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Emergency Support Function #8: Current Challenges and Future Directions
InterAgency BoardOctober Board Meeting
Milwaukee, WIOct 17, 2012
Kevin Yeskey, MDSenior Advisor
MDB, Inc
ESF#8 has provided a mostly successful framework for recent domestic disasters◦ A fragmented public health and medical response system
functions within acceptable limits for “routine” disasters A national health and medical preparedness and
response system can be developed only when administrative and legislative barriers are removed◦ Incentives need to be provided to volunteers and private
industry for their participation ESF#8 should to shift to capabilities-based core
functions to better align with the public health and medical preparedness cooperative agreements
Take Home Points
Core functions of ESF #8 under the NRF
Agricultural safety and security* Public Health technical assistance
and support* Behavioral health+ Public health and medical
information* Vector control* Potable water/wastewater and
solid waste disposal* Mass fatality management, victim
identification, and decontaminating remains+
Veterinary medical support+
Assessment of public health/medical needs*
Health Surveillance* Medical care personnel+ Health/medical/veterinary
equipment and supplies Patient Evacuation+ Patient Care+ Safety and security of drugs,
biologics, and medical devices* Blood and Blood Products Food Safety and Security*
+ NDMS* PH function
“Uncomplicated” disasters◦ Single event, small geographic area, few
jurisdictions, limited duration, natural cause Disasters we have recent experience with
◦ Hurricanes, Tornados, Floods “Notice” events DomesticThe typical Stafford Act incident
*No standard metrics to support this claim
In 15+ Years of Preparedness Efforts, What We Do Well*:
Hurricane ‘saac
Complicated Disasters◦ Large geographic area,
long-term event, multiple jurisdictions Catastrophic events
◦ Novel Not recently seen, beyond the
imagination
◦ No-notice events◦ International/Multi-
national◦ Engaging all potential
resources
*No standard metrics to support this claim
What We Struggle With:
SARS
DWH
H1N1
Earthquake
Organizational structure is different and sometimes untested/unrehearsed◦ Who was in charge of the pandemic response?◦ When was the last time we responded to something like Haiti?◦ The leadership bench is thin◦ Management by CNN
Complex jurisdictional issues◦ Situational awareness is difficult◦ Uneven levels of preparedness across jurisdictions◦ Different places do things differently◦ Prioritization is harder and timelines are different
Scarce resources◦ Competing demands for the same limited resources
50 DMATs and more can’t be rapidly manufactured Complex events are harder by nature and expectations aren’t well managed
◦ Japan earthquake, tsunami, nuclear PP meltdown◦ Haven’t linked ESF#8 core functions to public health and medical preparedness
capabilities as defined by PHEP and HPP preparedness grants No real measures of success Many other factors
◦ Funding
Why We Struggle
What are the fundamental challenges
with responding to catastrophic health events and ESF#8?
Federal resources cannot be used locally and local resources cannot be used nationally
What are the fundamental challenges with catastrophic
health events and ESF#8?
Federal System Can’t be Used Locally◦ NDMS is federal asset
No access to resources by State or local jurisdictions Homeland Security Act
Federalized all NDMS members No protections unless federalized Cannot deploy for free Can use federal caches but have to reimburse
Reimbursement goes to the US Treasury and not Program
NDMS is expensive to deploy: $1000/person/day◦ USPHS requires SG Activation◦ VA and others require reimbursement to activate◦ DSNS is centrally controlled
Local Resources Cannot be Used Nationally◦ Local licensed medical volunteers from MRC,
ESAR-VHP, ARC cannot cross State lines unless federalized or Gubernatorial declaration waiving licensure requirements EMAC doesn’t generally apply to medical/nursing Don’t have benefits without federalization
USERRA, FTCA, WC, Pay To federalize takes weeks
Application process is tortuous Background checks Credentialing
Make NDMS a local asset Return 501(c) 3 status to teams Permit teams to use federal caches for local missions
Manage local op tempo so national readiness is not compromised
Fund teams accordingly Continue to recruit medical/surgical subspecialties
Make the application process less cumbersome
What are the Solutions?
Make local assets available nationally◦ Enact model volunteer laws in all states/territories/tribes
in order to protect victims, providers, and hospitals◦ Eliminate burdensome federalization requirements◦ Establish a national disaster credential (license) that
enables holders to practice across state borders when requested and in times of emergency, not just a bad day.
◦ Incentivize locals to participate Incentivized reimbursement rates for prepared providers
and facilities Provide workers comp, FCTA, job protection
Engage the outpatient sector and private sector
What are the Solutions?
National Guard Model◦ State asset that can be federalized when
necessary to address national crisis Can be used in EMAC scenarios Regional support of states without teams
◦ State receives funding and cache Must meet/exceed federally determined readiness
standards ◦ Teams can still fund raise for team purposes
Future Medical Preparedness
Federal resources cannot be used locally and local resources cannot be used nationally
Ask private institutions/providers to perform “inherently governmental” functions
What are the fundamental challenges with catastrophic
health events and ESF#8?
Private sector involvement◦ Given the standards, why can’t private sector
provide medical and public health assets? Requirements
Admin/legal relief-liability, licensure, workers’ comp Demonstrated daily utility Performance standards
Training/Exercises Readiness Testing
Reimbursement for preparedness
Preparedness is Everyone’s Responsibility
Federal resources cannot be used locally and local resources cannot be used nationally
Ask private institutions/providers to perform “inherently governmental functions”
Disconnect between preparedness and response
What are the fundamental challenges with catastrophic
health events and ESF#8?
Community Preparedness (Healthcare System Preparedness) Community Recovery (Healthcare System Recovery) Emergency Operations Coordination Emergency Public Information and Warning Fatality Management Information Sharing Mass Care MCM dispensing Medical Material Management and Distribution Medical Surge Non-pharmaceutical intervention Public Health laboratory testing Public Health Surveillance and Epidemiological investigation Responder Safety and Health Volunteer Management
* Over $1 Billion awarded annually for the past 11 years
Public Health and Medical Capabilities in the HHS Preparedness Grants*
ESF #8 Core Functions are not linked to Grant Capabilities
Agricultural safety and security* Public Health technical assistance
and support* Behavioral health+ Public health and medical
information* Vector control* Potable water/wastewater and
solid waste disposal* Mass fatality management, victim
identification, and decontaminating remains+
Veterinary medical support+
Assessment of public health/medical needs*
Health Surveillance* Medical care personnel+ Health/medical/veterinary
equipment and supplies Patient Evacuation+ Patient Care+ Safety and security of drugs,
biologics, and medical devices* Blood and Blood Products Food Safety and Security*
+ NDMS* PH function
Federal resources cannot be used locally and local resources cannot be used nationally
Ask private institutions/providers to perform “inherently governmental” functions
Disconnect between preparedness and response
Absence of substantial regional preparedness
What are the fundamental challenges with catastrophic
health events and ESF#8?
Template for ESF#8 Regional Preparedness
Medical Surge Capability and Capacity Handbook
Planning◦ Joint planning with State and locals
Hurricanes-Gulf Coast plans resulted in FEMA ambulance contract
Floods-plans with ND resulted in no requests for federal assistance in 2010 floods
Earthquake-Multi-state New Madrid planning NSSE’s-close coordination with host sites better defined
needs; improved plans; and better federal support◦ Regional planning
Federal support for regional planning resulted in public health support moving across state lines for several disasters
Integration With All Levels
Federal resources cannot be used locally and local resources cannot be used nationally
Ask private institutions/providers to perform “inherently governmental” functions
Disconnect between preparedness and response
Absence of substantial regional preparedness
Absence of science-based decision making
What are the fundamental challenges with catastrophic health events and ESF#8?
◦ Integration with other public services◦ EMS ◦ Fatalities management◦ Patient movement◦ Force protection◦ International deployment◦ Funding
What are examples of ESF#8 responsibilities that require a re-look?
Law enforcement Issues: perishable information, duplication of efforts, operational security and info sharing Solutions:
Joint investigations with public health PH officials are provided security clearance and pilot testing getting them secure commo
equipment Still haven’t included providers/hospitals
◦ EMS: ◦ Issue: Not fully integrated into the health and ◦ medical strategy
Solutions Expanded scope of practice in disasters Treat and release should be reimbursable Transport options-reimburse for taking patient to other than hospital Specific federal funding for EMS preparedness Support FICEMS
Integration with other Sectors
ESF # 8 Missions◦ Fatalities Management
Issue: fatalities management lacks a comprehensive national strategy
Solutions:Need to work past the jurisdictional laws for ME/coroners
Incorporate fatalities management into a comprehensive missing persons strategy HHS performs victim identification Assign body recovery to an agency
or to private industry
◦ Patient movementIssue: critical care patient transport lacks operational capacity for large eventSolutions Shelter in place strategy Coalitions/regional planning
Dead
Missing
Hospitalized
Force Protection◦ Issues: Teams, equipment and facilities need
protection during transport and deployment.◦ Solutions
Arm teams-very bad idea DoD/NGB-cannot reliably perform these functions ESF#13 Support
Don’t always understand ESF#8 mission, operations MOU
Currently have an MOU with USPP (with special deputization) to provide initial assessment and liaison for deploying teams
◦ What to do on the international front?
Future of ESF#8
International Deployments◦ Issues
No license to practice medicine in foreign countries Some countries malpractice is a criminal not civil offense
Logistics support is very difficult Force protection is a show stopper for HHSSolutions
????????
Future of ESF#8Non-Stafford Act Incidents
Budget-federal PH and medical preparedness funding decreased by 38% between FY’05 and FY’12◦ 40 States and DC have cut
PH budgets in the past year/15 States have cut for 2 years
◦ Personnel Since 2008, 49,000 PH jobs lost
(15K State/34K local)
◦ Equipment/Supplies/Facilities States unable to sustain
inventories on current budgets
◦ Training One of the first items to be
eliminated during shortfalls
Funding Gap
2002
2005
2008
2011
0
500
1000
1500
SNSPHEPHPP