Geographic Cure

The emergency medical system returns home, hopefully to better health.

Federal emergency response faltered in the face of a crippling wave of hurricanes in 2004 and 2005. National Disaster Medical System teams were short on staff, lacked vital equipment and had to rely on their cell phones to overcome communications problems, according to reports by legislative investigators and internal critics.

They blamed the system's ills on the decision to move it from the Health and Human Services Department into the Homeland Security Department as part of the Federal Emergency Management Agency.

Now, NDMS is headed back to HHS, where its medical mission isn't on foreign turf. The hope is that the move will result in a healthy recovery. The federal entity with primary responsibility for providing medical care after disasters spent almost five years at DHS after the 2002 Homeland Security Act moved it.

NDMS is a partnership of health care providers and federal, state and local governments. At the core of the system are disaster medical assistance teams, regional groups of volunteer doctors, nurses and other health care workers who are deployed during crises and paid by the federal government.

Rear Adm. W. Craig Vanderwagen, HHS' chief preparedness officer and deputy assistant secretary for preparedness and response says the system's 107 full-time federal employees were transferred to HHS in January. Part-time employees in the disaster medical assistance teams, as well as the system's storage leases, contracts and other records were to move in February and March.

"It has been extremely challenging logistically to make sure we make this a seamless transfer and maintain the capacity to deploy these folks if needed" during the transition, Vanderwagen says.

But will the transfer work? Critics ripped the medical response to recent disasters. During four major hurricanes in Florida and South Carolina in 2004, poor planning and insufficient logistical support left some NDMS teams without enough staff to cover 24-hour operations and many other teams without enough oxygen machines, antibiotics and other equipment and drugs, according to a December 2005 report by the Democratic staff of the House Government Reform Committee.

The report noted that FEMA, NDMS' parent agency at DHS, ignored earlier requests to restock equipment and provided balky communications systems, forcing some teams to rely on their personal cell phones. The assessment in a 2005 internal report by Jeffrey Lowell, senior medical adviser to then-Homeland Security Secretary Tom Ridge, was even more blunt: "NDMS is considered by many insiders to be woefully underfunded, undermanned and too remote from DHS leadership to gain the visibility it needs."

Lowell said that then-FEMA chief Michael Brown rejected the report's findings and recommendations. Then, Lowell left the department, a month after Ridge's departure. Lowell's successor, Chief Medical Officer Dr. Jeffrey W. Runge, started a week after Hurricane Katrina.

That storm illuminated all of the previously identified problems, and more, as many disaster medical assistance teams reported making urgent requests for food, water and medical supplies in the first days of operation, without success. "NDMS had been severely degraded and was unprepared for this devastating national disaster," the 2005 Government Reform Committee report found.

Many blamed the degradation on NDMS' being moved and dropped into the bureaucracy of FEMA, inside DHS - a department with multiple, competing missions. Lowell's report said the system lacked "the medical oversight required to effectively" prepare for and respond to disasters, noting that NDMS' 57 management personnel - down from 144 while at HHS - included no physicians, logisticians or medical planners.

The transfer back to HHS - made official by the Pandemic and All-Hazards Preparedness Act signed by President Bush on Dec. 18, 2006 - was predicated on the idea that NDMS would be better positioned in an agency whose primary focus is medical care. "We're doctors talking to doctors, nurses talking to nurses, EMTs talking to EMTs," Vanderwagen says.

But even when the system resided at HHS, officials found problems. An internal department memo reported in 2002 that poor management, insufficient funding and the absence of standards created gaps in NDMS' readiness. And even now HHS does not seem to have a precise inventory of how many and what kinds of doctors and responders are available and how many would be needed for different disaster scenarios.

"What we have is not necessarily what we need," says a former health official. "Right now the size of NDMS is just based on the number of people who raise their hand and volunteer."

Vanderwagen says NDMS' focus will be clearer at HHS. "We are more organized and coherent in understanding what assets are available [and] which kinds of missions we would deploy them to," he says.

Vanderwagen, who led the federal medical response in Louisiana during Katrina, says that on the Gulf Coast, NDMS teams were held accountable for tasks outside their typical responsibilities. HHS will be able to prevent that, he says.

The first test came during the transition. DHS designated the state funeral for former President Gerald Ford on Dec. 30 as a national security special event, meaning NDMS teams had to be on the scene in case something happened and to offer medical assistance to those visiting the Capitol to see Ford lying in state. The deployment went "extremely well," Vanderwagen says.

But the real gauge of success could come next budget cycle. Other than a one-time allocation of $100 million to cover Katrina-related costs, NDMS funding has been stationary at $34 million for several years. Most observers say the system needs more cash. There are reasonable arguments to be made for more funding, Vanderwagen says, and. "We'll try to make that case."

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