Testimony from Robert Kadlec, M.D. on Hurricane Response before Committee on Energy and Commerce

Mr. Chairman and Ranking Member DeGette, it is a privilege and an honor to appear before you and members of the Subcommittee to discuss our nation’s medical and public health response to the unprecedented string of hurricanes that have hit the U.S. this season.  I am Dr. Robert Kadlec, Assistant Secretary for Preparedness and Response – or ASPR – at the U.S. Department of Health and Human Services (HHS).  

After being confirmed in August, I barely had enough time to introduce myself to the ASPR staff before Hurricane Harvey made landfall in Texas.  The past few months have been very challenging, testing our capabilities and resources.  I can proudly appear before you today and say that HHS, as well as our interagency partners, have pushed forward in equally unprecedented ways to save lives and support the communities and people impacted by three major hurricanes, while at the same time dealing with a fourth hurricane and standing ready to respond to potential  requests from California for health (especially mental health) support with respect to the California wildfires and from Nevada health authorities with respect to the mass shooting in Los Vegas. I recognize that in some regions, especially Puerto Rico, people are still facing dire conditions and it feels like the government has not done enough.  I saw the devastation first hand and want to reassure you all that HHS will continue working as hard and smart as we can until conditions improve.

Since this is my first time testifying as the ASPR, please let me begin with a brief description of my background and my view on the role of ASPR.  Then, I will describe what ASPR has done in leading the medical and public health responses, as well as supporting human services responses, to Hurricanes Harvey, Irma, and Maria.  Lastly, I will share some initial lessons learned.

The Role and Vision of ASPR

During my confirmation hearing, I told Senators that assuming the role of ASPR would be both exciting and daunting.  It is exciting because I now lead an organization that I helped create in 2006 when I was staff director of the Senate Subcommittee on Bioterrorism and Public Health Preparedness.  It is daunting due to the immense responsibility of this position and the increasingly challenging threat landscape we face. 

When ASPR was originally established in the Pandemic and All-Hazards Preparedness Act (PAHPA) under the bipartisan leadership of Senator Richard Burr and the late Senator Ted Kennedy, the objective was to create “unity of command” by consolidating all public health and medical preparedness and response functions under the ASPR.  This approach was modeled on the Goldwater-Nichols Act that created the Department of Defense (DoD) combatant commands and the impetus was the disorganized and fragmented response to Hurricane Katrina in 2005.  Recognizing this, as I took over as the ASPR two months ago, one of my top priorities was to transform ASPR from a policy-centric organization to an operations-centric agency.

ASPR’s mission is to save lives. On behalf of HHS, ASPR leads the public health and medical response to disasters and public health emergencies, in accordance with the National Response Framework and Emergency Support Function #8.  HHS also supports other federal entities who lead Emergency Support Function 6, with respect to the human/social services.  In addition, HHS leads Federal health and human services recovery support under the Health and Social Services Recovery Support Function.  Today, the threats facing our country are increasingly diverse and more lethal. My main objective is to improve national readiness and response capabilities for 21st century health security threats.  I aim to do that through four key priority areas:

• First, provide strong leadership, including clear policy direction, improved threat and situational awareness, and secure adequate resources.
• Second, seek the creation of a “national contingency healthcare system” by better leveraging and augmenting existing programs – such as the Hospital Preparedness Program (HPP) and the National Disaster Medical System (NDMS) – to create a more coherent, comprehensive, and capable system integrated into daily care delivery.
• Third, support the sustainment of robust and reliable public health security capabilities, including an improved ability to detect and diagnose infectious diseases and other threats, as well as the capability to rapidly dispense medical countermeasures in an emergency.
• Fourth, advance an innovative medical countermeasures enterprise by capitalizing on advances in biotechnology and science to develop and maintain a robust stockpile of safe and efficacious vaccines, medicines, and supplies to respond to emerging disease outbreaks, pandemics, and chemical, biological, nuclear, and radiological incidents and attacks. 

Medical and Public Health Responses to Hurricanes Harvey, Irma and Maria

The scale and scope of this year’s hurricane season has been unprecedented.  Hurricanes Harvey, Irma, Maria, and Nate’s proximity and severity have created unique challenges.  For example, while we were responding to Hurricane Harvey, teams had to be mobilized for Hurricane Irma, which devastated the U.S. Virgin Islands, and made landfall again in Florida.  In the wake of Hurricane Irma, Hurricane Maria made landfall in the U.S. Virgin Islands and was extremely destructive to the Commonwealth of Puerto Rico.  It took out large portions of Puerto Rico’s fragile electrical grid, which impacted the entire island.  Additionally, Puerto Rico faced public health and health system infrastructure challenges prior to the hurricane that exacerbated the hurricane’s effects.  Especially in Puerto Rico, no place, no person, no life was untouched by these hurricanes – the physical destruction was unfathomable.  But during my trip there, I was overwhelmed by the resilience of the citizens who were making do in extraordinarily difficult situations.

For the three hurricanes to date, ASPR activated the National Disaster Medical System (NDMS) and deployed more than 2,500 personnel and hundreds of other Federal employees to communities impacted by the storms.  NDMS teams were deployed from 21 states outside the affected areas for all three hurricanes.  In fact, HHS through ASPR deployed NDMS teams and U.S. Public Health Service Commissioned Corps (USPHS) teams before the hurricanes hit so they were ready to respond immediately. HHS sent tons of equipment and supplies to affected areas and declared public health emergencies in TX, FL, LA, AL, MS, SC, GA, USVI and PR, as well as for California with respect to the wildfires.  This enabled the Centers for Medicare & Medicaid Services (CMS), in response to requests from State/territorial public health or health departments, to waive certain Medicare/Medicaid, CHIP and the Emergency Medical Treatment and Labor Act (EMTALA) requirements, in order to expedite patient care in affected areas.  We cared for more than 10,000 patients and evacuated patients to facilities that could provide the expert care needed.  HHS requested activation of a FEMA national ambulance contract, which provided aeromedical and ground ambulances to move patients from harm’s way to hospitals.  HHS activated the Emergency Prescription Assistance Program, which provides medications to disaster victims who cannot afford to pay.

Under the National Response Framework, HHS is the coordinator and primary Federal agency responsible for Public Health and Medical Emergency Support Function #8 (ESF #8).  ASPR leads this coordination on behalf of the Secretary.  Our strategy in the hurricane response has been three fold: save lives, stabilize the healthcare system, then restore services.  In some areas, such as Puerto Rico, we are still in the response mode of saving lives and stabilizing healthcare services. 
HHS has 17 core medical and public health functions under ESF #8.  One of those functions is to assess medical needs.  ASPR worked closely with State, local, and territorial public health departments in each of the affected areas to determine their needs and to best integrate our support.  I maintained contact with them throughout our response, and personally visited several of the affected States and territories.  Our field personnel worked closely with the Federal Emergency Management Agency (FEMA), and were placed as liaison officers within State and territorial operations centers, in order to provide immediate support and services to local officials.   In Puerto Rico, we assessed all 67 hospitals and continue to monitor nursing homes and skilled nursing facilities. And, the Health Resources and Services Administration (HRSA) has been supporting its community based grantees who operate primary care delivery sites in these areas by connecting them to local, state, and Federal resources.  
Another ESF #8 responsibility is public health surveillance.  Working with the Centers for Disease Control and Prevention (CDC), we supported the monitoring of diseases within the shelters we staffed and responded to State requests for assistance with post-hurricane disease surveillance.  In Puerto Rico, we provided CDC environmental health officers and epidemiologists to support their public health response efforts.  Additionally, CDC sent experts to Puerto Rico to assist with restoring and augmenting their public health laboratory capacity.  Our HHS team has worked with Puerto Rico to provide testing for waterborne diseases such as leptospirosis, an infectious disease endemic to PR, though traditionally with low case numbers.

Another ESF #8 responsibility is to provide healthcare services.  HHS provided medical services in the form of emergency department decompression, hospital augmentation, Federal medical stations, and free-standing medical teams.  Through the NDMS, ASPR engaged in the evacuation of patients, when necessary.  We proactively evacuated more than 200 dialysis patients from USVI before Hurricanes Irma and Maria struck.  Our partners from DoD and the Department of Veterans Affairs (VA) were key components of these moves.  Once the hurricanes passed, teams provided on-site medical care through Federal medical stations (FMS) with 50 to 250 beds provided through the Strategic National Stockpile. In Puerto Rico, ASPR developed an innovative approach to providing medical care.  Using a “hub and spoke” approach, we were able to cover all seven regions of PR and provide care and evacuation to each region.  ASPR collaborated with the VA and DoD to increase the number of patients who could be seen.
An important lesson learned from events such as Hurricanes Katrina and Sandy and during the 2010 Haiti earthquake was the impact that disasters have on persons who rely on durable medical equipment (DME), especially energy dependent DME.  To rectify this problem, ASPR and CMS created the emPower tool.  EmPower provides information to local public health officials about the number of Medicare beneficiaries in each impacted area who rely on 14 types of life-maintaining and assistive equipment, ranging from oxygen concentrators to electric wheelchairs, as well as data on the number of people who rely on dialysis, oxygen, and home health services.  Citizens who use durable medical equipment tend to be at-risk populations with access and functional needs, including the chronically ill and aging populations – those who are the most vulnerable in their communities and most likely to need life-saving assistance in prolonged power outages.  EmPower also provides real-time severe weather tracking information from the National Oceanic and Atmospheric Administration to help communities track and plan for emergencies.  In Florida and St. Thomas (USVI), for the first time in its history, NDMS personnel joined DoD’s Urban Search and Rescue (USAR) teams to locate dialysis patients whom authorities were unable to reach during the initial evacuation, using EmPower data. 
HHS’s Food and Drug Administration (FDA) monitored pharmaceutical supplies impacted by the storms to help prevent hurricane-related devastation from causing drug shortages.  ASPR also worked with FDA, Red Cross, and the American Association of Blood Banks to ensure the blood supply was sufficient in the impacted areas.  HHS deployed mental health teams and activated behavioral health hotlines in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA) to aid people in coping with the effects of the storm and help those in impacted areas connect with local behavioral health professionals.  HHS created and distributed information and education on carbon monoxide poisoning, worker safety, food safety, vector control, and other health related topics.  Our partners at CDC provided expertise in controlling mosquitoes.  CDC and FDA also provided technical expertise with potable water ranging from municipal systems to individual wells.  Finally, HHS provided mortuary affairs teams that assisted with respectful re-interment of human remains uncovered by flooding of cemeteries.  

ASPR coordinated these broad range of activities through daily ESF #8 Federal interagency calls across all departments and agencies that play a role in health and medical responses, including Federal Emergency Management Agency (FEMA), DoD combatant commands (e.g., NORTHCOM, TRANSCOM, and SOUTHCOM) and other DoD entities, VA, and all HHS operating divisions such as CDC and FDA.

Conclusion

ASPR is still actively in response mode with respect to the impact of Hurricane Maria in Puerto Rico. Now that much of the response effort is concluding, the recovery effort will continue for years. We will continue to partner with FEMA over the next several years during this long period of recovery.
We have a team who has been tracking information throughout the response for an after action report. This report will be critical to future operations. We will be building on things we performed well, and fixing areas that need improvement.
The Pandemic and All-Hazards Preparedness Act (PAHPA) was designed to improve our nation’s public health and medical preparedness and response capabilities for emergencies, whether they are naturally occurring disasters, infectious disease outbreaks, or acts of terrorism.  ASPR’s forward leaning response during this challenging hurricane season was made possible thanks to PAHPA and its 2013 reauthorization.  Indeed, our nation is better prepared thanks to this landmark legislation, which has brought cohesion and efficiency to the Federal public health and health response.  PAHPA is due for reauthorization in 2018, and I look forward to working closely with you to move this important legislation forward.  Together, we can continue to strengthen our nation’s readiness and response capabilities for 21st century health security threats. I thank you again for this opportunity to address these issues and am happy to answer any questions.