Introduction
In an era marked by an unsettling evolution in conflict, the intensification of terrorist activities, particularly in the Middle East, and North Africa (MENA) region poses unprecedented challenges to global security, and public health. Over 46 000 attacks (including the potential use of chemical, biological, radiological, and nuclear (CBRN) agents) have been reported in the MENA region from 2003 to 2020, making it a hotspot for terrorism. Reference Tin, Fares and Al Mulhim1,Reference Tin, Margus and Ciottone2 It was stated that “the first time a chemical weapon capable of killing hundreds of thousands to millions was available for purchase, was on the street or from the dark web.” Reference Ciottone3 The consequences of these are far-reaching, straining healthcare systems, causing long-term health complications, and necessitating innovative approaches like Counter-Terrorism Medicine (CTM) which has now been established as a new discipline.
These terrorist attacks have repercussions that echo far beyond immediate destruction and loss of life. They disrupt social structures, incite fear, as well as mistrust, and impose an enormous strain on healthcare systems in both short- and long-term perspectives. From 2003 to 2020, the pattern of complexity in these attacks has expanded to include unconventional tactics and psychological warfare, further compounding the challenges of defence and response. Reference Tin, Fares and Al Mulhim1,4 While conventional forms of terrorism continue to wreak havoc, the accessibility of mass-casualty weapons (including CBRN agents) intensifies the potential destruction of these attacks, leading to mass casualty incidents, and putting the lives of frontline health care providers at grave risk. Reference Farhat, Alinier and Gangaram5 These weapons, combined with the use of various sophisticated technologies such as drones, pose unfamiliar threats with intricate methods of attack. Reference Yaacoub, Noura and Salman6
The severity and complexity of this growing threat have not gone unnoticed. In response, the field of Disaster Medicine has considered this issue with utmost seriousness. CTM represents an innovative, pro-active approach to address this emerging threat, aiming to develop cutting-edge research, and education programs to enhance healthcare provider preparedness, as well as response for any man-made incident. Reference Court, Edwards and Issa7–Reference Tin, Hertelendy and Ciottone9
In an era characterized by an ever-evolving landscape of threat, our defences and strategies must adapt accordingly. Utilizing a rigorous, evidence-based approach, we intend to provide a comprehensive epidemiological description of CBRN attacks. This will entail a meticulous analysis of the types of weapons used, the nature of these attacks, and their consequent injury patterns. By grounding this research in empirical evidence, we aim to offer an authoritative account of the CBRN threat landscape in the MENA region.
In addition to unravelling the mechanisms of these attacks, the research aims to assess the toll they take on human lives and healthcare infrastructures. The consequences of CBRN attacks are far-reaching and devastating, affecting not just the immediate victims, but also stretching the resources of health systems to their limits. Reference Veenema10 Recent examples of such incidents show the need for increased resilience in healthcare infrastructures, heightened medical preparedness, as well as the crucial importance of swift, and effective response mechanisms. A thorough understanding of the potential fallout from these weapons can provide invaluable insights into developing effective countermeasures and safeguards for healthcare providers and systems alike. Reference Veenema10
The results derived from this study will not only enhance our understanding of these formidable threats but also serve as an indispensable resource for healthcare providers. Through meticulous analysis and data interpretation, the study aims to better inform training programs, equipping healthcare providers with the knowledge to anticipate the type of injuries and potential attacks they might confront. This anticipatory knowledge could prove to be a game-changer, enhancing preparedness, and shaping response strategies to be more targeted and effective.
Transforming the theoretical knowledge derived from this research into practical preparedness and response strategies is critical. This is no trivial pursuit, the gravity of the threat demands practical solutions, and actionable measures that can be implemented in real-world scenarios. By demystifying the complexities of CBRN attacks, we aspire to turn the fear of the unknown into a defined set of response strategies, empowering those on the frontlines of healthcare to tackle these threats head-on.
In the face of disturbing CBRN threats, this research represents more than an academic endeavour. It seeks to provide practical, actionable strategies in the global fight against terrorism. Each counter-terrorism success signifies a triumph for humanity. Our shared responsibility is to mitigate these risks, enhance healthcare system resilience, and foster global cooperation. By translating theory into practice, this research aims to turn the tides in our favour, providing real-world solutions that save lives and protect communities.
The primary objective of this work was to conduct a comprehensive epidemiological analysis of CBRN incidents in the MENA region between 2003 and 2020, examining their frequency, modalities, and impacts.
Materials and Methods
Study Design
A retrospective study was conducted to investigate CBRN incidents in the MENA region, utilizing the Global Terrorism Database (GTD). 11 This comprehensive and open-access database details terrorism-related incidents and adheres to the specific 2021 GTD definition of terrorist attacks as “the threatened or actual use of illegal force and violence by a non-state actor to attain a political, economic, religious, or social goal through fear, coercion, or intimidation.” 11
The methodology employed in this research allows for a rigorous examination of CBRN incidents in the MENA region over the studied period. By utilizing a well-established database and applying a systematic approach to data collection and analysis, this study establishes a solid foundation for interpreting the complex landscape of CBRN threats within a region that is particularly susceptible to terrorist activities. The findings derived from this methodological approach will contribute significantly to the broader understanding of CBRN threats.
Data Collection
Data were collected from GTD for the years 2003 to 2020, with a focus on the MENA region. The inclusion criteria for the database search included parameters such as CBRN weapon type, date of incident, perpetrator group, and target type, as well as country, city, number of injuries, and fatalities. Data for 2021 - 2023 were not available at the time of the search.
Data Analysis
The extracted data were exported into an Excel sheet for further analysis. A quantitative approach was adopted, applying descriptive statistics to delineate patterns and trends relevant to CBRN incidents in the MENA region. This included evaluations of percentages, frequencies, and distributions across various categorical parameters.
Results
Over the study period, a total of 84 such incidents were identified, spanning across several countries including Iraq, Syria, and Palestine, as well as Yemen, Israel, Iran, and Tunisia. These incidents are further detailed in Table 1.
Table 1. CBRN incidents in the Middle East
Total number of deaths resulting from these incidents was 205, while the total injuries were reported to be 2205. Iraq had the grim distinction of experiencing 2 catastrophic CBRN incidents in 2016: the first incident, involving the use of a weaponized form of Chlorine gas, resulted in the highest number of deaths, and a total of 72 fatalities. The second incident, which involved the use of rockets armed with mustard gas, resulted in the highest number of injuries, causing harm to 1500 individuals.
To provide a more detailed perspective, these 2 incidents not only stood out in the country’s history but also on the global scale of CBRN events. Such high fatality and injury rates emphasize the severity and potential devastating impacts of CBRN events in a war-like situation.
Despite considerable international efforts for disarmament and prevention, these incidents demonstrate that the use of CBRN materials as weapons of war and terror continues to be a significant threat. Furthermore, the concentration of these incidents in areas of conflict underscores the strategic significance of CBRN materials and the importance of further efforts in preventing their misuse.
Table 2 provides an overview of the number and proportion of CBRN incidents across various countries in the Middle East. Iraq clearly stands out, having reported 57 incidents, or 68.67% of the total. Syria is second, contributing 13 incidents (15.66%), followed by Palestine with 6 incidents (7.23%), and Israel with 3 (3.61%). Yemen, Iran, and Tunisia each reported fewer incidents; contributing 2 (2.41%), 1 (1.20%), and 1 (1.20%) respectively to the total count (Table 2).
Table 2. Number of CBRN incidents in the middle east countries
It is worth noting that the countries with the most incidents—Iraq and Syria—are those that have seen significant conflict during this period, which may suggest a correlation between political instability or warfare and the prevalence of CBRN incidents. An analysis of the type of weapons used reveals that chemical weapons were the most employed, often in the form of fired, chemical-laced rockets. These accounted for 35.71% of incidents. Chlorine gas was used in 11.90% of the incidents. Alarmingly, in 9.52% of incidents, the type of weapon used was unknown, and this indicated potential gaps in detection or documentation efforts. Other notable weapon types include poisoned food (5.95%), explosives combined with chlorine gas (4.76%), and fired rockets containing mustard gas (3.57%).
The list also includes some more unconventional types of attacks, such as acid combined with a screwdriver, which demonstrates the breadth of methods used in CBRN incidents in some settings. This emphasizes the complexity and breadth of threats posed by CBRN weapons, requiring extensive planning, readiness, and countermeasures. Table 3 presents these findings in greater detail, illustrating the array of agents used during the period under study. This data highlights the critical need for robust and diverse countermeasures to tackle the wide range of CBRN threats. The MENA region’s experience with these attacks underscores the urgency of understanding and addressing this global security issue.
Table 3. Type of agents used in MENA
Discussion
The present study offers a comprehensive analysis of CBRN incidents in the MENA region, shedding light on a disturbing pattern that spans from 2003 through 2020. Among the 84 incidents recorded, resulting in 205 deaths and 2205 injuries, chemical agents emerged as the primary weapon of choice, and this result demonstrated a notable trend that aligns with global occurrences.
The alarming frequency of chemical attacks within the MENA region parallels other high-profile instances of chemical warfare across the world. For example, the Tokyo subway sarin attack in 1995 was 1 of the deadliest peacetime chemical incidents, causing more than 6000 victims. Reference Sugiyama, Matsuoka and Sakamune12,Reference Sakurada and Ohta13 This incident illustrated how easily accessible and deployable these chemical agents can be, and how devastating their effects are. In a similar vein, the repeated use of chemical weapons in the Syrian conflict underscores the persistence of this threat on a global scale. Reference Price14
The study’s findings highlight the acute public health impacts of chemical agents, which can cause symptoms ranging from drooling, vomiting, and diarrhoea to paralysis, asphyxiation, death, or long-term neurological damage. Reference Brooks, Erickson and Kayden15 These symptoms not only reveal the severity of chemical attacks but also underscore the urgency of a proper healthcare response. Healthcare preparedness and competent public health response including the use of antidotes, evacuation, and decontamination are vital to survival and can mean the difference between life and death. Reference Rice, Mann and Armstrong16,Reference Mani, Kuhn and Plummer17 Moreover, the risk of secondary toxicity due to inappropriate use of personal protective equipment by rescuers or family members are common. Reference Brooks, Erickson and Kayden15 This highlights an essential need for rigorous training and awareness among public health healthcare providers and first responders. Despite the development of recent evidence related to emergency care competencies in similar settings, Reference Mani, Kuhn and Plummer17–19 there seems to be a research gap concerning healthcare providers’ competencies, particularly CBRN attacks, involving mass casualty scenarios.
Furthermore, the identification of various chemical weapons, leading to high morbidity and mortality, emphasizes a critical need for healthcare personnel to familiarize themselves with the categorization, clinical profiles, and management principles of these agents. Reference Santos, El Zahran and Weiland20 This extends beyond immediate response to encompass long-term care and psychological support for victims, as seen in the aftermath of chemical attacks in places like Halabja in Iraq and Ghouta in Syria.
Moreover, the findings of this study underline the multifaceted nature of the problem, encompassing not only the immediate medical response but also the wider societal, economic, and political implications of public health. Chemical attacks have the potential to disrupt entire communities, inflict long-lasting trauma, and undermine trust in public safety and governance. Reference Karimi, Miller and Castro Bigalli21 This has been particularly evident in the MENA region, where political instability and ongoing conflict have further exacerbated the challenges posed by chemical weapons.
In response to our findings, it is imperative to integrate mental health services and community resilience programs into existing public health policies and emergency response strategies. Reference Khorram-Manesh, Gray and Goniewicz22 This integration not only addresses the immediate and long-term health impacts of CBRN incidents but also fosters a holistic approach to disaster preparedness. Strengthening psychosocial support systems, alongside physical health services, Reference Alyaseen, Goniewicz and Jebreel23 will ensure a comprehensive response framework capable of addressing the full spectrum of needs arising from CBRN terrorism. Such measures are vital for building resilient communities that are better equipped to withstand and recover from these catastrophic events.
Other studies highlighted strategies that are applicable for emergency responders to maintain their security and safety in similar situations of armed conflict. This included preparing themselves holistically and ensuring their personal safety and the safety of others, maintaining a personal and family preparedness plan, identifying human behaviors that put individuals at risk, and identifying common human stress reactions. Reference Mani, Kuhn and Plummer17,Reference Mani, Kuhn and Plummer24
The situation calls for a comprehensive approach, including improved surveillance, enhanced preparedness, and supply streams at the healthcare level, as well as international cooperation to prevent the proliferation of these weapons. Health systems must develop robust strategies for immediate and long-term care, incorporating specialized treatment protocols, mental health support, and community-based rehabilitation services. Reference Khorram-Manesh, Mortelmans and Robinson25
Considering the study’s primary focus on the prevalence and impact of CBRN incidents in the MENA region, it becomes imperative to elaborate on actionable strategies that can help mitigate these challenges. Central to the efforts in countering CBRN threats is the need for enhanced surveillance and early detection. Governments and international bodies should channel their resources towards acquiring state-of-the-art detection systems and technologies capable of quickly identifying and categorizing CBRN agents. Such advancements would not only expedite alerts to emergency services and the public but also facilitate more efficient evacuation and containment measures.
Yet, these technological advancements should be bolstered by strengthened international collaboration. The globalized nature of threats necessitates international partnerships, underscoring the importance of regular dialogues, intelligence sharing, and collaborative research. Such an approach would facilitate the development of unified strategies and preventative measures against CBRN incidents, transcending borders, and political differences.
From a public healthcare perspective, the potential aftermath of CBRN events highlights the need for a continuous capacity-building approach. Healthcare providers should be subjected to ongoing training programs, emphasizing the identification, treatment, and long-term care of affected individuals. Reference Khorram-Manesh, Goniewicz and Burkle26,Reference Kamalakannan, Rushton and Giesbrecht27 Furthermore, this capacity building should encompass rigorous training sessions on the proper use of personal protective equipment and the management of mass casualty scenarios.
Parallel to these efforts, community awareness and preparedness cannot be overlooked. Governments, NGOs, and other stakeholders should spearhead public education campaigns, aiming to inform citizens about the inherent risks of CBRN incidents. These campaigns should be multifaceted, providing guidance on immediate actions during exposure, understanding shelter-in-place procedures, and even recognizing early signs of exposure.
In the realm of innovation, there’s an unequivocal need to invest in research and development. This entails pushing for initiatives aiming to develop advanced antidotes, refine protective equipment, and establish effective decontamination methods. The spirit of collaboration should persist here, fostering environments conducive to innovative solutions that are both effective, and widely accessible. Reference Goniewicz, Włoszczak-Szubzda and Al-Wathinani28
In a broader policy context, the onus falls upon governments to prioritize the formulation of all-encompassing policies that cater to the prevention, mitigation, and response to CBRN threats. Such an endeavor could involve enacting stricter regulations on the storage and transport of hazardous materials, coupled with a steadfast commitment to international conventions explicitly prohibiting the use of such weapons. Reference De Rouck, Benhassine and Debacker29,Reference Visser and Montejano30
On the often-overlooked psychological front, the traumatic nature of CBRN incidents necessitates the establishment of robust psychosocial support systems. Reference Khorram-Manesh, Goniewicz and Burkle31,Reference Mani and Goniewicz32 This should be realized in the form of therapy, counselling, and community-based rehabilitation programs; all designed to expedite the recovery process for victims and the broader community.
Lastly, as an outer line of defense, enhancing border and import controls is essential. By fortifying border checks and placing stringent controls on imports, especially those materials potentially utilized in CBRN weapon creation, nations can better secure their peripheries. This measure would greatly benefit from collaborating with neighboring countries, ideally establishing a harmonized system of checks and balances of health systems, staff, and supplies, as well as services. Reference Borowska-Stefańska, Balážovičová and Goniewicz33
By weaving these strategies into the fabric of our defenses, the MENA region in harmony with global partners, can aspire towards a stance that’s not just reactive but also proactive against the looming threat of CBRN terrorism. The roadmap laid out not only addresses immediate response imperatives but also charts a course towards the long-term vision of preventing such incidents and nurturing resilient communities. Reference Alperen34
Limitations
The present study, despite its comprehensive analysis, has certain limitations. Primarily, the study’s sole reliance on the GTD introduces potential biases or omissions. While GTD is a robust source, it may not capture all incidents and it may contain inaccuracies. A lack of cross-verification with other databases or primary sources could result in under or over-representations of certain incidents, affecting the findings’ validity and generalizability.
By focusing on incidents from 2003 to 2020, the study omits data beyond this timeframe, possibly leading to a limited understanding of recent trends and developments. Such a temporal constraint might obscure emerging patterns or shifts in CBRN usage in the MENA region. The study also grapples with discrepancies in reporting or data collection across the MENA countries. Variations in government transparency, media freedom, and local data collection methods might introduce inconsistencies; further complicating the generalizability of the findings.
The unique nature of CBRN incidents also presents challenges. Such incidents might often be under-reported, misclassified, or concealed due to political sensitivities, and national security concerns, among others. This could result in an underestimation or misinterpretation of true incident patterns, affecting the perceived frequency and nature of CBRN attacks.
Although the study furnishes crucial quantitative data on CBRN incidents, it lacks qualitative insights. This omission restricts the exploration of the psychological and societal impacts, motives, ideologies, or broader human contexts surrounding these incidents. Furthermore, potential confounders like socio-political factors, cultural dynamics, and historical contexts that could influence CBRN incidents were not addressed. These overlooked elements might distort the interpretation of results, leading to a potentially skewed understanding of the factors driving CBRN attacks.
The study did not delve deeply into the secondary toxicity risks and the competencies of healthcare providers during mass CBRN incidents, which could offer vital insights into immediate post-incident scenarios. Future research should seek to address these limitations, encompassing multi-source data triangulation, an extended temporal range, and qualitative insights, as well as a deeper exploration of the contextual factors affecting CBRN incidents. Achieving a nuanced understanding of CBRN terrorism in the MENA region necessitates a more holistic approach to data gathering, analysis, and interpretation.
Conclusions
The findings of this research shed light on the pressing nature of CBRN threats in the MENA region, with a notable discovery of 84 CBRN incidents between 2003 and 2020, leading to 205 deaths and 2205 injuries. Predominantly, Iraq bore the brunt of these attacks, accounting for 68.67% of incidents, followed by Syria at 15.66%. This distribution underscores the heightened susceptibility of specific countries in the region to CBRN attacks.
A salient aspect of the data indicates that chemical agents were predominantly used in these incidents. This trend underscores a sombre reality: the sustained preference for chemical warfare as a tool of terror, causing profound distress both immediately and in the long term.
Beyond the immediate harm, the repercussions of these attacks manifest as prolonged health issues, an overwhelmed healthcare system, societal upheavals, and a diminished faith in governing entities.
The concentration of CBRN incidents in Iraq and Syria signals deeper socio-political, economic, and possibly historical issues; necessitating a more encompassing response than traditional counter-terrorism strategies. These findings emphasize the need for a cohesive, cross-sectoral strategy involving governments, medical institutions, and global agencies, as well as local communities. Such a holistic approach should address immediate prevention and response mechanisms, as well as invest in the sustained recovery, rehabilitation, and resilience of affected populations.
This study also delineates areas warranting deeper exploration. This includes understanding the rationale behind selecting specific chemical agents, fortifying the expertise of healthcare providers in CBRN scenarios, and bolstering international cooperation for the enforcement of conventions against chemical weaponry. Implementing the insights from this study into pragmatic strategies, transformative solutions, and collective accountability is paramount.
In light of our findings, future research should delve deeper into the psychosocial dimensions of CBRN incidents, exploring the psychological resilience and societal adaptation in the aftermath of such events. This exploration is crucial for developing comprehensive disaster response strategies that address not only the physical but also the mental health needs of affected populations. Further studies on the long-term psychological impacts on survivors and healthcare providers, as well as community-based recovery models, are imperative to inform holistic public health preparedness and response frameworks.
In essence, this research accentuates the enduring menace of CBRN, especially chemical attacks, in the MENA region. It underscores the exigency for united, persistent, as well as informed measures to comprehend, and curtail/counter these challenges. This call to action reverberates beyond regional boundaries, emphasizing the global community’s shared responsibility in combating terrorism. The pursuit to safeguard lives, uphold public safety, as well as reinforce global security remains an inclusive mission, and 1 that demands unwavering commitment, compassion, and sagacity.
Data availability statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Acknowledgments
The authors extend their appreciation to the Deputyship for Research and Innovation of the Ministry of Education in Saudi Arabia for funding this research work through the project number ISP-2398.
Funding statement
This research received no external funding.
Competing interests
The authors declare no conflict of interest.
Institutional review board statement
Not applicable.
Informed consent statement
Not applicable.
