Lessons Learned as a Result of Terrorist Attacks

Acknowledgment

A special thank you to my mentor, Kenneth Grey (retired Centers for Disease Control and Prevention [CDC] branch chief and developer of the CDC’s first emergency operations unit and center).

The threat of terrorism is a high-priority national security and law enforcement concern in the United States. Modern policy on combating terrorism against the United States has been evolving over the past 30 years. A series of Presidential Decision Directives (PDDs), along with implementing guidance, executive orders, interagency agreements, and legislation, now provide the basis for counterterrorism programs and activities in more than 40 federal agencies, bureaus, and offices. Unfortunately, public policy and societal reactions regarding disasters do not always translate into effective outcomes of “lessons learned.”

Terrorism itself has been an age-old threat to the public health and security of many populations throughout the world. Since the 1980s, terrorist attacks against the United States have led to legislative, regulatory, organizational, and programmatic actions associated with comprehensive and ambitious expectations. Further study is needed before we can conclude the extent to which these major changes will have a lasting and significant effect upon the practice of disaster medicine as a health science.

Nevertheless, two major accomplishments have been realized since the terrorist attacks of 2001: (1) National capacity of emergency management appears to have been increased and (2) awareness and possibly even commitment to the issue of emergency preparedness appears to be greater. This chapter will identify recent terrorist events that have had a significant effect upon U.S. society and public policy.

Historical perspective

U.S. domestic emergency management policy has evolved over the past 70 years. Since the 1990s, terrorist events have taken an increasingly important role in shaping larger response strategies related to U.S. emergency management policy, the implementation of the incident management system, and the development of comprehensive disaster mitigation strategies. One must first understand the fundamentals of these three major historical developments to appreciate fully the lessons learned and residual pitfalls.

The Development of Current U.S. Emergency Management Policy

Modern emergency management policy in the United States began with the “Unlimited National Emergency” (Proclamation 2487 of May 27, 1941), immediately prior to World War II. Over three decades later, out of concern for a catastrophic earthquake predicted to occur in the central United States, the Earthquake Hazards Reduction Act of 1977 mandated the development of a Federal Response Plan for a Catastrophic Earthquake. In July 1979 Executive Order 12148 delegated authority to the Federal Emergency Management Agency (FEMA) to establish federal policies and to coordinate civil defense, as well as civil emergency planning, management, mitigation, and assistance functions, of executive agencies. Then, FEMA was also assigned the lead responsibility for response to consequences of terrorism. The Robert T. Stafford Disaster Relief Act, P.L. 100-707 was enacted in 1986 to formalize a coordinated federal policy that included development of a Federal Response Plan. In 1990 FEMA issued the Federal Response Plan to establish a process for coordinated delivery of federal disaster assistance. Acting upon lessons learned during the Hurricane Andrew response in 1992, Congress adopted a formal “all-hazards approach” to emergency management in the National Defense Authorization Act of 1994, PL 103-160.

In June 1995 President Clinton issued PDD-39, the central blueprint for the U.S. counterterrorism strategy. PDD-39 elaborated a strategy for combating terrorism consisting of three main elements: (1) reducing vulnerabilities and preventing and deterring terrorist acts before they occur; (2) responding to terrorist acts that occur, including managing crises and apprehending and punishing terrorist perpetrators; and (3) managing the consequences of terrorist attacks. All three elements of the strategy apply to terrorism involving weapons of mass destruction (WMD). Emergency managers will recognize these elements as phases of the risk-reduction cycle, including disaster prevention, mitigation, and response.

The Defense against WMD Act of 1996, P.L. 104-201 (also known as the Nunn-Lugar-Domenici Act), September 23, 1996, drew upon the convergence of federal assets at the Atlanta 1996 Olympic Science and Technology Center ^,and directed this momentum to set in place a long-term effort to prepare domestic response for terrorist threats.

The Development of Incident Management Systems

The Incident Command System (ICS) was conceptualized more than 30 years ago, in response to a devastating wildfire in California. The Congress mandated that the U.S. Forest Service design a system that would improve the ability of wildland fire-protection agencies to coordinate interagency action effectively and to allocate suppression resources in dynamic situations. This system became known as the Firefighting Resources of California Organized for Potential Emergencies (FIRESCOPE) ICS. Although FIRESCOPE ICS was originally developed to assist in the response to wildland fires, it was quickly recognized as a system that could help public safety responders provide effective and coordinated incident management for a wide range of situations, including floods, hazardous materials accidents, earthquakes, and aircraft crashes. In 1982 all FIRESCOPE ICS documentation was revised and adopted as the National Interagency Incident Management System (NIIMS). In Homeland Security Presidential Directive 5 (HSPD-5), President Bush called on the Secretary of Homeland Security to develop a national incident management system (NIMS) to provide “a consistent nationwide approach for federal, state, tribal, and local governments to work together to prepare for, prevent, respond to, and recover from domestic incidents,” regardless of cause, size, or complexity.

The Development of Disaster Risk-Reduction Strategies

U.S. policy related to terrorism has also developed within a global context of strategies trending over the past two decades toward a more comprehensive approach to disaster risk management that also includes disaster risk-reduction efforts, such as prevention, protection, and mitigation. In 1994, the States Members of the United Nations, having met at the World Conference on Natural Disaster Reduction, in the city of Yokohama, Japan, in partnership with nongovernmental organizations and with the participation of international organizations, the scientific community, business, industry, and the media, affirmed, “Disaster prevention, mitigation, and preparedness are better than disaster response in achieving the goals and objectives of the Decade. Disaster response alone is not sufficient, as it yields only temporary results at a very high cost ” [emphasis added]. We have followed this limited approach for too long. This has been further demonstrated by the recent focus on response to complex emergencies, which, although compelling, should not divert from pursuing a comprehensive approach. Prevention contributes to lasting improvement in safety and is essential to integrated disaster management ” [emphasis added]. Although focused on natural disasters, this declaration represented an early recognition of the importance of a more comprehensive approach to managing disasters that also includes pre-event activities of prevention, mitigation, and preparedness.

One decade later, The World Conference on Disaster Reduction was held from January 18 to 22, 2005, in Kobe, Hyogo, Japan, and it adopted the present Framework for Action 2005-2015. The conference provided a unique opportunity to promote a strategic and systematic approach to reducing vulnerabilities and risks to hazards. It underscored the need for, and identified ways of, building the resilience of nations and communities to disasters. The resultant Hyogo declaration concluded, “ an integrated, multi-hazard approach to disaster risk reduction should be factored into policies, planning and programming (emphasis added) related to sustainable development, relief, rehabilitation, and recovery.”

In 2011 the Obama administration released Presidential Policy Directive 8 (PPD-8) that includes “a series of integrated national planning frameworks, covering prevention, protection, mitigation, response, and recovery.” The National Prevention Framework describes what the whole community—from community members to senior leaders in government—should do upon the discovery of intelligence or information regarding an imminent threat to the homeland in order to thwart an initial or follow-on terrorist attack.

Recent Terrorist Events That Have Influenced U.S. Policy

The development of new disaster policy is dependent upon a society’s perception of risk. Public perception of risk is known to be higher immediately after the occurrence of a major disaster. Terrorist attacks have a particularly powerful effect on the human psyche and subsequently often result in rapid, sometimes drastic, public policy changes. During such times, there is a notable window of opportunity for change in disaster reduction policy. Table 63-1 is a listing of select major terrorist events that have occurred over the past three decades and their corresponding influence on resultant U.S. policy.

Table 63-1

Thirty Years of Selected Terrorist Events That Have Influenced U.S. Policy

Date	Event	Description	Changes in U.S. Policy
1983	Bombing of Lebanon Marine Barracks	• Truck bomb detonated near U.S. military barracks • Linked to Moslem International Extremists (MIE) • Early asymmetric attack on U.S. military facility by MIE	• National Security Decision Directive 138: Combating Terrorism authorizes “Preemptive Strikes against Terrorists,” April 26, 1984
1984	Bahgwan Rajneesh Salmonella Release	• Salmonella bacteria released in restaurants in The Dalles, Oregon • Years later, the outbreak was linked to the Bhagwan Shree Rajneesh religious cult • No deaths, but over 800 were infected • First biological attack in the United States, and with highest morbidity rate	• None; for years, the outbreak went largely unrecognized as an intentional event
1985	Rome and Vienna Airport Attacks	• Abu Nidal terrorists perpetrate nearly simultaneous shooting and bombing terrorist attacks aimed at Israelis in airports in Rome and Vienna • Linked to Libya • The event illustrates the effectiveness of multiple, simultaneous urban attacks using small arms and hand-carried explosives • The terrorist attack is directed at public transportation	• National Security Decision Directive 205: Acting Against Libyan Support of International Terrorism, 1986 • National Security Decision Directive 207: The National Program for Combating Terrorism, 1986
1988	Bombing of Pan Am Flight 103	• A parcel bomb is detonated on a plane en route from London to New York; it explodes over Lockerbie, Scotland • Linked to a Libyan MIE terrorist cell • The event represents state-sponsored (Libyan) terrorism against a primarily U.S. target • The terrorist attack is directed at public transportation	• Executive Order 12686, President’s Commission on Aviation Security and Terrorism, 1989 • Public Law 101-604: Aviation Security Improvement Act of 1990 • National Security Directive 47: Counterintelligence and Security Countermeasures, 1990 • Executive Order 12705: Extending the President’s Commission on Aviation Security and Terrorism, 1990 • Presidential Decision Directive 2: Organization of the National Security Council, 1993
1993	World Trade Center (WTC) Bombing	• A truck bomb is detonated in the WTC parking garage • Linked to MIE, including multiple Arab nationalities	• Congress enacts the National Defense Authorization Act for Fiscal Year 1995 • It prepares federal response plans and programs for the emergency preparedness of the United States • It sponsor and directs such plans and programs to coordinate with state efforts
1994-1995	Aum Shinrikyo sarin attacks	• In 1994, Japanese religious cult, Aum Shinrikyo, released Sarin nerve agent in a residential area of Matsumoto, Japan, killing seven and injuring hundreds • In 1995, the same group released Sarin in the Tokyo subways, killing 12 and injuring thousands • Evidence of extensively coordinated planning and execution • This was the first time that a nonstate group used a chemical weapon against civilians • Represented the escalation effect of larger attacks • Demonstrated how terrorist groups could recruit scientists, obtain deadly chemicals or biological agents, and put plans into action	• “The Defense Against WMD Act,” also known as the “Nunn-Lugar-Domenici Act” • Federal Emergency Management Agency (FEMA) adopts the Terrorist Annex to the Federal Response Plan, 1997 • Executive Order 12938: Proliferation of WMD, 1994 • Executive Order 13094: Proliferation of WMD, 1998
1995	Bombing of the Murrah Federal Building in Oklahoma City	• A truck bomb is detonated near the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma • The bombing is linked to U.S. right-wing extremists • First instance of large-scale bombing attack by U.S. domestic terrorists • Experts other than foreign policy and security specialists become more involved in terrorist preparedness and response (most notably including disaster medicine) • Increased awareness of occupational health concerns among disaster responders (most notably, including behavioral health)	• First use of the president’s authority under the Stafford Act to “self-initiate” an emergency declaration for emergencies with federal involvement • Presidential Decision Directive 39: U.S. Policy on Counterterrorism, 1995 • Public Law 104-132: Antiterrorism and Effective Death Penalty Act of 1996 • Executive Order 13010: Critical Infrastructure Protection, 1996
1995	Chechnyan Threat of Using a Radiological Dispersion Device (RDD)	• Chechen separatists direct news reporter to a Moscow park, where a Cesium-137 RDD weapon is found • First credible threat for use of a radiological dispersion device (a.k.a., a “dirty bomb”) by a subnational group	• No specific action other than increased awareness and improved threat characterization
1996	Khobar Towers Bombing	• Truck bomb detonated near U.S. military barracks in Dhahran, Saudi Arabia • Linked to MIE • Asymmetric attack on a U.S. military facility by MIE	• No specific action other than increased awareness and improved threat characterization
1996	Crash of TWA Flight	• Explosion of an airliner during takeoff in New York • Initially believed to be result of a terrorist attack using a surface-to-air missile • Later ruled to be accidental • Occurred within days of the start of the 1996 Olympics • Shoulder-fired surface-to-air missiles are later used by MIE to attack aircraft in Kenya, Saudi Arabia, and Iraq during 2003-2004	• In 1997, the White House Commission on Aviation Safety and Security (Gore Commission) considers “aviation security as a national security issue and provide substantial funding for capital improvements”: • The Dept. of Homeland Security 2005 budget includes $61 million for research and development of countermeasures to protect commercial aircraft from shoulder-fired and surface-to-air missiles • Airport Security Improvement Act of 2000, Public Law 106-528, November 22, 2000
1996	Bombing of Atlanta Olympic Games	• Pipe bomb explodes at Centennial Olympic Park, in Atlanta, Georgia, during the ninth day of the 1996 Summer Olympics • First incident coordination by federal interagency WMD response teams • First forward staging of a medical stockpile in preparation for WMD casualties during the Atlanta Olympic Games	• Unprecedented State and Federal preparedness activities related to the 1996 Olympic games associated with implementation of Presidential Decision Directive 39: U.S. Policy on Counterterrorism, 1995 • Adoption of Title XIV of the Defense Authorization Act of 1996, “The Defense Against WMD Act,” also known as the “Nunn-Lugar-Domenici Act” • Terrorist Annex to the Federal Response Plan adopted by FEMA, 1996
1998	U.S. Embassy Bombings in Kenya and Tanzania	• Truck bombs detonated simultaneously near U.S. embassies in Nairobi and Dar es Salaam • Evidence of extensively coordinated planning and execution • Linked to MIE and the Al Qaeda terrorist network • First large-scale attack on U.S. embassies caused by MIE terrorists	• U.S. responds with cruise missile strikes against Al Qaeda training site in Afghanistan and Khartoum chemical factory, August 1998 • First HHS/CDC public health and medical response to overseas terrorism • Presidential Decision Directive 67: Enduring Constitutional Government and Continuity of Government Operations, 1998
2000	Attack of the U.S.S. Cole	• Explosion occurred on the destroyer U.S.S. Cole , docked at the harbor in Aden, Yemen • Linked to MIE and the Al Qaeda terrorist network • First asymmetric attack on a U.S. naval warship perpetrated by MIE	• Presidential Decision Directive 75: Counterintelligence for the 21st Century, 2001
2001	WTC and Pentagon Attacks	• Hijacked airliners deliberately flown into the WTC towers and the Pentagon • Linked to MIE and the Al Qaeda terrorist network • Attack has significant and long-term economic and sociopolitical significance for the United States	• U.S. response includes at least 10 pieces of national legislation; 12 Executive Orders; 15 Homeland Security Decision Directives; and one new federal department: the Department of Homeland Security • Major reorganization of U.S. intelligence organizational structure in 2004, consistent with recommendations of the 9/11 Commission report • Public Law 110-53: Implementing Recommendations of the 9/11 Commission Act of 2007 • A series of executive orders provide for a clear order of succession for U.S. cabinet-level officials
2001	Anthrax Letter Attacks	• Letters containing anthrax spores are mailed to news media personnel and Congress • Leads to the first cases of intentional anthrax infection in the United States • Infections follow a 3-year history of over 1500 anthrax-letter hoaxes, many targeting Planned Parenthood clinics • Perpetrators remain unconfirmed • Second largest-scale biological attack in the United States and the highest mortality rate • Reports cite speculation regarding the U.S. domestic origin of the terrorist(s) • Revealed the challenges and shortcomings facing the nation’s public health system • The federal Concept of Operations Plan (CONPLAN) for responses to terrorist attacks was not used • The Federal Bureau of Investigations (FBI) did not exercise its crisis-management authority; FEMA did not exercise its consequence-management authority, as called for by PDD 39	• The Federal Response Plan was never activated • Public Law 107-188: Public Health Security and Bioterrorism Preparedness and Response Act of 2002 • Public Law 108-276: Project BioShield Act of 2004 • Homeland Security Presidential Directive 9: Defense of United States Agriculture and Food, 2004 • Homeland Security Presidential Directive 10: Biodefense for the 21st Century, 2004 • Public Law 109-374: Animal Enterprise Terrorism Act of 2006 • Homeland Security Presidential Directive 18: Medical Countermeasures against WMD, 2007 • Homeland Security Presidential Directive 21: Public Health and Medical Preparedness, 2007 • Presidential Policy Directive 2: National Strategy for Countering Biological Threats, 2009 • Executive Order 13486: Strengthening Laboratory Biosecurity in the United States, 2009 • Executive Order 13527: Establishing Federal Capability for the Timely Provision of Medical Countermeasures Following a Biological Attack, 2009 • Executive Order 13546: Optimizing the Security of Biological Select Agents and Toxins in the United States, 2010
2001	Airliner Shoe Bomb Attempt	• A British man tries to blow up a U.S.-bound airliner with explosives in his shoes but is subdued by passengers and crew • The event illustrates the need for heightened airport security that includes protection against chemical explosives • The event illustrates the value of public awareness in foiling terrorist plots • A terrorist attack directed at public transportation	• Public Law 107-197: Terrorist Bombings Convention Implementation Act of 2002 • Homeland Security Presidential Directive 11: Comprehensive Terrorist-Related Screening Procedures, 2004
2002	LAX Airport Shooting	• Egyptian immigrant shoots and kills two people at the (Israeli) El Al Airlines counter in the Los Angeles (LAX) airport • The event illustrates the need for heightened airport security before security-screening areas • Reminiscent of tactics used during the 1985 Rome and Vienna airport attacks • A terrorist attack directed at public transportation	• No specific action other than increased awareness and improved threat characterization
2002-2004	Bombings and Attacks in Russia, Indonesia, the Philippines, Kenya, Saudi Arabia, Afghanistan, and Iraq	• A series of terrorist bombings and attacks involving numerous nations • Shoulder-fired surface-to-air missiles are used by MIE to attack aircraft in Kenya, Saudi Arabia, and Iraq in 2003-2004 • Most attacks are linked to MIEs, and some to national separatist movements • Events illustrate MIE tactics for attacks against broader pro-Western interests • Events related to national separatist movements reveal a growing level of sophistication in coordination and execution of attacks • Nations other than the United States become frequent targets • Some terrorist attacks are directed at public transportation	• Department of Homeland Security 2005 budget includes $61 million for research and development of countermeasures to protect commercial aircraft from shoulder-fired surface-to-air missiles
2004	Attack on the U.S. Consulate in Jeddah, Saudi Arabia	• A car bomb detonation and subsequent small arms attack of the U.S. Consulate in Jeddah, Saudi Arabia • Linked to MIE, and possibly Al Qaeda	• Recent U.S. activities resulting in hardening and increasing security of U.S. Embassies and Consulates prove valuable in mitigating the effects of the attack
2004	Madrid Train Bombings	• Nearly simultaneous, coordinated bombings against the commuter-train system of Madrid • Linked to an Al Qaeda-inspired cell • Event illustrates the need for heightened security, including modes of public transportation other than airlines • Event illustrates the “lone wolf” phenomenon of U.S. domestic attackers sympathetic with MIE ideals • Nations other than the United States become frequent targets • The terrorist attack is directed at public transportation	• No specific action other than increased awareness and improved threat characterization
2005	London Subway Bombings	• On July 7, nearly simultaneous coordinated bombings of five locations in the London subway system • Two weeks later, four more attacks (unconnected with those on July 7) were attempted but unsuccessful • Both linked to MIE • The events illustrates the need for heightened security, including modes of public transportation other than airlines • Nations other than the United States become frequent targets • Terrorist attacks are directed at public transportation	• Homeland Security Presidential Directive 15 [War on Terrorism], 2006
2008	Mumbai Attacks	• Twelve coordinated shooting and bombing terrorist attacks lasting 4 days across Mumbai, India’s largest city • Linked to Pakistani terrorist organization • Event illustrates the effectiveness of multiple, simultaneous urban attacks using small arms and hand-carried explosives • Reminiscent of tactics used during the 1985 Rome and Vienna airport attacks	• No specific action other than increased awareness and improved threat characterization
2009	Shootings at Fort Hood	• Shooting rampage by an Army psychiatrist who killed 13 and wounded 30 more • Perpetrator was a Sunni extremist • Highest number of fatalities for a terrorist attack in the United States since 9/11 • Event illustrates the “lone wolf” phenomenon of U.S. domestic attackers who are sympathetic with MIE ideals • Similar the attacks to military facilities that lead to the creation of the National Joint Terrorism Task Force in 2002	• No specific action other than increased awareness and improved threat characterization
2009	Underwear Bomb Attempt	• A Nigerian man tries to blow up a U.S.-bound airliner with explosives in his underwear but is subdued by passengers and crew • Linked to MIE and the Al Qaeda terrorist network • Event illustrates the need for heightened airport security, including protection against chemical explosives • The event illustrates the value of public awareness in foiling terrorist plots	• No specific action other than increased awareness and improved threat characterization
2010	Times Square Bomb Attempt	• Failed attempt by a Pakistani man to set off a car bomb in Times Square • The event illustrates the “lone wolf” phenomenon of U.S. domestic attackers who are sympathetic with MIE ideals • The event illustrates the value of public awareness in foiling terrorist plots • A terrorist attack on a mass gathering	• No specific action other than increased awareness and improved threat characterization
2010	Parcel Bomb Attempt on Cargo Planes	• Two packages sent by air from Yemen to Chicago, containing bombs placed within printer cartridges • Linked to MIE and the Al Qaeda terrorist network • Event illustrates the ongoing threat posed by Al Qaeda in the Arabian Peninsula • The event illustrates the continued vulnerability of U.S.-bound cargo planes	• Executive Order 13611: Blocking Property of Persons Threatening the Peace, Security, or Stability of Yemen, 2012
2010	Attempted Bombing of a Christmas-Related Mass Gathering	• Failed attempt by a Somali-American to bomb a mass gathering event in Portland, Oregon • The event illustrates the “lone wolf” phenomenon of U.S. domestic attackers who are sympathetic with MIE ideals • Event illustrates the value of public awareness in foiling terrorist plots • Terrorist attack on a mass gathering	• No specific action other than increased awareness and improved threat characterization
2011	U.S. Embassy Attack in Benghazi, Libya	• Islamic militants attacked the American diplomatic mission at Benghazi, in Libya, killing a U.S. Ambassador • The third such large-scale attack on U.S. Embassies or Consulates caused by MIE terrorists	• No specific action other than increased awareness and improved threat characterization
2013	Nairobi, Kenya, Shopping Mall Attack	• Mass shooting and bombings by four Islamic militants in an upscale shopping mall • Reminiscent of tactics used during the 1985 Rome and Vienna Airport Attacks and 2008 Mumbai Attack	• No specific action other than increased awareness and improved threat characterization
2013	Boston Marathon Bombing	• Two Chechen-American brothers, working alone, detonate two homemade bombs in a crowd at the Boston Marathon • The event illustrates the “lone wolf” phenomenon of U.S. domestic attackers who are sympathetic with MIE ideals • A terrorist attack on a mass gathering	• No specific action other than increased awareness and improved threat characterization