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Since 2001, the world has encountered an increase in terrorist attacks on civilian targets, during which conventional as well as unconventional modalities are being used. Terrorist attacks put immediate strains on health care systems, whilst they may also directly threaten the safety of first responders, health care workers, and health care facilities.
Study Objective:
This scoping review aimed to systematically map the existing research on terrorist attacks targeting health care facilities, health care workers, and first responders, and to identify opportunities to improve future research and health care response to terrorist attacks.
Methods:
A scoping review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. A systematic search for relevant literature was conducted through electronic databases including PubMed, Cochrane, and Embase. Inclusion and exclusion criteria were applied to check eligibility. Extracted data from the articles included the title, first author, year of publication, journal, study design, number of attacks, number of injured, number of fatalities, target type, and weapon modalities. Furthermore, methodological quality assessment was performed.
Results:
The initial search within three major databases yielded 4,656 articles, including 2,777, 1,843, and 36 articles from PubMed, Embase, and Cochrane Library, respectively. Finally, 11 studies were included, which were all database reviews.
Conclusions:
This scoping review included 11 studies focusing on terrorist attacks against health care facilities, health care workers, and first responders. Nearly all studies were exclusively based on the Global Terrorism Database (GTD). An increase of attacks on health care-related targets was consistently reported by all studies in this review, but there were significant discrepancies in reported outcomes. In order to improve counter-terrorism preparedness and the future protection of health care workers, counter-terrorism medicine (CTM) research may benefit from a more standardized and transparent approach to document and analyze terrorist attacks, as well as the inclusion of additional databases other than the GTD.
In this unprecedented history of intelligence cooperation during the Cold War, Aviva Guttmann uncovers the key role of European intelligence agencies in facilitating Mossad's Operation Wrath of God. She reveals how, in the aftermath of the 1972 Munich Olympics Massacre, Palestinians suspected of involvement in terrorism were hunted and killed by Mossad with active European cooperation. Through unique access to unredacted documents in the Club de Berne archive, she shows how a secret coalition of intelligence agencies supplied Mossad with information about Palestinians on a colossal scale and tacitly supported Israeli covert actions on European soil. These agencies helped to anticipate and thwart a number of Palestinian terrorist plots, including some revealed here for the first time. This extraordinary book reconstructs the hidden world of international intelligence, showing how this parallel order enabled state relations to be pursued independently of official foreign policy constraints or public scrutiny.
The introduction provides an overview of the book, presents the core arguments, highlights the contribution to current literature, explains the book’s methods and sources, and outlines the structure of the book. The overarching argument of the book is that intelligence cooperation was so beneficial for all parties that European authorities therefore let Mossad carry out its operation and tolerated the use of its intelligence to kill Palestinians. Hence, the book demonstrates that the extensive advantages that European agencies gained through Club de Berne intelligence-sharing led them to turn a blind eye towards, or even tacitly support, Israeli covert actions on their respective territories.
Thematic series were introduced to BJPsych Open by the current Editor-in-Chief to address key topics in psychiatry and mental health, specifically considering the impact on the global burden of diseases with associated treatments, outcomes, policy and research priorities. The increasing submission to BJPsych Open of articles about the psychosocial and mental health impacts of terrorism and collective violence naturally led to this thematic series. This paper introduces the journal’s series of published papers about terrorism and collective violence. While we identify the topics covered by the series and hope to generate conversation, this paper does not report a systematic review of the series. The thematic series consists of 13 articles; 9 were open submissions and 4 were commissioned. They include this review, an editorial concerning research methods and 11 papers reporting how people have responded to terrorist and violent incidents in 4 countries. Including this review, one paper was published in 2020, three in 2022, two in 2023, five in 2024 and two in 2025. The commissioned papers were added to broaden coverage of the Utøya attack on young people in Norway, and the shootings in Christchurch, New Zealand in 2019. Our intention was to enable the papers on these two incidents to sit alongside papers already submitted about them and the Manchester Arena bombing as well as articles about attacks in Germany. We begin by introducing the papers and comment in the discussion on a series of topics that we have selected as prominent in the series.
How do counterterrorism policies enable terrorist groups to thrive and survive? This article examines the relationship and how counterterrorism policies and political structures impact terrorist group success. While studies of terrorism have tended to separate the two phenomena, there is considerable complexity in the interactions between violent action and coercive state response. To demonstrate the complexity of these interactions, this article examines the persistence of three transnational terrorist groups from 1989 to 2022 – the Lashkar-e-Taiba, Jaish-e-Mohammad, and the Hizbul Mujahideen – that operate in the Kashmir region despite India’s coercive counterterrorism policies. While existing research emphasises macro-level factors in transnational terrorism, this article, based on original qualitative data, demonstrates the critical importance of granular, localised opportunities for terrorist groups to carry on. We show how these structures interact with civilian perceptions of state legitimacy and security to create nuanced patterns of support. In doing so, we challenge simplistic explanations of terrorist recruitment and resilience. The article dispels existing misconceptions about the efficacy of coercive counterterrorism to end militant groups and further suggests that softer, non-coercive approaches might not necessarily generate public sympathy. In fact, select counterterrorism policies might inadvertently legitimise violence by extremist groups to their constituency and increase sympathy in the process.
In the context of the appalling inter-communal violence and killings of Northern Ireland during the 1970s, Seamus Deane felt dismayed by those who found parallels between that situation and O’Casey’s Dublin trilogy. For Deane, O’Casey’s most famous works subject political ideologies to hostile scrutiny, whilst offering a form of sentimental humanism as the norm of the ‘ordinary’ people. This chapter examines how the views that Deane expressed about O’Casey fitted with Deane’s broader thinking about politics and society, and shows how Deane provided a telling critique that proved influential for O’Casey’s reputation, as well as for Irish literary and cultural studies more widely.
This chapter considers the overlaps and divergences between cults and terrorist movements. It begins by considering whether terrorism has entered a new era that increasingly overlaps with apocalyptic religious cults. It then takes into account the historical tension between defining groups that engage in extremist violence for ideological purposes as terrorist groups, as cults, or as a combination of the two. Following this, an analysis of the Islamic State of Iraq and Syria provides a vehicle for drawing out the commonalities and dissimilarities between the two concepts. Finally, the chapter concludes by considering any need to differentiate between terrorism and cults when engaging in risk assessment for individuals at risk of violence, along with strategies for intervention.
An extreme overvalued belief is shared by others in a person’s cultural, religious, or subcultural group. The belief is often relished, amplified, and defended by the possessor of the belief and should be differentiated from a delusion or obsession. Over time, the belief grows more dominant, more refined, and more resistant to challenge. The individual has an intense emotional commitment to the belief and may carry out violent behavior in its service. This chapter discusses the historical foundations of overvalued idea as first described by neuropsychiatrist Carl Wernicke. Case examples of phenomenology in forensic psychiatry are described, as well as implications for the diagnosis of folie a deux. Case examples of Jacob Chansley (U.S. Capitol attack), Anders Breivik, and Malik Hassan are discussed in detail. Finally, a discussion of Gestalt psychology, moral schemas, as well as binary bias and emotional tagging is presented as important to understanding how extreme overvalued beliefs develop.
Research on the political consequences of terrorism often finds a rally around the flag effect: terrorist attacks, as other types of threats, tend to produce spikes in popularity and support for the incumbent, as citizens turn to those in power seeking protection. Most research, however, is based on single case studies that analyze very salient attacks from international terrorist organizations. Even if these studies are well identified, the question of generalizability remains, as the studied attacks are often very idiosyncratic. In this paper, we explore the rally around the flag effect in an arguably difficult context: a sustained terrorist campaign held by domestic terrorist groups in a parliamentary democracy (Spain). To overcome the limitations of the single-attack studies, we use a multiple unexpected event approach: we developed a systematic process of matching the occurrence of terror attacks during the fieldwork of official public opinion surveys in Spain, through which we identified 142 valid attack-survey pairs. We find that in the attacked region support for the incumbent increases, on average, around 4 percentage points right after an attack, while support for the opposition decreases in a similar amount. These effects seem to occur mostly for the conservative incumbent and are especially relevant for the attacks that target civilians. We use a survey experiment to provide additional evidence in support for our interpretation of the findings.
The September 11, 2001, attacks on the United States further propelled the global focus on terrorism. Despite international efforts, the threat of terrorism remains throughout the world. In this chapter, the challenges in defining and analyzing terrorism are established by articulating the characteristics, structures, and motivations of groups that terrorize others. These definitions of terrorism, and the features of relevant groups, are then placed within the wider context of intrastate conflict. Key questions addressed include: Why does terrorism more frequently occur in war-torn countries? And how does its occurrence lower prospects for sustainable peace? This analysis is then used to inform modern counterterrorism methods, and how their evolution is critical for future international and national security along with peace mediation studies.
The forces that fight asymmetric wars are so distinct that one side avoids direct military confrontation in favor of political, social, or otherwise unorthodox means of resistance. These conflicts have been a mainstay of modern times, though scholars have often separated them into various designations by era. Observers have referred, in chronological order, to Indian warfare, petite guerre (small war), guerrilla warfare, irregular or revolutionary war, and terrorism. The proliferation of labels over time has obscured the continuity of asymmetric wars throughout modernity. Stark distinctions in resources and capabilities have shaped the reasons why states and societies have decided to fight, and the manner in which they have fought. Across the modern era, mismatches arose in the domains of technology, intelligence production, and law. But in recent decades, so-called weak powers have neutralized many of the typical advantages of strong military states.
War is bad for nature, yet relatively little attention has been devoted to environmental military ethics by just war theorists and philosophers of war. Most wars since 1945 have been civil conflicts, often in areas containing the greatest biodiversity. Combining environmental ethics with ethics of war, this Element examines how the environmental crisis should challenge and change the rules of war. While environmental wartime regulation has been addressed rarely by just war theorists, environmental jus ad bellum has hardly been tackled at all. Can environmental harm trigger a new justification for war? Can targeting nature constitute terrorism? And what would be a proportionate response to 'environmental aggression'? With global degradation and climate change right around the corner, this Element discusses some of the most pressing practical ethics issues of our times, suggesting that grave environmental transgressions should be combatted by measures that do not themselves cause disproportionate harm to nature.
This Element aims to better understand the role of the internet in the radicalization process, focusing on how online factors contribute to self-radicalization. Specifically, it examines the neurocognitive process of online radicalization by analyzing the impact of terrorist and extremist propaganda videos on individuals' cognitive empathy using electroencephalography (EEG). Ultimately, this research aims to provide a more comprehensive understanding of online radicalization and the psychological effects of exposure to extremist content on the internet.
The end of Operation Barkhane in the Sahel in 2022 raises many questions about French foreign policy in Africa. Yet the government has stifled public debate by insisting on the urgency of other wars in the world. As for the Members of Parliament, they never demanded an inquiry into the setbacks of France’s biggest overseas military operation since the Algerian war. Clearly, lessons were not learned. This article reviews the arguments and the political, military, historical and cultural reasons that led the Elysée to conceal, or even deny, a failure that also resulted in a loss of influence in its Francophone ‘preserve’ and among European Union partners who had overestimated the former colonial power’s ability to solve crises south of the Sahara. Blaming others, conspiracy theories and complaints about a lack of resources or the restrictions of international mandates to fight a global war on terror’ were part of the rhetorical weapons used to counter criticism, while some claimed that the end of Operation Barkhane was only a political defeat but not a military one.
This chapter explores denationalization, focusing on Indonesian foreign terrorist fighters (FTFs). Post-9/11 and during the Arab Spring, Western democracies tightened border control to combat terrorism, enabling the stripping of citizenship from involved individuals. Denationalization, via law or public-authority decisions, emerged as a contentious counter-terrorism tool. Indonesia, as a Muslim-majority Southeast Asian nation, partially embraced denationalization, refusing to repatriate Indonesian FTFs. This aligns with global security concerns but raises statelessness questions. The chapter examines denationalization’s legal framework, international obligations, and the blurred line between de jure and de facto statelessness. Critics argue that disproportionately applying denationalization to Muslims undermines human rights, inter-state cooperation and international justice. Refusal to repatriate Indonesian FTFs raises concerns about long-term consequences and due process. Understanding denationalization nuances is vital, considering its impact on the citizenship rights of individuals involved in terrorism.
Deprivation of national citizenship is one of the strategies used to counter the phenomenon of foreign terrorist fighters, that is, individuals traveling abroad for the purpose of terrorism. This Article begins with a short overview of the case-law of the European Court of Human Rights on the deprivation of citizenship. In these cases, the contestation of the deprivation of citizenship was based on the infringement of the rights to private and family life. We then turn to the limits imposed by EU law on decisions made by national authorities of Member States concerning citizenship deprivation of foreign terrorist fighters. Focusing on recent cases of the Court of Justice of the European Union (CJEU) concerning the European citizenship, we address the evolving role that EU law plays in the assessment of the proportionality of Member States’ decisions to strip individuals of national citizenship. We also consider the national practice, focusing on a recent decision in Denmark. In addition, we consider legal issues arising from the repatriation of Foreign Terrorist Fighters and their children. We argue that EU citizenship thus offers a further layer of protection against the deprivation of citizenship and that Member States are under a positive obligation to repatriate EU citizens who are the children of Foreign Terrorist Fighters on account of the case-law stemming from the Ruiz-Zambrano and X (Thai national) cases. For the moment, no common approach to repatriation of foreign fighters, or their children, is taken by EU member States in the context of the EU.
We introduce a dynamic game of outbidding where two groups use violence to compete in a tug-of-war fashion for evolving public support. We fit the model to the canonical outbidding rivalry between Hamas and Fatah using newly collected data on Palestinian public support for these groups. Competition has heterogeneous effects, and we demonstrate that intergroup competition can discourage violence. Competition from Hamas leads Fatah to use more terrorism than it would in a world where Hamas abstains from terrorism, but competition from Fatah can lead Hamas to attack less than it otherwise would. Likewise, making Hamas more capable or interested in competing increases overall violence, but making Fatah more capable or interested discourages violence on both sides. These discouragement effects of competition on violence emerge through an asymmetric contest, in which we find that Fatah uses terrorism more effectively to boost its support, although Hamas has lower attack costs. Expanding on these results, we demonstrate that outbidding theory is consistent with a positive, negative, or null relationship between measures of violence and incentives to compete.
Heroes and villains, idealists and mercenaries, freedom fighters and religious fanatics. Foreign fighters tend to defy easy classification. Good and bad images of the foreign combatant epitomize different conceptions of freedom and are used to characterize the rightness or wrongness of this actor in civil wars. The book traces the history of these figures and their afterlife. It does so through an interdisciplinary methodology employing law, history, and psychoanalytical theory, showing how different images of the foreign combatant are utilized to proscribe or endorse foreign fighters in different historical moments. By linking the Spanish, Angolan, and Syrian civil wars, the book demonstrates how these figures function as a precedent for later periods and how their heritage keeps haunting the imaginary of legal actors in the present.
The architecture of international counterterrorism law is the subject of Chapter 2. It is a branch of public international law that has emerged from an evolving special legal regime to regulate action to prevent and punish terrorism and to tackle terrorists. International counterterrorism law is a matrix of global terrorism treaties and dedicated United Nations Security Council resolutions that require the incorporation of offences into domestic law combined with the salient rules of international humanitarian law and the law of law enforcement. These rules, which regulate when and against whom force may be used in counterterrorism, are supplemented by (though are sometimes inconsistent with) the content of regional treaties and domestic legislation. The standards and laws are subject to the constraints and oversight of international human rights law. The chapter also describes the content and adherence of regional counterterrorism treaties.
Continuing the analysis in Chapter 9, this chapter considers how changing international security constellations have contributed to the remilitarization of democracy. It argues that international antiterror programmes have destabilized the foundations of constitutional law. On one hand, such policies have redefined national security objectives, such that the negotiated component of constitutional law is weakened. On the other hand, such policies have fundamentally altered the role of international human rights law in global society. As a result, states have been able to legitimate more directly militarized actions towards their own populations and towards the populations of other states.