The mornings were early, and though I tried, I rarely beat Joe in. SCIFs jammed into a 120-year-old Eisenhower Executive Office Building, overdue for renovations, meant that I had to walk through his office to get to mine. He’d been there for at least an hour already, sitting at the conference table in his office, with a yellow highlighter and a ruler, going line by line through the terrorist threat matrix. On paper, our job was to coordinate domestic counterterrorism policy across the interagency on behalf of the president. But the first four hours of our day weren’t about policymaking or briefing memos. No, in those early days coordinating federal agencies’ responses to homeland threats fell to us: the Domestic Counterterrorism Directorate at the White House. I was a junior policy staffer on a small team, made up mostly of field operators from the alphabet soup of security agencies, including FBI, CIA, Secret Service, and DOD Special Forces.
The Department of Homeland Security (DHS) and the Terrorist Threat Integration Center (TTIC), established in 2003, were still getting their feet underneath them. The 9/11 Commission Report wasn’t out yet, but discussions on how to ‘break down the wall’ between intelligence and law enforcement were ongoing. The TTIC would eventually become the National Counterterrorism Center (NCTC) and take over our function (it is generally believed that it is best not to have operations run out of the White House), but for a small period in between the wake of the attacks of September 11, 2001, and the establishment of formalized multi-agency institutions like NCTC, such coordination was run out of the White House Situation Room. We would sit around Joe’s conference table every morning reviewing each new piece of intel that had come in and preparing questions we were going to ask the agencies of the national security apparatus at the 0700 secure video conference (known as a SVTC and pronounced “civits”), which we co-chaired with the National Security Council’s Office of Combating Terrorism. Around that time of day, the President’s Daily Briefing in the Oval Office would be ending, and we would often be passed notes by the Homeland Security Advisor: POTUS wants an update on the plan to address this threat by this afternoon.
We were looking for the dots on the map that, if connected, might indicate the planning of a complex, coordinated attack. These were attacks that took months to years to plan, involved multiple people and lots of logistics. Those dots might be communications, funding, training, operative travel, rumors of plans, bomb-making material, dry-runs, and command and control. Consequently, the early days of preventing terrorist attacks were viewed as the mission of intelligence, military, and law enforcement communities.
Early Prevention Efforts: A Limited Approach Amidst an Evolving Threat
The first official definition of prevention, issued in December 2003 as part of the Homeland Security Presidential Directive on National Preparedness (HSPD-8), was extremely narrow: “Activities undertaken by the first responder community during the early stages of an incident to reduce the likelihood or consequences of threatened or actual terrorist attacks. More general and broader efforts to deter, disrupt, or thwart terrorism are not addressed in this directive.”
In the years that followed, the definition was expanded and law enforcement investigations, intelligence analysis and information sharing efforts were incorporated as part of the prevention-related “target capabilities” in the National Preparedness Goal. Domestically, we invested in Joint Terrorism Task Forces, fusion centers, information sharing including secure communications between federal and state and local governments, and the tactical equipment needed to prevent WMD and mass-casualty events.
As the years passed, we learned from our successes and failures and matured capabilities but mostly viewed through the lens of preventing another 9/11 — a complex, coordinated attack plotted and trained largely overseas and in which operatives had to travel into the United States to execute.
It took over a decade, but we pushed the borders out and strengthened our ability to identify, vet, and screen potential terrorists before they came to the U.S. But by then, their tactics had changed. It started in Minnesota in 2007 with al-Shabaab recruiting Somali-American youth to travel overseas to join their fight. Six years later, ISIS mastered the art of leveraging the combination of social media and encrypted communications to widely disseminate its message, radicalize its target audience, and convince them to travel to join the caliphate. They even provided guidance and assistance remotely using virtual plotters who are a part of the group’s external operations bureaucracy. When ISIS began losing territory, it encouraged homegrown terrorists to bring their own weapons to the fight and eschew international travel in favor of acting at home. The late ISIS spokesman Abu Muhammad al-Adnani exhorted followers to kill disbelieving Americans and Europeans “in any manner or way however it may be,” providing a laundry list of techniques to be employed: “Smash his head with a rock, or slaughter him with a knife, or run him over with your car, or throw him down from a high place, or choke him, or poison him.”
But another part was not so much a threat change as a belated recognition of a systemic and durable threat from domestic terrorism. 2019 was domestic terrorists’ deadliest year since the bombing of the Murrah Federal Building Oklahoma City in 1995. The Center for Strategic and International Studies (CSIS) assessed terrorist attacks and plots going back to 1994 and found “far-right terrorism has significantly outpaced terrorism from other types of perpetrators, including from far-left networks and individuals inspired by the Islamic State and al-Qaeda.”
It is understandable, given the shock and scale of the attacks of 9/11, why we focused so much attention on al-Qaeda. But in our nearly exclusive focus on terrorist groups “over there,” we missed that significantly more people in the United States were dying from white supremacist and anti-government violent extremists, and we missed that significant growth in domestic violent extremist movements has been underway for the past 10 years. A recent poll conducted for the University of Chicago’s Project on Security and Threats study on American Political Violence found 1 million Americans were a part of, or “personally knew, a member of a militia or extremist group.” This staggering number far exceeds the ability of our nation’s law enforcement to track and disrupt potential attacks.
“We missed that significant growth in domestic violent extremist movements has been underway for the past 10 years.”
In addition to terrorism, no description of the threat landscape can be considered complete absent mention of the continued drumbeat of attacks that can be defined as targeted violence. Targeted violence includes attacks that lack political, ideological, or religious motivation (i.e., terrorism) but where the attacker intends to inflict casualties or destroy property commensurate with the damage done in a terrorist attack. Examples of targeted violence include the slaying of 58 concertgoers in Las Vegas in 2017, the killing of 12 employees at D.C.’s Navy Yard in 2013, and the infamous massacre of 26 grade-school students and their teachers in Newton, Connecticut, in 2012.
Expanding and Investing in Prevention
When I rejoined the government in 2017, there was a growing discomfort in the counterterrorism community. Though we had successfully prevented another attack on the scale of 9/11 on our homeland, it was believed there were more terrorists worldwide today than we had on September 11, 2001. So, we asked ourselves: Are we actually defeating terrorism? That led us to a logical follow-on question: Can we prevent people from radicalizing and moving toward violence in the first place? That realization, combined with law enforcement’s concerns that they could not keep up with the increased volume and velocity at which we were seeing people radicalize (in part due to the widespread adoption of social media and the changes that it wrought in radicalization patterns), led us to realize it was time to change our approach. We needed to move “upstream” and address root causes that drive people to radicalize and seek violence in the first place.
While some in the federal government had been exploring this question already, the prevention mission at DHS remained stuck in the proof-of-concept phase. In late 2017, DHS asked the RAND Corporation to look at what measures had proven effective in terrorism prevention and make recommendations on what changes DHS should make to improve its prevention efforts. The results from that study, Practical Terrorism Prevention: Reexamining U.S. National Approaches to Addressing the Threat of Ideologically Motivated Violence, released in February 2019, directly informed the policy and programs we developed. Key findings included:
- Prevention works.
- Prevention capabilities should be locally based and led. The federal government’s role is to support and enable.
- Prevention is significantly under-resourced.
While the RAND study was underway, we watched the uptick in targeted violence and antisemitic and racist hate crimes circa 2017-2018. I was tasked by Secretary Nielsen to develop the department’s first ever Counterterrorism Strategy and to incorporate domestic terrorism and an expanded vision of prevention into our approach. The resulting Strategic Framework for Countering Terrorism and Targeted Violence was released in September 2019. Goal 3 — simply titled “Prevent terrorism and targeted violence” — calls for DHS to enable states and local communities to develop societal resistance to radicalization and develop threat assessment and management capabilities to “off-ramp” susceptible individuals before they commit a crime or violent act.
It’s important to acknowledge that initial efforts at designing interventions over a decade ago were largely focused on countering ideology. This proved to not only be ineffective, but also led to a backlash from communities who felt targeted by law enforcement based on their race, religion, or nationality.
Instead, a growing base of evidence has demonstrated that prevention techniques should be based on behaviors and risk factors. The U.S. Secret Service National Threat Assessment Center (NTAC) and other researchers have studied individuals who have carried out acts of mass violence and found that regardless of ideology or motivation — whether the attacks were acts of workplace violence, domestic violence, school-based violence, or terrorism — similar themes are evident among the perpetrators. This allows us to design threat assessment and management capabilities that are behavioral based.
Prevention needs to be a multidisciplinary capability that involves experts from public and behavioral health, education, social services, civic organizations, the private sector, and others working alongside state and local governments, including law enforcement. The goal of these efforts is to reduce the number of individuals vulnerable to radicalization and, for those who have radicalized, to attempt to help them find healthier ways to address their grievances or problems before they cross a criminal threshold. While law enforcement has an important role to contribute to threat assessment and management, prevention practitioners report that efforts are best led by non-law enforcement personnel.
The paths of terrorists and other violent actors are not linear. Even in the past few months we have seen a variety of ideological drivers, grievance-based violence, and targeted attacks. However, the factors that drive individuals to violence are almost consistently observed by those who know them best. Multiple studies have demonstrated that families, friends, and other bystanders who are concerned for the wellbeing of these individuals are critical to prevention, as they are often the ones who will recognize behavioral changes over time that may be indicative of radicalization and mobilization to violence.
We have too many anecdotes of mass attackers who were reported to law enforcement in advance of their attack, and law enforcement was unable to do anything other than a “knock and talk.” In the aftermath of the attack, law enforcement would often validate that the individual showed concerning signs but that there was no legal mechanism for them to act because no crime had been committed. This was true of the El Paso Walmart attacker, the Marjorie Stoneman Douglas school shooter, and, more recently, both the Nashville Christmas bomber and the shooter at the Indianapolis FedEx facility, to name only a few.
Building local prevention frameworks allows bystanders — the neighbors, colleagues, friends, and loved ones — that notice something is wrong to consult with experts when they have concerns, BEFORE an individual has committed a criminal act. This is the linchpin of prevention efforts. And it’s working. The following examples demonstrate how state and local governments, the academic community, NGOs, a technology company and even parents and the network of adults that influence youth are contributing to preventing violence.
The Colorado Model of Prevention
Colorado state and federal officials had slightly different drivers that led them to invest in prevention. For the state of Colorado, it was the state’s tragic history of school shootings and the Joshua Cummings killing of a transit security officer: another example of the community warning violence was likely, but law enforcement did not have probable cause to arrest. For DHS and DOJ, it was the phenomenon of increasingly younger individuals being recruited by ISIS, and in particular three Colorado teens traveling to join them. Federal law does not allow minors to be charged with material support to terrorism, so new approaches were needed. And for both state and federal officials, the gnawing concern that they were seeing increases in domestic terrorism — especially after Robert Dear attacked a Planned Parenthood in Colorado Springs, yet another example of neighbors and other bystanders expressing concerns about his behaviors prior to the attack.
By now you might recognize a pattern. The tools of intelligence, law enforcement and the criminal justice system have limitations. State and federal officials were convinced that prevention could address international and domestic terrorism, as well as targeted violence.
Colorado’s prevention framework draws on the public health interventions model. In the context of preventing targeted violence, primary prevention focuses on building community resilience and mitigating risk factors that studies have shown are associated with attackers. Secondary prevention involves detecting and intervening with individuals who are in the process of radicalizing and/or at risk of mobilization to violence. Tertiary prevention occurs within the criminal justice context, either developing threat management plans as alternatives to prosecution or incarceration, or during community re-entry after serving a prison sentence.
Colorado’s efforts are about five years old. It took about a year to identify stakeholders, build trust, and develop a common lexicon across disciplines. Another year to conduct training on the threat, educate on prevention, conduct a gap analysis, and build a plan to fill the gaps. Around the third year, Colorado’s prevention framework became reality. They estimate it will take 7-10 years to reach all the partners in the state and truly institutionalize the prevention capability at the level of the other preparedness disciplines (i.e., protection, response, and recovery).
The individuals behind the Colorado effort are quick to point out that much of what exists now occurred through trial and error and stitching together existing programs. Kevin Klein, Colorado’s director of Homeland Security and Emergency Management, believes the reason they were successful was in large part due to DHS placing a regional prevention coordinator in the area. “You need someone whose day-to-day job is to coordinate across multiple stakeholders and build out this new discipline,” he said.
They advise others embarking on building out prevention capabilities to leverage existing programs and services at the state level, which can provide wraparound services during the threat management phase. And they noted the biggest gap was trained frontline personnel: public health, social workers, counselors. Not only is there a shortage of behavioral health professionals in the country, but most also have no training in violence prevention and were intimidated at the idea of engaging with an extremist.
Which is why the University of Denver launching the Colorado Resilience Collaborative (CRC) in the fall of 2017 proved crucial to the prevention framework. Housed within the university’s Graduate School of Professional Psychology’s MA in International Disaster Psychology: Trauma and Global Mental Health program and seed-funded by the Colorado’s U.S. Attorney’s Office, the Collaborative is addressing the frontline personnel training gap: building the capacity of professionals engaging with individuals on pathways to violent extremism and targeted violence. Acting Director Maria Vukovich noted that the recent DHS Targeted Violence and Terrorism Prevention grant has been a “game-changer” for them. They’ve been able to scale their team and activities and develop longer-term approaches to equipping potential responders with the awareness and skills to prevent and intervene.
In five years, the Colorado model has facilitated at least 1,200 interventions. The vast majority of these are categorized as individuals at risk of committing “targeted violence” — including hate crimes, mass violence, and school shootings. Approximately 100 interventions were for individuals identifying with violent extremist ideology, over three quarters of which were associated with anti-government/anti-authority extremism and racially or ethnically motivated violent extremism. The good news is that Colorado’s evidence-based prevention framework is designed to help off-ramp individuals regardless of their ideology. So, no matter how the threat morphs, they’ll be able to help reduce violence in their community.
Moonshot: Intervening Online and Redirecting to Offline Support
While research varies as to the precise role social media plays in radicalization, the counterterrorism community observes that social media has changed radicalization processes making it more difficult to detect and disrupt terrorist threats. FBI Director Christopher Wray asserted “terrorism moves at the speed of social media” and reported homegrown and domestic violent extremists largely self-radicalize online and mobilize to violence sometimes in a matter of weeks or days. So, if we’re going to work “upstream,” finding ways to disrupt the online radicalization process is critical. And it’s part of the reason why I was delighted to join the Moonshot Team earlier this summer.
Moonshot, established 6 years ago, leverages technology to combat violent extremism and other online harms. They build evidence bases around the scale and trends of extremism, violence, and disinformation online and they run programs to engage and redirect at-risk online audiences. Think of this as an online complement to what the Colorado model does offline. And just like Colorado, their engagement with “at-risk” audiences online is based on at-risk behaviors, not demographics.
The work they do to assess the nature of extremism online assists practitioners and security officials to better understand the threat environment. For example, Moonshot recently released a report on understanding and preventing involuntary celibates, or incel, violence, a result of ongoing engagement with Public Safety Canada, that can help practitioners understand this online community and, in turn, design evidence-based interventions that support individuals who want to disengage from the incel ideology.
Moonshot can also detect near-real time trends in online extremism engagement, which is crucial for security officials. For example, at the start of the pandemic, Moonshot tracked a 37 percent increase in attempts to access white supremacist content via search engines in the US over the prior year. By April 2021, it had skyrocketed to 140 percent higher engagement nationwide. And they can analyze this information to the county level.
“Engagement with ‘at-risk’ audiences online is based on at-risk behaviors, not demographics.”
We know that extremist movements thrive on moments of crisis. For white supremacists in particular, their ideology is premised on what one expert describes as “racial imperilment,” a belief that the “white race” is under attack by racialized enemies. Crises are moments where we typically see these actors exploiting high levels of fear and anxiety in society and turning that into an opportunity to reach new audiences by “explaining” the crises in terms that fit their worldview. The COVID-19 pandemic provided that opportunity, along with other multiple concurrent crises.
Seeing this dramatic trend of heightened engagement with hate content online, and extremist actors essentially preying on vulnerable individuals in our communities, last year, Moonshot tested the delivery of psychosocial service content, via advertising, aiming to de-escalate individuals from violence. This content had various themes aiming to de-escalate, including empathetic responses to anger, encouraging calm and self-reflection, promoting positive and shared American values, and providing access to a 24/7 text helpline to speak to a counselor. The content was seen over 105 million times by Americans consuming white supremacist, armed group, or anti-government conspiracy theory content. The most successful messages in terms of engagement were messages that acknowledge the emotional state of at-risk individuals, including their feelings of anger, grief, or loneliness. Moonshot continues to offer a 24/7 text helpline to audiences at-risk of violent extremism across the United States, and over 100 counseling sessions have taken place to date this year through online referrals.
Equipping Parents and Caregivers to Detect Radicalization
Equipping communities, particularly parents and adults that interact with youth, with the ability to detect potentially harmful behavior is a crucial part of primary prevention approaches. As pandemic mitigation measures set in last year, Dr. Cynthia Miller-Idriss — a scholar and expert on youth extremism and radicalization, and director of the Polarization and Extremism Research Innovation Lab (PERIL) at American University — recognized this would lead to youth spending significantly more time online. So last year, she partnered with the Southern Poverty Law Center (SPLC) to develop a first-of-its-kind guide to assist parents and caregivers in recognizing the warning signs of youth radicalization and understanding the drivers and grievances that create susceptibility to extremist rhetoric, and intervene more effectively.
This year, PERIL and SPLC expanded and revised the guide for broader communities of practitioners with research including focus groups with teachers, educators, school counselors, mental health practitioners and more. They found that in as little as seven minutes, parents and caregivers can improve their ability to detect potential radicalization and intervene. When I spoke with her earlier this month, Dr. Miller-Idriss emphasized how critical it is that we “build earlier off-ramps.” Parents and caregivers are most likely to be the first to detect the behavioral changes indicative of radicalization. While parents and the network of adults that engage with youth alone can’t solve our country’s violent extremism challenge, they can play a crucial part in building societal resilience to radicalization and detecting and disrupting radicalization early.
What Can We Do to Advance Prevention Capabilities?
Targeted violence and terrorism have not only rattled the sense of security we expect to feel in our republic, but they also inflict lasting harm upon everyone directly and indirectly impacted. Too many families have buried loved ones. Too many first responders have arrived at scenes of unimaginable devastation and are forced to live with those images for the rest of their lives. The National Center for PTSD at the U.S. Department of Veterans Affairs estimates that 28 percent of people who witness terrorism, targeted violence, and other mass shootings develop post-traumatic stress disorder, while another third will have acute stress disorders that require lengthy and sometimes intensive treatments.
We are very early in the process of maturing prevention. I believe this is at least a decade-long investment in building to a baseline level of capability across the country. But it is one that will eventually provide significant returns on investment — reducing costs associated with attacks and law enforcement activities — and, more importantly, saving lives and restoring peace of mind to the communities that are too frequently targeted by violence. And there is some early evidence that prevention and intervention efforts can be leveraged to combat other harms facilitated both on and offline, including fostering resilience to gangs, disinformation, human trafficking, and child sexual exploitation and abuse.
Here are some practical ways the homeland security community can contribute to maturing prevention:
Governors and Homeland Security Advisors Should Lead. The RAND Study on Prevention made it clear that prevention efforts should not be run out of Washington. Several states and cities have piloted prevention efforts over the past few years. One of the key findings of these efforts is that it may be easier to start at the state level to ensure rural communities and smaller municipalities, which likely lack the resources to provide all the steps in a prevention capability, can be covered with prevention resources. Further, states usually manage the wraparound services that are key to successful interventions. Cities and counties will have local resources to incorporate into the potential suite of prevention services, but ideally prevention efforts are organized at the state level.
The National Governors Association’s Center for Best Practices released a Roadmap on Preventing Targeted Violence to assist Governors and Homeland Security Advisors in establishing prevention capabilities.
Invest in Prevention’s Frontline Workers. Multiple experts advised that the biggest gap in our capability is trained “frontline” personnel, primarily behavioral health providers, as well as educators. We need graduate schools to incorporate prevention training — particularly on how to identify and intervene with individuals that are radicalizing or are extremists — into their curriculums for social work, education, mental health and public health. We need the professional associations for these disciplines to work with experts to develop mid-career training and certifications. One bright spot advancing this important work is the McCain Institute’s creation of a national network for practitioners providing direct prevention and intervention services. This effort will help professionalize and self-govern the discipline as it matures.
Congress Should Authorize and Rapidly Scale Prevention Resources
In my recent testimony before the U.S. Senate Committee on Homeland Security and Governmental Affairs, I recommended Congress:
- Authorize the Center for Prevention Programs and Partnerships at DHS and find a permanent home for it outside the Office of Policy given its programmatic nature and field activities.
- Increase dedicated grant funding for prevention from $20M to $200M over a multi-year period.
- Increase funding and provide for hiring exemptions so that the Center for Prevention Programs and Partnerships can rapidly place prevention coordinators in every state.
While each of these items might seem like bureaucratic niceties, they are critical to transition the DHS prevention mission from start up to enduring. Without a permanent and accountable home for the DHS prevention mission, prevention will remain vulnerable to being ignored by DHS’ immature and overtaxed administrative functions or rapidly dismantled at the behest of a future secretary. Without adequate support for state and local partners, prevention efforts will never be brought to the scale needed to work. And without a federal commitment to state and locals in the form of dedicated personnel, states are not likely to have that dedicated person who can help coordinate and stitch together the various state, local, and private sector capabilities that make up a prevention framework.
Longitudinal studies. Evaluations on the efficacy of intervention programming tend to focus on near-term success. This field needs longitudinal studies that identify individuals at risk, the interventions that were used to mitigate the factors that were likely to lead those individuals down a path of radicalization, and the impact of those interventions over time. These studies will need to be highly individualized, measuring how long various radicalization pathways take, as well as how long interventions must be implemented to have impact. For example, if we intervene with an at-risk 20-year-old, we need to know if he is still resisting violent extremist beliefs at age 25, 35, and beyond. Broadly speaking, several key questions remained unanswered: at what point in the radicalization process are intervention efforts most impactful, and what types of interventions are the most effective? These studies will need to feature dependent variables such as internet/social media activity and behaviors often associated with radicalization and extremist beliefs. Such studies would not only need to be longitudinal but also ongoing in order to measure the efficacy of interventions modified based on the findings unearthed throughout the research process. Intervention programming needs to be more refined and prescriptive, and longer-term research is needed to achieve that goal.
The prevention discipline should maintain its continuous learning culture and be transparent as we innovate and adapt to emerging threats. Governments, especially politicians, tend to be risk-averse. However, risk is innate to innovation and innovation is necessary to effectively counter extremism. Like any experiment, interventions and prevention work have suffered failures. These failures have bred lessons learned, and those working in this space are doing our due diligence to ensure that these lessons learned are built into future endeavors. With that said, and as noted above, there is still much to learn. Further, Congress, the Executive Branch, foundations, and other private funders must be aware of a significant obstacle in proving the efficacy of prevention work: you cannot prove a negative. While we can leverage funding to examine success rates of intervention and prevention programming to some extent, it is all but impossible to yield how many people were successfully dissuaded from adopting extremist beliefs, becoming radicalized, and committing violent acts. Those conducting work in this space, as well as the entities that fund us, need to be open to innovation, iteration, and transparency regarding what works and what doesn’t. Lives are at risk, and the necessary innovation — and risk that comes along with it — cannot wait.
As we approach the 20th anniversary of that dark day, I’ve been thinking more often of our small domestic counterterrorism team operating out of the tiny SVTC facility in the back of the White House Situation Room. Joe, Nina, Wayne, Geoff, John, Phil, and I represented different parts of the government, different disciplines if you will. We strived to ensure all security agencies and state and local law enforcement had the information they needed and were playing their respective roles to keep us safe. While those intelligence, military, law enforcement and homeland security disciplines are still needed, we’ve learned after 20 years that they are not enough to defeat terrorism. Though the landscape of extremism within our country today is dark, we now have several years of evidence that prevention works when we expand beyond security disciplines, incorporate behavioral health practitioners, integrate existing wraparound services, and empower bystanders to detect early stages of radicalization. Let’s build this capability up over the next five years, so that we can reduce violence and prevent the next generation of extremism from taking root in our country.
Parts of this article were adapted from testimony provided to the U.S. Senate Homeland Security and Governmental Affairs Committee on August 5, 2021, and a speech given on March 3, 2020, to the Washington Institute. A heartfelt thanks to the following individuals for their contributions to this piece: Kevin Klein, Director of the Colorado Department of Homeland Security & Emergency Preparedness; Maria Vukovich, Acting Director, and Gwen Mitchell of the Colorado Resilience Collaborative; Cynthia Miller-Idriss, Director of Research at PERIL; and Vidhya Ramalingam, Caroline Wade, Meghan Conroy, and Alex Amend, Moonshot. And a special thanks to my former colleagues at the DHS Center for Prevention Programs and Partnerships who continue to advance the prevention mission in the face of constant obstacles and headwinds.
 Public health primary prevention approaches, such as healthy nutrition and vaccinations, aim to prevent illness or disease before it occurs. Secondary prevention involves screening for early onset of disease, while tertiary prevention involves treating or managing the disease.
 Officials cautioned that they only recently began collecting statistics on a routine basis, so these numbers demonstrate trends and scope, but are probably an underestimate.