Hurricane Katrina: What we learned, Then and Now

By Karen DeSalvo, Former Acting Assistant Secretary for Health, U.S. Department of Health and Human Services

This story was published in Ready or Not? 2017.

There are a significant amount of vital lessons that need to and have been learned from the preparation for, response to, and recovery from Hurricane Katrina. One long-term lesson that I think is worth highlighting and has shown its importance during recent weather-related emergencies is the need for public health to take a significant leadership and coordinator role before, during and after an emergency.

In the immediate aftermath of Hurricane Katrina, it was evident that connections were missing—whether it be local public health to state officials, public health to first responders, or public health to the community.

Public health leaders simply weren’t the chief health strategists for their communities. The field was focused on an important set of discrete responsibilities or program but not on the need to build connections with community leaders, first responders and other critical infrastructure that could ensure people had safe places to go and access to medications and other critical supports.

With this realization, it was apparent public health had to connect more with the full gamut of organizations and people involved with an emergency response. And, since then, we have done so not only in New Orleans, but in communities across the country.

For example, during subsequent hurricanes in New Orleans, public health was able to work directly and quickly with hospitals and other care facilities to know if power was on and what beds and medications were available.

And, if you look at the response in Houston, you’ll note that public health was everywhere. They were in communities meeting people and alerting them to potential dangers and infectious diseases, what food and water was safe, etc. And, they were all over social media in a culturally competent way, reaching more and more people.

If you compare the Houston Harvey response to Katrina, it should be apparent that one of the benefits in Houston was the high level of connectedness between public health and the community they serve.

How we can better Prepare for the Next Emergency

In addition to public health continuing to be the coordinator for health for our communities in disaster and every day, to better respond to the next public health emergency, the nation needs to:

  • Expand funding;
  • Improve the foundational capabilities of public health;
  • Better leverage technology;
  • Increase training; and
  • Focus on the underlying health and resiliency of our communities—particularly those who are most vulnerable.

We need more funding for public health—we need public health departments at the local and state levels to have the foundational capabilities required to respond to public health emergencies but also to help build resilience between events.  These funds can’t be categorical, they have to provide core funding that can be nimble for a community to address their biggest health needs. For instance, parts of California might be more prone to wildfires while the Gulf Coast needs to focus on hurricanes. If we don’t have these capabilities in place, we’re forcing our public health workers to just react, rather than prepare to respond.

We also need more funding to go directly to local health departments. States have a huge responsibility during an emergency and often can’t funnel as many resources as you’d think to the local level. During Katrina, we saw this front and center.

While more funding is important, it must be paired with concrete expectations and accountability. Every single health department in the country should be accredited which will help ensure that they can stand up emergency operations when necessary.

When Katrina hit, we were using flip phones, Blackberries and an early version of Google maps. We’ve come a long way with technology in little over a decade, but our preparedness hasn’t quite kept up. We must do better with technology.

We have a great start with this by better leveraging the Department of Health and Human Services’ emPOWER, an online tool that houses and provides Medicare claims data to hospitals, first responders, and health officials to help map the electricity needs during an emergency. emPOWER enables responders to prioritize evacuations and can identify vulnerable populations who will need follow-up services. But it’s limited to the Medicare population.  This type of tool must be expanded to or created for Medicaid and, where appropriate, private payers. First responders and public health must have real-time population level data.

An additional reason more resources are needed is to increase drills and training that specifically focuses on local leadership and the U.S. Public Health Service Commissioned Corps. Annually, public health workers should drill in a vulnerable area alongside the Commissioned Corps—an invaluable resource. Currently, when the Commissioned Corps deploys to an emergency the connections with local responders aren’t there and often the Commissioned Corps can be underutilized.

Lastly, we simply must do more to improve the resiliency of our communities. The healthier a group of people are, the better they respond to an emergency.

In-between emergencies, public health must use data and find opportunities to engage more with vulnerable populations. For example, this could include creating pilot programs with Medicare providers, home health organizations and others involved with the care of older adults. We must improve the health of our older population and, at the same time, have the processes in place that can maintain their connection to care during an emergency that might result in evacuations and/or loss of power.

The nation’s preparedness has improved immensely since Hurricane Katrina—we must keep improving.

Q/A with Celeste Philip, MD, MPH Surgeon General and Secretary of the Florida Department of Health

This was published in Ready or Not? 2017.

TFAH: What are state public health responsibilities before a storm?

Dr. Philip: The Florida Department of Health (DOH) is designated as the lead agency for State Emergency Support Function 8 (EFS8), health and medical services. DOH coordinates the availability and staffing of special needs shelters; supports patient evacuation; ensures the safety of food and drugs; provide critical incident stress debriefing; and provides surveillance and control of radiological, chemical, biological and other environmental hazards.

DOH administers two statewide preparedness grants to build local capacity within the public health and health care community. The federal Public Health Emergency Preparedness (PHEP) grant supports all 67 county health departments (CHD) and public health laboratories in developing community preparedness, epidemiological surveillance and investigation, and medical countermeasure delivery. The Hospital Preparedness Program (HPP) funds 10 health care coalitions to build capabilities for medical surge, continuity of health care delivery, and preparedness partnerships among local health care partners.

TFAH: What are state public health responsibilities after a storm?

Dr. Philip: ESF8 assesses and stabilizes the public health and medical system; supports the ongoing sheltering of persons with special medical needs; coordinates patient movement and evacuations of health care facilities; conducts public health messaging; monitors, investigates and controls any threats to human health; and coordinates disaster behavioral health services with a sister agency.

During Hurricane Irma, ESF8 assisted with 76 patient movement missions that supported the transport of hospital, skilled nursing facility and assisted living facility clients. We conducted more than 1,000 post-impact facility inspections and more than 2,600 tests of public and private water systems and operated 113 special needs shelters.

TFAH: How do state health departments coordinate the public health response to a major storm?

Dr. Philip: Preparedness and response are driven by local leadership, personnel and assets. In Florida, each CHD coordinates and works directly with their local Emergency Management to meet the preparedness and response needs of their community. If the county Emergency Operations Center (EOC) cannot meet the local need, they request assistance through the state EOC via a web-based system that allows us to track and ensure completion of mission requests.

Based on these mission requests, the state ESF8 assesses regional and state assets. If the requested resources are not available in-state, ESF8 next looks to resources available from other states through the Emergency Management Assistance Compact (EMAC), or, in the case of a declared state of emergency, potential federal assets such as Disaster Medical Assistant Teams.

TFAH: Why are federal investments in public health critical on an ongoing basis?

Dr. Philip: During a major event, we are often shoulder-to-shoulder with our federal partners in the state EOC.  This includes representatives from HHS, ASPR, and also FEMA who help to coordinate any requests we make for federal assistance.

Federal investment is critical for building a public health infrastructure that has the capacity to prepare for and recover from weather and other hazardous situations. If states are better prepared to respond, requests for federal assistance may be lessened.  With the close succession of Hurricanes Harvey, Irma, and Maria, and wildfires in California, federal response agencies had to sustain their efforts across time and location which may not be feasible in the future.

TFAH: What federal programs and supports are critical for preparedness and response?

Dr. Philip: Both the PHEP and HPP statewide preparedness grants are important for public health preparedness and response. Preparedness programs in various HHS agencies hold meetings that provide training and networking opportunities for states.

TFAH: What is needed from the federal government to improve preparedness and response?

Dr. Philip: Knowing and having a relationship with our federal counterparts that will be deployed to the state EOC improves communication and manages expectations more effectively. A federal system that allows for tracking of deployed assets would improve situational awareness and real-time decision-making.

Better coordination of credentialing health care professionals between states would be helpful for patients who evacuate with their provider and for providers coming into disaster areas.

Streamlined and flexible funding to allow for nimble response as needed would greatly enhance public health’s ability to be effective.

TFAH: What lessons did you learn from the most recent storm? Was there anything different or new that happened?

Dr. Philip: Hurricane Irma posed a unique challenge because the track was very unpredictable, meaning that more hospitals decided to evacuate and more residents decided to shelter. This storm at some points was 500 miles wide – which exceeded the width of our state. And, personnel could not be moved around in advance of the storm as the track changed to support other counties in the new path. EMAC, federal and contracted assets were mobilized to support sheltering operations but some counties had to wait until the storm passed to receive additional staffing.

Because of the surge in last minute registrations to special need shelters, comprehensive planning and placement for each registrant could not be conducted resulting in the shelter having to accept clients with medical needs that exceeded the shelters’ level of care capacity.

Moving forward, we recognize a need to anticipate future storms that may impact much, or all of the state, a scenario not contemplated prior to Hurricane Irma. For DOH, statewide emergency response efforts could be bolstered by improving planning for our special needs residents, including better training and increased collaboration with other state agencies and the private sector to support Floridians with special needs.

Ready or Not? 2017

«state» Achieved «score_num» of 10 Indicators in Report on Health Emergency Preparedness

«state»’s Flu Vaccination Rate is «fvr_num» Percent, «flu_rank_upper»

Washington, D.C., December 19, 2017 – In Ready or Not? Protecting the Public’s Health from Diseases, Disasters and Bioterrorism, «state» achieved «score_lower» of 10 key indicators of public health preparedness.

In total, 25 states scored a 5 or lower—Alaska scored lowest at 2 out of 10, and Massachusetts and Rhode Island scored the highest at 9 out of 10.

The report, issued today by the Trust for America’s Health (TFAH), found the country does not invest enough to maintain strong, basic core capabilities for health security readiness and, instead, is in a continued state of inefficiently reacting with federal emergency supplemental funding packages each time a disaster strikes.

According to Ready or Not?, federal funding to support the base level of preparedness has been cut by more than half since 2002, which has eroded advancements and reduced the country’s capabilities.

“While we’ve seen great public health preparedness advances, often at the state and community level, progress is continually stilted, halted and uneven,” said John Auerbach, president and CEO of TFAH.  “As a nation, we—year after year—fail to fully support public health and preparedness. If we don’t improve our baseline funding and capabilities, we’ll continue to be caught completely off-guard when hurricanes, wildfires and infectious disease outbreaks hit.”

No. Indicator «state» Number of States Receiving Points
A “Y” means the state received a point for that indicator
1 Public Health Funding Commitment: State increased or maintained funding for public health from FY 2015 to FY 2016 and FY 2016 to FY 2017. «phfc» 19 + D.C.
2 National Health Security Preparedness Index: State increased their overall preparedness scores based on the National Health Security Preparedness Index™ between 2015 and 2016. «nhspi» 33
3 Public Health Accreditation: The state public health department is accredited. «pha» 30 + D.C.
4 Antibiotic Stewardship Program for Hospitals:  State has 70 percent or more of hospitals reporting meeting Antibiotic Stewardship Program core elements in 2016. «asp» 20 + D.C.
5 Flu Vaccination Rate: State vaccinated at least half of their population (ages 6 months and older) for the seasonal flu from Fall 2016 to Spring 2017.* «fvr» 20
6 Enhanced Nurse Licensure Compact (eNLC): State participates in an eNLC. «enlc» 26
7 United States Climate Alliance: State has joined the U.S. Climate Alliance to reduce greenhouse gas emissions consistent with the goals of the Paris Agreement. «usca» 14
8 Public Health Laboratories: State laboratory provided biosafety training and/or provided information about biosafety training courses (July 1, 2016 to June 30, 2017). «lab_safety» 47 + D.C.
9 Public Health Laboratories: State laboratory has a Biosafety Professional (July 1, 2016 to June 30, 2017). «phl_staff» 47 + D.C.
10 Paid Sick Leave: State has paid sick leave law. «sick_leave» 8 + D.C.
Total «score_num»

Ready or Not? features six expert commentaries from public health officials who share perspectives on and experiences from the historic hurricanes, wildfires and other events of 2017, including from California, Florida, Louisiana and Texas.

The report also examines the nation’s ability to respond to public health emergencies, tracks progress and vulnerabilities, and includes a review of state and federal public health preparedness policies. Some key findings include:

  • Just 19 states and Washington, D.C. increased or maintained funding for public health from Fiscal Year (FY) 2015-2016 to FY 2016-2017.
  • The primary source for state and local preparedness for health emergencies has been cut by about one-third (from $940 million in FY 2002 to $667 million in FY 2017) and hospital emergency preparedness funds have been cut in half ($514 million in FY 2003 to $254 million in FY 2017).
  • In 20 states and Washington, D.C. 70 percent or more of hospitals reported meeting Antibiotic Stewardship Program core elements in 2016.
  • Just 20 states vaccinated at least half of their population (ages 6 months and older) for the seasonal flu from Fall 2016 to Spring 2017—and no state was above 56 percent.
  • 47 state labs and Washington, D.C. provided biosafety training and/or provided information about biosafety training courses (July 1, 2016 to June 30, 2017).

The Ready or Not? report provides a series of recommendations that address many of the major gaps in emergency health preparedness, including:

  • Communities should maintain a key set of foundational capabilities and focus on performance outcomes in exchange for increased flexibility and reduced bureaucracy.
  • Ensuring stable, sufficient health emergency preparedness funding to maintain a standing set of core capabilities so they are ready when needed. In addition, a complementary Public Health Emergency Fund is needed to provide immediate surge funding for specific action for major emerging threats.
  • Strengthening and maintaining consistent support for global health security as an effective strategy for preventing and controlling health crises. Germs know no borders.
  • Innovating and modernizing infrastructure needs – including a more focused investment strategy to support science and technology upgrades that leverage recent breakthroughs and hold the promise of transforming the nation’s ability to promptly detect and contain disease outbreaks and respond to other health emergencies.
  • Recruiting and training a next generation public health workforce with expert scientific abilities to harness and use technological advances along with critical thinking and management skills to serve as Chief Health Strategist for a community.
  • Reconsidering health system preparedness for new threats and mass outbreaks.  Develop stronger coalitions and partnerships among providers, hospitals and healthcare facilities, insurance providers, pharmaceutical and health equipment businesses, emergency management and public health agencies.
  • Preventing the negative health consequences of climate change and weather-related threats. It is essential to build the capacity to anticipate, plan for and respond to climate-related events.
  • Prioritizing efforts to address one of the most serious threats to human health by expanding efforts to stop superbugs and antibiotic resistance.
  • Improving rates of vaccinations for children and adults – which are one of the most effective public health tools against many infectious diseases.
  • Supporting a culture of resilience so all communities are better prepared to cope with and recover from emergencies, particularly focusing on those who are most vulnerable.   Sometimes the aftermath of an emergency situation may be more harmful than the initial event.  This must also include support for local organizations and small businesses to prepare for and to respond to emergencies.

The report was supported by a grant from the Robert Wood Johnson Foundation (RWJF) and is available on TFAH’s website at www.healthyamericans.org.

Score Summary:

A full list of all of the indicators and scores and the full report are available on TFAH’s website.  For the state-by-state scoring, states received one point for achieving an indicator or zero points if they did not achieve the indicator.  Zero is the lowest possible overall score, 10 is the highest.  The data for the indicators are from publicly available sources or were provided from public officials.

  • 9 out of 10: Massachusetts and Rhode Island
  • 8 out of 10: Delaware, North Carolina and Virginia
  • 7 out of 10: Arizona, Colorado, Connecticut, Hawaii, Minnesota, New York, Oregon and Washington
  • 6 out of 10: California, District of Columbia, Florida, Illinois, Maryland, Nebraska, New Jersey, North Dakota, South Carolina, South Dakota, Utah, Vermont and West Virginia
  • 5 out of 10: Georgia, Idaho, Maine, Mississippi, Montana and Tennessee
  • 4 out of 10: Alabama, Arkansas, Iowa, Louisiana, Missouri, New Hampshire, Oklahoma and Pennsylvania
  • 3 out of 10: Indiana, Kansas, Kentucky, Michigan, Nevada, New Mexico, Ohio, Texas, Wisconsin and Wyoming
  • 2 out of 10: Alaska

 Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. www.healthyamericans.org

The Senate’s Latest Obamacare Replacement Effort will not improve the Nation’s Health, Affordable Care Act

Washington, D.C., July 25, 2017 – The below is a statement from John Auerbach, president and CEO, of Trust for America’s Health (TFAH) on the Senate’s motion to proceed.

“Each new iteration of Obamacare repeal legislation has failed to do what a health bill should: improve the nation’s health.

We know—according to the Congressional Budget Office’s scores on any number of the attempted bills—that tens of millions of people will quickly lose access to health insurance and the preventive services and programs which keep them from developing debilitating and costly chronic diseases.

That is, simply, the opposite of what a bill—intended to improve the nation’s health—should do.

Continued attempts to eliminate the Prevention and Public Health Fund would irreparably harm the nation’s health. States and communities rely on the hundreds of millions of dollars they receive annually to work on the critical health issues—including the opioid epidemic, lead poisoning, obesity, tobacco use and vaccine-preventable illnesses—facing their citizens.

To date, any funding included in repeal legislation for the opioid crisis has been nowhere near enough to solve the problem and will not make up for the substantially larger cuts to Medicaid and the Prevention Fund.

Estimates have found that the total coverage cost for people receiving treatment for substance misuse disorders could reach $220 billion over the next decade. And, people with substance misuse disorders often suffer from additional health problems – for example, mental illness and chronic conditions such as heart disease or diabetes – and need the routine access to care and services provided by Medicaid. As such, substance misuse treatment must remain part of the Medicaid integrated care system.

TFAH encourages the Administration and Congress to start over and create a true healthcare bill that will improve upon Obamacare, keep people covered and safeguard the nation’s health.”

Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

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Public Health Leaders Make Urgent Joint Call to Protect Prevention and Healthcare

Joint Statement from American Public Health Association, Prevention Institute, Public Health Institute and Trust for America’s Health

June 20, 2017

The fight to protect public health is more important than ever.

The Senate is moving quickly—and secretively—on their version of legislation to repeal the Affordable Care Act (ACA). While we don’t know the content of the bill, we do know that the House-passed repeal bill—the American Health Care Act—would cause over 23 million people to lose their healthcare, restructure Medicaid, pare down essential benefits like maternity and newborn care, result in the loss of over a million American jobs, and zero out the Prevention and Public Health Fund. As leaders of organizations dedicated to protecting and advancing the public’s health, we call on Congress now to protect federal investments in public health funding, the Prevention and Public Health Fund, and affordable, high-quality healthcare.

Public health is at the very core of keeping our country safe, healthy, resilient, and secure. It works behind the scenes to ensure we have clean water to drink, safe food to eat, and healthy air to breathe. It works to safeguard us from infectious diseases like measles or Ebola by preventing the onset or spread of disease. It builds on time tested strategies to reduce the toll of chronic diseases and injuries. Public health works to redress long-standing inequities in health and safety, by investing in communities of greatest need. Through prevention, evidence-based treatment of substance use, prescription drug monitoring, and improved opioid prescribing, public health can solve the opioid epidemic, which kills ninety-one Americans a day. From opioid overdoses to rising infant and maternal mortality rates, Americans are seeing both the length and quality of their lives decline—and we need more, not fewer, investments in public health to turn the tide.

Repealing the ACA and its investments in public health and prevention dismantles the capacity of public health to do its work. The pain will be felt in every state, every congressional district, and every neighborhood, and those who are most vulnerable will suffer the most. If the Prevention Fund is eliminated, over the next five years states stand to lose over $3 billion they rely on to prevent chronic disease, halt the spread of infections, and invest in the community resources that support health and safety. Repealing the ACA and the Prevention Fund ensures there is no progress to reduce healthcare spending or improve the health of our workforce. Repealing the ACA will result in an America where preventable suffering and death are more widespread, and an America where the poorest and sickest communities fall even farther behind.

A strong public health infrastructure is at the very core of making our country safe, healthy, and secure. We need to act now to protect it.

The President’s FY 2018 Budget Proposal Would be Perilous for the Nation’s Health

Washington, D.C., May 23, 2017 – The below is a statement from John Auerbach, president and CEO, of Trust for America’s Health (TFAH) on the President’s Fiscal Year (FY) 2018 proposed budget announcement.

“The proposed $1.2 billion cut to the Centers for Disease Control and Prevention (CDC) would be perilous for the health of the American people.

From Ebola to Zika to opioid misuse to diabetes to heart disease, the CDC is on the frontlines keeping Americans healthy. Cutting nearly 20 percent of the CDC’s Chronic Disease Prevention and Health Promotion center’s budget would be disastrous.

Enormous cuts are also proposed throughout the rest of the agency including to programs that protect the American people from infectious diseases, environmental contaminants, exposure to tobacco and much more. If these budget cuts were to occur, they would cripple CDC’s operations and result in increased illnesses, injuries and preventable deaths.

CDC has already lost more than $580 million in funding since 2010 – and the proposed American Healthcare Act would, in FY 2019, repeal the Prevention and Public Health Fund, which supplies 12 percent of CDC’s budget—of which more than $620 million goes yearly to states.

Even now, with a relatively stable FY 2017 budget, CDC is operating with nearly 700 vacancies and will function with diminished resources once the Zika emergency supplemental funding runs out.

As such, this unprecedented and dramatic cut would have unparalleled and drastic consequences for our nation’s health and would likely lead to staggering increases in our healthcare service costs. It would also create massive holes in state public health funding, as states and local communities rely on the hundreds of millions they receive from CDC every year.

In essence, the proposed budget would force CDC to fight epidemics and health threats with both hands tied behind their back while wearing a blindfold.

We urge the Administration and Congress to work together to ensure CDC is able to protect the American people and help Americans be healthy and thrive.”

 

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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

House ACA Replacement will Cripple the Nation’s Health, Trust for America’s Health Statement

Washington, D.C., May 4, 2017 – The below is a statement from John Auerbach, president and CEO, of Trust for America’s Health (TFAH).

“As historic as the passage of the Affordable Care Act was, any passage of the American Health Care Act will be just as infamous.

Tens of millions of American citizens will lose coverage. And millions of people on private insurance and Medicaid may lose access to life- and cost-saving clinical preventive services.

In particular, the Meadows-MacArthur Amendment would permit states to eliminate the requirement around essential health benefits (EHBs) and allow for the discrimination of people with pre-existing conditions.

Research tells us time and again two truths: Americans with coverage of preventive services are more likely to access these services and investing in preventive services improves health and reduces costs, yielding massive returns on investment.

Additionally, the agencies responsible for keeping us safe daily from ever-increasing public health threats will have their budgets slashed.

If the bill eventually becomes law, the Centers for Disease Control and Prevention (CDC) will lose 12 percent of its budget, of which a significant portion—$625 million a year—goes directly to state and local health departments.

This is a double whammy to the nation’s health.

Every day, the CDC and local public health departments are on the front lines in preventing disease outbreaks like Zika and Ebola, in protecting our children from lead poisoning, in lowering rates of heart disease, in stopping epidemics like prescription drug misuse and in helping people quit tobacco.

If the bill eventually passes, the results won’t be celebrated—they’ll be infamous.

We will likely see more overdoses and untreated STDs, rises in infant mortality and increases in innumerable other preventable health issues—not to mention mounting healthcare costs. All the while, our most vulnerable—the elderly, children, sick and less advantaged—will be at most risk.

That should not be the result of a health law.

We hope the United States Senate sees the many problems in the legislation.”

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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.