Storm victims waiting at the airfi eld

Photo © 2005 The Times-Picayune Publishing Co., all rights 

reserved. Used with permission of the Times-Picayune
399

Chapter 24

Medical Assistance

Introduction to the Health Impacts of Hurricane Katrina

I

n both Mississippi and Louisiana, the onset of Hurricane Katrina found signifi cant 

populations of acutely ill patients in hospitals and patients in nursing homes who were 

not evacuated.1

 In the case of acutely ill hospital patients, most hospitals decided that 

the medical risk of moving these patients outweighed the benefi t, and chose to shelter-inplace. Unfortunately, the majority of the hospitals were not adequately equipped to carry 

out this function in the face of a storm the magnitude of Katrina.2

 Some nursing homes 

made similar decisions based on diffi culties they encountered in previous evacuations or for 

other reasons. All told, some 235 deaths occurred in 28 of Louisiana’s hospitals and nursing 

homes.3

 Special-needs patients transported themselves or were evacuated to the Superdome 

and to other shelters.4

 Although an estimated 450 special-needs patients were evacuated 

from the Superdome prior to landfall and transferred to a state-supported shelter in Baton 

Rouge, many more remained in the city.5

So on the eve of Katrina’s landfall, federal, state, and local medical emergency managers 

found themselves confronted with the need to evacuate and care for thousands of medically compromised individuals – a circumstance forewarned in the Hurricane Pam exercise 

a year before Katrina.6

 Even more telling is the fact that these offi cials were apparently well 

aware of the situation that they would face. For example, a U.S. Department of Health and 

Human Services (HHS) e-mail describes information communicated on a FEMA-arranged 

conference call on Sunday night, August 28, just hours before landfall. Th e e-mail stated 

that 40 to 50 patients at the Superdome special-needs shelter were critical-care medical 

patients and that there were approximately 2,500 hospital patients still in New Orleans. Th e 

e-mail goes on to say, “Advanced planning was never completed on how the patients left in 

the hospitals will be evacuated aft er the event,” and later noted, “it is assumed that many of 

the hospital generators will lose power given the expected height of the water.”7

Similar circumstances were reported in Mississippi. A report from HHS Region IV emergency representatives in Atlanta, also on Sunday evening, reported that in Mississippi there 

were “no hospital evacuations other than 8 critical patients from VA [Veterans Aff airs]” 

and “out of 29 Skilled Nursing Facilities only 2 reported evacuations.”8

Aft er the storm, federal, state, and local offi cials, and health-care workers in Mississippi and 

Louisiana faced extraordinary demands for health services, including evacuation of thousands of hospital and nursing-home patients. In addition, the health-care response system 

was taxed to its limits dealing with care of survivors and tens of thousands of people who 

had fl ed from the coastal regions and required medical care for pre-existing illnesses and 

chronic diseases, as well as preventing the spread of disease among these evacuees, many of 

whom were now living in crowded shelters.9

All of this had to be done in areas where major portions of the health-care system had been 

damaged or destroyed. All but three hospitals in the New Orleans area were incapacitated10

and essentially all hospitals in the Mississippi Gulf Coast area sustained some level of physical damage and operational disruption (from loss of power, evacuation of staff , disruption 

of their supply systems, etc.). Charity Hospital in New Orleans, rendered inoperable by 

fl ood water, was one of only two major trauma centers in the entire state.11
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400

Medical Assistance: Louisiana

As Hurricane Katrina approached Louisiana, hospitals and nursing homes had to decide 

which of their thousands of patients and residents could be safely evacuated, and to where. 

Once Katrina struck, hospitals and nursing homes had to care for those left behind, as well 

as new arrivals – all while dealing with fl ooding, power outages, supply shortages, security 

problems, and other issues.

Medical Evacuations

Temporary triage and medical-care facilities, developed as part of the Hurricane Pam exercise, provided triage for tens of thousands of evacuees and victims. Th e plan called for searchand-rescue teams to drop people at Search-and-Rescue Bases of Operations (SARBOOs) near 

the fl ooded areas, where paramedics would perform initial triage. Rescuees would then be 

transported to Temporary Medical-and-Operations Staging Areas (TMOSAs), larger areas 

with temporary medical facilities, for care and triage. Using this system, the state successfully 

triaged approximately 60,000 people.12 With a capacity of 800 beds to provide medical care, 

the TMOSA at the Pete Maravich Center on the Louisiana State University (LSU) campus in 

Baton Rouge was the largest temporary emergency facility ever built, according to Dr. Jimmy 

Guidry, the Medical Director for the Louisiana Department of Health and Hospitals (DHH).13

However, while the SARBOO/TMOSA structure was critical to handling the large volume of 

people needing attention, the plan did not work exactly as intended. For example, the New 

Orleans airport became a major triage center, especially for critically ill patients evacuated 

from hospitals, even though it was not part of the state plan. And as stated by Dr. Guidry, the 

state also lacked adequate transportation resources to evacuate all of the victims:

Most of the hospitals did not have helipads, so they either had to go to the 

Superdome helipad or to another hospital’s helipad. Th e helicopters that we 

did have were not willing to make a fl ight beyond picking them up there and 

bringing them to the airport, because they had to go back and pick up some 

more folks. So they weren’t going to take them to anywhere [else] in the state 

by helicopter if they could avoid it because that would be loss of time. So most 

of the helicopter pick ups were from a helipad next to a hospital, to the airport 

or to the Causeway, depending on the critical [condition] of the patient. From 

the airport and from the Causeway, then it was buses or planes. 14

Many victims did eventually arrive at the TMOSAs, although this created a signifi cant 

transportation problem because of the large number of evacuees in New Orleans. Eventually buses were organized to carry out this function, as further described by Dr. Guidry, the 

buses were used

when we started evacuating the large numbers at Causeway and the large 

numbers at the Superdome. Th ose buses would then bring the patients by the 

TMOSA and at the TMOSA, then we would triage them to see whether they 

could continue on the trip that the buses was taking them to, either a general 

shelter in Louisiana or a general shelter outside of Louisiana.15

Some of the diffi culties experienced in moving victims into the state’s medical-triage system 

were compounded by the fact that the evacuation of hospitals was simply not addressed in 

Hurricane Pam, despite the presumption that New Orleans would fl ood and that the hospitals would become inoperable. In fact, the Hurricane Pam exercise assumed that some 2,000 

patients would be sheltered in place in area hospitals that would cease to operate as functional medical facilities due to fl ooding – a prediction that came strikingly close to reality 

during Katrina.16 Little action was taken to address this daunting scenario prior to Katrina. 
Medical Assistance

401

As explained by Dr. James Aiken, Medical Director for Emergency Preparedness for the 

Medical Center of Louisiana in New Orleans (a.k.a. Charity and University Hospitals):

Well, to start with my own hospital, it [Pam] did not change our planning at 

all. I don’t think it changed anyone else’s planning that I am aware of ... Th e 

focus of the health care planning that I participated in [during the exercise]

had to do with not what happens within what we call the aff ected areas [that] 

have fl ooding but what happened on dry land. And most of the activities that 

happened in the health care breakout sessions had to do with standing up the 

temporary medical support sites.

[M]any of my colleagues registered our concerns that we were literally writing 

off any serious planning above and beyond what we had then, which was to tell 

the hospitals they were going to have to be self-suffi cient for three to fi ve and 

now seven days. ... 

So the Hurricane Pam, again, exercises and planning eff orts, as far as I know, 

never addressed the issue of pre-threat evacuation or actually serious detailed 

planning for the aff ected area. 17

Notwithstanding the failure of emergency planners during the Hurricane Pam exercise to 

address the need to evacuate hospitals, the hospitals were required to have emergency and 

evacuation plans. For example, DHH regulations required hospitals to have such plans, and 

for those plans to be made available to regional emergency offi cials upon request.18 Nonetheless, these requirements proved woefully inadequate. As Dr. Guidry explained:

It is not a requirement for licensure [for hospitals] to have generators at a 

certain level, at a certain place. It is not a requirement for licensure that [the 

hospital] show proof that your plan is operational. 

It was not a requirement prior to this event [Hurricane Katrina] that they 

would turn in plans defi ning what their evacuations plans [are].

When I had discussions with a number of these hospitals in this area over the 

years, the questions was, “How are you going to evacuate?” And their response 

was always, “We do not plan to evacuate. Our evacuation plan will be to get 

those people out that can travel, elective surgeries. But we will remain here 

with the people that are not able to get out and the people that are going to 

need our care so that we can be here aft er the event.”

I can tell you that next hurricane season, there are going to be a lot more people 

leaving and the plan is going to change drastically. Th ose that do stay will be the 

hospitals that have the capability of hardening their structures and putting their 

generators higher because it does not make sense to stay in a bowl, if you will.19

In the end, hospitals in southeastern Louisiana were simply reluctant to follow their plans 

and evacuate the critically ill because of the danger, expense, and uncertainty of the hurricane path itself. As LSU’s Dr. Aiken put it:

Hurricanes have a remarkable capability of changing directions quickly. And so 

when you say, “In the line of the path of a storm,” you know, for us, that path 

actually gets realized aft er the fact. So when you talk about evacuating patients 

from the number of hospitals that now exist, and we have to expand this conversation beyond New Orleans, because, quite frankly, a lot of the destination 
Chapter 24

402

hospitals that some of the areas use would be the same ones that we [LSU] would 

want to use. ...

How do you decide which hospitals should evacuate and where should they 

go? I mean, do we evacuate the entire coastline? ...

And again, remember 24 hours [prior to landfall of the hurricane], we do not 

want anybody on the road. So the risk benefi t [issue arises], and also remember every single patient who is critically ill requires almost their own means of 

transportation, whether it’s an ambulance or helicopter. We certainly could 

put a couple in. But for our critical care patients, school buses [are] not usually 

the answer.20

In addition, evacuation would have required New Orleans area hospitals to confront the 

diffi cult problem of fi nding other hospitals that could take their patients. As Dr. Guidry 

explained, in Louisiana under normal situations, sick or emergency patients with pressing 

needs are sent to the New Orleans region, which hosts a large number of medical facilities, 

the state’s “medical Mecca.” However, Katrina reversed that burden, causing 25 hospitals in 

the area to try to fi nd places for their patients outside of New Orleans, and “the rest of the 

state can’t absorb it.”21

However successful it had been in prior hurricanes, the strategy of hospitals to stay open for 

critically ill patients and storm victims proved untenable in Katrina. Aft er a few days, most 

hospitals that had stayed open were running out of fuel for their backup generators, making 

it impossible to operate eff ectively or, in some cases, at all, due to fl ooding. In desperation, 

they appealed to DHH to help them evacuate. Dr. Guidry found that helicopters and other 

transportation assets were tied up in search-and-rescue eff orts:

And so their plan was stock up, be prepared to stay in place a few days. Most 

hurricanes, three days, fi ve days out, you’re done with it and be ready to take 

care of people aft er. Th e calls started coming in saying we’re about to lose 

power, we’re going to have to bag [manually ventilate] patients. We got to 

get them out of here. We got to get them out of here. We got to get them out 

of here. And I was asking for the resources to move them. Search and rescue 

is going to have to move them. I got to have the helicopters, I got to have the 

planes to move them out. ... So it then becomes where do I send them, how do 

I get them there, how do I get them out of there. So the Hospital Association 

is coming to me in tears, the folks there are in tears trying to help their folks 

and I’m beating my head to try to get the help. And you’ve got the search and 

rescue that’s trying to get people out of water and rooft ops and out of hospitals. 

And that’s all the competing needs for the limited assets.22

First responders attempting to answer hospital-evacuation calls faced chaotic conditions, 

particularly in the early days aft er landfall. Security concerns, including rumors of snipers, 

thwarted rescue eff orts.23 Communications were poor, making it diffi cult to coordinate with 

ambulances and helicopters. Flooded streets thwarted attempts to drive through New Orleans. Dr. Fred Cerise, Secretary of DHH, who participated in evacuation missions in New 

Orleans, described the challenge of attempting to take seven patients by truck from Charity 

Hospital to the Superdome special-needs shelter:

And we picked up seven people, some that needed dialysis, to take back to the 

Superdome. By this time it was dark; it was late, probably midnight. And there 

were people ... outside of the Superdome that were sleeping all around the outer 

concourse. And so the truck had to – made its way up the external ramp to get 
Medical Assistance

403

to the helipad. And the guard was trying to clear the path, and by this time it’s 

... late, late Wednesday night. ... It’s very tense in the Superdome by this point. 

People are belligerent, not wanting to get – they’re getting woken up to move. ...

I’m in the back of the truck and I hear this loud, “Move it, move, move, move.” 

And I look back and there’s like 30 Guardsmen running at the crowd with 

their rifl es drawn. I – my initial thought was they were just trying to scatter 

the crowd, which they did. But then they turned into the Superdome and I saw 

a medic team come running against traffi c at me, and this is when they had a 

Guardsman that was shot in the Superdome. Th ese guys were going in to get 

their guy out that had gotten shot.24

Evacuating special-needs patients from the Superdome presented its own set of challenges, 

partly because they were next to the general-population shelter. As noted elsewhere, evacuation of the general public didn’t get under way until late Wednesday, due to the delayed 

arrival of buses. Meanwhile, state offi cials had begun evacuating special-needs patients 

from the site by helicopter and boat. Seeing the special-needs evacuation proceeding, some 

members of the general public “fi gured out that if they were sick they might get out earlier. 

And so they started having chest pains and they started getting sick so they could get out 

earlier.”25 Offi cials were also concerned that the general population, angry at having to stay 

behind, would become violent. 26

Flooding around the Superdome also interfered with medical evacuations. Offi cials had 

staged ambulances before landfall on the upper and outer concourses, expecting to use 

them for evacuation once the storm passed. Unfortunately, rising water on Monday evening 

prevented their use.27 Th ereaft er, patients who could tolerate the ride were transported in 

high-water trucks to ambulances at other locations; others had to wait for helicopters.28 Patients were loaded in ambulances, boats, high-water vehicles, aircraft , and even 18-wheeler 

trucks.29 Many patients required continuous, individual medical care while in transit.30 Th e 

logistics were nearly overwhelming, as described by Dr. Cerise:

It’s not a simple ordeal. Put them on manual bagging for people off the ventilator; put them on a spine board. Th e interior of the hospital was dark, and so they 

would carry them down 12 fl ights of stairs on the external stairwell over their 

heads on a spine board making tight turns to get these people down onto the boat.

Got them to boat and we took them over to the hospital. I can tell you we had 

a policeman on the boat, because I remember the people throwing stuff at us 

from the Interstate, Claiborne overpass. And there was a shouting match that 

went on with the police and the guys that were throwing boxes and stuff down 

at the boats.31

Overall, Aiken described the process of evacuating patients as “one of the issues that I feel 

less than satisfi ed, most unsatisfi ed about. I think it sort of overwhelmed us, and I think we 

had a fi ngers-crossed attitude.”32

Aiken also felt that the State Emergency Operations Center (EOC) did not always appreciate the urgency of his requests for assistance. While acknowledging that his demands were 

competing with those of other responders, he believed he would have fared better if EOC 

offi cials involved in handling requests had been at the scene of the crisis:

I don’t know if it was because the right decision maker wasn’t at the desk at the 

time, like with ESF-8 or whatever. But there was always this, “I will see what I 
Chapter 24

404

can do.” And then they would come back and say, “I think we need – we got 

the information, but I got a feeling we better start looking at other options.”

If we could just work out a system. Either bring in distant EOC personnel down 

to the scene, whether it’s FEMA or whoever else the lead agents are, and work 

side by side. Conditions are horrible, but they are not impossible. Th at to me 

could be the optimal eyes and ears. But if you don’t have that, I felt like I was negotiating a lot. And I know I had competing of interest, and I understood that.33

Nursing Home Evacuations

Nursing homes in the metropolitan New Orleans area had their own Emergency Operations Plans (EOPs) that incorporated evacuations. In addition, Louisiana law required 

nursing homes to maintain EOPs and provide them to their parish emergency managers 

to “review and approve” the plans. 34 In reality, the Committee staff found that few parishes 

followed through on this guidance. One parish emergency manager from the metropolitan 

area thought he only had to review the plan.35 Th e emergency manager for the City of New 

Orleans felt that the law did not provide parish emergency managers with the means to 

enforce the regulations.36

Th e Committee also found that there was no process to vet the plans for consistency and 

practicability. For example, many nursing homes rely on ambulance services to evacuate 

their populations. During a crisis, however, ambulance services may be in use by other 

nursing homes or hospitals. Furthermore, nursing homes and hospitals are not required 

to evacuate.37 Th e facility’s plan could simply be to weather the storm – even if the nursing home is in a fl ood-prone area. In short, nursing homes are only required to have their 

emergency plans on the books, which is a far cry from ensuring that they will actually work 

during a time of crisis.

Th e results were predictable. As Katrina approached, nursing homes found themselves without 

evacuation resources. In some cases, they turned to hospitals to take their patients, even though 

hospitals couldn’t guarantee patient safety. Aiken described the situation aft er nursing-home 

offi cials discovered that their memoranda of understanding (MOUs) with government agencies 

or other entities for transportation or other resources had been overtaken by events:

We get a panic call 24 to 36 hours out. Th ey have exhausted their MOUs. Th ey 

have been told “No” on their level, we don’t have what we said we would have 

for you in terms of buses or ambulances or even helicopters. And they call us ...

We are not saying no. We are saying, “We may go under water. Our patients 

may die. You putting them with us [has] not increased their likeliness or likelihood to survive necessarily.”

We do everything we can to assist them in getting out. If somebody does show 

up, we take them in, which is what we do. Again, it’s a very awkward. It’s very 

frustrating and, quite frankly, very scary, and I will even say a deadly situation.38

Medical Supply and Preparations

Medical institutions also struggled in obtaining adequate supplies, such as fuel. Dr. Aiken 

described Charity Hospital generators as “running on fumes for the fi rst day or two.”39 For 

many hospitals, lack of fuel became the decisive factor, forcing them to shut down and 

evacuate. As there was no statutory or regulatory requirement that generators be located 

above levels exposed to fl ooding, 40 many generators fl ooded. Hospitals lost power abruptly, 

making rapid evacuation essential. Th e LSU computer system was also heavily damaged, 

seriously impairing access to patient records.41
Medical Assistance

405

On the other hand, pre-stocked food and medical supplies at Charity Hospital were adequate to carry the facility through until the National Guard could re-supply.42 Dr. Kevin Stephens, Director of the New Orleans Department of Health, who oversaw medical care for 

special-needs patients at the Superdome, also said that he had “no problems with supplies,” 

although medical oxygen ran low at one point.43

DHH managed to keep supplies fl owing, but only through extraordinary measures. On 

Sunday, August 28, DHH put the Centers for Disease Control (CDC) on notice that it 

might need supplies from the Strategic National Stockpile, which CDC would deliver within 

12 hours of the request. However, when DHH did make the request shortly aft er Katrina 

passed, CDC did not come through promptly, and Guidry was forced to obtain needed supplies elsewhere: “I personally signed for an order of fi ve million dollars’ worth of medical 

equipment from a private vendor because I didn’t know where else to go, who was ready to 

deliver to me when I needed it. And so I did not have the funding for that, but I signed for it 

and got the Governor’s backing to make that happen.”44

Support from Federal Medical Teams

Apart from supplies, the state depended heavily on a steady fl ow of outside medical personnel, including Federal Emergency Management Agency (FEMA) Disaster Medical 

Assistance Teams (DMATs), which are nominally 35-member self-contained emergency 

medical teams, to stay on top of health-care needs.45 DHH opened seven special-needs 

shelters around the state46, and every one of them wanted to have a DMAT with its medical 

personnel and supplies to assist them.47 According to Dr. Guidry, “we couldn’t get enough 

teams here quick enough to meet those demands, so we went for quite some time before we 

got enough teams to meet the demand.”48 A team of U.S. Public Health Service (USPHS) 

offi cers also arrived in Louisiana on Tuesday night, August 30, and USPHS helped staff the 

state’s triage facility at LSU for the duration of the event.49

State and local health offi cials described two occasions when DMATs redeployed from the 

special-needs facility at the Superdome, leaving an increased burden for medical professionals still on site. According to these offi cials, the fi rst instance occurred either late on 

Monday or Tuesday, shortly aft er the special-needs operations were relocated from the 

inner concourse of the Superdome to the neighboring basketball arena. At that point, state 

and local health offi cials stated that two DMAT teams assigned to the facility left , apparently 

concerned about their equipment getting wet.50 It should be noted, however, that according 

to the National Disaster Medical Systems (NDMS) Management Support Team Commander on site, Ronald Martin, the teams did leave the arena fl oor, but that he redeployed the 

DMAT teams to avoid the rising water. He stated that he moved one team to the mezzanine 

area and one team out of the Superdome to the adjacent elevated highway. Martin explained 

that he was concerned about keeping all of his assets within the Superdome if further fl ooding were to occur51. At least one local offi cial was concerned about this change, and it did 

have the practical eff ect of reducing available resources inside the Superdome. According to 

Dr. Stephens, those teams were needed to help relieve his medical staff in their third straight 

day of caring for special needs patients and facing burnout.52

Th e second occasion occurred on Th ursday when all of the DMAT teams at the Superdome 

(as well as city health department and Emergency Medical Services (EMS) personnel) pulled 

out due to security concerns.53 General Gary Jones of the Louisiana National Guard, and 

Incident Commander at the Superdome, claimed that he was surprised by their abrupt departure, leaving behind at least 500 critical-care patients with no provisions for the transition:

Dr. Lupin came up to me and he said, “Sir” – and he was pretty irate – he said, 

“You know, how do you expect me to deal with all of these critical care patients 

here?” And I said, “What are you talking about?” ... And he said, “All the pa-
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406

tients over there on that ramp.” And I said, “Why are you dealing with them?” 

... He said, “FEMA left .” He said, “Th ey left ”; and he said, “Th ey didn’t leave 

any supplies, I don’t have charts, I don’t know what’s wrong with these people, 

I don’t know – they got IVs in their arms, I don’t even know really what’s supposed to happen, what the plan is or anything else.”54

General Jones said he made no secret of his displeasure to FEMA offi cials:

[Th e FEMA team leader] came back and she said we’re back, and this is soand-so, and he’s going to be the lead guy. And I said, “Are you going to stay 

this time?” And they said, “Oh, yeah, we’re going to stay.” And I said, “Well, 

good, because I would hate to have to shoot somebody.” And they laughed and 

they said, “You’re joking.” And I said, “Th ink so?” You know, and I – and I 

was joking. Obviously, I mean, I wasn’t going to shoot anybody. But I kind of 

voiced my displeasure with the fact that they had left me unsupported.55

Hundreds of special-needs patients were cared for at the Superdome and eventually evacuated. In the end, 19 nursing homes evacuated pre-landfall, and leaving 34 to do so aft er the 

hurricane.56 Moreover, a total of 12,000 patients and caregivers were evacuated from hospitals before and aft er Katrina with 25 hospitals evacuating in the fi rst fi ve days post-landfall.57

Many of these patients endured terrible suff ering. Of the 400 patients at Charity Hospital, 

nine died, including some directly as a result of the prolonged evacuation process.58 Dr. 

Stephens described rushing special-needs cases out of the Superdome before they started “to 

decompensate” [lose their vital functions]. He said, “I knew that I had to get people from 

the Dome to somewhere else ... another day or two, [and] these fragile elderly people were 

going to start dropping out on me [dying].”59 Similarly, Dr. Cerise, Secretary of DHH, said 

that many special-needs patients in the Superdome were elderly people who couldn’t take 

care of themselves, and that it was clear some had not received necessary attention when 

they were moved from the Superdome to the neighboring arena.60

Th e severity of these patients’ problems was made even more clear as this investigation developed more information on pre-storm planning and emergency coordination during the 

response. Some of the more troubling information came from the Executive Director of the 

Louisiana Nursing Home Association (LNHA), Joseph Donchess, who has been with the 

LNHA for nearly 20 years. Although the LNHA had an established seat at the state EOC, 

and was initially allowed access to E-Team, the state’s electronic emergency request tracking 

system, these practices were interrupted during the response to Katrina. Donchess said:

It’s my personal opinion that nursing homes and hospitals are just too low of 

a priority and I’m very disappointed in that because here you’re talking about 

the most frail population there is and they’re relying on two non-profi t associations to pretty much get this work done and it was never intended for us to be 

that kind of life saver organizations. ... And that’s what we had to act as during 

this last storm.61

For the fi rst two days, LNHA was on its own to improvise and fi nd ways to 

rescue the elderly in nursing homes. We helped members and nonmembers 

alike. At fi rst, LNHA could submit E-Team missions, but by the fourth day our 

E-Team missions were denied because we were not a governmental agency.62

Once the LNHA was denied access to the E-Team system, Donchess and other LNHA 

personnel sought Dr. Guidry and DHH’s authorization for LNHA’s needs. However, this 

practice also proved ineff ective, as Dr. Guidry “had 100 diff erent things” he had to do him-
Medical Assistance

407

self, so it was still very diffi cult for the LNHA to get its requests approved for the benefi t of 

the many nursing home residents counting on assistance. 63

Another troubling aspect of the state’s emergency-preparedness structure was a gaping hole 

in the state’s planning and coordination as it related to hospitals and nursing homes under 

the State’s Emergency Operations Plan (EOP). Under the State’s EOP, Emergency Support Function 8 (ESF-8, Public Health and Medical Services), responsibilities were divided 

between two state agencies. DHH was responsible for public health, sanitation, medical, 

and health assistance to special-needs shelter operations, mental health, and crisis counseling. Th e LSU Health Sciences Center, which runs the state’s public hospital system, was 

responsible for providing and coordinating hospital care and shelter for nursing-home and 

home-health patients with acute care requirements, as well as casualties of emergencies and 

disasters. LSU also had the lead role in coordinating hospital planning and actions with 

private hospitals and other facilities.64

Unfortunately, the emergency-preparedness and response system laid out in the Louisiana 

EOP did not refl ect reality for nursing homes and hospitals in Louisiana. LSU did not, and 

was not equipped to provide and coordinate hospital care and shelter for nursing-home, 

special-needs, or home-health patients as called for in the plan. Nor did LSU coordinate the 

overall planning and actions of private hospitals during emergencies as it was required to 

do.65 To the extent any agency met these responsibilities, it was DHH, which did so through 

a program to prepare hospitals to respond to bioterrorist attacks. Th is program was funded 

through the U.S. Health Resources and Services Administration (HRSA), an agency of the 

U.S. Department of Health and Human Services (HHS), and was not intended to deal with 

issues such as hurricane preparations.66

However, some aspects of the HRSA program did come into play. For example, under the 

HRSA program, DHH had previously worked with hospitals to establish a hospital emergency 

network to track available hospital beds and communicate information among hospitals 

which was used during Katrina.67 However, while the HRSA program did provide some level 

of preparedness among the hospital community, this safety net for the charges and responsibilities that were supposed to have been shouldered by LSU under the state plan did not fully 

replace the work that LSU was supposed to do either before or during the response to Katrina.

Th e investigation sought to determine why this aspect of the state emergency plan was not followed. For one, LSU simply did not accept its responsibilities under the State’s EOP, though it 

appears to have been understood that these responsibilities existed. As explained by Aiken: 

Oh, I understand the confusion because we are not doing it the way – exactly 

the way – the Emergency Operations Plan. ... Th e way it realistically and the 

way it has operated, not only during Hurricane Katrina but for some of the 

other instances where hurricanes have come very close to us over the last 

couple of years, that LSU actually does not coordinate the overall hospital 

response. Th ey tend to focus – and, obviously, since I don’t sit there, I can’t say 

exactly what they do minute to minute. ... But I have a feeling that people ... 

who sat in that chair [at the state EOC and have] been assigned that responsibility, they tend to focus on LSU hospitals and the HRSA, the people who have 

been employed through the HRSA grant and have traditionally been present 

to help coordinate the overall network, which certainly includes us, but also 

includes all the private hospitals. What you see in the plan is not what actually 

happens. It’s certainly a job deserving of many more people than the plan calls 

for. And, again, these are all comments that I made public during the revision 
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process earlier this year. In my opinion, the plan is not realistic. It should be 

more refl ective of how we really do it, and I certainly hope that changes.68

LSU’s responsibilities under the State’s 2005 EOP were not new. Prior iterations, specifi cally 

the 2001 plan, made LSU’s responsibilities for planning and coordinating hospital care and 

shelter for nursing-home and home-health patients even more explicit.69

As a result of LSU’s failure, there was inadequate attention to emergency planning for 

important components of the health-care system in Louisiana. Dr. Aiken said he was not 

aware of any planning by LSU or other involved agencies at the state level for nursing-home 

and home-health patients under the State’s EOP:

I don’t know of any substantial act of involvement that LSU has on nursinghome and home-health patients, truly across the board on an emergency basis, 

planning, preparation, or the actual response itself. Nursing homes in this state 

have always been a huge concern for us. ... We over the years through the local 

emergency-preparedness committees, through every level of emergency planning that I have been involved with, we have always been concerned over their 

involvement, what they do during storms, that kind of thing. And I am not 

aware of any instance where LSU has had a – again, on Baton Rouge, on a State 

Offi ce of Emergency Preparedness or Emergency Operation Center level – has 

had any real impact or infl uence on [them].70

Dr. Aiken also noted that he was “99 percent sure” that his boss, Don Smithburg, Chief Executive Offi cer of LSU Health Care Services Division (HCSD) and Executive Vice President 

for the LSU system, “didn’t spend much time in providing or coordinating care for nursing home or home health placement, except for those patients that may have arrived at our 

hospital, which they did, the night before at Charity.”71 Smithburg admitted to LSU’s shortcomings, stating that the individual charged with the overall planning and coordination for 

emergency preparedness and management for the Charity and University Hospitals, the 

Chief Operating Offi cer “was weak and not engaged and not communicative with the rest of 

our staff in that responsibility.”72 (Smithburg terminated this employee in February 2005.)73

Furthermore, when asked by Committee staff if LSU had the resources or manpower to 

meet its charges under the State’s EOP, regardless of whether the Chief Operating Offi cer 

for the system was competent in his/her position or not, Smithburg said, “Th ere’s no way.”74

Dr. Aiken spoke of his concerns about the fl aws in the state EOP to superiors in the LSU 

HCSD, to Colonel Jadwin W. “Jay” Mayeaux, Louisiana’s Deputy Director of Homeland Security, and to the State Medical Offi cer, Dr. Guidry.75 But the responsibilities stayed with LSU.76

Despite this notable vacuum in the State’s EOP, Dr. Aiken was reasonably certain that the 

HRSA network acted as a surrogate for LSU in meeting the hospital-related responsibilities 

under ESF-8.77 However, the Committee’s investigation revealed that this safety net did not 

work as well as some would have hoped. Erin Downey, the HRSA Program’s Director of 

Emergency Preparedness at the time, on contract with the DHH, was at the State EOC in 

Baton Rouge for the Katrina response, and had a diff erent view:

So you had emergency preparedness people calling and asking for resources, 

expressing their concerns, calling the command center or ... they would call 

their coordinator, and then their coordinator would call ... When requests 

were coming in to us, ... our marching orders were to put everything in ETeam, okay, because what that was, was a way of facilitating that or standardizing all of the requests, funneling them through one main decision point, and 
Medical Assistance

409

that was the total breakdown. Now, I would love to say something diff erent 

about that, but that was a total breakdown.78

Medical Assistance: Mississippi

Hurricane Katrina devastated the medical infrastructure of south Mississippi, destroying or 

severely damaging 14 of the 16 hospitals in the region’s six counties.79 Th ree hospitals were 

damaged so severely that they were forced to close, including the only acute-care hospital 

in Hancock County.80 One hospital, Select Specialty Hospital in Gulfport, was destroyed in 

the storm.81

Th e storm also damaged or destroyed other medical facilities in the southernmost six counties. More than a third of primary-care clinics were closed or destroyed.82 In addition, the 

damage done to the local physical infrastructure has resulted in longer response time for 

ambulances and a greater reliance on airlift ing patients for care.83 Seventy-three nursing 

homes were aff ected, including 16 in the southernmost six counties; two were destroyed.84

As the lead state agency under the Mississippi Comprehensive Emergency Management 

Plan’s ESF-8 for health and medical services, the Mississippi Department of Health (MDH) 

played the lead state role in response to this catastrophe. Under that plan, MDH is charged 

with providing state assistance to local governments in response to public-health and medical-care needs following a disaster.85 While the MDH does not provide primary care, once 

the Governor declares an emergency, all health and medical considerations fall within the 

purview of MDH.86

Dr. Brian Amy, Mississippi’s State Health Offi cer and the top health offi cial in the state,

explained that although MDH was prepared and had recently increased its capacity to 

respond, it did not have the capacity to deal with disasters of Katrina’s magnitude.87 MDH 

activated its EOC at the MDH central offi ce in Jackson on August 27, two days before 

landfall. Th e department pre-positioned response personnel, such as public-health nurses in 

special-needs shelters throughout South Mississippi and emergency-response coordinators 

in coastal county EOCs. It also worked with representatives from FEMA’s National Disaster 

Medical System and HHS that arrived before landfall to request that additional federal help 

be readied, including DMATs, medical personnel capable of providing medical care following disaster.88 Th ese teams were eventually positioned at every aff ected hospital, treating 

15,500 patients (out of 17,649 reported injuries), in the fi rst days aft er landfall.89

MDH also supports pre-landfall evacuation. In these eff orts, MDH assists in evacuating 

nursing-home, special-needs, and sometimes hospital patients.90 Th ese facilities are generally evacuated well prior to the general evacuation so that ambulances do not have to fi ght 

traffi c congestion.91 MDH also has a “decompression plan,” to assist in discharging patients 

who can safely leave the hospital early.92

MDH regulates nursing homes in Mississippi. Jim Craig, MDH’s incident commander during Katrina, reported that nursing homes asked to evacuate prior to Katrina did so.93

Th is hasn’t always been the case. According to Governor Haley Barbour, one nursing home 

resisted evacuation prior to Hurricane Ivan. In response, Governor Barbour had the director of the state-run, low-income Medicaid program call them:

We had to make one of the nursing homes evacuate, and that’s where Medicaid 

comes in because that is who pays them. And if they get sort of uncertain of 
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410

whether they need to evacuate, I get 

the Director of Medicaid to call them, 

and they get a better attitude.94

Ultimately, MDH responded to Katrina with 

over 1,400 personnel.95 Immediately following landfall, MDH began to assess and 

support local medical facilities. In addition, 

MDH’s state epidemiologist led a team to 

the coast to assess damage to hospitals. Th e 

largest immediate problem was a severe fuel 

shortage. With power out in the area, many 

health-care facilities were forced to rely on 

generators. As a result, MDH offi cials began 

procuring and delivering fuel. Th e other 

major post-landfall challenge was maintaining security at health-care facilities, as they 

generally had power, drawing local residents 

displaced by the storm.96

In addition to federal help, Mississippi 

received considerable help from other states 

under the Emergency Management Assistance Compact (EMAC). Dr. Amy has stated 

that Mississippi “owe[s] a special debt of gratitude to our friends from other state public 

health agencies, particularly Florida, Kentucky, Indiana, Illinois, and North Carolina.” He 

singled out for special praise the Florida Department of Health, which dispatched more 

than 300 personnel to Mississippi, and Kentucky, which sent more than 100 personnel.97

One of the most signifi cant resources deployed to Mississippi under EMAC was Carolina-1. 98 Carolina-1 is a portable hospital unit that includes a surgical suite, x-rays, a laboratory, a 

pharmacy, and 100 beds. 99 According to Craig, when Mississippi fi rst contacted Carolina1, it was bound for Louisiana. Due to legal-liability issues it re-deployed to Mississippi. 100

Ultimately, Carolina-1 deployed to the Bay St. Louis area in Hancock County, where it became the central health-care provider in the county, replacing the Hancock County Medical 

Center devastated by Katrina.101

Mississippi also became the fi rst state to receive, stage, store, and distribute the Strategic 

National Stockpile (SNS) Push Pack. Within 12 hours of Dr. Amy’s offi cial request, the 

CDC delivered eight truckloads of SNS medical supplies for Mississippi medical facilities. 

Supplies continued to fl ow into Mississippi for two weeks until Mississippi’s facilities were 

able to reestablish their regular supply channels.102

Federal Health Response 

Use of the National Disaster Medical System

Th e National Disaster Medical System (NDMS) is the nation’s primary federal response 

capability to meet medical needs in times of disaster when state and local systems are overwhelmed. Part of FEMA’s Response Division, the NDMS has two basic components.103 Th e 

fi rst is a collection of special medical and response teams that are on call to provide medical 

care during national emergencies.104 Th e second component is a partnership of FEMA, the 

Veterans Aff airs (VA), the Defense Department (DOD) and HHS that maintains a network 

Flooded reception area, Hancock 

Medical Center, Mississippi

Provided to Committee
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411

of hospitals and coordination centers throughout the United States to transport and care 

for large numbers of patients in an emergency.105 Th is network was originally established 

to provide medical care within the United States for military casualties, but was used essentially for the fi rst time on a large scale during Katrina to evacuate medical patients from 

New Orleans.106

NDMS teams comprise some 9,000 volunteers.107 Th ese volunteers organize, train, and 

deploy as part of geographically dispersed teams supported by local sponsors. When they 

deploy, the team members become temporary federal employees, which provides them a 

salary, reimbursement for expenses, and liability coverage.108 Th e basic unit of the NDMS is 

the DMAT. NDMS also contains specialty teams which can deliver logistical support, mortuary, veterinary, burn- and crush-injury care, and other services. Ideally, a DMAT consists of 35 health professionals who are deployable within six hours with a well maintained 

supply and equipment cache, and have the capability to treat 250 casualties and sustain 

themselves over a 72-hour period.109 A full DMAT typically has three to four physicians and 

a mix of nurses, pharmacists, paramedics, and physician assistants. Hurricane Katrina led to 

activation of 98 percent of the NDMS teams.110

Notwithstanding this extensive deployment, the NDMS teams were hampered by numerous 

problems. Beall described DMAT medical supply cache shortfalls as a common condition

At last year’s conference in Orlando, I asked every team there, if you have your 

complete federal cache, raise your hand. Not one team raised their hand because we’ve never been able to fi nish out buying the cache. ... We had ordered 

all the stuff to fi nish these teams 100 percent, and as I had been advised, the 

million dollars had been pulled back for some reason. Some people talk about 

[a “tax”] or whatever DHS may have applied [to FEMA’s budget]. I cannot 

testify that was the reason, but know that that order was cut by $1 million, and 

that these teams did not have 100 percent cache when we deployed them for 

Katrina, so we went into a response with a shortfall.111

FEMA was also limited in its ability to make all of the teams fully operational and to expand 

the number of NDMS teams due to lack of resources.112 Of the 52 DMATs, only 25 are considered fully operational.113

NDMS also lacked suffi cient administrative resources to sustain NDMS operations, let alone 

improve them. NDMS was transferred from HHS in 2003 pursuant to the Homeland Security 

Act,114 but some administrative-support positions did not transfer from HHS. Other support 

positions were moved out of NDMS to FEMA’s own logistics section.115 To compound the 

situation, when activated, NDMS routinely sends its administrators to be part of fi eld operations. Beall said, “At the initial launch of Katrina, I was really the only operations person in 

NDMS left in the section, and the other people that were there were operational specialists, 

which I had to send to the fi eld ... I never went home. I slept on the fl oor in my offi ce.”116

NDMS Team Deployment Problems

As described more fully in Chapter 12, on Th ursday, August 25, four days prior to Katrina’s 

landfall, FEMA Response Division Chief Ed Buikema activated the NDMS system and 

began to mobilize and pre-position its medical and mortuary teams. Although FEMA 

understood that states were relying on these resources to help them cope with the expected 

aft ermath of the storm, FEMA had delays in mobilizing, deploying and staging its teams. 

For example, although the NDMS regional representative for Louisiana told NDMS leadership on Saturday, August 27, that Louisiana would need nine DMATs to staff its medical 

triage centers, these teams were not available before landfall.117 FEMA also selected team 

staging areas that were hundreds of miles away from the coastal areas where they ultimately 
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412

expected to be deployed and eff orts by Louisiana to get FEMA to bring them closer were 

apparently unsuccessful.118

Some delays in deployment were the result of the logistics and travel system that FEMA 

uses for NDMS. For example, a DMAT from San Diego was mobilized on Sunday, August 

28, the day before landfall. (Th e team would ultimately be deployed to the New Orleans Airport to assist in the medical evacuation there.) By the time NDMS headquarters approved 

the team roster late on Sunday night, there were no fl ights remaining to transport the team. 

Th e team’s aft er-action report said, “We could have been to Houston [one of the NDMS 

staging areas] half a day earlier, and to Baton Rouge a day earlier” if there had been a more 

effi cient travel-approval process.119 NDMS also relies on team supply trucks to transport 

medical supplies. In this case, the San Diego team’s medical-supply trucks were to drive all 

the way from San Diego to Louisiana.120 Finally, because team drivers are also “essential key 

team members,” the San Diego team found itself short “six more team members, when we 

became engaged at the airport.”121

Inadequate DMAT Team Support

By all accounts, NDMS teams delivered excellent care given the constraints of the environment in which they were working and living.122 NDMS team members worked tirelessly 

and heroically in diffi cult and sometimes desperate conditions. Th ree NDMS DMATs were 

also deployed on August 30 to the New Orleans airport to support the medical evacuation 

eff ort being established there.123 Th e DMATs provided care to more than 4,000 patients in 

what would become one of the largest contemporary mass-casualty triage and evacuations 

in the United States.124 For the fi rst two-and-a-half days, the three DMATs provided care to 

patients without relief in what one NDMS doctor called the “hospital from Hell.”125

Th e NDMS teams could not operate without rest. It is unclear why more medical teams 

did not arrive at the airport until Friday, September 2, when the NDMS log indicates the 

presence of two additional DMATs, MA-2 and FL-3.126 Th eir help was still desperately 

needed, but additional medical support should have deployed sooner. As described by the 

commander of a logistical support team sponsored by the U.S. Forest Service – an Incident Management Team (IMT) – that arrived at the airport on September 1, the situation 

demanded more medical and support assets, and sooner:

Upon arrival at the Louis Armstrong New Orleans International Airport on 

September 1, the scene the IMT encountered could best be described as surreal. DMAT’s had hundreds of patients scattered about the main terminal and 

ticketing area. Over 300 of these were confi ned to stretchers. Most were elderly 

and infi rmed, but many had encountered injuries due to the accidents related 

to the hurricane. Medical personnel were stretched to the breaking point.127

Th e shortage of personnel also meant it was more diffi cult to provide adequate triage. Th e 

NDMS teams operated from the perspective that the best care was simply to put patients 

on planes and get them out of the facility. DOD and private-sector planes were used to 

transport patients to hospitals wherever possible.128 When asked how patients were tracked, 

Captain Art French, one of the NDMS doctors who tried to manage the DMATs at the 

airport, replied, “We wrote down their names, where they were going, and with whom on a 

piece of paper. Th ose pieces of paper I hope are still there.”129 In between was an “expectant 

area” where failing patients were provided comfort care. In the end, 26 patients died at the 

airport, mostly in this area. Capt. French said that despite conditions at the airport the care 

of these patients was fully adequate and that these patients would have probably died in any 

medical setting.130
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413

Although DMATs are supposed to deploy 

with management support from Management 

Support Teams (MSTs), no organized MST 

deployed to the airport.131 Instead, an ad-hoc 

MST was created from NDMS personnel 

on-site. In fact, neither of the two men who 

would eventually co-direct the NDMS medical operations of the New Orleans Airport 

was formally assigned that duty.132 Th ey had 

traveled on their own to the airport to help 

out when their other assignments were canceled. When they arrived Wednesday, they 

were confronted with three medical teams, 

CA-4, TX-4, and WA-1, without any management support, facing growing numbers 

of patients, and increasingly diffi cult conditions, so they assumed leadership roles.133

Th is ad-hoc management team did its best to 

manage the situation, but had no ability to 

communicate even with NDMS leadership in 

Baton Rouge.134 When asked why he thought 

an MST was not deployed to the airport given 

the diffi culty and complexity of the mission, 

Capt. French observed that there were no 

MST staff left to send.135

Th e lack of experienced MST members led to 

other problems. At one point, Beall e-mailed 

that his fi eld operators were not supporting 

the DMATs suffi ciently: “I need a plan put 

together on how the teams will be supported. 

Many of the leaders in the fi eld are not well 

versed on NDMS fi eld ops.”136 Th e response: 

“Th en they shouldn’t be leaders, nor should 

they be in the fi eld without supervision.”137

One team complained, “We all know what 

disasters are, we would not be here if we did 

not want to help. But when the situation is 

compounded by mismanagement it makes our jobs much more diffi cult to do. We have 

asked for items and heard nothing as to the status of the request.”138

Many teams had diffi culty communicating. Th e DMATs at the Superdome had satellite phones, but had diffi culty utilizing them because they were initially not programmed 

properly and the truck-mounted units would not work inside the building.139 Th e NDMS 

MST commander on-scene deployed with only his personal cell phone.140 Management was 

aware of the problem, but seemed unable to resolve it. On September 1, Beall complained, 

“Communication has been the worst I have seen.”141 Eight days aft er Katrina’s landfall, he 

was still desperately trying to obtain communications capability. He e-mailed, “Where are 

the sat[ellite] phones for the NDMS teams? Teams do not have communications.”142

Beall attributes some of these problems to the way in which DHS absorbed NDMS from 

HHS. Th e NDMS logistics personnel were transferred to the FEMA logistics branch rather 

than remaining with their agency. Beall remarked, “So all the logistic shortfalls and all the 

Medical evacuation

U.S. Air Force photo
Chapter 24

414

things that we’re starting to see in the aft er action, it’s because the person working the logistics side of the house did not have any background in NDMS. ... we need a lot of supplies, 

and what I don’t need is somebody to tell me, `Why do you need this, why are you asking 

for that?’ I don’t need someone to slow up that request, and that’s what you’ll see”14

NDMS Patient Movement

On the night of Tuesday, August 30, federal emergency managers authorized the medical evacuation of hospital and other acute-care patients from New Orleans.144 Th is was the 

fi rst time a full-scale operation using the NDMS patient-movement capability had ever 

been initiated. 145 Th e plan called for DMATs to establish a triage center at the New Orleans 

airport and to utilize assigned Air Force aircraft to move the patients to hospitals around 

the country.146 As described above and in the aft er-action reports of the agencies that participated, more than 4,000 patients were evacuated through the airport although less than 

half (approximately 1,800) were actually placed on Air Force aircraft .147 Th e remainder were 

placed on National Guard and private aircraft . Th e distinction is important because only 

those patients who were placed on the Air Force aircraft were logged into the NDMS patient 

movement-tracking system. Th e tracking system was not accessible for all patients and as a 

result, there was no systematic way of knowing what had become of everyone.148

As noted above, medical teams on site were overwhelmed by the volume of patients. Th ere 

was essentially no overall command structure governing the medical evacuation, especially 

during the fi rst three or four critical days.149 Operations at the airport were also plagued by a 

lack of eff ective management of the airport complex and the simultaneous civilian evacuation, a shortage of security, and a lack of logistical support. Although a U.S. Forest Servicesponsored Incident Management Team arrived at the airport on Th ursday, September 1, 

and began to provide badly needed logistical support to the NDMS teams and other federal 

personnel, their deployment to the airport was essentially accidental.150 While the evacuation was a success in that it succeeded in moving thousands of patients, and the NDMS 

network operated largely as intended, it clearly did not work as well as it should have. 

Medical Surge

HHS is the coordinating federal agency for federal public-health and medical-assistance 

activities under the National Response Plan (NRP) (ESF-8, Public Health and Medical Services).151 Within HHS, the Offi ce of Public Health and Emergency Preparedness (OPHEP) 

leads the Department’s preparedness and response activities and is tasked with coordinating activities within HHS and with other federal agencies. During Hurricane Katrina, one 

of OPHEP’s primary responsibilities was to meet medical-surge needs, which involved 

increasing capacity to provide medical care by providing more healthcare personnel, more 

health-care facilities, and more health-care supplies across the aff ected region.

Personnel

HHS drew from four primary sources to meet emergency health-personnel needs. First, 

the U.S. Public Health Service (USPHS) is the principal personnel surge resource for HHS. 

Th ere were approximately 6,000 offi cers in the USPHS under the command of the U.S. 

Surgeon General in 800 locations around the country at the time of Hurricane Katrina.152

In the immediate aft ermath of Katrina, from August 30–September 16, HHS deployed 

2,132 USPHS offi cers. Second, the Medical Reserve Corps (MRC), comprising 62,000 local 

volunteer healthcare workers in state-sponsored teams across the country, deployed approximately 6,900 volunteers during Katrina.153 Th e third source of federal health personnel 

was a federal volunteer database created in the immediate aft ermath of Katrina that had 

approximately 34,000 volunteers. Of this total, only 1,400 eventually deployed. 154 Th e fourth 

source was turning to other federal agencies such as the Department of Defense (DOD) or 

Veterans Aff airs for assistance.
415

U.S. Public Health Service

Under the Public Health Service Act, the Secretary of HHS has broad authority to mobilize 

and direct the USPHS in times of a public health emergency. USPHS offi cers work in many 

parts of the federal government around the country.155 Th ey include physicians, nurses, 

pharmacists, engineers, environmental health offi cers, dentists, mental-health providers, 

scientists, therapists, epidemiologists, and other public-health professionals.156 Th ey are a 

uniformed service, and can be directed to leave their normal jobs to deploy under the direction of the Secretary of HHS in an emergency.

As described more fully in Chapter 12, the HHS Offi ce of Force Readiness and Deployment 

(OFRD), which is responsible for overseeing USPHS offi cers deployed in an emergency, 

began identifying personnel for deployment (known as “rostering”) well before landfall, 

starting August 25. HHS’s original goal was to create a 100-person team to deploy to the 

area prior to landfall.157 However, only 37 offi cers arrived – in Jackson, Mississippi, mere 

hours before landfall, late Sunday night. Th ey were far from their original destination of the 

Superdome in New Orleans. 

Once in Jackson, the team had limited capability. USPHS offi cers are not issued medical 

equipment or supplies nor are there pre-arranged teams or equipment caches.158 Th ese offi cers did not have any capacity to provide care by themselves without additional logistical 

support, especially to support special-needs patients such as individuals with heart conditions, diabetes, or oxygen requirements. Th e team remained in Jackson, Mississippi, until 

Tuesday due to high winds, lack of electricity, and lack of communications.159 When they 

were fi nally able to leave, they traveled to Baton Rouge to staff the state-run medical triage 

center at the athletic center of LSU.160

Th ere are several reasons why HHS, with 6,000 USPHS offi cers theoretically available, could 

not send a complete team to the aff ected parts prior to landfall. Each time a USPHS team is 

needed, it is formed ad-hoc: offi cers are not assigned to pre-existing teams, so teams must 

be assembled from lists of available offi cers matching both needed skills and the numbers of 

offi cers. Th ey must then fl y in from multiple locations using commercial transport. Because 

the 100 team members originally identifi ed to deploy were spread across the country, there 

was no practical way to move them into New Orleans at the last moment.161

In addition to these early eff orts, on Monday, August 29, rostering continued in an eff ort 

to identify USPHS offi cers to deploy to the New Orleans area.162 According to Rear Admiral John Babb, the USPHS offi cer who heads OFRD, teams were identifi ed for deployment 

by Tuesday, August 30, but mission assignments were not made.163 For instance, many of 

the offi cers were slated to staff mobile fi eld hospitals, known as Federal Medical Shelters or 

FMSs. During the course of that week, Admiral Babb fulfi lled staffi ng requests for ten 250-

bed FMS units,164 but the units were not ready. Consequently, there was initially no place 

to send the teams.165 Furthermore, once placed on a team roster, USPHS offi cers were then 

sent to a travel contractor to arrange commercial travel.166 However, the travel contractors 

did not deploy the teams as OFRD had them structured due to commercial fl ight limitations 

and disruptions.167 Admiral Babb said deployment of the USPHS teams “would have been 

much more successful had we had geographically connected teams so that we could have 

deployed people from a given location instead of from all over the place.”168 Th e reliance on 

an outside travel contractor without the capacity to deploy and rotate approximately 3,000 

personnel from around the country did not result in a uniform and predictable deployment 

process and adversely impacted HHS’s response.

As a result of these factors, and despite its eff orts to begin to roster personnel before landfall, no signifi cant USPHS deployments, other than the initial team of 37, occurred until the 

end of the fi rst week following Katrina.169

Medical Assistance
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416

USPHS deployment diffi culties also relate to a number of organizational factors. USPHS 

teams do not have their own medical and support supplies, pharmaceuticals, food, housing, and other logistical capabilities that allow them to be self-sustaining.170 Admiral Babb 

specifi cally cited a lack of medical and supply resources as contributing to deployment 

delays.171 USPHS also relies upon commercial travel services. Robert Lavender, Deputy 

Director of Information Technology and Communications within OPHEP, cited problems 

with closed airports, ground-transportation problems, and lack of hotels and other housing options as impeding deployment.172 In essence, HHS personnel depend on the local 

economy, infrastructure, and commercial transportation for deployment and ongoing support – a requirement that could not be easily met in the wake of a catastrophic hurricane or 

likely in other emergency situations. Deployment logistics were further strained by the fact 

that USPHS offi cers were rotated out of the fi eld every two weeks, signifi cantly adding to the 

logistical workload.173

USPHS deployments were also compromised by the daily professional commitments of 

USPHS offi cers.174 Many USPHS offi cers were also federal employees playing essential roles 

in their agencies, such as the Indian Health Service and the Bureau of Prisons, making them 

unavailable for deployment. USPHS offi cers were also supposed to notify the Medical Affairs Branch in the USPHS about any changes in their deployment availability.175 However, 

status updates did not systematically occur. 176 Numerous e-mails were sent to OFRD from 

USPHS offi cers stating that they could not leave their agencies because of employment obligations or other reasons such as illnesses or pregnancies.177 In other cases, USPHS personnel 

were members of other emergency teams, such as the NDMS teams managed by FEMA. If 

they had already deployed as part of those teams, they were no longer available to deploy as 

part of USPHS.178

Hurricane Katrina was not the fi rst time these problems with USPHS deployment have been 

identifi ed. An aft er-action report published by the CNA Corporation, a non-profi t research 

fi rm, following Hurricanes Frances and Ivan, documented many of the same issues.179 A key 

criticism in the CNA report was that USPHS rotational rosters were not “ready-go” personnel 

assets, which means they did not have supplies and equipment to provide clinical services.180

Again, this continued to be a problem for deployments pre-landfall and aft erwards for Hurricane Katrina. CNA also cited limited travel and logistics support for offi cers as problematic.181 Travel-logistics problems continued into Hurricane Katrina, as OPHEP relied again on 

an outside contractor with insuffi cient capacity to eff ectively deploy a signifi cant number of 

people. OFRD also had no mechanism in place for tracking the movement and placement of 

USPHS personnel in the fi eld at the time of Hurricanes Frances and Ivan,182 and again did not 

have the capacity to do so during Katrina. As a result, Admiral Babb stated that OFRD “didn’t 

have visibility necessarily about where people were. Were they still at home? Were they in 

fl ight status? Were they there and gainfully employed?”183 Problems with the USPHS team 

identifi cation and notifi cation process were not resolved for the 2005 hurricane season despite 

the diffi culties during the Frances and Ivan deployments. Th e prior year’s diffi culties were 

compounded, because Katrina required signifi cantly more personnel than Frances and Ivan.184

It is clear that the USPHS, in its current form, cannot respond to public-health and medical 

emergencies quickly. When the local economy, and physical and health infrastructure are 

compromised, the USPHS deployment process is crippled because they require supplies, facilities, and transportation to be individually arranged for each USPHS offi cer and/or team. 

All of these issues raise questions as to what the USPHS’s emergency-deployment capabilities truly are, what should be expected of it, and what its future role should be.

If USPHS is truly going to be a fi rst responder for medical emergencies, signifi cant changes 

must be made. As Assistant Secretary Stewart Simonson said, “I think it’s clear that one of 
Medical Assistance

417

the things we need is a quick-response force within the Public Health Service and the ability 

to move people pre-identifi ed into emergencies in a much faster way than we can now.”185

Credentialing and the Medical Volunteers

Any signifi cant medical or public health response will require that health-care personnel 

move across localities and states to assist in meeting personnel surge needs, as illustrated by 

Hurricane Katrina. Th e Public Health Service and Bioterrorism Preparedness and Response 

Act of 2002 (P.L. 107-188) mandated a national credentialing system for all health professionals to ensure that health-personnel surge needs are quickly and effi ciently met.186 In 

response, HRSA187 created the Emergency System for Advance Registration of Volunteer 

Health Professionals (ESAR-VHP) to provide a credentialing system to move health professionals within and across states in the event of an emergency. Each state individually joins 

the ESAR-VHP system in order to provide advance registration of their volunteer health 

professionals. At the time of Hurricane Katrina, only 12 states were part of the credentialing 

system. 188 Credentialing criteria for health-care workers were not standardized across states. 189 And even for those 12 states, HHS had no oversight of the states’ credentialing systems in 

order to determine which volunteers might be available or whether volunteers were registered in multiple systems.190

In the immediate aft ermath of Katrina, HHS began receiving numerous calls from health 

professionals wanting to volunteer their time and services to the aff ected region. In response, 

HHS created an entirely new federal volunteer-signup website.191 For lack of a national 

credentialing system, HHS decided to rely on a private contractor to individually verify the 

credentials of the 34,000 individuals who volunteered in the weeks aft er Katrina.192

Th e volunteering and deploying process was time- and resource-consuming at best. Aft er 

registering on the website, volunteers were contacted by the private contractor to verify 

their credentials. Volunteers were sent to the HHS Human Resources Offi ce to be hired as 

temporary employees, then to OPHEP for deployment. Credentialing became a signifi cant 

bottleneck in the process, and there seemed to be no consistent plan as the weeks went on.193

Numerous documents indicate credentialing delays by the private contractor, who was hired 

and started work only aft er landfall.194 Because diff erent organizations were handling credentialing, hiring, and deployment, HHS had limited information on volunteers in the system 

and where they were being deployed.195 Th e volunteers also posed a host of diffi culties for 

the HHS logistics department because volunteers were not familiar with travel regulations, 

procedures, and reimbursement protocols, among other issues.196 Creating this massive 

federal volunteer eff ort during the crisis took a signifi cant amount of eff ort and resources at 

the federal and the local level and impaired HHS’s ability to function as effi ciently as possible. 

Once created, the new volunteer system experienced many problems. Numerous documents 

indicate constant additions and changes to the website,197 underscoring the unplanned nature 

of this project in the midst of a signifi cant national catastrophe. Th is was also singularly a 

federal eff ort. Staff to the Secretary of HHS made clear in an e-mail to those administering the 

database that there was a lack of coordination with states around volunteer recruitment.198

States felt that the HHS volunteer-recruitment eff ort confl icted with their own eff orts to recruit and organize volunteers, who they would dispatch themselves, and the HRSA-sponsored 

credentialing programs they had been encouraged to establish.199 It also failed to directly 

include state emergency-management agencies which were trying to fi ll requests for medical 

assistance from the Gulf Coast to ensure the eff orts were coordinated and not duplicative.200

Eventually, approximately 1,400 out of 34,000 volunteers in HHS’s volunteer system actually deployed, or only 3.5 percent of those that signed up on the volunteer website. Th e costs 

of HHS’s constructing and maintaining this database, and of contracting with a private credentialing entity, are not known. In the end, it was unable to effi ciently process volunteers. 
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Th e federal volunteer-deployment eff ort was a haphazard attempt to respond to undoubtedly well-intentioned people off ering help in the immediate aft ermath of Katrina. While it is 

human nature to want to volunteer and assist in the face of a major disaster, the signifi cant 

eff ort made to attempt to accommodate individual volunteers may not have been the best 

use of resources.201

To date, HHS has failed to meet its statutory mandate to create a national credentialing 

system to allow health professionals to work across localities and states to meet healthcare personnel surge needs. Had a national credentialing system been in place for Katrina, 

volunteer health professionals would likely have been utilized more quickly and eff ectively, 

obviating the need to create an entirely new federal volunteer database and deployment effort in the midst of a national crisis.

Facilities 

Katrina devastated much of the medical infrastructure in Louisiana and Mississippi, leaving some 2,500 hospital patients in New Orleans alone in need of relocation. Th ousands of 

elderly nursing-home and assisted-living patients, and others with chronic medical conditions, such as heart disease, diabetes, and mental illness, required medical care. However, 

surviving local capacity to meet their needs was limited. Anticipating these medical needs, 

HHS launched a major eff ort to deploy mobile hospitals units even though the concept was 

still in development and HHS’s capability was very limited.

Federal Medical Shelters (FMS)

OPHEP’s Offi ce of Mass Casualty Planning had started to develop a Federal Medical Shelter 

(FMS) capability to establish fi eld hospitals for a mass-casualty event. HHS hoped to expand 

its response capability and avoid relying on DOD medical units, which historically can take 

some time to deploy.202 Th e FMSs would act as all-hazards medical facilities with the capacity to treat patients with basic medical needs. An FMS unit would include hospital cots and 

medical supplies. Healthcare personnel would also be needed to staff the unit. However, 

at the time of Hurricane Katrina, the FMSs were still under development and not ready 

for fi eld units to be established.203 Assistant Secretary Simonson said, “Th ey were not an 

operational asset, really. Th ey were still at a concept asset.”204 Assistant Secretary Simonson 

nonetheless ordered HHS to supply and staff mobile units.205

Supply Procurement for FMS 

Th e Strategic National Stockpile (SNS) at the Centers for Disease Control and Prevention 

played a key role in acquiring supplies to staff the mobile FMS units. Assistant Secretary 

Simonson tasked the stockpile program with procuring a total of 10,000 hospital beds’ worth 

of equipment and supplies for the FMSs and asked HHS staff “to lean forward and be very 

aggressive” in making the acquisitions.206 He sent an e-mail on Wednesday, August 31, to his 

staff and to the CDC Director that HHS needed “to get the fi rst 2,500 beds for the Federal 

medical shelters staged by midnight on Friday. ... I must tell you there is no margin for error. 

I implore you – please go all out on this.”207 Th e entire FMS program was only at the conceptual stage: HHS had two of their own FMS units they were developing with a capacity of approximately 500 beds, with a “fairly modest pharmaceutical cache,” and with approximately 

three days’ worth of material support for non-acute patients for their mobile units.208

Procuring the FMS units was the “fi rst foray into a broader all-hazards support function”209

for the stockpile program and it placed an enormous burden on it. So signifi cant was the 

impact, that on Saturday, September 3, less than a week into the event, Assistant Secretary 

Simonson himself e-mailed the director of the offi ce overseeing the SNS and the Acting Director of the SNS, and asked them to place less eff ort on FMS acquisition and refocus their 

eff orts on medical resupply for Mississippi.210 At the time, Mississippi was experiencing 
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great diffi culty in getting needed medical supplies, and as explained below, required HHS 

to ship them a 50-ton emergency Push Pack to tide the state over until other supplies could 

reach them.

FMS Location

Deployment of the FMS units was further hampered by a lack of coordination with states 

on where or how the mobile units should be placed to maximize their utility; negotiations 

initially only occurred with DOD in advance of any state requests for the facilities.211 An email stated, “HHS is completing the delivery of the 1st Wave – 2,500 beds etc. Now working 

the 2nd Wave of 2,500 and early working of the 3rd Wave of 5,000 (total 10K beds). However, this has – for the most part – [been] accomplished without feedback from the States.”212

To its credit, OPHEP attempted to anticipate health needs and worked with HHS partners 

to develop estimates of personnel required to operate FMSs, but they did not have adequate 

intelligence from states, FEMA, or their own personnel to generate concrete estimates of the 

need for the 10,000 beds or the locations at which to deploy them. As late as September 2, 

days aft er procurement for additional beds had been aggressively undertaken by the SNS,213

OPHEP was still trying to develop relationships with the DOD medical facilities at which 

they hoped to place the units214 and some locations proved impractical. At Eglin Air Force 

Base in Florida and Ft. Polk, Louisiana, FMSs were deployed but never used, requiring these 

units to be redeployed. In short, initial placement decisions were not made in consultation 

with state emergency managers or with adequate situational awareness of medical needs, so 

resources had to be redirected and reprioritized.215

Blu-Med and USNS Comfort

HHS spent a considerable eff ort acquiring the use of two Blu-Med hospital surge units 

– mobile medical facilities – one from Nevada and one from North Carolina. Th ese are 

commercially available medical units manufactured by Blu-Med Response Systems in Kirkland, Washington. Like the FMS units, they were a means to increase medical-facility surge 

capacity. Deployment of these units became the subject of protracted negotiations among 

sponsors, host states, and emergency managers.

In the end, the Nevada unit was the subject of confl ict about need between NDMS and 

HHS. NDMS argued it was not needed, while HHS wanted it deployed. By the time the 

Nevada unit was to fi nally arrive at the New Orleans airport, NDMS concluded that there 

was no need for it, saying, that “Stu Simonson did not want to turn off Blu-Med, saying that 

PHS staff would staff it if needed.”216 Confi rming NDMS’s assessment, the Blu-Med hospital 

unit shipped from Nevada to the New Orleans airport was never used there. It was shipped 

several days later to Gulfport, Mississippi217, but took an extended period of time to set 

up.218 Th e Carolina unit was shipped directly to Mississippi, where it was used extensively,219

suggesting that the deployment of the units was a mixed success.

Th e hospital ship USNS Comfort was another asset made available to meet medical surge 

needs aft er Katrina. It is a DOD asset with a signifi cant hospital-bed capacity and its own 

personnel and supplies. However, it is not quickly deployable. On September 2, Assistant 

Secretary Simonson sent a letter to Assistant Secretary of Defense for Homeland Security 

Paul McHale requesting that the Comfort be deployed with personnel and supplies to treat 

1,000 patients;220 however, it did not arrive at its location in Pascagoula, MS, until Friday, 

September 9. By that time, an e-mail within the Secretary’s offi ce reported, “Nobody could 

think of a mission for [the Comfort]. State Health Department was clear that they had nothing at this time.”221 Th e Comfort was eventually redeployed to Louisiana. Th e FMS and BluMed units and the Comfort took a signifi cant amount of time to deploy and, in some cases, 

became available only aft er the greatest need for medical care had passed. 
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Medical Supply Capacity

One of the major challenges in preparing for and responding to medical emergencies is 

acquiring and delivering medical supplies, including pharmaceuticals, to address a broad 

range of health conditions and threats. During Katrina, medical supplies were needed for 

a range of situations: (1) hospitals and other health care facilities cut off from their normal sources of supply by the storm, (2) large evacuee populations, (3) medical responders, 

including medical teams from HHS and other agencies, and (4) unique medical problems 

caused by the storm, such as the need for tetanus vaccines. Despite its role as the coordinator of ESF-8, HHS has limited medical assets.222 During the event, HHS relied primarily 

on the CDC, as an HHS operating division, to provide medical supplies, equipment, and 

pharmaceuticals through their SNS division.

Supplying HHS Personnel and HHS Assets

USPHS offi cers are not normally issued basic supplies or equipment. Consequently, during 

Katrina HHS had to procure supplies to equip its personnel. For instance, the OPHEP logistics offi cial reported purchasing 1,200 “primary medical bags.”223 Budgetary considerations 

were the primary reasons why purchases such as these were not made previously, though 

concerns about shelf life of products and logistics considerations were also factors.224

Strategic National Stockpile 

HHS maintains a stockpile of medicine and medical supplies for use in public health emergencies through its SNS program. Th ese materials are supplied from both regional government warehouses and from vendor-managed inventories (VMI), which are private medical-supply companies that fi ll orders as needed during emergencies. However, the primary 

assets in the SNS are “Push Packs.” Th ese pre-packaged units contain about 50 tons of pharmaceutical and medical supplies, and are intended to arrive anywhere in the United States 

within 12 hours of a deployment decision. States are expected to formally request supplies 

from the SNS and are periodically evaluated by CDC on their ability to accept and distribute 

supplies from the stockpile. Once a state’s request is approved by HHS, SNS dispatches the 

Push Pack with a security escort and a special assistance team to help state and local health 

agencies receive and distribute the supplies. If an emergency requires additional or diff erent 

medical supplies, the SNS turns to their private vendors, who are expected to ship supplies 

to arrive within 24 to 36 hours of a request.225

Supply Requests

Normal procedures for deploying SNS supplies were overtaken by events from the outset. 

On Sunday, August 28, the day before landfall, Assistant Secretary Simonson directed SNS 

to dispatch a select set of medical supplies to the Superdome.226 Although these supplies were 

shipped on Sunday, they did not reach Louisiana until Monday, when they were turned over 

to the state.227 While the vast majority of medical supplies provided by HHS came from vendors, the State of Mississippi formally requested deployment of a Push Pack because no other 

supply requests were being fi lled quickly.228 Although a Push Pack can be delivered quickly, it 

is not the fi rst choice when general medical supplies and pharmaceuticals to treat chronic conditions are requested, because its contents are tailored to terrorist attacks and other medical 

countermeasures. When Mississippi’s Push Pack arrived, HHS had to separate general medical supplies and pharmaceuticals out of the 50-ton shipment.229 A Push Pack request from 

Louisiana was apparently discussed, but there was no formal request for deployment.230

Mississippi’s letter requesting a Push Pack was sent to HHS on Th ursday, September 1.231

However, there was uncertainty and tension between HHS headquarters and CDC as to 

who was responsible for authorizing its release.232 OPHEP noted that it had no direct control over assets provided by the SNS.233 An SNS offi cial stated, “I think, probably this is one 

of the areas where we’ve not really practiced around the optimal way to go through com-
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mand and control around a protracted natural disaster. ... I think that there could be value 

in formalizing some of the processes around release of the stockpile.”234 Th e movement of 

requests and approvals through multiple channels created confusion at senior OPHEP and 

CDC levels, though there is no evidence that this confusion delayed deployment. 

Medical Supply Problems

Th e SNS was never designed to serve as sustained operation delivering medical supplies 

directly to health-care providers. Informal reports from USPHS offi cers deployed to the LSU 

triage center stated that the medical-supply packages sent by SNS did not arrive labeled and 

lacked basic items, such as bandages and alcohol.235 Generally, SNS supplies were tailored for 

use by an acute-care facility for people with life-threatening injuries or illnesses. However, 

many of the patients passing through the triage center suff ered from long-term, chronic 

diseases such as diabetes. As a result, the triage center ran out of key pharmaceuticals needed 

for chronic care within one day of initiating operations.236 Th ere was no organized method for 

resupply and USPHS offi cers reported calling multiple sources – the HHS Secretary’s Operations Center (SOC), the SNS, and private vendors – to try to meet resupply needs.237

Th e USPHS offi cers reported that most of the medical problems encountered were acute 

exacerbation of chronic diseases, such as hypertension, diabetes, congestive heart failure, and 

psychiatric conditions,238 which usually require daily medications. Th ey also reported numerous patients in need of kidney dialysis and of oxygen, both of which were in short supply.239

However, the SNS has historically focused on bioterrorist attacks and not routine health 

problems, even in large evacuations such as that which occurred in Katrina.240 Th us, they did 

not anticipate and were not prepared to meet the medical needs of a general population that 

had been displaced by a disaster, despite the key preparedness role HHS plays under the NRP. 

As one HHS headquarters offi cial stated, “I don’t believe the Stockpile is as comprehensive 

as everyone believes it is.”241 Katrina highlighted the need for broader medical preparation 

and planning that includes chronic-disease groups,244 as states and localities turned to the 

federal government to fi ll gaps in its medical-supply chains. Th e SNS was also not designed 

to be an on-going medical supply operation. 242 However, the CDC acknowledges that there 

must be a national capacity to tailor medical-supply delivery for diff erent types of disasters 

when normal chains of delivery are disrupted.243 Katrina has highlighted the need to ensure 

a national capacity to move supplies and pharmaceuticals to areas in need when local health 

infrastructure is compromised. 

Conclusions

According to HHS, between August 30 and September 16, the SNS acquired or distributed 

some $38 million worth of medical supplies, including 14 FMS units accounting for some 

3,500 patient beds, 440,000 doses of various vaccines valued at $9 million, and hundreds of 

thousands of doses of antibiotics and maintenance medications for chronic diseases such as 

diabetes, heart disease, high blood pressure, and other conditions.245 HHS adapted the SNS 

system, which was not designed or prepared to provide basic medical supplies and pharmaceuticals, to become a de facto medical-supply chain for a devastated region. However, 

the ad-hoc system created in the wake of Katrina is not geared to handle a broad range of 

emergency health needs, especially ones related to the day-to-day health problems of the 

U.S. population. One HHS offi cial summarized it best when he stated, “From a medical supply standpoint, we were ill prepared. We didn’t have and we don’t have today, the assets, the 

medical assets, to support this kind of an incident.”246

Emergency Support Function 8: Coordination Issues

Th e NRP designates the HHS as the coordinator and primary response agency for ESF-8, Public Health and Medical Services. ESF-8 provides both public-health and medical-care support 
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ranging from deployment of medical-care personnel, to the provision of medical equipment 

and supplies, to patient evacuation.247 In this role, HHS theoretically becomes the lead agency 

for federal medical response in a federally declared emergency, working with and coordinating the deployment of assets from other federal agencies.248 Within HHS, this function is carried out primarily by the Assistant Secretary for Public Health Emergency Preparedness.249

Confl icts with FEMA and NDMS

During Katrina, HHS had mixed success in carrying out its role as the lead agency for ESF8. Some agencies, notably DOD, appear to have accepted HHS as the ESF-8 lead. Others, 

notably FEMA, did not. Although an eff ort was made to establish a unifi ed incident command for ESF-8 at the agency-headquarters level to resolve confl icts and improve coordination, this did not occur until September 5, a week aft er landfall.250 It is unclear whether 

establishing such a structure would have substantially aided the initial response eff orts or 

fully resolved ESF-8 coordination issues, but it is clear that there were interagency-coordination problems during the event. Th ese occurred principally between HHS and FEMA, 

and ranged from a failure to share basic operational information, to more complex tasks 

such as making asset-deployment decisions.

NDMS teams were staged and deployed with minimal, if any, coordination with HHS. 

When asked about coordination between FEMA and HHS in the deployment and prestaging of NDMS teams and his eff orts to get a DMAT to the Superdome before landfall, 

Assistant Secretary Simonson explained that even though he was able to convince the acting 

head of FEMA’s Response Division, Ed Buikema, to send a DMAT to the Superdome, this 

was the exception, not the rule:

Now I should say, contrary to what has been reported in other places, the 

NDMS was not overly concerned with our views on where particular assets should go. And so it’s not clear to me that we have – we had then much 

say in where they would go. I think the Superdome situation revealed to Ed 

[Buikema] how weak the pre-deployment was and I think it was very diffi cult 

for them to resist that it was a logical deployment at that point. But that was 

between me and Ed. Th at wasn’t part of a structure.251

Another example of this deployment issue is documented in an e-mail exchange between 

Simonson and Beall, the NDMS chief, on Saturday, September 3. At the time, eff orts were 

still under way to evacuate the Superdome and the Convention Center. Th e medical teams 

handling the medical evacuation at the airport were being overwhelmed. Beall and Simonson exchanged a series of e-mails about replacing DMATs providing medical care at 

evacuation centers in Texas. 252 Beall later reported that there were fi ve NDMS teams in 

Texas.253 Th is exchange raises questions such as why these capable NDMS teams were staff -

ing evacuee centers when there was a critical need for them in New Orleans, and how these 

deployment decisions were made.

 ESF-8 also included oversight of mortuary aff airs and deployment of the NDMS Disaster 

Mortuary Operational Response Teams (DMORT).254 Operational insight by ESF-8 was no 

better in deployment of these teams. When asked about HHS’s participation in a plan for 

addressing the large number of expected fatalities in the Gulf, the Deputy Assistant Secretary at HHS charged with this responsibility said:

It didn’t come for approval. FEMA runs its own operations so they didn’t ask 

if we approve or not. But, as I said, we had a liaison. We had a DMORT person 

working upstairs. So he, he writes this up and shares it with us and it served 

as an, it served as an important thing for us to work with. Th is is, this was not 

developed with our input.255
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Th ese examples raise basic questions not only about whether the right medical assets were 

being deployed to the right locations during the response, but also, more fundamentally, 

about who was in charge of those decisions. It clearly was not HHS, the lead for ESF-8 in 

the NRP. HHS/NDMS coordination problems are unfortunately not a new issue and were 

identifi ed as a problem in responding to the 2004 hurricanes.256 Th e causes were not addressed then and obviously remain.

HHS Coordination Resources

Th e reasons for these ESF-8 coordination problems are perhaps best articulated by an analysis 

prepared by one HHS OPHEP staff member at the height of the crisis on September 3. Th is 

analysis locates the problem in a lack of situational awareness by HHS and a lack of direct 

cooperation from NDMS: “Given NDMS’s: superior situational awareness; no mandate to 

share their Intel [intelligence]; and clear and forceful decision to NOT allow us to be a part of 

their operational planning, OPHEP lacks the ability to properly lead ESF#8.”257 Implicit in the 

analysis is that HHS lacks suffi cient emergency-response and coordination assets in the fi eld. 

Whether the ESF-8 command-and-control problems can be attributed solely to the factors 

identifi ed in the HHS analysis, there does appear to be an inadequate level of HHS emergency planning and coordination capability both in the fi eld and headquarters. As the staff 

analysis points out, HHS has only recently established 10 regional emergency coordinators – one for each federal region.258 Th e Region VI coordinator who was responsible for 

covering Louisiana did not assume that position until April 2005, and so was not familiar 

with the situation in Louisiana.259 In addition, she was responsible for a large, fi ve-state area 

covering Arkansas, New Mexico, Oklahoma, and Texas, as well as Louisiana.260 At the time 

Katrina made landfall, the Region VI coordinator had not yet visited Louisiana, nor had she 

met or communicated with Louisiana’s ESF-8 offi cials.261

Th is lack of awareness of Louisiana’s hurricane or health preparations was further exacerbated 

by the fact that no one from OPHEP participated in the Hurricane Pam exercise – which 

shaped much of the state’s medical-response plan used for Katrina – or follow-up medical 

workshops, including one held the week before Katrina. As a result, the Region VI coordinator had to oft en depend on the NDMS regional staff for information and insight into the crisis 

in Louisiana as it unfolded.262 In addition, virtually all of the HHS regional emergency coordinators were deployed to Mississippi and Louisiana response operations. 263 Th is left a gap in 

their own regions in the event of another crisis, or even, in this event, when Katrina evacuees 

began to fl ow to other regions and required health and medical coordination services. 

Lack of Emergency Preparedness Program and Response Integration

Although HHS has several medical-emergency preparedness programs to help state and local public-health offi cials and health-care facilities prepare for emergencies, these programs 

are not carried out by OPHEP. HRSA264 carries out a bioterrorism hospital-preparedness 

program and a medical-volunteer credentialing program. CDC carries out a public-health 

bioterrorism cooperative-grant program and a program to deliver emergency medical 

supplies from the SNS. Although OPHEP has general oversight of these programs within 

HHS,265 as do the emergency coordinators at the regional level, they do not administer these 

programs. HRSA and CDC personnel administer the programs and have the primary interactions with state and local health offi cials.266

Although these HHS preparedness programs are primarily focused on the threat of bioterrorism, several of them did provide demonstrable “all-hazards” benefi ts which were utilized during Katrina (Th e exception is the HRSA credentialing program). For example, the 

HRSA hospital-preparedness program was used to procure satellite phones for hospitals in 

Mississippi, which allowed the state to establish and maintain communications throughout 
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424

the hospital system during Katrina despite the loss of most other communications alternatives.267 In Louisiana, the HRSA hospital program was used to establish a statewide hospital 

network before Katrina that was used to track available hospital beds during the event and 

provide information about the status and emergency needs of the hospital system.268 Th e 

CDC stockpile program was used extensively both to provide medical supplies through 

vendor managed inventories and through the deployment of a Push Pack in Mississippi. 

Th ese programs and the relationships that are established between HHS and state and local 

personnel are not integrated into OPHEP emergency-preparedness and response eff orts. 

A similar situation occurred between health-care delivery facilities – both hospitals and 

community clinics – and the HHS operating divisions that provide reimbursement and 

fi nancial support to those facilities and maintain close day-to-day relationships. During 

Katrina, HRSA became a conduit for status reports and requests for emergency assistance 

from community-health clinics to HHS emergency-operations center, and the administrator of HRSA provided facility-specifi c needs from HRSA funded programs, primarily health 

centers and rural hospitals.269 Th e Centers for Medicare and Medicaid Services played a 

similar role for hospitals.270

It is clear that HHS and its operating divisions provided signifi cant medical-preparedness 

capabilities before the event and response capabilities during it. However, as witnesses and 

interview subjects repeatedly said during this investigation, joint planning, exercises, and 

relationships among emergency responders are essential to eff ective, coordinated operations in a crisis. OPHEP, as the lead HHS organization for emergency preparedness and 

response, had very limited interaction with state and local offi cials. It also had limited ability 

to ensure that the Department’s own agencies were truly providing eff ective preparedness 

programs and emergency-response capability.

SERT Deployment

Although HHS deployed emergency response coordinators to staff the Louisiana and Mississippi EOCs prior to landfall, HHS did not send the Secretary’s Emergency Response Team 

(SERT) to those states until several days into the event.271 Th ese teams are supposed to be the 

Secretary’s direct, on-scene representative and the local command-and-control organization 

for health resources. Th e Louisiana SERT team leader, Admiral Craig Vanderwagen, USPHS, 

did not arrive in Baton Rouge until Friday aft ernoon, September 2. Th e Mississippi SERT 

team leader, Admiral Brenda Holman, USPHS, did not arrive in Jackson until Sunday aft ernoon, September 4. It then took additional time for them to fully constitute their SERT teams. 

As explained in an e-mail from the deputy commander for the Mississippi SERT, on Monday, 

September 5, a week aft er landfall, “We are a little behind with this response. ... Members of 

the MST [management support team] and added SERT members are arriving slowly.”272

Th e impact on response eff ectiveness of HHS’s not having additional “boots on the ground” 

more quickly is hard to evaluate. However, there is evidence that a greater HHS presence 

was needed earlier. For example, HHS began to acquire and deploy mobile fi eld-hospitaltype facilities to the region early in the event. HHS identifi ed several military bases to host 

these facilities, including Eglin Air Force Base in Florida and Fort Polk in Louisiana. Although this deployment plan allowed HHS to begin bringing signifi cant amounts of medical 

supplies into the region, the Louisiana SERT team quickly recommended abandoning the 

Fort Polk operation and redistributing its supplies to other locations in Louisiana.273 Similar 

adjustments had to be made in Florida, where they were never used, and Mississippi, inviting the question whether quicker, better deployment decisions could have been made with 

the benefi t of a greater SERT presence earlier in the event.

Another example where greater SERT presence appears to have been needed was in the 

diffi cult, chaotic, fi rst-of-a-kind evacuation of patients from the New Orleans airport, where 
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425

there was little command and control, and insuffi cient medical personnel, supplies, communications, and security.274 Despite the importance of this mission and the extraordinarily 

diffi cult circumstances, it appears there was little if any HHS presence. As reported by a 

NDMS representative at the airport to the NDMS Director, Beall, as operations were winding down on Sunday, September 4: “Just a heads-up. Th ere has not been any HHS/ESF-8 

representation at the airport operation site during any portion of this evolution.”275

Advance Deployment and Procurement

Early in the event, HHS enlisted DOD’s help to deploy resources in advance of state assistance requests. HHS began to request DOD assistance in staffi ng mobile medical facilities 

shortly aft er landfall on Monday, August 29.276 Although no formal state request had been 

made for these resources, HHS took the initiative to acquire and deploy some 2,250 beds 

initially, in anticipation of large numbers of patients. In the absence of an actual mission assignment, HHS formalized the request in a letter from Assistant Secretary Simonson to Paul 

McHale, Assistant Secretary of Defense for Homeland Security, on August 31.277 Th e letter 

justifi ed the request as follows: “In light of the grave situation in the southern coastal regions, 

and consistent with the National Response Plan’s Catastrophic Incident Annex, Secretary 

Leavitt has directed the deployment of multiple Federal Medical Shelters. I am therefore 

writing to request assistance from the Department of Defense (DOD), as outlined below in 

completing this deployment in a timely fashion.”278 DOD accepted the request even though 

the Catastrophic Incident Annex had not yet been formally invoked, and promptly tasked 

its fi eld elements to respond that day.279 Later the same week, Simonson made an additional 

written request to McHale, again invoking the Catastrophic Incident Annex, for deployment 

of the hospital ship USNS Comfort and outlining expected future requests.280 Again, DOD 

accepted the request and the Comfort embarked from Baltimore the same day.281

While not unique to ESF-8, the procedure for deploying and requesting federal assets in 

advance of state requests is unclear. Although the Catastrophic Incident Annex was invoked 

here to enable the federal government to “lean forward” and to begin to deploy signifi -

cant medical assets in anticipation of Mississippi’s and Louisiana’s needs, this Annex was 

not formally in eff ect at the time, nor is it clear how such decisions should be made in the 

future. In the cases cited here, circumstances required these decisions to be made at a senior 

political level in the absence of a formal process, as Assistant Secretary Simonson explained:

What I should have written was in the spirit of the Catastrophic Incident [Annex]. ... But there was substantive agreement on these procedural legalistic 

issues that we were trying to work with. What I was trying to do was to get out 

on the ice so that if we were needed I wouldn’t have to start from a standing 

stop. I wanted to be there. I wanted to be out there so that we could advance 

in two places where we were needed with as little lead time as possible. And so 

no, there were no ARFs or MAs or anything else issued. Th is was coming right 

from us. And thank God much of this wasn’t needed, as it turned out. But in 

the end I think it was the right thing to do. What authority? Th e authority is a 

general one. We have fairly general authority under the Public Service Health 

Act to assist the states.282

HHS also relied upon its own limited funds to begin advance procurements of FMS units 

and take other actions in advance of formal mission assignments. For example, it used some 

$5 million in surplus funds available in its Public Health and Social Service Emergency 

Fund appropriation to begin these purchases. As Assistant Secretary Simonson explained, 

“Th ere’s no money in the Public Health Service’s emergency fund, other than the monies 

that are being channeled through the CDC and to HRSA for their grant programs. It’s not 

like there’s a big contingency fund there.”283 He also explained that although Section 319 of 
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the Public Health Service Act provides for the creation of a special emergency fund, “Th ere’s 

just nothing in the fund and I don’t think there ever has been.”284 HHS also deferred other 

purchases for the SNS, such as a planned purchase of antibiotics, to free additional funds to 

buy medical supplies for Katrina.285 It is not clear that this approach to incurring costs in the 

absence of a formal Staff ord Act request from a state provides HHS with suffi cient capability 

to “lean forward” in catastrophic public health emergency.

Mortuary Responsibilities

Although it is clear that ESF-8 is responsible for victim identifi cation and mortuary functions, 

a serious problem developed during Katrina in collecting and transporting deceased victims. 

Th e usual capabilities of local coroners and fi rst responders were limited or nonexistent in 

aff ected parts of Louisiana. Although FEMA initially accepted responsibility for collecting 

bodies of victims and tried to hire a contractor to recover bodies, FEMA was unsuccessful 

in negotiating a contract. NDMS DMORT teams were pressed into service to perform this 

function286 and federal-level resolution of the problem became the responsibility of ESF-8, 

although this responsibility had not previously been assigned to ESF-8, or any other ESF. 

Th is made an already diffi cult task more so. As the Deputy Assistant Secretary with responsibility for this function at OPHEP explained,

[Given] the number of bodies and the complexity that came with the hurricane, there wasn’t any coordinated way to go ahead and fi gure how we’re going 

to do the recovery. And ... that’s not an ESF 8 function, that is recovering bodies is not a health and medical thing. Processing them in terms of identifying 

them through the pathologic and mortuary aff airs part, that is in ESF-8. So one 

of the gaps that existed is . . . what kind of national coordination policy do we 

have for recovery of remains?287

1 Th e remaining patient population in southeast Louisiana was estimated at between 2,000 and 2,500 at the time of 

landfall, and more than 625 in Mississippi. New Orleans planned to shelter some 400 special- needs patients at the Superdome, but there has been no precise number established for the special-needs population in New Orleans expected or 

treated. U.S. Department of Health and Human Services (HHS), Secretary’s Operations Center, Flash Report #4 – Hurricane Katrina, Aug. 29, 2005, 8:30 a.m. ET. Provided to Committee; fi led as Bates no. OPHEP 28247; HHS, Secretary’s 

Operations Center, Flash Report #5 – Hurricane Katrina, Aug. 29, 2005, 3 p.m. ET. Provided to Committee; fi led as 

Bates no. OPHEP 28249; Mississippi Emergency Management Agency (MEMA), Hurricane Katrina Situation Report 

#19, Aug. 30, 2005, 6:30 p.m. ET, p. 8. Provided to Committee; fi led as Bates no. MEMA-0010984.

2 Hospitals in the New Orleans area, for example, had not relocated their emergency generators and electric switch gear 

above fl ood level. In the case of the LSU hospitals in New Orleans, Charity and University, the hospital system had been 

unable to obtain funding from the legislature to accomplish this goal. Committee staff interview of James Aiken, M.D., 

Medical Director, Offi ce of Emergency Preparedness, Medical Center of Louisiana in New Orleans, conducted on Jan. 

11, 2006, transcript pp. 73-75; Committee staff interview of Don Smithburg, Executive Vice President and Chief Executive Offi cer, Health Care Services Division, Louisiana State University, conducted on Feb. 7, 2006, transcript pp. 15-17.

3 Th e Attorney General of Louisiana, Charles Foti, is investigating these deaths. Criminal charges have already been 

brought in the case of one nursing home and eight cases, involving fi ve nursing homes and three hospitals are active and 

open at this time. Kris Wartelle, e-mail to David Berick, Senate Committee staff member, Mar. 21, 2006, 3:02 p.m.

4 Committee staff interview of Avis Gray, Regional Administrator, Region I, Offi ce of Public Health, Louisiana Department of Health and Hospitals, conducted on Dec. 8, 2005, transcript pp. 99-100, 108-109.

5 Gray interview, Dec. 8, 2005, pp. 179-180. See also: HHS, Secretary’s Operations Center, Flash Report #6 – Hurricane 

Katrina, Aug. 30, 2005, 3 a.m. ET. Provided to Committee; fi led as Bates no. OPHEP 28252.

6 Southeast Louisiana Catastrophic Hurricane Plan, prepared by IEM, Inc. for LOHSEP and FEMA, Sept. 2005, pp. 99-

111 [hereinaft er Southeast Louisiana Catastrophic Hurricane Plan, Sept. 2005]. Section 14.0 “Temporary Medical Care,” 

includes the following planning assumption “All 40 medical treatment facilities in the impacted area are aff ected by the 

high-water levels, loss of electricity, loss of communications, and storm-force winds, rendering them isolated and useless. 

At best, they will shelter-in-place whatever patients they were not able to discharge prior to landfall. In addition, refugees 

(non-injured or ill individuals) will come to those treatment facilities for sheltering. All patients, staff , family members, and 
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427

refugees will require evacuation from nonfunctional facilities. Th ese treatment facilities may require restoration of power, 

as well as medical, water, and food re-supply, until evacuation is complete.” Th e planners also estimated that there would 

be more than 2,000 hospital and a minimum of 900 special needs patients needing evacuation aft er landfall along with 

hospital and nursing home staff . See also: Southeast Louisiana Catastrophic Hurricane Plan, Sept. 2005, Appendix A.

7 Philip Navin, e-mail to EOC Report, Aug. 29, 2005, 6:58 a.m. Provided to Committee; fi led as Bates nos. CDC 747 

through 749.

8 EOC Report, e-mail to Donald Benken and others, Aug. 28, 2005, 1 p.m. Provided to Committee; fi led as Bates nos. 

CDC 725 through 726.

9 Th e low incidence of infectious-disease outbreaks among survivor and evacuee populations appears to be the result of 

successful public health surveillance of shelters and public-health intervention. During August 29-October 30, 2005 a 

total of 81 reports were investigated by Louisiana infectious-disease epidemiologists. MMWR Morbidity and Mortality 

Weekly Report, Surveillance in Hurricane Evacuation Centers – Louisiana, September – October 2005, Jan. 20, 2006, Vol. 

55, No. 2, pp. 31-35.

10 Suzan Dunaway, e-mail to Monica Giovachino, Sept. 3, 2005, 12:45 p.m. Provided to Committee; fi led as Bates no. 

OPHEP 932.

11 Committee staff interview of Erin Downey, Louisiana Hospital Association, Director of Emergency Preparedness 

(Liaison to Health and Resources and Services Administration), conducted on Jan. 20, 2006, transcript pp. 43-44.

12 Committee staff interview of Jimmy Guidry, M.D., Medical Director and State Health Offi cer, Louisiana Department 

of Health and Hospitals, conducted on Dec. 20, 2005, transcript p. 116.

13 Testimony of Jimmy Guidry, M.D., Medical Director and State Health Offi cer, Louisiana Department of Health and 

Hospitals, before the U.S. Senate, Committee on Homeland Security and Governmental Aff airs, hearing on Challenges in 

a Catastrophe: Evacuating New Orleans in Advance of Hurricane Katrina, Jan. 31, 2006.

14 Dr. Guidry interview, Dec. 20, 2005, pp. 42-45.

15 Dr. Guidry interview, Dec. 20, 2005, pp. 44-45.

16 Southeast Louisiana Catastrophic Hurricane Plan, Sept. 2005, pp. 99-111. 

17 Dr. Aiken interview, Jan. 11, 2006, pp. 66-68. See also: Keith Holtermann, e-mail to Robert Blitzer and others, Aug. 

29, 2005, 1:38 a.m. Provided to Committee; fi led as Bates nos. CDC 747 through 749 (“Advanced planning was never 

completed on how the patients left in the hospitals will be evacuated aft er the event. Th e use of boats to support the other 

ESFs has been fairly comprehensive, and ESF #8 has yet to be completed.”).

18 La. Admin. Code 48:1, Chapter 93, § 9335 (Nov. 2003). Moreover, the regulations state that “as a minimum,” the plan 

shall include the following: Emergency procedures for evacuation of the hospital; Comprehensive measures for receiving 

and managing care for a large infl ux of emergency patients; Comprehensive plans for receiving patients who are being 

relocated from another facility due to a disaster; and the system or procedure to ensure that medical charts accompany 

patients in the event of a patient evacuation and that supplies, equipment, records and medications would be transported 

as part of an evacuation. Furthermore, and as noted by the Feb. 16, 2006, U.S. Senate Committee on Health, Education, Labor and Pensions, Chairman’s Report on Elder Evacuations During the 2005 Gulf Coast Hurricane Disasters, 

issued by Senator Michael B. Enzi, p. 2, the Centers for Medicare and Medicaid Services mandate that nursing homes 

and hospitals maintain EOPs as a prerequisite to receiving Medicare and Medicaid payments. Th e Joint Commission 

on Accreditation of Healthcare Organizations has a similar requirement as a prerequisite to accreditation. U.S. Senate, 

Committee on Health, Education, Labor and Pensions, Chairman’s Report on Elder Evacuations During the 2005 Gulf 

Coast Hurricane Disasters, Feb. 16, 2006.

19 Dr. Guidry, Senate Committee hearing, Jan. 31, 2006.

20 Dr. Aiken interview, Jan. 11, 2006, pp. 62-63.

21 Dr. Guidry interview, Dec. 20, 2005, p. 87.

22 Dr. Guidry interview, Dec. 20, 2005, pp. 86-87.

23 Dr. Aiken interview, Jan. 11, 2006, pp. 91-92; Dr. Guidry interview, Dec. 20, 2005, p. 71.

24 Committee staff interview of Sec. Fred Cerise, M.D., Louisiana Department of Health and Hospitals, conducted on 

Dec. 2, 2005, transcript pp. 164-166. Ironically, on Sunday evening, before it was known that the hospitals would fl ood, 

some special-needs patients who were too ill to be treated at the Superdome had been moved to one of the hospitals. See 

also: Committee staff interview of Col. Pat Prechter, State Chief Nurse, Louisiana Army National Guard and Deputy 

Commander, Louisiana Medical Command, conducted on Jan. 6, 2006, transcript pp. 41-42.

25 Dr. Guidry interview, Dec. 20, 2005, p. 68.

26 Dr. Guidry interview, Dec. 20, 2005, pp. 70-71 (“And so you had those large numbers of people in the Dome without 

power, without sewerage, waiting for buses, waiting for transportation. And you had the special-needs patients getting 

fl own out by helicopter or taken out by boat. And our intent was to get the sick out fi rst. And that’s real diffi cult to do 

when there’s 20,000 people right next door. And there was a lot of discussion and I hear this from my boss as well who 

was there, that they were afraid that the people were going to get violent. Th at time was taking too long, that they were all 

in each others’ faces and they were afraid that violence was going to break out and everybody was afraid for their life.”).

27 Dr. Cerise interview, Dec. 2, 2005, pp. 229-230.
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428

28 Dr. Cerise interview, Dec. 2, 2005, pp. 212, 230-231.

29 Dr. Aiken interview, Jan. 11, 2006, pp. 100-101.

30 Dr. Aiken interview, Jan. 11, 2006, pp. 90-91, 94.

31 Dr. Cerise interview, Dec. 2, 2005, pp. 156-157.

32 Dr. Aiken interview, Jan. 11, 2006, pp. 134.

33 Dr. Aiken interview, Jan. 11, 2006, pp 143.

34 La. Admin. Code 48:1, Chapter 97, § 9729 (January 1998). Th e law also states that each plan “shall be activated at least 

annually, either in response to an emergency or in a planned drill,” and that “the nursing home’s performance during 

the activation of the plan shall be evaluated and documented.” Moreover, “[a]s a minimum,” the written plans must 

describe: the evacuation of residents to a safe place, either within the nursing home or to another location; the delivery of 

essential care and services to nursing home residents; the provisions for the management of staff , including distribution 

and assignment of responsibilities and functions; a plan for coordinating transportation services required for evacuating 

residents to another location; and assurance that the resident’s family or sponsor is notifi ed if the resident is evacuated to 

another location.

35 Walter Maestri, emergency manager for Jeff erson Parish, said “Nursing homes are required by state law and by licensing statutes to have in place an emergency operations plan. ... Th e enforcement is in the hands of the State of Louisiana 

and the parishes through the emergency management offi ce. Each nursing home that functions in Jeff erson Parish is 

mandated by State law to send to me once a year a copy of their emergency plan. We peruse that plan, we have no requirement, the State does not require us to approve or disapprove the plan. But we must peruse it and affi rm to the State 

that there is a plan.” Committee staff interview of Walter Maestri, Ph.D., Director, Jeff erson Parish Offi ce of Emergency 

Management, conducted on Oct. 27, 2005, transcript p. 218.

36 Joseph Mathews, emergency manager for Orleans Parish said, “Hospitals, nursing homes, special care – yeah, they 

should have an adequate plan. It’s required by the State that they have an adequate plan. [I review e]ach one of them 

individually, page by page – I look at it and basically [inaudible]. Th ey are supposed to submit a plan to my offi ce, yes. 

... An adequate plan includes a plan of evacuating and moving those persons. ... Basically they’re governed by the State, 

and all I can do at my offi ce is ask that they comply. As far as any punitive measures or anything like that, I don’t have 

the authority to do anything. I can – the best I can do is report it to the State, send them correspondence [inaudible] it’s 

basically up to the State.” Committee staff interview of Joseph Matthews, Director, New Orleans Offi ce of Emergency 

Preparedness, LA, conducted on Nov. 23, 2005, transcript pp. 130-131, 133.

37 Dr. Guidry interview, Dec. 20, 2005, pp. 107-108; Dr. Aiken interview, Jan. 11, 2006, pp. 49-51.

38 Dr. Aiken interview, Jan. 11, 2006, pp. 49-52.

39 Dr. Aiken interview, Jan. 11, 2006, pp. 85, 118. It should be noted, however, that while Dr. Aiken did say that Charity Hospital generators were “running on fumes for the fi rst day or so,” he also noted that “[a]nd then I think maybe 

Wednesday or Th ursday, we had more [generator fuel] than we needed.” 

40 Dr. Guidry, Senate Committee hearing, Jan. 31, 2005. In a special session aft er Katrina, the Louisiana legislature enacted 

legislation calling for a re-examination of hospital building codes. Source: 2005 La. Acts 41 (1st Extraordinary Session).

41 Dr. Aiken interview, Jan. 11, 2006, pp. 127-128.

42 Dr. Aiken interview, Jan. 11, 2006, p. 118.

43 Committee staff interview of Kevin Stephens, M.D., Director, New Orleans Health Department, LA, conducted on 

Nov. 19, 2005, transcript pp. 65-66.

44 Dr. Guidry interview, Dec. 20, 2005, pp. 32-33, 105.

45 Committee staff interview of Roseanne Pratts, Director, Emergency Preparedness, Louisiana Department of Health 

and Hospitals, conducted on Jan. 31, 2006, transcript p. 18.

46 Dr. Guidry, Senate Committee hearing, Jan. 31, 2006.

47 Dr. Guidry interview, Dec. 20, 2005, p.65.

48 Dr. Guidry interview, Dec. 20, 2005, p. 65.

49 U.S. Public Health Service, PHS Katrina Response: Baton Rouge Deployment Alpha Team, briefi ng slides, Oct. 16, 

2005. Provided to Committee.

50 Dr. Stephens interview, Nov. 10, 2005, pp. 25-26; Dr. Guidry interview, Dec. 20, 2005, pp. 58-59, 61-63; Pratts interview, Jan. 31, 2006, pp. 18-19; Col. Prechter interview, Jan. 6, 2006, p. 55.

51 Committee staff interview of Ronald Martin, Deputy Commander, Management Support Team, National Disaster 

Medical System, FEMA, conducted on Jan. 13, 2006, transcript pp. 53, 63-68.

52 Dr. Stephens interview, Nov. 10, 2005, pp. 25-26.

53 Col. Prechter interview, Jan. 6, 2006, pp. 100, 102, 109, 115.

54 Committee staff interview of Brig. Gen. Gary Jones, Louisiana National Guard, conducted on Dec. 7, 2005, transcript 

p. 180; Col. Prechter interview, Jan. 6, 2006, p. 115.
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55 Jones interview, Dec. 7, 2005, p. 189.

56 Dr. Guidry interview, Dec. 20, 2005, p. 75. However, it should be noted that Joseph Donchess, Executive Director of 

the Louisiana Nursing Home Association, stated that 21 nursing homes were evacuated pre-storm and 36 were evacuated post-storm, amounting to a total of about 5,500 to 6,000 nursing home residents evacuated pre- and post-storm. 

Testimony of Joseph Donchess, Executive Director, Louisiana Nursing Home Service Corporation, before the U.S. Senate, Committee on Homeland Security and Governmental Aff airs, hearing on Challenges in a Catastrophe: Evacuating 

New Orleans in Advance of Hurricane Katrina, Jan. 31, 2006.

57 Dr. Guidry, Senate Committee hearing, Jan. 31, 2006.

58 Dr. Aiken interview, Jan. 11, 2006, pp. 106-107.

59 Dr. Stephens interview, Nov. 10, 2005, pp. 26-27.

60 Dr. Cerise interview, Dec. 2, 2005, p. 177.

61 Committee staff interview of Joseph Donchess, Executive Director, Louisiana Nursing Home Service Corporation, 

conducted on Jan. 9, 2006, transcript p. 128.

62 Donchess, Senate Committee hearing, Jan. 31, 2006.

63 Donchess, Senate Committee hearing, Jan. 31, 2006.

64 Louisiana Offi ce of Homeland Security and Emergency Preparedness (LOHSEP), Emergency Operations Plan, Apr. 

2005, p. ESF–8–1 (emphasis added). Provided to Committee. 

65 Dr. Aiken interview, Jan. 11, 2006, pp. 20-21, 32-33, 34; Smithburg interview, Feb. 7, 2006, pp. 55, 60-61.

66 Downey interview, Jan. 20, 2006, pp. 17-21.

67 Downey interview, Jan. 20, 2006, pp. 50-54. 

68 Dr. Aiken interview, Jan. 11, 2007, pp. 20-21 (emphasis added).

69 Under the 2001 EOP, LSU was responsible for the following: “Th e [CEO] of the [LSU] Health Sciences Center (HSC) 

Health Care Services Division (HCSD) shall be primarily responsible for participating in state, regional and parish 

planning to coordinate the provision of hospital care and shelter for nursing home and home health care patients with 

acute care requirements, and casualties of emergencies and disasters. Th e LSU-HSC-HCSD will have the lead role among 

state agencies in such planning.” Source: LOHSEP, Emergency Operations Plan, March 2001, pp. M–1 through M–2. 

Furthermore, as explained by James Aiken, M.D., Medical Director for Emergency Preparedness for the Medical Center 

of Louisiana in New Orleans (a.k.a. Charity and University Hospitals), these sorts of responsibilities were held by LSU 

dating back to 1992. Source: Dr. Aiken interview, Jan. 11, 2006, pp. 18-21.

70 Dr. Aiken interview, Jan. 11, 2006, pp. 32-33 (emphasis added).

71 Dr. Aiken interview, Jan. 11, 2006, p. 34.

72 Smithberg interview, Feb. 7, 2006, p. 55.

73 Smithberg interview, Feb. 7, 2006, p. 55.

74 Smithberg interview, Feb. 7, 2006, pp. 60-61.

75 Dr. Aiken interview, Jan. 11, 2006, pp. 24-25.

76 Dr. Aiken interview, Jan. 11, 2006, p. 28.

77 Dr. Aiken interview, Jan. 11, 2006 pp. 21-22.

78 Downey Interview, Jan. 20, 2006, pp. 67-68, 69.

79 Th e six counties are Hancock, Harrison, Jackson, Pearl River, Stone, and George. Committee staff interview of Jim Craig, 

Director, Offi ce of Health Protection, Mississippi Department of Health, conducted on Jan. 25, 2006, transcript p. 28.

80 Th e three hospitals were Hancock Medical Center in Bay St. Louis, Gulf Coast Medical Center in Gulfport, and L.O. 

Crosby in Picayune. U.S. Department of Health and Human Services and the Mississippi Department of Health, Hurricane Katrina: Medical Support/Demobilization/Transition Plan for the State of Mississippi, Jan. 2006, p. 3 [hereinaft er 

Mississippi Medical Support/Demobilization/Transition Plan].

81 Mississippi Medical Support/Demobilization/Transition Plan, p. 3.

82 Mississippi Medical Support/Demobilization/Transition Plan, p. 3.

83 Mississippi Medical Support/Demobilization/Transition Plan, p. 7.

84 Mississippi Medical Support/Demobilization/Transition Plan, p. 3.

85 Th e plan provides that MDH is responsible for “the overall public health response, the triage, treatment and transportation of victims of a disaster, immediate support to hospitals and nursing homes, the provision of emergency mental 

health crisis counseling for individuals and the community, and the re-establishment of all health, medical and social 

service systems.” MEMA, Mississippi Emergency Operations Plan, Volume II: Mississippi Comprehensive Emergency 

Management Plan (CEMP), May 14, 1999, pp. ESF 8–1 through ESF 8–16. Provided to Committee.

86 Craig interview, Jan. 25, 2006, pp. 11-12.
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430

87 Written Statement of Brian Amy, M.D., State Health Offi ce, Mississippi Department of Health, for the U.S. House, 

Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina, hearing on Hurricane Katrina: Preparedness and Response by the State of Mississippi, Dec. 7, 2005, p. 3.

88 Written Statement of Dr. Amy, House Select Committee hearing, Dec. 7, 2005, pp. 9-10.

89 Written Statement of Dr. Amy, House Select Committee hearing, Dec. 7, 2005, p. 6.

90 Craig interview, Jan. 25, 2006, pp. 12-13.

91 Craig interview, Jan. 25, 2006, p. 36.

92 Craig interview, Jan. 25, 2006, pp. 12-13.

93 Th ere is a potentially contrary report from HHS Region IV on the evening of August 28, 2005 stating that not all, in 

fact only two of 29 skilled-nursing facilities reported evacuations. EOC Report, e-mail to Donald Benken and others, 

Aug. 28, 2005, 10:04 p.m. Provided to Committee, fi led as Bates no. CDC 725; Craig interview, Jan. 25, 2006, pp. 37-38.

94 Testimony of Gov. Haley Barbour, Mississippi, before the U.S. Senate, Committee on Homeland Security and Governmental Aff airs, hearing on Hurricane Katrina: Th e Role of the Governors in Managing the Catastrophe, Feb. 2, 2006.

95 Craig interview, Jan. 25, 2006, p. 8.

96 Written Statement of Dr. Amy, House Select Committee hearing, Dec. 7, 2005, pp. 10-11.

97 Written Statement of Dr. Amy, House Select Committee hearing, Dec. 7, 2005, p. 15.

98 Craig interview, Jan. 25, 2006, pp. 28-29. In his testimony before the House Committee investigating Katrina, Dr. 

Amy recalled Carolina-1 being deployed by HHS. Written Statement of Dr. Amy, House Select Committee hearing, Dec. 

7, 2005, p. 6.

99 Craig interview, Jan. 25, 2006, p. 24.

100 Craig interview, Jan. 25, 2006, pp. 30-31.

101 Craig interview, Jan. 25, 2006, pp. 28-29.

102 Written Statement of Dr. Amy, House Select Committee hearing, Dec. 7, 2005, pp. 16-17.

103 Th e National Disaster Medical System (NDMS) was formerly within the Department of Health and Human Services 

(HHS), Offi ce of Emergency Preparedness (OEP). Th e Homeland Security Act transferred NDMS to DHS in 2003. 

“Homeland Security Act of 2002.” (P.L. 107-296), 6 U.S.C. § 201.

104 U.S. Department of Homeland Security, National Disaster Medical System. http://www.oep-ndms.dhhs.gov/index.

html. Accessed on Mar. 6, 2006.

105 U.S. Department of Veterans Aff airs, National Disaster Medical System. http://www1.va.gov/EMSHG/page.

cfm?pg=45. Accessed on Apr. 21, 2006. 

106 U.S. Department of Veterans Aff airs, “National Disaster Medical System (NDMS), Patient Movement Aft er Action 

Review Meeting, December 12-13, 2005.” http://www1.va.gov/emshg/page.cfm?pg=111. Accessed on Apr.21, 2006 [hereinaft er NDMS Patient Movement AAR, Dec. 2005].

107 FEMA, Current NDMS Overview, Jan. 6, 2006. Provided to Committee.

108 FEMA, Current NDMS Overview, Jan. 6, 2006. Provided to Committee.

109 FEMA, Current NDMS Overview, Jan. 6, 2006. Provided to Committee.

110 Deployments included 40 DMAT’s, 16 strike teams, 8 DMORTs, 4 VMATs and 3 MSTs. In the Louisiana and Mississippi this meant 1,265 and 667 personnel, respectively, for a total of 1,932 NDMS team members. FEMA, Hurricane 

Katrina NDMS Resource Status Report, Sept. 5, 2005, 11 p.m. Provided to Committee.

111 Committee staff interview of Jack Beall, Chief, National Disaster Medical System, FEMA, conducted on Jan. 10, 

2006, transcript p. 11.

112 Committee staff interview of Capt. Art French, M.D., U.S. Public Health Service, Deputy Chief Medical Offi cer, Disaster Medical Assistance Team PHS-1, National Disaster Medical System, FEMA, conducted on Mar. 2, 2006, transcript p. 98.

113 National Disaster Medical System, Team Ratings 12-20-05.xls, Jan. 6, 2006. Provided to Committee.

114 “Homeland Security Act of 2002,” (P.L. 107-296), 6 U.S.C. §§ 313, 503.

115 “I know there were 144 positions that were in OEP. I’ve been given that number, and I was led to believe, when were 

transferred to FEMA, that HHS kept 40 of these positions – I think that’s a number – and then the rest, I think it was 17 

moved into logistics. Th ose personnel would have come out of that operations division.” Beall interview, Jan. 10, 2006, p. 16. 

116 Beall interview, Jan. 10, 2006, p. 7. 

117 Mick Cote, e-mail to Jack Beall, Aug. 27, 2005, 3:24 p.m. Provided to Committee; fi led as Bates no. DHS-FEMA0098-0004489.

118 William Lokey, e-mail to Jack Beall, Aug. 28, 2005, 1:13 p.m. Provided to Committee; fi led as Bates no. DHS-FEMA0098-0003831.

119 FEMA, NDMS Aft er-Action Report, Disaster Medical Assistance Team San Diego CA-4, Mission: Hurricane Ka-
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431

trina, Dec. 29, 2005. Provided to Committee.

120 Additional delays resulted when one truck had a mechanical problem an hour outside of San Diego resulting in 

an additional seven to eight hour delay. Th e cause of the mechanical failure was a part that had been the subject of a 

manufacturer’s recall, but had not yet been repaired because of instructions from FEMA to delay the repair. FEMA, 

NDMS Aft er-Action Report, Disaster Medical Assistance Team San Diego CA-4, Mission: Hurricane Katrina, Dec. 29, 

2005. Provided to Committee. 

121 FEMA, NDMS Aft er-Action Report, Disaster Medical Assistance Team San Diego CA-4, Mission: Hurricane Katrina, Dec. 29, 2005. Provided to Committee.

122 Craig Interview, Jan. 25, 2006, pp. 24-26.

123 FEMA, Hurricane Katrina NDMS Resource Status Report, Aug. 30, 2005, 10 p.m. Provided to Committee. 

124 Capt. Art French, M.D., Aft er-Action Presentation, “New Orleans Airport Evacuation: Th e MST Perspective on the 

Hospital from Hell,” briefi ng slides, Feb. 2006.

125 Capt. Art French, M.D., Aft er-Action Presentation, “New Orleans Airport Evacuation: Th e MST Perspective on the 

Hospital from Hell,” briefi ng slides, Feb. 2006.

126 FEMA, Hurricane Katrina NDMS Resource Status Report, Sept. 2, 2005. Provided to Committee.

127 George Custer, Aft er Action Report – FEMA Hurricane Katrina, Southern Area Incident Management Team, p. 1. 

Provided to Committee.

128 Capt. French interview, Mar. 2, 2006, pp. 14, 17-18, 25-26, 36.

129 Capt. French interview, Mar. 2, 2006, p. 55.

130 Capt. French interview, Mar. 2, 2006, pp. 22-26.

131 Capt. Art French, M.D., Aft er-Action Presentation, “New Orleans Airport Evacuation: Th e MST Perspective on the 

Hospital from Hell,” briefi ng slides, Feb. 2006; Capt. French interview, Mar. 2, 2006, pp. 10, 15

132 Capt. French interview, Mar. 2, 2006, pp. 6-11.

133 Capt. French interview, Mar. 2, 2006, pp. 10, 16.

134 Capt. French interview, Mar. 2, 2006, p. 16.

135 Capt. French interview, Mar. 2, 2006, p. 15.

136 Jack Beall, e-mail to EC William Piggot, Sept. 1, 2005, 4:11 p.m. Provided to Committee; fi led as Bates no. DHSFEMA-0098-0002099.

137 William Piggot, e-mail to Jack Beall, Sept. 1, 2005, 4:51 p.m. Provided to Committee; fi led as Bates no. DHS-FEMA0098-0002099.

138 Chris Turner, e-mail to Jack Beall, Sept. 2, 2005, 8:48 a.m. Provided to Committee; fi led as Bates no. DHS-FEMA0098-0001737.

139 Martin interview, Jan. 13, 2006, pp. 54-58, 146-148.

140 Martin interview, Jan. 13, 2006, p. 32.

141 Jack Beall, e-mail to Th omas Bowman, Sept. 1, 2005, 7:27 a.m. Provided to Committee; fi led as Bates no. DHSFEMA-0098-0002216.

142 Jack Beall, e-mail to Chris Turner, Sept. 6, 2005, 10:21 p.m. Provided to Committee; fi led as Bates no. DHS-FEMA0098-004204.

143 Beall interview, Jan. 10, 2006, p. 48.

144 FEMA, Mission Assignment, 1603DR-LA-HHS-02, Aug. 31, 2005. Provided to Committee; fi led as Bates no. 

OPHEP-28877; FEMA, Mission Assignment, 1603DR-LA-HHS-02, Aug. 31, 2005. Provided to Committee; fi led as Bates 

nos. OPHEP 28878 through 28879.

145 Beall interview, Jan. 10, 2006, pp. 43-44; Capt. Art French, M.D., Aft er-Action Presentation, “New Orleans Airport 

Evacuation: Th e MST Perspective on the Hospital from Hell,” briefi ng slides, Feb. 2006.

146 Robert Jevec, e-mail to Gary Kleinman and others, Aug. 31, 2005, 10:41 a.m. Provided to Committee; fi led as Bates 

nos. DHS-FEMA-0098-0004357 through 0004358.

147 NDMS Patient Movement AAR, Dec. 2005.

148 Capt. French interview, Mar. 2, 2006, pp. 13-14, 54-56.

149 Capt. French interview, Mar. 2, 2006, pp. 64-65; See also: FEMA, NDMS Aft er-Action Report, Disaster Medical 

Assistance Team San Diego CA-4, Mission: Hurricane Katrina, Dec. 29, 2005. Provided to Committee; See also: OR-2 

DMAT, Hurricane Katrina – Aft er Action Report, Sept. 25, 2005. Provided to Committee. 

150 Th e Incident Management Team was designed to provide food, showers, and other logistical support for emergency 

teams working in the fi eld. Upon arriving in Louisiana, the Team literally sent out “scouting parties” to determine where 

their logistical support could be used aft er they determined that their original mission assignment to establish a base camp 
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in Port Allen, Louisiana was already being met by another agency. One of the scout teams identifi ed the airport as a critical need and the team got permission from its regional coordinator to relocate there. George Custer, Aft er Action Report 

– FEMA Hurricane Katrina, Southern Area Incident Management Team, TX=FEM-05004, Provided to Committee.

151 U.S. Department of Homeland Security, National Response Plan. Washington: Government Printing Offi ce, Dec. 

2004, p. 12.

152 Committee staff interview of Rear Adm. John Babb, Director, Offi ce of Force Readiness and Deployment, U.S. Public Health Service, U.S. Department of Health and Human Services, conducted on Feb. 8, 2006, transcript, pp. 5, 24.

153 Rear Adm. Babb interview, Feb. 8, 2006, pp. 5.

154 Rear Adm. Babb interview, Feb. 8, 2006, pp. 41-45.

155 U.S. Department of Health and Human Services, Concept of Operations Plan (CONOPS) for Public Health and 

Medical Emergencies, Jan. 2005, p. 4, Appendix A.

156 U.S. Public Health Service, “History of the Commissioned Corps.” http://www.usphs.gov/html/history.html. Accessed on Apr. 21, 2006.

157 Rear Adm. Babb interview, Feb. 8, 2006, p. 22; Committee staff interview of U.S. Public Health Service, Alpha Team 

members, Jan. 12, 2006 (untranscribed). 

158 Rear Adm. Babb interview, Feb. 8, 2006, pp. 14-15.

159 Rear Adm. Babb interview, Feb. 8, 2006, p. 33; U.S. Public Health Service, Alpha Team members interview, Jan. 12, 

2006; U.S. Public Health Service, briefi ng on Hurricane Katrina: PHS Response, Team Alpha, given to Senate Committee 

staff , Jan. 12, 2006.

160 U.S. Public Health Service, briefi ng on Hurricane Katrina: PHS Response, Team Alpha, given to Senate Committee staff , Jan. 12, 2006; U.S. Public Health Service, briefi ng on PHS Katrina Response: Baton Rouge Deployment Alpha 

Team, Oct. 16, 2005. Provided to Committee. Th e USPHS team at the PMAC worked with a team of volunteers from 

Illinois obtained through an EMAC agreement and a DMAT team that was stationed there for approximately one week.

161 Rear Adm. Babb interview, Feb. 8, 2006, pp. 22-24.

162 Offi cers were identifi ed to support NDMS and the Strategic National Stockpile (SNS), a LA hospital, and to staff the 

FMSs which were part of OPHEP’s strategy to increase facility surge capacity. See also: John T. Babb, e-mail to William 

C. Vanderwagen and others, Aug. 29, 2005, 2:12 p.m. Provided to Committee; fi led as Bates no. OSG170.

163 Rear Adm. Babb interview, Feb. 8, 2006, p. 62.

164 Rear Adm. Babb interview, Feb. 8, 2006, pp. 69-70.

165 It was explained that since USPHS personnel do not have pharmaceuticals, medical supplies and equipment, and 

other supports, it would be best to couple their deployments to the FMS shelters. Rear Adm. Babb interview, Feb. 8, 

2006, pp. 61-63, 66-67.

166 Rear Adm. Babb interview, Feb. 8, 2006, p. 72.

167 Rear Adm. Babb interview, Feb. 8, 2006, pp. 69-71 (“Basically, we had been told to put together people that would 

staff ten 250-bed federal medical shelters, which we did. But when they began to deploy them, they didn’t necessarily 

deploy the teams the way we had them structured. ... When the travel contractor deployed people, well, parts of teams 

arrived in diff erent places. ... New Orleans airport was almost non-functional. It was accepting very few fl ights. Baton 

Rouge had – every seat was full. Every time we turned around, we were trying to get fl ights in there and couldn’t get 

people there.”). 

168 Rear Adm. Babb interview, Feb. 8, 2006, pp. 71-72.

169 Rear Adm. Babb interview, Feb. 8, 2006, p. 62.

170 Rear Adm. Babb interview, Feb. 8, 2006, pp. 14-15, 35-37.

171 Rear Adm. Babb interview, Feb. 8, 2006, p. 67: “So to look at the delay in the deployment as thought it was because 

offi cers didn’t get down fi eld is assuming that the resource was there and waiting on them or that they were taking it with 

them, and that was not the case. Th ey had to wait until the resource got there.”

172 Committee staff interview of Robert E. Lavender, Jr., Deputy Director of Information Technology Communications, 

U.S. Department of Health and Human Services, conducted on Feb. 3, 2006, transcript p. 10 (“In this year’s hurricane 

season, you couldn’t get into airports, so we had to fi nd the closest airport and fi nd a way to transport our people from 

that remote airport into the area in which we were asking them to provide services. So it was – this year was diff erent 

from anything I’ve ever experienced in that it required a lot of creativity. Th ere were no hotels, so one of the things that 

I did was – we call them rock star buses. We had sleeper buses sent in that slept 12 people. And so we did the best we 

could to provide as reasonable an accommodation as we could for the people that we were deploying.”).

173 Lavender interview, Feb. 3, 2006, pp. 74-75. Two week deployments have traditionally been used because of the dual 

federal role of many USPHS offi cers and the nature of the typical disaster deployment. 

174 Rear Adm. Babb interview, Feb. 8, 2006, p. 16. Despite Secretary of HHS Michael Leavitt activating the USPHS on 

Sunday, August 28, which made all USPHS deployments mandatory, many USPHS offi cers were still unable to deploy 

due to professional commitments at their daily positions. Committee staff interview of Rear Adm. Craig Vanderwagen, 

Acting Chief Medical Offi cer, Indian Health Service, and Offi cer, U.S. Public Health Service, U.S. Department of Health 
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433

and Human Service, conducted on Feb. 7, 2006, transcript pp. 2, 62-64; Lavender interview, Feb. 3, 2006, pp. 74-75.

175 Rear Adm. Babb interview, Feb. 8, 2006, pp. 79-80. USPHS offi cers are required to update their status and obtain 

medical waivers when necessary as they come on-call and they receive e-mail reminders each time they are on-call to 

update their availability status. However, there are no sanctions for not reporting changes in deployment status or for 

not deploying.

176 Rear Adm. Babb interview, Feb. 8, 2006, pp. 79-80.

177 Noreen Hynes, e-mail to John Babb, Aug. 30, 2005, 3:55 a.m. Provided to Committee; fi led as Bates no. OSG162.

178 Capt. French interview, Mar. 2, 2006, p. 67.

179 Monica Giovachino, et al., Hurricanes Frances and Ivan: Improving the Delivery of HHS and ESF#8 Support, Th e 

CNA Corporation, IPR 11208, Feb. 2005, pp. 42-43 [hereinaft er, Hurricanes Frances and Ivan: Improving the Delivery 

of HHS and ESF#8 Support]. Th e report focused on improving the HHS ESF-8 response and focused a section on the 

USPHS. Prior to Hurricane Katrina, Hurricanes Frances and Ivan involved the largest deployment of personnel from 

HHS and its ESF-8 partners. Th e report stated that offi cers were deployed from each region of the country and each 

USPHS rotational roster was “tapped for personnel.” Th e CNA report concluded, “Th is examination reveals a fractured 

system that does not have the manpower or administrative infrastructure necessary to support a major deployment.” Th e 

report concluded that OFRD does not have the capacity to coordinate major personnel deployments, as evidenced by the 

fact that senior level staff spent the weekend to identify and contact offi cers individually by phone for deployment.

180 Hurricanes Frances and Ivan: Improving the Delivery of HHS and ESF#8 Support, p. 45 (“Each roster is not set up to 

be a ‘ready-go’ asset for OASPHEP. Instead it is a pool of personnel that may be available in a time of need.”).

181 Hurricanes Frances and Ivan: Improving the Delivery of HHS and ESF#8 Support, p. 46.

182 Hurricanes Frances and Ivan: Improving the Delivery of HHS and ESF#8 Support, p. 43.

183 Rear Adm. Babb interview, Feb. 8, 2006, p. 78.

184 PHS deployed 138 offi cers for Frances and 263 for Ivan. Source: Hurricanes Frances and Ivan: Improving the Delivery 

of HHS and ESF#8 Support, pp. 39-40. A total of 1,885 were deployed to aff ected areas and 247 to other locations for 

Katrina. Source: U.S. Department of Health and Human Services, Response to the U.S. Senate, Committee on Homeland 

Security and Governmental Aff airs, Feb. 28, 2006, p. 42. 

185 Committee staff interview of Stewart Simonson, Assistant Secretary for Public Health Emergency Preparedness, U.S. 

Department of Health and Human Services, conducted on Feb. 16, 2006, transcript p. 107.

186 “Public Health Security and Bioterrorism Preparedness and Response Act of 2002.” (P.L. 107-188), 42 U.S.C. § 201 

(“Th e Secretary shall, directly or though an award of a grant, contract, or cooperative agreement, establish and maintain 

a system for the advance registration of health professionals for the purpose of verifying the credentials, licenses, accreditations, and hospital privileges of such professionals when, during public health emergencies, the professionals volunteer 

to provide public health services. ... In carrying out the preceding sentence, the Secretary shall provide for an electronic 

database for the verifi cation system.”).

187 HRSA’s mission is to provide national leadership, program resources and services needed to improve access to 

culturally competent, quality health care. Th ey support healthcare systems that are culturally competent, comprehensive, 

and provide quality care for the goal of optimal health for all.

188 Simonson interview, Feb. 16, 2006, p. 112.

189 Rear Adm. Babb interview, Feb. 8, 2006, p. 39.

190 Rear Adm. Babb interview, Feb. 8, 2006, pp. 54, 39; Simonson interview, Feb. 16, 2006, p. 112. In FY2005, HHS 

asked for funding for a portal that would have pooled the data across all states to create a national credentialing mechanism; however, the request was not funded. 

191 Norman Coleman, e-mail to Norman Coleman and others, Sept. 2, 2005, 12:06 a.m. Provided to Committee; fi led as 

Bates no. OPHEP 9408. On Saturday September 3, the Web site was opened to the public.

192 Rear Adm. Babb interview, pp. 19, 44.

193 Clara Witt, e-mail to Th omas Christl and others, September 7, 2005, 1:20 p.m. Provided to Committee; fi led as Bates 

no. OPHEP 9779. Even aft er the private contractor was hired and work was under way, there were talks within HHS to 

use states to assist in credentialing in the process aft er the federal contractor had already initiated the process

194 Clara Witt, e-mail to Ann Knebel, Sept. 7, 2005, 8:31 p.m. Provided to Committee; fi led as Bates no. OPHEP 9990.

195 John Babb, e-mail to Ann Knebel, Sept. 5, 2005, 9:02 a.m. Provided to Committee; fi led as Bates no. OPHEP 9660. 

Rear Admiral Babb stated, the volunteers, “are going straight to OPHEP and we don’t have any visibility. At this point, 

that’s fi ne. But I would like to know what kinds of personnel are being deployed.”

196 Lavender interview, Feb. 3, 2006, pp. 66-67.

197 For instance, numerous changes were made to the website to include specialties of healthcare workers left off the original list. Lynn May, e-mail to Norman Coleman, Sept. 3, 2005, 5:37 p.m. Provided to Committee; fi led as Bates no. OPHEP 

8636; Mary Couig, e-mail to Ann Knebel, Sept. 4, 2005, 8:42 a.m. Provided to Committee; fi led as Bates no. OPHEP 8635.

198 Teresa Brown-Jesus, e-mail to Ann Knebel, Sept. 6, 2005, 5:26 p.m. Provided to Committee; fi led as Bates no. 

OPHEP 9805 (“States ... have continued to express their concerns about the way that federal volunteer recruitment ef-
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forts have been implemented.”).

199 Th e Federal volunteer database also created confl ict with the purpose and mission of the Medical Reserve Corps 

(MRC). Th e MRC is comprised of health professionals who voluntarily join locally-sponsored medical units that can be 

called upon to provide additional medical personnel in an emergency. Th e Director of the MRC expressed concerns almost 

one week aft er the hurricane about the confusion surrounding the deployment process and how the MRC units would be 

integrated into the federal volunteer database that HHS had established. Because there was no clear connection between the 

MRC and the Federal volunteer database eff orts, HHS created confl icting and overlapping volunteer systems. Ann Knebel, 

e-mail to Norman Coleman and others, Sept. 7, 2005, 5:55 a.m. Provided to Committee; fi led as Bates no. OPHEP 9755; 

Robert Tosatto, e-mail to Ann Norwood, Sept. 7, 2005, 3:39 p.m. Provided to Committee; fi led as Bates no. OPHEP 9670.

200 Ann Knebel, e-mail to Norman Coleman and others, Sept. 7, 2005, 5:55 a.m. Provided to Committee; fi led as Bates 

no. OPHEP 9755; Robert Tosatto, e-mail to Ann Norwood, Sept. 7, 2005, 3:39 p.m. Provided to Committee; fi led as 

Bates no. OPHEP 9670.

201 Dr. Guidry interview, Dec. 20, 2005, pp. 53, 56 (“To try to match up the resources with where they were needed became a full-time job...(t)he teams that worked the best, were like Illinois had a medical team. Th ey came and you could 

hand them off a shift and they could pretty much handle it because they came trained and working together. Th ey were 

organized. Other professionals who showed up as volunteers really have not trained in such events and really makes it 

diffi cult to perform when it’s not well organized.”). 

202 Simonson interview, Feb. 16, 2006, p. 31. Th e FMS capacity for OPHEP has not been funded to date, but all development occurred using year-end money. 

203 Lavender interview, Feb. 3, 2006, p. 57.

204 Simonson interview, Feb. 16, 2006, p. 66.

205 Th e Logistics section of OPHEP bore much of the burden for acquiring and coordinating movement of the FMSs, 

such as personnel and supplies. Given the growing list of demands for the mobile medical units, personnel, and supplies, 

OPHEP logistics had to exponentially increase their staff of four full-time employees; thus, many new staff did not have 

experience with procedures of the Logistics offi ce. Th e lack of experience in the Logistics offi ce, with the added burden of 

coordinating the establishment of unproven and never utilized FMS units prototype, compounded the logistical diffi culties 

in Washington and on the ground. Lavender interview, Feb. 3, 2006, pp. 6-9, 31-32, 89-90. See also: Stewart Simonson, letter to Paul McHale, Aug. 31, 2005. Provided to Committee; fi led as Bates no. OPHEP 27874. OPHEP requested assistance 

to support the following FMS unit deployments: 500 beds at Eglin Air Force Base in Pensacola, FL; 750 beds at Fort Polk, 

LA; 500 beds at Naval Air Station in Meridian, MS; and 500 beds at Mississippi Air National Guard Base in Jackson, MS.

206 Committee staff interview of Robert E. Blitzer, Deputy Assistant Secretary, Operations Security Program, U.S. Department of Health and Human Services, conducted on Feb. 2, 2006, transcript p. 96.

207 Stewart Simonson, e-mail to William Gimson and others, Aug. 31, 2005, 6:33 p.m. Provided to Committee; fi led as 

Bates no. OPHEP 27771.

208 Committee staff interview of Richard Besser, Director of Coordinating Offi ce for Terrorism Preparedness and 

Emergency Response, Centers for Disease Control and Prevention, and Steve Adams, Acting Director of the Strategic 

National Stockpile, Centers for Disease Control and Prevention, conducted on Feb. 14, 2006, transcript p. 14.

209 Besser and Adams interview, Feb. 14, 2006, p. 12.

210 Stewart Simonson, e-mail to William Gimson and others, Sept. 3, 2005, 7:22 a.m. Provided to Committee; fi led as 

Bates no. OPHEP 27077 (“We are struggling right now with a Miss hospital resupply mission. Th e Push Pack may tide 

them over for a little while, but I need to pick-up the pace on this order. Please tell me if we cannot do both (FMS and 

Miss Hosp) resupply at once – if this is the case, we may have to back-off for a bit on the FMS ordering. I cannot have 

Miss run out of provisions.” To which, SNS staff eventually replied “...we are doing this right now, SNS is focusing in 

the MS re-supply right now and will see if they can move back to the FMCS ordering this aft ernoon.”). See also: Galen P. 

Carver, e-mail to Stewart Simonson, Sept. 3, 2005, 9:13 a.m. Provided to Committee; fi led as Bates no. OPHEP 27076.

211 Simonson interview, Feb. 16, 2006, pp. 71-72.

212 Tom Sizemore, e-mail to Michael L. Vineyard, Sept. 3, 2005, 8:45 a.m. Provided to Committee, fi led as Bates no. 

OPHEP 24464.

213 Centers for Disease Control and Prevention, Division of the Strategic National Stockpile, “Hurricane Katrina Update,” Aug. 31, 2005. Provided to Committee; fi led as Bates no. OPHEP 27774.

214 Robert Claypool, e-mail to William “Contact” Vanderwagen, Sept. 2, 2005, 7:49 a.m. Provided to Committee; fi led as 

Bates no. OPHEP 24227.

215 Stewart Simonson, e-mail to Richard Chavez, Sept. 2, 2005, 5:29 p.m. Provided to Committee; fi led as Bates no. 

OPHEP 27839 (“We have been turned away from the gate at the Mississippi Air National Guard Base in Jackson. We are 

diverting the beds scheduled for that facility to Meridian. Can you confi rm with the base commander there that they will 

accept them. Th is is urgent.”). For instance, MS could not transport their residents to Eglin Air Force Base in Pensacola, 

FL; therefore, two FMS units were moved to MS. Source: Sandy Bogucki, e-mail to Stewart Simonson, Sept. 4, 2005, 3:24 

p.m. Provided to Committee; fi led as Bates no. OPHEP 27584. In Louisiana, Mike Milner was assisting Adm. Vanderwagen in redeploying the FMSs that OPHEP had mapped out. He stated that at Ft. Polk there had been no patients and that 

the mission was redefi ned to support special needs shelters based on the state requests; this was only one of several FMS 

staffi ng and placement decisions that had to be interrupted by the SERT in Louisiana alone. Source: Mike Milner, e-mail 
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435

to William C. Vanderwagen, Sept. 5, 2005, 11:35 p.m. Provided to Committee; fi led as Bates no. OPHEP 8198.

216 Stewart Simonson, letter to Paul McHale, Sept. 2, 2005. Provided to Committee; fi led as Bates no. OPHEP 27877.

217 Shayne Brannman, e-mail to Gregory Davis, Sept. 8, 2005, 11:05 a.m. Provided to Committee; fi led as Bates no: 

OPHEP 8745.

218 Craig interview, Jan. 25, 2006, pp. 72, 75.

219 Craig interview, Jan. 25, 2006, pp. 24-25; 28-29.

220 Paul McHale, letter to Stewart Simonson, Sept. 2. 2005. Provided to Committee; fi led as Bates no. OPHEP 27880.

221 Gregory Banner, e-mail to KC Decker, Sept. 9, 2005, 10:39 p.m. Provided to Committee; fi led as Bates no. OPHEP 

8196. 

222 Lavender interview, Feb. 3, 2006, pp. 35-49.

223 Lavender interview, Feb. 3, 2006, p. 35. Lavender acquired “primary medical bags ... so that ... when our people 

arrived on the ground, they could provide primary treatment, whether it be bandaging or removing a splinter, whatever 

it happened to be. But I procured those early in the event because we didn’t have them,” unfortunately, USPHS teams 

were not equipped with these materials and supplies prior to the event or as a matter of procedure because it was not 

“perceived to be a requirement.”

224 Lavender interview, Feb. 3, 2006, pp. 45-46.

225 Centers for Disease Control and Prevention, “Strategic National Stockpile (SNS),” Apr. 14, 2005. http://www.bt.cdc.

gov/stockpile/. Accessed on Apr. 21, 2006.

226 Th ese supplies were dispatched by truck from Atlanta and Tennessee on the aft ernoon of September 28 and arrived 

at Camp Beauregard, LA aft er landfall.

227 HHS, Secretary’s Operation Center Flash Report #6 – Hurricane Katrina, Aug. 30, 2005, 3 p.m., p. 2. Provided to 

Committee; fi led as Bates no. OPHEP 28253. 

228 Gregory Banner, e-mail to Keith Holtermann, Sept. 2, 2005, 2:39 a.m. Provided to Committee; fi led as Bates nos. 

OPHEP 27869 through 27870 “My understanding of the situation is that hospitals and medical facilities along the coast 

are in desperate need of resupply for a variety of expendables. Supply requests have been submitted but the planned 

delivery times are still more than 24 hours away. Th e SNS push packages contain a number of needed items and so in the 

interest of speeding up the delivery of supplies to the hospitals, a push package was requested. Th is appeared to be the 

quickest way to obtain at least part of the needed supplies.”).

229 Sandy Bogucki, e-mail to SNS OPS Center Lead, Sept. 2, 2005, 8:27 a.m. Provided to Committee; fi led as Bates no. 

OPHEP 27642.

230 Besser interview, Feb. 14, 2006, pp. 53-55 (“I don’t think that there was a complete understanding of what it meant 

to request a push pack and what that provided ... we were trying to make sure the people on the ground specifi ed 

clearly what it was that they wanted. And in Louisiana, a lot of what ... people wanted was a restoration of their supply 

chains and their facilities, and a lot of chronic medications that weren’t in push packs ... sending out a push pack is an 

extremely expensive endeavor which is justifi able when the parties receiving it need what’s in it. But it’s, in my mind 

not justifi able for expense, plus a waste of people’s time if they’re getting, you know, 50 tons of material that isn’t what 

they’re looking for.”).

231 Brian W. Amy, letter to Phil Naven, Sept. 1, 2005. Provided to Committee; fi led as Bates no. OPHEP 27639 (“Mississippi’s hospitals are in dire need of supplies from the Strategic National Stockpile’s Push Packages ... Sixteen hospitals 

located south of Interstate 20 are totally out of basic supplies, such as IV solutions and oral doses of broad spectrum antibiotics ... as well as saline solutions, sterile water ... syringes, etc. and all other related supplies. Th us far, supply requests 

have not been fulfi lled for a variety of reasons. ... Please note that the longer we are delayed in distributing supplies to 

hospitals, the more likely it will be that emerging infections will compound our all-ready overwhelming situation.”).

232 Evidenced by an internal OPHEP e-mail “FYI, just got pinged by the DEOC [CDC’s emergency operations center]. 

Gerberding [the Director of CDC] wanting to know who gave the permission to move SNS assets.” Keith Holterman, 

e-mail to Stewart Simonson, Sept. 2, 2005, 6:33 a.m. Provided to Committee; fi led as Bates no. OPHEP 28195.

233 Lavender interview, Feb. 3, 2006, p. 43.

234 Besser and Adams interview, Feb. 14, 2006, pp. 46-47.

235 U.S. Public Health Service, briefi ng on Hurricane Katrina: PHS Response, Team Alpha, given to Senate Committee 

staff , Jan. 12, 2006. Th ese materials arrived on Tuesday, August 30 and the PHS team reported that the packages were not 

very manageable and were not well-suited to meet the needs of a 200-bed special needs shelter. 

236 U.S. Public Health Service, briefi ng on Hurricane Katrina: PHS Response, Team Alpha, given to Senate Committee 

staff , Jan. 12, 2006.

237 U.S. Public Health Service, briefi ng on Hurricane Katrina: PHS Response, Team Alpha, given to Senate Committee 

staff , Jan. 12, 2006. Th ey reported that there was no organized method for obtaining supplies – they oft en went to the 

SNS who reported that it would take 1-2 days aft er ordering for delivery, they would then speak with the SOC to push 

the SNS orders, and would also speak with private vendors and pharmacies.

238 U.S. Public Health Service, briefi ng on Hurricane Katrina: PHS Response, Team Alpha, given to Senate Committee 
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staff , Jan. 12, 2006.

239 U.S. Public Health Service, briefi ng on Hurricane Katrina: PHS Response, Team Alpha, given to Senate Committee 

staff , Jan. 12, 2006.

240 Besser interview, Feb. 14, 2006, pp. 9-10, 60-61 (“it’s [the SNS] an asset that was developed around the bioterrorism, 

and has morphed to pandemics, but [it’s] not been constructed in the same all-hazards approach as CDC as an agency 

is for public health events. For what it’s worth, with all the hurricanes that have occurred since the program’s inception 

in 1999, to my recollection, we’ve never deployed anything to a hurricane before, so it doesn’t mean that we shouldn’t 

have been thinking more broadly or – but in a environment of fi xed resources, you know, we focus on missions that are 

clearly defi ned.”).

241 Lavender interview, Feb. 3, 2006, p. 41.

242 Besser interview, Feb. 14, 2006, p. 10 (“I think, one of the things we saw with Katrina, here we had an organization 

that was designed for moving material, moving material very effi ciently and eff ectively. It very quickly adapted to a situation where it was moving products that it hadn’t been designed for. ... What we saw in Louisiana was a complete loss of 

the supply chain for quite a large are in terms of medical supplies, and the stockpile was able to step up and become that 

chain – that delivery chain.”). See also: Besser and Adams interview, Feb. 14, 2006, pp. 24-32.

243 Besser interview, Feb. 14, 2006, pp. 10-11 (“As we look at the [mission] for the stockpile ... what we are looking at is, 

should the mission be broader, and if so ... means developing logistical plans that are very diff erent from a model where 

you are taking a large push pack delivering it and turning it over to the States ... it’s developing a logistical chain so that 

you’re dealing with a wider array of products; you’re dealing with ongoing consumption of products and replacement; 

you’re putting in place systems for being able to look at what kind of patients are being seen so you can tailor your supplies in a very unique way. And I think, what Katrina demonstrates for us is a capacity that as country we need to have.”).

244 Besser interview, Feb. 14, 2006, p. 76 (“I think that, I mean, Hurricane Katrina clearly identifi ed chronic disease as 

an area that has to be addressed as part of response to major natural disasters. And if the SNS is the body that’s going to 

do that, we need to put the systems in place to make that work.”).

245 U.S. Department of Health and Human Services, Response to the U.S. Senate, Committee on Homeland Security 

and Governmental Aff airs information request, Feb. 28, 2006, p. 41. 

246 Lavender interview, Feb. 3, 2006, p. 50.

247 “As the primary agency for ESF #8, HHS coordinates the provision of Federal health and medical assistance to fulfi ll 

the requirements identifi ed by the aff ected State, local and tribal authorities. ESF #8 uses resources primarily available 

from: HHS, including the Operating Divisions and Regional Offi ce; the Department off Homeland Security (DHS); and 

other ESF #8 support agencies and organizations.” NRP, p. ESF #8–4.

248 HHS possesses additional statutorily assigned health responsibilities under the Public Health Service Act, the 

Social Security Act, and the Federal Food, Drug, and Cosmetic Act. In fact, the Secretary of HHS declared public health 

emergencies for Louisiana, Mississippi and surrounding states pursuant to this independent authority beginning on 

Wednesday, August 31, 2005. U.S. Department of Health and Human Services, Concept of Operations Plan (CONOPS) 

for Public Health and Medical Emergencies, Jan. 2005, pp. 4-5, Appendix A. 

249 NRP, p. 5

250 An initial planning meeting to establish “an interagency incident management system to address the ESF 8 public 

health and medical response” to Katrina was formally established held on Monday, September 5, 2005. A Unifi ed Incident Management Team was established at the HHS headquarters in the Humphrey Building on that day. Secretary’s 

Operations Center, e-mail to Allen Dobbs and others, Sept. 5, 2005, 2:44 p.m. Provided to Committee; fi led as Bates nos. 

DHS-FEMA-0098-0000635 through 0000640.

251 Simonson interview, Feb. 16, 2006, pp. 64-65.

252 Jack Beall, e-mail to Stewart Simonson, Sept. 3, 2005, 10:56 a.m. Provided to Committee; fi led as Bates no. OPHEP 

27922.

253 Stewart Simonson, e-mail to Gerald Parker, Sept. 3, 2005, 2:55 p.m. Provided to Committee, fi led as Bates nos. 

OPHEP 27922 through 27924.

254 NRP, pp. ESF 8–6, ESF 8–10.

255 Committee staff interview of Robert Claypool, M.D., former Deputy Assistant Secretary, Director of Mass Casualty 

Planning, Offi ce of Public Health Emergency Preparedness, U.S. Department of Health and Human Services, conducted 

on Feb. 14, 2006, transcript p. 67.

256 Th e aft er-action report for HHS concerning the response to Hurricane Frances and Ivan recommended that the 

HHS Offi ce of the Assistant Secretary for Public Health Emergency Preparedness work with the National Disaster Medical System (NDMS) “... to (i)mprove coordination between HHS and NDMS during response operations (the separation 

of NDMS from HHS has fractured ESF #8).” Hurricanes Frances and Ivan: Improving the Delivery of HHS and ESF #8 

Support, p. 2.

257 Keith Holtermann, e-mail to Robert Love, Sept. 3, 2005, 1:27 a.m. Provided to Committee; fi led as Bates nos. 

OPHEP 19978 through 19979.

258 NDMS and the Offi ce of Emergency Preparedness at HHS were transferred to the Department of Homeland Security 
Medical Assistance

437

when the Homeland Security Act was enacted in November, 2002, eff ective March, 2003 (P.L. 107-296 §503). Although 

the existing Offi ce of Public Health Emergency Preparedness (OPHEP) was created by statute on June 12, 2002, and predates the transfer, the resulting changes created a vacuum in HHS’ emergency response capability which it is still trying 

to fi ll. See also P.L. 107-488 § 102.

259 Committee staff interview of Jean Bennett, Regional Emergency Coordinator, Region VI, Offi ce of Public Health and 

Emergency Preparedness, U.S. Department of Health and Human Services, conducted on Mar. 1, 2006, transcript p. 5.

260 Bennett interview, Mar. 1, 2006, p. 5.

261 Bennett interview, Mar. 1, 2006, pp. 15-17.

262 HHS/OPHEP provided three reasons why it did not participate in any of the 2004 or 2005 Hurricane Pam medical 

discussions – (1) the exercise was sponsored by FEMA and they were not specifi cally invited, (2) a Region VI REC was 

not yet in place when the bulk of the exercise took place in 2004, and (3) the Region VI REC was unable to take part in the 

fi nal ESF-8 Hurricane Pam follow-up workshop (which occurred just days before Katrina hit) due to a scheduling confl ict. 

263 Robert Blitzer, e-mail to Robert Claypool, Sept. 5, 2005, 11:37 a.m. Provided to Committee; fi led as Bates no. OPHEP 

28178.

264 HRSA is the agency within HHS that provides funding and training programs to health care providers, such as 

health clinics, to provide care to the uninsured, people with HIV/AIDS, and pregnant women, mothers, and children.

265 Dr. Claypool interview, Feb. 14, 2006, p. 38.

266 Bennett interview, Mar. 1, 2006, p. 20.

267 Craig interview, Jan. 25, 2006, p. 25.

268 Downey interview, Jan. 20, 2006, pp. 46-48; Dr. Guidry interview, Dec. 20, 2006, pp. 78-79.

269 Betty Duke, e-mail to Richard Carmona, Sept. 7, 2005, 6:02 p.m. Provided to Committee; fi led as Bates nos. OPHEP 

27217 through 27220.

270 Dianne Whittington, e-mail to Brian Kamoie, Sept. 4, 2005, 2:30 pm. Provided to Committee; fi led as Bates nos. 

OPHEP 22014 through 022017; Committee staff interview of Gerald Parker, M.D., D.V.M., Ph.D., Principal Deputy 

Assistant Secretary, Offi ce of Public Health Emergency Preparedness, U.S. Department of Health and Human Services, 

conducted on Feb. 10, 2006, pp. 52-54.

271 Vanderwagen interview, Feb. 7, 2006, pp. 46-47; Brian Kamoie, e-mail to Stewart Simonson, Sept. 3, 2005, 2:33 p.m. 

Provided to Committee; fi led as Bates no. OPHEP 27072.

272 Clara Cobb, e-mail to Robert Love, Sept. 5, 2005, 11:19 a.m. Provided to Committee; fi led as Bates no. OPHEP 8344.

273 Mike Milner, e-mail to William C. Vanderwagen, Sept. 5, 2005, 11:35 p.m. Provided to Committee; fi led as Bates 

nos. OPHEP 8198 through 8199. 

274 Capt. Art French, M.D., USPHS, Aft er-Action Presentation, “New Orleans Airport Evacuation: Th e MST Perspective on the Hospital from Hell,” briefi ng slides, Feb. 2006.; Capt. French interview, Mar. 2, 2006.

275 George Havens, e-mail to Jack Beall, Sept. 4, 2005, 10:47 a.m. Provided to Committee; fi led as Bates no. DHS-FEMA0098-0001413.

276 Mark Roupas, e-mail to Paul McHale, Aug. 29, 2005, 5:54 p.m. Provided to Committee; fi led as MMTF 00418-05.

277 Stewart Simonson, letter to Paul McHale, Aug. 31, 2005. Provided to Committee; fi led as Bates nos. OPHEP 27874 

through 27875.

278 Stewart Simonson, letter to Paul McHale, Aug. 31, 2005. Provided to Committee; fi led as Bates nos. OPHEP 27874 

through 27875.

279 Offi ce of the Assistant Secretary of Defense (Homeland Defense), Hurricane Katrina/Rita/Ophelia Interim Timeline, Nov. 2, 2005, p. 7. Provided to Committee (“Oral approval of SecDef and Draft MOD$ to SecDef EXORD tasks 

SECARMY to provide Ft. Polk deployment site, SECNAV to provide Naval Air Station Meridian site, SECAF to provide 

Eglin AFB site, and CNGB to coordinate use of MS Army National Guard Base.”). 

280 Stewart Simonson, letter to Paul McHale, Sept. 2, 2005. Provided to Committee; fi led as Bates nos. OPHEP 27884 

through 27885.

281 U.S. Joint Forces Command, Hurricane Katrina Comprehensive Timeline, Nov. 15, 2005, p. 8. Provided to Committee, fi led as Bates no. MMTF 00500-05.

282 Simonson interview, Feb. 16, 2006, pp. 97-98.

283 Simonson interview, Feb. 16, 2006, p. 74

284 Simonson interview, Feb. 16, 2006, p. 75

285 Simonson interview, Feb. 16, 2006, p. 76

286 Stewart Simonson, e-mail to Jack Beall, Sept. 2, 2005, 9:18, p.m. Provided to Committee; fi led as Bates no. OPHEP 

27927.

287 Dr. Claypool interview, Feb. 15, 2006, pp. 63-64.