Although horrible in their own right, they are not seen as inspired by any belief system. Conversely, terrorist violence is driven by ideological, political, or religious motivation. The terrorist’s intended target is not just innocent individuals, but an entire nation or society. The aim is not just to kill but to demoralize, to demean, and ultimately to bend the will of the population.

Terrorism remains a threat

The Boston attack has reanimated the pain of 9/11 along with questions about the country’s vulnerability. Many uncertainties remain. But the attack underscored the danger of holding the illusory notion that terrorism is not a serious threat. It also demonstrated how, with proper preparedness, lives could be saved and the national will strengthened.

The Boston assault was consistent with past efforts by terrorists to damage prominent American symbols. This annual marathon event has not only typically been festive, but iconic. It is held on Patriot’s Day, which commemorates the first battles of the Revolutionary War. The nature of the event also meant that many protective measures were in place. Both security personnel and medical support were readily available. This led to a quicker and more effective response than might be expected in other venues.

The two bombs exploded seconds apart about 100 yards from the finish line. After the blasts, race participants and bystanders immediately began to comfort the injured and move them to safer areas. Police, emergency medical technicians, physicians, and nurses appeared almost as quickly. Later, all the responders received high praise for their courageous and selfless rescue efforts. But scant notice has been given to the unusual circumstances that permitted this exemplary response.

In any marathon, the strenuous 26.2-mile run is likely to result for some in injury and illness. Runners experience falls, abrasions, sprained ankles, dehydration, exhaustion, and more. The exertion at times can even be life threatening: Participants in past marathons have had heart attacks and died. Thus, stationing medical resources at these races has become common practice. New York City marathons, for example, have attracted more than 1,000 medical volunteers to provide emergency care at a network of tented field hospitals along the route.

This year’s Boston marathon included several medical tents including a block-long command tent near the finish line. Thus medical professionals could be at the scene moments after the explosions. This was especially fortunate for victims whose limbs had been torn from their bodies. “There are so many people without legs,” a shocked runner had observed in the wake of the bombings. Without that immediate professional help to quickly stop the bleeding, more victims would likely have died.

In addition to the onsite facilities, a dozen renowned hospitals were only a mile or two from the bombed area. They included the Harvard-affiliated Brigham and Women’s, Massachusetts General, and Beth Israel Deaconess, and hospitals connected to Tufts and Boston Universities. Victims were taken to these institutions, where they were treated by highly skilled practitioners.

First responders must prepare

The confluence of favorable medical opportunities at the Boston marathon was unusual and lucky. All the more important, then, that responders and institutions elsewhere be primed to address mass casualty terror and disaster. Regrettably, such preparedness has been lagging in much of the country. Funding for public health throughout the nation has been shrinking; hospitals and staff seldom engage in large-scale disaster exercises, and medical curricula rarely include instruction concerning terrorism.

Perhaps events of the past week will stimulate efforts to rectify these deficiencies. Coincidentally, I had already been enlisted to teach a forthcoming course on “terror medicine” at the New Jersey Medical School in Newark. This new field, while incorporating aspects of emergency and disaster medicine, focuses on the distinctive features of medical responses to terrorist attacks. The more that individuals and institutions learn about terror medicine, the more they will be able to offer help and protection to others.

In the coming months the country should benefit from further analyses of the Boston attack including how better to prevent a recurrence. But this much has already been demonstrated by last week’s experience: The best preparedness in the event of an attack requires quick availability of responders, rescuers, and an informed medical community.

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The views expressed in this publication are solely those of the author(s) and do not necessarily reflect the views of the International Institute for Counter-Terrorism (ICT).

*Leonard A. Cole is Director of the Program on Terror Medicine and Security at the University of Medicine and Dentistry of New Jersey. His most recent book, co-edited, is Local Planning for Terror and Disaster: From Bioterrorism to Earthquakes.