Overview The anthrax attacks of 2001 and the newly emerging global threat of severe acute respiratory syndrome (SARS) have illuminated the critical role of America’s hospitals in dealing with naturally occurring and deliberately disseminated microbial pathogens. In the face of increasing regulatory challenges, workforce shortages, and expanding numbers of underinsured and uninsured Americans, hospitals are expected to have staff familiar with bioterrorist disease agents, implement protocols that prevent disease transmission to hospital personnel and patients, and participate in surveillance, reporting, and alerting strategies with other critical community responders. These responsibilities challenge the most agile and fiscally sound of the nation’s 5000 acute care facilities; they place a profound burden upon our roughly 2,000 rural hospitals. While rural hospitals throughout the nation have achieved different levels of preparedness, many remain inadequately prepared to respond to either a bioterrorist event or an emerging infectious disease. This lack of preparedness has many causes, including limitations on general resources, inadequate bioterrorism preparedness-specific resources, and the ability and time to train hospital personnel. 6,7,8 A recent report by the U.S. General Accounting Office (GAO) on the ability of American hospitals to respond to a bioterrorist attack surveyed only urban hospitals and overlooked the importance of preparedness among rural hospitals. 9 National Rural Health Association (NRHA) President Wayne Myers responded, "By not taking rural hospitals and populations into consideration, the GAO is failing to acknowledge the health and safety concerns of more than 65 million Americans who call rural communities home." 10 According to the NRHA, rural areas and industries provide the majority of the nation’s food and water supplies. Rural America, therefore, offers a particular vulnerability to terrorists who aim to threaten the U.S. economy. Furthermore, the majority of U.S. land bordering on Mexico and Canada supports rural communities. 11 Our porous borders, especially the 3,900 mile Canadian border, which is guarded by fewer than 400 patrol agents at a given time, present rural communities with threats of exposure to smuggled biological, chemical, radiological, and explosive weapons.12 Rural communities may also be particularly vulnerable because of their proximity to chemical stockpiles, missile silos, and other sites that present terrorists with attractive targets. 13 Community leaders in rural areas generally acknowledge the reality of terrorist threats, and trust that anticipated access to preparedness funding would provide dual-benefit opportunities, like improvements in emergency and decontamination equipment, communications infrastructure, laboratory services, and telemedicine capabilities. 14,15 Perhaps one indication of the perceived threat environment is the market for terrorism insurance, which insurance companies were required to offer to all of their policyholders following the Terrorism Risk Insurance Act of 2002. Using mathematical models and information from terrorism experts, risk modelers have calculated that only two percent of the country's zip codes face more than 90 percent of the risk of experiencing a terrorist attack. Accordingly, the premiums of terrorism insurance in areas found to be high-risk by these models, New York City and Chicago for example, are so high that most businesses are declining the policies. Business owners in rural areas and even smaller cities, where terrorism insurance policies are much cheaper, are declining coverage because the do not perceive a risk. 16 The potential threat of terrorist attacks in rural American communities stems from the attractive targets presented by those components of our critical infrastructure that are most concentrated in rural areas. Particularly vulnerable to biosecurity threats are the agriculture and food production industries, which contribute $1.24 trillion to the U.S. economy annually and account for one in eight American jobs. 17 In 2002, Secretary of Agriculture Ann M. Veneman testified before the U.S. Senate Committee on Agriculture, Nutrition and Forestry regarding the vital role of the U.S. Department of Agriculture (USDA) in homeland security, charging her department with the responsibility “to better protect agriculture, our food supply and consumers from potential terrorist threats.” 18 Reacting to the urgency of the post-9/11 threat environment, the USDA initiated a series of exercises in late 2002 to illustrate barriers to biosecurity preparedness for agricultural terrorism, or agroterrorism. The first simulation, “Crimson Sky,” demonstrated that a deliberately deployed outbreak of foot and mouth disease (FMD), a disease caused by a highly contagious virus that infects all cloven-hoofed animals, presents a grave threat to the security and economic stability of the U.S. The second simulation, “Crimson Guard,” examined the operational issues revealed in Crimson Sky, involving federal and state animal health and emergency response officials, and the third, “Crimson Winter,” was designed to examine issues specifically related to the Food Safety and Inspection Service. 19 A recent press release from the U.S. Department of Homeland Security (DHS) states, “Today’s world poses unprecedented new threats to U.S. agriculture. While inspections have traditionally focused on accidental introduction of harmful pests and diseases, a post-September 11 world demands that we also focus on the deliberate introduction of these threats.” 20 This press release followed on the heels of President Bush’s announcement of Homeland Security Presidential Directive Nine (HSPD-9), which acknowledges that the nation’s “agriculture and food system is an extensive, open, interconnected, diverse, and complex structure providing potential targets for terrorist attacks,” and calls for the establishment of “a national policy to defend the agriculture and food system against terrorist attacks, major disasters, and other emergencies.” Clearly, acts of agroterrorism using non-zoonotic agents, such as FMD, pose little or no threat to human health, and would require a veterinary, not necessarily medical, response. However, threats to such a key component of our critical infrastructure in turn compromise civil order and the safety of citizens in rural communities, which also justifies efforts to strengthen medical response capabilities in those communities. Non-zoonotic infectious diseases and other non-biosecurity specific concerns, such as nuclear facilities, chemical plants, and military installations, pose direct threats to human health. The existence of these hazards suggests a need to improve rural hospital preparedness capabilities. 6. “What's Different About Rural Health Care?”
National Rural Health Association. Available at http://www.nrharural.org/pagefile/different.html.
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