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R ural and frontier America representimportant aspects of the country, in

terms of population and psychologicalcontribution to the national identity [1].Conger notes that rural areas are found inall states, regardless of the fact that mostpeople imagine only certain states whenthey hear the term used [2]. Even thoughthe majority of United States policy is fo-cused on urban areas, rural and frontierareas have specific needs and resourcesthat vary from urban communities. Thislack of awareness has been termedurbancentrism. [1], [3]. Urbancentrismmay be fueled by popularly held mythsabout rural living that include the beliefthat rural residents are rugged and

self-sufficient people who live in safe,clean communities with unchanging,close-knit nuclear families and providetheir own safety-net without outsidehelp [4]. As will be noted in this article,rural communities are fighting for theirlives, even though they are necessary tosupport the increasing urbanization ofthe United States.

Characteristics of Rural AmericaSince its inception, the United States

has experienced a steady march from a ru-ral- to an urban-based society with the tip-ping point to urban occurring in 1920 (seeFigure 1). Prior to 1920, the majority ofpeople in the United States lived in rural

settings. By the beginning of the 21st cen-tury, only 20% of U.S. citizens lived innonurban settings [5], [6], as many as fivegenerations from their nonurban, agrarianroots [7]. Younger people moved to thecities to seek their fortunes, and today,those that remain in rural and frontier ar-eas are disproportionately aging com-pared to the national average [8].

Defining Rural: A Difficult TaskThere are multiple definitions of rural

and frontier and they are nearly as diverseas the places and populations they try toclassify. The definitional characteristicsof rural environments vary based on thefocus of the purpose for the definition [9].In fact, the definitions for rural and fron-tier are so troublesome, the Office of Ru-ral Health Policy (ORHP) of the HealthResources and Services Administration(HRSA) at the United States Departmentof Health and Human Services (HHS)commissioned a review of the definitionsof rural [10]. This review did not make arecommendation for a single definition ofrural or frontier.

Population density is the basis for mostdefinitions of urban, rural, or frontier areas.Perhaps the definition with the greatestconsensus is that of frontier, which refersto a density of six to seven people persquare mile. These remote communitiestend to have harsh climates with difficultterrain, water problems, a lack of exploit-

100 IEEE ENGINEERING IN MEDICINE AND BIOLOGY September/October 20020739-5175/02/$17.00©2002IEEE

Terrorism Risks in Ruraland Frontier AmericaTheir Importance to the Successful Functioning of Urban AmericaMakes Rural and Frontier Areas Ripe Targets for Terrorism

B. Hudnall StammInstitute of Rural Health andDepartment of Psychology,Idaho State University










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able resources, and are located far frommetropolitan areas [11], [12].

Interestingly, the United Statesgovernment defines nonrural areas inmore than one way, yet these definitionsare profoundly different. The Bureau ofthe Census defines as urban all territory,populat ion, and housing units inurbanized areas and in places of 2,500 ormore persons outside urbanized areas.The Bureau of the Census also uses theOffice of Management and Budget term,Metropolitan Statistical Area (MSA),which is defined as an area with 50,000 ormore inhabitants and includes the closelysettled areas around it that are tied to iteconomically and socially [13], [14].Other options have been offered includingdefining as urban those areas with adensity of 50 people per square mile orusing a rural-urban continuum, asopposed to a single dichotomy [2],[15].The definition of rural is the mostconfusing of all. Generally, rural isdefined by negation that is, “non-MSA,” adefini t ion that may or may notdifferentiate rural from frontier.

Generalizing across definitions, ruralAmerica contains just over 80% of theland in the U.S., and about 20% (56.2 mil-lion) of the people [6], [16]. Figure 2 pro-vides a map of the United States thatcombines definitions to result in shadingto show both cities and population den-sity. The darkest areas represent the mostdensely populated places (urban cities).Urban areas historically developedaround shipping centers [17]. With the ad-vent of air transportation, shipping centersare not predicated on sea ports, but the ma-jority of large urban areas continue to beclustered on the East or West coasts or byimportant inland ports such as Chicago,Memphis, or St. Louis. The lightestshaded areas represent very low popula-tion densities, which are primarily ob-served west of the 98th meridian,representing 45% of the landmass and 1%of the population. There are some verylow population density areas in the East,most notably in upstate New York and inMaine. A shared characteristic of thesevery low population density areas is chal-lenging geography and climate; quite of-ten associated with water—very littlewater or water in large amounts such as aswamp. The medium-shaded areas, ge-nerically rural, tend to contain the major-ity of farmland in the United States. Aninteresting phenomenon is developing ascities expand their subdivisions into what

has been informally termed the “ruralmargins.” These areas are combined sub-urbs and farming. As increasing urbaniza-tion takes place, farm land is lost and foodmust be transported over greater distancesto the urban centers.

Rural Healthcareand Health Disparities

As a result of the economic downturnsin rural America during the late 1980s, na-tional interest in rural health care led to theestablishment of the Advisory Committeeon Rural Health and the ORHP in 1987[18], [19]. It quickly became apparent thatfor most rural areas, significant health dis-parities existed; rural health risks wereconsiderably higher urban health risks.Although some aspects of rural health dis-parities are the result of inadequate fed-

eral and state policies, many factors areindependent of legislative intervention.Healthcare access and health behaviorsare influenced by governmental policiesbut are also influenced by individual, so-cial, geographical, and climatological fac-tors [1]. Two areas in which the federalgovernment has sought to intervene arearound rural hospitals and provider re-cruitment and retention.

Critical Access HospitalsIn 1996, rural hospitals accounted for

over half of all hospitals, 2,226 of the na-tion’s 5,134 hospitals. During the 1980s,rural hospitals, heavily dependent on fed-eral reimbursem*nt due to disproportion-ate numbers of Medicare patients, facedsevere financial crises and closed at therate of 30 per year [20]. To stem the tide of


Census Year







General Population

Rural Population

*Urban Percent Surpassed Rural















1. United States general and rural population, 1780-2000.



Frontier County 0-7.00 People Per Sq. Mi.

Rural County, 7.01-6,694 People Per Sq. Mi.,No City of 50,000 or MoreCounty Population < 100,000

City 40,000 to 124,999 (1990Census, 2000 not Available)

City 125,000 to 750,000

City 750,000 and Larger

2. Urban, rural, and frontier areas of the United States using combined definitionsfrom the OBM and Census.

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hospital closures, The Balanced BudgetAct of 1997 (Public Law 105-33) estab-lished the Medicare Rural Hospital Flexi-bility Program (RHFP) for rural hospitals.This program allowed small but region-

ally significant hospitals to apply for Crit-ical Access Hospital (CAH) status. CAHstatus allows for cost-based reimburse-ment under Medicare and encourageshealth network development. Most hospi-tals that have gained the CAH designationare sole community hospitals, located inisolated areas and deemed essential to thecommunity. The CAH program hashelped, but most rural hospitals operate atvery small profit margins. As a rule,cost-based reimbursem*nt allows hospi-tals to pass on most costs, yet prospectivepayment or capitation makes viabilitynearly impossible in areas with small pop-ulation. Thus, the CAH program may ac-tually hinder expansion of services andmakes it difficult to tolerate the ever-growing costs of healthcare.

Recruitment and Retentionof Health Professionals

Recruiting healthcare professionals torural and frontier areas is also a challenge.Health professionals may be hesitant tochoose rural locations due to heavy work-loads, reduced professional quality of life,and lower incomes. Even when profes-sionals are successfully recruited, theymay not stay long due to the professionalhardships that they face in rural and fron-tier practice. The problems run the gamutfrom simple to complex. At the simpleend, there are not enough professionalsavailable to meet the workload demands.Rural and frontier regions have fewerphysicians per 100,000 people than do ur-ban areas. In rural and frontier areas theratio of provider-to-patient is 30-68/100,000 compared to an urban 180/100,000 [21]. There are no clear estimatesof how many health professionals are

needed, but there are shortages in everystate, and these shortages are usually asso-ciated with geographic regions [22]. Ruralproviders usually work for less moneythan their urban counterparts, making it

harder for them to pay off student loans.Rural and frontier providers work morehours and see more patients than their ur-ban counterparts. Rural providers havefewer opportunities for vacation and evenless continuing education [23]. All ofthese challenges can translate into in-creased risk for medical error and for thenegative effects of caregiving such asburnout and compassion fatigue [24].

Rural residents, both providers and pa-tients, have lower overall incomes thanthose living in urban areas. Rural areas aremore likely than urban or suburban areasto experience economic hardship andpoverty [25]. Moreover, when comparedto their urban counterparts, rural and fron-tier areas generally have less infrastruc-ture [26], including telehealth technologythat can support increased quality of care[27]. Poverty is a strong demographic cor-relate of poor overall health, includingmental [28] and oral health [29]. Ruralresidents are more likely than their urbancounterparts to work in high-risk occupa-tions such as farming, mining, and manu-facturing. Due to the types of occupationsin rural areas, exposure to some types ofextremely stressful events that can lead toboth physical and psychological trauma ishigher than in urban areas. For example,injury-related death rates are 40% higherin rural populations than in urban popula-tions [30].

DisastersThere are a number of types of disas-

ters. While classifying disasters is conve-nient for planning purposes, classificationof disasters brings with it limitations. Notonly does the classification process limitthe ability to describe fully any particular

disaster, it has consequences for respond-ing to those who may find themselves inits path. For example, disaster planningspecifies that certain types of services areneeded for this or that type of event. In ad-dition, because exposure to an extremelystressful event is required as an etiologicfactor in the diagnosis of medically signif-icant psychiatric human reactions to thatexposure, the type of event may play a rolein whether or not someone receivesneeded medical care following an event.In this section, a general survey of types ofdisasters will be presented, followed by abrief discussion of the types of reactionsthat may follow exposure to extremelystressful events.

Types of DisastersStorms

Hurricane season runs June throughNovember and sees an increased numberof gales, tropical storms, and hurricanes.While costal areas are the most directly af-fected by these storms, inland and coastalflooding may occur. Tornadoes and se-vere thunderstorms are most common inearly spring and fall and are characterizedby violent and destructive winds as well ashail, flooding, and lighting strikes. Flashflooding, which is the rapid accumulationof storm water, is increasingly of concerndue to the build up of homes and busi-nesses in flood-prone areas. Winterstorms are characterized by freezing rain,sleet, or snow, accompanied by below-freezing temperatures. Icy roads pose par-ticularly dangerous threats to populationsunprepared for them. Power outages maybe caused by falling trees, high winds, orfrozen lines. While it is unlikely that a ter-rorist attack will take the form of a storm,all types of storms increase the degree ofdifficulty in responding to mass casualty,particularly in rural areas where there maybe few workers trying to provide coverageover large areas.

EarthquakesEarthquakes are vibrations associated

with shifting subsurface materials or geo-thermal events. They may result in groundshaking, surface faulting (movement ofsurface fractures), the liquefaction of soils(ground failures), land slides, and suddenmassive waves called tsunamis. Likestorms, earthquakes are not likely to becaused by terrorists, but terrorists couldtake advantage of the infrastructure insta-bility following an earthquake.


Due to the types of occupations in ruralareas, exposure to some types of extremelystressful events that can lead to both physicaland psychological trauma is higher thanin urban areas.

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Transportation AccidentsMotor vehicle accidents, or MVAs, are

the single most common extremely stress-ful event experienced by U.S. citizens[31]. Mass transportation accidents suchas rail or multivehicle accidents not onlyhave the potential of causing loss of lifebut hazardous materials may be releasedand there may be major disruptions oftransportation routes. Air transportationdisaster events can occur anywhere, butthey are particularly likely to over-whelm local emergency medical re-sources in smaller rural and frontiercommunities with fewer resources. Asevidenced by the events of September11, transportation disasters are amenableto terrorism.

Nuclear/Hazardous Chemical AccidentsNuclear accidents can involve the re-

lease of radioactive fallout from a fixednuclear facility or from a nuclear weapon.Hazardous chemical releases, as notedabove, may be intentional or accidentaland can result from the storage, use, andtransportation of materials that are haz-ardous. These events may precipitatequick evacuations of proscribed, butsometimes very large, geographic areas.Some releases are accompanied by explo-sions and fires, while others are not visiblebut nonetheless present. These types ofevents are stereotypically the most com-mon targets of terrorists.

FiresThere are two main types of fires, for-

est/wild fires and urban fires. Althoughmany fires begin due to natural phenom-enon (e.g., lightening from dry thunder-storms) or accidents (e.g., old wiring inbuildings), some fires are the result of in-tentional human action. Wildfires havebeen the focus of a large amount of U.S.resources in the past few years due todrought conditions in multiple areas ofthe country. In addition, as the rural mar-gin is expanded and more people moveinto semi-urban areas, the risks for envi-ronment-human clashes increase. Urbanfires are particularly dangerous in multi-story structures or in areas where thereare adjacent buildings that may ignitefrom each other. Because fires can easilyinvolve human agency, they are amena-ble to manipulation by terrorists. As withstorms and earthquakes, the resulting in-stability could be used to the advantageof terrorists.

Civil Disorder/RiotsDemocracy provides venues for

peaceful assembly, but enthusiasm, zeal,and at times malice, can fuel assembliesinto chaos. Many civil-disorder eventswere precipitated by changes in economic

or political structures or controversialevents or court cases. The resultant chaoscan cause anxiety and stress even for thosenot directly affected. When events of civildisorder or riots occur in rural and frontierareas, they tend to galvanize the countryand challenge the belief of rural pastoralsociety. Stand-offs between isolationistsliving in compounds and federal law offi-cials have provided ample evidence of thelevel of commitment of those who areactants in these systems and the astound-ing amount of destruction that can resultwhen officials challenge belief-based de-cisions on the part of those who belong tothe groups in question.

Bomb Threats/Terrorist AttacksLike civil disturbances and riots, bomb

threats are associated with human action.

Human-made disasters seem to have moredevastating psychological affects than donaturally occurring events [32], perhapsbecause of the betrayal of trust [33]. Bombthreats are more likely to refer to a specificidentifiable area in contrast to terrorism,

which depends, in large part, on an unspec-ified amorphous threat to be effective.

Human Reaction to Extreme StressHuman beings can react to extreme

stress in many ways. Some who experienceextremely stressful events will be strength-ened by their ability to overcome obstaclesassociated with the event. Others maydecompensate dramatically as a result ofexposure. Still others may have no reactionat all, usually because they do not perceivethe event to be threatening. None of thesereactions are uncommon in the face of ex-posure to extremely stressful events.

The cardinal pathological reaction toextreme stress is post-traumatic stressdisorder. This diagnosis requires that aperson be exposed directly or indirectlyto a life-threatening event (Criterion A1)


Urban CountyAirports, = 287


Rural CountyAirports, = 105


Frontier CountyAirports, = 36


3. Distribution of airports by urban, rural, and frontier counties.

National plans should address the increasedcosts of operating in rural areas and theincreased burdens placed on most healthand safety workers who work longer hoursand take fewer days off.

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and that they react with “intense fear,helplessness, or horror” (Criterion A2).Three categories of symptoms also exist,intrusive thoughts and images of theevent (B criterion), avoidance of theevent or reminders of the event (C crite-

rion), and physiological arousal associ-ated with event-related biochemicalchanges (D criterion) [34]. Other reac-tions may include depression or a rangeof physical symptoms including gastro-intestinal distress.

As will be discussed below, personswho help those in harm’s way may alsoexperience symptoms similar to the pri-mary victim. This can even happen to vol-unteer lay helpers [35].

Rural Areas asPotential Terrorist Targets

Policy generally focuses on getting thegreatest amount of service to the mostpeople with the least burden on the sys-tem. Consequently, most policy focuseson the 220 million who live in the urbanareas of the United States. Yet, post-Sep-tember 11, we have reconsidered the secu-

rity risks of the country with an eye to-ward terrorism and bioterrorism. From astrategic standpoint, rural areas are espe-cially vulnerable to terrorist attacks andmay represent substantial threats to thecountry’s security as a whole. National

energy or nuclear sites, such as LosAlamos in New Mexico or Idaho NationalEngineering and Environmental Labora-tory (INEEL), were intentionally locatedaway from urban centers. Factories thatmanufacture or use hazardous materialsare over-represented in rural areas com-pared to urban areas. Rural areas are theorigins of most food and water; contami-nation could easily spread from thousandsto millions of people as water and food aretransported into our cities. Additionally,much of the country’s power sources arein rural areas (or at least pass through suchregions) and provide the opportunity tocreate mass urban chaos by disruption ofthe power grid. Each of these risks will bediscussed in the following section.

Airports and Flight SecurityThere are 428 commercial airports

that were considered in the 2000 Census

(see Figure 3). Of these, 287 (67%) werelocated in urban counties. The balanceare located in rural or frontier counties,with 105 (24.5%) in rural counties and 36(8.4%) in frontier counties. The newTransportation Security Administration(TSA, www.tsa.dot.gov) is responsiblefor civil aviation security. By November19, 2002, they will deploy federal pas-senger screeners and by December 31,2002, federal baggage screeners to the428 plus one new commercial airport,bringing the total to 429. All airports areheld to the same federal security stan-dards and host official government in-spectors at regular intervals. There are,however, some unique aspects to airportsin more remote, low-density locations.Rural airports often have different oper-ating patterns than do large-volume com-mercial airports. One of the most salientaspects of low-volume airports is thatthey may be open only for flights andclose their operations between scheduledflights. Additionally, while security per-sonnel will be federalized by the end of2002, employees of low-volume airportswho handle other aspects of the flightsmay be called upon to complete multipletasks, including passenger check-in, bag-gage handling, marshaling the airplane(on-ground flight direction), and otheraspects of staffing airline operations. Airtraffic control, like security, is generallycovered under federal regulations, butthere are airports with regularly sched-uled flights that have no air traffic con-trollers and require pilots to visuallylocate and assess the weather and trafficconditions prior to landing or take off.

Because September 11 focused on theair transportation, regulations and securitymeasures in commercial airports have re-ceived a great deal of attention and are thusless subject to security breaches than othertypes of facilities. However, in addition tothe 428 commercial airports monitored bythe federal government, there are scores ofprivate airports and grass landing stripsthat may or may not be catalogued on mapsor other public resources. These smallstrips are especially prevalent in rural areasdue to the use of crop dusters in farming.These airstrips could be used as a stagingground in that many are in isolated loca-tions where take offs and landings may notbe noticed by anyone. In particular, con-cerns have been raised about crop dusterswho conceivably could over-fly cities orwater sources and drop contaminants.




Frontier County 0-7.00 People Per Sq. Mi.


Rural County, 7.01-6,694 People Per Sq. Mi.,No City of 50,000 or MoreCounty Population < 100,000

City 40,000 to 124,999 (1990Census, 2000 not Available)

City 125,000 to 750,000

City 750,000 and Larger

4. Location of airports by urban, rural, and frontier location.

Factories that manufacture or usehazardous materials are over-represented inrural areas compared to urban areas.

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Hazardous Materials: Chemicals,Industry, and Biohazards

It is impossible to ascertain the amountof hazardous materials that is produced ormanufactured in rural areas and whichcould be used in harmful ways in terroristactivities. Factories and plants may con-tain or use hazardous materials as toolsfor production or as the consumer prod-uct(s) of the facility. Manufacturingand chemical plants are commonly lo-cated in rural areas due to lower costs,fewer regulations, and in some cases,due to the lack of objection to the facilitieson the part of local residents. Because ru-ral and frontier economies are so fragile,many communities are willing to offersubstantial benefits to companies as in-ducements to locate in their community.At least anecdotally, community mem-bers seeking economic sustainability aremore tolerant of the negative effects offactories and plants than their urban coun-terparts. Regardless of the reasons, thereare a great number of industrial facilitiesin rural areas. In rural and frontier areas,manufacturing accounted for 21% percentof total rural earnings in 1999, comparedwith 15% percent in urban areas [36].

All of these facilities pose potential se-curity threats. For example, in Wisconsin,there are 450 to 500 chemical companiesstatewide. According to the Wisconsin De-partment of Natural Resources, the fivelargest chemical facilities in the state gen-erate approximately 33 million pounds of

hazardous waste annually with the remain-ing companies generating approximately16 million pounds annually (WisconsinDepartment of Natural Resources,www.dnr.state.wi.us). Industry is not the

only source of chemical security hazards.Chemicals used for farming and gardeningalone translate into the fact that nearly ev-ery county in United States has the raw ma-terials for some type of nefarious activity.Even in rural communities without manu-facturing facilities, there are large stores ofchemicals kept for farming uses.

In an attempt to provide guidance for its1,700 member facilities, the AmericanChemistry Council (www.american chem-istry.com) has produced post-September11 guidelines with the purpose of helping“protect people, property, products, pro-cesses, information and information sys-tems by enhancing security, includingsecurity against potential terrorist attack,throughout the chemical industry valuechain” [37]. This document does not spe-cifically mention rural and frontier facili-ties, but due to its aspirational nature, it

could apply equally to rural and urban fa-cilities. Even with its high goals, somequestion its sufficiency as compliance isvoluntary and monitoring is from withinindustry sources [38].

There are endless numbers of bio-hazards, both naturally occurring and cre-ated, that can be found in rural areas.Traditionally, rural biohazards have beenassociated with farming practices that in-clude the destruction of protective naturalhabitats by clearing land for crops or graz-ing, poorly managed irrigation, or inappro-priate applications of chemical nutrientsthat contaminate streams or water sources.Other biohazards may be associated withthe healthcare industry or with the foodprocessing industry such as meat packingplants. Moreover, an astonishing numberof Superfund National Priorities List(NPL) sites are located in rural areas andrepresent concentrations of hazardouswaste from mining and disposal activities.

What makes all of these hazards differ-ent in rural areas is the ability to respondto and neutralize them. There are few





















































Farm Acres Total Acres

Alaska 365,039,360Total Acres Texas 167,624,960

Total Acres



5. Total acres and farm acres by state.

Food distribution systems nearly guaranteethat any contamination will be distributedacross the county, not contained locally.

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teams trained in managing hazardous ma-terials (HAZMAT teams). They are mostoften located in cities, where the sheernumber of people makes it probabilisticallymore likely that they will be needed. Insome rural areas, a number of communi-ties spread out over a large distance shareone HAZMAT team. Thus, rural and fron-tier first responders may have little or notraining in HAZMAT containment. Se-curing the area and minimizing the con-tamination of place and people can be afrightening challenge while literally wait-ing for hours until a full-scale hazmat

team can be transported to the site. In ad-dition, the lack of decontamination facili-ties at small hospitals may make itnecessary to import field decontaminationunits. If there are many people involved inthe incident, there may not be enoughmedical personnel or facility space to ac-commodate those who are injured. Diffi-cult geography and climate can lengthenthe wait time. Even after the arrival of out-side assistance, cultural differences be-tween local public safety units, many ofwhom are volunteers, and the profession-als who have arrived on the scene to man-

age the situation may cause strife and con-fusion.

Food and FarmingAs noted above, the United States has

an agrarian heritage but a current urbanexistence. Interestingly, although 80% ofthe population lives in an urbanized area,41% of the land in the United States is stillclassified as farm and grazing land. Figure5 shows the total acres and farm acres perstate, Figure 6 shows the percentage offarm acres per state, and Figure 7 showsthe distribution of states across quartilesof percentage in farmland. Regardless ofhow the data are examined, it is clear thatevery state, including Alaska, whichshows at 0% due to its overall massivesize, has a relationship with farming andfood production. Urban areas cannot pro-duce enough food to support their popula-tions and are symbiotically dependent onrural farming areas.

In the first weeks post-September 11,concerns were raised in relation to thesafety of the food supply. One responseto this concern was the founding of theFood Security Alliance. This group,working through the U.S. Food and DrugAdministration (FDA) issued the “FoodSecurity Guidance” [39]. The focus ofthis document is on preventive measuresthat can be taken to minimize the risk tofood of tampering, criminal, or terrorist

























































6. Percent of farm to total acres by state.

States 75-100%Farmland

= 8,16%n

States 50-74%Farmland= 7, 14%n

States 0-24%Farmland= 12, 24%n

States 25-49%Farmland= 20, 40%n

7. Number of states in each quartile of percentage farmland.

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actions. The document takes a “farm-to-table” approach and includes farms,aquaculture facilities, fishing vessels,producers, transportation operations,processing facilities, packing facilities,warehouses, and retail and food-serviceestablishments. Concerns about contam-ination of the nation’s food source arestill present but at a lesser level than inthe initial days following September 11.The FDA has responded with additionalinspections and monitors as well as in-creasing the FDA’s oversight of food incase of emergency.

As with biohazards, there may be lim-ited response capacity to food emergen-cies in rural areas. Furthermore, manyfarm products are harvested and immedi-ately shipped to distant locations aroundthe country or the world without beingconsumed locally. This leads to two con-cerns. First, food may be distributed be-fore anyone is aware that there areproblems. Second, because agriculturehas begun to specialize (e.g. Californiaraisins, Florida oranges), food from a sin-gle farm may be shipped to nearly everymarket in the country. Food distributionsystems nearly guarantee that any con-tamination will be distributed across thecounty, not contained locally.

Water SuppliesUrban areas generally cannot support

their population’s need for water anybetter than they can support the need forfood. They are reliant on rural and frontierareas for water, with the source some-times thousands of miles distant. It is dif-ficult to pinpoint the sources of water forthe general population, although approxi-mately 80% of the U.S. gets water fromone of 4,500 water utilities (www.awwwa. rg). Figure 8 shows the locationsof dams in the United States, at best aproxy measure of the locations of reser-voirs and controlled water sources.

Water sources can be grossly classi-fied into two sources: surface water andsubsurface water or aquifers. The risk tocontamination of subsurface water islikely greater from slow leaching that maybe associated with industry or an ecologi-cal imbalance than it is from terrorism.Even water-borne biological contami-nants are few when viewed against thebase rate. According to the Centers forDisease Control and Prevention, therewere 13 states that reported 17 outbreaksassociated with drinking water from 1997to 1998. From these 17 outbreaks, approx-

imately 2,038 people become ill, but nonedied from the contaminations [40]. Figure9 shows the pattern of outbreaks of wa-ter-borne diseases (n=691) recorded1971-1998.

The contamination risk of surface wa-ter is also small when one considers thedilution aspects of water; that is, a largeamount of the contaminant is needed topollute a population’s water source.However, many cities get their waterfrom rural reservoirs or watersheds.These surface water sources are often re-mote with little human activity around

them. It is possible that hours, or evendays, of terrorism effort could be sus-tained before anyone discovered the ac-tivity, making it possible to transportsufficient contaminants to affect a water-shed or reservoir.

Title IV of the Public Health Securityand Bioterrorism Preparedness and Re-sponse Act (H.R. 3448) requires waterutilities to complete a vulnerability assess-ment if they serve more than 3,300 people.The review includes assessment of pipesand constructed conveyances, physicalbarriers, water collection, pretreatment,


Frontier County 0-7.00 People Per Sq. Mi.

Rural County, 7.01-6,694 People Per Sq. Mi.,No City of 50,000 or MoreCounty Population < 100,000

City 40,000 to 124,999 (1990Census, 2000 not Available)

City 125,000 to 750,000

City 750,000 and Larger



8. Location of dams in the United States.

9. Number of waterborne-disease outbreaks associated with drinking water by yearand etiologic agent—United States, 1971-1998 (I=691).

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treatment, and storage and distribution fa-cilities. It is unclear as to whether or not theassessment will routinely look “upstream”to the rural and frontier areas from whichthe water originates.

PowerNuclear power plants have long been a

source of security concern. Post-Septem-ber 11, other sources of electrical power

are also being considered as possible tar-gets of terrorism, with widespread loss ofelectrical power through massive outagesbeing the most likely outcome of terroristactivities. This could lead to equally wide-spread chaos and inability to provide cru-cial services in both urban and rural areas.

Nuclear power plants, like other haz-ardous materials facilities, have oftenbeen sited near, but not in, urban areas.These plants experience some of thesame gain that industry does in that theyoffer rural communities the prospect ofeconomic stability. Nuclear powerplants have elaborate security plans, butthose located in rural areas must strug-

gle with the reduced infrastructure forresponding to a nuclear crisis. More-over, nuclear plants that are located inisolated areas must transport nuclearfuel or waste material across long dis-tances of uninhabited land, which maybe ripe for attack.

Non-nuclear power, including coal,water, wind and other means, is often pro-duced and shipped great distances. Mas-

sive power lines crisscross the UnitedStates. Sometimes power produced lo-cally is not used there but shipped statesaway. One such example is the FooteCreek Rim wind project in Wyoming.This wind-based electricity production lo-cation produces an average output of 17.8MW, which is enough to power12,000-25,000 families [41]. The power issold across the Pacific Northwest. Facil-ities such as these, which ship poweracross sparsely populated avenues, mustdeal with the possibility of the power be-ing disrupted prior to arriving at its urbandestination. Most cities cannot survivesafely without electricity.

Rural Preparedness for MassCasualty and Terrorism

Disaster ResponseAs noted in the first section, the

healthcare response capacity in rural areasis seriously limited by both the size andfragility of its hospitals and the serioushealth professions shortages. Tradi-tionally, a state’s offices of disaster ser-vices, working in collaboration with theFederal Emergency Management Agency(FEMA), the Red Cross, and the state’sDepartment of the Military (DOM), havebeen the cornerstones of disaster re-sponses. Although some provisions aremade for rural and frontier areas, mostplans conceptualize “mass casualty” in re-lation to large populations. The fear of anyemergency command and control centeris the need to quickly evacuate a city andattend to the health and daily living needsof large numbers of people, as with Hurri-cane Andrew [42] or the Loma Preietaearthquake [43]. However, there arewell-known disasters that have occurredin rural and frontier areas such as BuffaloCreek Dam [44], [45], and the Teton Damdisaster [46]. Both Buffalo Creek andTeton Dam highlighted the unique atten-dant difficulties of responding to low pop-ulation density, geographically remote,and low infrastructure areas.

While most communities are reassess-ing their preparedness, particularly forterrorism, rural communities seem partic-ularly vulnerable [47]. To compound thedifficulties in planning, very little litera-ture exists on mass casualty or disasterpreparedness and rural or frontier areas.There is a 1979 manual for responding todisasters in rural areas, but it does not takeinto consideration over two decades of ex-cellent research in trauma responding[48]. FEMA has no specific guidelines forrural and frontier communities. The cur-rent Federal Response Plan as requiredby Public Law 93-288 and amended byPublic Law 100-707, re-titled as the Rob-ert T. Stafford Disaster Relief and Emer-gency Assistance Act (Public Law93-288, as amended), has a special sectionon urban responding, but it only mentionsrural in the context of wildfires and pro-tection of public utilities.

Recent studies have suggested thateven existing resources may not be wellused due to lack of planning and training[49], [50]. Low infrastructure disaster re-sponses cost more per person cared for,have poorer outcomes, and have longer




Frontier County 0-7.00 People Per Sq. Mi.

Rural County, 7.01-6,694 People Per Sq. Mi.,No City of 50,000 or MoreCounty Population < 100,000

City 40,000 to 124,999 (1990Census, 2000 not Available)

City 125,000 to 750,000

City 750,000 and Larger

Nuclear Plants

10. Location of nuclear power plants by urban, rural, and frontier location.

The stresses that rural health and safetypersonnel experience in the course oftheir work are likely higher than thoseof urban areas.

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displacement of residents. Research hasdemonstrated the impact of a commu-nity’s predisaster function as a predictorof successful postdisaster survival. Con-trary to expectations, even though povertywas a strong demographic variable, astrong economy was not as important ascommunication skills [51].

The co*keville, Wyoming, hos-tage/bombing [52], in which a person at-tacked a rural school, provides an exampleof a terrorist event in a rural area and high-lights the need to address both physical andpsychological aspects of crises and thefear that arises from them. Horror sto-ries and research about providing hu-manitarian responses to remote warzones provide a sobering warning ofwhat could occur in remote areas in theUnited States in the event of a terrorist at-tack. Another consequence may be greaterpressure on urban healthcare facilities asthe fragile rural delivery system faltersfrom a disaster. This possibility makes theentire system much less viable. The na-tion’s healthcare delivery system is highlyinterrelated and its operation is contingenton functioning of its disparate parts. Abreakdown in the rural delivery systemwill have a disproportionate effect uponthe already stressed and overburdened ur-ban system.

Risks to RespondersSecondary traumatization of people

who work in “helping professions” is po-tentially a higher risk in rural areas fortwo primary reasons. First, there is agreater workload on the fewer availablehelpers. Second, documents and manualsabout disaster site management weremost likely written with more developedinfrastructure areas in mind [53]. Helpersare called to respond to individual, com-munity, national, and even internationalcrises. Healthcare professionals, socialservice workers, teachers, attorneys, po-lice officers, firefighters, clergy, airlineand other transportation staff, disastersite clean-up crews, and others who offerassistance at the time of the event or latermay be negatively affected by their con-tact with these events [54]-[56]. Helpersare exposed to primary (i.e., direct) andvicarious sources of traumatic stress, andthey may feel a positive effect associatedwith their ability to help [57], [58]. Theymay also feel negative, secondary ef-fects, called vicarious or secondarytrauma. For example, the healthcareworkers who responded to the Omagh

Bomb experienced increases in negativepsychological symptoms, includingpost-traumatic stress disorder (PTSD)[59]. Thirty-five hundred workers weresurveyed four to six months after thebombing. Of the respondents (n=1,235),half reported being involved in the eventin some way. Of those involved, nearlytwo thirds (n=359, 67%) sought profes-sional help and had elevated PTSD

scores as a direct result of the bombing.The study indicated that helping was apractical way to manage one’s distressrelated to the event but that the effects ofthe bombing caused psychological dis-tress of significant proportions. One ofthe most important aspects of this dis-tress was the devastating additive forthose who were directly exposed as a re-sult of personal relationships to victimsand indirectly exposed as a result of theirwork roles in responding to the event.

September 11, 2001, highlighted thepsychological stress of emergency re-sponding. The stresses that rural healthand safety personnel experience in thecourse of their work are likely higher thanthose of urban areas. Caregiving in ex-tremely stressful events that often in-cludes exposure to gruesome or grotesquematerial may have negative conse-quences, which are heightened by the in-tensity of exposure. Because of the fewresponders working in rural areas, thereare not enough workers to provide relief,increasing the amount of time rural re-sponders are exposed to traumatic mate-rial. Moreover, they live in, and respondto, crises in their own communities. Thus,rural health and public safety workers areat risk for increased intensity of exposureand the subsequent potential for experi-encing negative effects of caregiving. Be-cause rural health and safety personnelusually know the people with whom theywork, work longer hours, with fewer re-sources, and go home to the communitythat is effected by the event, they may ex-perience considerably higher risks than

their urban counterparts. When the help-ers are at risk, there is the potential forgreater errors in responding and more riskfor negative outcomes in the resolution ofthe events.

RecommendationsPolicy for the safety of the United

States must include an awareness of theimportance of rural and frontier areas to ur-

ban areas. Water, power, and food are notavailable in sufficient amounts to supporturban areas and are routinely shipped infrom rural areas. National plans should ad-dress the increased costs of operating in ru-ral areas and the increased burdens placedon most health and safety workers whowork longer hours and take fewer days off.Other factors are also important, such asthe status of regional hospitals (e.g. criticalaccess, secondary, tertiary) and the type ofEmergency Medical Service (volunteerversus paid), and the availability ofHAZMAT teams and decontaminationunits. Regional infrastructure plays a part.It can include access to public transporta-tion, highway systems, and the telecom-munications network, as well as basicclimate and geographical considerations,which includes proximity to an MSA thatmay provide resources for responding todisasters and terrorist attacks. Finally, it isimportant to take into consideration thebase population, its median income, andthe region’s status as a health professionsshortage area or otherwise medicallyunderserved area.

Because of the diversity of rural com-munities, policy and plans should becustomizable based on local conditionsand resources. Plans must also considerlocal exposure to routine types of poten-tially traumatic events that form the con-text in which a disaster or bioterroristattack occurs. The types will include anunderstanding of the community’s rou-tine experiences. Health and publicsafety response competencies havelikely developed as a result of the geog-


Strong communities not only take bettercare of their citizens on a day-to-day basis:they are less attractive to terrorists lookingfor system vulnerabilities to exploit.

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raphy, climate, or industry of an area.For example, mountain rescue and ava-lanche control skills are likely to becommon in a rural Idaho community,whereas skills with hazardous materialmanagement for nitrogen are commonin Iowa where nitrogen-containing fer-tilizer is manufactured. In general, ruraland frontier areas function best using in-tegrated care where physical, oral, andmental/behavioral healthcare are woveninto a single fabric supported by the so-cial service, public safety, educational,governmental, and faith-based sectorsof the community [60]. The develop-ment and preservation of this type ofsystem integration is challenged by thelack of infrastructure that plagues ruraland frontier areas. For example, whilethe digital divide has been highlightedas a major infrastructure threat, it is butone of the frailties of the rural physicaland human infrastructure.

The difficulties of sustaining physicalinfrastructure such as transportation,utilities, government, and economies arewell known. A less recognized problemis sustaining the human infrastructure.Medical and healthcare training, in par-ticular, is urbancentric, presuming thatgood care comes exclusively from thetypes of large tertiary care facilities thatcan only be sustained in densely popu-lated areas. These biases, coupled withdifficult recruitment and retention ofhealth professionals, crystallize in thelack of caregiver support. This lack ofsupport threatens patients and providersalike by placing professionals at risk forburnout, secondary traumatization, andmedical error.

Rural communities at best are surviv-ing in frail balance with their urbancounterparts. Their delicate rural envi-ronments, so necessary for the work ofthe city, are ripe for terrorist attack. Rec-ognizing and addressing the needs of ru-ral and frontier communities will benefitall who live in the United States. Regard-less of the type of policy solutions of-fered to address terrorism risks in ruralareas, the final product must be inte-grated across the health, public safety,and economic sectors of the communityand must be respectful of the commu-nity’s strengths. Respecting the contribu-tions to our urban areas of our rural andfrontier areas is the first step. In fact,shoring up the frailties of our rural andfrontier communities serves a greaterpurpose. Strong communities not only

take better care of their citizens on aday-to-day basis, strong communities areless attractive to terrorists looking forsystem vulnerabilities to exploit.

AcknowledgmentsI wish to thank Heather C. Conley,

Ph.D., for her persistence in producing theGIS maps used to illustrate this article;Kelly Davis for her assistance in editingthe manuscript; and the staff at thePocatello Regional Airport for helping meunderstand the post-September 11changes in the air transportation systemand for so often seeing me safely into theair and back home again.

B. Hudnall Stamm, edu-cated in psychology andstatistics at Appala-chian State University(B.S., M.A.) and theUniversity of Wyoming(Ph.D.), is a researchprofessor, the directorof Telehealth, and dep-

uty director of the Idaho State UniversityInstitute of Rural Health. Her previous ap-pointments include the VA National Cen-ter for Posttraumatic Stress Disorder,Dartmouth Medical School, and Univer-sity of Alaska, Anchorage. Working pri-marily with rural underserved peoples,Stamm’s efforts focus on health policy,cultural trauma, and work-related trau-matic stress. Her books include Measure-ment of Stress, Trauma and Adaptation(1995, Sidran Press); Cultural Issues andthe Treatment of Trauma and Loss (withNader and Dubrow, 1999, Brunner/Ma-zel); Secondary Traumatic Stress(1995/1999, Sidran Press), and the forth-coming Rural Behavioral Healthcare(APA Books). Her work is used in over 22countries and diverse fields includinghealthcare, disaster responding, news me-dia, and the military. She lives with herhistorian spouse in a log cabin in themountains of Idaho. See www.isu.edu/~bhstamm and www.isu.edu/irh for moreinformation.

Address for Correspondence: B.Hudnall Stamm, Campus Box 8174, Insti-tute of Rural Health, Idaho State Univer-sity, Pocatello, ID 83209. Tel: +1 208282.4436. E-mail: [emailprotected].

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What are the 4 P's of preventing terrorism? ›

Pursue: to stop terrorist attacks. Prevent: to stop people becoming terrorists or supporting terrorism. Protect: to strengthen our protection against a terrorist attack. Prepare: to mitigate the impact of a terrorist attack.

What are the 4 types of terrorism? ›

Wilkinson has defined four types of terrorism: criminal, psychic, war, and political. One of the aims of terrorism is to provoke the authorities into using illegal, unconstitutional, and repressive measures and thereby to lose public support.

What are the five components of terrorism? ›

There are five crucial components of terrorism, an involvement of an act of violence, an audience, the creation of a mood of fear, innocent victims, and political goals or motives.

What are the five major hazards associated with terrorism? ›

  • BIOLOGICAL THREATS. Biological agents are organisms or toxins that can kill or incapacitate people, livestock and crops. ...
  • CHEMICAL THREATS. Chemical agents are poisonous vapors, aerosols, liquids and solids that have toxic effects on people, animals or plants. ...

What are the three elements of terrorism? ›

This customary rule requires the following three key elements: (i) the perpetration of a criminal act (such as murder, kidnapping, hostage-taking, arson, and so on), or threatening such an act; (ii) the intent to spread fear among the population (which would generally entail the creation of public danger) or directly ...

What are the three factors of terrorism? ›

Perceived injustice, need for identity and need for belonging are common vulnerabilities among potential terrorists. Mental illness is not a critical factor in explaining terrorist behavior. Also, most terrorists are not “psychopaths.”

What are the different types of terrorism in PDF? ›

Accepted typologies include the following: The New Terrorism, state terrorism, dissident terrorism, religious terrorism, ideological terrorism, and international terrorism. Sub-classifications of accepted typologies include nationalist terrorism, ethno-national terrorism, and racial terrorism.

What are the two general types of terrorism? ›

The Federal Bureau of Investigation (FBI) categorizes terrorism in the United States as one of two types - domestic terrorism or international terrorism. Domestic terrorism involves groups or individuals whose terrorist activities are directed at elements of our government or population without foreign direction.

What are the six categories of acts of terrorism? ›

Acts of terrorism include threats of terrorism; assassinations; kidnappings; hijack- ings; bomb scares and bombings; cyber attacks (computer-based); and the use of chemical, biological, nuclear and radiological weapons.

What are the 7 signs of terrorism? ›

Seven Signs:
  • Surveillance.
  • Information Gathering.
  • Testing Security.
  • Planning.
  • Suspicious Behavior.
  • Rehearsal.
  • Getting into Position.

What are risk factors for terrorism? ›

However, there are some risk factors which are unique to terrorism, such as endorsem*nt of extremist ideologies and justification of terrorism (Dhumad et al., 2020; Al-Amery et al., 2011) reported that terrorists were more likely to come from a stable family background and less likely to be subjected to psychosocial ...

What is the current threat level in the US? ›

The United States Homeland Security Advisory System Threat Level is currently at yellow ("elevated"), indicating a "significant risk of terrorist attacks".

What is a key element of terrorism? ›

Use of violence. • The perpetration of a criminal act (such as murder, kidnapping or hostage-taking) is a key element of terrorism.

What are the 8 types of terrorism? ›

Sub-state terrorism
  • Social revolutionary terrorism.
  • Nationalist-separatist terrorism.
  • Religious extremist terrorism. Religious fundamentalist Terrorism. New religions terrorism.
  • Right-wing terrorism.
  • Left-wing terrorism. Communist terrorism.

What are the 8 signs of terrorism cert? ›

8 Signs of Terrorism
  • Surveillance. Someone recording or monitoring activities. ...
  • Elicitation. People or organizations attempting to gain information about military operations, capabilities, or people. ...
  • Tests of Security. ...
  • Acquiring Supplies. ...
  • Suspicious Persons Out of Place. ...
  • Dry Run/Trial Run. ...
  • Deploying Assets. ...
  • Funding.

What are the 4 elements of counter terrorism strategy? ›

It's based on 4 themes:
  • prevent: to stop people becoming terrorists or supporting terrorism.
  • pursue: to stop terrorist attacks happening.
  • protect: to strengthen our protection against a terrorist attack.
  • prepare: to minimise the impact of a terrorist attack.
Jul 18, 2023

What do the 4 P's stand for safety? ›

“Safe to Operate” refers to the as-designed safety for places, property/materiel, people and processes/procedures.

What are the 4 P's in security? ›

In general, Information Security professionals suggest that protecting sensitive data requires a combination of people, processes, polices, and technologies.

What are the ways to prevent terrorism? ›

You can help reduce the chance of a terrorist attack by keeping an eye out for suspicious situations and reporting a suspicious situation if you see one.
  • Be vigilant. ...
  • Emergency number. ...
  • Reporting suspicious situations that are not an emergency.

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Author: Cheryll Lueilwitz

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Name: Cheryll Lueilwitz

Birthday: 1997-12-23

Address: 4653 O'Kon Hill, Lake Juanstad, AR 65469

Phone: +494124489301

Job: Marketing Representative

Hobby: Reading, Ice skating, Foraging, BASE jumping, Hiking, Skateboarding, Kayaking

Introduction: My name is Cheryll Lueilwitz, I am a sparkling, clean, super, lucky, joyous, outstanding, lucky person who loves writing and wants to share my knowledge and understanding with you.