Order Code RL33096
CRS Report for Congress
Received through the CRS Web
Hurricane Katrina:
The Public Health and Medical Response
September 21, 2005
Sarah A. Lister
Specialist in Public Health and Epidemiology
Domestic Social Policy Division
Congressional Research Service { The Library of Congress

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Hurricane Katrina:
The Public Health and Medical Response
Summary
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 is one of the worst natural disasters in the
nation’s history. Early estimates are that hundreds of people were killed and about
one million displaced.
In response to a series of disasters and terrorist attacks over the past decade, and
especially since 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 bioterrorism
preparedness legislation in 2002. Congress also created a new 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, has 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 Hurricane Katrina 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 resultant difficulties
in coordination challenged response efforts in this disaster as with others before it.
Hurricane Katrina also pushed some response elements, such as plans for surge
capacity in the healthcare workforce, to their limits for the first time in recent
memory. The public health and medical 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 National Response Plan 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 Hurricane Katrina.
This report will be updated as circumstances warrant.

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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Federal Authorities and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The Stafford Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The National Response Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Declarations of Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . 4
The Public Health Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Public Health Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
HHS Agency Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
HHS Office of the Secretary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Agency for Toxic Substances and Disease Registry . . . . . . . . . . . . . . . 8
Centers for Disease Control and Prevention . . . . . . . . . . . . . . . . . . . . . 8
Food and Drug Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
National Institutes of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Substance Abuse and Mental Health Services Administration . . . . . . . 9
The Medical Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Medical and Healthcare Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
HHS Agency Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Centers for Medicare and Medicaid Services . . . . . . . . . . . . . . . . . . . 11
Health Resources and Services Administration . . . . . . . . . . . . . . . . . . 12
DHS Agency Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
National Disaster Medical System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Department of Defense . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Department of Veterans Affairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Issues for Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
All-Hazards Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Coordinated Needs Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
National Disaster Medical System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Continuity of Operations and Evacuation of Healthcare Facilities . . . . . . . 19
Volunteer Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Health Information Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Additional CRS Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

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Hurricane Katrina:
The Public Health and Medical Response
Introduction
Hurricane Katrina struck the Gulf Coast in late August 2005, causing
catastrophic wind damage and flooding, and leading to Presidential disaster
declarations for Alabama, Florida, Louisiana and Mississippi. The storm is one of
the worst natural disasters in the nation’s history. Early estimates are that hundreds
of people were killed and about one million dislocated.
Public health and medical response personnel have been faced with a myriad of
challenges in assuring the health of Katrina’s victims. First, there are the immediate
medical needs of persons who were injured, or whose care for chronic conditions
lapsed when they were cut off from services. Rendering ongoing care to thousands
of displaced persons involves restoring lost medical records and reworking the
mechanisms that finance their care. The short and long-term mental health needs of
victims and responders also have to be addressed.
Assuring access to fresh water and restoring safe sewage handling is an
immediate public health need. Additional public health challenges include keeping
response workers safe, preventing diseases from spreading in shelters, assuring the
safety of food supplies, and controlling mosquitoes. Public health surveillance and
laboratory systems must be ramped up to take in and analyze important information
about population health status in affected areas, host states, shelters and other sectors,
in order that problems can be recognized and addressed promptly.
The logistical hurdles posed by Hurricane Katrina have been 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 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 remains a challenge.
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,

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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. In the wake of Hurricane Katrina, Congress is likely to review the
Hurricane Katrina response in light of recent public health preparedness laws and the
NRP. Even the best plan and response may still be temporarily 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 Hurricane Katrina. The roles and response
activities of selected agencies in HHS and the Department of Homeland Security
(DHS) will be discussed. Finally, a number of issues that Congress may decide to
consider will be presented. 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 declarations,
whereupon federal agencies are authorized to provide assistance to states
overwhelmed by disasters.1 Through executive orders, the President has delegated
to the Federal Emergency Management Agency (FEMA), within the (DHS),
responsibility for administering the major provisions of the Stafford Act. Thus far
in calendar year 2005, President Bush has issued 32 major disaster declarations,
including those in Alabama, Florida, Louisiana, and Mississippi for Hurricane
Katrina.2
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 care, 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
1 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.
2 For a list of major disaster declarations, see FEMA, “Federally Declared Disasters by
Calendar Year,” at [http://www.fema.gov/library/drcys.shtm].

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to the FEMA assistance authorized by the Stafford Act, a wide range of aid is
provided by other federal agencies under 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.3 The NRP was
released by the 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.4 HHS is responsible for coordinating the following
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;
! Health surveillance;
! Medical care personnel;
! Health and medical equipment and supplies;
! Patient evacuation;
! Patient care;
! 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).
3 See CRS Report RL32803, The National Preparedness System: Issues in the 109th
Congress, by Keith Bea.
4 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.

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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.5
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
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
commence.
Most of HHS’s primary 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.
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.6 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
expansions of federal public health authority in emergencies.
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.7
Following the 2001 terror attacks, Congress updated this authority in the Public
5 HHS, “Concept of Operations Plan (CONOPS) for Public Health and Medical
Emergencies,” Mar. 2004, at [http://www.hhs.gov/nvpo/pandemicplan/hhs_conops.pdf].
6 A listing of legal authorities invoked by Hurricane Katrina-affected states is provided by
the American Health Lawyers Association at
[http://www.healthlawyers.org/Content/NavigationMenu/News_Center/Hurricane_Katri
na_Resources.htm]. For a discussion of the exercise of federal and state authorities in
response to the recent shortage of influenza vaccine, see CRS Report RL32655, Influenza
Vaccine Shortages and Implications, by Sarah A. Lister.
7 42 U.S.C. §247d.

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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.)8 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 —
(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 in
paragraphs (1) and (2).9
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 7.10 Before Hurricane Katrina, the only prior 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 and assume public health
authorities that are generally reserved to states, though the Secretary does have
8 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.
9 42 U.S.C. §247d.
10 HHS public health emergency declarations in response to Hurricane Katrina are found at
[http://www.hhs.gov/emergency/emergency.html].

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specific emergency authority elsewhere in statute to impose domestic quarantine
restrictions when warranted.11
The Public Health Response
Overview
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)12 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 Hurricane Katrina, the costs of HHS response
activities will generally be reimbursed through the DRF administered by FEMA.13
Given the scope of the public health disaster caused by Hurricane Katrina,
virtually all agencies and offices in HHS are engaged in the response.14 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
section.
Public Health Challenges
Many of the public health challenges posed by Hurricane Katrina are 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 in the aftermath of hurricanes and floods.
Hurricanes and floods also carry in their wake some predictable causes of death,
11 See CRS Report RL31333, Federal and State Isolation and Quarantine Authority, by
Angie Welborn.
12 For more information, see the OPHEP Home Page at
[http://www.hhs.gov/ophep/index.html]. The role of the OPHEP is further explained in
HHS, “Office of Public Health Emergency Preparedness Statement of Organization,
Functions, and Delegations of Authority,” 70 Federal Register 5183, Feb. 1, 2005.
13 For more information, see CRS Report RL33053, Federal Stafford Act Disaster
Assistance: Presidential Declarations, Eligible Activities, and Funding, by Keith Bea.
14 For more information on specific agency activities see HHS, “What HHS Agencies Are
Doing,” at [http://www.hhs.gov/katrina/hhsagencies.html].

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including automobile crashes, drowning, carbon monoxide poisoning, and chronic
conditions exacerbated by the loss of access to the healthcare system.15
The catastrophic scope of Hurricane Katrina has led to some unusual public
health threats. News reports suggest 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, or where they had pre-existing
medical conditions. There were also reports of homicides and suicides.
CDC has made several specific recommendations for infectious disease control
in the aftermath of Hurricane Katrina, including the immunization of emergency
responders, relief workers and evacuees. The agency has expressed particular
concern about the risks of tetanus from wounds, and of influenza, measles,
chickenpox and hepatitis A in crowded conditions where some children may not have
current immunizations.16 CDC also alerted health officials and others to cases of
Vibrio infection in hurricane victims.17 CDC has 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. As of September 11, CDC reported 22 cases and five
deaths from Vibrio infection.
As the waters in southern Louisiana recede, New Orleans and surrounding
parishes will ideally be evaluated for potential environmental health hazards before
dwellings are reoccupied. CDC and the Agency for Toxic Substances and Disease
Registry (ATSDR) may assist the Environmental Protection Agency (EPA) in this
activity.
The short-and long-term mental health needs of victims and responders must 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.
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 has set up a website cataloging departmental and agency actions and
15 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].
16 See CDC, “Immunization Information for Hurricane Katrina,” at
[http://www.bt.cdc.gov/disasters/hurricanes/immunizations.asp].
17 CDC, “Vibrio Illnesses After Hurricane Katrina — Multiple States, August-September
2005,” MMWR, vol. 54/Dispatch, Sept. 14, 2005. Vibrio is a bacterial pathogen found in
salty and brackish waters, that can cause foodborne illness or severe wound infection.

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other information regarding Hurricane Katrina.18 As noted above, the HHS Secretary
has declared federal public health emergencies in several states. The Office of the
Surgeon General and the OPHEP are in the process of mobilizing and identifying
healthcare professionals and relief personnel to assist in relief efforts.
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. 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 all 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 11th and anthrax attacks of 2001, though
there is still work to be done in assuring that all relevant state agencies have
continuous EOC communication with those at the federal level.19
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 of
exposure to hazardous substances in the environment.20 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. While ATSDR has not reported any
Katrina-related activity in the early weeks of the response, the agency may be asked
by various parties, including affected states and localities, to carry out these
activities.
Centers for Disease Control and Prevention. The CDC has launched
a website to provide public health information in the aftermath of Hurricane
Katrina.21 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 provides daily updates
18 See [http://www.hhs.gov/katrina/index.html].
19 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.
20 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.
21 See [http://www.bt.cdc.gov/disasters/hurricanes/index.asp].

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from the CDC Director’s EOC.22 Once activated, the EOC is 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.
As of September 16, 2005, CDC had more than 150 staff in 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 has deployed more than 350
staff to its EOC response. The agency has also deployed the Strategic National
Stockpile of drugs and medical supplies to affected states. Among the specific
supplies delivered for this disaster are: 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) ventilator kits. The agency has also made numerous public
health recommendations to address the anticipated and atypical threats posed by
Hurricane Katrina and its aftermath.
Responder groups may be at increased risk from certain hazards in the aftermath
of disasters. CDC’s National Institute for Occupational Safety and Health (NIOSH)
has developed assessment tools for occupational safety and health in hospitals, health
departments, and shelters involved in the response to Hurricane Katrina.23
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, as well as guidance in ensuring the
safety of food.24
National Institutes of Health. The National Institutes of Health (NIH) has
set up a phone-based medical consultation service for providers treating victims or
evacuees from the Hurricane Katrina disaster, and has mobilized bed capacity within
its medical system, among other activities.25
Substance Abuse and Mental Health Services Administration.26 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) is focused on providing resources to aid in the recovery process following
22 See [http://www.cdc.gov/od/katrina/].
23 See CDC NIOSH, [http://www.cdc.gov/niosh/topics/flood/#new].
24 See [http://www.fda.gov/oc/opacom/hottopics/hurricane.html].
25 See [http://www.nih.gov/about/director/hurricanekatrina/index.htm].
26 This section contributed by Erin D. Williams, Specialist in Bioethical Policy.

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CRS-10
Hurricane Katrina, and has established a toll-free hotline for people in crisis in the
aftermath of this disaster.27
SAMHSA has three main mechanisms to provide funding to address Katrina
victims’ mental health needs: 1) the Crisis Counseling Assistance and Training
program (CCP), 2) SAMHSA Emergency Response Grants (SERG), and 3)
supplemental appropriations. The CPP 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.28 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.
The Medical Response
Overview
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.29
Another critical medical response asset, the National Disaster Medical System
(NDMS) was transferred from HHS to DHS in the Homeland Security Act (P.L. 107-
296) effective in March 2003.
Though national disaster planning has long anticipated the need to be able 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.
27 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.
28 See [http://www.fema.gov/library/stafact.shtm#sec416], and 66 FR 51873, Oct. 11, 2001.
29 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
[http://oep.osophs.dhhs.gov/ccrf/].

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CRS-11
Hurricane Katrina is such an incident and will no doubt prompt a careful evaluation
of the response and the structures and authorities supporting it. Hurricane Katrina
is also a mass fatality event.30 There have been such events in the United States
recently, including the terrorist attacks of September 11, 2001, and several jetliner
crashes.
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 themselves
and 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 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.
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 medical
records along the way. Public health emergencies were declared in nine states that
did not suffer primary impacts from the storm but that became hosts to large numbers
of evacuees needing healthcare. HHS granted a series of emergency waivers to assist
individuals and providers in host states, so that those who were eligible for Medicaid
or SCHIP would continue to be covered when displaced.31 Healthcare facilities
sought assistance in covering the costs of care for those who were previously
uninsured or newly uninsured.
While the dead have yet to be fully counted, Hurricane Katrina was a mass
fatality event. Urban Search and Rescue Teams and everyday citizens attended first
to rescue missions for the living, then transitioned to recovery missions for those who
did not survive. Morgues have been set up in Louisiana and Mississippi to house and
identify the dead.
30 A mass fatality event is defined as any situation in which there are more human bodies to
be recovered and examined than can be handled by the usual local resources.
31 HHS, “HHS Declares Public Health Emergency for Hurricane Katrina: Waiver Under
Section 1135 of the Social Security Act,” Sept. 4, 2005, at
[http://www.hhs.gov/katrina/ssawaiver.html].

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CRS-12
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, has taken several actions to streamline access to healthcare for
those displaced by Hurricane Katrina and their providers. Many evacuees have
crossed state lines and may not have proper documentation of program eligibility.
HHS Secretary Leavitt has 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 providers. Implementation plans for these
waivers are in development.32
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. 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.33 The agency has issued a Program Information Notice clarifying
that providers who normally provide services under the liability protections of federal
employment in certain HRSA-supported health centers will continue to receive
protection in providing services at temporary locations established in response to the
hurricane.34 HRSA also administers two relevant programs in bioterrorism
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.35 The other
is a program for the advance registration of volunteer health professionals.36 The
latter program is discussed in a subsequent section on Issues for Congress.
DHS Agency Actions
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.37 NDMS was most recently
32 See CRS Report RL33083 , Hurricane Katrina: Medicaid Issues, by Evelyne Baumrucker,
April Grady, Jean Hearne, Elicia Herz, Richard Rimkunas, Julie Stone, and Karen Tritz.
33 HHS, “Secretary Leavitt Announces Advance of Health Center Funds to Hurry Services
to Hurricane-Affected Areas,” press release, Sept. 9, 2005.
34 See HRSA, “Federal Tort Claims Act Coverage for Deemed Consolidated Health Center
Program Grantees Responding to Hurricane Katrina,” Program Information Notice 2005-19,
Sept. 6, 2005, at [http://www.hrsa.gov/katrina/].
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, p. 42.
36 See [http://www.hrsa.gov/bioterrorism/index.htm].
37 See the NDMS home page at [http://www.ndms.dhhs.gov/], and Jerry L. Mothershead et
(continued...)

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CRS-13
reauthorized through 2006 in the Public Health Security and Bioterrorism
Preparedness and Response Act (P.L. 107-188),38 and was transferred to DHS in the
Homeland Security Act effective in March 2003.39 NDMS is administered by FEMA
in the DHS Emergency Preparedness and Response Directorate, 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. As of September 9, 2005, FEMA reported that
it had deployed more than 87 NDMS teams in response to the hurricane.40
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 reports 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.41
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.42
37 (...continued)
al., “Bioterrorism Preparedness III: State and Federal Programs and Response,” Emergency
Medicine Clinics of North America, vol. 20, 2002, pp. 477-500.
38 42 U.S.C. §300hh.
39 6 U.S.C §312 et. seq.
40 See DHS, “Hurricane Katrina: What Government Is Doing,” Sept. 9, 2005, at
[http://www.dhs.gov/interweb/assetlibrary/katrina.htm].
41 Jeff Jones, “N.M. Team Has Praise for Superdome: Medical Staff Says Stadium Saved
Katrina Victims’ Lives,” Albuquerque Journal, Sept. 8, 2005.
42 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.

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CRS-14
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 local medical examiners, with assistance from DMORT personnel and
federal funding through the NDMS appropriation. DMORT sites have been set up
in Gabriel, Louisiana, and Gulfport, Mississippi, each site with four DMORT teams
and one portable morgue.43
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. All four VMAT teams were deployed to the
Gulf Coast and are providing care for displaced companion animals and support for
damaged or destroyed veterinary practices.44
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.45
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 Disaster Relief Fund, it has a regular annual
appropriation. NDMS is funded through the Public Health Programs account under
43 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.
44 See VMAT Team home page at [http://www.avma.org/disaster/vmat/default.asp]; and
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].
45 See NDMS FCC page at [http://ndms.dhhs.gov/fcc.html].

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the DHS Preparedness and Response title, and received $34 million in FY2005.46 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 Disaster Relief Fund to maintain Katrina-related NDMS
response operations.
Department of Defense
During a presidentially-declared disaster and pursuant to the NRP, the
Department of Defense assists the Secretary of HHS with numerous ESF#8
responsibilities. These include evacuating patients, locating or providing hospital
beds, and additional personnel and supplies, and providing specialized laboratory
testing and other technical assistance.47
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.48
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.49
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
storm-ravaged areas50
46 See Table 6 in CRS Report RL32302, Appropriations for FY2005: Department of
Homeland Security, by Jennifer E. Lake and Blas Nuñez-Neto.
47 See NRP ESF Annex #8, Public Health and Medical Services, p. 9.
48 DHS, “What Government Is Doing,” press release, Sept. 13, 2005.
49 See NRP ESF Annex #8, Public Health and Medical Services, p. 12.
50 VA Under Secretary for Health Jonathan B. Perlin, briefing to congressional staff on
Hurricane Katrina response, Sept. 8, 2005.

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CRS-16
Issues for Congress
All-Hazards Preparedness
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 comparable 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.”51 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).52
Early 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 shut down,
operations were quickly diverted to branch public health laboratories in Shreveport,
Lake Charles and Amite.53 State authorities worked with the national association,
neighboring states, and the U.S. Postal Service to re-route test specimens ( including
ramped-up surveillance for infectious diseases) through appropriate neighboring
facilities. This 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.
51 42 U.S.C. §247d-3a.
52 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.”
53 Association of Public Health Laboratories, Hurricane Katrina information, at
[http://www.aphl.org/].

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CRS-17
Coordinated Needs Assessments
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. 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 activities.54
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.55 The tool is not designed to assess critical medical or mental health needs.
The CDC has conducted these assessments for several foreign disasters, and most
recently following Tropical Storm Allison in Texas in 2001.56
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 them as effectively as possible. However, the response to
public health and medical needs may be delayed until response has been made to
other problems such as civil disorder or the lack of physical access. Therefore,
coordinating the assessments across all sectors is essential.
Policy issues may include how well the FEMA ERT-A process supported the
more specific goal of assessing public health needs following Hurricane Katrina, and
how effective medical and mental health needs assessments conducted following a
disaster are. 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?
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
Homeland Security Act of 2002 (P.L. 107-296). The cited intent of this transfer,
which was proposed by the Administration, was to assure a coordinated federal
response to terrorism and other disasters. The Government Accountability Office
54 NRP, p. 40.
5 5 See CDC Disaster Epidemiology and Assessment home page at
[http://www.cdc.gov/nceh/hsb/disaster/surveillance.htm].
56 CDC, “Tropical Storm Allison Rapid Needs Assessment — Houston, Texas, June 2001,”
MMWR, 51(17), 365-9, May 3, 2002.

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CRS-18
(GAO) supported the transfer.57 But since then, some NDMS team members have
complained that the program has not received adequate administrative support under
FEMA.58 There are two organizational issues that may be relevant to this concern.
In addition, there are concerns that teams may not be adequately prepared for events
they do not regularly encounter, such as biological or chemical attacks.
Regarding organizational issues, the mission of NDMS teams is to provide
direct medical services. Some team members have stated that the specific needs and
challenges of the medical mission are not understood by FEMA management.59 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.60 Chertoff announced that he proposed to split the existing
Emergency Preparedness and Response Directorate (which houses FEMA and
NDMS) into two separate directorates, for distinct activities in preparedness and
response, respectively. He announced the appointment of a chief medical officer, 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
state governments.
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 mitigate
biologically-based attacks on human health or on our food supply.61
While not stated in Chertoff’s remarks or in other publicly available documents,
FEMA has confirmed that according to the 2SR proposal, NDMS is to remain under
57 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.
58 See, for example, Star Lawrence, “Culture Shock,” Homeland Protection Professional,
Apr. 2005.
59 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.
60 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.
61 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?theme=44&content=4597&print=true].

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CRS-19
FEMA in the proposed response division.62 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 chief medical officer position,
since that individual would be in a different directorate. The 2SR proposal was to
be implemented on October 1, 2005, and there are no reports that this timeline has
been altered in the aftermath of Hurricane Katrina.
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.63
FEMA has historically operated under the planning assumption that while it would
mount a response as soon as possible, state and local officials were responsible for
emergency response in the first 72 hours following a disaster.64 After Hurricane
Katrina, a DMAT team member stated that FEMA was unable to support the
historical rapid-deployment capability of NDMS.65
An additional concern about NDMS, which may be independent of a discussion
about its administrative home, is that team members may not be prepared to address
medical challenges which they do not regularly encounter. Most DMAT team
members come from a background in emergency medicine. They generally have the
versatility and breadth of expertise needed to handle the polyglot of maladies seen
in emergency departments, and this is likely to have served them well in their
response to Hurricane Katrina. The concern is whether they are ready to handle
something none of them may have seen before, such as an attack with a biological or
chemical weapon.
NDMS teams are required to submit after-action reports following deployment,
in order that response planners can benefit from lessons learned in disaster response.
As after-action reports on the Katrina response become available, policymakers likely
will review the mission of NDMS and its alignment with national goals for terrorism
and disaster response. For example, Congress may decide to review the functions of
NDMS and the role of DHS and FEMA in supporting them, in general, and
specifically in response to Hurricane Katrina.
62 Communication with Raymond Miller, Senior Congressional Liaison, DHS/FEMA, July
26, 2005.
63 See comments of Kevin Yeskey, then chief executive officer of NDMS, on p. 30 in Paula
Hartman Cohen, “The Three Faces of NDMS,” Homeland Protection Professional, Aug.
2003.
64 See, for example, FEMA, “Can You Go It Alone For Three Days?” press release number:
1354-41, Jan. 31, 2001, at [http://www.fema.gov/news/newsrelease.fema?id=7591].
65 Knox, “National Public Radio, Sept. 14, 2005.

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CRS-20
Continuity of Operations and Evacuation of Healthcare
Facilities
There were numerous reports of problems in healthcare facilities in southeastern
Louisiana (including the city of New Orleans and surrounding parishes) that did not
evacuate and were flooded by Hurricane Katrina’s storm surge, or that had to be
evacuated on an emergency basis when they were unable to care for their patients
after power, water and food were cut off for several days. Charges of negligent
homicide were filed against the owners of a nursing home whose residents were not
evacuated before the hurricane, and later died in the facility.66 There were also
reports of successful evacuations. For example, VA evacuated two of its stricken
facilities — one in Biloxi, Mississippi, before the storm, the other in New Orleans
after the storm had passed and the city flooded — without loss of life.
The mandatory evacuation order issued by the city of New Orleans on August
28 excluded hospitals and their patients.67 Given the nature of their business,
hospitals are generally able to continue operations in the face of power outages
because they employ generators to maintain critical life-support functions in an
emergency. For this and other reasons, hospitals are generally better equipped to
“ride out” an incident than are many other types of facilities. 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. Health care 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 chose to continue operations ultimately had
to evacuate.
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),68 as well as through conditions of participation
(CoPs) for Medicare and Medicaid. Numerous references are made in regulation
governing CoPs referring to the need for evacuation plans and drills, usually with
respect to fire emergencies.69 In addition, facilities are required to have
comprehensive disaster plans, which are to include evacuation components.70
66 Doug Simpson, “La. Nursing Home Owners Charged in Deaths,” Associated Press, Sept.
13, 2005.
67 Civil District Court for the Parish of New Orleans, State of Louisiana, City of New
Orleans, “Promulgation of Emergency Orders,” undated document, at
[http://www2a.cdc.gov/phlp/docs/NewOrleansEmergencyOrders.pdf].
68 See “Evacuation Strategies for Disaster Planning,” Healthcare Hazard Management
Monitor, vol. 15, no. 8, Apr. 2002.
69 See, for example, 42 C.F.R. §482.41, 42 C.F.R. §483.470, and 42 C.F.R. §485.62.
70 See, for example, 42 C.F.R. 485.64 and 42 C.F.R. 485.727.

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CRS-21
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.
Volunteer Health Professionals
Despite the deployment of all FEMA DMATs 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.71 The NDMS, which was transferred from HHS to the
DHS in 2002,72 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.73
Volunteers could also potentially be deployed as temporary volunteers in the Public
Health Service, or as temporary federal employees.74 By September 19, the call for
additional personnel had been lifted. It is not known whether health professionals
who signed up in response to the earlier HHS announcement were deployed, or if so,
what legal mechanism was used for their deployment.
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 governs reciprocity in order to assure that
VHPs are protected from liability in the requesting state.75 One of the more
challenging aspects of accepting mutual aid in this case is the ability to verify an
individual’s credentials. The Health Resources and Services Administration (HRSA)
notes:
71 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/].
72 6 U.S.C §312.
73 42 U.S.C. §300hh-11.
74 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.net/Research/Katrina.htm].
75 See CRS Report RS22255, Emergency Response: Civil Liability of Volunteer Health
Professionals, by Kathleen Swendiman and Nathan Brooks.

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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. In
effect, this precious, needed health workforce surge capacity could not be used.76
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.77 The Emergency System for Advance Registration of
Volunteer Health Professionals (ESAR-VHP), which is 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 the database. 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,
and $8 million was requested for FY2006.78 FY2006 appropriations are pending.
Whether the mechanisms available to HHS and DHS to deploy VHPs in
emergencies are adequate, and how well those mechanisms would coordinate with
each other, may be an issue. Congress may decide to review whether there is an
adequate oversight and command structure to support deployments of federalized
volunteers, as an alternative or complement to assisting states in identifying and
deploying them. Relatedly, the federal role in assisting states with license
verification and other matters involved in using VHPs during an emergency may be
assessed. Relevant legislation introduced following the hurricane includes S. 1638,
which would establish a National Emergency Health Professionals Volunteer Corps
under the Secretary of HHS, among other provisions.
Health Information Technology
On September 8, HHS Secretary Mike Leavitt said that about 1 million people
had been displaced because of Hurricane Katrina, and that most of them did not have
access to their medical records.79 The department has launched a nationwide
electronic records system for Katrina evacuees, incorporating records from pharmacy
chains and, eventually, laboratories, VA health facilities, and the Mississippi and
Louisiana Medicaid programs.80
76 See HRSA, Emergency System for Advance Registration of Volunteer Health
Professionals Background, at [http://www.hrsa.gov/bioterrorism/esarvhp/].
77 Section 107, Public Health Security and Bioterrorism Preparedness and Response Act of
2002 (P.L. 107-188), 42 U.S.C. § 247d-7b.
78 In their reports on appropriations for FY2006, both the House (H.Rept. 109-143) and
Senate (S.Rept. 109-103) comment on an administration proposal to consolidate
credentialing activities within the Office of the Secretary.
79 American Health Line, “Leavitt Promotes Health Care IT Uses in National Emergencies,”
Sept. 9, 2005.
80 Jonathan Krim, “Health Records of Evacuees Go Online,” Washington Post, Sept. 14,
(continued...)

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Leavitt commented that the disaster had made the case for a national system of
electronic health records (EHR), noting that such a system would 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.81 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, S. 1355.) On July 27, the Senate Committee on Health, Education, Labor,
and Pensions reported a bipartisan health IT bill, S. 1418. Similar legislation is being
developed in the House.
Additional CRS Reports
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.
80 (...continued)
2005.
81 See CRS Report RL32858, Health Information Technology: Promoting Electronic
Connectivity in Healthcare, by C. Stephen Redhead.

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CRS Report RL31719, An Overview of the U.S. Public Health System in the Context
of Emergency Preparedness, by Sarah A. Lister.

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