Public Health and Terrorism Research Paper

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Definition And Overview

We have defined terrorism as ‘‘politically motivated violence or the threat of violence, especially against civilians, with the intent to instill fear’’ (Levy and Sidel, 2007). (Bioterrorism is defined as the use of, or threat to use, biological weapons for this purpose.) Terrorism is intended to have psychological effects that go beyond the immediate victims to intimidate a wider population, such as a rival ethnic or religious group, a national government or political party, or an entire country (Hoffman, 1998). It is often intended to establish power were there is none or to consolidate power where there is little. While many nations, including the United States, differentiate terrorism from war – especially a war formally declared by a nation, we perceive little difference between terrorism and a war directed largely against civilian populations.

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The term terrorism is ‘‘generally applied to one’s enemies and opponents, or to those with whom one disagrees and would otherwise prefer to ignore’’ (Hoffman, 1998). The use of the term terrorism, therefore, depends on one’s point of view. The term terrorism implies a moral judgment; if one group can attach the term to its opponent, then it may have persuaded others to adopt its moral perspective ( Jenkins, 1980). In civil wars, revolutions, and other conflicts, those considered terrorists by one side are often considered freedom fighters by the other. In these situations, groups that have been relatively powerless, in contrast to very powerful foes, have often utilized terrorist tactics, believing that these tactics represent their own effective weapon against superior force. An analysis of 109 definitions of the term terrorism revealed that the most frequent definitional elements were the words violence, force, political, and fear (Schmidt et al., 1998). Because of ambiguity in the use of the term, some organizations avoid its use in formal communication.

Terrorism can be construed as encompassing the use by countries of weapons designed to cause casualties among civilian populations. Examples of such terrorism include the bombing of Guernica, Spain, by Nazi forces in 1937 and during World War II, the bombing of Warsaw, Rotterdam, London, Coventry, and other cities by Germany; the bombing of Dresden, Hamburg, and other cities by the Allies; the bombing of Tokyo and other Japanese cities by the United States; and the detonation of nuclear weapons at Hiroshima and Nagasaki by the United States. There is controversy about whether these ‘acts of war’ should be considered terrorism (Geiger, 1997).

U.S. law defines terrorism as ‘‘premeditated, politically motivated violence perpetrated against noncombatant targets by subnational groups or clandestine agents’’ (U.S. Code, 22, }2656f(d)). Based on this definition, the National Counterterrorism Center reported that during 2006, 14 352 terrorist attacks occurred worldwide and resulted in 20 573 deaths (13 340 in Iraq), with an additional 36 214 people wounded. Nearly 300 incidents resulted in ten or more deaths, 90% of which were in the Near East and South Asia. Armed attacks and bombings led to 77% of the fatalities during 2006 (National Counterterrorism Center, 2006).

The bombings of the World Trade Center in 1993, the Alfred P. Murrah Federal Building in Oklahoma City in 1995, and U.S. military and diplomatic facilities abroad in the late 1990s awakened Americans to the reality of terrorism directed at U.S. targets at home and abroad. Americans’ concerns about terrorism on U.S. soil were tragically confirmed by the September 11, 2001, attacks on the World Trade Center and the Pentagon, followed soon afterward by letters contaminated with anthrax spores that were mailed to two U.S. senators and several news-media organizations.

In recent decades, terrorist incidents have occurred in many countries worldwide: the killing of nine Israeli athletes by Palestinian terrorists at the Olympics in Munich in 1972; the use of explosives on airplanes, such as the bombing of an Air India 747 over the Atlantic in 1985, which killed all 329 people on board; numerous attacks on embassies, with kidnapping and killing of diplomats; and thousands of attacks on civilians in many countries. Among major terrorist attacks since 2002 have been the detonation of bombs on a train in Madrid in 2004, which killed 191 people and injured 1700, and on local public transport in London in 2005, which killed 56 people, including four perpetrators, and injured 700 people; the occupation of a theater in Moscow in 2002 by Chechen guerillas, in which 170 people were killed, including 41 of the guerillas – deaths that were mainly caused by fentanyl and halothane used in gaseous form by the police in a rescue attempt; and the seizure of a public school in Beslan in southern Russia in 2004 by a Chechen group, which led to the death of 332 people, mostly students, teachers, and parents.

Terrorist events have highlighted the important roles of public health professionals and their agencies and organizations in responding to these events and helping prepare for and prevent future terrorist attacks. The involvement in this response, not only of public health professionals but also of others throughout society, has underscored the fact that public health is what we, as a society, do collectively to ensure the conditions in which people can be healthy.

Roots Of Terrorism

There are many different roots of terrorism, including historical and political; economic and social; and philosophical, ideological, and religious roots (Easley and Allen, 2007).

Political factors have influenced the development of terrorism over many centuries in many parts of the world. Terrorism has been defined as ‘‘simply the contemporary name given to, and the modern permutation of, warfare deliberately waged against civilians with the purpose of destroying their will to support either leaders or policies that the agents of such violence find objectionable’’ (Carr, 2002). Using this definition, several historical and contemporary figures have been classified as terrorists, ranging from the Roman emperor Augustus and King Louis XIV of France to former U.S. President Richard Nixon and former Secretary of State Henry Kissinger (Carr, 2002). Terrorism may be viewed as a pragmatic political strategy of the weak who lack political or military power.

Poverty is an important contributing cause to terrorism. It has been described as a powder keg that can explode with debilitating and negative consequences. Through the news media, many people in less-developed countries who live in poverty and despair continually perceive the affluence and waste of many Western countries. There are gross economic disparities in the world; for example, the richest one-fifth of the world’s population owns about 85% of the world’s wealth, while the poorest one-fifth owns about 1%. One-third of the extremely poor people in the world subsist on less than a dollar per day.

Various manifestations of religious fundamentalism have influenced the development of terrorism, although the religious bases for these manifestations have not generally supported or condoned terrorist acts. In addition, the concepts of honor and shame, which are critical to understanding certain cultures, play a role in the development of terrorism; perceived humiliation may lead some people to engage in terrorist acts.

Psychological traits of terrorists may play a role. Terrorists have been described as action-oriented, aggressive, and stimulus-hungry. They are likely to have experienced psychological damage during childhood that has led to a self-concept in which the good aspects of their personalities are idealized, whereas the bad aspects are projected onto others. Some of these people may have come from fragmented families and may find in terrorist groups their first experiences of belonging and identity. The absolutist ideology of terrorist groups becomes the intellectual justification for their morality (Post, 1998).

Terrorist Weapons

Small Arms, Explosives, And Incendiaries

The categories of weapons that have been most frequently used in terrorist acts have been small arms, explosives, and incendiaries. Small arms kill an estimated 500 000 people worldwide each year and injure and traumatize many more. However, the percentage of small-arms deaths worldwide that are thought to be terrorist acts is very small. Terrorist organizations appear to stockpile small arms to support many activities, ranging from robberies and kidnappings to armed conflict. Small arms are the primary tools of terrorists. A review of 400 recorded terrorist incidents from 1997 to 2001 demonstrated that small arms were clearly used in 30% of them and probably used in kidnappings and abductions that amounted to another 10% of these incidents.

Explosives and incendiaries are frequently used by terrorists worldwide. Between 1980 and 1990, there were 12 216 bombings in the United States, causing 1782 injuries, 241 deaths, and almost US$140 million in property damage. Between 1990 and 1994, there were 8567 bombings and nearly 2000 additional bombing attempts in the United States. Most of these explosions – 53% of the explosions in 1990 – involved pipe bombs; pipe bombs are charged with a low-velocity filler, such as black powder, and packed with fragments that extend fragmentary and thermal injuries. An analysis of 400 documented terrorist incidents between 1997 and 2001 demonstrated that more than 250 of them involved bombs, explosives, or incendiaries. The impact of bombs goes well beyond mortality and morbidity, given that the main objective is to create psychological terror and subsequent chaos and panic.

Chemical Weapons

A chemical weapon is ‘‘any chemical which, through its chemical effect on living processes, may cause death, temporary loss of performance, or permanent injury to people and animals,’’ (Chemical Weapons Convention, 1993). Explosives and incendiary weapons also use chemicals, but the destructive force of these weapons depends on blast and heat that chemicals can produce; chemical weapons, by definition, depend on the direct toxic effects of chemicals. Although the first International World Peace Conference in The Hague in 1899 forbade the use of chemical weapons, these weapons were extensively developed and used during World War I, with 110 tons of toxic chemicals disseminated, affecting 1.3 million people and causing 90 000 deaths. Chemical weapons used during World War I included chlorine, phosgene, and mustard gas (dichloroethylsulfide), the last of which was delivered by artillery shells. Because mustard gas is heavier than air, it settles in low-lying areas, and because of its persistence, it remains active for days.

In 1925, the Geneva Protocol outlawed the use of chemical weapons, but most nations viewed it as a ‘no first use treaty.’ During subsequent years many new chemical weapons were developed. In the 1920s and 1930s in Afghanistan, Morocco, and Ethiopia, colonial powers used mustard bombs against native populations. During World War II, the Germans developed and manufactured the lethal nerve agents tabun, sarin, and soman but did not field these gases militarily. (The Nazis used other gases in the concentration-camp gas chambers: carbon monoxide, pesticides, prussic acid, and hydrogen cyanide.) The Allies also developed and stockpiled chemical weapons; the explosion of 100 tons of mustard gas, resulting from the German bombing of a U.S. ship in the harbor of Bari, Italy, caused the deaths of more than 600 military personnel and many civilians. Since World War II, chemical weapons have been used in several parts of the world. In the 1980s, Iraq, in its war against Iran, used mustard gas and the nerve agent tabun and possibly the nerve agent sarin. Later the Iraqi government used hydrogen cyanide against its own Kurdish population. By the end of the Cold War, the Soviet Union had accumulated 40 metric tons of chemical weapons, and the United States had stockpiled 29 metric tons. In addition to the huge known stockpiles not yet destroyed in the United States and Russia, stockpiles remain in several other countries, such as India and Libya.

The Convention on the Prohibition of the Development, Production, Stockpiling, and Use of Chemical Weapons and on Their Destruction (the Chemical Weapons Convention, or CWC) was opened for signature in 1993 and entered into force in 1997. The CWC is the first disarmament agreement negotiated within a multilateral framework that provides for the elimination of an entire category of weapons of mass destruction. The CWC prohibits all development, production, acquisition, stockpiling, transfer, and use of chemical weapons and requires each state party to destroy its chemical weapons and chemical weapons production facilities, as well as any chemical weapons it may have abandoned in the territory of another state party. The verification provisions of the CWC affect not only the military sector but also the civilian chemical industry worldwide through certain restrictions and obligations regarding the production, processing, and consumption of chemicals that are considered relevant to the objectives of the Convention. The Organization for the Prohibition of Chemical Weapons in The Hague is responsible for the implementation of the CWC. As of 2007, 182 states were parties to the CWC.

Chemical weapons include nerve agents, such as sarin and tabun; vesicants or blistering agents, such as mustard gas; blood agents, such as hydrogen cyanide and arsine; choking agents and lungor pulmonary-damaging agents, such as chlorine and phosgene; incapacitating agents, such as fentanyls; riot-control or tear agents, such as chloropicrin; and vomiting agents, such as adamsite. Sarin was used in attacks in Japan in 1994 and 1995 by the Aum Shinrikyo¯ sect, in which 19 people were killed and more than 5000 others were adversely affected.

Biological Weapons

Biological weapons are living organisms – usually microorganisms – or their toxic products, used intentionally to cause illness or death in humans, animals, or plants. They are produced or used with the goal of causing illness or death in humans, limiting food supplies or agricultural resources, and evoking fear in populations.

Use of biological weapons dates at least to the sixth century BCE, when Persia, Greece, and Rome used diseased corpses to try to contaminate sources of drinking water. In CE 1346, Mongols besieging the Crimean seaport of Kaffa placed cadavers on hurling machines and threw them into Kaffa. In 1710, Russian troops used cadavers of plague victims to start an epidemic among enemy Swedes. During the French and Indian War, in the mid-1700s, British commander Sir Jeffrey Amherst sent smallpox-infected blankets to Native Americans. During the U.S. Civil War, dead animals were left in wells and ponds to deny fresh water to retreating troops.

During World War I, Germany is alleged to have used the equine disease glanders against the cavalries of eastern European countries. In the 1930s, Japanese troops dropped rice and wheat mixed with plague-carrying fleas from planes, resulting in plague in areas of China that had been previously free of it. During World War II, Japanese laboratories conducted extensive experiments on prisoners of war, testing a wide variety of organisms for possible use as biological weapons, including organisms that cause anthrax, plague, gas gangrene, encephalitis, typhus, typhoid, hemorrhagic fever, cholera, smallpox, and tularemia. Also during World War II, prisoners in German concentration camps were infected during tests of biological weapons. Great Britain and the United States, fearing the Germans would use biological weapons in World War II, developed their own. Gruinard Island, off the coast of Scotland, was contaminated in 1942 by a test use of anthrax spores by the United Kingdom and the United States; the island remained uninhabitable for decades. The United States developed anthrax spores, botulinum toxin, and other agents as biological weapons but did not use them.

After World War II, development of biological weapons continued, and these weapons were extensively tested. In the 1950s and 1960s, for example, the University of Utah conducted secret, large-scale field tests of biological weapons, including tularemia, Rocky Mountain spotted fever, plague, and Q fever, at the U.S. Army Dugway Proving Ground in western Utah. In 1950, U.S. Navy ships released as simulants (materials believed to be nonpathogenic that mimic the spread of biological weapons) large quantities of bacteria in the San Francisco Bay Area to test the efficiency of their dispersal. Some analysts attributed subsequent infections and deaths to one of these organisms. During the 1950s and 1960s, the United States conducted 239 top-secret, open-air disseminations of simulants, involving such areas as the New York City subways and Washington National Airport. The U.S. military developed a large infrastructure of laboratories, test facilities, and production plants related to biological weapons. By the end of the 1960s, the United States had stockpiles of at least ten different biological and toxin weapons. In 1979, the accidental release of anthrax spores near Sverdlovsk in the Soviet Union resulted in at least 77 cases of inhalation anthrax and at least 66 deaths. In 1984 in a community in central Oregon, 751 people were identified with Salmonella typhimurium gastroenteritis that was related to working or eating at ten restaurants in the area. The outbreak was eventually traced to members of a religious commune in the area who had deliberately contaminated restaurant salad bars in the area.

In 1969, the Nixon administration – with the concurrence of the Defense Department, which declared that biological weapons lacked military usefulness – unconditionally renounced U.S. development, production, stockpiling, and use of biological weapons and announced that the United States would unilaterally dismantle its biological weapons program. In 1972, the Soviet Union, which had urged a more comprehensive treaty, including restrictions on chemical weapons, ended its opposition to a separate biological weapons treaty. The United States, the Soviet Union, and other nations negotiated the Convention on the Prohibition of the Development, Prevention and Stockpiling of Bacteriological (Biological) and Toxin Weapons and on Their Destruction (the Biological Weapons Convention, or BWC). The BWC prohibits – except for ‘‘prophylactic, protective and other peaceful purposes’’ – the development or acquisition of biological agents or toxins, as well as weapons carrying them and means of their production, stockpiling, transfer, or delivery. The U.S. Senate ratified the BWC in 1975, the same year it ratified the Geneva Protocol of 1925. As of 2007, there were 158 parties to the BWC.

Invoking the specter of possible new biological weapons and unproven allegations of aggressive biological weapons programs in other countries, the Reagan administration initiated intensive efforts to conduct ‘defensive research,’ permitted under the BWC. The budget for the U.S. Army Biological Defense Research Program, which sponsors programs in a wide variety of academic, commercial, and government laboratories, increased dramatically during the 1980s. Much of this research is medical in nature, including the development of immunizations and of treatments against organisms that might be used as biological weapons.

While research and development of new biological weapons are outlawed by the BWC, it is possible that it will still occur. Defectors from the Soviet Union and Russia report that these nations developed new biological weapons. In addition, some people wonder whether the defensive research on biological weapons performed by the United States and other countries is permitted under the provisions of the BWC. Novel dangers lie in new genetic technologies, which permit development of genetically altered organisms not known in nature. Stable, tailor-made organisms used as biological weapons could travel long distances and still be infectious, rapidly infiltrate a population, cause debilitating effects very quickly, and resist antibiotic treatment.

The Centers for Disease Control and Prevention (CDC) has identified three categories of diseases and the biological agents that cause them, prioritized according to their likelihood of bioterrorist use and the severity of the diseases they produce. According to the CDC, category A (high-priority) agents include ‘‘organisms that pose a risk to national security because they can be easily disseminated or transmitted from person to person; cause high mortality; and have the potential for major public health impacts; might cause public panic and social disruption; and require special action for public health preparedness.’’ These agents cause the diseases anthrax, botulism, plague, smallpox, tularemia, and viral hemorrhagic fevers such as Ebola, Marburg, Lassa, and Machupo fever. Category B (second-highest priority) agents include ‘‘those that are moderately easy to disseminate; cause moderate morbidity and low mortality and require specific enhancements of CDC’s diagnostic capacity and enhanced disease surveillance.’’ Category B agents cause such diseases as brucellosis, psittacosis, Q fever, typhus fever, and viral encephalitis, and include water safety threats, such as Vibrio cholerae and Cryptosporidium parvum. Category C (third-highest priority) agents include ‘‘emerging pathogens that could be engineered for mass dissemination in the future because of availability, ease of production and dissemination, and potential for high morbidity and mortality and major health impact.’’

Nuclear Weapons

Nuclear weapons represent the most serious terrorist threat. There is great concern that nuclear weapons might be acquired and used by terrorist groups or that these groups may be able to build nuclear weapons from fissile materials acquired from existing nuclear weapons states. A nuclear weapon suddenly releases vast amounts of energy by splitting the nucleus of atoms (fission) and/or by fusing the nuclei of pairs of atoms (fusion). Even a crude nuclear weapon may have the potential explosive force 1000 times higher than the most powerful conventional explosive. Nuclear weapons were used twice, at the end of World War II, when they were detonated over Hiroshima and Nagasaki, causing 200 000 immediate deaths and many more deaths later from cancer and other chronic diseases. There are approximately 27 000 nuclear weapons thought to be possessed by nine nations: the United States, Russia, France, China, the United Kingdom, Israel, India, Pakistan, and possibly North Korea. Most of these are strategic weapons, which are capable of intercontinental delivery. Others are tactical weapons with ranges less than 310 miles (500 km). The United States is thought to possess approximately 10 000 nuclear weapons, 5200 of which are strategic; Russia is thought to possess 16 000 nuclear weapons, 3500 of which are strategic. Open-air testing of nuclear weapons has led to environmental contamination, with increased rates of leukemia and other cancers among populations who were downwind of these tests. Production of nuclear weapons has led to major environmental contamination, such as in the area around Chelyabinsk, Russia, which has been heavily contaminated with radioactive materials from the nuclear-weapons production facility in that area.

There is no comprehensive treaty that bans the use or mandates the destruction of nuclear weapons but rather a series of overlapping, incomplete treaties, which includes the Comprehensive Nuclear Test Ban Treaty, which was open for signature in 1996 and has not entered into force; the Treaty on the Non-Proliferation of Nuclear Weapons (the Non-Proliferation Treaty), which was opened for signature in 1968 and entered into force in 1970; the Anti-Ballistic Missile Treaty between the United States and Soviet Union, from which the United States has withdrawn; and the Strategic Arms Reduction Treaties Process.

The threat of nuclear terrorism is related largely to the existence of nuclear weapons and weapons-usable material available to states and nonstate groups that may be willing to use them for their own political agendas. To address the threat of nuclear terrorism, there is a need to develop a comprehensive primary prevention approach that includes (a) concerted international safeguarding of nuclear weapons and their constituent materials that are already dispersed throughout the world in nuclear power facilities and nuclear weapon stockpiles; (b) utilizing and strengthening of existing treaties aimed at curbing proliferation and promoting nuclear disarmament; and (c) moving beyond current treaty obligations to develop even stronger global agreements to drastically reduce and ultimately eliminate materials in weapons that could have catastrophic consequences for humankind.

Radiological Weapons (‘Dirty Bombs’)

Radiological weapons disperse radioactive materials with a conventional device rather than with a nuclear explosion. During World War II, the United States initiated a research program to determine the feasibility of dispersing radioactive material with the use of conventional weapons. More recently, Iraq has acknowledged to the United Nations that it explored the use of radiological weapons against Iran. Iraq reportedly tested a radiological bomb meant to weaken enemy forces by inducing radiation sickness but abandoned this type of weapon because radiation levels created were not sufficiently high. Although radiological weapons, if used, would not likely kill large numbers of people, they would likely cause vast disruption, even after areas contaminated with radioactivity had been decontaminated.

Antipersonnel Land Mines

Antipersonnel land mines are explosives and are considered by many to be weapons of indiscriminate mass destruction, one person at a time. An estimated 80 million land mines have been strewn in at least 78 countries, and an estimated 180 million land mines are stockpiled by about 54 countries. It is estimated that each year, antipersonnel land mines kill between 15 000 and 20 000 people, primarily civilians. Land mines also render large areas of land uninhabitable. The people who are most likely to encounter land mines are rural poor people, including peasants tilling fields or foraging for food and wood, and children herding livestock. In 1997, the Convention on the Prohibition of the Use, Stockpiling, Production, and Transfer of Anti-Personnel Landmines and on Their Destruction (the Mine-Ban Treaty) was opened for signature. As of 2007, 157 nations had signed or accessioned the Mine-Ban Treaty, including all nations in the Western hemisphere, except the United States and Cuba, and all nations in the North Atlantic Treaty Organization, except the United States and Turkey. Other nations that have not signed the treaty included Russia, most of the former Soviet Republics, most nations in the Middle East, and many Asian nations, including China, India, and Pakistan. As a result of the treaty, there is less use of antipersonnel mines, a dramatic decrease in production, an almost complete halt in trade of land mines, rapid destruction of mines that have been stockpiled, fewer mine victims in critically affected countries, and more land de-mined – although an enormous amount of expensive and dangerous de-mining remains to be done.

Current Challenges And Opportunities

Strengthening Public Health Programs And Services

Public health programs and services need to be strengthened so that public health problems can be addressed appropriately. Since September 11, 2001, billions of dollars have been spent by federal, state, and local governments in the United States on emergency preparedness and response capabilities for potential terrorist attacks. While some of this huge allocation of money was used to improve public health capabilities, work to prepare for low-probability events has actually diverted much attention and many resources from widespread existent public health problems, such as smoking-related diseases, alcoholism and other forms of substance abuse, domestic and community violence, diabetes, and environmental problems. A recently published book, Are We Ready? Public Health Since 9/11, details how public health workers responded effectively to the September 11 attacks and the anthrax outbreak that followed soon afterwards and also explores how needed reforms to the United States public health system have been undermined since then.

Ensuring Emergency Preparedness

Public health workers need to support measures to ensure emergency preparedness, not only for potential terrorist attacks, but also for chemical emergencies, radiation emergencies, natural disasters, severe weather events, and large outbreaks of disease.

Addressing Underlying Causes Of Terrorism

Public health workers can contribute to addressing the underlying causes of terrorism and promoting a greater understanding of these issues. Public health workers should promote programs and other activities that support better understanding and tolerance among people of different backgrounds and nations, and work to ensure that basic human needs are met and human rights are protected. The ‘global war on terror’ initiated by the United States and its invasion of Iraq may have actually increased the threat of terrorism (Mazzetti, 2006).

Controlling Weapons Of Mass Destruction

Public health workers can engage in many activities to broaden the understanding of the general public and policy makers concerning weapons of mass destruction. They can, for example, enable others to recognize the overwhelming catastrophes that would occur if nuclear weapons were ever used. Public health workers can also do much to promote existing international treaties and conventions to control weapons of mass destruction and work toward the ultimate elimination of nuclear, chemical, and biological weapons.


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