Discussion

Middle Eastern and North African countries have historically been clustered into a single MENA region by international, economic, and academic organizations based on geographical, political, and cultural similarities. It is, however, important to acknowledge that socio-political circumstances, counter-terrorism mechanisms, and health care systems are unique to individual countries and as such, discussions regarding CTM analysis should ideally be individualized to each specific country. As such, several concepts in the discussion may not be generalized to all MENA regions, given the differences in the geopolitical situation among the different countries.

While there has been a downtrend in terrorist attacks both globally and in the Middle East the past several years, and especially since the start of the COVID-19 pandemic, experts predict a surge in activity as the world emerges from lockdowns and restrictions. ⁶ Western countries are facing problematic right-wing, white supremacy, and political extremist activity whereas countries in the Middle East, such as Iraq and Yemen, have their unique problems: on-going humanitarian, security, and political crises are often intertwined with deteriorating health care systems, with high burnout rates among physicians, nurses, and other medical professionals in the region associated with harsh work conditions, stress, and exposure to violence and conflict. ^{Reference Tin, Hart and Ciottone7–Reference Alsabri, Alhadheri, Alsakkaf and Cole9} Health care workers have always been at the forefront of the response to terrorist attacks. Despite that, the effect on them has been very limited in the literature, especially during the “Arab Spring” and the subsequent events. ^{Reference Bou-Karroum, Daou and Nomier10,Reference Bou-Karroum, El-Harakeh and Kassamany11} The Arab Spring destabilized several governments resulting in a significant increase in terrorist attacks with many today still arguing that the instability in the MENA region is not only about differences in religion, cultures, or identities, but about power, political control, and social privileges. ^{Reference Horton12}

In the 1970s, Iraq had developed a free, centralized, and universal health care system, funded by the country’s oil export profits. It was considered at the time to have some of the best health care facilities in the Middle East with 97% of the urban population and 71% of the rural population having access to free health care. ¹³ The 1980s and 1990s, under the rule of Saddam Hussein, were marked by significant deterioration of the socio-political circumstances in Iraq. Health care funding was de-prioritized, sectarian conflict, and the rise of ISIL led to unrest and a pro-terrorism dictatorship led to sanctions, forcing nongovernmental organizations (NGOs) to evacuate and thousands of local health care workers to flee or risk being killed or kidnapped. ^{Reference Lafta and Al-Nuaimi14–Reference Woods16} Iraq’s health care system remains in crisis today with a shortage of drugs and staffing, with an average life expectancy of 70 years, far below average for the region. ¹⁷

As a result, the cultural and religious factors can influence disaster response strategies differently than in most Western countries. In Lebanon, for example, hospitals perform cultural analyses, taking into consideration the prevailing political parties within their catchment, and have strategies in place to physically separate patients and families from opposing sides of the feud whilst they are in hospital. ^{Reference Iskandar, Rahbany and Shokor18} Gender-based sensitivities around the mixing of the sexes may also delay access to acute medical care in vulnerable populations. ^{Reference Van der Zee19–Reference Davis22}

The use of explosives and firearms as primary attack modalities in the Middle East follows the global trend in terrorist methodologies. ^{Reference Tin, Margus and Ciottone1} Chemical, biological, radiological, nuclear (CBRN) attacks, though rare, remain a significant threat in the region. Syria saw the use of Sarin gas in 2013 which killed 1,400 civilians and severely affected thousands more and Sulfur Mustard filled rockets were launched in Iraq in 2016. ^{Reference Sezigen and Kenar23,Reference Rosman, Eisenkraft and Milk24}

Emerging technologies are also likely to feature in near-future terrorist attacks. The Islamic State and Houthi rebels have already demonstrated alacrity and capability to deploy unmanned aerial systems for both reconnaissance and offensive operations. ^{Reference Marcus25–Reference Clarke27} This poses a real risk on much bigger communities, given the long-range reach of such technologies, and steps must be taken to prepare health care systems to deal with any unexpected incidents resulting from emerging technologies. ^{Reference Tin, Kallenborn, Hart, Hertelendy and Ciottone26,Reference Pledger28}

The emergence of CTM as a Disaster Medicine sub-specialty was borne out of the increasingly complex health care impacts of terrorist events. Health care systems and professionals, as well as security and intelligence agencies, need to be aware of historic and potential future attack methodologies and understand the unique death and injury patterns of specific attack modalities and target types. While retrospective studies provide enormous educational benefits, CTM specialists also need to be forward looking and both leverage the positive utilities and anticipate the nefarious use of novel and emerging technologies. ^{Reference Tin, Kallenborn, Hart, Hertelendy and Ciottone26,Reference Tin, Hart, Hertelendy, Kallenborn and Ciottone29}