Continuous Exposure to Terrorism during the COVID-19 Pandemic: A Moderated Mediation Model in the Israeli Context.

This study tested the role of perceived social support as a moderating factor in the mediation of COVID-19-related concerns in the association between continuous traumatic stress (CTS) and depression. The study participants were 499 college students who responded to an anonymous online questionnaire. Measures included the assessment of prior continuous exposure to threats of terrorism, COVID-19-related distress, perceived social support and depressive symptoms. The results demonstrated that COVID-19-related concerns mediated the relationship between continuous exposure to threats of terrorism and depression symptoms, and that perceived social support moderated the association between COVID-19-related concerns and depression. The implications of the study highlight the role of prior exposure to traumatic stress as a risk factor for depression and the role of social support as a protective factor. These results point to the need to develop accessible and non-stigmatic mental health services for populations exposed to other types of continuous traumatic stress.

[Management of Clinical Capacity Overload Due to Mass Patient Influx]. / Management einer klinischen Kapazitätenüberlastung durch Massenanfall von Patienten.

Hospitals play a crucial role in the management of large-scale emergencies or disasters. This has been clearly demonstrated by the recent terrorist attacks in Europe, by the SARS-CoV-2 pandemic, and currently by the Ukraine war. In order to cope with extraordinary situations and large-scale emergencies, such as mass casualty incidents, hospitals need to be prepared in detail - by preparing and implementing a hospital contingency plan. The article presented here describes in hospital preparation for a mass casualty incident.

The manipulation of minds:reckoning with the legacy of the american post 9/11 torture program.

In this article, we argue that the government's post 9-11 torture program was a big lie, in that the designers, executors and enablers knew all along that torture does not elicit reliable information. We review the government's own research on the matter, and we discuss the ways in which methods known to be unreliable were implemented, most saliently at the detention facility at Guantánamo Bay. We review the secrecy and propaganda surrounding the scope and horror of the torture program at Guantánamo and black sites around the world, and the painful truth of how the government knowingly adopted the terror policies of the torture program, against their own knowledge, against international human rights, and against the law. On January 20, 2021, Joseph R. Biden, Jr. became the 46th President of the United States, following what might very well have been the most chaotic election in the recent history of the United States. The turmoil reached a peak on Jan 6, 2021, when Trump supporters stormed the Capitol in Washington, DC. At the center of this extended and ongoing political upheaval is what has been labeled "The Big Lie" - the completely disproven notion that Biden's win was based on fraudulent grounds, and that the election was stolen from Trump because of a corrupted voting process. President Biden has consistently rejected reality warping and presents himself on the national stage as a man of reason, and a strong supporter of science. He has proclaimed "Science is discovery. It's not fiction", as he announced that his team of scientific advisors would summon "science and truth" to combat climate change, the COVID-19 pandemic and other challenges facing his new administration, adding "The same laws apply, the same evidence holds true regardless of whether you accept them." President Biden can show his self-proclaimed commitment to truth by following through on his words with action. In particular, he can fulfil the task which his two predecessors, Trump and Obama, both failed to do: Closing the detention facility at Guantánamo Bay. The same United States law and international law apply; the same evidence, or lack thereof holds true for those remaining 38 prisoners being held within the confines of a US-run concentration camp in the Caribbean. The laws of science apply, the rules of evidence apply, and the rule of law applies. Science and truth cannot be situationally applied to suit political agendas, especially not within the confines of a facility once called a "Battle Lab" (Leopold, 2015), where the military touts phrases like "honor bound" and "defend freedom" at the entrance, yet the truths of what goes on inside are withheld from the public record, via the government's complex layers of secrecy, including classification, redactions, and obfuscations. There can be no justice without truth. The system has derailed every effort to bring the suspected 9/11 terrorists to justice before tribunals that have failed and have been derailed by torture. While President Biden can't remove the stain of the national torture policies, he can show that the Constitution endures; that the rule of law prevails, by illuminating the shadowland of the torture regime. Joe Biden needs to demonstrate that truth matters - even painful truths. In this article, we will describe that through a painstaking and laborious process of discovery, we now know that behind the gates of Guantánamo Bay and its related archipelago of black sites there were prisoners, often held on dubious grounds or no reasonable grounds at all. We know that these prisoners were submitted to treatments aimed squarely at generating complete psychological disintegration. As we will lay out in the article, prisoners captured during Operation Enduring Freedom and Operation Iraqi Freedom were subjected to physical violence, sexual violence, and an astonishing array of psychologically abusive tactics under the misnomer 'interrogation'. We also know that the torture program metastasized into a monster, as if lifted from the pages of the most absurd of postmodern fictions, and that the United States has never held anyone accountable, nor faced any reckoning for this disaster of human rights (Senate Select Committee Study of the Central Intelligence Agency Detention and Interrogation Program, 2014). And we know that the disaster that was the torture program was all based on lies, one big lie in particular - that torture worked to break through to truth. The chief argument, which we will defend below, is that the schemers behind the system of torture knew all along that this was bogus; that torture does nothing to produce truth, that what it breaks is a person's autonomy and very selfhood, rendering them compliant in the extreme. Indeed, the CIA and United States military, who both committed war crimes, knew all along that they propagated falsehoods - our main argument is that the historical record shows that the CIA itself has a long history of studying precisely the effect of techniques like those employed post 9/11. As we shall see, the so called architects had no interrogation experience, but were well-versed in communist-based methodologies known to produce false information.

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

BACKGROUND: Violence against primary care providers (PCPs) has increased during the current pandemic. While some of these violent acts are not defined as terrorist events, they are intentional events with an aim to disrupt, kill, or injure. Despite their pivotal role in health care, little is known about the risk for PCPs as targets of terrorism. METHODS: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all terrorist attacks against PCPs and their offices from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary attack and weapon type, location (country, world region), and number of deaths and injuries were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: There were 29 terrorist attacks against PCPs and their offices from 1970-2019. The majority of attacks occurred during or after 2010. There were 58 fatalities, 52 injured, and 13 hostages. Most documented attacks took place in Pakistan, the United States, and Sri Lanka. Bombings concerned 55% of cases and 21% were hostage-takings. CONCLUSION: Although less common than attacks on other health care related targets, terrorist attacks against PCPs have occurred. The majority of attacks occurred during the last decade. Future studies are warranted to further assess the risk of terrorist attacks against PCPs: before, during, and beyond the current pandemic.

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

INTRODUCTION: Over the past five decades, Eastern Europe has seen relatively little in terms of terrorist attacks. The recent escalation of the Russo-Ukrainian conflict has, however, placed a new spotlight on the region, and new questions and concerns around war, conflict, insurgency, and terrorism are being posed. The Russian invasion and extensive combat operations, the largest in Europe since World War II, are occurring across Ukraine where there are 15 active nuclear reactors, not including the Chernobyl site, that are vulnerable to attack or sabotage. In addition, Eastern Europe has been heavily affected by COVID-19, exposing broad vulnerabilities in an otherwise fragile health care system. This raises concerns over the ability of Eastern European health care institutions to absorb surge and manage terrorist attacks or acts of violent extremism. This study provides an epidemiological description of all terrorism-related fatalities and injuries in Eastern Europe sustained from 1970 - 2019. METHOD: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database functions for all terrorism events which occurred in Eastern Europe from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of this study. Primary weapon type, country where the incident occurred, and number of deaths and injured were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: There were 3,901 terrorism-related events in Eastern Europe between the years 1970 and 2019, inclusive. In total, the attacks resulted in 5,391 deaths and 9,538 persons injured. Explosives were the most commonly used weapon type in 59.2% of all attacks in the region, followed by firearms in 27.6%. CONCLUSION: From 1970 through 2019, a total of 3,901 terrorist attacks occurred in Eastern Europe, inflicting 5,391 deaths and 9,538 injuries. Of those, 72.3% occurred in Russia and Ukraine. Terrorist attacks sharply declined since the peak in 2014, but there is an overall uptrend in attacks since the 1970s.

The Impact of a Workplace Terrorist Attack on the Psychosocial Work Environment: A Longitudinal Study From Pre- to Post-disaster.

The psychosocial work environment is of great importance for regaining health and productivity after a workplace disaster. Still, there is a lack of knowledge about the impact of a disaster on the psychosocial work environment. The purpose of this study was to examine whether employees' perceptions of role clarity, role conflicts, and predictability in their work situation changed from before to after a workplace terrorist attack. We combined data from two prospective work environment surveys of employees in three governmental ministries that were the target of the 2011 Oslo terrorist attack. A first two-wave survey was conducted 4-5 years and 2-3 years before the attack, and a second three-wave survey took place 10 months, 2 years, and 3 years after the attack. Of 504 individuals who were employed at the time of the bombing, 220 were employed in both pre- and post-disaster periods, participated in both the first and the second survey, and consented to the linking of data from the two surveys. We found no significant changes in levels of role clarity, role conflict, and predictability from before to after the terrorist attack. Adjusting for sex, age and education had no effect on the results. The findings suggest that perceptions of the psychosocial working environment are likely to be maintained at previous levels in the aftermath of a workplace disaster. Considering the importance of the psychosocial work environment for regaining health and productivity, the findings are important for the preparation for, and management of, future crises.

Bioterrorism: An analysis of biological agents used in terrorist events.

BACKGROUND: The Covid19 pandemic has reignited debates and discussions around healthcare systems' biosecurity vulnerabilities and cast a spotlight on the potential weaponization of biological agents. Terrorist and violent extremist groups have already attempted to incite the intentional spread of Covid19 and to use it as an improvised form of a biological weapon. This study aims to provide an epidemiological description of all terrorism-related attacks using biological agents sustained between 1970 and 2019. METHODS: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events using biological weapons between January 1, 1970 - December 31, 2019. RESULTS: 33 terrorist attacks involving biological agents were recorded between 1970 and 2019, registering 9 deaths and 806 injuries. 21 events occurred in the United States, 3 in Kenya, 2 each in both the United Kingdom and Pakistan and a single event in Japan, Columbia, Israel, Russia and Tunisia. CONCLUSION: The reported use of biological agents as a terrorist weapon is extremely rare and accounts for 0.02% of all historic terrorist attacks. Despite its apparent rarity, however, bioterrorism has the ability to inflict mass injuries unmatched by conventional weapons. Anthrax has been the most commonly used in previous bioterrorism events with the vast majority of reported attacks occurring in the United States by a single suspected perpetrator. Counter-Terrorism Medicine (CTM) and Disaster Medicine (DM) specialists need to be proactive in delivering ongoing educational sessions on biological events to first responder communities, and anticipate emerging novel biotechnology threats.

COVID-19 vs. terrorism: Contribution of the COR theory to the process of coping with invisible threats.

Two years have passed since the outbreak of the COVID-19 pandemic. The entire world is still struggling with the virus and its mutations, and governments have been imposing various restrictions, including social distancing and quarantine. This paper leans on the Conservation of Resources (COR) theoretical model in comparing the impact of COVID-19 with that of an ongoing threat of terror attacks, allowing us to understand the similarities and differences between them. Such exploration could result in an understanding that may guide devising psycho-social interventions to minimize the negative psychological consequences of a continuous life-threatening situation. By applying the extensive available literature on the aftermath of terrorist attacks to the little-known long-run consequences of the COVID-19 pandemic, this paper comes up with several guidelines such as increasing online social support and enhancing adaptive coping with stress, that are applicable on the individual, community, and societal levels.

Opioid Attack and the Implications for Counter-Terrorism Medicine.

While the opioid epidemic engulfing the United States and the globe is well-documented, the potential use of powerful fentanyl derivatives as a weapon of terror is increasingly a concern. Carfentanyl, a powerful and deadly fentanyl derivative, is seeing a surge in popularity as an illegal street drug, and there is increasing congressional interest surrounding the classification of opioid derivatives under the Chemical Weapons Convention (CWC) given their potential to cause harm. The combination of the potency of opioid derivatives along with the ease of accessibility poses a potential risk of the use of these deadly agents as chemical weapons, particularly by terrorist organizations. Disaster Medicine specialists in recent years have established a sub-specialty in Counter-Terrorism Medicine (CTM) to address and research the unique terrorism-related issues relating to mitigation, preparedness, and response measures to asymmetric, multi-modality terrorist attacks.

Children and Adolescents with Disabilities and Exposure to Disasters, Terrorism, and the COVID-19 Pandemic: a Scoping Review.

PURPOSE OF REVIEW: This paper reviews the empirical literature on exposures to disaster or terrorism and their impacts on the health and well-being of children with disabilities and their families since the last published update in 2017. We also review the literature on studies examining the mental health and functioning of children with disabilities during the COVID-19 pandemic. RECENT FINDINGS: Few studies have examined the effects of disaster or terrorism on children with disabilities. Research shows that children with disabilities and their families have higher levels of disaster exposure, lower levels of disaster preparedness, and less recovery support due to longstanding discriminatory practices. Similarly, many reports of the COVID-19 pandemic have documented its negative and disproportionate impacts on children with disabilities and their families. In the setting of climate change, environmental disasters are expected to increase in frequency and severity. Future studies identifying mitigating factors to disasters, including COVID-19; increasing preparedness on an individual, community, and global level; and evaluating post-disaster trauma-informed treatment practices are imperative to support the health and well-being of children with disabilities and their families.

Prehospital major incident management: how do training and real-life situations relate? A qualitative study.

OBJECTIVE: To explore the relationship between preparations and real-life experiences among prehospital major incident commanders. DESIGN: An explorative, qualitative design was used. SETTING: Prehospital major incidents in Sweden. Data were collected between December 2019 and August 2020. PARTICIPANTS: Prehospital major incident commanders (n=15) with real-life experiences from major events, such as fires, bus accidents, a bridge collapse and terrorist attacks, were included. All but one had participated in 2-day training focusing on the prehospital management of major incidents. In addition, about half of the participants had participated in simulation exercises, academic courses and other training in the management of major incidents. METHODS: Data from two-session individual interviews were analysed using inductive thematic analysis. RESULTS: The conformity between real-life major incidents and preparations was good regarding prehospital major incident commanders' knowledge of the operational procedures applied in major incidents. However, the preparations did not allow for the complexities and endurance strategies required in real-life incidents. Personal preparations, such as mental preparedness or stress management, were not sufficiently covered in the preparations. To some extent, professional experience (such as training) could compensate for the lack of formal preparations. CONCLUSIONS: This study identified perceived gaps between preparations and real-life experiences of being a prehospital major incident commander. To minimise the gaps between demands and expectations on perceived control and to better prepare individuals for being prehospital major incident commanders, the training and other preparations should reflect complexities of real-life incidents. Preparations should develop both technical skills required, such as principles and methodology used, and personal preparedness. Personal preparations should include improving one's mental preparedness, self-knowledge and professional self-confidence required to successfully act as a prehospital incident commander. Since little is known about what pedagogical methods that should be used to enhance this, further research is needed.

50 Years of Mass-Fatality Terrorist Attacks: A Retrospective Study of Target Demographics, Modalities, and Injury Patterns to Better Inform Future Counter-Terrorism Medicine Preparedness and Response.

BACKGROUND: Terrorism-related deaths have fallen year after year since peaking in 2014, and whilst the coronavirus disease 2019 (COVID-19) pandemic has disrupted terrorist organizations capacity to conduct attacks and limited their potential targets, counter-terrorism experts believe this is a short-term phenomenon with serious concerns of an escalation of violence and events in the near future. This study aims to provide an epidemiological analysis of all terrorism-related mass-fatality events (>100 fatalities) sustained between 1970-2019, including historical attack strategies, modalities used, and target selection, to better inform health care responders on the injury types they are likely to encounter. METHODS: The Global Terrorism Database (GTD) was searched for all attacks between the years 1970-2019. Attacks met inclusion criteria if they fulfilled the three terrorism-related criteria as set by the GTD codebook. Ambiguous events were excluded. State-sponsored terrorist events do not meet the codebook's definition, and as such, are excluded from the study. Data analysis and subsequent discussions were focused on events causing 100+ fatal injuries (FI). RESULTS: In total, 168,003 events were recorded between the years 1970-2019. Of these, 85,225 (50.73%) events recorded no FI; 67,356 (40.10%) events recorded 1-10 FI; 5,791 (3.45%) events recorded 11-50 FI; 405 (0.24%) events recorded 51-100 FI; 149 (0.09%) events recorded over 100 FI; and 9,077 (5.40%) events recorded unknown number of FI.Also, 96,905 events recorded no non-fatal injuries (NFI); 47,425 events recorded 1-10 NFI; 8,313 events recorded 11-50 NFI; 867 events recorded 51-100 NFI; 360 events recorded over 100 NFI; and 14,130 events recorded unknown number of NFI. Private citizens and property were the primary targets in 67 of the 149 high-FI events (100+ FI). Of the 149 events recording 100+ FI, 46 (30.87%) were attributed to bombings/explosions as the primary attack modality, 43 (28.86%) were armed assaults, 23 (15.44%) hostage incidents, two (1.34%) were facility/infrastructure attacks (incendiary), one (0.67%) was an unarmed assault, seven (4.70%) had unknown modalities, and 27 (18.12%) were mixed modality attacks. CONCLUSIONS: The most common attack modality causing 100+ FI was the use of bombs and explosions (30.87%), followed by armed assaults (28.86%). Private citizens and properties (44.97%) were most commonly targeted, followed by government (6.04%), businesses (5.37%), police (4.70%), and airports and aircrafts (4.70%). These data will be useful for the development of training programs in Counter-Terrorism Medicine (CTM), a rapidly emerging Disaster Medicine sub-specialty.

Terrorism-Related Chemical, Biological, Radiation, and Nuclear Attacks: A Historical Global Comparison Influencing the Emergence of Counter-Terrorism Medicine.

BACKGROUND: Terrorist attacks are growing in complexity, increasing concerns around the use of chemical, biological, radiation, and nuclear (CBRN) agents. This has led to increasing interest in Counter-Terrorism Medicine (CTM) as a Disaster Medicine (DM) sub-specialty. This study aims to provide the epidemiology of CBRN use in terrorism, to detail specific agents used, and to develop training programs for responders. METHODS: The open-source Global Terrorism Database (GTD) was searched for all CBRN attacks from January 1, 1970 through December 31, 2018. Attacks were included if they fulfilled the terrorism-related criteria as set by the GTD's Codebook. Ambiguous events or those meeting only partial criteria were excluded. The database does not include acts of state terrorism. RESULTS: There were 390 total CBRN incidents, causing 930 total fatal injuries (FI) and 14,167 total non-fatal injuries (NFI). A total of 347 chemical attacks (88.9% of total) caused 921 FI (99.0%) and 13,361 NFI (94.3%). Thirty-one biological attacks (8.0%) caused nine FI (1.0%) and 806 NFI (5.7%). Twelve radiation attacks (3.1%) caused zero FI and zero NFI. There were no nuclear attacks. The use of CBRN accounted for less than 0.3% of all terrorist attacks and is a high-risk, low-frequency attack methodology.The Taliban was implicated in 40 of the 347 chemical events, utilizing a mixture of agents including unconfirmed chemical gases (grey literature suggests white phosphorous and chlorine), contaminating water sources with pesticides, and the use of corrosive acid. The Sarin gas attack in Tokyo contributed to 5,500 NFI. Biological attacks accounted for 8.0% of CBRN attacks. Anthrax was used or suspected in 20 of the 31 events, followed by salmonella (5), ricin (3), fecal matter (1), botulinum toxin (1), and HIV (1). Radiation attacks accounted for 3.1% of CBRN attacks. Monazite was used in 10 of the 12 events, followed by iodine 131 (1) and undetermined irradiated plates (1). CONCLUSION: Currently, CBRN are low-frequency, high-impact attack modalities and remain a concern given the rising rate of terrorist events. Counter-Terrorism Medicine is a developing DM sub-specialty focusing on the mitigation of health care risks from such events. First responders and health care workers should be aware of historic use of CBRN weapons regionally and globally, and should train and prepare to respond appropriately.

United States medical preparedness for nuclear and radiological emergencies.

With the end of the Cold War in 1991, U.S. Government (USG) investments in radiation science and medical preparedness were phased out; however, the events of 11 September, which involved a terroristic attack on American soil, led to the re-establishment of funding for both radiation preparedness and development of approaches to address injuries. Similar activities have also been instituted worldwide, as the global threat of a radiological or nuclear incident continues to be a concern. Much of the USG's efforts to plan for the unthinkable have centred on establishing clear lines of communication between agencies with responsibility for triage and medical response, and external stakeholders. There have also been strong connections made between those parts of the government that establish policies, fund research, oversee regulatory approval, and purchase and stockpile necessary medical supplies. Progress made in advancing preparedness has involved a number of subject matter meetings and tabletop exercises, publication of guidance documents, assessment of available resources, clear establishment of anticipated concepts of operation for multiple radiation and nuclear scenarios, and identification/mobilization of resources. From a scientific perspective, there were clear research gaps that needed to be addressed, which included the need to identify accurate biomarkers and design biodosimetry devices to triage large numbers of civilians, develop decorporation agents that are more amenable for mass casualty use, and advance candidate products to address injuries caused by radiation exposure and thereby improve survival. Central to all these activities was the development of several different animal constructs, since efficacy testing of these approaches requires extensive work in research models that accurately simulate what would be expected in humans. Recent experiences with COVID-19 have provided an opportunity to revisit aspects of radiation preparedness, and leverage those lessons learned to enhance readiness for a possible future radiation public health emergency.

A Decade of Terrorism in the United States and the Emergence of Counter-Terrorism Medicine.

BACKGROUND: The United States (US) is ranked 22nd on the Global Terrorism Index (2019), a scoring system of terrorist activities. While the global number of deaths from terrorism over the past five years is down, the number of countries affected by terrorism is growing and the health care repercussions remain significant. Counter-Terrorism Medicine (CTM) is rapidly emerging as a necessary sub-specialty, and this study aims to provide the epidemiological context over the past decade supporting this need by detailing the unique injury types responders are likely to encounter and setting the stage for the development of training programs utilizing these data. METHODS: The Global Terrorism Database (GTD) was searched for all attacks in the US from 2008-2018. Attacks met inclusion criteria if they fulfilled the three terrorism-related criteria as set by the GTD. Ambiguous events were excluded when there was uncertainty as to whether the incident met all of the criteria for inclusion in the GTD. The grey literature was reviewed, and each event was cross-matched with reputable international and national newspaper sources online to confirm or add details regarding weapon type used and, whenever available, details of victim and perpetrator fatalities and injuries. RESULTS: In total, 304 events were recorded during the period of study. Of the 304 events, 117 (38.5%) used incendiary-only weapons, 80 (26.3%) used firearms as their sole weapon, 55 (18.1%) used explosives, bombs, or dynamite (E/B/D), 23 (7.6%) were melee-only, six (2.0%) used vehicles-only, four (1.3%) were chemicals-only, two (0.7%) used sabotage equipment, two (0.7%) were listed as "others," and one (0.3%) used biological weapon. There was no recorded nuclear or radiological weapon use. In addition, 14 (4.6%) events used a mix of weapons. CONCLUSIONS: In the decade from 2008 through 2018, terrorist attacks on US soil used weapons with well-understood injury-causing modalities. A total of 217 fatal injuries (FI) and 660 non-fatal injuries (NFI) were sustained as a result of these events during that period.Incendiary weapons were the most commonly chosen methodology, followed by firearms and E/B/D attacks. Firearm events contributed to a disproportionality high fatality count while E/B/D events contributed to a disproportionally high NFI count.