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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program 2 Community Emergency Management and Available Federal Assistance A previous Institute of Medicine (IOM) study (Institute of Medicine, 1999) pointed out that despite the justifiable emphasis on the novel aspects of a possible terrorist attack with a chemical or biological agent, frameworks for responding to incidents of both types already exist. An attack with a chemical agent would be similar to the hazardous materials incidents that metropolitan safety personnel confront regularly; a major mission of public health departments is the prompt identification and suppression of infectious disease outbreaks; and poison control centers deal with poisonings from both chemical and biological sources on a daily basis. In addition, most major metropolitan areas have, and are occasionally called upon to use, plans to cope with natural disasters that could result in a large number of casualties. As the IOM report emphasized, It would be a serious tactical and strategic mistake to ignore (and possibly undermine) these mechanisms in efforts to improve the response of the medical community to additional, albeit very dangerous, toxic materials. Strengthening existing mechanisms for dealing with unintentional releases of hazardous chemicals, for monitoring food safety, and for detecting and responding to infectious disease outbreaks is preferable to building a new system focused solely on potentially devastating but low-probability terrorist events. Indeed, a major reason for the committee’s decision to focus the report on response to aerosol attacks with the short list of agents thought to be a threat by U.S. military forces was that these agents are unfamiliar to the U.S. civilian medical system. Regardless of relative probability of use or relative lethality, there are mechanisms in
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program place for dealing with a wide variety of other agents and routes. Our concern was not to foster construction of yet another mechanism, but to encourage the incorporation of these unfamiliar agents and routes into existing mechanisms (Institute of Medicine, 1999, p. 185). This chapter briefly describes those existing mechanisms for dealing with emergencies and disasters other than chemical, biological, and radiological (CBR) terrorism; delineates four other federal programs aimed at improving state and local capabilities to deal with CBR terrorism; and thus, puts the Metropolitan Medical Response System (MMRS) program into a larger perspective. EMERGENCY MANAGEMENT TERMINOLOGY To understand modern emergency management, it is important to first describe the terminology used to define hazards, the magnitudes of emergencies, and management activities. Communities in the United States face a variety of hazards that can cause loss of life and injury, property damage, and significant economic consequences. A hazard, in its simplest definition, is a condition or event with the potential to cause harm to the community or environment (Federal Emergency Management Agency, 1997b). Three categories of hazards can be distinguished: natural, technological, and conflict (Sylves, 1998). Natural hazards are phenomena brought about by “nature,” including tornadoes, earthquakes, floods, volcanoes, fires, severe storms, temperature extremes, and disease. Technological hazards (also referred to as man-made or human-caused hazards) include aircraft crashes, plant explosions, and hazardous materials incidents. Recently, a third category, conflict hazard, has been used to distinguish human-caused incidents that involve intentional destruction of life or property. They include war, terrorism, civil unrest, and riots. These categories can be used to define the initial cause of a disaster, but they are not always mutually exclusive. For example, a small flash flood may damage a chemical plant and cause a massive hazardous material release. This is a case of a natural hazard triggering an even greater technological hazard. Hazards of comparable magnitude can cause very different amounts of damage. To continue with the flash flood example, if the flood were to enter a rural area, it may require an immediate response by public safety and medical personnel. This event would be defined as an emergency, an unexpected event that jeopardizes life or property and that requires an immediate response through the use of available community resources and procedures (Drabek, 1996). If this same flood were to enter a crowded, industrial area, it could overwhelm the local community’s capacity to re-
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program spond and recover, requiring additional resources from outside agencies. A disaster is defined as a calamity beyond the coping capacity of the affected population, whether triggered by natural or technological hazards or by human action (Disaster and Emergency Reference Center, 1998) A major disaster causes “damage of sufficient severity and magnitude to warrant major disaster assistance under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. § 5121 et seq. ) to supplement the efforts and available resources of states, local governments, and disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused thereby” (Federal Emergency Management Agency, 1999a). Human impact depends not only upon the magnitude of the hazard but also its evolution. Earthquakes, tornadoes, and explosions, for example, occur suddenly and without warning, whereas temperature extremes and infectious diseases generally have a slower and even insidious onset. All hazards, however, are addressed through four basic phases of emergency management: mitigation, preparedness, response, and recovery. Mitigation activities are designed to alleviate the effects of a major disaster or emergency or to minimize the potentially adverse effects of those that are unavoidable (Federal Emergency Management Agency, 1996a, 2000b). This may include enforcing building codes and developing safety regulations. Preparedness encompasses activities, programs, and systems that exist before an emergency and that are used to prepare people to respond appropriately or bolster resources for effective response (Federal Emergency Management Agency, 2002a). Preparedness includes evacuation and hardening of buildings, short-term activities that can be performed to lessen damage before a disaster. Response is defined as activities that address the immediate and short-term effects of an emergency or disaster. Response includes immediate actions to save lives, protect property, and meet basic human needs (Federal Emergency Management Agency, 1999b). Finally, recovery consists of long-term activities and programs that occur beyond the initial crisis period of an emergency or disaster and that are designed to restore systems to normal status or to rebuild them in a less vulnerable condition (Federal Emergency Management Agency, 1996b). These phases occur cyclically within a community; for example, a community that has just recovered from a recent hurricane may begin mitigation projects to protect itself against the next one. Although disasters are not new, several trends are cause for concern: the costs of disasters are rising as increases in populations and rates of development occur in hazard-prone areas, technological disasters are also on the rise as a result of the development of new industries and the aging of the existing infrastructure, and conflict hazards have become increas-
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program ingly menacing. The field of emergency management is evolving to minimize the growing impacts of disasters. EMERGENCY MANAGEMENT IN THE UNITED STATES Emergency management is the management of personnel and complex systems to address hazards and their impacts through the four phases described above. It is a rapidly evolving profession and therefore is not practiced in a uniform manner throughout the United States. Within the last century, a number of emergency services have emerged to save lives and prevent property damage, including emergency medical, fire, police, and public health services. The coordination of these services has its roots in wartime civil defense measures but has evolved to cover a broader spectrum of resources and emergencies. The Federal Emergency Management Agency (FEMA) defines emergency management as “organized analysis, planning, decision-making, and assignment of available resources to mitigate (lessen the effect of or prevent), prepare for, respond to, and recover from the effects of all hazards. The goal of emergency management is to save lives, prevent injuries, and protect property and the environment if an emergency occurs” (Federal Emergency Management Agency, 1995, p. 3). Today, emergency management also includes mitigation to build disaster-resistant communities. By definition, a “system” is a set of interrelated parts working together to achieve a common goal. The goal of the emergency management system is to reduce the loss of life, property, and environmental damage through the close coordination and cooperation of people, organizations, and resources. As stated by researcher Richard Sylves, “No single agency can manage a disaster effectively. In the American system, the response effort requires the resources and expertise of law enforcement, the fire service, emergency medical personnel, public health and public works people, and many others” (Sylves, 1998, p. 145). These parts must work together in a coordinated manner, each understanding their roles “so that they can effectively use resources and aid disaster victims” (Sylves, 1998, p. 145). The importance of the systems approach is reflected in an important concept in U.S. emergency management: “all-hazards” management. In the past, localities developed individual plans for each type of hazard, with separate mechanisms to respond to each. A community would have separate plans for tornadoes, flooding, severe storms, nuclear emergencies, and industrial explosions. Emergency management professionals have recognized that a range of management functions is common to all incidents and that the availability of a single set of systems for managing emergency responses is advantageous and is the basis for the all-hazards
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program approach to emergency management. For example, the function of warning is necessary in every emergency so that people will understand, trust, and respond appropriately to the message, regardless of the type of hazard. Similarly, incident management, patient tracking, health surveillance, information management, and restoration of lifeline services are common functions that are addressable through a common and consistent system. By recognizing that multiple hazards can be responded to with a single set of management and response systems, communities benefit from cross-training, increased efficiency, and avoidance of duplication. The process of developing an all-hazards plan also promotes coordination across organizations, prevents conflicts in planning, and avoids gaps in disaster response. Emergency management formulated on the basis of multiple hazards also promotes flexibility and an increased ability to respond to the unexpected. Concurrently, practitioners of the all-hazards approach must recognize that disasters may vary in terms of their predictability, duration, speed of onset, magnitude, scope, and impact and in terms of the possibility of secondary impacts. Special actions (such as radiation monitoring) may also be required for specific hazards. In the United States, emergency management follows a bottom-up approach; its core is at the local jurisdiction, with supplementation and assistance from outside resources as necessary. The immediate post-impact response relies heavily on local emergency service personnel and other resources from the affected community, which networks to provide essential aid. This network often involves volunteers, businesses, media, nonprofit organizations, and academia. As the size or complexity of an event increases or as the event crosses local boundaries, resources may be acquired from outside the local jurisdiction, often from higher levels of government. The first level of assistance comes from regional resources; neighboring local governments often develop mutual-aid agreements to fill special needs or combine resources to aid a locality in a time of crisis. Many large incidents affect areas across local (and often state) jurisdictional boundaries, requiring response assistance throughout metropolitan areas for adequate management. (For the purpose of this chapter, metropolitan areas will be referred to generically as regions.) If the event threatens to overwhelm the resources of a region or requires specialized assistance, the role of the state increases to provide resources and to serve as a conduit to the federal level. Federal emergency management primarily provides aid through the states. This assistance is not intended to supersede or replace activities at lower levels but is instead intended to supplement these activities. Bottom-up emergency management is a result of the U.S. federalist system in which sovereignty is shared among multiple levels of govern-
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program ment. Although the federal government provides national legislation and executive direction, it is the direct responsibility of the local and state political jurisdictions to protect their residents and provide emergency services. Historically, no federal disaster response force has the authority to assume control and manage emergency operations unless local responsibility has been abdicated. The U.S. disaster response architecture therefore evolved to one based upon shared authority and decentralization of responsibilities. The involvement of numerous resources with shared responsibility demands close coordination and cooperation among multiple levels of government and among the general public, business and industry, and nonprofit organizations. LOCAL EMERGENCY MANAGEMENT Emergency management efforts at the city or county level begin long before an incident with the implementation of mitigation measures such as enforcement of building codes, careful land management, development of written emergency response plans, creation of an emergency response structure, and other community investment to reduce vulnerabilities and preparation for hazards. At the outset of an incident, emergency managers are directly involved in coordinating personnel and resources for response, usually from an emergency operations center, where multiple city departments work together. It is the local public safety organizations (police and fire departments, emergency medical services [EMS], public works departments, and others) that will be the first on scene for sudden emergencies and that will arrive within the most critical time frame for saving lives and protecting property. Local and regional medical and public health personnel will also be rapidly involved and will very likely be the first to notice atypical symptoms and developing trends among the victims of hazards involving infectious disease agents or insidious toxins. Local leaders are the ones who understand both local priorities and the consequences of critical decisions. During the recovery period, it is the local jurisdiction that will be performing the rebuilding long after additional resources have dispersed. The response to the 1995 bombing in Oklahoma City illustrates the practice of a local jurisdiction that provided immediate resources and whose efforts were supplemented, but not supplanted, by state and federal resources. On April 19, 1995, the Alfred P. Murrah Federal Building was the target of a massive terrorist bomb. The Murrah Building partially collapsed, and many surrounding structures were severely damaged by the explosion. The Oklahoma City Fire Department (OCFD) responded to the scene to provide immediate rescue efforts, established incident com-
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program mand, and coordinated the interagency response throughout the disaster under a local incident commander (Marrs, 1995). A total of 759 people were injured or killed in the blast (Mallonee et al., 1996). Health and medical issues were handled by a number of organizations at all levels of government and private business that all reported to the same command system. Emergency Medical Services Authority, a private ambulance service, transported victims to hospitals. Fire, emergency medical, and police departments in surrounding areas provided mutual aid by performing services at the bombing site and by responding to baseline emergencies in other areas of the jurisdiction while city resources were busy at the scene. The state medical examiner’s office tracked missing persons, identified recovered victims, and notified families. The state office of emergency services interfaced with the FEMA urban search-and-rescue teams, which assisted OCFD with the rescue of victims and the recovery of bodies. Local, state, and federal resources provided security on the scene and carried out investigations. The Oklahoma City Police Department (OCPD) established perimeters, identified the evidence recovery area, and maintained control of the surrounding streets. OCPD worked with the Federal Bureau of Investigation (FBI) in the recovery of evidence and criminal investigations and directed state and federal military personnel resources. Public works personnel were essential to scene safety and maintenance; they cut off electric power and natural gas to affected buildings, established sanitary facilities for rescue workers and lighting for nighttime operations, and picked up refuse. The local telephone company installed an emergency cellular phone system to assist with communications. Fire, police, EMS, and other resources from surrounding jurisdictions responded through preestablished mutual-aid agreements to assist at the scene and to cover public safety functions in areas of Oklahoma City unaffected by the bombing (Marrs, 1995). The OCFD incident commander attributed much of the success of the response to the emergency training that personnel of all city departments received and to an effective incident management structure. Investment in adequate training and other preparedness measures can be a significant obstacle for communities, however. Disasters are low-probability, high-consequence events, meaning that they occur infrequently, but when they do occur their effects are devastating. The infrequency of disasters often makes it difficult for communities to justify spending on emergency management when faced with seemingly more urgent and ongoing public needs. Once a disaster occurs, funding for response and recovery activities can be substantiated because the needs are apparent. Preparation and mitigation measures, which could save many more lives and cost much less, often become “back-burner” issues, as the funding needs are
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program not as obvious. Potential funding is also limited by the fact that local governments are “at the end of the line” for pass-through federal and state emergency management funding (National Academy of Public Administration, 1993). One result of such funding decisions is that local jurisdictions often focus primarily on hazards that are most threatening to their area or develop capabilities to meet their most recent event. For example, cities in California may be very well prepared for earthquakes, cities in the Mid-west have warning systems and procedures that specifically deal with tornadoes, and cities along the East Coast have designed emergency systems such as evacuation procedures around the threat of hurricanes. Although they are prepared for their highest-probability hazards, communities in these regions are often not well prepared to respond to other, less expected hazards. Communities that have strong systems in place rather than resources directed primarily at specific hazards, conversely, can respond better to unexpected events. This is especially true in hazardous materials incidents when responders must often deal not only with unknown substances but also unknown combinations of substances. In July 2001, a 60-car freight train derailed in a 1.5-mile-long tunnel near the heart of Baltimore, Maryland. The train was carrying several containers of hazardous materials, some of which ignited an extremely hot fire. The incident triggered a response from five fire departments; shortly thereafter, a hazardous materials task force was also called in from South Baltimore. The disaster was complex because the responders were combating a mixture of multiple hazardous materials; in addition, the fire was located in a confined space, but smoke and liquid runoff affected a wide area (Kiehl and Niedowski, 2001). To protect public health and safety, Baltimore police shut down area roads, including interstate highways and the U.S. Coast Guard blocked access to portions of Baltimore’s Inner Harbor. Health officials monitored air quality, and members of the Baltimore Fire Department went door to door to warn residents to shelter in place and keep windows closed (Layton and Phillips, 2001). This incident resulted in no deaths because the teams were prepared with appropriate training and equipment. A formal command system that enabled decision makers to make informed and coordinated judgments about the health and safety of the responders and the community was also established. The coordination of information must extend beyond the incident command system to instruct the public on appropriate actions. These difficulties will also be present in a large-scale chemical terrorism event if an MMRS program is not successfully developed. It is especially important for emergency public health and medical systems to be well integrated with local and regional emergency manage-
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program ment systems so that measures to protect public health are appropriate and timely. In the summer of 1995, several heat waves hit Chicago, Illinois, posing a subtle yet extremely serious hazard to public health. Chicago implemented a plan to provide air-conditioned shelters. Shelters went unoccupied, however, as elderly individuals perished in their homes because of their reluctance to leave, a lack of access to transportation, or a lack of knowledge of the services that were available. The city recognized this problem and revised its plan. During a second heat wave several days later, the city dispatched city workers to knock on the doors of elderly individuals to deliver food and water and to provide transportation to the cooling shelters (Terry, 1995). Coordination between local and state public health departments, physicians, and emergency management officials was also key in the West Nile virus outbreak in New York City in 1999 (Fine and Layton, 2001; Nash et al., 2001). During that year, the West Nile virus killed seven people and infected numerous others in the New York City area. This virus had never before been seen in the United States, and the response of New York City to this outbreak shows how the public health system operates to detect and respond to disease outbreaks, regardless of the source. In this case, a physician in Queens noticed a pattern of unusual symptoms in two patients and, because encephalitis is a reportable condition in New York City, contacted the New York City Department of Public Health. which immediately began a search for possible additional cases at area hospitals. Six more cases were identified in Queens within a week, and initial laboratory tests by the New York State Department of Health and the Centers for Disease Control and Prevention (CDC) suggested a flavivirus infection. The symptoms of the patients were consistent with a diagnosis of St. Louis encephalitis (SLE), which is not uncommon along the Eastern seaboard. SLE is known to be transmitted by Culex mosquitos, so mosquito control measures were immediately begun in the area affected by the outbreak. These included aerial spraying, distribution of mosquito repellent, door-to-door searches for potential mosquito breeding sites, and a major public education effort. A final piece of the puzzle fell into place when public health officials learned that zoo and veterinary experts were conducting another investigation of unusual deaths among birds in the same area. Flaviviruses were not thought to kill birds, but the fact that many of the dead birds showed evidence of viral encephalitis suggested that the two outbreaks might be related nonetheless. Four weeks after the recognition of the outbreak in humans a flavivirus later identified as West Nile virus was isolated from tissue of crows and a flamingo in a local zoo and subsequently determined to be the common cause of both the avian and human disease outbreaks. West Nile virus is transmitted by Culex mosquitos, just as SLE is,
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program and no additional cases had occurred in the Queens area where mosquito control measures had been initiated. The fact that avian cases had been observed over a much larger range led to both additional case-seeking in all 72 New York City hospitals and a massive expansion of the mosquito control effort. A September 2000 study of New York City’s response to the West Nile virus outbreak found that this communication and coordination between responding agencies was a key lesson that could be applied to public health preparedness for bioterrorism (U.S. General Accounting Office, 2000a). The study noted, however, that although the system worked, there were several obvious places for improvement. A single alert physician at a local hospital initiated the investigation early enough that an effective intervention was possible before the outbreak became a disaster, but the investigation subsequently found many other cases which were either not properly diagnosed or not reported to the health department. Much more systematic surveillance and reporting at the local level is needed. Similarly, improved communication among public health agencies, including those dealing with animal health, is needed. Increased laboratory capacity will also be important to an efficient and effective response to disease outbreaks (only one public health laboratory in the country was initially equipped to diagnose West Nile virus). STATE ASSISTANCE Local jurisdictions request state assistance to obtain specialized resources, to supplement local resources, or to act as a financial or operational conduit to federal resources. State governors have the legal responsibility to carry out emergency preparedness, response, and recovery actions; and declaration of an emergency provides him or her with additional powers. These powers include the authority to mobilize the National Guard, to order an evacuation, to commandeer and use private property (within prescribed limits), to use emergency funds, and to enter into mutual-aid agreements with other states. Every state has an emergency management office, but the organization and proximity of that office to the governor vary widely. Ten states have emergency management agencies at the cabinet level within the office of the governor. Beauchesne (2001) reported that 22 states have emergency management functions within the department of military affairs and that 12 others have such functions within departments of public safety. The remainder of states structure emergency management functions within combined public safety-military affairs agencies, within community or local affairs departments, or within the state police department. During nonemergency periods, the role of the state is to develop emer-
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program gency management programs that complement and promote local emergency management capabilities. The state has the legal authority to enact codes and regulations and to enforce state and national laws (Sylves, 1998). The state emergency management office often maintains the state emergency management plan, an emergency operations center, and services that are activated upon local request for assistance. The National Academy of Public Administration observes that the states are in a unique position to gauge the emergency management needs of more than one of its political subdivisions, assess its own and to some extent the federal government’s resources, and facilitate the acquisition and application of these resources (National Academy of Public Administration, 1993). State agencies are responsible for coordination of emergency services, horizontally with other states (for mutual assistance) and vertically when federal resources are necessary, for the state often serves as the conduit between local and federal governments. The Emergency Management Assistance Compact provides a framework for coordinating interstate assistance (Emergency Management Assistance Compact, 2002), whereas the federal response plan’s concept of operations details the framework for requesting and managing federal assets (Federal Emergency Management Agency, 1992). Some states provide assistance for a wide variety of emergencies; others have responsibilities and resources only for certain types of incidents (Beauchesne, 2001). These services may include the provision of specialized resources (e.g., search-and-rescue teams and hazardous materials technicians), emergency management training, or management assistance. States have very different approaches and devote different resources to emergency management. California employs approximately 800 people in its Office of Emergency Services (OES). The California OES is located within the governor’s office and is well funded to provide Internet-based systems to coordinate and manage state disaster responses, response equipment (including 120 state-owned fire engines), and, among many other services, a fully staffed training institute for emergency management. California not only provides resources but also has a strong hand in responses to emergencies and events through the coordination of mutual aid within the state (California Office of Emergency Services, 2002). Maryland, on the other hand, operates a 40-person emergency management agency within the Maryland Military Department. The Maryland Emergency Management Agency operates an emergency operations center on an as-needed basis, coordinates federal programs, and organizes a rapid response team consisting of 13 state organizations frequently involved in disaster response (Maryland Emergency Management Agency, 2002).
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program THE FEDERAL EMERGENCY RESPONSE PLAN When the demands of disasters exceed local, regional, and state capabilities, the federal government is called upon to provide supplemental assistance. If needed, the federal government can mobilize an array of resources to support state and local efforts. Various emergency teams, support personnel, specialized equipment, operating facilities, financial assistance programs, and the provision of access to private-sector resources constitute the overall federal disaster operations system. Under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. § 5121 et seq. ), a governor may request the President to declare a major disaster or an emergency if an event is beyond the combined response capabilities of the state and the local governments that are affected. If an emergency involves an area or facility for which the federal government exercises exclusive or primary responsibility and authority, the President may unilaterally direct the provision of emergency assistance under the Stafford Act. The governor of the affected state will be consulted if possible. Federal assistance takes many forms—including the direct provision of goods and services, financial assistance (through insurance, grants, loans, and direct payments), and technical assistance—and can come from various sources. Initial sources include internal government supplies (available surplus and excess property or agency stock previously acquired from the Disaster Relief Fund or on hand). Agencies also may acquire needed goods and supplies from outside the federal government, such as from the private sector and possibly nonaffected state and local governments. FEMA has been given responsibility for coordinating, planning, and managing this assistance, a task that it carries out in accordance with the Federal Response Plan (FRP) (Federal Emergency Management Agency, 1992). The FRP describes the policies, planning assumptions, concept of operations, response and recovery actions, and responsibilities of 27 federal departments and agencies and the American Red Cross that guide federal operations following a presidential declaration of a major disaster or emergency. The FRP uses a functional approach that groups under 12 emergency support functions (ESFs) the types of direct federal assistance that a state is most likely to need (e.g., mass-casualty care or health and medical services), as well as the kinds of federal operational support necessary to sustain a federal response (e.g., transportation and communications support). Each ESF is headed by a primary agency designated on the basis of its authorities, resources, and capabilities in the particular functional area. The 12 ESFs are
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program transportation, communications, public works and engineering, firefighting, information and planning, mass care, resource support, health and medical services, urban search and rescue, hazardous materials, food, and energy. Emergency Support Function 8, Health and Medical Services The U.S. Department of Health and Human Services (DHHS) is the lead federal agency with responsibility for ESF 8, health and medical services. In that role DHHS coordinates the provision of federal health and medical assistance to fulfill the requirements identified by the affected state and local authorities. Included in ESF 8 are the overall public health response; triage, treatment, and transportation of victims of the disaster; and evacuation of patients out of the disaster area. Resources for this aid come from the following: within DHHS; ESF 8 support agencies (e.g., the U.S. Department of Defense [DOD], the U.S. Department of Transportation, the American Red Cross, and the Environmental Protection Agency [EPA]); the National Disaster Medical System (NDMS), a nationwide medical mutual-aid network between the federal and nonfederal sectors that provides patient evacuation and definitive medical care; at the federal level, it is a partnership between DHHS, DOD, the U.S. Department of Veterans Affairs (VA), and FEMA; and specific nonfederal sources such as major pharmaceutical suppliers, hospital supply vendors, the National Foundation for Mortuary Care, certain international disaster response organizations, and international health organizations. ESF 8 describes 15 specific functional areas of federal health and medical assistance, as follows: Assessment of health and medical needs. DHHS deploys an assessment team to the disaster area to assist in determining the specific
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program health and medical needs and priorities. This function includes the assessment of the infrastructure of the health care system and health care facilities. Health surveillance. CDC helps establish surveillance systems to monitor the general population and special high-risk segments of the population, carry out field studies and investigations, monitor injury and disease patterns and potential disease outbreaks, and provide technical assistance and consultations on disease and injury prevention and precautions. Medical care personnel. The Office of Emergency Preparedness (OEP) provides Disaster Medical Assistance Teams (DMATs) and individual public health and medical personnel to assist in providing care for ill or injured victims at the location of a disaster or emergency. DMATs can provide triage, medical and surgical stabilization, and continued monitoring and care of patients until they can be evacuated to locations where they will receive definitive medical care. Specialty DMATs can also be deployed to address burn injuries, pediatric care requirements, chemical injury or contamination, and so forth. In addition to DMATs, active-duty and reserve military units and National Guard units with casualty clearing-casualty staging and other missions are deployed as needed. Individual clinical health care and medical care specialists may be provided to assist state and local personnel. VA is one of the primary sources of these specialists. Health and medical care equipment and supplies. OEP provides health and medical care equipment and supplies, including pharmaceuticals, biological products, and blood and blood products, in support of DMAT operations and for the restocking of health and medical care facilities in an area affected by a major disaster or emergency. Patient evacuation. OEP, through NDMS, moves seriously ill or injured patients from the area affected by a major disaster or emergency to locations where definitive medical care is available. NDMS patient movement will primarily be accomplished with the fixed-wing aeromedical evacuation resources of DOD. In-hospital care. OEP, through NDMS, provides definitive medical care to victims who become seriously ill or injured as a result of a major disaster or emergency. For this purpose, NDMS has established and maintains a nationwide network of voluntarily precommitted, federal and nonfederal acute-care hospital beds in the largest U.S. metropolitan areas. Food, drug, and medical device safety. The Food and Drug Administration ensures the safety and efficacy of regulated foods, drugs, biological products, and medical devices following a major disaster or emergency. It also arranges for the seizure, removal, and destruction of contaminated or unsafe products.
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program Worker health and safety. CDC assists with monitoring the health and well-being of emergency workers, performs field investigations and studies addressing worker health and safety issues, and provides technical assistance and consultation on worker health and safety measures and precautions. Radiological, chemical, and biological hazards consultation. CDC assists with assessing the health and medical effects of radiological,1 chemical, and biological exposures on the general population and on high-risk population groups; conducts field investigations, including collection and analysis of relevant samples; provides advice on protective actions that can be taken to prevent direct human and animal exposure and indirect exposure through radiologically, chemically, or biologically contaminated food, drugs, water supplies, and other media; and provides technical assistance and consultations on medical treatment and decontamination of radiologically, chemically, or biologically injured or contaminated victims. Mental health care. The Substance Abuse and Mental Health Services Administration assists in assessing mental health needs; provides disaster-related mental health training materials for disaster workers; and provides liaisons with the assessment, training, and program development activities undertaken by federal, state, and local mental health officials. Public health information. CDC assists by providing public health and disease and injury prevention information that can be transmitted to members of the general public who are located in or near areas affected by a major disaster or emergency. Vector control. CDC assists with assessing the threat of vector-borne diseases after a major disaster or emergency; conducts field investigations, including the collection and laboratory analysis of relevant samples; provides vector control equipment and supplies; and provides technical assistance and consultation on protective actions regarding vector-borne diseases and the medical treatment of victims of vector-borne diseases. Potable water and disposal of wastewater and solid waste. The Indian Health Service assists in assessing potable water and issues related to the disposal of wastewater and solid waste; conducts field investiga 1 The lead agency and federal response to a radiological emergency will be based on the type or amount of radioactive material involved, the location of the emergency, the impact on or the potential for an impact on the public and environment, and the size of the affected area. The Federal Radiological Emergency Response Plan spells out the roles of federal agencies and takes precedence over the FRP.
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program tions, including collection and laboratory analysis of relevant samples; provides water purification and wastewater and solid-waste disposal equipment and supplies; and provides technical assistance and consultation on potable water and issues related to the disposal of wastewater and solid waste. Victim identification and mortuary services. OEP and NDMS assist by providing victim identification and mortuary services, including NDMS Disaster Mortuary Teams; temporary morgue facilities; victim identification by fingerprinting, forensic dental, molecular biology, and forensic pathology-anthropology methods; and processing, preparation, and disposal of remains. Veterinary services. OEP and NDMS assist in delivering health care to injured or abandoned animals and performing veterinary preventive medicine activities after a major disaster or emergency, including conducting field investigations and providing technical assistance and consultation as required. In 1995, Presidential Decision Directive 39 (PDD-39), U.S. Policy on Counterterrorism, was issued to “establish policy to reduce the Nation’s vulnerability to terrorism, deter and respond to terrorism, and strengthen capabilities to detect, prevent, defeat, and manage the consequences of terrorist use of weapons of mass destruction (WMD)” (Federal Emergency Management Agency, 1999b, p. 1). Approximately 2 years later, FEMA created the Terrorism Incident Annex to the FRP to describe the roles of federal agencies in responding to the consequences of terrorism within the United States. The annex defines two phases of the response to terrorism that may overlap: crisis management and consequence management. As described in the FRP Terrorism Incident Annex, crisis management “refers to measures to identify, acquire, and plan the use of resources needed to anticipate, prevent, and/or resolve a threat or act of terrorism” (Federal Emergency Management Agency, 1999b, p. 1). Crisis management is defined as a federal responsibility, predominantly involving law enforcement activities, with state and local assistance as appropriate. The FRP Terrorism Annex describes consequence management as “measures to protect public health and safety, restore essential government services, and provide emergency relief to governments, businesses, and individuals affected by the consequences of terrorism” (p. 1). As opposed to crisis management, consequence management is the responsibility of state and local governments, with support from the federal level as needed (Federal Emergency Management Agency, 1999b).
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program The Chemical and Biological Appendix to ESF 8 In recognition of some of the distinctive features of a major act of domestic terrorism with chemical or biological agents, DHHS has formulated an appendix to the ESF 8 section of the FRP specifying the federal government’s response to urgent health and medical care needs resulting from such acts (U.S. Department of Health and Human Services, 1996). This support plan identifies 20 specific, specialized, and time-sensitive health and medical services functions, in addition to the 15 identified in ESF 8 proper; assigns responsibility for the response to each of those 20 functions to federal departments, agencies, and offices; and describes some of the assets available for the responses required. It carefully notes that any or all of the plan may be activated before a presidentially declared disaster to save lives and that the need for rapid action demands that some elements of the plan be organized and prepositioned ahead of any terrorist event. Whether DHHS is assisting the FBI in evaluating a threat or responding to requests for assistance from FEMA and the affected community after an actual release of a chemical or biological agent, the special contributions of DHHS deal with threat assessment, emergency consultation, and specialized technical assistance. One of the first actions to be undertaken by DHHS after telephonic or electronic consultation would be deployment of an interagency Chemical and Biological Rapid Deployment Team of 23 technical specialists from DHHS, DOD, the U.S. Department of Energy, and EPA. Since the appendix was written, OEP has equipped and trained four specialized National Medical Response Teams (NMRT) to provide medical care for victims of weapons of mass destruction. Like the 23 DMATs, the NMRT can deploy to disaster sites within 12 to 24 hours and sustain themselves for a period of 72 hours while providing medical care at a fixed or temporary medical care site. THE NATIONAL CONTINGENCY PLAN The National Oil and Hazardous Substances Contingency Plan (also known as the National Contingency Plan [NCP]) is the plan for the federal response to oil spills and the release of hazardous substances. This plan outlines the National Response System for the reporting, containment, and cleanup of spills. It also established regional and national reaction teams and a response headquarters. Originally published in 1968, NCP was broadened several times to remain current with new legislation. It now covers hazardous-substance spills, oil discharges, and emergency removal actions for hazardous waste sites (Environmental Protection Agency, 1999). In the event of a spill, the plan is immediately activated,
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program requiring no request from state or local levels; up to 16 federal agencies led by EPA and the U.S. Coast Guard may be involved, depending on the expertise and resources required. THE FEDERAL RADIOLOGICAL EMERGENCY RESPONSE PLAN After the Three Mile Island nuclear power plant accident in 1979, the lead role in offsite planning for radiological emergencies was transferred from the U.S. Nuclear Regulatory Commission (NRC) to FEMA. On-site activities continue to be the responsibility of NRC. Today FEMA is the federal lead for all types of peacetime radiological emergencies; through its Radiological Emergency Preparedness (REP) program, the agency works to ensure the health and safety of residents near nuclear power plants and to educate the public about radiological emergency preparedness. The REP program includes regional assistance committees, which assist with the development of state and local plans, and the Federal Radiological Preparedness Coordinating Committee, which issues policy and guidance on emergency response plans and procedures with the assistance of additional federal agencies (Federal Emergency Management Agency, 2000c). The Federal Radiological Emergency Response Plan provides the framework for the federal response to peacetime radiological emergencies (Federal Emergency Management Agency, 2002c). State and local agencies are responsible for the measures needed to protect life and property in facilities and areas that are not controlled by the federal government (e.g., private reactors). However, they can request assistance directly from the federal agencies that are a part of the Federal Radiological Emergency Response Plan. All costs are the responsibility of the participating agencies. TERRORISM-SPECIFIC FEDERAL SUPPORT TEAMS In addition to the DMATs and related teams that constitute part of the DHHS response to a request for support from a community or communities suffering a catastrophic terrorist incident, a myriad of teams from other agencies are prepared to respond. Figure 2-1, taken from a September 2001 review of federal assets for combating terrorism conducted by the U.S. General Accounting Office (GAO), shows only the key consequence management teams (U.S. General Accounting Office, 2001a). Appendix B, from a slightly earlier GAO report (U.S. General Accounting Office, 2000b), provides selected information on the capabilities of many of those teams.
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program FIGURE 2-1 Key federal consequence management response teams for CBR terrorism (U.S. General Accounting Office, 2001a).
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program GAO (U.S. General Accounting Office, 2000b) and several high-level advisory groups (Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction, 2000; Cilluffo et al., 2000; Rudman, 2001) have repeatedly pointed out the need for better coordination among the many agencies with antiterrorism or counter-terrorism programs. Terrorism is both a crime and a national security issue, so an array of crisis management teams and personnel, headed by the FBI, may also arrive at the scene, with or without a request from local law enforcement officials. In May 2001 President George W. Bush reinforced the position of FEMA as the coordinator of federal responses to acts of domestic terrorism by establishing the Office of National Preparedness in that agency and charging it with coordinating and implementing all federal programs providing relief or support to local governments responding to acts of terrorism. Under this plan, the FBI remained the leader of criminal investigations of acts of terrorism, but in October 2001 President Bush signed an executive order establishing the Office of Homeland Security within the Executive Office of the President (Bush, 2001) and named Tom Ridge, a former governor of Pennsylvania, to head it as Assistant to the President for Homeland Security. The mission of the Office of Homeland Security is to develop and coordinate the implementation of a comprehensive national strategy to secure the United States from terrorist threats or attacks, including coordinating the executive branch’s efforts to detect, prepare for, prevent, protect against, respond to, and recover from terrorist attacks within the United States. CONCLUSION The focus of this report is on planning and preparation for a terrorist attack in local communities before a terrorist attack occurs. However, it should be clear from this brief review of the federal resources available to assist with the consequence management of a completed act of terrorism that planning conducted before an incident occurs must address not only when and how to obtain federal help but also how to accommodate and coordinate that help upon its arrival. In this case, it is clearly possible to receive too much of a good thing. Nevertheless, it would be reasonable to conclude from the information presented in this chapter that the larger metropolitan areas of the United States have initiated substantial preparations for CBR terrorism, have in place some well-developed systems for coping with mass-casualty incidents of many sorts, have practiced the use of those systems, and have access to a large number and a wide variety of
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Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program specialized federal resources. The next chapter reviews the much smaller number of federal programs aimed specifically at helping state and local authorities better adapt their systems to respond to the specific threats posed by CBR weapons.
Representative terms from entire chapter: