J R Army Med Corps 2001; 147: 142-146 J R Army Med Corps: first published as 10.1136/jramc-147-02-06 on 1 June 2001. Downloaded from SPECIAL ARTICLE

Terrorism – New threats, new challenges?

I Greaves

Introduction indistinct and broader movements. Groups The conviction of David Copeland for the appear to be more loosely connected or bombings which culminated in the atrocity at indirectly linked through networks of the Admiral Duncan in Soho, London on professional (full time) terrorists and Friday 30th April 1999 has given us another amateur supporters, sympathisers and would eponymous terrorist, the Soho Bomber, to add be terrorists who may lack the expertise of to a long catalogue of those who chose such their more established counterparts. methods to further their political, sectarian The absence of any central command or or personal aspirations. Yet the Soho Bomb authority is significant in that it may be a was in a number of ways different to the long factor in removing any previous inhibitions run of more familiar terrorist atrocities. This on the terrorist’s desire to inflict widespread article reviews the changing demographics of casualties. In addition, the potential terrorism and their likely effects on law locations for terrorist atrocities are likely to enforcement and the health services be much more diverse than before: we are all response. potential victims, irrespective of location. The victimisation of traditional terrorist The New Terrorism? adversaries is likely to be much less obvious In the past, terrorism has been largely than previously. practiced by groups of individuals belonging It seems characteristic of the new terrorist to an identifiable organisation with defined that no responsibility is claimed for incidents. political, economic or social objectives. Such By maintaining their anonymity, they may organisations include the Japanese Red believe that they are able to capitalise further Army, Germany’s Red Army Faction and on the fear and alarm generated by their Italy’s Red Brigade as well as nationalist violence. terror groups such as the Abu Nidal The likelihood of casualties in a terrorist Organisation, the Provisional IRA and the incident, whatever the agent, is directly Basque separatist group ETA. linked to the notice given prior to the attack. http://militaryhealth.bmj.com/ These groups issued communiqués taking It is the actions of the police following the credit for and explaining their activities and receipt of such a warning that will largely however distasteful their actions might be, determine how many people are killed and their ideology and motivation was usually injured. The Omagh bomb on 15th August clear. 1998 showed only too clearly what can All these familiar terrorist groups engaged, happen if the security services are given for the most part, in highly selective and maliciously false information. Unfortunately, mostly discriminate (in their own eyes at it is characteristic of the many smaller least) acts of violence. They bombed various terrorist groups and isolated operators that,

symbolic targets representing the source of just as they tend not to claim responsibility on October 1, 2021 by guest. Protected copyright. their discontent : embassies, associations of for incidents, neither do they give prior the “opposition”, the security forces and warnings. This is particularly likely to be the National Airlines. The aim of each atrocity case when the atrocity is not designed to was to attract attention to themselves and publicise a political agenda. Apparent their cause and to spread terror. “humanitarian” actions, in avoiding The new generation of terrorist seems to casualties, may bring some positive benefit be different to this familiar paradigm. to organised groups, by creating an Terrorists are increasingly part of far more impression of clemency, those who kill for

This paper is based on presentations by Colonel Peter Roberts L/RAMC, Professor of Military Surgery Royal Defence Medical College and Royal College of Surgeons of England, Major Ian Greaves RAMC Consultant in Emergency Medicine British Army, Dr Duncan MacPherson Head of the Emergency Planning Unit, Department of Health, Deputy Maj Ian Greaves RAMC Assistant Commissioner Alan Fry, National Co-ordinator, Anti-Terrorist Branch, Regimental Headquarters, Metropolitan Police and Detective Chief Inspector David Johnson, Metropolitan Police given Keogh Barracks, at the Terrorism: New Threats, New Challenges Colloquium at the RUSI on 15th June 2000. Ash Vale, It originally appeared in the Journal of the Royal United Services Institute (October 2000 Vol Aldershot, 145 No 5) and is reproduced by kind permission of the RUSI to whom the editor is most Hants GU12 5RQ grateful. I Greaves 143

other reasons or none, or for the apparent includes representatives from the NHS, the J R Army Med Corps: first published as 10.1136/jramc-147-02-06 on 1 June 2001. Downloaded from pleasure of killing, are unlikely to be Armed Forces (offering expertise in ballistic motivated by such considerations. injury and chemical and biological warfare.), It might be argued that the Soho Bomber The Department of Health, The Home is the archetype of the new terrorist, a lone Office (Terrorist Protection Unit) and the operator representing no-one but himself, Security and Police Services. not subject to any apparent code, however This group has identified three areas of perverted, and armed with the expertise of concern: education, expertise and data the internet. collation (and analysis). If this is truly the face of terrorism to come, With regard to education, clinicians, police then the changing demographics of terrorism officers and other professionals who are will have dramatic effects on the two main involved in the response to terrorism need to agencies responsible for responding to be educated and informed at a level which is terrorism: the health services and the police. appropriate and relevant to their personal Having said that, it would be an extremely responsibilities. Similarly, appropriate sanguine individual who predicted the end of expertise needs to be readily available, by conventional politically motivated terrorism. means of a clear easily accessible process in What seems likely is a general shift of all parts of the country and at all times. emphasis. Finally, medical and forensic data from Furthermore, where apparently organised previous (and future) terrorist incidents groups continue to indulge in terrorist needs to be collected, collated and analysed. activities, examples such as the sarin release Initiatives are now in place regarding by the Aum Shinriko sect on the Tokyo education and expertise, our third aspiration underground in 1995 suggest that we are may be harder to achieve. The threats from likely to see the increasing use of chemical conventional weapons and chemical and and biological agents. Fortunately, to date, biological agents are different and are although terrorists are classically more discussed separately. imitative than innovative, there has not yet been a further significant chemical (or Conventional Threats - bombs biological) atrocity. and bullets Medicine and Terrorism The conventional weapons of the terrorist In medical terms, there is no doubt that it is are the bomb and the bullet. Despite the the civilian services, namely the National changes discussed above, it seems likely that, Health Services, which have to provide the for the most part, terrorist casualties will initial response to the injuries associated with continue to result from the use of

terrorism. In the case of the Soho bomb, commercial and improvised ballistic http://militaryhealth.bmj.com/ these injuries were all the more devastating as weapons. a result of the six inch nails packed into the There are undoubtedly pockets of explosive device. Such injuries, of course, are knowledge about the clinical and forensic all the more difficult to manage because of aspects of blast and gunshot injuries, but the numbers of casualties typically many areas of the United Kingdom have no associated with terrorist incidents. Such large direct experience of the consequences of numbers of casualties are all too likely to terrorism. The response to the Soho bomb overwhelm hospital emergency departments. only confirmed once again the effects of such In the aftermath of the Soho bombing, a an atrocity on unprepared medical, nursing and other health services staff.The nails that

number of the clinicians involved on October 1, 2021 by guest. Protected copyright. commented that the response might have lacerated the flesh of the victims were been more effective and less traumatic for designed not only to mutilate and to their staff if they had had previous experience terrorise the victims and survivors, but also or training in this area and if access to expert to terrorise those who would be called upon advice had been available to them. Just as to respond to the incident. Such reactions such expertise is not widely available to the can not improve the quality of patient care. NHS, there is no formal national means of Although there can be no substitute for access to it for the police and similar direct clinical experience, education, in agencies. providing vicarious experience can have a Furthermore, were we in the UK ever to positive effect in preparing not only clinicians experience a chemical or biological terrorist but all those who are likely to be confronted incident, even greater problems would be with the results of terrorism. Thus the likely to arise in terms of its initial “terror effect” of terrorism can be reduced. recognition and management. Although This might be considered to be a form of there is a co-ordinated response at “psychological prophylaxis”. government level, there is undoubtedly a Educational initiatives are also important deficit at clinical level. in improving the clinical management of As a consequence of comments such as individual patients. Clinicians and others these, the Forensic and Medical Aspects of need to be informed about the clinical Terrorism Group was established. This body spectrum of the injuries that result from 144 Terrorism-New Threats, New Challenges?

these agents. This is as important for the Birmingham Pub Bombings in 1974 when J R Army Med Corps: first published as 10.1136/jramc-147-02-06 on 1 June 2001. Downloaded from policeman called upon to perform first aid at two bombs exploded at the Tavern in the the scene as it is to the surgeon. Town and Mulberry Bush public houses To give a dramatic example, amputations killing eleven people and wounding eighty due to blast are “avulsive” with tissues being nine. In these cases as in most others, the torn and damaged much higher up the limb emphasis has been on the analysis of post- than the apparent level of the amputation. A mortem forensic data and of the scene. Yet comparison might be made to the tearing of apart from the still relatively limited the tendons out of a chicken leg which published data (all of it published over occurs when the ends of the legs are removed twenty five years ago) none of this raw whilst preparing Sunday lunch. The result is forensic data is accessible or available for use that amputated parts can never be re- by scientists or clinicians. In addition in this implanted and complex procedures in an and in every other case, published discussion attempt to do this may compromise the of the clinical management of the survivors patients survival and use precious resources (including those who died later of their and personnel who could be more effectively injuries) was limited and this data is now lost. employed with other victims. Yet in military The only area in the UK where there is an rather than civilian practice, amputation of identifiable single source for forensic data blast damaged limbs and provision of a related to terrorist atrocities is Northern suitable stump has been accepted doctrine Ireland. Small pockets of important data are for 200 years. This issue can be effectively located in the areas of individual incidents addressed by education, it can also be and no one is able to assess the bigger picture answered by the making available of which might be afforded by central data appropriate expertise and experience. As collection. stated above, it is one of the aims of the In addition, clinical data is of inestimable FAMAT Group that such provision should value both to scientists and clinicians, and be available and that an effective mechanism unless it is specifically collected and retained is in place to obtain it. will be lost under NHS procedures designed It might be suggested that this initiative to avoid the uncontrolled accumulation of would tread on sensitive ground in old medical records. It is therefore essential attempting to thrust assistance on those who that a central body is established to collate have not sought it. However a more this information. appropriate analogy is to the National Why? Collection of data is not a sterile Poisons Unit which provides twenty four activity of appeal only to those who wish to hour access to information on a subject accumulate data for its own sake. Clinical which is not a common part of most and pathological data is essential to the

clinicians’ day to day practice. The clinicians correct management and planning of the http://militaryhealth.bmj.com/ who will be involved in this rota not only response to all future terrorist incidents and include members of the armed forces and to developing appropriate treatments and civilians with extensive experience of methods of protection. Three examples will terrorism but may also include those with demonstrate the potential importance of this experience gained through work for such data. organisations as Medecins Sans Frontieres The ceramic plates familiar to all those and the other internationally recognised who wear the conventional British “flak major aid agencies. jacket” are placed where they are simply It is likely that, even taking into account the because analysis of data shows that that is

changes in the demography of terrorism where the majority of fatal single bullet shots on October 1, 2021 by guest. Protected copyright. discussed above, such incidents will remain land in casualties. Conversely, some relatively uncommon. An additional authorities on blast protection have designed advantage of the rota of experts is that it will a blast suit which protects the neck from tend to concentrate whatever clinical hyper-extension. They believe that this is a experience is available in the hands of a significant cause of death in blast injuries. relatively small but identifiable group who Expert British opinion does not support this, will be able to bring this experience to bear and yet the definitive data on cervical spine when it is required. As a consequence, this injuries is lacking and a definitive answer experience will not be dissipated or lost. This cannot therefore be given. will allow the build up of what has been The British Army is currently considering called “institutional memory”. Just as its medical response to blast injuries and is institutional memory is essential for the unable to predict the incidence of primary correct management of the wounds of war, blast lung in military casualties. Although so it is necessary to ensure the best results for the situations are not immediately the victims of terrorism. comparable, this question might in some part The third priority identified above was the be answered by comparison to the incidence collection, collation and analysis of data. of blast injury in terrorist incidents, From a medical and forensic point of view, particularly if the comparison is to troops in perhaps the most studied terrorist incidents the OBUA (Operations in built-up areas) in the United Kingdom were the role. Yet once again this information is I Greaves 145

simply not available, although it undoubtedly education and the provision of expert advice J R Army Med Corps: first published as 10.1136/jramc-147-02-06 on 1 June 2001. Downloaded from exists in pockets throughout the UK. apply even more dramatically to chemical Collation of all this clinical and forensic and biological agents than they do to data will allow us to answer, to a greater or conventional weapons, although, fortunately, lesser extent, these and many other in the UK there is no outstanding backlog of questions. This will not only improve the data to collate. The National Poisons Unit treatment of casualties but will also improve “Toxbase” internet database currently the protection of those whose work takes provides information on a wide range of them into this hostile environment. potential chemical hazards, but no such information is similarly available for The new armamentarium? biological agents. In either event, there is no Chemical and biological agents doubt that the provision of rapid expert Although it would appear that the risk of a advice will be essential in the management of chemical or biological attack remains low, deliberate releases. there is no doubt that the potential The majority of health care professionals consequences could be very severe. The require a far greater understanding of the deliberate terrorist release of such agents risks, consequences and appropriate brings fears of the sort of Doomsday management of the casualties of a biological and chemical release. Efforts to achieve this, Scenario of which sensationalist novels are lead by the Department of Health, are made. Compared to the relatively small already in place but there is clearly a great numbers who are likely to be involved in deal of work to be done. “conventional terrorism” the casualty It must be clearly understood that there are numbers in chemical or biological terrorism a number of significant differences between are potentially enormous: thousands, tens of incidents due to chemical and biological thousands or millions rather than (at the agents.These will be discussed briefly below. most) hundreds. Yet a rational response has In general chemicals such as nerve agents to be available, were such an event to occur. (for example Sarin) and blistering agents (for Preparedness for such an event has been example mustard gas) have rapid onset, identified as a priority by the Department of require immediate treatment and have the Health which has recently issued guidelines potential for contaminating rescuers. to the NHS for dealing with such a situation. (Choking agents such as phosgene are Judging the appropriateness of this classically slower in onset.) On the other response is immensely difficult and will hand, biological agents such as the bacteria almost certainly generate criticism whatever which cause plague or anthrax, or the viruses level of response is chosen. The key to this responsible for smallpox or the haemorrhagic

preparedness is the balance between the fevers have a much longer onset period, http://militaryhealth.bmj.com/ statistical chance of a release and the sometimes up to days or weeks. In this case, magnitude of the consequences. In addition, therefore, recognition of an incident may be over preparedness may generate panic, much more difficult since the typical cluster increase the number of hoax incidents, of immediately affected individuals will be reduce the day to day operational efficiency absent. Diagnosis is much more likely to of the health services and cost a fortune in an depend on public health surveillance of already cash starved environment. In general, unusual symptom clusters and it may be the effects of under-preparedness will only be some time before a pattern is recognised.The demonstrated in the event of an incident. longer this takes, the greater the No-one would accept a complete absence of

consequences of the release are likely to be. on October 1, 2021 by guest. Protected copyright. preparations, but the issuing of respirators to This phenomenon has been amply every member of the community and the demonstrated in a number of unusual provision of high security isolation facilities disease outbreaks not related to terrorism , at each and every district hospital would, of which the recent outbreak of clostridial clearly, be equally unacceptable. It must be disease amongst heroin abusers in Glasgow accepted that there is no way that the NHS (June 2000) provides an informative can be fully prepared for the “nightmare” example. Once the release has been scenario. To be so would divert resources recognised, and the causative organism away from patient care which would be identified, antibiotics may be effective neither socially or politically acceptable. It is against bacteria but there is unlikely to be the responsibility of the NHS and its central any effective treatment for viral disease, few planners therefore to ensure that the most vaccines are likely to be available, and the effective use is made of whatever resources potential for some viruses to spread from are deemed appropriate. It would seem person to person, as opposed to direct reasonable that a hospitals response to a contamination, such as occurs with chemical or biological incident be based on chemicals, is a significant concern. For all the conventional Major Incident Plan which these reasons, hoax announcements of is a statutory requirement for every NHS release may cause as much concern as an Trust . actual release. Earlier comments about the importance of In the case of chemical and biological 146 Terrorism-New Threats, New Challenges?

agents, the initial key step in preparation is the event of them being used. J R Army Med Corps: first published as 10.1136/jramc-147-02-06 on 1 June 2001. Downloaded from awareness training coupled with improved A number of novel weapons are now surveillance systems. In addition, available, one of which is the fuel-air contingency plans must be available to deal explosive. This weapon is capable of with large numbers of infected patients. producing devastating injuries due to the There are currently only two high security blast wave and severe burns. Active steps are infectious disease units in the United being taken to find ways of treating the Kingdom. It must be accepted, however, that injuries caused by these weapons in a formal isolation facilities are never going to military context. Successful initiatives in be available on a scale sufficient for a mass this area would be equally important were casualty incident resulting from chemical or these weapons ever to be used in a terrorist biological terrorism. Similarly, there must be role. more widespread decontamination facilities and an initiative designed to achieve this is Conclusion currently underway, once again lead by the The future of terrorism appears to be Department of Health. Health Service changing. It seems that the “lone terrorist” is planners will also need to consider the likely to be much more prominent than stockpiling of antibiotics and the before, when terrorism was largely seen to be optimisation of the availability of vaccines the province of organised political groups where they exist. Wherever possible, new with a clear stated agenda, an apparent vaccines should be developed. command structure, and a willingness to give Thus, with the exception of the initiatives prior warning of attacks and to admit listed above, once again the main thread in responsibility for their acts. The “new the medical response to chemical and terrorist” is likely to be much more biological weapons is education. anonymous, working to a personal or less clearly defined agenda. The Role of the Defence Medical With the exception of Northern Ireland, Services terrorist activity has, until recently remained for most of us an event we were unlikely to There can be no doubt that many members experience, an event associated with of the Defence Medical Services (DMS) conditions of civil unrest or disorder which have expertise in the management of bomb is rightly the province of the security forces. and bullet wounds in the peace and war This reassuring assumption is probably no settings. Service doctors already act as a longer valid. It would seem that in the future repository of that “institutional memory” all areas of the United Kingdom will be at referred to above. All service doctors need to risk of terrorist atrocities.

know about ballistic injury and themselves Despite the use of sarin by Aum Shinriko, http://militaryhealth.bmj.com/ have access to relevant material in the it remains the case that the majority of Journal of the Royal Army Medical Corps terrorist atrocities will result from the use of and to the Principles of War Surgery Course. conventional weaponry, namely bombs and The armed forces would also have a pivotal bullets. The use of chemical and biological role to play following the release of chemical agents can not, however, be ruled out, and or biological agents, they may also call upon indeed to many it seems only a matter of the expertise of DERA Porton Down. It time before such an incident occurs. must be accepted, however, that in both Thus it seems that terrorism, in one form cases, the initial response, and in terms of or another will be always with us. The numbers of personnel, the predominant

predicted changes in its demography and on October 1, 2021 by guest. Protected copyright. response must come from the civilian potential choice of weapon have a number of services, namely the NHS. important implications for the police and What the DMS can do is to provide clinical security services on the one hand and the advice and act as a source for educational health service on the other. New methods of initiatives, not only with regard to the clinical policing are likely to be necessary in order to management of patients, but also concerning apprehend terrorists and prevent incidents. the management of situations involving large The health service response, which has to numbers of casualties, bringing their date been the “Cinderella” of the terrorist expertise in triage and patient prioritisation world will need to be organised and to bear. developed. The key themes in achieving this A further role of the DMS is likely to be will be the education of clinical staff in the prediction of future weapon systems and relevant specialities, the making available of agents. It is often said that any weapon appropriate expert advice and experience which starts out in the hands of the forces of and the central collection, collation and law and order, will, eventually, fall into the analysis of medical and forensic data. The hands of the terrorist. The DMS working Armed Forces Medical Services are likely to with associated agencies are in an ideal play a key role in this, and will also be position to monitor future threats and to required to work closely with other agencies assess their terrorist potential as well as the in order to identify new threats and to medical response which will be required in develop appropriate responses.