The Big Country

Although rural communities across America vary greatly in terms of economy and geography, there are important similarities within these communities, particularly when considering emergency preparedness. For instance, many rural areas are subject to extreme weather conditions, such as blizzards, tornadoes or flash floods. Also, many rural communities report having limited personnel with experience responding to large-scale disasters or emergencies. In terms of biohazards and chemical emergencies, rural areas often have limited access to HAZMAT equipment and resources, and have limited facilities to quarantine and decontaminate small or large groups of people.

According to the Office of Rural Health Policy, "Adequate emergency preparedness in rural communities depends on public health departments, hospitals and emergency medical services (EMS) providers. However, rural public health departments tend to have less capacity and resources than their urban counterparts. For example, mental health providers are much more common in metropolitan public health agencies. In addition, hospitals are often the nucleus of health planning, activity and resources in rural communities. However, national policy changes have encouraged hospitals to downsize bed capacity in an effort to contain costs and, as a result, rural hospitals lack surge capacity for personnel and beds. Furthermore, rural EMS often relies on volunteers and may lack funding and adequate equipment."

A Question of Priorities
According to the Michigan Rural Health Association, rural communities have fewer financial and staff resources to assist in compliance with the numerous federal and state-level emergency preparedness activities. In spite of its importance, participation in emergency preparedness planning is viewed as an "unfunded mandate" in many rural communities. Also, excepting communities near nuclear or hydroelectric plants, most rural Americans believe themselves to be much less at risk from terrorist activity. Their health system leaders express ambivalence about emergency preparedness and perceive it as a low risk in comparison to the significant burdens they face in financial, human resource and regulatory matters. The Michigan Rural Health Association reports that hospital administrators in particular express additional ambivalence about investing time and resources into emergency preparedness while facing so many other pressures in finance, staffing, quality and regulatory compliance. The perceived low risk of a terrorist event places emergency preparedness quite low on rural hospital administrators' priorities list.

Recommendations

The National Rural Health Association, a national nonprofit membership organization that provides leadership on rural health issues, maintains that, while tenets for preparedness can be legislated and resources centrally collated, funding and requirements need to be flexible enough to accommodate appropriate solutions, in accordance with rural local needs. Also, the rural health infrastructure (which includes work force, EMS, laboratory and information systems) and components of the public health system (which includes education and research) must be strengthened to increase the ability to identify, respond to and prevent problems of public health. Further recommendations from the National Rural Health Association include:

· Health professionals, volunteers/ first responders and the public must be educated to better identify, respond to and prevent the health consequences of terrorism and promote the visibility and availability of health professionals in the communities they serve.

· Mental health needs of populations that are directly or indirectly affected by terrorism must be addressed.

· The protection of the environment and food and water supplies, and the health and safety of rescue and recovery workers must be ensured.

· Clarification and communication of roles, relationships and responsibilities among health agencies, law enforcement and first responders must be assured.

· Simultaneous and coordinated systems planning must occur at the local, regional and state levels.

· Hospitals must be included as first responders in planning, funding and training.

· Hospitals and health systems cannot be expected to absorb the costs of disaster preparedness alone, and will need additional resources to fulfill their role in the emergency response system.

The National Rural Health Association concludes with a reminder that "not all areas are directly served by hospitals, therefore flexibility in funding will also be needed. In addressing these rural needs, the variability of health infrastructures, capacity, capabilities and needs must be taken into consideration. Furthermore, the most rural frontier areas may lack even the basic health and infrastructure access. Federal legislation addressing national preparedness must recognize that public health threats can emerge anywhere at any time. A basic level of care for a national response must be developed and funded to ensure our national and rural preparedness."

Taking Action

Rural participants in regional planning must be assertive in identifying obstacles in newly developing emergency plans, and in presenting alternatives that accommodate rural situations and the unique needs of rural communities. In addition, communities in rural areas should develop coalitions to facilitate planning and communication between multiple counties, and should seek to plan in conjunction with any nearby urban centers, if possible. It is also crucial that rural communities vigorously participate in the development, execution and review of disaster drills. These drills must be designed as a realistic test of rural capacities. An emergency drill can be a large-scale enactment or a smaller, less dramatic exercise. Drills are essential in preparing communities for unfamiliar scenarios.