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53–119 PDF 2010

S. Hrg. 111–313 

FOCUSING ON CHILDREN AND DISASTERS: 

EVACUATION PLANNING AND MENTAL 

HEALTH RECOVERY 

HEARING 

BEFORE THE

AD HOC SUBCOMMITTEE ON DISASTER RECOVERY 

OF THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

AUGUST 4, 2009 

Available via http://www.gpoaccess.gov/congress/index.html 

Printed for the use of the Committee on Homeland Security 

and Governmental Affairs 

( 

(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

JOSEPH I. LIEBERMAN, Connecticut, Chairman 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

THOMAS R. CARPER, Delaware 

MARK L. PRYOR, Arkansas 

MARY L. LANDRIEU, Louisiana 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

ROLAND W. BURRIS, Illinois 

MICHAEL F. BENNET, Colorado 

SUSAN M. COLLINS, Maine 

TOM COBURN, Oklahoma 

JOHN MCCAIN, Arizona 

GEORGE V. VOINOVICH, Ohio 

JOHN ENSIGN, Nevada 

LINDSEY GRAHAM, South Carolina 

ROBERT F. BENNETT, Utah 

MICHAEL L. ALEXANDER, Staff Director 

BRANDON L. MILHORN, Minority Staff Director and Chief Counsel 

TRINA DRIESSNACK TYRER, Chief Clerk 

AD HOC SUBCOMMITTEE ON DISASTER RECOVERY 

MARY L. LANDRIEU, Louisiana, Chairman 

CLAIRE MCCASKILL, Missouri 

ROLAND W. BURRIS, Illinois 

LINDSEY GRAHAM, South Carolina 

BEN BILLINGS, Staff Director 

ANDY OLSON, Minority Staff Director 

KELSEY STROUD, Chief Clerk 

(III) 

C O N T E N T S 

Opening statement: Page 

Senator Landrieu .............................................................................................. 1 

Prepared statements: 

Senator Landrieu .............................................................................................. 29 

Senator Bennett ................................................................................................ 33 

WITNESSES 

TUESDAY, AUGUST 4, 2009 

Craig Fugate, Administrator, Federal Emergency Management Agency, U.S. 

Department of Homeland Security ..................................................................... 5 

Rear Admiral Nicole Lurie, M.D., M.S.P.H., Assistant Secretary for Preparedness, U.S. Public Health Service, U.S. Department of Health and Human 

Services ................................................................................................................. 6 

Cynthia A. Bascetta, Director, Health Care, U.S. Government Accountability 

Office ..................................................................................................................... 9 

Mark Shriver, Vice President and Managing Director of U.S. Programs at 

Save the Children, and Chairperson, National Commission on Children 

and Disasters ........................................................................................................ 17 

Irwin Redlener, M.D., Professor, Clinical Population and Family Health, and 

Director, National Center for Disaster Preparedness, Mailman School of 

Public Health, Columbia University, and President, Children’s Health 

Fund ...................................................................................................................... 19 

Teri Fontenot, President and Chief Executive Officer, Woman’s Hospital, 

Baton Rouge, Louisiana ....................................................................................... 21 

ALPHABETICAL LIST OF WITNESSES

Bascetta, Cynthia A.: 

Testimony .......................................................................................................... 9 

Prepared statement .......................................................................................... 57 

Fontenot, Teri: 

Testimony .......................................................................................................... 21 

Prepared statement with an attachment ....................................................... 77 

Fugate, Hon. Craig: 

Testimony .......................................................................................................... 5 

Prepared statement .......................................................................................... 35 

Lurie, Rear Admiral Nicole, M.D., M.S.P.H.: 

Testimony .......................................................................................................... 6 

Prepared statement .......................................................................................... 41 

Redlener, Irwin, M.D.: 

Testimony .......................................................................................................... 19 

Prepared statement .......................................................................................... 71 

Shriver, Mark: 

Testimony .......................................................................................................... 17 

Prepared statement .......................................................................................... 67 

APPENDIX 

Additional information submitted for the record by Senator Landrieu .............. 91 

Questions and responses submitted for the record from: 

Mr. Fugate ........................................................................................................ 110 

Admiral Lurie ................................................................................................... 113 

Ms. Bascetta ...................................................................................................... 116 

Mr. Shriver ........................................................................................................ 119 

Page

IV 

Questions and responses submitted for the record from—Continued 

Dr. Redlener ...................................................................................................... 121 

Ms. Fontenot ..................................................................................................... 123 

(1) 

FOCUSING ON CHILDREN AND DISASTERS: 

EVACUATION PLANNING AND MENTAL 

HEALTH RECOVERY 

TUESDAY, AUGUST 4, 2009 

U.S. SENATE,

AD HOC SUBCOMMITTEE ON DISASTER RECOVERY,

OF THE COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, 

Washington, DC. 

The Subcommittee met, pursuant to notice, at 10:04 a.m., in 

room SD–342, Dirksen Senate Office Building, Hon. Mary L. Landrieu, Chairman of the Subcommittee, presiding. 

Present: Senator Landrieu. 

OPENING STATEMENT OF SENATOR LANDRIEU 

Senator LANDRIEU. Good morning, I would like to call the hearing to order this morning of the Subcommittee on Disaster Recovery, which I am proud and happy to Chair. I thank the staff for 

helping prepare this hearing for this morning. 

Today’s hearing is entitled, ‘‘Focusing on Children and Disasters: 

Evacuation Planning and Mental Health Recovery.’’ The Subcommittee’s objective today is to evaluate the very special needs of 

children during the preparedness, response, and recovery phases of 

disaster and the extent to which our current planning and programs either meet or fail to meet these special needs. 

We are focusing on children and their needs for several reasons. 

First, children in most families are the focal point, and parents 

who cannot find an available school, a day care center, or access 

to health care for their children may be forced to relocate after a 

disaster or, worse in some ways, be forced to stay out of the workforce when they are actually badly needed to help rebuild their 

communities, starting with their own homes, businesses, and 

places of worship. 

According to the Bureau of Labor Statistics, about half the Nation’s families include children, and 90 percent of those families include a parent that is a member of the workforce. So getting your 

workforce back to work after a disaster is one of our primary goals. 

That will be very difficult if we are not doing our best to provide 

them help and support with proper placement during those daylight hours for their children, either in schools or day care, and provide the mental health counseling that children need and families 

need to sustain themselves. 

2 

1The chart referred to by Senator Landrieu appears in the Appendix on page 95. 

So we must be mindful of the fact that people cannot return to 

work or begin rebuilding until they locate a safe and productive environment for their children. These parents, I may remind everyone, are the nurses, the doctors, the first responders, the police officers, the grocery store owners, the gas station operators, the electric line repairmen, and the citizens who play an important role in 

the community’s return. That means the provision of child care and 

reopening of schools must be a top priority. 

I would like to show a chart of the number of day care centers 

that were operating.1 In August 2005, the purple line shows how 

many day care centers were open, and then, of course, you can see 

the dramatic falloff over time. 

The second reason we are focusing on children here today is that 

children are a vulnerable population with unique needs that require special planning to address, but in my view, they have not 

received the same level of attention that some other populations, 

whether it be the adult homeless or the disabled or the elderly generally. A broader goal of this hearing is to encourage the Nation 

to consider the mental well-being of the community as a key indicator of recovery, every bit as important as the restoration of infrastructure, housing, and the return of the economic tax base. 

I would like to take a moment to commend the Washington 

Times for their particularly insightful articles, actually published 

the last couple of days—it was a coincidence that they were running these in line with our hearing—and I want to quote from one 

of the articles that was published on August 3. It says, ‘‘Almost 4 

years after the massive hurricanes inundated much of New Orleans 

that killed about 1,800 people, millions of words have been written 

about the devastating physical damage to the city and hundreds of 

millions of dollars have been spent on fitful efforts at reconstruction. But almost nothing is said and relatively little has been spent 

on the more silent wreckage, the health of New Orleans residents 

who were pushed over the edge by the terror and turmoil of the 

storm and have been unable to recover emotionally or mentally.’’ 

And when I say New Orleans, I mean the greater New Orleans 

area, and in large measure, you could almost substitute the Gulf 

Coast for New Orleans. 

Local response plans must be provided for evacuation, sheltering, 

and continued care of children from facilities where they are likely 

to be clustered at the time of the disaster or call for evacuation, 

either at day care centers, schools, and hospitals, including the neonatal wards and maternity wards. Katrina showed us the impact 

of failing to include the nursing home sector in our evacuation 

plans and we must ensure in the future that facilities which house 

other vulnerable members of our society are included fully in these 

planning processes. 

Save the Children issued a report last month called ‘‘The Disaster Decade,’’ indicating, shockingly, that only seven States currently require schools and day care centers to develop comprehensive evacuation and reunification plans. Those States are Alabama, 

Arkansas, Hawaii, New Hampshire, Maryland, Massachusetts, and 

Vermont. 

3 

Local emergency managers and facility owners can do more to 

expand planning efforts. States with planning gaps may consider 

requiring these facilities to develop plans, as some States have already done, and obviously the Federal Government has a role to 

play. 

Another concern raised by the report is the fact that child care 

is not eligible for funding under the Stafford Act as an essential 

service. I would like to ask and plan to ask our FEMA Director, 

Craig Fugate, who is here, to address this in his testimony, and I 

understand that he will. 

In addition to schools and day care centers, we will also consider 

newborn infants and mothers who may be in hospital wards when 

disasters strike. According to HHS, an average of 36 babies are 

born each day in New York City, and in Los Angeles, the daily average is 416. If an evacuation was called in any of those cities, you 

can understand the difficulties of moving that kind of population, 

if necessary. 

The Senate version of the Homeland Security Appropriations bill 

for fiscal year 2010 includes an amendment I offered encouraging 

DHS to conduct mass evacuation planning with States, local governments, and nonprofits, including monitoring, tracking, and continued care for neonatal and obstetric patients. Woman’s Hospital 

will be testifying on the second panel. They executed this function 

for the State during the response to Hurricanes Katrina, Rita, and 

Gustav, and they have a great deal to share. 

I am going to summarize the rest of my statement for the record 

because I am anxious to get on to the panel, but let me just say 

a few more things. 

After the hurricanes, the demand for mental health services 

spiked due to increased trauma, depression, and substance abuse. 

That was combined with the loss of inpatient beds and mental 

health professionals which created a severe gap that strained medical workers and facilities, host communities, and first responders. 

The LSU Department of Psychiatry screened 12,000 children in 

schools in Louisiana during the 2005 and 2006 school year. Some 

of the results of that study are startling. Eighteen percent of them 

had a family member who was killed in the hurricane. Forty-nine 

percent of them met the threshold for mental health referral. One 

year later, the rate was lower, but it was still 30 percent. Twentyeight percent of displaced children in Louisiana are still suffering 

from depression or anxiety. 

The suicide and attempted suicide rates for adults are also startling. I am going to include those in the record, but some are reporting that the suicide rates are three times higher than the national average. [National Average of Adults: 25–64: 14.88 per 

1000.000, New Orleans, Louisiana Pre-Katrina: 9 per 100,000, and 

New Orleans, Louisiana Post-Katrina: 27 per 100,000]. I was 

struck not only by the number of suicides, but also the number of 

suicide attempts. It was something like, if I remember, 116 people 

had committed suicide in 1 year, but 750 had attempted suicide. 

The Crisis Counseling Assistance and Training Program is jointly administered by FEMA and SAMHSA. It is intended to counsel 

disaster survivors and teach them coping skills. We obviously need 

to do a great deal more. 

4 

1The chart appears in the Appendix on page 91. 

1The prepared statement of Senator Landrieu appears in the Appendix on page 29. 

There is a chart that shows the number of Federal programs that 

are available,1 to support mental health and substance abuse services for disaster survivors. Basically this is a list of all the different 

programs offered through the Federal Government, grant programs, etc., for this purpose. There are 21 different Federal programs, and three of the 21—Medicaid, SCHIP, and Head Start— 

have income eligibility requirements that limit their ability to provide services in a seamless way after a disaster. But they are 

stovepiped, and there is no sort of comprehensive community delivery system, in my view, in place right now to cover the extraordinary needs after a catastrophic disaster that affects a community 

the way it did the greater New Orleans area and across large 

swaths of the Gulf Coast. 

The Consolidated Appropriations Act of 2008 established the National Commission on Children and Disasters to conduct a comprehensive study and examine children’s needs. Mr. Shriver and 

Dr. Redlener are both members of the Commission, and we are 

pleased to have them with us today to talk about their recommendations in their testimony later. 

I would like to conclude with a quote from Chris Rose, who was 

a columnist for the Times Picayune that probably wrote more extensively on a daily basis about this issue than any person in the 

country. He gave the commencement address at Ursuline Academy 

a year after the storm, my alma mater high school that has been 

in New Orleans for 275 years. ‘‘My daughter was asked to write 

about her experiences over the past year when she came back to 

New Orleans, and this is what she wrote. ‘There was a hurricane. 

Some people died. Some of them were kids.’ My daughter was six 

when she wrote that. It just doesn’t strike me as what you would 

wish for your child to write in her first grade journal, but there it 

is. You, all of us, are marked by life, by what happens. Like it or 

not, this storm and circumstances have marked you.’’ 

I think this is a good place to start this hearing because these 

are real consequences and lessons from the terrible catastrophe 

that happened. We are still struggling with how to respond better, 

how to plan better, and how to recover, and the needs of children 

are of primary interest to me, and particularly the mental and 

emotional needs of the community at large as we seek to build a 

better and stronger community. 

So with that, let me submit the rest of my statement to the 

record.1

I would like to introduce the first panel. We have Craig Fugate, 

Administrator of FEMA, who has been on the job now for about 2 

months and is already making some very positive changes. 

We have Rear Admiral Nicole Lurie, the Assistant Secretary for 

Preparedness, U.S. Public Health, Department of Health and 

Human Services. We are happy to have you, Admiral. 

And Cynthia Bascetta, Director of Health Care, U.S. Government 

Accountability Office. They have issued a recent report, and we are 

interested in hearing about that report relative to the subject. 

5 

1The prepared statement of Mr. Fugate appears in the Appendix on page 35. 

I will introduce the second panel at the appointed time, but Mr. 

Fugate, let us begin with you, and thank you for being here this 

morning. 

TESTIMONY OF HON. CRAIG FUGATE,1 ADMINISTRATOR, FEDERAL EMERGENCY MANAGEMENT AGENCY, U.S. DEPARTMENT OF HOMELAND SECURITY 

Mr. FUGATE. Well, good morning, Chairman Landrieu. I have 

submitted my written testimony. I would ask that be entered into 

the record and then I have some opening remarks, if that is OK 

with you. 

Senator LANDRIEU. That is fine. Thank you. 

Mr. FUGATE. As a paramedic, one of the things that I was taught 

early on in dealing with medical emergencies was that children are 

not small adults. That may seem like, duh, but it points out that 

not only are the pharmacological needs of children different, how 

you would treat certain conditions, it goes to the whole aspect that 

an adult, you just don’t size down to a child and get the same outcome. You really have to focus on children. Their brain development, their mental capabilities, and their physiology are vastly different from adults. And so your treatment approach has to be 

geared towards a child, not merely taking what you would normally do for an adult and make it smaller. 

And I think that is one of the challenges we have when we look 

at planning. Historically, when we look at communities and we 

write planning documents, my observation, and I have been doing 

this for a while, is we tend to write plans for us, the adults, people 

that have a high school education. They speak English, or they 

have more education. They have a car. They drive. They have resources. And they can pretty well take care of much of their needs. 

And so we tend to write a plan for that population. 

Then we will go back and go, well, now we have this other group. 

They have different challenges. We need to write a plan for those. 

So we will come up with a second plan, and a third plan, and a 

fourth plan. And that has been our approach. 

We are going to try something different. Based on the concerns 

that have been raised by the Commission on Children and Disasters and the GAO reports and the issues you have raised, we decided to take a different approach in FEMA, and instead of writing 

our plan for the adults and then try to figure out how we deal with 

everything else, let us write plans that actually reflect the communities we live in. They have children. There are people with disabilities. There are frail elderly. But let us quit putting all these populations in a special box that we will get to after we get the plan 

written and let us do this from the beginning. 

So we are going to start with children. As you point out, there 

are cross-cutting issues, not only when we talk about disasters, but 

just in the daily delivery of service programs, that oftentimes we 

do not take advantage of when disaster strikes. There are many 

things that, I think if we looked at children up front, at the beginning, across all the areas, and we are starting internally with 

FEMA. But we also want to look at and work with our partners, 

6 

because again, as we continue this journey, as I have completed my 

second month and look forward to completing my third, I hope, is 

FEMA is not the team. FEMA is part of a team. 

I think we have to do a better partnership with our Federal partners where they have the expertise in how these programs need to 

be delivered, the needs that we are going to face, particularly when 

it is talking about in this hearing, children, both from their physical needs as well as dealing with emotional and mental support so 

that we reduce that trauma. 

We know that historically in disasters, that in high stress and 

the events that children face, the quicker we are able to get to a 

sense of providing routine, to intervene early, the better the longterm outcome is for those children. Well, that means you cannot 

just look at what FEMA may be able to bring or fund, but look at 

how do we take existing programs that are already every day in 

a community and leverage that, and particularly when we look to 

our Federal partners, their expertise in helping us design programs 

that achieve a change in outcome, not just merely look at an administration of a grant program and hope we get where we need 

to go, but really get our partners to drive that process of how we 

need to structure and put together these programs so we effect real 

change. 

So we have put together and have worked with Secretary Napolitano to form within FEMA a working group whose sole focus is to 

make sure that throughout FEMA, we are addressing children 

issues, from preparedness grants, training, exercising, all the way 

through our response and recovery activities. 

And again, we continue to work on these issues, everything from, 

some of the issues we ran into with unaccompanied children, all 

right, working with the Center for Missing and Exploited Children 

to establish a child locator center, working with some of our programs like Citizen Corps, where we have the Community Emergency Response Team that now has programs designed for teenagers to become involved in that. Also working and looking at how 

we incorporate this across with our State and local partners. 

The day care centers particularly are a challenge, because in a 

hurricane, these are going to be part of the overall—they are closed 

down as children are reunited with their parents before evacuation 

orders are issued. But an earthquake would happen during those 

time frames. We have seen other incidents that have occurred 

when children are in school, and we know that if people don’t have 

good family communication plans and they don’t know what those 

day care centers and schools are doing, it can cause a lot of trauma 

and stress to families as they try to reunite after a disaster. 

So with that, I will conclude my opening remarks and look forward to the questions, ma’am. 

Senator LANDRIEU. Thank you. Admiral Lurie. 

7 

1The prepared statement of Admiral Lurie appears in the Appendix on page 41. 

TESTIMONY OF REAR ADMIRAL NICOLE LURIE, M.D., M.S.P.H.,1

ASSISTANT SECRETARY FOR PREPAREDNESS, U.S. PUBLIC 

HEALTH SERVICE, U.S. DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Admiral LURIE. Good morning, Madam Chairman, and thank 

you, first, for your continued interest in and support of the issues 

that we are here to talk about today. 

As we are coming up on the anniversary of Hurricane Katrina 

and reflect on it, it has been a really good time for us again to reflect on both the strengths and the gaps that remain in our National Emergency Preparedness, Response, and Recovery efforts. 

We all know that throughout this, and as you have pointed out 

and Mr. Fugate has, that children and their families are often the 

most impacted and bear the most long-lasting scars of this. And let 

me say, first, having now spent a lot of time in New Orleans, my 

heart goes out to all of those who continue to suffer through all of 

this. 

What I want to do is talk to you today briefly about HHS’s efforts 

in the last 4 years to address particularly the needs of children, 

with the focus, as you requested, on evacuation, particularly of neonates and obstetrical patients, as well as mental health. 

We all know that preparedness is a critical part of what we do. 

We are completely in sync with Mr. Fugate about the need to plan 

for the entire community, and a community it is, and communities 

are different and we need to plan to their needs. For that reason, 

my office has now more than 30 Regional Emergency Coordinators 

who are actually on the ground in communities, sort of the eyes 

and ears to really know how to plan exactly for those needs. We 

know that, in the long run, this preparedness and planning promotes resilience and enables communities to cope with the emergencies that come upon them. So building community resilience is 

a really important part of what we do. 

By way of example, one of the important programs that we have 

gotten underway over the past couple years are partnerships to 

really look across the population spectrum, as we just heard about, 

and to integrate really at the front end all of the groups that might 

be considered in the vulnerable category, because when you add 

them all up, there are an awful lot of the population that is vulnerable, but kids and pediatric populations often very much rise to the 

top of the list. 

Other kinds of programs that we have developed in response to 

this include training curricula for school crisis teams, disaster communication messaging, and a lot of work to develop programs in 

emotional first aid to early on address those emotional and mental 

health needs of children. And it is important, as we just heard, to 

do that at a developmentally appropriate level, and that means 

across the whole age range of kids as well as adults. 

The National Child Traumatic Stress Network has been really 

instrumental in this regard and launched the Psychological First 

Aid Field Operations Guide immediately after the hurricane. We 

are really proud of the fact that those materials have now been 

picked up and adapted throughout the country. 

8 

On the response side per se, obviously, during an emergency, it 

is critical to support the State efforts to provide quick and competent assistance to everybody, children being no exception. The 

National Disaster Medical System (NDMS), otherwise, I think 

NDMS is the primary Federal program that supports patient care 

and transfer during this evacuation of patients. It has both pediatric and obstetric capacity, and I think since the storms has really 

worked very hard to upgrade its training, its material, and its 

transportation capacity in this regard. So this ranges from specialized equipment to transport teams who are really specially trained 

and capable, and to be sure that all of our teams now have those 

special capabilities involved in them. 

In addition, as I think the Pediatric Disaster Coalition was 

formed by advocates in Planning Region VI, which includes New 

Orleans and the Gulf Coast, and its goals have also been focused 

on not only getting people out, but then identifying the appropriate 

receiving facilities for these children and their families and anyone 

else, and being sure that everybody knows about them, and that 

planning is integrated into community operations plans at every 

level. 

Mental health needs can’t be separated from the rest of other 

children’s response needs, and how we respond early on is going to 

really impact the mental health of children and their families going 

forward. The Crisis Counseling Assistance Program, as is an example of collaboration between HHS and FEMA, as this is administered by the Substance Abuse and Mental Health Administration, 

and has crisis counselors routinely working at all of the places 

where children congregate. 

As a complement, the National Child Traumatic Stress Network 

also has a cadre of rapid response teams that can be mobilized nationally, regionally, or locally after a Presidential directive. 

Recovery is really complex, and I think as we all appreciate, it 

has been really sort of under-attended-to until the storm, and for 

this reason we are very excited about the new directions that 

FEMA is taking and are looking forward to working on the children’s discovery efforts that have just been described. 

HHS also started its own recovery coordination efforts and now 

has Recovery Coordinators identified in each district and a concept 

of operations that integrates many of these stovepiped programs, 

particularly within the HHS family, and we are continuing to work 

on building that out. 

I think that we have made a great deal of progress in addressing 

the needs of children in disasters in the last 4 years. We also have 

a long way to go, and I think we would be the first to tell you that. 

As we look forward to the future, we have a lot of planning and 

preparedness efforts underway. There is terrific research that has 

gotten started over the last 4 years. The challenge now is to take 

what we learned from that research and translate it into practice 

and best practices that are going to help communities all over the 

country and on the ground. 

We are committed to the highest level of planning, response, and 

assistance for recovery for children in emergency events. We are 

most appreciative of the important work that the National Committee on Children and Disasters has done to highlight these imVerDate Nov 24 2008 08:11 Mar 19, 2010 Jkt 053119 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 P:\DOCS\53119.TXT SAFFAIRS PsN: PAT
9 

1The prepared statement of Ms. Bascetta appears in the Appendix on page 57. 

portant efforts. I also want to call out the work of the National Biodefense Science Board, which had a work group focused very specifically and make recommendations for us on the important needs 

and mental health needs of children and their families going forward, and we are now moving forward to integrate a number of 

those efforts, and I think during the Q and A, I will probably have 

an opportunity to tell you more about those things. So thank you 

very much. 

Senator LANDRIEU. Thank you. Ms. Bascetta. 

TESTIMONY OF CYNTHIA A. BASCETTA,1 DIRECTOR, HEALTH 

CARE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE 

Ms. BASCETTA. Madam Chairman, thank you for inviting me to 

testify today about our recent report on barriers to mental health 

services for children in greater New Orleans, and to update you on 

our recommendations to FEMA in its efforts to support States 

faced with the mental health consequences of catastrophic disasters. My remarks will be a reminder of why ASPR and FEMA’s 

commitment to children is so very important. 

As the psychological trauma experienced by so many children in 

the aftermath of Hurricane Katrina increased the incidence of depression, PTSD, risk-taking behavior, and other potentially longlasting behavioral and emotional effects. It is well known that children who grow up in poverty may be at even greater risk of developing mental health disorders, and in New Orleans, the slow pace 

of recovery and the recurring threat of hurricanes may further exacerbate their trauma. 

Against this backdrop, we found persistent barriers to providing 

and obtaining mental health services, although Federal grants are 

helping to address them. Lack of mental health providers was identified as the No. 1 barrier to providing services. HRSA’s designation of the parishes in the greater New Orleans area as Mental 

Health Professional Shortage Areas underscored this barrier, and 

State data showed a large decrease in the number of psychiatrists 

and clinical social workers who received Medicaid and CHIP reimbursement. To help address this shortage, funding from HRSA and 

CMS provided incentives to almost 90 mental health professionals 

who either relocated to or decided to stay in New Orleans. 

The second most frequently identified barrier was sustainability 

of funding. We found that although most of the Federal grants we 

identified existed before Hurricane Katrina, the hurricane-related 

programs have been a key source of support for mental health services for children. Much of this funding is temporary and it is too 

early to know whether sustainability can be achieved by these programs. 

We also reported on barriers to obtaining services for children 

and the top three were a lack of transportation, competing family 

priorities, and concern about stigma. Officials told us that funding 

from several programs had been used to provide children with 

transportation to mental health services, although none of the programs were designed solely for that purpose. Examples include 

10 

1The charts submitted by Senator Landrieu appears in the Appendix on page 93 and 95 respectively. 

Medicaid, the Community Mental Health Services Block Grant, 

and the Social Services Block Grant, as well as SAMHSA funding. 

Similarly, block grants and disaster housing assistance program 

funds were used to help families struggling with housing, unemployment, and other expenses. There was also Federal support for 

case management and referral services designed to help families locate and obtain mental health services for their children, although 

we found a lack of continuous and reliable funding for case management. 

Stigma, as well as transportation and competing family priorities, was addressed by the use of Federal funds to support services 

delivered in schools. During the 2007–2008 school year, nine 

school-based health centers were operating and at least four more 

were in the planning stages. The advantages of the school settings 

are that, first, it is not obvious that students are receiving mental 

health services; second, the transportation problem is solved; and 

third, the financial burden on the family is reduced because parents don’t have to take time off from work and the services are offered at low or no cost. 

Stigma can also be reduced by media campaigns, including the 

one run by FEMA and SAMHSA’s Crisis Counseling Program 

(CCP). We made recommendations to FEMA in February 2008 to 

improve this program by revising its reimbursement policy to pay 

for indirect costs, as it does for other post-disaster response grant 

programs, and by determining what types of expanded crisis counseling services should be incorporated into CCP. Expanded services 

would provide more intensive services, especially in the aftermath 

of a disaster, when provider availability can be limited. And FEMA 

and SAMHSA have allowed the States to develop pilot programs 

along these lines. 

The Department concurred with our recommendations, but has 

not yet implemented them. FEMA also recently concurred with additional recommendations we made to expedite and improve the effectiveness of its case management services. Taking these actions 

expeditiously before the next disaster would improve services for 

children and their families as well as for all adults. 

That concludes my remarks. 

Senator LANDRIEU. Thank you very much. 

I would like to call attention, before I get into the questions, to 

two charts that I think are very telling.1 The first is to my left, 

your right, and you will see the green lines or bars are mental 

health resources in New Orleans in August 2005. So starting from 

the left, emergency rooms in New Orleans, 9; psychiatric beds in 

New Orleans, 350; psychiatric beds in greater New Orleans, 668; 

and then physicians in New Orleans, 617; psychiatrists in New Orleans is the next bar, 196; and number of New Orleans doctors participating in Medicaid, 400. 

Now, when you go to the orange, which is 2 years after the 

storm—you would think you would be well on your way to recovery 

2 years after the storm. We are going into the fourth year. But 2 

years after, in 2007, instead of having 350 psychiatric beds, we had 

11 

1The chart referred to by Senator Landrieu appears in the Appendix on page 95. 

77. Instead of 617 physicians in New Orleans, we had 140. Instead 

of 196 psychiatrists, we had 22. And instead of 400 doctors participating in Medicaid, we had 100. 

Now, just this one chart shows that there is something terribly 

wrong with the system of support at either the local, the State or 

the Federal level, for shoring up the core of mental health stability 

in a community. It is one thing when you don’t have access to mental health because of lack of funding. If you don’t have the professionals to deliver the services, you could just start with this chart 

and work backwards from there. You don’t have enough physical 

beds. You don’t have enough professionals, etc. This is 2 years after 

the storm, when you would think that people would be really trying 

to return after a catastrophe. This isn’t 4 years. This is 2 years. 

And the trauma that occurs in a community struggling with limited services—I want to call your attention to this next chart I 

would like you to put up.1 This is the child care center situation 

as of August 2007, and there are a couple of pretty startling graphs 

here. Again, this is 2 years after the storm. Hundreds of thousands 

of people have fled to Houston and Atlanta. They are trying to get 

back. A year has passed. Their neighborhood has finally been 

cleared of debris. They are coming back to try to build their life, 

and this is what they find 2 years after the storm. 

The blue graph is the number of child care centers in the greater 

New Orleans area that were open before Hurricane Katrina, 275. 

The green is the marker of August 2007, is 100. In Jefferson Parish, that wasn’t as affected, it was 197, and then it was, I think, 

down to 170. 

But this is interesting, very interesting to me. In St. Bernard, 

which is the small little bars on the side, St. Bernard was a parish 

of 67,000 people that was virtually completely destroyed. Only five 

homes survived in the whole entire parish. Before the storm, there 

were 26 day care centers in St. Bernard Parish, a very tight-knit, 

middle-class, working-class community. Two years later, after all of 

our combined efforts, which obviously weren’t enough, they only 

had 2 day care centers open—two in a parish that was completely 

destroyed. 

Now, if we are asking parents to return and rebuild their communities, how is it possible for parents to do that if they only have 

2 day care centers in the whole parish? What do they do? Do they 

strap their children on their backs while they gut their homes? Or 

do they bring their children in and let them sit while the parents 

gut their homes and they can play in the dirt and the nails? I am 

not understanding how we think that the system that we have is 

appropriate in any way, shape, or form. 

So I could show you the statistics 4 years out from the storm, but 

this really grabbed me when I saw that after 2 years of all of our 

efforts, there were 2 day care centers open in St. Bernard Parish. 

Mr. Fugate, how is FEMA working to provide safe places for children, whether it is schools or day care opportunities, while parents 

are struggling to rebuild their communities after a catastrophic disaster, and what would some of your comments be about what you 

have heard this morning? 

12 

Mr. FUGATE. Chairwoman, Mark Shriver, who currently chairs 

the National Commission on Children and Disasters, I think he 

was probably one of my first meetings after I was sworn in, and 

laid out the concerns and issues, many of which you have laid out, 

and asked the same question. What is FEMA going to do about it? 

The easy answer would have been to put another box in there 

and say, we will write a plan for children and that will satisfy 

everybody’s concerns. However, I didn’t think that was going to do 

real change. And so as we talked with Mark and we talked with 

members of the Commission and we had an opportunity to go to 

one of the Commission meetings, I kept asking, we have historically looked at special populations as special as an afterthought, 

and I said, let us try something different. And maybe it is just semantics, but I have got to try this. 

Why don’t we write plans for the community and quit writing 

plans for just one part of the community, the people that can pretty 

well take care of themselves, and really look at what are the needs 

of the community. And as you point out, my experiences in the 

2004 hurricanes, one of the first things we really pushed hard to 

do was to get things like the pre-K and schools open, and there 

were several reasons for that. 

One is we recognized the stress to children going and that we did 

not have the resiliency in the mental health community because 

they were impacted like the rest of the facilities. All three hospitals 

in Charlotte County were shut down. And we knew that if we could 

get schools open, we could bring counselors to the schools and start 

working with children. It wasn’t that we wanted schools back to 

normal. We just wanted to get them open to get children back into 

an environment that would get them into a routine that would both 

get them a chance to start dealing with this, but also give their 

parents a chance to deal with what had happened with their children somewhere safe. 

The challenge has always been when you get into day care that 

it depends upon States and localities, but that can be a quasi-state 

function, local function, or a private investor-owned, and the Stafford Act, again, historically has been looking at what government’s 

responsibilities have been when you look at reimbursement and 

programs. 

So we are working with the Commission, and their report, we are 

saying, we don’t have time for the report. We need to—as soon as 

you guys have identified this, how do we go back in FEMA and 

look at the Stafford Act, look at grants, look at program guidance, 

look at training, to start encouraging and recognizing that children 

from in the home—again, you cannot just do one for all children. 

You have to really look at them developmentally from infants up 

through a certain age and different grades. How do we change 

what we have been doing so that if disaster strikes in the future, 

we are addressing these issues? 

Senator LANDRIEU. OK, and I appreciate that comprehensive look 

and I think it is important. That brings me to your other point 

when you said FEMA is a partner in this effort. Yes, I do believe 

that FEMA is a partner, but I would say that FEMA is the leader. 

FEMA should be the experts on disaster with your other Federal 

13 

partners. FEMA should be the driver. FEMA should be the 

motivator, the communicator. 

I mean, I look at FEMA and Homeland Security as not being the 

only entity that responds after a disaster, but being the lead entity 

that helps to coordinate and manage your other Federal partners, 

gives guidance to your State and local partners, provides technical 

assistance and support to the private sector. But I wouldn’t just 

say that FEMA is just any old partner. FEMA is the lead. 

Two, when we talk about day care centers, part of this is, you 

are right, some of them are nonprofit. And some of them are forprofit. But a good plan that would make sure that Head Start 

teachers and early childhood education teachers and counselors are 

part of that first responder team coming back from rebuilding, 

loans from the Small Business Administration to make sure that 

these day care centers can get the loans they need. 

And think about how difficult it is for a for-profit day care center 

operator under our current laws and current requirements to get 

a $200,000 loan to reopen a day care center. Any bank or even 

under any regular system would look at her and say, why are you 

opening a day care center? There are no children in your parish. 

And she says, ‘‘Well, we will never have children in my parish unless I open and provide a space for them.’’ But she is not—or he 

is not, whoever is running the center—is not deemed creditworthy, 

or their business plan is ‘‘not viable.’’ 

Well, that is true on its face, but that is where the Federal Government has to step up and say, under normal circumstances, you 

wouldn’t lend this person $200,000 to open a day care center where 

there are no children. But under this plan, under a disaster response plan, we are going to require you, basically, to lend the 

money at a lower interest rate and extend out the repayment, or 

if you don’t get a day care center back in this parish, you are not 

going to have a parish back because there have got to be safe 

places for children in order for parents to return. 

And I would submit another thing that is all interconnected, and 

I think, Mr. Fugate, you have hit the nail on the head. But when 

we are trying to encourage doctors to come back, we have lost 

many doctors, we think of them as doctors. We don’t think of them 

as parents. Most of them are probably parents with children. They 

can’t come back if there is not a day care center or a school for 

their children. 

So all of our efforts to rebuild our community are really spinning 

our wheels if that plan, as you said, Mr. Fugate, doesn’t have at 

its essence rebuilding safe places for children, which represent not 

only a special population, but a central population to the families 

that we need to rebuild, I guess is my point. And I just think that 

has really been overlooked. 

They said there has been a vote that has been called, and unfortunately, because I am here by myself, I am going to need to probably call a brief recess and come back. But if the witnesses could 

remain on hand, I am going to go vote and then we will reconvene. 

I have a few more questions for the panelists, and then we will 

move probably right at 11 o’clock or a little bit after to our second 

panel. 

Thank you, and the Subcommittee will stand in recess. 

14 

[Recess.] 

Senator LANDRIEU. Thank you all for your patience. Our meeting 

will now resume. 

I have just a couple of questions, and because of the time, I am 

going to submit the rest of them in writing. But let me just ask 

again, Mr. Fugate, you have heard the GAO recommendations for 

FEMA to modify program rules to allow reimbursement of indirect 

costs and consider expanded services when it comes to mental 

health counseling. How did you receive this recommendation and 

what are your plans to implement it, and if not, what will you do 

as an alternative? 

Mr. FUGATE. Senator, we received them favorably, and this is 

prior to my arrival. We have been working with HHS to go through 

the implementation. We are, I believe, getting to the point of finalizing those and then sending those back out for final comment so 

we can go forward. Again, but we did receive these recommendations favorably. We are working to achieve that, and those are 

things that are still in process. 

But I think it goes back to earlier when I said we are part of the 

team. On behalf of the Secretary and the President, my job is to 

coordinate all the Federal family when a governor requests and receives disaster assistance. But part of that is recognizing that subject matter expertise in existing programs have to be part of that 

response, and that is what I was referring to as we are part of that 

team, is I don’t think FEMA has done a good job of understanding 

and working with our partner agencies to leverage all their programs and we have defaulted oftentimes to merely the Stafford 

Act, which may be appropriate in some cases but may not be the 

most effective way and doesn’t build upon the existing expertise in 

programs that are already in a community. 

And that is again why we are going to use this Children’s Working Group to step back from our traditional, what I call the FEMAcentric approach that is always focused on the Stafford Act, and 

really look at what all the Federal family has and do a better job 

of leveraging those resources as a team so that we know where the 

expertise is, where core competencies exist, and again, with HHS 

and the programs they have dealing with mental health issues, 

particularly designed for children. 

Then how do we leverage the Stafford Act so that we are, again, 

as you show these charts, not having the locals and the State have 

to go through and figure out who has got what, but we can present 

a program that focuses on outcomes, and in this case, particularly 

focus on the outcomes from children as the Federal family, working 

under that authority that the President has vested in FEMA, to 

support a governor and those local jurisdictions. 

Senator LANDRIEU. Well, I agree with that, and I think your 

analysis that it has been a FEMA-centric approach and it needs to 

change to where FEMA is the lead of the team, marshaling the 

other forces, coordinating, being the link and designing the programs, not necessarily assuming responsibility to deliver them all, 

but to have them delivered through partnerships. 

One more question and then I have a few others. In November 

2005, I led the effort, along with Senator Kennedy and Senator 

Enzi—and without the support of these two Senators, I have to say 

15 

publicly, it never would have happened. But Senator Kennedy and 

Senator Enzi led a one-time unprecedented effort to establish basically a plan for the 300,000 children that had been displaced from 

the storm in the week of August 29, which is approaching soon, to 

try to find them a school somewhere in America where they could 

start school on a Monday, the following Monday, because children 

that are out of school for 2 or 3 weeks sometimes have to skip a 

whole year. And under their extraordinary leadership, this plan 

was implemented and basically provided vouchers for up to 300,000 

children to attend school for that year. And as a result, the Katrina 

Class graduated, many of them. 

This was one time, though. Mr. Fugate, are you going to recommend a continuation of this approach, and if so, how, and if not, 

what plan is going to be put in place the next time a catastrophic 

disaster happens? 

Mr. FUGATE. Well, again, that is some of the issues we want to 

raise with our Children’s Working Group. In Florida, our experience was that as many of the families—I think when we looked at 

the FEMA registration, we ended up with about 25,000 families 

that had come to Florida. They weren’t part of any directed evacuation, either through churches or family associations or just coming 

to Florida. We were able to make decisions in the State of Florida 

pretty matter-of-factly that any of these folks that had children 

that were school-aged that wanted to go to school would enroll. We 

did that through our State Department of Education. 

And again, we did this across the board, realizing that at some 

point, we would have to look at how we would come back to our 

Federal partner agencies that provided funding and get funding. 

We didn’t want to take money away from the State of Louisiana, 

but we did recognize that many of these would be additional burdens for our local taxing authorities and how we do that. 

And I think that is one of the things that we want to come back 

and go over, what is the best mechanism, so if a State has children 

coming into their State, or a jurisdiction has children coming in 

from outside of where the taxing base was at, how do we provide 

that assistance without——— 

Senator LANDRIEU. Well, I would suggest, respectfully suggest to 

you, look at this program that seemed to work amazingly well. And 

again, it was a very simple voucher program, up to $7,500 as I recall worth of the cost of a Catholic school tuition, whether children 

left a private school to go to public or public school to private or 

Catholic school, because you have to have a program that snaps 

into place within the first week of the disaster, if it is a catastrophic disaster and it is obvious after a few days of analysis that 

there are no schools to come back to. You have got to have a button 

you press and this program operates. 

Right now, as I understand it, although Senator Kennedy and 

Senator Enzi put this in place for Hurricanes Katrina and Rita, it 

was one time and it is not in place today. So if another catastrophic 

disaster happens this summer and either Texas or Mississippi or 

Alabama is hit and hundreds of thousands of children are displaced, as they were after Hurricane Katrina, we have to start all 

over again and get an Act of Congress to give people a back-up 

plan in the event that their school is destroyed. 

16 

So I only raise this to say that while we have done a lot of talk 

and we have had some actions, there are so many other steps that 

need to be taken. 

One more question to GAO. The GAO recently released another 

report, as you mentioned, on disaster case management programs. 

Case managers are meant to help their clients find job training, 

permanent housing, relief supplies, access to critical services. Particularly after a disaster, case managers can be extremely helpful 

in trying to make sense of things, trying to identify the programs 

that are still operating and out there and making them real for clients. 

What in your study could you share with us about the need for 

case managers? Did we have enough on the ground? How did the 

case management program work generally? I think you testified to 

this. Could you elaborate just a moment? 

Ms. BASCETTA. Yes, I can. Overall, because of the chart that you 

showed with the multiplicity of funding streams, case management 

is really important. It is very difficult for families, especially lowincome families or families under stress, to try to figure out how 

they themselves can put together the package of services that they 

need to stabilize and to regain their self-sufficiency. 

We had two major findings. One was, as we found in the mental 

health area, there was a significant lack of case management providers and also limited referral services. This links back to the fact 

that if there aren’t enough providers in the area, there is nobody 

to refer people to. 

The other major concern was sustainability of funding and 

breaks in funding. There was one situation in which a Federal program was about to make a handoff to the State. The State program 

wasn’t up and running yet. So there was about a 2-month gap in 

case management services when families were unable to access 

anything at all. 

Senator LANDRIEU. Access anything whatsoever. 

Ms. BASCETTA. That is correct. 

Senator LANDRIEU. And I also understand that Catholic Charities, which is a very reputable and large and capable nonprofit, 

stepped forward to provide case management. But under the current law, they were not allowed to recoup indirect costs. So as a 

result, they were basically losing money as a nonprofit trying to deliver services for the Federal and State Government. Is that your 

understanding? 

Ms. BASCETTA. I am not sure I have the details of the situation 

you are describing. I do know that Catholic Charities had dropped 

out as a provider of crisis counseling services because they weren’t 

able to recoup their indirect costs, and this was part of the reason—part of the basis for our recommendation to expedite that reimbursement under FEMA’s rules. 

Senator LANDRIEU. OK. Thank you all very much. I am going to 

ask the second panel to come forward. I really appreciate your participation this morning and look forward to continuing to work with 

you. 

As the second panel comes forward, just to save time, let me 

begin to introduce them. 

17 

1The prepared statement of Mr. Shriver appears in the Appendix on page 67. 

Our first witness will be Mark Shriver, who served as the First 

Chair of the National Commission on Children and Disasters since 

July 2008. The Commission authorized under the Consolidated Appropriations Act of 2008 is tasked with the duty to conduct a comprehensive study that examines children’s needs as they relate to 

all hazards and evaluate existing laws, regulations, and policies 

and programs relevant to the needs of children during and after a 

disaster. He is also Vice President and Managing Director of U.S. 

Programs for Save the Children. He served as a member of the 

Maryland House of Delegates and is not new to this subject. We 

are pleased and honored to have Mr. Shriver with us today. 

Dr. Redlener also serves on the National Commission on Children and Disasters. Dr. Redlener is the President and Co-Founder 

of the Children’s Health Fund, which works to educate the general 

public about the needs and barriers to health care. I want to say 

on a personal note, he really stepped up after Hurricanes Katrina 

and Rita, working through Senator Clinton’s office at the time, to 

give tremendous support and encouragement to us along the Gulf 

Coast and we are grateful, Doctor, for your help and support. 

And finally, Teri Fontenot, President and Chief Executive Officer 

of Woman’s Hospital in Baton Rouge. Ms. Fontenot assumed this 

position in 1996 after serving as a Health Care Finance Operations 

Executive in Louisiana and Florida. She chairs the Louisiana Hospital Association Malpractice and General Liability Trust and is 

leading one of the finest hospitals, in my view, in Louisiana, with 

expertise in birthing and maternity for 8,500 mothers and children 

every year and is the designated hospital in Louisiana to coordinate disaster response for neonates, which is a very special group 

of infants that we need to focus our attention on, during a disaster. 

But let us start, Mr. Shriver, with you. Thank you very much. 

TESTIMONY OF MARK SHRIVER,1 VICE PRESIDENT AND MANAGING DIRECTOR OF U.S. PROGRAMS, SAVE THE CHILDREN, 

AND CHAIRPERSON, NATIONAL COMMISSION ON CHILDREN 

AND DISASTERS 

Mr. SHRIVER. Thank you very much, Madam Chairman, for 

hosting this hearing and for your interest in this issue. I have submitted a longer report, and frankly, you said most of the things 

that I was interested in saying and points to try to get across. 

Just for the record, I am Mark Shriver, Vice President and Managing Director for Save the Children’s U.S. Programs, and Chair 

the National Commission on Children and Disasters. I just want to 

summarize, Madam Chairman, and just say a couple of quick facts. 

The bottom line is that children are 25 percent of the population, 

yet this Federal Government and State governments and really all 

across the board, we have spent more time and energy and money 

focused on the needs of pets in disaster planning response than we 

have on kids. That is 25 percent of the population has received less 

time and focus and resources than pets, and I think that for this 

country in this situation, that is absolutely outrageous. 

Kids, as we all know and as you have eloquently said, Madam 

Chairman, are lumped in under at-risk, vulnerable, or special 

18 

needs populations, and as Mr. Fugate just said, I think what he is 

proposing to do at FEMA through the efforts over there are really 

an exciting first step in the right direction, to try to address children’s needs in a comprehensive and an effective manner rather 

than just creating window dressing, as he already has said. 

A little background on the Commission, Madam Chairman. We 

had our first meeting last year. Our interim report is due in October of this year. Our final report is due to Congress and the President in 2010. We have had a field hearing in Baton Rouge where 

Dr. Redlener joined me down there, as well. We have engaged a 

large community of entities to gather information and try to assess 

where there are gaps in the services, and those folks are not just 

Federal Government, State, and local government, but nonprofits, 

as well. 

I do just want to comment again that what Administrator Fugate 

has started at FEMA is very exciting from the Commission’s perspective and from Save the Children’s perspective and I just want 

to say a couple of quick words on child care. 

You have already had the Save the Children report up there, but 

the issue is critically important, not just from a kids’ perspective, 

which obviously is, I think, paramount, but the fact is that following a disaster, if you don’t have child care facilities, you have 

a loss of economic opportunity, as you have already eloquently stated it. Save the Children’s Disaster Decade Report, which is up 

there, shows that only seven States meet the basic requirements 

for licensed child care providers to have basic written emergency 

plans in place addressing evacuation, reunification, and accommodating children with special needs. Seven States in this country 

have the basic minimums in place. That, too, I think is absolutely 

outrageous and should be addressed through—can be addressed 

through Federal legislation, and some of the steps that we are proposing are in my written statement, Madam Chairman, but I will 

just highlight a couple of them. 

Mr. Fugate talked about the Stafford Act and the importance of 

creating child care or saying that child care can be deemed an essential service. Clearly, we are very supportive of this concept. We 

think that funding is necessary for the establishment of temporary 

emergency child care and recovery of child care infrastructure. 

The Child Care Development Block Grants are being authorized, 

Madam Chairman, as—and we would propose that during that reauthorization—that State child care plans include guidelines for recovering temporary emergency child care operating standards after 

a disaster, that be made a requirement, and that States also are 

required to have child care providers have comprehensive all-hazard plans that incorporate specific capabilities such as shelter in 

place, evacuation, relocation, family reunification, staff training, 

continuity of services, and accommodation of children with special 

needs. The Federal Government has the ability to put these requirements in the Child Care Development Block Grant reauthorization and we encourage you to look into that, Madam Chairman. 

I know time is of the essence, so I will just wrap up by saying 

that a lot of the ideas that you and your staff have been working 

on and mentioning today are critically important, and I would only 

encourage you, as the Chair of this Commission and as a member 

19 

1The prepared statement of Dr. Redlener appears in the Appendix on page 71. 

of the nonprofit community, to follow up, to follow up, and to follow 

up again. If you don’t hold everyone’s feet to the fire, kids, because 

they don’t vote, and particularly poor kids, are not actively engaged 

in the political process. You are their voice, and if you do not stand 

up and your staff doesn’t follow up diligently with all levels of the 

government, they will, unfortunately, suffer from benign neglect, 

which is what David Paulison told me has been the modus operandi in the past, and that benign neglect, I don’t think, is the way 

that this country should be acting for poor children and especially 

vulnerable poor children across the country. 

So thank you, Madam Chairman. 

Senator LANDRIEU. Thank you, Mr. Shriver. I appreciate it. 

And I want to note for the record that Administrator Fugate has 

stayed for the second panel and I would like that to be noted. It 

is important to me that he didn’t testify and leave, but he is staying to hear these comments and I appreciate it. Thank you, Mr. 

Fugate. 

Doctor Redlener. 

TESTIMONY OF IRWIN REDLENER, M.D., PROFESSOR,1 CLINICAL POPULATION AND FAMILY HEALTH, AND DIRECTOR, 

NATIONAL CENTER FOR DISASTER PREPAREDNESS, MAILMAN SCHOOL OF PUBLIC HEALTH, COLUMBIA UNIVERSITY, 

AND PRESIDENT, CHILDREN’S HEALTH FUND 

Dr. REDLENER. Thanks, Madam Chairman, and again, I just 

want to echo our great appreciation for you holding these hearings 

and learning more about this terribly difficult problem that we are 

facing. 

So I am a pediatrician, as you noted. I am President of the Children’s Health Fund, but I am also Director of the National Center 

for Disaster Preparedness at Columbia University, and I have the 

honor of serving on the National Commission and chair there the 

Subcommittee on Human Services Recovery. 

By way of background, shortly after Hurricane Katrina, and 

working with local officials, we dispatched seven of Children’s 

Health Fund’s fully contained mobile pediatric clinics and professional teams to the Gulf to provide acute medical and mental 

health care for survivors and evacuees, and eventually those became permanent programs which are still there in the Gulf, in Mississippi and Louisiana, affiliated with LSU, Tulane, and other institutions. But to date, for the record, we have seen over 60,000 

health and mental health encounters in children. 

In addition to that, the National Center, my Center, has conducted long-term periodic interviews with a cohort of 1,000 families, and I just want to summarize a couple of the key points out 

of many that I think are germane to our discussions today. This 

comes from our clinical information and our studies. 

So more than three in five parents have felt now, over time, that 

their general situation currently is either uncertain or significantly 

worse than it was before Hurricane Katrina. 

Second, approximately a third of displaced children are at least 

one year older than appropriate for their grade level in school. 

20 

Third, according to interviewed parents, more than two-thirds of 

children displaced by the hurricanes are experiencing emotional or 

behavioral problems as we speak, and in a study last fall of our 

program in Baton Rouge, 41 percent of children were found to have 

iron deficiency anemia, a third had impaired hearing or vision, and 

55 percent were reported to have behavior or learning difficulties. 

And as far as the overall situation for children is concerned, and 

to give some sense of scale, I believe that the number of disasterrelated excessively vulnerable children right now, 4 years after 

Hurricane Katrina’s landfall, is unacceptably high, with some 

17,000, at the minimum, to, in my opinion, over 30,000 children 

still in limbo and still at substantial risk. In fact, many children 

who are now developing chronic emotional problems or who are 

failing in school will not easily recover. We are undermining not 

just their current well-being, but their future potential, as well. 

In my opinion, the overall management of the recovery process 

from the hurricanes in the Gulf, while less visible than the images 

seen around the world of people waiting on their rooftops for rescue, has been more mishandled than the initial response to the disaster. The extraordinary failures of recovery and the persistence of 

trauma and profound disruption to children have been far more insidious and invisible than the acute situation. 

Unfortunately, the failures of recovery have lost the attention of 

the media, for the most part, the public, and, I am sorry to say, 

perhaps many in government, as well. 

The basic concept of long-term recovery is fraught with confusion 

and lack of leadership on every level. There is a lack of clarity of 

what we even mean by the term recovery. That is, are we talking 

about rebuilding physical environment or working to help families 

reestablish conditions of normal life as rapidly as possible? 

Although a National Disaster Recovery Strategy was mandated 

under the Post-Katrina Emergency Management Reform Act of 

2006, that strategy has yet to appear. That said, I believe that 

under new and highly motivated and capable leadership now at 

DHS and FEMA and HHS, we are hopeful that we may soon see 

the emergence of this critical road map. 

Until very recently, there has been no apparent recognition that 

the needs of children must be understood and absorbed in all aspects of disaster response, planning, mitigation, and recovery, and 

we think this is changing, as well, as Mr. Shriver was just pointing 

out. 

But perhaps most egregious of all, there is a growing sense, and 

I consider it a monumental misunderstanding, that recovery from 

large-scale disasters is a local problem to be solved and managed 

by States and local jurisdictions. But the destruction at the level 

we saw in the Gulf post-Hurricanes Katrina and Rita and the 

flooding of New Orleans was and remains a national problem. The 

well-being of the affected States is highly material to the wellbeing, the economy, and indeed the security of the United States. 

So I want to just conclude with a few general recommendations, 

and then a couple of points just to emphasize what Mr. Shriver 

was saying about children. So in general—I have dozens of these, 

but let me just hit three of them. 

21 

Senator LANDRIEU. That is OK. Take another minute or two. We 

appreciate it. 

Dr. REDLENER. So, first of all, the National Disaster Recovery 

Strategy must be completed as rapidly as possible, and preferably, 

were I you, I would ask for that by the end of this calendar year. 

There is absolutely no reason why that needs to be delayed any 

more than that, and if we don’t have that, we are going to be still 

flailing around and trying to understand who is doing what for 

whom in the issue of long-term recovery. 

Second, I would strongly recommend a high-level directorate reporting to the President that needs to be established to oversee and 

coordinate all relevant Federal assets and agencies with respect to 

long-term recovery. I mean rebuilding, and I also mean revitalizing, sustaining, and protecting the needs of children and families 

during this terrible, difficult transition. 

Third, recovery must be seen as responding at every level to 

these human services needs during the recovery transition, and we 

would like to see how this National Recovery Strategy actually addresses them. 

And then some of the other issues around children which represent, to me, the most dangerous problem that we are facing right 

now, because as I said before, the problems will not be sometimes 

at all reversible. Children that lose a year or two in school cannot 

be recaptured in terms of their academic success. Emotional problems rooted in 4 years of trauma—and by the way, we think it will 

take another 2 years to get everybody housed, if, in fact, we have 

housing available—those children, we ignore at their peril and our 

peril. 

So I have been thrilled to be on the National Commission with 

Mr. Shriver and here are a couple of things I would just point out. 

The National Recovery Strategy, when it develops, should have 

an explicit emphasis on safeguarding the health, mental health, 

and academic success of displaced children. This addresses the 

point you raised before. It cannot be ad hoc. It has to be part of 

our basic understanding about how we deal with recovery for this 

disaster and anything else that happens in the future. It may be 

a storm in the Gulf. It could be terrorism in New York. It could 

be an earthquake in San Francisco. We don’t want to be redoing 

this and we need that road map. 

Second, the Federal Government must assure a robust, uniform, 

and accountable case management program for every child displaced by a major disaster. I don’t have time to go into it, but I 

had to medicate myself in order just to absorb the complexity and 

dysfunctionality of what our country called case management in 

the aftermath of this disaster. It is shameful. 

And third, I would say that the health, dental, and mental health 

services for every displaced child should be assured and funded 

under a ‘‘medical home’’ comprehensive care model. And again, this 

is because somebody has got to take responsibility for not permitting children to fall through the cracks. They can’t afford the 

delays and the interruptions in their safety net. 

So I think I am going to leave it at that and would be happy to 

respond to any questions. But again, our profound gratitude to you, 

Senator, for taking and keeping the leadership on this vital issue. 

22 

1The prepared statement of Ms. Fontenot with an attachment appears in the Appendix on 

page 77. 

Senator LANDRIEU. Thank you, Doctor Redlener. Ms. Fontenot. 

TESTIMONY OF TERI FONTENOT,1 PRESIDENT AND CHIEF EXECUTIVE OFFICER, WOMAN’S HOSPITAL, BATON ROUGE, 

LOUISIANA 

Ms. FONTENOT. Madam Chairman, it is a privilege to come before 

you today to describe our hospital’s response to the evacuation and 

care of critically ill patients in the horrific aftermath of Hurricane 

Katrina, our preparations for Hurricanes Rita, Gustav, and Ike, the 

important lessons learned, and our recommendations for emergency 

management and medical treatment of neonates. 

Woman’s Hospital is 70 miles northwest of New Orleans and a 

2-hour drive from the Gulf Coast. Hospitals are usually a place of 

refuge rather than a complex evacuation site, so the need to evacuate one or a whole city of hospitals had not been considered. But 

in the catastrophe of Hurricane Katrina, Woman’s Hospital did just 

that, by evacuating 122 infants from flooded hospitals in New Orleans in 4 days. 

Working with our heroic colleagues in New Orleans under 

unfathomable conditions, not one transferred baby or mother died. 

Unquestionably, this remarkable achievement was the result of 

dedication and hard work by thousands of people, not because of 

carefully crafted and effective planning. 

In fact, the chaos was overwhelming. Blackhawk helicopters 

brought men, women, and children day and night to our hospital. 

We received, stabilized, and transferred many patients to other facilities. But the most critically ill infants and women remained at 

Woman’s Hospital. For a month after Hurricane Katrina, we cared 

for twice the usual number of critically ill infants and delivered 150 

babies from the affected areas. For several days, there were 125 infants in our 82-bassinet neonatal intensive care unit. We also received and provided care for over 1,100 other patients and worked 

with area churches to provide shelters for 110 newly delivered 

mothers and families because they were rejected at governmentrun and Red Cross shelters. 

What began as a rescue became a response to their overwhelming needs beyond medical care. This feat was successful because of our incredibly dedicated staff and expansion to our neonatal intensive care unit that was completed just weeks before 

Hurricane Katrina, and a drill held early in 2005 that yielded valuable information about needed equipment and processes. Fortunately, the rescue was adequate, but coordinated planning by all 

agencies involved could have vastly improved the response. 

Hurricane Rita came 3 weeks after Hurricane Katrina. For Hurricane Rita and each storm since that time, neonates and high-risk 

obstetrical patients were evacuated to Woman’s Hospital from hospitals before the storm, a key lesson learned. 

In early 2006, providers of obstetrical and neonatal services 

throughout Louisiana convened and produced a plan for emergency 

management of neonates. We also contacted neighboring States to 

discuss evacuation, especially if Baton Rouge became the disaster 

23 

site, since no other hospital in our State has the capacity to take 

our large number of NICU patients. We took part in research with 

Tulane University to study the effects of the stress of the storms 

on maternal and infant outcomes, and we are the officially designated provider for infants in Louisiana’s Medical Institution 

Evacuation Plan. In short, we are committed to anything and everything that will prevent the chaos of Hurricane Katrina. 

Hospitals in Louisiana have strengthened their infrastructure 

and plan to shelter in place, with the notable exception of especially fragile patients, such as ill newborns. Those hospitals still 

depend on us to transport and care for their patients. 

Woman’s Hospital’s performance after Hurricane Katrina and the 

three hurricanes since that have threatened the Louisiana coast 

demonstrate that an expert organization with adequate capacity is 

critical for the emergency management of certain populations of 

fragile patients. The expert hospital is the coordinator of care and 

has capacity to care for displaced infants. Named Operation Smart 

Move, it is an initiative to ensure that infants and mothers 

throughout the Gulf Coast have a safe place, as well as a network 

of care and services to mitigate the devastating stress and overwhelming anxiety of recovery. 

A remarkable opportunity exists to further implement these concepts as we build a replacement hospital. Surge capability was included in the original design, but was removed due to the high interest rates on tax-exempt debt and deep Medicaid cuts to hospitals. Building stand-by and surge capacity is now unaffordable 

for us and most hospitals, even though the hospitals in Louisiana 

have counted on us three times in less than 4 years to fulfill this 

need. Financial support for the capital and stand-by costs for hospitals to be ready at all times is critical for proper disaster preparedness. 

The relocation of our hospital to a new campus will provide a 

unique learning opportunity. Representatives from hospitals like 

Woman’s from across the Nation will participate in a real-time 

evacuation drill as our NICU is moved from one campus to another. 

Another recommendation is the amendment of the Stafford Act 

so that private organizations will qualify for reimbursement of 

costs associated with evacuation. Many private organizations assist 

or replace governmental agencies before, during, and after disasters, yet are prohibited from directly receiving FEMA funds. 

Your concern about the impact of disasters on children is appropriate and important. On behalf of the staff of Woman’s Hospital, 

we are honored to share our experience and knowledge to improve 

the response and care of our most vulnerable citizens. 

I will close with a special thank you for your ongoing support of 

Woman’s Hospital, Operation Smart Move, and the opportunity to 

speak today, and I look forward to answering any questions. Thank 

you. 

Senator LANDRIEU. Thank you very much, Ms. Fontenot. We appreciate your leadership. You continue to make this Senator very 

proud of the work that you are doing. 

We will only have one question for each of you because of our 

time limitations. Let me, Ms. Fontenot, start with you, if you could 

24 

just restate two points for the record. One, despite the fact that 

your hospital did such extraordinary work in the storm, could you 

say again for the record what the current law allows you to get in 

terms of reimbursement? I understand that you are a private facility, so therefore while the government depended on you to help in 

so many ways, that you are not in line for any reimbursement. 

Could you explain that just a moment? 

Ms. FONTENOT. My understanding is because we are not a governmental agency, that we are not able to receive funds directly 

from FEMA, that we have to have a contract with the State for any 

type of service that we provide and it goes through the State as the 

fiscal intermediary. 

Senator LANDRIEU. And could you talk a minute about the surge 

capacity issue, because as we debate the health care bill and how 

we may reshape the health care delivery system for the country, 

I think this would be important. So again, if you could just comment about the lack of surge capacity. 

Ms. FONTENOT. Thank you. Most hospitals are faced with cuts 

because of inadequate reimbursement, and particularly Medicaid, 

which, of course, that is the primary payer for children and particularly infants. Sixty percent of the babies in our NICU are covered by Medicaid. Half of the deliveries in our hospital are covered 

by Medicaid, and two-thirds are covered in our State by Medicaid. 

So whenever there are Medicaid cuts, as there have been announced just this week in Louisiana, and, of course, that is being 

repeated around the country, hospitals are not able to provide the 

financial support for additional beds to be on stand-by, or equipment or supplies or planning or any of those things. Any reimbursement they receive has to go directly for the core medical services, and that is taking care of those babies that are in the hospital 

that day without being able to have anything on the side, so to 

speak, so that we can be surge hospitals, or expert hospitals, for 

that matter, because it is very expensive to have the planning and 

the drills and that sort of thing. 

Senator LANDRIEU. Thank you very much. 

Mr. Shriver, let me ask you if you could sum up, besides the excellent recommendation that a strategy be enacted by the end of 

the year and a requirement put down to receive that strategy, and 

that the Child Block Grants not be reinstated without the requirement that States step up to at least have evacuation, reunification, 

special needs, and written procedures for disaster planning, are 

there one or two other specific suggestions that you would like to 

mention that you think from your study and review should be really at the top of our list to address in the next few weeks and 

months? 

Mr. SHRIVER. Well, I think, as Dr. Redlener mentioned, coming 

up with the national framework for recovery is critically important. 

I think, honestly, Senator, if you look at the Child Care Development Block Grant and can put those requirements in there, you 

come up with a recovery framework in the next 51⁄2 months and 

you have all child care facilities in this country looking at the issue 

of reunification, an evacuation plan, making sure that children 

with special needs, that their needs are incorporated into their 

planning and that is tied in with the local emergency management 

25 

community, I would consider that a hugely successful 51⁄2 months. 

I think that would be fantastic. 

I think the issue that Administrator Fugate talked about regarding the Stafford Act and having those child care facilities be reimbursed, I know there are some intricacies involved in that, but I 

think if you can address that issue and come up with recommendations and funding for that, I think that would be hugely successful. 

And I think, frankly, if you could have another hearing to make 

sure that we are all doing what we are supposed to be doing, that 

would make the next 51⁄2 months be very successful. 

Administrator Fugate, to his credit, at the first meeting we had 

said about halfway through it, what do you need, and we rattled 

off a couple of the recommendations we had put here, and he and 

the Secretary are working aggressively on that and he has set up 

meetings every 30 days to gauge progress or lack thereof. 

So if you and this Subcommittee could look at and have another 

hearing and hold our feet to the fire and the Executive Branch’s 

feet to the fire, that would make the next 51⁄2 to 6 months highly 

successful, as well. 

Senator LANDRIEU. Thank you very much. 

Doctor, you said that the case management—I think you would 

say—I am putting these words in your mouth—you would hardly 

call it case management. It was not really managing much of anything, so fragmented and unable to deliver in a timely, appropriate 

way. When we think about creating a new kind of system, I read 

in some of GAO’s and RAND’s recommendations that part of the 

delivery system might be done through the schools after they reopen through school-based counseling services. Do you want to 

comment on that? Should there be opportunities community-wide, 

and what is it about school-based counseling that you think is particularly desirable? 

Dr. REDLENER. Well, first of all, we have to have a system that 

makes sure that every child who is school-age is in school and kids 

that are preschool-age are in appropriate day care facilities and 

that there are after-school programs. So the school and the related 

institutions, can become the basis of stability for lots of families, 

and especially lots of children. So from that point of view, if we 

could have services emanating out of that model, so every child is 

in school, every child has a family, and it is possible to think about 

a system that would mandate not only the kids being in school, but 

that appropriate safety net programs and assistance for the families be generated by that relationship, as well. 

And I want to say one other word about the case management 

issues. There were lots and lots of very good people doing case 

management in the Gulf who still are—Catholic Charities, the 

other organizations that are down there that are governmental and 

non-governmental. The problem is it is so fragmented and disorganized and competing case management programs that many families are just slipping through the cracks. 

So I just want to clarify that lots of good work was done. It is 

just that far too many—in fact, we don’t even know how many children—getting the numbers that I cited, 17,000 to 30,000, was one 

of the most difficult challenges I have had in research in 20 years 

26 

because there isn’t a single agency that feels itself as responsible 

for tracking these families who have been displaced. 

So if we start with that, we have an inability to even figure out 

how many or where they are. We begged them—this is FEMA and 

the State—to make sure that no families were discharged from 

those horrendous trailer parks before we knew who they were and 

where they were going so we could provide services to them. But 

all sorts of bureaucratic snafus between the Federal Government, 

the State Government, and then the private agencies delivering 

services yielded, first, that one of the largest case management programs never got implemented, not one dime out of the original $33 

million was spent, I guess, until very recently, and second, we 

couldn’t track families. We have no idea where they are. I don’t 

know where all those kids are that you cited that were part of the 

evacuees. 

I would challenge the Federal Government to try to figure out, 

where are they? How many are in Houston or in Mobile, Alabama, 

and so forth, and how many are still struggling, in limbo, in displacement conditions that are really hurting these children and 

their opportunity for success. 

Senator LANDRIEU. OK. Thank you so much. 

I would like to just close with a couple of comments. One, the 

Louisiana Family Recovery Corps, I understand, delivered some 

very good work. 

Dr. REDLENER. They did. 

Senator LANDRIEU. Unfortunately, their contract was not able to 

be renewed and I hope that they can be called in for comments as 

we try to come up with a better system. 

And my final comment is, from my own personal experience, not 

only in my own family experience recovering from the disaster—as 

you all know, I am one of nine siblings and four of my brothers and 

sisters lost their homes and their children were displaced, so 

watching it up close and personal within my own family, and then 

expanding that out to our own neighborhood, Broadmoor, which 

was destroyed, and then out to the community, I have concluded 

one thing that I know without reading one report, that schools became the center of life when those neighborhoods were struggling 

to come back. Whether it was Saint Dominic’s or Holy Cross or Wilson Public School that is getting ready to open, or Lusher that 

opened, it became the only stable place, building, in a neighborhood 

that is completely destroyed. 

And the government at its own peril fails to recognize the importance of these schools. They brought stability to the life of parents 

that otherwise had no stability. They needed to turn from just 

schools to community centers that provide counseling and medical 

support, particularly when your hospitals are closed. Getting your 

schools open, getting children back in touch with their teachers, 

which is a familiar face at that moment, is very significant to children that have had such trauma. 

It is just—I can’t overestimate and overstate how important this 

is, and the Federal Government that doesn’t recognize the importance of schools, be they public, private, Catholic, or independent, 

and the ability of schools to be sort of step-in-the-gap until the rest 

of the community comes back, I think is kind of the model that I 

27 

envision. And the celebration of joy, that when a school would open 

in a neighborhood, what it meant to that community cannot be 

overestimated. 

So I would like to end with that. We have a great deal of challenge before us. The Subcommittee record will stay open for 15 

days. Please, anyone can submit information for the record, and we 

will, Mr. Shriver, take you up on your strong recommendation to 

hold people accountable for the outcomes that we have discussed 

today. 

Thank you all very much. The hearing is adjourned. 

[Whereupon, at 11:43 a.m., the Subcommittee was adjourned.] 

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