Introduction
Terrorism in China is intertwined with separatism and religious extremism and is considered one of the nation’s “three evils” threatening social stability and political order. Reference Li1 While there is increasing recognition of terrorist threats against Chinese citizens abroad, the government remains focused on activities on home soil, including some of the most notable events such as the 2009 Ürümqi riots, the 2014 Ürümqi attack, and the 2014 Kunming Station massacre attributed to Pan-Turkism, Uyghur nationalism, and Islamism movements in China. Reference Castets2
China today ranks 42nd on the Global Terrorism Index (2019), an annual report that systematically ranks the nations of the world according to terrorist activities. This ranking is similar to countries such as Russia (37th) and Germany (44th), falling into the “medium” terrorism impact zone. However, China ranks above Tajikistan (50th), Australia (71st), and Japan (78th) in the “low” zone. 3
Terrorism events have a significant health care and psychosocial impact on the population. While forward-looking and traditional counter-terrorism measures are critical in preventing future events, it is paramount to also understand the historical context and methodologies of past attacks in order to better prepare emergency first responders.
This study aims to provide the epidemiological context for the past decade detailing the unique injury types responders are likely to encounter and to aid in the development of training programs utilizing these data.
Aims
An epidemiological evaluation was used of all terrorism-related injuries and fatalities in China which occurred between 2008-2018. This includes historical attack modalities, allowing health care responders to be better informed about the unique injury types they are likely to encounter. These data will be useful for the development of nation-specific training programs in Counter-Terrorism Medicine (CTM).
Methods
The study is designed as an epidemiological description of terrorist attacks in China which caused injuries and fatalities. It was performed using retrospective data from the Global Terrorism Database (GTD). This database is open-access with publicly available data collection methodology, including artificial intelligence identifying events from news media around the world daily, as well as human evaluation of the events by the National Consortium for the Study of Terrorism and Responses to Terrorism (START). The GTD was searched using the internal database search functions for all attacks which occurred in China between the years 2008-2018 inclusive. 4 The years 2019 and 2020 were not available at the time of study. These were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. Attacks met inclusion criteria if they fulfilled the following three terrorism-related criteria as set by the GTD. Ambiguous events were excluded when there was uncertainty as to whether the incident met all criteria as a GTD terrorist incident. These criteria are determined within the database, rather than by the authors.
– Criterion I: The act must be aimed at attaining a political, economic, religious, or social goal.
– Criterion II: There must be evidence of an intention to coerce, intimidate, or convey some other message to a larger audience (or audiences) than the immediate victims.
– Criterion III: The action must be outside the context of legitimate warfare activities, ie, the act must be outside the parameters permitted by international humanitarian law, particularly the admonition against deliberately targeting civilians or non-combatants.
In addition to GTD listed events, the English language grey literature was searched to ensure no events meeting these criteria were missed. A focused search of online English language newspaper articles was also performed for any terrorist events between 2008-2018.
Each event to be included was cross-matched with reputable international and national newspaper sources online to confirm the attack, if possible, to add details regarding weapon type used, and whenever available, details of victim/perpetrator fatalities and injuries.
Results
One-hundred and eight terrorist attacks occurred in the study time period. Of the 108 incidents, 47 used only explosives/bombs/dynamite (E/B/D; 43.5%). Twenty-seven used only bladed or blunt weapons in melees (25.0%), five used only incendiary devices (4.6%), two used only chemical weapons (1.8%), and two events had unknown weapon types (1.8%). One event used a firearm (0.9%) and one event used a vehicle (0.9%). Twenty-three attacks used a mix of weapons (21.2%; Figure 1; Table 1).
Figure 1. Individual Weapon Types Used in Terrorist Attacks in China.
Table 1. Breakdown of Mixed Weapon Types in 23 Attacks
Abbreviation: E/B/D, Explosives/Bombs/Dynamite.
In total (including mixed weapon types which counted towards two or more categories), 57 attacks used E/B/D (52.7%), 47 involved melees/bladed weapons (43.5%), 18 incendiary devices (16.6%), seven vehicles (6.4%), three chemicals (2.7%), two unknown (1.8%), one firearm (0.9%), and one nail strip (0.9%; Figure 2).
Figure 2. Total Weapon Types Used in Terrorist Attacks in China.
A total of 89 out of 108 attacks (82.4%) led to one or more casualties. Nine attacks were listed as “unknown” in terms of fatalities or injuries. A total of 809 fatalities were recorded with 956 non-fatal injuries.
Thirty-five of 47 (74.4%) E/B/D only attacks led to casualties with a total of 137 deaths and 352 injuries. Twenty-four out of 27 (88.9%) melee/bladed weapon only attacks caused casualties totaling 263 deaths and 238 injuries. Three out of five (60.0%) incendiary attacks led to casualties for a total of 12 deaths and 36 injuries. Two out of two (100.0%) chemical only attacks led to morbidity with 54 persons injured. There were no fatalities from the chemical only attacks. One of the two attacks with an unknown modality led to a single death. The sole firearm only incident led to one death and the sole vehicle only incident led to one death. Twenty-two out of 23 (95.6%) mixed attacks led to morbidity and mortality totaling 394 deaths and 276 injuries (Figure 3).
Figure 3. Deaths and Injuries by Weapon Type.
On average, this corresponded to 2.9 fatalities and 7.5 injuries per E/B/D only event, 9.7 fatalities and 8.8 injuries per melee/bladed weapon only attack, 2.4 fatalities and 7.2 injuries per incendiary only event, 0.0 fatalities and 27.0 injuries for chemical only attacks, 1.0 fatality and 0.0 injuries per firearm only event, 1.0 fatalities and 0.0 injuries per vehicle only event, and 17.1 fatalities and 12.0 injuries for every mixed event (Table 2).
Table 2. Breakdown of Casualty Count and Average Fatality and Injury Count per Event by Weapon Type
Abbreviation: E/B/D, Explosives/Bombs/Dynamite.
The three events with the highest casualty toll were: 184 fatalities + unknown injuries in a mixed melee/incendiary event, 33 fatalities + 143 injuries in a melee event, and 36 fatalities + 94 injuries in a mixed E/B/D + vehicular event. The remaining events individually recorded fewer than 100 combined fatalities and injuries.
Sixty-two (57.4%) events had no person or group claiming responsibility, 33 (30.5%) events were attributed to Uyghur Separatists, and 10 (9.3%) attacks were attributed to either the Turkistan Islamic Party or the Eastern Turkistan Islamic Movement. The remaining three (2.7%) events were attributed to Tibetan separatists and the Kaichin Independence Army.
Discussion
The term “terrorist” was first used by the philosopher François-Noël Babeuf in 1794 during the Reign of Terror period of the French Revolution, but it wasn’t until the 1970s amidst the Israeli-Palestinian and Northern Ireland conflicts that the concept of terrorism in the West began re-emerging through definable events. Reference Palmer5,Reference Crenshaw6 Over the years, the definition of terrorism has changed, shaped by social, cultural, and political shifts around the globe. While there still is no consensus on the legal definition of terrorism internationally, the 2004 UN Security Council Resolution 1566 defined terrorism as:
[C]riminal acts, including against civilians, committed with the intent to cause death or serious bodily injury, or taking of hostages, with the purpose to provoke a state of terror in the general public or in a group of persons or particular persons, intimidate a population or compel a government or an international organization to do or to abstain from doing any act. 7,8
The concept of terrorism in China, while slowly merging today with international consensus, took a different formative path. Though certain elements of terrorism such as political criminality were recognized during the days of Imperial China, it wasn’t until the 1990s during the violent ethnic conflicts in Xinjiang that terrorism started appearing in Chinese political discussions. Reference Tanner and Bellacqua9
In the wake of the United States’ declared “Global War on Terror” following the September 11 attacks in 2001, the Chinese government made significant reforms and amendments to its Criminal Law, Criminal Procedure Law, and relevant administrative laws regarding the regulation of terrorism, with the latter term now much more widely adopted and used when describing domestic events. Reference Roach10 In 2015, China consolidated the country’s counter-terrorism legal framework and bureaucracy by enacting National Security Law and Counter- Terrorism Law. Subsequently, a new counter-terrorism agency was established, the military and police were given broader powers and expanded use of force in emergency circumstances, and internet providers and telecommunication organizations were mandated to provide decryption and technical expertise and to prevent the dissemination of information on extremism. Apart from pre-approved media outlets, the new measures also mandated that no one be allowed to report on a terror attack or the authorities’ response, either online or offline. Reference Tanner and Bellacqua9 The sweeping new reforms prompted several human rights groups to speak-out regarding concerns that the new laws would give these national agencies enormous discretionary powers which could be used to crackdown on dissidents and religious minorities. Reference Evans11
Emergency Medical Services in China have been undergoing a rapid evolution, but remain a significant challenge for the Chinese Government. Reference Yan, Jiang and Qiu12 There is no officially recognized paramedic profession in China, and the prehospital services are run by physicians and nurses, in some cases without specialized training or qualifications. Reference Hou and Lu13 Significant efforts are being made to develop the country’s prehospital first responder service by developing training programs and centers, as well as formal education and career pathways, while observing and collaborating with foreign organizations such as Queensland Ambulance Services in Australia. Reference Hou and Lu13,Reference Hung, Cheung, Rainer and Graham14
Melee events involving bladed weapons were responsible for the top two highest fatality and injury toll attacks in China and accounted for a large proportion of overall fatalities and injuries. While information on exact numbers of perpetrators for each event is limited (especially for large perpetrator groups), it is important to remember this is likely a reflection of both the lethality of the choice of weapon as well as the scale of the attack (ie, the number of perpetrators involved.) The 2009 event in the city of Urumqi in Xinjiang saw protestors from the Uyghur Muslim ethnic group take to the streets carrying a mix of bladed and blunt weapons and incendiary devices, attacking Han Chinese with a reported death toll of 184, making it the deadliest terrorism-related attack between 2008-2018 in China. The Kunming Railway Station attack of 2014 involved eight perpetrators armed with bladed weapons, inflicting a death toll of 33 (including four perpetrator deaths) and 143 injured, which was the second highest casualty toll.
While detailed injury patterns as a result of these events are not available, the wounding mechanism of penetrating knife injury is well-documented in the medical literature. Learning points for the medical system do not necessarily only lie in the prehospital management of a singular knife injury, but rather in the emergency management of large-scale, mass-casualty incidents.
The most frequently chosen methodology was E/B/D attack in attacks which caused casualties, and also accounted for a large proportion of overall fatalities and injuries. Five suicide bombers detonated a pair of explosives-laden vehicles at a market in Urumqi in Xinjiang in 2014, killing 36 people and injuring 94 others (third highest casualty toll). In that same year, in the Luntai District of the Xinjiang province, a series of explosive devices were set off over the course of a single day, totaling over 50 deaths and 54 injuries.
Melee only events and E/B/D attacks accounted for 68.5% of terrorist attacks in China. These trends are in direct contrast to those seen in Australia where the combined E/B/D/melee events only accounted for 8.1% of terrorism attacks over a similar time period. Reference Tin, Hart, Hertelendy and Ciottone15
Chemical attacks were rare with only two isolated events and one mixed chemical/incendiary/melee event documented between 2008-2018. In 2009 in Hong Kong, a corrosive acid was thrown from the top of buildings into crowded spaces, causing burn chemical injuries to 54 people in two separate events. In 2015, in the city of Ejin Horo in Inner Mongolia, approximately 100 assailants attacked a police checkpoint with clubs, tear gas (considered a chemical weapon for the purposes of the GTD and this study), and incendiary devices wounding 13 people and damaging 11 police vehicles. These chemical attacks did not cause any fatalities, however they resulted in the highest injury count per event, likely a reflection of the dispersible nature of chemical agents. Reference Dogaroiu16
Only one firearm-related attack was recorded, which is likely a reflection of strict regulations on gun ownership in China, with a minimum three-year jail sentence for sales or illegal possession of firearms. Reference Zhe17
Mixed weapon attacks accounted for the highest average fatality count per event compared to single modality attacks, reflecting a known but concerning trend in terrorist methodologies of using mixed conventional and unconventional methods in asymmetric attacks, further emphasizing the importance of developing CTM as a sub-specialty.
While a baseline standard of prehospital medical care needs to be established first as a foundation for dealing with disaster and mass-casualty events, there is an increasing global recognition that CTM is a sub-specialty needed to consolidate research, academia, and response agencies to provide evidence-based, best practice guidelines to providers on the frontline. Reference Court, Edwards, Issa, Voskanyan and Ciottone18
Limitations
Trying to determine the exact nature and scale of China’s terrorism problem is extremely difficult given the restrictions on reporting and the lack of independent corroboration of such events. The Chinese government’s strict control on information flow relating to national security is a limitation. Differing definitions of terrorism within and beyond China also introduces potential bias in reporting, in addition to any political implications of declaring an event a “terrorist attack.” Reference Zou19
There is heavy reliance on the GTD’s data, and grey literature searches were limited to English language reports, potentially missing Chinese language reports published online in local Chinese newspapers.
The on-going conflict between Chinese authorities and the Chinese Uyghurs remains a contentious topic far beyond the discussion scope of this manuscript, but there needs to be recognition that there are often definitional overlaps between terrorism and other forms of intentional violence and political repercussions of labelling events as such. Reference Wilson20 For the purpose of this manuscript, the GTD’s Codebook definition and inclusion criteria of terrorism and their incident determination algorithm were used. 21
Conclusion
One-hundred and eight terrorist attacks were recorded between 2008-2018 on Chinese soil using well-understood modalities. This resulted in a total of 809 recorded fatalities with 956 non-fatal injuries. The most commonly chosen methodology was E/B/D, followed by melees and the use of bladed weapons. Three events individually recorded a combined casualty toll of over 100 people. This analysis may support the need for CTM.
Conflicts of interest
The authors declare no conflict of interest.
