strategies for regional coalitions, and the role of alternative care systems in cases when traditional surge capacity is exhausted. From this work, the HPA has developed numerous materials for local communities that address the needs of special populations (e.g., pediatrics), concerns of individual provider groups (e.g., primary care physicians and emergency responders), and integrated communications and information sharing strategies (CDC, 2009a). Thus, building trust among MCI responders is the work of local, regional, state, and federal efforts.

Native American Reservations: Coordination and Collaboration Overcome Amplified Obstacles

The National Highway Traffic Safety Administration (NHTSA) has rated the county around Window Rock and Fort Defiance, Arizona, as having the highest rate of single vehicle rollover accidents in the nation. Working the night shift in a small hospital on the reservation, with one nurse and one technician, it takes very few victims to overwhelm the system, notes Glenn Mitchell, especially when someone has to drive 15 miles to wake up the surgeon and bring them back to the hospital. Though currently chief medical officer of the Sisters of Mercy Health System, with hospitals in Arkansas, Oklahoma, Kansas, and Missouri, Mitchell speaks from experience with the Indian Health Service at Fort Defiance, Arizona.

Mitchell explained that the basic problems of responding to causalities in a rural environment are compounded on a reservation. The largest area in the United States without cell phone coverage is the Navajo reservation in Northern Arizona. Tribal boundaries, law enforcement jurisdictions on and off the reservation, difficulties between tribal and federal officials, and a lack of adequate resources for any EMS-related planning, education, or even daily mission execution plague reservation communities. Native American reservations are also home to amplified societal problems like pervasive alcoholism, diabetes, poverty, and the delivery of inadequate medical care.

Yet despite these considerable hurdles, Mitchell related how the planning and execution of a mass vaccination/pandemic emergency preparedness exercise employed integration to meet its metrics of success. An intergovernmental, multiagency taskforce convened in Window Rock with the goal of developing a broad mechanism to respond to a pandemic crisis across the 27,000 square miles of the Navaho Nation and adjoining lands in Arizona and New Mexico. Comprehensively inclusive, the planning group was composed of participants from tribal, county, state, and federal agencies; the New Mexico and Arizona state governments; the county governments in the adjoining Apache and McKinley Counties; and nonprofit groups like school boards, public safety agencies, and the Boy Scouts. Inclusion came not only in the form of an invitation to attend, but an opportunity for each



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