Discussion

This study is important, as it is the first to describe the medical consequences of 4629 terrorist attacks that took place in the Turkic states between 1970 and 2019, along with weapons and attack types. The Organization of Turkic States is an international organization consisting of 7 countries in total, including 4 founding members (Azerbaijan, Kazakhstan, Kyrgyzstan, and Turkey), 1 full member (Uzbekistan), and 2 observer members (Hungary and Turkmenistan). While this organization is a platform for the development of interstate relations, one of the main purposes of this organization is to act together against terrorist attacks. ^{Reference Tessler, Mooney and Witt15} These countries have been fighting different forms of terrorist organizations for years, such as the Fethullah Terrorist Organization (FETO), the People’s Protection Units or the People’s Defense Units (YGP), the Kurdistan Workers’ Party (PKK), the Revolutionary People’s Liberation Party/Front (DHKP-C), the Armenian Secret Army for the Liberation of Armenia (ASALA), Al-Qaeda, and the Islamic State of Iraq and the Levant (DEAS). ¹⁶

Between 1970 and 2019, 4629 terrorist attacks occurred in the Turkic states and 7496 people lost their lives and 10 928 people were injured. Between 2009 and 2019, terrorist attacks reached their peak in terms of frequency, as shown in Figure 1. Moreover, an alarming trend shows that terrorist organizations successfully achieved their intended targets in approximately 90% of these attacks within the mentioned countries. Seven percent of the terrorist attacks by terrorist organizations in the Turkic states include suicide attacks. Suicide attacks, also known as suicide bombers, are defined as a type of attack in which persons end their own lives by placing an explosive device on their bodies, either intentionally or unintentionally. ^{Reference Markovic17} Although the rate of suicide bombings is low, defensive response to these attacks is tactically difficult and causes more casualties than other forms of terrorism. ^{Reference Tin, Galehan, Markovic and Ciottone18} Other bomb attacks occur more frequently than suicide bomb attacks and cause many injuries. The most common type of attack in the Turkic states, which injures many people, is a bomb attack. For example, the biggest bombing attack in the Turkic states in recent years occurred in Turkey on November 15 and 20, 2003. In this attack, 63 people lost their lives and approximately 750 people were injured. ^{Reference Rodoplu, Arnold and Tokyay19} The medical consequences of this type of attack vary widely, depending on the type of bomb, the method of detonation, the environment in which it occurs, its proximity to the source, and the weather. ^{Reference Tin, Hertelendy, Hart and Ciottone20} Pressure during a bomb attack directly affects health, resulting in penetrating and thermal injury; injury to sensitive areas such as the ears, lungs, and abdomen; skin ecchymosis, abrasion, and tearing; head trauma; and bone fractures. ^{Reference Aslıer, Gül, Aslıer and Arşivi21–Reference Yavuz, Asirdizer and Cetin25} However, flying objects, blast waves, and complicated events occur in bomb attacks. These events cause medical consequences such as blunt trauma, fractures, burns, crush syndrome, and immune system problems. ^{Reference Crabtree26}

Turkey has been, and continues to be, one of the countries frequently targeted in terrorist attacks. According to different studies, Turkey ranks 23rd among the countries most affected by terrorism in the world and ranks first among the European and Turkic states. ²⁷ Due to Turkey’s geopolitical position, the Iran-Iraq and Gulf wars in the Middle East, the Russia-Ukraine war in the Northeast, the Bosnia-Herzegovina and Kosovo crises in the Balkans, and the Nagorno-Karabakh wars in the Caucasus took place in the close vicinity of the country and left Turkey at risk of being involved in regional conflicts for its own borders. ^{Reference Aydin28} There is a power vacuum in the states of Syria and Iraq located in the Southern region of Turkey. This power vacuum causes a significant increase in the number of irregular migrants and asylum seekers, who move from the Middle East, travel through Turkey, and try to reach Europe. Thus, the rate of irregular migrants and asylum seekers in Turkey has increased. ^{Reference Içduygu and Toktas29} In addition, Turkey has disputes with Greece in the Sea of Islands. ^{Reference Avar and Lin30} It can be stated that all these factors support terrorist activities of structures with different goals and objectives in Turkey. For example, on the night of July 15, 2016, a coup attempt against Turkey took place by the Fethullah Terrorist Organization. Although the desired goal was not achieved by the terrorist organization in this attack, 240 people lost their lives and nearly 2000 people were injured as a result of the attack. ^{Reference İçener31} Firearms and explosive weapons were preferred as the types of weapons used in this coup attempt. ³² It is seen that the most used type of weapon in the terrorist attacks in the Turkic states are explosives and firearms. In similar studies on terrorism, it is stated that fire and explosive weapons are widely used in terrorist attacks. ^{Reference Tin, Barten and De Cauwer1,Reference Tin, Hart and Ciottone33,Reference Ulmer, Barten and De Cauwer34} Among the reasons for the widespread use of explosive weapons are that this type of weapon is relatively easy and inexpensive to manufacture, simple to use, and easy to execute with a small number of attackers. Although firearms are used relatively less than explosive weapons among the Turkic states, they have the highest death rate among weapon types. In similar studies, the lethal rate of firearm incidents was found to be high. ^{Reference Tin, Barten and De Cauwer1,Reference Ulmer, Barten and De Cauwer34} In addition, firearms, which are widely publicized and easy to access, cause mass murders. ^{Reference Court, Edwards and Issa4} Although these conventional weapons have been favored by aggressors, non-traditional weapons, such as chemical-biological-radiological-nuclear weapons, are perceived by governments as a serious potential weapon of mass destruction threat. ^{Reference Jasani, Alfalasi and Cavaliere2} Although this type of weapon is almost never used in the Turkic states, Turkey has laid the foundations of its defense system against chemical and biological weapons. ^{Reference Yaren, Kenar and Karayilanoglu35}

Finally, terrorist attacks not only cause death and injury, but also damage both the country and society economically. ^{Reference Ruiz Estrada, Park and Khan36} In particular, 61% of the terrorist attacks that occurred in the Turkic states caused material damage, and it is seen that most of the material damage occurred in Turkey. While material damage increases the vulnerability of the society, it negatively affects the social welfare and causes public health problems and health inequalities. In the literature, there are also various studies examining the effects of terrorist attacks in Turkey on the economy. ^{Reference Ruiz Estrada, Park and Khan36–Reference Bilgel and Karahasan38}