Preparedness to Non-conventional Incidents in the Civilian Medical Arena

Abstract

There is no doubt that for many years the threat of weapons of mass destruction (WMD) imposes a great concern on citizens as well as on nation leaders. President Bush recognized the possibility of a secret and sudden attack with chemical or nuclear weapons as the greatest threat before humanity [1]. Since the first use of chemical agents in modern era during World War I, very few examples were documented where non-conventional weapon (NCW) was used by a state. However, in the Middle-East region in recent years several chemical attacks have been carried out in Syria by the government forces against their opponents, and in the 1980s by Iraq forces against Kurd civilians. The response of the international community against these incidents was much more significant than the one given after conventional attacks that caused a higher death toll along the years of fighting. This reflects the fear and different attitude that people and governments have towards the use of NCW. The September 11, 2001 terror attack in New York was the turning point of modern terrorism. The large number of casualties, the serious economic damage, and the psychological effects of this “mega-terrorism event” were unprecedented. It was expected that this achievement of a single terror attack would encourage terror groups to mimic it by attempting more conventional mega-terrorism attacks, or using non-conventional materials that would cause the same effect [2]. Although seemingly NCW can be considered an ideal choice for terrorist organizations, only very few terrorist attacks using these materials have been carried out in the past [3]. Non-conventional mass-casualty events (MCE) may be caused by toxicological, radiation, or biological agent dissemination. The MCE may be of natural cause, like a global viral flu event (e.g., the Spanish flu in 1918–1920 with millions of deaths) or a MCE after a terrorism act like the Anthrax envelope scare in Boca Raton, Florida in 2001. Best known chemical incidents in a civilian setup are the attacks carried out in Japan by the Aum Shinrikyo (Supreme Trust) group in 1994–1995. In the Tokyo subway attack in 1995 which involved releasing sarin nerve gas, twelve were killed and thousands injured. In 2007, multiple terrorist bombings had been reported in Iraq using chlorine gas. Recently in 2018, a former Russian spy and his daughter were supposedly poisoned in London by a potent nerve gas. Toxicological incidents can occur not just by a terrorist act but also and even more often as an accident, for example an explosion in a chemical factory producing hazardous materials, or a road accident of a truck transferring such materials. Radiological materials can find their way to terrorist organizations that might use them to make a “dirty bomb.” This low-tech radiological weapon is actually a conventional explosive bomb with a radiation side effect. Although the radiation effect will probably be negligible compared to a nuclear bomb, it can induce a heavy emotional impact and neutralize large contaminated areas. Until now, only few terrorist attacks using radiation materials have been reported. In 1995 and 1998, two attempts of dirty bombs use by a Chechen group were thwarted. Another case is the radiation poisoning of Alexander Litvinenko, a former KGB agent, by ingestion of Polonium∗210. A radiation event may also be the result of an accident in a nuclear plant, in a medical isotopes imaging institution, or in a laboratory using radiation materials. In all the forms of non-conventional events, the victims may suffer from the combination of conventional and non-conventional injuries, or either one of these types of injury. Bio-terrorism is even rarer though it is also very tempting to terrorists to use. Different US security organizations as well as other governments share a global war against terror. That includes the fight to prevent the possible use of NCW by terror organizations. The efforts and resources are aimed on the four premises of deterrence, prevention, defense, and consequence management [4]. The fact that the incidental use of NCW is relatively so scarce is encouraging and emphasizes the vital continuous need for international supervision of the development, manufacture, and marketing of NCW, and for coordinated steps to prevent access by unauthorized groups to these agents. Unfortunately, there is always a chance that the ability and the motivation of a terrorist group will meet and will result in translating the potential into reality. The probability of such an event has even increased in the last decade after the disintegration of states like Libya, Iraq, and Syria that made their military NCW arsenal easily available to different terror organizations. In most if not all NCW attacks, the nation health system is almost immediately involved. As a consequence of the described situation, the civilian health system must be prepared to non-conventional incidents. This chapter delineates the challenges, preparedness, special equipment, and organizational requirements that a medical center faces when dealing with a non-conventional MCE.