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.

Medico-Legal Opinion Based on Autopsy Findings of a Victim of an Explosion Involving Mass Fatality

Introduction: Investigation into explosions is one of the major areas in forensic medicine and pathology. Medico legal issues associated with these deaths are diverse and forensic experts are often expected to make clarifications. Assistance of a methodical scientific investigation of such a death in evaluation of unanswered medico legal issues, of an autopsy of one of the victims of Easter Sunday explosions is discussed. Case history: The deceased was a 15-year-old girl who was participating in the Easter mass at St. Sebastian’s Church - Kattuwapaitya, Negombo, Sri Lanka when a suicide bomber blew himself up. The mother of the deceased noticed the deceased being rushed to the hospital. However, she was pronounced dead on admission. Pre-autopsy radiology revealed spherical shrapnel in the temporal region. At autopsy, the fatal injury was found on the head and a detailed study revealed skull fractures associated with penetration by 3 shrapnels. There was a keyhole lesion among the penetrations. Internal examination revealed an extensive dural tear underlying the compound fracture. The brain was grossly edematous with lacerations on the frontal and parietal lobes associated with localized subarachnoid hemorrhage. There were multiple underlying contusions on bilateral frontal white matter. Small subarachnoid haemorrhage was noted on the basal aspect of the brain. Discussion: Careful evaluation of the autopsy findings assisted in formulating the opinion scientifically on event reconstruction including the proximity of the victim to the epicenter of explosion and nature of explosive device, period of survival, mechanism of causation of skull fractures and the mechanism of death in addition to the cause of death. Conclusion: A forensic pathologist following a meticulous autopsy examination, along with a team of ballistic experts and specially trained police personnel play a pivotal task in analyzing a scene of explosion and an autopsy of a victim, in concluding the case and in bringing justice to all the victims and survivors of the catastrophe.

The need for innovation in deathcare leadership

PurposeThe purpose of this viewpoint essay is to examine deathcare leadership during the COVID-19 pandemic and recommend innovations to employ a more human-centric approach.Design/methodology/approachThis viewpoint essay uses scholarly and popular literature to explore deathcare practices during the ongoing COVID-19 pandemic and to identify limitations of existing mass fatality management policies.FindingsDeathcare leadership in the USA lacks a human-centric approach. Rationalistic mass fatality management during COVID-19 left families struggling with grief and mourning because many burial rituals could not take place. This essay suggests a humanistic approach to death management through leadership innovations as a remedy to this problem. Such leadership innovations can improve responses to deathcare during this ongoing pandemic and future public health emergencies.Originality/valueThis essay offers practical improvements to make deathcare more human-centric.

COVID-19 and Mass Fatality Management: A Public Health Challenge

ABSTRACTThe COVID-19 pandemic has posed a serious question over preparedness to deal with mass fatality. The current trend shows that there would be more bodies than the capacity and resources to handle them. The international agencies have alerted governments that the number of deaths may overwhelm the local capacity to handle dead bodies properly. Mass fatality management and planning are important to respecting the dignity of the deceased and surviving family. Inadequate capacity to deal with dead bodies may affect the psychological well-being of survivors which may result in distress to families and community.

Identification of subgroups of terror attacks with shared characteristics for the purpose of preventing mass-casualty attacks: a data-mining approach

Security and intelligence agencies around the world invest considerable resources in preventing terrorist attacks, as these may cause strategic damage, national demoralization, infringement of sovereignty, and government instability. Recently, data-mining techniques have evolved to allow identification of patterns and associations in criminal data that were not apparent using traditional analysis. The aim of this paper is to illustrate how to use interpretable classification algorithms to identify subgroups (“patterns”) of terrorist incidents that share common characteristics and that result in mass fatalities. This approach can produce insights far beyond those of conventional macro-level studies that use hypothesis-testing and regression models. In addition to this methodological contribution, from a practical perspective, exploring the characteristics identified in the “patterns” can lead to prevention strategies, such as alteration of the physical or systemic environment. This is in line with situational crime prevention (SCP) theory. We apply our methodology to the Global Terrorism Database (GTD). We present three examples in which terror attacks that are described by a particular pattern (set of characteristics) resulted in a high probability of mass casualties, while attacks that differ in just one of these characteristics (i.e., month of attack, geographical area targeted, or type of attack) resulted in far fewer casualties. We propose exploration of the differentiating characteristic as a means of reducing the probability of mass-fatality terrorist incidents.