Medical Catastrophe

No one's in charge, the plan's incomplete and resources aren't sufficient if we suffer mass casualties in an overwhelming disaster.

As the White House and Congress grow increasingly alarmed over the possibility of a deadly flu pandemic and scramble to spend billions on vaccines, health experts say the United States is incapable of delivering mass care. For evidence, they say, look no further than the bumbling efforts to help victims of Hurricane Katrina.

In the weeks following Katrina, Americans helplessly watched the news accounts of patients suffering in flooded hospitals, waiting for an evacuation too late in coming. Outside the disaster zone, government doctors stood by hundreds of empty cots, watching for patients who never arrived. Paltry resources were predeployed. Experts fear that sick and injured victims died for lack of timely care. The problems stemmed from a lack of planning and preparation, experts say. And they pale in comparison to what would happen if the government had to respond to a pandemic or other catastrophe.

The difference between a catastrophe and a disaster is crucial: State and local officials can be counted on to assess their needs and direct federal response to a disaster. A catastrophe, however, over-whelms state and local governments and requires a federal response that anticipates needs instead of waiting for requests from below.

A classified government plan on how to respond to a catastrophe-the first ever, according to several sources-was drafted in 2003, but despite numerous revisions it never has been approved by all agencies involved.

Thus the federal government remains without a comprehensive plan to handle the injuries and sickness resulting from a "mass casualty incident," such as a major terrorist attack, an epidemic, or an earthquake. In fact, it's not even clear which government agency is in charge of mounting a coordinated medical response to a catastrophe. The Homeland Security and the Health and Human Services departments are each identified as the lead response agency by a conflicting knot of laws, presidential orders and planning documents. What's more, the two do not have a history of working well together.

Medical response to Katrina tells the tale, observers say. "Lack of coordination, lack of adequate supplies," says Dr. Elin Gursky, a public health and disaster response expert, listing the hallmarks of the medical response failures she observed by reading news accounts and talking to doctors involved. "Inadequate forethought," she adds. She pauses on the last item, considering her words carefully: "Possibly preventable mortality."

Those same results could be expected from the federal government's response to an avian flu pandemic, she says. Most of the basic functions of a medical response-making room in hospitals, triaging casualties, coping with mass mortality-are the same for both, or for a terrorist attack. "We're no more prepared for a pandemic outbreak than we were for Katrina," Gursky says.

Where Were the Feds?

A medical volunteer, Dr. Clyde Martin, a Tennessee doctor, spent several days after Katrina hit waiting for the Louisiana government to assign him to a response team. They never called, so he signed up with a private outfit. "I didn't see anybody from Health and Human Services, I didn't see anybody from the Louisiana Department of Health," he says. Martin spent a week in southern Louisiana parishes treating hundreds of patients as part of the private relief effort.

Riding in a friend's pickup truck, Martin saw patients and delivered medicines in New Orleans and three parishes north of the city. Those working alongside him were almost all locals, and the supplies they used were donated by private citizens and organizations. Both people and supplies were stretched beyond their limits, Martin says: "Surely, they [federal responders] were somewhere, but I didn't see anybody in all those places I was."

At the same time, doctors working in federal response elsewhere didn't see a single patient. Dr. Laurence Grummer-Strawn, a Centers for Disease Control and Prevention researcher and an HHS Public Health Service member, was deployed to central Louisiana with a team of 125 medical personnel to construct a temporary 1,000-bed hospital. The plan, Grummer-Strawn understood, was for that facility to treat "overflow patients" transferred from hospitals in the southern part of the state.

Arriving Saturday, Sept. 3, six days after Katrina hit, his team spent two days setting up the hospital before they were told they weren't needed there. The team left Alexandria, La., Wednesday-it took a day to pack up the beds and equipment-and fanned out to conduct needs assessments at shelters across the state.

Dr. Gerald Parker, the deputy chief of HHS' emergency response office, says despite never seeing a patient, the effort was effective. "In hindsight, it's very easy to criticize and find fault in some decisions that were made to deploy to some certain location," he says. "When you look at it in the whole . . . we had the flexibility to . . . redeploy assets and get them to where the patients were."

When told of Martin's private efforts to give aid, Parker refers to a recent news report of other volunteer doctors who came to the region and weren't used. "[They were] getting in the way of . . . needs being met," he says. "[They were] putting more burden on the system, as opposed to needs being met."

'We Have a Plan'

The federal government has planned for a catastrophe that overwhelms states' resources; the guidelines are included in an attachment to DHS' National Response Plan. A massive document hammered out by agencies to determine who will be in charge of what in the event of a disaster, the NRP is what government officials point to when they say, "We have a plan."

The six-page, bulleted attachment anticipates the failure of states and cities to cope, and directs federal agencies to deploy assets they believe are needed despite the lack of information from an affected state. "The response capabilities and resources of the local jurisdiction may be insufficient and quickly overwhelmed," states the document, known as the Catastrophic Incident Annex.

"Federal support must be provided in a timely manner to save lives, prevent human suffering and mitigate severe damage. This may require mobilizing and deploying assets before they are requested via normal NRP protocols." To underscore the point, the annex reiterates: "The [federal-state] coordination process should not delay or impede the rapid mobilization and deployment of critical federal resources."

The annex is brief, giving only cursory guidance to officials facing a catastrophe-a comprehensive plan is on the way, it says. No government official or agency contacted by Government Executive could confirm that the plan has since been approved. The Homeland Security Department could not confirm that the guidance in this annex was ever implemented as part of its response to Katrina.

Who's in Charge?

Which agency is responsible for planning for and responding to a medical catastrophe depends on who you ask. According to Congress, DHS is in charge. The Homeland Security Act, passed in 2002, puts the department at the helm of all disaster-related efforts, including medical response and preparedness. President Bush, however, thinks otherwise: In 2004 he gave Health and Human Services the lead to develop response plans for bioterror attacks, with an edict known as Homeland Security Presidential Directive 10.

If that wasn't confusing enough, the NRP does little to clarify the roles of the two agencies. It says FEMA (part of DHS) has the lead in responding to all disasters of any type. The medical aspect of the response will be led by Health and Human Services. HHS, however, has few assets to mount a medical response. For example, the National Disaster Medical System-a network of thousands of doctors, veterinarians, nurses, morticians and others who have volunteered to respond to disasters, formed geographic teams, trained and stockpiled equipment and supplies-moved to FEMA when DHS was created.

The NRP therefore foresees the federal medical response unfolding in this way: When a state requests federal aid, FEMA takes the lead in the government's response. It then turns to HHS to lead its medical efforts. HHS then turns back to FEMA to order it to deploy its medical personnel. It is not clear how and when HHS deploys its own assets, including the nation's largest cache of pharmaceuticals and medical equipment, known as the Strategic National Stockpile, controlled by CDC, and the nation's only standing civilian federal medical responders, the 6,000-member Public Health Service. Nor is it clear how it coordinates that with FEMA.

The agencies themselves are reluctant to explain how the NRP process works. Spokesmen from HHS and FEMA at first referred questions to the other agency. After repeated inquiries to both agencies, HHS made available Parker, the No. 2 official in its office of public health and emergency preparedness. "The request originates at the local level, state level, through an action request form," Parker explains. "That request form goes to FEMA," which forwards it to HHS. Health and Human Services then contacts the federal agency that controls the asset the state or local government needs, he says.

But Parker says it doesn't always work that way. Sometimes HHS employees on the ground in the affected area note a need and inform HHS headquarters without going through FEMA. At other times FEMA receives a request and forwards it directly to Defense or another agency to respond directly. Sometimes FEMA deploys its own assets without asking HHS; at times HHS deploys its own assets without consulting FEMA.

"In the end of the day, all those movements have our visibility," Parker says, explaining that HHS knows where all the assets are. "We have our daily [situation reports], we have daily information on all the . . . deployments."

Not so, according to the supervising medical officer for NDMS teams in Louisiana. "I've never seen such poor coordination between federal agencies," says Dr. Susan Briggs, a surgeon at Harvard Medical School. "Simple things were not told to us," she recalls, such as what other medical teams were operating in their vicinity. "That's what a coordinating group is supposed to do."

Briggs, who helped build the NDMS system in the mid-1980s, said the medical response to Katrina was the worst she had seen in 20 years.

In Washington, observers and former staff members confirm privately that coordination between the two agencies has been lacking. The assistant secretary for HHS' Public Health Emergency Preparedness Office, Stewart Simonson, refused for months to meet with former DHS Secretary Tom Ridge's chief medical adviser, Dr. Jeffrey Lowell, according to several sources. Neither Lowell nor Simonson were available for comment. Parker, Simonson's second-in-command, says he would characterize the relationship between DHS and HHS as "good."

Simonson has come under fire for lacking experience. A former Amtrak lawyer, he was given the post by former HHS Secretary Tommy Thompson in 2004. Simonson had more experience as an aide to Thompson than as a health and disaster preparedness manager. "He's the Mike Brown of HHS," Jerome Hauer-Simonson's predecessor-told CQ Homeland Security on Oct. 11. Democrats and others have labeled him a crony and a political hack.

Lowell, who informed his superiors in January of the troubled relationship between DHS and HHS, left his post in February. Despite his efforts, coordination between the two agencies appears not to have improved greatly. The new chief medical officer for DHS, Dr. Jeffrey Runge, told the Associated Press in late September that he would like to create a network of trained volunteers to respond to disasters. But the Surgeon General's Office at HHS has been operating just such a program, the Medical Reserve Corps, since 2002.

"Jeff was not aware that we had already done that at HHS," says Surgeon General Richard H. Carmona, who oversees the corps. The two have since talked about how to "combine our efforts," Carmona says. DHS did not make Runge available for comment.

Short of People and Supplies

Even with plans and responsibilities established, some say catastrophic medical response still would be inadequate: The United States simply doesn't have the medical personnel to attend to large numbers of casualties, or the means to distribute supplies needed to provide care to thousands of sick or injured.

According to the January study by Lowell, the National Disaster Medical System cannot adequately respond to mass casualty events, find beds for the sick and injured or manage a quarantine, which could be required during a pandemic.The all-volunteer NDMS is no longer capable of supporting the new demands placed on the system, Lowell told DHS leadership, according to sources familiar with his findings. He also found that the NDMS teams often are deployed without being prepared. The system was "pretty much shot" trying to respond to Katrina and Rita, Lowell told the Associated Press in September.

To be able to respond to a catastrophe, Lowell recommended DHS develop a highly trained medical reserve corps, on the model of the National Guard, complete with rank and uniform. Lowell's report, stamped "For Official Use Only," never has been made public.

Trained medical personnel are important, but so are supplies and medicine. The Strategic National Stockpile is a $400 million program to make sure medical response to a disaster does not fail for lack of vaccines, antibiotics, and other medicines and equipment. The effort to amass those supplies and deliver them-a 747-full can be "pushed" anywhere in the United States within 24 hours-has been celebrated, but it does only half the job. The states are required to distribute the medicines to their affected areas, and that hasn't gone so smoothly. A 2004 study by the nonprofit Trust for America's Health found that 44 states are incapable of quickly and effectively breaking down pallets of supplies and delivering them to responders.

According to the 2004 study, Louisiana is one of the six states supposedly capable of distributing SNS supplies. Florida and Illinois also are capable, according to the report; the other three states are not identified. Recent events might cause revisions.

In New Orleans, Clyde Martin ran out of vaccines for police officers working in the flooded city. After trying in vain to obtain them through official channels, he called doctor friends back home in Athens, Tenn., who raided supply closets at their hospitals. A local Tennessee rescue team brought the medicine to New Orleans for him before supplies from the strategic stockpile ever arrived. "SNS had been activated almost a week before," Martin says incredulously. "What the hell happened to the SNS?"

Handwriting on the Wall

Even if sufficient national medical emergency plans were in place, experts warn of gross deficits in the nation's ability to cope with large numbers of casualties. Now, the job of transporting the sick and injured from a disaster area falls to the Pentagon's Transportation Command. Planners worry that relying on assets normally used for supporting Defense efforts might be unwise, particularly in a time of escalating military involvement around the world.

"Any time you're planning on using the Department of Defense for anything . . . you have the risk of putting together a system where you can't rely on the asset," says Dr. Joseph Barbera, a consultant to HHS' emergency response office. "It's a balancing act," says Lt. Col. Scott D. Ross, spokesman for the Transportation Command. So far, he says, U.S. Transportation Command has met the needs of both civil support and the war on terrorism.

Another worry is the ability of hospitals to absorb thousands of casualties. At present, most hospitals operate at or near capacity. In major cities, it's not unusual to find patient beds in hallways, says Dr. Arthur Kellerman, the head of Emory University's emergency medicine department in Atlanta. Evacuees from Hurricane Katrina put intense stress on his city's emergency rooms and doctors. He worries about what hospitals would do if they were forced to absorb hundreds or thousands of seriously ill or injured from an attack or natural catastrophe.

Pietro "Peter" Marghella retired as chief medical planner for the Defense secretary in April, and went into business for himself. His company, Medical Planning Resources Inc., tries to help government agencies plan for and respond to catastrophes, something, he says, they still aren't doing adequately. "I am upset by seeing very clearly what should have happened versus what did happen," Marghella says of the government's hurricane response. "The handwriting's been on the wall for a long time."

HHS' Parker sees things differently. "I think we did real good when you look at it in total," he says when asked to assess medical response to Katrina.

Back home in Tennessee, Martin sides with Marghella. "We failed," he says, frustration in his voice. "And unless there are dramatic major changes, we'll fail in the next one. These bureaucrats get wrapped up in making the system work, they forget the goal, to get people medical care. That's the important thing. I'm embarrassed for the guy saying we did a good job but didn't take care of anybody," Martin says. "Think about it."