HEQ-2016-0016-ver9-Alcala_3P 87..95


NARRATIVE REVIEW Open Access

Social Determinants of Health, Violent
Radicalization, and Terrorism:
A Public Health Perspective
Héctor E. Alcalá,1,{,* Mienah Zulfacar Sharif,2,{ and Goleen Samari3,{

Abstract
Background: Terrorism-related deaths are at an all-time high as there were 32,685 and 29,376 terrorism-related
deaths in 2014 and 2015, respectively. Terrorism is defined as the use of violence and intimidation in the pursuit
of political aims. Terrorism is detrimental for mental health, premature mortality, and economic losses and un-
dermines the central tenets of public health to improve the health and well-being of populations. Despite the
impact terrorism has on avoidable morbidity and mortality, population health research largely overlooks social
determinants of terrorism and risk factors that contribute to terrorist activities.
Methods: Drawing from what is known about commonly studied social determinants of health topics, including
the relationships between structural and interpersonal discrimination, social cohesion, and gang violence and
health, we present a public health framework, rooted in the social determinants of health, for identifying poten-
tial factors influencing terrorism and violent radicalization.
Results: Social determinants of health provide unique insight into how interpersonal and structural factors can
influence risk for violent radicalization and terrorist activity. Each of the topics we review provides an entry point
for existing public health and behavioral science knowledge to be used in preventing and understanding violent
radicalization and terrorism. For example, anti-Muslim sentiment has promoted discrimination against Muslims,
while also serving to marginalize and stigmatize Muslim communities. These conditions limit the social resources,
like social cohesion, that Muslims have access to and make political violence more appealing to some.
Conclusions: Public health can contribute much to the ongoing debate around terrorism. The field must take a
more prevention-focused approach to the problem of terrorism. Failure to do so only perpetuates approaches
that have not been successful.

Keywords: discrimination; gang violence; social cohesion; terrorism; United States

Introduction
Around the world, the death toll due to terrorism has
reached unprecedented levels. From 2013 to 2014,
there was an 80% increase in the number of terrorism-
related deaths rising from 18,111 in 2013 to 32,685 in

2014.1 However, only 2.6% of all deaths from terrorism
have occurred in the West, and 72% of terrorism-
related deaths are concentrated in five countries—
Syria, Pakistan, Iraq, Nigeria, and Afghanistan.1 In
addition to premature mortality, terrorism is associated

1Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia.
2Department of Medicine, University of California, Irvine, Irvine, California.
3Population Research Center, University of Texas, Austin, Texas.
{These three authors contributed equally to this work.

*Address correspondence to: Héctor E. Alcalá, PhD, Department of Public Health Sciences, University of Virginia, 560 Ray C. Hunt Drive, Charlottesville, VA 22902, E-mail:
hectorapm@ucla.edu

ª Héctor E. Alcalá et al. 2017; Published by Mary Ann Liebert, Inc. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited. Mary Ann Liebert, Inc. offers reprint services for those who want to order professionally produced copies of articles published
under the Creative Commons Attribution (CC BY) license. To obtain a price quote, email Reprints@liebertpub.com. Please include the articlé
title or DOI, quantity, and delivery destination in your email.

Health Equity
Volume 1.1, 2017
DOI: 10.1089/heq.2016.0016

Health Equity

87



with a myriad of mental health outcomes, including
depression, anxiety, and posttraumatic stress disorder
(PTSD).2 Terrorism-based fear also dissuades travel
and reduces consumerism, leading to economic losses.3

As such, terrorism is a focus of United States (U.S.) for-
eign policy, with the U.S. federal government annually
spending an average of $600 billion for defense and an-
nually increasing counterterrorism spending in a range
anywhere from $17 to $60 billion.4

Despite the influence terrorism has on population
well-being and political and economic systems, a public
health framework for better understanding the risk fac-
tors for terrorist activities is lacking. Terrorism is de-
fined as the use of violence and intimidation in the
pursuit of political aims. Terrorism is often perpetuated
by those who have been violently radicalized.5 Violent
radicalization means the process of adopting or pro-
moting an extremist belief system for the purpose of
facilitating ideologically based violence to advance po-
litical, religious, or social change. While public health is
largely involved in preparedness strategies and address-
ing the aftermath of terrorist events, social determi-
nants of terrorism and violent radicalization and risk
factors for terrorism are glaringly absent from main-
stream population health discourse. This is a short-
coming of public health—given that one of the main
goals of the perpetrators is to instill a population
level of fear, uncertainty, and vulnerability6 and that
terrorism undermines the central tenet of public health,
namely, to improve the health and well-being of popu-
lations and prevent avoidable morbidity and mortality.

Terrorism is not an individual experience; it is vio-
lence at a population level and worthy of attention in
fields focusing on socioecological understanding of so-
cial processes and human behavior. A public health
perspective can provide insights on the risk factors
for radicalization and social determinants of terrorism.
We recognize the unpredictability of terrorist attacks
and by no means claim to have identified strategies
for ‘‘terrorism prevention.’’ Rather, given public
health’s ecological perspective and unique role in iden-
tifying factors that protect or hinder the health of com-
munities, we describe how to use commonly used
theories and frameworks to start and disentangle po-
tential risk factors for either promoting and/or engag-
ing in violent terrorist activity.

Methods
The goal of this article is to incite critical dialogue
on how social determinants of health researchers and

professionals can advance our understanding of risk
factors for radicalization and future tragic terrorist
events. A case study from the United Kingdom shows
that violent radicalization is an outcome of a complex
interaction among social, political, cultural, historical,
and interpersonal factors.7 This article builds on this
work for the U.S. context and explains how a public
health understanding of health, namely, the relation-
ship between discrimination, social cohesion, and
gang violence and health, can help identify potential
risk factors for terrorism from violent radicalization.
Then, this review explores future directions for public
health, behavioral and social science researchers and
practitioners to understand and contribute to research
on terrorism and health.

Results
Discrimination and health
There is a mounting body of evidence linking discrimina-
tion, at multiple levels (individual, as well as institutional)
to poor health outcomes and health disparities.2,8,9 Per-
ceived discrimination has been associated with an increase
in risk factors for physical health, including high blood
pressure and substance abuse, and also in physical health
outcomes, including hypertension and breast cancer.8

However, the most compelling evidence suggests a link
between discrimination and mental health outcomes, in-
cluding depression, anxiety, and psychological distress.10

Discrimination is a specific type of stressor that is ‘‘un-
controllable and unpredictable.’’11 The experience of dis-
crimination is associated with the onset of physiological
responses to stress that then have longer term implica-
tions for health outcomes, including a ‘‘wear and tear’’ im-
pact on regulatory systems as a result of ongoing
activation of the allostatic systems.11 Over time, discrimi-
nation can also erode protective resources, decrease one’s
engagement in health-promoting behaviors (e.g., cancer
screening), as well as increase their engagement in un-
healthy behaviors (e.g., substance abuse), explained as
maladaptive coping mechanisms to the stressor.8

Moreover, scholars argue that ‘‘context matters’’ as it
is possible that the relationships (and/or magnitudes)
of the effects of discrimination vary by racial and ethnic
groups.10,12 Or, as Gee et al.12 argue, we should not as-
sume a ‘‘one race fits all’’ effect on the relationship of
indicators of discrimination on health outcomes. This
holds true for many Muslim Americans or those who
may be perceived as Muslim Americans (including
Sikhs), who have experienced heightened levels of dis-
crimination, post-9/11.13,14 This discrimination exists

Alcalá, et al.; Health Equity 2017, 1.1
http://online.liebertpub.com/doi/10.1089/heq.2016.0016

88



despite the fact that many Muslim Americans, who
come from the 22 Arab countries of the Middle East
and North Africa, are classified as ‘‘White’’ by the cat-
egories set forth by the Office of Management and
Budget, even though a large proportion of them do
not identify as White.15 Research on racial and ethnic
health disparities among people categorized as White
is limited as it is assumed that this category is ‘‘racially
neutral.’’15

This disconnect is likely attributed to the rampant
xenophobia and heightened levels of Islamophobia in
the post-9/11 context. As Rousseau (2011) explains,
‘‘.the discourse on security stemming from the war
on terror generated suspicions and increased prejudice
toward all groups considered a potential threat.’’ Fol-
lowing 9/11, rhetoric within the media and policy
realm has disproportionately singled out the Islamic
faith and Muslims as evidenced through legislation
sanctioning deportation of Muslims and media cover-
age portraying Arab or Muslim Americans as the ‘‘ter-
rorist’’.16 This xenophobic framing fails to acknowledge
the small faction of Muslims the perpetrators of these
violent acts actually represent and ignores Muslim vic-
tims of terrorism. For example, when looking specifi-
cally at the victims of Al-Qa’ida, Muslims are seven
times more likely to be killed by Al-Qa’ida than non-
Muslims17 and Muslims represent between 82% and
97% of fatalities perpetrated by the Islamic State of
Iraq and Syria (ISIS).18 In the context of health dispar-
ities research, xenophobia and Islamophobia are im-
portant forms of discrimination that contribute to
health disparities.19

Immigration policies contribute to discrimination of
Muslims and Middle Eastern Americans. Immigration
policies racialize and construct particular groups of im-
migrants as a threat to the nation’s health.9 Several pol-
icies following 9/11 establish that all immigrants of
Middle-Eastern origin should be viewed as potential
terror threats and only second as newcomers.20 The
threat of terrorism has misappropriated immigration
laws as a means to promote antiterrorism goals.21

Immigrants, particularly from the Middle East, are
thus framed as a national security risk, igniting xeno-
phobia and fear of the ‘‘Other.’’22 Immigrant integra-
tion is a complex process that is based partially on
the reception experience at destination. Many immi-
grants experience discrimination, oppressive living
conditions, and a lack of access to basic services, all
of which are known determinants of health.23 The
discrimination of Muslims and/or Middle Eastern

Americans, largely formed by structural factors like im-
migration policies, curtails the benefit of racial central-
ity described as ‘‘strength of positive identification with
one’s racial group,’’ among Muslim and Middle Eastern
Americans.24 Thus, identifying as Muslim in our
current sociopolitical context can be conceptualized
more as a stressor than a sense of support and, thereby,
be more detrimental as opposed to protective for health
and behaviors.

Social cohesion, terrorism, and health
The ongoing stress related to being viewed as a threat
can undermine social cohesion and social capital,
both of which are important determinants of popula-
tion health and preventing community violence.25

Thus, pathways to violent radicalization and terrorism
can be better understood if health research investigates
variables from the social and behavioral sciences like
social cohesion and capital.26

Social cohesion refers to the extent of connectedness
and solidarity among groups in society, including the
absence of social conflict and the presence of social
bonds.27 Social capital is defined as the features of so-
cial structures, like levels of interpersonal trust and
norms of reciprocity and mutual aid, that act as re-
sources for individuals and facilitate collective action.27

Social capital is the resources or trust, norms, and the
exercise of sanctions available to members of social
groups (a work place, voluntary organization, neigh-
borhood, etc.) and/or the actual resources—social sup-
port, information channels, and social credentials that
are embedded in social networks.28 Social capital can
yield social networks that bring people together in at
least two different ways: (1) bring people who are
alike together (i.e., bonding networks) and (2) bring
people who are not alike together (i.e., bridging net-
works).29,30

The presence of oppressive conditions for relation-
ship building among new immigrants may deter the so-
cial participation that is crucial for the formation of
social capital. Social capital is achieved through the in-
vestment in social relations and resources by individu-
als to enhance their expected returns or expressive
actions.31 The potential impact of social capital on so-
cial cohesion will vary depending on the ways in which
its effects are enhanced or diminished by the wider so-
cial, political, economic, and cultural environment.22

The current social environment is not conducive to fos-
tering social capital and cohesion of Muslim and Arab
Americans, because identifying with these respective

Alcalá, et al.; Health Equity 2017, 1.1
http://online.liebertpub.com/doi/10.1089/heq.2016.0016

89



groups leaves people vulnerable to discrimination and
excluded from positive social bonds. Coupled with
the discrimination faced by Muslims and Arabs in
the West, individuals may not have the opportunity
to form either bridging or bonding networks due to
pressures to distrust individuals like themselves and
hostility faced from those who are unlike themselves.

The relationship between social cohesion and health
is well established across several indicators of health,
including self-rated health, cardiovascular disease, can-
cer, diabetes, and infectious diseases.32 Trust, at the in-
dividual and community level, frequently serves as an
indicator of social cohesion and then linked to health.
Greater social capital is also an important determinant
of health and mental health of children, adolescents,
adults, and aging populations.28,33 Social capital is a
means of consolidating resources and protecting
against losses like physical health, mental health, and
life satisfaction.31 The relationship between social cap-
ital and health is embedded in the broader social con-
text as socially active individuals report good health in
countries with high levels of social capital, but are less
likely to do so in countries with low levels of social cap-
ital.34 Although few studies have sought to directly as-
sess the mechanisms linking social capital to health, a
variety of hypothesized pathways have been proposed
by which cohesion may affect health, including the dif-
fusion of knowledge about health promotion, promo-
tion of access to local services and amenities, and
psychosocial processes which provide affective support
and mutual respect.27

Low levels of social capital, however, can be risk factors
for population health. Prevention of vandalism and vio-
lent crime is rooted in collective efficacy.33 The link be-
tween social capital and violent crime is repeatedly
shown.35 There is a ‘‘dark side’’ of social capital or the
contagion of high risk behaviors within networks like
the spread of suicidal ideation36 and alcohol and other
drug use among adolescents.37 Suicide and crime are
both related to low levels or absence of social cohesion.32

As such, one potential motivator of terrorist-driven sui-
cide bombings and violence could be an indication of a
lack of, or low levels of, social cohesion.

Terrorism and gangs
A useful approach to examining the role that public
health and behavioral and social sciences can play to
better understanding the etiology of violent radicaliza-
tion and/or terrorism prevention is to examine another
source of organized violence such as gang violence.

Terrorist and gang members have some key similar-
ities. For example, both groups are comprised dispro-
portionately of males, individual members form a
collective that supports its members and their actions,
both groups attempt to counter the efforts of law en-
forcement, and both engage in violent acts as a
means of social control.38 At the individual level,
gangs and terrorist organizations appeal to individuals
who are psychologically deviant, have limited access to
socioeconomic opportunities, or are marginalized
members of society.39–44 In fact, terrorist groups attract
a range of unstable individuals.45 Joining these groups
provides individuals with group identification and be-
longing that they cannot find in mainstream society.
In addition, group membership for both the terrorist
and gang member is a source of power and protec-
tion.39 Overall, terrorism and gang membership appeal
to members of society who are on the margins and view
joining either group as a means of obtaining power
and/or exercising influence.

There are also characteristics that gangs have that ter-
rorists (or terrorist networks) do not. These include the
following: (1) goals with symbolic (and not political)
ends; (2) a less rigid organizational structure; (3) shorter
periods of cooperation among members; (4) transitory
group membership; and (5) a physical space that is iden-
tifiable and defendable.46 In this study, the key distinc-
tion is that the motivations of terrorist groups are
political, while those of the gang member are not al-
ways.47 In addition, much of the understanding of
gangs does not view them as transnational actors in
the same way that we frequently understand terrorists.

Despite theorized differences between terrorists and
gang members, governments have not consistently dis-
tinguished between the two, revealing the very subjec-
tive, or politicized, nature of the ‘‘terrorist’’ label. For
example, in New York, gang related murders have
been successfully prosecuted using antiterrorism legis-
lation.48 However, subsequent courts ruled that terror-
ism laws could not be used to prosecute cases of gang
violence.49 Similarly, the Salvadoran government has
labeled the Mara Salvatrucha and Barrio 18 gangs as
terrorist groups.50 In effect, these actions advance the
argument, explicitly and implicitly, that gang activity
can serve to ‘‘intimidate or coerce’’ civilians, in the
same way that terrorists do. While all of this is occur-
ring, the media amplifies the threat of terrorism perpe-
trated by Arabs and Muslims, while downplaying and
providing excuses for domestic terrorism.24 The end
result is that the term ‘‘terrorist’’ is applied by

Alcalá, et al.; Health Equity 2017, 1.1
http://online.liebertpub.com/doi/10.1089/heq.2016.0016

90



governments to denote extra condemnation and not
necessarily to label specific acts with specific motives.
As a result, terrorism becomes hard to define, and
thus, harder to study and prevent. In addition, because
the distinction between gangs and terrorism is highly
subjective, it may be possible to use what we know
about the former to address the latter.

Discussion
This review shows that public health and behavioral
science concepts can be applied to our understanding
of risk factors for engaging in, or promoting, violent
acts of terrorism. Importantly, this work does not con-
done or justify these acts of violence; instead, we aim to
emphasize how existing public health and social sci-
ence frameworks can do more to understand, and po-
tentially prevent, this epidemic of violence. Specifically,
pertinent to a public health perspective on terrorism
include discrimination, socialization processes like so-
cial cohesion, and other forms of radicalization like
gang membership and violence. Prior research consis-
tently demonstrates that individual and structural dis-
crimination are detrimental for population health, and
social cohesion and integration are integral for physical
and mental health.8,51 The following discussion shows
how these concepts are salient for a theoretical and em-
pirical understanding of terrorism.

Experiencing discrimination is a marker of social
isolation and exclusion, which makes people vulnerable
to extremist influences and ideologies while weakening
their social cohesion.52 Hate crimes against Muslims in
the United States remain five times more common
since 9/11 than they did before.53,54 From reports and
opinion polls, we know that hate speech and crimes
against Muslim Americans are commonplace.54 In ad-
dition, Muslim Americans must contend with govern-
ment surveillance and monitoring, which is associated
with anxiety and behavior modification, to avoid con-
texts that might lead to government suspicion.55 This
anxiety and behavior modification includes fear of
hate crimes, distress about threats to safety, loss of
community, isolation, and stigmatization.53

As discussed above, immigration policy is also a
form of structural discrimination that contributes to
social segregation.9 Social and economic policy are syn-
onymous with health policy. Therefore, immigration
policy fueled by ‘‘antiterrorism policy’’ can be a deter-
minant of health. Although there are well-documented
effects that immigration policies have on limiting ac-
cess to health and social services for immigrants, the

idea that those policies also directly impact the social
determinants of disease by shaping access to life oppor-
tunities is understudied.9 The effects of anti-immigrant
policies can, thus, be far reaching in their ability to un-
dermine the health of immigrants and their families
across the life course. Furthermore, since anti-
immigrant policies racialize anyone perceived to be
an immigrant, the effects extend to subsequent genera-
tions. There is a pattern of racial and religious profiling
in the naturalization process to block citizenship of in-
dividuals from Muslim countries.16 As a result, anti-
immigrant sentiments create hostile environments
that can compromise health of entire communities.

Discriminatory acts and policies also inhibit other
social determinants of health like social cohesion.
Young people are particularly vulnerable to radicaliz-
ing influences because of isolation, marginalization,
and a lack of social capital.56 Muslims, specifically,
are the object of political scrutiny and the target of neg-
ative media discourses. Counterterrorism policies,
however well intentioned, can damage social cohesion
by isolating a group of people like Muslim Americans25

in that they perceive to be ‘‘targeted’’ because of their
ethnic and/or religious identity.2 For example, the
Antiterrorism and Effective Death Penalty Act led to
investigation of Muslim American political and social
activity and to the deportation of Muslims with links
to terrorist activity.20 The 2001 Patriot Act extended
this legislation and gave the state new powers, includ-
ing surveillance, which profiles Muslim Americans or
‘‘Muslim-like’’ Americans.20 These policies isolate
Muslim or Arab Americans, promote discrimination,
and create barriers to the health promoting effects of
social cohesion.

Feelings of marginalization have been shown to lead
to decreased self-worth and, in turn, increase radicali-
zation.57 Structural marginalization of a group under-
mines social cohesion and can lead to fragmentation,
including the forming of groups with militant or ex-
tremist views, thereby undermining our national secu-
rity and public health goals. A need for social respect
and ties can drive individuals toward radicalization
when coupled with one’s fear of security and oppres-
sion.45 Engaging people from all political, religious,
and demographic backgrounds is essential to foster co-
hesion, which prevent individuals from being drawn
into extremist groups. Peace psychology has long ar-
gued that the promotion of positive intergroup rela-
tions is integral to the prevention of violent
episodes.58 Moreover, peace psychology posits that in

Alcalá, et al.; Health Equity 2017, 1.1
http://online.liebertpub.com/doi/10.1089/heq.2016.0016

91



addition to efforts to prevent incidents of violence, or
‘‘negative peace,’’ we must equally emphasize efforts fo-
cusing on ‘‘positive peace,’’ meaning we must strive to-
ward a more equitable society that is rooted in social,
economic, gender and racial justice.59 In other words,
this holistic view recognizes the importance of address-
ing underlying factors, related to sense of exclusion,
that drive people to extremists, including lack of eco-
nomic and educational opportunities and trauma
resulting from ongoing conflict.60

Taken together, a public health perspective can argue
that current efforts to tackle terrorism may have, in fact,
increased our risk for further violent attacks (Fig. 1).
Specifically, anti-terrorism policies have promoted the
discrimination of Muslims. In turn, these actions by
non-Muslims erode social cohesion in Muslim commu-
nities, as Muslims are incentivized to distance them-
selves and mistrust their peers. As a result, some
individuals may become isolated and marginalized. For
a small minority, this may make them receptive to rad-
icalization. For fewer still, this may motivate them to en-
gage in acts of terrorism. The government responds to
terrorist acts by enacting anti-terrorism policies that
fuel discrimination and continues the cycle.

Implications for public health research and practice
Threats of terrorism operate across borders and require
public health attention to globalization and the trans-
national nature of people. Greater awareness of the
negative reverberations for U.S. policies for people

around the globe is needed. Thus, although public
health training programs emphasize their interdisci-
plinary focus, courses on U.S. foreign policy and inter-
national relations are not included in the common
topic areas of focus. Public health training programs
should integrate U.S.’s foreign policy into their curric-
ula and emphasize awareness of global events, given the
global origins of many of our most critical public health
concerns. Specific to foreign policy, it is critical that we,
as a field, challenge the systems that implement certain
policies, which then result in the anti-U.S. sentiment
that can foster radicalization. For example, some have
argued that the American-led invasion of Iraq, under
the pretense of anti-terrorism, led to the death of thou-
sands of Iraqis and the displacement of millions more
and laid the groundwork for the rise of newer terror
threats like ISIS.61 To truly understand the context of
terrorism, multilevel thinking is required–the individ-
ual, group, state, and global dynamics.62 To take a pub-
lic health perspective of determinants of terrorism,
greater attention needs to be paid to U.S. foreign policy
and issues around the world that can ultimately influ-
ence public health and national security.

Given the heightened experiences of discrimination
and social isolation among immigrations, the global di-
mension of terrorism also pertains to immigrants.
Immigration research increasingly recognizes that im-
migrants operate in a transnational space. Transna-
tionalism involves the maintenance of occupations or
activities that necessarily require regular social contacts

FIG. 1. Public health framework of terrorism and violent radicalization.

Alcalá, et al.; Health Equity 2017, 1.1
http://online.liebertpub.com/doi/10.1089/heq.2016.0016

92



over time, across national borders and/or across cul-
tures.63 Transnationalism recognizes that immigrants
have ties with their country of origin as they adopt
ties in the host country. However, public health and be-
havioral and social science research often fail to recog-
nize the interaction and integration of people across
borders, drawing only on the destination contexts.
Implications of transnationalism remain largely un-
tested in health research. Research can be enhanced
by considering the context and conditions of both
sending and receiving countries to fully understand so-
cial determinants of terrorism. Transnationalism and
migration-related factors are integral to understanding
terrorism.7

Given the similarities between terrorism and the
problem of gang violence, it may be possible to extend
the public health approach that some have advocated
for use against gang violence and adopt approaches
that have been advocated to curb political violence
or terrorism. Briefly this public health approach in-
volves four stages: (1) Describing the problem; (2)
Identifying risk and protective factors; (3) Developing
and evaluating prevention strategies; and (4) Dissem-
inating prevention strategies.7,64 In this study, the
focus is on preventing both individuals from joining
gangs and preventing gang-related violence and dif-
fers radically from the current policing and criminal
justice approach toward Muslims in the anti-
terrorism context that relies heavily on stigmatizing
Muslims in the West and can be counterproductive.65

In fact, gang prevention and intervention efforts that
focus on police suppression are not effective, while ef-
forts focusing on local contexts, gang prevention
among youth, and comprehensive community pro-
grams tend to show promise.66 Furthermore, others
have argued that a public health approach to the prob-
lem of political violence can involve primary (i.e., pre-
venting violence), secondary (i.e., shortening the
duration of violence), and tertiary prevention (i.e.,
preventing violence from becoming chronic and en-
gaging in rehabilitation and reconstruction).25 In
this way, strategies to deal with terrorism should be
rooted in evidence and science and not politics and
fearmongering.

For social cohesion, a potentially effective approach
to counterterrorism would include: legal and political
efforts that champion human rights for all members
of society, embracing the development of cultural liter-
acy approach to community engagement, and affirm-
ing the importance of intermediate and long-term

relationships between individuals and communities.
Interventions should focus on how social exclusion
and marginalization can generate grievances that are
not processed through political engagement or demo-
cratic nonviolent negotiations.52 This also has wider
health benefits of cohesive communities with greater
social capital, economic resources, and fair access to
health. Furthermore, efforts must be undertaken to en-
courage the formation of bonds among Muslims and
Arabs in the West and between these groups and oth-
ers. In this way, the features of social networks can be
leveraged to both increase access to outside resources to
marginalized groups and promote the internal stock of
resources among these groups.

Approaches to reducing radicalization have taken
advantage of knowledge of social capital and social net-
works. For example, Denmark has taken a different ap-
proach toward reducing the risk of radicalization in
their response to people returning from Syria, whereas
other European countries (and the U.S.) impose legal
consequences for travelling to Syria. Danish police of-
ficers ‘‘welcomed’’ returnees from Syria by offering a
psychiatrist or mentor, assistance finding an apartment
and returning to school, or ‘‘whatever they needed to
fully integrate back into society.’’67 This innovative ap-
proach toward deradicalization is guided by the idea
that ‘‘fighting’’ terrorism through policing and/or ‘‘pro-
filing’’ people will only incite perceived discrimination,
humiliation, and/or marginalization, which is what
they believe is at the root of the problem and will
only make matters worse.

Conclusion
Adopting a social determinant of health approach to
the multifaceted and transnational dimensions of ter-
rorism is not without an array of challenges, including
how one goes about ‘‘defining’’ or ‘‘identifying’’ a ter-
rorist. However, given the climate of heightened dis-
crimination toward Muslims and high risk for violent
radicalization, social and behavioral scientists are in a
unique position to inform and become actively in-
volved in debates and initiatives to understand and ad-
dress terrorism by applying a social determinant
framework. Specifically, we have discussed how litera-
ture on discrimination, social cohesion, and gang vio-
lence can inform such efforts. These efforts are now
more urgent as the current U.S. President had prom-
ised policies that target Muslims for increased govern-
ment scrutiny or prevent Muslims from entering the
country as refugees.

Alcalá, et al.; Health Equity 2017, 1.1
http://online.liebertpub.com/doi/10.1089/heq.2016.0016

93



Acknowledgment
The authors thank Dr. Jennifer Jee-Lyn Garcı́a for her
helpful comments on a draft of this article.

Funding
The research was supported by the National Institute
of Child Health and Human Development grants at
the University of Texas at Austin (T32HD007081
and R24HD042849). The content does not necessar-
ily represent the official views of the National Insti-
tutes of Health.

Author Disclosure Statement
No competing financial interests exist.

References
1. Institute for Economics and Peace. Global Terrorism Index. New York, NY.

2015.
2. Rousseau C, Jamil U, Bhui K, et al. Consequences of 9/11 and the war on

terror on children’s and young adult’s mental health: a systematic review
of the past 10 years. Clin Child Psychol Psychiatry. 2015;20:173–193.

3. Frey BS, Luechinger S, Stutzer A. Calculating tragedy: assessing the costs
of terrorism. J Econ Surv. 2007;21:1–24.

4. Desilver D. U.S. spends over $16 billion annually on counter-terrorism.
Pew Research Center. 2013. Available at www.pewresearch.org/fact-tank/
2013/09/11/u-s-spends-over-16-billion-annually-on-counter-terrorism
Accessed May 22, 2016.

5. Golder B, Williams G. What is ‘terrorism’? Problems of legal definition.
Univ NSW Law J. 2004;27:270–295.

6. Yehuda R, Hyman SE. The impact of terrorism on brain, and behavior:
what we know and what we need to know. Neuropsychopharmacology.
2005;30:1773–1780.

7. Bhui KS, Hicks MH, Lashley M, et al. A public health approach to under-
standing and preventing violent radicalization. BMC Med. 2012;10:1–8.

8. Williams DR, Mohammed SA. Discrimination and racial disparities in
health: evidence and needed research. J Behav Med. 2009;32:20–47.

9. Gee GC, Ford CL. Structural racism and health inequities: old issues, new
directions. Du Bois Rev. 2011;8:115–132.

10. Abdulrahim S, James SA, Yamout R, et al. Discrimination and psycho-
logical distress: does Whiteness matter for Arab Americans? Soc Sci Med.
2012;75:2116–2123.

11. Pascoe EA, Smart Richman L. Perceived discrimination and health: a
meta-analytic review. Psychol Bull. 2009;135:531–554.

12. Gee GC, Spencer MS, Chen J, et al. A nationwide study of discrimination
and chronic health conditions among Asian Americans. Am J Public
Health. 2007;97:1275–1282.

13. Abu-Ras WM, Suarez ZE. Muslim men and women’s perception of dis-
crimination, hate crimes, and PTSD symptoms post september 11. Trau-
matology. 2009;15:48–63.

14. Ahluwalia MK, Pellettiere L. Sikh men post-9/11: misidentification, dis-
crimination, and coping. Asian Am J Psychol. 2010;1:303–314.

15. Abdulrahim S. Whiteness and the Arab immigrant experience. Race Arab
Am Before After. 2008;9:131–146.

16. Allen C. Islamophobia. Burlington, VT: Ashgate Publishing Ltd. 2010.
17. Helfstein S, Abdullah N, Al-Obaidi M. Deadly vanguards: a study of al-

Qa’ida’s violence against muslims. Combating terrorism center at west
point. 2009. Available at www.ctc.usma.edu/v2/wp-content/uploads/
2010/10/deadly-vanguards_complete_l.pdf Accessed March 23, 2017.

18. US Department of State. National counterterrorism center: annex of sta-
tistical information. Washington DC: US Department of State. 2012.
Available at www.state.gov/j/ct/rls/crt/2011/195555.htm?goMobile=0
Accessed March 23, 2017.

19. Samari, G. Islamophobia and public health in the United States. Am J
Public Health. 2016;106:1920–1925.

20. Love E. Confronting islamophobia in the United States: framing civil
rights activism among Middle Eastern Americans. Patterns Prejudice.
2009;43:401–425.

21. Tumlin KC. Suspect first: how terrorism policy is reshaping immigration
policy. Calif Law Rev. 2004;92:1173–1239.

22. Cheong PH, Edwards R, Goulbourne H, et al. Immigration, social cohesion
and social capital: a critical review. Crit Soc Policy. 2007;27:24–49.

23. Viruell-Fuentes EA, Miranda PY, Abdulrahim S. More than culture: struc-
tural racism, intersectionality theory, and immigrant health. Soc Sci Med.
2012;75:2099–2106.

24. Saeed A. Media, racism and islamophobia: the representation of islam
and muslims in the media. Soc Compass. 2007;1:443–462.

25. Husband C, Alam Y. Social cohesion and counter-terrorism: a policy
contradiction? Portland, OR: Policy Press. 2011.

26. De Jong JT. A public health framework to translate risk factors related to
political violence and war into multi-level preventive interventions. Soc
Sci Med. 2010;70:71–79.

27. Kawachi I, and Berkman L. Social cohesion, social capital, and health. In:
Kawachi I, Berkman L. (eds.) Social Epidemiology. New York, NY, 2000,
pp. 174–190.

28. Kawachi I, Subramanian SV, Kim D. Social Capital and Health. New York,
NY: Springer, 2008.

29. Geys B, Murdoch Z. Measuring the ‘‘bridging’’ versus ‘‘bonding’’ nature of
social networks: a proposal for integrating existing measures. Sociology.
2010;44:523–540.

30. Son J, Lin N. Social capital and civic action: a network-based approach.
Soc Sci Res. 2008;37:330–349.

31. Lin N, Cook KS, Burt RS. Social Capital: Theory and Research. New Bruns-
wick, NJ: Transaction Publishers, 2001.

32. Kim D, Subramanian SV, Kawachi I. Social capital and physical health. In:
Social Capital and Health. Edited by Kawachi I, Subramanian SV, Kim D.
New York, NY: Springer New York, 2008, pp. 139–190.

33. Almedom AM, Glandon D. Social capital and mental health. In: Social
Capital and Health. Edited by Kawachi I, Subramanian SV, Kim D. New
York, NY: Springer New York, 2008, pp. 191–214.

34. Poortinga W. Social capital: an individual or collective resource for health?
Soc Sci Med. 2006;62:292–302.

35. Lederman D, Loayza N, Menendez AM. Violent crime: does social capital
matter? Econ Dev Cult Change. 2002;50:509–539.

36. Bearman PS, Moody J. Suicide and friendships among American adoles-
cents. Am J Public Health. 2004;94:89–95.

37. Valente TW, Gallaher P, Mouttapa M. Using social networks to understand
and prevent substance use: a transdisciplinary perspective. Subst Use
Misuse. 2004;39:1685–1712.

38. Forst B, Jack R, Greene, et al. Lynch e. Criminologists on Terrorism and
Homeland Security. New York, NY: Cambridge University Press, 2011.

39. Turnley JG, Smrcka J. Terrorist Organizations and Criminal Street Gangs:
An Argument for an Analogy. Report. Livermore, California: Advanced
Concept Group. Sandia National Laboratories, 2002.

40. Spataro A. Why do people become terrorists? A prosecutor’s experiences.
J Int Crim Just. 2008;6:507–524.

41. Choi S-W, Luo S. Economic sanctions, poverty, and international terror-
ism: an empirical analysis. Int Interact. 2013;39:217–245.

42. Meierrieks D. Economic determinants of terrorism. In Chatterji M. (ed.)
Contributions to Conflict Management, Peace Economics and Development.
Bradford, UK: Emerald, 2014, pp. 25–49.

43. Pyrooz DC, Sweeten G. Gang membership between ages 5 and 17 years
in the United States. J Adolesc Health. 2015;56:414–419.

44. Freytag A, Krüger JJ, Meierrieks D, et al. The origins of terrorism: cross-
country estimates of socio-economic determinants of terrorism. Eur J
Polit Econ. 2011;27:S5–S16.

45. Wagner RV. Terrorism: a peace psychological analysis. J Soc Issues.
2006;62:155–171.

46. Decker S, Pyrooz D. Gangs, terrorism, and radicalization. J Strateg Secur.
2011;4:151.

47. Smith CF, Rush J, Burton CE. Street gangs, organized crime groups, and
terrorists: differentiating criminal organizations. Invest Sci J. 2013;5:1–18.

48. Tortoroli C. Gangs of New York are terrorists: the misapplication of the
New York antiterrorism statute due to the lack of comprehensive gang
legislation. John’s L Rev. 2010;84:391.

49. Weissner D. New York State’s Top Court Rules Gang Activity Is Not Terrorism.
Chatterji M. (ed). Albany, NY: Reuters, 2012.

Alcalá, et al.; Health Equity 2017, 1.1
http://online.liebertpub.com/doi/10.1089/heq.2016.0016

94



50. Daugherty A. El salvador supreme court labels street gangs as terrorist
groups. insight crime. 2015. Available at www.insightcrime.org/news-
briefs/el-salvador-supreme-court-labels-street-gangs-as-terrorist-groups
Accessed May 22, 2016.

51. Berkman LF, Glass T. Social integration, social networks, social support,
and health. Soc Epidemiol. 2000;1:137–173.

52. Atran S. Genesis of suicide terrorism. Science (New York, NY).
2003;299:1534–1539.

53. Abu-Ras W, Abu-Bader SH. The impact of the September 11, 2001, attacks
on the well-being of Arab Americans in New York City. J Muslim Ment
Health. 2008;3:217–239.

54. Federal Bureau of Investigation. Uniform Crime Reports. Washington, DC,
2015.

55. O’Connor AJ, Jahan F. Under surveillance and overwrought: American
muslims’ emotional and behavioral responses to government surveil-
lance. J Muslim Ment Health. 2014;8:95–106.

56. McCauley C, Moskalenko S. Mechanisms of Political radicalization:
pathways toward terrorism. Terrorism Polit Violence. 2008;20:
415–433.

57. Lyons-Padilla S, Gelfand MJ, Mirahmadi H, et al. Belonging nowhere:
marginalization and radicalization risk among Muslim immigrants. Behav
Sci Policy. 2015;1:1–12.

58. Christie DJ. What is peace psychology the psychology of? J Soc Issues.
2006;62:1–17.

59. Christie DJ, Tint BS, Wagner RV, et al. Peace psychology for a peaceful
world. Am Psychol. 2008;63:540.

60. Aubrey M, Aubrey R, Brodrick F, et al. Why young Syrians choose to fight:
vulnerability and resilience by violent extremist groups. International
Alert. London, United Kingdom. 2016.

61. Rogers P. Blowback: Iraq war to Islamic State. Open Democracy. 2015.
Available at www.opendemocracy.net/paul-rogers/blowback-iraq-war-
to-islamic-state Accessed May 22, 2016.

62. Zimmermann E. Globalization and terrorism. Eur J Polit Econ.
2011;27:S152–S161.

63. Portes A, Guarnizo LE, Landolt P. The study of transnationalism: pitfalls
and promise of an emergent research field. Ethn Racial Stud.
1999;22:217–237.

64. McDaniel DD, Logan JE, Schneiderman JU. Supporting gang violence
prevention efforts: a public health approach for nurses. Online J Issues
Nurs. 2014;19.

65. McDonald B, Mir Y. Al-Qaida-influenced violent extremism, UK govern-
ment prevention policy and community engagement. J Aggress Confl
and Peace Res. 2011;3:32–44.

66. Stinchcomb JB. Promising (and not-so-promising) gang prevention and
intervention strategies: a comprehensive literature review. J Gang Res.
2002;10:27–46.

67. Rosin H. How A Danish town helped young muslims turn away from ISIS.
NPR. 2016. Available at www.npr.org/sections/health-shots/2016/07/15/
485900076/how-a-danish-town-helped-young-muslims-turn-away-from-
isis Accessed October 5, 2016.

Cite this article as: Alcalá HE, Sharif MZ, Samari G (2017) Social de-
terminants of health, violent radicalization and terrorism: a public
health perspective, Health Equity 1.1, 87–95, DOI: 10.1089/
heq.2016.0016.

Abbreviations Used
ISIS¼ Islamic State of Iraq and Syria

PTSD¼posttraumatic stress disorder

Publish in Health Equity

- Immediate, unrestricted online access
- Rigorous peer review
- Compliance with open access mandates
- Authors retain copyright
- Highly indexed
- Targeted email marketing

liebertpub.com/heq

Alcalá, et al.; Health Equity 2017, 1.1
http://online.liebertpub.com/doi/10.1089/heq.2016.0016

95

http://www.liebertpub.com/heq