A Proposed Universal Medical and Public Health Definition of Terrorism

April – June 2003 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine THEORETICAL DISCUSSION Abstract The lack of a universally applicable definition of terrorism has confounded
the understanding of terrorism since the term was first coined in 18th
Century France. Although a myriad of definitions of terrorism have been
advanced over the years, virtually all of these definitions have been crisis-
centered, frequently reflecting the political perspectives of those who seek to
define it. In this article, we deconstruct these previously used definitions of terror- ism in order to reconstruct a definition of terrorism that is consequence-cen-
tered, medically relevant, and universally harmonized. A universal medical
and public health definition of terrorism will facilitate clinical and scientific
research, education, and communication about terrorism-related events or
disasters. We propose the following universal medical and public definition of ter- rorism: The intentional use of violence — real or threatened — against one
or more non-combatants and/or those services essential for or protective of
their health, resulting in adverse health effects in those immediately affect-
ed and their community, ranging from a loss of well-being or security to
injury, illness, or death. Arnold JL, Örtenwall P, Birnbaum ML, Sundnes KO, Aggrawal A, Al
Musleh AW, Arantharaman V, Asai Y, Burkle FM, Chung JM, Vega FC,
Debacker M, Corte FD, Delooz H, Dickinson G, Hodgetts T, Holliman
CJ, MacFarlane C, Rodoplu U, Stok E, Tsai M-C: A proposed universal
medical and public definition of terrorism. Prehosp Disast Med
2003;18(2):47-52. 1. Office of Emergency Preparedness, Yale New Haven Center for Emergency and
Terrorism Preparedness, Yale New Haven
Health System, New Haven, Connecticut
USA 2. Beredskapsenheten, Goteborg, Sweden
3. Emergency Medical Services Program, University of Wisconsin-Madison,
Madison, Wisconsin USA 4. Office for War Surgery and Emergency Medicine, Joint Medical Command,
Norwegian Defense Forces, Sessvollmoen,
Norway 5. Professor of Forensic Medicine, Maulana Azad Medical College, New Delhi, India 6. Chairman of Accident and Emergency and EMS, Assistant Medical Director,
Director of Hamad International Training
Center, Hamad General Hospital, Doha,
Qatar 7. Department of Emergency Medicine, Singapore General Hospital, Singapore 8. Chairman, Department of Traumatology and Critical Care Medicine, Sapporo
Medical University, Sapporo, Japan 9. The Center for International Emergency, Disaster and Refugee Studies, The
Schools of Public Health and Medicine,
Johns Hopkins University Medical
Institutions, Baltimore USA 10.Chairman and Professor, Department of Emergency Medicine, Kyungpook
National University Hospital, Taegu,
South Korea 11.Disaster Division Head, Mexican Social Security Institute, Mexico City, Mexico 12.Senior Lecturer in Disaster Medicine, Free University Brussels and Catholic
University of Leuven, Belgium 13.Department of Anesthesiology and Intensive Care, Università del Piemonte
Orientale, Novara, Italy 14.Department of Emergency Medicine, Free University of Brussels, Belgium 15.Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario,
Canada 16.Royal Centre for Defence Medicine, Selly Oak Hospital, Birmingham, United
Kingdom A Proposed Universal Medical and Public
Health Definition of Terrorism Jeffrey L. Arnold, MD; 1 Per Örtenwall, MD; 2 Marvin L. Birnbaum, MD PhD; 3 Knut Ole Sundnes, MD; 4 Anil Aggrawal, MD; 5 V. Arantharaman, FRCP (Edin), FRCS Ed (A&E), FAMS; 7 Abdul Wahab Al Musleh, MD; 6 Yasufumi Asai, MD; 8 Frederick M. Burkle, Jr., MD, MPH, FAAP, FACEP; 9 Jae Myung Chung, MD, PhD; 10 Felipe Cruz Vega, MD; 11 Michel Debacker, MD; 12 Francesco Della Corte, MD; 13 Herman Delooz, MD, PhD, FCCM, FFAEM (hon.); 14 Garth Dickinson, MD, FRCPC; 15 Timothy Hodgetts, MMEd, FRCP FRCSEd, FFAEM, FIMC; 16 C. James Holliman, MD; 17 Campbell MacFarlane, FRCS, FACEM, FFAEM; 18 Ulkumen Rodoplu,MD; 19 Edita Stok, MD; 20 Ming-Che Tsai, MD, MPH 21 17.Department of Emergency Medicine, Milton S. Hershey Medical Center,
Pennsylvania State University, Hershey,
Pennsylvania USA 18.Head of EMS Training, Gauteng Provincial Government, South Africa
and Department of Surgery, University
of the Witwatersrand, Johannesburg,
South Africa 19.Emergency Medicine Association of Turkey, Izmir, Turkey 20.Ministry of Health, Ljubljana, Slovenia
21.Department of Emergency Medicine, National Cheng Kung University
Hospital, Tainan, Taiwan Republic of
China Correspondence: Jeffrey Arnold, MD
Medical Director Yale New Haven Center for Emergency and Terrorism
Preparedness 1 Church Street, 5th floor
New Haven, CT 06510USA
E-mail: arnoldmdcs@cs.com Keywords: adverse effect; death; definition; disaster; event; health;
healthcare system; injury; medical
definition; non-combatant; public
health; psychological injury; terror-
ism; violence; vulnerable Abbreviations: OED = Oxford English Dictionary Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol.18, No. 2 48 Universal Medical and Pubklic Health Definition of Terrorism Introduction The lack of a universally applicable definition of terrorism
has confounded the understanding of terrorism for cen-
turies. While the term “terrorism” was first used during the
French Reign of Terror in 1793–1794, the first acts of ter-
rorism occurred at least two millennia ago. 1 Since its coinage, terrorism has been applied to actions that have
occurred in countries worldwide, to actions by individuals,
groups, or governments, and to actions against populations
of every type. 2 Previous Definitions of Terrorism A myriad of definitions of terrorism have been advanced in
recent years. 1–10 The vast majority of these definitions of terrorism can be deconstructed into elements concerning
the perpetrators of terrorism, their actions, their victims,
and their effects (Table 1). 1–10 These elements, in turn, can be further subdivided according to a number of descriptors
and modifiers. The sheer heterogeneity of these elements,
descriptors, and modifiers accounts for the wide variability
in how terrorism is defined. Virtually all previous definitions of terrorism have been concerned with the crisis of terrorism. Accordingly, these
definitions are fixated on the identity of the terrorists, their
motivations, and the unlawfulness of terrorist acts. 1–10 Not infrequently, these definitions reflect the political agendas
of those who seek to define it. 1–10 As a result, these crisis- centered definitions of terrorism have set-off endless
debate about what constitutes terrorism with little hope of
resolution. Are all terrorists criminals? Are some terrorists
actually freedom fighters? Can a government commit ter-
rorist acts? Is terrorism always premeditated? Typically ignored in this controversy are those issues that concern healthcare providers the most—the impact of
this uninvited violence on the health of human beings. To date, no medical or public health definition of “terror- ism” has been proffered. Although, the term “terrorism” has
appeared widely in the medical and public health literature
in recent years, it typically has been used with the tacit
assumption that the international medical community
already knows what terrorism means and has been in com-
plete agreement with this definition. On the rare occasion,
when terrorism has been defined in the medical or public
health literature, the definition usually has been borrowed
from an organization with a special interest, such as the US
Federal Bureau of Investigation (FBI): 11 Terrorism is…the unlawful use of force or violence against persons or property to intimidate or coerce a gov-
ernment, the civilian population, or any segment there-
of, in furtherance of political or social objectives. 6 Recently, an ad hoc workgroup formed by the US National Center of Health Statistics (NCHS) developed a
new set of codes within the framework of the World
Health Organization (WHO) International Classification of
Diseases, Tenth Revision (ICD 10) for deaths associated
with terrorism and the US Clinical Modification of the
ICD, Ninth Revision (ICD-9-CM) for injuries and ill-
nesses associated with terrorism. This new classification
depends on the non-medical/public health definition pro-
vided by the FBI, 8.12 Element Descriptor Modifier Perpetrator Type Individual vs. group Government vs. non-govern-
ment National vs. sub-national Motivation Intentional vs. unintentional Premeditated vs. impulsive
Political vs. criminal vs. reli-
gious Action Methods Violence
Force
Conventional vs. unconventional
Explosion of marine weapons Destruction of aircraft Other explosions and frag- ments Fires, conflagration, and hot substances Firearms
Nuclear weapons
Biological weapons
Chemical weapons
Lasers
Battle wounds
Piercing or stabbing objects Drowning and submersion Reality Real vs. threatened Recognizability Covert vs. overt Predictability Unpredictable vs. predictable Legality Criminal vs. lawful Victim Type Non-combatant vs. combatant civilian vs. miltary Government vs. non-govern- ment Symbolic vs. non-symbolic Intended vs. unintended Vulnerability Vulnerable vs. invulnerable Innocence Innocent vs. guilty Effect Physical health Death
Injury
Illness Mental health Anxiety
Stress
Terror, fear
Loss of well-being
Loss of security Property Property damage
Economic loss
Environmental damage Politics Intimidation
Coercion
Political influence
Social change
Publicity, attention Prehospital and Disaster Medicine © 2003 Arnold Table 1—Core elements, descriptors, and modifiers pre-
sent in previously published definitions of terrorism 1–10 April – June 2003 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine Arnold et al 49 national governments, the fruits of terrorism are the same—
innocent human beings are killed, injured, and terrified.
What matters most to healthcare providers and public
health systems are the underlying mechanisms and out-
comes of terrorism, not the exact identity of the perpetra-
tors or the laws they violate. This medical/public health definition of terrorism includes the essential point that the violence of terrorism is
intentional. The Oxford English Dictionary (OED)
defines “intentional” as “done on purpose” or “resulting
from intention” (definition 2). 13 For terrorism to have occurred, the act should have deliberately targeted at least
a subset of its victims. The fact that terrorists may unin-
tentionally harm others along the way (e.g., postal workers
in the 2001 US anthrax letter attacks) does not subtract
from the fact that the act was a terrorist one. Should “col-
lateral damage” against civilians during war or armed hos-
tilities be included in the medical definition of terrorism?
After all, unintentional violence against non-combatants,
like terrorism, still constitutes violence against non-com-
batants and produces similar health challenges. The dis-
tinction between terrorism and collateral damage should be
viewed as a matter of intent. When an act clearly is intend-
ed to harm non-combatants, then the act is consistent with
terrorism. When the act clearly is unintentional, then the
act is consistent with “unintentional violence against non-
combatants”. When the intent behind an act is unclear,
then the act should be identified via the more generic term,
“violence against non-combatants”. This suggests that all
terrorist acts constitute violence against non-combatants,
but not all violent acts against non-combatants constitute
terrorism. This medical and public health definition of terrorism brings together the many disparate methods of terrorism
under the horizontal descriptor of violence. The OED
defines “violence” as “the exercise of physical force so as to
inflict injury on…persons” (definition 1a) and “ undue con-
straint applied to some natural process…so as to prevent its
free development or exercise” (definition 1d). 13 The New Shorter OED defines “violence” as “the action or an act of
constraining or forcing unnatural change upon some-
thing”. 14 Paralleling this definition, the World Health Organization defines “violence” as “the intentional use of
physical force or power…that either results in or has a high
likelihood of resulting in injury, death, psychological harm,
maldevelopment or deprivation”. 15 A broader definition of violence is required, because ter- rorist actions include, but are not limited to bombings, mass-
shootings, hijackings, hostage-takings, kidnappings and
extortion (conventional terrorism) as well as chemical, bio-
logical, radiological, and nuclear releases (unconventional
terrorism). In addition, threats of violence may also disrupt
social order and cause psychological consequences, such as
terror in the effected population. Other forms of violence
that force unnatural change in human populations including:
(1) agricultural terrorism (food terrorism), which may pro-
duce psychological harm, maldevelopment, injury, or death;
(2) international starvation, which may produce a range of
injuries related to deprivation; and (3) cyberterrorism, which Medical and Public Health Definition of Terrorism A universal medical/public health definition of terrorism is
not merely a theoretical concern, but has important opera-
tional implications for healthcare systems. A universal
medical/puablic health definition of terrorism will help
emergency managers examine the effectiveness of systems
of emergency planning, preparedness, and response, and
share their results in an internationally harmonized manner.
It will help public health scientists investigate the epidemi-
ology of terrorism-related events or disasters (and readily can
be married to the classification system already created by the
NCHS). It will help educators across a range of health-relat-
ed disciplines, teach students about the impact of terrorism
on the health of individuals and communities across a
range of circumstances. It will help healthcare providers
across a spectrum of social, political, economic, and cultur-
al contexts recognize and respond to the common physical
and psychological effects of terrorism on its victims. It will
help healthcare providers communicate their experiences
and knowledge about the health consequences of terrorism.
In short, the development of effective medical strategies
against terrorism requires agreement about what we are
dealing with. What are the desirable features of a medical/public health definition of terrorism? Because healthcare systems
exist to serve the needs of individual victims as well as for
populations, a medical/public health definition of terrorism
should be victim andpublic health population-centered.
Because healthcare systems are confronted with the physi-
cal and psychological aftermath of terrorism, a
medical/public health definition of terrorism should pref-
erentially address the health consequences of terrorism.
Because medicine and public health are scientific disci-
plines, a related definition of terrorism should be based on
objective information about terrorism. Because terrorism is
an international phenomenon, a medical/public health def-
inition of terrorism should be acceptable to the total med-
ical community across a spectrum of countries and cultures.
Accordingly, the words or terms used in this definition
should consist of words or terms that resist misinterpreta-
tion and that are clearly defined or generally acknowledged
by the medical and public health communities. Given these provisions, we propose the following uni- versal medical/public health definition of terrorism: The intentional use of violence — real or threatened — against one or more non-combatants and/or those services
essential for or protective of their health, resulting in adverse
health effects in those immediately affected and their communi-
ty, ranging from a loss of well-being or security to injury, ill-
ness, or death. Discussion This definition differs from the many political or legal def-
initions of terrorism in several important ways. First, this
definition consciously avoids identifying who is or is not a
terrorist. From medical and public health perspectives, the
identity of those who commit terrorist acts is immaterial to
the task at hand. Whether the actors are lone wolves, hard-
line groups, guerilla fighters, organized military forces, or Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol.18, No. 2 50 Universal Medical and Pubklic Health Definition of Terrorism 5a). 13 The New Shorter OED defines “service” as “the organized system for providing labor, equipment, etc., to a
meet a public need such as health” and “system” as “a set of
related or associated material or immaterial things…shar-
ing a common cause”. 14 In other words, terrorism not only consists of acts against non-combatants, but also includes
acts against the infrastructures or organizations of services
essential for or protective of their health [public health]. Most importantly, this medical/public health definition of terrorism incorporates the adverse health effects of ter-
rorism on its victims. To understand what constitutes an
adverse health effect, it is helpful to first consider the
meaning of health. The World Health Organization
defines “health” as “a state of complete physical, mental,
and social well-being and not merely the absence of disease
or infirmity. 16 Dorland’s Medical Dictionary echoes this definition, identifying “health” as “a state of optimal physi-
cal, mental, and social well-being, and not merely the
absence of disease or infirmity”. 17 The OED is even more liberal in its definition, equating health with “well-being,
welfare, safety; deliverance” (definition 5a). 13 This suggests that adverse health effects include not only injury and ill-
ness (which are more familiar and more conveniently quan-
tifiable), but also a loss well-being or security mediated by
fear or terror (which admittedly are more difficult to mea-
sure, but nonetheless relevant to health). What are the direct adverse health consequences of ter- rorism? The most characteristic and widespread adverse
health effects are the spectrum of psychological conse-
quences mediated through fear or terror in the affected
population (Figure 1). Adverse psychological effects are a
mandatory result of terrorism and range from a general loss
of personal well-being or security at the most fundamental
level to numerous specific acute and chronic psychological
conditions, including acute anxiety, acute depression, stress
reaction, hysteria, and post-traumatic stress disorder. In
addition, terrorism frequently, but not always, is associated
with an assortment of physical injuries or illnesses. At the
apex of this hierarchy is the ultimate adverse health
effect—human death. Terrorism also may produce a range of indirect adverse health effects, particularly when it is directed against those
services essential for or protective of health. These adverse
health consequences occur when terrorist acts: (1) threaten
or damage the healthcare system itself, leading to a loss of
access to or the availability of medical care; (2) threaten or
damage essential public health services, resulting in a loss
of access, and/or availability of clean water, food, sanita-
tion, or shelter; or (3) lead to economic loss that limits
access to food, shelter, or health care. For example, the
threatened or real bioagent contamination of the public
water supply or the deliberate destruction of a public health
laboratory, hospital or clinic will—at a minimum—provoke
fear, increase vulnerability to disease, and decrease access to
and availability of health services. Terrorism accomplishes
all of this without any direct injury or loss of life. In the
case of complex emergencies, indirect consequences con-
tribute to a far greater mortality and morbidity overall than
direct causes. A related concept is “state capacity”, which is
defined by Price Smith as a country’s capacity to maximize may cause produce direct psychological effects as well as
indirectly limiting access to essential or protective health
services. This medical definition of terrorism includes
threatened acts of terrorism, which like real acts of terror-
ism, are capable of producing psychological injury. The
word “threatened” is derived from “threaten”, which is
defined by the OED as “to try to influence (a person) by
menaces” (definition 2a). 13 The New Shorter OED defines “threaten” as “appears likely to do something unwelcome or
undesirable.” 14 While some threatened actions clearly are acts of terrorism (e.g., bomb threats), some may be more
ambiguous. For example, does mailing an envelope contain-
ing innocuous white powder constitute terrorism from the
medical perspective? The complete answer to this question
depends on whether such an event meets the entire defini-
tion above. Nevertheless, the conditions for terrorism exist
when the perception exists that the white powder is likely to
do “something undesirable” (e.g., cause an infection or even
generate an increased risk of infection) and that “something
undesirable” relates back to the previous definition of vio-
lence (e.g., exposure to the white powder would force an
unnatural change). This medical/public health definition of terrorism iden- tifies victims of terrorism as one or more non-combatants.
The OED defines “combatant” as “one who combats, a
fighter” (definition B) and a “non-combatant” as “one who
is not a combatant” (definition a). 13 The New Shorter OED defines a “combatant” as “a participant in active
fighting during a war”, “war” as “the operations by which
armed hostilities are carried on”, and a “noncombatant” as
“a person who is not a combatant”. 14 The horizontal term —non-combatant—is used not only to distinguish those
actively engaged in combat or war from those who are not,
but also to create a broader category of inclusion into
which are placed civilians, political leaders, and military
personnel not actively engaged in war. What is meant by
military personnel not actively engaged in war? These are
military personnel who are not actively engaged in opera-
tions through which armed hostilities are taking place.
This includes not only military forces during times of peace
(i.e., not war), but also non-combatant military personnel
during times of war, such as chaplains, medical personnel,
off-duty soldiers, or even disarmed prisoners of war. This medical/public health definition of terrorism also indicates that terrorism may take place against those ser-
vices essential for or protective of their health. The OED
defines “service” as “a branch of public employment, or
body of public servants, concerned with a particular kind of
work or the supply of some particular need” (definition Prehospital and Disaster Medicine © 2003 Arnold Figure 1—The health consequences of terrorism Death Physical injury or illness Psychological injury or illness Loss of well being or security April – June 2003 http://pdm.medicine.wisc.edu Prehospital and Disaster Medicine Arnold et al 51 to Zwi, health effects are the most sensitive measures of the
political impact of terrorism—underscoring the fundamen-
tal relevance of defining terrorism through its health conse-
quences. 20 Furthermore, it is noteworthy that this medical defini- tion of terrorism does not attempt to define what constitutes
a war crime. The International Committee of the Red Cross
characterizes “war crimes” as “serious violations of interna-
tional humanitarian law committed during international or
non-international armed conflicts. 21 According to the OED, a war crime is “an offense against the rules of war, for-
merly excluding, but since the 1939–1945 war including, any
such act performed on the orders of a higher authority” (def-
inition 11). 13 Depending on the circumstances and the legal definition of war crime, some medically defined acts of ter-
rorism may be defined legally as war crimes, while other
legally defined war crimes may be defined medically as acts
of terrorism. In other situations, the two entities may be
completely distinct. Finally, users of this definition of terrorism undoubted- ly will recall historical examples of events throughout the
world in which atrocities were deliberately committed
against civilian or other non-combatant populations. They
understandably will ask, “Was this terrorism?” Table 2 lists
seven questions about the event that will be answered in
the affirmative if terrorism has occurred from the med-
ical/public health perspective. It is not our intention to revise history, affix blame, or usurp the various legal definitions of terrorism. However, it
is our goal to produce a medical/public health definition of
terrorism, which prospectively addresses the impact of ter-
rorism on human health and which can be used by the total
medical community. Conclusion As terrorism becomes an increasingly familiar feature of the
modern landscape, it is essential that the medical communi-
ty adopt a definition of terrorism that serves its universal protection of its population from infectious agents. 18 When terrorism is directed against essential or protective
health services, the state capacity of the affected govern-
ment is compromised (and terrorists will have met their
goals). 18,19 Therefore, this medical definition of terrorism must recognize the potential that threats or actions against
essential or protective services have on health. The medical/public health definition of terrorism indi- cates that the consequences of terrorism are experienced by
both those immediately affected and their community. The
OED defines “community” as “a body of individuals” (defin-
ition II). 13 By specifying that the effects of terrorism are not only felt by its immediate targets, but also by a larger body
or community, this definition suggests that terrorism is a
special type of interpersonal violence that affects more than
just its direct victims; it affects populations. This not only
helps avoid the implication that all interpersonal acts of vio-
lence are terrorism, but is consistent with the empiric obser-
vation that terrorism characteristically creates a climate of
fear that extends beyond any primary victim. 3 Because the psychological or indirect health consequences of terrorism
go beyond the zone of immediate impact, it is essential to
consider those who are secondarily affected. For example,
the 11 September World Trade Center attacks produced
secondary psychological consequences that impacted the
greater New York City region (and indirect health conse-
quences that arguably affected a large part of the world). Although this medical/public health definition of ter- rorism does not incorporate in direct language, per se, the
political effects of terrorism, such as coercion, intimidation,
political influence, or social change, the authors also recog-
nize that health does not exist in a political vacuum. While
the political consequences of terrorism are extremely difficult
to identify and measure, the political consequences of terror-
ism remain relevant to the provision of health care in that
they exist as “threats” to one’s access to or the availability of
health. Zwi suggests that political terrorism, no matter
where it is focused, first affects health. 20 As such, according Questions Term in Medical Definition 1. Did the action relate to constraining or forcing unnatural change in its vic- tims? Violence 2. Did the action deliberately target any of its victims? Intentional 3. Did the action of constraining or forcing unnatural change actually occur or did it appear likely to occur to its victims? Real or threatened 4. Was the action directed against one or more persons not actively partici- pating in operations through which armed hostilities were being carried
out or against the infrastructures or organizations of those services
essential for or protective of their health? One or more non-combatants or those services
essential for or protective of their health 5. Did adverse health effects occur in those immediately affected? Those immediately affected 6. Did adverse health effects occur in the community Community 7. Did the action result in any minimal adverse psychological health effects, such as a loss of well being or security? Loss of well being or security at a minimum 8. Did the action result in any other adverse psychological or physical health effects, such as an injury, illness or death? Injury, illness, or death Prehospital and Disaster Medicine © 2003 Arnold Table 2—Questions to be considered to define an act as terrorism (Affirmative answers to questions 1-7 are mandato-
ry; affirmative answer to question 8 is supportive, but not mandatory) Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol.18, No. 2 52 Universal Medical and Pubklic Health Definition of Terrorism 11. Beaton R, Murphy S: Psychosocial responses to biological and chemical ter- rorist threats and events. Implications for the workplace. AAOHN Journal
2002;50:182–189. 12. Centers for Disease Control and Prevention: New classification for deaths and injuries involving terrorism. MMWR 2002;51(special issue):18–19. 13. The Oxford English Dictionary (CD-ROM, version 3.0) 2nd ed. New York, NY: Oxford University Press; 2002. 14. Brown L (ed): The New Shorter Oxford English Dictionary on Historical Principles.4th ed. New York: Oxford University Press, 1999, pp 1–3801. 15. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R (eds): World Report on Violence and Health. Geneva: World Health Organization, 2002, p 5. 16. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed
on 22 July 1946 by the representatives of 61 States (Official Records of the
World Health Organization, no. 2, p 100) and entered into force on 07 April
1948. 17. Friel JP (ed): Dorland’s Illustrated Medical Dictionary. 26th ed. Philadelphia: WB. Saunders Company, 1981, p 583. 18. Price-Smith AT. Wilson’s bridge: A Consilient Methodology for Analysis of Complex Biological-Political Relationships. Program on Health and Global
Affairs (PHEGA), University of Toronto: Center for International Studies
working paper 1998-8. November 1998. pp 2–43. 19. Burkle FM: Mass casualty management of a large-scale bioterrorist event: An epidemiological approach that shapes triage decisions. Emerg Med Clin
N Am 2002;20:409–436. 20. Zwi A, Uglade A: Political violence in the third world: A public health issue. Health Policy and Planning 1991;6:203–217. 21. International Committee of the Red Cross: International Humanitarian Law. Answers to Your Questions. Geneva: International Committee of the
Red Cross, 2002, p 35. References 1. Council on Foreign Relations: Terrorism: An introduction. Council on Foreign Relations. Web site. Available at www.terrorismanswers.com Accessed 01
June 2003. 2. Malik O: Enough of the Definition of Terrorism. London: Royal Institute of International Affairs, 2000, pp 1–66. 3. Altran S: Genesis of suicide terrorism. Science 2003; 299:1534–1539.
4. Commission of the European Communities: Proposal for a Council Framework Decision on Combating Terrorism. The European Union On-Line
Web site. Available at
http://europa.eu.int/eur-lex/en/com/pdf/2001/en_501PC0521.pdf.
Accessed 20 June 2003. 5. Department of Justice, Canada: Royal Assent of Bill C-36, The Anti-Terrorism Act. Department of Justice Web site. Available at
http://canada.justice.gc.ca/en/news/nr/2001/doc_28217.html. Accessed 20
June 2003. 6. Federal Bureau of Investigation: Terrorism in the United States 1999. Federal Bureau of Investigation Web site. Available at www.fbi.gov. Accessed 01 June
2003. 7. Ganor B: Defining terrorism: Is one man’s terrorist another man’s freedom fight- er? The International Policy Institute for Counter-Terrorism Web site.
Available at www.ict.org.il. Accessed 01 June 2003. 8. National Center for Health Statistics: Classification of death and injury result- ing from terrorism. Centers for Disease Control Web site. Available at
www.cdc.gov/nchs/about/otheract/icd9/terrorism_code.htm. Accessed 01
June 2003. 9. United Kingdom Parliament: Terrorism Act 2000. HMSOnline Web site. Available at www.legislation.hmso.gov.uk/acts/acts2000/00011--b.htm#1.
Accessed 20 June 2003. 10. United Nations Office on Drug and Crime: Definitions of terrorism. United Nations Office on Drug and Crime. Web site. Available at
www.undcp.org/odccp/terrorism_definitions.html. Accessed 01 June 2003. relevant, and universally applicable. Therefore, new med-
ical definition of terrorism has been proposed. mandate and supercedes the political agenda alone of any
one country or any one special interest group. Accordingly,
this definition should be consequence-centered, medically

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