Civil unrest , also termed civil disturbance , is a spectrum of activities progressively disruptive to public order and tranquility. Civil unrest can occur whenever a group in the community feels, accurately or not, that some aspect of society is antithetic or apathetic to their views, rights, or needs. Examples of civil disturbance include labor strikes, large demonstrations, and riots. As the extreme situation, a riot is a violent disruption of the public order that threatens public safety. Proper planning, preparedness, and response strategies can result in significant reductions in violence and injuries, while preserving the fundamental rights of individuals to assemble peacefully. In describing civil unrest, it is valuable to consider first a historical perspective, then to discuss the etiology and evolution of these incidents.
Civil unrest has been a part of the fabric of life in the United States since before the country was founded, dating back to the Boston Massacre in 1770. Governed by a set of laws that define mechanisms for expressing constitutional rights and advocating different viewpoints, American society has experienced many instances throughout its history of both peaceful demonstrations and violent riots. Recent notable events include the widespread turbulence of the late 1960s, the civil unrest surrounding the Rodney King incident (1992), the clashes between the police and protesters at World Bank Demonstrations in Washington, DC (2000), and the confrontations surrounding the Occupy Movement (2012). Especially when it turns violent, civil unrest can strain or even shatter the delicate equilibrium between the societal need for public order and the individual’s constitutional right to freedom of expression.
Civil unrest arises from the interplay of several factors. It is important to understand that in any large social gathering, all of the factors necessary for violence exist; it is a question of whether these factors will interact with the volatile chemistry necessary to precipitate an actual riot. These factors include confrontational participants, catalyst causes, group dynamics, group leadership, and emotional electricity. To understand the spectrum of civil unrest better, it is important to discuss briefly the role of each causal factor separately and then how they interact together in civil unrest situations.
Across the spectrum of various events, participants in civil unrest span demographic, political, and socioeconomic categories. At baseline, participants are generally connected to the group by a variable degree of investment in a specific cause. Some core persons are highly committed to the issue, whereas others merely become caught up in the frenzied periphery of an event.
Catalyst causes that trigger civil disturbance include any perceived wrongful policy or event felt worthy of active dissent. These issues include special interest topics, perceived law enforcement injustices, and political grievances. Rioting can occur when the group directs its frustration over a given issue toward persons with opposing views or police officers charged with keeping the peace.
As a behavioral dynamic, groups foster an environment in which individual inhibition is lowered because of a collective sense of anonymity, diffusion of personal responsibility, strong social urge toward conformity, and loss of individual decision making. Additionally, during moments of uncertainty or frustration, persons in groups also become more susceptible to suggestion, manipulation, and imitation by strong leaders who are often the first and most assertive agitators. The emotional volatility of a group can also be a powerful unifying force, creating an almost electric connectivity between participants when sparked.
Given the right circumstances and the volatile interplay of these factors, a critical transition can occur in any group that can precipitate violence in civil unrest situations, including large-scale rioting. In any crowd, isolated or progressive violence can occur because of the presence of agitators , individuals who incite the crowd by engaging in unlawful disruptive conduct, such as throwing objects. This tactic is increasingly used in international settings, such as Turkey (2013-2014) and Ukraine (2014). The transition from rioting to violence that is widespread hinges on the development of group cohesion . Most large groups, such as at demonstrations or sporting events, are considered crowds . Crowds are gatherings that lack significant group cohesion. With the evolution of group cohesion, the crowd becomes, in essence, its own autonomous organism with a collective identity, purpose, focus, emotional tone, and coordinated response. At this point, its members are more prone to participate in activities that they would not otherwise do if alone. If the tone of the group shifts toward anger or frustration, a “mob mentality” may take over that converts the crowd into a mob ; violence can erupt like a contagion, and a riot can ensue. Rooted in group cohesion, this transition from crowd to mob is the central key to the emergence of rioting.
Within this framework, several recognized patterns exist for the development of a riot. First, classically, civil unrest can be a fluid event that escalates along a progressive continuum of disruption. For example, the incident may begin as a planned demonstration . A demonstration is a group of people (termed protesters or demonstrators ) in a crowd specifically called together for a common purpose, such as to protest a political policy. Under ordinary circumstances in the United States, demonstrations are peaceful expressions of First Amendment rights, and they remain law-abiding entities. However, some demonstrations become increasingly disruptive, with individuals in the group engaging (e.g., agitators) in unlawful activity, such as vandalism or direct violent confrontation with authorities. If violent tactics are adopted, the situation can then degenerate into the anarchy of a riot, and the group becomes a mob. During a tense confrontation, violence can beget violence, requiring law enforcement measures to defuse the situation and to restore order. Second, a crowd may assemble as an unrelated group of people, without common purpose, brought together because of similar circumstances, such as for a sporting event or a court proceeding. A catalyst event, often a verdict in a law enforcement incident or a high-stakes outcome in a sporting event, incites a small ultraviolent group in the crowd to riot in immediate response. Sometimes deep underlying schisms along racial, ethnic, or socioeconomic lines within the community fuel these actions. This core group engages in random acts of violence and looting, subsequently engulfing larger segments of the population. These incidents typically overwhelm the initial public safety resources, requiring an influx of outside support to defuse the situation. Third, and most recently, technology has permitted the formation of flash mobs . Coordinated by cellular and Internet technology, flash mobs occur when multiple participants converge abruptly on a given location. These spontaneous gatherings have sometimes focused on demonstrations for specific social issues, but also have resulted in riots characterized by targeted violence and looting.
Preplanning saves lives when time counts. It is critical to plan for civil unrest events because time is limited for lifesaving intervention if violence should erupt. Baseline preparation should focus on the development of infrastructure necessary for mitigation of a worst-case scenario, such as widespread rioting. Involving both training and resource coordination, effective medical preplanning for civil unrest involves preparation for the continuum of patient care from the field through initial hospitalization. Important planning aspects include: (1) integration of the field medical response with the law enforcement tactical response; (2) coordination of regional medical resources at all levels; and (3) development of individual hospital response procedures.
Building on this underlying foundation, preparation for specific events (such as announced demonstrations) should involve the completion of a medical threat assessment (MTA). To ensure optimal medical care for all participants on the frontline, it is important that medical support be integrated into the initial law enforcement tactical response. At the flashpoint of a violent incident, the tactical response involves containment and control of the riot through use of a mobile field force (MFF), a special response team for civil disturbance. Successful integration of medical support into the MFF requires the establishment of a working relationship prior to an actual incident. Planning for organic medical support of such tactical operations should focus on many areas, including the following:
Logistics—deploying, training, and equipping medical personnel for the field
Preventive strategies—ensuring that needs are met for hydration and adequate protective equipment during deployment of the MFF
Rehearsal of rescue tactics and techniques—appropriate MFF formations to facilitate extraction of injured individuals from a crowd or mob
Acute care delivery—coordinating injury treatment and casualty evacuation from the scene
Decontamination systems—identifying and eliminating contamination thrown by protesters
Advanced care access issues—connecting MFF field response to the emergency medical system and hospitals
On a regional level, prior planning must ensure that medical resources will be coordinated on all levels of the health care response to function seamlessly within the Incident Command System (ICS). First, the regional disaster plan for large incidents of civil unrest should include a medical annex that focuses on the integration of health care delivery with other public safety functions under such conditions. Resource planning for patient care should address issues related to emergency medical services (e.g., protection of ambulance crews and field rehabilitation logistics), hospital transport (e.g., ensuring safe travel routes), local hospital capabilities (e.g., determining trauma level and diversion status), and mutual aid. Second, the development in advance of a reliable communication system to facilitate information sharing between the lead law enforcement agency, the emergency medical system dispatch, and regional health care facilities is essential. This system may be effectively adapted from preexisting disaster networks to function as well in the limited scope of civil unrest incidents.
Individual hospitals also need to look at planning for civil unrest incidents, particularly in the emergency department setting. In many respects, this preparation may be incorporated into the existing disaster plan, with such provisions as increased staffing and the establishment of an emergency operations center. Unique aspects of preparation for civil unrest include hospital security concerns in the face of violent agitators outside, management of injured disorderly protesters requiring treatment, management of family and friends (nonpatients), contamination issues, the potential for mass casualty situations, and the control of arrested persons.
Regional medical planners should also develop an MTA to address unannounced demonstrations. The MTA is an approach used to prepare for the foreseeable medical issues associated with a particular event by analyzing various health threats, assessing medical vulnerabilities, identifying possible countermeasures, and exploring different resources to optimize health care delivery. Relevant information tied to the anticipated circumstances can be gathered in advance through several methods, such as hospital site surveys, route surveys, open-source material, and information known about the past behavior of the protest group. Specific MTA components may include an analysis of environmental conditions, hospital capabilities, and substances likely to be thrown by demonstrators.
In the wake of violence associated with widespread civil unrest, the medical community should strive to promote recovery efforts both within its ranks and within the region. In the short term, attention should be paid to responder safety and the emotional effect of the civil disturbance on health care workers. Response efforts should support any persons suffering residual critical incident stress. Hospital personnel should continue to provide care for victims and their families, as well as to release appropriate information to the community as indicated and authorized by the designated public information officer (PIO). Accurate, timely, and strategic communication is critical in the immediate aftermath of dynamic, community disturbances. In the long term, it is valuable for medical professionals to meet with civic representatives to debrief medical aspects of the incident. The focus should be an effort to enhance the medical response to similar situations in the future. By discussing what worked and what did not, lessons learned can be applied to improve patient care delivery in the event of a future civil disturbance.
Medical Treatment of Casualties
Several important factors should be considered with regard to the medical treatment of casualties from civil unrest. For a large-scale incident, the care should be delivered under conditions defined in the disaster plan of the hospital or agency. Important and unique aspects of medical treatment during civil disturbance are the potential for large numbers of patients, the nature of the injuries seen in riots, high likelihood of contamination with crowd control agents such as oleoresin capsicum (e.g., pepper spray), and the use of less-lethal weapons.
The number of casualties from an incident varies widely with the scope of the disturbance. Depending on available resources, medical providers may need to implement mass casualty triage protocols in given situations. The need for this approach may also depend on the timing of the injuries over the course of the incident and the distribution of patients among different hospitals. Particular attention should be paid to scene security and crowd control at the triage and treatment sites.
As exemplified in the civil disturbance surrounding the Rodney King incident, three main patterns of injury have been identified in civil unrest. The first type of injury involves assaults suffered by active participants in rioting or other criminal behavior such as looting. With a mixture of blunt and penetrating trauma, these persons may present with gunshot wounds, stab wounds, or injuries incurred in beatings. A second category of injury that has been noted in civil disturbances involves automobile accidents. Suffering primarily blunt trauma, these patients include struck pedestrians and victims of motor vehicle collisions that result from disruption of traffic patterns, erratic driving, or broken traffic signals. The last group of patients present with an acute decompensation or exacerbation of a chronic medical condition because they were unable to obtain needed care. Included in this group are patients receiving dialysis and persons with diabetes.
Less-lethal weapons are routinely used in the context of modern civil unrest. Less-lethal weapons are devices designed to incapacitate persons or to disperse groups without causing serious harm. As reflected in the term less lethal , the potential does exist, however, for serious harm or even death with these devices. There are two general categories of less-lethal agents used in the law enforcement response to civil disturbance. Chemical agents, such as tear gas or pepper spray, cause noxious upper respiratory irritation when deployed. Treatment should focus on removing ongoing contamination, maintaining access to fresh air, and applying cool water. The injury pattern for projectile munitions, such as “bean bag” rounds, ranges from minor lacerations to significant internal injury. It is advisable for health care providers to be familiar with these less-lethal devices and their effects.
Medical personnel should remember three unique considerations during a response to civil disturbance. These considerations include awareness of the threat environment, the medical-legal context, and the role of field testing. These three considerations are applicable across the spectrum of medical care settings. The most important consideration for health care providers during civil unrest is to recognize that care is being delivered in a high-threat environment . A high-threat environment is a situation in which a person is at risk for harm or injury during the performance of a given task. In civil unrest, there are several personal safety concerns for the provider, such as violent demonstrators, dangerous crowd tactics, contamination from thrown substances (e.g., feces), denial of essential supplies, and the presence of improvised weapons. The provider must provide simultaneous care to different categories of patients placed in confrontation by the event-arrested demonstrators, injured bystanders, and wounded law enforcement officers. In addition to using appropriate protective equipment, medical providers must continually maintain situational awareness, and practice scene safety in the threat environment posed by civil unrest. During violent demonstrations, protesters may throw a variety of substances at responding police officers. One significant concern with both medical and legal implications is the potential exposure to contaminated blood in this setting. A field blood sampling protocol to assess thrown red liquids can help clarify this issue. This protocol can be developed using screening field assays in conjunction with professional laboratory confirmation.
Providers should also appreciate the medical-legal environment created by civil unrest and the consequent implications for health care delivery. In the care of patients, providers must be careful (to the extent possible) not to destroy evidence such as collected weapons, bullets, or clothing. In the event that court testimony is later required, the medical practitioner should also have a basic understanding of forensics as it applies to recognition of injury patterns.