The Rising Threat of Terrorist Attacks Against Hospitals

Addressing abdominal trauma from conflict and warfare in under-resourced regions: A critical narrative review

Introduction

The prevalence of abdominal injuries in war and conflict zones, particularly in low- and middle-income countries (LMICs), presents a significant healthcare challenge. These injuries, often resulting from explosive devices, firearms, and shrapnel, lead to high morbidity and mortality rates due to delayed diagnoses, inadequate medical infrastructure, and limited access to specialised care. This review aims to summarise the literature on conflict-related abdominal injuries in LMICs, highlighting the impact of such trauma on healthcare systems and patient outcomes, and suggesting strategies for improvement.

Methods

A comprehensive narrative review was conducted, focusing on studies from contemporary and historical conflict-ridden nations. Databases such as PubMed, EMBASE, Google Scholar, the Cochrane Library, and Scopus were searched using specific keywords. Inclusion criteria encompassed various study designs and both paediatric and adult populations, with studies providing raw data prioritised. Exclusions included non-English articles, non-peer-reviewed studies, and those not reporting outcomes or involving high-income countries.

Results

The review identified significant challenges in managing war-related abdominal trauma in LMICs, including a shortage of healthcare personnel and infrastructure, socio-political barriers, and research gaps. Clinical implications of such injuries include elevated mortality rates, with surgical and nonsurgical management outcomes varying significantly. Positive advancements in diagnostics and surgical techniques have improved survival rates, yet the need for further infrastructural and workforce enhancements remains critical.

Conclusion

Abdominal trauma in conflict-affected LMICs necessitates focused efforts to improve healthcare delivery, including targeted funding for infrastructure and equipment, development of training programs for trauma specialists, and increased humanitarian aid. Bridging research gaps and fostering collaborative efforts are essential for advancing the management of abdominal trauma and enhancing patient outcomes in these challenging environments.

Lessons of the Boom: A Playbook for Crisis Centers to Prevent, Survive, and Respond to Active Assailants, Targeted Violence, and Mass Violence

Modern crisis centers need to be prepared for mass shootings, active assailant incidents, and related forms of targeted violence. While crisis engagement has traditionally been seen as a "right of boom" or post-incident responder, crisis leaders need to prepare their teams to identify people at risk for violence, use tools like Behavioral Threat Assessment and Management to reduce risk in those persons, and prepare their teams for potential incidents in their community. Evidence suggests that acute stressors are a common proximal risk factor for severe violence implying a potential synergy for using crisis services as a tool for prevention of violence.

Insights from Evidence-Based Medicine Method for Building Security Systems Against Terrorist Attacks in Hospitals

Hospitals have become soft targets for terrorism, with increasing terrorist attacks observed in the last two decades. Not only the counter-terrorism and law enforcement agencies but the hospitals also need to be actively involved and undertake the responsibility of safeguarding hospital security by establishing an effective security system. Evidence-based medicine emphasizes the significance of scientific evidence, and in practice, research methods for the generation, collection, and utilization of evidence may offer new insights to overcome the issue of terrorism. The present study discusses the potential application of methods in evidence-based medicine for developing security systems against terrorist attacks in hospitals. First, hospitals can use simulated scenarios of terrorist attacks to generate evidence. For example, combining virtual technology with virtual reality technology and selecting appropriate algorithms or models to generate evidence. Second, they can apply tabletop exercises to propose measures, as a means of collecting evidence. The collection of data can be obtained through questionnaires or interviews. Some biological methods, such as collecting salivary markers of acute stress (α-amylase and secretory immunoglobulin A), can also be used to assess emotional states. Third, they can use the collected evidence to practically test and refine the implemented measures. To verify the effectiveness and feasibility of the formulated solutions in real-life scenarios, simulations, models, drills, and similar methods can be used. This approach may provide new perspectives for the development of hospital security systems.

An Epidemiological Analysis of Terrorist Attacks in the Nordic and Baltic Countries from 1970 through 2020

BACKGROUND

Russia's annexation of Crimea in 2014, and the recent Russo-Ukrainian war that started in 2022, were triggers that radically changed the perception of security in the Nordic and Baltic countries. The on-going Russian hybrid war has resulted in a renewed global interest in the safety and security of many countries (eg, the Nordic-Baltic Eight). The prospective North Atlantic Treaty Organization (NATO) membership of Finland and Sweden may drastically change the regional military and political landscape.The objective of this study was to identify and characterize all documented terrorist attacks in this region as reported to the Global Terrorism Database (GTD) from 1970 through 2020.

METHODS

The GTD was searched using the internal database functions for all terrorism incidents in the Nordic-Baltic states: Denmark, Estonia, Finland, Iceland, Latvia, Lithuania, Norway, and Sweden.Temporal factors, location, target type, attack and weapon type, perpetrator type, number of casualties, and property value loss were collated. Results were exported into an Excel spreadsheet for analysis.

RESULTS

There were 298 terrorism-related incidents from 1970 through 2020. Most attacks occurred in Sweden, followed by Norway and Finland. No entries were recorded for the Baltic states prior to their independency in 1991. The 298 incidents resulted in a total of 113 fatalities and 277 injuries.Facility/infrastructure attacks were the most frequently identified attack type (35.0%), followed by bombings and explosions (30.9%). Armed assaults were responsible for 80 fatalities and 105 injuries, followed by bombings/explosions with 15 fatalities and 72 injuries. The predominant target types were immigrants and refugee shelters (64/298 incidents). In only 33.6% of the incidents, perpetrators were known. Right-wing assailants represented the largest group, accounting for 27 incidents.

CONCLUSION

From 1970 through 2020, there were 298 terrorist attacks in the Nordic-Baltic Eight. Sweden accounted for 50% of incidents.The profile of terrorist attacks was very diverse, as were the perpetrators and targets. Every country had its own incident characteristics. The surge of right-wing extremism must be closely monitored.

Terrorist Attacks against Health Care Targets that Provide Abortion Services

INTRODUCTION

Terrorist attacks against hospitals and health care providers have disproportionally increased during the last decades. A significant proportion of these attacks targeted abortion clinics and abortion providers. In the light of the overturning of Roe v. Wade in 2022, an increase of anti-abortion terrorist attacks is anticipated. Therefore, it becomes imperative to gain further insight into the risk and characteristics of past terrorist attacks. This study aimed to review terrorist attacks against health care targets providing abortion services from 1970 through 2020.

METHODS

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database functions for all terrorist attacks against abortion health care providers from January 1, 1970 - December 31, 2020. Temporal factors, location, attack and weapon type, and number of casualties or hostages were analyzed using descriptive statistics.

RESULTS

In total, 262 terrorist attacks were identified in five different countries. The majority (96.6%) occurred in the United States, with the highest counts during the last 20 years of the 20th century. Facility and infrastructure attacks were the most common attack types, followed by bombings and explosions. The attacks resulted in 34 injuries and nine fatalities. Kidnapping took place in three incidents. Of all successful attacks, 96.9% resulted in property damage.

CONCLUSION

Abortion-related health care facilities and providers have repeatedly been the target of terrorists over the past decades. Nearly all of these attacks took place in the United States, with the highest counts during the last 20 years of the 20th century.

Terrorist attacks against emergency departments

INTRODUCTION

Emergency departments (EDs) play an integral role in a community's response to disaster. Terrorist attacks targeting EDs have the potential to disrupt the emergency response apparatus. Understanding prior attacks against EDs can yield important lessons to mitigate the impact of future violence.

METHODS

In this review, the authors used the Global Terrorism Database to conduct a search on terrorist attacks targeting EDs between 1970 and 2018. Using the search terms "doctor," "nurses," "hospital," "healthcare," "clinic," "vaccinators," and "vaccinations," a total of 2322 healthcare-specific incidents were isolated. The database was further narrowed down to terrorist attacks targeting EDs, using the search terms "emergency," "emergency department," and "emergency ward."

RESULTS

A total of six attacks involving five countries were isolated. These attacks occurred between 1991 and 2016, with the majority involving the use of explosive devices, killing a total of 57 victims and leaving 26 wounded.

CONCLUSION

Attacks against EDs, while rare, have the potential to lead to loss of life through both the direct attack and subsequent disruptions to healthcare.