Code Black: Hospitals as Terrorist Targets
By Carey Pelto, M.D.


The ability of the U.S. healthcare system to respond to a large terrorist attack has been analyzed extensively since 9/11, and reports have not been positive. Our national emergency medical system is strained to the breaking point. In numerous urban emergency departments (EDs), overcrowding issues like boarding, rising patient volumes, and long wait times are common. Each year, the national volume of emergency patients increases, yet emergency departments continue to close due to decreased funding and increasing expenses.

According to a recent Center for Disease Control (CDC) report, during the decade ending in 2006, the number of ED patient visits rose 32% in the United States- yet the number of EDs dropped by 4.6%. A May, 2008 House oversight committee report studied 34 hospitals in seven major cities and concluded that U.S. hospital ED's are overwhelmed- and most are not prepared to deal with the surge of patients that would result from a major terrorist attack.

The strategic importance of a hospital to the health and wellbeing of its community cannot be overstated. Yet, this integral role has not seemed to merit a great deal of attention from homeland security strategists.

The role of hospitals in disaster planning has been focused primarily upon the medical response to local mass casualty incidents. But what would happen if the hospital were the actual terrorist target? Unfortunately, this notion is not implausible. In fact, it has happened numerous times in recent history. A recent internet search revealed dozens of incidents in recent years in which hospitals have been specifically targeted by terror groups. Many of these incidents received little or no attention from the Western press. Consider the following incidents:
Russia, June 14-19, 1995: Islamist terrorists in Chechnya attacked the Budyonnovsk Hospital in a 5 day siege, holding 1800 hostages. Russian Special Forces stormed the hospital on Day 5- final toll 147 dead, over 400 injured.

Thailand, Jan 25, 2000: 10 Burmese rebels attacked Ratchaburi Hospital, and held 700 hostages in a hospital siege. Thai commandos eventually stormed the building and killed the gunmen.
Pakistan, August 2002: An Islamist suicide bomber attacked a Christian hospital in Taxila (40 km outside of Islamabad), killing 3 nurses.

Russia, Aug. 2, 2003: A Chechen suicide bomber drove a Vehicle Borne Improvised Explosive Device (VBIED) into a hospital in Modzok, killing 50 and injuring 100. The four story hospital was leveled, leaving a crater 3 meters deep.

Gaza, June, 2005: A 21 year old Palestinian woman was stopped at border checkpoint with suicide bomb- and admitted that she had planned to use her special medical clearance to gain access to a Beersheva hospital and blow herself up. She admitted that she had been given intensive medical care at the hospital for severe burns 5 months earlier.
Iraq, Nov. 24, 2005: A suicide bomber drove a VBIED into the Mahmoudiyah Hospital gate, killing 30. Russia, January 9, 2006: In a "copycat raid" of the 1995 attack, Chechen Islamist terrorists attacked a hospital in Kizlyar, taking 1200 hostages (3400 by some sources). Final toll 19-34 dead (open source accounts vary).

India, Feb, 2006: 5 suspects were arrested, and charged with plot to blow up the Coimbatore Medical College Hospital. Bombs and a detailed map were confiscated. The Indian government linked the suspects to a Hindu terrorist group.
India, July, 2008: A suicide bomber drove a VBIED into the crowd outside Civil Hospital in Ahmedabad- 23 killed.

Pakistan, August, 2008: A suicide bomber attacked the Emergency Department of a hospital in Dera Ismail Khan- 32 people were killed, 55 wounded. The Taliban claimed responsibility.
India, October 2008: 17 bombs rocked hospitals in Maninagar (LG Hospital) and Ahmedabad (Vadilal Hospital). Final toll: 29 dead.

India, November 2008: During the bloody 24 hour Mumbai terrorist siege, two gunmen attacked the Cama hospital with automatic weapons and hand grenades. Two policemen and three hospital personnel were killed during the attack. The terrorists tried to breach the hospital maternity ward, but were unsuccessful. Lashkar-e-Taiba, a Pakistan-based militant Islamist group, claimed responsibility.

Reaching a conclusion about terrorist trends from the above incidents is difficult, but it appears that the most successful tactic used against soft domestic targets is a fedayeen- style attack. This usually involves multiple assailants armed with assault weapons and explosives, an extended siege (hours or days), with multiple hostages and high body counts. The longer the incident can be extended, the greater the global media attention. Thus, the assailants will often attempt to negotiate their demands in return for the hostages' lives.

Unfortunately, this tactic only buys more time for media coverage- the terrorist's final goal is execution of the hostages and a martyr's death. This style of attack was used in Mumbai, Kizlyar, Ratchaburi, and Budyonnovsk, and Beslan. Hardened targets- military hospitals, or hospitals in areas of frequent conflict (and therefore increased security) - require different tactics. These targets are usually the victims of lone bombers, wearing suicide vests or driving VBIED's.

Why Attack A Hospital?
Deliberate hospital attacks are a relatively modern phenomenon. The advent of aerial bombing in World War I resulted in rare hospital casualties when random bombs strayed from their intended targets. World War II ushered in a new era of massive aerial assaults on urban areas. Strategic bombing campaigns often resulted in hospital destruction as entire cities were razed. Again, hospitals were not deliberately targeted; they were simply casualties of carpet bombing tactics. Hospitals have traditionally held sacrosanct status as islands of refuge amid the chaos of war. Any damage inflicted upon a hospital, inadvertent or not, was considered reprehensible by Western standards. Thus, the conventional strategy has been to avoid damage to enemy hospitals- or suffer a public relations defeat.

The current war against global terrorism is markedly different from previous conflicts, however. This new breed of malevolence, often coined "Fourth Generation Warfare (4GW)," or "asymmetrical warfare," represents a paradigm shift in strategy from conventional warfare. 4GW is a strategy used by small, ideologically based groups to wage war on large nation-states. In this modern version of David vs. Goliath, the intent is not to destroy an enemy outright using superior resources and military might.

Instead, terrorist groups use 4GW to destroy a larger enemy from within by eroding its confidence, disrupting its infrastructure, and weakening its will to fight a protracted campaign. There is no formal battlefield, and no distinction between military and civilian combatants. This war of attrition is waged with endless acts of violence that attract worldwide media attention. As international terror expert Brian Jenkins has stated, "Terrorism is theatre." To promote their message and garner global press coverage, terrorists pick targets with maximum shock value- and large body counts. The 2008 Mumbai terror attacks, resulting in 175 deaths, and the 2005 school siege at Beslan- resulting in 340 deaths - were strategic missions that utilized worldwide media coverage and massive carnage to achieve specific goals.

U.S. school massacres at Columbine, Bailey, and Virginia Tech awakened the American consciousness to the horrors of mass murder in schools. The Beslan school siege of 2005 resulted in 340 deaths in Chechnya, and brought school terrorism to the world stage. The shocked worldwide response to these tragedies was to accelerate law enforcement training for the "active shooter" doctrine, and consider schools as uniquely vulnerable targets. Their psychological value as targets is obvious- large numbers of defenseless, innocent victims confined in a small area that has traditionally been held as immune to social strife. Psychologically, the effects of a school attack meet the terrorist goals perfectly.

About the Author:

Dr. Pelto is a SWAT physician and emergency medical director who resides in Colorado Springs, Colorado. He is the TEMS director for the Central Mountain Training Foundation, a non-profit organization dedicated to law enforcement training in the Front Range, and holds a limited commission as a Deputy Sheriff for Fremont County, Colorado.

Dr. Pelto has been an instructor at numerous Active Shooter exercises in Colorado, and he is a frequent keynote speaker on topics of tactical medicine at conferences in the U.S. and overseas. He can be reached at tacticalmd@comcast.net .

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