2005 Gulf Coast Hurricanes: The Pubic Health and Medical Response
CRS Report for Congress
2005 Gulf Coast Hurricanes:
The Public Health and Medical Response
Updated January 20, 2006
Sarah A. Lister
Specialist in Public Health and Epidemiology
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress
The Public Health and Medical Response
Hurricane Katrina struck the Gulf Coast in late August 2005, causing
catastrophic wind damage and flooding in several states, and a massive dislocation
of victims across the country. The storm was one of the worst natural disasters in the
nation’s history. Estimates are that more than 1,200 people were killed and about 2
million displaced. Hurricane Rita, which made landfall along the Gulf Coast in late
September 2005, was ultimately less lethal than Katrina, but prompted aggressive
preparedness efforts by governments and citizens shaken by the devastation of the
In response to a series of disasters and terrorist attacks over the past decade, in
particular the terror attacks of 2001, Congress, the Administration, state and local
governments and the private sector have made investments to improve disaster
preparedness and response. New federal authorities and programs to strengthen the
nation’s public health system were introduced in comprehensive legislation in 2002.
Congress also created the Department of Homeland Security (DHS) in 2002 to
provide national leadership for coordinated preparedness and response planning. A
new National Response Plan (NRP), launched by DHS in December 2004, met its
first major test in the response to Hurricane Katrina.
According to the NRP, the Department of Health and Human Services (HHS)
is tasked with coordinating the response of the public health and medical sectors
following a disaster. HHS works with several other agencies to accomplish this
mission, which includes assuring the safety of food, water and environments, treating
the ranks of the ill and injured, and identifying the dead. HHS activities are
coordinated with those of other lead agencies under the overall leadership of DHS.
Congress and others will review the response to Hurricanes Katrina and Rita
with an eye toward assessing how well the NRP worked as an instrument for
coordinated national response, and how well various agencies at the federal, state and
local levels carried out their missions under the plan. Hurricane Katrina dealt some
familiar blows in emergency response. The failure of communication systems, and
subsequent difficulties in coordination, challenged response efforts in this disaster
as with others before it. Hurricane Katrina also pushed some response elements,
such as surge capacity in the healthcare workforce, to their limits. The response to
Hurricane Katrina has also called attention to the matter of disaster planning in
healthcare facilities, and the potential role of health information technology in
expediting the care of displaced persons. Policymakers will no doubt study these
elements of the Katrina response and seek options for continued improvement in
national disaster preparedness and response.
This report discusses the NRP and its components for public health and medical
response, provides information on key response activities carried out by agencies in
HHS and DHS, and discusses certain issues in public health and medical
preparedness that have been raised by the response to the 2005 Gulf Coast hurricanes.
This report will be updated as circumstances warrant.
In troduction ......................................................1
Federal Authorities and Responsibilities................................3
The Stafford Act..............................................3
The National Response Plan.....................................3
Declarations of Public Health Emergencies..........................5
The Public Health Response.........................................7
Public Health Challenges........................................7
Selected HHS Agency Actions...................................8
HHS Office of the Secretary.................................8
Agency for Toxic Substances and Disease Registry...............9
Centers for Disease Control and Prevention.....................9
Food and Drug Administration..............................10
The Medical Response.............................................11
Medical and Healthcare Challenges...............................11
Selected HHS Agency Actions..................................12
Centers for Medicare and Medicaid Services...................12
Health Resources and Services Administration..................12
National Institutes of Health................................13
Substance Abuse and Mental Health Services Administration......13
Department of Homeland Security................................14
National Disaster Medical System............................14
Department of Defense........................................16
Department of Veterans Affairs..................................17
Issues for Congress...............................................17
Coordinated Needs Assessments.................................18
Disaster Planning in Healthcare..................................19
Regulation of Institutions and Services........................20
Community-based Disaster Planning..........................21
Options for Congress......................................23
National Disaster Medical System................................23
Volunteer Health Professionals..................................25
Health Information Technology..................................27
Additional CRS Reports...........................................28
2005 Gulf Coast Hurricanes:
The Public Health and Medical Response
Hurricane Katrina struck the Gulf Coast in late August 2005, causing extensive
wind damage and catastrophic flooding, and leading to Presidential disaster
declarations for Alabama, Florida, Louisiana and Mississippi. The storm was one of
the worst natural disasters in the nation’s history. Hurricane Rita, which made
landfall along the Gulf Coast in late September 2005, was somewhat less severe than
Katrina when it hit. But a few days earlier in the Gulf it had been a powerful
category five hurricane. Government officials and citizens shaken by the devastation
of the earlier storm mounted aggressive preparedness efforts in anticipation of
Hurricane Rita, drawing on lessons learned from Katrina just weeks earlier.
Hurricane Katrina is estimated to have killed more than 1,200 people, and
displaced about 2 million. The death toll continues to be revised, as bodies continue1
to be found, and investigations into the causes of death of others continue. More
than 4,000 persons are still reported missing. The Federal Emergency Management
Agency (FEMA) recently increased its estimate of the number of persons displaced
by Hurricanes Katrina and Rita to about 2 million.2
The logistical hurdles posed by Hurricane Katrina were formidable.
Communications were knocked out in hard-hit areas, which compromised the process
of assessing and prioritizing needs. Physical access was blocked in some areas, and
civil disorder was a problem in some others. Each kept responders from delivering
aid. In some cases, victims were isolated without water and medicines, and hospitals
that had not been evacuated before the hurricane were unable to sustain operations.
Each circumstance required the emergency evacuation of critically ill patients to a
triage center, which then itself became overwhelmed. Federal, state, and local
governments, businesses and corporations, the faith community and other volunteers
all pitched in to speed relief to Katrina’s victims, but keeping all of it coordinated
was a challenge.
Responding to a catastrophe of the scope of Hurricane Katrina requires that a
variety of public health and medical activities be carried out and coordinated. Public
health activities are those that identify, address or prevent health problems in
1 National Oceanic and Atmospheric Administration, National Weather Service, National
Hurricane Center, “ Tropical Cyclone Report, Hurricane Katrina,” Dec. 20, 2005, p. 10 ff.,
2 Spencer S. Hsu, “2 Million Displaced by Storms,” Washington Post, Jan. 13, 2006
populations. Examples include assuring the safety of food and water, preventing the
spread of disease in shelters, evaluating the safety of neighborhoods for rehabitation,
and assuring the health and safety of responders. Medical activities are those that
deliver healthcare services to individuals. Examples include treatment of injuries,
continuity of care for those with chronic illnesses, mental health counseling, and
The medical response to Hurricane Katrina may have posed the greater
challenge. The public health response required the coordination of variety of
agencies, community-based organizations, and private parties at different levels of
government, though these entities had generally worked together in the past. The
medical response, in contrast, required the coordination of a broader mix of federal,
state and local government agencies, private parties and others, with no comparable
recent precedent or experience in such an effort on this scale.
Over the past decade, in response to the Oklahoma City bombing, the terror
attacks of 2001 and several serious natural disasters, Congress and the
Administration created new authorities, structures and plans to assure that
government at all levels can respond well to disasters like Hurricane Katrina. Local
and state governments are to be the first responders in a disaster. When their
resources are overwhelmed, federal assistance is provided under the Robert T.
Stafford Disaster Relief and Emergency Assistance Act (the Stafford Act) and other
authorities. A new National Response Plan (NRP) places the Secretary of Homeland
Security in charge of coordinating the overall federal response. The Secretary of
Health and Human Services (HHS) is in charge of coordinating the federal public
health and medical response during a disaster.
In the wake of Hurricanes Katrina and Rita, Congress is likely to review
response efforts, recent public health preparedness laws and the NRP. While even
the best plan and response may be overwhelmed in a disaster of the scope of
Hurricane Katrina, Congress may nonetheless find opportunities to revisit
management structures, programs and goals in order that national response capability
can be steadily improved.
This report will discuss relevant authorities and response plans that guided the
public health and medical response to the 2005 hurricanes. Given its catastrophic
scope, the response to Hurricane Katrina will be the primary focus of this report, with
reference to the Hurricane Rita response when relevant. The roles and response
activities of selected agencies in HHS and DHS will be discussed. Finally, a number
of policy issues will be discussed. This report will be updated as circumstances
warrant. For a broader discussion of all-hazards public health and medical
preparedness, see CRS Report RL31719, An Overview of the U.S. Public Health
System in the Context of Emergency Preparedness.
Federal Authorities and Responsibilities
The Stafford Act
The Stafford Act authorizes the President to issue major disaster and emergency
declarations, whereupon federal agencies are authorized to provide assistance to
affected states.3 Through executive orders, the President has delegated to the Federal
Emergency Management Agency (FEMA), within DHS, responsibility for
administering the major provisions of the Stafford Act. In calendar year 2005,
President Bush issued 48 major disaster declarations, including those for Alabama,
Florida, Louisiana, and Mississippi for Hurricane Katrina, and for Texas and
Louisiana for Hurricane Rita.4
Activities undertaken under authority of the Stafford Act are provided through
funds appropriated to the Disaster Relief Fund (DRF). Federal assistance supported
by DRF money is used by states, localities, and certain non-profit organizations to
provide mass feeding and shelter, restore damaged or destroyed facilities, clear
debris, and aid individuals and families with uninsured needs, among other activities.
Federal agencies that receive mission assignments from DHS and provide assistance
pursuant to the NRP are also reimbursed through funds appropriated to the DRF. In
addition to the FEMA assistance authorized by the Stafford Act, a wide range of aid
is provided by other federal agencies under their general statutory authority.
The National Response Plan
The National Response Plan (NRP) is the framework under which federal and
voluntary agencies are instructed to operate when a disaster occurs.5 The NRP was
released by DHS in December 2004, replacing the previous Federal Response Plan.
The NRP is an administrative plan and does not establish new federal authorities. In
general, federal responsibilities in the plan are intended to assist state and local
authorities, not to replace them.
According to the NRP, which is under the overall coordination of the Secretary
of Homeland Security, the Secretary of HHS is tasked with Emergency Support
Function (ESF) #8, the coordination of public health and medical services, as laid out
in the plan’s ESF#8 annex.6 HHS is responsible for coordinating the following
3 42 U.S.C. §5121 et seq, available at [http://www.fema.gov/library/stafact.shtm]. Also see
CRS Report RL33053, Federal Stafford Act Disaster Assistance: Presidential Declarations,
Eligible Activities, and Funding, by Keith Bea.
4 For a list of federal disaster declarations, see [http://www.fema.gov/news/disasters.fema].
5 See CRS Report RL32803, The National Preparedness System: Issues in the 109th
Congress, by Keith Bea.
6 Department of Homeland Security, National Response Plan, Dec. 2004, (hereafter called
the NRP), Annex ESF#8, at [http://www.dhs.gov/interweb/assetlibrary/NRP_FullText.pdf].
See also HHS, “HHS Maintains Lead Federal Role for Emergency Public Health and
Medical Response,” press release, Jan. 6, 2005.
activities under ESF#8, and may request assistance from 14 designated support
agencies and the American Red Cross as needed:
!Assessment of public health and medical needs;
!Medical care personnel;
!Health and medical equipment and supplies;
!Safety and security of human drugs, biologics, and medical devices,
veterinary drugs, and other HHS-regulated products;
!Blood and blood products;
!Food safety and security;
!Agriculture safety and security (principally with regard to food-
producing animals and animal feeds and drugs);
!Worker health and safety;
!All-hazard public health and medical consultation, technical
assistance and support;
!Behavioral health care;
!Public health and medical information;
!Vector control (e.g., control of disease-carrying insects and rodents);
!Potable water, wastewater and solid waste disposal;
!Victim identification and mortuary services; and
!Protection of animal health (principally with regard to HHS-
regulated animal feeds and drugs).
The HHS Concept of Operations Plan (CONOPS) for Public Health and
Medical Emergencies outlines how HHS plans to implements its emergency
preparedness and response authorities and establishes the department’s policies for
emergency preparedness and response.7 The CONOPS plan designates the Secretary
of HHS as the official responsible for the overall response to public health
emergencies. The Assistant Secretary for Public Health Emergency Preparedness
(ASPHEP) is to act on behalf of the Secretary to direct and coordinate the
department’s efforts, including on-scene operations and liaison with the DHS and
other federal agencies. The plan lays out additional responsibilities of HHS offices
and agencies during an emergency.8
HHS does not bear primary responsibility for mass care, which is the
coordination of non-medical services such as shelter, feeding, emergency first aid,
and efforts to reunite displaced family members. Mass care is the responsibility of
DHS and is carried out by FEMA and the American Red Cross according to ESF#6.
HHS is also not responsible for urban search and rescue, which is also the
7 HHS, “Concept of Operations Plan (CONOPS) for Public Health and Medical
Emergencies,” Mar. 2004, at [http://www.hhs.gov/nvpo/pandemicplan/hhs_conops.pdf].
8 For more information, see [http://www.hhs.gov/ophep/index.html]. The role of the
ASPHEP is further explained in HHS, “Office of Public Health Emergency Preparedness
Statement of Organization, Functions, and Delegations of Authority,” 70 Federal Register
responsibility of DHS and FEMA pursuant to ESF#9. Furthermore, HHS may
depend on numerous other agencies to carry out certain of their ESF activities (e.g.,
public safety, road clearing and power restoration) before some ESF#8 activities can
Many of HHS’s responsibilities under ESF#8 are within the department’s
primary control. An important exception is the National Disaster Medical System
(NDMS), which comprises teams of medical professionals who are pretrained to
deploy and provide medical services in the immediate aftermath of a disaster before
other federal assets arrive. NDMS, which previously operated under the Public
Health Service in HHS, was transferred to DHS in the Homeland Security Act of
2002 (P.L. 107-296), and now operates under FEMA. NDMS will be discussed in
greater depth in subsequent sections of this report. Certain other critical components
of the medical response are housed in the Departments of Defense and Veterans
Affairs, and the private sector.
Declarations of Public Health Emergencies
Absent an emergency, most public health authority, such as mandatory disease
reporting, licensing of healthcare providers and facilities, and quarantine authority,
rests with states as an exercise of their police powers. Most states have considerable
powers in responding to public health events, and most can also declare public health
emergencies to expand their powers further when needed.9 The federal role is largely
assistive through the provision of funding, additional personnel, and specialized
services such as laboratory testing and surveillance. This model does not change
substantially in emergencies, though there are statutory provisions for some specific
emergency expansions of federal public health authority.
Section 319 of the Public Health Service Act provides broad authority for the
Secretary of HHS to declare a public health emergency at the federal level.
Following the 2001 terror attacks, Congress updated this authority in the Public
Health Security and Bioterrorism Preparedness and Response Act of 2002 (P.L. 107-
188). One provision in the bioterrorism act allows the Secretary, during a public
health emergency, to waive certain requirements for provider participation in serving
individuals enrolled in Medicare, Medicaid and the State Children’s Health Insurance
Program (SCHIP.)10 Otherwise, the statutory authority for a federal declaration of a
public health emergency rests in broad language, as follows:
If the Secretary determines, after consultation with such public health officials
as may be necessary, that —
9 A listing of legal authorities invoked by Hurricane Katrina-affected states is provided by
the American Health Lawyers Association at
[ h t t p : / / www.h e a l t h l a w y e r s . o r g/ C o n t e n t / N a vi ga t i onM e nu/ Ne ws _Ce n t e r / Di s a s t e r _Re l i e f _
Resources.htm]. For a discussion of the exercise of federal and state authorities in response
to recent shortages of influenza vaccine, see CRS Report RL32655, Influenza Vaccine
Shortages and Implications, by Sarah A. Lister.
10 42 U.S.C. §1320b-5. This waiver authority also requires a concurrent Presidential
declaration of a major disaster or emergency pursuant to the Stafford Act.
(1) a disease or disorder presents a public health emergency; or
(2) a public health emergency, including significant outbreaks of infectious
diseases or bioterrorist attacks, otherwise exists,
the Secretary may take such action as may be appropriate to respond to the public
health emergency, including making grants, providing awards for expenses, and
entering into contracts and conducting and supporting investigations into the
cause, treatment, or prevention of a disease or disorder as described in11
paragraphs (1) and (2).
The declaration expires upon the Secretary’s determination that an emergency no
longer exists, or in 90 days, whichever comes first, but is renewable upon the
Secretary’s finding that an emergency persists.
In response to Hurricane Katrina, the HHS Secretary Michael Leavitt declared
public health emergencies in Alabama, Florida, Louisiana and Mississippi on August
31, 2005, two days after the storm made landfall along the Gulf Coast. On
September 4, as thousands of evacuees from the devastated city of New Orleans
began arriving in Texas, the Secretary declared a public health emergency in that host
state. The additional host states of Arkansas, Colorado, Georgia, North Carolina,
Oklahoma, Tennessee, West Virginia, and Utah were declared by the Secretary on
September 7. On December 31, HHS Secretary Leavitt renewed the determinations
of public health emergency for all Katrina-affected states through January 31, 2006.12
On September 23, in anticipation of Hurricane Rita’s landfall the following day, the
Secretary declared public health emergencies in Texas and Louisiana. These
declarations have since expired.13 Prior to Hurricane Katrina, the only recent incident
for which a federal public health emergency had been declared was the terror attack
of September 11, 2001. That declaration applied to all states.
There is no additional statute or regulation that clarifies this authority with
regard to stipulating thresholds or conditions of the determination. The decision to
declare emergencies in certain host states in response to Hurricane Katrina, but not
in all states, appears to be an exercise of the Secretary’s discretion. There is also no
precedent for this authority to be used to supercede or assume public health
authorities that are generally reserved to states, though the Secretary does have
specific emergency authorities elsewhere in statute, such as the authority to impose
domestic quarantine restrictions when warranted.14
11 42 U.S.C. §247d.
12 HHS public health emergency declarations in response to Hurricane Katrina are found at
13 HHS public health emergency declarations in response to Hurricane Rita are found at
14 A listing of HHS emergency authorities is found in Table 2 of CRS Report RL33064,
Organization and Mission of the Emergency Preparedness and Response Directorate:
Issues and Options for the 109th Congress, by Keith Bea. See also CRS Report RL33201,
Federal and State Quarantine and Isolation Authority, by Kathleen S. Swendiman and
Jennifer K. Elsea.
The Public Health Response
Federal leadership for public health emergency response rests with the Secretary
of HHS, with important responsibilities in the Office of Public Health Emergency
Preparedness (OPHEP) and the Centers for Disease Control and Prevention (CDC).
Much of the support provided by HHS to affected states and communities could
normally be provided in the absence of federal or state declarations of public health
emergencies or disasters, through assistance mechanisms that are used regularly in
response to public health threats such as outbreaks of foodborne disease. Because
there has been a presidentially-declared disaster and HHS has received mission
assignments from DHS in the wake of Hurricanes Katrina and Rita, the costs of HHS
response activities will generally be reimbursed through the DRF administered by
FEM A . 15
Given the scope of the public health disaster caused by Hurricane Katrina,
virtually all agencies and offices in HHS were engaged in the response.16 Key public
health challenges and response efforts are described below. A number of HHS
agencies have medical response roles as well, which are discussed in a subsequent
Public Health Challenges
Many of the public health challenges posed by Hurricane Katrina were familiar
and anticipated, based on experience with other hurricanes and floods. Flooding
compromises the safety of water supplies and the integrity of sewage disposal,
leading to threats of food and waterborne illness. Power line damage and power
outages increase the risk of foodborne illness and electrocution. Hurricane wind
damage may cause primary traumatic injury, while also setting the stage for
subsequent chain saw injuries, punctures, and other wounds. Bites from dogs,
venomous snakes, and insects are also seen. Hurricanes and floods also carry in their
wake some predictable causes of death, including drowning, automobile crashes,
carbon monoxide poisoning, and chronic conditions exacerbated by the loss of access
to the healthcare system. 17
15 For more information, see CRS Report RL33053, Federal Stafford Act Disaster
Assistance: Presidential Declarations, Eligible Activities, and Funding, by Keith Bea.
16 For more information on specific agency activities see HHS, “What HHS Agencies Are
Doing,” at [http://www.hhs.gov/katrina/hhsagencies.html].
17 CDC has prepared a list of public health reports on several recent floods, hurricanes, and
the 2004 Asian tsunami at [http://www.bt.cdc.gov/disasters/hurricanes/mmwr.asp].
CDC notes that before 1990, the majority of hurricane-related deaths in the
United States resulted from drowning caused by storm surges.18 With more attention
to early warning and evacuation since then, indirect causes of death such as
electrocution, carbon monoxide poisoning and injury associated with cleanup have
predominated. But despite warnings of the advancing storm, the majority of deaths
from Hurricane Katrina resulted from coastal storm surges and from flooding in New
The catastrophic scope of Hurricane Katrina presented some unusual public
health threats. News reports suggested that deaths may have resulted from
dehydration and heat stress, especially in situations in which fresh water was scarce
and where victims were crowded into poorly ventilated areas, especially where they
had pre-existing medical conditions. There were also reports of homicide, suicide
Selected HHS Agency Actions
HHS Office of the Secretary. The HHS Office of the Secretary is the point
of coordination for all ESF#8 public health and medical support functions under the
NRP. HHS set up a website cataloging departmental and agency actions and other
information regarding Hurricanes Katrina and Rita.19 As noted above, the HHS
Secretary declared federal public health emergencies in several states. The Office of
the Surgeon General and the OPHEP sought to identify and mobilize healthcare
professionals and relief personnel to assist in relief efforts. In addition, more than
and after Hurricanes Katrina and Rita, to assist in a number of public health and
One immediate element of HHS response was the activation of Emergency
Operations Centers (EOCs) at HHS headquarters in Washington, DC and at
numerous HHS agencies. When activated, the EOCs are staffed round-the-clock, are
electronically connected with each other, and are also connected with the Homeland
Security Operations Center (HSOC) at DHS, which in turn receives inputs from other
Cabinet departments. This system of continuous communication and coordination
is an example of the changes that have been made in national public health response
capability in the aftermath of the September 11 and anthrax attacks of 2001, though
there is still work to be done in assuring that all relevant state agencies have21
continuous EOC communication with those at the federal level.
18 CDC, “Public Health Response to Hurricanes Katrina and Rita — Louisiana, 2005,”
MMWR, vol. 55(2), pp. 29-30, Jan. 20, 2006.
19 See [http://www.hhs.gov/emergency/hurricane.html].
20 HHS, “New Initiative Announced to Transform the U.S. Public Health Service
Commissioned Corps,” press release, Jan. 18, 2006.
21 A listing of federal coordinating mechanisms in emergencies is found in Table 3 in CRS
Report RL33064, Organization and Mission of the Emergency Preparedness and Response
Directorate: Issues and Options for the 109th Congress, by Keith Bea.
Agency for Toxic Substances and Disease Registry. The Agency for
Toxic Substances and Disease Registry (ATSDR), which is administratively under
the Centers for Disease Control and Prevention (CDC), is directed by congressional
mandate to perform specific functions concerning the effect on public health of22
exposure to hazardous substances in the environment. These functions include
public health assessments of hazardous waste sites, health consultations concerning
specific hazardous substances, health surveillance and registries, response to
emergency releases of hazardous substances, applied research in support of public
health assessments, information development and dissemination, and education and
training concerning hazardous substances. ATSDR has conducted health hazard
assessments following a large oil spill in St. Bernard Parish, LA, that resulted from
Centers for Disease Control and Prevention. The CDC launched a
website to provide public health information in the aftermath of Hurricane Katrina.24
The site includes a variety of fact sheets and other information for health
professionals, response and cleanup workers, evacuation center staff, school officials,
state grantees and the general public. In addition, the site provided regular updates
from the CDC Director’s EOC through October 7.25 Once activated, the EOC was
the point of contact for state health departments, other CDC grantees, and other
interested parties to request assistance or to provide the agency with new or updated
information about public health concerns on the ground.
CDC deployed several hundred of its staff to affected states, including
individuals in the following specialties: medicine, epidemiology, sanitation,
environmental health, assessment, disease surveillance, public information and health
risk communication. In addition, the agency deployed more than 600 staff to its EOC
response. The agency also deployed the Strategic National Stockpile of drugs and
medical supplies to affected states. Among the specific supplies delivered for this
disaster were: 1) many thousands of doses of vaccines for tetanus/diphtheria, and
hepatitis A and B; 2) vials of insulin; 3) prescription pain medications; and 4)
The agency also made numerous public health recommendations to address the
anticipated and atypical threats posed by Hurricane Katrina and its aftermath. CDC
made several specific recommendations for infectious disease control, including the
immunization of emergency responders, relief workers and evacuees. The agency
expressed particular concern about the risks of tetanus from wounds, and of
22 ATSDR is required to conduct various activities under the Comprehensive Environmental
Response, Compensation, and Liability Act of 1980 (CERCLA or “Superfund”) and
subsequent amendments, and the Resource Conservation and Recovery Act of 1976. See
[http://www.atsdr.cdc.gov/congress.html] and CRS Report RL31154, Superfund: A
Summary of the Law, by Mark Reisch.
23 See ATSDR, “Health Consultation: Murphy Oil Spill,” Dec. 9, 2005, at
24 See [http://www.bt.cdc.gov/disasters/hurricanes/index.asp].
25 See [http://www.cdc.gov/od/katrina/].
influenza, measles, chickenpox and hepatitis A in crowded conditions, especially if
some children may not have had current immunizations.26 CDC also alerted health
officials and others to cases of Vibrio infection in hurricane victims, which caused
22 illnesses, five of them fatal.27 Vibrio, a bacterial pathogen found in salty and
brackish waters, can cause foodborne illness or severe wound infection. CDC made
an effort to alert health workers to this unusual hazard because Vibrio infections are
especially severe, leading to loss of an affected limb or death within a matter of days,
sometimes despite aggressive treatment.
On September 17, CDC and the Environmental Protection Agency (EPA) issued
a joint report of their initial assessment of environmental health and infrastructure
hazards in New Orleans, to assist state and local officials in planning for
reoccupation of the city.28 FEMA requested CDC assistance in evaluating any
potential health effects of housing displaced persons in trailers sited on former
agricultural fields. The agency has also evaluated the potential health threat posed
by exposure to mold,29 and provided assistance in the federal environmental cleanup
Responders may be at increased risk from certain hazards in the aftermath of
disasters. CDC’s National Institute for Occupational Safety and Health (NIOSH)
developed resources for occupational safety and health for responders, and in
hospitals, health departments, and shelters involved in the response to Hurricane
Food and Drug Administration. In the aftermath of Hurricane Katrina, the
Food and Drug Administration (FDA) issued numerous recommendations regarding
the handling of drugs, biologics and medical devices that may have been harmed by
exposure to floodwaters or loss of refrigeration. The agency also issued guidance in
ensuring the safety of food, and participated in evaluations of the safety of fish and
shellfish in affected Gulf Coast waters.32
26 See CDC, “Immunization Information for Hurricane Katrina,” at
27 CDC, “Vibrio Illnesses After Hurricane Katrina — Multiple States, August-September
28 CDC and EPA, “Hurricane Katrina: Environmental Health Needs & Habitability
Assessment,” Sept. 17, 2005, at
29 See CDC, “Environmental Concerns after Hurricane Katrina,” at
30 See CRS Report RL33115, Cleanup after Hurricane Katrina: Environmental
Considerations, by Robert Esworthy, Linda Jo Schierow, Claudia Copeland, and Linda
31 See CDC NIOSH, [http://www.cdc.gov/niosh/topics/flood/#new].
32 See [http://www.fda.gov/oc/opacom/hottopics/hurricane.html].
The Medical Response
The medical response to a disaster may be more challenging than the public
health response. Most public health activities are inherently governmental and
involve agencies that work together regularly, though often at different levels of
government. Medical response capabilities, in contrast, span a wide array of sectors,
both public and private, and involve more non-traditional partnerings such as the
coordination of DHS and Department of Defense (DOD) activities by HHS. A
successful medical response to a disaster requires the coordination of six elements:
patients in need; a site where care is provided; the needed drugs, supplies and
equipment; a provider workforce; a system of record keeping; and a financing
Though national disaster planning has long anticipated the need to respond to
a mass casualty incident, such a situation, with overwhelming numbers of non-fatal
illness and injury victims, has not happened recently in the United States. While
certain recent events (e.g., the September 11, 2001 attack and some jetliner crashes)
have tested the national system for mass fatality management, Hurricane Katrina is
the only event in recent times that has caused non-fatal mass casualties of a scope
that could not easily be absorbed into the existing healthcare system. Scrutiny of the
response to this challenge is ongoing.
As discussed earlier, federal leadership for medical emergency response is based
in HHS per its coordinating responsibility under NRP ESF#8. Numerous medical
response programs and activities reside in HHS agencies within the Public Health
Service (PHS). In addition, the Commissioned Corps of the PHS, headed by the
Surgeon General, is composed of many healthcare professionals who are expected
to maintain current skills and deploy to support emergency responses when needed.33
Another critical medical response asset, the National Disaster Medical System
(NDMS) was transferred from HHS to DHS in March 2003. Additional critical
assets such as personnel, bed capacity, equipment and patient transport capability are
based in the Departments of Defense and Veterans Affairs, as well as the private
Medical and Healthcare Challenges
Hurricane Katrina posed a number of challenges to the healthcare system, many
without recent precedent. Physical access to healthcare facilities was hampered
across the Gulf Coast following the storm, and many facilities sustained primary
damage. Several facilities that did not evacuate prior to the storm found their
patients in dire circumstances when rising floodwaters made it progressively more
difficult to maintain standards of care. Individuals with pre-existing health
conditions worsened as they were cut off from access to essential medications and
33 See the HHS Office of the Surgeon General at [http://www.surgeongeneral.gov/] and the
U.S. Public Health Service Office of Force Readiness and Deployment at
treatments such as oxygen, insulin, or kidney dialysis. In some flooded areas, access
to fresh water was so scarce that victims and their caregivers suffered from
dehydration. In the wake of large-scale evacuations of New Orleans beginning on
September 1, victims from shelters and from failing healthcare facilities were
evacuated to a temporary field hospital at the New Orleans airport, where medical
response teams, initially overwhelmed, conducted triage and prioritized victims for
airlift to available healthcare facilities outside the flood zone. Meanwhile, medical
workers continued their efforts to reach numerous isolated communities along the
Mississippi and Louisiana coast. Morgues were set up in Louisiana and Mississippi
to house and identify the dead.
In the wake of the catastrophe, victims were sent for treatment to numerous
permanent and temporary healthcare facilities across a wide area of the south central
United States, often becoming separated from their loved ones and important
medications and medical records along the way. Public health emergencies were
declared in nine states that did not suffer primary impacts from Hurricane Katrina but
that became hosts to large numbers of evacuees needing care. Healthcare facilities
sought assistance in covering the costs of care for those who were previously or
The short-and long-term mental health needs of victims and responders had to
be assessed. Immediate problems such as Post-Traumatic Stress Disorder receive
considerable popular attention, but some evidence shows that victims of catastrophic
disasters may continue to suffer from major depression and other disorders for
several years. Mental health services following disasters must also account for pre-
existing mental health and substance abuse problems in some victims.
Selected HHS Agency Actions
Centers for Medicare and Medicaid Services. The Centers for Medicare
and Medicaid Services (CMS), which administers the Medicare, Medicaid and
SCHIP programs, took several actions to streamline access to healthcare for those
displaced by Hurricanes Katrina and Rita. Many evacuees crossed state lines without
proper documentation of program eligibility. HHS Secretary Leavitt exercised
certain authorities under Sections 1115 and 1135 of the Social Security Act and
waived several program requirements, in order to assist displaced victims and their
Health Resources and Services Administration. The Health Resources
and Services Administration (HRSA) provides grants to Federally Qualified Health
Centers, Ryan White HIV/AIDS outpatient providers and some other providers and
clinics that offer health services to underserved populations. HRSA administers
several relevant programs in emergency preparedness. One is a grant program for
state and local hospital preparedness for public health emergencies, which is meant
to help states identify and coordinate hospital bed capacity, personnel and medical
supplies in an emergency. Another is a program for the advance registration of
34 See CRS Report RL33083 , Hurricane Katrina: Medicaid Issues, by Evelyne Baumrucker,
April Grady, Jean Hearne, Elicia Herz, Richard Rimkunas, Julie Stone, and Karen Tritz.
volunteer health professionals.35 The latter program is discussed in a subsequent
section on Issues for Congress.
HRSA undertook a number of response efforts following Hurricane Katrina,
including staff deployments.36 On September 9, HHS Secretary Leavitt announced
that HRSA would advance approximately $2.3 million in FY2005 funds to establish
26 new health center sites in areas impacted by Hurricane Katrina.37 The agency
issued a notice clarifying that providers who normally provided services under the
liability protections of federal employment in certain HRSA-supported health centers
would continue to receive protection while serving at temporary locations established
in response to the hurricane. In addition, in affected areas, the agency offered
expedited procedures for designating Health Professions Shortage Areas, and for
reviewing loan repayment applications for National Health Service Corps personnel.
National Institutes of Health. The National Institutes of Health (NIH) set
up a phone-based medical consultation service for providers treating victims or
evacuees from the Hurricane Katrina disaster, which it operated through September
among other activities. The National Institute of Environmental Health Sciences
developed an interactive Geographic Information System (GIS) for Texas, Louisiana
and Mississippi to help model the movement of contaminants and identify sources
of human exposure.39
Substance Abuse and Mental Health Services Administration.40 The
Substance Abuse and Mental Health Services Administration (SAMHSA) has as its
mission to build resilience and facilitate recovery for people with or at risk for
substance abuse and mental illness. SAMHSA’s Center for Mental Health Services
(CMHS) focused on providing resources to aid in the recovery process following
Hurricanes Katrina and Rita, and established a toll-free hotline for people in crisis in
the aftermath of this disaster.41
35 For more information, see CRS Report RL31719, An Overview of the U.S. Public Health
System in the Context of Emergency Preparedness, by Sarah A. Lister, and
36 See HRSA, “Hurricane Katrina Relief and Recovery,” at [http://www.hrsa.gov/katrina/].
37 HHS, “Secretary Leavitt Announces Advance of Health Center Funds to Hurry Services
to Hurricane-Affected Areas,” press release, Sept. 9, 2005.
38 See [http://www.nih.gov/about/director/hurricanekatrina/index.htm].
39 See [http://www-apps.niehs.nih.gov/katrina/].
40 For further information see CRS Report RS22292, Hurricanes Katrina & Rita:
Addressing the Victims’ Mental Health and Substance Abuse Treatment Needs, by Erin D.
41 See SAMHSA, “Hurricane Katrina and Disaster Relief Information,” at
[http://www.mentalhealth.samhsa.gov/cmhs/katrina/], and HHS, “HHS Awards $600,000
in Emergency Mental Health Grants to Four States Devastated by Hurricane Katrina,” news
release, Sept. 13, 2005.
SAMHSA has three main mechanisms to provide funding to address disaster
victims’ mental health needs: 1) the Crisis Counseling Assistance and Training
program (CCP), 2) SAMHSA Emergency Response Grants (SERG), and 3)
supplemental appropriations. The CCP is administered by SAMHSA through an
interagency agreement with FEMA. Eligible entities (state mental health agencies
and tribal authorities) work with SAMHSA to apply for and receive grants for
counseling outreach and training local crisis counselors to provide assistance after
federal relief workers leave the area. SERG are available when local resources are
overwhelmed and other resources are unavailable. SAMHSA may provide SERG for
crisis mental health and substance abuse services in accordance with SAMHSA’s
Mental Health and Substance Abuse Emergency Response Criteria.42 Supplemental
appropriations may be used by SAMHSA for emergency mental health and substance
abuse counseling and related services not addressed by the CCP, the SERG, or other
existing funding. These may include, for example, substance abuse and mental
health treatment services, psychotropic medication expenses, methadone treatment,
suicide prevention programs, and major administrative expenses for mental health
and substance abuse resulting from the disaster.
Department of Homeland Security
National Disaster Medical System. The National Disaster Medical System
(NDMS) was established in HHS in 1984 to provide medical and ancillary services
when a disaster overwhelms local emergency services.43 NDMS was most recently
reauthorized through 2006 in the Public Health Security and Bioterrorism
Preparedness and Response Act (P.L. 107-188),44 and was transferred to DHS in the45
Homeland Security Act (P.L. 107-296) effective in March 2003. NDMS is
administered by FEMA and is a partnership of HHS, DHS, the Departments of
Defense and Veterans Affairs, state and local governments, and the private sector.
NDMS consists of a number of response teams that can deploy to a scene
rapidly and set up field operations that are self-sustaining for up to 72 hours, until
additional federal support arrives. NDMS also provides for transportation of large
numbers of casualties from an impacted site to distant locations for care. There are
several types of NDMS teams, which are typically comprised of 20-35 individuals.
Team members train as a group between deployments, under a defined team
commander, and are versed in incident command and other emergency management
protocols in addition to their disaster medicine skills. NDMS teams can be requested
by the Secretary of HHS pursuant to NRP ESF#8. Medical professionals on the
teams must be licensed to practice in at least one U.S. jurisdiction and are not
generally federal employees unless deployed, at which time they are considered
federalized for liability and compensation purposes. On September 9, 2005, FEMA
42 See [http://www.fema.gov/library/stafact.shtm#sec416], and 66 FR 51873, Oct. 11, 2001.
43 See the NDMS home page at [http://www.ndms.dhhs.gov/], and Jerry L. Mothershead et
al., “Bioterrorism Preparedness III: State and Federal Programs and Response,” Emergency
Medicine Clinics of North America, vol. 20, 2002, pp. 477-500.
44 42 U.S.C. §300hh.
45 6 U.S.C §312 et seq.
reported that it had deployed more than 87 NDMS teams in response to Hurricane
Katrina. Information about specific deployment activities follows.
Disaster Medical Assistance Teams (DMATs) are teams of physicians, nurses
and other medical professionals who provide medical care. FEMA reported that it
deployed all of the nation’s more than 50 DMATs in the initial response to Hurricane
Katrina. At least one team was predeployed to the New Orleans Superdome shelter.46
The Louis Armstrong International Airport outside New Orleans served as a
temporary field hospital for hurricane victims as they were evacuated from the city.
DMAT members from a dozen teams deployed at the airport reported overwhelming
numbers of patients, some of whom could not be saved under the austere conditions
they faced. Teams fanned out across the affected Gulf Coast, doing what they could
to accommodate victims of the hurricane which, by some reports, also robbed the
region of 6,000 hospital beds.47
Disaster Mortuary Operational Response Teams (DMORTs) are composed of
medical examiners, coroners, pathologists, forensic dentists, radiologists, mental
health counselors, funeral directors and support personnel. Teams typically consist
of 26 members. They assist in handling the dead and conducting two types of
investigations in mass fatality incidents: disaster victim identification (DVI) and
death investigation. DVI involves the identification of victims, in order that their
loved ones can have documentation of their deaths, claim the remains, and carry out
funeral rites. It is considered an essential responsibility of governments in assisting
survivors in their recovery. Death investigation involves establishing the cause, time
and other circumstances of death. These investigations are conducted under the
authority of state or local medical examiners, with assistance from DMORT
personnel and federal funding through FEMA. DMORT sites were set up in Gabriel,
Louisiana, and Gulfport, Mississippi, each site with four DMORT teams and one
Veterinary Medical Assistance Teams (VMATs) are composed of veterinarians,
technicians and support personnel who provide animal rescues, health assessments
and other services during a disaster. Following Hurricane Katrina, all four VMAT
teams were deployed to the Gulf Coast to provide care for displaced companion
animals and support for damaged or destroyed veterinary practices.49
46 Jeff Jones, “N.M. Team Has Praise for Superdome: Medical Staff Says Stadium Saved
Katrina Victims’ Lives,” Albuquerque Journal, Sept. 8, 2005.
47 Anne Jungen, “DMAT Member: New Orleans Airport Was Like ‘Third World,’” Erie
Times-News, Pa. Knight Ridder/Tribune Business News, Sept. 9, 2005; and Ceci Connolly,
“Improvising to Replace Services for Many Thousands,” Washington Post, Sept. 6, 2005.
48 FEMA, “Medical Assistance and Supplies Flow into Hurricane-Hit Areas,” press release
number HQ-05-205, Sept. 5, 2005; Alan Levin, “Morgue Units Preparing as Katrina’s Dead
Uncovered,” USA Today, Sept. 8, 2005; and Darryl E. Owens, “Katrina’s Aftermath,
Helping the Dead Reclaim Identity,” Orlando Sentinel, Sept. 9, 2005.
49 See Susan C. Kahler and R. Scott Nolen, “AVMA Mounts Preparedness, Response to
Katrina,” Journal of the American Veterinary Medical Association, Sept. 13, 2005, at
[http://www.avma.org/onlnews/javma/oct05/x051001b.asp], and VMAT Team situation
NDMS also supports National Pharmacy Response Teams of pharmacists,
pharmacy technicians, and students of pharmacy who assist in mass-dispensing of
medications during disasters, and National Nurse Response Teams to assist if a
disaster such as a bioterrorism event were to require a mass prophylaxis or mass
vaccination campaign, or if the healthcare workforce is otherwise overwhelmed.
Federal Coordinating Centers (FCCs) are based in the Departments of Defense
(DOD) and Veterans Affairs (VA), where they identify available nationwide hospital
bed capacity in civilian and military hospitals, and coordinate planning and
distribution of patients evacuated from a disaster area.50
Since NDMS deploys in situations other than disasters (e.g., National Special
Security Events such as political conventions) and much of its work is, therefore, not
eligible for reimbursement from the DRF, the program has a regular annual
appropriation. NDMS is funded through the Public Health Programs account under
the DHS Preparedness and Response title, and received $34 million in FY2005 and
in FY2006.51 On September 8, the President signed the second emergency
supplemental appropriation for Hurricane Katrina relief (P.L. 109-62), which
authorized the transfer of up to $100 million from the DRF to maintain Katrina-
related NDMS response operations. In its weekly report to Congress on Hurricane
Katrina expenditures, FEMA reported that it had transferred the entire amount.52
Department of Defense
During a presidentially-declared disaster and pursuant to the NRP, the DOD
assists the Secretary of HHS with numerous ESF#8 responsibilities. These include
evacuating patients, locating or providing hospital beds, additional personnel and
supplies, and providing specialized laboratory testing and other technical assistance.53
On September 13, DHS reported that DOD had: 1) 789 beds available in field
hospitals at Louis Armstrong New Orleans International Airport in New Orleans, the
14th Combat Support Hospital, and aboard USS Bataan, USS Iwo Jima, USS Tortuga
and USS Shreveport; and 2) 20 Navy ships on station in the region to provide
medical support, humanitarian relief, and transportation.54
reports at [http://www.avma.org/disaster/situation_reports/default.asp].
50 See NDMS FCC page at [http://ndms.dhhs.gov/fcc.html].
51 See Table 8 in CRS Report RL32863, Homeland Security Department: FY2006
Appropriations, by Jennifer E. Lake and Blas Nuñez-Neto.
52 DHS/ FEMA, Weekly Report on Hurricane Katrina Allocations, Commitments, and
Obligations, Sept. 22, 2005.
53 See NRP ESF Annex #8, Public Health and Medical Services, p. 9.
54 See DHS, “What Government Is Doing,” press release, Sept. 13, 2005; and DOD website
on Katrina relief efforts at [http://www.dod.mil/home/features/2005/katrina/news/].
Department of Veterans Affairs
During a presidentially-declared disaster and pursuant to the NRP, the
Department of Veterans Affairs (VA) assists the Secretary of HHS with numerous
ESF#8 responsibilities. These include coordinating available hospital beds,
additional personnel and supplies, and providing technical assistance.55
The VA evacuated veterans from two of its own medical centers impacted by
Hurricane Katrina, one in Biloxi, Mississippi, which was evacuated prior to landfall
and demolished by the storm, and the other in New Orleans, which was evacuated
after the city was flooded. The VA also activated 17 of its NDMS Federal
Coordinating Centers to coordinate the relocation of evacuated veterans, as well as
of civilian patients who were evacuated from permanent and temporary hospitals in
Issues for Congress
In the aftermath of Hurricane Katrina there were concerns that federal readiness
for the disaster had been hampered by an overemphasis on planning for terrorism at
the expense of planning for natural disasters. A similar debate exists for public
health preparedness, namely how the balance should be struck between all-hazards
preparedness versus readiness for specific threats such as a cyanide attack or
pandemic influenza. In comprehensive bioterrorism preparedness legislation after
the 2001 terror attacks, Congress authorized grants to states to “address the following
hazards in the following priority: (i) Bioterrorism or acute outbreaks of infectious
diseases (and) (ii) Other public health threats and emergencies.”57 Discussions have
followed about whether a focus on terrorism (e.g., the civilian smallpox vaccination
program) has hampered preparedness for other threats, or, on the other hand, whether
flexible all-hazards grant guidance has failed to assure state preparedness for some
specific threats (e.g., a cyanide or plague attack).58
Some reports suggest that the public health response to Hurricane Katrina was
streamlined by some all-hazards improvements made since 2001. For example,
when the Louisiana state public health laboratory in New Orleans was disabled by the
storm, operations were quickly diverted to branch public health laboratories in
55 See NRP ESF Annex #8, Public Health and Medical Services, p. 12.
56 VA Under Secretary for Health Jonathan B. Perlin, briefing to congressional staff on
Hurricane Katrina response, Sept. 8, 2005. See also CRS Report RS22279, Hurricane
Katrina and Veterans, by Sidath Viranga Panangala.
57 42 U.S.C. §247d-3a.
58 For further discussion, see CRS Report RL31719, An Overview of the U.S. Public Health
System in the Context of Emergency Preparedness, by Sarah A. Lister, section on “Issues
for Congress: Overview.”
Shreveport, Lake Charles and Amite, or to other states as needed.59 The swift
response was facilitated by inter-state electronic communications systems and
relationships that had been established since 2001.
Upon completing their missions, disaster response personnel are typically
required to report to supervisors on their activities. These after-action reports are
expected to be prepared and submitted to a variety of agencies involved in the
response to Hurricane Katrina. As after-action reports become available, Congress
may review the public health and medical response to Hurricane Katrina to determine
how well it met the goals Congress laid out for achieving a flexible, efficient national
system for response to health emergencies. Part of this review may be the
consideration of the process of developing standards for federal, state and local
public health preparedness, a process which has proven difficult in the past.
Coordinated Needs Assessments
Needs assessments are considered critical in the response to catastrophic
disasters. When it is likely that response assets will be overwhelmed, lives may be
saved by prioritizing the response as effectively as possible (e.g., matching the
deployment of NDMS teams as well as possible to defined areas of medical need).
However, the response to public health and medical needs may have to be delayed
until response has been made to other problems such as civil disorder or a lack of
physical access. Therefore, coordinating the assessments across all sectors is
Following a disaster, the NRP calls for the early deployment of Emergency
Response Teams for Assessment (ERT-A), which are FEMA-led teams that work
with state Emergency Operations Centers (EOCs) and others to conduct initial and
ongoing impact assessments. Early assessments define the extent of problems such
as flooding, the integrity of roads and bridges, and damage to the electricity grid.
Representatives from selected ESF support agencies are to be included in ERT-A
deployments. The ERT-A teams are to report back to an Interagency Incident
Management Group (IIMG), which is tasked to report to the Secretary of DHS with
recommendations for those areas in most critical need of response assets and
The CDC manages a program in Disaster Epidemiology and Assessment, which
includes development of a disaster rapid needs assessment tool designed to quickly
provide emergency managers with reliable information about potential public health
threats.61 The CDC has conducted these assessments for several domestic and
59 Announcement from the Louisiana Office of Public Health, “Public Health Laboratory
Capacity in Louisiana After Hurricanes Katrina and Rita,” updated Oct. 17, 2005, at
60 NRP, p. 40.
61 See CDC Disaster Epidemiology and Assessment home page at
[http://www.cdc.gov/ nceh/hsb/disaster/surveillance.htm] .
foreign disasters, including Hurricane Katrina.62 The tool is not designed for the
rapid assessment of medical or mental health needs. CDC has reported on longer-
term assessments of medical and mental health needs in areas affected by Hurricanes
Katrina and Rita, and on surveillance systems, set up in evacuee shelters, that
allowed for the measurement of the burden of certain chronic diseases such as
diabetes and mental illness.63 Further review of this information will inform efforts
to improve the tools used for needs assessment, though it is not know whether there
are efforts underway to develop a process specifically for the rapid assessment of
medical and mental health needs in the immediate aftermath of a disaster.
Policy issues may include the performance of the FEMA ERT-A process in
supporting the more specific goals of assessing public health, medical and mental
health needs following Hurricane Katrina, and, indeed, whether an effective process
of medical and mental health needs assessment exists. In particular, are the federal
mechanisms to support rapid public health, medical and mental health needs
assessments in place and adequate to support a capable national response? Also, are
these processes integrated well within the larger FEMA-led process of overall
assessment, in order that appropriate public health, medical and mental health
responses can reach their targets quickly and efficiently?
Disaster Planning in Healthcare
Overview. Following Hurricane Katrina, there were numerous reports of
problems experienced by fragile or medically needy persons. These problems
included 1) drownings and dehydration in facilities that did not evacuate and were
flooded by the hurricane storm surge; 2) emergency evacuations of deteriorating
patients from hospitals that were unable to care for patients after power, water and
food had been cut off for several days; and, 3) chronic conditions exacerbated by the
loss of access to needed care such as insulin, oxygen therapy or kidney dialysis. In
preparing for Hurricane Rita, authorities in many communities on the Texas and
Louisiana coast paid particular attention to identifying and helping those with special
health needs, providing public transportation to support the evacuation of nursing
homes and those receiving other health services.
Hurricane Katrina also exposed a number of problems that healthcare facilities
experienced as a result of the scope of the disaster. The failure of communications
systems across the Gulf Coast made it difficult for facilities to seek assistance, or for
emergency responders to know that a facility was in need. In addition, since all
facilities were simultaneously affected, the use of shared resources (“double-
counting”) led to problems. For example, single ambulance companies had
contracted to evacuate multiple facilities. This arrangement, which would work well
if facilities had been affected in isolation, was untenable in a wide scale disaster.
62 CDC, “Hurricane Katrina Response and Guidance for Health-Care Providers, Relief
Workers, and Shelter Operators,” MMWR, 54(35), p. 877, Sept. 9, 2005.
63 CDC: “Assessment of Health-Related Needs After Hurricanes Katrina and Rita —
Orleans and Jefferson Parishes, New Orleans Area, Louisiana, October 17-22, 2005,”
MMWR, vol. 55(2), pp. 38-41; and, “Surveillance in Hurricane Evacuation Centers —
Louisiana, September - October 2005,” MMWR, vol. 55(2), pp. 32-35, Jan. 20, 2006.
Following the hurricanes, experts have stressed the need for coordinated disaster
planning in healthcare. They note that in addition to assuring that facilities are well
prepared on their own, they must be integrated into community-wide emergency
management activities. Further, identifying vulnerable non-institutionalized
populations and assuring their care before, during and after a disaster also requires
a community-wide coordinated approach.
Regulation of Institutions and Services. Healthcare facilities (e.g.,
hospitals and nursing homes) are regulated by state and local authorities, with varying
degrees of federal involvement. Regulations provide an opportunity for oversight of
two critical disaster planning functions: evacuation and continuity of operations. (In
this context, continuity of operations, the ability to sustain life-saving operations in
the absence of power, water and other external supplies, could also be considered
sheltering in place.) Given the nature of their business, hospitals are generally able
to continue operations in the face of power outages, at least temporarily, because they
employ generators to maintain critical life-support functions in an emergency.
Furthermore, it is difficult to evacuate hospital or nursing home patients as their
special needs may require special transport and host facilities. This may motivate
better preparedness for continuity of operation as a more feasible option than
evacuation. Healthcare facilities should be able to do both, though, as different types
of disasters would require one or the other response. Hospitals in New Orleans that
initially chose to continue operations ultimately had to evacuate.
Evacuation policies and regulations for healthcare facilities have long focused
on fire safety, for which the need to evacuate is evident, and for which drills are
regularly conducted by local fire safety authorities. Evacuation planning for a
predicted threat such as a hurricane may be more challenging. The decision to
evacuate or not may hinge on emergency management rather than healthcare
expertise, and may be guided by local officials rather than facility managers. For
example, the mandatory evacuation order issued by the city of New Orleans on
August 28 excluded “essential personnel of hospitals and their patients,” but did not
exempt other types of healthcare facilities.64 In preparing for Hurricane Charley in
Florida in 2004, one county issued a countywide mandatory evacuation order, while
a neighboring county issued a mandatory order for nursing homes only.65
While healthcare facilities are licensed and regulated by state and local
authorities, there is a role for federal oversight of their disaster preparedness and
response capabilities through standards developed by the Occupational Safety and
Health Administration (OSHA) and the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), as well as through conditions of participation66
(CoPs) for Medicare and Medicaid. Following Hurricane Katrina, a JCAHO
64 Civil District Court for the Parish of New Orleans, State of Louisiana, City of New
Orleans, “Promulgation of Emergency Orders,” undated document, at
[ h t t p : / / www2a.cdc.go v/ phl p/ docs/ NewOr l e ansEme r gencyOr der s .pdf ] .
65 CDC, “Epidemiologic Assessment of the Impact of Four Hurricanes — Florida, 2004,”
MMWR, 54(28), pp. 693-697, July 22, 2005.
66 See “Evacuation Strategies for Disaster Planning,” Healthcare Hazard Management
witness testified that the commission certifies 85% of U.S. hospitals encompassing
96% of hospital beds.67 JCAHO-certified hospitals are deemed by federal law as
meeting the conditions of participation for Medicare and Medicaid reimbursement.
The commission’s 2005 accreditation manual for hospitals includes standards
regarding emergency management, in addition to standards addressing certain
specific threats such as fire and hazardous materials.68 The Government
Accountability Office (GAO) has reported concerns regarding enforcement of
JCAHO certification standards.69
While JCAHO has certification programs for other types of healthcare
institutions besides hospitals, some of the programs are voluntary or do not cover a
majority of the relevant industry. Conditions of participation for Medicare and
Medicaid reimbursement for other institutions, as well as for various non-institutional
services (e.g., home-based care), vary in the degree to which disaster planning is
addressed. The role of state and local authorities in assuring disaster preparedness
for these facilities and services appears to dominate.
Community-based Disaster Planning. In Congressional testimony
following Hurricane Katrina, a JCAHO witness stressed the need for hospitals to
prepare for disasters within a community-wide structure, not in isolation.70 The
commission’s 2005 emergency management standards include a requirement that
hospitals conduct a “hazard vulnerability analysis” to determine the types of hazards
the facility is likely to face. There are also several standards requiring that hospitals
have and test emergency backup systems for electricity and other utilities. Careful
planning of this type could prevent planning errors such as the placement of back-up
generators in the basement of a flood-prone facility. In addition, hospitals are
required to coordinate various planning tasks with local emergency management
Problems in delivering care to the chronically ill after hurricanes were described71
in reports following four hurricanes in Florida in 2004. The emphasis of disaster
Monitor, vol. 15, no. 8, Apr. 2002; and 42 C.F.R. §482 through §485.
67 Testimony of Joseph Cappiello for JCAHO, hearing before the House Committee on
Energy and Commerce, Subcommittees on Health and on Oversight and Investigations, on
“Assessing Public Health and the Delivery of Care in the Wake of Hurricane Katrina,” Sept.thst
68 JCAHO, “Management of the Environment of Care,” Comprehensive Accreditation
Manual for Hospitals, 2005.
69 GAO, “CMS Needs Additional Authority to Adequately Oversee Patient Safety in
Hospitals,” GAO-04-850, July 2004.
70 JCAHO testimony.
71 See, for example: CDC, “Epidemiologic Assessment of the Impact of Four Hurricanes —
Florida, 2004,” MMWR 54(28), pp. 693-697, July 22, 2005; and CDC, “Rapid Assessment
of the Needs and Health Status of Older Adults After Hurricane Charley — Charlotte,
DeSoto, and Hardee Counties, Florida, August 27 — 31, 2004,” MMWR 53(36), pp.
planning for non-institutional services is based on assuring continuity of care during
and after a disaster. Some communities have developed programs to identify
vulnerable individuals and assure continuity of care. The massive dislocation of the
victims of Hurricane Katrina demonstrates how challenging this task can be.
Following the terror attacks in 2001, Congress created a national program of
grants to states to improve the ability of communities to respond to emergencies that
cause mass casualties.72 The National Bioterrorism Hospital Preparedness Program
is administered by the Health Resources and Services Administration (HRSA).73
Grants are awarded to state health officials to develop coordinated state and regional
mass casualty plans. Though grant guidance directs that a majority of funds be
passed through to healthcare institutions, the program is not designed to assure
preparedness for each facility or service in a state. It could be a means, however, for
states to develop reliable communications systems between hospitals and emergency
management authorities, or to address other aspects of coordination. There is limited
publicly available information on how states have used hospital preparedness grant
Promising Practices. Some states and communities with disaster experience
have come up with approaches to address problems of disaster planning in74
healthcare. For example, Florida has a requirement (in statute and regulation) that
home health agencies include in patients’ records individual disaster plans (e.g., an
individual evacuation plan) that have been discussed with the patient and the
patient’s caregivers.75 Florida also established Special Needs Shelters for vulnerable
persons during the 2004 hurricanes. The state facilitated evacuation to the shelters
of individuals who were pre-identified by county health departments. This
arrangement facilitated care of those whose needs were not so great that they required
hospitalization, but that nonetheless exceeded the expertise available in Red Cross76
and other community shelters.
In New York City, the Office of Emergency Management serves as the focal
point of coordination for the Department of Aging and other city agencies to identify
and plan for the care of special-needs populations during a disaster. Individuals are
pre-identified from certain databases such as home-delivered and group meals
72 42 U.S.C. 247d-3a.
73 For more information, see CRS Report RL31719, An Overview of the U.S. Public Health
System in the Context of Emergency Preparedness, by Sarah A. Lister.
74 See Senate Committee on Aging, hearing on “Preparing Early, Acting Quickly: Meeting
the Needs of Older Americans During a Disaster,” Oct. 5, 2005, 109th Congress, 1st sess.,
75 State of Florida, “Provision of Services During an Emergency,” State Health Care Law
76 Association of State and Territorial Health Officials, “Special Needs Shelters Are Key
Component of the Public Health Response to the 2004 Hurricanes,” fact sheet, undated, at
[ ht t p: / / www.ast ho.or g/ pubs/ Speci al Needs.pdf ] .
programs and the electric utility’s list of clients who are on life support equipment.
The Greater New York Hospital Association has testified on the value of redundant
communications systems that were established in city hospitals and the Office of
Emergency Management prior to the northeast blackout in 2003.77
Options for Congress. Congress could decide to look specifically at
whether the federal requirements for facility disaster and evacuation plans are
adequate, and adequately enforced. If it did so, it might consider options to improve
general emergency preparedness in healthcare facilities, including the elements of
planning, staffing, training, stockpiling of supplies, evacuation procedures, and
coordination with emergency management authorities. In addition, the role of the
HRSA hospital preparedness grant program as a mechanism for coordinated disaster
planning in healthcare could be examined.
National Disaster Medical System
As previously discussed, the NDMS was created in the 1980s under the U.S.
Public Health Service in HHS, and was transferred to DHS under FEMA in the 2003.
The cited intent of this transfer, proposed by the Administration, was to assure a
coordinated federal response to terrorism and other disasters. The Government
Accountability Office (GAO) supported the transfer.78 But since then, a review of
DHS medical response capabilities, conducted at the request of then-Secretary Tom
Ridge in 2004, found “... that the nation’s medical leadership works in isolation, its
medical response capability is fragmented and ill-prepared to deal with a mass
casualty event and that DHS lacks an adequate medical support capability for its field79
operating units.” Further, some NDMS team members have complained that the
program has not received adequate administrative support under FEMA.80 Two
organizational issues may be relevant to this concern.
First, some NDMS team members have stated that their mission — to provide
direct medical services — is not understood by FEMA management.81 The Lowell
report had recommended the appointment of a DHS Assistant Secretary for Medical
77 Testimony of the Greater New York Hospital Association before the New York City
Council, Committee on Health, regarding “New York City Hospitals in the Blackout of
78 Government Accountability Office, Homeland Security: New Department Could Improve
Coordination but Transferring Control of Certain Public Health Programs Raises
Concerns, GAO-02-954T, July 16, 2002. At the time of publication, the agency was called
the General Accounting Office.
79 Jeffrey A. Lowell, “Medical Readiness Responsibilities and Capabilities: A Strategy for
Realigning and Strengthening the Federal Medical Response,” report to DHS Secretary Tom
Ridge, Jan. 3, 2005, hereafter called the Lowell report, at
[http://www.democrats.reform.house.gov/ Docume nts/20051209101159-27028.pdf].
80 Star Lawrence, “Culture Shock,” Homeland Protection Professional, Apr. 2005.
81 Ibid. This concern had been repeated in the aftermath of Hurricane Katrina. See, for
example, Richard Knox, “New Orleans Airport as Field Hospital,” Morning Edition,
National Public Radio, Sept. 14, 2005.
Readiness to address this concern.82 In July 2005, DHS Secretary Michael Chertoff
announced his proposal to reorganize DHS following a comprehensive review, which
became known as the “Second Stage Review” or 2SR.83 Chertoff announced that he
proposed to split the existing Emergency Preparedness and Response Directorate
(which housed FEMA and NDMS) into two separate directorates, for distinct
activities in preparedness and response, respectively. He announced the appointment
of a chief medical officer (CMO), a position that had not previously existed in DHS,
within the proposed preparedness directorate, as follows:
...as part of our consolidated preparedness team, I will appoint a chief medical
officer within the preparedness directorate. This position will be filled by an
outstanding physician who will be my principal advisor on medical preparedness
and a high-level DHS representative to coordinate with our partners at the
Department of Health and Human Services, the Department of Agriculture and
The chief medical officer and his team will have primary responsibility for
working with HHS, Agriculture and other departments in completing
comprehensive plans for executing our responsibilities to prevent and mitigate84
biologically-based attacks on human health or on our food supply.
The following day, Chertoff announced the appointment of Dr. Jeffrey Runge to the
Under the new structure, NDMS remains within FEMA, while the CMO is
within the new Directorate for Preparedness. While NDMS is logically a response
asset, some critics say the proposed structure may blunt the benefit that NDMS might
have received from leadership provided by the new CMO position, since that
individual would be in a different directorate.
A second organizational concern with the transfer of NDMS to DHS is that
NDMS and FEMA take different temporal approaches to deployment in response to
a disaster. Historically, DMAT teams trained to be able to deploy rapidly and set up
self-supporting field hospitals in austere conditions, without external water or power
sources, within the first 72 hours after a disaster, before other federal assets arrive.86
FEMA has historically operated under the planning assumption that while it would
82 Lowell report, p. ii.
83 See CRS Report RL33064, Organization and Mission of the Emergency Preparedness and
Response Directorate: Issues and Options for the 109th Congress, by Keith Bea; and CRS
Report RL33042, Department of Homeland Security Reorganization: The 2SR Initiative, by
Harold C. Relyea and Henry B. Hogue.
84 DHS, “Secretary Michael Chertoff, U.S. Department of Homeland Security Second Stage
Review Remarks,” Ronald Reagan Building, Washington, DC, July 13, 2005, at
[http://www.dhs.gov/dhspublic/display?t heme =44&content=4597&print=true].
85 DHS, “Secretary Michael Chertoff Announces the New Chief Medical Officer for the
Department of Homeland Security,” press release, July 14, 2005.
86 See comments of Kevin Yeskey, then chief executive officer of NDMS, in Paula Hartman
Cohen, “The Three Faces of NDMS,” Homeland Protection Professional, Aug. 2003.
mount a response as soon as possible, state and local officials were responsible for
emergency response in the first 72 hours following a disaster.87 After Hurricane
Katrina, a DMAT team member stated that FEMA was unable to support the
historical rapid-deployment capability of NDMS.88
NDMS teams are required to submit after-action reports following deployment,
in order that response planners can benefit from lessons learned in disaster response.
Some analyses of the NDMS response to Hurricane Katrina response have become
available, and more are expected, including one from DHS.89 Policymakers likely
will review the mission of NDMS and its alignment with national goals for terrorism
and disaster response. NDMS program authority expires at the end of FY2006.
Congress may decide to review the mission of NDMS and the role of DHS and
FEMA in supporting it, in general, and specifically in response to Hurricane Katrina,
as it considers reauthorization of the program.
Volunteer Health Professionals
Despite the deployment of all FEMA DMAT teams in the wake of Hurricane
Katrina, there were reports of overwhelmed field hospitals and triage centers, and
urgent calls from hospitals for more medical personnel. On September 3, HHS
issued a call for more volunteer health professionals (VHPs) to deploy, as federalized
employees, to the affected areas. All officers of the U.S. Public Health Service were
also put on alert for possible deployment.90 The NDMS, which was transferred from
HHS to the DHS in 2002, remains authorized within the Public Health Service Act,
where it is stated that the Secretary of HHS can augment emergency response
personnel by deploying volunteers as intermittent disaster response personnel under
NDMS.91 Volunteers could also potentially be deployed as temporary volunteers in
the Public Health Service, or as temporary federal employees.92 By September 19,
the call for additional personnel had been lifted.
87 See, for example, FEMA, “Can You Go It Alone For Three Days?” press release number:
88 Richard Knox, “New Orleans Airport as Field Hospital,” Morning Edition, National
Public Radio, Sept. 14, 2005.
89 See “The Decline of the National Disaster Medical System,” Committee on Government
Reform, Minority Staff, Special Investigations Division, Dec. 2005, at
[http://www.democrats.reform.house.gov/]; and Mimi Hall, “‘Significant Gaps’ Reported
in Disaster Medical System,” USA Today, Jan. 18, 2006.
90 HHS, “HHS Releases Website and Toll Free Number for Deployment by Health Care
Professionals,” press release, Sept. 3, 2005, and website at [https://volunteer.ccrf.hhs.gov/].
91 42 U.S.C. §300hh-11.
92 For a discussion of the three legal mechanisms, see James G. Hodge, Jr., et al., “Hurricane
Katrina Response, Legal Protections for Federalized Volunteer Health Personnel under a
Federal Declaration of Public Health Emergency,” The Center for Law and the Public’s
Health at Georgetown and Johns Hopkins Universities, memorandum, Sept. 15, 2005, at
[http://www.publichealthlaw.ne t/Research/K atrina.htm] .
The licensing of medical professionals is the responsibility of state authorities.
Federalized VHPs must hold a current license in at least one U.S. jurisdiction, and
the federal agency responsible for deployment bears the burden of verifying
credentials. Federalized VHPs are considered to be federal employees for purposes
of liability and compensation. VHPs can also deploy at the request of affected states,
as long as their state’s licensure and certification are recognized by the requesting
state. A number of legal mechanisms govern reciprocity in order to assure that VHPs
are protected from liability in the requesting state.93 One of the more challenging
aspects of accepting mutual aid is the ability to verify an individual’s qualifications.
The Health Resources and Services Administration (HRSA) notes:
According to reports, hospital administrators involved in responding to the
World Trade Center tragedy reported that they were unable to use medical
volunteers when they were unable to verify the volunteer’s basic identity,
licensing, credentials (training, skills, and competencies), and employment. In94
effect, this precious, needed health workforce surge capacity could not be used.
Following the terrorist attacks of 2001, Congress established a program to
develop a national database for verifying the licensure and credentials of VHPs
during emergencies.95 The Emergency System for Advance Registration of Volunteer
Health Professionals (ESAR-VHP), administered by HRSA, is designed to assist
state and local authorities in verifying the status of volunteer healthcare workers by
developing standards for a nationwide database and providing funding and technical
assistance to states in linking to it. The program is in its early stages, with pilots
beginning in several states, and was not ready for use in response to Hurricane
Katrina. The program was funded at $8 million in FY2005. The Administration
requested $8 million for FY2006, and Congress provided $4 million in final
appropriations. Senate appropriators had commented that states could use their
hospital preparedness grant funds to support this activity. Authority for the ESAR-
VHP program expires at the end of FY2006.
While Congress has explicitly tasked HHS, through HRSA, with a federal role
in creating a nationwide system for health professionals volunteers, the DHS Chief
Medical Officer (CMO) has also voiced an interest in coordinating this activity.96
DHS is expected to publish, in the Federal Register, a notice of delegation of
authority to the CMO. Until such time, comprehensive information on the scope of
the responsibilities and activities of this office, and how the CMO will coordinate
efforts with HHS, is not publicly available.
93 See CRS Report RS22255, Emergency Response: Civil Liability of Volunteer Health
Professionals, by Kathleen Swendiman and Nathan Brooks.
94 See HRSA, Emergency System for Advance Registration of Volunteer Health
Professionals, background, at [http://www.hrsa.gov/bioterrorism/esarvhp/].
95 42 U.S.C. § 247d-7b.
96 Comments of Jeffrey Runge, Chief Medical Officer, Department of Homeland Security,
before the House Committee on Homeland Security, Subcommittee on Management,
Integration, and Oversight, hearing on “The Department of Homeland Securityth
Second-Stage Review: The Role of the Chief Medical Officer,” Oct. 27, 2005, 109st
Congress, 1 sess., Washington, D.C., CQ Transcriptions.
The federal role in assisting states with licensure verification and other matters
involved in using VHPs during an emergency has been of interest to Congress.
Relevant legislation introduced following Hurricane Katrina includes S. 1638, which
would establish a National Emergency Health Professionals Volunteer Corps under
the Secretary of HHS, among other provisions, and H.R. 3736, which would provide
Hurricane Katrina volunteers, including health workers, immunity from liability. The
latter bill has passed the House and been referred to the Senate Judiciary Committee.
Health Information Technology
In response to Hurricane Katrina, the HHS Office of the National Coordinator
for Health Information Technology, working in collaboration with more than 150
public and private healthcare organizations, established an online service for
authorized health professionals to gain electronic access to prescription medication
records for evacuees. Medication data from a variety of government and commercial
sources — Medicaid, the Veteran’s Health Administration, private insurers, and
pharmacy benefit managers — was indexed and made accessible through a single
Internet portal (www.katrinahealth.org) to any licensed physician or retail pharmacist.
Comparable efforts made the immunization records of children who evacuated from
Louisiana available to public health officials in host states, and, through the use of
Medicaid billing records, allowed the reconstruction of rudimentary health records
for some of those who were displaced.97
HHS Secretary Leavitt noted that the disaster had made the case for a national
system of electronic health records (EHR), and that such a system could be useful in
general as well as for other emergencies such as pandemic influenza. The VA, which
uses a system of electronic health records for its beneficiaries, was able to provide
uninterrupted care to several hundred veterans who were evacuated from its medical
centers in Biloxi, Mississippi, and New Orleans, Louisiana, due to the hurricane.
Congress has taken several steps in recent years to implement a nationwide
health information technology (health IT) infrastructure.98 Several bills have been
introduced in the 109th Congress to boost federal investment and leadership in health
IT and provide incentives both for EHR adoption and for the creation of regional
health information networks, which are seen as an important step towards the goal
of interconnecting the health care system nationwide. (Examples include H.R. 2334,
S. 1262 and S. 1355.) On November 18, 2005, the Senate passed a bipartisan health
IT bill, S. 1418, which has been referred to the House for further consideration.
97 See Jennifer Jones and Bob Brewin, “Dodged the Storm but not the Crisis; Diaspora
Dispatches,” Federal Computer Week, Nov. 14, 2005; and CRS Report RS22310, Hurricane
Katrina: HIPAA Privacy and Electronic Health Records of Evacuees, by Gina Marie
98 See CRS Report RL32858, Health Information Technology: Promoting Electronic
Connectivity in Healthcare, by C. Stephen Redhead.
Additional CRS Reports
CRS Report RS22292, Hurricanes Katrina & Rita: Addressing the Victims’ Mental
Health and Substance Abuse Treatment Needs, by Erin D. Williams.
CRS Report RS22279, Hurricane Katrina and Veterans, by Sidath Viranga
CRS Report RL33083, Hurricane Katrina: Medicaid Issues, by Evelyne
Baumrucker, April Grady, Jean Hearne, Elicia Herz, Richard Rimkunas, Julie Stone,
and Karen Tritz.
CRS Report RS22254, The Americans with Disabilities Act and Emergency
Preparedness and Response, by Nancy Lee Jones.
CRS Report RS22255, Emergency Response: Civil Liability of Volunteer Health
Professionals, by Kathleen Swendiman and Nathan Brooks.
CRS Report RS22252, Older Americans Act: Disaster Assistance for Older Persons
After Hurricane Katrina, by Carol O’Shaughnessy.
CRS Report RS22235, Disaster Evacuation and Displacement Policy: Issues for
Congress, by Keith Bea.
CRS Report RL32803, The National Preparedness System: Issues in the 109th
Congress, by Keith Bea.
CRS Report RL32858, Health Information Technology: Promoting Electronic
Connectivity in Healthcare, by C. Stephen Redhead.
CRS Report RS22310, Hurricane Katrina: HIPAA Privacy and Electronic Health
Records of Evacuees, by Gina Marie Stevens.
CRS Report RL31719, An Overview of the U.S. Public Health System in the Context
of Emergency Preparedness, by Sarah A. Lister.