Immediate Domestic Vulnerabilities
Beyond the obvious that there is a strong movement to impose Sharia law globally, the concept of which alone out lies the scope of this article, are health care vulnerabilities – risks to the patient and community.
I. U.S. Health Care Facilities
Are our health care facilities (HCF) safe from terrorism? Are they low threat targets? Should they be considered as such? Consider the panic and loss of public confidence if a community hospital or venerable medical center was attacked? Beyond the immediate loss of life would be the loss of a valuable component of public preparedness and critical infrastructure. In 2005 a homeland security bulletin was sent to California hospitals stating that "U.S. Hospitals offer easy public access and would be recognized by terrorist planners as easy, accessible targets."
Illustrating the point in the ridiculous, at a recent chemical terrorism drill, while on "lockdown" the hospital forgot to lock the back door entrance to the Emergency Department. Video cameras are infrequently reviewed at best, or are inoperable systems designed to provide a perception of increased observation/safety. Security needs are consistently balanced against hospitality – given hospitals are sites of confidential and critical information, and vulnerable people, such asset protection must be balanced against the human nature of illness and the need for support and family. The resulting ease of entry, especially with a white lab coat and a stethoscope, make HCF vulnerable to outside crazies, terrorists, criminals and "insiders" like extremist converts. Numerous hospitals around the country are "low hanging fruit" for individuals or groups intent upon sabotage. Consider the HCF with a large propane storage tank 30 feet from the emergency room, or the hospital with a railroad track running through it carrying toxic inhalation hazards virtually unguarded. Even an innocent derailment can cause severe damage with loss of life.
Therapies, especially IV bags, can be easily tampered with. Hospital security is lacking. Patients are extremely vulnerable, especially if they are alone, which is often the case at night. Consider the number of patients murdered over the years by severely disturbed health care workers using readily available medications from crash carts and medicine cabinets – paralyzing agents such as succinylcholine, the cardiac drug potassium chloride, or sleeping agents.
In spite of increased concern over the security of radioactive materials – even small quantities of medical and research isotopes – the fact remains it is relatively easy to locate and remove such materials from many hospitals, universities and labs. Several well respected academic institutions post large signs at loading docks informing delivery services where to drop off radioactive materials. Many of those offices are well marked and unsecured! While those materials are not useful for thermonuclear weapons, they can be utilized for dirty bombs or poisoning – in either case public concern even panic could result along with morbidity and mortality.
Hospital vulnerability remains a significant threat to preparedness.
II. Direct Patient Care
A. Evil in the guise of good
Think about the scope of economic, political, social and human influence of the health care industry and the dynamic interplay between hospitals and medical personnel and virtually every segment of society – law enforcement, fire rescue, intelligence if an event occurs, political, economic, social and legal. Health care is an economic driver, a public benefit and source of community safety. Physicians participate in critical community roles.
In the U.S., physicians with extremist leanings raise funds through work at universities and in the community and/or assist in the takeover of moderate mosques to impose more radical ideologies.
A strategy employed by extremists is to influence young minds; where better than at schools and universities? Recently the School of Medicine at Harvard University received a multimillion dollar endowment for Middle East and Islamic Studies – under the admirable objective of educating young physicians to be more culturally attuned to their patients and to promote greater collaboration between the two regions. Increasingly, Islamic Studies are being mandated in universities; and while only a handful of medical schools have such courses to date, the Harvard experience is likely only the beginning. Relating to the article by Peter Probst, can benign programs be co-opted for more radical agendas?
One also wonders, in the name of tolerance, the impact of 'religious practice' on medical care. Insulin can come from pigs. Reproductive rights and end of life issues and their attendant legal procedures and organ transplants also may conflict with extremist views – consider extremist Muslim health care workers who refuse to treat women, or even refuse to study about certain medical procedures. There are an increasing number of extremist Muslim health care workers refusing to use hand sanitizers because of the alcohol content in those products. Yet hospital-acquired infections is one of the leading causes of death in the United States and largely preventable by consistent hand washing. In the pursuit of tolerance we have abandoned our values and common sense.
Using the tools of "soft power" to mold public opinion and influence public policy – a strategy embraced by the Muslim Brotherhood – is not wasted on physicians as extremists. Articles published in the medical literature about "studies" on issues such as "the perceived role of Islam in medical practice in the U.S. give the appearance of scientific pursuit when, in effect, some of these articles may be thinly veiled propaganda efforts to enhance the image and acceptance of radical Islam. Organizations such as the Islamic Medical Association no doubt offer, like other peer group associations, positive reinforcement and mentoring. But, like other large organizations, they also wield enormous influence. The key questions for security professionals, leaders in health care and the public at large – do these organizations harbor radical extremists or provide valuable resources for extremist organizations? Can good organizations be hijacked?
Reaching out to poverty-stricken areas would always seem benign, right? Perhaps true enough, but it is also an ideal and seemingly innocuous way to develop recruits. Radical Islamic groups responded to the 2005 earthquake in Kashmir in spite of being banned by then-President Musharraf. In all, at least 17 Jihadist and radical Islamic organizations provided aid to refugees. These outreach programs allow money laundering, recruiting of grateful survivors, and fundraising. An example is the Holy Land Foundation for Relief and Development which solicited funds for medical relief but, according to the U.S. Treasury, provided millions of dollars to Hamas. HLF has operatives in the U.S., as does the Global Relief Foundation (of Illinois) which helped raise money for al Qaeda. Given medical organizations often need spokespersons or a front man, recruiting physicians will remain a priority, as seen in the UK where several radical sects target scientists, engineers and doctors. In a strategy developed by Ayman al Zawahiri, provision of local health care is given in exchange for opportunities to recruit youth in extremist ideology. This strategy has been successfully employed in Egypt and Sudan, under the auspices of Osama Bin Laden. One wonders if it couldn't be employed in the US.
Of note, Muslim clinics and health care facilities are emerging. On the surface this seems to be a good notion – provide medical care within the communities needing help. By developing such clinics, the opportunity to more widely recruit is obvious. Given prime targets have been prisons, where the conversion of African-Americans to radical Islam is growing, can we not expect other recruiting targets such as the education system and areas where racial tensions allow for a cultural offensive, especially disadvantaged areas? Physicians are the ideal agents of influence. Offering to provide care to prisoners allows the radical Muslim extremist to foment anger by emphasizing abandonment by the "white establishment," demonstrate a kindred spirit, promote recruitment to the Muslim Brotherhood, and foment greater dissention.
B. International Medical Graduates (IMG)
The United States, like the United Kingdom, is increasingly reliant upon international medical graduates and foreign educated nurses – FEN, especially in overcrowded urban hospitals, underserved (prisons, inner cities, projects), public health clinics in disarray, or disadvantaged regions (rural). According to the AMA 2005 Member Fact Book, the number of physicians in the U.S 794,893; there are 185,234 international medical graduates (IMG) from 127 countries. The number of IMG is expected to increase. Among the top 20 countries of origin or education for IMG physicians, seven of these nations are known terrorist havens. In 2001- 2002, there were 100,958 graduates in ACGME accredited residency training programs; 26% were from non-U.S. schools.
IMG play a vital role in providing care to underserved regions. Many impoverished and underserved people might go without even basic medical care were it not for IMG. Potentially hiding within the kind and devoted IMG majority are the dangerous minority – a group well versed in using every means at their disposal – the law, intimidation, money or political influence – to achieve their objectives. The opportunity for IMG, especially those with extremist loyalties to overtake public health departments and their systems – which, in the aftermath of 9/11 and October 2001 (anthrax) were designated as the "go to" players for bioterrorism and emerging pathogens – poses a grave risk to our infrastructure. The British National Health Service is a cautionary example of such vulnerability.
One advantage that preparedness experts have is the reality that physicians not only occupy high positions in their own countries but in their newly transplanted communities in the U.S. Physicians are thus readily visible members of what might otherwise be difficult communities to locate or identify.
It is worth noting, even in a post 9/11 environment, special visas for foreign alien MDs and other health care personnel, as well as gravely ill individuals from abroad (the veracity of their illness often is suspect) putatively scheduled to receive advanced treatments, remain relatively easy to obtain, especially if rural and other disadvantaged areas need clinicians. And as the more individuals relay upon public care, the likelihood that restrictions to IMG will diminish to fill gaps emerges. Taking advantage of this opportunity, proponents of IMG extol the values of easing immigration restrictions. Where security and health care collaborate or collide is predicated upon how we address this issue.
IMG Physician population overview
Number of Physicians in U.S 794,893
Number of IMG Physicians 185,234 (from 127 countries)
Of the top 20 countries where IMG physicians received their education IMG physicians, three of the top five harbor extremists and terrorists – India, the Philippines and Pakistan, representing almost 40% of the total: over 4,000 each from Egypt and Iran, with approximately 3,000 from Syria and Lebanon.
Source: 2005 AMA Membership Fact Book
C. Community Risks
Anyone with a scientific background can tamper with the community infrastructure – whether the water supply, food, energy or transportation. Though beyond the scope of this paper, it is important to recognize that extremist physicians and scientists have the capacity – as demonstrated in 1993, 9/11 and other events – to identify, disrupt and undermine critical components of society. Anyone who says the water supply cannot be poisoned is sadly misinformed. Trains carry a wide array of toxicants and can be derailed, or individual chemical cars tampered with. We must balance our concern over safety with the reality that some security measures are just plain goofy. Bunker mentality is both counterproductive and can lead to preparedness fatigue – something we cannot afford. An example of this is banning photographing ferry boats to Long Island from the dock, something tourists like to do; it will not enhance safety. Zoom lenses from the shoreline can accomplish the same thing; so we punish the innocent over what? When we apply concern about a fifth column, let us employ some common sense!
Part Four will feature a Discussion and Conclusion.
FamilySecurityMatters.org Contributing Editor Dr. Robin McFee is a physician and medical toxicologist. An expert in WMD preparedness, she is a consultant to government agencies, corporations and the media. Dr. McFee is a member of the Global Terrorism, Political Instability and International Crime Council of ASIS International. She has authored numerous articles on terrorism, health care and preparedness, and coauthored two books: Toxico-Terrorism by McGraw Hill and The Handbook of Nuclear, Chemical and Biological Agents, published by Informa/CRC Press.