Health Preparedness And Australian Counterterrorism Strategy

Killings carried out by terrorists are becoming worse and more gruesome to achieve the shock factor. While there is no suggestion of any new specific terrorist threat to Australia, the Australian Government is looking again at security for public events following last year’s Bastille Day attack to make sure that all necessary arrangements are in place. The Nice attack, where Mohamed Lahouaiej Bouhlel ploughed a truck through crowds of Bastille Day revellers on the Promenade des Anglais and killed at least 84 people and seriously injured more than 200, could easily happen here.

There have been three terrorist attacks in Australia in the past 14 months, with nine disrupted plots foiled. Australia’s security agencies are investigating about 400 terrorism cases. The planned Christmas Day attack allegedly included multiple-venue and mass-casualty attacks in public places in Melbourne’s CBD, including improvised explosive devices. Arrests made in Sydney and Melbourne last year included charges of conspiring to obtain illegal firearms and manufacture explosive devices. Terrorists in Australia intend to inflict mass-casualty fatal attacks.

Violent extremists will draw inspiration from the Nice atrocity. No doubt, Australia’s home-grown Gen Y jihadists will look to emulate the Nice attack modus operandi. By the depraved standards of terrorism, the Nice attack was a great success. It made a huge impression right across the jihadist world: one does not need to use a plane as a weapon like 9/11; simply grabbing a lorry and ploughing into a crowd can mount an effective attack.

On the protective security side at mass gatherings here, close attention will need to be paid to the feasibility of putting up barriers to keep out vehicles, especially trucks. (But even here there will be a requirement to allow in cleaners, rubbish collection, media and other vehicles.) However, it will be impossible to secure some open sites – think of events such as a marathon or an Anzac Day march.

One of the lessons for Australia from the Nice attack is it must think about how to protect areas beyond capital cities. Just as the terror attack occurred in the south of France, Australia needs to consider security arrangements for regional centres. Local councils will need to review security arrangements for public gatherings, particularly their plans with first aid responders, like the St John Ambulance. However, events should not be cancelled – that way, the jihadists win.

But no matter how many bollards are erected, protection of soft targets against the sort of unsophisticated attack seen in Nice will not be possible. These attacks can only be stopped if there is intelligence prior to a potential attack. What needs to be done here is to focus more on the consequence management side. How would services practically cope with huge numbers of fatalities? In the Black Saturday bushfires, given the number of people who died in the fires, there was a need to rapidly assemble temporary refrigerated rooms as morgues. How would services cope with hundreds of seriously injured people, particularly in a regional centre?

Across Australia, there is a lack of available air assets and retrieval teams that would be able to provide support and respond to mass-casualty events. There are only two, sometimes three, medical helicopters covering greater Sydney. The nearest others are in Orange, Newcastle and Wollongong, any of which may be more than an hour’s flying time from Sydney if on a task. With minimal investment and a contractual agreement with Qantas and Virgin, up to four aircraft from their commercial fleets on the east and west coasts could be configured with the requisite kit for medivac use as required. as part of the commercial fleet on the east and west coasts.

Suitable military transport aircraft might be available, but the Royal Australian Air Force (RAAF) must balance this role with military operations, training and maintenance. In any event, defence assets rely on doctors and nurses who often have to balance their civilian life with their part-time military service as specialist reservists.

There is a lot that could be done to prevent the adverse health consequences that will flow from disasters, but Australia is not doing enough to prepare for a mass-casualty attack. Disaster response requires a whole-of-service response: hot zone and tactical emergency medical response, pre-hospital care, retrieval, emergency department and intensive care theatre. All elements should be drilled simultaneously and with simulated failings at each stage to prepare for the reality of a terrorist disaster.

There has been no real action to address the findings several years ago of a major study in the Medical Journal of Australia of the surge capacity for people in emergencies in Australia’s hospitals. It predicted that hospitals would be quickly overwhelmed and that 60 to 80 percent of seriously injured patients would not have immediate access to operating theatres, and that there would be a similar lack of access to intensive care unit (ICU) beds for the critically injured and to X-ray facilities for the less critically injured patients. It would be useful for those responsible for counterterrorism to engage those in the health system who understand what is required to manage a mass-casualty event.

The Improvised Explosive Device Guidelines For Places Of Mass Gathering guidelines were issued last year by the Australia-New Zealand Counter-Terrorism Committee. The guidelines rightly note: “Terrorist or insurgent attacks using explosives occur regularly around the world. Terrorists favour explosives because of their proven ability to inflict mass casualties, cause fear and disruption in the community and attract media interest. Explosives are also generally within the financial and technical capabilities of terrorists and IEDs can be assembled with relative ease and used remotely.”

The guidelines provide general guidance to those operating places of mass gathering – such as shopping centres, sporting arenas, theatres and railway stations – in terms of emergency service requirements and security principles. The document provides useful guidance on detecting suspicious activity.

But one of the weaknesses of the guidelines is its treatment of healthcare issues. There is no mention of post-blast planning and response, including the fact that the site of such an attack would be a crime scene, especially if injuries have occurred. In a post-blast incident, there would also be implications for immediate first aid and rescue before emergency medical services arrive.

The guidelines refer to ‘injuries’ and ‘people hurt’, but not that multiple fatalities and a correspondingly larger number of casualties in a terrorist bombing in one of Australia’s major cities are likely. There is no discussion in the document of longer term health issues; not all casualties will be immediately apparent and there will be a need to record those who felt the blast effects for medical observation and monitoring. There is no discussion in the guidelines either of on-the-scene triage or on how venue managers might work with emergency medical services to transfer the injured to definitive care.

The truth is that Australia is unprepared to respond to a major disaster. Surge capacity – the ability of the medical system to care for a massive influx of patients – remains one of the most serious challenges for national emergency preparedness. No major metropolitan hospital in NSW, Victoria, Western Australia, Tasmania or Queensland met state emergency department benchmarks in the first six months of last year.

In developing the health response to a disaster, there are some fundamental constraints:

  • Most ambulance and hospital services are overstretched on a daily basis. Pre-hospital and paramedic capacity, along with medical and nursing shortages, limit surge capacity for a large influx of critically injured patients.
  • Few of Australia’s hospital staff and paramedics have been involved in no-notice, large-scale disaster exercises, using the equipment with which they are supposed to be competent.
  • Finding adequate numbers of ambulances will be a problem for most states in the event of a disaster. There are no formal protocols between the states for the deployment of paramedics and ambulances.

Clearly, there is a problem. The first step in working out a response is to identify the shortfalls and set some performance goals. An audit of the national healthcare preparedness for large-scale disasters is needed on a regular basis, then the healthcare system would know what it is reasonably expected to be able to cope with and could plan appropriately, including the funding required. While it would not be that hard, it would require some goodwill and cooperation between the health departments of the commonwealth and state governments and the involvement of local councils.

It would be much better to deal with this proactively rather than in an after a ‘lessons learned’ report.


Anthony Bergin is senior research fellow at Australian National University’s National Security College and senior analyst, Australian Strategic Policy Institute (ASPI). He is the author of Are we ready? Healthcare preparedness for catastrophic terrorism, published by ASPI.