In the Middle East (ME), although there are no large heart failure (HF) epidemiologic studies, HF prevalence seems to be high as the rest of the world. Middle East HF patients are younger by a decade on average compared with the western HF population.1,2 This in large related to increase prevalence of cardiovascular risk factors3,4 as well as delayed revascularization caused by either late presentation postmyocardial infarction or lack of primary angioplasty facilities and lack of awareness.5 This will lead to patients reaching advanced stage D HF at a relatively younger age. Therapeutic options for this advanced population are limited. Heart transplantation programs are scarce with very limited number of heart donors. Few countries in the region recently have started implanting left ventricular assist devices (LVADs), basically as destination therapy. Currently, the most commonly used LVADs in the ME region are the Heartware (Heartware Corporation, Framingham, MA) and the HeartMate II (Thoratec Corporation, Pleasanton, CA). There are 425 Heartware LVAD implants since 2010 and 59 HeartMate II LVAD implants since 2009 in the ME, and these numbers are increasing yearly (numbers are provided by industry).
Terrorism and terrorist activities have been expanded worldwide especially in this part of the world. The incidence of suicide bombers is high in this region and recently posing a persistent and evolving threat.6–8 This has led security forces in different Middle Eastern countries to develop strict security measures to limit and prevent these dynamic threats and to make the best decisions at an early stage. Identifying suicide bombers and intervening at the appropriate moment is crucial for security authorities and being enforced consistently.
What Is the Relation Between Suicide Bombers and LVAD Patients? The Following Case Will Highlight This Relation
The relation between suicide bombers and LVAD patients has been developed recently after several incidences where LVAD patients’ were in danger as being mislabeled as suicide bombers endangering many lives in the vicinity. One incidence is related to a 45 year old lady, an LVAD patient, who sustained a major car accident and was locked in an upside down car position. People and security forces trying to help were scared and confused regarding the driveline and batteries suspecting a suicide bomber. They ran away keeping the patient stuck in the car whereas some even tried to cut the driveline while the patient was shouting to clear the misunderstanding. Similar incidences for several LVAD patients at big malls have been reported and scared the security personnel. Patients were subjected to different antiterrorism actions.
The relation between LVAD and suicide bombers is becoming more valid as currently the bomber activates an improvised explosive device worn under their clothing also called the suicide body.6,9 The body bombs typically weigh 0.5 to 10 kg. This type may pose the most significant security challenge. The suicide body suit has evolved and is becoming increasingly smaller for better concealment. Initially, the device was a block that is worn on the chest and belly region. Nowadays, these blocks are smaller in size and could be worn as vests, placed above the naval or around the abdomen.6,8,9 This type of worn vests makes it similar to the vests worn by LVAD patients. Security authorities might not be able to differentiate between a bomber and an LVAD patient. To avoid premature detonation in an effort to stop a suicide attack, police officers or security agents will be more inclined to react and in occasions shoot these innocent civilians prematurely.
The aim of this review is to shed the light on the characteristics of suicide bombers and what are the differences between bombers and LVAD patients as well as what measures should be taken in the ME region to prevent subjecting these few saved lives to the risk of noncardiac terroristic-related death.
The most commonly used LVADs in the ME region are the HeartMate II (Thoratec Corporation) and the HeartWare (HeartWare). Both devices have, in addition to the part implanted in the chest, other parts that appear outside the patient’s body. These include the driveline, the controller, and the batteries. They can be either placed in a bag held near the body at the level of the lower abdomen or can be worn as a vest consisting of batteries placed on each side at the midaxillary line at the abdominal level with a belt holding the controller at the belt line. Whatever the way the outer parts are worn, they can subject the patient at suspicion of placing a body suite containing explosive materials. More so, the controller has usually a green light and the driveline is thick white wire. Both, if seen by others should signify that electronics being used. This is a major part suicide bombers will not show if available and try to keep it hidden.
Usually suicide volunteers wear suits that have limited electronics. This will make it difficult to be detected by security agents that use counter-technologies to detect electronic devices. Usually it is a cheap suit constructed from commercial items. The device usually is simple because the more sophisticated it is, the more challenging becomes to operate and the risk of failure is higher and troubleshooting is more challenging.8,9
In addition to explosives, the detonator is the most important element. This is the part that the suicide bomber needs to hold in his/her hand whether inside a pocket or by making a tight fist (if not determined to explode by another bystander from a distance). Usually small volt batteries are needed and the button is hard so it cannot be detonated easily and explode in nontargeted areas.6,8,10
How Can We Differentiate Suicide Bombers from LVAD Patients?
Most of the data have been adopted from the Israeli experience over the past 20 years.6,7,11 Most of these bombers are young ranging from 17 to 23 years although some may reach 40s in age. Mostly are men although the female’s involvement is increasing in some regions. There are certain behavioral measures suicide bombers can show or explicit. These include the appearance of being nervous or anxious. They seem preoccupied or have a blank stare with a focused intent that they may not respond to verbal or any other kind of contact, an awkward attempt to blend in, avoidance behaviors toward authorities as trying to avoid security, and the appearance of talking or whispering to someone as a result of praying fervently. That being said, this behavior alone is not uncommon and in many occasions has no meaning as some people may talk to themselves or talk on cell phones through headset.
In addition, there are general characteristics include profuse sweating that is out of synch with weather conditions, walking deliberately toward a specific object or target, lack of mobility of the lower abdomen may cause upper body stiffness. A recently shaved beard or short haircut to disguise the appearance may be noticed too. Other clues to the appearance include clothing that does not match with the weather or that is excessively loose giving the appearance of the head is out of proportion with the body and thus appearance of excessive weight. Long coats or skirts may be used to hide explosive belts and devices. Also suicide bombers have a clenched fist caused by the tight grapping of the detonator. An unusual gait may appear too like a robotic walk indicating a person forcing himself or herself to go to a mission.10,11
Because it is possible to counter the threat effectively through proper attention, training, and preparations, there should be some effective measures needed by the governments, security forces, and agencies as well as LVAD programs in the ME region. These measures could include the following:
- Educating the security forces and agents about the presence of LVAD patients and the appearance of the outer parts of the device.
- Patients carrying identification cards about their device and educate them how to handle situations when they are suspects.
- Patients avoiding areas with high possibility of bomber attacks if possible.
- Educating the public through media on LVAD patients and the differences from suicide bombers.
- Patients deliberately showing and expressing their willingness to identify themselves when they feel they are suspects.
- LVAD program role in educating patients to avoid such situations, educating security agents, and population through special training and media.
Indeed increasing the awareness to identify these patients appropriately will be a major task that needs full collaboration from health care providers and general public/government. Initially, we should rather focus on certain groups with the highest exposure to such patients (e.g., security) and implement tools to increase awareness among these groups such as remote coded identification cards or a password that only LVAD patients can provide when they are being subjected to serious situations.
There are many similarities and differences among suicide bombers and LVAD patients as highlighted in our review. Educating the authorities, LVAD patients, and general public is crucial to avoid any costly misperceptions and actions.
1. AlHabib KF, Elasfar AA, Alfaleh H, et al.: Clinical features, management, and short- and long-term outcomes of patients with acute decompensated heart failure: Phase I results of the HEARTS database. Eur J Heart Fail 2014.16: 461469.
2. Sulaiman K, Panduranga P, Al-Zakwani I, et al.: Clinical characteristics, management, and outcomes of acute heart failure patients: Observations from the Gulf acute heart failure registry (Gulf CARE). Eur J Heart Fail 2015.17: 374384.
3. Rahim HF, Sibai A, Khader Y, et al.: Non-communicable diseases in the Arab world. Lancet 2014.383: 356367.
4. Motlagh B, O’Donnell M, Yusuf S: Prevalence of cardiovascular risk factors in the Middle East: A systematic review. Eur J Cardiovasc Prev Rehabil 2009.16: 268280.
5. Alhabib KF, Sulaiman K, Al-Motarreb A, et al.; Gulf RACE-2 investigators: Baseline characteristics, management practices, and long-term outcomes of Middle Eastern patients in the Second Gulf Registry of Acute Coronary Events (Gulf RACE-2). Ann Saudi Med 2012.32: 918.
6. Hassan R: Global rise of suicide terrorism
: An overview. Asian J Soc Sci 2008.36: 271291.
7. Rosner Y, E. Yogev, Y. Schweitzer: A Report on Suicide Bombings in 2013.
INSS Insight 2014; No. 507:[Available from: http://www.inss.org.il/index.aspx?id=4538&articleid=6408
. [Accessed: 13 Jan 2016].
8. Network LET: Confronting the Suicide Bomber: Determining Agency Policy.
2006: [Available from: http://www.popcenter.org/
] [Accessed 13 Jan 2016].
9. Margalit A: The Suicide Bombers.
2003; No. 1, January 16 2003: [Available from: http://www.nybooks.com/articles/archives/2003/jan/16/the-suicide-bombers/
. [Accessed: 13 Jan 2016].
10. Weinberg L, Pedahzur A, Canetti-Nisim D: The social and religious characteristics of suicide bombers and their victims. Terror Polit Violence 2003.15: 139153.
11. Sela-Shayovitz R: Suicide bombers in Israel: Their motivations, characteristics, and prior activity in terrorist organizations. Int J Conflict Violence 2007.1: 160168.