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Not war, not terrorism, the impact of hybrid warfare on emergency medicine

a b s t r a c t

Introduction: healthcare facilities and medical providers are not immune to aggression and threat from terrorists, criminals and rogue states. The concept of Hybrid Warfare is often described as a mix of conventional warfare, irregular warfare, terrorism, criminality and different types of other hybrid threats such as cyberattacks and drone technology. healthcare systems can either be primary or secondary targets of hybrid warfare with potentially devastating consequences.

Objective: The aim of this paper is to serve as a primer for clinicians, researchers and emergency managers in understanding the basic aspects of hybrid warfare, how healthcare can be affected, and to provide a framework for mitigation and resilience, especially in an emergency medicine setting. Different hybrid threats and their effect on emergency medicine, and healthcare in general, is discussed.

Discussion: Hybrid warfare is an increasing, multimodal, threat for all segments of healthcare, particularly prehos- pital care and emergency medicine. Disrupting the healthcare system in a country using hybrid warfare has the ultimate aim of destabilizing organizations and society as well as directly reducing the effectiveness and capabil- ities of healthcare as a key strategic resource. In this aspect prehospital care and emergency medicine are main targets of aggression.

Conclusion: Clinicians and healthcare managers of all levels should have a basic knowledge of the different components of hybrid warfare so as to mitigate effects of an attack. It is suggested that an emergency department do not aim to create totally new solutions for hybrid threats but use an all hazards approach and the available guidelines for handling generic threats. However, there must be a preparedness for the different ways hybrid warfare can play out, how the threats can be combined in synergistic ways and the potential compounding effects on healthcare and society.

(C) 2022 Published by Elsevier Inc.

  1. Introduction

Healthcare facilities and medical providers are not immune to aggression and threat from terrorists, criminals and rogue states [1].

The concepts of hybrid warfare build on longstanding military tradi- tions and strategies, but in the last decade these ideas have been fueled by globalization, technology, demographics and the “Great Power Com- petition” where the United States (US), China and Russia are competing to shape security, trade and development on a global scale [2]. Hybrid

Abbreviations: CTM, Counter-Terrorism Medicine; CBRN, Chemical, Bilogical, Radiological, Nuclear.

* Corresponding author.

E-mail addresses: [email protected] (F. Granholm), [email protected] (D. Tin), [email protected] (G.R. Ciottone).

1 Address: Bradgatan 9, 85460 Sundsvall, Sweden.

warfare is often described as a mix of conventional warfare, irregular warfare, terrorism, criminality and different types of other hybrid threats such as cyberattacks and drone technology. Healthcare systems can either be primary or secondary targets of hybrid warfare with potentially devastating consequences [3]. This type of conflict takes full advantage of the intentionally blurred line between war and peace, and the confusion it creates [4]. Even though there has been an increasing military and security sector interest in this topic during the past 10 years very little has been discussed on hybrid warfare’s impact on healthcare and emergency medicine.

  1. Objectives

The aim of this paper is to serve as a primer for clinicians, researchers and emergency managers in understanding the basic aspects of hybrid

https://doi.org/10.1016/j.ajem.2022.10.021 0735-6757/(C) 2022 Published by Elsevier Inc.

warfare, how healthcare can be affected, and to provide a framework for mitigation and resilience, especially in an emergency medicine setting.

  1. Methods

The narrative review methodology was chosen given the sparsity of scientific research regarding this topic. The Medline (Pubmed) and Google Scholar were searched for English language articles from 2005 and onwards. Keywords used included hybrid warfare, healthcare, emergency medicine, ems, emergency department, emergency medical services, counter terrorism-medicine and combinations of these key- words. In addition, Google was used for non-indexed articles and grey literature. To cover the more military, and security based, aspects of the topic the JSTOR Security Studies collection was used with the same keywords. Titles were initially screened for relevance and the po- tential to fulfill the objectives of the paper. The selected articles were thereafter read in full before a final decision on inclusion. Article inclu- sion was determined by author consensus based on relevance to the ob- jectives. Key papers were also hand searched for additional unidentified references.

  1. Discussion
    1. The context of hybrid warfare

Future conflicts will probably see a mix of irregular and regular forces together with terrorists and criminals operating in environments with a high density of civilians [5]. This mix of forces and modalities to- gether with hybrid threats like cyberattacks and disruptive technologies will create very complex scenarios. Another term often used together with the concept of hybrid warfare is the grey zone of conflict, the zone between peace and war without crossing the line of open war. Irregular methods can also include guerilla warfare, sponsoring terror- ism or unofficially using criminal activities and cyberattacks as a tool.

Some combination of advanced weapons systems are likely to be used in hybrid warfare, including unconventional modalities such as chemical, biological, radiological, nuclear, and high-yield explosives (CBRNE), as well as disruptive technologies like drones and cyberterrorism. social media can also be exploited as a powerful tool [6], used to sow confusion and create instability within and between organizations, as well as within a society. Finally, criminal activity and corruption may play a role in hybrid warfare as it destabilizes basic functions of society and decreases trust and safety [7].

By its very nature, hybrid warfare creates difficulties in understand- ing the origin or intention of a hostile action, especially when third parties are unofficially sponsored by the state. Activities may be opera- tionally and tactically directed and coordinated to achieve synergistic effects in both physical and psychological dimensions. Like in other multimodal terrorist attacks, it is the synergy that makes it effective and destabilizing on a larger scale.

    1. Hybrid warfare and similarities with terrorism

There are several similarities between hybrid warfare and terror- ism. The intentional attacks on civilians, medical responders, and hospitals are common ground between hybrid warfare and terror- ism with potentially profound effects on healthcare systems. As in terrorism, the Geneva convention does not apply in grey zone activ- ities and hybrid warfare. This includes the treaty regarding protec- tion of civilians and medical personnel, and the treatment of wounded soldiers and prisoners of war [8]. A major difference be- tween hybrid warfare and terrorism is the duration of the attack, which may be important for mitigation and preparedness, as well as response and surge capacity planning.

A terrorist attack is often over in a fairly short time period, typi- cally with a clear onset and finish. Hybrid warfare may have a longer

duration, as seen in protracted conflicts, which can put a prolongED strain on the healthcare system and significantly impact the civilian population, as has been seen in the ongoing Ukraine war. There are exceptions, however, such as the Mumbai terror attacks in 2008 and the Beslan School Siege in 2004, both of which went on for sev- eral days [9]. Though these events can be considered an exception, their time scales remain relatively short compared to conflicts and wars. The varying arcs of time will affect everything from response algorithms to security issues for responders, and can impact the long-term Psychological effects.

    1. How will hybrid warfare affect emergency medicine and the healthcare system?

Disrupting the healthcare system in a country using hybrid threats has the ultimate aim of destabilizing trust in government and key orga- nizations, but as well as directly reducing the effectiveness and capabil- ities of healthcare as a key strategic resource. In this aspect prehospital care and emergency medicine are main targets of aggression, since a de- crease in their capacity would seriously affect a country if the situation would turn into open conflict and war. Health professionals are at risk of being directly targeted in hybrid conflicts [10]. All modalities seen in hybrid warfare can be used to directly attack healthcare and warrant detailed multi-agency work regarding mitigation, preparedness, response, and recovery.

      1. Cyberattacks on healthcare

Cyberattacks on healthcare are increasing every year and represent a serious threat to all parts of the system, from the prehospital setting to the emergency department, intensive care unit (ICU) and outpatient care. The US Department of Health keeps track of cyberattacks and breaches and attacks against healthcare providers. In 2021, there were 679 such events [11]. Most are perpetrated by criminal hackers and non-state actors, but there are also attacks made by state sponsored groups.

IT systems in healthcare are soft targets as they often use outdated security systems with exploitable flaws [12]. The use of many different interacting products and devices also makes it easy to breach security and get access to everything from patient records and medical equip- ment technology software, to booking systems.

Researchers have found hospitals that experienced cyber events were more likely to suffer hospital strain (measured by ICU bed utiliza- tion), worse health outcomes, and increased mortality. In a US survey- based report from 2021, out of nearly 600 respondent healthcare facili- ties just over 40% said that they had a ransomware attack in the last two years. A ransomware attack is a cyberattack that freezes computer sys- tems and demands payment to unlock them. Around 70% of the organi- zations facing ransomware attacks said that those disruptions led to longer hospital stays for patients and delayed tests or procedures. In ad- dition, 36% said that there were more complications from medical pro- cedures, and 22% said they had increased mortality [13].

This problem is universal. In 2017 the United Kingdom (UK) Healthcare system was seriously disrupted by the WannaCry ransomware attack, causing long delays in care and thousands of cancellations of visits due to problems with labs, radiology and access to patient records [14].

A more recent attack occurred at Boston Children’s Hospital in 2021, which was stopped by the Federal Bureau of Investigation (FBI). Accord- ing to the FBI, the cyberattack was a state sponsored attack by Iran [15]. In Emergency Medical Services (EMS) daily operations there is constant use of digital maps and digital information for dispatch and coordination, which can be a soft target for perpetrators wishing to disrupt prehospital care. The research in this topic is limited but indi- cates significant regional impact on EMS volumes during a healthcare

cyberattack [16].

      1. CBRNE attacks and the healthcare system

CBRNE can be used by various rogue groups and state players in a ci- vilian setting, and may be used in assassination attempts of political tar- gets, as well as in Mass casualty incidents (MCI). In full-scale hybrid warfare the use of a chemical agent is likely to be combined with the use of other weapons, such as firearms and explosives, resulting in mul- tiple victims who could be mistakenly identified as casualties of a con- ventional attack [17].

From the experience in the UK, even a small number of affected peo- ple will cause an enormous pressure on healthcare, police, CBRNE ex- perts and government [18]. In 2006 a Russian former FSB officer was poisoned, in London, with the radioactive isotope Polonium-210, and died within a couple of weeks [19]. On 4 March 2018, Sergei Skripal, a former Russian military officer, and his daughter were poisoned with the Novichok military grade nerve agent in the city of Salisbury, En- gland. A police officer was also taken into intensive care after attending the incident and was later discharged. Two other people were poisoned after having found a perfume bottle with the nerve agent and one later died in the hospital. In 2017 the half-brother of North Korean dictator Kim Jung Un was assassinated at the Kuala Lumpur Airport after having been attacked by two women using the nerve agent VX [20].

In hybrid warfare the use of CBRNE is a real threat and familiarity with toxidromes is critical to alert clinicians to potential agents being in- volved in mass casualty incidents [17,21]. It is also important to train emergency First responders to elevate their index of suspicion to inten- tional attacks, as it can significantly alter their response algorithm.

      1. Disinformation and healthcare

Disinformation in healthcare can be a weapon with both short- and long-term impact. During the Covid-19 pandemic, state sponsored mis- information and fake news, as well as a myriad of online conspiracy the- ories, created confusion and impacted public health responses [22]. Disinformation often spreads rapidly in the social media echo chamber causing suspicion of official guidelines and vaccine recommendations [23]. The promotion of ineffective and unsafe products, as well as mis- leading information about unproven treatments, can significantly affect public health response to a pandemic.

      1. Refugees and migration as a hybrid weapon

Refugees and migration can also be used as weapons in Hybrid War- fare, and there are examples from Syria, Ukraine and Belarus [24]. In the current war in Ukraine, healthcare facilities and civilians have been ac- mitigation strategies “>tively targeted creating the largest refugee crisis in Europe since World War 2. This puts extreme pressure on the healthcare system in Ukraine and neighboring countries due to the amount of trauma cases, as well as chronic illnesses worsening due to lack of medications and treatment resources, such as dialysis [25]. In addition, the mental health effects on refugees and medical personnel is also an important issue likely to af- fect society for a long time [26].

      1. Drones used to disrupt healthcare

Drone technology has improved enormously over the past 5 years, with smaller recreational and larger military drones both posing a sub- stantial threat to civilian healthcare [27]. The main targets could be HEMS (Helicopter Emergency Medical Service) and fixed wing air am- bulances, as it is relatively simple for a drone to close an airport or hin- der the possibility for safe take-off and landing [28]. The use of drones to carry CBRNE agents has also been proposed. From the current war in Ukraine there is unconfirmed information about drone-delivered Chemical agents.

      1. Criminality and disruptive behaviour in the streets and in the hospitals

Criminality can be a very potent weapon for an adversary. Criminality could include narcoterrorism, smuggling of advanced weapons, exploita- tion of urban gang networks and socially disruptive behaviour [29].

Criminal disorder can be fueled by misinformation and social media campaigns and aimed at attacks on ambulances and fire/rescue, as well as rioting and looting which can impede access to certain parts of a city. The exploitation of urban gangs can also pose an extreme threat to civilian society, since the use of military weapons and explosives have been increasing in gang wars over the past decade.

In addition to the immediate threat to civilians and medical responders, criminal activity may also lead to a high influx of trauma patients to hospitals. In several western countries there have been attempts by criminals to breach hospital security when gang members are being treated in the facility, thus creating a very dangerous situation for staff and other patients and clearly pointing at the need for healthcare target hardening [30].

      1. Terrorism

Terrorism is one of the most important components that make up the challenge posed by hybrid warfare [31]. When co-mingled with eth- nic tension, political corruption and strains on resources, contemporary terrorism demonstrates an extraordinary potency that can be utilized by multiple state and non-state actors. From past experience we know it will probably take the form of complex, multimodal attacks [32], caus- ing a surge of trauma patients and long and short-term strain on healthcare.

  1. Hybrid warfare and counter-terrorism medicine

The increasing complexity, frequency and multimodal nature of terrorism has led to the emergence of the Disaster Medicine sub- specialty Counter-Terrorism Medicine (CTM) focusing on the unique healthcare aspects of these situations [33]. The similarities between hybrid warfare and terrorism makes it possible to use the CTM frame- work to analyze events, as well as to use it as a tool for mitigation, preparedness, response, and recovery, using the medical, strategic and organizational lessons learned from terrorist attacks and from the bat- tlefield to navigate situations with underlying confusion and limited in- formation. CTM deals with the impact of intentional man-made events on the Healthcare sector and explores the operational challenges and risks to national, regional and local medical systems [34]. CTM also translates research and multi-agency after-action report learnings and discussions into operational, policy and protocol changes both at a sys- tems level, as well at an on-ground, pre-hospital and in-hospital, clinical level. CTM community initiatives are also being launched [35].

  1. Countering and mitigation strategies for the emergency department

As described in this paper the range of measures applied as part of a hybrid warfare may be very wide and a detailed description of counter- ing and mitigating an attack is beyond the scope of this narrative review. However, there are a few fundamental pillars regarding emergency de- partment mitigation, preparedness, response and recovery that should be applied in the case of hybrid threats.

A good start, for emergency departments, hospitals and other orga- nizations, is to have proper situational awareness, and to pro-actively surveil emerging threats is a crucial step in achieving protection against hybrid attacks [36]. It is therefore important to work across organiza- tional and departmental boundaries in a multidisciplinary fashion in all phases of an incident, or ongoing threat.

When a hazard vulnerability analysis (HVA) is done it is important to think about the compounding effects that may follow hybrid attacks and how this may differ from more traditional hazards [37]. Specialized task forces for certain threats (for ex cyberattacks) can accelerate the preparedness goals in the emergency department [38]. The work in mit- igating and countering hybrid threats should have the foundation in the well-known all-hazards approach [39]. In which a hospital or depart- ment will have the competence and capacity to address a broad range

of related emergencies. Standard operating procedures are espe- cially important for unfamiliar emergency scenarios and these should be available for the threats recognized in the HVA analysis for hybrid at- tacks [40]. Many of the threats in hybrid warfare have often already been a part of disaster plans and vulnerability analysis in emergency de- partments, but in another context. This makes it possible to initially use core generic solutions for many threats. However, the compounding ef- fects that may follow grey zone activities and hybrid warfare must be taken into account. Especially for protracted events. Examples of re- sources already available, and applicable in hybrid warfare, are the American College of Emergency Physicians’ best practices and safety tips on workplace violence, the Department of Homeland Security’s guidelines on Planning Considerations: Complex Coordinated Terrorist Attacks and the Public Health England guidelines on clinical manage- ment and health protection in a CBRN incident [41-43]. Furthermore, a number of terror medicine and counter-terrorism medicine courses which aims to educate medical professionals on the healthcare impact of nefarious events, are available today [44,45]. It is therefore suggested that an emergency department does not aim create totally new solu- tions for hybrid threats but use available national and international guidelines for generic threats. These guidelines should be used in a mul- tidisciplinary approach together with a “hybrid threat mindset”. Being able to rapidly counter and mitigate new threats, prolonged threats or the compounding effects of a more complex multimodal attack.

  1. Limitations

Research looking at hybrid warfare, and how it can impact healthcare in general and emergency medicine in particular, is very sparse. The material used in this paper consists of expert opinion, case reports/lessons learned and research papers in an effort to mit- igate the lack of topic specific research witha triangulation method. The similarities between the multimodal aspects of hybrid warfare and modern day terrorism makes it possible to use lessons learned from the latter and apply this to the analysis. However, it must be acknowledged that this approach generates a risk for personal bias, and it is imperative to be aware of this when analyzing data, cases and literature. To mitigate the problem the authors of this paper have individually made a critical analysis before the final conclusions have been stated.

  1. Conclusion

Hybrid warfare is an increasing, multimodal, threat for all segments of healthcare, particularly prehospital care and emergency medicine. The complexities of this threat necessitate a truly multi-organizational approach when discussing mitigation preparedness, response, and recovery.

It is suggested that an emergency department or emergency medical service (EMS) do not aim to create totally new solutions for hybrid threats but use an all hazards approach and the available national and international guidelines for handling generic threats. However, there must be a preparedness for the different ways hybrid warfare can play out, how the threats can be combined in synergistic ways and the potential compounding effects on healthcare and society.

Clinicians and healthcare managers of all levels should have a basic knowledge of the different components of hybrid warfare so as to miti- gate the confusion that arises in an attack and in grey zone situations.

CRediT authorship contribution statement

Fredrik Granholm: Writing – review & editing, Writing – original draft, Conceptualization. Derrick Tin: Writing – review & editing, Writing – original draft. Gregory R. Ciottone: Writing – review & editing, Writing – original draft, Supervision.

Declaration of Competing Interest

We declare no conflicts of interest and no financial interests.

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