Commentary on physical security and emergency preparedness for island hospitals with limited backup capacity.
Commentary on physical security and emergency preparedness for island hospitals with limited backup capacity. Free under Creative Commons Attribution 4.0 — no registration required.
Summary of the paper
"The Hospital at the End of the Road" is an ISPI commentary on security policy for island healthcare facilities, which are both critical infrastructure and a community lifeline. It opens with Maui Memorial Medical Center, the only trauma center on Maui, which was the island's receiving hospital during the August 8, 2023 Lahaina wildfire; patients needing a higher level of care had to be flown to Oahu.
The commentary argues that island hospitals are the end point of every emergency response chain in their community, and that this status creates security and emergency management requirements standard healthcare security frameworks do not adequately address.
What the paper finds
- There is no nearby backup. A continental hospital hit by a security incident can divert and transfer patients through a regional network. An island hospital's alternatives are leaving patients untreated or limited, expensive air transport.
- Continuity is a security objective. Threat assessment for island hospitals has to weight threats to operational continuity differently from frameworks built for hospitals with backup capacity nearby.
What it recommends
- Develop island hospital security frameworks that treat operational continuity as a primary security objective.
- Fund security hardening for sole-provider island hospitals through FEMA and HHS infrastructure grants.
- Develop island hospital security assessment protocols integrating physical security, insider threat, emergency preparedness and supply chain continuity.
Who it's for
Hospital executives, security and emergency management directors, state and territorial health departments, and FEMA and HHS program staff.
This research connects to the 39 Small Island Developing States worldwide through the Samoa Pathway and BPOA+30 framework. Every ISPI research product carries a mandatory SIDS global bridge per the ISPI Research Architecture.
Cite as
Pulley, Warren (2026). The Hospital at the End of the Road: Security Policy for Island Healthcare Facilities That Are Both Critical Infrastructure and Community Lifeline (ISPI CM-12). Island Security Policy Institute, Honolulu. https://ispiglobal.com/papers-landing/cm12-hospital-security https://doi.org/10.5281/zenodo.23449936
BibTeX
@techreport{ispicm122026,
author = {Pulley, Warren},
title = {The Hospital at the End of the Road: Security Policy for Island Healthcare Facilities That Are Both Critical Infrastructure and Community Lifeline},
institution = {Island Security Policy Institute},
address = {Honolulu, HI},
number = {ISPI CM-12},
year = {2026},
url = {https://ispiglobal.com/papers-landing/cm12-hospital-security},
doi = {10.5281/zenodo.23449936}
}Related analysis
AnalysisWhat Is Island Emergency Management? Why Continental Frameworks Don't Apply →AnalysisHow to Implement an Insider Threat Program in a Small Island Organization →AnalysisBehavioral Threat Assessment in Island Communities — Why Cultural Calibration Changes Everything →PaperCM-11 — Diversity and Representation in Island Law Enforcement →PaperCM-13 — Drug Trafficking Networks in the Pacific — 2026 Update →GuideInsider Threat in Island Communities: Research and FAQ →Pulley, Warren. "Hospital Security in Island Communities." Island Security Policy Institute, 2026. https://ispiglobal.com/papers-landing/cm12-hospital-security
