The impact of terrorism on global healthcare

 

Eric van den Berg

 

With the American government now spending over 40.2 billion dollars on 'homeland security' and the European Commission appointing a special anti-terrorism coordinator, terrorism indeed seems to be a hot item on the global political agenda. As a potential threat to the wellbeing of millions, terrorism is a relevant medical issue. How do healthcare professionals prepare for terrorism, and cope with its bloody aftermath?

 

From a medical point of view, terrorism is best considered within the larger framework of emergency management. Most developed countries now have specialized agencies handling disaster. They are generally supervised from a national level, but conduct most of their operational effort and prerequisite preparation locally. Bart Hamers heads one of these agencies: The Amsterdam bureau for Medical Assistance in Emergencies (GHOR). Hamers: "When people ask me what I do, I tell them: 'I'm in medical disaster management'. When disaster strikes I coordinate our emergency response units and am chief responsible for our policy and operational teams. Effectively, I'm the medical counterpart for the chief of police and the fire commissioner." As a cog in the machinery of municipal emergency services, he cooperates closely with his 'counterparts', and trains his people to do the same. Hamers: "People have to know their place within the 'disaster-structure', and what their relationship is to the police and fire department." Luckily enough, disaster doesn't strike daily in Amsterdam, but preparing for it is a full time job. "We plan, we make sure the materials are there. We train 60 times a year." Considering the fact that Hamers and his colleagues are called to the fray quite frequently, it's a good thing they do" "Nationally I would estimate we are called upon once or twice a year."

 

Nothing usual

Disaster, unpredictable by definition, comes in all shapes and sizes. Hamers' area of work covers all of them, ranging from crashing planes, trains and automobiles to chemical spills and structure fires. Seen from this point of view, the question raises itself whether terrorism really is a whole new ballgame for medical emergency professionals. Hamers thinks not: "Its business as usual. My task is delivering wounded to hospitals. For us, it doesn't matter whether a bomb was planted by terrorists or not." Others beg to differ with Hamers. Edward Gabriel, in charge of emergency medical assistance for the New York City Office of Emergency Management (OEM) is one of them: "There's nothing usual about it. Imagine a large scaleattack with a biological agent like [inhaled] anthrax. Most people affected would display flulike symptoms, but might be dead within days. Part of your medical staff might be infected." Of course, epidemics aren't exactly a new phenomenon for medical science, but attacks employing some kind of biological agent do seem to pose specific problems to healthcare. The fear of such an attack in itself is one. Gabriel, referring to the incident in which cult members released sarin gas in the Tokyo subway in 1995: "EMS's (Emergency Medical Services) might be flooded by so called 'worried well'. People not affected, but concerned that they might be." The uncertainty concerning the type of agent that might be used is another. Gabriel: "After 9-11 nobody could assume that anthrax would be used as a weapon." Gabriel's antidote for nagging doubt about the nature of a terrorist attack is a simple one: "You have to be prepared for all of them"

 

Discrepant

This is obviously easier said than done. Hamers admits to being ill prepared in the event of a 'biological attack': "We recently did an assessment of 18 different types of disaster, and how to react. Chemical spills, train crashes and floods for instance. One of the types we looked at was an ABC disaster. We weren't quite able to figure out how to handle that one." Hamers assures that the problem is being dealt with. It is always good to be prepared of course, but so far, instances in which terrorist have effectively used chemicals or infectious agents as a weapon are very rare. The Tokyo incident of '95 set a record death toll for such an attack conducted by terrorists, claiming12 lives. Accidentally occurring biological havoc has caused far more suffering, and continues to do so. One average worldwide, more people are killed in such incidents monthly then ever have died in 'biological' terrorist attacks. Taking these hugely discrepant numbers into account, the concern of New York City's OEM with such an attack seems exaggerated for the time being. Zvi Feigenberg is director of the medical division of Israel's Magen David Adom (MDA), which provides emergency medical assistance to a country, which has a long history of dealing terrorism and war's unpleasant effects on the human well being. This has made the Israeli emergency healthcare professionals experts in dealing with the aftermath of terrorist attacks, a dubious distinction at best. Feigenberg: "Around '94-'95, after the first intifada, we started looking at published material, and who had the most experience with this type of problems. Most literature we found was from Northern Ireland. Now, unfortunately, I would say that we have the largest body of experience in this area."

 

Shrapnel

Feigenberg acknowledges terrorism's impact on the healthcare system, but puts it into proper medical perspective: Feigenberg: "related injuries only account for about 1 to 2% of all our total trauma cases." Even so, he stresses the fact that terrorism does require unique efforts from healthcare professionals. According to him, terrorist attacks are different from other medical emergencies, for a number of reasons. One of them is that the types of injury victims sustain in terrorist attacks aren't comparable to those you would expect in an average car crash. Feigenberg: "These are very different, especially in the event of an explosion. We've had cases of people who were walking around on the scene, then when they were brought into the hospital all of a sudden they were in a very bad condition: even a lifethreatening one." This problem is mainly caused by small bits of debris being propelled into critical parts of the body. Feigenberg: "Shrapnel entering important organs like the heart, liver and brain and causing internal bleeding can lead to this type of problem." A fact, terrorists are very much aware of. Feigenberg: "They put nails, screws and other metals into the bombs which enlarge the number of casualties and cause these types of injuries." The problem is no news to New York City's OEM either. Gabriel: "Displacement of glass into internal organs is a type of injury specific to explosions" Prevalence of this type of injury requires that paramedics on the scene be prepared for it. Feigenberg: "This is a problem in triage"

 

Prepare

Of course, even with careful planning and distribution, medical resources remain finite, and therefore, exhaustible. Feigenberg: "We are now preparing for what we call a 'mega-terror' attack, in which more than 1000 people are injured at the same time. We don't have the manpower or the vehicles to treat more than 2000 injured." If the toll rises above this number, everybody will have to pitch in. Military doctors, reserve forces, but also private enterprise. Feigenberg: "in such an event only urgent cases will be evacuated by ambulance. All others will be evacuated by bus. Bus companies will bring busses to the scene. We're working on a plan for this." Hamer fatalistically points out that even creativity and cooperation do not diminish the fact that some emergencies cannot be managed. Hamers: "There are disasters that no one can prepare for." Recalling the Bophal disaster of 1984, in which a gas leak claimed nearly ten thousand lives, Hamers states: "No country can ever be ready for this." And what happens if a disaster like this would strike again? Hamers: "Then people die."