Preparedness and response to terrorism
A framework for public health action
Rosa GofinCorrespondence: Rosa Gofin, MD, MPH, The Braun School of Public Health and Community Medicine, Hebrew University and Hadassah, POB 12272, Jerusalem 91120, Israel, Email: gofin{at}cc.huji.ac.il
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Abstract |
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Political group violence in the form of terrorist actions has become a reality worldwide, affecting the health and economies of populations. As a consequence, preparedness and response are becoming an integral part of public health action. Risk appraisal, preservation of human and civil rights and communications within and between countries are all issues to be considered in the process. The combination of the natural history of terrorist actions and the epidemiological triangle model has been adapted in this paper and suggested as a comprehensive approach for preparedness and action. It covers preparedness (pre-event), response (event) and the consequences (post-event) of a terrorist attack. It takes into account the human factor, vectors and environment involved in each one of the phases.
Key points
- Terrorism is a global reality with varying underlying causes, manifestations and impact on the health of the public.
- Preparedness, response and rehabilitation are an integral part of public health action.
- Consideration of the pre-event, event and post-event phases in terrorist actions, together with the human factor, vector/agent and environment in each of these phases, offers a framework for public health preparedness, response and rehabilitation.
- Planning should consider risk assessment, risk communication, inter-sectorial cooperation, enactment of laws and regulations which consider protection of the public's health and civil liberties.
- Allocation of resources would need to make allowance for maintenance and development of ongoing public health activities.
Keywords: preparedness, response, political group violence, terrorism, human rights
Political group violence as expressed by terrorist actions, by their very nature, intimidate the general public by disrupting all spheres of life and communal organization, by inflicting damage and destruction, pain and disease, injury and death. Terrorism has been a reality for centuries and is a worldwide problem. However, its practice and impact reached new heights with the attack on major US cities in 2001, in particular in New York. The size of the attack, the settings, the sophisticated level of planning and organization and the methods employed were completely unprecedented. The consequences of the events on September 11th, 2001, have had global repercussions and will be felt for many years.
These events sparked renewed interest by governments, organizations, professionals and the population in general regarding the prevention and response to this form of violence and the treatment and care of its victims. The integral role of public health in all three aspects has been stressed, with prestigious and influential medical journals1–3 dedicating editorials and articles to the preparedness, epidemiology and treatment of different agents or vectors of terror. Indeed the number of articles dedicated to the issue has increased exponentially in the last years,4 and this bears no relation to the actual number of victims that it has caused nor when these are compared to the disability figures and lives lost each year in traffic crashes or due to smoking, obesity and inactivity.
Political group violence, while varying in its underlying causes, manifestations, degree of frequency and impact in different parts of the world, is a global reality. Given the widespread threat and the uneven distribution, a realistic appraisal of risk at the local level is needed for rational planning. Some countries are, or perceive themselves to be, vulnerable to the risk, while for others it might be a distant reality. Thus, appropriate alternative actions for the response to the threat requires fore-planning with consideration of the level of risk and the local reality. For the public health sector it may imply the development of models, examining alternative actions according to the different types of risks, and the selection of the most appropriate settings for preparedness and response. The allocation of resources would need to make allowance for continuation of the usual public health actions, their maintenance and development.
Laws and regulations may need to be enacted for the protection of citizens, heeding the preservation of democratic principles, human and civil rights with assurance of accountability and transparency, reaching an appropriate balance between the protection of the public's health and civil liberties.5–7 Consideration of populations with special needs (such as the uninsured and undocumented migrants), and the safeguarding of their access to medical care would need to be addressed. This might be done in a timely manner, and not under the pressure of a crisis. Public health professionals and population representatives would advisedly collaborate in this process.
In the process of preparedness and response, appropriate channels of communication and cooperation among the different sectors involved are of paramount importance. Risk communication and preparedness actions should take into account local values and culture, diversity of languages and the local community organization. Transmission of knowledge, sharing of information and cooperation in order to coordinate response may ensure a more effective response to the threat of terror, the actual event and its consequences. Transmission of scientific knowledge is not without controversy,8–9 considering the possibility that this knowledge may be misused. There exists today a global inter-relation regarding the prevention of and response to, as well as the health consequences of, terrorist actions. Therefore, cooperation and the sharing of expertise and information between nations should be routine.
Defining the problem and its magnitude is one of the first steps in a public health approach. However, in the case of terrorist action, a contested concept, definitions are elusive. The Webster dictionary10 refers to terrorism as ‘violence (as bombing) committed by groups in order to intimidate a population or government into granting their demands.’ Yet, it is assumed that a general and detailed definition is not likely to be agreed upon in the foreseeable future, and even then it may not contribute to its understanding.11 Regarding the underlying causes of terrorism, they are of a multifactorial nature and may have historical and present roots. Social inequalities, oppression, discrimination, religious beliefs, feelings of disenchantment, may all be contributors to the development of political violence. However it is still not clear why in some societies this is conducive to terrorism and not in others.11,12 The consequences of terrorism are more easily defined, although even here the categorization may be accurate but the description of the intent is inadequate. The possible cause of death for victims, or the physical consequences for those surviving terrorist action, are any combination of injury, poisoning and/or disease. A breakdown of cause and nature of injury and poisoning exists in the 9th edition of the World Health Organization International Classification of Diseases (ICD),13 although this breakdown does not include ‘terrorist actions’ when classifying intentionality. The codes categorize interpersonal intentional injuries as either ‘homicide and injury purposely inflicted by other persons’, ‘legal interventions’ or ‘injury resulting from operations of war’. The latter group relates to conventional warfare, nuclear weapons and other forms of unconventional warfare. The 10th edition of the ICD14 has not solved this problem.
Despite the problems of definition and classification, using a comprehensive approach may help in identifying factors influencing action and outcome. The natural history of a terrorist action can be broken down into its pre-event, event and post event phases. The traditional epidemiological triangle model (the host/human, agent/vector and environmental factors) identifies the factors operating in each phase of the natural history. Combining and integrating both provides us with a matrix similar to the Haddon matrix. The Haddon matrix was developed for the analysis and prevention of motor vehicle crashes15 and has since been modified for the study of all types of injury16 and violence.17 Such an analysis may prove useful not only in understanding the evolution of the event, but also for the planning of preventive measures, as well as for the development of an infrastructure for preparedness and the treatment of victims in order to minimize damages.
Prevention of terrorist actions is usually very difficult given the clandestine nature of the networks developed for their perpetration. The ultimate goal of prevention, however, should be the understanding and treatment of the underlying causes. Given this reality, public health professionals need to be in the frontlines of prevention, preparedness, treatment and rehabilitation, considering a realistic appraisal of threat for the local situation.
This article presents a public health framework for preparedness and response to such events, using an adaptation of the Haddon matrix (Fgure 1 ).
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Pre-Event Phase |
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The issues to be considered in this first phase are those that need to be contemplated prior to the event's occurrence, and the preparedness required to maximize a speedy and efficient response that will neutralize an attack, or at least minimize damage incurred.
Human factors
Age is one of the most significant human factors to be considered. Although risk exposure to terrorism is ostensibly the same for all age groups, the physical and psychological attributes of children and the elderly increase their vulnerability to such events. These two age groups are less likely to survive significant physical harm and are more vulnerable to post-traumatic infections. Children are more susceptible to infectious agents, such as smallpox, that may be used in a biological attack.18
Their understanding and experience levels, their capacity to assess and respond appropriately to sudden danger situations, as well as their speed reaction times, differentiate them from other groups. Specific groups, such as pregnant women, or those affected by chronic or disabling conditions also require special attention.
Planning and implementation of pre-emptive measures would take these factors into account. For example, schools require greater security measures and appropriate safety drills, as well as a range of appropriate education programs, adapted to the comprehension levels of the different age groups, in order to build resilience in vulnerable populations.
Agents/vectors
The agents involved in terrorist attacks may be mechanical, thermal, chemical, biological or involve radiation. The US Centers for Disease Control (CDC),19
has published a comprehensive list of potential agents that may be used in such attacks. Thermal agents, resulting in conflagration, may be caused by any number of substances. Chemical agents include a wide variety of substances that may have any one, or a number of, the following effects: blisters/vesicants, poison the bloodstream, induce choking or damage the lung/pulmonary system, induce sudden vomiting, affect the nervous system or incapacitate the whole body organism (e.g. those agents used in riot control). Biological agents have been classified according to their dissemination, public health impact, social impact and type of preparedness required, as follows: Category A (botulism, anthrax, smallpox, plague, tularaemia and hemorrhagic diseases); Category B (Brucellosis, Clostridium perfringes, food and water safety threats, and others); Category C (emerging infectious diseases such as Nipah and Hanta virus).
In the case of smallpox, modelling techniques have been developed regarding whether mass vaccination programs should be implemented prophylactically or only in response to attack with this agent.20–23 Consensus statements have been achieved and published for response to anthrax attacks and other biological agents.24–26
Radiation, most likely in the form of nuclear reaction, may involve the attack of a nuclear power plant, an attack with a dirty bomb or a nuclear explosion.27 Conventions or treaties prohibiting the proliferation and use of these agents of mass destruction27–28 are a way of preventing their use, although enforcement is needed.
In addition to the variety of agents available, the use of a human vector for the agent has become common practice. Thus, suicide bombers who can respond to last minute changes in the environment, maximize the potential for increased harm causing greater loss of human life. Recently, these ‘human bombs’ have been rigged with both explosives and small metal objects such as nails, screws, bolts, balls and other penetrating devices,29 in order to increase the number of victims and the harm inflicted. Different forms of screening for possible vectors and/or access prevention of these to public areas are required in an effort to prevent such events.
Environment
Politics, culture and the religious makeup of a specific population group, all contribute to the norms and beliefs within its environment. Political differences have often been the basis for conflict within and between countries. Geopolitics and the globalization of terror have compounded such conflicts. In the same way, religion and differing interpretations of religious scriptures has historically been, and continues to be, a source of conflict within and between countries. Enlisting the support of religious and political leaders and other key and influential personalities is therefore vital in the development of preventive initiatives and actions as well as for preparedness. Guidelines have been proposed for the involvement of the public as partners in bioterrorism preparedness.30
The health system in general, and the public health system in particular, have a crucial role to play in preparing for any terrorist eventuality. Systems of disease surveillance require upgrading, as does the capacity for laboratory diagnosis,31 in order to afford early detection of biological and/or chemical terrorist attacks. A network of laboratories across the country32 is necessitated to handle a quick and efficient sentinel alert response. An assessment of personnel and specialized training needs at all levels and within different disciplines is required.
Treatment and care of victims of chemical, biological or other agents as a discrete population group, could be included in medical and paramedical school curricula. In the same way, planning and preparation for the impact of terrorist action could be included in the curricula of public health schools, so that in case of a local emergency or when international help is needed, trained personnel could be available. Although the danger may appear remote for many populations, it is advisable that hospitals should develop and maintain emergency plans to cope with a sudden influx of large numbers of critically injured, poisoned or sick.33,34
Leadership initiative at all levels is essential for a planned, coordinated response. The design and exercise of response plans for any type of terrorist event of any scale ought to be operational and coordinated between national and local governments, army and police, non governmental organizations, health, educational, social and welfare frameworks, as well as formal and informal community organizations. Appropriate alert systems at the community level need to be developed according to type of action, as well as realistic response plans for a variety of potential scenarios and according to estimates of risk exposure. These plans should specify channels for information dissemination to the public without creating panic, and include population level action plans, such as mass vaccination.21
Physical arrangements for protection need to be made in advance. Vaccines and other relevant medications and equipment could be purchased and stored appropriately and the system should be ready for their quick dissemination, if required. Appropriate agent-specific shelters could be built and equipment, protective gear and counter-attack materials for biological and chemical agents could be strategically distributed within the population. A rational assessment on the need for materials or equipment that could be stored in the household should be done, including mechanisms for their maintenance.
Research, and the allocation of funds for it, on preparedness, treatment and rehabilitation need to be considered according to the priorities of each country.
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Event Phase |
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This phase considers those factors and actions that should be taken in response to a terrorist event in order to minimize impact and adverse outcome.
Human factors
In this phase, the human factors that need to be considered are two-fold: the degree of population exposure to the event, and the type of event (explosion, thermal, chemical, biological or radiation agents). The age distribution of surviving victims will dictate the relative vulnerability of those hurt (as described above) and consequently, the type of on-the-spot action to be taken.
Agent/vector
Effective and speedy measures should be taken to identify and counteract the agent or vector. In case of an infectious agent, speedy action to limit its spread is essential. Appropriate antidotes and protective devices should be used (e.g. gas masks, in the event of chemical agent exposure). According to reports, suicide bombers have also posed a biological threat. Body parts of these bombers, such as bone and tissue, have also carried and spread disease (e.g. hepatitis B), infecting both medical personnel and already vulnerable victims.35
This risk potential highlights the importance of vaccination of all medical and paramedic personnel.
Environment
Consideration should be given to the physical and geographical location of the terror event. For example, in the case of an explosion, whether it occurred in a closed or open space.36
A blast wave in a closed space may have a devastating effect and cause specific types of injury, distinct from those in open areas.
Relevant response teams must coordinate their actions and cooperate with one another. Appropriate on-site triage should be carried out, with arrangements for speedy evacuation to appropriate treatment facilities.37 The affected area should be cleared as soon as possible, and determination of its further use assessed. Emergency lines designed to handle the influx of queries by relatives and friends of those injured must be up and running quickly. The responsibility for guidelines and general information to the public should be provided by a pre-nominated, recognized authority. The coordinated efforts of radio, television and other mass media channels to disseminate this information is essential.
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Post-Event Phase |
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In this final phase, actions should be carried out to minimize damage and the morbidity sequelae of the event.
Human factors
For the directly affected, children and the elderly are again at greatest risk of morbidity and mortality. In particular, the elderly may be at risk of injuries/diseases requiring prolonged care, rehabilitation and recovery processes. This situation may be further complicated by their health status and medication use prior to the incident. Post-traumatic stress disorder (PTSD) is a common response to a terrorist event, amongst both victims and witnesses to the attack. Its diagnosis and treatment are crucial to the speedy recovery of those affected.38
Family and social supports available to the victim have an enormous impact on recovery. The impairment of these social supports, by bereavement for other family members killed in an attack, may influence the surviving member's rehabilitation processes. Family support structures may collapse altogether, where one or more significant members of a family are injured or killed. For all those affected—survivors, their families, bystanders to the event and emergency care staff—the resilient factors and support networks at each individual's disposal must be identified and reinforced.
Vectors/agents
Agents used must be identified and analysed and future access must be minimized or eliminated. Agent-specific facilities and equipment for trauma centre staff, and other services on-site, should be periodically updated and reviewed. Rehabilitation and psychological services may require augmentation after a significant terrorist event.
Environment
Barriers to health care access for certain groups, such as the uninsured or undocumented migrants should be identified and lifted. Support systems and economic assistance may need to be increased.
Appropriate rehabilitation systems should be developed and maintained for those physically or mentally affected by the terror attack. Recognition of PTSD as a ‘natural’ response to the event, and the organization of the health and welfare systems to attend to this condition should be available to the victims. Debriefing and appropriate interventions for medical and para-medical personnel attending victims should be a priority.
The framework presented here offers a comprehensive approach for the identification of significant factors and their practical implications on effective preparedness, response and treatment.
Public health professionals are key partners and have a leadership role in the intricate web of preparedness and response while continuing the commitment of safeguarding the health of the public in such challenging times. Addressing the roots of the problem may be the most promising preventive measure.
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Acknowledgments |
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The author acknowledges Jaime Gofin, MD, MPH, for his constructive comments during the preparation of the manuscript and Carol Runyan, PhD, and Susan Baker, PhD, for sparking the idea about this article.
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References |
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