What the Experts Are Saying Is Very Little

The primary reason that hospitals and other medical facilities in America are largely unprepared to prevent and/or deal appropriately with a terrorist attack is that we have not decided to accept our vulnerability in this sector of society. In all aspects of terrorism prevention, we must learn to think like terrorists and begin to think the unthinkable.
In the same vein, healthcare workers in Europe have begun to explore the possibilities that “terror” could unleash in a hospital setting. Authors Charles Hancock and Chris Johnson, from the University of Glasgow, devised a fictional scenario to better appreciate how bad things could get in the event of a terrorist attack against the National Health Service. In addition, they used computer simulation to more realistically understand how various facilities would confront an assault and deal with the evacuation and treatment of patients.

Through these analyses, it was estimated that it would take almost six times longer to remove nonambulatory patients from a trouble zone than it would for those able to move out on their own accord. The authors, in their piece “Thinking the Unthinkable: the NHS and Terrorist Action,” conclude that access to medical facilities is relatively unimpeded, that internal communication systems are mostly inadequate to deal with crisis situations, and that facilities need to maintain disaster response plans, which are routinely practiced by all staff members.

Some U.S. hospitals and medical personnel are moving in the right direction toward improved planning and coordination in the event a major catastrophe should occur. For example, the Northern Virginia Emergency Response Coalition (NVERC), comprising fourteen hospitals in Northern Virginia and representatives from public health agencies (as well as police, fire, and rescue departments), was created to establish the framework for a workable, regional response team. This coalition was charged with developing a communications network called MEDCOMM (a direct connection with the District of Columbia’s Hospital Mutual Aid Radio System).

There is evidence that this type of local/regional alliance can lead to decreased costs, shared resources, a mutual buy-in on emergency protocols and procedures, and an improved delivery of medical care. This type of regional response team is a subset of the larger National Disaster Medical System (NDMS). The NDMS is a partnership between government and private entities; it is “fed” by the U.S. Department of Homeland Security (DHS), the Department of Defense (DOD), the Department of Veterans Administration, the Department of Health and Human Services, and the Federal Emergency Management Agency (FEMA). The NDMS serves to back up military operations in the event of overwhelming civilian casualties, and to respond independently to regional crises. The NVERC of the Washington, D.C. area is one of about one hundred NDMS groups throughout the country.

These groups, composed of doctors, nurses, and ancillary medical support staff, train to respond to just about any type of disaster; unfortunately, they are too few and far between. The average NDMS team is composed of only about fifty to possibly one or two hundred dedicated and reliable professionals. Those making up the team are predominantly, if not exclusively, volunteers. Assuming these dedicated individuals forego taking care of their own families in a time of emergency, their effect will be limited in a city of several million reeling from a disaster of any significant proportion. The point here is not to minimize the incredible and necessary function of the NDMS regional teams, but to, again, reflect on the lack of attention currently paid to “prevention” instead of predominantly “preparedness.” These volunteers should be commended for the arduous task they have agreed to confront.

It is important to recognize the significance of the previous point about giving “prevention” parity with “preparedness” efforts in terms of community planning and strategies to decrease the incidence of tragedies occurring within the U.S. health system. Consider those catastrophic entities for which prevention is of little value, and for which preparedness must take precedence:

• Major drought
• Earthquake
• Tornado
• Tsunami
• Severe snow and ice storms
• Flood
• Fire

These and other disaster scenarios are, for the most part, so far out of the realm of human control that they speak for themselves in terms of the need for adequate community planning and preparation in the event that tragedy strikes.

Now, consider those areas of society where prevention can, has, and does make a difference in disaster planning:

• Transportation-related failure or crash
• Power grid failure
• Contamination and/or sabotage of public utilities
• Communication system failure
• Terrorism or terrorist-like activity

Clearly, these areas demand intense scrutiny, study, and strategy to devise improved mechanisms to detect and prevent disasters from occurring in the first place. Healthcare is simply one of these areas that is integrally tied to all of the others; it is an area that has, unfortunately, received less attention than it deserves and needs.

In the Journal of Homeland Security, March 2003, Stungis and Schori, describe a mathematical model, which they believe to be similar in principle to that “mindset” used by Al Qaeda in choosing targets and executing attacks. In their analyses, the authors look at a Florida county and presume 99 potential terrorist “events.” They then discussed the impact, circumstances, and potential measures, which could be utilized to prevent or thwart the terrorist action. Again, these writers turn to the concept of “thinking like the terrorists” and identified what they considered to be “soft” targets such as shopping malls, schools, and hospitals.

The chosen Florida location of Charlotte County was not merely picked out of the air by Stungis and Schori. This spot, comprising about 150,000 residents, was the site where it is believed that Mohammed Atta and possibly several other members of the 9/11 hijack team stayed. In fact, Atta arranged overseas cash transfers, received care in a local hospital, and ate at restaurants in Charlotte County. The predominant industries of this county are local government functions, retail shops, and healthcare. The team of planners for the hypothetical model consisted of senior military personnel, physicians, public healthcare managers, experts in mathematics and physics, and specialists in psychology, infectious diseases, radiation oncology, and emergency medicine.

The mathematical model concluded that the most likely location (i.e., most vulnerable, least well-guarded, and most “bang for the buck”) for a terrorist attack would be the town shopping mall. Another expected target would be a sports stadium. The most likely mode of attack in the shopping mall would be “biological.” Falling closely behind, other highly probable sites or events to fall victim to a terrorist attack would be as follows: festival (suicide bomb, vehicular bomb, chemical attack), shopping mall setting (chemical attack), hospital (chemical attack), food store (biological agent), hospital (biological agent), and so forth. At the bottom of the list of potential terrorist events was a vehicle bomb at either a hospital or shopping mall setting.

In the scenario of a biological attack within a hospital setting, the researchers imagined three terrorists — armed with small hairspray-type containers of smallpox — contaminating the hospital cafeteria salad bar during the lunch and dinner meals over a two-day period. They calculated that after nearly two weeks about 80 percent of the healthcare workers (and likely visitors) and 90 percent of patients would show signs of infection. They imagined that the perpetrators would heighten the effect of their terror by releasing videotape of their actions to the media to create a national panic. Their estimation is that the consumer markets would begin to take a nosedive and the U.S. economy would possibly spiral into a steep recession or depression.