Terrorist Attacks Against Emergency Medical Services: Secondary Attacks are an Emerging Risk

Abstract

Introduction: Terrorists increasingly aim at so-called soft targets, such as hospitals. However, little is known about terrorist attacks against Emergency Medical Services (EMS). Objective: This study aims to review all documented terrorist attacks against EMS that occurred world-wide from 1970-2019 using the Global Terrorism Database (GTD). Methods: Reports of terrorist attacks against EMS were extracted from the GTD from 1970-2019. Data collection included temporal factors, attack and weapon type, number of casualties, and if it was a primary or secondary attack (secondary attack: deliberate attack against the first responders of an initial terrorist attack). Reports were excluded if EMS were not a target or if it was unclear whether they were a target. Chi-square tests were performed to evaluate trends over time. Results: There were 184 terrorist attacks against EMS, resulting in 748 deaths and 1,239 people injured. Terrorist attacks against EMS significantly increased over the past two decades. The “Middle East & North Africa” was the most frequently affected region with 81 attacks (44.0%) followed by “South Asia” with 41 attacks (22.3%). Bombings and explosions were the most common attack type (85 incidents; 46.2%) followed by armed assaults (68 incidents; 35.3%). Combined prehospital and hospital attacks were first reported in 2005 and occurred seven times. The first secondary attack against EMS dates from 1997, after which an increase was observed from 10 to 39 incidents in the periods 2000-2009 and 2010-2019, respectively. Conclusions: This analysis of the GTD, which identified 184 terrorist attacks against EMS over a 50-year period, demonstrates that terrorist attacks against EMS have significantly increased during the years and that secondary attacks are an emerging risk. Bombings and explosions are the most common attack type. Terrorist attacks against EMS are most prevalent in countries with high level of internal conflicts, however, they have also occurred in western countries. These incidents may hold valuable information to prevent future attacks.

Hybrid warfare and counter-terrorism medicine

“…Since the start of the Ukrainian war, multiple attacks against healthcare workers and facilities have been reported [ 3 ]. Ambulances have been shot at, hindered, used as Trojan horses and targeted in secondary attacks, something witnessed in other acts of terrorism [ 9 , 10 ], and multiple hospitals have sustained indiscriminate or deliberate attacks, all certifying that this invasion constitutes hybrid warfare.…”

“…After the 2022 Russian invasion of Ukraine, the UHC team concentrated on war-related initiatives, collecting, verifying and documenting data points similar to those published in many recent CTM research articles: attack modalities and weapons used, death and injury tolls, and damage sustained to critical health infrastructure [ 9 , 10 , 17 ].…”

An Epidemiological Analysis of Terrorism-Related Attacks in Eastern Europe from 1970 to 2019

“…18 Previous studies found four terrorist attacks against Emergency Medical Services (EMS) in Eastern Europe from 1970 through 2019 (two percent of 184 world-wide attacks) and 13 terrorist attacks against hospitals in the region (three percent of 454 world-wide attacks). 19,20 During the Russo-Ukrainian war, over one-third of the hospitals and clinics in the Donbas region of Ukraine had been damaged or destroyed from early 2014 through 2017. 21 Chechen separatists' suicide bombing attacks in 2010 on Moscow's transport system, a combination that is particularly lethal, ISIL's 2017 St Petersburg Metro bombing, and the escalation of the Russo-Ukrainian conflict in early 2022 are all causes for concern for modern-day Russia and the surrounding region's health care systems.…”

Primary Care as Primary Target: A Review of Terrorist Attacks Against Primary Care Providers and Their Offices

“…From 1970 through 2019, there were 454 terrorist attacks against hospitals and 148 terrorist attacks against Emergency Medical Services causing 2,381 fatalities and 4,016 injured. 1,2 In the same period, vaccinators have been targeted 133 times, most of which have occurred since 2010. 3 Despite their pivotal role in health care, little is known about the risk for primary care providers (PCPs) and their offices as targets of terrorism.…”