a b s t r a c t

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 data- base 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.

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1. Introduction

Emergency departments (EDs) fulfill a unique role in the healthcare system, remaining open at all hours to care for the injured and ill. In times of disaster, EDs play an integral part in receiving and treating ca- sualties. Ease of access can render EDs vulnerable to terrorist attacks seeking to disrupt a community’s emergency response apparatus. Characterization of previous attacks targeting EDs can inform future mitigation and Prevention efforts. This report analyzes attacks against EDs documented in the Global Terrorism Database.

1. Methods

The Global Terrorism Database is an open-source collabora- tive publication produced by the National Consortium for the Study of Terrorism and Responses to Terrorism (START; College Park, Maryland, USA). The database reports intentional incidents perpetrated by sub- national actors that entail a degree of violence or an immediate threat of violence. In order for an incident to be included in the GTD, it must satisfy two of the three following criteria:

• • Corresponding author at: 110 S Paca St 6^th floor, Ste 200, Baltimore, MD 21201, USA.

E-mail addresses: [email protected] (G. Jasani), [email protected] (S.Y. Liang).

• • 1. There must be evidence of an intention to coerce, intimidate, or con- vey some other message toa larger audience than the immediate victims,
    2. The act must be aimed at attaining a political, economic, religious, or social goal, and,
    3. The action must be outside the context of legitimate warfare activities.

Between 1970 and 2018, a total of 191,465 global incidents were identified by the GTD. A total of 2322 healthcare-specific incidents were isolated using the search terms “doctor,” “nurses,” “hospital,” “healthcare,” “clinic,” “vaccinators,” and “vaccinations.” This database was further narrowed down to terrorist attacks targeting EDs, using the search terms “emergency,” “emergency department,” and “emer- gency ward.” To ensure that these entries accurately represented at- tacks targeting EDs, a manual review of each entry was performed to confirm appropriateness for inclusion in the analysis. This study was de- termined to be exempt from review by the Washington University School of Medicine Human Research Protection Office.

1. Results

Six terrorist attacks targeting EDs were identified in the GTD, affect- ing five countries. Two attacks occurred in Pakistan, and the remaining

https://doi.org/10.1016/j.ajem.2022.11.011

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Table 1

Attacks on EDs documented in the GTD.

Year	Country	Attack Type	Weapon Type	Suicide	Group Name	Number Killed	Number Wounded
1991	India	Bombing/	Explosive Device	0	Sikh Extremists	0	0
2004	Iraq	Explosion Bombing/	Unknown	1	Unknown	6	0
2010	Pakistan	Explosion Bombing/	An improvised explosive device	0	Jundallah (Pakistan)	13	20
2010	Pakistan	Explosion Armed Assault	Unknown	0	Unknown	1	5
2011	Columbia	Bombing/	Grenades and mortar rounds	0	National Liberation Army of Colombia (ELN)	0	1
2016	Syria	Explosion Bombing/	Explosives-laden belt and three rockets	1	The Islamic State of Iraq and the Levant (ISIL)	37	0
		Explosion

attacks occurred in India, Iraq, Colombia, and Syria. The first instance of a targeted attack occurred in 1991. The next attack occurred in 2004, followed by two attacks in 2010, one in 2011, and one in 2016. Most attacks involved an explosive device; one attack involved an armed assault. An explosive-laden belt and three rockets were used in one attack, grenades and mortar rounds were used in another attack, an explosive device was used in two attacks, and two attacks involved the use of an unknown weapon. Two of the attacks involved suicide bombings. The total number of victims killed in these attacks was 57; 26 were wounded. (Table 1)

1. Discussion

Emergency departments are expected to play a central role in the healthcare response following a terrorist attack. This also makes them potential targets for terrorist organizations looking to disrupt a community’s emergency response capabilities. Previous studies have examined terrorist attacks against hospitals and healthcare facilities [1-3], but this study is, to our knowledge, the first to explore terrorist at- tacks that have specifically involved EDs.

The impact of a terrorist attack directed against an ED can be several-

fold. The attack itself may result in immediate casualties among those physically present in the ED at the time of the attack. However, patients relying upon the ED later for emergency care unrelated to the attack can become secondary casualties due to the loss of Healthcare personnel, lifesaving medical equipment, and patient care areas. An attack against an ED can therefore impact a disproportionate number of people.

EDs remain open to the public at all hours of the day or night, provid- ing lifesaving care. However, this ease of access to healthcare in the ED can also pose a risk. EDs must be cognizant of the direct threat that ter- rorist attacks may pose. Two attacks documented in the GTD involved suicide bombers who were able to gain access to the ED. This would seem to highlight the need to increase security and screening for anyone attempting to access the treatment area of the ED. In 2018, over 30,000 weapons were confiscated from individuals entering Cleveland Clinic- affiliated facilities [4]. Domestically, screening practices for individuals entering EDs vary widely, with no uniform standards or best practices in place [5]. However, increased security measures may also have the unintended consequence of decreasing public access to ED services. The openness of EDs is central to their mission within the healthcare system, and any action that would limit this could be antithetical to their identity as a safety net for the community. Such measures need to be undertaken with extreme care, and efforts should be made to find the ideal balance between physical security and maintaining open, easy access to the ED by the general public.

The GTD currently has six instances of documented terrorist attacks against EDs, confined mostly to the Middle East and Southeast Asia. However, this is likely an underestimate of the true toll that terrorist at- tacks have taken on EDs globally. The GTD currently has 430

documented instances of attacks targeting hospitals [2]. However, many do not specify which part of the hospital was involved. This is, of course due to the retrospective nature of the GTD as well as the fact that independently verifying reports globally can be challenging. Simi- larly, the GTD does not account for threats of violence that were not acted on. In the U.S., Boston Children’s Hospital (BCH) received several bomb threats in response to the provision of care to transgender chil- dren [6]. Threats of violence can be disruptive in themselves and dis- suade patients from seeking care in hospitals. Sadly, other hospitals have been targeted for similar reasons [6]. It is likely that more EDs have been targeted than those described in this study. Further studies are certainly warranted to determine both the true toll that terrorist at- tacks have taken on EDs and best practices to mitigate these threats.

1. Limitations

This analysis was a retrospective, university-sponsored, government- funded database search of unclassified terrorist attacks. The source of the data is government and private partnerships of reported incidents in a non-classified database. There is no reliable way to know how many at- tacks are not reported. Additionally, the database itself does not include foiled or failed plots, attacks in which violence is threatened as a means of coercion, nor acts of violence carried out against EDs by state- sponsored organizations such as military forces. There is also a gap in data collection from 1993 as the handwritten report cards were lost, how- ever, some data was recovered [7]. Since this is a security issue, there is a theoretical concern that the true nature, mechanism and extent of some attacks can be altered to avoid giving terrorists the means to incorporate evidence-based data into their attack planning. Due to the retrospective nature of this brief report, no statements of causality can be made.

The significance of this data, however, shows that terrorist organiza- tions can and have targeted EDs to further their agenda and have the ability to cause significant morbidity and mortality. All attacks reported occurred in either the Middle East or South Asia. The applicability of this data for local risk stratification is reasonably questioned, especially given Regional variations in security practices, infrastructure protection, healthcare delivery, and cultural norms. The goal of this brief report, however, was to show that terrorist attacks against EDs have historical precedence so that healthcare personnel and security experts can in- creasingly work to mitigate such actions.

1. Conclusion

While rare, terrorist attacks against EDs can lead to significant loss of life both through the immediate attack and subsequent disruptions to the healthcare system. EDs must strive to create a safe and secure envi- ronment while not discouraging patients from seeking care.

Author contributions

GJ and SL conceived the study. RA and SL conducted the review of data from the GTD to determine relevant data. GJ and SL did data anal- ysis and authored the manuscript. All authors edited the manuscript.

CRediT authorship contribution statement Gregory Jasani: Writing - review & editing, Writing - original draft,

Conceptualization. Reem Alfalasi: Investigation, Formal analysis,

Data curation. Stephen Y. Liang: Writing - review & editing, Writing -

original draft, Investigation, Conceptualization.

Declaration of Competing Interest

The authors have no conflicts of interest to declare.

Acknowledgments

SYL received support through the Foundation for Barnes-Jewish Hospital and the Washington University Institute of Clinical and Trans- lational Sciences which is, in part, supported by the NIH/National Center for Advancing Translational Sciences (NCATS), Clinical and Translational Science Award (CTSA) program (UL1TR002345).

References

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