WORKING

> P A P E R

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**TABLE OF CONTENTS**

[Summary i](#summary)

[Chapter 1: Introduction 1](#chapter-1-introduction)

[Purpose of Study and Specific Objectives
2](#purpose-of-study-and-specific-objectives)

[Organization of the Report 4](#organization-of-the-report)

[Chapter 2: Analytical Approach 5](#chapter-2-analytical-approach)

[Document Review 5](#document-review)

[Site Visits 5](#site-visits)

[Chapter 3: Background and Context
10](#chapter-3-background-and-context)

[Overview of Major Reports 10](#overview-of-major-reports)

[Overview of the Magnitude and Effects of Hurricane Katrina
12](#overview-of-the-magnitude-and-effects-of-hurricane-katrina)

[Chapter 4: The Role of Public Health in an Emergency
18](#chapter-4-the-role-of-public-health-in-an-emergency)

[Tratditional Roles of Public Health
18](#traditional-roles-of-public-health)

[Public Health and Emergency Response
19](#public-health-and-emergency-response)

[Key Observations 20](#key-observations)

[Implications for Public Health 29](#implications-for-public-health)

[Chapter 5: Workforce Issues 32](#chapter-5-workforce-issues)

[Key Observations 33](#key-observations-1)

[Implications for Public Health 42](#implications-for-public-health-1)

[Chapter 6: Medical Supply and Pharmaceuticals
45](#chapter-6-medical-supply-and-pharmaceuticals)

[Key Observations 45](#key-observations-2)

[Implications for Public Health 54](#implications-for-public-health-2)

[Chapter 7: Communications 58](#chapter-7-communications)

[Key Observations 58](#key-observations-3)

[Implications for Public Health 67](#implications-for-public-health-3)

[Chapter 8: Special Needs Populations
69](#chapter-8-special-needs-populations)

[Key Observations: Community-based Special Needs Populations
70](#key-observations-community-based-special-needs-populations)

[Key Observations: Nursing Home Populations
79](#key-observations-nursing-home-populations)

[Implications for Public Health 87](#implications-for-public-health-4)

[Chapter 9: Concluding Thoughts 90](#chapter-9-concluding-thoughts)

[Recommendations 92](#recommendations)

#  

# ACKNOWLEDGEMENTS

> The authors would like to thank the state and local health
> organizations that participated in the study for sharing their
> experiences from the public health response to Hurricane Katrina. We
> appreciate their thoughtful responses. We also wish to thank Dr.
> Benjamin Springgate for commenting on an early draft of our workplan
> and for helping to make connections with local health organizations
> and personnel in Louisiana. Finally, we thank Ms. Lara Lamprecht who
> reviewed and commented on earlier drafts of this report. Of course,
> any errors or omissions are the sole responsibility of the authors.
>
> **LIST OF FIGURES**
>
> **Figure 1:** Public Health Functions and Cross-cutting Issues in the
> Response to
>
> Hurricane Katrina: A Conceptual Framework
> ................................................... 7
>
> **Figure 2:** The Distribution of Public Health Functions: Day-to-Day
> and in an
>
> Emergency.......................................................................................\......23

# 

# SUMMARY

Hurricane Katrina was one of the largest and most costly natural
disasters in U.S. history, and its effects will be felt for many years
to come. Though there were many compelling stories of individual acts of
heroism in response to the disaster, it is widely agreed that most
aspects of the response, including the public health and medical
response, fell short of expectations. Hurricane Katrina tested the
public health system in terms of its emergency response role; a number
of problem areas were exposed in the process. It is important to examine
the public health response to Hurricane Katrina to determine what worked
well and what did not, so that public health agencies can learn from its
experiences and improve its preparedness before another disaster
(whether natural or manmade) strikes.

This study seeks to contribute to this effort by collecting and
synthesizing the public health lessons learned from the response to
Hurricane Katrina. We focused our efforts on areas that we knew were
tested by Hurricane Katrina and around which significant problems arose,
including the coordination of the medical workforce, the coordination of
medical supplies and equipment, communications, and caring for special
needs populations. Our findings are based on a review of relevant
documents such as government reports, newspaper articles, and national
and state-level emergency response plans, as well as a series of
interviews with public health officials and other governmental and
emergency management personnel in Louisiana, Mississippi, Georgia,
Texas, and Florida.

**The CHANGING Role of Public Health**

Hurricane Katrina revealed new challenges for the public health system
with respect to its roles and responsibilities in emergency response.
Traditionally, public health agencies have had responsibility for three
broad types of functions: addressing population health issues by
collecting and analyzing data on the health needs of a community
(assessment), implementing the necessary action steps to meet the
community's health needs through direct service provision and/or
regulation (assurance), and advocating for the use of evidence-based
research in the implementation of public policy that promotes the
public's health (policy development).

The heightened attention in the United States toward emergent infectious
disease, the threat of bioterrorism, and the inevitability of natural
disasters has placed new emphasis on how well emergency response is
reflected and/or incorporated in these three public health functions. At
the same time, public health agencies have been required to marshal
resources and build competencies in new areas, including command and
control in emergency response, use of protective equipment, flexible
problem solving, and disaster communications.

**There Remains a Lack of Consensus Regarding the Role of Public Health
in an Emergency**

Our analysis found wide disagreement regarding the role of public health
agencies in the provision of health care during an emergency. While it
was clear to all that public health has the responsibility to *assure*
that health care services are available in an emergency, there was
disagreement over the extent to which public health agencies have the
responsibility to *provide* that care. The majority of interviewees
(cutting across public health, hospitals, emergency management, and
other government agencies) felt that public health agencies do not have
the skills or capacity to assume significant responsibility for
providing direct health services. However, a sizeable minority argued
that public health has an obligation to supply direct health services,
and that this duty is expanded during an emergency response given the
immeasurable need.

**Incorporating Emergency Response Functions and Approaches into Public
Health Has Reshaped the Field**

The experience of Hurricane Katrina represents a definitive milestone in
post 9/11 preparedness in terms of the incorporation of emergency
management in public health. All states are now using emergency
management approaches such as the use of the Incident Command System
(ICS). Public health leaders noted that the incorporation of emergency
management into the role of public health has raised public health's
visibility to the community, focused more attention on the assurance
core function, and emphasized new partnerships with other emergency
responders, the private sector, and the community as well.

At the same time, tensions remain between those who want public health
to fully embrace emergency management approaches and those that are more
reluctant. Public health leaders in states impacted by Katrina cautioned
that a complete transformation of public health to the emergency
management model might overshadow public health's community assessment
skills (which emphasize careful and deliberate examination of an issue
from all sides).

**Public Health Role in Emergency Response Should Be Better Defined**

Our findings suggest that public health agencies need to work with the
other agencies involved in public health emergency response to better
define their respective roles in disaster response and develop a plan
that institutionalizes these roles. In particular, agencies must
coordinate with their response partners to specify how medical care
services will be provided in an emergency and by whom. The experience of
Katrina indicates that emergency management practices could be better
integrated into traditional public health functions, and several
characteristics of traditional public health work (e.g., ability to work
in communities and use multidimensional approaches to assess need) could
be more fully incorporated into emergency response planning and
training.

## Lessons Learned from the Public Health Response to Hurricane Katrina

We now summarize key observations from our analyses of workforce,
medical supplies and pharmaceuticals, communications, and special needs
care.

### Responsibility of Public Health in Hospitals and Nursing Homes with Workforce Issues Is Not Well Established

In all the states we visited, there was an obvious need for additional
health care personnel to assist with the patient surge in hospitals, the
patient and evacuee volume moving through triage centers, the general
shelter population's primary care needs, and the specialized health care
needs of those in the special needs shelters. Maintaining a sufficient
workforce was challenging because of the level of physical and emotional
stress experienced by first responders.

The role of public health in addressing workforce issues is unclear.
Other than providing regulatory oversight and managing its own clinics,
public health has no designated role in managing the public or private
health care workforce. During an emergency, the role of public health in
this capacity is to *assure* that health and medical services are
provided to the public, not necessarily to deliver acute health care
services. Local and state public health departments' roles varied
regarding care at triage sites and general mass care shelters in the
aftermath of Hurricane Katrina (e.g., monitoring for infectious
diseases, providing nurses to help staff the triage centers and shelter
clinics, opening and staffing special needs shelters.

### Coordination of Health Care Personnel Was Difficult in All Care Settings

As news spread of Hurricane Katrina's devastation, many health care
professionals volunteered their time and effort. However, public health
lacked systems to coordinate volunteers and match their skills to sites'
identified needs. The absence of an agreed-upon method for verifying the
credentials and skills of the health care professionals was problematic.

### Public Health Might Build on Its Traditional Roles to Assist in Addressing Workforce Issues

In preparing for future emergency situations, it will be useful for
public health practitioners to consider how it might use some of its
traditional functions to assist other health care organizations in
addressing workforce issues. For example, public health could apply its
traditional responsibility of educating the public to improve the
public's awareness of sheltering issues in a disaster. Information could
be provided regarding appropriate shelters, which would likely relieve
some of the hospital staffing burden that can occur when the public goes
to the hospitals for shelter rather than the appropriate sites. As
another example, public health could develop systems to match better
volunteer personnel resources with identified needs.

**There Were Problems in Managing Supply and Distribution of
Pharmaceuticals and Medical Equipment**

Responsive medical support in the form of medical supplies and
pharmaceuticals was crucial to enable health care providers to provide
medical care to hurricane victims and evacuees. Interviewees noted that
while supplies were delivered to the affected areas, there was no
effective way to inventory and allocate them in efficient and equitable
ways.

Supplies lacked medications and medical equipment required by people
with special needs. Many patients with chronic medical problems either
did not receive their medications in a timely fashion, or did not
receive the exact or equivalent medication. A deficiency in oxygen
supplies in some states caused serious problems for oxygen dependent
evacuees and caused health department staff to spend substantial time
and resources attempting to replenish oxygen supplies.

**Public and Private Organizations' Efforts Lacked Coordination**

After the hurricane had passed, both public and private organizations
provided medications and supplies to evacuees. The state of Florida had
caches of supplies pre-positioned around the state. Many states relied
upon the Strategic National Stockpile (SNS), although some reported that
many of the supplies in the SNS did not match their needs because it was
configured for responses to a bioterrorist attack.

Private-sector companies, including large drug store chains, played
important roles in addressing pharmaceutical shortfalls but did not have
a clear picture of what supplies were needed,. Public health agencies
also had difficulties in getting the funds to reimburse private-sector
companies in a timely fashion. In particular, interviewees felt the
Stafford Act, the federal reimbursement mechanism for emergency
situations, created unnecessary delays.

**Better Planning Can Help Address Supply and Distribution Issues**

To expedite the delivery of medical supplies to storm-hit areas, public
health agencies at the state and local level may, as part of their
preparedness planning, want to pre-designate strategic areas for
supplies and consider establishing advance arrangements with private
suppliers. It will also be important for public health to 1) develop a
comprehensive and rapid system to conduct a needs assessments and 2)
provide a centralized means of receiving, inventorying, and allocating
resources at the state level. Current reimbursement rules should be
clarified as part of preparedness planning efforts.

**Communication Within and Across Organizations Was Poor**

Some communications problems during Hurricane Katrina were due, not so
much to technical failure on the part of the communications
infrastructure, but to a lack of coordination between the relevant
parties, whether within public health agencies or between public health
and other public or private entities. For example, in some cases, one
part of the health department did not know what another part was doing,
leading to a duplication in tasks. In other cases, hospital
administrators noted that they had received multiple visits by public
health personnel asking them to fill out the same paperwork multiple
times.

**The Incident Command System Typically Facilitated Agency
Communication**

One of the communications success stories arising from our analysis
concerns the implementation of an Incident Command System (ICS) and the
National Incident Management System (NIMS). Interviewees indicated that
when personnel across agencies were familiar with ICS, the response ran
more smoothly because people knew both their individual roles and the
responsibilities of the agencies they represented. In addition,
interviewees indicated that ICS provided a common language and process
to all responders, so personnel could focus on decision making rather
than trying to explain the process, thus saving time.

### Public Health Requires Mixture of Communication Technologies, Better Planning

Many of the communications problems that public health departments
encountered during Hurricane Katrina can be overcome through improved
planning and training. Interorganizational communications could be
improved significantly if participating organizations know precisely who
they will interact with during an emergency, know their respective roles
and responsibilities, and know what to expect from each other. In
particular, public health needs to incorporate non-traditional partners
(e.g., the military, NGOs, private-sector organizations, and other
government agencies, including mental health) into the planning
process\--and to do so at an early stage. On a technical level, an
effective communications plan requires a mixture of communications
technologies and techniques to ensure that when one method fails,
another is available.

**States Faced Challenges in Defining Special Needs Populations**

As has been widely reported, the evacuation and sheltering of special
needs populations were put to the test by Hurricane Katrina. Individuals
with special needs who live in the community (as opposed to nursing
homes or assisted living facilities) require separate shelters, which in
some states are the responsibility of the public health department. One
underlying challenge for states is to establish criteria for identifying
special needs populations, particularly during an emergency to ensure
their prompt evacuation and to direct them to appropriate shelter
arrangements. "Special needs" is a generic term that can be applied to a
number of different disabled and elderly populations, as well as
low-income populations, people with serious mental illness, people with
intellectual or cognitive disabilities, people with sensory impairments
(e.g., low vision, impaired hearing), and those with mobility problems
or activity limitations. Also included may be those who rely on special
equipment such as oxygen or wheelchairs, or those who lack
transportation during a disaster.

Even in states with clear definitions of what constitutes a special
need, finding those populations can be challenging, especially in the
aftermath of a hurricane or other emergency. Many special needs
populations do not have regular contact with the health care system and
therefore may be overlooked. Florida allows special needs populations
(defined in terms of medical needs) to pre-register, although most of
these populations are not required to do so; state and local officials
noted that only a small portion of those who show up at special needs
shelters were pre-registered.

**Procuring Transport and Shelter for Community-Based Special Needs
Populations Was Often Difficult**

Transportation of special needs populations became a serious issue in
the aftermath of Hurricane Katrina. Individuals who were triaged to
special needs shelters often lacked any means of getting to the shelter,
to medical facilities for treatment, or doctors' appointments (once at
the shelter). In some cases, transportation was also needed to move
special needs populations from one shelter to another to manage
overflow.

In each state we visited, public health had an important role in
assuring that shelter was provided to special needs populations.
However, the exact role of the public health department in setting up
and operating the shelters differed across states. In Louisiana, for
example, the Department of Social Services has responsibility for
administering special needs shelters while the Department of Health and
Hospitals is responsible for the medical care provided in the shelters.
In Georgia, the Department of Public Health established a special needs
shelter, but required help from local hospitals with staffing and
supplies.

**The Magnitude of the Need for Mental Health Services Was
Unanticipated**

The need to provide mental health care in shelters posed another
significant problem. Prior to the storm, many shelter operators had not
anticipated the magnitude of the need for mental health care, nor had
they realized the extent to which a disaster such as Katrina would
itself cause mental health problems, transforming individuals who would
otherwise be self-supporting and healthy into special needs populations.
The states we visited generally did not have sufficient professional
staff to care for mental health populations, and inpatient psychiatric
beds were scarce.

**Nursing Homes Faced Challenges in Evacuating, Finding Host
Facilities**

Although the responsibility for nursing home populations normally falls
to the nursing home administrators, public health occasionally played an
important role in coordinating with administrators to ensure that
nursing home residents received adequate care in the aftermath of the
storm. Many nursing home administrators, especially in Louisiana, faced
challenges in deciding when to evacuate and in making plans for how the
evacuation would be carried out.

Prior to and during Hurricane Katrina, many nursing homes in the
affected areas experienced problems related to the poor execution of
emergency plans. In some cases, facilities ignored their own emergency
plans completely. In other cases, the impact of the storm was far
greater than anticipated and existing resources were woefully
inadequate. Nursing facilities that are part of a larger corporate chain
often had corporate resources to support their decision to evacuate;
however, the "mom and pop" owned facilities did not have the same
resources available to them. There were also some reported problems in
tracking nursing home residents after evacuation.

### Public Health Needs to Lead Effort to Define Special Needs Populations

Public health should continue to lead the effort to define special needs
and develop methods for identifying individuals in the community meeting
these criteria in advance, if possible. Public health also needs to
clarify its role in providing staff and assuring transportation to
shelters. States might consider establishing a team-based approach to
staffing, under which multi-capability teams divide responsibilities
across shifts. Public health might identify opportunities to partner
with other organizations to provide transportation for special needs
patients and ensure adequate security at shelters. Public health should
also work to establish better relations with nursing homes and to ensure
that they are involved in emergency response planning. Special effort
also needs to be directed toward caring for mental health needs during
an emergency.

## Conclusions and Recommendations

Many of the breakdowns we observed in communications, the distribution
of needed medical and other supplies, and serving special needs
populations primarily occurred because there was considerable ambiguity
regarding the respective roles of federal, state, and local public
health agencies and other governmental institutions. This finding
highlights the idea that coordination between all involved organizations
must be improved to mount an effective response. In this regard, we were
particularly struck by how public health's experience during Katrina
raised issues related to its assurance function --i.e., linking people
with services--and whether, and to what extent, health departments
should engage in the direct provision of care during public health
emergencies. This issue became especially critical in caring for special
needs populations.

Many of the problems that arose in the response to Katrina could have
been prevented or minimized if public health agencies had done a better
job in educating the public beforehand on the individual's roles and
responsibilities in emergency response. Stronger partnerships and
improved planning among the partners, should also lead to the more
effective use of volunteers.

We close with a brief set of recommendations that reflect largely
cross-cutting concerns. We should point out that although these
recommendations relate to the lessons learned from Hurricane Katrina and
in some cases are specific to hurricane preparedness, most apply more
broadly to other types of disasters, whether natural or manmade.

**Conduct Drills and Exercises with Multiple Levels of Government and
Non-Governmental Partners.** A good way to address the need for
clarifying roles and responsibilities for public health partners is for
state and local health departments to make a greater effort to include a
wider range of community partners in planning activities and exercises
for both natural and manmade disasters. Exercises should cover a variety
of scenarios, including natural disasters, especially those that might
require evacuation of a large number of people. Moreover, it is
important to conduct drills and exercises that test specific
capabilities because they are much more likely than generic exercises to
result in performance improvements.

**Explore Prospect of Extending ICS Training and Planning to Key Private
Sector Partners.** The effectiveness of ICS in public health emergencies
could be strengthened if private sector partners were included in the
training and planning processes. Such partners include, but are not
limited to, school officials, pharmacies and pharmaceutical companies,
medical equipment suppliers, long-term care facility operators, and
representatives from large local businesses.

**Develop Systems for Quickly Matching Available Resources with Needs.**
Effective matching requires coordination between state and local
officials. At the local level, communities need to be able to quickly
conduct a needs assessment, so they can request the specific set of
resources that will serve their needs. At the state level, officials
need to identify the resources that are available both within the state
and from outside sources and determine how to best allocate those
resources to address needs across the affected areas.

**Each Community Must Examine How it Can Increase Its Level of Public
Health Preparedness.** To mount an effective and efficient response,
officials at all levels of government, business owners, and individuals
must all contribute their resources and ingenuity. Due to differences in
how the public health system is organized across geographic areas, there
is no single definition of the public health's role in an emergency.
Rather, each community must bring the relevant organizations together to
determine how to best allocate responsibility for the public health
emergency response within their community. The outcome of such a meeting
should be institutionalized through incorporation into the emergency
response plan, the use of Memoranda of Understanding (MOUs) between
organizations, and any other mechanism that will allow the community to
hold organizations accountable for the roles and responsibilities they
have agreed to take on.

# Chapter 1: Introduction

Hurricane Katrina was a devastating storm that wreaked havoc on the gulf
coast. The vast scope of the destruction and displacement makes
Hurricane Katrina one of the largest and most costly natural disasters
in the nation's history, the effects of which will remain for many years
to come.

Since the terrorist attacks of September 11, 2001, the Federal
Government has sharpened its focus on emergency preparedness and
provided substantial resources for related planning, exercising, and
equipment. While there is little doubt that this infusion of resources
has improved general preparedness at the federal, state, and local
levels, the response to Hurricane Katrina highlights that there is still
much work to be done. Though there are many compelling stories of
individual acts of heroism, it is widely agreed that most aspects of the
response to Hurricane Katrina, including the public health and medical
response, were substandard. Hurricane Katrina exposed a number of gaping
holes in the public health system's emergency response capabilities.

Underlying many of these problems was a lack of consensus regarding the
roles and responsibilities of public health agencies in an emergency.
Public health is but one of a number of sectors involved in the response
and must coordinate its efforts with other partners (e.g., hospitals,
emergency management, law enforcement, transportation). While some roles
such as disease surveillance and infection control, are clearly in the
realm of public health, it is less clear how public health fits into
other roles such as patient evacuation and patient care. There are still
other roles such as mortuary services, body recovery, and identification
that perhaps only become part of public health's domain when the scope
of the disaster is particularly large.

Defining public health's role is complicated further by the fact that
there is wide variation in the organization of the public health and
medical care systems across geographic areas. This difference in
structure leads to variation in how responsibility for emergency
response functions is best allocated across the participating
organizations. In other words, there is no "one-size-fits-all"
definition for public health's role in a disaster. Nonetheless there
appears to be expectations on the part of the public, hospitals, and
nursing homes, and other stakeholders about what public health agencies
*should* be able to do (whether it is legally or formally the
responsibility of public health). For instance, many people have
expectations that public health agencies will serve as the direct care
safety net in a disaster, in addition to assuring that services are
available. However, in many cases, public health agencies do not have
the resources to effectively play this role (e.g., do not have personnel
to provide medical care services). These potentially misguided
expectations illustrate the need to clearly delineate the emergency
response roles and responsibilities of public health agencies within
each community.

## Purpose of Study and Specific Objectives

It is important now, approximately two years later, to take a step back
and examine the public health response to Hurricane Katrina to determine
what worked well and what did not, so that public health can learn from
its experiences and prepare to do better the next time a disaster
(natural or manmade) strikes. More specifically, Hurricane Katrina
provided the opportunity to test the nation's response capabilities
through direct experience and make improvements in response. It is
important to implement the needed changes, so that the lessons learned
from Hurricane Katrina are acted upon and not lost as life returns to
normal and personnel changes occur. The RAND Corporation was asked to
contribute to this effort by collecting and synthesizing the public
health lessons learned from the response to Hurricane Katrina and making
them available to federal, state, and local responders.

From a practical standpoint, this study could not examine all areas of
the public health response, so we focused our attention on a few key
areas. That is, we faced a tradeoff between breadth and depth, and we
chose to explore a few areas in substantial detail rather than
increasing coverage and considering each area only superficially.

In choosing the areas to emphasize, we sought to focus on those public
health functions that were tested by Hurricane Katrina and around which
significant problems arose. For example, the coordination of medical
care personnel was seriously tested by Hurricane Katrina and in some
cases led to significant problems; thus, we chose to emphasize this
function because of its potential to provide lessons learned. In
contrast, we chose not to focus on disease investigation and control and
surveillance because, even though these functions of public health were
used in the response to Hurricane Katrina, on the whole these functions
were carried out effectively. By focusing on those functions in which
the most significant problems arose, we maximize the opportunity to
learn from the experience, identify potential improvements, and
contribute to what is known about effective emergency response. At the
same time, we recognize that this chosen emphasis will result in a story
that focuses more on failures than successes (though there are some of
the latter as well).

To choose the functions on which to focus, we began by creating a master
list of potential public health functions gleaned primarily from the
National Response Plan (NRP) (US DHS 2004) Emergency Support Function #8
(ESF-8) and state-level emergency response plans (ERPs). We then
conducted a review of Hurricane Katrina-related reports (from government
agencies, foundations, and research institutions) and newspaper
articles. To ensure that we had identified the most relevant public
health functions, we shared our shortened list with a number of people
involved in the response and requested their feedback.

The critical public health functions that we identified through our
research include the coordination of the medical workforce, the
coordination of medical supplies, and communications. These functions
are critical to many other important medical and public health response
functions. As a result, when there are breakdowns in these functions,
the effects can be widespread. To illustrate this point, we also
examined the evacuation and treatment of special needs populations
during Hurricane Katrina as a means of highlighting workforce, medical
supply, communication, and other issues.

Our research was guided by three basic questions:

-   What is the role of public health in an emergency (e.g., direct
    provision of care vs. an assurance role)?

-   Which elements of the response worked well and which did not?

-   What changes could be made to improve response capabilities?

To provide a comprehensive assessment of the lessons learned in each of
the critical areas of the public health response, we were guided by two
additional objectives. First, we sought to collect varied perspectives
on the public health response to Hurricane Katrina. Public health
emergency preparedness requires public health agencies to partner with a
number of entities. Thus, we felt it would be important to include
perspectives from these other organizations (e.g., emergency management,
police, fire, and health care) in our study. In addition, our findings
were informed by the perspectives of key informants in states directly
affected by the hurricane as well as those indirectly affected through
the receipt of evacuees. Second, we sought to document and disseminate
the lessons learned in a manner that is accessible and useful to all
state and local public health officials because many of the lessons
learned will not only be applicable to hurricane preparedness, but to
emergency preparedness overall.

## Organization of the Report

The remainder of the report is organized as follows. In Chapter 2, we
describe our methodology for collecting and synthesizing the lessons
learned from the public health response to Hurricane Katrina. In Chapter
3, we provide an overview of other key reports that have examined
Hurricane Katrina and summarize important issues for each of the states
included in our study. This information is meant to provide the context
for interpreting our findings. In Chapter 4, we discuss the role of
public health agencies in emergency response, how this role has changed
over time, and how the lack of consensus regarding the roles and
responsibilities affected the response to Hurricane Katrina. In Chapters
5 through 7 we present our findings for each of the primary functions of
the public health response: workforce issues, medical supplies and
pharmaceuticals, and communications. In Chapter 8, we consider the
evacuation and sheltering of special needs populations as an example of
what can happen when there are breakdowns in the critical areas of the
public health response. In Chapters 4-8, we highlight key observations
and discuss their implications for public health emergency preparedness.
In the final chapter, we summarize the overarching lessons learned and
make recommendations regarding changes that might improve public health
emergency preparedness.

[]{.mark}

# Chapter 2: Analytical Approach

In this chapter, we describe the two-step approach used to collect and
synthesize the lessons learned from the public health response to
Hurricane Katrina. First, we discuss the approach used to identify and
review relevant documents, including government reports, newspaper
articles, and national and state-level emergency response plans. Then,
we discuss the methods used to conduct a series of site visits, which
aimed to collect detailed information concerning the key functions of
the public health response (coordination of the medical workforce,
coordination of medical supplies, communications, and treatment of
special needs populations) described in the previous chapter.

## Document Review

We conducted extensive web-based searches for reports from government
agencies, foundations, and research institutions to document the public
health response to Hurricane Katrina. In addition, we monitored the
progress of congressional hearings on the subject and collected relevant
testimony as well. To better understand the range of roles and
responsibilities taken on by public health agencies during a disaster
response, we obtained and reviewed copies of the NRP as well as
emergency response plans from several different states.

To capture a more local perspective, we searched Lexis-Nexis for
newspaper articles about the response to Hurricane Katrina. Besides
providing important background and contextual information about the
local response, these stories facilitated the identification of key
local-level interviewees.

## Site Visits

There were five main components to the approach used during the site
visits: site selection, development of the interview guide, selection of
interviewees, data collection, and data analysis.

### Site Selection

We selected five states for in-depth site visits. We visited Louisiana
and Mississippi in order to capture perspectives from states that were
directly affected by Hurricane Katrina. We also selected three states
(Texas, Florida, and Georgia) that were indirectly affected by Hurricane
Katrina, yet face a direct risk from hurricanes in general. We chose to
examine the indirectly affected states in order to explore the issues
surrounding the receipt of evacuees as well as to understand whether
these states had altered their hurricane preparedness planning in
response to what they observed with Hurricane Katrina.

Within each state, we selected one or more local regions to visit.
Selection of local regions was informed by our document review. In the
directly affected states, the primary criterion for selection was that
the local region was significantly affected by the hurricane. In the
indirectly affected states, criteria included receipt of evacuees from
Hurricane Katrina in the local region and a location in a coastal region
that is vulnerable to hurricanes. To protect the privacy of study
participants and to encourage frank discussions, we did not identify the
specific local regions that we visited in this report but instead
summarize information at the state level.

### Development of the Interview Guide

We used a multi-step process to develop the interview guide. As part of
this process, we developed a conceptual framework to guide our selection
of the public health functions on which to focus and to identify
cross-cutting topics to address in the interviews. The conceptual
framework (see Figure 1) illustrates the relationship between public
health emergency response functions and issues such as leadership,
planning, and coordination that cut across all functions and support
their effective implementation.

To build the conceptual framework, we reviewed the NRP ESF#8: Public
Health and Medical Services as well as state emergency response plans on
the roles and responsibilities of public health agencies in a disaster.
These documents provided a master list of public health functions, from
which we identified the functions that we felt were most relevant to the
Hurricane Katrina response. We then circulated our shortened list to
several individuals involved in the response to Hurricane Katrina and
requested feedback. Suggestions from these experts were incorporated
into our final list of public health functions. We then divided the
public health functions into two basic categories\--primary and
secondary\--based on the function's relevance in the response to
Hurricane Katrina.

**Figure 1: Public Health Functions and Cross-cutting Issues In The
Response to Hurricane Katrina: A Conceptual Framework**

![](media/image3.png){width="6.65in" height="4.727777777777778in"}

Once the list of functions was finalized, we used information from the
document review to identify cross-cutting issues that would be relevant
to consider for each function. The cross-cutting issues included
leadership, legal issues, status of planning (e.g., plan in place and
exercised), and breadth of coordination with a wide range of partners at
the federal, state, and local level.

We developed separate interview guides for directly and indirectly
affected states. For directly affected states, the interview guide
focused on the primary public health functions (i.e., evacuation of
special needs populations, coordination of medical care personnel,
coordination of medical supplies, and communications). For each of these
functions, the interview discussion guide included questions focused on:

-   Organizations that are involved in this activity

-   The role public health plays

-   Key successes during the response (i.e., what worked well)

-   Problems that arose during the response (i.e., what didn't work
    well)

-   How things might be done differently in the future

For the secondary public health functions, the interview guide probed
about key successes, problems that arose, and any potential changes. The
complete interview guide for directly affected states is provided in
Appendix A.

For the indirectly affected states, the interview guide covered two
broad topics: experiences with the receipt of evacuees and planning for
future disasters. To probe about experiences with the receipt of
evacuees, the interview was quite similar to that of the directly
affected states. It focused on the primary public health functions and
addressed the main topics outlined above. To address planning for future
disasters, the interview guide probed interviewees about what they
observed during the response to Hurricane Katrina and whether those
observations prompted changes in emergency preparedness planning in
their state and/or local area. The complete interview guide for
indirectly affected states in provided in Appendix B.

### Selection of Interviewees

Interviews were conducted at both the state and local levels. We first
identified potential interviewees through searches of state and local
health department websites and through our document review. Following
this, we contacted potential interviewees, discussed the project and its
goals, and used a snowball sampling approach to identify additional
people to contact both inside and outside the health department. Within
the health department, we sought to interview people with a variety of
perspectives, including high-level health department officials (e.g.,
the director, the deputy director), the emergency preparedness
coordinator, the public information officer, and the chief
epidemiologist. We also sought to interview other community
representatives, including emergency management personnel, hospital
personnel, first responders, volunteers (primarily the Red Cross), and
politicians.

### Data Collection

Interviews were typically conducted in person, with the exception of the
interviews conducted in Georgia, which were done by telephone and served
as pilot tests for the interview protocols. Telephone interviews were
also conducted with other sites when schedule conflicts arose, when a
potential interviewee was identified during a site visit but not
immediately available to be interviewed, or when we had follow up
questions. In most cases, two RAND researchers and one note-taker
participated in the interview. In addition to the interview data, we
asked for relevant documentation from each state and local area visited,
including emergency response plans and after-action reports.

### Data Analysis

We conducted a descriptive analysis of the qualitative data. Our process
comprised three basic steps: data reduction, data analyses, and drawing
conclusions. In the data reduction phase, we abstracted the relevant
information from the interview notes and organized the data around the
primary public health functions and our research questions. The data
analysis phase compared data both within states and across states. For
the within-state comparisons, we examined the level of correspondence in
the observations made and key themes noted by interviewees across
different levels of government (i.e., state and local) and organizations
(e.g., public health, emergency management, hospitals). In the
cross-state comparisons, we focused on identifying similarities and
differences in the key themes that emerged across states. Going a step
further, we sought to identify any factors that helped explain any
observed differences across interviewees within a state or across
states. In the final stage, we synthesized the information from the
within-state and cross-state analyses to identify the lessons learned
and drew conclusions regarding steps that could be taken to improve
public health emergency preparedness.

# Chapter 3: Background and Context

Given the scope of the disaster and the near-universal disappointment in
the response, it is not surprising that there have already been numerous
studies of Hurricane Katrina. Here, we provide a high-level overview of
the major reports that have been released in an effort to provide some
background and context for interpreting our findings and, more
importantly, to highlight how our findings contribute to the existing
literature.

## Overview of Major Reports

### Federal Level

The most comprehensive studies of the response to Hurricane Katrina have
been produced at the federal level by the White House, the Senate, the
House of Representatives, and the Government Accountability Office
(White House 2006; US Senate 2006; US House of Representatives 2006; GAO
2006a). By design, the reports focus heavily on the Federal Government's
role in the response. Moreover, these reports are comprehensive in
nature and thus, public health and medical care comprise only a portion
of the overall response considered in these reports. While the reports
differ to some extent in their purpose, approach, and level of detail, a
number of common themes arise. First, all of the reports acknowledge
that there are aspects of the medical response to Katrina that went
well. For example, these reports all commend the medical personnel,
including both local and out-of-state volunteers, who made heroic
efforts in very difficult situations to help care for storm victims.
While the death toll from Hurricane Katrina was high\--approximately
2,000 people---it is widely thought that it could have been much worse
if not for the efforts of the volunteer medical personnel. Second, there
appears to be general consensus across the federal reports on the
aspects of the response that were most problematic. Breakdowns were
noted in communication, the understanding of roles and responsibilities,
resource coordination and distribution, and the evacuation of special
needs populations. Finally, the GAO report notes that many of the
problems that arose during the response to Hurricane Katrina were
similar to those that arose in previous disasters (e.g., Hurricane
Andrew), indicating that a better process is needed for developing and
implementing improvement plans based on lessons learned (GAO 2006a).

### State and Local Levels

In addition to these federal reports, many of the involved states and
communities have produced after-action reports. These after action
reports are meant to help identify what went well and what went poorly,
so that improvements can be made in advance of future disasters. Looking
across these reports, we found that many of the same breakdowns noted at
the federal level were also found at that state and local levels. The
aspects most commonly cited as requiring change were communications,
planning, evacuation, and sheltering (Morrill et al, 2006; North
Carolina Division of Emergency Management 2006).

### Contribution of This Report

This report contributes to the existing literature on the response to
Hurricane Katrina in a number of important ways. First, we have narrowed
our focus to the public health response and, more specifically, to
several key areas within public health. The aspects we have chosen to
focus on are consistent with the key problem areas identified in the
prior reports: communications, resource supply and distribution, and the
evacuation of special needs populations. In doing so, we are able to
explore the lessons learned in these areas in considerable depth, thus
providing a more comprehensive understanding of what worked well and
what did not.

Second, our study presents lessons learned from two basic perspectives:
those states directly hit by Hurricane Katrina and those states that
were indirectly affected through the receipt of evacuees. Previous
reports have focused primarily on the directly affected states.
Considering the perspective of the indirectly affected states as well
adds depth to the analysis and potentially broadens the applicability of
the lessons learned captured here.

Finally, the report is aimed at outlining the lessons learned from
Hurricane Katrina for authorities at the state and local levels to aid
in their emergency preparedness planning efforts. Elements of the
disaster and its response can inform other planning scenarios. Whereas
the response to the hurricane-force winds and storm surges could begin
prior to landfall (e.g., evacuation notices), the levees breaking in New
Orleans and the subsequent flooding presented response issues more akin
to a no-warning disaster such as a bioterrorist (BT) attack. The goal of
this report is to synthesize the lessons learned from Katrina and frame
them in a way that makes them useful for all-hazards emergency response
planning.

## Overview of the Magnitude and Effects of Hurricane Katrina 

To provide context for interpreting our findings, here we present a
general overview, culled from our review of the documents summarized
above, of the magnitude and effects of Hurricane Katrina. As part of
this overview, we provide synopses for each state in our study (LA, MS,
FL, TX, GA) in order to facilitate understanding of each state's key
issues and to contextualize the information gleaned from the interviews.

### General Overview

Hurricane Katrina was the most expensive hurricane ever recorded in the
United States. The storm formed over the Bahamas on August 23, 2005 and
grew in strength to a Category 1 storm by the time it crossed Southern
Florida on August 26. Once in the Gulf of Mexico, it became a Category 5
hurricane. On August 29, 2005, Katrina, now a Category 3 storm, made
landfall in Louisiana (DeLozier and Kamp, 2005).

The storm was large in magnitude. The hurricane force winds extended 100
miles from the storm's center and the associated storm surge was as high
as 37 feet in some places. Severe flooding and wind damage occurred
throughout the coastal communities and across a wide swath of the gulf
states. In New Orleans, levee failure resulted in flooding for weeks
after the hurricane hit (DeLozier and Kamp, 2005).

### Directly Affected States

***Louisiana***

On the evening of Friday, August 26, 2005, Hurricane Katrina increased
in strength and changed its course from a Florida panhandle path toward
the Louisiana-Mississippi coast. Landfall was expected on Monday
morning, August 29, allowing only 48 hours for preparations and
evacuation (U.S. DOT, 2006). Damage from Hurricane Katrina was
widespread, affecting approximately 93,000 square miles across the Gulf
region (White House, 2006). The storm disrupted basic
utilities--electricity, water and sewage disposal--as well as food and
supply distribution systems and communications. As a result, many
hospitals, nursing homes and other health care facilities across the
Gulf, not just those sustaining direct damage, were significantly
impacted by the Hurricane. This interfered with the delivery of health
care services. Although Mississippi suffered extensive destruction,
Louisiana was most severely affected due to the massive storm
surge-induced flooding in New Orleans. At the peak of the flooding, 80%
of the city was under water. Thousands were trapped, over 400,000
residents were displaced (CDC, 2006), and over 1,000 people died in
Louisiana, most as a result of the flooding and its aftermath (US House
of Representatives, 2006).

Approximately 500 Evacuation Centers (ECs) or shelters\--a term
referring to any facility that housed displaced persons overnight\--were
established across the state by local governments, faith-based
organizations, the American Red Cross, and others. More than 50,000
displaced residents were housed in these ECs, which held from fewer than
ten to as many as 7,000 evacuees (CDC, 2006). The majority of evacuees
fled their homes quickly and did not have time to gather personal
belongings. Although most were generally healthy, some were injured;
furthermore, many had chronic medical conditions (e.g., diabetes,
asthma, hypertension, psychiatric disorders) that required medications
and ongoing monitoring. The abrupt withdrawal from medications caused
many people in the shelters to become acutely ill or to be at risk of
becoming ill. Shelters varied in their capacity to deliver health care;
some shelters had staffed, on-site clinics, but many had no health care
services (CDC, 2006). Seven special needs shelters that cared for
approximately 2,000 special needs evacuees were also opened across the
state by the Louisiana Department of Health and Hospitals. Many of these
special needs shelters remained open for two months (Guidry, 2006).

The health care delivery system suffered greatest loss of functionality
in Louisiana, especially in the New Orleans area. Flooding caused three
of the largest acute-care health facilities in New Orleans - Tulane,
Charity and University Hospitals -- to experience unprecedented
equipment and communication failures that resulted in a lack of
electrical power and sanitation and limited food, water, and medical
supplies. Eventually all three hospitals were evacuated and still remain
closed, thus significantly weakening the health care infrastructure in
the New Orleans area.

In the state of Louisiana, the public health system is centralized. The
Office of Public Health (OPH) is part of the Louisiana Department of
Health and Hospitals and all OPH employees are state employees. 
However, the City of New Orleans is separate from the state-wide public
health system and has its own City Health Department. The state is
divided into 64 "parishes" (analogous to counties in other states) of
varying size. The public health system is divided into nine public
health regions, with each region encompassing 4 to 12 parishes. 
Although all coastal regions of Louisiana were hard-hit by Hurricane
Katrina and later by Hurricane Rita, the most devastated areas were in
Region 1, which included Orleans (including the City of New Orleans),
St. Bernard, Plaquemines and Jefferson Parishes in the southeast area of
the state. 

***Mississippi***

The Mississippi Gulf Coast experienced some of Hurricane Katrina's most
powerful winds and its highest storm surge (Knabb et al, 2006). Parts of
the Mississippi coast experienced an immense storm surge that exceeded
27 feet above normal sea levels (US Senate, 2006) and in some places
stretched almost 10 miles inland, past Interstate 10. After surveying
the region from the air, Mississippi Governor Haley Barbour likened the
scene to that of a nuclear detonation, stating, "I can only imagine that
this is what Hiroshima looked like sixty years ago."

Mississippi Emergency Management Agency (MEMA) activated its Emergency
Operations Center (EOC) one day before Hurricane Katrina made landfall
in Florida (White House, 2006). At that time, Mississippi's three
coastal counties began urging residents to evacuate, especially those
living in low-lying areas and mobile homes (White House, 2006). In the
end, 231 Mississippians died as a result of the storm (White House,
2006).

Hurricane Katrina devastated the medical and public health
infrastructure in Mississippi (White House, 2006). The storm damaged 14
of 16 hospitals in the affected region, three of them so severely that
they were forced to close (US Senate, 2006). In addition, more than
one-third of all primary care clinics in the region were closed due to
storm damage (US Senate, 2006). Similarly, 73 nursing homes were
affected by Hurricane Katrina, with two being fully destroyed (US
Senate, 2006).

The Mississippi Department of Health is a centralized system in which
all Department of Health employees are state employees. It is organized
into nine districts, with the district health officers reporting to the
state health officer in Jackson. The three coastal counties in
Mississippi that suffered the greatest financial and structural damage
from Hurricane Katrina (Hancock, Harrison and Jackson) comprise District
IX of the Department of Health.

The Department of Health is designated as the lead agency for the
medical and public health response (ESF #8) according to Mississippi's
Comprehensive Emergency Management Plan. As such, the Department of
Health is responsible for providing leadership in directing,
coordinating, and integrating the overall state efforts to provide
health, medical, and public health assistance. In this capacity, the
Department of Health plays an assurance role rather than being a direct
provider of services. On August 27, two days before landfall, the
Department of Health opened its EOC in Jackson and began preparing for
the storm. Preparations included prepositioning medical personnel and
medical supplies and sending representatives to the EOCs in each coastal
community. In addition, the Department requested and worked with
Disaster Medical Assistance Teams (DMATs) to assure the provision of
care to storm victims. Ultimately, these teams treated approximately
15,000 patients in the days after Hurricane Katrina made landfall (US
Senate, 2006).

After the storm made landfall, the Mississippi Department of Health sent
teams out to assess local medical facilities, many of which were found
to be lacking security and fuel for generators (US Senate, 2006). The
Department began to procure and distribute fuel to the medical
facilities. Maintaining security at the medical facilities was
problematic because these facilities had electrical power, water, and
food, and thus attracted members of the general population who otherwise
did not have access to these resources.

### Indirectly Affected States

***Florida***

As Hurricane Katrina moved toward Florida on August 25, 2005, Governor
Jeb Bush declared, pre-landfall, a Florida state of emergency (DeLozier
and Kamp, 2005). State and local emergency management and public health
responders prepared for a significant storm. Upon Hurricane Katrina's
departure for Mississippi and Louisiana, Florida sent medical personnel
teams and supplies to Mississippi and, to a lesser extent, Louisiana.
The Florida Department of Health sent 384 medical assistance personnel
to Mississippi and Louisiana. Emergency Medical Service (EMS) personnel,
advanced life support units, logistical support vehicles, oxygen tanks,
and vaccines were all shipped as part of the Emergency Management
Assistance Compact (EMAC)(floridadisaster.org).

The Florida Department of Health is a centralized system that provides
state funding to support local health departments (Wasserman et al.,
2006). Each locality responds locally, but the state provides guidance
(e.g., plan templates) and extra support when needed. The state
typically pre-positions supplies in logistical staging areas before a
storm, whether or not local officials have requested assistance. The
major role of the Health Department during hurricanes is to stand up
shelters for populations with special needs such as the chronically ill,
people requiring oxygen, and the disabled.

***Texas***

Even though Texas was not directly affected by Hurricane Katrina, it was
heavily involved in the immediate and long-term responses to the
disaster. Before Katrina made landfall, Texas sent many medical
emergency personnel and other health care resources to Lousisana. More
importantly, the state served as a major receiving site for Katrina
evacuees, particularly those from New Orleans. Texas received over
450,000 evacuees from Louisiana and Mississippi, and opened over 177
shelters throughout the state. Two of the major sites receiving evacuees
were Houston and San Antonio. Houston received 250,000 evacuees, and San
Antonio received between 25,000 and 35,000 evacuees (Godoy, 2006).

An unprecedented coalition of local agencies, health departments, and
not-for-profit organizations quickly organized to provide shelters,
health care and social services to the incoming victims. It has been
estimated that nearly 60,000 volunteers assisted with the support
efforts in Houston alone.

Because Texas's public health system is relatively decentralized
compared to that of other states, much of the local health and emergency
response to the hurricane was initiated and implemented by local health
departments. In Houston, for example, the Harris County Department of
Public Health and Environmental Services worked closely with the Houston
Department of Health and Human Services to provide medical services to
evacuees and to manage two large shelters in the city (Astrodome and
George R. Brown Center). Similarly, management and sheltering of special
needs population were provided by local health departments and
non-governmental organizations. (Morill et al, 2006)

***Georgia***

Georgia received many of the evacuees from Alabama, Mississippi, and
Louisiana. Georgia's governor, Sonny Perdue, mobilized the Georgia
National Guard and several state agencies to assist in processing
incoming evacuees and to provide disaster relief to Mississippi,
Louisiana, and Alabama. Governor Perdue signed several executive orders
on August 31, 2005 in anticipation of the arrival of evacuees and called
on all state agencies to develop plans for assisting the states affected
by Katrina and preventing price gouging on motor fuel. A State
Operations Center (SOC) was activated and staffed with representatives
from the Office of Homeland Security-Georgia Emergency Management Agency
(OHS-GEMA), Georgia State Patrol, Georgia Division of Public Health,
Georgia Department of Human Resources, and Georgia Department of
Defense.

Georgia has a decentralized health system; thus, the public health
district in which the evacuation site was located operated relatively
autonomously, with some technical assistance from the state. Airplanes
landed at the evacuation site every other hour over the course of two
days, and the site ultimately received 14,000 people (22 airplanes).
Staff from the district Department of Public Health and the Veterans
Affairs (VA) hospital mobilized to respond to the needs of people
arriving at the evacuation site. Members of the District Health
Emergency Response Team (DHERT), a local group (with branches across the
state) that plans public health emergency exercises and helps craft
policy, was called to assist at the military base. The DHERT, and
particularly nurse members, met basic needs while the VA conducted
triage as evacuees arrived.

# Chapter 4: The Role of Public Health in an Emergency

Hurricane Katrina revealed new challenges for the public health system,
particularly with respect to roles and responsibilities of public health
agencies in emergency response (Daley, 2006). Public health's presence
in emergency or disaster response is not new, but the last five years
have sharpened the focus on the need for better integration of emergency
preparedness and more traditional public health functions. It has been
argued that emergency preparedness has not only transformed the response
of public health agencies in catastrophic events, but also has
precipitated changes in how the discipline of public health organizes
and addresses a range of public health issues (Gebbie and Merrill, 2002;
Gebbie and Turnock, 2006; Katz et al., 2006, Lurie et al., 2006)

This study of the public health response to Hurricane Katrina presents
two critical perspectives on the relationship between emergency
preparedness and public health. First, the multi-state analysis of the
public health experience in the aftermath of Hurricane Katrina provides
a unique status report on how the discipline has incorporated new
emergency management methodologies and how health leaders perceive these
approaches. Second, the experience of Hurricane Katrina highlights
continued challenges for the field of public health in emergency
response.

The first sections of this chapter briefly describe the traditional
roles of public health agencies and how emergency preparedness has
transformed the functions of public health. The rest of the chapter
outlines key themes about Hurricane Katrina from our study interviews;
this discussion is intended not only to further our knowledge of the
hurricane response, but also contributes to our understanding of the
emergency response capabilities that public health will need in the
future.

## TRADITIONAL ROLES OF PUBLIC HEALTH

The public health system is vast, including governmental agencies,
private entities, community-based organizations, and academia (IOM,
2002). Historically, public health agencies work to address population
health issues by implementing educational programs, developing policies,
administering services, and conducting research**.** The Institute of
Medicine report on the *Future of Public Health* (1988) outlines the
three core functions of public health agencies: assessment, assurance,
and policy development. Public health's role in *assessment* includes
the systematic collection and analyses of data on community health
needs, including epidemiologic surveillance. Through *assurance*, public
health agencies implement the necessary action steps to meet
communities' health needs through direct service provision and/or
regulation. In addition, public health is charged with *policy
development*, or advocating for the use of evidence-based research in
implementing public policy that promotes the public's health.

## PUBLIC HEALTH AND EMERGENCY RESPONSE

In the last five years, public health emergency preparedness has moved
to the top of the national agenda, and much attention has focused on how
well emergency response is reflected and/or incorporated in the core
public health functions. The CDC's Public Health Emergency Response
Guide for State and Local Public Health Directors (CDC, 2004) outlines a
set of key preparedness activities for public health departments, and
these activities closely match the core functions. Specifically, the
Response Guide indicates that public health agencies should conduct
capacity and risk assessments (*assessment*); ensure that public health
personnel are trained in safety practices and that procedures have been
developed for all-hazard response and communications (*assurance*); and
participate in the design and evaluation of preparedness exercises,
which can be used to inform procedures and guidelines (*policy
development*).

Gebbie and Merrill (2002) contend that emergency preparedness is now a
responsibility of both public health agencies and individual public
health staff. Preparedness requires marshaling resources and building
competencies in command and control, use of protective equipment,
flexible problem-solving, and disaster communications. These demands
have led to changes in the roles of the public health workforce (e.g.,
new staff who can respond to biological agents) and advances in
information technology. Health departments have implemented various
public health preparedness and disaster training curricula (Weiner et
al., 2005; Rottman et al., 2005; Parker et al, 2005). In addition,
public health has begun to actively cultivate a corps of volunteers to
support public health staff in emergency response (Matthews et al.,
2005).

Despite these changes, challenges still remain with respect to
leadership, performance measurement, and integration of preparedness
activities into other public health functions (Asch et al., 2005; Lurie
et al., 2006). For instance, it is unclear whether public health is
fully prepared for another disaster event. Moreover, some in public
health are concerned that the emphasis on public health emergency
preparedness has overshadowed other public health activities (McHugh et
al., 2004).

## KEY OBSERVATIONS

The following sections outline overarching themes concerning the
integration of public health and emergency response during and following
the hurricane, and identify lessons and challenges to inform public
health's future emergency response efforts. In particular, we highlight
themes that emerged from the interviews about the role of public health.
In reviewing interview notes, we looked for frequently shared
perspectives as well as views that revealed important contradictions
regarding this role. Two main observations emerged from our analysis: 1)
there remains a lack of consensus regarding the role of public health
agencies in an emergency; 2) the field of public health has been
reshaped by the integration of emergency response functions and
approaches.

**There Is No Consensus Regarding the Role of Public Health in an
Emergency**

There is wide disagreement as to whether public health should be the
lead agency in emergency medical response. In addition, while our
interviewees agreed that public health has the responsibility to assure
that health care services are available in an emergency, there was
disagreement over the extent to which public health agencies have the
responsibility for providing that care. Below we discuss each of these
areas of disagreement in more detail.

***Public health's role as the lead agency in emergency medical
response***

Significant debate continues regarding the position of public health as
the central agency in emergency medical response. Public health agencies
received funds to address bioterrorism and related public health threats
well before Hurricane Katrina. However, the hurricane represented a
watershed moment during which state government agencies as a whole had
to test their roles and negotiate the role of the public health
department relative to other agencies (e.g., military, fire, EMS). Our
interviews indicated that public health agencies played a pivotal role
during and after Hurricane Katrina in all the states visited, but did
not serve as the sole lead agency in the public health and medical
response. Indeed, there was no consensus among public health leaders
about whether public health should take the sole leadership role. Some
interviewees, particularly those with public health backgrounds,
indicated that public health should assert itself as the lead agency in
future emergency medical response efforts. However, a few public health
leaders as well as individuals with more traditional emergency
management backgrounds indicated that public health should be in a
support role, while recommending that another agency (e.g., Emergency
Management) should take the lead in providing command and control during
an emergency. This split tended to occur between those with an academic
health background who thought public health should play a support role
and others focused on public health practice who thought public health
should be the sole lead agency; we did not see a division between those
concentrated in states with centralized health department structures
(Florida, Mississippi, Louisiana) compared to those with more
decentralized (Georgia) or mixed models (Texas).

For many public health officials, Hurricane Katrina revealed that public
health should be identified as the lead agency, due to the level of
expertise, experience, and quality of training found among public health
as well as public health's knowledge of the community. For example, a
Georgia official asserted:

> *"I see us as a lead agency and no one knows this community like we do
> so we should take a key role in any kind of a disaster. We are still
> carving out this role as we go along*." (GA official)

Those who believed that public health should be the lead agency during
an emergency argued that the emergency management responsibilities
required in a hurricane or other disaster are appropriately matched to
all of public health's core functions. A Florida official noted:

> *"I think that everything we are given (which is basically the
> oversight of the system) is appropriate for public health. We are a
> logical choice \[as lead agency\] because that is our role and it
> includes coordinating with the hospitals. Coordinating that the health
> system is up and running and our traditional public health role:
> epidemiology and vector born diseases and injury prevention is also
> part of our role. Assuring access to care should also be our role
> (including everyone having pharmaceuticals that they need). And in the
> bigger picture would we have the capability to take care of all of
> these things."* (FL official)

Those who supported the role of public health as the lead agency during
emergencies expressed concern that there was no plan for public health
to undertake that function, nor was there necessary support or funding.
Those who believed that public health should *not* assume a lead role
but rather take on a partnership or supporting role stated that, while
it was appropriate that federal and state plans assign public health as
the responsible agency for Emergency Support Function (ESF)-6 and ESF-8,
public health did not have the skill set or staff to go beyond these
duties and therefore must partner with other agencies. A Mississippi
respondent explained that public health's primary role should be in the
surveillance of health need:

> *"Public health should be working in collaboration with other agencies
> if for nothing else to articulate what problems exist from a medical
> perspective. For example, we have this many patients with special
> needs, this many with medications who have no way of getting
> medications, this is what happens when people dehydrate. Public health
> plays a role to articulate the health problems related to it."* (MS
> official)

Those who claimed that public health should not take on the lead role
reasoned that public health should be in charge of more targeted health
activities in conjunction with the capacity that the discipline brings.
For example, public health's well-established capabilities in
sanitation, injury prevention, post-acute phase disease care, and health
education were of utmost importance in the Katrina response. In
Mississippi and Louisiana, the public health response to address
polluted water systems and poor environmental health conditions due to
standing flood waters, lack of sewage facilities, and unrecovered bodies
was effective. Because these functions were carried out relatively
smoothly they have not received as much media attention as those aspects
of the response that were problematic.

***Public health's responsibility in providing direct health services
during an emergency***

Another theme concerned the extent to which public health agencies
should provide direct services during an emergency response effort. The
perspectives in this area were also mixed. A sizeable minority argued
that public health has an obligation to supply direct health services,
and this duty expands during an emergency response given the
immeasurable need. However, the majority of interviewees (cutting across
public health, hospitals, emergency management, and other government
agencies) were concerned that public health agencies do not have the
skills or capacity to assume significant responsibility in providing
direct health services.

Interviewees who asserted that public health should have responsibility
for direct service provision believed that public health needs to be
involved when the health care need outweighs resources, particularly in
a disaster situation in which a significant part of the population has
acute health issues requiring immediate attention. One Louisiana
official remarked:

> *"Absolutely. It depends on the type of disaster because the private
> sector cannot do it alone. We \[public health\] must keep the capacity
> to expand open, because when the chips fall public health will be the
> one to treat the masses as the private sector becomes overwhelmed."*
> (LA official)

Another Louisiana official described a model illustrating the typical
roles of public health agencies and the modified distribution of
resources and activities in an emergency (see Figure 2). According to
this perspective, the direct provision of health care services on a
day-to-day basis constitutes a small portion of public health's
functions. However, when emergency strikes, the role of public health
agencies changes and activities become more evenly distributed,
indicating an increase in public health's provision of direct health
services.

![](media/image4.png){width="6.916666666666667in"
height="3.8958333333333335in"}

Despite the support from some interviewees regarding this altered model
(right side of Figure 2) of public health functioning during an
emergency, many shared concerns about how long public health's
responsibility to provide direct health care would continue after a
disaster due to limited funding and the density of destruction. They
argued that public health could be more efficient if it devoted more
time to the educational arm of direct health services, such as informing
people about evacuation and other emergency response issues, rather than
providing health care services.

While a few interviewees asserted that public health agencies should
provide direct health service provision, many public health and
emergency management leaders cited obstacles to this approach.
Interviewees maintained the belief that traditionally trained public
health staff do not have the clinical skills needed to serve the
population's health needs and should have an oversight role only.
Therefore, the scope of functions (Figure 2) would not shift markedly in
emergency response. One Georgia respondent commented on the challenges
when public health agencies had to staff a special needs shelter while
caring for Katrina evacuees:

> *"Public health stood up one \[special needs shelter\] but didn't put
> people in it because they didn't have staff members who were
> comfortable providing the needed care (e.g., starting IV, doing
> procedures). Public health finally came to the realization that they
> have to carve out their role; the role of public health is assurance,
> but not providing care. Now, public health has more consideration to
> linking with home health agencies and nurse volunteers with different
> skills."* (GA official)

These interviewees thought that public health was already well-equipped
to organize systems, develop information portals for health care
providers, and ensure that the public receives health care. Public
health agencies should be in control of asset matching in order to link
providers with resources. One Louisiana leader remarked:

> *"Public health should say these are our goals and we want to enable
> you as a provider to work on the highest level possible."* (LA
> official)

**The Integration of Emergency Response Functions and Approaches into
Public Health Has Reshaped the Discipline**

Another theme from our interviews concerned the integration of emergency
response functions and approaches into public health and the challenges
associated with that integration. Many interviewees noted that using
Incident Command System (ICS) improved their response capabilities, but
also generated tension between traditional public health and emergency
management. More broadly, interviewees argued that the move toward
emergency management requires public health departments to reevaluate
their priorities, capabilities, and related staffing needs.

***Public health's integration of emergency management approaches and
the associated challenges***

The experience of Hurricane Katrina represents a clear post-9/11
milestone in emergency management public health integration. States that
experienced the direct impact of the hurricane and states that were
instrumental in the receipt of evacuees shared examples of how pre-storm
training improved their response to Hurricane Katrina. This experience
showed how well states incorporated these tools. However, it also
revealed continued tensions between those desiring public health to
fully embrace emergency management approaches and those in opposition.
In particular, public health officials in the states directly impacted
by Hurricane Katrina expressed caution about the potential effects on
other more traditional public health functions if public health
transformed completely to an emergency management model, asserting that
public health has skills in community assessment that would be
overshadowed by exclusively using this model.

Katrina demonstrated how all states are using emergency management
approaches, including the Strategic National Stockpile (SNS), Incident
Command System (ICS), and the processes of the National Disaster Medical
System (NDMS). In Georgia, the understanding of NDMS was instrumental in
quality care for Louisiana evacuees:

> *"Public health staff were familiar with NDMS 2 years prior to
> Katrina. We thought we might have to participate with regards to the
> war and didn't know how many casualties would be returning. We went to
> the VA \[Veteran's Administration\] to get briefing on NDMS and 1
> month before Katrina we did an exercise. We had familiarity and knew
> our respective roles." (GA official)*

In Mississippi, bioterrorism preparedness and the SNS were significant
factors in the success of the Katrina response. Prior to the hurricane,
the state gave public health nurses \$200 per month in standby pay as
part of the bioterrorism grant to participate in emergency training and
secured the commitment of these nurses in a disaster. A state leader
commented:

> *"It made nurses commit ahead of time and they had to be up-to-date on
> training... By them signing up in advance they couldn't wait to help.
> They were prepared."* (MS official)

Public health officials responded positively to using the ICS system,
although it was clear that the adoption of this practice was not yet
fully complete. In several states, interviewees described how ICS is
becoming more integrated into public health. One Georgia official shared
his/her thoughts on the matter:

> *"ICS was initially confusing but worked well over time and will work
> much smoother over time. It is an issue of knowing exactly what your
> role is; it is an innate response for individuals to want to help how
> ever they can and not stick with the small task assigned to them. The
> need to jump in and do whatever needs to be done must be controlled
> for the sake of organization."* (GA official)

Some public health officials believed that the discipline needs to
embody all aspects of emergency management in public health
preparedness. They maintained that public health is not traditionally
part of a response culture, and should change its orientation from a
"public health system" to a "public health response system."

The Hurricane Katrina response indicated that, while public health
agencies are becoming increasingly adept in using emergency management
strategies, continued tensions remain between public health and
emergency management due to differences in staff backgrounds, training,
and working styles. Staff with backgrounds in military health and/or
emergency management were appreciative of public health's ability to
engage in high levels of methodical analysis but were concerned about
the field's reluctance to assume leadership. They argued that public
health training teaches the importance of examining an issue from all
sides, but that the time required for such an analysis can impede action
in emergency situations. This problem is partially attributed to the
fact that traditional public health staff do not work in short-term,
quick-response modalities like other fields. A Texas leader matter-of
factly stated:

> *"Public health needs to have more of a shift change/sign out
> mentality similar to hospitals and emergency responders. Knowledge was
> lost in shift changes."* (TX official)

Despite increasing acceptance that emergency management needs to be
incorporated into public health's focus on disaster preparedness,
several public health leaders warned that the discipline cannot
completely adopt this model. Public health needs to retain its intrinsic
qualities and capacities related to care of the public and understanding
of community health needs. One Mississippi respondent commented:

> *"Public health folks learn the vernacular of ICS but we still have to
> look at the people. ICS is not specifically designed to totally
> encompass Public Health. It is not them versus us. The emergency folk
> tell me I can't go out alone, that it's a war zone, but I know the
> people. How does it work with public health and emergency response? We
> learn the terminology of ICS but you still can't forget public health.
> The people are missing as a part of this. You have to address and
> survey the needs of the community."* (MS official)

Many interviewees were concerned about the limitations of taking an
exclusively military focus in emergency response. In Louisiana, there
was praise for the military's organizational skills, yet some
interviewees acknowledged that security concerns need to be balanced
with empathy and a more intimate approach.. One respondent remarked:

> *"The military did a great job and they understand a military detail,
> but they ran the Superdome like a military operation. They need to
> have a more touchy-feely attitude. For example a bus got stopped at
> midnight and their bus got searched while all of the occupants were in
> need of care and did not need to be searched. I think this is another
> lesson we need to look at but we need to cross-train the military for
> domestic details."* (LA official)

***Impact of emergency response on the discipline of public health***

This study of the response to Hurricane Katrina also provides insights
on how the newfound emphasis on preparedness has affected the discipline
as a whole. Interviewees noted that the emphasis on emergency management
has raised the visibility of public health in the community, focused
more attention on the core function of assurance, and emphasized new
partnerships. In addition, the emphasis on emergency response has
introduced new priorities in public health staffing and related
capabilities.

Interviewees noted that the focus on preparedness and emergency
management methods has changed the way public health agencies perceive
their mission and their responsibility to the community. For many
southeastern states, which have traditionally viewed public health only
as a "safety net" agency, the Hurricane Katrina response has propelled
public health into a more prominent position. Interviewees argued that
emergency response shifted attention toward the assurance function of
public health and has broadened public health's responsibilities to
assume more control in linking health services. In addition,
interviewees reported that the regular exercising for emergency
readiness has forced public health to build relationships with agencies
that may be beneficial in responding to future health issues. One leader
stated:

> *"Exercises put us in better shape to respond to anything. It made
> them \[public health\] have conversations with long-term care
> facilities and faith communities for less acute needs. For example,
> the partnerships with the faith community also showed the value of
> additional partnerships-looking at nontraditional partners and trying
> to push down to the most local level by asking who those
> nontraditional partners are."* (GA official)

Public health staffing needs have changed in the wake of the Hurricane
Katrina response, especially with respect to nursing and disease
surveillance. Interviewees explained that the shift towards emergency
response has threatened to diminish the current pool of nurses because
they are less comfortable with this role, as they have received less
training in this area and the job requirements are generally less well
articulated. One-third of public health staff consists of nurses, and
public health already faces obstacles in retaining and adequately
compensating these nurses. As public health departments receive funding
for staffing and training related to preparedness, key questions loom
about nursing and the general public health staff structure\-- namely,
what nursing capacity is required during an emergency and how is the
nurse's role defined between emergencies?

Additionally, interviewees indicated that certain recent hires are
likely to benefit public health's disease monitoring and clinical care
activities. Interviewees described how preparedness funds have been
spent on hiring surveillance nurses and enhancing lab techniques, thus
augmenting the quality of disease surveillance activities in general.
This finding is consistent with other studies that have indicated that
the preparedness "all-hazards approach" has facilitated investments in
multiple-use systems for the entire public health system (Katz et al.,
2006). One Mississippi official hypothesized that staff enhancements in
one area are likely to produce benefits in other aspects of public
health, such as clinical programming:

> *"So basically we have enhanced the epidemiology surveillance function
> and one might argue that this may relieve pressure from other staff so
> they can spend more time in clinic operations. If you enhance one
> vital activity it provides staffing to make that function independent.
> We do have extra manpower in our districts as a result of
> terrorism/CDC monies. This may indirectly benefit heavily clinical
> programs."* (MS official)

## IMPLICATIONS FOR PUBLIC HEALTH

This analysis of public health and Hurricane Katrina illustrates how far
the discipline has progressed in developing emergency response
capabilities and adopting new organizational approaches (e.g., ICS).
This study also reveals that states continue to grapple with how public
health agencies should function during disasters, how the assets of the
discipline can be maximized, and how public health works with other
agencies not only during a crisis but in day-to-day activities. Here we
offer some considerations for both practice and research.

-   **Clearly define the role public health agencies will play in a
    disaster and develop a plan that institutionalizes those roles.**
    The response to Hurricane Katrina highlighted the need for the
    public health system to reflect on how a public health agency should
    operate in a community, both during disasters and in daily practice.
    While several public health leaders asserted that public health
    should be a lead or coordinating agency in emergency response, the
    continued resistance to this model (e.g., public health lacks
    coordination skills) highlights the need to revisit this issue and
    formalize the structure of the disaster management process. If
    public health assumes a lead role, staffing and capacity need to be
    augmented. On the other hand, if public health has a support role,
    functions and boundaries need to be defined. Clearly, continued
    discussions are necessary regarding public health's emergency
    response role relative to other stakeholders. The relevant
    organizations within each community should meet to develop a
    coordinated plan that clearly delineates each organization's roles
    and responsibilities. Without such a plan, there is no
    accountability, and response efforts will continue to be hampered by
    confusion over roles and responsibilities.

-   **Develop a plan for how medical care services will be provided in
    an emergency.** Within the broader emergency response plan, public
    health agencies must come together with their response partners to
    determine precisely how medical care services will be provided in an
    emergency and by whom. The analysis of public health's
    responsibility in providing direct health services revealed two
    opposing points: a) public health must be involved, given the
    extensive need during emergencies; and b) public health has limited
    skills to provide these health services and should focus on its
    assurance role. This tension is important and indicates that public
    health should consider if and how its capacities (e.g., staffing,
    training, resources) can be improved to incorporate more direct
    health service activities. If it is decided that public health's
    role should only encompass the assurance of services, the field of
    public health needs to critically examine how it is going to
    relinquish any direct health service responsibilities and partner
    with hospitals, community health organizations, and other providers
    to streamline the provision of these services.

-   **Work to incorporate the best elements of public health and
    emergency management into disaster response plans.** While the
    response to Hurricane Katrina revealed that significant progress has
    been made in bringing the public health and emergency response
    sectors together in terms of communication and understanding, there
    is still more to be done. From the perspective of several public
    health officials interviewed for this study, the merging of the two
    sectors has not fully reflected the assets of both. The experience
    of Hurricane Katrina indicates that there are several aspects of
    traditional public health (e.g., ability to work in communities, use
    multidimensional assessment approaches) that should be reflected in
    emergency response planning and training. Future studies should also
    explore how principles of public health are communicated to the new
    public health workforce (e.g., traditional emergency responders).

-   **Identify opportunities to apply emergency management approaches in
    more traditional public health functions.** Many public health
    officials hypothesized about the ways in which emergency management
    has influenced the discipline of public health, particularly with
    respect to new staffing and new capacities. This study further
    endorses research that explores how to maximize the multiple
    benefits of integrating emergency management resources into other
    public health activities (e.g., how the principles of ICS can be
    used to address chronic disease).

# Chapter 5: Workforce Issues

In this chapter we examine health care workforce issues that arose
during Hurricane Katrina and its aftermath. Workforce issues pose a
particularly complex challenge for public health. Other than providing
regulatory oversight and managing its own clinics, public health has no
role in managing the workforce of public and private health care
organizations. At the same time, public health is the designated agency
responsible for ESF-8: Health and Medical Services. The role of public
health in this capacity is to *assure* that health and medical services
are provided to the public, not necessarily deliver acute health care
services. However, many view public health as the health care safety net
for the community when disaster strikes. Whether or not workforce
management is an official public health function, hospitals, nursing
homes, and other health care organizations, as well as many members of
the public, often rely on public health agencies to provide stability
and control in a situation that is overwhelming and chaotic.

Health care workforce issues are especially challenging for another
reason. The process of building a health care workforce is typically
slow and deliberate by design. Job candidates are carefully screened and
their credentials verified. After all, these individuals are being hired
to perform duties and make decisions that directly affect people's
health and well-being. In contrast, during an emergency, organizational
structures and processes--and the related paperwork--are often left
behind or lost, or cannot be procured or established in time to meet the
need of the immediate crisis. During a crisis, workforce needs must be
met by attempting to strike a balance between the desire to maintain
established organizational procedures for the workforce and the
immediate demands of those in need of care.

Adding to the complexity of workforce issues is the fact that the health
care workforce provided services in a range of different settings during
the response to Hurricane Katrina including triage centers, mass care
shelters, and special needs shelters. Triage centers were areas set up
to receive evacuees, for example in Georgia at the Dobbins Air Force
base; the medical conditions of the evacuees were assessed at these
triage centers.  People who needed immediate acute care were sent to a
hospital; nursing home patients were sent to a nursing home in the
receiving region.  And, evacuees with no immediate problems were sent to
a shelter.  Shelters of various sizes were set up by many different
groups (e.g., faith groups).  However mass care shelters established by
the Red Cross housed and fed large numbers of evacuees (in some cases
2,000 - 5,000 people); many of these large shelters contained improvised
clinics to provide medical support to the shelter residents.  Special
needs shelters were centers set up by public health officials to care
for people with a wide range of ongoing medical needs such as continuous
oxygen, mental health problems, or functional limitations.

As seen in this chapter, many of the workforce problems that arose in
the aftermath of Hurricane Katrina are not fully within the scope of
public health's control. At the same time, the public health workforce
did play an important role in addressing health care needs in the
aftermath of the hurricane. We explore the problems that arose, and
discuss the implications for planning to address similar emergencies in
the future.

## KEY OBSERVATIONS

Health Care Staffing Needs Caused Problems for Hospitals and Nursing
Homes Leading Some to Call on Public Health for Assistance

Hospitals directly affected by the hurricane faced many staffing
challenges. There were situations in which the public flocked to local
hospitals seeking care and shelter, overwhelming staff capacity and
creating security problems. In general, few health care institutions
plan for sheltering and feeding people from the community during a
disaster, yet hospitals are often viewed by the public as a refuge. As
one hospital official stated,

> *"We emptied out the long-term patients who had places to go. So we
> planned for beds but I never planned for Public Health capacity*." (MS
> Official)

In other hospitals, storm damage and flooding isolated hospitals from
outside assistance for a number of days. Health care personnel were
exhausted and faced increasingly stressful conditions as generators
failed, supplies of food and water dwindled, and basic patient care
supplies became scarce.

In the hospital setting, the initial staffing need during a disaster is
for additional physicians and registered nurses who can deliver care to
an influx of people with acute injuries, illnesses, and chronic
conditions. If the emergency lasts longer than 24 hours, there is a
demand for "relief" staff so that medical providers can obtain ample
rest . In events such as hurricanes where there is advance notice, most
hospitals will call in off-duty staff, discharge as many patients as
possible, and cancel elective procedures. Many hospitals in the states
we visited require staff to participate in disaster response as a
condition of employment, and staff are allowed to bring their families
and in some instances, their pets.

Nursing homes also require additional staff in emergencies, primarily
practical nurses and nursing assistants as opposed to physicians and
registered nurses. Volunteers can play an important role, but only if
their skills match the needs of the facilities. As one official stated,

> *"The problem we had is that we had a lot of \[general\] volunteers,
> but we needed CNAs*
>
> *and LPNs"* (LA Official*)*

Nursing homes differ from hospitals in that the former are more likely
to evacuate in anticipation of hurricanes or other predictable
emergencies. With the help of the Nursing Home Association staff, 21
nursing homes in Louisiana were evacuated pre-event and another 35 were
evacuated after the storm. Nursing homes are also more likely than
hospitals to be part of a larger chain, thus increasing their ability to
transfer patients out of the path of the hurricane and in some cases to
send staff to facilities in need. Although this occurred to some extent
in Louisiana and Mississippi, the precise scope is unclear.

Although hospitals and nursing homes in the directly affected states had
their own plans in place, the magnitude of Hurricane Katrina exceeded
the ability of many to meet staffing needs. Although a few hospitals
that are part of larger corporations were able to request and received
additional staff from other locations, such as from Federal Disaster
Medical Assistance Teams (DMATs), most hospitals had little capacity to
increase their staffing. In addition, emergency conditions lasted more
than 24 hours, thus increasing the strain on the existing staff.

Hospitals and nursing homes receiving evacuated patients in the states
we visited were faced with large increases in patient volume for an
extended period of time. Although a few hospitals received assistance
from Federal DMATs and some brought in nurses from other areas, most
hospitals had few additional staffing resources. One hospital official
in Florida expressed frustrations with the staffing problems encountered
during the storm,

> *"When we requested nurses and physicians the \[emergency management\]
> bureaucracy was so thick we could not get the people we needed in the
> time we needed them\... This is a work force challenge."* (FL
> Official)

The Role of Public Health in Helping Hospitals and Nursing Homes with
Workforce Related Issues is Not Well Established

While our interviews confirmed the enormous need for health care staff
during the event, the research did not result in any clear answer as to
what the role of public health agencies should be. Public health does
not have surplus health care staff for mitigating surge needs. However,
there has been increased pressure on public health departments (through
the CDC PHEP and the Bioterrorism Hospital Preparedness Program (BHPP)
Cooperative Agreement requirements administered by the Assistant
Secretary for Preparedness and Response (ASPR)) to develop a cadre of
volunteer health professionals to rely on in a public health emergency
(such as the need to vaccinate populations in a short period of time).
There is also pressure on hospitals and public health departments to
collaborate to develop groups of volunteer health professionals who are
available to meet the increased need for health care providers in the
hospitals, in shelters, and in the community during disaster situations.
This organized effort to increase the workforce during emergencies is
still early in the development phase in Louisiana and Mississippi.

State regulations, Medicare rules and accrediting bodies such as JCAHO
require health care institutions to establish disaster plans for
responding to emergencies, and these plans include a staffing component.
However, each institution is responsible for its own staffing. The
workforce details of these disaster plans are left up to each
institution, and public health is typically not involved and thus the
role that public health agencies can or should play is not well
established. Moreover, the extent to which the hospital disaster plans
are integrated with public health preparedness plans was uncertain.

**Coordination of Health Care Personnel Was Difficult in All Care
Settings**

During which there was tremendous need for medical personnel, there
were, fortunately, many health care professionals willing to volunteer
their time and efforts. However, while the supply of medical personnel
may have been sufficient, systems were lacking to coordinate volunteers
and match their skills to sites with identified needs (clinics,
shelters, etc.).

For example, interviewees who helped with receipt of evacuees in Georgia
reported that the disorganization of arriving health care volunteers
created chaos. As a result of this experience, Georgia added to their
emergency plans an access point for checking in and briefing volunteers.
Louisiana and Mississippi also had many volunteers, yet little
organization for processing and training them. At the EOC in Baton
Rouge, Louisiana employees from the Department of Health and Hospitals
attempted to match volunteers with areas of need. However,
communications were so poor in the affected regions that it was unclear
where health care services were being provided and which sites were in
need of personnel.

An overwhelming number of interviewees noted problems in matching
available resources to needs. For example, in Houston, available
personnel were overwhelmed by the volume of evacuees (approximately
68,000) who arrived at the triage center in a short period of time. One
interviewee reported that DMAT teams were requested but never sent. The
Houston Fire and Police departments worked closely with the medical team
to provide manpower for the convention center, as well as transportation
and other logistical support. Health professional volunteers from the
local hospitals and medical schools, as well as personnel from the
health department, helped staff the triage center.

To accommodate the large number of evacuees with varied needs, the
triage teams had to make real-time adjustments to their plans and
maintain flexibility. Interviewees reported that triage procedures were
generally satisfactory. Sick patients who required hospital care were
promptly identified and those requiring further medical attention at the
shelter were given care at clinics set up at the shelter. One Texas
public health official suggested that, in the future, they more
effectively utilize community resources, such as community clinics, to
provide medical care:

> *"I want to establish a closer relationship with the community based
> clinics to help do the work and not create an imaginary structure that
> may never be used -- we want to build on structures already in
> place."* (TX Official)

Staffing needs for triage centers could change rapidly depending on who
arrived in need of care. For example, in Georgia, the NDMS was activated
and a triage center was established in a military hangar to receive
adult patients who had been evacuated from hospitals in Louisiana and
Mississippi. A medical team from the Department of Veterans Affairs (VA)
was poised to accept and triage the evacuated patients, who were
expected to bring their medical records, at the hangar and then transfer
them to one of the region's 37 NDMS participating hospitals in the
Atlanta region, all of which were prepared to take patients. However,
the patients arriving at the triage center came not only from hospitals
but also from nursing homes, and few had medical records. In addition,
many pediatric patients arrived at the center. Although the medical team
did not have the equipment or the training to care for children, staff
in the operations center were successful in quickly bringing in
physicians, nurses and pediatric equipment from Children's Healthcare of
Atlanta.

The Georgia triage center not only received large volumes of hospital
and nursing home patients, but also evacuated citizens in need of
medical care. The arrival of citizens in need of care was totally
unexpected and thus created a staffing problem. In order to adequately
triage the large volume of patients and evacuees, a second ICS team was
quickly assembled and brought in to manage a second hangar. Volunteer
physicians and nurses, many from hospitals in the metropolitan Atlanta
area, staffed this hangar and triaged evacuated citizens for medical
needs before they were sent to a shelter.

**Mechanisms Were Lacking to Verify Credentials and Skills of
Volunteers**

A related problem was the lack of an agreed-upon method for verifying
the credentials and skills of the health care professionals who
volunteered to help. As many interviewees noted,

> *"People just came and showed up to say they were here to help."* (MS
> Official)

This situation created a dilemma for triage centers, hospitals and
shelters, eager for help, yet concerned that volunteers had proper
credentials and training to provide quality care. There was special
concern about the potential liability of hospitals and public health
agencies in the event a volunteer accidentally caused harm to a patient.

State licensure laws limit practice to those professionals licensed in
that state. Louisiana relaxed those requirements and allowed licensed
professionals from other states to practice; however, Mississippi did
not. In states that were not directly affected by the hurricane there
was not as much of a problem with unsolicited out-of-state volunteers.
However, even though a volunteer health professional holds an active
license to practice in that state, there is no way to promptly verify
his or her license or to determine skill levels. One Mississippi
hospital accepted unsolicited volunteers with a Mississippi license, but
then either limited their practice to low-risk activities such as
administering tetanus injections, or paired the volunteers with
qualified hospital employees.

There are efforts underway in each state we visited to improve the
coordination and to address the credentialing issue. In Texas public
health officials are in the process of organizing a registry of
volunteers and planning how to mobilize a workforce for future
emergencies. They have identified medical schools, professional
associations and licensing boards as potential sources of volunteer
health professionals and are also exploring ways to make better use of
federal, state and local personnel assets.

A public health official in Louisiana suggested a tiered approach to
categorize the levels of ability possessed by volunteers\--a ranking
system for volunteers to insure that those volunteers sent into the
disaster sites have the required skills to provide quality care. Other
options for recruiting volunteers include a national registry. There are
currently federal efforts to provide this resource through HHS's
Emergency System for Advanced Registration of Volunteer Health
Professionals (ESAR-VHP) program. However, the system has not been fully
implemented in any of the states that we visited.

Florida has taken steps to build a base of volunteers after its
experience in past emergencies such as Hurricane Andrew. One public
health official explained that, when a hurricane is in the gulf, 5000
volunteers are initially e-mailed. When the storm is 48 hours from
landfall, volunteers are placed on standby. Florida uses an online
database both to track standby volunteers and to allow volunteers to
indicate their availability. Florida has also pre-credentialed
approximately 400 nurses from North Carolina.

Although Florida's practice is exemplary in comparison to other states
we visited, there are still many difficulties in establishing a
pre-credentialed on-call volunteer health professional workforce.
Florida has been involved with implementing the ESAR-VHP program, but
some interviewees stated that that the program is moving too slowly. One
official was concerned that keeping credentials up to date would be a
major issue even as the new system becomes more widespread.

> *"We work on bringing nurses through other states and credentialing is
> a huge problem. I cannot move staff from one hospital to the other and
> that is really absurd. I think ESAR-VHP is moving very slowly and this
> is a tremendous problem. Credentialing people within the state if you
> do not have credentials in the hospital then state credentials should
> be enough during a disaster. How can we have more flexibility in the
> medical system?\...Liability and reimbursement are the major issues
> for credentialing."* (FL Official)

**Public Health Provided Valuable Assistance at Triage Sites and Mass
Care Shelters**

Local and state public health departments had varying roles at triage
sites and general mass care shelters. In some cases, public health's
role was to monitor for infectious diseases, while in others, they
provided nurses to help staff the triage centers and shelter clinics. In
Georgia, the public health epidemiology team assessed residents of the
shelter to identify medical conditions in need of treatment, such as
diarrhea, respiratory infections, and cuts and sores. The team took an
initial health status history on each resident and then returned to the
shelter each day to monitor conditions. The public health nurse on the
epidemiology team worked in conjunction with the Red Cross nurses and
the nurses in the shelter's clinic.

At times, public health personnel provided treatment at mass care
general shelters. Such shelters, run primarily by the Red Cross, were
opened in all of the states we visited and many stayed open for weeks,
sometimes housing more than 3,000 evacuees. The Red Cross typically does
not provide medical care beyond first aid, and was thus unable to
provide sufficient staff to address the medical needs of a number of
evacuees, mostly for chronic conditions. In various locations, medical
clinics were set up in or adjacent to the shelters to treat injuries,
illnesses and chronic conditions. Local health departments exercised a
role in staffing these clinics, working alongside staff from medical
schools, hospitals, and other volunteers. In addition, the US Public
Health Service federalized a group of volunteers from Southern
California so that each day, physicians and nurses could be assigned to
help in different places. Louisiana State University helped organize and
staff clinics along with volunteers from the local area and from out of
state. But again, the major problem was matching staff resources to
areas of need.

In Georgia there was a different organization of health care services,
which could be a model for public health. A "Mega Center," organized by
the Red Cross and supported by the Georgia Emergency Management Agency
(GEMA) and other local agencies, was set up close to the shelter and
housed all of the health and social services needed by shelter
residents. Health care was provided by volunteers from a local health
system and included social workers and pharmacists. Social workers
proved invaluable in discharge planning, and the pharmacists worked
closely with the physicians to provide primary care medications and
medication consulting. Involving pharmacists in the care of evacuees
worked well in Georgia, and this practice may have resulted in fewer
emergency room visits and hospitalizations for evacuees with chronic
conditions requiring regular medications. Often, the pharmacist was able
to decipher medications that residents were taking and to recommend
doses based on what the super center had available. Thus, evacuees could
go to the Mega Center to obtain all of their needed health and social
services.

**Staffing Special Needs Shelters Was a Major Problem**

Special needs sheltering during a disaster response has been a problem
in every state we visited, whether in the aftermath of Hurricane Katrina
or during a previous hurricane response. Because the issue of special
needs shelters will be covered in detail in Chapter 8, we will only
briefly touch upon a few points relevant to workforce issues here.
Although public health officials generally agree that state and local
public health agencies are responsible for *assuring* the care of
special needs populations, there are different views as to who should
*provide* that care.

> *"Special needs shelters pose tremendous challenges. We don't have the
> skill set and staff. We can't do it all alone. Our partners are
> critically necessary. We don't DO these things but must make sure they
> are done."* (GA Official)

In Georgia, for example, state public health officials assert that the
role of public health is ensuring that people receive care, but not
providing the care. In Texas, public health staff set up special needs
shelters, but Texas officials believed that public health workers needed
more first response training in order to be better prepared to assist
special needs populations in future emergencies. In Mississippi,
hospitals and public health agencies staffed the few special needs
shelters that were established.

Perhaps the most challenging workforce issues emerged in Louisiana,
where a legislative mandate required the public health department both
to open and staff special needs shelters during public health
emergencies. This requirement has posed a significant challenge for the
health department because they lack sufficient personnel to staff the
shelters, and the majority of their health care personnel either have no
training to care for special needs patients, or have not provided
patient care in many years. In addition, the patient acuity level was
much greater than anticipated.

> "*The staff is more comfortable with the special needs shelter, but it
> turned into much more during Katrina. It turned into (GI bleeders,
> gunshot wounds, hospitals were off loading to us) a field hospital
> over night. So everyone was coming for help from us. Nurses who do
> STD, well child exams, pap smears and pelvic exams were running an ER.
> We were doing IVs, drawing blood..."* (LA Official*)*

The challenge increased after Hurricane Katrina because the volume of
special needs patients was also much greater than expected.

**The Physical and Emotional Stress of the Disaster Intensified
Workforce Problems**

All of the workforce issues highlighted in this chapter were made more
difficult due to the physical and emotional stress experienced by those
working during and after the hurricane. Long hours, less than ideal
working conditions, and a sense of tragedy were the norm in all of the
response sites. Health care workers were exhausted. Some interviewees
described workers falling asleep on the hospital floor. Others noted
crowded and austere living conditions such as sleeping in a tent with
386 other people. The situation was made more difficult because there
was no place to escape the disaster. One interviewee remarked,

> *"There needed to be a tent or something during the event and not just
> after, where the workers could release. You need a place to go to and
> someone who is not actually part of the disaster to run it; someone
> from the outside to come in and listen and let people unwind."* (GA
> Official)

Another interviewee reported,

> *"My (nursing) staff worked 16 days without a day off; no one came
> prepared and no one had anything. We took care of 11,000 people."* (LA
> Official)

Although health care workers in all areas were stressed by the
emergency, the situation was much worse in states directly affected by
the hurricane, where the workers were also victims of the storm. As one
Mississippi official stated,

> *"Health care providers worked around the clock without knowing the
> status of their own home and family."* (MS Official)
>
> *"We did the best we could with what we had. We did the best we
> could."* (LA Official)

In a sense, one of the key lessons of Hurricane Katrina lies in the
difficulty health care personnel had in serving as caretakers when they
too were victims of the disaster. Many responders suffered emotional
distress over their own losses or from observing tragedies first-hand.

> *"One of our emergency responders showed up dazed and he lost his home
> and they told him to go home but all he wanted to do was work. It was
> very stressful. We had to get mental support for our folks to deal
> with it."* (MS Official)

Others experienced (and are still suffering from) longer-term mental
health conditions such as depression and post-traumatic stress disorder.
In addition, some health care workers were victims not only of the storm
but also of the strain of rebuilding the community and health care
infrastructure. One public health official stated,

> *"We didn't think enough about mental health. We underestimated the
> stress and strain on our own workforce...That is the invisible thing
> that has to be addressed."* (MS Official)

## Implications for Public Health

In all the states we visited, there was a clear need for additional
health care personnel to assist with the surge in many of the hospitals,
the high volume of patients and evacuees moving through triage centers,
and the primary care needs of the general shelter population as well as
the specialized care needs of those in the special needs shelters.
Further, there was a need for "relief" staff in all care settings as the
emergency extended longer than 24 hours. Although the number of
volunteer health professional staff may have been adequate to meet the
demand, there was poor matching of staff resources to places of need.
This was likely the result of breakdowns in communications as well as a
lack of organization and coordination. Other major barriers to
effectively using volunteer health professionals were lack of systems
for verifying licensing credentials and determining skill levels, state
laws prohibiting legal practice by health professionals licensed in
other states, and liability and reimbursement concerns.

Most of these issues have no easy solutions. While there are steps that
public health agencies can take to improve their internal response
capability, many of the most significant questions raised in this
chapter ultimately require planning and coordination across the medical
and public health sectors. Who should be staffing a hospital when
hospital staff themselves are victims of disaster? How can the immediate
health care needs of the injured and the ill be addressed while also
ensuring that adequate organizational safeguards are in place to check
and approve the credentials of health care volunteers? Who is
responsible for managing those volunteers and ensuring the quality of
their service?

The development of standardized procedures might be useful to address
some of the needs described in this chapter, but uniform standards would
be nearly impossible to implement because workforce licensing laws are
state-based. Each state will ultimately need to make its own decisions
about how workforce needs can be better addressed in future crises.

Although some significant issues are not likely to be resolved soon, we
note the following issues that might be given additional consideration
in preparing to respond to future emergencies.

-   **Consider ways in which public health can build on its traditional
    roles to assist other health care organizations in addressing
    workforce issues.** Although many interviewees felt that the role of
    public health should be limited to assuring that care is delivered
    to the populations at risk, most recognized that public health must
    be involved in planning for health care workforce needs during a
    disaster. While public health agencies cannot keep extra health care
    staff on hand to assist during a crisis response, there may be ways
    for public health to use its more traditional roles as a means of
    assisting in the process of meeting workforce needs. For example,
    public health could use its traditional responsibility of educating
    the public about sheltering during a disaster in order to direct
    people to appropriate shelters and relieve some of the hospital
    staffing burden that occurs when the public tries to use hospitals
    as a source of shelter. This could be accomplished by further
    publicizing the location of general shelters, and educate the public
    about what to do (and not do) during a disaster via public
    information campaigns. In addition, preparedness information
    distributed by public health agencies should encourage people to go
    to hospitals only in the event of injuries and illnesses.

-   **Develop systems to better match personnel resources with
    identified needs.** The difficulty faced in coordinating health care
    personnel and matching them with identified needs was a common theme
    that emerged in many of our interviews. With this in mind, state and
    local health departments must work with their public health response
    partners to develop systems that can better assess needs, coordinate
    resources, and allocate them across affected areas.

-   **Identify means to attend to the emotional and mental health needs
    of the population, including public health staff who are themselves
    victims of disaster.** Many of our interviewees experienced physical
    and/or emotional stress first-hand or knew someone who did.
    Short-term and long-term mental health issues were more pronounced
    than anticipated and were particularly prevalent among workers who
    were also victims of the storm. These issues need to be addressed.

-   **Give special consideration to the realities of staffing special
    needs shelters during an emergency.** Staffing the special needs
    shelters was especially problematic during the hurricane and
    remains, to this day, an unresolved issue. Although public health
    officials generally acknowledge that state and local public health
    staff are responsible for assuring the care of special needs
    populations, it is inexplicit as to who should actually provide
    this. The experience in Louisiana in particular highlights the need
    for more attention to the realities of staffing special needs
    shelters during a major disaster where large numbers of displaced
    people require sheltering.

# Chapter 6: Medical Supply and Pharmaceuticals

Responsive medical support in the form of medical supplies and
pharmaceuticals was crucial to enable health care providers to provide
medical care to hurricane victims and evacuees. Medical supplies and
pharmaceuticals were also needed to support evacuees with chronic
illness and/or those who require long-term medications or medical
equipment. A variety of public and private organizations were involved
in supplying and distributing medical supplies and pharmaceuticals in
the aftermath of the hurricanes, but, as will be discussed in this
chapter, there were noticeable gaps in the supply and distribution
process.

In some cases, the available supply of pharmaceuticals and medical
equipment was insufficient to meet the needs of the population, and
distribution processes were also problematic. Problems also arose
surrounding the extent to which various public health and other
government agencies as well as nongovernmental and private-sector
organizations were successful in coordinating their efforts to provide
medications and equipment to those in need. At the end of the chapter,
we discuss the implications of our findings for public health and offer
some recommendations to improve planning for future disasters.

## KEY OBSERVATIONS

**There Was No Comprehensive System for Managing Supplies**

The systems in place to match available supplies with need were
inadequate during Hurricane Katrina. Many interviewees noted that there
were many supplies from a wide array of sources (e.g., from other states
through EMAC, private companies) flowing into the affected areas, but
there was no effective way to inventory the supplies (i.e., identify and
catalog what they were receiving) and allocate them equitably and
efficiently. Many public health officials noted they did not always know
exactly what supplies had been sent. This had negative implications for
patient care as it created delays in getting the supplies out to people
in need. One official in Louisiana stated that,

> *"It \[managing supplies\] definitely needs to be more organized. A
> lot of the time was spent on the phone (sometimes from 7 am --
> midnight) talking to people who wanted to help."* (LA Official)

If the resource allocation system had been more organized, officials
would not have had to turn to these more time-consuming and
labor-intensive methods, such as phone calls, to take inventory and
match supplies with needs.

There were some important gaps in supply, which appeared to have
affected some states more than others. Public health departments in some
states were overwhelmed with calls from hospitals or individual patients
in need of medications. For example, a public health official in
Mississippi noted:

> *"Initially, there was trouble with everything...we were getting
> individual calls that someone in a rural county was going to die if
> they didn't get their meds...We just didn't turn down any calls and
> help them get help -- there's chaos in that. It was very stressful".*
> (MS Official)

Other reports from the region have also noted that on occasion, support
teams in the field lacked supplies. For example, interviewees noted that
Disaster Medical Assistance Teams (DMATs) arrived in disaster areas
without adequate medical equipment and drugs and there was a lack of
standardization among some types of equipment, which inhibited efficient
delivery of care.

Supply problems also arose in the states receiving evacuees. Officials
in Georgia noted that when receiving hospital evacuees they did not have
the supplies that they needed for effective patient care.

> *"We didn't have enough medical staff and equipment to fully assess
> people at the hangars \[triage centers\]. Now we are looking at what
> equipment we should have but didn't."* (GA Official)

Some of these supply problems were due to lapses in communications. For
example, officials in Georgia were not expecting to receive any
pediatric cases and thus did not have pediatric equipment or specialists
on hand. Fortunately, as infant evacuees began arriving, Georgia
officials were able to identify suppliers and obtain the needed
equipment. As one official noted,

> *"The other unexpected surprise was the receipt of pediatric patients.
> In their \[National Disaster Medical System (NDMS)\] plan they were
> only prepared for adults and did not have pediatric equipment. They
> called Children's Healthcare of Atlanta and were immediately sent the
> needed equipment."* (GA Official)

In response to this problem, officials in Georgia are updating their
NDMS plan to include the personnel and equipment needed to treat a
broader range of patients and conditions.

### Supplies Were Not Always Well Matched with Needs

Many supply problems arose because the resources flowing into the area
were not well matched with needs. Such mismatches created shortages in
some areas and surpluses in others. As one Mississippi official put it:

> *"...there was no mechanism for needs matching. Ice, water, etc just
> showed up. There were real needs but they weren't matched up
> correctly."* (MS Official)

The problems during the event appear to have stemmed primarily from an
inefficient, and in some cases, nonexistent system for organizing and
managing supplies in any centralized way. Effective matching requires
coordination between state and local officials. At the local level,
communities need the ability to promptly conduct a needs assessment, the
purpose being to request the specific set of resources that will serve
their needs. At the state level, officials need to identify what
resources are available and determine how to best allocate those
resources to address the needs across the affected areas.

Interviewees suggested various options for addressing future problems
with the management of supplies. For example, some suggested that it
would be useful to develop a system that could inventory and track the
distribution of supplies during a disaster. In addition, some of our
interviewees noted that standardized inventory lists could be used to
help with the set-up of clinics or mobile pharmacies during a crisis.

> *"We need to create a pallet or list of things you need in order to
> open a clinic. We created a system. Otherwise you would get donated
> parts of a clinic but not what you needed in total."*(LA Official)

Inventory lists would be useful in producing a realistic assessment of
the needs in a community and thus enable a better matching of resources
with needs.

[]{.mark}

**The Size of the Disaster Contributed to Supply Problems**

The scope and magnitude of Hurricane Katrina also contributed to supply
and distribution problems. The scope of the disaster was greater than
expected and surpassed what most facilities had planned for. As a
result, their stockpiles of food and other supplies were not sufficient
to meet their needs in the immediate aftermath of the storm. To address
this concern, public health officials in both Louisiana and Mississippi
plan to revise their stockpiling recommendations. In Louisiana, one
official articulated that,

> *"For Katrina for the most part everyone had 3 to 5 days worth of
> supplies. We are telling them this year to have 5 to 7 days worth of
> supplies."* (LA Official)

Mobile hospital units proved to be very useful in the response to
Hurricane Katrina. However, due to supply problems in Mississippi,
interviewees noted that in the future they would recommend that the
mobile hospitals increase their stockpiles of supplies.

> *"In a disaster \[the mobile unit\] has stuff to keep it alive for the
> operational period. We had a 3-day supply ....That was nothing.
> Florida changed to 5 days. We recommend 10 days." (MS Official)*

**There Were Shortages of Medications and Supplies for Special Needs
Populations**

Many gaps in supply involved medications and medical equipment required
by people with special needs. Shortages of prescription medications
created significant strain on providers' ability to deliver care,
particularly to patients with chronic medical conditions.

> *"There was a lot of fear about contagious infections in the
> aftermaths of disasters but probably more problems arose from chronic
> disease because they couldn't get medications"* (MS Official)

Many patients with chronic medical problems either did not receive their
medications in a timely fashion or did not receive the right medication
at all.

Other reports from the region have also noted shortages in supplies. For
example, Kerber (2005) described how evacuees with diabetes were often
unable to obtain adequate medications. Our interviews revealed a similar
problem. In some cases, the lack of medication caused diabetic patients
to become acutely ill, to the point that some people developed
complications requiring hospitalization.

In addition to medication shortages, deficiency of oxygen supplies
generated major health care emergencies in some states, as one public
health official from Louisiana noted:

> *"We had a night with 70-90 people in O2 wards and we could not find
> oxygen anywhere in the state. The state hospital gave me the last
> supply that they had."* (LA Official)

Health departments spent time and resources attempting to replenish
oxygen supplies. In many cases the local health departments found the
needed assistance from local and national pharmacies willing to donate
supplies or fronted supplies on good faith.

Tragically, the lack of needed medical supplies for special needs
populations ended in death in some cases.

> *"One of the ventilator facilities had deposited patients without
> ventilators and they had dropped them off at Charity, LSU and the
> dome. We were there to do the assessment and there are 8
> ventilator-dependent patients without ventilators. They were all just
> lying there and the doctor said, "there is nothing to do except make
> them as comfortable as possible because they are going to die." There
> was some electricity but there were no ventilators."* (LA Official)

While the lack of ventilators was a key reason for the death of these
patients, it was a fundamental gap in planning and communication that
was the underlying source of this problem. In the future, to avoid this
type of problem there will need to be better coordination and planning
amongst the organizations responsible for providing care for special
needs populations.

**Both Public and Private Organizations Contributed to the Response, But
Some Efforts Lacked Coordination**

In the aftermath of the hurricane, both public and private organizations
provided medications and other supplies to evacuees. In Florida, for
example, the state public health department had caches of supplies
pre-stationed around the state (coming from all directions). This
preparation allows the state to push supplies to the affected areas as
soon as a hurricane subsides.

> *"There is statewide coordination. The state knows what is happening
> with the counties and our role is the support role. We have Logistical
> Staging Areas (LSA) and supplies would be pushed forward from the
> stockpile cache. The state has their own logistics and supplies and
> they are supported by the national infrastructure."* (FL Official).

As this statement implies, logistical staging not only allows for the
prompt distribution of assets, but also provides better region-wide
coordination of resources across the state, and with surrounding states
as well.

In Florida, separate staging and distribution areas have been set up
according to the source of the assets provided. For example, the county
distribution area is separate from SNS distribution area (i.e., local
assets are kept separate from federal assets). The rationale for the
distinction is to better manage coordination of resources coming into an
impacted area.

Private-sector companies also played an important role in addressing
shortfalls. Many interviewees believed that the generous and prompt
response from private medical supplies and pharmaceutical companies, and
local pharmacies had helped in reducing the impact of the disaster. Many
of these companies fronted supplies without assurance of reimbursement.

> *"When pharmacies became needed we got truckloads of samples, expired
> drugs, etc. I called Wal-Mart on the phone and moments later all of
> the major chains on a conference call and they had loads for trucks
> when they open a new store and they sent them down. They had portable
> stocks. They never asked about reimbursement."* (MS Official)

A Florida official said he had learned to work with pharmaceutical
companies prior to the storm to organize medication and oxygen supplies:

> ***"**Some county health departments have pharmacies and we work with
> them and our local providers. Work with Walgreen's and others and we
> have warehouses across the state. It is a problem when people are
> unable to get their 30-day supply of medication."* (FL Official)

Similarly, a Mississippi official noted that when oxygen supplies were
needed Wal-Mart took the lead in organizing all of the local suppliers
to help address the shortage.

> *"Most of \[the facilities\] indicated they needed additional oxygen
> because of the additional patients. So after landfall I didn't know
> what to do. Wal-Mart called me. About an hour later he had all 8
> companies that supply oxygen and by morning they had refilled all the
> oxygen."* (MS Official)

While the private-sector contribution was critical, the role played by
private companies in the aftermath of Hurricane Katrina was ad hoc and
unorganized. Private companies did not always have a clear picture of
what supplies were needed, particularly for special needs persons. For
example, in Houston, national corporations such as Walgreen and CVS set
up pharmacy at the large Reliant Park shelter, but were reported not to
be fully prepared to meet the immense medical needs of mental health
patients. They lacked sufficient inventories to fill the astonishingly
high amount of prescriptions (Appleseed, 2006).

Interviewees noted that a number of supply chain problems resulted
because many private pharmaceutical companies were not trained in ICS
communication structure. Though this did not create major difficulties,
it affected the distribution of medical supplies and medications in some
cases. An official from Georgia cited the following example:

> ***"**We used at least one business to dispense pharmaceuticals and
> supplies that was not being trained in ICS. We are trying to reach out
> ...to educate people about ICS."* (GA Official)

Interviewees emphasized the importance of increasing the involvement of
private companies in the emergency preparedness planning process and ICS
structure.

In some cases, supply problems arose because the suppliers with whom the
health departments had contracts were themselves victims of the storm.
In Mississippi, one official noted that,

> *"The biggest supply issue was linen. We have services here but the
> company was in New Orleans. Within 2 days we did a contract with a
> company in Florida."* (MS Official)

While they were able to address the problem swiftly during Hurricane
Katrina, there was nevertheless a general consensus that public health
needs to establish relationships with a wider array of organizations in
order to manage the medical supply chain effectively. Many interviewees
indicated that they would consider having multiple contingency contracts
in the future so that if one supplier was unable to provide the
contracted goods there would be an immediate alternative. Some felt that
public health agencies should plan for the worst case scenario in which
private companies provide no supplies.

**Funding for Supplies Was Also Problematic**

In cases when public health agencies did not have adequate supplies on
hand and needed to purchase them, a number of officials had difficulty
in obtaining the funding to purchase the material. As a public health
official from Georgia stated,

> *"The biggest challenge was getting funding. Simple things like we
> needed baby formula there was so much red tape we could not provide
> the supplies that were needed to treat evacuees."* (GA Official)

This conformed to what others had reported in the field. Public health
officials were especially frustrated by their inability to identify
sources of short-term funds to procure medical supplies and equipment
(Morill et al., 2006).

Florida has addressed this problem by establishing pre-existing
arrangements with suppliers and providing purchasing cards in advance:

> *"There is no way to avoid going to Wal-Mart a lot. The whole idea is
> to be prepared locally and we have purchasing cards for a local
> Wal-Mart. We have already met with everyone and talked about ordering
> supplies"* (FL Official)

Many interviewees also expressed concern that problems in reimbursing
private sector pharmaceutical or medical supply companies may affect the
willingness of these corporations to provide support in future emergency
response efforts. They noted that the current system of reimbursing
private companies for their assistance is inadequate. Indeed, some of
our interviewees felt that the experience of Hurricane Katrina might
provide an incentive for some private companies *not* to help in future
disasters. In particular, interviewees felt the Stafford Act, a federal
mechanism designed to address reimbursement during emergency situation,
created unnecessary barriers and delays. Many local pharmacies that have
donated resources and time, set up mobile pharmacies, and provided
medications for free, still have not been reimbursed as of this writing.
Our interviewees commented:

> *"The local pharmacies stepped up to the plate, but they have not been
> reimbursed and so they are not going to be able to help in another
> storm"* (LA Official).
>
> *"The Stafford act states that FEMA will only reimburse after the
> disaster hit. What we had to do was take the EMS people and get them
> to give us supplies to the tune of \$65,000 in supplies in the
> superdome. I could not get the money back to pay him for the
> supplies"* (LA Official).

Interviewees worried that in the event of another major hurricane,
restocking supplies using local businesses may not be feasible ,since
businesses might be concerned that they will not be reimbursed for
replenishing medications and other supplies.

### There Were Also Problems in Distribution

Some public health officials noted that the distribution process was
disorganized. Interviewees reported difficulties in storing and
transporting supplies to the populations in need. For example, in
Louisiana, one public health official talked about the difficulties they
had in keeping track of supplies, which were stored wherever space could
be found.

> *"There was not organized distribution....Drug companies donated
> supplies. We would store \[supplies\]...\[in the\] back of our car, in
> our garage, etc."* (LA Official)

Delays in receiving supplies were one outcome of the distribution
problems. An official in Louisiana stated simply that:

*"By the time the supplies got here all of the evacuees were gone"* (LA
Official).

**Experiences with the Strategic National Stockpile (SNS) Were Mixed**

State and local public health agencies also called upon the Federal
Government and the SNS to supplement medical supplies in the response to
Hurricane Katrina. The use of the SNS in the response generated both
positive and negative experiences for the affected states. On the
positive side, interviewees in both Mississippi and Louisiana noted that
once SNS arrived in the state, distributing the supplies typically went
well. Officials in Mississippi attributed the efficiency in distributing
supplies to frequent exercise and practice.

> *"Because we had practiced SNS so much...8 18-wheelers were here the
> next morning and it took us 29 minutes to unload. In 3 hours and 35
> minutes had broken down and stuff was going to hospitals. Practice
> makes flawless execution. We are still the only state who has ever
> gotten and dispersed an SNS push pack. One thing we did right was take
> an all hazards approach and we practiced a lot. If people are trained
> nothing makes them afraid. They weren't afraid to go into a hurricane
> because they knew what they were going to do."* (MS Official)

While interviewees in Louisiana indicated that the overall SNS release
was a success, they did note one glaring issue that arose. The
pre-identified sites for SNS warehousing and distribution were not
available during Hurricane Katrina because they were already being used
as shelters.

> *"Your regional and local PODS were pretty much all used up. We were
> trying to find places at the last minute trying to find a location to
> store (SNS) supplies."* (LA Official)

Officials were able to identify new sites and the distribution was able
to proceed. However, interviewees noted that they will revise their SNS
distribution plan accordingly.

Both states that called upon the SNS to supplement their own caches of
medical supplies found that the supplies available through the SNS did
not match their needs. The SNS was configured for responding to a
bioterrorist attack and as a result did not contain basic medications
needed to treat chronic conditions. As one Mississippi official put it,

> *"...the interesting thing about it is if you have a bioterrorism
> problem SNS is great. The types of things we needed were not available
> in the ways we needed. We need to modify it so that it has different
> kinds of things"* (MS Official).

An official in Louisiana noted the same issue,

> *"...the SNS is configured \[for\] bio-terrorism stuff. The supplies
> in the SNS were wrong."* (LA Official)

To address this problem, officials in Louisiana are developing
formularies for chronic disease issues, so that in the future the right
types of medications will be available in an emergency.

## IMPLICATIONS FOR PUBLIC HEALTH 

Issues of pharmaceutical and medical supply coordination and
distribution are crucial to public health related emergency response.
Careful pre-planning and coordination with public, nongovernmental, and
private sector organizations is important in mounting a prompt response,
yet not all health departments are engaged in such dialogues.

There are two issues to address: first, whether there are supplies
available and who supplies them; and second, how the supplies are being
distributed. Going forward, health departments may benefit by formally
integrating private entities into the preparedness planning process
through formal agreements such as memoranda of understanding (MOUs). It
will also be important to exercise preparedness plans based on these
relationships to identify and eliminate any problems in their execution.

Once suppliers have been identified and relationships established, the
planning is still not complete. We found that communication issues
affected the response and the ability to distribute supplies. ICS has
been instrumental in coordinating efforts and improving communication
between governmental entities. Public health departments may want to
expand ICS to include private pharmaceutical and medical supplies
companies as a means of improving communication with these groups. If
all parties were familiar with ICS and communicated with a common
language, the distribution of supplies during an emergency could be
carried out more effectively and efficiently. Many public health
departments are also working to involve private companies in the
planning process. Such participation plays an important role in
developing the relationships that will improve response capabilities
(e.g., knowing who to call within the company).

We were encouraged to learn of many positive steps that are being taken
by public health departments and other organizations to improve
preparedness in the area of pharmaceuticals and supplies. Below, we
highlight several key issues for public health officials to consider
including in their own plans for emergency response.

-   **Pre-stage supplies before storm**. To reduce delays in delivering
    medical supplies to storm-hit areas, public health agencies at the
    state and local level may want to pre-designate strategic areas for
    supplies. As described above, Florida has used this method
    successfully in its disaster response efforts.

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-   **Make arrangements with suppliers before storm**. As our interviews
    and experiences with past hurricanes have demonstrated quite
    clearly, local and private entities play a big role in responding to
    the medical needs of victims in a local area. To better work
    together and coordinate local efforts to respond to the next
    emergency, public health departments should consider establishing
    arrangements\-\--whether formal or informal---to coordinate the
    response. Florida provides an example of how such arrangements might
    work. It must be noted that contracts, MOUs and informal
    relationships with private entities do not ensure positive outcomes,
    but, at a minimum, these relationships provide local health
    departments with additional options to call upon in a disaster.
    Another advantage, as reported by one Georgia official, is that, by
    knowing that they will be able to get supplies from private
    suppliers, public agencies will require less warehouse capacity for
    their own supplies.

-   **Develop a system to better match available resources with needs**.
    Interviewees noted that many supply problems stemmed not from
    shortages, but rather from a mismatch between resources and needs. A
    comprehensive system would entail rapid needs assessments at the
    local level and a centralized system for receiving, inventorying,
    and allocating resources at the state level. This sort of system
    would be able to distribute supplies more efficiently and equitably
    across the affected areas.

-   **Develop standardized inventory lists for use during a crisis.**
    Standardization helps identify needs in advance and thus facilitates
    the ability to respond during an emergency. This process can be
    especially important to ensure that adequate supplies of medications
    for chronic disease are available during a disaster. A standardized
    inventory list can help public health agencies and other
    organizations know exactly what is available where, thus making it
    easier to respond to requests when they come in. Standardized
    request forms are equally important. Similarly, creating a standard
    drug formulary allows local jurisdictions or health departments
    across the state to work more effectively with local vendors to
    identify what is required and where best to obtain the medications.
    Some states, including Louisiana, have begun to develop such
    formularies to address chronic disease issues.

-   **Clarify rules and streamline the reimbursement process**. There is
    a need for clarification of current reimbursement rules for
    assistance given in advance. In addition, a critical path analysis
    that would identify the key roadblocks in the reimbursement process
    seems warranted. Such an analysis might indicate the need to revisit
    the Stafford Act to identify the barriers and streamline the process
    of reimbursing private companies for assistance (e.g.,
    pharmaceuticals, medical equipment) provided in an emergency.

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-   **Practice the plan with all partners**. As with any component of
    emergency preparedness response, practicing medical supply plans
    contributes to the success of the plan's implementation. Moreover,
    it is important for exercises to include all partners, including
    private companies, if warranted. Inclusion of the full set of
    distribution partners in exercises and planning more generally will
    aid in clarifying the roles and responsibilities of each in an
    emergency.

# Chapter 7: Communications

One common theme in the many after-action and "lessons learned" reports
generated after Hurricane Katrina is that communications posed a serious
problem both during the storm and in its immediate aftermath (GAO,
2006a; North Carolina Division of Emergency Management, 2006; US House
of Representatives, 2006; US Senate, 2006; White House, 2006). As
indicated in these reports, communications problems touched all levels
of government, including the public health agencies that are the focus
of this study.

While communications problems are not solely a public health issue per
se, the need for effective communications is critical to nearly every
aspect of public health's response during an emergency -- including:
providing care, coordinating with response organizations, informing and
educating the public, and engaging the media. Many of the public health
officials we interviewed cited the criticality of communications:

> "*Our problems almost all boiled down to communications breakdowns."*
> (TX Official)
>
> *"Communications were the main problem and ineffective communication
> was a downfall."* (LA Official)
>
> *"Communications were the worst thing that happened to us in the
> storm."* (MS Official)

In this chapter, we examine the communications problems that confronted
local and state agencies that were involved in the public health
response to Hurricane Katrina and identify lessons that can be used to
better prepare for future emergencies. Much of the discussion in this
chapter focuses on communications *policy*\--e.g., who needs to be
communicating with whom, what information needs to be conveyed, how
different kinds of information can best be conveyed. However, we also
focus on technical considerations surrounding the communications media
used, i.e., which communications technologies worked well and which did
not.

## KEY OBSERVATIONS

**Some Forms of Technology Did Not Function Well After the Storm**

As has been well documented, breakdowns in communications technologies
affected the ability of public health agencies to carry out their
response functions. In any storm's immediate aftermath public health
staff assess the situation and identify where public health resources
are needed. Conducting these assessments can be very difficult and
time-consuming without basic communications technologies such as
landline telephones, cell phones, and email. In these situations, public
health staff may have to visit affected sites and cannot easily
coordinate with one another. During Hurricane Katrina, the most
problematic forms of communication were land lines and cell phones. In
some areas, cell phone service was down for days and in many cases,
weeks. One Louisiana official said that cell phone service was down for
about five weeks after the storm and some landlines were down until
January (five months). In areas where the cell phone infrastructure was
not completely destroyed (such as parts of Louisiana), some officials
noted that cell phones were useful in sending text messages; however,
their utility was limited without electrical power to recharge
batteries.

**Successful Technologies Included Satellite Phones, Nextel Devices, HAM
Radios, and Others**

Satellite phones proved to be an effective means of communication. For
the most part, interviewees said that the use of satellite phones was
helpful during and after Hurricane Katrina. In several places in
Mississippi, satellite phones were the only means of communication that
remained in place after the storm. During our interviews, we heard only
one comment regarding the poor functioning of satellite phones during
the storm. However, several interviewees mentioned that they have not
been able to purchase satellite phones because they are prohibitively
expensive.

Web-based communications were used successfully by some public health
agencies. During Hurricane Katrina Georgia successfully used WEBEOC, a
real-time internet-based collaborative tool designed to coordinate
response activities and resources. As a result of this experience, the
state health department is working to train more clinical personnel on
the system and keep their training up to date. Texas also uses WEBEOC
and Louisiana is considering adopting its use. In addition, the Georgia
public health department set up a website that served as a mechanism for
all shelters to use to communicate. According to one Georgia official:

> *"wireless broadband Internet access and mini-laptops were
> invaluable."* (GA Official)

In Louisiana, the Greater New Orleans EMS website provided information
on bed availability at local hospitals. According to interviewees, this
website proved very helpful in providing real-time information regarding
bed availability and facilitated the directing of patients to hospitals
that were not overwhelmed. In Florida, the state is moving toward a
web-based database to provide information on the condition of nursing
homes during a storm, emergency contact information and the types of
assets that are needed at each facility. Of course, web-based
communications require a reliable Internet connection, and so would not
be useful in some situations.

Other technologies, such as HAM radios, were also used successfully
during and after Hurricane Katrina. Their use was especially important
in Mississippi, where a local HAM radio operator served as the only
lifeline from one local EOC to the rest of the outside world:

> *"We lost contact with the outside world at 10am the day the storm
> hit. The only thing we had was our Ham Operator who climbed the tower
> at 50 MPH winds to get his radio back up."* (MS Official)

Officials in Florida, Georgia, Louisiana and Mississippi all indicated
that HAM radios were now a component of their preparedness plans and
that public health personnel would be trained and certified to use the
devices. One Georgia official said:

> *"Our new communication plan incorporates HAM operators -- you have to
> plan for the worst. HAM operators will be in hospitals, emergency
> operations centers, one in each center. This is new in the plan. They
> are routinely in emergency operations but were not part of the plan
> before."* (GA Official)

Two-way radios often proved a functional means of communication in the
aftermath of the storm, but many were unfamiliar with their use.
Training has been an issue both for public health and for hospitals that
have purchased 800 MHz radios as part of the PHEP and HPP Cooperative
Agreements. In one of the states that received evacuees, an official
mentioned that public health personnel received assistance in using
their new 800 MHz radios from fire and rescue personnel who were more
familiar with them.

One overarching conclusion to be drawn from our findings on
communications technologies is that a mix of redundant communications
technologies seems to be the best approach to planning. While
technologies such as satellite phones may be cost-prohibitive for some
health departments, other less expensive technologies like HAM radios
seem to be successful backup alternatives to cell phones and landlines.

**Interoperability Problems Inhibited Communications**

Our analysis also found that interoperability problems inhibited
communication during and after Hurricane Katrina. Difficulties arose
because public health departments were not using common communication
devices. For example, in Georgia, some agencies were using cell phones
and 800 MHz radios, while others were using 400 MHz radios. They finally
needed to use a mobile command center communications van to allow the
different agencies involved to talk to one another. This finding
reinforces what other state and federal reports have found and
emphasizes the need for interoperability across state, federal and local
agencies (US House of Representatives, 2006; US Senate, 2006; White
House, 2006).

**Communications Problems Made It Difficult for Public Health to Assess
What Was Needed**

The extensive damage to the communications infrastructure in the
affected areas and the failure of some communication technologies left
many facilities, most notably those in New Orleans, isolated for several
days. The communications breakdown made it difficult for public health
personnel in some areas to get a clear picture of what was needed in
hospitals, nursing homes, and shelters. Moreover, as discussed in the
previous chapter, these breakdowns negatively affected the coordination
and distribution of medical equipment and supplies. In Mississippi, the
state lost contact with several nurses in shelters for 48 hours, and
local public health agencies had trouble tracking down personnel after
the storm because cell phone service and landline telephone service were
down.

The technological breakdown in communications was problematic, but it
was intensified by the rural nature of the areas impacted by the storm.
For instance, some rural counties in Mississippi did not have phone
service for a week and therefore, a public health official had to go to
the facilities, such as nursing homes, in person and check on them. In
Louisiana, communicating with nursing homes was made more difficult
because most of the state's nursing homes are "mom and pop operations."
Most small, independent nursing homes did not have redundant
technologies in place and were not part of a corporate network that
could have tracked their status and forwarded that information to the
state.

**There Was Often Poor Communication Within and Across Organizations**

Some communications problems during Hurricane Katrina were due, not so
much to technical failure on the part of the communications
infrastructure, but to lapses in communication between the relevant
parties, whether within public health agencies or between public health
and other public or private entities. Breakdowns in communications tend
to undermine the credibility of public health departments and can damage
relationships between public health departments and the organizations
with which they need to coordinate during an emergency.

For example, in some cases, one part of the health department did not
know what another part was doing, leading to a duplication in tasks. In
one instance, a public health official noted:

> *"There was duplication with calling facilities. We were calling twice
> a day checking on status and another group upstairs was checking on
> bed capacity for the trauma care system. They thought the Department
> of Health was always calling them."* (MS Official)

If there had been better communication within the health department, the
same information could have been collected with one telephone call and
thus reduced the efforts of the health department and the burden on the
facilities

Similar concerns were expressed by hospital administrators in Florida
and Mississippi, who said that they received multiple visits by public
health personnel asking them to fill out the same paperwork multiple
times. In these cases, hospital personnel felt very strongly that the
public health department became more of a hindrance than a facilitator.
In Louisiana, one interviewee emphasized that:

> *"Public health became a hindrance to us -- we need this information
> and what is your status? People were asking for duplicative
> information. We had one phone line and public health was clogging it
> for status reports while we were trying \[to use that line\] to place
> people...."* (LA Official)

Officials in Texas stated that many of that state's problems with
evacuee populations could be attributed to "poor communication between
the evacuating agency and the receiving counterpart." While it was clear
that some states were overwhelmed by the difficulties of communicating
within their own state's organizational structure, such problems were
exacerbated when evacuee issues crossed state lines. For instance, in
Georgia, the NDMS responders were prepared to receive adult patients
from hospitals in the affected areas. However, as the planes began to
arrive, it was quickly apparent that they contained a mix of adult,
pediatric and nursing home patients, as well as large numbers of general
population evacuees---information that had not been communicated from
those sites sending evacuees. In addition, Georgia officials assumed
that evacuees had been checked for weapons and drugs before boarding the
military planes. They later discovered that this was not the case, and
needed to confiscate weapons and drugs from a number of evacuees.

**Community Partners Need to Be Incorporated into the Planning Process
Early**

To address the interpersonal and interorganizational communications
problems that arose during Hurricane Katrina, interviewees indicated
that public health can benefit from the early involvement of both
traditional and non-traditional partners in the process of planning for
disaster response. Examples of non-traditional partners include
private-sector organizations, NGOs, the military, and mental health
organizations. As noted in the previous chapter, some public health
officials argued that in order to improve communication and overall
response capabilities, non-traditional partners should not only be
included in the planning process, but also trained in ICS.

Communication across organizations could be substantially improved
through the planning process. Planning requires organizations to work
through the details of their respective roles and responsibilities and
helps forge relationships among all relevant parties in the process.
Such relationships could be further strengthened through the use of
exercises and drills to practice emergency response capabilities. These
relationships are particularly important in maintaining the flow of
information during an emergency.

Interviewees in all five of the states in our analysis mentioned the
important role played by the private sector in the response to Hurricane
Katrina and many emphasized the value of including community partners in
preparedness exercises and plans. For example, one Louisiana respondent
said:

> *"It's important to train, respond, and plan with community partners.
> Knowing community partners was a big help; we didn't need to introduce
> anyone -- we all knew each other. Much of the relationship came out of
> SNS planning."* (LA Official)

Another described the importance of including the private sector in
state planning:

> *"You need to call in your private sector so they know their role and
> where to go during a disaster. You have to communicate with the
> private sector with many methods to disseminate information. They have
> to understand the state plan and the rules by which we were playing."*
> (LA Official)

Interviewees also noted the need to include mental health departments in
the planning and exercise processes. One state official said, "the
downstream communication did not happen. The plans were made in a vacuum
without telling the partners." In Mississippi, officials stated that:

> *"Mental health wasn't \[at the state public health EOC\] and I have
> learned and fixed that for this coming year. They are going to be with
> us at the command center this year. I saw that as a big deficit and
> they were late getting in."* (MS Official)

Many interviewees stated that, although they had not included mental
health as planning partners in the past, given their experience from
Hurricane Katrina, they plan to give mental health a seat at the
planning table as well as at the state EOCs. In addition, we heard that
there needs to be better planning and coordination (including ICS
training) between civilian and military agencies so that they speak a
common language and can better coordinate their efforts.

**The Incident Command System Typically Facilitated Agency
Communication**

While many communications problems arose in the aftermath of Hurricane
Katrina, there were a number of important successes as well. One such
success story that arose from our analysis concerns the implementation
of an Incident Command System (ICS) and the National Incident Management
System (NIMS). For example, officials in Texas indicated that "the
presence of an ICS was regarded as the key to the success of response to
Katrina." Officials from Louisiana remarked that "language and semantics
are crucial-all of the players have to be able to speak the same
language." Interviewees indicated that when all personnel were familiar
with ICS, the response ran more smoothly because people knew their
individual roles as well as the responsibilities of the agencies they
represented. In addition, interviewees stated that ICS saved time during
the response because it provided a common language and process to
personnel from various agencies and as a result, personnel could focus
on decision making rather than trying to explain the process. Much of
the success with ICS during the response to Hurricane Katrina was
attributed to the fact that the public health agencies had practiced its
use extensively prior to the storm. It should be noted that, while many
public health personnel spoke glowingly of ICS and NIMS, not everyone
was enthusiastic. We heard in our interviews that in certain cases some
public health personnel have been resistant to NIMS and ICS training.

However, interviewees further mentioned that communication problems may
have occurred because ICS was not utilized by all emergency responders.
For example, officials in Georgia indicated that ICS worked well among
public health personnel, who were trained in its use, but that
communications issues arose between public health agencies and the
military because the military did not use ICS.

**Strong Leadership at the State Level Can Facilitate Communication**

Another communications success story concerns the role of state-level
leadership in establishing an organizational framework for preparedness.
This was seen most clearly in Florida. Interviewees in Florida
repeatedly mentioned that Florida's emphasis on preparedness came
directly from former Governor Jeb Bush. Through the creation of Regional
Domestic Security Task Forces (RDSTFs), Florida has created an
organizational framework through which preparedness for both manmade and
natural disasters has become a priority. This framework clarified the
roles and responsibilities of public health agencies and their partners
in emergency response, thus laying the foundation for effective
communications during a disaster. Public officials in Florida knew what
their responsibilities were and what they could expect from other
agencies and partners, regardless of which agency they represented, or
what level of government they worked for.

As a component of the RDSTFs, disaster response communications, training
and equipment have been standardized across the state. More importantly,
by convening various state agencies under the umbrella of domestic
security, those agencies have adopted domestic security and emergency
response as their priorities. Training and exercises have also allowed
stakeholders to understand their respective roles, responsibilities,
strengths, and weaknesses. One hospital administrator in Florida told
us:

> *"I think that Florida works so well because you actually do know that
> an emergency really will happen. You have to have really good
> communications and a great EOC building in town. That building
> represents the importance the community places on the EOC function
> during an emergency. Someone talked about one of the EOCs in
> Mississippi that was not supported by the community. There needs to be
> good communications during the event and all through the event. At
> least once a year we try to have a community drill."* (FL Official)

## IMPLICATIONS FOR PUBLIC HEALTH

Our analysis reinforces post-Katrina reports which found that problems
with communications further impeded the response to Hurricane Katrina.
The discussion in this chapter points to both problems and successes
with communications technology---and, perhaps more importantly---with
communication planning and procedures.

Our findings point to some alternatives for public health agencies to
consider in improving their emergency response capabilities.

-   **Improve communications planning.** Many of the communications
    problems that public health departments encountered during Hurricane
    Katrina can be overcome through improved planning and training.
    Interorganizational communications could be ameliorated if
    participating organizations know who the other players are that they
    will interact with during an emergency, are aware their respective
    roles and responsibilities, and are familiar with what to expect
    from each other. This can be achieved by bringing all relevant
    parties to the planning table. Communications problems can be
    prevented or minimized through improved planning, exercising of
    emergency plans, and increased ICS training for public health staff.

-   **An effective communications plan requires a mixture of
    communications technologies and techniques.** Our analysis reveals
    that health departments had the most success communicating during
    and after Hurricane Katrina if they had a mixture of communications
    technologies and techniques at their disposal. When land lines and
    cell phones did not function, departments relied on alternative
    technologies, such as satellite phones and HAM radios. Departments
    also were successful in using non-technical means of communication,
    such as distributing fliers by hand, to inform the public. Public
    health agencies can benefit from having a combination of technical
    and non-technical communication techniques ready for use during a
    crisis.

-   **Expand the role of community partners in the planning process.**
    Public health needs to incorporate non-traditional partners (e.g.,
    the military, NGOs, private-sector organizations, including mental
    health) into the planning process -- and to do so at an early stage.
    Community partners from many different sectors need to develop a
    common language so that they can better coordinate their efforts in
    responding to a natural or manmade disaster.

Many of the alternatives discussed here, with the exception of some
communications technologies, can be implemented with relatively few new
financial investments. The most important investments are those of time
and effort in building relationships, defining roles and
responsibilities, and exercising emergency response plans, all of which
are critical for improving the ability of public health agencies to
respond to future emergencies.

# Chapter 8: Special Needs Populations

In this chapter, we take a closer look at the impact of Hurricane
Katrina on special needs populations (e.g., the chronically ill, the
physically disabled, the mentally ill, nursing home residents) and
discuss lessons learned from public health's disaster response. As has
been reported, the evacuation and sheltering of special needs
populations is a function of the public health was and medical response
that was seriously tested by Hurricane Katrina. Indeed, all the issues
covered in the previous three chapters--workforce shortages, problems in
the supply of medications and medical equipment, and breakdowns in
communications\--were relevant to special needs populations in the
aftermath of the storm. Evacuation of these populations, many of whom
lived in special facilities, created a substantial demand for specially
trained personnel to assist with their care, as well as adequate
supplies of medications and special equipment (e.g., dialysis machines)
to provide treatment. The challenge of addressing these needs was
sometimes compounded by failures to adequately communicate with shelters
and facilities about what was needed.

Individuals with special needs who live in the community (as opposed to
nursing homes) require separate shelters, which in many states are the
responsibility of public health. One reason for separate shelters is to
provide safety for people with special needs by separating them from
those in the general population. In addition, many special needs
populations require more intensive medical care (e.g., dialysis, oxygen,
medications) and enhanced facilities beyond those available in general
population shelters.

Nursing home residents are treated differently from the
"community-based" special needs population during an emergency, and are
generally not eligible for special needs shelters. If evacuation is
required, it is the responsibility of the nursing home administrators
either to transfer residents to another nursing home or to find some
other form of shelter for them.

The experiences of both community-based populations and nursing home
residents during the response to Hurricane Katrina provide lessons
relevant to public health, however, so we address both in this chapter.
We present key observations from the evacuation and sheltering of
community-based special needs populations and nursing home populations
separately. At the end of the chapter, we discuss the implications for
public health and offer some considerations to assist in the process of
preparing for future emergencies.

## KEY OBSERVATIONS: COMMUNITY-BASED SPECIAL NEEDS POPULATIONS

**States Faced Challenges in Defining Special Needs Populations**

One underlying challenge for states is to establish criteria for
identifying special needs populations, in advance if possible, and
particularly during an emergency so that they can be evacuated and
directed to appropriate shelter arrangements. We found that in the
aftermath of Hurricane Katrina, there was much confusion over what
constitutes a "special need." "Special needs" is a generic term that can
be used to describe disabled and elderly populations (GAO 2006b), but
may also refer to low-income populations, people with serious mental
illness, people with intellectual or cognitive disabilities, people with
sensory impairments (e.g., low vision, impaired hearing), and those with
mobility problems or activity limitations (National Organization on
Disability 2005). Also included may be those who rely on special
equipment such as oxygen or wheelchairs (US DOT 2006). In a disaster
situation, people without transportation may also be included in the
definition of "special needs" (GAO 2006b).

Many states faced problems because of inconsistencies in defining
special needs populations. For example, the State of Louisiana defines
special needs populations as those who are home bound, chronically ill,
physically or mentally disabled, have limited mobility or lack the
ability to function on their own. However, New Orleans has a broader
definition of special needs than does the rest of the state. This
inconsistency created problems in determining who belonged in special
needs shelters, particularly when populations had to be moved out of New
Orleans to other locations within the state.

Some states, including Mississippi and Texas, did not have a clear
definition of special needs during Hurricane Katrina. Mississippi is
currently considering applying a definition that had been used in
Florida, which defines special needs populations as those with medical
needs, particularly those who require special equipment. In Texas, local
jurisdictions were responsible for their own populations following the
hurricane and there was no systematic way of defining a special needs
person. Since Hurricanes Katrina and Rita, the state has been working to
establish a special needs definition. Houston conducted a recent
exercise with state officials to practice identifying special needs
patients with rapid response assessment teams.

Georgia organizes populations into five levels based on need in
preparation for sheltering. The five levels of shelter placement are:

> Level 1 -- capable of self-care and independent and suffering from
> minor injury or illness

Level 2 -- minor assistance needed

Level 3 -- persons with conditions that require privacy but not lots of
care

Level 4 -- requires constant surveillance

Level 5 -- needs an emergency room

Although this definition was in place during the hurricane response,
Georgia was not well-prepared to accept and shelter special needs
populations, in part because the definition did not provide specific
enough guidance about what is needed to care for those with special
needs. Since the storms, Georgia's Emergency Management Administration
has led an effort to get all involved agencies together to discuss who
is responsible for what activities related to special needs. Local
emergency management officials have been tasked with better categorizing
special needs populations and coordinating with other agencies to
prepare for their needs.

One other consideration in defining "special needs" is that some
populations that do not have regular contact with the health care system
may be overlooked during an emergency. Some individuals who typically
live independently may require special assistance only during an
emergency, due, for example, to a lack of personal transportation.
However, most working definitions of special needs populations do not
include "lack of access to personal transportation" as a criterion for
inclusion in special needs populations.

**States Had Problems in Identifying Special Needs Populations During
Katrina**

Even in states with clear definitions of what constitutes a special
need, finding those populations can be challenging, especially in the
aftermath of a hurricane or other emergency.

Florida allows special needs populations (defined in terms of medical
needs) to pre-register. Individuals complete a form, which is then
reviewed by public health staff. Oxygen providers must also make sure
their patients are registered, and at the state level, legislation was
recently passed to require home health providers to register their
patients. We also learned from public health staff that, since Hurricane
Ivan in 2004, dialysis facilities have been required to develop internal
plans and prepare patients so that they know where to get dialysis
during an emergency if their usual facility is not available. Recently
passed state legislation also requires dialysis facilities to
participate in identifying and registering special needs populations.
Dialysis facilities will be required to pre-dialyze their patients in
the days before a storm is expected to make landfall and then provide
the patient with instructions on where to go and when to have their next
treatment.

However, while Florida makes it possible for special needs populations
to pre-register, most special needs populations are not required to do
so. Both state and local officials we spoke to in Florida noted that
only a small portion of those who show up at special needs shelters were
pre-registered. Use of the registry might be improved by engaging more
health care providers who have regular contact with special needs
populations; nonetheless, the demand for special needs sheltering may
still exceed the available supply.

The experience of Hurricane Katrina has inspired several states to
improve efforts to identify special needs populations. For example,
Mississippi is now considering the distribution of standardized
bar-coded identification cards to give to special needs populations;
these cards would include information about next of kin, primary
caregiver, dietary needs, etc. The cards would be presented to shelter
staff when the person with special needs arrives and staff would be able
to scan the card, verify that the person should be at the shelter, and
determine what his/her needs are. Of course, the cards would only be
useful as long as people can find and remember to bring the cards with
them to the shelter. Louisiana is working closely with dialysis patients
to prepare them in case there is a storm and they need to evacuate. In
Georgia, public health officials are working with other agencies to
develop a system that geocodes the location of special needs populations
so that they can set up a system to transport and shelter those in need.
In Texas, where local jurisdictions are responsible for their own
populations, one county health department is creating rapid response
assessment teams to help identify special needs populations during an
emergency. The Texas health department is also conducting a campaign to
get people with special needs to voluntarily pre-register, similar to
the system in place in Florida. They are partnering in this effort with
local community services such as Meals on Wheels. The State has plans to
include information about the program in residents' electricity bills.

**Transportation Challenges Became a Problem for Community-Based Special
Needs Populations**

In the course of the response to Hurricane Katrina, the transportation
of special needs populations became a serious issue. Individuals who
were triaged to special needs shelters often lacked any means of getting
to the shelter, to medical facilities for treatment, or to doctors'
appointments once at the shelter. In some cases, transportation was also
needed to move special needs populations from one shelter to another to
manage overflow. The New Orleans Health Department had evacuation plans
that involved Amtrak but could not identify partners along the Amtrak
line that would be willing to open up another special needs shelter.
Even after dry roads were available, resources were lacking to evacuate
people.

Some promising partnerships developed in the course of the response to
Hurricane Katrina. The faith-based community in several states,
including Louisiana and Georgia, became involved in transporting special
needs shelter residents and also helped identify dialysis and other
facilities that could support the needs of the shelter residents.

**Responsibilities for Establishing Special Needs Shelters Differed
Across States**

Public health agencies play an important role in assuring that special
needs populations are sheltered and receive appropriate care. However,
the responsibility for establishing the shelters differed across states:

-   In Louisiana, the Department of Social Services was responsible for
    administering special needs shelters while the Department of Health
    and Hospitals was responsible for the medical care provided in the
    shelters. Eight main shelters were established across the state just
    prior to Hurricane Katrina's arrival, with the shelter in Baton
    Rouge addressing the most serious medical needs. Hospitals often
    partnered with the shelters to provide staffing and supplies.

-   In Mississippi, special needs populations were the responsibility of
    the State Department of Human Services prior to and during Hurricane
    Katrina. However, due to some confusion over responsibilities
    concerning the Katrina response, the Department of Health has
    subsequently taken over responsibility for special needs
    populations. During the Katrina response, hospitals appeared to
    provide staffing for shelters in at least some instances.

-   In Georgia, the Department of Public Health established a special
    needs shelter, but required help from local hospitals with staffing
    and supplies.

-   In Texas, local health departments established special needs
    shelters, which were often located near general population shelters.
    The State Department of Health Services supported local health
    department efforts through the provision of various resources,
    including transportation. A number of additional shelters were set
    up in and around Houston by non-governmental organizations such as
    the Red Cross and churches.

-   In Florida, county health departments were responsible for
    sheltering special needs evacuees. To address staffing needs
    associated with this responsibility, some counties established
    partnerships with local hospitals.

**There Were Staffing Shortages at Some Special Needs Shelters**

As discussed in Chapter 5, Hurricane Katrina created a number of
workforce challenges for both public health agencies and private health
care facilities, such as hospitals. The workforce problems associated
with providing care for special needs individuals were particularly
acute, though the extent of the problem varied significantly across
sites.

In Louisiana, for example, some shelters were severely understaffed, in
part because of the sheer demand on their services. One person recounted
the experience of walking into the special needs shelter area of the
Superdome and finding 30 to 40 individuals in wheelchairs in one room
with only two staff members providing care. On the other hand, a public
health physician who helped to run another special needs shelter
described good working relationships with providers in the local
community, some of whom came on a scheduled basis (such as for dialysis)
and others who came in to help triage. These efforts helped to relieve
the burden for the public health staff. We learned that Louisiana used a
variety of means to ensure that sufficient staffing was available for
the shelters, including involving the US Public Health Service and
calling in DMAT teams.

A related problem is that public health staff at shelters were sometimes
asked to provide care (especially clinical care) for which they were not
prepared. While public health nurses have been trained in traditional
nursing activities, many have worked outside of a hospital or other
direct clinical care setting for many years and in many cases are not
qualified or simply not comfortable with providing the kind of care that
was needed.

Counties in Florida have successfully used a team-based approach to
address staffing needs for special needs sheltering. The staff is
organized into multi-capability teams, with one team providing care
during the day shift, the other working the night shift. The teams
include both clinical staff as well as housekeeping personnel to
maintain the shelter. Other states are considering using a similar
approach in the future.

**Ensuring Security for Special Needs Shelters Was Difficult**

As noted at the beginning of this chapter, it is important to separate
special needs populations from the general population in order to ensure
that special needs populations get the care they need and to provide
safety for all. However, the large number of people in need of food and
shelter following Hurricane Katrina made it difficult to keep the two
populations separate.

> *"A big problem was that many times individuals were sent to a shelter
> when they didn't belong there -- evacuees with special needs. These
> were people who could not take care of themselves on a daily basis.
> There were people with mental health problems mixed in with substance
> abusers and the elderly. It becomes a safety issue when all of these
> types of people are mixed into the general population shelters."* (GA
> Official)

The general population often sought shelter wherever they could and if
they found a facility with power, they would try to enter. As an
official from Mississippi noted:

> *"There are security issues of trying to keep a special needs shelter
> 'special needs.' Other people are hungry and dazed."* (MS Official)

In some cases, shelters lacked sufficient staff to provide security. For
example, a special needs shelter located at Louisiana State University
(LSU) in Baton Rouge initially had only two security guards, but the
guards did not stay long and replacements were not provided. LSU
provided some security staff out of its Sheriffs Unit, but, as more and
more individuals arrived at the shelter, existing security was unable to
manage the flow. The shelter was closed until more security personnel
could be made available. Another shelter in Louisiana had eight doors to
secure and only two people to secure them. In some instances, there was
insufficient staff to monitor all of the special needs patients.

But while it was important for shelters to provide adequate security to
control the flow of people moving in and out of the shelters, other
problems arose in relation to the "type" of security provided. For
example, in Louisiana, the military provided security at the Superdome,
and not surprisingly, both public health personnel and evacuees felt
that security was run too much like a "military operation." The problem
was that the military was trying to secure a facility that contained
many traumatized individuals, who needed varying levels of care. One
official with whom we spoke suggested that security needed to be better
integrated with public health in order to make sure that evacuees were
well cared for. As this official stated:

> *"There have to be better ways to ensure security and individuality
> and respect. I think that...another lesson we need to look at...we
> need to cross-train the military for domestic details."* (LA Official)

One solution to the security dilemma proposed by interviewees is to
facilitate security staff's duties by ensuring that all shelters have a
method to identify shelter residents effectively, such as using
color-coded wrist bands and only allowing access to and from the
facility from limited entry/exit points.

**Electrical Power and Appropriate Food Supplies Were Not Sufficient At
Some Shelters**

Ensuring that there was power and sufficient food was especially
important for special needs shelters, since many individuals with
special needs, such as dialysis patients, need medical equipment or
medications requiring refrigeration. Others using oxygen or depending on
a ventilator also required electricity. Officials in both Louisiana and
Mississippi cited problems with supplying electricity to special needs
shelters. Over half of the state of Mississippi was without power.

In the New Orleans Superdome, the special needs shelters were maintained
in the "party rooms" in order to (segregate/separate) this population
from the general population. Unfortunately, these rooms were not linked
to generators as was the rest of the facility; therefore, when the
Superdome lost power, these rooms had no back-up source of power.

Although not widely reported to be a problem, many special needs
shelters had insufficient food supplies to meet all residents' dietary
needs. For example, many special needs shelter residents were diabetics.
As one Mississippi official stated, "(w)e had food issues...diabetics
can't eat peanut butter and jelly three times a day." Given the length
of time that the shelters were operating, food needed to be prepared for
the varying dietary needs of the shelter residents. To address this
problem in future emergencies, in Mississippi, one community has
proposed to collaborate with local community colleges, which have
dieticians and a food supply that could support the special needs
shelters for their areas.

**Shelters Were Not Adequately Prepared to Address the Need for Mental
Health Care**

Mental health issues were prominent in both the special needs
populations and general population shelters. As one Mississippi official
stated: "I think mental health was as big as 'health health'." However,
prior to the storm, many shelter operators had not anticipated the
magnitude of the need for mental health care, nor had they realized the
extent to which a disaster such as Katrina would itself cause mental
health problems, transforming individuals who would otherwise be
self-supporting and healthy into special needs populations. Some of the
mental health-related need arose because people did not have access to
the medications that had kept them stable. In other cases, the stress of
the event caused individuals to act out in ways they had not previously.
In either case, neither general population shelters nor special needs
population shelters were prepared for the extra demands that mental
health issues would pose.

The states we visited generally had insufficient professional staff to
care for mental health populations. There was a shortage of inpatient
psychiatric beds. In most cases, mental health professionals had not
been included in pre-disaster preparedness planning. For example, in
Louisiana, the Office of Mental Health had not previously been involved
in emergency operations and there was little collaboration between the
Offices of Mental Health and Public Health. Since Hurricane Katrina,
there has been greater effort to coordinate activities between the
offices, both in terms of providing services and in preparing for
another emergency. Similarly, although mental health professionals in
Mississippi did not have a place at the state EOC prior to Hurricane
Katrina, there are now plans for mental health representatives to be at
the command center along with public health officials during a future
emergency.

In Texas, state public health officials made mental health services
available to the local health departments, but had challenges in getting
the mental health professionals where they were needed. The Houston
Health Department hired Louisiana evacuees to discuss their experiences
in Hurricane Katrina with fellow evacuees in the shelters and elsewhere.
Many of these individuals formed strong relationships with the people
they were helping and continued with the program until funds were
depleted. The health department is now looking for ways to continue this
program in the long term through non-profit organizations.

Another challenge for shelter operators was to determine whether people
with mental health issues should be sheltered separately from other
special needs populations. Louisiana officials proposed this idea, which
was opposed by mental health advocacy groups, who argued that separate
shelters would create an additional stigma for those with mental health
problems. Instead, the current plan is to create an area for mental
health patients within each special needs shelter and to try to reduce
the amount of stimulation these patients receive. Mental health
professionals from the Office of Mental Health would be responsible for
staffing that area of the shelter under this proposed solution.

Conducting mental health needs assessment within the shelters was
important. In Florida, mental health personnel have developed support
teams who conduct assessments to identify needs. These teams are
comprised of six to ten individuals, (staff and volunteers), to assess
the population. These teams determine what resources are needed and
report this information to the public health agency, which mobilizes
response professionals. As one official we spoke with said:

> *"This system relies on experts to make decisions during an event.
> This support is short term and they provide surge capacity for
> behavioral health."* (FL Official)

The state, community, and faith-based organizations are developing a
collaborative for mental health response.

In a Georgia locality, mental health professionals have become members
of the District Health Emergency Response Team (DHERT). During the
hurricane response, they identified proactively a number of mental
health needs by deploying professional teams to areas where evacuees
congregated, such as motels, so that they could conduct physical and
mental health evaluations and identify individuals who needed additional
intervention.

Georgia changed its policies after Hurricane Katrina to improve
assessment quality. For example, the initial evacuee assessment did not
include a question about psychotropic drug use, as a result many
patients in shelters did not receive their psychotropic medications and
thus experienced problems. In the future, triage staff will include an
assessment question concerning the use of psychotropic drugs. Mental
health nurses will also be equipped with a brief mental health
assessment tool that includes questions about signs and symptoms, thus
enabling nurses to better triage evacuees by providing more information.

## KEY OBSERVATIONS: NURSING HOME POPULATIONS

Although the responsibility for evacuating and caring for nursing home
populations lies with the nursing home administrators, public health
sometimes played an important role in coordinating with administrators
to ensure that nursing home residents received adequate care in the
aftermath of the storm.

**Nursing Homes Faced Challenges in Deciding When to Evacuate**

While nursing home administrators had the advantage of understanding the
needs of those in their care, they faced other challenges during
Hurricane Katrina in terms of deciding when to evacuate and in making
plans for how the evacuation would be carried out.

For example, nursing home residents are among the most vulnerable
populations and a move from one facility to another can often cause more
harm than good.

> *"The nursing homes were supposed to have a plan for evacuation. It is
> their responsibility to take their people out. When you move people,
> they do, and did, die in transport, so evacuating is a big decision."*
> (LA Official)

Sometimes it is safer to shelter residents in place. In deciding whether
to evacuate, nursing home administrators must weigh the risks of
evacuation against the risks of sheltering in place and must estimate
what the storm might do in terms of damage to the infrastructure and to
their access to necessary resources and supplies. In many cases,
administrators will choose to shelter in place but the risks are
significant:

> *"\[Officials\] did not want to see us err on the side of evacuate and
> if you can shelter in place then shelter in place. What do you do to
> prevent the greatest loss of life?"* (LA Official)

The decision to evacuate is based on the type of storm and the
geographic area predicted to be affected as well as other variables that
may be region- or facility-specific. In the New Orleans area, there was
also the problem of civil unrest. At least one facility, which was not
affected by the floods, evacuated after the storm because of safety
issues.

For the State of Louisiana, the scope of the nursing home evacuation was
particularly challenging. The State is host to 312 free-standing nursing
homes and 40 hospital-based facilities. The geographic areas most
affected by Hurricane Katrina included about 60 nursing homes.
Twenty-one homes evacuated prior to the storm, while 35 evacuated after
the storm hit.

Although state and local governments can order evacuations, nursing
homes and other health care facilities are often exempt and not required
to comply (GAO, 2006b). A recent report released by the Department of
Health and Human Services' Office of the Inspector General (OIG, 2006)
reported that nursing homes in the Gulf States, while not required to
evacuate, were strongly influenced by mandatory evacuation orders. The
only facilities that are required to evacuate are those in storm surge
zones. Recently passed legislation in Louisiana also calls for mandatory
evacuation for any facility in any storm surge zone. Prior to Hurricane
Ivan, in 2004, there was substantial resistance to evacuate in
Mississippi. However, after that storm, facilities were more amenable to
evacuation, and local governments have sometimes stepped in to require
evacuation:

> *"We didn't expect to have as big of a problem because we tell them
> they are in jeopardy and we use the big stick and say you are
> closed."* (MS Official)

One official described a situation two years prior in which a facility
refused to evacuate and local law enforcement was sent in to inform the
facility that if it's staff did not evacuate the patients, the penalty
would be jail time for staff and the facility would lose its license.

**Better Coordination Is Needed Between States and Nursing Homes**

Prior to and during Hurricane Katrina, many nursing homes in the
affected areas experienced problems related to the poor execution of
emergency plans (OIG, 2006). In some cases, facilities ignored their
plans completely. In other cases, the impact of the storm was far
greater than anticipated and existing resources were not sufficient.

The nursing home industry is not always involved in state or local-level
emergency preparedness or emergency response. This raises a number of
challenges as nursing homes face decisions regarding whether they should
evacuate. Most of our interviewees noted that, in an emergency, nursing
homes are "on their own." Nursing home residents are not eligible for
relocation to a special needs shelter; rather, the facility is
responsible for residents' welfare whether they decide to evacuate or
shelter in place.

As one official in Texas described it, the lack of coordination between
the nursing home industry and governmental and other entities resulted
in glaring problems:

> *"The nursing home industry as a whole does not have an overall plan
> for evacuation during an event; individual providers are supposed to
> have their own plans. The long-term care industry has received very
> little direction from policymakers. The state merely requires
> facilities to have emergency plans in place. This results in poor
> coordination of evacuation efforts and resources. The after-storm plan
> is not present too: where are evacuees housed? How are they moved back
> to their facilities? Where will they get their meds?"* (TX Official)

Only Louisiana and Florida had established relationships with nursing
homes prior to Hurricane Katrina. These states have state nursing home
associations which provide assistance during an emergency. The nursing
home associations have a seat in their respective state's EOC. In
Louisiana, the nursing home provider association was invited to
participate at the EOC following Hurricane Andrew in 1992. In Florida,
the state EOC involves the nursing home association in planning, but
there is no similar consistent relationship with the nursing homes at
the local level. In Pensacola, the hospitals have a local representative
who works at the local EOC during a storm but the nursing homes do not.
The county has a list of all the nursing homes in the area and it is the
local health department's responsibility to call the facilities and
ensure that they have the resources they need or to support evacuation.

At the time of Hurricane Katrina, Mississippi, Texas and Georgia EOCs
did not have formal relationships with the nursing home provider
associations. In Mississippi, the provider associations designated a
point of contact to stay in touch with the state EOC to provide
information, but it was the association's responsibility to contact the
EOC. During the hurricane, Mississippi Department of Health staff---in
the EOC---conducted status checks of facilities. In the future, the
state is planning to develop a more formalized relationship with the
state nursing home association and plans to designate an individual at
the State EOC who will facilitate calls from the facilities and manage
the information in order to avoid duplication of efforts and streamline
the flow of information.

The Texas nursing home association served as a communication network
during Hurricane Katrina, "which was the main thing brought to the table
when dealing with Katrina, but not so much with high-level activities."
*(TX Official)* Their role was to identify nursing home needs. The
availability of beds was determined by facilities locally. i.e.,
evacuating facilities contacted potential host facilities directly to
check on bed availability. The nursing home association in Texas has
done little to connect with local government. Their approach "has been
to rely on the structure of the state and its long-standing
communication systems with the locals." *(TX Official)* The association
emphasizes that it is facilities' responsibility to keep in contact with
their local health departments in an emergency.

In Georgia, state officials did not coordinate with nursing homes prior
to the arrival of evacuees. Likewise, nursing homes did not expect
response involvement and had not been involved in emergency planning. As
a result of the state's experience with Hurricane Katrina, nursing homes
were subsequently asked to develop emergency plans, which are reviewed
and commented upon by the state and local agencies. Important contacts
were made between the health department and the nursing homes and most
nursing homes in the area have been involved in recent emergency
preparedness planning meetings.

**Some Facilities Lacked the Resources to Evacuate**

Nursing facilities that are part of a larger corporate chain often had
corporate resources to support their decision to shelter in place or
evacuate. The larger issue, particularly in Louisiana, was what the
smaller, independent facilities would do. The "mom and pop" owned
facilities are predominant in the state and did not have the same
resources available to them. Since Hurricane Katrina, the Louisiana
legislature has passed legislation (Act 540), subsequently signed into
law by the governor, that requires the Department of Health and
Hospitals, in consultation with the Governor's Office of Homeland
Security and Emergency Preparedness, to establish criteria for
evacuation of or sheltering in place of nursing home residents during a
hurricane.

Given the significant experience Florida has had with hurricanes, the
procedures in place for evacuating nursing homes in that state have been
well-practiced. Facilities are supposed to have several back-up plans
for evacuation so that if 'Plan A' does not work, they have a 'Plan B or
C' on which to rely. The state relies on systems in place to predict a
storm's path, allowing for early warning and preparation in advance of a
storm.

Nonetheless, the nursing facilities in Florida face challenges in their
decision to evacuate. Facilities have business interruption insurance
that will cover the costs of evacuation; however, the insurance will not
pay until an emergency is declared. As a result, facilities may wait
until it is too late to conduct a safe evacuation because they do not
want to be saddled with the costs of an unnecessary evacuation. Although
this issue was specifically raised in Florida, it is likely that
facilities in other states face the same consideration.

As with community-based special needs populations, nursing home
facilities that choose to evacuate are faced with the challenge of
identifying appropriate transportation for their residents and engaging
that transportation in a timely manner. There is speculation that the
challenge of getting transportation may have affected nursing home
administrators' decisions to evacuate, although there was no evidence
brought forth to confirm this during our site visits.

Nursing homes are individually responsible for identifying a
transportation company and establishing a contract to provide
transportation services during evacuation, but many had problems
obtaining needed services. In Louisiana, facilities had contracts in
place but the bus companies did not provide the service. In part, this
was due to the fact that multiple facilities engaged the same
transportation company and the company was unable to meet all requests
for transportation services prior to the storm. Florida reported similar
problems. Some officials in Louisiana also reported that buses
originally en route to evacuate facilities were diverted by FEMA or
other federal or state entities for other uses. Facilities that were
part of a larger corporate chain were able to call upon the corporate
resources to provide evacuation support, but few nursing homes in
Louisiana are part of a larger corporation.

Act 540 passed by the Louisiana legislature after Hurricane Katrina
requires each nursing home in the state to have written plans, reviewed
by the DHH, which detail which company will be providing transportation
for the facility in the event of an evacuation. However, if the
facility's efforts to obtain transportation fail, this act holds DHH
responsible for moving residents to a safe location. Increasingly,
nursing homes are asking families about their own evacuation plans in
advance and encouraging family members to get their loved ones out of
the facility in advance of a storm. Nursing homes in Louisiana are also
now working to establish Memoranda of Understanding (MOUs) with bus
companies to ensure better coordination for evacuation. Still, officials
noted that even when the transportation companies were available, there
would be no guarantee that anyone would be available to drive the
busses.

Florida officials also raised concerns about the timing of nursing home
evacuations:

> *"\[Nursing homes\] are not notified any sooner than the general
> public is and if you do not get them out of there first, you have a
> disaster with elderly people sitting in traffic. Frail people with
> health care problems cannot tolerate being tied up in a traffic jam.
> We need to get people evacuated earlier."* (FL Official)

Still, Florida is well-practiced at evacuating nursing facilities, and
other states may learn from this model. Nursing facilities in the
Florida Keys must evacuate if a hurricane is heading toward the state as
they are in a storm surge zone. Facilities are responsible for providing
transportation to residents and generally begin evacuation approximately
96 hours pre-landfall. They make efforts to transport residents at night
when there is less activity on the roads and the residents can avoid the
heat of the day. They will, when appropriate, use aircraft for
evacuation. The State of Florida provides other forms of transportation
if the local facility cannot arrange it and will subsequently bill the
facility for the costs of evacuation. The State has set a maximum
evacuation distance of 75 miles for nursing home residents so that they
do not spend too much time en route but move far enough away from the
storm to be out of harm's way.

**Nursing Homes Also Faced Workforce Shortages**

Like special needs shelters, nursing homes faced problems with
maintaining sufficient staffing in nursing facilities that either chose
to shelter in place or evacuate. In Mississippi, fuel shortages made it
difficult for nursing staff to get to the nursing homes to care for
residents. In one county, nursing home staff lived in a tent and worked
16 hour shifts due to limited staff.

In Louisiana, staff who were in the nursing home at the time of the
storm had no place to go so they continued to provide care to residents;
however, many were concerned about their own families and homes and left
the facilities as soon as they could. A number of volunteers arrived to
assist in providing care but the facilities needed Certified Nursing
Assistants (CNAs) and Licensed Practical Nurses (LPNs), who were hard to
find. The state EOC helped solve problems for facilities that were short
on staff. For example, the EOC helped one facility to identify
volunteers from the local fire departments who could help with resident
evacuation. Faith-based organizations also provided help; this is a
relationship that will be cultivated for the future.

Florida nursing homes have developed plans that can serve as a model for
the future. In preparation for a storm, nursing homes allow staff to
bring their families and their pets to the facility to stay with them.
The goal is to make the staff as comfortable as possible so that they
will remain to provide care to the residents.

**Nursing Homes Faced Challenges in Identifying Host Facilities**

Nursing homes that evacuate are responsible for identifying a suitable
host facility for their residents. Few nursing homes had existing
relationships with other facilities prior to Hurricane Katrina that
could be called upon to help absorb the residents that needed to be
evacuated. Facilities that accepted additional nursing home residents
typically did not have sufficient staffing support to provide complete
care to these residents. Nursing homes that were part of a larger
corporate chain had an easier time in that they were typically able to
move residents to another facility within their system.

In Louisiana, the nursing home association worked with facilities that
wanted to evacuate to identify available beds. Officials reported that
this effort worked well in most cases. The DHH also provided a bed
availability website to help facilities identify sites that could
receive evacuees, but coordination problems arose on several occasions
when multiple facilities sent residents to the same host facilities.

Some nursing facilities in Louisiana attempted to transfer the entire
facility to another location rather than split up residents among
different facilities. Some facilities relocated to a gymnasium or other
large facility, even when there were still beds available in other
nursing facilities. Several officials reported that this was done to
ensure that the nursing home would continue to receive reimbursement for
the care of those residents. This created an incentive for facilities to
shelter in place or to make attempts to shelter the entire nursing home
in another facility that may not have been well-equipped to house
nursing home residents even if it was not in the best interest of the
patients.

In Texas, nursing home residents evacuated from Louisiana were sometimes
sheltered in locations such as a gymnasium or a college with a nursing
school. In some cases, faith-based organizations, including churches,
became the host sites for nursing home residents. Officials from
Mississippi reported that they are currently working to identify a large
facility that could serve as a central evacuation center.

**Tracking Nursing Home Residents and Records**

Officials in Louisiana and Mississippi reported problems in tracking
nursing home residents and their medical records following evacuation.
Families called to ask where their loved ones were, and in some cases
neither the facilities nor state public health officials could provide
an answer. In these cases, the resident may have been evacuated as part
of a federal effort and there was a lack of communication between the
different levels of government about the location of the nursing home
resident. Recently, Mississippi facilities are pre-incident planning to
identify options for sheltering in place or evacuating. If facilities
decide to evacuate, their plan must specify where the residents will go
and how the evacuation will be accomplished. The host facility receiving
evacuees will be responsible for contacting state officials to inform
them of the evacuation. This will facilitate tracking of residents.

Texas also reported challenges in retaining medical records with
residents when they were moved, particularly if they were evacuated by
emergency airlift. As one Texas official stated, efforts are underway to
coordinate with all levels of government and agencies:

> *"We need to make sure the identification system works without fail,
> and the state has recognized that. We have been in meetings with the
> federal Department of Defense, HHS, NDMS---everyone is concerned about
> that. There needs to be a way to make sure that happens, to make sure
> basic identification stays with them."* (TX Official)

## IMPLICATIONS FOR PUBLIC HEALTH

We conclude this chapter by summarizing some key issues for public
health to consider in preparing for future emergencies.

-   **Public health should continue to lead the effort to define special
    needs and develop methods for identifying individuals in the
    community meeting these criteria in advance, if possible.** The
    states face significant challenges in defining and identifying
    special needs populations. Even where specific definitions exist,
    such as in Louisiana, we learned that the substantial demand for
    special needs sheltering forced many shelter operators to include
    individuals that may have not been a part of the original
    definition, often including those who were far more impaired than
    allowed by definition. In many states we visited, public health is
    leading the efforts to better identify special needs in the
    community. More often, public health agencies are relying on
    providers (e.g., dialysis facilities, home health, hospice) to help
    identify and develop emergency plans for their patients. This is
    particularly true in Florida, but is also an emerging trend among
    other states. We recommend that public health agencies continue such
    efforts.

-   **Public health agencies need to clarify their roles in staffing and
    ensuring transportation to shelters.** Staffing and transportation
    were prominent issues raised during our site visits. Not only were
    there problems getting obtaining the right mix of staff to work in
    special needs shelters, but also issues in finding the right staff
    to care for the special needs populations (e.g., CNAs, LPNs,
    respiratory therapists, mental health professionals). Public health
    staff do not always have the training to adequately address the
    specific needs of shelter residents. There is debate whether the
    direct provision of shelter staff is the responsibility of public
    health agencies or whether public health's role should be to assure
    that shelters are appropriately stafffed. States might consider
    establishing a "team-based" approach to staffing, such as that used
    in Florida. Similarly, the role of public health in fulfilling
    transportation needs for nursing facilities requires clarification.

-   **Public health might identify opportunities to partner with other
    organizations to provide transportation for special needs
    patients.** Non-traditional partners, such as faith-based
    organizations, played a vital role in caring for special needs
    populations, both in the community and in nursing facilities. For
    example, these organizations were instrumental in both arranging for
    shelter, and providing transportation to special needs populations,
    including nursing home residents. States are exploring ways to
    formalize relationships with these non-traditional partners.

-   **Coordination between public health and other agencies is needed to
    ensure that appropriate security is available for shelters.**
    Shelter operators face challenges in terms of balancing the need to
    maintain security at shelters and providing a comfortable place for
    special needs populations who are already traumatized and impaired.
    In certain cases, security was insufficient; in others, it was too
    visible and disconcerting to shelter residents. Public health needs
    to establish better coordination with law enforcement and other
    security agencies at the local, state and federal levels to ensure
    that the appropriate level of security is available to assist
    shelter operators.

-   **Nursing homes need to be involved in emergency response
    planning.** Nursing homes are currently uninvolved with state and
    local-level emergency response planning or preparedness, resulting
    in poor coordination of evacuation efforts and resources. The
    establishment of better relationships between nursing homes and
    government agencies can help improve the quality of future response
    efforts.

-   **More effort needs to be directed toward caring for mental health
    needs during an emergency.** Although mental health problems were
    the overriding concern in the general and special needs shelters,
    mental health services were substandard during Hurricane Katrina.
    Psychiatric beds were difficult to find and mental health staff were
    neither well-organized nor sufficiently prepared to provide services
    to evacuees and shelter residents. Some state and local public
    health agencies developed innovative responses and others are
    currently exploring ways to partner with other government agencies
    and with private partners to better serve mental health needs. These
    and other efforts should be expanded.

# Chapter 9: Concluding Thoughts

In the preceding four chapters, we presented key observations and public
health implications associated with our main areas of study: workforce,
medical supplies and pharmaceuticals, communications, and special needs
populations. In this chapter, we discuss some of the cross-cutting
themes that we identified and offer some concluding thoughts.

Our analysis of the public health response to Hurricane Katrina brings
into sharp relief some of the general lessons learned in recent years
regarding public health emergency preparedness. The Hurricane Katrina
response highlights the gaps that result when public health officials at
all levels of government are uncertain about their respective roles. In
fact, we would argue that many of the breakdowns we observed in
communications, the distribution of needed medical and other supplies,
and serving special needs populations primarily occurred because there
was considerable ambiguity regarding the respective roles of federal,
state, and local public health agencies and other governmental
institutions. This finding highlights the idea that coordination between
all involved organizations must be improved to mount an effective
response.

In this regard, we were particularly struck by how public health's
experience during Hurricane Katrina raised issues related to its
assurance function--i.e., linking people with services--and whether, and
to what extent, health departments should engage in the direct provision
of care during public health emergencies. This issue became especially
critical in caring for special needs populations. In all of the affected
states, there was virtually no consensus on who should provide the care,
the types of care that public health should be responsible for, and
whether the skill mixes for delivering such care even exist within most
public health agencies.

Moreover, it became clear that even before care could be rendered,
public health agencies had to grapple with additional challenges related
to special needs populations, including: defining what constitutes a
special health care need under various circumstances, determining
methods to identify special needs individuals in communities, and
resolving a broad range of staffing and transportation issues related to
this population.

The response to Hurricane Katrina also illustrates the importance of
creating solid partnerships-- among public health agencies, other
response agencies, the private sector, the public at large, and
non-traditional partners such as faith-based organizations-- as well as
the consequences of failing to do so. For example, as we have seen,
faith-based organizations played key roles in arranging shelter and
transportation for special needs populations. Partnerships with these
and other organizations will be key to ensuring an effective response in
future emergencies.

Along these lines, we also believe that it is critical for public health
agencies to undertake additional efforts to engage the public at large
in public health emergency preparedness activities. Many of the problems
that arose in the response to Katrina could have been prevented or
minimized if public health agencies had done a better job in educating
the public, well in advance of the disaster, on the individual's roles
and responsibilities in emergency response. This would include educating
the public on disaster-related sheltering issues (both when it's
appropriate to shelter in place as well as the locations of shelters
that could be accessed during emergencies) and the importance of
self-identifying special health care needs. Doing so would have
alleviated demands placed on hospitals and other health care facilities.
The public message that needs to be conveyed is that people should go to
hospitals only if sick or injured.

Stronger partnerships and improved planning among the partners should
also lead to the more effective use of volunteers, a critical
shortcoming in the Katrina response. Using volunteers to supplement the
public health workforce poses a set of challenges: maintaining a current
registry, credentialing professionals, and matching needs with skills.
Much of this can be done well in advance of emergencies, and illustrates
an area where health departments have underinvested in the past.
However, although it is clear that more resources need to be devoted to
planning for anticipated workforce needs during emergencies and to
training individuals to assume various roles during emergencies, a
necessary precondition in using such resources effectively and
efficiently is the establishment of public health partnerships within
and across locales and levels of government.

Finally, the aftermath of 9/11 has led to what amounts to a significant
cultural upheaval for public health. Now more than ever before, public
health officials are being trained in ICS and are being asked to
integrate much of their work with that of other emergency response
agencies. However, although progress has been made in this area, tension
between these groups remains. Incorporating elements of both disciplines
is essential to mounting an effective response. In many instances,
public health has resisted incorporating emergency management techniques
into their operations while in others, traditional public health
capabilities including the ability to work with community partners and
conduct needs assessments, have not been reflected in emergency response
planning and training.

Our case studies confirm the value of ICS training in clarifying roles
in an emergency and in enhancing communications across agencies at all
levels of government. However, as described earlier, there were
breakdowns in communication, both technical (e.g., interoperability
issues, lack of power to charge cell phones) and intra- and
inter-organizational that reduced the effectiveness of the response.

## RECOMMENDATIONS

Earlier chapters contained recommendations specific to the substantive
concerns discussed in those chapters. Here, we close with a brief set of
recommendations that reflect largely cross-cutting concerns. Although
these recommendations relate to the lessons learned from Hurricane
Katrina and in some cases are specific to hurricane preparedness, most
apply broadly to other types of disasters, whether natural or manmade.

**Conduct Drills and Exercises with Multiple Levels of Government and
Non-Governmental Partners**

We believe that a good way to address the need for clarifying roles and
responsibilities for public health partners is for state and local
health departments to make a greater effort to include a wider range of
community partners in planning activities and exercises for both natural
and manmade disasters. Doing so will help resolve ambiguities over roles
and responsibilities. Here it should be noted that since the terrorist
attacks of September 11, 2001 there has been a sharpened focus on
preparedness for bioterrorist or other manmade disasters. As such, the
focus of many exercises has been on scenarios involving infectious
disease outbreaks. However, the experience of Hurricane Katrina
illustrates importance of developing exercises for public health
departments for a variety of scenarios including natural disasters,
especially those that might require evacuation of a large number of
people. Moreover, it is important to conduct drills and exercises that
test specific capabilities because they are much more likely than
generic exercises to result in performance improvements.

**Explore Prospect of Extending ICS Training and Planning to Key Private
Sector Partners**

Our case study results indicated that ICS training and planning were
powerful tools for responding to the devastation caused by Hurricane
Katrina. We believe that the effectiveness of ICS in public health
emergencies could be strengthened if other government and private sector
partners were included in the training and planning processes. Such
partners include, but are not limited to, school officials, pharmacies
and pharmaceutical companies, medical equipment suppliers, long-term
care facility operators, and representatives from large local
businesses.

**Develop Systems for Quickly Matching Available Resources with Needs**

Although opinions differ on whether the overall resources available
during Hurricane Katrina and its immediate aftermath were adequate to
meet the needs, an overwhelming majority of the people we spoke with in
the case studies indicated that most of the problems arose because these
resources were not well matched with needs. Such mismatches created
shortages in some areas and surpluses in others. Effective matching
requires coordination between state and local officials. At the local
level, communities need to be able to quickly conduct a needs
assessment, so they can request the specific set of resources that will
serve their needs. At the state level, officials need to identify what
resources are available and determine how to best allocate those
resources to address needs across the affected areas.

**Each Community Must Examine How it Can Increase Its Level of Public
Health Preparedness**

Public health emergency preparedness is a shared responsibility. To
mount an effective and efficient response, officials at all levels of
government, business owners, and individuals must contribute their
resources and ingenuity. Moreover, greater attention must be paid to
unique challenges and issues that surround special needs populations in
an emergency. But here, as in many areas of public policy, one size does
not fit all. Due to differences in how the public health system is
organized across geographic areas there is no one right role of public
health in an emergency. Rather, each community must bring the relevant
organizations together to determine how best to allocate responsibility
for the public health emergency response within their community. The
outcome of such a meeting should be institutionalized through
incorporation into the emergency response plan, the use of Memoranda of
Understanding (MOUs) between organizations, and any other mechanism that
will allow the community to hold organizations accountable for the roles
and responsibilities they have agreed to take on.

**References**

Asch SM, Stoto M, Mendes M, Valdez RB, Gallagher ME, Halverson P, Lurie
N. (2005). A review of instruments assessing public health preparedness.
*Public Health Reports*. 120 (5): 532-542.

Appleseed (2006) A continuing storm: The ongoing needs of Hurricane
Katrina Evacuees.
<http://www.appleseeds.net/servlet/PublicationInfo?articleId=207> Last
accessed May 31, 2007.

CDC (2004) Public Health Emergency Response Guide for State Local, and
Tribal Public Health Directors.

CDC (2006) Surveillance in Hurricane Evacuation Centers Louisiana,
September -- October 2005. *Morbidity and Mortality Weekly Report*.
55(2):32-35.

Daley WR. (2006). Public health response to Hurricanes Katrina and
Rita-United States. *Morbidity and Mortality Weekly Report*.
55(9):229-231.

DeLozier E, Kamp N. (2005) Hurricane Katrina timeline. Brookings
Institution,
<http://www.brookings.edu/fp/projects/homeland/katrinatimeline.pdf>,
Last accessed May 31, 2007.

Gebbie KM, Merrill J. (2002). Public health worker competencies in
emergency response. *Journal of Public Health Management and Practice*.
8(3):73-81.

Gebbie KM, Turnock BJ (2006). The public health workforce 2006: New
challenges. *Health Affairs*. 25 (4): 923-933.

Godoy, M. (2006) Tracking the Katrina diaspora: A tricky task. National
Public Radio,
<http://www.npr.org/news/specials/katrina/oneyearlater/diaspora/> Last
accessed May 31. 2007.

Guidry J. (2006) Hospital disaster preparedness: Past, present, and
future. Presentation to U.S. House of Representatives Committee on
Energy and Commerce Subcommittee on Oversight and Investigations.
<http://energycommerce.house.gov/reparchives/108/Hearings/01262006hearing1772/Guidry.pdf>,
Last accessed May 31, 2007.

Institute of Medicine. (1988). The future of public health. Washington,
DC: National Academy Press.

Institute of Medicine. (2002) The future of the public's health in the
21^st^ century. Washington, DC: National Academy Press.

Katz A, Staiti AB, McKenzie KL. (2006). Preparing for the unknown,
responding to the known: Communities and public health preparedness.
*Health Affairs*. 25 (4): 946-957.

Kerber, R. (2005, October 5) Diabetes Put at Risk amid Hurricane Exodus;
shortages of drugs, supplies reveals holes in government disaster plans
for patients. *The Globe*.

Knabb RD, Rhome JR, Brown DP (2005) Tropical cyclone report: Hurricane
Katrina. National Weather Service, National Hurricane Center, Washington
DC. <http://www.nhc.noaa.gov/pdf/TCR-AL122005_Katrina.pdf>

Lurie N, Wasserman J, Nelson C (2006). Public health preparedness:
Evolution or revoluation? *Health Affairs*. 25 (4): 935-945.

Matthews AK, Sprague K, Girling E, Dapice L, Palumbo MV, Berry P.
(2005). Emergency preparedness volunteer training program. Journal of
Public Health Management and Practice. S63-67.

McHugh M, Staiti AB, Felland LE. (2004). How prepared are Americans for
public health emergencies? Twelve communities weigh in. *Health
Affairs*. 23(3): 201-209.

Morill JB, Litaker JR, Markovich RJ et al. (2006) The Health and Medical
Response to Hurricanes Katrina and Rita by the Texas Department of State
Health Services: An After Action Assessment.

National Organization on Disability (2005). Report on Special Needs
Assessment for Katrina Evacuees (SNAKE) Project. Washington, DC.
<http://www.nod.org/Resources/PDFs/katrina_snake_report.pdf> (Accessed
April 11, 2006).

North Carolina Division of Emergency Management, North Carolina Division
of Public Health, North Carolina Office of Emergency Medical Services
(2006). *Hurricane Katrina After Action Report and Recommendations:
Emergency Support Function 8, Health and Medical, State of Mississippi*.

Parker CL, Barnett DJ, Fews AL, Blodgett D, Links M. (2005). The Road
Map to Preparedness: A competency based approach to all-hazards
emergency readiness training for the public health workforce. *Public
Health Reports.* 120 (5): 504-514.

Rottman SJ, Shoaf KI, Dorian A. (2005). Development of a training
curriculum for public health preparedness. *Journal of Public Health
Management and Practice*. S128-31.

U.S. Department of Health and Human Services Office of Inspector General
(OIG) (2006). Nursing Home Emergency Preparedness and Response During
Recent Hurricanes. Washington, DC.
<http://oig.hhs.gov/oei/reports/oei-06-06-00020.pdf>

U.S. Department of Homeland Security (US DHS) (2004) National Response
Plan., Washington, DC.
<http://www.dhs.gov/xlibrary/assets/NRPbaseplan.pdf>

U.S. Department of Transportation (US DOT) (2006a). Catastrophic
Hurricane Evacuation Plan Evaluation: A Report to Congress. Washington,
DC.
<http://www.fhwa.dot.gov/reports/hurricanevacuation/rtc_chep_eval.pdf>

U. S. Government Accountability Office (2006a) "Statement by Comptroller
General David M. Walker on GAO's Preliminary Observations Regarding
Preparedness and Response to Hurricanes Katrina and Rita" (GAO-06-365R).

U.S. Government Accountability Office (GAO) (2006b). Disaster
Preparedness: Preliminary Observations on the Evacuation of Vulnerable
Populations Due to Hurricanes and Other Disasters. Washington, DC.
<http://www.gao.gov/new.items/d06790t.pdf>

U.S. House of Representatives (2006). A Failure of Initiative, Final
Report of the Select Bipartisan Committee to Investigate the Preparation
and Response to Hurricane Katrina, Washington, DC: U.S. Government
Printing Office.

U.S. Senate (2006). Hurricane Katrina: A Nation Still Unprepared, Report
of the Committee on Homeland Security and Governmental Affairs,
Washington, DC.

Wasserman J, Jacobson P, Lurie N, Nelson C, Ricci K, Shea M, Zazzali J,
Nelson M. (2006) Organizing state and local health departments for
public health preparedness. Santa Monica CA, RAND TR-318-DHHS.

Weiner E, Irwin M, Trangenstein P, Gordon J. (2005). Emergency
preparedness curriculum in nursing schools in the United States.
*Nursing Education Perspectives*. 26(6): 334-339.

White House (2006) The Federal Response to Hurricane Katrina: Lessons
Learned.

**Appendix A: Interview Protocol for Directly Affected States**

RAND is working with the US Department of Health and Human Services
(HHS), Office of the Assistant Secretary for Public Health Emergency
Preparedness to develop resources and to prepare analyses to describe
and enhance key aspects of state and local public health emergency
preparedness. The project is composed of several tasks. One of these
tasks is to investigate and document some of the main, initial lessons
learned from the public health response to Hurricane Katrina.

It is not our intent to evaluate the performance of any specific
organization; rather, we hope to collect and synthesize information
about what did and did not work during the response effort to use as a
tool for improving preparedness for future disasters. It is our
expectation that this information will be useful in improving public
health preparedness in both those localities directly affected by
Hurricane Katrina and those that were spared this time, but face the
risk of hurricanes each year.

***Required (Consent Procedures):*** Thank you for agreeing to talk with
us about the lessons learned from the public health response to
Hurricane Katrina. Before we begin, let me assure you that your
responses to these questions will be held in strict confidence, except
as required by law. Summary information from these interviews, together
with material taken from public documents, will be presented at the
state level; however, no specific individual or agency will be
identified by name or affiliation in any reports or publications.
Findings from the study will be shared with all participants.

Your participation in this discussion is completely voluntary. We would
like to have your responses to all of the questions; however, if you are
uncomfortable with any question we can skip it. We estimate that the
interview will take about 1 hour.

Do you have any questions about our confidentiality procedures before we
begin? (If yes, respond to all questions. If no, proceed with
discussion).

I. Background

-   To provide context for the interview, get background information on
    the respondent.

    -   Current position: title and responsibilities

    -   How long have you held your current position?

    -   How long have you been with the local public health department
        (LPHD)?

    -   What did you do before coming to the LPHD?

II\. Evacuation

A. Hospitals

-   Organizations that are involved

-   The role public health plays

-   Key successes (provide probes if needed)

    -   Trigger points -- weighing risks, legal authorities

    -   Finding suitable evacuation sites

    -   Logistics of evacuation -- transportation

    -   Coordination with other organizations/levels of government

    -   Leadership

-   Problems that arose (use above probes if needed)

-   How things might be done differently in the future

    -   Existing plan in place? Followed? Exercised?

    -   Revisions?

    -   The role public health should play

B. Nursing home populations

-   Organizations that are involved

-   The role public health plays

-   Key successes (provide probes if needed)

    -   Trigger points -- weighing risks, legal authorities

    -   Finding suitable evacuation sites

    -   Logistics of evacuation -- transportation

    -   Coordination with other organizations/levels of government

    -   Leadership

-   Problems that arose (use above probes if needed)

-   How things might be done differently in the future

    -   Existing plan in place? Followed? Exercised?

    -   Revisions?

    -   The role public health should play

C. Other special needs populations, not in institutions

-   Organizations that are involved

-   The role public health plays

-   Key successes (provide probes if needed)

    -   Identifying special needs people for evacuation

    -   Logistics of evacuation -- transportation

    -   Finding suitable evacuation sites

    -   Coordination with other organizations/levels of government

    -   Leadership

-   Problems that arose (use above probes if needed)

-   How things might be done differently in the future

    -   Existing plan in place? Followed? Exercised?

    -   Revisions?

    -   The role public health should play

III\. Medical Care Personnel

A. Identifying and mobilizing personnel

-   Organizations that are involved

-   The role public health plays

-   Key successes (provide probes if needed)

    -   Identifying volunteers

    -   Legal issues -- licensing, credentials

    -   Trigger points -- when to mobilize

    -   Determining where personnel were needed

    -   Logistics -- communication, getting people out to affected areas

    -   Allocation of scarce resources

    -   Coordination with other organizations/levels of government

    -   Leadership

-   Problems that arose (use above probes if needed)

-   How things might be done differently in the future

    -   Existing plan in place? Followed? Exercised?

    -   Revisions?

IV\. Medical supplies

A. Assessing needs, procuring and distributing supplies

-   Organizations that are involved

-   The role public health plays

-   Key successes (provide probes if needed)

    -   Assessing needs -- type of supplies needed, quantity, and
        location

    -   Obtaining needed supplies -- right mix of materials in
        stockpiles or from other sources

    -   Trigger points -- accessing SNS or state stockpiles

    -   Allocation of scarce resources

    -   Distribution logistics -- transportation

    -   Security of drug supply

    -   Coordination with other organizations/levels of government

    -   Leadership

-   Problems that arose (use above probes if needed)

-   How things might be done differently in the future

    -   Existing plan in place? Followed? Exercised?

    -   Revisions?

    -   The role public health should play

V. Communications

A. Within and across organizations

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

B. With the media and public

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

VI\. Disease surveillance

A. In affected areas

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

B. In shelters

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

VII\. Infection Control

A. In affected areas

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

B. In shelters

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

VIII\. The role of public health in a disaster

A. Define public health

-   Roles/functions that it encompasses

B. Functions not traditionally in the public health sphere

-   Identify (1) organizations involved, (2) lead organization, (3)
    public health's role, (4) point at which public health becomes
    involved, and (5) the role public health should play for the
    following activities

    -   Patient care

    -   Medical information (e.g., medical records)

    -   Behavioral health

    -   Body recovery and identification

    -   Mortuary services

**Appendix B: Interview Protocol for Indirectly Affected States**

RAND is working with the US Department of Health and Human Services
(HHS), Office of the Assistant Secretary for Public Health Emergency
Preparedness to develop resources and to prepare analyses to describe
and enhance key aspects of state and local public health emergency
preparedness. The project is composed of several tasks. One of these
tasks is to investigate and document some of the main, initial lessons
learned from the public health response to Hurricane Katrina.

It is not our intent to evaluate the performance of any specific
organization, rather we hope to collect and synthesize information about
what did and did not work during the response effort to use as a tool
for improving preparedness for future disasters. It is our expectation
that this information will be useful in improving public health
preparedness in both those localities directly affected by Hurricane
Katrina and those that were spared this time, but face the risk of
hurricanes each year.

***Required (Consent Procedures):*** Thank you for agreeing to talk with
us about the lessons learned from the public health response to
Hurricane Katrina. Before we begin, let me assure you that your
responses to these questions will be held in strict confidence, except
as required by law. Summary information from these interviews, together
with material taken from public documents, will be presented at the
state level; however, no specific individual or agency will be
identified by name or affiliation in any reports or publications.
Findings from the study will be shared with all participants.

Your participation in this discussion is completely voluntary. We would
like to have your responses to all of the questions; however, if you are
uncomfortable with any question we can skip it. We estimate that the
interview will take about 1 hour.

Do you have any questions about our confidentiality procedures before we
begin? (If yes, respond to all questions. If no, proceed with
discussion).

Background

-   To provide context for the interview, get background information on
    the respondent.

    -   Current position: title and responsibilities

    -   How long have you held your current position?

    -   How long have you been with the local public health department
        (LPHD)?

    -   What did you do before coming to the LPHD?

-   Define public health

    -   Roles/functions that it encompasses

Part 1 -- Planning for Future Disasters

I. Evacuation

A.  Hospitals

-   Existing plans in place before Katrina

    -   Organizations involved in planning

    -   Means of coordination with organizations during planning process

    -   Lead organization

-   Changes made since Katrina?

    -   Communication of changes in plans with other organizations

-   The role public health currently plays

-   The role public health should play

B.  Nursing home populations

-   Existing plans in place before Katrina

    -   Organizations involved in planning

    -   Means of coordination with organizations during planning process

    -   Lead organization

-   Changes made since Katrina?

    -   Communication of changes in plans with other organizations

-   The role public health currently plays

-   The role public health should play

C.  Other special needs populations, not in institutions populations

-   Existing plans in place before Katrina

    -   Organizations involved in planning

    -   Means of coordination with organizations during planning process

    -   Lead organization

-   Changes made since Katrina?

    -   Communication of changes in plans with other organizations

-   The role public health currently plays

-   The role public health should play

II\. Medical Care Personnel

A.  Identifying and mobilizing personnel

-   Existing plans in place before Katrina

    -   Organizations involved in planning

    -   Means of coordination with organizations during planning process

    -   Lead organization

-   Changes made since Katrina?

    -   Communication of changes in plans with other organizations

-   The role public health currently plays

-   The role public health should play

III\. Medical Supplies

A.  Assessing needs, procuring and distributing supplies

-   Existing plans in place before Katrina

    -   Organizations involved in planning

    -   Means of coordination with organizations during planning process

    -   Lead organization

-   Changes made since Katrina?

    -   Communication of changes in plans with other organizations

-   The role public health currently plays

-   The role public health should play

Part 2 -- Receiving evacuees

I.  Identifying and mobilizing medical personnel

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A.  Organizations that are involved

B.  The role public health plays

C.  Key successes or problems that arose with (provide probes if needed)

-   Identifying volunteers

-   Legal issues -- licensing, credentials

-   Trigger points -- when to mobilize

-   Determining whether personnel were needed

-   Allocation of scarce resources

-   Coordination with other organizations/levels of government

-   Leadership

D.  How things might be done differently in the future

-   Revisions to existing plans

-   Timing of mobilization

-   Coordination between organizations

-   Coordination of volunteers

II\. Assessing needs, procuring and distributing medical supplies

A.  Organizations that are involved

B.  The role public health plays

C.  Key successes or problems that arose with (provide probes if needed)

-   Assessing needs -- type of supplies needed

-   Obtaining needed supplies -- right mix of materials in stockpiles or
    from other sources

-   Legal or financial issues -- receiving medical supplies

-   Trigger points -- accessing SNS or state stockpiles

-   Allocation of scarce resources

-   Distribution logistics -- transportation

-   Security of drug supply

-   Coordination with other organizations/levels of government

-   Leadership

D.  How things might be done differently in the future

-   Revisions to existing plans

-   Coordination between organizations

-   Communication of supply needs to other organizations/levels of
    government/media/public

Part 3 -- Other Public Health Issues for States Receiving Evacuees

I. Disease surveillance and infection control

A.  Hospitals

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

B.  Shelters

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

C.  General population

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

II\. Communications

A. With and across organizations

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

B.  With the media and public

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

III\. Incorporating shelter populations into public health system

-   Key successes and/or problems that arose

-   Any changes to be made for future disasters

Part 4 -- Reassessing the role of public health in a disaster

I. Functions not traditionally in public health sphere

A.  Identify (1) organizations involved, (2) lead organizations, (3)
    public health's role, (4) point at which public health becomes
    involved, and (5) the role public health should play for the
    following activities

-   Patient care

-   Medical information

-   Behavioral health

-   Body recovery and identification

-   Mortuary services