Analysis of the Medical Consequences of Global Terrorist Attacks in Turkic States in the Last 50 Years by Weapon and Attack Type

Abstract

Objective:

This research aimed to conduct an epidemiological analysis of the terrorist attacks, which took place in the Turkic states between 1970 and 2019, and their medical consequences in terms of weapons and attack types. The data collected from this research will be valuable for the development of preventive systems against attacks on Turkic states and offer insights on how to effectively prepare for potential future attacks.

Methods:

The population of the research consisted of the weapons and types of attacks of the terrorist attacks in the Turkic states drawn from the Global Terrorism Database provided free of charge by START. The number of deaths, injuries, property damage, primary weapons, and types of attacks were analyzed by country.

Results:

Between 1970 and 2019, 4629 terrorist incidents occurred and 7496 people lost their lives and 10 928 people were injured. Among the types of weapons, the number of people who lost their lives was mostly in firearms, whereas the number of the injured was mostly in explosive weapons. Among the types of attacks, the number of people who lost their lives was mostly observed in the armed attack, whereas the injuries occurred mostly in the bombing attacks. Among the Turkic states, Turkey is the country most affected in terms of medical outcomes.

Conclusion:

The terrorist attacks in the Turkic states reached their maximum number in the last 10 years. It is predicted that this number will increase further in the next years and affect more people medically.

Terrorist attacks are universally harmful acts against both the state and society. Terrorists who commit these acts are considered enemies of both the state and the people. ¹ Although human-made disasters are generally unplanned and accidental, terrorist attacks consist of a pre-designed structure in which the feeling of death, injury, destruction, and fear in the society is targeted at the highest level. ^2,3 In particular, global terrorist attacks have a significant impact on health and have a history dating back thousands of years, and their health outcomes are becoming more complex each day. ⁴

Terrorism includes many types of attacks, including kidnapping, hijacking, bombing, assassination, and armed and unarmed attacks. The weapons chosen to carry out these types of attacks began to develop in the early 1990s, and terrorist attacks have increased since 2001. ⁵ It is assumed that this increase in terrorist incidents is related to the terrorist attacks of September 11, 2001, and marks the beginning of the “new era” of terrorism. ^6–8 With the onset of the new era of terrorism, countries have begun to take measures both nationally and internationally. For example, the United Nations established the Counter-Terrorism Committee (CTC) with its decision numbered 1373 against the increase in terrorist attacks. ⁹ Turkey, which is part of the CTC, established an international organization in 2009 to promote comprehensive cooperation among the Turkic states. The founding members of the organization are Azerbaijan, Kazakhstan, Kyrgyzstan, and Turkey. Hungary, Uzbekistan, and Turkmenistan were later included in this organization. Among the main objectives of this organization are the fight against international terrorism, separatism, extremism, and cross-border crime. ¹⁰ It is also crucial to understand the historical context and methodologies of past attacks to support this fight, prevent terrorist incidents, and better prepare first responders for prospective terrorist attacks. ¹¹ This study, in this context, aimed to conduct an epidemiological analysis of the medical consequences of the terrorist attacks, which took place in the Turkic states between 1970 and 2019, in terms of weapons and type of attack.

Methods

In this cross-sectional epidemiological study, the data from the Global Terrorism Database (GTD) provided free of charge by START (the National Consortium for the Study of Terrorism and Responses to Terrorism), which systematically records worldwide terrorist incidents, were used. It was aimed to analyze the weapons, attack types, and medical consequences of the terrorist attacks that took place in the Turkic states between 1970 and 2019.

Data Source

To realize the purpose of the study, the metadata on terrorism were downloaded from the START website. The metadata file consisted of free and publicly available data containing more than 200 000 events related to terrorist incidents occurring worldwide until the date of download (August 21, 2021). ¹² The GTD data included the data from news sources from 1970 to 2019 (except 1993). For each incident in the GTD, information was available about the date and place of the incident, the types of weapons used, the nature of the target, the number of casualties, and the responsible group or person, where identifiable. The codebook on the use of the GTD described data management, data validation methods, inclusion criteria, data variables, and staff training. ¹³ Publications produced from the GTD data can be accessed regularly on the START site. This study constitutes a secondary research of the GTD data.

Definitions

The GTD is a database containing systematic data on national and international terrorist incidents. According to this database, a terrorist attack is defined as the unlawful use of force, threat of violence or action by a non-state person or persons (actor) to achieve a political, economic, religious, or social goal through fear, coercion, or intimidation. ¹³ For an incident to be included in the GTD, it must be intentional, posing a certain level of violence or an immediate threat of violence.

The Organization of Turkic States, formerly the Turkic Council, is an international organization established in 2009 to promote comprehensive cooperation among the Turkic states. This organization consists of 7 countries in total, including 4 founding members (Azerbaijan, Kazakhstan, Kyrgyzstan, and Turkey), 1 full member (Uzbekistan), and 2 observer members (Hungary and Turkmenistan). ¹⁴

Inclusion Criteria, Search Strategy, and Data Preparation

For an incident to be considered terrorism by the GTD, it is subject to criteria for inclusion in GTD’s raw data file if it meets 3 predetermined criteria. Uncertain incidents are excluded when there is uncertainty as to whether an incident meets any of the 3 criteria for GTD inclusion as terrorism. For an incident to be included, at least 2 of these 3 criteria must be present. The GTD’s inclusion criteria are set within the database:

• Criterion 1: The act must be aimed at attaining a political, economic, religious, or social goal.

• Criterion 2: 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 3: The action must be outside the context of legitimate warfare activities.

In line with the purpose of the study, an inclusion criterion was developed among 135 variables in the GTD (Table 1). The terrorist incidents, including these developed criteria, were included in the study.

Table 1. GTD variables and subcategories included in the study

Data Preparation

The GTD metadata file was a free download. This file was uploaded to IBM SPSS Statistics version 22 (IBM Corp, Armonk, NY), and the terrorist attacks against the Turkic states were searched. As a result of the search, the information that met the inclusion criteria of the study was saved in the Microsoft Excel file. Since the data for the years 2020–2022 were not yet available during the transfer phase, the relevant years were not recorded.

Data Analysis and Ethics

Ethics committee review was not sought since this study was designed to retrospectively analyze the weapon type, number of casualties, and medical outcomes of the terror data in the Turkic states, based on an open-access data set. No information was recorded about other countries other than the Turkic states. The identities of the individuals included in the GTD database were extracted from the study data file. The original sources were not consulted to evaluate the accuracy of the GTD data. The frequency distributions were analyzed to determine the number of incidents, the number of casualties, and property damage by years of terrorist incidents that met the inclusion criteria of the study. In addition, frequency analysis was conducted to determine the total number of casualties according to the type of weapon and attack of each incident that occurred in the Turkic states.

Results

General Results

From 1970 to 2019, there were 4629 terrorist incidents that met the GTD inclusion criteria and the study’s inclusion criteria. In 124 of these attacks, the nationality of the attackers was different from the country where the attack took place. In 335, the nationality of the attacker was different from the nationality of the victims of the attack. In 339, the country where the attack occurred and the nationality of the victims were different (Table 2). In most of the attacks, it was seen that the desired target was achieved by the terrorist organizations (n = 4208; 90.9%); 88 incidents included suicide attacks.

Table 2. Analysis of incidents by country

* International logistical;

** International ideological;

*** International miscellaneous.

Attack by Year

Figure 1 shows the number of terrorist attacks that occurred at 10-year intervals in the countries within the Turkic states. There was an increasing trend in the terrorist incidents between 1990 and 1999 in the Turkic states. While the minimum terrorist incidents were observed in these countries between 2000 and 2009, terrorist incidents reached the maximum level in the last 10 years.

Figure 1. Terrorist attacks by country.

Attack Types, Weapon Types, and Property Damage

Table 3 shows the number of incidents and casualties by weapon types. Explosives were the most frequently identified weapon types (n = 2235; 48.2%). While firearms used in 1670 (36.0%) incidents took the second place, biological, nuclear, and radiological weapons were not used. Among the weapon types, the most deaths (n = 4390; 58.5%) were observed in firearms, whereas the most injuries in weapon types occurred in explosives (n = 8452; 77.3%). Among the weapon types, the least deaths and injuries were seen in vehicle (n = 1; 0.0%; n = 1; 0.0%, respectively) weapon types.

Table 3. Number of incidents and number of casualties by weapon types

The number of incidents and casualties according to attack types is given in Table 4. Bombings (n = 2123; 45.8%) are considered the most common type of attack, whereas armed attacks (n = 1352; 29.2%) take the second place. In 4629 terrorism incidents, 10 928 people were injured and 7496 people lost their lives (see Table 4). It was concluded that more than half of the attacks involved a certain degree of property damage (n = 2836; 66.1%), as determined by the GTD. While material losses due to terrorism were mostly seen in Turkey, material losses were not observed in Turkmenistan (see Table 2).

Table 4. Number of incidents and number of casualties by types of attacks

Incidents by Country and Their Impact on Human Health

Among the Turkic states, the country most frequently affected by terrorist attacks was Turkey with 4464 (96.4%) incidents. Azerbaijan ranked second with 50 attacks (1.0%), followed by Kyrgyzstan (n = 37; 0.8%), Kazakhstan (n = 28; 0.6%), Hungary (n = 27; 0.5%), Uzbekistan (n = 21; 0.4%), and Turkmenistan (n = 2; 0.0%) (see Table 2).

In total, 18 424 people (7496 dead and 10 928 injured) were adversely affected by the terrorist incidents that took place in the Turkic states. Among the Turkic states, the most affected country in terms of medical outcomes was Turkey with 7086 deaths and 10 304 injuries, and the least affected country was Turkmenistan with 3 deaths and 3 injuries (see Table 2).

Discussion

This study is important, as it is the first to describe the medical consequences of 4629 terrorist attacks that took place in the Turkic states between 1970 and 2019, along with weapons and attack types. The Organization of Turkic States is an international organization consisting of 7 countries in total, including 4 founding members (Azerbaijan, Kazakhstan, Kyrgyzstan, and Turkey), 1 full member (Uzbekistan), and 2 observer members (Hungary and Turkmenistan). While this organization is a platform for the development of interstate relations, one of the main purposes of this organization is to act together against terrorist attacks. ¹⁵ These countries have been fighting different forms of terrorist organizations for years, such as the Fethullah Terrorist Organization (FETO), the People’s Protection Units or the People’s Defense Units (YGP), the Kurdistan Workers’ Party (PKK), the Revolutionary People’s Liberation Party/Front (DHKP-C), the Armenian Secret Army for the Liberation of Armenia (ASALA), Al-Qaeda, and the Islamic State of Iraq and the Levant (DEAS). ¹⁶

Between 1970 and 2019, 4629 terrorist attacks occurred in the Turkic states and 7496 people lost their lives and 10 928 people were injured. Between 2009 and 2019, terrorist attacks reached their peak in terms of frequency, as shown in Figure 1. Moreover, an alarming trend shows that terrorist organizations successfully achieved their intended targets in approximately 90% of these attacks within the mentioned countries. Seven percent of the terrorist attacks by terrorist organizations in the Turkic states include suicide attacks. Suicide attacks, also known as suicide bombers, are defined as a type of attack in which persons end their own lives by placing an explosive device on their bodies, either intentionally or unintentionally. ¹⁷ Although the rate of suicide bombings is low, defensive response to these attacks is tactically difficult and causes more casualties than other forms of terrorism. ¹⁸ Other bomb attacks occur more frequently than suicide bomb attacks and cause many injuries. The most common type of attack in the Turkic states, which injures many people, is a bomb attack. For example, the biggest bombing attack in the Turkic states in recent years occurred in Turkey on November 15 and 20, 2003. In this attack, 63 people lost their lives and approximately 750 people were injured. ¹⁹ The medical consequences of this type of attack vary widely, depending on the type of bomb, the method of detonation, the environment in which it occurs, its proximity to the source, and the weather. ²⁰ Pressure during a bomb attack directly affects health, resulting in penetrating and thermal injury; injury to sensitive areas such as the ears, lungs, and abdomen; skin ecchymosis, abrasion, and tearing; head trauma; and bone fractures. ^21–25 However, flying objects, blast waves, and complicated events occur in bomb attacks. These events cause medical consequences such as blunt trauma, fractures, burns, crush syndrome, and immune system problems. ²⁶

Turkey has been, and continues to be, one of the countries frequently targeted in terrorist attacks. According to different studies, Turkey ranks 23rd among the countries most affected by terrorism in the world and ranks first among the European and Turkic states. ²⁷ Due to Turkey’s geopolitical position, the Iran-Iraq and Gulf wars in the Middle East, the Russia-Ukraine war in the Northeast, the Bosnia-Herzegovina and Kosovo crises in the Balkans, and the Nagorno-Karabakh wars in the Caucasus took place in the close vicinity of the country and left Turkey at risk of being involved in regional conflicts for its own borders. ²⁸ There is a power vacuum in the states of Syria and Iraq located in the Southern region of Turkey. This power vacuum causes a significant increase in the number of irregular migrants and asylum seekers, who move from the Middle East, travel through Turkey, and try to reach Europe. Thus, the rate of irregular migrants and asylum seekers in Turkey has increased. ²⁹ In addition, Turkey has disputes with Greece in the Sea of Islands. ³⁰ It can be stated that all these factors support terrorist activities of structures with different goals and objectives in Turkey. For example, on the night of July 15, 2016, a coup attempt against Turkey took place by the Fethullah Terrorist Organization. Although the desired goal was not achieved by the terrorist organization in this attack, 240 people lost their lives and nearly 2000 people were injured as a result of the attack. ³¹ Firearms and explosive weapons were preferred as the types of weapons used in this coup attempt. ³² It is seen that the most used type of weapon in the terrorist attacks in the Turkic states are explosives and firearms. In similar studies on terrorism, it is stated that fire and explosive weapons are widely used in terrorist attacks. ^1,33,34 Among the reasons for the widespread use of explosive weapons are that this type of weapon is relatively easy and inexpensive to manufacture, simple to use, and easy to execute with a small number of attackers. Although firearms are used relatively less than explosive weapons among the Turkic states, they have the highest death rate among weapon types. In similar studies, the lethal rate of firearm incidents was found to be high. ^1,34 In addition, firearms, which are widely publicized and easy to access, cause mass murders. ⁴ Although these conventional weapons have been favored by aggressors, non-traditional weapons, such as chemical-biological-radiological-nuclear weapons, are perceived by governments as a serious potential weapon of mass destruction threat. ² Although this type of weapon is almost never used in the Turkic states, Turkey has laid the foundations of its defense system against chemical and biological weapons. ³⁵

Finally, terrorist attacks not only cause death and injury, but also damage both the country and society economically. ³⁶ In particular, 61% of the terrorist attacks that occurred in the Turkic states caused material damage, and it is seen that most of the material damage occurred in Turkey. While material damage increases the vulnerability of the society, it negatively affects the social welfare and causes public health problems and health inequalities. In the literature, there are also various studies examining the effects of terrorist attacks in Turkey on the economy. ^36–38

Limitations

This study has several limitations. First, as mentioned before, the data of the study were obtained from the GTD database. The GTD database comprehensively records global terrorism incidents. This database uses media reports to collect data. Therefore, there is a possibility of bias and data gaps in the available data. However, since the database records terrorist attacks by non-state actors, it may not include all terrorist attacks that occurred in the Turkic states between 1970 and 2019. Finally, there are terrorist attacks that occurred between 1970 and 2019 in the GTD database. Due to the new establishment of some countries within the Turkic states, information about the terrorist incidents that took place in those regions for the last 50 years could not be accessed.

Conclusion

In the last 50 years, 4629 terrorist attacks occurred in the Turkic states and 7496 people lost their lives and 10 928 people were injured; 96% of these terrorist attacks occurred in Turkey. The terrorist attacks were carried out with many types of attacks, including bombing, armed, and unarmed attacks. The most common type of attack in the Turkic states was bombing. While this type of attack caused the most injuries, the most deaths occurred in the types of armed attacks. The terrorists targeting the Turkic states mostly preferred explosives and firearms to carry out the attack. Among these weapon types, the most deaths occurred in firearms, while the most injuries were observed in explosive weapons. Among the non-traditional weapon types, only chemical weapons were used in the Turkic states. For this reason, the Turkic states should also be prepared for the management of the medical consequences of chemical-biological-radiological-nuclear weapons, which are unconventional and have a high potential to cause mass losses, although traditional weapons are used.