Executive Summary Over the past decade, acts of international and domestic terrorism have demonstrated to government officials and policy makers the urgency of preparing systems to support the detection of atypical health events and the provision of preventive and interventional medical services in mass care events. The 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City resulted in 168 deaths and required the efforts of nearly 5,500 emergency responders dispatched to the scene over 17 days in chaotic and feverish attempts to rescue and facilitate subsequent medical and surgical interventions to save the lives of over 600 injured victims. 1 The September 11, 2001 attacks on the World Trade Center and the Pentagon resulted in over 3,000 deaths and nearly 2,400 injured.2 The lethality of the attacks averted strain on hospitals but, once again, required the coordinated efforts of emergency responders and medical providers. The anthrax attacks of 2001 resulted in relatively few victims. However, despite only 21 illnesses and five deaths, hospitals in the five anthrax epicenters were required to institute triage for a novel disease and to devise new protocols of health screening, prophylaxis, and treatment. Eventually both public health and medical care systems were required to dispense antibiotics to an estimated 32,000 individuals. 3 Most recently on March 11, 2004, terrorist bombings on several trains in Madrid resulted in nearly 200 deaths and about 1,800 injured. 4 Madrid’s hospitals were swamped with casualties and appealed urgently for blood donations. 5 Acts of terrorism upon civilian populations necessitate a robust response by health and medical care systems and present particular challenges to America’s almost 5,000 acute care hospitals. As the locus of medical diagnosis and intervention for a wide array of routine activities, ranging from the provision of primary care for the uninsured to the delivery of tertiary procedures for life-threatening diseases, hospitals face the intricacies of terrorism preparedness and response with limited budgets and insufficient trained human staff. These deficits are even more acutely experienced by the nation’s approximately 2,000 rural hospitals, which have a comparatively smaller repertoire of medical resources and unique vulnerabilities. The spectrum of weapons of mass destruction demands a diverse set of response capabilities. An explosive device necessitates an urgent and massive medical effort to save the lives of injured persons not immediately killed. A communicable pathogen requires a response that grows greater over time as the incidence of human infection increases. The resulting epidemic consumes the workforce, requiring voluminous amounts of human resources and medical equipment to interrupt disease transmission and reduce rates of mortality through disease tracking and monitoring, verification of exposure, administration of medical countermeasures where available (e.g., vaccines and preventive antibiotics), and supportive care and clinical treatment. The case studies described below offer a view of the challenges facing rural hospitals as they prepare for the threat of bioterrorism as well as non-intentional, naturally-occurring epidemics of emerging contagious diseases, such as severe acute respiratory syndrome (SARS). The findings are sobering, and include a pervasive perception among study participants that major medical emergencies in America’s rural areas and heartland would quickly overwhelm the capabilities of their small hospitals. Many of these facilities, owing to financial restraints, are relatively old and structurally porous, incapable of containing or preventing the aerosolized spread of an infectious disease throughout the medical units and to previously non-exposed patients and health care workers. They have relatively few “extras,” as they are limited in medical supplies, life-sustaining equipment (such as ventilators), auxiliary power sources, and trained physicians and nurses. Communication systems across rural communities to ancillary hospital support systems (e.g., police, safety and EMS, and other potential sources of person-power and assistance) are unreliable and easily interrupted by terrain and weather. Most local officials acknowledge that they would be on their own for at least the first 24 to 48 hours. A catastrophic event, or an act of bioterrorism, will require that rural hospitals receive outside assistance to sustain ongoing operations, intervene upon the potentially unremitting flow of medical emergencies, and contain the epidemic sequelae of a deliberately deployed pathogen. However, coordinated and reliable systems of hospital support still evade current response paradigms attributable in large part to the stovepiped streams of money and non-integrated planning efforts prevalent across the spectrum of civilian and non-civilian sectors that have identified terrorism response roles and responsibilities. The delivery of medical care to infected populations and the containment of disease epidemics require that hospitals occupy a central role in community-based bioterrorism preparedness planning. The author provides this report to inform future initiatives to prepare America’s hospitals against threats to homeland security. 1. Final Report of the American Psychological Association
Task Force on the Mental Health Response to the Oklahoma City Bombing.
July 1997.
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