AOAV: all our reportsImprovised Explosive Devices2013 Boston Marathon Bombings reportHealth and explosive violence

Blood on the Streets of Boston: the 2013 Boston Marathon bombings and their health impacts

This report is part of AOAV’s research on the bombing at the Boston Marathon in 2013. The full report, ‘Blood on the Streets of Boston’, can be read here. The main findings and summary can be seen here. The report considered the mental health support offered to survivors and witnesses, for more on this see here, as well as the services that were offered, see here. As part of the report it AOAV also researched the medical care and financial support provided to survivors – this report can be read here – and the health impacts the bombing had – here. It was also important to consider the ‘Victims’ Voices’, from those who survived the attack. To read these please go here, here, and here.

Improvised Explosive Devices (IEDs) cause severe human suffering across the globe. The use of these homemade bombs results in death, life- affecting injuries, and harm to infrastructure.

In 2013, AOAV recorded that at least 22,829 civilians in 41 countries were killed or injured by IEDs, a 35% increase compared to 2012. But casualty figures alone do not begin to convey the real horror of these bombings. The depressing reality is that the media and researchers often only provide a superficial overview of the harm these attacks cause, or the support their victims require.

Often too little consideration is paid to the long- term care needed by those affected by such attacks. Cases of good practice in how best to respond to such attacks in terms of victim assistance are few and far between.

The Boston Marathon

In 2013, two IEDs were detonated at the finish line of the Boston Marathon. The attacks killed three individuals and physically injured 264. This report, Blood on the streets of Boston, considers the impact of the bombings both on the survivors and on the Boston community at large, specifically assessing the support provided to those most affected by the lethal attack.

The actions of those who provided short and long term assistance to the Boston bombing survivors can be seen, broadly, as examples of good practice when responding to an IED attack. While AOAV recognises that the response was shaped by the fact that there are significant resources available for support in a country such as the US, we believe that concrete lessons can be learnt from it from a global perspective.

The actions of state institutions, charitable organisations and other bodies in the wake of the bombings demonstrate both the myriad needs of those impacted by IED attacks, and the benefit of a quick and coordinated response. From immediate health care to financial and mental health responses, those injured in the bombings were largely supported and provided with high levels of care.

And so, while lessons can always be learned from the assistance provided to victims of the attacks, the US response to the Boston marathon tragedy must be largely applauded. We hope this report highlights the good and provides a pathway for city officials and emergency responders whose role it might be to prepare for the worst.

Research for this report was carried out through publicly-available open-source material. Additionally, interviews were undertaken in Boston
in September 2014 with academics, the first responders, health care professionals, mental health workers, service providers, State officials, survivors and witnesses.

The attack and its aftermath

The blasts

At 2.49pm on 15 April 2013 two improvised explosive devices (IEDs) were remotely- detonated near the crowded finish line of the Boston Marathon. The bombs exploded 13 seconds and a city block apart, transforming an annual celebration into a scene of devastation and destruction.

Three people were killed and at least 264 were physically injured. Hundreds more witnessed the bombings and the aftermath. A Massachusetts Institute of Technology (MIT) police officer was also shot and killed by the suspected bombers on 18 April 2013.

The Boston Marathon is one of the biggest sport- ing events in America. It falls on Patriot’s Day, and is usually a day of celebration. The marathon’s medical tents are ordinarily there for minor medical care such as dehydration, stress fractures and exhaustion. On 15 April 2013 however, the medics were stretched to their limit.

Two backpacks, each containing an IED, had been left unattended on Boylston Street, near the Marathon finish line. The bombs were made from pressure cookers filled with metal pieces, explosives, and ball bearings. They had fuses made from Christmas lights and remote-control detonators from model car parts; “relatively sophisticated” according to federal prosecutors, and difficult to make “without training or assistance from others.” Both bombs were detonated remotely, with those allegedly behind them walking away from Boylston Street without suspicion, having sustained no injuries.

Boylston Street was instantly filled with grey smoke. The barriers that had previously separated spectators from the race were flattened, trapping some who had been injured. Nearby shop windows were blown in, although there was no major structural damage.

Two brothers, Dzhokhar (19) and Tamerlan (26) Tsarnaev, were strongly suspected of committing the attacks. Tamerlan was killed during a manhunt for the suspects in the days immediately following the attacks, and Dzhokhar is currently awaiting trial, charged with crimes including the use of a weapon of mass destruction and the malicious destruction of property resulting in death. If he is found guilty he could face the death penalty.

Deaths and Injuries


  • Krystle Marie Campbell, 29, from Medford, Massachusetts.
  • Lu Lingzi, 23, a graduate student studying at Boston University, originally from China.
  • Martin William Richard, an eight-year-old boy from Boston, Massachusetts.

The three individuals who were killed, two women and an eight-year-old boy, died almost instantly.

Physical Injuries

The physical traumas sustained by some of the 264 physically injured were catastrophic. Since the bombs were left on the street, the trajectory of the blasts was low, and the majority of injuries occurred below victims’ waists. Many of the injuries were to people’s limbs, especially legs, and there were relatively few torso injuries.

Life-threatening injuries were largely down to severe blood loss. Some arrived at hospitals flat-lining, having lost huge quantities of blood.

The explosions caused traumatic amputations, the blasts instantly severing bone and muscle. Sixteen people suffered from amputations, either traumatic or in surgery. Two of those were double amputees.

Others had severe soft tissue injuries to their legs and feet; wounds caused by the metal pieces and ball bearings packed into the homemade bombs.

Shrapnel, jagged metal fragments and debris flew upwards, injuring victims’ abdomens and faces, and resulting in eye injuries. Pieces of the bags holding the bombs were embedded into skin and muscle.

Victims lost extensive amounts of blood and suffered from 2nd and 3rd degree burns, open fractures and open wounds, as well as head injuries. There were concussive injuries, ear injuries such as inner ear ruptures, and some smoke inhalation.

Some of the survivors will have life-long health implications due to the injuries they sustained.

Those who became amputees may require further surgery as their bodies change, and will require new prosthetics every few years for the rest of their lives. Nineteen people with severe extremity injuries were categorized as having ‘limb salvage,’ and may require amputations in the future, or more surgeries to treat their existing injuries. Rebekah DiMartino, a 27-year-old who was injured in the bombings, had her left leg amputated in November 2014, a year and a half after the attacks, following 15 previous surgeries. Maureen Fagan, Executive Director, Centre for Patients and Families at Brigham and Women’s Hospital in Boston, told AOAV that a survivor being treated at their hospital was due to undergo her 28th surgery in late September, 17 months after the attacks.

A notable aspect of the Boston Marathon bombings was that a number of those who were injured were hurt alongside family members or friends. Two brothers, Paul and J.P. Norden, both lost a leg in the blasts, as did their friend Marc Fucarile.

A newly-married couple, Jessica and Patrick Downes, each lost a leg.

One of the survivors, Karen Brassard, went to watch the marathon with her husband, daughter, and some family friends. Every member of that group sustained injuries ranging from shrapnel wounds requiring outpatient care, to catastrophic extremity injuries. One member of the group, Celeste Corcoran, lost both of her legs.

Many of the survivors continue to require physical rehabilitative care. The vast majority of this care has been provided by Spaulding Rehabilitation Center, a state-of-the-art rehabilitative centre, which cared for all but one of the amputees after they were discharged from hospital.

Psychological Harm and Traumatic Brain Injury

Other injuries are less visible but have had devastating effects. Witnessing horrific violence and seeing its bloody aftermath can lead to psychological trauma and impact upon psychosocial well-being. Conditions such as Post Traumatic Stress Disorder (PTSD) have been associated with soldiers in conflict zones but can equally impact civilians suddenly faced with appalling tragedy.

Symptoms of PTSD, and of more minor psychological harms, can begin immediately after a traumatic event or can become evident months later. Traumatic Brain Injury (TBI) can affect survivors for life, impacting their ability to work, their intellectual faculties, and their mental health.

Every physically injured survivor AOAV interviewed spoke of the psychological impact of the bombing: all were impacted to a greater or lesser extent.

Karen Brassard, who sustained significant physical injuries, later realized she was having psychological problems. “I knew something was wrong. I knew that I was not who I was before,” she told AOAV. She was diagnosed with concussive brain injury and PTSD. She found herself forgetting words, having difficulties in conversation, and being unable to focus properly.

Her husband, who was in hospital for two and a half weeks after the bombings, was also impacted. He was unable to return to work for a year due to physical and emotional problems, and still finds it difficult to handle stress. Their daughter, who was injured in the attack, attends counselling at a rehabilitation center in Boston, but has taken more of a reclaiming attitude: “she loves this city, has always loved the city, and I think she has kind of an attitude that they’re not going to take that from her.”

One survivor, who underwent surgery to remove shrapnel from her abdomen, and had an eye injury, is from Minnesota. She remained in Boston until the 20th of April, five days after the bombing and then returned to Minnesota with her husband, where she continued to visit a doctor to treat her eye. She was unable to travel for work for six weeks after the bombing because of anxiety. She was also depressed for months. She was ultimately given a prescription for anxiety medication. Her job suffered due to her emotional issues, and she said she was “not a high performer that year.”

But one of the hardest aspects was the distance she felt from other survivors and the net- works of care that were established following the tragedy; “I just needed to talk to someone from Boston, who was experiencing the same thing or at least exposed to what other people are experiencing.” The survivor community within Boston was extremely strong, but she felt like “an outsider”. This made her “very angry and bitter, which is not who I am or who I want to be.”

Others have also suffered terribly from the mental impact of the bombings.

Ellen Sexton-Rogers was watching the marathon with her husband and daughter when the first bomb was detonated. Her husband was thrown seven feet, and she was thrown towards him. Her daughter was not physically injured, but ran around the corner away from the explosion and was separated from her parents.

None of the Rogers family required immediate hospitalisation, but Ellen later had surgery on an injury on her shoulder and has since been diagnosed with a TBI. Her life has significantly changed following the bombing, largely due to mental health and psychological harm. Ellen felt the psychological impacts immediately, “I was completely panic stricken. My head felt like it was going to explode… four days after I was completely hysterical.”

She has twice since been admitted into hospital as an inpatient for depression, the second time after an attempted suicide. Someone from the Massachusetts Office of Victim Assistance (MOVA) came to see her and recognized that she was suffering from PTSD, and likely something more severe, which is when she was diagnosed with a TBI.

She continues to be treated by a number of doctors and therapists. She undergoes physical, occupational and speech therapy, as well as seeing a psychologist and a brain doctor.

Her psychological and brain injuries have had a massive impact on her life. Before the bombings Ellen owned and ran a cleaning company which she has been unable to sustain.

She separated from her husband in January 2014, and is currently supporting her family on $854 per month disability allowance. Her speech has been affected, as has her ability to concentrate and follow a conversation. She gets confused easily, regularly forgetting where she parked her car, and is paranoid that people see her and notice her confusion. None of these symptoms were manifest before the bomb went off.

AOAV heard from survivors that emotional and psychological harm were often treated as a lesser priority than physical injuries, and often months after the incident has taken place, which makes issues harder to treat.

Rebecca Rosenblum, a clinical psychologist
with over 25 years experience, told AOAV that “people who were severely physically injured are so overwhelmed with addressing the physical injuries and the changes to their lives that they haven’t the bandwidth to think about what’s going on emotionally.” Those who were physically injured said similar. Karen Brassard reported that for months she and her husband did not have the energy to pursue trying to fix their psychological health issues once they had been discharged from hospital.

People who worked with those who had been physically injured in the immediate aftermath of the bombing, such as health workers and the police, were also affected. Members of the Boston Police Department, particularly those who were at the finish line and had immediate contact with those who were killed and injured, had emotional and psychological problems.

The same is true for medical personnel who attended to those who were injured. Those who cared for the victims at Massachusetts General Hospital needed psychological help for a long time after the incident, especially around the anniversary of the bombings. Hospital staff were still emotional when they talked about what happened nearly 18 months after the incident. At Brigham and Women’s Hospital every provider who worked on the day of the bombing got a one-on-one call with a counselling physician to ensure that those who felt psychologically affected had support from within the hospital.

Economic Impact

The total economic impact of the bombing is hard to quantify. The businesses in the vicinity of the blasts were adversely affected due to forced closures and external damage.

Once everyone had been cleared from the site, the police went into crime scene preservation mode and began collecting evidence. The crime scene spanned 15 city blocks, making it the biggest in the history of the Boston Police. Access to areas around Boylston Street was restricted to everyone, including business owners, for at least nine days.

Many of the businesses located in the crime scene were restaurants and cafes, and therefore felt
the economic impact both from being closed for nearly two weeks and from the loss of perishable goods. It is estimated that the total cost of business losses within the crime scene was $10 million. There were ancillary economic losses due to the aftermath of the bombing, such as the decision to cancel a Boston Symphony Orchestra concert. The single day closure of the Massachusetts Bay Transportation Authority cost an estimated $1.56 million in lost fares.

The economic impact of the immediate aftermath
of the bombing however, pales in comparison to the impact of the manhunt for the two suspects, and the subsequent citywide shutdown, which occurred on 19 April. The economic cost of the citywide shut down has been placed at $333 million.

To read the whole report, please click here.