Hurricane Katrina struck the Gulf Coast in late August 2005, causing extensive wind damageand catastrophic flooding, and leading to Presidential disaster declarations for Alabama, Florida,Louisiana and Mississippi. The storm was one of the worst natural disasters in the nation's history. Hurricane Rita, which made landfall along the Gulf Coast in late September 2005, was somewhatless severe than Katrina when it hit. But a few days earlier in the Gulf it had been a powerfulcategory five hurricane. Government officials and citizens shaken by the devastation of the earlierstorm mounted aggressive preparedness efforts in anticipation of Hurricane Rita, drawing on lessonslearned from Katrina just weeks earlier. Hurricane Katrina is estimated to have killed more than 1,200 people, and displaced about2 million. The death toll continues to be revised, as bodies continue to be found, and investigationsinto the causes of death of others continue. (1) More than 4,000 persons are still reported missing. The FederalEmergency Management Agency (FEMA) recently increased its estimate of the number of personsdisplaced by Hurricanes Katrina and Rita to about 2 million. (2) The logistical hurdles posed by Hurricane Katrina were formidable. Communications wereknocked out in hard-hit areas, which compromised the process of assessing and prioritizing needs. Physical access was blocked in some areas, and civil disorder was a problem in some others. Eachkept responders from delivering aid. In some cases, victims were isolated without water andmedicines, and hospitals that had not been evacuated before the hurricane were unable to sustainoperations. Each circumstance required the emergency evacuation of critically ill patients to a triagecenter, which then itself became overwhelmed. Federal, state, and local governments, businessesand corporations, the faith community and other volunteers all pitched in to speed relief to Katrina'svictims, but keeping all of it coordinated was a challenge. Responding to a catastrophe of the scope of Hurricane Katrina requires that a variety ofpublic health and medical activities be carried out and coordinated. Public health activities are thosethat identify, address or prevent health problems in populations. Examples include assuring thesafety of food and water, preventing the spread of disease in shelters, evaluating the safety ofneighborhoods for rehabitation, and assuring the health and safety of responders. Medical activitiesare those that deliver healthcare services to individuals. Examples include treatment of injuries,continuity of care for those with chronic illnesses, mental health counseling, and cause-of-deathinvestigation. The medical response to Hurricane Katrina may have posed the greater challenge. The publichealth response required the coordination of variety of agencies, community-based organizations,and private parties at different levels of government, though these entities had generally workedtogether in the past. The medical response, in contrast, required the coordination of a broader mixof federal, state and local government agencies, private parties and others, with no comparable recentprecedent or experience in such an effort on this scale. Over the past decade, in response to the Oklahoma City bombing, the terror attacks of 2001and several serious natural disasters, Congress and the Administration created new authorities,structures and plans to assure that government at all levels can respond well to disasters likeHurricane Katrina. Local and state governments are to be the first responders in a disaster. Whentheir resources are overwhelmed, federal assistance is provided under the Robert T. Stafford DisasterRelief and Emergency Assistance Act (the Stafford Act) and other authorities. A new NationalResponse Plan (NRP) places the Secretary of Homeland Security in charge of coordinating theoverall federal response. The Secretary of Health and Human Services (HHS) is in charge ofcoordinating the federal public health and medical response during a disaster. In the wake of Hurricanes Katrina and Rita, Congress is likely to review response efforts,recent public health preparedness laws and the NRP. While even the best plan and response maybe overwhelmed in a disaster of the scope of Hurricane Katrina, Congress may nonetheless findopportunities to revisit management structures, programs and goals in order that national responsecapability can be steadily improved. This report will discuss relevant authorities and response plans that guided the public healthand medical response to the 2005 hurricanes. Given its catastrophic scope, the response to HurricaneKatrina will be the primary focus of this report, with reference to the Hurricane Rita response whenrelevant. The roles and response activities of selected agencies in HHS and DHS will be discussed.Finally, a number of policy issues will be discussed. This report will be updated as circumstanceswarrant. For a broader discussion of all-hazards public health and medical preparedness, see CRS Report RL31719 , An Overview of the U.S. Public Health System in the Context of EmergencyPreparedness . The Stafford Act authorizes the President to issue major disaster and emergency declarations,whereupon federal agencies are authorized to provide assistance to affected states. (3) Through executive orders, thePresident has delegated to the Federal Emergency Management Agency (FEMA), within DHS,responsibility for administering the major provisions of the Stafford Act. In calendar year 2005,President Bush issued 48 major disaster declarations, including those for Alabama, Florida,Louisiana, and Mississippi for Hurricane Katrina, and for Texas and Louisiana for HurricaneRita. (4) Activities undertaken under authority of the Stafford Act are provided through fundsappropriated to the Disaster Relief Fund (DRF). Federal assistance supported by DRF money is usedby states, localities, and certain non-profit organizations to provide mass feeding and shelter, restoredamaged or destroyed facilities, clear debris, and aid individuals and families with uninsured needs,among other activities. Federal agencies that receive mission assignments from DHS and provideassistance pursuant to the NRP are also reimbursed through funds appropriated to the DRF. Inaddition to the FEMA assistance authorized by the Stafford Act, a wide range of aid is provided byother federal agencies under their general statutory authority. The National Response Plan (NRP) is the framework under which federal and voluntaryagencies are instructed to operate when a disaster occurs. (5) The NRP was released by DHS in December 2004, replacing theprevious Federal Response Plan. The NRP is an administrative plan and does not establish newfederal authorities. In general, federal responsibilities in the plan are intended to assist state andlocal authorities, not to replace them. According to the NRP, which is under the overall coordination of the Secretary of HomelandSecurity, the Secretary of HHS is tasked with Emergency Support Function (ESF) #8, thecoordination of public health and medical services, as laid out in the plan's ESF#8 annex. (6) HHS is responsible forcoordinating the following activities under ESF#8, and may request assistance from 14 designatedsupport agencies and the American Red Cross as needed: Assessment of public health and medical needs; Health surveillance; Medical care personnel; Health and medical equipment and supplies; Patient evacuation; Patient care; Safety and security of human drugs, biologics, and medical devices, veterinarydrugs, and other HHS-regulated products; Blood and blood products; Food safety and security; Agriculture safety and security (principally with regard to food-producinganimals and animal feeds and drugs); Worker health and safety; All-hazard public health and medical consultation, technical assistance andsupport; Behavioral health care; Public health and medical information; Vector control (e.g., control of disease-carrying insects androdents); Potable water, wastewater and solid waste disposal; Victim identification and mortuary services; and Protection of animal health (principally with regard to HHS-regulated animalfeeds and drugs). The HHS Concept of Operations Plan (CONOPS) for Public Health and MedicalEmergencies outlines how HHS plans to implements its emergency preparedness and responseauthorities and establishes the department's policies for emergency preparedness and response. (7) The CONOPS plan designatesthe Secretary of HHS as the official responsible for the overall response to public healthemergencies. The Assistant Secretary for Public Health Emergency Preparedness (ASPHEP) is toact on behalf of the Secretary to direct and coordinate the department's efforts, including on-sceneoperations and liaison with the DHS and other federal agencies. The plan lays out additionalresponsibilities of HHS offices and agencies during an emergency. (8) HHS does not bear primary responsibility for mass care, which is the coordination ofnon-medical services such as shelter, feeding, emergency first aid, and efforts to reunite displacedfamily members. Mass care is the responsibility of DHS and is carried out by FEMA and theAmerican Red Cross according to ESF#6. HHS is also not responsible for urban search and rescue, which is also the responsibility of DHS and FEMA pursuant to ESF#9. Furthermore, HHS maydepend on numerous other agencies to carry out certain of their ESF activities (e.g., public safety,road clearing and power restoration) before some ESF#8 activities can commence. Many of HHS's responsibilities under ESF#8 are within the department's primary control. An important exception is the National Disaster Medical System (NDMS), which comprises teamsof medical professionals who are pretrained to deploy and provide medical services in the immediateaftermath of a disaster before other federal assets arrive. NDMS, which previously operated underthe Public Health Service in HHS, was transferred to DHS in the Homeland Security Act of 2002( P.L. 107-296 ), and now operates under FEMA. NDMS will be discussed in greater depth insubsequent sections of this report. Certain other critical components of the medical response arehoused in the Departments of Defense and Veterans Affairs, and the private sector. Absent an emergency, most public health authority, such as mandatory disease reporting,licensing of healthcare providers and facilities, and quarantine authority, rests with states as anexercise of their police powers. Most states have considerable powers in responding to public healthevents, and most can also declare public health emergencies to expand their powers further whenneeded. (9) The federal roleis largely assistive through the provision of funding, additional personnel, and specialized servicessuch as laboratory testing and surveillance. This model does not change substantially inemergencies, though there are statutory provisions for some specific emergency expansions offederal public health authority. Section 319 of the Public Health Service Act provides broad authority for the Secretary ofHHS to declare a public health emergency at the federal level. Following the 2001 terror attacks,Congress updated this authority in the Public Health Security and Bioterrorism Preparedness andResponse Act of 2002 ( P.L. 107-188 ). One provision in the bioterrorism act allows the Secretary,during a public health emergency, to waive certain requirements for provider participation in servingindividuals enrolled in Medicare, Medicaid and the State Children's Health Insurance Program(SCHIP.) (10) Otherwise,the statutory authority for a federal declaration of a public health emergency rests in broad language,as follows: If the Secretary determines, after consultation with suchpublic health officials as may be necessary, that -- (1) a disease or disorder presents a public healthemergency; or (2) a public health emergency, including significantoutbreaks of infectious diseases or bioterrorist attacks, otherwise exists, the Secretary maytake such action as may be appropriate to respond to the public health emergency, including makinggrants, providing awards for expenses, and entering into contracts and conducting and supportinginvestigations into the cause, treatment, or prevention of a disease or disorder as described inparagraphs (1) and (2). (11) The declaration expires upon the Secretary's determination that an emergency no longer exists, orin 90 days, whichever comes first, but is renewable upon the Secretary's finding that an emergencypersists. In response to Hurricane Katrina, the HHS Secretary Michael Leavitt declared public healthemergencies in Alabama, Florida, Louisiana and Mississippi on August 31, 2005, two days after thestorm made landfall along the Gulf Coast. On September 4, as thousands of evacuees from thedevastated city of New Orleans began arriving in Texas, the Secretary declared a public healthemergency in that host state. The additional host states of Arkansas, Colorado, Georgia, NorthCarolina, Oklahoma, Tennessee, West Virginia, and Utah were declared by the Secretary onSeptember 7. On December 31, HHS Secretary Leavitt renewed the determinations of public healthemergency for all Katrina-affected states through January 31, 2006. (12) On September 23, inanticipation of Hurricane Rita's landfall the following day, the Secretary declared public healthemergencies in Texas and Louisiana. These declarations have since expired. (13) Prior to Hurricane Katrina,the only recent incident for which a federal public health emergency had been declared was the terrorattack of September 11, 2001. That declaration applied to all states. There is no additional statute or regulation that clarifies this authority with regard tostipulating thresholds or conditions of the determination. The decision to declare emergencies incertain host states in response to Hurricane Katrina, but not in all states, appears to be an exerciseof the Secretary's discretion. There is also no precedent for this authority to be used to supercede orassume public health authorities that are generally reserved to states, though the Secretary does havespecific emergency authorities elsewhere in statute, such as the authority to impose domesticquarantine restrictions when warranted. (14) Federal leadership for public health emergency response rests with the Secretary of HHS,with important responsibilities in the Office of Public Health Emergency Preparedness (OPHEP) andthe Centers for Disease Control and Prevention (CDC). Much of the support provided by HHS to affected states and communities could normallybe provided in the absence of federal or state declarations of public health emergencies or disasters,through assistance mechanisms that are used regularly in response to public health threats such asoutbreaks of foodborne disease. Because there has been a presidentially-declared disaster and HHShas received mission assignments from DHS in the wake of Hurricanes Katrina and Rita, the costsof HHS response activities will generally be reimbursed through the DRF administered byFEMA. (15) Given the scope of the public health disaster caused by Hurricane Katrina, virtually allagencies and offices in HHS were engaged in the response. (16) Key public healthchallenges and response efforts are described below. A number of HHS agencies have medicalresponse roles as well, which are discussed in a subsequent section. Many of the public health challenges posed by Hurricane Katrina were familiar andanticipated, based on experience with other hurricanes and floods. Flooding compromises the safetyof water supplies and the integrity of sewage disposal, leading to threats of food and waterborneillness. Power line damage and power outages increase the risk of foodborne illness andelectrocution. Hurricane wind damage may cause primary traumatic injury, while also setting thestage for subsequent chain saw injuries, punctures, and other wounds. Bites from dogs, venomoussnakes, and insects are also seen. Hurricanes and floods also carry in their wake some predictablecauses of death, including drowning, automobile crashes, carbon monoxide poisoning, and chronicconditions exacerbated by the loss of access to the healthcare system. (17) CDC notes that before 1990, the majority of hurricane-related deaths in the United Statesresulted from drowning caused by storm surges. (18) With more attention to early warning and evacuation since then,indirect causes of death such as electrocution, carbon monoxide poisoning and injury associated withcleanup have predominated. But despite warnings of the advancing storm, the majority of deathsfrom Hurricane Katrina resulted from coastal storm surges and from flooding in New Orleans. The catastrophic scope of Hurricane Katrina presented some unusual public health threats. News reports suggested that deaths may have resulted from dehydration and heat stress, especiallyin situations in which fresh water was scarce and where victims were crowded into poorly ventilatedareas, especially where they had pre-existing medical conditions. There were also reports ofhomicide, suicide and euthanasia. HHS Office of the Secretary. The HHS Officeof the Secretary is the point of coordination for all ESF#8 public health and medical supportfunctions under the NRP. HHS set up a website cataloging departmental and agency actions andother information regarding Hurricanes Katrina and Rita. (19) As noted above, the HHS Secretary declared federal publichealth emergencies in several states. The Office of the Surgeon General and the OPHEP sought toidentify and mobilize healthcare professionals and relief personnel to assist in relief efforts. Inaddition, more than 2,000 Commissioned Corps officers were deployed to the Gulf region before,during, and after Hurricanes Katrina and Rita, to assist in a number of public health and medicalactivities. (20) One immediate element of HHS response was the activation of Emergency OperationsCenters (EOCs) at HHS headquarters in Washington, DC and at numerous HHS agencies. Whenactivated, the EOCs are staffed round-the-clock, are electronically connected with each other, andare also connected with the Homeland Security Operations Center (HSOC) at DHS, which in turnreceives inputs from other Cabinet departments. This system of continuous communication andcoordination is an example of the changes that have been made in national public health responsecapability in the aftermath of the September 11 and anthrax attacks of 2001, though there is stillwork to be done in assuring that all relevant state agencies have continuous EOC communicationwith those at the federal level. (21) Agency for Toxic Substances and DiseaseRegistry. The Agency for Toxic Substances and Disease Registry (ATSDR), whichis administratively under the Centers for Disease Control and Prevention (CDC), is directed bycongressional mandate to perform specific functions concerning the effect on public health ofexposure to hazardous substances in the environment. (22) These functions include public health assessments of hazardouswaste sites, health consultations concerning specific hazardous substances, health surveillance andregistries, response to emergency releases of hazardous substances, applied research in support ofpublic health assessments, information development and dissemination, and education and trainingconcerning hazardous substances. ATSDR has conducted health hazard assessments following alarge oil spill in St. Bernard Parish, LA, that resulted from Hurricane Katrina. (23) Centers for Disease Control and Prevention. TheCDC launched a website to provide public health information in the aftermath of HurricaneKatrina. (24) The siteincludes a variety of fact sheets and other information for health professionals, response and cleanupworkers, evacuation center staff, school officials, state grantees and the general public. In addition,the site provided regular updates from the CDC Director's EOC through October 7. (25) Once activated, the EOCwas the point of contact for state health departments, other CDC grantees, and other interestedparties to request assistance or to provide the agency with new or updated information about publichealth concerns on the ground. CDC deployed several hundred of its staff to affected states, including individuals in thefollowing specialties: medicine, epidemiology, sanitation, environmental health, assessment, diseasesurveillance, public information and health risk communication. In addition, the agency deployedmore than 600 staff to its EOC response. The agency also deployed the Strategic National Stockpileof drugs and medical supplies to affected states. Among the specific supplies delivered for thisdisaster were: 1) many thousands of doses of vaccines for tetanus/diphtheria, and hepatitis A and B;2) vials of insulin; 3) prescription pain medications; and 4) ventilator kits. The agency also made numerous public health recommendations to address the anticipatedand atypical threats posed by Hurricane Katrina and its aftermath. CDC made several specificrecommendations for infectious disease control, including the immunization of emergencyresponders, relief workers and evacuees. The agency expressed particular concern about the risksof tetanus from wounds, and of influenza, measles, chickenpox and hepatitis A in crowdedconditions, especially if some children may not have had current immunizations. (26) CDC also alerted healthofficials and others to cases of Vibrio infection in hurricane victims, which caused 22 illnesses, fiveof them fatal. (27) Vibrio, a bacterial pathogen found in salty and brackish waters, can cause foodborne illness or severe woundinfection. CDC made an effort to alert health workers to this unusual hazard because Vibrio infections are especially severe, leading to loss of an affected limb or death within a matter of days,sometimes despite aggressive treatment. On September 17, CDC and the Environmental Protection Agency (EPA) issued a jointreport of their initial assessment of environmental health and infrastructure hazards in New Orleans,to assist state and local officials in planning for reoccupation of the city. (28) FEMA requested CDCassistance in evaluating any potential health effects of housing displaced persons in trailers sited onformer agricultural fields. The agency has also evaluated the potential health threat posed byexposure to mold, (29) and provided assistance in the federal environmental cleanup effort. (30) Responders may be at increased risk from certain hazards in the aftermath of disasters. CDC'sNational Institute for Occupational Safety and Health (NIOSH) developed resources for occupationalsafety and health for responders, and in hospitals, health departments, and shelters involved in theresponse to Hurricane Katrina. (31) Food and Drug Administration. In the aftermathof Hurricane Katrina, the Food and Drug Administration (FDA) issued numerous recommendationsregarding the handling of drugs, biologics and medical devices that may have been harmed byexposure to floodwaters or loss of refrigeration. The agency also issued guidance in ensuring thesafety of food, and participated in evaluations of the safety of fish and shellfish in affected GulfCoast waters. (32) The medical response to a disaster may be more challenging than the public health response. Most public health activities are inherently governmental and involve agencies that work togetherregularly, though often at different levels of government. Medical response capabilities, in contrast,span a wide array of sectors, both public and private, and involve more non-traditional partneringssuch as the coordination of DHS and Department of Defense (DOD) activities by HHS. A successfulmedical response to a disaster requires the coordination of six elements: patients in need; a sitewhere care is provided; the needed drugs, supplies and equipment; a provider workforce; a systemof record keeping; and a financing mechanism. Though national disaster planning has long anticipated the need to respond to a mass casualtyincident, such a situation, with overwhelming numbers of non-fatal illness and injury victims, hasnot happened recently in the United States. While certain recent events (e.g., the September 11,2001 attack and some jetliner crashes) have tested the national system for mass fatality management,Hurricane Katrina is the only event in recent times that has caused non-fatal mass casualties of ascope that could not easily be absorbed into the existing healthcare system. Scrutiny of the responseto this challenge is ongoing. As discussed earlier, federal leadership for medical emergency response is based in HHS perits coordinating responsibility under NRP ESF#8. Numerous medical response programs andactivities reside in HHS agencies within the Public Health Service (PHS). In addition, theCommissioned Corps of the PHS, headed by the Surgeon General, is composed of many healthcareprofessionals who are expected to maintain current skills and deploy to support emergency responseswhen needed. (33) Another critical medical response asset, the National Disaster Medical System (NDMS) wastransferred from HHS to DHS in March 2003. Additional critical assets such as personnel, bedcapacity, equipment and patient transport capability are based in the Departments of Defense andVeterans Affairs, as well as the private sector. Hurricane Katrina posed a number of challenges to the healthcare system, many withoutrecent precedent. Physical access to healthcare facilities was hampered across the Gulf Coastfollowing the storm, and many facilities sustained primary damage. Several facilities that did notevacuate prior to the storm found their patients in dire circumstances when rising floodwaters madeit progressively more difficult to maintain standards of care. Individuals with pre-existing healthconditions worsened as they were cut off from access to essential medications and treatments suchas oxygen, insulin, or kidney dialysis. In some flooded areas, access to fresh water was so scarce thatvictims and their caregivers suffered from dehydration. In the wake of large-scale evacuations ofNew Orleans beginning on September 1, victims from shelters and from failing healthcare facilitieswere evacuated to a temporary field hospital at the New Orleans airport, where medical responseteams, initially overwhelmed, conducted triage and prioritized victims for airlift to availablehealthcare facilities outside the flood zone. Meanwhile, medical workers continued their efforts toreach numerous isolated communities along the Mississippi and Louisiana coast. Morgues were setup in Louisiana and Mississippi to house and identify the dead. In the wake of the catastrophe, victims were sent for treatment to numerous permanent andtemporary healthcare facilities across a wide area of the south central United States, often becomingseparated from their loved ones and important medications and medical records along the way. Public health emergencies were declared in nine states that did not suffer primary impacts fromHurricane Katrina but that became hosts to large numbers of evacuees needing care. Healthcarefacilities sought assistance in covering the costs of care for those who were previously or newlyuninsured. The short-and long-term mental health needs of victims and responders had to be assessed. Immediate problems such as Post-Traumatic Stress Disorder receive considerable popular attention,but some evidence shows that victims of catastrophic disasters may continue to suffer from majordepression and other disorders for several years. Mental health services following disasters mustalso account for pre-existing mental health and substance abuse problems in some victims. Centers for Medicare and Medicaid Services. TheCenters for Medicare and Medicaid Services (CMS), which administers the Medicare, Medicaid andSCHIP programs, took several actions to streamline access to healthcare for those displaced byHurricanes Katrina and Rita. Many evacuees crossed state lines without proper documentation ofprogram eligibility. HHS Secretary Leavitt exercised certain authorities under Sections 1115 and1135 of the Social Security Act and waived several program requirements, in order to assistdisplaced victims and their providers. (34) Health Resources and Services Administration. The Health Resources and Services Administration (HRSA) provides grants to Federally QualifiedHealth Centers, Ryan White HIV/AIDS outpatient providers and some other providers and clinicsthat offer health services to underserved populations. HRSA administers several relevant programsin emergency preparedness. One is a grant program for state and local hospital preparedness forpublic health emergencies, which is meant to help states identify and coordinate hospital bedcapacity, personnel and medical supplies in an emergency. Another is a program for the advanceregistration of volunteer health professionals. (35) The latter program is discussed in a subsequent section on Issuesfor Congress . HRSA undertook a number of response efforts following Hurricane Katrina, including staffdeployments. (36) OnSeptember 9, HHS Secretary Leavitt announced that HRSA would advance approximately $2.3million in FY2005 funds to establish 26 new health center sites in areas impacted by HurricaneKatrina. (37) The agencyissued a notice clarifying that providers who normally provided services under the liabilityprotections of federal employment in certain HRSA-supported health centers would continue toreceive protection while serving at temporary locations established in response to the hurricane. Inaddition, in affected areas, the agency offered expedited procedures for designating HealthProfessions Shortage Areas, and for reviewing loan repayment applications for National HealthService Corps personnel. National Institutes of Health. The NationalInstitutes of Health (NIH) set up a phone-based medical consultation service for providers treatingvictims or evacuees from the Hurricane Katrina disaster, which it operated through September 2005.The agency also identified hospital bed capacity within its medical system, among otheractivities. (38) TheNational Institute of Environmental Health Sciences developed an interactive GeographicInformation System (GIS) for Texas, Louisiana and Mississippi to help model the movement ofcontaminants and identify sources of human exposure. (39) Substance Abuse and Mental Health ServicesAdministration. (40) The Substance Abuse and Mental Health ServicesAdministration (SAMHSA) has as its mission to build resilience and facilitate recovery for peoplewith or at risk for substance abuse and mental illness. SAMHSA's Center for Mental HealthServices (CMHS) focused on providing resources to aid in the recovery process followingHurricanes Katrina and Rita, and established a toll-free hotline for people in crisis in the aftermathof this disaster. (41) SAMHSA has three main mechanisms to provide funding to address disaster victims' mentalhealth needs: 1) the Crisis Counseling Assistance and Training program (CCP), 2) SAMHSAEmergency Response Grants (SERG), and 3) supplemental appropriations. The CCP is administeredby SAMHSA through an interagency agreement with FEMA. Eligible entities (state mental healthagencies and tribal authorities) work with SAMHSA to apply for and receive grants for counselingoutreach and training local crisis counselors to provide assistance after federal relief workers leavethe area. SERG are available when local resources are overwhelmed and other resources areunavailable. SAMHSA may provide SERG for crisis mental health and substance abuse servicesin accordance with SAMHSA's Mental Health and Substance Abuse Emergency ResponseCriteria. (42) Supplemental appropriations may be used by SAMHSA for emergency mental health and substanceabuse counseling and related services not addressed by the CCP, the SERG, or other existingfunding. These may include, for example, substance abuse and mental health treatment services,psychotropic medication expenses, methadone treatment, suicide prevention programs, and majoradministrative expenses for mental health and substance abuse resulting from the disaster. National Disaster Medical System. The NationalDisaster Medical System (NDMS) was established in HHS in 1984 to provide medical and ancillaryservices when a disaster overwhelms local emergency services. (43) NDMS was most recentlyreauthorized through 2006 in the Public Health Security and Bioterrorism Preparedness andResponse Act ( P.L. 107-188 ), (44) and was transferred to DHS in the Homeland Security Act ( P.L.107-296 ) effective in March 2003. (45) NDMS is administered by FEMA and is a partnership of HHS,DHS, the Departments of Defense and Veterans Affairs, state and local governments, and the privatesector. NDMS consists of a number of response teams that can deploy to a scene rapidly and set upfield operations that are self-sustaining for up to 72 hours, until additional federal support arrives. NDMS also provides for transportation of large numbers of casualties from an impacted site todistant locations for care. There are several types of NDMS teams, which are typically comprisedof 20-35 individuals. Team members train as a group between deployments, under a defined teamcommander, and are versed in incident command and other emergency management protocols inaddition to their disaster medicine skills. NDMS teams can be requested by the Secretary of HHSpursuant to NRP ESF#8. Medical professionals on the teams must be licensed to practice in at leastone U.S. jurisdiction and are not generally federal employees unless deployed, at which time theyare considered federalized for liability and compensation purposes. On September 9, 2005, FEMAreported that it had deployed more than 87 NDMS teams in response to Hurricane Katrina. Information about specific deployment activities follows. Disaster Medical Assistance Teams (DMATs) are teams of physicians, nurses and othermedical professionals who provide medical care. FEMA reported that it deployed all of the nation'smore than 50 DMATs in the initial response to Hurricane Katrina. At least one team waspredeployed to the New Orleans Superdome shelter. (46) The Louis Armstrong International Airport outside New Orleansserved as a temporary field hospital for hurricane victims as they were evacuated from the city. DMAT members from a dozen teams deployed at the airport reported overwhelming numbers ofpatients, some of whom could not be saved under the austere conditions they faced. Teams fannedout across the affected Gulf Coast, doing what they could to accommodate victims of the hurricanewhich, by some reports, also robbed the region of 6,000 hospital beds. (47) Disaster Mortuary Operational Response Teams (DMORTs) are composed of medicalexaminers, coroners, pathologists, forensic dentists, radiologists, mental health counselors, funeraldirectors and support personnel. Teams typically consist of 26 members. They assist in handlingthe dead and conducting two types of investigations in mass fatality incidents: disaster victimidentification (DVI) and death investigation. DVI involves the identification of victims, in order thattheir loved ones can have documentation of their deaths, claim the remains, and carry out funeralrites. It is considered an essential responsibility of governments in assisting survivors in theirrecovery. Death investigation involves establishing the cause, time and other circumstances of death. These investigations are conducted under the authority of state or local medical examiners, withassistance from DMORT personnel and federal funding through FEMA. DMORT sites were set upin Gabriel, Louisiana, and Gulfport, Mississippi, each site with four DMORT teams and one portablemorgue. (48) Veterinary Medical Assistance Teams (VMATs) are composed of veterinarians, techniciansand support personnel who provide animal rescues, health assessments and other services during adisaster. Following Hurricane Katrina, all four VMAT teams were deployed to the Gulf Coast toprovide care for displaced companion animals and support for damaged or destroyed veterinarypractices. (49) NDMS also supports National Pharmacy Response Teams of pharmacists, pharmacytechnicians, and students of pharmacy who assist in mass-dispensing of medications during disasters,and National Nurse Response Teams to assist if a disaster such as a bioterrorism event were torequire a mass prophylaxis or mass vaccination campaign, or if the healthcare workforce is otherwiseoverwhelmed. Federal Coordinating Centers (FCCs) are based in the Departments of Defense (DOD) andVeterans Affairs (VA), where they identify available nationwide hospital bed capacity in civilian andmilitary hospitals, and coordinate planning and distribution of patients evacuated from a disasterarea. (50) Since NDMS deploys in situations other than disasters (e.g., National Special Security Eventssuch as political conventions) and much of its work is, therefore, not eligible for reimbursement fromthe DRF, the program has a regular annual appropriation. NDMS is funded through the PublicHealth Programs account under the DHS Preparedness and Response title, and received $34 millionin FY2005 and in FY2006. (51) On September 8, the President signed the second emergencysupplemental appropriation for Hurricane Katrina relief ( P.L. 109-62 ), which authorized the transferof up to $100 million from the DRF to maintain Katrina-related NDMS response operations. In itsweekly report to Congress on Hurricane Katrina expenditures, FEMA reported that it had transferredthe entire amount. (52) During a presidentially-declared disaster and pursuant to the NRP, the DOD assists theSecretary of HHS with numerous ESF#8 responsibilities. These include evacuating patients, locatingor providing hospital beds, additional personnel and supplies, and providing specialized laboratorytesting and other technical assistance. (53) On September 13, DHS reported that DOD had: 1) 789 beds available in field hospitals atLouis Armstrong New Orleans International Airport in New Orleans, the 14th Combat SupportHospital, and aboard USS Bataan, USS Iwo Jima, USS Tortuga and USS Shreveport; and 2) 20 Navyships on station in the region to provide medical support, humanitarian relief, andtransportation. (54) During a presidentially-declared disaster and pursuant to the NRP, the Department ofVeterans Affairs (VA) assists the Secretary of HHS with numerous ESF#8 responsibilities. Theseinclude coordinating available hospital beds, additional personnel and supplies, and providingtechnical assistance. (55) The VA evacuated veterans from two of its own medical centers impacted by HurricaneKatrina, one in Biloxi, Mississippi, which was evacuated prior to landfall and demolished by thestorm, and the other in New Orleans, which was evacuated after the city was flooded. The VA alsoactivated 17 of its NDMS Federal Coordinating Centers to coordinate the relocation of evacuatedveterans, as well as of civilian patients who were evacuated from permanent and temporary hospitalsin storm-ravaged areas (56) In the aftermath of Hurricane Katrina there were concerns that federal readiness for thedisaster had been hampered by an overemphasis on planning for terrorism at the expense of planningfor natural disasters. A similar debate exists for public health preparedness, namely how the balanceshould be struck between all-hazards preparedness versus readiness for specific threats such as acyanide attack or pandemic influenza. In comprehensive bioterrorism preparedness legislation afterthe 2001 terror attacks, Congress authorized grants to states to "address the following hazards in thefollowing priority: (i) Bioterrorism or acute outbreaks of infectious diseases (and) (ii) Other publichealth threats and emergencies." (57) Discussions have followed about whether a focus on terrorism(e.g., the civilian smallpox vaccination program) has hampered preparedness for other threats, or,on the other hand, whether flexible all-hazards grant guidance has failed to assure state preparednessfor some specific threats (e.g., a cyanide or plague attack). (58) Some reports suggest that the public health response to Hurricane Katrina was streamlinedby some all-hazards improvements made since 2001. For example, when the Louisiana state publichealth laboratory in New Orleans was disabled by the storm, operations were quickly diverted tobranch public health laboratories in Shreveport, Lake Charles and Amite, or to other states asneeded. (59) The swiftresponse was facilitated by inter-state electronic communications systems and relationships that hadbeen established since 2001. Upon completing their missions, disaster response personnel are typically required to reportto supervisors on their activities. These after-action reports are expected to be prepared andsubmitted to a variety of agencies involved in the response to Hurricane Katrina. As after-actionreports become available, Congress may review the public health and medical response to HurricaneKatrina to determine how well it met the goals Congress laid out for achieving a flexible, efficientnational system for response to health emergencies. Part of this review may be the consideration ofthe process of developing standards for federal, state and local public health preparedness, a processwhich has proven difficult in the past. Needs assessments are considered critical in the response to catastrophic disasters. Whenit is likely that response assets will be overwhelmed, lives may be saved by prioritizing the responseas effectively as possible (e.g., matching the deployment of NDMS teams as well as possible todefined areas of medical need). However, the response to public health and medical needs may haveto be delayed until response has been made to other problems such as civil disorder or a lack ofphysical access. Therefore, coordinating the assessments across all sectors is essential. Following a disaster, the NRP calls for the early deployment of Emergency Response Teamsfor Assessment (ERT-A), which are FEMA-led teams that work with state Emergency OperationsCenters (EOCs) and others to conduct initial and ongoing impact assessments. Early assessmentsdefine the extent of problems such as flooding, the integrity of roads and bridges, and damage to theelectricity grid. Representatives from selected ESF support agencies are to be included in ERT-Adeployments. The ERT-A teams are to report back to an Interagency Incident Management Group(IIMG), which is tasked to report to the Secretary of DHS with recommendations for those areas inmost critical need of response assets and activities. (60) The CDC manages a program in Disaster Epidemiology and Assessment, which includesdevelopment of a disaster rapid needs assessment tool designed to quickly provide emergencymanagers with reliable information about potential public health threats. (61) The CDC has conductedthese assessments for several domestic and foreign disasters, including Hurricane Katrina. (62) The tool is not designedfor the rapid assessment of medical or mental health needs. CDC has reported on longer-termassessments of medical and mental health needs in areas affected by Hurricanes Katrina and Rita,and on surveillance systems, set up in evacuee shelters, that allowed for the measurement of theburden of certain chronic diseases such as diabetes and mental illness. (63) Further review of thisinformation will inform efforts to improve the tools used for needs assessment, though it is not knowwhether there are efforts underway to develop a process specifically for the rapid assessment ofmedical and mental health needs in the immediate aftermath of a disaster. Policy issues may include the performance of the FEMA ERT-A process in supporting themore specific goals of assessing public health, medical and mental health needs following HurricaneKatrina, and, indeed, whether an effective process of medical and mental health needs assessmentexists. In particular, are the federal mechanisms to support rapid public health, medical and mentalhealth needs assessments in place and adequate to support a capable national response? Also, arethese processes integrated well within the larger FEMA-led process of overall assessment, in orderthat appropriate public health, medical and mental health responses can reach their targets quicklyand efficiently? Overview. Following Hurricane Katrina, therewere numerous reports of problems experienced by fragile or medically needy persons. Theseproblems included 1) drownings and dehydration in facilities that did not evacuate and were floodedby the hurricane storm surge; 2) emergency evacuations of deteriorating patients from hospitals thatwere unable to care for patients after power, water and food had been cut off for several days; and,3) chronic conditions exacerbated by the loss of access to needed care such as insulin, oxygentherapy or kidney dialysis. In preparing for Hurricane Rita, authorities in many communities on theTexas and Louisiana coast paid particular attention to identifying and helping those with specialhealth needs, providing public transportation to support the evacuation of nursing homes and thosereceiving other health services. Hurricane Katrina also exposed a number of problems that healthcare facilities experiencedas a result of the scope of the disaster. The failure of communications systems across the Gulf Coastmade it difficult for facilities to seek assistance, or for emergency responders to know that a facilitywas in need. In addition, since all facilities were simultaneously affected, the use of shared resources("double-counting") led to problems. For example, single ambulance companies had contracted toevacuate multiple facilities. This arrangement, which would work well if facilities had been affectedin isolation, was untenable in a wide scale disaster. Following the hurricanes, experts have stressed the need for coordinated disaster planningin healthcare. They note that in addition to assuring that facilities are well prepared on their own,they must be integrated into community-wide emergency management activities. Further, identifyingvulnerable non-institutionalized populations and assuring their care before, during and after adisaster also requires a community-wide coordinated approach. Regulation of Institutions and Services. Healthcare facilities (e.g., hospitals and nursing homes) are regulated by state and local authorities,with varying degrees of federal involvement. Regulations provide an opportunity for oversight oftwo critical disaster planning functions: evacuation and continuity of operations. (In this context,continuity of operations, the ability to sustain life-saving operations in the absence of power, waterand other external supplies, could also be considered sheltering in place. ) Given the nature of theirbusiness, hospitals are generally able to continue operations in the face of power outages, at leasttemporarily, because they employ generators to maintain critical life-support functions in anemergency. Furthermore, it is difficult to evacuate hospital or nursing home patients as their specialneeds may require special transport and host facilities. This may motivate better preparedness forcontinuity of operation as a more feasible option than evacuation. Healthcare facilities should beable to do both, though, as different types of disasters would require one or the other response. Hospitals in New Orleans that initially chose to continue operations ultimately had to evacuate. Evacuation policies and regulations for healthcare facilities have long focused on fire safety,for which the need to evacuate is evident, and for which drills are regularly conducted by local firesafety authorities. Evacuation planning for a predicted threat such as a hurricane may be morechallenging. The decision to evacuate or not may hinge on emergency management rather thanhealthcare expertise, and may be guided by local officials rather than facility managers. Forexample, the mandatory evacuation order issued by the city of New Orleans on August 28 excluded"essential personnel of hospitals and their patients," but did not exempt other types of healthcarefacilities. (64) Inpreparing for Hurricane Charley in Florida in 2004, one county issued a countywide mandatoryevacuation order, while a neighboring county issued a mandatory order for nursing homes only. (65) While healthcare facilities are licensed and regulated by state and local authorities, there isa role for federal oversight of their disaster preparedness and response capabilities through standardsdeveloped by the Occupational Safety and Health Administration (OSHA) and the Joint Commissionon Accreditation of Healthcare Organizations (JCAHO), as well as through conditions ofparticipation (CoPs) for Medicare and Medicaid. (66) Following Hurricane Katrina, a JCAHO witness testified thatthe commission certifies 85% of U.S. hospitals encompassing 96% of hospital beds. (67) JCAHO-certified hospitalsare deemed by federal law as meeting the conditions of participation for Medicare and Medicaidreimbursement. The commission's 2005 accreditation manual for hospitals includes standardsregarding emergency management, in addition to standards addressing certain specific threats suchas fire and hazardous materials. (68) The Government Accountability Office (GAO) has reportedconcerns regarding enforcement of JCAHO certification standards. (69) While JCAHO has certification programs for other types of healthcare institutions besideshospitals, some of the programs are voluntary or do not cover a majority of the relevant industry.Conditions of participation for Medicare and Medicaid reimbursement for other institutions, as wellas for various non-institutional services (e.g., home-based care), vary in the degree to which disasterplanning is addressed. The role of state and local authorities in assuring disaster preparedness forthese facilities and services appears to dominate. Community-based Disaster Planning. InCongressional testimony following Hurricane Katrina, a JCAHO witness stressed the need forhospitals to prepare for disasters within a community-wide structure, not in isolation. (70) The commission's 2005emergency management standards include a requirement that hospitals conduct a "hazardvulnerability analysis" to determine the types of hazards the facility is likely to face. There are alsoseveral standards requiring that hospitals have and test emergency backup systems for electricity andother utilities. Careful planning of this type could prevent planning errors such as the placement ofback-up generators in the basement of a flood-prone facility. In addition, hospitals are required tocoordinate various planning tasks with local emergency management authorities. Problems in delivering care to the chronically ill after hurricanes were described in reportsfollowing four hurricanes in Florida in 2004. (71) The emphasis of disaster planning for non-institutional servicesis based on assuring continuity of care during and after a disaster. Some communities havedeveloped programs to identify vulnerable individuals and assure continuity of care. The massivedislocation of the victims of Hurricane Katrina demonstrates how challenging this task can be. Following the terror attacks in 2001, Congress created a national program of grants to statesto improve the ability of communities to respond to emergencies that cause mass casualties. (72) The National BioterrorismHospital Preparedness Program is administered by the Health Resources and Services Administration(HRSA). (73) Grants areawarded to state health officials to develop coordinated state and regional mass casualty plans. Though grant guidance directs that a majority of funds be passed through to healthcare institutions,the program is not designed to assure preparedness for each facility or service in a state. It could bea means, however, for states to develop reliable communications systems between hospitals andemergency management authorities, or to address other aspects of coordination. There is limitedpublicly available information on how states have used hospital preparedness grant funds. Promising Practices. Some states andcommunities with disaster experience have come up with approaches to address problems of disasterplanning in healthcare. (74) For example, Florida has a requirement (in statute andregulation) that home health agencies include in patients' records individual disaster plans (e.g., anindividual evacuation plan) that have been discussed with the patient and the patient'scaregivers. (75) Floridaalso established Special Needs Shelters for vulnerable persons during the 2004 hurricanes. The statefacilitated evacuation to the shelters of individuals who were pre-identified by county healthdepartments. This arrangement facilitated care of those whose needs were not so great that theyrequired hospitalization, but that nonetheless exceeded the expertise available in Red Cross and othercommunity shelters. (76) In New York City, the Office of Emergency Management serves as the focal point ofcoordination for the Department of Aging and other city agencies to identify and plan for the careof special-needs populations during a disaster. Individuals are pre-identified from certain databasessuch as home-delivered and group meals programs and the electric utility's list of clients who are onlife support equipment. The Greater New York Hospital Association has testified on the value ofredundant communications systems that were established in city hospitals and the Office ofEmergency Management prior to the northeast blackout in 2003. (77) Options for Congress. Congress could decide tolook specifically at whether the federal requirements for facility disaster and evacuation plans areadequate, and adequately enforced. If it did so, it might consider options to improve generalemergency preparedness in healthcare facilities, including the elements of planning, staffing,training, stockpiling of supplies, evacuation procedures, and coordination with emergencymanagement authorities. In addition, the role of the HRSA hospital preparedness grant program asa mechanism for coordinated disaster planning in healthcare could be examined. As previously discussed, the NDMS was created in the 1980s under the U.S. Public HealthService in HHS, and was transferred to DHS under FEMA in the 2003. The cited intent of thistransfer, proposed by the Administration, was to assure a coordinated federal response to terrorismand other disasters. The Government Accountability Office (GAO) supported the transfer. (78) But since then, a reviewof DHS medical response capabilities, conducted at the request of then-Secretary Tom Ridge in2004, found "... that the nation's medical leadership works in isolation, its medical responsecapability is fragmented and ill-prepared to deal with a mass casualty event and that DHS lacks anadequate medical support capability for its field operating units." (79) Further, some NDMSteam members have complained that the program has not received adequate administrative supportunder FEMA. (80) Twoorganizational issues may be relevant to this concern. First, some NDMS team members have stated that their mission -- to provide direct medicalservices -- is not understood by FEMA management. (81) The Lowell report had recommended the appointment of a DHSAssistant Secretary for Medical Readiness to address this concern. (82) In July 2005, DHSSecretary Michael Chertoff announced his proposal to reorganize DHS following a comprehensivereview, which became known as the "Second Stage Review" or 2SR. (83) Chertoff announced thathe proposed to split the existing Emergency Preparedness and Response Directorate (which housedFEMA and NDMS) into two separate directorates, for distinct activities in preparedness andresponse, respectively. He announced the appointment of a chief medical officer (CMO), a positionthat had not previously existed in DHS, within the proposed preparedness directorate, as follows: ...as part of our consolidated preparedness team, I willappoint a chief medical officer within the preparedness directorate. This position will be filled byan outstanding physician who will be my principal advisor on medical preparedness and a high-levelDHS representative to coordinate with our partners at the Department of Health and HumanServices, the Department of Agriculture and state governments. The chief medical officer and his team will haveprimary responsibility for working with HHS, Agriculture and other departments in completingcomprehensive plans for executing our responsibilities to prevent and mitigate biologically-basedattacks on human health or on our food supply. (84) The following day, Chertoff announced the appointment of Dr. Jeffrey Runge to the post. (85) Under the new structure, NDMS remains within FEMA, while the CMO is within the newDirectorate for Preparedness. While NDMS is logically a response asset, some critics say theproposed structure may blunt the benefit that NDMS might have received from leadership providedby the new CMO position, since that individual would be in a different directorate. A second organizational concern with the transfer of NDMS to DHS is that NDMS andFEMA take different temporal approaches to deployment in response to a disaster. Historically,DMAT teams trained to be able to deploy rapidly and set up self-supporting field hospitals in austereconditions, without external water or power sources, within the first 72 hours after a disaster, before other federal assets arrive. (86) FEMA has historically operated under the planning assumptionthat while it would mount a response as soon as possible, state and local officials were responsiblefor emergency response in the first 72 hours following a disaster. (87) After Hurricane Katrina,a DMAT team member stated that FEMA was unable to support the historical rapid-deploymentcapability of NDMS. (88) NDMS teams are required to submit after-action reports following deployment, in order thatresponse planners can benefit from lessons learned in disaster response. Some analyses of theNDMS response to Hurricane Katrina response have become available, and more are expected,including one from DHS. (89) Policymakers likely will review the mission of NDMS and itsalignment with national goals for terrorism and disaster response. NDMS program authority expiresat the end of FY2006. Congress may decide to review the mission of NDMS and the role of DHSand FEMA in supporting it, in general, and specifically in response to Hurricane Katrina, as itconsiders reauthorization of the program. Despite the deployment of all FEMA DMAT teams in the wake of Hurricane Katrina, therewere reports of overwhelmed field hospitals and triage centers, and urgent calls from hospitals formore medical personnel. On September 3, HHS issued a call for more volunteer health professionals(VHPs) to deploy, as federalized employees, to the affected areas. All officers of the U.S. PublicHealth Service were also put on alert for possible deployment. (90) The NDMS, which wastransferred from HHS to the DHS in 2002, remains authorized within the Public Health Service Act,where it is stated that the Secretary of HHS can augment emergency response personnel by deployingvolunteers as intermittent disaster response personnel under NDMS. (91) Volunteers could alsopotentially be deployed as temporary volunteers in the Public Health Service, or as temporary federalemployees. (92) BySeptember 19, the call for additional personnel had been lifted. The licensing of medical professionals is the responsibility of state authorities. FederalizedVHPs must hold a current license in at least one U.S. jurisdiction, and the federal agency responsiblefor deployment bears the burden of verifying credentials. Federalized VHPs are considered to befederal employees for purposes of liability and compensation. VHPs can also deploy at the requestof affected states, as long as their state's licensure and certification are recognized by the requestingstate. A number of legal mechanisms govern reciprocity in order to assure that VHPs are protectedfrom liability in the requesting state. (93) One of the more challenging aspects of accepting mutual aid isthe ability to verify an individual's qualifications. The Health Resources and ServicesAdministration (HRSA) notes: According to reports, hospital administrators involvedin responding to the World Trade Center tragedy reported that they were unable to use medicalvolunteers when they were unable to verify the volunteer's basic identity, licensing, credentials(training, skills, and competencies), and employment. In effect, this precious, needed healthworkforce surge capacity could not be used. (94) Following the terrorist attacks of 2001, Congress established a program to develop a nationaldatabase for verifying the licensure and credentials of VHPs during emergencies. (95) The Emergency Systemfor Advance Registration of Volunteer Health Professionals (ESAR-VHP), administered by HRSA,is designed to assist state and local authorities in verifying the status of volunteer healthcare workersby developing standards for a nationwide database and providing funding and technical assistanceto states in linking to it. The program is in its early stages, with pilots beginning in several states,and was not ready for use in response to Hurricane Katrina. The program was funded at $8 millionin FY2005. The Administration requested $8 million for FY2006, and Congress provided $4 millionin final appropriations. Senate appropriators had commented that states could use their hospitalpreparedness grant funds to support this activity. Authority for the ESAR-VHP program expires atthe end of FY2006. While Congress has explicitly tasked HHS, through HRSA, with a federal role in creatinga nationwide system for health professionals volunteers, the DHS Chief Medical Officer (CMO) hasalso voiced an interest in coordinating this activity. (96) DHS is expected to publish, in the Federal Register, a notice ofdelegation of authority to the CMO. Until such time, comprehensive information on the scope ofthe responsibilities and activities of this office, and how the CMO will coordinate efforts with HHS,is not publicly available. The federal role in assisting states with licensure verification and other matters involved inusing VHPs during an emergency has been of interest to Congress. Relevant legislation introducedfollowing Hurricane Katrina includes S. 1638 , which would establish a NationalEmergency Health Professionals Volunteer Corps under the Secretary of HHS, among otherprovisions, and H.R. 3736 , which would provide Hurricane Katrina volunteers,including health workers, immunity from liability. The latter bill has passed the House and beenreferred to the Senate Judiciary Committee. In response to Hurricane Katrina, the HHS Office of the National Coordinator for HealthInformation Technology, working in collaboration with more than 150 public and private healthcareorganizations, established an online service for authorized health professionals to gain electronicaccess to prescription medication records for evacuees. Medication data from a variety ofgovernment and commercial sources -- Medicaid, the Veteran's Health Administration, privateinsurers, and pharmacy benefit managers -- was indexed and made accessible through a singleInternet portal (www.katrinahealth.org) to any licensed physician or retail pharmacist. Comparableefforts made the immunization records of children who evacuated from Louisiana available to publichealth officials in host states, and, through the use of Medicaid billing records, allowed thereconstruction of rudimentary health records for some of those who were displaced. (97) HHS Secretary Leavitt noted that the disaster had made the case for a national system ofelectronic health records (EHR), and that such a system could be useful in general as well as forother emergencies such as pandemic influenza. The VA, which uses a system of electronic healthrecords for its beneficiaries, was able to provide uninterrupted care to several hundred veterans whowere evacuated from its medical centers in Biloxi, Mississippi, and New Orleans, Louisiana, due tothe hurricane. Congress has taken several steps in recent years to implement a nationwide healthinformation technology (health IT) infrastructure. (98) Several bills have been introduced in the 109th Congress toboost federal investment and leadership in health IT and provide incentives both for EHR adoptionand for the creation of regional health information networks, which are seen as an important steptowards the goal of interconnecting the health care system nationwide. (Examples include H.R. 2334 , S. 1262 and S. 1355 .) On November 18, 2005,the Senate passed a bipartisan health IT bill, S. 1418 , which has been referred to theHouse for further consideration. CRS Report RS22292, Hurricanes Katrina & Rita: Addressing the Victims' Mental Health andSubstance Abuse Treatment Needs, by [author name scrubbed]. CRS Report RS22279, Hurricane Katrina and Veteran s, by [author name scrubbed]. CRS Report RL33083 , Hurricane Katrina: Medicaid Issues , by Evelyne Baumrucker, [author name scrubbed],[author name scrubbed], Elicia Herz, [author name scrubbed], [author name scrubbed], and [author name scrubbed]. CRS Report RS22254 , The Americans with Disabilities Act and Emergency Preparedness andResponse, by [author name scrubbed]. CRS Report RS22255 , Emergency Response: Civil Liability of Volunteer Health Professionals, byKathleen Swendiman and [author name scrubbed]. CRS Report RS22252 , Older Americans Act: Disaster Assistance for Older Persons After HurricaneKatrina , by [author name scrubbed]. CRS Report RS22235, Disaster Evacuation and Displacement Policy: Issues for Congress , by KeithBea. CRS Report RL32803, The National Preparedness System: Issues in the 109th Congress , by KeithBea. CRS Report RL32858 , Health Information Technology: Promoting Electronic Connectivity inHealthcare, by [author name scrubbed]. CRS Report RS22310 , Hurricane Katrina: HIPAA Privacy and Electronic Health Records ofEvacuees, by Gina Marie Stevens. CRS Report RL31719 , An Overview of the U.S. Public Health System in the Context of EmergencyPreparedness , by [author name scrubbed].

Summary: Hurricane Katrina struck the Gulf Coast in late August 2005, causing catastrophic winddamage and flooding in several states, and a massive dislocation of victims across the country. Thestorm was one of the worst natural disasters in the nation's history. Estimates are that more than1,200 people were killed and about 2 million displaced. Hurricane Rita, which made landfall alongthe Gulf Coast in late September 2005, was ultimately less lethal than Katrina, but promptedaggressive preparedness efforts by governments and citizens shaken by the devastation of the earlierstorm. In response to a series of disasters and terrorist attacks over the past decade, in particular theterror attacks of 2001, Congress, the Administration, state and local governments and the privatesector have made investments to improve disaster preparedness and response. New federalauthorities and programs to strengthen the nation's public health system were introduced incomprehensive legislation in 2002. Congress also created the Department of Homeland Security(DHS) in 2002 to provide national leadership for coordinated preparedness and response planning. A new National Response Plan (NRP), launched by DHS in December 2004, met its first major testin the response to Hurricane Katrina. According to the NRP, the Department of Health and Human Services (HHS) is tasked withcoordinating the response of the public health and medical sectors following a disaster. HHS workswith several other agencies to accomplish this mission, which includes assuring the safety of food,water and environments, treating the ranks of the ill and injured, and identifying the dead. HHSactivities are coordinated with those of other lead agencies under the overall leadership of DHS. Congress and others will review the response to Hurricanes Katrina and Rita with an eyetoward assessing how well the NRP worked as an instrument for coordinated national response, andhow well various agencies at the federal, state and local levels carried out their missions under theplan. Hurricane Katrina dealt some familiar blows in emergency response. The failure ofcommunication systems, and subsequent difficulties in coordination, challenged response efforts inthis disaster as with others before it. Hurricane Katrina also pushed some response elements, suchas surge capacity in the healthcare workforce, to their limits. The response to Hurricane Katrina hasalso called attention to the matter of disaster planning in healthcare facilities, and the potential roleof health information technology in expediting the care of displaced persons. Policymakers will nodoubt study these elements of the Katrina response and seek options for continued improvement innational disaster preparedness and response. This report discusses the NRP and its components for public health and medical response,provides information on key response activities carried out by agencies in HHS and DHS, anddiscusses certain issues in public health and medical preparedness that have been raised by theresponse to the 2005 Gulf Coast hurricanes. This report will be updated as circumstances warrant.