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Public Health and Emergency

Management Systems

Connie J. Boatright and Peter W. Brewster

INTRODUCTION

Emergency management has always included a component that addresses the health of the public. The major concern during an emergency, whether in the form of a hazardous materials incident, terrorist event, disease outbreak, or other type of disas- ter, is its potential to harm the health and well-being of people. A formalized system that connects “emergency management” and “public health,” however, did not begin to emerge until the latter part of the 20th century. At this time, healthcare lead- ers and policymakers began promoting standardized processes and assigning functional responsibilities to specific government agencies and entities, ensuring consistent inclusion of the public health component in the management of emergencies. The result has been the creation of programs and implementation of con- cepts that, when appropriately applied, ensure accomplishment of the ultimate goal of managing emergencies. The final out- come of these processes is the reduction of morbidity and mor- tality and return of circumstances to the preemergency state or better.

This chapter addresses concepts and issues that are essen- tial for understanding how public health integrates with emer- gency management at all levels and in varying emergency cir- cumstances. It focuses on the following

1) A general overview of public health and emergency manage- ment systems and how they interface

2) Comprehensive Emergency Management, including the all- hazards approach

3) The Incident Command (Management) System, including the adoption within the United States of the National Inci- dent Management System (NIMS)

4) Interconnectivity of healthcare systems as it relates to pub- lic health and emergency management systems and activi- ties

5) Management of volunteers who spontaneously volunteer or are assigned to public health (and healthcare) and deploy in support of emergencies

6) Communications (technical and procedural) among public health and emergency management systems

CURRENT STATE OF THE ART

Overview of Public Health and Emergency Management Systems

An analysis of U.S. systems provides insights into the challenges of coordinating medical, public health, and emergency manage- ment entities. Perhaps one of the greatest defining events that measured how the United States manages emergencies and their inherent health elements was Hurricane Katrina, which made landfall August 29, 2005, impacting coastal Louisiana, Missis- sippi, and Alabama. The immediate medical and health impact of this storm resulted in 1,800 deaths, thousands of injuries and illnesses, and hundreds of thousands of displaced persons. Hur- ricane Katrina prompted response and recovery actions by all levels of the U.S. government and offers of assistance from many foreign governments.1 The number of dead continued to rise long after the event, as recovery personnel discovered bodies in previously submerged dwellings and other locations. The exact number of victims may never be known. Injuries and illnesses, including psychological and stress-related effects, also continued to emerge among the displaced thousands. Subsequent Hurri- canes Rita and Wilma added to the number of victims, although not in significant numbers.2

Prior to the September 11, 2001 terrorist attacks on New York City’s World Trade Center and the Washington, DC area– based Pentagon and Hurricane Katrina, the U.S. had neither experienced an emergency resulting in mass casualties from a single event nor one of a magnitude witnessed in foreign coun- tries since the time of the 1918 influenza pandemic. From 1975 to 1994, natural hazards (earthquakes, hurricanes, floods, and tornadoes) in the United States and its territories resulted in more than 24,000 deaths and approximately 100,000 injuries.3

This figure contributed to the U.S. government’s focus on refine- ment of emergency management strategies. This, followed by the September 11 terrorist events, created an unprecedented empha- sis on defining the country’s direction on matters related to comprehensive management of emergencies.

Several key initiatives in the form of legislation, directives, and guidelines impacting public health and emergency man- agement emerged during the latter part of the 20th century

133 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-07 11:36:19.

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134 ■ CO N N I E J. BOAT R I G H T A N D PE T E R W. BR E WS T E R

Table 9.1: U.S. Pandemic and All-Hazards Preparedness Act (2006)∗

Title I: National Preparedness and Response, Leadership, Organization & Planning

■ Creates a U.S. (HHS) Office of Assistant Secretary for Preparedness and Response (ASPR) and combines federal public health and medical emergency activities under that office

■ ASPR will appoint official to provide guidance to public health agencies for integration of needs of at-risk populations at federal, state, and local levels

■ ASPR will submit National Health Security Strategy to Congress every 4 years

Title II: Public Health Security Preparedness

■ Oversees cooperative agreements/grants to state/local public health entities for improvement of health security ■ Requires nonfederal (state or consortium) contributions to public health preparedness programs ■ Requires Secretary to collaborate with state, local, tribal, and private entities to develop measurable, evidence-based preparedness benchmarks ■ Secretary may award grants on disease detection improvements to hospitals, universities, and laboratories ■ Establish nationwide electronic public health situational awareness system ■ Provides grants to states for tuition loan repayment programs for individuals who agree to 2-year service at state, local, or tribal health

departments ■ Secretary cooperates with private industry during a pandemic on tracking initial distribution of federally purchased influenza vaccine

Title III: All-hazards Medical Surge Capacity

■ Transfers NDMS from DHS (back to) HHS ■ Appoints Director for federal support of MRC ■ Expands Epidemic Intelligence Service Program ■ Awards grants to hospital and healthcare facilities to improve surge capacity

Title IV: Pandemic and Biodefense Vaccine and Drug Development

■ Requires Strategic Plan for Countermeasure Research, Development, and Procurement ■ Establishes Biomedical Advanced Research and Development Authority ■ Establishes Biodefense Medical Countermeasure Development Fund ■ Establishes National Biodefense Science Board ■ Directs Food and Drug Administration to provide technical assistance to developers of medical countermeasures ■ Establishes limited antitrust exemptions for biopharma companies for enhanced collaboration between companies and with government ■ Reforms BioShield procurement program

∗ Commonly termed the “PAPA Legislation.”

Adapted from Passage of S.3678: The Pandemic and All-Hazards Preparedness Act. Mair, M et al. Clinicians Biosecurity Network, University of Pittsburgh Medical Center. December, 2006.

and early years of the 21st century. Although U.S. philosophy is based on the premise that “disasters are local,” most initia- tives have been generated at the national level, resulting in a “top down” approach. The logical entity with primary responsibility for public health issues is the U.S. Department of Health and Human Services (HHS), so most initiatives connecting public health to emergency management include HHS in planning and implementation. A cabinet level department, HHS is the U.S. government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those least able to help themselves.4 With the federal gov- ernment’s increasing emphasis on emergency management, the HHS’s responsibilities in the areas of disaster and emergency management have become increasingly more pervasive and signi- ficant.

To understand the interconnectivity of public health and emergency management, it is helpful to have an awareness of key driving initiatives. A plethora of initiatives, derived from a sequence of reactions to unprecedented emergency events, have been introduced. Many of those initiatives in the public health realm, although under or influenced by HHS author- ity, became more closely aligned and consolidated when the U.S. President signed Senate Bill 3678: The Pandemic and All- Hazards Preparedness Act into law in December 2006.5 This leg- islation directed that a newly formed HHS Office of Preparedness

and Response be established and headed by an Assistant Secre- tary. The office serves as the umbrella organization for the various health-related emergency management programs that had previ- ously been under various HHS administrations (Table 9.1). This resulted in more streamlining of functions and programs essen- tial to management of public health emergencies. The Office of Preparedness and Response consolidates several functions under the Assistant Secretary, and more clearly delineates specific public health emergency management elements. The four Titles under the Act are: Title I: National Preparedness and Response, Lead- ership, Organization and Planning; Title II: All-Hazards Medical Surge Capacity; Title III: Public Health Security Preparedness; and Title IV: Pandemic and Biodefense Vaccine and Drug Devel- opment.5 (Table 9.1 outlines details of each Title cited in the legislation.6)

Descriptions of the derivation and components of specific programs included in the December 2006 legislation as well as other key initiatives linking public health and emergency man- agement systems are described here and include the: National Disaster Medical System (NDMS), National Response Plan (NRP)/National Response Framework (NRF), Strategic National Stockpile, Metropolitan Medical Response System (MMRS), Weapons of Mass Destruction Act of 1996, Homeland Security Act of 2002, and various Homeland Security Presidential Direc- tives (HSPDs) and bioterrorism focus and funding initiatives.

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-07 11:36:19.

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PU B L I C HE A LT H A N D EM E RG E N C Y MA NAG E M E N T SYS T E M S ■ 135

National Disaster Medical System

In 1984, the Reagan Administration expressed concern about the absence of an organized national approach to managing the human element (injury, illness, public health effects, and death) resulting from a disaster or other catastrophic event. Public health and emergency management leaders also expressed concern that local and state entities would be unable to manage the effects of large-scale events such as a catastrophic earthquake. The response to these concerns was the formation of the NDMS. The initial structure of NDMS was a partnership of federal agencies, includ- ing HHS, Department of Veterans Affairs (VA), Department of Defense (DoD), and Federal Emergency Management Agency (FEMA).7 NDMS was later codified into law within the Pub- lic Health Security and Bioterrorism Preparedness and Response Act [PL 107–188] of 2002.8 HHS was the original coordinating agency for NDMS. After September 11, 2001, FEMA was relo- cated to be within the Department of Homeland Security (DHS) and DHS became the NDMS partner agency in the place of FEMA. Oversight responsibility for NDMS was also transferred from HHS to DHS. In 2006, passage of the aforementioned Pan- demic and All-Hazards Preparedness Act returned oversight and coordination of NDMS to HHS.

The three primary NDMS missions are field medical response, patient transport, and definitive care. Each mission is described herein.

1) NDMS field medical response is provided by Disaster Med- ical Assistance Teams (DMATs), Disaster Mortuary Opera- tional Response Teams (DMORTs), and Veterinary Medical Assistance Teams (VMATs) deployed to the disaster site(s) in support of local and state resources engaged in response and recovery operations. Descriptions of these teams and their capabilities are addressed in the “volunteer” section of this chapter.

2) Patient transport includes the movement, distribution, and tracking of victims from the event site(s) to lesser-impacted areas of the United States. DoD manages the patient transport mission during federally declared disasters. Transport may be conducted by U.S. Air Force aircraft, in addition to commer- cial air, rail, bus, or other methods. The NDMS transport component is coordinated through memoranda of under- standing (MOUs) between representatives of NDMS and those of airports, local emergency medical services (EMS), and civilian hospitals that receive and treat casualties.

3) Definitive care involves expansion of national patient care capacity through agreement by civilian community-based hospitals nationwide to provide staffed beds for victims of casualty-producing events. At the time of this writing, approximately 1,800 U.S. hospitals or healthcare systems (“NDMS-enrolled facilities”) have signed MOUs that com- mit staffed beds for the definitive care component. Although it is clearly understood that beds do not take care of patients, use of the term “bed” in this context is meant to repre- sent a surrogate marker of patient care capacity.9 The MOUs outline how victims will be received, approximate num- bers of available staffed beds by clinical categories/services, and the process for reimbursement of services. Most large, comprehensive hospitals in the U.S. are NDMS enrolled. Federal Coordinating Centers (FCCs) provide oversight of this definitive care component. FCCs are managed by the VA and DoD and are located at VA medical centers or DoD

medical treatment facilities in approximately 70 locations throughout the U.S. (Table 9.2). VA and DoD FCC represen- tatives remain prepared for potential activation through rou- tinely conducted bed reporting exercises.8 This allows FCC planners to remain abreast of approximate available staffed beds in the five DoD-designated categories of med-surg, crit- ical care, burn, pediatric, and psychiatric. Bed reporting exer- cises are important planning tools for assessment of dynamic bed availability trends reflective of local and regional periodic impacts of seasonal influenza and other issues.10

Prior to the response and recovery efforts resulting from Hurri- cane Katrina, the three components of NDMS had never been fully activated. Instances of partial activation have included the deployment of DMATs in support of many presidentially declared disasters and high threat events and of DMORTs for the September 11, 2001 response/recovery, air crashes, and other high casualty–producing incidents. The Katrina event, however, overwhelmed local, state, and regional resources and resulted in full activation of all three NDMS components: field medical response, transport, and definitive care.

National Response Plan/National Response Framework

Within the U.S., when local and state resources are overwhelmed by disasters or other mass emergencies resulting in a Presidential disaster declaration, the National Response Plan (NRP) is usu- ally activated. In 1992, the newly published Federal Response Plan (later renamed the NRP) was first implemented when Miami- Dade County, Florida was devastated by Hurricane Andrew. The Plan became the official formal guide and remains the federal blueprint for managing disasters and other emergencies in the U.S. Prior to development and implementation of the Federal Response Plan, response and recovery activities were less orga- nized and there was a risk of misallocation of resources. The plan originally included 12 “Emergency Support Functions” (ESFs) assigned among 28 federal agencies and a single non-government agency, the American Red Cross, with FEMA as the lead federal agency. As part of the post–September 11, 2001 government reorganizations, in 2004, the NRP replaced the Federal Response Plan and expanded the number of ESFs from 12 to 15, assigned among 30 federal agencies and the American Red Cross. Each ESF is coordinated by a lead federal agency, with several supporting agencies.12 Each ESF is concentrated on a specific function or service area. In September 2006, DHS announced that the NRP would be expanded and renamed the National Response Frame- work (NRF).13 The NRF was later implemented in March 2008. The NRP/NRF appears to have vastly improved national response and recovery efficiency and effectiveness. States and many local entities have adopted or are in the process of adopting NRP/NRF guidelines and concepts.

Although all ESFs may potentially impact the direction of public health and healthcare aspects of an emergency, ESF #8 is of primary importance. The specific focus of ESF #8 is “pub- lic health and medical services.” HHS is the lead federal agency for ESF #8, with support from many other agencies. During activation of the NRP/NRF (and specifically ESF #8), HHS and applicable support agencies coordinate and implement an array of functions with the goal to decrease morbidity and mortality associated with response and recovery. ESF #8 personnel manage issues such as health and direct medical services, mortuary care, epidemiology, and environmental health and safety concerns.

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Table 9.2: VA and DoD FCC Sites

Responsible For Includes

Veterans Affairs Managed

VAMC Birmingham, AL Birmingham/Montgomery

VAMC Tucson, AZ Tucson

VAMC N. Little Rock, AK Little Rock

VAMC Long Beach, CA Long Beach/Greater Los Angeles

VA San Francisco, CA Oakland/San Francisco

VAMC Bay Pines, FL Tampa/Orlando

VAMC Miami, FL Miami

VAMC Atlanta, GA Atlanta

VAMC Indianapolis, IN Indianapolis

VAMC Kansas City, MO Wichita

VAMC Lexington, KY Louisville/Lexington

VAMC New Orleans, LA New Orleans/Baton Rouge

VAMC Jackson, MS Shreveport

VAMC MA (VA New England Healthcare System) Leeds, MA Boston/Eastern MA/Northampton

VAMC Detroit, MI Detroit/Flint/Ann Arbor/Grand Rapids

VAMC Minneapolis, MN Minneapolis/St. Paul

VAMC (VA New Jersey Medical Center) Lyons, NJ Newark/Northern/Central

New Mexico VA Healthcare System, Albuquerque, NM Albuquerque/Santa Fe

New York Harbor Healthcare System, NY, NY NYC (minus Bronx) and Northport

VAMC Albany, NY Albany/Buffalo/ Syracuse

VA Hudson Valley Healthcare System, Castle Point, NY Bronx

VAMC Salisbury, NC Charlotte, Raleigh, Durham, Richmond

VAMC Brecksville, OH Cleveland/Akron

VAMC Oklahoma City, OK Oklahoma City

VAMC Portland, OR Portland/Vancouver

VAMC Philadelphia, PA Philadelphia/S. New Jersey

VAMC Pittsburgh, PA Western PA/Northern W. Virginia

VAMC San Juan, PR Puerto Rico/Virgin Islands

VAMC Nashville, TN Nashville/Knoxville

VAMC Dallas, TX Dallas/Ft. Worth

VAMC Houston, TX Houston

VAMC San Antonio, TX San Antonio

VAMC Denver, CO Salt Lake City

VAMC Hines, IL Milwaukee, WI

DoD Managed

Keesler Air Force Base, MS Mobile/Pensacola/Gulfport

Luke Air Force Base, AZ Phoenix

Naval Hospital Camp, Pendleton, CA Orange County

Travis Air Force Base, CA Sacramento/Travis

Naval Medical Center, San Diego, CA San Diego

Evans Army Hospital, Ft. Carson, CO Denver/Boulder

Naval Ambulatory Care Center, Groton, CT New Haven/Hartford

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PU B L I C HE A LT H A N D EM E RG E N C Y MA NAG E M E N T SYS T E M S ■ 137

Responsible For Includes

Dover Air Force Base, DE Wilmington/Dover

Jacksonville Naval Hospital, FL. Jacksonville

Fort Gordon, GA Augusta

Tripler Army Medical Command, Hawaii Honolulu

POMI, Naval Hospital, Great Lakes, IL Chicago/Gary/Hammond

Walter Reed Army Medical Center, Washington, DC Baltimore

National Naval Medical Center, Bethesda, MD DC/Maryland

Scott Air Force Base, O’Fallon, IL. St. Louis

Offutt Air Force Base, NE Omaha/Lincoln

Newport Naval Ambulatory Care Clinic, Newport, RI Providence

Wright-Patterson Air Force Base, WP, OH Cincinnati/Columbus/Dayton/Toledo

Charleston Naval Hospital, Charleston, SC Charleston

Moncrief Army Command Hospital, Ft. Jackson, SC Columbia/Greenville/Spartanburg

Wm. Beaumont Army Medical Center, El Paso, TX El Paso/La Cruces

Marine Naval Medical Center, Portsmouth, VA Norfolk/Virginia Beach

Andrews Air Force Base, MD Northern Virginia Suburbs

Madigan Army Medical Center, Tacoma, WA Seattle/Olympia/ Tacoma

These include food, water, and vector control and other key issues through deployed personnel, supplies, and equipment. The NRP/NRF also includes a series of annexes that contain incident- specific guidelines. For instance, in 1998, policymakers added a Terrorism Annex. With the formation of DHS (and its oversight of FEMA), the NRP/NRF has been revised to reflect these orga- nizational changes and additional annexes.8 The NRP/NRF is a dynamic document that will continue to be updated as new threats emerge and as processes are determined or refined.

Strategic National Stockpile

One critical strategy to maintain public health in health-related emergencies is containment and prevention of disease. The U.S. Strategic National Stockpile supports this strategy through pro- vision of life-saving pharmaceuticals, vaccines, antidotes, and other medical supplies and equipment for use in prevention and treatment of effects from biological pathogens, toxins, chemi- cal agents, or other emergency events (see Chapter 16). Man- aged by the U.S. Centers for Disease Control and Prevention (CDC) within HHS, the Strategic National Stockpile includes 12-hour “push packages,” as well as vendor-managed inven- tory. These resources are stored in classified, strategic locations, ready for immediate delivery to impacted sites. The stockpile pro- gram includes comprehensive public health and medical support through epidemiology, medical treatment, prophylaxis, disease prevention and environmental decontamination. The U.S. CDC coordinates with states in developing processes for deployment of Strategic National Stockpile resources in an emergency.14

In the U.S., VA supports CDC in coordinating movement and delivery of stockpile assets. In addition, many VA medical centers throughout the country have their own on-site pharmaceutical caches. Although primarily for use in treating veterans, these caches may be requested for use in a civilian community-wide incident.15

Metropolitan Medical Response System

When national coordination and deployment of resources is needed, U.S. government officials may activate NDMS and the NRP. Examples of such events include Presidentially declared disasters and emergencies. A more locally based resource is the Metropolitan Medical Response System (MMRS). HHS developed the MMRS in 1996, as concern grew about potential public health crises associated with events involving weapons of mass destruction (WMD). Originally aligned under and funded by HHS, the MMRS was supported by direct funding to local governments in major metropolitan areas. The MMRS uses local volunteers for initial public health, emergency, and medical management until federal resources arrive (typically 24–48 hours). Although the initial MMRS focus was on WMD incidents, focus now includes all types of disasters and hazardous materials incidents.16

In 2004, the MMRS program was realigned under the U.S. DHS Office of State and Local Government Coordination and Preparedness, Office for Domestic Preparedness. Grant guidance and funding were transferred to the state administration agency in each state, which further provides oversight to and collabora- tion with local MMRS programs.17

Weapons of Mass Destruction Act of 1996

The U.S. federal government’s emphasis on addressing the grow- ing concern about terrorism and weapons of mass destruction (WMDs) began in the 1990s. The 1993 attack on the World Trade Center in New York City and 1995 sarin nerve agent attack on the Tokyo subway system fueled the preparedness efforts. U.S. Senators Nunn, Lugar, and Domenici were also worried about the instability of rogue nations and their potential access to WMD. This led to the 1996 Defense Authorization (WMD) Act, which resulted in the formation of the DoD’s Domestic

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Preparedness Program. This program provided funding for equipment and training for civilian first responders and health- care providers in communities throughout the U.S. These activi- ties served to strengthen partnerships and planning among pub- lic health, healthcare, and emergency management entities.8

Homeland Security Act of 2002 (Public Law 107-296)

This Act, which was signed into law in November 2002, called for the formation of the U.S. DHS. In the largest federal government reorganization in more than 50 years, DHS combined functions of other departments and agencies, including consolidation of responsibilities under a single department.18 NDMS and other public health elements were among those functions realigned under DHS. The creation of DHS influenced the continuing necessity of public health and emergency management entities to work collaboratively at all levels.8

Homeland Security Presidential Directives

Several HSPDs have significantly influenced how public health and emergency management systems interface. Of particular rel- evance are HSPDs 5 and 8.

The President of the U.S. signed HSPD 5 in February 2003. HSPD 5

■ Directed the development of a National Incident Manage- ment System

■ Established a Unified Command System for national response

■ Renamed the Federal Response Plan to the National Response Plan

HSPD 8, signed in December 2003, mandated a national domes- tic all-hazards preparedness goal, including measurable readiness priorities, targets, and metrics. The nationally mandated goals include involvement of state and local responders, and health, and medical entities.19

Bioterrorism Focus and Funding

A dramatic sequence of events continued to influence interna- tional direction involving public health and emergency man- agement systems in the early years of the 21st century. Con- firmed cases of severe acute respiratory syndrome, threat of avian influenza (and a possible pandemic), anthrax incidents following the September 11, 2001 terrorist attacks, and other global threats led to new funding and policy and procedures in many countries. Within the U.S., national leaders mandated programs that would strengthen focus on public health and emergency management programs. Several key initiatives emerged that would shape pub- lic health and emergency management systems integration at national, state and local levels.

The Public Health Security and Bioterrorism Preparedness and Response Act of 2002

This Act established the HHS Office of Public Health Prepared- ness, an effort to improve the ability of the U.S. to prevent, prepare for, and respond to bioterrorism and other public health emergencies. This initiative also improved coordination among entities responsible for the nation’s emergency management.8

Health Resources and Services Administration National Bioterrorism Hospital Preparedness Program

In 2002, the U.S. HHS Health Resources and Services Adminis- tration (HRSA) assumed responsibility for guidance and grant funding to states (primarily public health departments) for the development of programs to prepare hospitals and other health- care entities to manage bioterrorism or other events involving infectious disease and epidemics.20 This initiative was a signifi- cant step in addressing needs and roles of healthcare resources at local levels. The grant awards have supported hospitals, emergen- cy departments, community health centers, outpatient centers, EMS systems, rural health clinics, home healthcare, and other systems in building surge capacity and programs for mass pro- phylaxis, immunization, treatment, quarantine, isolation, and other essential measures. Although the program’s focus was “bio- terrorism,” the processes it initiated have significantly enhanced the cooperation among healthcare, public health, and emergency management, resulting in improved all-hazards, comprehensive emergency management plans and systems. With passage of the 2006 Pandemic and All-Hazards Preparedness Act, Biohazard Hospital Preparedness Program functions transferred from HRSA to the Office of the Assistant Secretary for Preparedness and Response. With the alignment under the Assistant Secretary for Preparedness and Response, the aforementioned program is no longer limited to “bioterrorism preparedness,” but is now termed the Hospital Preparedness Program. Although the pro- gram title implies a focus on “hospitals,” in reality, the program includes more comprehensive support that comprises prepared- ness initiatives in nonhospital healthcare organizations as well.

CDC’s Cooperative Agreement on Public Health Preparedness and Response for Bioterrorism

The intent of this grant-based program has been to enhance public health preparedness and response at local and state lev- els. Under this program, states receive funding and, in turn provide funding and guidance to local public health entities, enabling the development of statewide plans for improvement of response to bioterrorism and other infectious disease out- breaks. Targeted areas of improvement outlined under the agree- ment are planning and readiness assessment, surveillance and epidemiology, laboratory capacity/biological agents, health alert network/communications and information technology, commu- nicating health risks and health information dissemination, and education and training.21 (Table 9.3) As with the aforemen- tioned Hospital Preparedness Program, that focuses on “bioter- rorism,” benefits of planning and processes extend well into the all-hazards arena. Also similar to the Hospital Preparedness Pro- gram, this initiative has been a catalyst for continued integration and partnerships between public health and emergency manage- ment systems.

The aforementioned initiatives and resulting programs have not only brought attention to the importance of public health in the management of emergencies, they have served to integrate local, regional, and state entities into comprehensive, nationally directed emergency planning. The concept of comprehensive emergency management, coupled with application of a process, such as the incident command (management) system, became the cornerstone for effective management of the vast number of entities with related, but distinct functions. The formalized approaches for managing emergencies are addressed herein.

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Table 9.3: U.S. CDC Grant Programs to Improve Public Health Preparedness and Response for Bioterrorism

Planning and readiness assessment establishes strategic leadership, direction, assessment, and coordination of activities (including the Strategic National Stockpile response) to ensure statewide readiness; interagency collaboration; and local and regional preparedness (both intrastate and interstate) for bioterrorism, other outbreaks of infectious disease, and other public health threats and emergencies.

Surveillance and epidemiology capacity focuses on enabling state and local heath departments to enhance, design, and/or develop systems for rapid detection of unusual outbreaks of illness that may be the result of bioterrorism, other outbreaks of infectious disease, and other public health threats and emergencies.

Laboratory capacity – biological agents develops the capability and capacity at all state and major city/county public health laboratories to conduct rapid and accurate diagnostic and reference testing for select biological agents likely to be used in a terrorist attack.

Health Alert Network enables state and local public health agencies to link public health and private partners at all times through Internet capability. The program provides for rapid dissemination of public health advisories and ensures secure electronic data exchange.

Communication of health risks and dissemination of health information ensures timely information dissemination to citizens during a bioterrorist attack, other outbreak of infectious disease, or other public health threat or emergency.

Education and training assesses the training needs of key public health professionals, infectious disease specialists, emergency department personnel, and other healthcare providers related to preparedness for and response to bioterrorism, other outbreaks of infectious disease, and other public health threats and emergencies.

Sources: U.S. Centers for Disease Control and Prevention (CDC), 2003. “Continuation Guidance for Cooperative Agreement on Public Health Preparedness and Response for Bioterrorism – Budget Year Four.” [Online article; retrieved 8/03] http://www.bt.cdc.gov/planning/ continuationguidance/pdf/guidance intro.pdf.

THE ALL-HAZARDS APPROACH – COMPREHENSIVE EMERGENCY MANAGEMENT

The context for today’s U.S. all-hazards emergency manage- ment programs emanates from a subcommittee of the National Governors’ Association chartered in 1977.22 At the time, federal policy and funding were centered in two areas: civil defense and disaster assistance. The bulk of the funding was for civil defense activities such as preparedness for enemy attacks, population relocation planning, and radiological monitoring programs. No funding was available for preparing for any other type of hazard. When natural and technological hazards did strike, federal assis- tance to state and local governments was provided by a variety of up to 16 agencies. This assistance was not always well coordi- nated, leading some state directors to describe it as the “second disaster.”

The National Governors Association formed the subcom- mittee to study the problems and make recommendations to the incoming President Jimmy Carter. One recommendation was to combine the various federal agencies with disaster relief missions into a single agency. This single agency became known as FEMA. Another recommendation was for “dual use” of civil defense funding to prepare for other hazards. This notion was tied to a

Comprehensive Emergency Management:

4 Phases

Figure 9.1. Phases of comprehensive emergency management.

third recommendation, which promoted a new vision of federal disaster policy.

Comprehensive Emergency Management is a conceptual framework that encompasses all hazards, all disciplines, and all levels of government (including the private, nonprofit, and vol- unteer sectors). It views disaster management activities as occur- ring across four phases that are cyclical: mitigation, preparedness, response, and recovery (Figure 9.1). Mitigation efforts are aimed at eliminating or reducing the effects of hazards, such as improv- ing building codes, zoning, structural design, and construction. Preparedness activities (planning, training, resource identifica- tion, and exercises) are designed to build capabilities necessary to manage the effects of hazards. Response actions include those taken to stop the ongoing negative effects of the disaster, and recovery actions are those that restore services and rebuild infras- tructure, housing, and the economy after a disaster. The recov- ery phase of a disaster can last for years. Reviews conducted in the recovery phase are intended to identify potential improve- ments to future mitigation, preparedness, response, and recovery efforts.23

To assist state and local government implementation of the comprehensive emergency management concept, FEMA devel- oped what is referred to as the Integrated Emergency Manage- ment System. The Integrated Emergency Management System was developed with input from the disaster research commu- nity, which provided three principles that continue to remain significant guidelines in emergency management. The first was the recognition that disaster planning must be inclusive of the various groups that respond to disasters. Prior to this, govern- ment agencies were prone to engage in isolated planning pro- cesses, without including other government entities, business and industry, nonprofit, and faith-based organizations. Sec- ond, the Integrated Emergency Management System provided a framework that organized emergency management programs into multiyear development processes (Figure 9.2). The third key principle was that emergency operations plans should be orga- nized around functions, not agencies or hazards. This was the beginning of the “all hazards” focus for emergency planning.24

Planners had developed multiple, unique emergency plans for the variety of hazards that threatened a jurisdiction but researchers argued that a single, comprehensive all-hazards plan should be the standard because similar activities needed to be performed regardless of the cause of the disaster.

Agent-generated demands such as search and rescue, medical care, evacuation, and so forth represented only limited compo- nents of disaster operations. Quarantelli argued that there were two sets of demands that occur during disasters – agent-generated and response-generated demands25 (Figure 9.3). The response- generated demands are the requirements for the exercise of

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Maximum Capability Required

Optimally Integrated

Plans

Continual Maintenance

CAPABILITY ASSESSMENT

EMERGENCY OPERATIONS

PLANS

EMERGENCY OPERATIONS

PLANS CAPABILITY

MAINTENANCE

CAPABILITY MAINTENANCE

MITIGATION EFFORTS

EMERGENCY OPERATIONS

CAPABILITY SHORTFALL

MULTI-YEAR DEVELOPMENT

PLAN

MULTIYEAR DEVELOPMENT

PLAN

ANNUAL DEVELOPMENT

INCREMENT

ANNUAL DEVELOPMENT

INCREMENT

HAZARDS ANALYSIS

EVALUATIONEVALUATION

STATE/ LOCAL

RESOURCES

STATE/ LOCAL

RESOURCES

FEDERAL RESOURCES

ANNUAL WORK

INCREMENT

ANNUAL WORK

INCREMENT

2 3 4

6 7

8 9 10

Figure 9.2. The Integrated Emergency Management System program development process flowchart.

authority, decision making, communications, and coordination that occur within an organization and between organizations as they attempt to provide assistance. The response-generated demands are those that are most often cited in after-action reviews of disaster responses. As a general rule, emergency plans do not address these needs, but the Incident Command System (ICS) does. This is one reason why it is so important to integrate ICS into emergency operations plans and to mandate ICS use by all agencies with roles in disaster response.25

THE INCIDENT COMMAND SYSTEM

In the 1970s, challenges with the on-scene coordination of wild land firefighting efforts in California resulted in a U.S. Congres- sional mandate to develop a solution. The Firefighting Resources of Southern California Operational Procedures task force was formed and produced the National Interagency Incident Man- agement System in 1983.23 The National Interagency Incident Management System consisted of the ICS and four subsystems: training, qualifications and certification, supporting publica- tions, and related technologies.26 (See Table 9.4 for a listing of the components of the ICS27.) In 2003, after minor revisions, the National Interagency Incident Management System was renamed and became the NIMS. One significant change was the 2002 Pres- idential executive order that mandated the use of ICS by federal,

Warning Preimpact Preparations Search & Rescue Care of Injured & Dead Welfare Needs Restoration of Essential Services Protection against Continuing Threat Community Order

Communication Continuing Assessment of Situation Mobilization & Utilization of Resources Coordination Exercise of Authority

“Agent-Generated Demands”

“Response-Generated Demands”

Two Sets of Demands Occur Simultaneously!

Figure 9.3. Agent-generated and response-generated demands in disaster management. Source: Quarantelli, Enrique, Major Criteria for Judging Disaster Planning and Managing and Their Applicability in Developing Societies. Disaster Research Center, University of Delaware, Newark, Delaware, 19716 USA. 1998.25

Table 9.4: Incident Command System Components

Components of the Incident Command System

■ Common Terminology ■ Integrated Communications ■ Unified Command Structure ■ Manageable Span of Control ■ Consolidated Action Plans ■ Comprehensive Resource Management ■ Designated Incident Facilities

National Interagency Incident Management System, Washington, DC; 2003.27

state, local, and tribal governments and the private sector (HSPD 5, Management of Domestic Incidents). HSPD 5 also directed the revision of the former Federal Response Plan into the NRP. The NRP exemplified the functional approach to planning created under the Integrated Emergency Management System and the incorporation of ICS.

To ensure that the various federal, state, local, and tribal government agencies and private sector organizations (e.g., hos- pitals that accept federal grants such as those for bioterrorism preparedness) would begin to apply ICS, the DHS issued NIMS compliance requirements.28 The NIMS requirements for hospi- tals, released in 2006, were modeled after those for local and tribal governments. An overview of the 17 NIMS requirements is found in Table 9.5.29

Various models exist for applying ICS to healthcare orga- nizations. The Hospital Emergency Incident Command System gained popularity with hospitals in the 1990s and was revised in 2006 into the Hospital Incident Command System.30 The U.S. Department of Veterans Affairs, Veterans Health Administration guidance sets forth a simplified ICS structure, explaining how ICS is integrated within the organization’s emergency operations plan and overall emergency management program.31 The Vet- erans Health Administration’s guidance heavily influenced the outcomes of the Hospital Incident Command System revision process within the U.S.

One barrier that organizations have faced in incorporating ICS into their emergency operations plans has been a lack of useful guidance. Most ICS resources do not explain how the ICS structure relates to an organization and how ICS is imple- mented in response to emergencies. This has led staff having little knowledge or background in using ICS to inappropriately

Table 9.5: National Incident Management System Compliance Elements for U.S. Hospitals (2006)

■ 17 Elements of Compliance ■ 5 Categories:

– Organizational Adoption – Command and Management – Preparedness Planning – Preparedness Training – Preparedness Exercises – Resource Management – Communications and Information Management

NIMS Integration Center, Washington DC; 2006.29

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Table 9.6: Three ICS Management Elements

ICS Management Elements

■ Agency Executive – Director/CEO at the hospital facility, regional, or national level

– Set overall policies and priorities

■ Policy Coordination Entity – Operating unit/department managers

– Support the Agency Executive and the Incident Management Team with technical assistance and program coordination

■ Incident Management Team – Staff trained to perform ICS command and general positions

– Staff the Emergency Operations Center and Response Support Unit

– Develop the Incident Action Plan – Provide the Situation Briefings and Operations Briefings

Emergency Management Strategic Healthcare Group, Department of Veterans Affairs, Martinsburg, West Virginia. 2002.32

design an organization-specific application that reflects a “blend” of ICS and the organization’s day-to-day administrative struc- ture and/or terminology. The result is often exactly what ICS was designed to avoid – inconsistent terminology and organizational structures between agencies responding to emergencies.

An ICS organization is separate and distinct from the day- to-day administrative structure. In particular, the diagram for an ICS is not simply the standard organization chart. There are three basic ICS elements that relate to any organization: the agency executive, the policy coordinating entity, and the incident management team (Table 9.6).32 Staff members are assigned to agency executive and policy coordinating entity roles based on expertise gained from their day-to-day positions, but the assign- ment of staff to the incident management team is based on staff training and qualifications.

ICS implementation differs depending on whether the inci- dent occurs with or without warning. If there is a warning period, such as with a slowly developing hurricane, the Incident Man- agement Team would use the incident action planning process to initiate preimpact activities. If the incident occurs without warning, any employee who detects the emergency should initi- ate the response through activation of pre-event plans designed to defend and protect people and property, and a supervisor should provide initial command. The initial command role includes situation assessment, notifications, designation of staff into ICS positions, and actions designed to defend and protect people, property, records, and the environment. The pre-event designated Incident Management Team would be mobilized, be briefed, and assume responsibility for managing the event (from the initial command staff). The incident action planning pro- cess would be initiated to manage further response and recovery activities.

INTERCONNECTIV ITY OF HEALTHCARE SYSTEMS, PUBLIC HEALTH, AND EMERGENCY MANAGEMENT

Various means of coordinating healthcare, public health, and emergency management have evolved over time. With some notable exceptions such as Israel, however, standardization at

all levels of government did not exist in most countries, includ- ing the U.S., until recently. Within the U.S., in the mid-1980s, many local community entities coordinated their preparedness activities via regional or local planning groups. In 1986, Local Emergency Planning Committees began to emerge primarily as collaborative forums for private industry and the public that were concerned about hazardous materials production. Local Emer- gency Planning Committees were mandated by the Emergency Planning and Community Right to Know Act (Title III of the Superfund Amendment and Reauthorization Act).33 Over time, committee membership expanded to include representatives of the public health and healthcare communities. Local Emergency Planning Committees continue to be active in many commu- nities. In addition, many municipalities, particularly those with NDMS FCC sites, began to sponsor forums and planning meet- ings that included participation by representatives of public health, healthcare, first response, and emergency management entities. With the 2002 HRSA-sponsored Bioterrorism Hospital Preparedness Programs, states began to emphasize collaboration of healthcare, public health and emergency management through the formation of planning committees and other means. This col- laboration is projected to continue or be enhanced following the 2006 Pandemic/All-hazards legislation.

At the national level in the U.S., integration of healthcare, public health, and mental health was first described in a sys- tem that became known as the NRP/NRF. This framework, first used for designing emergency operations plans, has been repli- cated at the state and local government levels. In these plans, a “primary” agency (usually the entity having legal authority and responsibility for a particular function) heads the ESF. This lead organization coordinates assistance to states and localities with the support of related agencies and organizations. (See Table 9.7 for a list of the types of assistance provided under ESF 8, Public Health and Medical Services of the NRP/NRF.)

Although various local, state, and federal initiatives sought to provide interconnectivity to the many layers and levels of healthcare, public health and emergency management were not formally connected in a standardized fashion. In the early 1980s, Quarantelli concluded that the principles that support effective disaster planning were not the same as those that support disaster management. A universal management framework was needed to operationalize the relationships and activities described in the

Table 9.7: Types of Assistance Provided under Emergency Support Function (ESF) 8, Public Health and Medical Services

■ Assessment of public health and medical needs ■ Health surveillance ■ Medical care personnel ■ Health/medical equipment and supplies ■ Patient evacuation ■ Patient care ■ Safety and security of human drugs and biologics ■ Blood and blood products ■ Worker health and safety ■ Food safety and security ■ Agriculture safety and security ■ Behavioral healthcare ■ Public health and medical information ■ Vector control ■ Protection of animal health ■ Technical assistance

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EC 1 Design

EC 2 Teach & Implement

EC 3 Measurement

EC 2.1 Staff can describe/demonstrate

EC 2.9 Drills are

conducted

EC 2.5 Plan is implemented

EC 1.4 Design

management plan

EC 3.1 Collect information about deficiencies

EC 3.2 Corrective action

PREPAREDNESS

MITIGATION

RESPONSE, RECOVERY

Figure 9.4. Relationship of EC to EM.

emergency operations plans. This framework was only embraced over a decade later by the medical and health communities to include such vital components as the use of ICS.

In January 2001, acting on an unsolicited recommendation from the National Director of Emergency Management Office at the Department of Veterans Affairs, the Joint Commission on the Accreditation of Healthcare Organizations (renamed the Joint Commission in 2007) promulgated landmark changes in their emergency management standards that required hospitals to use an IMS “consistent with that in use by the local commu- nity.” In addition, the new standards required healthcare facilities to use an all-hazards approach and address the four phases of comprehensive emergency management (mitigation, prepared- ness, response, and recovery). Figure 9.4 shows the relation- ship between the Joint Commission Environment of Care stan- dards and comprehensive emergency management. These new requirements have helped to ensure healthcare facilities coor- dinate with local public safety agencies. The Joint Commission further improved development of an operational system at the local level with its “cooperative planning” requirement, which calls for healthcare facilities to share names and contact infor- mation of staff assigned to ICS positions.34

Until 2002, no widely known published models existed that explained how healthcare systems integrated with public health, public safety, and emergency management at the local jurisdic- tion level. Barbera and Macintyre’s Medical and Health Incident Management (MaHIM) System was developed to correct this critical deficiency. MaHIM provides a framework for integrating and organizing the various medical, public health, emergency management, and support disciplines at the jurisdictional or community level and describes the functional requirements for responding to a mass casualty incident (Figure 9.5).35

Despite the MaHIM system, clear guidance was still lacking that described how the medical and health system integrated with emergency management at all levels of government. Barbera and Macintyre’s Medical Surge Capacity and Capability Model pro- vides a management framework that serves as a foundation for current health system preparedness. The Model defined six tiers that interact during major incidents and affect the resiliency of a health system and/or require medical surge (Table 9.8).36 Med- ical surge is defined as “the ability to provide adequate medical care under circumstances where demands resulting from a mass casualty or complex incident challenge or exceed the medical infrastructure.” Two medical surge components are surge capac- ity and surge capability. Surge capacity is the ability to respond to a markedly increased number of patients, whereas surge capa-

Planning

Information Processing

Planning & Assessment

Logistics Finance Operations

Monitoring

Liaison

Safety

Jurisdictional Medical & Health

Coordinator

Medical & Health Agency

Administrators

Public Information

Technical Support

Transportation Support

Supplies & Equipment

Personnel Support

Finance Support

Regulatory Compliance

Business Continuity

Staging

Medical Care

Prehospital Care

Epidemiological Profiling

Mass Fatality Care

Mental Health

Hazard Containment

Figure 9.5. Medical and Health Incident Management (MaHIM) Sys- tem (Barbera, JA and Macintyre, AG, Medical and Health Incident Management (MaHIM) System: A Comprehensive Functional System Description for Mass Casualty Medical and Health Incident Manage- ment, Institute of Crisis, Disaster and Risk Management, The George Washington University, Washington, D.C., October 2002. Supported by a grant from the Sloan Foundation.)35

bility is the ability to address unusual or very specialized medical needs.35

A key concept that deserves emphasis is that the broader public health and healthcare system extends beyond first respon- ders, disaster teams, and hospitals. Emergency planners should conduct prospective assessments of multiple systems whose mis- sions address patient/victim care and integrate these systems into comprehensive public health and emergency management plans and programs. Although there are thousands of primary care practices throughout the U.S., there are also organized, for- mal representatives of other resources. Outpatient clinics and health centers are large assets that are often overlooked in com- prehensive emergency management planning. Within the U.S., Community Health Centers (CHCs) are local, community-based facilities that serve low-income and medically underserved com- munities. CHCs can be health centers, migrant clinics, care to homeless clinics, and public housing–based clinics. The U.S. National Association of Community Health Centers reported that in 2006, more than 1,000 federally qualified health centers served more than 15 million people, many of whom were low income or other vulnerable populations.37 In addition to feder- ally funded CHCs, there are thousands of state and other-funded health centers, as well as Rural Health Clinics. Home and hospice care and nursing facilities are other critical entities that must be included in disaster planning, and represent a tremendous pop- ulation of underserved and vulnerable patients, including the elderly, disabled, and chronically ill. Each year in the U.S., almost

Table 9.8: Tiers within the Medical Surge Capacity and Capability Management System

Six Tiers

■ Individual healthcare asset ■ Healthcare coalition ■ Local jurisdiction ■ State response and coordination of intrastate jurisdictions ■ Interstate regional management and coordination ■ Federal support to state and local jurisdictions

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2 million adults are admitted to the nation’s 16,800 nursing facil- ities. The literature cites multiple examples of consequences of failure to adequately include nursing facilities in emergency plan- ning.38 State departments of health maintain contact informa- tion for these entities. Public health and emergency management planners would be remiss to exclude CHCs, nursing facilities, and other cited critical resources when planning.

Management of Volunteers

In some systems, the success of public health and emergency management systems depends in large part on volunteers. In the U.S., volunteers have been essential; the only formal approach to managing public health crises was through the activation or deployment of uniformed personnel, such as the Armed Forces or Public Health Service Corps, and supportive services of civilian groups like the American Red Cross. Volunteerism and “neigh- bor helping neighbor” had long been the approach to managing local disasters and emergencies, until the late 20th century. The advent of NDMS and later, the NRP sparked the development or organization of volunteers to address public health and health- care at the national level. Many specific disaster public health issues, for example epidemiology, infectious disease prevention and management, and surveillance had been addressed by paid staff of the CDC, uniformed Public Health Service personnel, other components of HHS, or state and local public health enti- ties. The delivery of direct care services to disaster victims, how- ever, required more specialized resources than the uniformed or paid-employee systems could provide. This led to the growth and expansion of nationwide systems of volunteers. This section highlights significant U.S. initiatives affecting the organization of volunteers used for disasters and other emergencies.

National Disaster Medical System Volunteers

Organized under NDMS, ESF 8, and ultimately, the NRP/NRF, NDMS volunteers represent the U.S. federal government’s approach to providing organized teams of professionals who deploy to or near-by the disaster site to deliver direct healthcare services. Formed in the mid-1980s, the first type of NDMS team was the DMAT, composed of healthcare professionals and ancil- lary support personnel, who are locally based and sponsored. The “original” DMAT mission was to deploy to disasters and provide healthcare beyond their local areas or states. Over time, many local areas and states have emulated the DMAT model, forming teams that are also intended for use in local and state emergency events.7,8 For example, in 2007, the State of Cali- fornia formed CAL-MATs and the County of Los Angeles has LAC-MATs. This approach is compatible with the U.S. approach of local-state-federal response to emergencies. DMAT personnel represent individuals who are usually employed in local hospitals, EMS, and other healthcare systems. In addition to performing their routine, daily roles, the individuals volunteer as members of DMATs in their geographical areas.

Although local resources, DMATs are “registered” with NDMS and may be activated as federal resources for declared disasters, terrorist incidents, or high-profile events where on- site medical care may be required. DMATs, located through- out the nation, bear the titles of their respective cites, states, or sponsoring organizations. Over the years, they have evolved to a level where each DMAT has characteristic uniforms, and DMATs routinely meet and train as teams and are equipped

with medical supplies, as well as supplies and equipment to sus- tain life in austere conditions associated with disaster sites. If activated for disasters or emergency events, DMATs are “federal- ized,” and members are sworn in as temporary federal employees. After authorization from their respective day to day employers, the NDMS arranges transportation and, if applicable, lodging for DMAT members at the deployment site. While performing duties under federalized status, DMAT members or their organi- zations are paid at “federal rates” and are provided malpractice insurance by the Federal Tort Claims Act. NDMS maintains a current database reflecting licenses and credentials of enrolled volunteers. The “normal” duration of deployment is 14 days, but this can vary according to each unique situation and its require- ments.39 As DMATs evolved since the 1980s, they have been deployed to hundreds of events and personnel have cared for thousands of victims. Specialized DMATs, defined by purpose (e.g., pediatrics) or composition (e.g., pharmacists) have also been created. NDMS leaders quickly identified additional needs for mass fatality management and expertise in pet and animal health issues. This resulted in the development of DMORTs and VMATs, respectively.39 DMORTs, like DMATs, are locally formed teams of professional and support staff volunteers with expertise in managing human remains and associated activities. Members are commonly employed as funeral directors, morticians, and anthropologists, and the team is formed, trains, and deploys in a similar manner as a DMAT. DMORTs have been deployed in support of commercial air crashes; major floods, where cemetery integrity has been compromised; the U.S. Oklahoma City bomb- ing and the September 11, 2001 terrorist attacks; and many hur- ricanes, tornadoes, earthquakes, and other events. More recently, VMATs, composed of veterinarians and support personnel, have been formed and have deployed to events where pets and other animals are affected. Hurricane Katrina was one notable example of VMAT deployment. Other NDMS-approved volunteer teams have emerged to meet evolving challenges. An example is the National Medical Response Teams, which are focused on events involving WMD.39 Table 9.9 lists the types of NDMS volunteer teams.40

Medical Reserve Corps

During the 2002 U.S. State of the Union Address, President George W. Bush asked all Americans to volunteer in support of their country. Subsequently, the Medical Reserve Corps (MRC) was founded. A partner program with Citizens Corps and a national network of volunteers dedicated to ensuring homeland security, the MRC, along with the Citizens Corps, AmeriCorps, Senior Corps, and the Peace Corps, are part of the President’s USA Freedom Corps. The basic premise of this initiative is to promote volunteerism and service nationwide.

The mission of the MRC is to establish teams or units of local public health and medical professionals who are willing to contribute time and skills both throughout the year and in times of emergencies. Whereas DMATS, DMORTs, and VMATs are organized nationally under NDMS, the MRC is organized under the Office of the U.S. Surgeon General. The Office of the Surgeon General issues direction on specific target areas that strengthen the public health infrastructure of communities. Much of the routine MRC focus is on improvement of health literacy, disease prevention, and eliminating health disparities. MRC volunteers include physicians, nurses, pharmacists, dentists, veterinarians, and epidemiologists. Support positions are filled by volunteer

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Table 9.9: Types of NDMS Teams

Category Capability Composition

DMAT Provide acute medical care Physicians, nurses, and other medical support staff

DMORT Provide fatality management Funeral directors, medical examiners, and forensic experts

Specialized Disaster Medical Assistance Teams (e.g., burn, surgical, mental health)

Provide care specific to the disaster needs Physicians, nurses, and other medical and support staff in specialization area

National Medical Response Team Specially trained for response to events involving agents defined as WMD

Physicians, nurses, epidemiologists, chemists, and other medical and support staff

Management Support Team Provide management support to deployed teams and interface with local medical disaster system

Leadership and administrative support staff

VMAT Provide emergency support for rescued pets and other animals affected by disaster

Veterinarians and support staff

National Nursing Response Team Activated for situations specifically requiring nurses and not full DMATs

Nurses

National Pharmacy Response Team Activated for situations specially requiring pharmacists and not full DMATs

Pharmacists

Source: VHA Emergency Management Strategic Healthcare Group (EMSHG) 2002. Emergency Management Program Guidebook, Section 3. Department of Veterans Affairs, Martinsburg, West Virginia. (∗Revised Jan-10–2008)

chaplains, legal advisors, interpreters, administrators, and other workers.41

Although the primary focus of the MRC is on local commu- nity public health and medical services, opportunity exists for volunteers to deploy outside their local jurisdictions, particularly in times of disaster or other emergencies. During the 2004 hur- ricane season, more than 30 MRC units supported hospitals and shelters around the country, assisting the Red Cross and FEMA in response and recovery. In 2005, hundreds of MRC volun- teers assisted the Red Cross through support of shelters, special needs services, first aid, health, and mental health. Hundreds more deployed in support of HHS response and recovery opera- tions following Hurricane Katrina and for other events. The Red Cross, HHS, public health, and other state agencies where MRC volunteers reside have coordinated deployments.

The MRC is headquartered at the Office of the Surgeon General, but is coordinated by this office in collaboration with local, regional, state, and national organizations that establish, implement, and maintain MRC units nationwide. The MRC maintains a website and sponsors an annual leadership confer- ence, as well as serves as a clearinghouse to support this volunteer initiative.41

American Red Cross

Although Red Cross volunteerism is inherent in its role in ESF 6 (Mass Care) of the NRP, there is an array of Red Cross vol- unteer services affiliated with ESF 6 and beyond. The Red Cross is a vast private, nonprofit agency and the only nongovernment U.S. agency/department that has functioned as an NRP/NRF lead federal agency. In 2007, FEMA took over as the ESF 6 lead federal agency, with the Red Cross remaining as a significant ESF 6 support agency. In addition to the NRP mass care mis-

sion, the Red Cross, both through its national headquarters and local chapters throughout the country, delivers disaster recov- ery assistance through a 1905 Charter with the U.S. Congress. Each year, the Red Cross responds to more than 70,000 disas- ters/emergencies, including residential fires, which comprise the majority of its response activities. Thousands of healthcare and other types of volunteers, supported by national and chapter- based Red Cross paid staff, facilitate and deliver response and recovery missions for victims of fires, tornadoes, floods, win- ter storms, power outages, earthquakes, hurricanes, hazardous materials, technological incidents, and other types of events. Red Cross volunteers provide multiple services including shelter (and special needs shelters), food, first aid, health and disaster mental healthcare, disaster welfare inquires, and administration of blood and blood products. (“Special needs” is a term that FEMA and other response/recovery entities apply to individuals who require assistance for disabilities that are medical, mental, or psychological.)42 The Red Cross also establishes and staffs mobile kitchens and feeds emergency workers at response and recovery sites. Throughout the year, the Red Cross provides many community-based courses, including programs on subjects such as disaster services, disaster mental health, cardiopulmonary resuscitation, automated external defibrillators and first aid, and shelter management. The U.S. Red Cross also offers many web- based and printed educational and support tools for disaster workers and victims, including those unique to persons with dis- abilities and non-English speaking individuals.43 The Red Cross is therefore a significant volunteer resource in public health and emergency management.

Although the American Red Cross emphasizes disaster pre- paredness, response, and recovery initiatives, the International Committee of the Red Cross is more focused on issues involving armed conflict (war) and internal violence. The International

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Committee, headquartered in Geneva, Switzerland, is an inde- pendent humanitarian organization whose operations are based on a mandate (the Geneva Conventions and International Com- mittee of the Red Cross Statutes). As a neutral body, the Interna- tional Committee supports prisoners and victims of war, and of internal violence and strife.44 More aligned with the American Red Cross mission, but on an international scale, is the Interna- tional Federation of Red Cross and Red Crescent Societies. This organization, funded by appeals for contributions and support, includes three components: health, disaster management, and promotion of humanitarian principles and values. The Inter- national Federation of Red Cross and Red Crescent Societies is composed of many partner organizations, including the Red Cross, the World Health Organization and other internationally based groups. Its disaster management component includes: an information system (e.g., tools, databases), relief fund, emer- gency response units (teams) and field assessment and coordina- tion teams. The International Federation includes paid staff and volunteers situated around the globe.45

Community Emergency Response Team

The Community Emergency Response Team (CERT) concept was first developed and implemented by the Los Angeles City Fire Department in California in 1985. The department’s pur- pose in implementing this concept was to strengthen local fire and hazardous materials response efforts through training and coordination of citizens and private and government employ- ees. Over time, FEMA’s Emergency Management Institute and National Fire Academy, both located in Emmitsburg, Maryland, adopted the CERT model and training on a national level, and expanded the emphasis to one of all-hazards.46

Since 1993, FEMA has provided CERT training nationally, and 28 states and Puerto Rico have formed teams, trained, and exercised as CERTs. Although CERTs are formed and based locally, they are supported (with training, exercise, and equip- ment) by their respective states and FEMA. CERTs are designed to supplement existing local resources and prepare under the axiom that disasters and response are local.46

Other Volunteer Initiatives

Even within the U.S., there are hundreds, if not thousands, of volunteers and volunteer cells or groups that are not cited in the aforementioned initiatives. Some are borne of local organiza- tions whose philosophy is based on a neighbor-helping-neighbor mindset, whereas others are embodied in organizations that are nongovernmental and not reflected in the NRP/NRF or other for- mal government agency structures. Some of the nongovernment, nonprofit entities are focused on specific aspects of healthcare in response and recovery activities. An example of this is the distinct focus on stress management and mental health issues associated with disasters and other events.

Locally based stress management teams, whose primary mis- sions are to support local, smaller scale incidents, but whose members, in many incidents, are willing to deploy in support of events that are external to their locations are present through- out the United States. The International Critical Incident Stress Foundation lists 682 locally based teams worldwide that include members who are trained and can apply principles of “Critical Incident Stress Management (CISM)” in support of victims of disasters and other events.47 Many of these teams are composed

of first responders who are certified in CISM. In many incidents, the team’s focus is on “caring for its own,” applying specific CISM concepts. Other mental health professionals are members of locally sponsored teams that may or may not endorse specific CISM principles and that are not affiliated with the International Critical Incident Stress Foundation.

Certain U.S. federal departments and agencies also list volun- teerism in disasters and emergency events as components of their mission(s). In 1997, the U.S. Department of Veterans Affairs, Veterans Health Administration, a major participant in the exter- nal federal/national response, developed a volunteer program, the Disaster Emergency Medical Personnel System. The Disas- ter Emergency Medical Personnel System includes a database of Veterans Health Administration employees and retirees from throughout the U.S. who are willing to deploy in support of VA facilities or non-VA emergencies. Volunteers are registered and trained and may be deployed for up to 2 weeks. Volunteers include doctors, nurses, pharmacists, mental health, and other clinical and support personnel. Volunteers have deployed to sev- eral VA facilities and also nationally to Presidentially declared disasters. Veterans Health Administration Directive 2003–052 describes the scope, mission, and other formalized guidelines.48

Faith-based organizations are another emerging group with interest in volunteerism. Following a disaster or other emergency, it is not uncommon for churches and other faith-based institu- tions and groups to volunteer and contribute to response and recovery efforts, especially at the local grass roots level. In January, 2001, U.S. President George W. Bush signed Executive Order 13199, creating a formal White House Office of Faith-Based and Community Initiatives. Subsequently, offices began to emerge at the state level. Additional Executive Orders created several Cen- ters for Faith-Based and Community Initiatives. Although the primary mission of then Office of Faith-Based and Community Initiatives extends well beyond “disaster volunteers,” Faith-Based and Community Initiative entities have become increasingly engaged in collaboration with local faith-based and government groups in identifying, organizing, and training volunteers for victim support following disasters. In March 2006, U.S. Exec- utive Order 13397 created a new Center for Faith-Based and Community Initiatives at DHS in Washington, DC.49

National Voluntary Organizations Active in Disaster

The National Voluntary Organizations Active in Disaster was formed in 1970 by representatives of seven U.S. voluntary orga- nizations whose missions include “disaster response.” The pur- pose of this nonprofit agency is to “improve effective service to those affected by disaster.” By 1995, the organization’s member- ship had grown to 28 members, including the Red Cross, and various public, nonprofit, and faith-based groups. The agency functions primarily by collaboration through annual meetings and other forums involving its elected officers and members, training, communication, and resources. The agency’s principles are cited as cooperation, communication, education, mitigation, serving as a convening mechanism, and outreach. Although the agency does not directly provide or manage volunteers to disas- ters and other emergencies, it serves as an oversight and advisory body to its members and to those managing response and recov- ery. The agency also serves as a body that can assess, monitor, and advise on volunteer resource assignments, ensuring lack of redundancy and appropriate volunteer preparedness and use of resources. In 1993, FEMA Director James Lee Witt appointed the

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agency chairperson to a permanent seat on the FEMA Advisory Board.50

Convergent Volunteerism

Throughout the history of disaster response, there have been many anecdotal accounts of “convergent volunteerism.” Con- vergent volunteerism is the arrival of unexpected or uninvited personnel, asking to render aid at the scene of large-scale emer- gency incidents.51 Convergent volunteerism or “freelancing” by doctors, nurses, firefighters, and others can pose difficulties for those responsible for managing the response. Although many of these individuals may be legitimate professionals in their respec- tive fields and well intentioned, specific areas of concern are worth noting.

1) Safety – Convergent volunteers often are not properly trained or equipped for the unique response environment, which can include hazardous materials or other threats. Safety of the volunteer, as well as of the victims, may be in jeopardy, and liability is a concern.

2) Accountability – A well-organized and managed response includes knowledge by the manager(s) of “who’s who.” Inte- grating those who are not “on the list” creates disruption of the team structure and can result in liability issues.

3) Training – It is axiomatic that those responding be appropri- ately trained in response principles and other areas unique to the specific event. The untrained “volunteer” interferes with response efficiency and effectiveness.

4) Skill levels – In addition to training in the general sense, specific training, education, and experience are key to how responders are selected and assigned. The convergent volun- teer poses the problem of requiring supervision and assess- ment of skills on the spot, detracting from effective and effi- cient operations.

5) Security – Checking identification, reviewing credentials, providing access and other security processes are labor inten- sive and require resources. Staff time and effort is impacted when “undocumented” volunteers converge.51

Those charged with managing response, as well as planners and on-scene responders must be vigilant to the potential prob- lem of convergent volunteerism and be prepared to implement steps to manage the issue.

Volunteer Credential and the U.S. Emergency System for Advance Registration of Volunteer Health Professionals

During and following a crisis, appropriately qualified volunteers are critical to successful health and medical outcomes. In the U.S., the terrorist attacks of September 11, 2001, the subsequent anthrax incidents, Hurricane Katrina, and other public health emergencies have resulted in the mobilization of significant healthcare and support resources. Assessments of these activi- ties, along with focus on building surge of nationwide healthcare capabilities, prompted national leaders to propose a system to ensure readiness of potential volunteer healthcare profession- als. Heretofore, a nationwide credentialing system for healthcare professionals has not existed and its absence has lessened the effectiveness and efficiency of providing qualified profession- als for response to emergency events in a timely manner.51,52

Recognizing the need for optimizing volunteer health personnel

in emergencies, the U.S. Congress authorized the development of the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP). HRSA was initially appointed to take responsibility for ESAR-VHP development and oversight, until the passage of S.3678, which transferred responsibility to the HHS Office of Preparedness and Response.53,54

Under ESAR-VHP, national guidelines were issued to U.S. states and territories to establish standardized, volunteer regis- tration systems. Each state’s system is to include readily avail- able, verifiable, current information on each volunteer’s identity, licensing, credentialing, and accreditation to hospitals and other healthcare facilities. The system will allow each state/territory the ability to identify and rapidly access healthcare professionals in an emergency or disaster. The goal is that eventually, states may share information across borders and even nationally.53 States have progressed in establishing ESAR-VHP especially through use of existing databases managed by state and local health departments. Effective ESAR-VHP registration has occurred in some states through methods such as including registration as part of professional license renewal programs. The ESAR-VHP program is a collaborative effort among federal, state, and local entities, and accrediting and professional organizations.53

Volunteers with healthcare, public health, and related exper- tise are important resources for emergency events of all scopes, levels, and locations. Management of volunteers is crucial in ensuring appropriate use of resources, avoidance of redundancy, cost effectiveness, and ultimately, timely and quality support and care of those most affected by the event. Integration of vol- unteers into local, state, and national established and recognized systems is key goal. At the time of this writing, the development of ESAR-VHP is ongoing, and adequate evaluation of its success has not occurred. Experts in disaster medicine have voiced concerns about its process and progress.52 Specific areas of apprehension include

1) The system requires active recruiting of professionals on the part of those involved in development and implementation. This is time-consuming and the process may hinder success- ful recruitment of all potential candidates.

2) There appears to be no standardization or uniformity in approach by states charged with administering the program. Some states are “attaching” credentialing to professional license renewal, others are recruiting through local health departments, yet others have not yet determined a formal approach.

3) The program is costly. Federal funding has been provided for initial program development, but there is concern that funding may not be sustained for the long-term. Funds will continue to be necessary for staff, information technology, record maintenance, and continued recruitment.

4) The program, for the most part, is targeting physicians, nurses, and mental health professionals. There are con- cerns in the response community, however, that pharma- cists, licensed technicians, and other vital responders must be included to ensure an adequate pool of credentialed resources.52

COMMUNICATIONS

Following exercises and actual disasters, leaders routinely con- duct after-action reviews to identify areas for improvement.

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Communication – or lack thereof – is almost always cited as one of the greatest areas of failure during disasters and emergency events, particularly during the response and recovery phases. Communication applies to both processes of relating among indi- viduals, agencies, and entities, and to physical means of commu- nicating, that is radios, phones, recorded reports, and other tools used to convey information, direction, and issues.

Much of the content of this chapter has addressed efforts to improve communication processes through implementation of standards and systems, including the application of ICS. As cited, U.S. legislation and Presidential Directives, such as HSPD 5 (which directs the adoption of NIMS) have been issued with the goal to enhance effective communication and thereby provide more effective management of emergency events. The contents of two documents, the NRP/NRF and NIMS are the two pri- mary texts for all engaged in roles inherent in public health and emergency management as applied to disasters and other emer- gencies. In a general sense, the content of both documents is designed to provide the framework for effective communication; both also include components that are specifically dedicated to communication.

U.S. National Response Plan/National Response Framework

Several components of the NRP/NRF specifically address communications.

■ NRP ESF 2 is the “Communications Annex.” The ESF Coordinator and Primary Agency for ESF 2 is the DHS/ Information Analysis and Infrastructure Protection/National Communications System. The National Coordinating Cen- ter for Telecommunications is the ESF 2 operational com- ponent in a domestic incident. Support agencies include the Federal Communications Commission, General Services Administration, and the Departments of Agriculture, Com- merce, Defense, Homeland Security, and Interior. ESF 2 coordinates federal actions that provide telecommunication resources and restore telecommunications infrastructure for a particular incident. When activated, ESF 2 coordinates and supports national security/emergency preparedness require- ments. In an incident, ESF 2, if activated, works closely with the Regional Response Coordination Center and Joint Field Office of the activated NRP. A Federal Emergency Commu- nications Coordinator represents ESF 2 at the incident area and coordinates closely with the affected state telecommuni- cations officer, ensuring that federal requirements are com- patible with state needs. As with all NRP/NRF ESFs, ESF 2 supports, not replaces, affected state and local assets and sys- tems. ESF 2 applies uniform emergency telecommunications management and operational plans, procedures, and hand- books in the operating environment. 55

■ The NRP/NRF “Cyber Incident Annex” addresses commu- nications when cyber security and systems are involved. The Annex is conjointly coordinated by DHS, DoD, and the Department of Justice, with several cooperating agencies. The Cyber Incident Annex addresses cyber-related incidents of all origins, such as an organized cyber attack, uncon- trolled exploits such as a virus or worm, a disaster with significant cyber consequences, or other incidents that com- promise infrastructure or key assets. The Annex is closely aligned with ESF 2 and functions as directed by the NRP-

cited principals and processes. Because cyberspace is largely privately owned and operated, Cyber Incident Annex author- ities must work closely with applicable nongovernment and private sector entities.55

■ ESF 15 is the “External Affairs Annex.” The primary agency is DHS/FEMA, and all agencies cited in the NRP/NRF are support agencies. ESF 15 coordinates federal actions to pro- vide external affairs support to federal, state, local, and tribal incident management elements. ESF 15 collaborates closely with and issues guidance to the NRP/NRF “Public Affairs Support Annex.” ESF 15 actions are pervasive throughout all other ESFs and Annexes and function in supportive roles. ESF 15 assists with providing accurate information on the incident and its effects, such as public health and safety. It also serves to support affected jurisdictions with informa- tion dissemination and coordination, enhancing a unified approach to information sharing and dissemination.55

■ The NRP/NRF includes a “Public Affairs Support Annex.” This Annex describes the interagency policies and procedures for incident communications with the public, whereas ESF 15 outlines resources and capabilities for the Public Affairs Annex. As with ESF15, DHS is the coordinating agency and all NRP/NRF agencies are cited as cooperating agencies. To ensure continuity and standardization for incident commu- nications, policies and procedures are based on and flow through the NRP/NRF, NIMS, ICS, and the Joint Informa- tion Center. Integration among federal, state, local, and tribal entities is maintained throughout and following the incident, ensuring that uniformity and applicability of information to the public is synchronized. The NRP/NRF Public Informa- tion Annex contains a detailed description of entities and operations involved in the development, dissemination, and monitoring of information.55

The other principal document/guidance (in addition to the NRP/NRF) that is essential in effective communication manage- ment in an incident is the NIMS. Communication is addressed throughout specific NIMS components.

National Incident Management System

■ Chapter I – Command and Management – includes a specific component on “Public Information Systems.” The focus of this section is on systems and protocols for communicating timely and accurate information to the public during cri- sis or emergency situations. The section emphasizes a Joint Information System, as well as the Joint Information Center, cited in the NRP/NRF.56

■ Chapter V is devoted exclusively to Communications and Information. The chapter describes common communica- tions and data standards and emphasizes interoperability. Through policies and protocols outlined in this chapter, standards are applied to incident notification and situation reporting; status reporting; analytical data; geospatial infor- mation; wireless communications identification and authen- tication; and the national database of incident reports.56

■ Under NIMS-TAB 4, Logistics, “Communications” is cited as a specific unit. This NIMS section describes that the Communications Unit develops the Communications Plan (in accordance with ICS) and ensures the most effective use of communications equipment and facilities assigned to the incident. In addition, the Unit installs and tests equip- ment; supervises and operates the incident communications

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center; distributes and recovers communications equipment assigned to incident personnel; and maintains and repairs equipment on site.56

As state and local emergency management, public health, and other entities have adopted ICS and NRP/NRF-like systems and move toward NIMS compliance, those who have roles dur- ing disasters and other emergencies must also become aware and informed of these important guiding principles and prac- tices. No event is too small for which to prepare and establish adequate communication. Many have adopted standard com- munication equipment and systems, such as 800-MHz radio networks, allowing timely and accurate information sharing sur- rounding an incident. In all settings, communications planning and dedicated personnel are critical to successful response and recovery.

RECOMMENDATIONS FOR FURTHER RESEARCH

This section of the chapter addresses several areas that continue to evolve and that will benefit from continuing assessment and deliberation. Areas for future research include the following.

National Response Framework Implementation

As noted, the U.S. NRP “evolved” into the NRF. Rationale for the “framework” (rather than “plan”) approach is presumably to better align the document with its intended purpose, that is, written guidance for integration of community, state, tribal, and federal response efforts. The NRF is for use by senior leaders (e.g., governors, mayors) as well as practitioners and responders.13 In essence, the NRF should enhance and improve comprehensive emergency management programs and activities in the United States. Deliberate review and evaluation of the NRF implementa- tion process, by those at all levels, locations, and roles, is needed to provide information and validate the success of the NRF and its intended purpose. Evidence that the NRF is successful must be visible through actions, exercise, and response by all intended users.

Change in Population Focus

There is a trend toward increased numbers of uninsured and underserved populations, as well as in the numbers of elderly and chronically ill, associated with the aging of the “baby boomer” generation. The U.S. is also experiencing an increase in the num- ber of non-English speaking residents. This explosion of vulnera- ble populations must be actively addressed if future response and recovery initiatives are to be successful. The six-tier paradigm, cited in the chapter’s discussion on medical surge, aids in pro- viding a framework for including the vast number of groups, as well as resources that extend beyond the “usual” first response and hospital-targeted groups. It is unclear whether this is suf- ficient and how success can be measured. How can health pol- icy researchers design and implement better systems to address the needs of already vulnerable groups, rendered more vulner- able by disaster or other emergencies? The solution lies in part with inclusion of those who routinely serve the vulnerable and underserved, but more work remains to be done. The Assistant Secretary for Preparedness and Response Hospital Preparedness

Program is evolving to include CHCs, nursing facilities, home and hospice care entities, and other nonhospital organizations, but this work is in the early stages, and inclusion must extend beyond a cursory “checking-the-box” if the needs of all potential victims are to be addressed.

Medical and Health Incident Management (and Other) System Changes

The chapter describes MaHIM, a paradigm and system that is designed to improve vastly, at the “ground level,” how public health, healthcare, emergency management, and others across jurisdictional lines can best integrate and successfully respond to public health emergencies and other disasters. HHS and other national authorities have endorsed MaHIM, and many local and state authorities are adopting the model. Deliberate assessment and sharing of results of implementing MaHIM (and other mod- els) should be fluid and ongoing to determine the best practice for working together during the most challenging circumstances.

Funding and Support

The sustainability of most public health and emergency man- agement programs relies on government funding, in the form of grants, earmarked dollars, or other forms. Many in the pub- lic health/emergency management realm have been involved in programs that “lost” funding or experienced the concern that funding may not be renewed or may be drastically reduced. Recipients of MMRS funds, for example, have heard or believed that, every year is the last year for funding (only to eventually receive funding for the next cycle). Many resources are devoted to trying to “find money” to sustain existing programs rather than concentrating on developing future strategies to improve emergency management systems. Competitive grant recipients are almost always told that their programs and products are suc- cessful only if the grantee can demonstrate how the program will be sustained when funding expires. The future direction aspect of funding and support lies in a more aggressive collaboration with private enterprise, and exploration of other means of sustain- ing programs as a component of being a professional in public health and emergency management. This brief attention to fund- ing is intended to highlight a vital issue of program success and to urge planners to include funding as a consistent and preva- lent component in public health and emergency management programs.

Global Public Health and Emergency Management

The September 11, 2001 terrorist attacks on the U.S. were an awakening for public health and emergency management system leaders about the importance of international collaboration. Since that event, U.S. authorities have extended invitations to international experts and those with real-world experience, for example in preparing and managing such horrific events, to col- laborate on preparedness activities. Beyond the common bond of fighting terrorism, however, is the threat of an avian influenza pandemic and similar large-scale public health emergencies. Through fear and concern often come partnerships. Because of terrorism and a possible pandemic, the U.S. is involved in many unprecedented initiatives. For example, the U.S. DoD and civil- ian (DHS and HHS) leaders have enhanced their relationships with the Israeli Home Front Command and Ministry of Health,

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focusing on training, consultation, and site visits for sharing of information on emergency management issues.57

One measure of commitment to programs is the amount of dedicated government expenditures. In May 2004, the U.S. Congress amended the National Defense Authorization Act, resulting in a shifting of significant funding from DHS to the Technical Support Working Group, a U.S. national forum focused on research and development for combating terrorism. An initial $25 million was earmarked for collaborative programs among the governments of the U.S. and those of Israel and the United Kingdom for the advancement of technology and equipment.58

Public health officials, emergency managers, basic scientists, and other key representatives of the U.S., Canada, and Mexico are closely collaborating on the North American Plan for Avian and Pandemic Influenza. The plan addresses a plethora of mutual concerns and actions, including the sharing of technology, infor- mation, surveillance, training and exercise, and vaccines and stockpiles. The plan is part of the Security and Prosperity Part- nership of North America.59

Involvement, assessment, and implementation of interna- tional public health and emergency management initiatives are critical to global success in decreasing morbidity and mortality from public health crisis and other disasters.

CONCLUSION

The continuing threat of terrorism, along with real-world expe- riences with challenging disasters such as Hurricane Katrina; the 2001 terrorist attacks in New York and Washington, DC; the 2002 terrorist bombings in Bali, Indonesia; the 2004 Indian Ocean Tsunami and bombings in Madrid, Spain; the 2005 Lon- don subway attacks; the 2007 cyclone in Bangladesh; the 2008 terrorist attacks in Mumbai, India; ongoing terrorist events in Israel and other areas of the Middle East; and countless other events demand that public health and emergency management systems become better strategically and operationally aligned. An unprecedented number of laws and authorities, along with requirements of standards, are designed to improve incident out- comes at all levels. Those charged with the care of victims, as well as those responsible for management of healthcare and related systems are directly affected by public health and emergency management activities at all levels and will benefit most through remaining informed and contributing to evolving advancements.

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re ss

. A ll

rig ht

s re

se rv

ed .