Two forms of world violence, international terrorism and major armed conflicts, have escalated exponentially in the post-world wars era. Since 1945, 160 wars and armed conflicts resulted in an estimated 22 millions deaths and over 60 million injuries. Between 1990 and 2000, 56 different major armed conflicts in 44 different locations were recorded, with 25 conflicts still active in 2000.^1,2 Similarly, since 1968 over 14,000 international terrorist attacks have taken place throughout the world.^3,4

Similar characteristics exist between the recent armed conflicts and the various conventional terrorist incidents in terms of demographics, method of wounding, causes of injury, risk factors and the implications for the trauma and critical care communities.

An extensive review of governmental documents and published experiences dealing with wartime injuries and prominent international terrorist incidents from 1961-2001 revealed specific trends in demographics, etiologies and methods of wounding. 392 terrorist incidents from 1961 to 2001 resulted in 27,312 casualties and 5,682 deaths resulted. 70% of all terrorist incidents were against civilian targets which constituted 92% of all casualties. Bombings were the most frequent terrorist events (44%) and accounted for 74% (20,221) of all casualties and over 90% of all death. Similar results were observed in recent wars. Civilians were the major targets in recent armed conflicts and accounted for most of the killed and wounded (80-90%).  A shift toward more powerful explosive devices (artillery shells and mines) was also noted. Whereas non civilian victims (army, paramilitary, government agents) were mainly male and restricted to the 21- to 40-year old age group in both armed conflicts and terrorist incidents, civilians victims were of all ages and genders. The risk factors for lethal injuries identified in both wartime and terrorist incidents were similar and included (1) the intentional targeting of civilians (2) the confinement of a large number of people in a single area (bomb shelters and hospitals in the armed conflicts, transportation vehicles such as buses and commercial airplanes in the terrorist incidents)  (3) personal and environmental vulnerability of the targeted victims and (4) the exponential increase in firepower and lethality of modern explosives. These factors also lead to higher mortality rates among critically injured survivors due to the enormous number of wounded from secondary blast injuries that can overwhelm triage, treatment, and resource/personnel allocation. An epidemiological shift in the demographics of the victims and lethality of injuries corresponds to the shift in targeting of civilians and the methods of fatal wounding.

Strong data therefore exist regarding conventional terrorist incidents, and armed conflicts. History however points to various rare but key incidents where non-conventional methods were used in armed conflicts and war situations to alter the course of significant historical victories. The question is: Can such non-conventional methods be similarly used by terrorist groups to alter the course of history? It is long known and feared that the perfect weapon for mass destruction and hysteria is germ warfare or biological terrorism.

Unlike the history of conventional weapons and terrorism, the history of biological warfare is confounded by several factors including 1) difficulties confirming allegations of biological attacks 2) lack of reliable microbiological and epidemiological data 3) the use of allegations of biological attack for propaganda and 4) secrecy surrounding biological weapons program. ⁵   It is clear that significant efforts and skills are needed to carry out large scale biological terrorist attacks. This has led to the appropriate skepticism regarding the plausibility and immanency of such attacks.  However the most devastating terrorists attack on both military and civilians were successful because of lack of imagination and inappropriate preparation of the victims. This was clearly demonstrated in the 1983 attack on the US Marines in Beirut Lebanon, and the 2001 attack on the World Trade Center in New York, USA.

The implications to the international aid agencies and to the trauma and critical care communities are highly significant.  Prevention strategies, targeted preparation and medical response toward the disease agents with the greatest potential for bioterrorism (Anthrax, tularemia, plague, smallpox, botulism toxins, and viral hemorrhagic fevers, such as Ebola) must be developed.

References

1. Taylor B. Seybolt. Major armed conflicts. SIPRI yearbook 2001. Armaments, disarmaments and international security. Oxford: Oxford University Press, 2001

2. Wallensteen, Peter & Margareta Sollenberg.Armed Conflict, 1989–98. Journal of Peace   Research, Vol. 36, No. 5, 1999

3. Federal Bureau of Investigation, Terrorism in the United States .Washington, DC: FBI, 1999.

4. U.S. department of State. Patterns of Global Terrorism. 1999.

5. Christopher et al. Biological warfare: A historical Perspective. United States Army Medical Research Institute of Infectious diseases, Fort Detrick, Maryland, 2001.