[Senate Hearing 111-313]
[From the U.S. Government Printing Office]
S. Hrg. 111-313
FOCUSING ON CHILDREN AND DISASTERS:
EVACUATION PLANNING AND MENTAL
HEALTH RECOVERY
=======================================================================
HEARING
before the
AD HOC SUBCOMMITTEE ON DISASTER RECOVERY
of the
COMMITTEE ON
HOMELAND SECURITY AND
GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
AUGUST 4, 2009
__________
Available via http://www.gpoaccess.gov/congress/index.html
Printed for the use of the Committee on Homeland Security
and Governmental Affairs
----------
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COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan SUSAN M. COLLINS, Maine
DANIEL K. AKAKA, Hawaii TOM COBURN, Oklahoma
THOMAS R. CARPER, Delaware JOHN McCAIN, Arizona
MARK L. PRYOR, Arkansas GEORGE V. VOINOVICH, Ohio
MARY L. LANDRIEU, Louisiana JOHN ENSIGN, Nevada
CLAIRE McCASKILL, Missouri LINDSEY GRAHAM, South Carolina
JON TESTER, Montana ROBERT F. BENNETT, Utah
ROLAND W. BURRIS, Illinois
MICHAEL F. BENNET, Colorado
Michael L. Alexander, Staff Director
Brandon L. Milhorn, Minority Staff Director and Chief Counsel
Trina Driessnack Tyrer, Chief Clerk
AD HOC SUBCOMMITTEE ON DISASTER RECOVERY
MARY L. LANDRIEU, Louisiana, Chairman
CLAIRE McCASKILL, Missouri LINDSEY GRAHAM, South Carolina
ROLAND W. BURRIS, Illinois
Ben Billings, Staff Director
Andy Olson, Minority Staff Director
Kelsey Stroud, Chief Clerk
C O N T E N T S
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Opening statement:
Page
Senator Landrieu............................................. 1
Prepared statements:
Senator Landrieu............................................. 29
Senator Bennett.............................................. 33
WITNESSES
Tuesday, August 4, 2009
Craig Fugate, Administrator, Federal Emergency Management Agency,
U.S. Department of Homeland Security........................... 5
Rear Admiral Nicole Lurie, M.D., M.S.P.H., Assistant Secretary
for Preparedness, U.S. Public Health Service, U.S. Department
of Health and Human Services................................... 6
Cynthia A. Bascetta, Director, Health Care, U.S. Government
Accountability Office.......................................... 9
Mark Shriver, Vice President and Managing Director of U.S.
Programs at Save the Children, and Chairperson, National
Commission on Children and Disasters........................... 17
Irwin Redlener, M.D., Professor, Clinical Population and Family
Health, and Director, National Center for Disaster
Preparedness, Mailman School of Public Health, Columbia
University, and President, Children's Health Fund.............. 19
Teri Fontenot, President and Chief Executive Officer, Woman's
Hospital, Baton Rouge, Louisiana............................... 21
Alphabetical List of Witnesses
Bascetta, Cynthia A.:
Testimony.................................................... 9
Prepared statement........................................... 57
Fontenot, Teri:
Testimony.................................................... 21
Prepared statement with an attachment........................ 77
Fugate, Hon. Craig:
Testimony.................................................... 5
Prepared statement........................................... 35
Lurie, Rear Admiral Nicole, M.D., M.S.P.H.:
Testimony.................................................... 6
Prepared statement........................................... 41
Redlener, Irwin, M.D.:
Testimony.................................................... 19
Prepared statement........................................... 71
Shriver, Mark:
Testimony.................................................... 17
Prepared statement........................................... 67
APPENDIX
Additional information submitted for the record by Senator
Landrieu....................................................... 91
Questions and responses submitted for the record from:
Mr. Fugate................................................... 110
Admiral Lurie................................................ 113
Ms. Bascetta................................................. 116
Mr. Shriver.................................................. 119
Dr. Redlener................................................. 121
Ms. Fontenot................................................. 123
FOCUSING ON CHILDREN AND DISASTERS:
EVACUATION PLANNING AND MENTAL
HEALTH RECOVERY
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TUESDAY, AUGUST 4, 2009
U.S. Senate,
Ad Hoc Subcommittee on Disaster Recovery,
of the Committee on Homeland Security
and Governmental Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:04 a.m., in
room SD-342, Dirksen Senate Office Building, Hon. Mary L.
Landrieu, Chairman of the Subcommittee, presiding.
Present: Senator Landrieu.
OPENING STATEMENT OF SENATOR LANDRIEU
Senator Landrieu. Good morning, I would like to call the
hearing to order this morning of the Subcommittee on Disaster
Recovery, which I am proud and happy to Chair. I thank the
staff for helping prepare this hearing for this morning.
Today's hearing is entitled, ``Focusing on Children and
Disasters: Evacuation Planning and Mental Health Recovery.''
The Subcommittee's objective today is to evaluate the very
special needs of children during the preparedness, response,
and recovery phases of disaster and the extent to which our
current planning and programs either meet or fail to meet these
special needs.
We are focusing on children and their needs for several
reasons. First, children in most families are the focal point,
and parents who cannot find an available school, a day care
center, or access to health care for their children may be
forced to relocate after a disaster or, worse in some ways, be
forced to stay out of the workforce when they are actually
badly needed to help rebuild their communities, starting with
their own homes, businesses, and places of worship.
According to the Bureau of Labor Statistics, about half the
Nation's families include children, and 90 percent of those
families include a parent that is a member of the workforce. So
getting your workforce back to work after a disaster is one of
our primary goals. That will be very difficult if we are not
doing our best to provide them help and support with proper
placement during those daylight hours for their children,
either in schools or day care, and provide the mental health
counseling that children need and families need to sustain
themselves.
So we must be mindful of the fact that people cannot return
to work or begin rebuilding until they locate a safe and
productive environment for their children. These parents, I may
remind everyone, are the nurses, the doctors, the first
responders, the police officers, the grocery store owners, the
gas station operators, the electric line repairmen, and the
citizens who play an important role in the community's return.
That means the provision of child care and reopening of schools
must be a top priority.
I would like to show a chart of the number of day care
centers that were operating.\1\ In August 2005, the purple line
shows how many day care centers were open, and then, of course,
you can see the dramatic falloff over time.
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\1\ The chart referred to by Senator Landrieu appears in the
Appendix on page 95.
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The second reason we are focusing on children here today is
that children are a vulnerable population with unique needs
that require special planning to address, but in my view, they
have not received the same level of attention that some other
populations, whether it be the adult homeless or the disabled
or the elderly generally. A broader goal of this hearing is to
encourage the Nation to consider the mental well-being of the
community as a key indicator of recovery, every bit as
important as the restoration of infrastructure, housing, and
the return of the economic tax base.
I would like to take a moment to commend the Washington
Times for their particularly insightful articles, actually
published the last couple of days--it was a coincidence that
they were running these in line with our hearing--and I want to
quote from one of the articles that was published on August 3.
It says, ``Almost 4 years after the massive hurricanes
inundated much of New Orleans that killed about 1,800 people,
millions of words have been written about the devastating
physical damage to the city and hundreds of millions of dollars
have been spent on fitful efforts at reconstruction. But almost
nothing is said and relatively little has been spent on the
more silent wreckage, the health of New Orleans residents who
were pushed over the edge by the terror and turmoil of the
storm and have been unable to recover emotionally or
mentally.'' And when I say New Orleans, I mean the greater New
Orleans area, and in large measure, you could almost substitute
the Gulf Coast for New Orleans.
Local response plans must be provided for evacuation,
sheltering, and continued care of children from facilities
where they are likely to be clustered at the time of the
disaster or call for evacuation, either at day care centers,
schools, and hospitals, including the neonatal wards and
maternity wards. Katrina showed us the impact of failing to
include the nursing home sector in our evacuation plans and we
must ensure in the future that facilities which house other
vulnerable members of our society are included fully in these
planning processes.
Save the Children issued a report last month called ``The
Disaster Decade,'' indicating, shockingly, that only seven
States currently require schools and day care centers to
develop comprehensive evacuation and reunification plans. Those
States are Alabama, Arkansas, Hawaii, New Hampshire, Maryland,
Massachusetts, and Vermont.
Local emergency managers and facility owners can do more to
expand planning efforts. States with planning gaps may consider
requiring these facilities to develop plans, as some States
have already done, and obviously the Federal Government has a
role to play.
Another concern raised by the report is the fact that child
care is not eligible for funding under the Stafford Act as an
essential service. I would like to ask and plan to ask our FEMA
Director, Craig Fugate, who is here, to address this in his
testimony, and I understand that he will.
In addition to schools and day care centers, we will also
consider newborn infants and mothers who may be in hospital
wards when disasters strike. According to HHS, an average of 36
babies are born each day in New York City, and in Los Angeles,
the daily average is 416. If an evacuation was called in any of
those cities, you can understand the difficulties of moving
that kind of population, if necessary.
The Senate version of the Homeland Security Appropriations
bill for fiscal year 2010 includes an amendment I offered
encouraging DHS to conduct mass evacuation planning with
States, local governments, and nonprofits, including
monitoring, tracking, and continued care for neonatal and
obstetric patients. Woman's Hospital will be testifying on the
second panel. They executed this function for the State during
the response to Hurricanes Katrina, Rita, and Gustav, and they
have a great deal to share.
I am going to summarize the rest of my statement for the
record because I am anxious to get on to the panel, but let me
just say a few more things.
After the hurricanes, the demand for mental health services
spiked due to increased trauma, depression, and substance
abuse. That was combined with the loss of inpatient beds and
mental health professionals which created a severe gap that
strained medical workers and facilities, host communities, and
first responders.
The LSU Department of Psychiatry screened 12,000 children
in schools in Louisiana during the 2005 and 2006 school year.
Some of the results of that study are startling. Eighteen
percent of them had a family member who was killed in the
hurricane. Forty-nine percent of them met the threshold for
mental health referral. One year later, the rate was lower, but
it was still 30 percent. Twenty-eight percent of displaced
children in Louisiana are still suffering from depression or
anxiety.
The suicide and attempted suicide rates for adults are also
startling. I am going to include those in the record, but some
are reporting that the suicide rates are three times higher
than the national average. [National Average of Adults: 25-64:
14.88 per 1000.000, New Orleans, Louisiana Pre-Katrina: 9 per
100,000, and New Orleans, Louisiana Post-Katrina: 27 per
100,000]. I was struck not only by the number of suicides, but
also the number of suicide attempts. It was something like, if
I remember, 116 people had committed suicide in 1 year, but 750
had attempted suicide.
The Crisis Counseling Assistance and Training Program is
jointly administered by FEMA and SAMHSA. It is intended to
counsel disaster survivors and teach them coping skills. We
obviously need to do a great deal more.
There is a chart that shows the number of Federal programs
that are available,\1\ to support mental health and substance
abuse services for disaster survivors. Basically this is a list
of all the different programs offered through the Federal
Government, grant programs, etc., for this purpose. There are
21 different Federal programs, and three of the 21--Medicaid,
SCHIP, and Head Start--have income eligibility requirements
that limit their ability to provide services in a seamless way
after a disaster. But they are stovepiped, and there is no sort
of comprehensive community delivery system, in my view, in
place right now to cover the extraordinary needs after a
catastrophic disaster that affects a community the way it did
the greater New Orleans area and across large swaths of the
Gulf Coast.
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\1\ The chart appears in the Appendix on page 91.
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The Consolidated Appropriations Act of 2008 established the
National Commission on Children and Disasters to conduct a
comprehensive study and examine children's needs. Mr. Shriver
and Dr. Redlener are both members of the Commission, and we are
pleased to have them with us today to talk about their
recommendations in their testimony later.
I would like to conclude with a quote from Chris Rose, who
was a columnist for the Times Picayune that probably wrote more
extensively on a daily basis about this issue than any person
in the country. He gave the commencement address at Ursuline
Academy a year after the storm, my alma mater high school that
has been in New Orleans for 275 years. ``My daughter was asked
to write about her experiences over the past year when she came
back to New Orleans, and this is what she wrote. `There was a
hurricane. Some people died. Some of them were kids.' My
daughter was six when she wrote that. It just doesn't strike me
as what you would wish for your child to write in her first
grade journal, but there it is. You, all of us, are marked by
life, by what happens. Like it or not, this storm and
circumstances have marked you.''
I think this is a good place to start this hearing because
these are real consequences and lessons from the terrible
catastrophe that happened. We are still struggling with how to
respond better, how to plan better, and how to recover, and the
needs of children are of primary interest to me, and
particularly the mental and emotional needs of the community at
large as we seek to build a better and stronger community.
So with that, let me submit the rest of my statement to the
record.\1\
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\1\ The prepared statement of Senator Landrieu appears in the
Appendix on page 29.
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I would like to introduce the first panel. We have Craig
Fugate, Administrator of FEMA, who has been on the job now for
about 2 months and is already making some very positive
changes.
We have Rear Admiral Nicole Lurie, the Assistant Secretary
for Preparedness, U.S. Public Health, Department of Health and
Human Services. We are happy to have you, Admiral.
And Cynthia Bascetta, Director of Health Care, U.S.
Government Accountability Office. They have issued a recent
report, and we are interested in hearing about that report
relative to the subject.
I will introduce the second panel at the appointed time,
but Mr. Fugate, let us begin with you, and thank you for being
here this morning.
TESTIMONY OF HON. CRAIG FUGATE,\1\ ADMINISTRATOR, FEDERAL
EMERGENCY MANAGEMENT AGENCY, U.S. DEPARTMENT OF HOMELAND
SECURITY
Mr. Fugate. Well, good morning, Chairman Landrieu. I have
submitted my written testimony. I would ask that be entered
into the record and then I have some opening remarks, if that
is OK with you.
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\1\ The prepared statement of Mr. Fugate appears in the Appendix on
page 35.
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Senator Landrieu. That is fine. Thank you.
Mr. Fugate. As a paramedic, one of the things that I was
taught early on in dealing with medical emergencies was that
children are not small adults. That may seem like, duh, but it
points out that not only are the pharmacological needs of
children different, how you would treat certain conditions, it
goes to the whole aspect that an adult, you just don't size
down to a child and get the same outcome. You really have to
focus on children. Their brain development, their mental
capabilities, and their physiology are vastly different from
adults. And so your treatment approach has to be geared towards
a child, not merely taking what you would normally do for an
adult and make it smaller.
And I think that is one of the challenges we have when we
look at planning. Historically, when we look at communities and
we write planning documents, my observation, and I have been
doing this for a while, is we tend to write plans for us, the
adults, people that have a high school education. They speak
English, or they have more education. They have a car. They
drive. They have resources. And they can pretty well take care
of much of their needs. And so we tend to write a plan for that
population.
Then we will go back and go, well, now we have this other
group. They have different challenges. We need to write a plan
for those. So we will come up with a second plan, and a third
plan, and a fourth plan. And that has been our approach.
We are going to try something different. Based on the
concerns that have been raised by the Commission on Children
and Disasters and the GAO reports and the issues you have
raised, we decided to take a different approach in FEMA, and
instead of writing our plan for the adults and then try to
figure out how we deal with everything else, let us write plans
that actually reflect the communities we live in. They have
children. There are people with disabilities. There are frail
elderly. But let us quit putting all these populations in a
special box that we will get to after we get the plan written
and let us do this from the beginning.
So we are going to start with children. As you point out,
there are cross-cutting issues, not only when we talk about
disasters, but just in the daily delivery of service programs,
that oftentimes we do not take advantage of when disaster
strikes. There are many things that, I think if we looked at
children up front, at the beginning, across all the areas, and
we are starting internally with FEMA. But we also want to look
at and work with our partners, because again, as we continue
this journey, as I have completed my second month and look
forward to completing my third, I hope, is FEMA is not the
team. FEMA is part of a team.
I think we have to do a better partnership with our Federal
partners where they have the expertise in how these programs
need to be delivered, the needs that we are going to face,
particularly when it is talking about in this hearing,
children, both from their physical needs as well as dealing
with emotional and mental support so that we reduce that
trauma.
We know that historically in disasters, that in high stress
and the events that children face, the quicker we are able to
get to a sense of providing routine, to intervene early, the
better the long-term outcome is for those children. Well, that
means you cannot just look at what FEMA may be able to bring or
fund, but look at how do we take existing programs that are
already every day in a community and leverage that, and
particularly when we look to our Federal partners, their
expertise in helping us design programs that achieve a change
in outcome, not just merely look at an administration of a
grant program and hope we get where we need to go, but really
get our partners to drive that process of how we need to
structure and put together these programs so we effect real
change.
So we have put together and have worked with Secretary
Napolitano to form within FEMA a working group whose sole focus
is to make sure that throughout FEMA, we are addressing
children issues, from preparedness grants, training,
exercising, all the way through our response and recovery
activities.
And again, we continue to work on these issues, everything
from, some of the issues we ran into with unaccompanied
children, all right, working with the Center for Missing and
Exploited Children to establish a child locator center, working
with some of our programs like Citizen Corps, where we have the
Community Emergency Response Team that now has programs
designed for teenagers to become involved in that. Also working
and looking at how we incorporate this across with our State
and local partners.
The day care centers particularly are a challenge, because
in a hurricane, these are going to be part of the overall--they
are closed down as children are reunited with their parents
before evacuation orders are issued. But an earthquake would
happen during those time frames. We have seen other incidents
that have occurred when children are in school, and we know
that if people don't have good family communication plans and
they don't know what those day care centers and schools are
doing, it can cause a lot of trauma and stress to families as
they try to reunite after a disaster.
So with that, I will conclude my opening remarks and look
forward to the questions, ma'am.
Senator Landrieu. Thank you. Admiral Lurie.
TESTIMONY OF REAR ADMIRAL NICOLE LURIE, M.D., M.S.P.H.,\1\
ASSISTANT SECRETARY FOR PREPAREDNESS, U.S. PUBLIC HEALTH
SERVICE, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Admiral Lurie. Good morning, Madam Chairman, and thank you,
first, for your continued interest in and support of the issues
that we are here to talk about today.
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\1\ The prepared statement of Admiral Lurie appears in the Appendix
on page 41.
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As we are coming up on the anniversary of Hurricane Katrina
and reflect on it, it has been a really good time for us again
to reflect on both the strengths and the gaps that remain in
our National Emergency Preparedness, Response, and Recovery
efforts.
We all know that throughout this, and as you have pointed
out and Mr. Fugate has, that children and their families are
often the most impacted and bear the most long-lasting scars of
this. And let me say, first, having now spent a lot of time in
New Orleans, my heart goes out to all of those who continue to
suffer through all of this.
What I want to do is talk to you today briefly about HHS's
efforts in the last 4 years to address particularly the needs
of children, with the focus, as you requested, on evacuation,
particularly of neonates and obstetrical patients, as well as
mental health.
We all know that preparedness is a critical part of what we
do. We are completely in sync with Mr. Fugate about the need to
plan for the entire community, and a community it is, and
communities are different and we need to plan to their needs.
For that reason, my office has now more than 30 Regional
Emergency Coordinators who are actually on the ground in
communities, sort of the eyes and ears to really know how to
plan exactly for those needs. We know that, in the long run,
this preparedness and planning promotes resilience and enables
communities to cope with the emergencies that come upon them.
So building community resilience is a really important part of
what we do.
By way of example, one of the important programs that we
have gotten underway over the past couple years are
partnerships to really look across the population spectrum, as
we just heard about, and to integrate really at the front end
all of the groups that might be considered in the vulnerable
category, because when you add them all up, there are an awful
lot of the population that is vulnerable, but kids and
pediatric populations often very much rise to the top of the
list.
Other kinds of programs that we have developed in response
to this include training curricula for school crisis teams,
disaster communication messaging, and a lot of work to develop
programs in emotional first aid to early on address those
emotional and mental health needs of children. And it is
important, as we just heard, to do that at a developmentally
appropriate level, and that means across the whole age range of
kids as well as adults.
The National Child Traumatic Stress Network has been really
instrumental in this regard and launched the Psychological
First Aid Field Operations Guide immediately after the
hurricane. We are really proud of the fact that those materials
have now been picked up and adapted throughout the country.
On the response side per se, obviously, during an
emergency, it is critical to support the State efforts to
provide quick and competent assistance to everybody, children
being no exception. The National Disaster Medical System
(NDMS), otherwise, I think NDMS is the primary Federal program
that supports patient care and transfer during this evacuation
of patients. It has both pediatric and obstetric capacity, and
I think since the storms has really worked very hard to upgrade
its training, its material, and its transportation capacity in
this regard. So this ranges from specialized equipment to
transport teams who are really specially trained and capable,
and to be sure that all of our teams now have those special
capabilities involved in them.
In addition, as I think the Pediatric Disaster Coalition
was formed by advocates in Planning Region VI, which includes
New Orleans and the Gulf Coast, and its goals have also been
focused on not only getting people out, but then identifying
the appropriate receiving facilities for these children and
their families and anyone else, and being sure that everybody
knows about them, and that planning is integrated into
community operations plans at every level.
Mental health needs can't be separated from the rest of
other children's response needs, and how we respond early on is
going to really impact the mental health of children and their
families going forward. The Crisis Counseling Assistance
Program, as is an example of collaboration between HHS and
FEMA, as this is administered by the Substance Abuse and Mental
Health Administration, and has crisis counselors routinely
working at all of the places where children congregate.
As a complement, the National Child Traumatic Stress
Network also has a cadre of rapid response teams that can be
mobilized nationally, regionally, or locally after a
Presidential directive.
Recovery is really complex, and I think as we all
appreciate, it has been really sort of under-attended-to until
the storm, and for this reason we are very excited about the
new directions that FEMA is taking and are looking forward to
working on the children's discovery efforts that have just been
described.
HHS also started its own recovery coordination efforts and
now has Recovery Coordinators identified in each district and a
concept of operations that integrates many of these stovepiped
programs, particularly within the HHS family, and we are
continuing to work on building that out.
I think that we have made a great deal of progress in
addressing the needs of children in disasters in the last 4
years. We also have a long way to go, and I think we would be
the first to tell you that.
As we look forward to the future, we have a lot of planning
and preparedness efforts underway. There is terrific research
that has gotten started over the last 4 years. The challenge
now is to take what we learned from that research and translate
it into practice and best practices that are going to help
communities all over the country and on the ground.
We are committed to the highest level of planning,
response, and assistance for recovery for children in emergency
events. We are most appreciative of the important work that the
National Committee on Children and Disasters has done to
highlight these important efforts. I also want to call out the
work of the National Biodefense Science Board, which had a work
group focused very specifically and make recommendations for us
on the important needs and mental health needs of children and
their families going forward, and we are now moving forward to
integrate a number of those efforts, and I think during the Q
and A, I will probably have an opportunity to tell you more
about those things. So thank you very much.
Senator Landrieu. Thank you. Ms. Bascetta.
TESTIMONY OF CYNTHIA A. BASCETTA,\1\ DIRECTOR, HEALTH CARE,
U.S. GOVERNMENT ACCOUNTABILITY OFFICE
Ms. Bascetta. Madam Chairman, thank you for inviting me to
testify today about our recent report on barriers to mental
health services for children in greater New Orleans, and to
update you on our recommendations to FEMA in its efforts to
support States faced with the mental health consequences of
catastrophic disasters. My remarks will be a reminder of why
ASPR and FEMA's commitment to children is so very important.
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\1\ The prepared statement of Ms. Bascetta appears in the Appendix
on page 57.
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As the psychological trauma experienced by so many children
in the aftermath of Hurricane Katrina increased the incidence
of depression, PTSD, risk-taking behavior, and other
potentially long-lasting behavioral and emotional effects. It
is well known that children who grow up in poverty may be at
even greater risk of developing mental health disorders, and in
New Orleans, the slow pace of recovery and the recurring threat
of hurricanes may further exacerbate their trauma.
Against this backdrop, we found persistent barriers to
providing and obtaining mental health services, although
Federal grants are helping to address them. Lack of mental
health providers was identified as the No. 1 barrier to
providing services. HRSA's designation of the parishes in the
greater New Orleans area as Mental Health Professional Shortage
Areas underscored this barrier, and State data showed a large
decrease in the number of psychiatrists and clinical social
workers who received Medicaid and CHIP reimbursement. To help
address this shortage, funding from HRSA and CMS provided
incentives to almost 90 mental health professionals who either
relocated to or decided to stay in New Orleans.
The second most frequently identified barrier was
sustainability of funding. We found that although most of the
Federal grants we identified existed before Hurricane Katrina,
the hurricane-related programs have been a key source of
support for mental health services for children. Much of this
funding is temporary and it is too early to know whether
sustainability can be achieved by these programs.
We also reported on barriers to obtaining services for
children and the top three were a lack of transportation,
competing family priorities, and concern about stigma.
Officials told us that funding from several programs had been
used to provide children with transportation to mental health
services, although none of the programs were designed solely
for that purpose. Examples include Medicaid, the Community
Mental Health Services Block Grant, and the Social Services
Block Grant, as well as SAMHSA funding.
Similarly, block grants and disaster housing assistance
program funds were used to help families struggling with
housing, unemployment, and other expenses. There was also
Federal support for case management and referral services
designed to help families locate and obtain mental health
services for their children, although we found a lack of
continuous and reliable funding for case management.
Stigma, as well as transportation and competing family
priorities, was addressed by the use of Federal funds to
support services delivered in schools. During the 2007-2008
school year, nine school-based health centers were operating
and at least four more were in the planning stages. The
advantages of the school settings are that, first, it is not
obvious that students are receiving mental health services;
second, the transportation problem is solved; and third, the
financial burden on the family is reduced because parents don't
have to take time off from work and the services are offered at
low or no cost.
Stigma can also be reduced by media campaigns, including
the one run by FEMA and SAMHSA's Crisis Counseling Program
(CCP). We made recommendations to FEMA in February 2008 to
improve this program by revising its reimbursement policy to
pay for indirect costs, as it does for other post-disaster
response grant programs, and by determining what types of
expanded crisis counseling services should be incorporated into
CCP. Expanded services would provide more intensive services,
especially in the aftermath of a disaster, when provider
availability can be limited. And FEMA and SAMHSA have allowed
the States to develop pilot programs along these lines.
The Department concurred with our recommendations, but has
not yet implemented them. FEMA also recently concurred with
additional recommendations we made to expedite and improve the
effectiveness of its case management services. Taking these
actions expeditiously before the next disaster would improve
services for children and their families as well as for all
adults.
That concludes my remarks.
Senator Landrieu. Thank you very much.
I would like to call attention, before I get into the
questions, to two charts that I think are very telling.\1\ The
first is to my left, your right, and you will see the green
lines or bars are mental health resources in New Orleans in
August 2005. So starting from the left, emergency rooms in New
Orleans, 9; psychiatric beds in New Orleans, 350; psychiatric
beds in greater New Orleans, 668; and then physicians in New
Orleans, 617; psychiatrists in New Orleans is the next bar,
196; and number of New Orleans doctors participating in
Medicaid, 400.
---------------------------------------------------------------------------
\1\ The charts submitted by Senator Landrieu appears in the
Appendix on page 93 and 95 respectively.
---------------------------------------------------------------------------
Now, when you go to the orange, which is 2 years after the
storm--you would think you would be well on your way to
recovery 2 years after the storm. We are going into the fourth
year. But 2 years after, in 2007, instead of having 350
psychiatric beds, we had 77. Instead of 617 physicians in New
Orleans, we had 140. Instead of 196 psychiatrists, we had 22.
And instead of 400 doctors participating in Medicaid, we had
100.
Now, just this one chart shows that there is something
terribly wrong with the system of support at either the local,
the State or the Federal level, for shoring up the core of
mental health stability in a community. It is one thing when
you don't have access to mental health because of lack of
funding. If you don't have the professionals to deliver the
services, you could just start with this chart and work
backwards from there. You don't have enough physical beds. You
don't have enough professionals, etc. This is 2 years after the
storm, when you would think that people would be really trying
to return after a catastrophe. This isn't 4 years. This is 2
years.
And the trauma that occurs in a community struggling with
limited services--I want to call your attention to this next
chart I would like you to put up.\1\ This is the child care
center situation as of August 2007, and there are a couple of
pretty startling graphs here. Again, this is 2 years after the
storm. Hundreds of thousands of people have fled to Houston and
Atlanta. They are trying to get back. A year has passed. Their
neighborhood has finally been cleared of debris. They are
coming back to try to build their life, and this is what they
find 2 years after the storm.
---------------------------------------------------------------------------
\1\ The chart referred to by Senator Landrieu appears in the
Appendix on page 95.
---------------------------------------------------------------------------
The blue graph is the number of child care centers in the
greater New Orleans area that were open before Hurricane
Katrina, 275. The green is the marker of August 2007, is 100.
In Jefferson Parish, that wasn't as affected, it was 197, and
then it was, I think, down to 170.
But this is interesting, very interesting to me. In St.
Bernard, which is the small little bars on the side, St.
Bernard was a parish of 67,000 people that was virtually
completely destroyed. Only five homes survived in the whole
entire parish. Before the storm, there were 26 day care centers
in St. Bernard Parish, a very tight-knit, middle-class,
working-class community. Two years later, after all of our
combined efforts, which obviously weren't enough, they only had
2 day care centers open--two in a parish that was completely
destroyed.
Now, if we are asking parents to return and rebuild their
communities, how is it possible for parents to do that if they
only have 2 day care centers in the whole parish? What do they
do? Do they strap their children on their backs while they gut
their homes? Or do they bring their children in and let them
sit while the parents gut their homes and they can play in the
dirt and the nails? I am not understanding how we think that
the system that we have is appropriate in any way, shape, or
form.
So I could show you the statistics 4 years out from the
storm, but this really grabbed me when I saw that after 2 years
of all of our efforts, there were 2 day care centers open in
St. Bernard Parish.
Mr. Fugate, how is FEMA working to provide safe places for
children, whether it is schools or day care opportunities,
while parents are struggling to rebuild their communities after
a catastrophic disaster, and what would some of your comments
be about what you have heard this morning?
Mr. Fugate. Chairwoman, Mark Shriver, who currently chairs
the National Commission on Children and Disasters, I think he
was probably one of my first meetings after I was sworn in, and
laid out the concerns and issues, many of which you have laid
out, and asked the same question. What is FEMA going to do
about it?
The easy answer would have been to put another box in there
and say, we will write a plan for children and that will
satisfy everybody's concerns. However, I didn't think that was
going to do real change. And so as we talked with Mark and we
talked with members of the Commission and we had an opportunity
to go to one of the Commission meetings, I kept asking, we have
historically looked at special populations as special as an
afterthought, and I said, let us try something different. And
maybe it is just semantics, but I have got to try this.
Why don't we write plans for the community and quit writing
plans for just one part of the community, the people that can
pretty well take care of themselves, and really look at what
are the needs of the community. And as you point out, my
experiences in the 2004 hurricanes, one of the first things we
really pushed hard to do was to get things like the pre-K and
schools open, and there were several reasons for that.
One is we recognized the stress to children going and that
we did not have the resiliency in the mental health community
because they were impacted like the rest of the facilities. All
three hospitals in Charlotte County were shut down. And we knew
that if we could get schools open, we could bring counselors to
the schools and start working with children. It wasn't that we
wanted schools back to normal. We just wanted to get them open
to get children back into an environment that would get them
into a routine that would both get them a chance to start
dealing with this, but also give their parents a chance to deal
with what had happened with their children somewhere safe.
The challenge has always been when you get into day care
that it depends upon States and localities, but that can be a
quasi-state function, local function, or a private investor-
owned, and the Stafford Act, again, historically has been
looking at what government's responsibilities have been when
you look at reimbursement and programs.
So we are working with the Commission, and their report, we
are saying, we don't have time for the report. We need to--as
soon as you guys have identified this, how do we go back in
FEMA and look at the Stafford Act, look at grants, look at
program guidance, look at training, to start encouraging and
recognizing that children from in the home--again, you cannot
just do one for all children. You have to really look at them
developmentally from infants up through a certain age and
different grades. How do we change what we have been doing so
that if disaster strikes in the future, we are addressing these
issues?
Senator Landrieu. OK, and I appreciate that comprehensive
look and I think it is important. That brings me to your other
point when you said FEMA is a partner in this effort. Yes, I do
believe that FEMA is a partner, but I would say that FEMA is
the leader. FEMA should be the experts on disaster with your
other Federal partners. FEMA should be the driver. FEMA should
be the motivator, the communicator.
I mean, I look at FEMA and Homeland Security as not being
the only entity that responds after a disaster, but being the
lead entity that helps to coordinate and manage your other
Federal partners, gives guidance to your State and local
partners, provides technical assistance and support to the
private sector. But I wouldn't just say that FEMA is just any
old partner. FEMA is the lead.
Two, when we talk about day care centers, part of this is,
you are right, some of them are nonprofit. And some of them are
for-profit. But a good plan that would make sure that Head
Start teachers and early childhood education teachers and
counselors are part of that first responder team coming back
from rebuilding, loans from the Small Business Administration
to make sure that these day care centers can get the loans they
need.
And think about how difficult it is for a for-profit day
care center operator under our current laws and current
requirements to get a $200,000 loan to reopen a day care
center. Any bank or even under any regular system would look at
her and say, why are you opening a day care center? There are
no children in your parish. And she says, ``Well, we will never
have children in my parish unless I open and provide a space
for them.'' But she is not--or he is not, whoever is running
the center--is not deemed creditworthy, or their business plan
is ``not viable.''
Well, that is true on its face, but that is where the
Federal Government has to step up and say, under normal
circumstances, you wouldn't lend this person $200,000 to open a
day care center where there are no children. But under this
plan, under a disaster response plan, we are going to require
you, basically, to lend the money at a lower interest rate and
extend out the repayment, or if you don't get a day care center
back in this parish, you are not going to have a parish back
because there have got to be safe places for children in order
for parents to return.
And I would submit another thing that is all
interconnected, and I think, Mr. Fugate, you have hit the nail
on the head. But when we are trying to encourage doctors to
come back, we have lost many doctors, we think of them as
doctors. We don't think of them as parents. Most of them are
probably parents with children. They can't come back if there
is not a day care center or a school for their children.
So all of our efforts to rebuild our community are really
spinning our wheels if that plan, as you said, Mr. Fugate,
doesn't have at its essence rebuilding safe places for
children, which represent not only a special population, but a
central population to the families that we need to rebuild, I
guess is my point. And I just think that has really been
overlooked.
They said there has been a vote that has been called, and
unfortunately, because I am here by myself, I am going to need
to probably call a brief recess and come back. But if the
witnesses could remain on hand, I am going to go vote and then
we will reconvene. I have a few more questions for the
panelists, and then we will move probably right at 11 o'clock
or a little bit after to our second panel.
Thank you, and the Subcommittee will stand in recess.
[Recess.]
Senator Landrieu. Thank you all for your patience. Our
meeting will now resume.
I have just a couple of questions, and because of the time,
I am going to submit the rest of them in writing. But let me
just ask again, Mr. Fugate, you have heard the GAO
recommendations for FEMA to modify program rules to allow
reimbursement of indirect costs and consider expanded services
when it comes to mental health counseling. How did you receive
this recommendation and what are your plans to implement it,
and if not, what will you do as an alternative?
Mr. Fugate. Senator, we received them favorably, and this
is prior to my arrival. We have been working with HHS to go
through the implementation. We are, I believe, getting to the
point of finalizing those and then sending those back out for
final comment so we can go forward. Again, but we did receive
these recommendations favorably. We are working to achieve
that, and those are things that are still in process.
But I think it goes back to earlier when I said we are part
of the team. On behalf of the Secretary and the President, my
job is to coordinate all the Federal family when a governor
requests and receives disaster assistance. But part of that is
recognizing that subject matter expertise in existing programs
have to be part of that response, and that is what I was
referring to as we are part of that team, is I don't think FEMA
has done a good job of understanding and working with our
partner agencies to leverage all their programs and we have
defaulted oftentimes to merely the Stafford Act, which may be
appropriate in some cases but may not be the most effective way
and doesn't build upon the existing expertise in programs that
are already in a community.
And that is again why we are going to use this Children's
Working Group to step back from our traditional, what I call
the FEMA-centric approach that is always focused on the
Stafford Act, and really look at what all the Federal family
has and do a better job of leveraging those resources as a team
so that we know where the expertise is, where core competencies
exist, and again, with HHS and the programs they have dealing
with mental health issues, particularly designed for children.
Then how do we leverage the Stafford Act so that we are,
again, as you show these charts, not having the locals and the
State have to go through and figure out who has got what, but
we can present a program that focuses on outcomes, and in this
case, particularly focus on the outcomes from children as the
Federal family, working under that authority that the President
has vested in FEMA, to support a governor and those local
jurisdictions.
Senator Landrieu. Well, I agree with that, and I think your
analysis that it has been a FEMA-centric approach and it needs
to change to where FEMA is the lead of the team, marshaling the
other forces, coordinating, being the link and designing the
programs, not necessarily assuming responsibility to deliver
them all, but to have them delivered through partnerships.
One more question and then I have a few others. In November
2005, I led the effort, along with Senator Kennedy and Senator
Enzi--and without the support of these two Senators, I have to
say publicly, it never would have happened. But Senator Kennedy
and Senator Enzi led a one-time unprecedented effort to
establish basically a plan for the 300,000 children that had
been displaced from the storm in the week of August 29, which
is approaching soon, to try to find them a school somewhere in
America where they could start school on a Monday, the
following Monday, because children that are out of school for 2
or 3 weeks sometimes have to skip a whole year. And under their
extraordinary leadership, this plan was implemented and
basically provided vouchers for up to 300,000 children to
attend school for that year. And as a result, the Katrina Class
graduated, many of them.
This was one time, though. Mr. Fugate, are you going to
recommend a continuation of this approach, and if so, how, and
if not, what plan is going to be put in place the next time a
catastrophic disaster happens?
Mr. Fugate. Well, again, that is some of the issues we want
to raise with our Children's Working Group. In Florida, our
experience was that as many of the families--I think when we
looked at the FEMA registration, we ended up with about 25,000
families that had come to Florida. They weren't part of any
directed evacuation, either through churches or family
associations or just coming to Florida. We were able to make
decisions in the State of Florida pretty matter-of-factly that
any of these folks that had children that were school-aged that
wanted to go to school would enroll. We did that through our
State Department of Education.
And again, we did this across the board, realizing that at
some point, we would have to look at how we would come back to
our Federal partner agencies that provided funding and get
funding. We didn't want to take money away from the State of
Louisiana, but we did recognize that many of these would be
additional burdens for our local taxing authorities and how we
do that.
And I think that is one of the things that we want to come
back and go over, what is the best mechanism, so if a State has
children coming into their State, or a jurisdiction has
children coming in from outside of where the taxing base was
at, how do we provide that assistance without------
Senator Landrieu. Well, I would suggest, respectfully
suggest to you, look at this program that seemed to work
amazingly well. And again, it was a very simple voucher
program, up to $7,500 as I recall worth of the cost of a
Catholic school tuition, whether children left a private school
to go to public or public school to private or Catholic school,
because you have to have a program that snaps into place within
the first week of the disaster, if it is a catastrophic
disaster and it is obvious after a few days of analysis that
there are no schools to come back to. You have got to have a
button you press and this program operates.
Right now, as I understand it, although Senator Kennedy and
Senator Enzi put this in place for Hurricanes Katrina and Rita,
it was one time and it is not in place today. So if another
catastrophic disaster happens this summer and either Texas or
Mississippi or Alabama is hit and hundreds of thousands of
children are displaced, as they were after Hurricane Katrina,
we have to start all over again and get an Act of Congress to
give people a back-up plan in the event that their school is
destroyed.
So I only raise this to say that while we have done a lot
of talk and we have had some actions, there are so many other
steps that need to be taken.
One more question to GAO. The GAO recently released another
report, as you mentioned, on disaster case management programs.
Case managers are meant to help their clients find job
training, permanent housing, relief supplies, access to
critical services. Particularly after a disaster, case managers
can be extremely helpful in trying to make sense of things,
trying to identify the programs that are still operating and
out there and making them real for clients.
What in your study could you share with us about the need
for case managers? Did we have enough on the ground? How did
the case management program work generally? I think you
testified to this. Could you elaborate just a moment?
Ms. Bascetta. Yes, I can. Overall, because of the chart
that you showed with the multiplicity of funding streams, case
management is really important. It is very difficult for
families, especially low-income families or families under
stress, to try to figure out how they themselves can put
together the package of services that they need to stabilize
and to regain their self-sufficiency.
We had two major findings. One was, as we found in the
mental health area, there was a significant lack of case
management providers and also limited referral services. This
links back to the fact that if there aren't enough providers in
the area, there is nobody to refer people to.
The other major concern was sustainability of funding and
breaks in funding. There was one situation in which a Federal
program was about to make a handoff to the State. The State
program wasn't up and running yet. So there was about a 2-month
gap in case management services when families were unable to
access anything at all.
Senator Landrieu. Access anything whatsoever.
Ms. Bascetta. That is correct.
Senator Landrieu. And I also understand that Catholic
Charities, which is a very reputable and large and capable
nonprofit, stepped forward to provide case management. But
under the current law, they were not allowed to recoup indirect
costs. So as a result, they were basically losing money as a
nonprofit trying to deliver services for the Federal and State
Government. Is that your understanding?
Ms. Bascetta. I am not sure I have the details of the
situation you are describing. I do know that Catholic Charities
had dropped out as a provider of crisis counseling services
because they weren't able to recoup their indirect costs, and
this was part of the reason--part of the basis for our
recommendation to expedite that reimbursement under FEMA's
rules.
Senator Landrieu. OK. Thank you all very much. I am going
to ask the second panel to come forward. I really appreciate
your participation this morning and look forward to continuing
to work with you.
As the second panel comes forward, just to save time, let
me begin to introduce them.
Our first witness will be Mark Shriver, who served as the
First Chair of the National Commission on Children and
Disasters since July 2008. The Commission authorized under the
Consolidated Appropriations Act of 2008 is tasked with the duty
to conduct a comprehensive study that examines children's needs
as they relate to all hazards and evaluate existing laws,
regulations, and policies and programs relevant to the needs of
children during and after a disaster. He is also Vice President
and Managing Director of U.S. Programs for Save the Children.
He served as a member of the Maryland House of Delegates and is
not new to this subject. We are pleased and honored to have Mr.
Shriver with us today.
Dr. Redlener also serves on the National Commission on
Children and Disasters. Dr. Redlener is the President and Co-
Founder of the Children's Health Fund, which works to educate
the general public about the needs and barriers to health care.
I want to say on a personal note, he really stepped up after
Hurricanes Katrina and Rita, working through Senator Clinton's
office at the time, to give tremendous support and
encouragement to us along the Gulf Coast and we are grateful,
Doctor, for your help and support.
And finally, Teri Fontenot, President and Chief Executive
Officer of Woman's Hospital in Baton Rouge. Ms. Fontenot
assumed this position in 1996 after serving as a Health Care
Finance Operations Executive in Louisiana and Florida. She
chairs the Louisiana Hospital Association Malpractice and
General Liability Trust and is leading one of the finest
hospitals, in my view, in Louisiana, with expertise in birthing
and maternity for 8,500 mothers and children every year and is
the designated hospital in Louisiana to coordinate disaster
response for neonates, which is a very special group of infants
that we need to focus our attention on, during a disaster.
But let us start, Mr. Shriver, with you. Thank you very
much.
TESTIMONY OF MARK SHRIVER,\1\ VICE PRESIDENT AND MANAGING
DIRECTOR OF U.S. PROGRAMS, SAVE THE CHILDREN, AND CHAIRPERSON,
NATIONAL COMMISSION ON CHILDREN AND DISASTERS
Mr. Shriver. Thank you very much, Madam Chairman, for
hosting this hearing and for your interest in this issue. I
have submitted a longer report, and frankly, you said most of
the things that I was interested in saying and points to try to
get across.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Shriver appears in the Appendix
on page 67.
---------------------------------------------------------------------------
Just for the record, I am Mark Shriver, Vice President and
Managing Director for Save the Children's U.S. Programs, and
Chair the National Commission on Children and Disasters. I just
want to summarize, Madam Chairman, and just say a couple of
quick facts.
The bottom line is that children are 25 percent of the
population, yet this Federal Government and State governments
and really all across the board, we have spent more time and
energy and money focused on the needs of pets in disaster
planning response than we have on kids. That is 25 percent of
the population has received less time and focus and resources
than pets, and I think that for this country in this situation,
that is absolutely outrageous.
Kids, as we all know and as you have eloquently said, Madam
Chairman, are lumped in under at-risk, vulnerable, or special
needs populations, and as Mr. Fugate just said, I think what he
is proposing to do at FEMA through the efforts over there are
really an exciting first step in the right direction, to try to
address children's needs in a comprehensive and an effective
manner rather than just creating window dressing, as he already
has said.
A little background on the Commission, Madam Chairman. We
had our first meeting last year. Our interim report is due in
October of this year. Our final report is due to Congress and
the President in 2010. We have had a field hearing in Baton
Rouge where Dr. Redlener joined me down there, as well. We have
engaged a large community of entities to gather information and
try to assess where there are gaps in the services, and those
folks are not just Federal Government, State, and local
government, but nonprofits, as well.
I do just want to comment again that what Administrator
Fugate has started at FEMA is very exciting from the
Commission's perspective and from Save the Children's
perspective and I just want to say a couple of quick words on
child care.
You have already had the Save the Children report up there,
but the issue is critically important, not just from a kids'
perspective, which obviously is, I think, paramount, but the
fact is that following a disaster, if you don't have child care
facilities, you have a loss of economic opportunity, as you
have already eloquently stated it. Save the Children's Disaster
Decade Report, which is up there, shows that only seven States
meet the basic requirements for licensed child care providers
to have basic written emergency plans in place addressing
evacuation, reunification, and accommodating children with
special needs. Seven States in this country have the basic
minimums in place. That, too, I think is absolutely outrageous
and should be addressed through--can be addressed through
Federal legislation, and some of the steps that we are
proposing are in my written statement, Madam Chairman, but I
will just highlight a couple of them.
Mr. Fugate talked about the Stafford Act and the importance
of creating child care or saying that child care can be deemed
an essential service. Clearly, we are very supportive of this
concept. We think that funding is necessary for the
establishment of temporary emergency child care and recovery of
child care infrastructure.
The Child Care Development Block Grants are being
authorized, Madam Chairman, as--and we would propose that
during that reauthorization--that State child care plans
include guidelines for recovering temporary emergency child
care operating standards after a disaster, that be made a
requirement, and that States also are required to have child
care providers have comprehensive all-hazard plans that
incorporate specific capabilities such as shelter in place,
evacuation, relocation, family reunification, staff training,
continuity of services, and accommodation of children with
special needs. The Federal Government has the ability to put
these requirements in the Child Care Development Block Grant
reauthorization and we encourage you to look into that, Madam
Chairman.
I know time is of the essence, so I will just wrap up by
saying that a lot of the ideas that you and your staff have
been working on and mentioning today are critically important,
and I would only encourage you, as the Chair of this Commission
and as a member of the nonprofit community, to follow up, to
follow up, and to follow up again. If you don't hold everyone's
feet to the fire, kids, because they don't vote, and
particularly poor kids, are not actively engaged in the
political process. You are their voice, and if you do not stand
up and your staff doesn't follow up diligently with all levels
of the government, they will, unfortunately, suffer from benign
neglect, which is what David Paulison told me has been the
modus operandi in the past, and that benign neglect, I don't
think, is the way that this country should be acting for poor
children and especially vulnerable poor children across the
country.
So thank you, Madam Chairman.
Senator Landrieu. Thank you, Mr. Shriver. I appreciate it.
And I want to note for the record that Administrator Fugate
has stayed for the second panel and I would like that to be
noted. It is important to me that he didn't testify and leave,
but he is staying to hear these comments and I appreciate it.
Thank you, Mr. Fugate.
Doctor Redlener.
TESTIMONY OF IRWIN REDLENER, M.D., PROFESSOR,\1\ CLINICAL
POPULATION AND FAMILY HEALTH, AND DIRECTOR, NATIONAL CENTER FOR
DISASTER PREPAREDNESS, MAILMAN SCHOOL OF PUBLIC HEALTH,
COLUMBIA UNIVERSITY, AND PRESIDENT, CHILDREN'S HEALTH FUND
Dr. Redlener. Thanks, Madam Chairman, and again, I just
want to echo our great appreciation for you holding these
hearings and learning more about this terribly difficult
problem that we are facing.
---------------------------------------------------------------------------
\1\ The prepared statement of Dr. Redlener appears in the Appendix
on page 71.
---------------------------------------------------------------------------
So I am a pediatrician, as you noted. I am President of the
Children's Health Fund, but I am also Director of the National
Center for Disaster Preparedness at Columbia University, and I
have the honor of serving on the National Commission and chair
there the Subcommittee on Human Services Recovery.
By way of background, shortly after Hurricane Katrina, and
working with local officials, we dispatched seven of Children's
Health Fund's fully contained mobile pediatric clinics and
professional teams to the Gulf to provide acute medical and
mental health care for survivors and evacuees, and eventually
those became permanent programs which are still there in the
Gulf, in Mississippi and Louisiana, affiliated with LSU,
Tulane, and other institutions. But to date, for the record, we
have seen over 60,000 health and mental health encounters in
children.
In addition to that, the National Center, my Center, has
conducted long-term periodic interviews with a cohort of 1,000
families, and I just want to summarize a couple of the key
points out of many that I think are germane to our discussions
today. This comes from our clinical information and our
studies.
So more than three in five parents have felt now, over
time, that their general situation currently is either
uncertain or significantly worse than it was before Hurricane
Katrina.
Second, approximately a third of displaced children are at
least one year older than appropriate for their grade level in
school.
Third, according to interviewed parents, more than two-
thirds of children displaced by the hurricanes are experiencing
emotional or behavioral problems as we speak, and in a study
last fall of our program in Baton Rouge, 41 percent of children
were found to have iron deficiency anemia, a third had impaired
hearing or vision, and 55 percent were reported to have
behavior or learning difficulties.
And as far as the overall situation for children is
concerned, and to give some sense of scale, I believe that the
number of disaster-related excessively vulnerable children
right now, 4 years after Hurricane Katrina's landfall, is
unacceptably high, with some 17,000, at the minimum, to, in my
opinion, over 30,000 children still in limbo and still at
substantial risk. In fact, many children who are now developing
chronic emotional problems or who are failing in school will
not easily recover. We are undermining not just their current
well-being, but their future potential, as well.
In my opinion, the overall management of the recovery
process from the hurricanes in the Gulf, while less visible
than the images seen around the world of people waiting on
their rooftops for rescue, has been more mishandled than the
initial response to the disaster. The extraordinary failures of
recovery and the persistence of trauma and profound disruption
to children have been far more insidious and invisible than the
acute situation.
Unfortunately, the failures of recovery have lost the
attention of the media, for the most part, the public, and, I
am sorry to say, perhaps many in government, as well.
The basic concept of long-term recovery is fraught with
confusion and lack of leadership on every level. There is a
lack of clarity of what we even mean by the term recovery. That
is, are we talking about rebuilding physical environment or
working to help families reestablish conditions of normal life
as rapidly as possible?
Although a National Disaster Recovery Strategy was mandated
under the Post-Katrina Emergency Management Reform Act of 2006,
that strategy has yet to appear. That said, I believe that
under new and highly motivated and capable leadership now at
DHS and FEMA and HHS, we are hopeful that we may soon see the
emergence of this critical road map.
Until very recently, there has been no apparent recognition
that the needs of children must be understood and absorbed in
all aspects of disaster response, planning, mitigation, and
recovery, and we think this is changing, as well, as Mr.
Shriver was just pointing out.
But perhaps most egregious of all, there is a growing
sense, and I consider it a monumental misunderstanding, that
recovery from large-scale disasters is a local problem to be
solved and managed by States and local jurisdictions. But the
destruction at the level we saw in the Gulf post-Hurricanes
Katrina and Rita and the flooding of New Orleans was and
remains a national problem. The well-being of the affected
States is highly material to the well-being, the economy, and
indeed the security of the United States.
So I want to just conclude with a few general
recommendations, and then a couple of points just to emphasize
what Mr. Shriver was saying about children. So in general--I
have dozens of these, but let me just hit three of them.
Senator Landrieu. That is OK. Take another minute or two.
We appreciate it.
Dr. Redlener. So, first of all, the National Disaster
Recovery Strategy must be completed as rapidly as possible, and
preferably, were I you, I would ask for that by the end of this
calendar year. There is absolutely no reason why that needs to
be delayed any more than that, and if we don't have that, we
are going to be still flailing around and trying to understand
who is doing what for whom in the issue of long-term recovery.
Second, I would strongly recommend a high-level directorate
reporting to the President that needs to be established to
oversee and coordinate all relevant Federal assets and agencies
with respect to long-term recovery. I mean rebuilding, and I
also mean revitalizing, sustaining, and protecting the needs of
children and families during this terrible, difficult
transition.
Third, recovery must be seen as responding at every level
to these human services needs during the recovery transition,
and we would like to see how this National Recovery Strategy
actually addresses them.
And then some of the other issues around children which
represent, to me, the most dangerous problem that we are facing
right now, because as I said before, the problems will not be
sometimes at all reversible. Children that lose a year or two
in school cannot be recaptured in terms of their academic
success. Emotional problems rooted in 4 years of trauma--and by
the way, we think it will take another 2 years to get everybody
housed, if, in fact, we have housing available--those children,
we ignore at their peril and our peril.
So I have been thrilled to be on the National Commission
with Mr. Shriver and here are a couple of things I would just
point out.
The National Recovery Strategy, when it develops, should
have an explicit emphasis on safeguarding the health, mental
health, and academic success of displaced children. This
addresses the point you raised before. It cannot be ad hoc. It
has to be part of our basic understanding about how we deal
with recovery for this disaster and anything else that happens
in the future. It may be a storm in the Gulf. It could be
terrorism in New York. It could be an earthquake in San
Francisco. We don't want to be redoing this and we need that
road map.
Second, the Federal Government must assure a robust,
uniform, and accountable case management program for every
child displaced by a major disaster. I don't have time to go
into it, but I had to medicate myself in order just to absorb
the complexity and dysfunctionality of what our country called
case management in the aftermath of this disaster. It is
shameful.
And third, I would say that the health, dental, and mental
health services for every displaced child should be assured and
funded under a ``medical home'' comprehensive care model. And
again, this is because somebody has got to take responsibility
for not permitting children to fall through the cracks. They
can't afford the delays and the interruptions in their safety
net.
So I think I am going to leave it at that and would be
happy to respond to any questions. But again, our profound
gratitude to you, Senator, for taking and keeping the
leadership on this vital issue.
Senator Landrieu. Thank you, Doctor Redlener. Ms. Fontenot.
TESTIMONY OF TERI FONTENOT,\1\ PRESIDENT AND CHIEF EXECUTIVE
OFFICER, WOMAN'S HOSPITAL, BATON ROUGE, LOUISIANA
Ms. Fontenot. Madam Chairman, it is a privilege to come
before you today to describe our hospital's response to the
evacuation and care of critically ill patients in the horrific
aftermath of Hurricane Katrina, our preparations for Hurricanes
Rita, Gustav, and Ike, the important lessons learned, and our
recommendations for emergency management and medical treatment
of neonates.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Fontenot with an attachment
appears in the Appendix on page 77.
---------------------------------------------------------------------------
Woman's Hospital is 70 miles northwest of New Orleans and a
2-hour drive from the Gulf Coast. Hospitals are usually a place
of refuge rather than a complex evacuation site, so the need to
evacuate one or a whole city of hospitals had not been
considered. But in the catastrophe of Hurricane Katrina,
Woman's Hospital did just that, by evacuating 122 infants from
flooded hospitals in New Orleans in 4 days.
Working with our heroic colleagues in New Orleans under
unfathomable conditions, not one transferred baby or mother
died. Unquestionably, this remarkable achievement was the
result of dedication and hard work by thousands of people, not
because of carefully crafted and effective planning.
In fact, the chaos was overwhelming. Blackhawk helicopters
brought men, women, and children day and night to our hospital.
We received, stabilized, and transferred many patients to other
facilities. But the most critically ill infants and women
remained at Woman's Hospital. For a month after Hurricane
Katrina, we cared for twice the usual number of critically ill
infants and delivered 150 babies from the affected areas. For
several days, there were 125 infants in our 82-bassinet
neonatal intensive care unit. We also received and provided
care for over 1,100 other patients and worked with area
churches to provide shelters for 110 newly delivered mothers
and families because they were rejected at government-run and
Red Cross shelters.
What began as a rescue became a response to their
overwhelming needs beyond medical care. This feat was
successful because of our incredibly dedicated staff and
expansion to our neonatal intensive care unit that was
completed just weeks before Hurricane Katrina, and a drill held
early in 2005 that yielded valuable information about needed
equipment and processes. Fortunately, the rescue was adequate,
but coordinated planning by all agencies involved could have
vastly improved the response.
Hurricane Rita came 3 weeks after Hurricane Katrina. For
Hurricane Rita and each storm since that time, neonates and
high-risk obstetrical patients were evacuated to Woman's
Hospital from hospitals before the storm, a key lesson learned.
In early 2006, providers of obstetrical and neonatal
services throughout Louisiana convened and produced a plan for
emergency management of neonates. We also contacted neighboring
States to discuss evacuation, especially if Baton Rouge became
the disaster site, since no other hospital in our State has the
capacity to take our large number of NICU patients. We took
part in research with Tulane University to study the effects of
the stress of the storms on maternal and infant outcomes, and
we are the officially designated provider for infants in
Louisiana's Medical Institution Evacuation Plan. In short, we
are committed to anything and everything that will prevent the
chaos of Hurricane Katrina.
Hospitals in Louisiana have strengthened their
infrastructure and plan to shelter in place, with the notable
exception of especially fragile patients, such as ill newborns.
Those hospitals still depend on us to transport and care for
their patients.
Woman's Hospital's performance after Hurricane Katrina and
the three hurricanes since that have threatened the Louisiana
coast demonstrate that an expert organization with adequate
capacity is critical for the emergency management of certain
populations of fragile patients. The expert hospital is the
coordinator of care and has capacity to care for displaced
infants. Named Operation Smart Move, it is an initiative to
ensure that infants and mothers throughout the Gulf Coast have
a safe place, as well as a network of care and services to
mitigate the devastating stress and overwhelming anxiety of
recovery.
A remarkable opportunity exists to further implement these
concepts as we build a replacement hospital. Surge capability
was included in the original design, but was removed due to the
high interest rates on tax-exempt debt and deep Medicaid cuts
to hospitals. Building stand-by and surge capacity is now
unaffordable for us and most hospitals, even though the
hospitals in Louisiana have counted on us three times in less
than 4 years to fulfill this need. Financial support for the
capital and stand-by costs for hospitals to be ready at all
times is critical for proper disaster preparedness.
The relocation of our hospital to a new campus will provide
a unique learning opportunity. Representatives from hospitals
like Woman's from across the Nation will participate in a real-
time evacuation drill as our NICU is moved from one campus to
another.
Another recommendation is the amendment of the Stafford Act
so that private organizations will qualify for reimbursement of
costs associated with evacuation. Many private organizations
assist or replace governmental agencies before, during, and
after disasters, yet are prohibited from directly receiving
FEMA funds.
Your concern about the impact of disasters on children is
appropriate and important. On behalf of the staff of Woman's
Hospital, we are honored to share our experience and knowledge
to improve the response and care of our most vulnerable
citizens.
I will close with a special thank you for your ongoing
support of Woman's Hospital, Operation Smart Move, and the
opportunity to speak today, and I look forward to answering any
questions. Thank you.
Senator Landrieu. Thank you very much, Ms. Fontenot. We
appreciate your leadership. You continue to make this Senator
very proud of the work that you are doing.
We will only have one question for each of you because of
our time limitations. Let me, Ms. Fontenot, start with you, if
you could just restate two points for the record. One, despite
the fact that your hospital did such extraordinary work in the
storm, could you say again for the record what the current law
allows you to get in terms of reimbursement? I understand that
you are a private facility, so therefore while the government
depended on you to help in so many ways, that you are not in
line for any reimbursement. Could you explain that just a
moment?
Ms. Fontenot. My understanding is because we are not a
governmental agency, that we are not able to receive funds
directly from FEMA, that we have to have a contract with the
State for any type of service that we provide and it goes
through the State as the fiscal intermediary.
Senator Landrieu. And could you talk a minute about the
surge capacity issue, because as we debate the health care bill
and how we may reshape the health care delivery system for the
country, I think this would be important. So again, if you
could just comment about the lack of surge capacity.
Ms. Fontenot. Thank you. Most hospitals are faced with cuts
because of inadequate reimbursement, and particularly Medicaid,
which, of course, that is the primary payer for children and
particularly infants. Sixty percent of the babies in our NICU
are covered by Medicaid. Half of the deliveries in our hospital
are covered by Medicaid, and two-thirds are covered in our
State by Medicaid.
So whenever there are Medicaid cuts, as there have been
announced just this week in Louisiana, and, of course, that is
being repeated around the country, hospitals are not able to
provide the financial support for additional beds to be on
stand-by, or equipment or supplies or planning or any of those
things. Any reimbursement they receive has to go directly for
the core medical services, and that is taking care of those
babies that are in the hospital that day without being able to
have anything on the side, so to speak, so that we can be surge
hospitals, or expert hospitals, for that matter, because it is
very expensive to have the planning and the drills and that
sort of thing.
Senator Landrieu. Thank you very much.
Mr. Shriver, let me ask you if you could sum up, besides
the excellent recommendation that a strategy be enacted by the
end of the year and a requirement put down to receive that
strategy, and that the Child Block Grants not be reinstated
without the requirement that States step up to at least have
evacuation, reunification, special needs, and written
procedures for disaster planning, are there one or two other
specific suggestions that you would like to mention that you
think from your study and review should be really at the top of
our list to address in the next few weeks and months?
Mr. Shriver. Well, I think, as Dr. Redlener mentioned,
coming up with the national framework for recovery is
critically important. I think, honestly, Senator, if you look
at the Child Care Development Block Grant and can put those
requirements in there, you come up with a recovery framework in
the next 5\1/2\ months and you have all child care facilities
in this country looking at the issue of reunification, an
evacuation plan, making sure that children with special needs,
that their needs are incorporated into their planning and that
is tied in with the local emergency management community, I
would consider that a hugely successful 5\1/2\ months. I think
that would be fantastic.
I think the issue that Administrator Fugate talked about
regarding the Stafford Act and having those child care
facilities be reimbursed, I know there are some intricacies
involved in that, but I think if you can address that issue and
come up with recommendations and funding for that, I think that
would be hugely successful. And I think, frankly, if you could
have another hearing to make sure that we are all doing what we
are supposed to be doing, that would make the next 5\1/2\
months be very successful.
Administrator Fugate, to his credit, at the first meeting
we had said about halfway through it, what do you need, and we
rattled off a couple of the recommendations we had put here,
and he and the Secretary are working aggressively on that and
he has set up meetings every 30 days to gauge progress or lack
thereof.
So if you and this Subcommittee could look at and have
another hearing and hold our feet to the fire and the Executive
Branch's feet to the fire, that would make the next 5\1/2\ to 6
months highly successful, as well.
Senator Landrieu. Thank you very much.
Doctor, you said that the case management--I think you
would say--I am putting these words in your mouth--you would
hardly call it case management. It was not really managing much
of anything, so fragmented and unable to deliver in a timely,
appropriate way. When we think about creating a new kind of
system, I read in some of GAO's and RAND's recommendations that
part of the delivery system might be done through the schools
after they reopen through school-based counseling services. Do
you want to comment on that? Should there be opportunities
community-wide, and what is it about school-based counseling
that you think is particularly desirable?
Dr. Redlener. Well, first of all, we have to have a system
that makes sure that every child who is school-age is in school
and kids that are preschool-age are in appropriate day care
facilities and that there are after-school programs. So the
school and the related institutions, can become the basis of
stability for lots of families, and especially lots of
children. So from that point of view, if we could have services
emanating out of that model, so every child is in school, every
child has a family, and it is possible to think about a system
that would mandate not only the kids being in school, but that
appropriate safety net programs and assistance for the families
be generated by that relationship, as well.
And I want to say one other word about the case management
issues. There were lots and lots of very good people doing case
management in the Gulf who still are--Catholic Charities, the
other organizations that are down there that are governmental
and non-governmental. The problem is it is so fragmented and
disorganized and competing case management programs that many
families are just slipping through the cracks.
So I just want to clarify that lots of good work was done.
It is just that far too many--in fact, we don't even know how
many children--getting the numbers that I cited, 17,000 to
30,000, was one of the most difficult challenges I have had in
research in 20 years because there isn't a single agency that
feels itself as responsible for tracking these families who
have been displaced.
So if we start with that, we have an inability to even
figure out how many or where they are. We begged them--this is
FEMA and the State--to make sure that no families were
discharged from those horrendous trailer parks before we knew
who they were and where they were going so we could provide
services to them. But all sorts of bureaucratic snafus between
the Federal Government, the State Government, and then the
private agencies delivering services yielded, first, that one
of the largest case management programs never got implemented,
not one dime out of the original $33 million was spent, I
guess, until very recently, and second, we couldn't track
families. We have no idea where they are. I don't know where
all those kids are that you cited that were part of the
evacuees.
I would challenge the Federal Government to try to figure
out, where are they? How many are in Houston or in Mobile,
Alabama, and so forth, and how many are still struggling, in
limbo, in displacement conditions that are really hurting these
children and their opportunity for success.
Senator Landrieu. OK. Thank you so much.
I would like to just close with a couple of comments. One,
the Louisiana Family Recovery Corps, I understand, delivered
some very good work.
Dr. Redlener. They did.
Senator Landrieu. Unfortunately, their contract was not
able to be renewed and I hope that they can be called in for
comments as we try to come up with a better system.
And my final comment is, from my own personal experience,
not only in my own family experience recovering from the
disaster--as you all know, I am one of nine siblings and four
of my brothers and sisters lost their homes and their children
were displaced, so watching it up close and personal within my
own family, and then expanding that out to our own
neighborhood, Broadmoor, which was destroyed, and then out to
the community, I have concluded one thing that I know without
reading one report, that schools became the center of life when
those neighborhoods were struggling to come back. Whether it
was Saint Dominic's or Holy Cross or Wilson Public School that
is getting ready to open, or Lusher that opened, it became the
only stable place, building, in a neighborhood that is
completely destroyed.
And the government at its own peril fails to recognize the
importance of these schools. They brought stability to the life
of parents that otherwise had no stability. They needed to turn
from just schools to community centers that provide counseling
and medical support, particularly when your hospitals are
closed. Getting your schools open, getting children back in
touch with their teachers, which is a familiar face at that
moment, is very significant to children that have had such
trauma.
It is just--I can't overestimate and overstate how
important this is, and the Federal Government that doesn't
recognize the importance of schools, be they public, private,
Catholic, or independent, and the ability of schools to be sort
of step-in-the-gap until the rest of the community comes back,
I think is kind of the model that I envision. And the
celebration of joy, that when a school would open in a
neighborhood, what it meant to that community cannot be
overestimated.
So I would like to end with that. We have a great deal of
challenge before us. The Subcommittee record will stay open for
15 days. Please, anyone can submit information for the record,
and we will, Mr. Shriver, take you up on your strong
recommendation to hold people accountable for the outcomes that
we have discussed today.
Thank you all very much. The hearing is adjourned.
[Whereupon, at 11:43 a.m., the Subcommittee was adjourned.]
A P P E N D I X
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