[Senate Hearing 111-313]
[From the U.S. Government Publishing 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

                                 ------                                
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

                              ----------                              


                        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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \1\ The chart appears in the Appendix on page 91.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \1\ The prepared statement of Senator Landrieu appears in the 
Appendix on page 29.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Fugate appears in the Appendix on 
page 35.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \1\ The prepared statement of Admiral Lurie appears in the Appendix 
on page 41.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \1\ The prepared statement of Ms. Bascetta appears in the Appendix 
on page 57.
---------------------------------------------------------------------------
    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.]
















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