Public Health Responses to CBRN Terrorism in the Middle East and North Africa.

OBJECTIVE: Escalating global challenges (such as disasters, conflict, and climate change) underline the importance of addressing Chemical, Biological, Radiological, and Nuclear (CBRN) terrorism for sustainable public health strategies. This study aims to provide a comprehensive epidemiological analysis of CBRN incidents in the Middle East and North Africa (MENA) region, emphasizing the necessity of sustainable responses to safeguard healthcare infrastructures. METHOD: Utilizing a retrospective approach, this research analyzes data from the Global Terrorism Database (GTD) covering the period from 2003 to 2020. The study focuses on examining the frequency, characteristics, and consequences of CBRN incidents in the MENA region to identify patterns and trends that pose significant challenges to public health systems. RESULTS: The analysis revealed a significant clustering of CBRN incidents in Iraq and Syria, with a predominant involvement of chemical agents. These findings indicate the extensive impact of CBRN terrorism on healthcare infrastructures, highlighting the challenges in providing immediate health responses and the necessity for long-term recovery strategies. CONCLUSIONS: The study underscores the need for improved healthcare preparedness, robust emergency response systems, and the development of sustainable public health policies. Advocating for international collaboration, the research contributes to the strategic adaptation of healthcare systems to mitigate the impacts of CBRN terrorism, ensuring preparedness for future incidents in the MENA region and beyond.

The Migration of Lynch Victims' Families, 1880-1930.

We examine the relationship between the lynching of African Americans in the southern United States and subsequent county out-migration of the victims' surviving family members. Using U.S. census records and machine learning methods, we identify the place of residence for family members of Black individuals who were killed by lynch mobs between 1882 and 1929 in the U.S. South. Over the entire period, our analysis finds that lynch victims' family members experienced a 10-percentage-point increase in the probability of migrating to a different county by the next decennial census relative to their same-race neighbors. We also find that surviving family members had a 12-percentage-point increase in the probability of county out-migration compared with their neighbors when the household head was a lynch victim. The out-migration response of the families of lynch victims was most pronounced between 1910 and 1930, suggesting that lynch victims' family members may have been disproportionately represented in the first Great Migration.

A Decade of Terrorism in the United States and the Emergence of Counter-Terrorism Medicine.

BACKGROUND: The United States (US) is ranked 22nd on the Global Terrorism Index (2019), a scoring system of terrorist activities. While the global number of deaths from terrorism over the past five years is down, the number of countries affected by terrorism is growing and the health care repercussions remain significant. Counter-Terrorism Medicine (CTM) is rapidly emerging as a necessary sub-specialty, and this study aims to provide the epidemiological context over the past decade supporting this need by detailing the unique injury types responders are likely to encounter and setting the stage for the development of training programs utilizing these data. METHODS: The Global Terrorism Database (GTD) was searched for all attacks in the US from 2008-2018. Attacks met inclusion criteria if they fulfilled the three terrorism-related criteria as set by the GTD. Ambiguous events were excluded when there was uncertainty as to whether the incident met all of the criteria for inclusion in the GTD. The grey literature was reviewed, and each event was cross-matched with reputable international and national newspaper sources online to confirm or add details regarding weapon type used and, whenever available, details of victim and perpetrator fatalities and injuries. RESULTS: In total, 304 events were recorded during the period of study. Of the 304 events, 117 (38.5%) used incendiary-only weapons, 80 (26.3%) used firearms as their sole weapon, 55 (18.1%) used explosives, bombs, or dynamite (E/B/D), 23 (7.6%) were melee-only, six (2.0%) used vehicles-only, four (1.3%) were chemicals-only, two (0.7%) used sabotage equipment, two (0.7%) were listed as "others," and one (0.3%) used biological weapon. There was no recorded nuclear or radiological weapon use. In addition, 14 (4.6%) events used a mix of weapons. CONCLUSIONS: In the decade from 2008 through 2018, terrorist attacks on US soil used weapons with well-understood injury-causing modalities. A total of 217 fatal injuries (FI) and 660 non-fatal injuries (NFI) were sustained as a result of these events during that period.Incendiary weapons were the most commonly chosen methodology, followed by firearms and E/B/D attacks. Firearm events contributed to a disproportionality high fatality count while E/B/D events contributed to a disproportionally high NFI count.

Preparing for a "dirty bomb" attack: the optimum mix of medical countermeasure resources.

BACKGROUND: In radiological emergencies with radionuclide incorporation, decorporation treatment is particularly effective if started early. Treating all people potentially contaminated ("urgent treatment") may require large antidote stockpiles. An efficacious way to reduce antidote requirements is by using radioactivity screening equipment. We analyzed the suitability of such equipment for triage purposes and determined the most efficient mix of screening units and antidote daily doses. METHODS: The committed effective doses corresponding to activities within the detection limits of monitoring portals and mobile whole-body counters were used to assess their usefulness as triage tools. To determine the optimal resource mix, we departed from a large-scale scenario (60,000 victims) and based on purchase prices of antidotes and screening equipment in Germany, we calculated efficiencies of different combinations of medical countermeasure resources by data envelopment analysis. Cost-effectiveness was expressed as the costs per life year saved and compared to risk reduction opportunities in other sectors of society as well as the values of a statistical life. RESULTS: Monitoring portals are adequate instruments for a sensitive triage after cesium-137 exposure with a high screening throughput. For the detection of americium-241 whole-body counters with a lower daily screening capacity per unit are needed. Assuming that 1% of the potentially contaminated patients actually need decorporation treatment, an efficient resource mix includes 6 monitoring portals and 25 mobile whole-body counters. The optimum mix depends on price discounts and in particular the fraction of victims actually needing treatment. The cost-effectiveness of preparedness for a "dirty bomb" attack is less than for common health care, but costs for a life year saved are less than for many risk-reduction interventions in the environmental sector. CONCLUSION: To achieve economic efficiency a high daily screening capacity is of major importance to substantially decrease the required amount of antidote doses. Among the determinants of the number of equipment units needed, the fraction of the potentially contaminated victims that actually needs treatment is the most difficult to assess. Judging cost-effectiveness of the preparedness for "dirty bomb" attacks is an issue of principle that must be dealt with by political leaders.

Evolution of hot zone care: MARA.

Modern conflict and terrorist events have moved from linear two-dimensional battlespaces into complex, continuously evolving three-dimensional environments. Contested spaces make traditional definitions of zones of response confusing and lead to delays in care. The presence of actual or perceived ongoing threats creates an environment in which the initiation of tactical field care (TFC) may be inappropriate, despite the absence of an immediate risk to life. This risks a 'time and space gap' between care under fire and TFC. Major haemorrhage, airway, respiration, analgesia is proposed as a rethought approach to care in such environments.

Palestinian Women in Terrorism: A Double-Edged Sword?

Drawing on a decade of research on terrorism in the Israeli-Palestinian conflict, we show how subjective "rational choices" motivate some women to engage in terrorist activism. Focusing on the motives of young women who engage in terrorism is consistent with feminist theory's insistence on women's agency-even at the extremes. In addition to the well-established motivations for terrorism reported in the literature, interviews with young women involved in terrorism reveal mixed personal motives for their gender-defying choices, including thrill-seeking and some conscious rebellion. However, we contend that women's subjective rationale for participation in such violent behavior needs to be contextualized. A cost-benefit approach, we maintain, highlights the strategic considerations supporting the deployment of women as combatants by Palestinian terrorist organizations. We argue that the inclusion of women in terrorist activism in the Israeli-Palestinian conflict exposes a major fault line in attitudes to the role and proper place of women in what remains largely a patriarchal culture. This social ambivalence accounts for why, on all measures, women fare worse than their male counterparts. The implications of the findings for feminist research as well as policy are discussed.

Securing the Emergency Department During Terrorism Incidents: Lessons Learned From the Boston Marathon Bombings.

Terrorist incidents that target hospitals magnify morbidity and mortality. Before a real or perceived terrorist mass casualty incident threatens a hospital and its providers, it is essential to have protocols in place to minimize damage to the infrastructure, morbidity, and mortality. In the years following the Boston Marathon bombings, much has been written about the heroic efforts of survivors and responders. Far less has been published about near misses due to lack of experience responding to a mass casualty incident resulting from terrorism. After an extensive review of the medical literature and published media in English, Spanish, and Hebrew, we were unable to identify a similar event. To the best of our knowledge, this is the first reported experience of a bomb threat caused evacuation of an emergency department in the United States while actively responding to multiple casualty terrorist incidents. We summarized the chronology of the events that led to a bomb threat being identified and the subsequent evacuation of the emergency department. We then reviewed the problematic nature of our response and described evidence-based policy changes based on data from health care, law enforcement, and counterterrorism. (Disaster Med Public Health Preparedness. 2019;13:791-798).

Cyber Attacks and Terrorism: A Twenty-First Century Conundrum.

In the recent years, an alarming rise in the incidence of cyber attacks has made cyber security a major concern for nations across the globe. Given the current volatile socio-political environment and the massive increase in the incidence of terrorism, it is imperative that government agencies rapidly realize the possibility of cyber space exploitation by terrorist organizations and state players to disrupt the normal way of life. The threat level of cyber terrorism has never been as high as it is today, and this has created a lot of insecurity and fear. This study has focused on different aspects of cyber attacks and explored the reasons behind their increasing popularity among the terrorist organizations and state players. This study proposes an empirical model that can be used to estimate the risk levels associated with different types of cyber attacks and thereby provide a road map to conceptualize and formulate highly effective counter measures and cyber security policies.

Terror in time: extending culturomics to address basic terror management mechanisms.

Building on Google's efforts to scan millions of books, this article introduces methodology using a database of annual word frequencies of the 40,000 most frequently occurring words in the American literature between 1800 and 2009. The current paper uses this methodology to replicate and identify terror management processes in historical context. Variation in frequencies of word usage of constructs relevant to terror management theory (e.g. death, worldview, self-esteem, relationships) are investigated over a time period of 209 years. Study 1 corroborated previous TMT findings and demonstrated that word use of constructs related to death and of constructs related to patriotism and romantic relationships significantly co-vary over time. Study 2 showed that the use of the word "death" most strongly co-varies over time with the use of medical constructs, but also co-varies with the use of constructs related to violence, relationships, religion, positive sentiment, and negative sentiment. Study 3 found that a change in the use of death related words is associated with an increase in the use of fear related words, but not in anxiety related words. Results indicate that the described methodology generates valuable insights regarding terror management theory and provide new perspectives for theoretical advances.

Fundamental patterns and predictions of event size distributions in modern wars and terrorist campaigns.

It is still unknown whether there is some deep structure to modern wars and terrorist campaigns that could, for example, enable reliable prediction of future patterns of violent events. Recent war research focuses on size distributions of violent events, with size defined by the number of people killed in each event. Event size distributions within previously available datasets, for both armed conflicts and for global terrorism as a whole, exhibit extraordinary regularities that transcend specifics of time and place. These distributions have been well modelled by a narrow range of power laws that are, in turn, supported by some theories of violent group dynamics. We show that the predicted event-size patterns emerge broadly in a mass of new event data covering all conflicts in the world from 1989 to 2016. Moreover, there are similar regularities in the events generated by individual terrorist organizations, 1998-2016. The existence of such robust empirical patterns hints at the predictability of size distributions of violent events in future wars. We pursue this prospect using split-sample techniques that help us to make useful out-of-sample predictions. Power-law-based prediction systems outperform lognormal-based systems. We conclude that there is indeed evidence from the existing data that fundamental patterns do exist, and that these can allow prediction of size distribution of events in modern wars and terrorist campaigns.

Developing a Hospital Disaster Preparedness Plan for Mass Casualty Incidents: Lessons Learned From the Downtown Beirut Bombing.

Mass casualty incidents (MCIs) are becoming more frequent worldwide, especially in the Middle East where violence in Syria has spilled over to many neighboring countries. Lebanon lacks a coordinated prehospital response system to deal with MCIs; therefore, hospital preparedness plans are essential to deal with the surge of casualties. This report describes our experience in dealing with an MCI involving a car bomb in an urban area of downtown Beirut, Lebanon. It uses general response principles to propose a simplified response model for hospitals to use during MCIs. A summary of the debriefings following the event was developed and an analysis was performed with the aim of modifying our hospital's existing disaster preparedness plan. Casualties' arrival to our emergency department (ED), the performance of our hospital staff during the event, communication, and the coordination of resources, in addition to the response of the different departments, were examined. In dealing with MCIs, hospital plans should focus on triage area, patient registration and tracking, communication, resource coordination, essential staff functions, as well as on security issues and crowd control. Hospitals in other countries that lack a coordinated prehospital disaster response system can use the principles described here to improve their hospital's resilience and response to MCIs. (Disaster Med Public Health Preparedness. 2018; 12: 379-385).

Optimizing Visits to the Site of Death for Bereaved Families After Disasters and Terrorist Events.

In recent years it has been common after disasters and terrorist events to offer bereaved families the opportunity to visit the place where their loved ones died. Many report that such visits are beneficial in processing their loss. Various factors, both cognitive (eg, counteracting disbelief) and existential or emotional (eg, achieving a sense of closeness to the deceased), are associated with the experienced benefit. Nonetheless, exacerbations of trauma and grief reactions (eg, re-enactment fantasies) are common, with some of the bereaved also reporting adverse reactions after the visit. Subsequently, proper preparations are a prerequisite before such visits take place. This article describes how to optimize collective visits to the site of death after disasters or terrorist events for bereaved families. Important questions-for example, concerning those who should be responsible for organizing a visit and those who should be invited, the timing of the visit, what can be done at the site, the need for support personnel, and other practical issues-are discussed and general guidelines are recommended. (Disaster Med Public Health Preparedness. 2018;12:523-527).

Pre-hospital management of mass casualty civilian shootings: a systematic literature review.

BACKGROUND: Mass casualty civilian shootings present an uncommon but recurring challenge to emergency services around the world and produce unique management demands. On the background of a rising threat of transnational terrorism worldwide, emergency response strategies are of critical importance. This study aims to systematically identify, describe and appraise the quality of indexed and non-indexed literature on the pre-hospital management of modern civilian mass shootings to guide future practice. METHODS: Systematic literature searches of PubMed, Cochrane Database of Systematic Reviews and Scopus were conducted in conjunction with simple searches of non-indexed databases; Web of Science, OpenDOAR and Evidence Search. The searches were last carried out on 20 April 2016 and only identified those papers published after the 1 January 1980. Included documents had to contain descriptions, discussions or experiences of the pre-hospital management of civilian mass shootings. RESULTS: From the 494 identified manuscripts, 73 were selected on abstract and title and after full text reading 47 were selected for inclusion in analysis. The search yielded reports of 17 mass shooting events, the majority from the USA with additions from France, Norway, the UK and Kenya. Between 1994 and 2015 the shooting of 1649 people with 578 deaths at 17 separate events are described. Quality appraisal demonstrated considerable heterogeneity in reporting and revealed limited data on mass shootings globally. CONCLUSION: Key themes were identified to improve future practice: tactical emergency medical support may harmonise inner cordon interventions, a need for inter-service education on effective haemorrhage control, the value of senior triage operators and the need for regular mass casualty incident simulation.

Insights Into French Emergency Planning, Response, and Resilience Procedures From a Hospital Managerial Perspective Following the Paris Terrorist Attacks of Friday, November 13, 2015.

On Friday, November 13, 2015, Paris was subjected to a multiple terrorist attack that caused widespread carnage. Although French emergency planning, response, and resilience procedures (Plan Blanc) anticipated crisis management of a major incident, these had to be adapted to the local context of Pitié-Salpêtrière University Teaching Hospital. Health care workers had undergone Plan Blanc training and exercises and it was fortunate that such a drill had occurred on the morning of the attack. The procedures were observed to work well because this type of eventuality had been fully anticipated, and staff performance exceeded expectations owing to prior in-depth training and preparations. Staff performance was also facilitated by overwhelming staff solidarity and professionalism, ensuring the smooth running of crisis management and improving victim survival rates. Although lessons learned are ongoing, an initial debriefing of managers found organizational improvements to be made. These included improvements to the activation of Plan Blanc and how staff were alerted, bed management, emergency morgue facilities, and public relations. In conclusion, our preparations for an eventual terrorist attack on this unprecedented scale ensured a successful medical response. Even though anticipating the unthinkable is difficult, contingency plans are being made to face other possible terrorist threats including chemical or biological agents. (Disaster Med Public Health Preparedness. 2016;page 1 of 6).