State and Local Disaster Plans Aren't Making the Grade

By Sandy Smith, with additional reporting by Leslie Drahos

Five years after the Sept. 11 and anthrax tragedies, adequate emergency preparedness at all levels – federal, state and local – remains catch-as-catch-can, say experts.

A new study reveals that most states are not prepared for a major health crisis such as a pandemic flu outbreak, while speakers at American Military University’s symposium, Homeland Security: The Ripple Effect, noted that local communities still have major, serious gaps in disaster plans.

Part of the preparedness issue lies in incomplete emergency plans, according to symposium speaker Lt. Gen. Russel Honore, former commander of Joint Task Force-Katrina.

“Did you take your understanding of the disaster to failure?” asked Honore. He was referring to disaster plans that miss critical elements. For example, many disaster plans end without addressing mass casualties.

Other conference speakers, who included U.S. House Homeland Security Committee Chair Bennie Thompson and Federal Emergency Management Agency (FEMA) Director R. David Paulison, said that many communities remain unprepared to handle evacuees and need to develop partnerships with private industry. Others addressed the necessity of personal preparedness and regional approaches to response and recovery.

Patrick McCrory, mayor of Charlotte, N.C., and a member of President George W. Bush’s Homeland Security Advisory Council, discussed the need for evacuation agreements with communities that may be hundreds of miles away, in other states. His city, for example, housed hundreds of victims from Hurricane Katrina.

James Spears, homeland security advisor and secretary of Military Affairs and Public Safety for West Virginia, discussed preparedness issues for states located near major metropolitan areas. He said his state could be left vulnerable should a major emergency occur at a nearby state. For example, if the West Virginia National Guard – an important state resource – was called in to support Washington, D.C.

Elements of Disaster

Spears’ concerns are well-founded, based on a new report that examines state preparedness for major events. The fourth annual report, “Ready or Not? Protecting the Public’s Health from Disease, Disasters and Bioterrorism,” released by Trust for America’s Health (TFAH), indicates that when local communities that are not ready to handle mass casualties turn to their state governments for help, they might find little additional help available.

Part of the problem, said Charlotte’s McCrory, are the difficulties of gathering information and deploying assistance in the first hours. “Many (people) put unrealistic expectations on government, especially in the first 48 hours,” McCrory said. That is true at all levels: local, state and federal.

To try to remedy the problem, FEMA Director Paulison says his agency is building partnerships with private industry. Private industry controls much of the nation’s infrastructure – communications, energy and transportation – so its cooperation is critical. He is also strengthening FEMA, including adding many positions.

But experts agree that despite increased emphasis on preparedness at the local, state and federal level, gaps wide enough to drive a truck through continue to exist.

Ready or Not Report

All 50 U.S. states and the District of Columbia were evaluated for the “Ready or Not? Protecting the Public’s Health from Disease, Disasters and Bioterrorism” report. Half the states scored 6 or less on the scale of 10 indicators. Oklahoma scored highest with 10 out of 10; California, Iowa, Maryland and New Jersey scored the lowest with 4 out of 10. States with stronger surge capacity capabilities and immunization programs scored higher, since four of the measures focus on these areas.

“Sept. 11, the anthrax attacks and Hurricane Katrina were all wake-up calls to the country, putting us on notice that the nation’s response capabilities were weak and that we needed to improve preparedness,” said Jeff Levi, Ph.D., executive director of TFAH. “But, across the board, it is clear that we haven’t learned the lessons from these tragedies – we are still too vulnerable to what might come next.”

Among the key findings of the report:

• Only 15 states are rated at the highest preparedness level to provide emergency vaccines, antidotes and medical supplies from the Strategic National Stockpile.
• Twenty-five states would run out of hospital beds within 2 weeks of a moderate pandemic flu outbreak.
• Forty states face a shortage of nurses.
• Rates for vaccinating seniors for the seasonal flu decreased in 13 states.
• Eleven states and Washington, D.C., lack sufficient capabilities to test for biological threats.
• Four states do not test year-round for the flu, which is necessary to monitor for a pandemic outbreak.
• Six states cut their public health budgets from FY 2005 to FY 2006; the median rate for state public health spending is $31 per person per year.

“The nation is nowhere near as prepared as we should be for bioterrorism, bird flu and other health disasters,” said Levi. “We continue to make progress each year, but it is limited. As a whole, Americans face unnecessary and unacceptable levels of risk.”

A Shared Responsibility

The TFAH report also examines the need to strengthen funding and accountability for public health preparedness. Preparedness is a shared responsibility among the federal, state and local governments, with the Centers for Disease Control and Prevention (CDC) and Health Resource Services Administration (HRSA) at the U.S. Department of Health and Human Services (HHS) in charge of overseeing the use of federal funds devoted to health emergency readiness.

Since 2004, more than $90 million have been cut from CDC’s preparedness funds that are allocated to states, and more than $23 million have been cut from HRSA funds allocated for state hospital preparedness. These cuts have occurred before many basic preparedness goals have been met. This threatens to halt or reverse progress that has been achieved. Additionally, the federal government currently does not consistently, objectively measure or provide state-by-state information to help Americans and policymakers assess how prepared their communities are to respond to health threats.

The report offers a series of recommendations to help improve preparedness. Some key recommendations include:

• The federal government should establish improved “optimally achievable” standards that every state should be accountable for reaching to better protect the public, and the results should be made publicly available. Appropriate levels of funding should be provided to the states to achieve these standards.
• The establishment of temporary health benefits for the uninsured or underinsured during states of emergency. This benefit is necessary to ensure that sick people will stay home, and the uninsured and underinsured will seek treatment in times of emergency, helping to prevent the unnecessary spread of infectious diseases, including resulting from acts of bioterrorism or a pandemic flu outbreak.
• A single senior official within HHS should be designated in charge of and accountable for all public health programs. The senior official would streamline government efforts and be the clear leader during times of crisis.
• Emergency surge capacity capabilities should be improved by integrating all health resources and partnering with businesses and community groups in planning and increasing stockpiles of needed equipment and medications.
• The volunteer medical work force should be expanded and an investment must be made in the recruitment of the next generation of the public health work force.
• Technology and equipment must be modernized and research and development must be strengthened.
• The public should be better included in emergency planning, and risk communication must be modernized.

Preparedness at the Local Level

In July 2006, the United States Conference of Mayors released a major emergency preparedness/homeland security survey. With responses from 183 cities representing 38 states, the District of Columbia and Puerto Rico, and including cities ranging in population from 30,000 to New York City, the survey paints a clear picture of disaster preparedness at the local level.

The survey gave mayors an opportunity to highlight key challenges, levels of improvement and areas where additional assistance is still needed, and many reached the same conclusions as speakers at the Homeland Security symposium: that more action is needed on key issues such as interoperable communications, evacuation planning and pandemic flu preparedness. The survey revealed a number of key findings:

• Eighty percent of cities felt they had not received sufficient funding from the federal government to allow their first responders to talk with one another.
  
• While 73 percent of the cities with populations over 300,000 had recently created or updated an evacuation plan, only 56 percent of cities on average had done so.
  
• Seventy-two percent of all cities had not been assigned a Principal Federal Official to work with them in the event of a disaster. However, when the largest cities were surveyed, 60 percent responded yes.
  
• Though 69 percent of cities had been contacted by federal or state governments to discuss possible pandemic flu outbreaks, only 30 percent of cities felt they were prepared to handle such an outbreak on their own for the first few days (and possibly weeks), before federal assistance would be made available.
  

“The nation’s mayors continue to focus on the need to strengthen emergency preparedness and homeland security … This new survey shows we must further strengthen our partnership with the federal government,” said Dearborn Mayor Michael Guido.

While this partnership between local and federal government is crucial to the protection of America’s cities, the two partners have not always seen eye to eye. Elizabeth (N.J.) Mayor J. Christian Bollwage cites a shift in focus from local law enforcement programs, such as COPS and the local block grant, to “a homeland security pot, which has then become competitive … and that’s the movement here that the mayors have become deeply concerned about.”

Mayor David Wallace notes that his city of Sugar Land, Texas, sheltered hurricane victims in the wake of Katrina, before Hurricane Rita forced refugees and residents of Sugar Land alike to head even further inland. Wallace has serious concerns over the results of the survey, especially the fact that “… 44 percent of cities have not created or updated their evacuation plans.”

Mayors Take the Lead

Despite these concerns, the mayors make it clear that they are willing to take the initiative to make their cities and their citizens safer.
One month following the terrorist attacks of Sept. 11, the leadership of the Conference of Mayors held an emergency homeland security summit in Washington, D.C., where mayors, police, fire and emergency management officials drafted the National Action Plan for Safety and Security in America’s Cities. Following the hurricanes of 2005, the plan was updated and presented to Homeland Security Secretary Michael Chertoff and Congress.

Key areas covered in the updated plan include:

• Fixing FEMA.
• Military involvement in disaster response and recovery.
• Communications interoperability.
• Enhanced transportation security.
• First responder funding.

During the forum, Baltimore Mayor Martin O’Malley discussed efforts put together by mayors to form city-to-city mutual aid agreements, a result of the lessons learned from Hurricane Katrina. These agreements would see neighboring cities providing immediate assistance to cities in need, without waiting for federal aid, in the event of another major disaster. “We have an obligation to one another, so that if something happens, we send the assets and the resources,” O’Malley said.

Philadelphia Mayor John Street said his city created an Emergency Preparedness Review Committee, which produced a report of 200 recommendations for cities and regions in the event of a disaster. Similar to the mutual aid agreements, this report focused on cities within a tri-state area and their ability “… to communicate, to share resources and to be prepared to respond to an emergency,” Street said.

Street added that he took some heat for commissioning a report that found Philadelphia was not where it needed to be on preparedness, but stresses that mayors cannot afford to be complacent and must first and foremost work to protect the public. Only through strong regional, state, interstate and national cooperation can a major metro area truly reach a level of adequate preparedness, he adds.

“As mayors, we’re the ones on the front lines,” said Mayor Douglas Palmer, whose city of Trenton has had three major floods in the past 18 months. “As mayors, we’re going to lead.”