Introduction

Recognizing that the medical consequences of a disaster can exceed local, state, or regional resources, the federal government’s response includes organizational frameworks, response resources, and legal authorities. The National Response Framework (NRF) guides the nation’s response to all types of incidents.

One of the NRF’s Emergency Support Function (ESF) annexes, ESF-8: Public Health and Medical Services, specifically addresses the federal medical response. The US Department of Health and Human Services (DHHS) serves as both coordinator and primary agency for ESF-8. ESF-8 includes a concept of operations and response components, e.g. the National Disaster Medical System (NDMS) and the US Public Health Service (USPHS).

Laws and presidential directives guiding the federal medical response to disasters include Emergency Management Assistance Compacts (EMAC), the Robert T. Stafford Disaster Relief and Emergency Assistance Act, the Pandemic and All-Hazards Preparedness Act and the Pandemic and All-Hazards Preparedness Reauthorization Act, the Social Security Act, the Homeland Security Act of 2002, Title 32 USC (National Guard), Presidential Policy Directive 8, and Homeland Security Presidential Directives #5: Management of Domestic Incidents and #21: Public Health and Medical Preparedness.

Overview of federal medical response to disasters

When an incident occurs, the local jurisdiction is responsible for organizing and managing the emergency response. Each sequential tier of response that may be required due to the size and complexity of the incident, whether mutual aid, regional, state, or federal, brings additional resources but takes time to fully deploy. Because of the delay involved in the formal process of requesting and receiving federal medical assets, it is imperative that local medical responders consider the types of assistance required as early as possible in the response. In many cases, state and federal resources may not reach an incident scene in time to be useful.

For example, a bridge collapse may seem like a disaster when viewed through the media, but the medical needs may not exceed local EMS and health care system resources. An infectious outbreak or large fire may involve fewer patients, but the patients may require specialized resources (e.g. burn center care) that outstrip local and state medical assets. The ability to perform a rapid needs assessment, matching emergency health care requirements to available resources, is imperative. Few initial assessments will end up being 100% accurate, but setting the process in motion will allow timelines for response to collapse, and future updates and reassessments may recast medical requests.

For disasters requiring medical response, requests for assistance are made through the local emergency management agency (EMA). Many of these will be organized into emergency support functions (ESFs) using the federal model outlined below, such as ESF-8 for health and medical care. That desk will typically receive and collate requests for medical or other health care assistance. These requests would then be conveyed to the mayor or town manager, who would make a formal request to the state governor for assistance if unable to fill them locally. While the requests for assistance are being processed through political channels, the local EMA will typically also directly inform the state EMA.

A governor may first look to see if he/she can provide the necessary resources by activating the EMAC and requesting help from other states. Only a governor or his/her designee (for example, the state public health director) may make a formal request to the President for a disaster declaration. Once a federal disaster is declared, the Stafford Act is engaged. The Stafford Act provides a funding and resource allocation mechanism. It allows the President, through the Federal Emergency Management Agency (FEMA), to direct federal agencies to support a local disaster response, and to establish the rates at which states or individuals share in the cost of response and recovery.

The president appoints a federal coordinating officer (FCO) to oversee the response in the involved region. This officer, working with FEMA, will task medical support requests to ESF-8. At the federal headquarters level, ESF-8 is overseen by the Office of the Assistant Secretary for Preparedness and Response (ASPR) within DHHS. DHHS has ten regional offices and the ASPR has regional emergency coordinators (RECs) in each of the regions. These individuals coordinate the ESF-8 response under the FCO’s FEMA staff.

Once this federal framework is established for a specific incident, detailed requests for assistance are formally passed by the state’s emergency operations center to FEMA’s National Operations Center (NOC). FEMA, in turn, validates the requests and converts the requests into mission assignments that are forwarded with appropriate funding to the most appropriate federal agency for completion.