Terrorist Attacks Against Healthcare Facilities: A Review

Introduction

Terrorism is the “threatened or actual use of illegal force and violence by a nonstate actor to attain a political, economic, religious or social goal through fear, coercion or intimidation.” ¹ Hospitals and healthcare facilities have an essential role in the response to terrorist attacks. In the aftermath of such attacks, healthcare facilities must be integrated into the response framework and quickly treat often complex ballistic and blast injuries to reduce morbidity and mortality. ² Hospitals and healthcare facilities not only treat victims of terrorism, they are also the direct targets of terrorist attacks. These facilities are considered “soft targets” because they are publicly accessible, operate 24 hours a day, ³ and security is generally limited compared with other government buildings. ⁴ Their vulnerability to terrorist attacks is well documented and remains a significant concern.^5,6

Prospective terrorists target healthcare infrastructure for several reasons. First, damage to the physical structure of the healthcare facility can significantly reduce the operational capacity of the facility, and prevents it from serving as a resource for community emergency medical services. Delays in delivering emergency care may result in increased ambulance boarding and extended emergency response times. ⁷ In addition to damaging the physical space, injuring healthcare workers also reduces the community's ability to respond to the attack and increases the number of casualties, both directly and indirectly,^5,8 due to the inability of healthcare workers to care for others injured in the primary attack. Finally, damage to a healthcare facility has significant psychological effects on communities when they perceive that trusted institutions of healing have been transformed into targets of violence. ⁹ This is due to a phenomenon known as “personalization,” in which a person's familiarity and experience with hospitals evokes fear that such an attack could have easily involved them or a loved one. ¹⁰

Concerns about attacks against healthcare facilities are ever present—terrorists do not adhere to the articles set forth by the Geneva Convention and hospitals represent targets that are both vulnerable and valuable. Any disruption in providing medical care can have long-lasting effects on the population. Proactive actions are therefore paramount to protect hospitals and healthcare facilities from terrorist attacks. A key step toward mitigation and preparedness against future attacks is to review past attacks against healthcare facilities.

Physician organizations, the media, and geographical case studies have reported violence against healthcare workers and facilities in the medical literature.^10-12 However, no comprehensive analysis of all terrorist attacks against healthcare facilities has been conducted. This study seeks to add to the paucity of literature by using the Global Terrorism Database (GTD) ¹ to conduct a comprehensive analysis of documented instances of terrorist attacks against hospitals and healthcare facilities.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard, ¹³ we performed a search of the GTD to identify instances of terrorist attacks against hospitals and healthcare facilities. The GTD is an open-source database that includes information on terrorist events from 1970 to 2018. ¹ The National Consortium for the Study of Terrorism and Responses to Terrorism (START) maintains the GTD and makes it publicly available in an effort to improve understanding of terrorist violence. START is based at the University of Maryland and is a US Department of Homeland Security Center of Excellence.

To qualify for inclusion in the database, a terrorist incident must fit the following definition as set forth by the GTD codebook: “The threatened or actual use of illegal force and violence by a non-state actor to attain a political, economic, religious, or social goal through fear, coercion, or intimidation.” ¹ Additionally, all 3 of the following attributes must be present:

The incident must be intentional.

And, 2 of the 3 criteria must be present:

The GTD includes a total of 191,465 incidents reported between 1970 and 2018. We identified healthcare-related entries using the search terms “healthcare,” “doctor,” “nurses,” “vaccinators,” “clinic,” and “hospital,” resulting in 2,322 healthcare-related entries. We then manually searched the dataset for incidents related to attacks on healthcare facilities, excluding ambiguous incidents that did not specifically relate to attacks on healthcare infrastructure. This resulted in a total of 901 attacks.

Data compiled in the GTD were obtained from 2 different sources. The raw data compiled on terrorist attacks between 1970 and 1997 were first acquired from the Pinkerton Global Intelligence Service—a private security agency; these were handwritten records digitalized in 2005. Data obtained between January 1998 through March 2008 were obtained from the Center for Terrorism and Intelligence Studies. The Center for Terrorism and Intelligence Studies then transitioned to the Institute for the Study of Violent Groups from March 2008 until October 2011. Beginning in November 2011, START staff at the University of Maryland assumed responsibility for conducting all data collection for the GTD. Data were collected through both automated and manual strategies, including daily media article sources that describe terrorist attacks in multiple languages. Data are further autonomously refined to prevent duplicate incidents and manually reviewed before incorporating into the database. For an event to be recorded in the GTD, it must be documented by at least 1 high-quality source, defined as an independent source (free of influence from governments, political perpetrators, or corporations) that routinely reports externally verifiable content from primary sources.

Results

In our search of the GTD, we identified 901 incidents that involved terrorist organizations targeting healthcare facilities. These documented intentional attacks occurred between 1970 and 2018, with 515 of those attacks occurring after September 11, 2001, and the subsequent launch of the Global War on Terrorism. The attacks on healthcare facilities affected a total of 74 countries worldwide. The largest number of attacks occurred in the United States (251 attacks), followed by Pakistan (97 attacks) and Iraq (93 attacks) (for full list of attacks on healthcare facilities by country, see Supplemental Table 1 www.liebertpub.com/doi/suppl/10.1089/hs.2021.0004). The highest frequency of attacks occurred in 2014 with 75 attacks, followed by 65 in 2015, and 50 in 2013. No attacks were documented in 1972, 1974, 1976, or 1993 (for full list of number of attacks by year, see Supplemental Table 2, www.liebertpub.com/doi/suppl/10.1089/hs.2021.0004).

As for the methods used in these incidents, 480 attacks involve explosives, 243 attacks targeted healthcare infrastructure, 117 attacks were armed assaults, and 31 attacks involved taking hostages. There were also 9 assassinations, 5 unarmed assaults, 1 hijacking incident, and 15 attacks that involved an undocumented attack method (Table 1). Targets of healthcare-related attacks were classified as abortion-related, educational institutions, businesses, governmental institutions, military and police, nongovernmental organizations, private citizens and property, religious figures and institutions, terrorists and nonstate militia, and other (Table 2).

We further classified the targeted healthcare facilities as hospitals, clinics, healthcare centers, and others. Of the 901 attacks, 418 occurred at hospitals, 360 at clinics, 76 at healthcare centers, and 47 at other healthcare facilities (Table 3). Unknown groups and individuals conducted the majority of these attacks, accounting for a total of 357 attacks, followed by 226 attacks inflicted by anti-abortion groups, 25 attacks by the Islamic State of Iraq and the Levant, and 23 attacks by Houthi extremists (Ansar Allah) (for full list of groups claiming responsibility for attacks, see Supplemental Table 3, www.liebertpub.com/doi/suppl/10.1089/hs.2021.0004). Of the 901 attacks, 793 were successfully conducted; 40 were performed as suicide attacks. The majority of incidents (n = 754) involved a single attack and 147 of the incidents involved multiple attacks. A total of 1,500 victims were killed and 2,359 victims were wounded.

Discussion

This study is the first analysis of terrorist attacks against healthcare facilities using the GTD database, based on our searches of PubMed and Google Scholar. Terrorist organizations target healthcare facilities for many reasons. In addition to the potential for enormous loss of life, targeting healthcare facilities also provides an opportunity for terrorists to disrupt a community's emergency response capabilities and inflict psychological trauma on the population.^5,7-9

Of the 901 incidents of terrorist attacks against healthcare facilities identified in our search of the GTD, 515 (57%) occurred after 2001. The last 10 years of data (2008-2018) show a particularly troubling trend, with each year recording over 20 attacks, and the most in a single year occurring in 2014 (n = 75). This suggests that terrorist organizations are not only increasing their attacks against healthcare facilities but they are also becoming more comfortable targeting these types of facilities.

The increasing frequency of attacks speaks to the overall vulnerability of healthcare infrastructure. Unlike traditional military or government targets, healthcare facilities have limited security, are easily accessible to the public, and are often located in populated areas.^4,5 These factors open up numerous opportunities for attack. Additionally, terrorist organizations are not bound by the Geneva Convention that prohibits conventional military forces from purposefully targeting healthcare facilities. ¹⁴ This increased targeting by terrorist organizations speaks to the need for hospital administrators to create and practice disaster and contingency plans to include direct attacks on the hospital. Terrorist attacks on healthcare facilities are becoming more common and facilities must be prepared.

Moreover, the GTD shows that many terrorist groups have conducted attacks against healthcare facilities. Over 137 terrorist groups have carried out attacks in 74 countries (Supplemental Table 3, www.liebertpub.com/doi/suppl/10.1089/hs.2021.0004). These groups represent a wide range of political, religious, and ideological beliefs. This suggests that terrorist organizations, regardless of their motivations, view healthcare facilities as viable targets and will continue to target them to further their agenda.

Interestingly, the data show that not all healthcare facilities targeted were involved in a community's emergency response. The most striking example is abortion facilities, which account for 249 (28%) of all reported attacks. Although no concrete conclusions can be made by this association, it is hypothesized that attacks on these facilities are not designed to disrupt the emergency response apparatus; rather, they are done purely to advance ideological and political agendas. Most attacks against abortion facilities have occurred in the United States, which is perhaps unsurprising because the issue of abortion is highly entangled with US politics and religion.^15,16 These data suggest that healthcare facilities providing services that may be considered controversial or immoral to certain segments of the population are at an increased risk of attack. These facilities require special considerations when it comes to threat mitigation and security planning.

The most common method of attack against healthcare facilities was bombings (n = 480). Terrorist organizations frequently use bombings against many types of targets because they inflict casualties with minimal risk to the terrorists. In addition to physical injuries, bombings also have a psychological toll on victims, as they are often viewed as random and hard to defend against. The fact that bombings are the most common type of attack used against healthcare facilities suggests that terrorist organizations are using tactics that are most familiar to them. This also highlights inherent vulnerabilities within the healthcare infrastructure.

The majority of attacks against healthcare facilities were single attacks. Only 147 (16%) of the 901 attacks against healthcare facilities were part of a multisite attack. The majority of terrorist organizations appear to be targeting healthcare facilities as single-site attacks, which is interesting because there are many documented cases of secondary attacks on emergency personnel responding to attacks.^17-19 Based on data from the GTD, however, many of these secondary attacks did not seem to target the actual healthcare facilities and infrastructure involved in responding to a terrorist attack. Executing successful concurrent primary and secondary attacks requires a significant degree of organization and coordination of multiple resources and personnel. Most likely, the relatively low frequency of healthcare facilities being targeted in multisite attacks is due to the logistical difficulty in achieving such an event rather than terrorist organizations' respect for the sanctity of the healthcare's lifesaving mission. An increase in the number of multisite attacks that involve healthcare facilities should prompt concern that terrorist organizations are gaining increased experience and comfort carrying out this complex mode of attack.

The low proportion of multisite attacks found in this study may be due to our inclusion of attacks against all healthcare facilities. Facilities such as abortion centers, as discussed earlier, are not a part of the emergency response apparatus and may be targeted for reasons other than increasing the number of casualties from an attack. A study that focuses on attacks specifically against hospitals may show a larger proportion of multisite attacks because of the important role hospitals play in the response to a terrorist event and is worth investigating.

Our study shows that healthcare facilities are especially vulnerable to attacks by terrorist organizations. Healthcare leaders and security experts should therefore work to ensure that their community's healthcare facilities are prepared not only to respond to a terrorist event but also to protect themselves from such an event. The GTD does not currently include information on possible motives for these attacks, but understanding these motives is necessary for mitigating and disrupting the attacks. Investigating the motives and origins of terrorist attacks would help policymakers, healthcare center administrators, and security experts mitigate them.

The database contains a variety of terms to describe different clinical settings such as clinics, healthcare centers, and hospitals. Some entries include terms such as “doctor's office,” “women's center” or “fertility center,” all of which did not provide the exact description of the nature of these clinical settings. Hence, the analysis of data does not accurately reflect the proportion of attacks that occurred at different clinical settings. The lack of standardization of entries in the database led us to create a separate category of “other” facilities, which includes facilities not clearly described as clinics, healthcare centers, or hospitals. These entries describe facilities as “basic health unit,” “health post,” “unknown medical facility,” “medical compound,” or “medical facility.” We also included miscellaneous entries such as “morgue” and “Ebola quarantine center” in the “other” category. Multiple entries were missing information on the total number of victims killed or wounded, which led to an inaccurate reflection of the total number of victims resulting from attacks on healthcare facilities.

This retrospective study of terrorist attacks on healthcare facilities was supported by the University of Maryland and relied on a government-funded database. The sources of data include government and private partnerships as well as media. There is limited means to confirm or verify these data and to determine the extent of underreporting. It is possible that better reporting, and increased ability to confirm attacks, contributed to the increase in the number of attacks recorded in recent years. Additionally, the database itself does not include foiled or failed plots, attacks in which violence is threatened as a means of coercion, incidents reported from low-quality sources, or attacks in conflict zones where the combatant may be “national” and fall out of the inclusion criteria of the GTD. The limited availability of high-quality sources in certain geographic areas results in conservative documentation of attacks in those areas. There is also a gap in data collection from 1993 as the handwritten report cards were lost, although some data were recovered. ¹ Because terrorism is a public safety and national security issue, there is a theoretical concern that the true nature, mechanism, and extent of some attacks could have been altered to avoid providing terrorists the means to incorporate evidence-based data into their attack planning. All of these factors may mean that the true incidence of healthcare facilities being targeted in terrorist attacks is underreported or misreported. The GTD also does not include contextual information for these attacks such as the political, economic, or health conditions in the country. Therefore, it is unclear if events such as civil wars or epidemics were related to attacks on healthcare facilities. Because of the retrospective nature of this study, no statements of causality can be made.

Conclusion

Hospitals and other healthcare facilities play a vital role in any response to an intentional attack. Yet, their lifesaving mission does not shield them from becoming targets of terrorist attacks themselves. Many different terrorist organizations, spanning numerous countries and countless ideologies, have targeted healthcare facilities to further their agendas. Counterterrorism experts and leaders in healthcare must be aware of this threat and coordinate their efforts to disrupt attacks against hospitals and other crucial healthcare infrastructure.