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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for appropriate balance.
Support for this project was provided by the Office of Emergency Preparedness, U.S. Department of Health and Human Services (Contract No. 282-99-0045, TO#5). This support does not constitute endorsement of the views expressed in the report.
Library of Congress Cataloging-in-Publication Data
Institute of Medicine (U.S.). Committee on Evaluation of the Metropolitan Medical Response Program.
Preparing for terrorism : tools for evaluating the Metropolitan Medical Response System program / Frederick J. Manning and Lewis Goldfrank, editors ; Committee on Evaluation of the Metropolitan Medical Response System Program, Board on Health Sciences Policy, Institute of Medicine.
p. ; cm.
Includes bibliographical references.
ISBN 0-309-08428-8 (pbk.)
1. Disaster medicine. 2. Emergency medical services. 3. Terrorism—Health aspects. 4. Weapons of mass destruction—Health aspects. 5. Emergency management. 6. Health planning.
[DNLM: 1. Disaster Planning—organization & administration. 2. Emergency Medical Services—organization & administration. 3. Health Planning. 4. Program Evaluation—methods. 5. Terrorism. WX 185 I59p 2002] I. Manning, Frederick J. II. Goldfrank, Lewis R., 1941- III. Title.
RA645.5 .I54 2002
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Institute of Medicine
National Research Council
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COMMITTEE ON EVALUATION OF THE METROPOLITAN MEDICAL RESPONSE SYSTEM PROGRAM
LEWIS GOLDFRANK (Chair), Director,
Emergency Medicine, New York University Medical Center, Bellevue Hospital Center, New York, New York
JOSEPH BARBERA, Director,
Disaster Medicine Program, The George Washington University, Washington, DC
GEORGES C. BENJAMIN, Secretary,
Maryland Department of Health and Mental Hygiene, Baltimore, Maryland
JAMES BENTLEY, Senior Vice President,
Strategic Policy Planning, American Hospital Association, Washington, DC
KENNETH I. BERNS, President and CEO,
Mount Sinai Medical Center, New York, New York
RAYMOND M. DOWNEY, Battalion Chief and Chief of Rescue Operations,
Special Operations Command, Fire Department, City of New York (from November 2000 to September 2001)
FRANCES EDWARDS-WINSLOW, Director,
Office of Emergency Services, San Jose, California
LINDA F. FAIN, Disaster Mental Health Consultant,
FRED HENRETIG, Director,
Clinical Toxicology, and
Poison Control Center, Children’s Hospital of Philadelphia, Pennsylvania
DARRELL HIGUCHI, Deputy Chief,
Los Angeles County Fire Department, Los Angeles, California (from November 2001)
ARNOLD HOWITT, Executive Director,
Taubman Center, Kennedy School of Government, Harvard University, Cambridge, Massachusetts
LAURA LEVITON, Senior Program Officer for Research and Evaluation,
Robert Wood Johnson Foundation, Princeton, New Jersey
WILLIAM MYERS, Health Commissioner,
DENNIS M. PERROTTA, State Epidemiologist and Chief,
Bureau of Epidemiology, Texas Department of Health, Austin, Texas
JEFFREY L. RUBIN, Chief,
Disaster Medical Services Division, Emergency Medical Services Authority, State of California, Sacramento, California
AMY E. SMITHSON, Senior Associate,
Henry L. Stimson Center, Washington, DC (from November 2000 to July 2001)
DARREL STEPHENS, Chief,
Charlotte-Mecklenburg Police Department, Charlotte, North Carolina
Board on Health Sciences Policy Liaison
BERNARD GOLDSTEIN, Dean,
Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
FREDERICK J. MANNING, Study Director
REBECCA LOEFFLER, Project Assistant
Institute of Medicine Staff
ANDREW POPE, Director,
Board on Health Sciences Policy
ALDEN CHANG II, Administrative Assistant,
Board on Health Sciences Policy
CARLOS GABRIEL, Financial Associate
LAUREN SCHIFF, Incident Commander and Operations Officer,
Appalachian Search and Rescue Conference, Charlottesville, Virginia.
Independent Report Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The contents of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report:
MARTIN BLASER, Professor of Internal Medicine and Chair, Department of Medicine, New York University
GREGORY M. BOGDAN, Research Director and Medical Toxicology Coordinator, Rocky Mountain Poison Center, Denver, Colorado
BARRY S. COLLER, David Rockefeller Professor of Medicine, Physician-in-Chief, The Rockefeller University Hospital, and Vice President for Medical Affairs, The Rockefeller University, New York, New York
GEORGE R. FLORES, Director of Public Health, San Diego Department of Health, San Diego, California
VINCENT T. FRANCISCO, Associate Director, Work Group on Health Promotion and Community Development, University of Kansas, Lawrence, Kansas
ROBERT MALSON, President, District of Columbia Hospital Association, Washington, D.C.
PAUL M. MANISCALCO, Past President, National Association of Emergency Medical Technicians
PETER ROSEN, Director, Emergency Medicine Residency Program, Department of Emergency Medicine, University of California, San Diego School of Medicine
ROBERT E. SHOPE, Professor of Pathology, University of Texas Medical Branch, Galveston, Texas
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by LESTER N. WRIGHT, Chief Medical Officer, New York Department of Correctional Services, Albany, New York, appointed by the Institute of Medicine, and ALEXANDER H. FLAX, Consultant, Potomac, Maryland, appointed by the NRC’s Report Review Committee. These individuals were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
This report is dedicated to Ray Downey, Chief of Rescue Operations, Fire Department, City of New York, our friend and colleague on this Institute of Medicine committee, killed in the line of duty while leading rescue efforts at the World Trade Center after the terrorist attack on September 11, 2001.
Having a vision, a mission, and a passion are invariably seen as conditions for success. The 1995 U.S. Department of Health and Human Services (DHHS) concept of a Metropolitan Medical Response System (MMRS) demonstrated that the leaders of DHHS had a vision for an effective response to a mass-casualty terrorism incident with a weapon of mass destruction. The mission was to expand the experimental model of the Metropolitan Medical Strike Team (MMST) established in Washington, D.C., and neighboring counties into a national program.
The problem that the Office of Emergency Preparedness (OEP) of DHHS faced was the dilemma of knowing what preparedness is and determining whether preparedness could be recognized if it was achieved. Under these circumstances, OEP requested that the Institute of Medicine determine how effective this MMRS program effort is and how valuable it could become.
A typically diverse Institute of Medicine working group consisting of leaders, strategists, practitioners, and analysts of societal needs in terms of readiness for disasters and terrorism with weapons of mass destruction was established in the autumn of 2000. Over the following 18 months we constructed a diversified analytic program that emphasizes continuous quality improvement to enhance relationships, understanding, and services, and improve equipment and personnel in the pursuit of preparedness. Our approach is based on the belief that all services are valuable, that they must be integrated, and that shared leadership with democratic, open management approaches will effectively be able to use each metro-
politan region’s assets. We have suggested that document and data analysis, site visits by a team of expert peer reviewers, and observations of exercises and drills be used to analyze a region’s accomplishments.
Some committee members’ theoretical approaches to the requirements of this project as well as the limited cooperative spirit seen in some MMRS program efforts were initial concerns for the committee. These limitations to the committee’s potential were dramatically altered by the September 2001 assault that toppled the World Trade Center and paralyzed the U.S. aviation system and by the mailing of anthrax-laden letters in October 2001 that almost toppled the U.S. public health and postal systems. The events led to the tragic death of a fellow committee member, Ray Downey, Chief of Rescue Operations, Fire Department, City of New York, and thousands of other Americans. These terrorist acts led to a disruption of the equanimity not just of New York City but of our entire country. Our committee, recognizing the timeliness and exceptional importance of our task, responded with the necessary passion to complete the tasks of this analytic process.
We believe that this product will allow OEP, state and federal governments, and all who create preparedness teams to offer a more informed, qualified, and integrated approach to preparedness and public health. This report will be an essential tool in analyses of the depth and breadth of governmental performance and interagency collaboration. This effort—and in particular, U.S. society’s recognition of the importance of our goals—will allow us to save lives and property in future biological, chemical, and radiological terrorist events. The vision was of vital importance. We hope that our passion has allowed us to accomplish the mission and that OEP will have the tools that it needs to determine if we in America are ready to protect ourselves from unknown potential assaults and will remain so for the future.
Lewis R. Goldfrank
Acronyms and Abbreviations
American Red Cross
Capability Assessment for Readiness
chemical, biological, and radiological
Chemical/Biological Rapid Deployment Team
Centers for Disease Control and Prevention
Center for Domestic Preparedness (U.S. Department of Justice)
Comprehensive HAZMAT Emergency Response-Capability Assessment Program
Chemical Stockpile Emergency Preparedness Program
U.S. Department of Health and Human Services
Disaster Medical Assistance Team
Disaster Mortuary Team
U.S. Department of Defense
U.S. Department of Energy
U.S. Department of Justice
U.S. Department of Veterans Affairs
Emergency Operations Center
emergency operations plan
emergency management assistance compact
Emergency Management Institute
emergency medical services
Environmental Protection Agency
emergency support functions
Federal Bureau of Investigation
Federal Emergency Management Agency
Federal Response Plan
General Accounting Office
Hazardous Devices School
health maintenance organization
Institute of Medicine
Joint Commission for Accreditation of Healthcare Organizations
Local Capability Assessment for Readiness
Local Emergency Planning Committee
Maryland Emergency Management Agency
Metropolitan Medical Response System
Metropolitan Medical Strike Team
memorandum of understanding
National Academy of Public Administration
National Contingency Plan or National Oil and Hazardous Substances Contingency Plan
National Disaster Medical System
National Domestic Preparedness Consortium
National Domestic Preparedness Office
National Emergency Management Association
National Medical Response Team
Oklahoma City Fire Department
Oklahoma City Police Department
Office of Domestic Preparedness (U.S. Department of Justice)
Office of Emergency Preparedness
Office of Emergency Services
Office of Management and Budget
Occupational Safety and Health Administration
Office of State and Local Domestic Preparedness Support
point of contact
Radiological Emergency Preparedness Program (Federal Emergency Management Agency)
Regional Operations Center
standard operating procedure
U.S. Army Reserve
U.S. Nuclear Regulatory Commission
Department of Veterans Affairs
weapons of mass destruction
LIST OF TABLES, FIGURES, AND BOX
Relationships among essential capabilities, preparedness indicators, preparedness criteria, and data collection methods,
Flow chart of probable actions in a chemical or overt biological agent incident,
Flow chart of probable actions in a covert biological agent incident,
Key federal consequence management response teams for CBR terrorism,
MMRS program participants, policy instruments, development activities, emergency capacity, and follow-up activities,
Accountability relationships for federal grantees and grant-making agencies,
Example of Preparedness Indicator for One Essential Capability, First Responder Protection,