The Stage of Alert refers to the time period leading up to a disaster or terrorism event, usually defined by warnings disseminated by the federal government about increased risk of a disaster or terrorism situation. The general consensus was the need for more accurate information from appropriate governmental agencies to the public about specific impending threats, to ensure better coping. The purpose of providing this information to the public is to avoid panic or inertia, and to encourage normal adaptive reactions. It is important for people in positions of leadership to realize that past experiences have shown that panic has not occurred if people were given accurate information about the anticipated threat and specific guidelines about what to do.

The lack of a universally applicable definition of terrorism has confounded the understanding of terrorism since the term was first coined in 18th Century France. Although a myriad of definitions of terrorism have been advanced over the years, virtually all of these definitions have been crisis-centered, frequently reflecting the political perspectives of those who seek to define it.

In this article, we deconstruct these previously used definitions of terrorism in order to reconstruct a definition of terrorism that is consequence-centered, medically relevant, and universally harmonized. A universal medical and public health definition of terrorism will facilitate clinical and scientific research, education, and communication about terrorism-related events or disasters.

We propose the following universal medical and public definition of terrorism: The intentional use of violence — real or threatened — against one or more non-combatants and/or those services essential for or protective of their health, resulting in adverse health effects in those immediately affected and their community, ranging from a loss of well-being or security to injury, illness, or death.

Major terrorist attacks in Argentina since 1990 have been limited to two bombings in Buenos Aires, which together caused 115 deaths and left at least 555 injured. Following these attacks, national, regional, and local institutions responsible for emergency response in Argentina sought to improve their planning and preparedness for terrorism-related events. In 1996, the national government enacted legislation, which launched the Sistema Federal de Emergencias (SIFEM) or Federal Emergency System under the direction of the president. Since 1997, several of Argentina's major cities have developed emergency plans for terrorism-related events, including intentional biological and chemical releases. Institutional participants in emergency preparedness for terrorism-related events include Emergency Medical Services, hospitals, and the public health system. Remaining challenges include: (1) Improving intra-agency coordination; (2) Improving intra-agency communication; and (3) Improving and expanding emergency response training programs for responders and the general population.

Recent world events have forced Australia to re-examine its role on the world stage and its susceptibility to terrorist attacks. The authors examine the brief historical exposure of Australia to the phenomenon of terrorism, and review the geopolitical climate and features that may render it more susceptible to attack in the future. Australia's emergency management structure is outlined, and its current state of medical preparedness for a terrorist incident is critically reviewed.

The Republic of Bulgaria is one of the smallest countries in southeastern Europe and has little experience with terrorist acts. During the past 20 years, only nine terrorism-related events have been recorded in Bulgaria, and no unconventional weapons have been used. Factors contributing to terrorism in Bulgaria have been: (1) Communist Party domination of the government and political process from 1944 to 1989; (2) ethnic and religious conflicts between the Bulgarian Orthodox Christian majority and the Turkish Muslim minority from 1983 to 1987; and (3) the relatively high level of organized crime after the Communist regime ended in 1990.

The structure and function of the Disaster Relief System in Bulgaria not only are focused on the prevention of terrorism, but also on preparedness for the emergency response to terrorism-related events. Institutional components of the Disaster Relief System structure responsible for the emergency response to terrorism-related events include: (1) the Government of Bulgaria; (2) the State Agency for Civil Protection with 28 regional directorates; (3) the Ministry of Health with five national hospitals, 28 regional hospitals, and 28 EMS systems; (4) the Ministry of Defense with special military units for response to unconventional terrorist events, including nuclear, biological, and chemical weapons; (5) the Ministry of Internal Affairs with 28 police departments, 28 fire departments, and specialized anti-terrorist units; and (6) the Bulgarian Red Cross.

A major future challenge in Bulgaria is the prevention of terrorism through political stability, economic prosperity, ethnic and religious tolerance, and more effective measures against organized criminal activities. A related challenge will be to improve the level of preparedness of all components of Disaster Relief.

This paper reviews terrorism in Canada, assessing the incidence and nature of terrorist activity, the potential targets of terrorist attacks, risk factors to Canadian nationals and institutions, and the responses of the Canadian government in dealing with the threat and the effectiveness of those responses.

Despite the fact that there have been no recent high-profile terrorist events in Canada, this country has a serious terrorism problem, the key manifestation of which is the multitude of terrorist organizations that have designated Canada as a base of operations. In addition, Canadians have been attacked overseas and Canadian organizations, both local and abroad, are potential targets of terrorist activity. Canadian attempts to deal with terrorism through foreign and domestic policy have been ineffective, primarily because the policies have been poorly enforced. Until recently, terrorist organizations legally could raise funds in Canada, in direct contravention of international treaties signed by Canada. It is possible that the ineffectiveness in enforcing the anti-terrorism legislation stems from hope that placating terrorist organizations, and the countries that support them, will prevent Canada from becoming a target. Unfortunately evidence from other countries has shown this strategy to be ineffective.

Colombia is a poor country that has been plagued by ongoing violence for more than 120 years. During the 1940s, subversive terrorist groups emerged in rural areas of the country when criminal groups came under the influence of Communism, and were later transformed into contemporary groups, such as the Ejercito de Liberacion Nacional (ELN) or National Liberation Army and Fuerzas Armadas Revolucionares de Colombia (FARC) or Revolutionary Armed Forces of Colombia). Paramilitary terrorist groups emerged in response to subversive groups and were later transformed into contemporary groups, such as the Autodefensas Unidas de Colombia (AUC) or United Self-Defense Forces of Colombia.

Terrorism has placed an enormous burden on modern Colombia. From 1995 to 2002, 9,435 people were killed by terrorism-related events, of which 5,864 were killed by subversive terrorist activities and 3,571 were killed by paramilitary terrorist activities. In 2002, at least nineteen attacks produced 10 or more casualties, of which 18 were bombings. In 2002, terrorists killed at least 12 mayors, 71 legislators, and internally displaced 300,000 persons from their homes. Since terrorist groups in Colombia are typically supported by drug manufacturing and trafficking, it has been difficult at times to distinguish violence due to terrorism from violence due to illicit drug trafficking. Terrorism has also had a major adverse effect on the economy, with restricted travel, loss of economic resources, and lack of economic investment. In addition to political, military, and commercial targets, terrorists have specifically targeted healthcare infrastructure and personnel.

At the national and local levels, much emergency planning and preparedness has taken place for terrorism-related events. The Centro Regulador de Urgencias (CRU) or Emergency Regulation Center in Bogota plays a major role in coordinating local prehospital and hospital emergency response in the capital city and the national level where necessary.

Abstract

France has experienced two waves of major terrorist bombings since 1980. In the first wave (1985–1986), eight bombings occurred in Paris, killing 13 and injuring 281. In the second wave (1995–1996), six bombings occurred in Paris and Lyon, killing 10 and injuring 262. Based on lessons learned during these events, France has developed and improved a sophisticated national system for prehospital emergency response to conventional terrorist attacks based on its national emergency medical services (EMS) system, Service d' Aide Medicale Urgente (SAMU). According to the national plan for the emergency medical response to mass-casualty events (White Plan), the major phases of EMS response are: (1) alert; (2) search and rescue; (3) triage of victims and provision of critical care to first priority victims; (4) regulated dispatch of victims to hospitals; and (5) psychological assistance.

Following the 1995 Tokyo subway sarin attack, a national plan for the emergency response to chemical and biological events (PIRATOX) was implemented. In 2002, the Ministries of Health and the Interior collaborated to produce a comprehensive national plan (BIOTOX) for the emergency response to chemical, biological, radiological, and nuclear events. Key aspects of BIOTOX are the prehospital provision of specialized advance life support for toxic injuries and the protection of responders in contaminated environments. BIOTOX was successfully used during the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak in France.

Indonesia has had its share of natural and manmade disasters. From 1997 to 2002, Indonesia has experienced 90 incidents of terrorist bomb attacks. In 13 (14.4%) of the terrorist attacks, the bombs did not explode. A total of 224 persons have been killed, and 340 persons have been injured. Most of those killed or injured were the result of the bombings in Jakarta and Bali. Besides bombings, there have been riots, especially in Jakarta. The Indonesian Surgeons Association established the 1–1–8 Emergency Ambulance Service Foundation to develop the Prehospital Emergency Medical Services in Indonesia. Despite difficulties, this service has been implemented in 18 cities. The occurrence of disasters, riots, ethnic conflicts, terrorist attacks, and the introduction of the Advanced Trauma Life Support (ATLS) course in 1995, have helped to convince the people and the government that it was important to develop this 1–1–8 Emergency Ambulance Services system, and agreed to accept a Safe Community Program. With the Safe Community Program, Jakarta with its Integrated 1–1–8 Emergency Ambulance Service managed to provide proper emergency medical care to the casualties caused by terrorist bombings, riots, and in the three weeks of floods during which 75% of Jakarta was submerged.

Although the 1995 Tokyo subway sarin attack probably was the most widely reported terrorist event in Japan to date (5,500 injured, 12 dead), the country has suffered numerous other large terrorism-related events in recent decades, including bombings of the headquarters of Mitsubishi Heavy Industries in Tokyo in 1974 (207 injured, 8 dead), the Hokkaido Prefectural Government office building in Sapporo in 1976 (80 injured, 2 dead), and the Yosakoi-Soran Festival in Sapporo in 2000 (10 injured, none dead). Japan also has experienced two other mass-casualty terrorist events involving chemical releases, including the 1994 Matsumoto sarin attack (600 injured, 7 dead) and the 1998 Wakayama arsenic incident (67 injured, 4 dead).

Until 1995, emergency management in Japan focused on planning and preparedness at the local level for the frequent disasters caused by natural events. Since that time, substantial progress has been made in advancing emergency planning and preparedness for terrorism-related events, including the designation of disaster centers in each prefecture, the implementation of several education and training programs for nuclear, biological, and chemical terrorism, and the establishment of a national Antiterrorism Office within the Ministry of Health, Labor, and Welfare.

In the peace-loving, moderate and progressive country of Muslim-dominated Malaysia, violence generally is alien to the culture. Terrorism initially took shape during the post-independence, communist era by jungle recalcitrant actions. In recent years, this has been superceded by a more internationally related trend of violence. Only very few incidents were based locally, while the majority were linked to international groups or organizations abroad, including the Kumpulan Mujahidin Malaysia (KMM), Jemaah Islamiyah (JI), and the Abu Sayyaf Group (ASG).

Kidnapping with ransom seemed to have been the most commone modus operandi, while killing and robbery accounted for very few of these incidents. The number of victims in each event so far has been small, and smaller for those physically harmed or killed. This pattern of terrorist attacks suggests that the current level of provision of emergency medical services is sufficient to handle such incidents. Recent advances in local emergency medicine also have witnessed the establishment of various teaching and training modules, a pivotal role played by university hospitals and supported by the Ministry of Health.

However, the spate of ongoing events of mass destruction such as the conflict in Israel/Palestine, wars in Afghanistan and Iraq, the World Trade Center and Pentagon tragedies of 11 September 2001, and the Bali bombing in Indonesia, remain as great concerns to Malaysians. Both the government and the people of Malaysia abhor such unjustified uses of terror, and take every measure to curtail them. The National Security Council policies of Arahan No. 18 and Arahan No. 20 detail specific roles and responsibilities of various agencies in managing terrorism and disasters respectively, while the use of the stern Internal Security Act that allows indefinite detention without trial, evidently has been an efficient intelligence and security apparatus.

With more recent developments of terrorist events regionally and globally, Malaysia continues to face an ongoing threat from such activities. Various measures have been and will be actively undertaken both by government and non-governmental agencies in facing these challenges.

Even though Mexico is considered internationally as a pacifist country, its economic, social, and geopolitical characteristics during the last half of the 20th century have resulted in internal events that can be considered acts of terrorism.

Most of the acts of terrorism during the last 15 years have had to do either with political movements or drug-dealing actions. After the 11 September 2001 attacks in the United States, Mexican Health Authorities have strengthened the epidemiological surveillance system. More than 1,372 calls asking for information or reporting suspicious envelopes were received between 16 October and 21 October 2001.

Following the earthquake in 1985 that caused great damage and many deaths in Mexico, the National Civil Protection System was created in 1986. This protection system is led by the President and the Secretary of Government. It was developed to improve preparedness for disaster coordination more than for terrorism responses. In addition, the emergency medical systems continue to lack organization, even though some states have shown significant progress in their emergency medical system.

Two major domestic terrorist groups have plagued Peru over the past 20 years, the Sendero Luminoso or “Shining Path” (SL) and the Revolutionary Movement Túpac Amaru (MRTA). On 28 August 2003, the Peruvian Truth and Reconciliation Commission reported that an estimated 69,280 persons were killed in the internal conflict in Peru from 1980 to 2000. Most of the victims were farmers (56%), most attacks occurred in rural settings (79%), and the SL was responsible for mostof the deaths (54%). Aggressive anti-terrorism efforts by police and military during this period, often at the expense of basic human rights, also contributed to this large burden of terrorism on Peru. During the 1990s, terrorist attacks in Peru had spread to its urban areas. On 17 December 1996, 22 members of MRTA took over the Japanese ambassador's residence in Lima, holding 72 hostages until the grounds were stormed by Peruvian special forces on 23 April 1997.

Until recently, emergency planning and preparedness for terrorism-related events in Peru were largely underdeveloped. In the last five years, Peru has taken two key steps towards developing a mature emergency response system, with the establishment of the country's first emergency medicine residency training program and the construction of the first dedicated trauma center in Lima.

The Republic of China on the island of Taiwan has experienced at least 20 terrorist events since 1979, including 13 aircraft hijackings and five bombings. Factors responsible for the relatively small burden of terrorism on Taiwan in the past include tight military control over political dissent until 1987, a warming relationship with the People's Republic of China in the 1990s, political inclusion of major internal cultural groups, geographic isolation, and a lack of other significant international enemies. Nevertheless, today Taiwan faces a new prospect of terrorism by adversaries of the United States and its allies and by an international paradigm shift in the types of weapons used by terrorists.

National emergency management has been enhanced significantly since the Ji Ji earthquake in 1999, including the assignment of lead government agencies to the planning and preparedness for specific types of terrorist events involving nuclear, biological, and/or chemical releases. Other significant improvements at the operations level, include the establishment of two national disaster medical assistance teams, four urban search and rescue teams, 13 local disaster medical assistance teams, and eight chemical emergency response hospitals. Future challenges include improving the coordination of inter-agency response at the national level and the quantity and quality of local disaster response assets.

The Republic of South Africa lies at the southern tip of the African continent. The population encompasses a variety of races, ethnic groups, religions, and cultural identities. The country has had a turbulent history from early tribal conflicts, colonialisation, the apartheid period, and postapartheid readjustment.

Modern terrorism developed mainly during the apartheid period, both by activities of the state and by the liberation movements that continued to the time of the first democratic elections in 1994, which saw South Africa evolve into a fully representative democratic state with equal rights for all.

Since 1994, terrorist acts have been criminal-based, evolving in the Cape Town area to political acts, largely laid at the feet of a predominantly Muslim organisation, People against Gangsterism and Drugs, a vigilant organisation allegedly infiltrated by Muslim fundamentalists. Along with this, has been terrorist activities, mainly bombings by disaffected members of white, right-wing groups.

In the apartheid era, a Draconian series of laws was enacted to suppress liberation activities. After 1994, most of these were repealed and new legislation was enacted, particularly after the events of 11 September 2001; this legislation allows the government to act against terrorism within the constraints of a democratic system. Disaster management in South Africa has been largely local authority-based, with input from provincial authorities and Civil Defence. After 1994, attempts were made to improve this situation, and national direction was provided. After 11 September 2001, activity was increased and the Disaster Management Act 2002 was brought into effect. This standardized disaster management system at national, provincial, and local levels, also facilites risk assessment and limitation as well as disaster mitigation.

The potential still exists for terrorism, mainly from right wing and Muslim fundamentalist groups, but the new legislation should stimulate disaster management in South Africa to new and improved levels.