State emergency officials say that to cope better with the health issues
resulting from future disasters, they need more training before catastrophes
occur, better coordination with other state and regional bodies, and improved
communication with U.S. government agencies.
Their views coalesced at a three-day meeting convened in May by the
Substance Abuse and Mental Health Services Administration (SAMHSA) to discuss
lessons for the mental health community from hurricanes katrina, Rita, and
Wilma. Talks at the New Orleans meeting and discussions with participants made
it clear that the burden of mental health readiness for future natural or
manmade disasters will fall to cities, counties, and states. Further regional
coordination with surrounding jurisdictions will be needed, too, as katrina
made clear last fall.
However, an infusion of new funding is unlikely to come from the federal
government. SAMHSA officials said they can offer localities only technical
assistance, but only Congress can authorize new funding.
"Planning starts on the state and local levels," said A.
kathryn Power, M.Ed., director of SAMHSA's Center for Mental Health Services."
Don't rely solely on the feds."
To rely more on themselves, representatives of states and localities agreed
that they must begin with explicit plans to cope with large-scale emergencies
and must hold training exercises to drill public employees and volunteers in
"Identify the role of your organization in times of disaster, know
those roles, and train for those roles," Michael Duffy, R.N., assistant
director of the Office of Addictive Disorders in the Louisiana Department of
Health and Hospitals, told the group.
"It helps to have a permanent crisis-response committee [for mental
health] to set up and coordinate response around the state," added Jeff
Bennett, L.C.S.W., director of the Gulf Coast Mental Health Center in
Last year's hurricanes taught mental health and substance abuse officials
who felt the storms' impact the need for thinking across jurisdictional lines
and beyond the usual short-term needs of storm victims. Agencies have to form
links with emergency management bodies well before disasters strike and
practice with the general disaster response team. Summed up one official:"
For instance, Mississippi is planning to establish a permanent cross-agency
group covering its emergency management agency; the state health department;
local agencies at state, regional, local levels; and governments, volunteer
organizations, and professional organizations.
Planning requires not just documents, but face-to-face contact among
personnel in advance of events, said participants. Setting up protocols with
nonprofit groups or religious organizations to establish a role for volunteers
can help. North Carolina has agreements in place to send groups of volunteers
anywhere in the state they are
"Plan for the fact that you won't have the capacity to handle
everything," Ken DeCerchio, M.S.W., C.A.P. (center), assistant secretary
for substance abuse and mental health in the Florida Department of Children
and Families, tells the Spirit of Recovery conference in New Orleans. He is
flanked by Lewis Gallant, Ph.D., executive director of the National
Association of State Alcohol and Drug Abuse Directors, and A. Kathryn Power,
M.Ed., director of the Center for Mental Health Services.
Planners must think beyond maps and organization charts, though.
"We tend to organize plans around a command and control structure,
not around human behavior," added Dave Wanser, Ph.D., deputy
commissioner for behavioral and community health in the Texas Department of
State Health Services. "For instance, before Hurricane Rita we ordered
an evacuation, and everybody left at once, jamming the roads. Planning needs
to accommodate how people really act in disasters. Plan for people who will
come to you and also for those you have to go to."
Katrina made clear the need for regional coordination, too, as storm and
flood victims were evacuated to neighboring states.
Merely keeping track of hundreds of thousands of people on the move was
difficult. Telephoning shelters for head counts might give wildly different
numbers in a matter of a few hours. New Orleans residents camped out in a
state park in Tennessee but were "lost" when they moved on without
informing anyone. Alabama also sheltered many evacuees in state parks, but the
evacuees were often in remote areas, away from bus lines, and didn't have easy
access to services or to Federal Emergency Management (FEMA) offices."
Next time, we'll put them in parks nearer to towns," said an
Special populations demanded closer attention as well. Children were a
special focus of psychiatrists and others after the storms (see story at
left), but the seriously ill were subject to conflicting policies, sometimes
left behind during evacuations.
"The federal view is to move the well populations, who have mostly
transient distress, but not to move fragile people," said one
participant. "We need to drop barriers to sheltering them."
Paying for behavioral health services also occupied participants. Many
complained that the current emergency grant process was slow and cumbersome.
Managing complex funding streams from multiple sources was further complicated
by different accounting and reporting standards from various government
"Expedite the hoops, procedures, and paperwork," said one."
Simplify the application process and provide help in applying. We don't
have a dedicated mental health disaster person to handle it."
Others complained of the gap between short-term emergency funding and
longer-term recovery funding that leaves both victims and service providers in
limbo for weeks or months. Funding should also follow evacuees, so that a
family sheltered and registered in a state other than their own would have
access to care there.
Communication is critical both before and during emergencies. Technically,
backups are needed for backups. After katrina, land lines and cell phones were
knocked out when power was lost to relay towers. Even satellite phones went
out because batteries couldn't be recharged. But communication involves more
"You need an incident command structure not to command but to
communicate," said ken DeCerchio, M.S.W., C.A.P., assistant secretary
for substance abuse and mental health in the Florida Department of Children
More opportunities for face-to-face sharing of information in advance and
ways to report relocation information across state lines during emergencies
are needed, possibly using a central, easily accessible database for needs
assessment, shelter occupancy, hotel use, and hospital capacity. Several
attendees recalled getting different answers to the same questions, depending
on when they called and who picked up the phone at FEMA. Words count, too.
Even familiar terms like "treatment" may mean different things to
different agencies, so development of a vocabulary common to all parties would
enhance communication and speed help to disaster victims.
"There's a need for consistent, accurate information during the
process of a disaster," said Duffy. "This helps the staff as well
as the public."
Clinically, the conventional approach to postdisaster health care also
needs revision, added Wanser. He decried a tendency among shelter directors to
recommend immediate removal and hospitalization of individuals who were
Federal stockpiles of pharmaceuticals should include psychotropic drugs,
which were not in the formulary last September, said Duffy.
Substance abuse requires more attention across the board, as both existing
abusers seek help and stressed individuals start or increase use. Specialized
professional experience is useful as well.
"Suppose a person is visiting doctors on each shift asking for pain
medications," Wanser said. "Public health people don't realize
this is a problem, but people who work in substance abuse treatment
Conference participants also argued for simplifying ways to allow outside
health care professionals into states for short periods during disasters.
"Why not set up a national registry to solve credentialing and
malpractice insurance problems?" said William R. Breakey, M.D., emeritus
professor of psychiatry at Johns Hopkins. "Helping out after a disaster
is an exciting, eye-opening learning opportunity that expands your range of
skills and experiences."
Physicians and other health professionals who volunteered for the
SAMHSA-coordinated program in effect after katrina and Rita usually served for
two weeks. One veteran of that experience said that the investment in learning
time would give a greater payoff if deployments were longer (that is, three
weeks) or a split four-week commitment. More money should be allocated for
advanced training and smoother transitions to following teams or to the local
health care system.
At every level, after the acute response to disasters or after disaster
training, recording what worked and what did not is essential, said Florida's
DeCerchio. "you have to do after-action briefings to be ready for the
next season and create documentation to help the person who comes behind
Finally, said one participant at the end of the meeting, federal agencies
should start thinking about an "all-hazards" approach to disaster.
Homeland security funding has been too narrowly focused on antiterrorism
efforts and not at all on the consequences of earthquakes, hurricanes, and
other natural disasters. If disaster knows no geographic borders, he implied,
neither is it bound by the source of the catastrophe.
Presentations from SAMHSA's "Spirit of Recovery Summit"
are posted at<www.spiritofrecoverysummit.com/presentations.htm>.▪