Trauma care and case fatality during a period of frequent, violent terror attacks and thereafter.

BACKGROUND: From September 1999 through January 2004 during the second Intifada (al-Aqsa), there were frequent terror attacks in Jerusalem. We assessed the effects on case fatality of introducing a specialized, intensified approach to trauma care at the Hebrew University-Hadassah Hospital Shock Trauma Unit (HHSTU) and other level I Israeli trauma units. This approach included close senior supervision of prehospital triage, transport, and all surgical procedures and longer hospital stays despite high patient-staff ratios and low hospital budgets. Care for lower income patients also was subsidized. METHODS: We tracked case fatality rates (CFRs) initially during a period of terror attacks (1999-2003) in 8,127 patients (190 deaths) at HHSTU in subgroups categorized by age, injury circumstances, and injury severity scores (ISSs). Our comparisons were four other Israeli level I trauma centers (n = 2,000 patients), and 51 level I U.S. trauma centers (n = 265,902 patients; 15,237 deaths). Detailed HHSTU follow-up continued to 2010. RESULTS: Five-year HHSTU CFR (2.62 %) was less than half that in 51 U.S. centers (5.73 %). CFR progressively decreased; in contrast to a rising trend in the US for all age groups, injury types, and ISS groupings, including gunshot wounds (GSW). Patients with ISS > 25 accounted for 170 (89 %) of the 190 deaths in HHSTU. Forty-one lives were saved notionally based on U.S. CFRs within this group. However, far more lives were saved from reductions in low CFRs in large numbers of patients with ISS < 25. CFRs in HHSTU and other Israeli trauma units decreased more through the decade to 1.9 % up to 2010. CONCLUSIONS: Sustained reductions in trauma unit CFRs followed introduction of a specialized, intensified approach to trauma care.

Malthusian pressures, genocide, and ecocide.

Historical models postulate that genocide cannot occur without the ideology and decisions of its authoritarian perpetrators and the indifference of bystanders. These models do not address genocidal risks from ecocide. Study objectives were to assess 1) the role of Malthusian pressures in recent genocides, 2) the role of ecocide and ecologic abuse in creating these pressures, and 3) strategies for prevention and deterrence. Analysis of reports, demographic studies, and time trends in recent genocides and recent ecocidal events from ecologic abuse suggests that Malthusian pressures and zero-sum rivalries over water, arable land, or natural resources by themselves do not lead to genocide. Such pressures may have exacerbated the political and socioeconomic predictors in Rwanda and Darfur, but not in former Yugoslavia. However, collapse of socioeconomic and governmental infrastructures following genocide can leave behind massive sustained damage to carrying capacity and sustainability. Surviving victims, if they return to their environments, will remain at risk for persecution. Ecocide--the large-scale destruction, depletion, or contamination of natural ecosystems--can result in widespread damage to health, survival, fertility, reproduction, and sustenance, and forced flight. International early warning and effective response systems are needed to deter or prevent political decisions to carry out genocide. Such systems must include long-term measures to resolve zero-sum conflicts over environmental resources and to prevent toxic risks to vulnerable populations and destruction of habitat by deliberate or wanton ecologic abuse, which itself should be redefined as a crime against humanity.

'Ethnic cleansing' bleaches the atrocities of genocide.

Genocide has been the leading cause of preventable violent death in the 20th-21st century, taking even more lives than war. The term 'ethnic cleansing' is used as a euphemism for genocide despite it having no legal status. Like 'Judenrein' and 'racial hygiene' in Nazi medicine, it expropriates pseudo-medical terminology to justify massacre. Use of the term reifies a dehumanized view of the victims as sources of filth and disease, and propagates the reversed social ethics of the perpetrators. Timelines for recent genocides (Bosnia, 1991-1996, 200,000; Kosovo 1998-2000, 10,000-20,000; Rwanda, 1994, 800,000; Darfur 2002-2006, >400,000) show that its use bears no relationship to death tolls or the scale of atrocity. Bystanders' use of the term 'ethnic cleansing' signals the lack of will to stop genocide, resulting in huge increases in deaths, and undermines international legal obligations to acknowledge genocide. The term 'ethnic cleansing' corrupts observation, interpretation, ethical judgment and decision-making, thereby undermining the aim of public health. Public health should lead the way in expunging the term 'ethnic cleansing' from official use. 'Ethnic cleansing' bleaches the atrocities of genocide, leading to inaction in preventing current and future genocides.