Reviewing the Health Care Impacts of Attacks on Critical Infrastructure.

Introduction: Health care provision depends on reliable critical infrastructure (CI) to power equipment and to provide water for medication and sanitation. Attacks on CI limiting such functions can have a profound and prolonged influence on delivery of care.

Methods: A retrospective analysis of the Global Terrorism Database (GTD) was performed of all attacks occurring from 1970-2020. Data were filtered using the internal database search function for all events where the primary target was "Utilities," "Food or Water Supply," and "Telecommunications." For the purposes of this study, the subtype "Food Supply" was excluded. Events were collated based on year, country, region, and numbers killed and wounded.

Results: The GTD listed 7,813 attacks on CI, with 6,280 of those attacks targeting utilities, leading to 1,917 persons directly killed and 1,377 persons wounded. In total, there were 1,265 attacks targeting telecommunications causing 205 direct deaths and 510 wounded. Lastly, 268 attacks targeted the water supply with 318 directly killed and 261 wounded. Regionally, South America had the most attacks with 2,236, followed by Central America and the Caribbean with 1,390. Based on infrastructure type, the most attacks on utilities occurred in El Salvador (1,061), and the most attacks on telecommunications were in India (140). Peru (46) had the most attacks on its water supply.

Conclusion: The regions with the highest number of total attacks targeting CI have historically been in South America, with more attacks against power and utilities than other infrastructure. Although the numbers of persons directly killed and wounded in these attacks were lower than with other target types, the true impacts on lack of health care delivery are not accounted for in these numbers. By understanding the pattern and scope of these attacks, Counter-Terrorism Medicine (CTM) initiatives can be created to target-harden health care-related infrastructure.