Could Hospitals Cope With Insider Terrorist Threats?

by DR. JAMES “JIM” BLAIR, COL RET, ARMY AMEDD November 8, 2010
Reported crimes of violence in America's hospitals have doubled in the last three years with women healthcare employees among the most frequent victims of violence in the nation's workplaces. At the same time, experts tell us these attacks are greatly under-reported and come from a wide variety of sources: they are attacked by patients, co-workers, strangers off the street and an attacker lurking in garages - the trend goes unabated.
These women caregivers don't have an exclusive corner on the violence; patients and their male counterparts are vulnerable to both inside and outside attacks. The looming depressed economic environment has further stressed an already financially-stressed industry. Serial reductions of staff create additional pressure on an already anxious and difficult workplace. While decision makers are always tempted to look at cost centers for cuts, reduction of safety and security elements within the organization may look reasonable but in reality have undeniable consequences.
Important human resources functions, degraded hiring practices with little regard to past performance and criminal background of applicants place all stakeholders at risk and the lack of national level reporting and loss of the two-decades-old healthcare-offenders list has added to the insider threat.
The healthcare's increased practice of “outsourcing” important and sensitive administrative and clinical functions has resulted in loss of direct control of many of these areas. Essential functions are left to the trust of contractors in hiring practices in general and low wage positions in particular. These workers often have access to areas where supervision is weak and sensitive patient information is there for the taking.
In addition, the “just in time” practice has greatly increased vendor activity within the system and has introduced an increase of 'in-house” traffic with the assumption that your vendors are taking due diligence in their own hiring practices, multiplying the potential for wrongdoing.
Recent in-hospital shooter events were covered in an earlier article but it is worth mentioning again. The industry brushed it off as a novel event. A gun in the hands of malcontents in hospitals is not a recent phenomenon; there is a long history death and injury in these settings. The issue of whether hospital security should be armed has a long and contentious history. 
Up to this point we have assumed that the threat is of a non-terrorist nature. We do not want to minimize violence against healthcare stakeholders from any source. The loss of property and sensitive documents by theft is of concern; however, weaknesses in existing practices also give rise to other insider and outsider terrorist activities.
 The anti-terrorism community was shocked by the notion that physicians could be numbered among suicide bombers. The terrorist ranks have been populated by physicians for some time, indeed, Osama bin Laden's second in command is an Egyptian pediatrician. Known for their suicide-bomber recruiting prowess and getting others to “blow themselves up”, and engaging in such activity themselves seemed counter intuitive. The evidence that they were willing to do so adds strength to the argument that ideology is a strong driving force in the terrorist movement and away from those who believe suicide bombers have little to lose or feel socially alienated.
Keeping this in mind, the United Kingdom's experience with physicians and super-scientists participation in acts of terrorism including suicide-bombing, should give us pause, especially as the ranks of our hospitals are filled with thousands of International Medical Graduates (IMGs). Here is why:
Shortly after recognition that physicians within the U.K. National Health System were active terrorists, the international healthcare and security organizations engaged in a “deep look-back” at the world-wide International Medical Graduate (IMG) community. They reviewed member documentation associated with acceptance by various national authorities to practice in country and while there is little open source information available, investigators were stunned by the level of unverifiable information on many applications.
According to recent reports from the Department of Homeland Security, the lack of integrity in the U. S. visa system is a danger to all the nation's work-sites.
Approximately one-fourth of the nation's physician workforce is populated with IMGs.
New demands placed on the U.S. Healthcare system by passage of healthcare reform legislation will probably add tens of thousands of IMGs to America's healthcare delivery system.
One needs only to “Google visa legal sites” to appreciate the intense competition for IMGs to fill existing positions in the nation's federal and non-federal healthcare workforce.
Post 9/11 many within and outside the profession have sounded the alarm for better safety and security in the nation's healthcare delivery system. The U.K. Experience should act as a “wake-up” call to the industry. There has been little official attention paid to this potential source of terrorism.
A careful reading of Jihad and American Medicine by Adam Frederic Dorin, M.D. will provide the reader with an excellent look into the potential for terrorism within today's healthcare community and also provides an insightful look into the systems “self-inflicted world of “treatment acquired infections and other treatment errors” which millions face as they navigate through the healthcare system.
Doctor Dorin does not stand alone in his call for increased safety and security in the healthcare workplace in general and hospitals in particular. Doctor Robin McFee, a physician, medical toxicologist and widely accepted expert on Weapons of Mass Destruction, has written extensively on the potential danger posed by radicalized   Islamist physicians and super-scientists. In her four part Exclusive: Doctor Evil? Physicians and Scientists-Terrorists and Murderers in an Era of Global Terrorism, she asks and answers her question “why” and “how” could a healer become a killer?'. FSM
We have written extensively about the vulnerabilities associated with the handoff of important and sensitive security functions from one administration to another. Transfer of these activities is fraught with danger even if it stays in the same political party. Transfer of these functions to another political party requires even more vigilance. This is particularly the case if the new administration is perceived as less well prepared and does not view the threat in traditional terrorism terms.
 The Department of Homeland Security has shown little appetite to push the industry to a higher level of preparedness. The introduction of women into the suicide bomber mix has greatly increased the threat in industries with women employees. Inquiries into what countermeasures may be needed to address this were met with silence. The same weaknesses in safety and security which allows dangerous non-terrorist events also promote a rich opportunity for terrorist to become part of the healthcare landscape. Contributor Dr. James Blair, DPA, MHA, FACHE, FABCHS, CAS, is president and CEO of the Center for HealthCare Emergency Readiness. This article was adapted from excerpts from Blair's book, Unready: To Err is Human: The Other Neglected Side of Hospital Safety and Security, which was published in June. He is also a career-retired army colonel with 28 years of active service. Among his private sector experiences, he served as VP of Hospital Corporation of America, Middle East Limited and as an independent consultant to Joint Commission International.

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