This study sought to compare terrorist attacks targeting healthcare in two different geographical areas that are economically and culturally similar: North America and Europe.

The Global Terrorism Database is a database that documents 214,666 worldwide terrorist events from 1970 to 2021. It was searched to identify terrorist attacks against healthcare using keywords. We manually excluded incidents that did not specifically relate to attacks on healthcare. This resulted in 311 and 150 entries in North America and Europe respectively.

The most common method of attack in Europe was bombing (42%) compared to attacks on infrastructure (66%) in North America. The primary target in North America was abortion related (84%). In Europe, the primary target was businesses (37%). In Europe, 18.7% of attacks were assassinations or attempts vs 3% in North America. The total number of fatalities in Europe is 51 vs 3 in North America.

Even though there were significantly more attacks in North America, there were far fewer total fatalities compared to Europe. Attacks in North America appear to be ideological, targeting infrastructure to send a message. Whereas, in Europe, the targets and methods used are more targeted towards the individual and their property.

In recent decades, an increasing number of terrorist attacks have been carried out against medical institutions, hospitals, and health care workers. These attacks, that often result in high numbers of casualties and impaired access to health services, have a more significant impact on people’s sense of security than attacks against military and police targets. Attacks on ambulances – especially on the African continent – have been sparsely studied. This study examines attacks on ambulances on the African continent during the period from 1992-2022 (until December 31, 2021).

Reports of ambulance terrorism were extracted from the Global Terrorism Database (GTD), RAND Database of Worldwide Terrorism Incidents (RDWTI), United Nation’s Safeguarding Health in Conflict Coalition (SHCC) database, Armed Conflict Location and Event Data Project (ACLED), Surveillance System for Attacks on Health Care (SSA) database, and Aid Worker Security Database (AWSD). Furthermore, a grey literature search was performed. The date and location of the attacks, perpetrators, weapon and attack types, and the number of victims (dead and wounded) and hostages were collected. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.

During the 30-year study period, 166 attacks were observed in 18 African countries. The number of attacks significantly increased since 2016, with 81.3% of the attacks taking place from 2016 to 2022. In total, 193 people died and another 208 were injured. Attacks with firearms were most frequently noted (92 cases; 55.4%), followed by attacks with explosive devices (26 cases; 15.7%). A significant number of ambulances were hijacked (26 cases; 15.7%) and subsequently used for other terrorist attacks. In seven attacks, ambulances were used as vehicle-born improvised explosive devices (VBIEDs).

In this database study on ambulance terrorism in Africa, it was found that the reported occurrence of attacks increased from 2013 onwards, including the rise of ambulances used as VBIEDs. These findings suggest that ambulance terrorism represents a real, significant risk that both governments and health care institutions must address.