Ten years ago, the nation watched in shock as Hurricane Katrina devastated the city of New Orleans. Katrina was followed closely by Hurricane Rita, impacting Western Louisiana, and these storms collectively have become synonymous with systemic failure of disaster preparedness, response, and recovery policy. They provided a wake-up call to government agencies, politicians, and community agencies alike.
That following year, Congress created, among other things, an Office of the Assistant Secretary for Preparedness and Response (ASPR) in the US Department of Health and Human Services (HHS), with a mandate to reach across government sectors and coordinate federal efforts to prevent, prepare for, and respond to the adverse health effects of public health emergencies and disasters. While we mark this 10-year anniversary with remarkable progress, we must acknowledge an ever growing obstacle: a national attention deficit.
The following blog post highlights the progress we have made and the challenges that remain.
Developing A National Response Capability
At the time of Hurricane Katrina, the public health, health care, and emergency management communities along the Gulf Coast were poorly integrated and lacked the systems, mechanisms, and plans to coordinate an effective, cross-jurisdictional response.
Today, our national approach to preparing for health emergencies is guided by a National Health Security Strategy, which recognizes that disasters require coordinated actions on the part of all stakeholders, governmental and non-governmental alike. It also recognizes that strong, day-to-day systems, ranging from public health surveillance to a well-functioning trauma and emergency care system, are critical to disaster response.
A National Response Framework informs a unified, multi-sector national approach to providing information to a broad coalition of community organizations during emergencies and disasters. Incident command systems are used not only by traditional first responders, but also by virtually every health department and a majority of hospitals in the country, improving coordination during disasters. Basic capabilities that public health and medical care systems must have to be disaster ready are clearly articulated, and federal guidance and funding supports states and health care entities in achieving these capabilities.
When disasters strike, ASPR coordinates the federal medical and public health aspects of the response across HHS and the rest of the United States government. The response to Superstorm Sandy, the largest natural disaster since Katrina, demonstrated progress and remaining gaps in this national response capability. Although far from perfect, there was better coordination between governmental components, the private sector, and emergency responders. The National Disaster Medical System and U.S. Public Health Service teams responded in hours, rather than days, to requests for assistance.
At times, the health sector and emergency managers lacked sufficient understanding of one another’s needs and challenges. For example, fuel shortages and restricted transportation into New York City meant that critical health care facility generators couldn’t refuel and their personnel, including those who provided substantial amounts of home health care, could not get to work or reach their patients, thus causing many more people to require evacuation to hospitals and shelters.
Strengthening Health Care System Preparedness
When Hurricane Katrina struck, many health care facilities in affected areas lacked the plans and resources to care for their patients through the disaster, especially as resources became scarce. Many facilities lacked basic evacuation plans, redundant communications infrastructure, electronic medical records, or backup generators. Thus, when hospitals lost power during the storm, they were unable to evacuate patients, their medical equipment stopped working, they were cut off from emergency managers who might have been able to provide help, and they were unable to transfer important health information because their paper-based records were destroyed.
We now recognize that all health care facilities, not just hospitals, must plan for disasters, have the basic equipment necessary to sustain operations and be able to allocate scarce resources fairly, and that such planning must take place with the recognition that each facility does not exist in a vacuum. The nation has invested significantly in public health and health care system preparedness and in strengthening these day-to-day systems through electronic health records, equipment such as generators and temporary hospitals, and through training and exercising, building resilience at the local, state, and federal levels.
The investments enhance the ability of communities and states to handle larger disasters without emergency federal assistance such as that provided through the National Disaster Medical System (NDMS). At the same time, the NDMS is stronger and its teams are able to deploy more quickly to support a broader array of needs when needed. A growing number of health care coalitions—increasingly comprised of most of the health care entities in a community—are better able to coordinate their local medical response during disasters.
For example, after both the 2013 Boston Marathon Bombings and the 2015 Philadelphia Amtrak crash, when casualties needed to be addressed within a few hours, coalitions, which had been developed with federal support, helped direct patients to specific hospitals so that no one facility was overwhelmed. The benefits of this broader community-based approach were evident during Superstorm Sandy, when hospitals were able to effectively implement their evacuation plans and safely transfer patients to other facilities while maintaining continuity of care.
In contrast, many nursing homes, adult care facilities, and some dialysis centers had not sufficiently planned how to care for patients if facilities flooded or lost power, and many patients needed to be evacuated to shelters or other facilities and receive care there. This shortcoming highlighted the need for sustained focus on community-wide disaster planning. Because of the extent of the damage and displacement of populations, the local health care system did require federal support; the National Disaster Medical System deployed teams and was operational within about four hours of the request for assistance.
In addition, electronic health records (EHRs) can provide support for accessing a patient’s health records during a disaster. Following Hurricane Katrina, the Office of the National Coordinator for Health Information Technology stepped in to support the development of a makeshift electronic health record to provide pharmacy and other information for evacuated residents. Funding from the HITECH Act subsequently offset the cost of adopting electronic health records in practice and supported community infrastructure to build information exchange platforms that can allow data to move with people, everyday and in disaster. After a tornado struck Joplin, Missouri in 2011, medical personnel working out of a temporary mobile hospital accessed patients’ electronic health records using remote support, and then transferred those records upon the patients’ move to other facilities. Many community health centers and physicians without EHRs never reopened.
The HHS Office of the National Coordinator for Health Information Technology has prioritized the need for individuals’ health data to follow them in times of disaster; remotely hosted and cloud back-up are making this increasingly possible. Unfortunately, interoperable EHRs are not yet a reality in many communities, but they should be. By sustaining emergency preparedness and continuing to strengthen our health data system, we can continue to improve response and ensure continuity of care during disasters.
Making Behavioral Health Part Of A Health Response
Following Hurricane Katrina, many individuals with chronic mental illness were displaced and unable to access care, resulting in an increase in suicides and mental health crises in the areas immediately affected by the storm as well as in neighboring states that absorbed displaced residents. Those without a history of mental illness were also severely affected, with some studies finding that the prevalence of mental illness among New Orleans residents doubled in the months following the storm. Emergency responders, who were exposed at high levels to significant death and destruction, experienced behavioral health challenges at even higher rates than the rest of the affected population.
Today, behavioral health is incorporated into the formal federal disaster response, addressing the needs of survivors and responders. Following the Sandy Hook shootings and the Boston Marathon bombings, HHS deployed mental health response teams to help affected communities along with first responders who, in the acute aftermath of the tragedy, provided services until the community could implement its own plans.
After the Deepwater Horizon Oil Spill, Substance Abuse and Mental Health Services Administration launched a national Disaster Distress Line for individuals in areas affected by disasters to access help or psychological support. The Distress Line often is publicized in communities affected by disasters, even those that do not require additional federal support.
Further, psychological first aid training and tools have been developed and made available so every community can better anticipate and address the behavioral needs of responders throughout the response and recovery phases. To sustain preparedness, both residents’ and responders’ behavioral health needs must be considered in community response and recovery plans.
‘Whole Community’ Approach To Disaster Planning
The failure to anticipate the profound health and social needs of the Katrina-affected population was avoidable. Numerous federal data sets that detailed population characteristics and their health status were widely available; the response system should not have been surprised that the population had high rates of chronic disease, and poverty was rampant.
Now, a mapping platform is used to aggregate and map information about populations (e.g. demographics, language spoken), community resources (e.g. location of health care facilities), and vulnerabilities (e.g. chronic disease status, electricity-dependent populations, flood-prone zones). Federally deployed teams, such as those of the National Disaster Medical System (NDMS), can be purposely amplified to include providers whose language skills match those of the affected population to enhance communication and better address their health care needs.
More recently, ASPR and the Centers for Medicare and Medicaid Services developed a way to identify individuals who have electricity-dependent durable medical equipment, are on dialysis, receive home health care services—or are oxygen-dependent; this information can now be used to inform local community disaster planning. In an emergency, additional information, such as addresses of individuals with particular access and functional needs, can be made available to a health department official in a HIPAA-compliant fashion to facilitate live-saving emergency response.
Up-to-date, accurate, de-identified information is now available to state public health agencies and responders for just-in-time planning with every approaching major storm anywhere in the U.S., and can be used to help prioritize areas for power restoration in the immediate aftermath of an event. Given the shift from hospital to home-based care, such real-time awareness of population-level needs, and the ability to respond to them, not just during disasters, but day to day, is critical. It allows health departments to plan for population health needs, emergency managers to more effectively deploy resources where they are needed most, and community organizations to better understand potential needs and offer additional support.
While the progress in health care and public health emergency preparedness in the last decade supports more timely, seamless, and holistic responses to disaster, there is more that must be done. Federal funding for state and local health preparedness declined by 38 percent from 2005 to 2012 and has continued to do so, placing communities at risk. Policymakers, like the public, seem to forget that disaster preparedness is critical, or subscribe to the view that preparedness can be ‘bought’ with a one-time purchase of equipment and supplies.
State and local agencies, as well as health care facilities, need to continually train and practice to respond to public health emergencies. Health information technology systems, though significantly advanced in the past few years, must become fully interoperable to support a coordinated and effective response to a catastrophic disaster or emergency. And, we must understand that recovery is as much a part of response as preparedness is, recognizing the broad scope of health recovery.
While Katrina was a local tragedy of national consequence, an even greater tragedy would be for communities across our nation to forget the importance of a trained, ready, nimble, and coordinated public health emergency preparedness system able to care for individuals and communities in the wake of disaster, including those who are most vulnerable.
Building sustained preparedness into the day-to-day decisions that enhance health care, public health, and emergency management must become the cultural norm. This will require continual planning, sustained funding, and attention among all sectors of society — including individuals and communities, governments, non-governmental organizations, and the business community. Doing so is vital to ensuring that all communities across the nation are prepared to respond to and recover from future public health disasters and fulfill our collective promise to never again repeat the chaos, disorder, and despair that followed Hurricane Katrina.
From Office of the Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, Washington, DC (N.L., K.F.); Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC (K.D.) The views expressed are those of the authors, and not necessarily those of the US Department of Health and Human Services.