Public Health Emergency Preparedness
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1. Disaster Management and Recovery
| Recommendation 1.1: Distinguish and comprehensively integrate the needs of children
across all inter- and intra-governmental disaster management activities and operations.
- The President should develop a National Strategy for Children and Disasters.
- The Executive Branch, Congress, and non-Federal partners should prioritize children
separately from "at-risk" population categories.
- The Executive Branch at all levels of government should establish and maintain
permanent focal points of coordination for children and disasters, supported by
sufficient authority, funding, and policy expertise. FEMA should establish Children's
Integration Specialists at the regional level.
- The Executive Branch and non-Federal partners should incorporate children as a
distinct priority in base disaster planning documents and relevant grant programs.
- The Executive Branch and non-Federal partners should incorporate education, child
care, juvenile justice, and child welfare systems into disaster planning, training, and
- The Executive Branch and non-Federal partners should incorporate children as a
distinct priority in relevant target capabilities, preparedness training, and exercises, with
specific target outcomes and performance measures.
- The Executive Branch and Congress should institute accountability and progress
monitoring measures to track implementation of Commission recommendations and
Children under the age of 18 comprise nearly 25 percent of the U. S. population, or 74 million Americans.5,6 Given the significant number of children in our Nation, the Commission recommends that the unique needs of children must be more thoroughly integrated into planning and made a clear and distinct priority in all disaster management activities.
The Nation's ability to prepare for, respond to, and recover from disaster—especially in regard to children?can neither depend on a single level or agency of government, nor be approached on a piecemeal basis. Disaster management is a shared responsibility, based on each team member doing what it does best and leveraging the expertise and strengths of others. Capabilities, policies, and programs currently are fragmented and need clearly stated desired outcomes, priorities, and resources for children, across and among all levels ofgovernment.
The lack of clear priorities and sufficient resources for children and families in times of disaster primarily is related to the lack of a national strategy. In the May 2010 Progress Report on Children and Disasters, the Commission, while recognizing marginal pockets of improvement, called for the President to develop, in coordination with Federal and non-Federal stakeholders, a National Strategy for Children and Disasters.7 This strategy would provide a platform for the development of short- and long-term goals, objectives, and capabilities to more cohesively address gaps in disaster preparedness, response, and recovery for children. The Commission stands by its previous recommendation that the Administration must provide leadership and a charge of urgency and innovation to move the Nation forward in addressing the critical needs of children in disasters.
Children's Unique Needs in Disasters
Children are not simply small adults. Throughout this report, the Commission notes
children's unique vulnerabilities in disasters that must be addressed in disaster
management activities and policies. For example:
- Children may experience long-lasting effects such as academic failure, post-traumatic
stress disorder, depression, anxiety, bereavement, and other behavioral problems such
as delinquency and substance abuse.
- Children are more susceptible to chemical, biological, radiological, and nuclear
threats and require different medications, dosages, and delivery systems than adults.
- During disasters, young children may not be able escape danger, identify themselves,
and make critical decisions.
- Children are dependent on adults for care, shelter, transportation, and protection
- Children are often away from parents, in the care of schools, child care providers,
Head Start or other child congregate care environments, which must be prepared to
ensure children's safety.
- Children must be expeditiously reunified with their legal guardians if separated from
them during a disaster.
- Children in disaster shelters require age-appropriate supplies such as diapers, cribs,
baby formula, and food.
A major impediment to the prioritization of children lies in the inclusion of children as a group within population categories labeled "at-risk," "vulnerable," or "special needs." The Department of Health and Human Services (HHS) recognizes children as "at-risk" along with 10 other populations.8 While well intentioned, the advent of these categories has resulted in diluting, rather than concentrating, a specific and necessary focus on children, and has led to plans in which children are addressed in annexes, if at all.
The Commission recommends that the Executive Branch, Congress, and non-Federal partners reconsider laws and policies, such as the 2006 Pandemic and All-Hazards Preparedness Act,9 that group children into broad "at-risk" population categories. Children typically have unique needs in all types of emergencies and disasters, and many of these needs can be anticipated; thus, disaster management agencies should place a specific and sustained focus on children in their daily and disaster response activities. For example, when children were disproportionately affected by the 2009 H1N1 pandemic, the Centers for Disease Control and Prevention (CDC) recognized the need to treat children as a distinct part of the general population and in response created a Children's Health Team with representation in the CDC's Emergency Operations Center. The team was instrumental in bringing attention to the needs of children and the necessity for offering national-level guidance to families, schools, and child care providers concerning personal precautions, the H1N1 vaccine, and school closures. Organizations with similar experiences during their disaster relief efforts, such as the American Red Cross, agree that children need to be considered as a distinct population in disaster planning, rather than as part of a larger "at-risk" or "special needs" categories.10
The Commission recommended in its Interim Report that the White House assume "a
central leadership and coordinating role" to advise the President, the Executive Branch, and
non-Federal partners on the need to make children a disaster planning imperative and to
foster integration of children across national security and domestic policymaking
priorities.11 The Commission recommends that the President implement this recommendation, with a corollary that the President also create a permanent focal point of responsibility and accountability for coordinating children's disaster needs across the Federal Government and with non-Federal officials. At the regional level, the Federal Emergency Management Agency (FEMA) should establish Children's Integration Specialists, who can coordinate with other Federal regional staff, such as the HHS Administration for Children and Families, and with state and local partners. Similarly, State and local governments could assign the duty of intra- and inter-agency coordination of children's disaster needs to the immediate office of the executive, for example led by a cabinet member from the public health office, social services department, or emergency preparedness agency.
The Commission also recommends that Executive branch leaders at all levels of government
create a centralized focal point to identify and fix gaps in disaster policies and programs for
children and families (Appendix C: Model Executive Order or Resolution Creating a
"Cabinet on Children and Disasters and Children and Disasters Advisory Council").
Relevant government agencies also may create such a mechanism. In August 2009, FEMA
formed a Children's Working Group to "create a lasting, positive change, at every level of
government" by ensuring that the needs of children are incorporated into all disaster
preparedness, response, and recovery efforts. The Working Group reports to the FEMA
Administrator and a counselor to the Homeland Security Secretary and is composed of
representatives from the Department of Homeland Security (DHS) and FEMA, including the
Office of the Administrator, key Program Directorates, the Regional Operations Office,
Specialty Areas, and Supporting Offices, as well as subject matter experts and FEMA staff
who participate on Commission subcommittees.12 In addition, the Working Group is
assisting in the development of disaster planning activities for children with partner
agencies, specifically HHS, the Department of Justice (DOJ), and the Department of
Education (ED), and with non-governmental partners.
In March 2010, HHS also formed a Children's Working Group co-chaired by the Assistant
Secretary for Preparedness and Response and the Assistant Secretary for Administration of
Children and Families. HHS' working group will assess current capabilities to address
children in disaster planning activities and seek to facilitate coordination across the agency.
To expedite progress, the Commission urges the HHS working group to synchronize priority
areas with critical gaps the Commission has identified, such as coordinated disaster
planning for children, development of pediatric medical countermeasures, and delivery of
disaster mental and behavioral health services to children.
The creation of advisory bodies is an important means to place a focus on children and
families; however, these entities are currently ad hoc in nature and may be eliminated
following a change in Administration. Therefore, the Commission urges these advisory
bodies be permanently established by statute and replicated across Federal and non-Federal
agencies, reporting directly to top-level leadership, with sufficient authority, funding,
staffing, and policy expertise to effectively expedite the implementation of the Commission's
recommendations and other related activities.
The Commission also recommended that the Executive Branch and non-Federal partners
incorporate children as a distinct priority throughout base disaster planning documents and
relevant grant programs. In response to these recommendations, Administrator Fugate
directed FEMA staff to review base planning guidance and work to ensure that the needs of
children are a core consideration in disaster planning.13 Also, the FEMA Children's Working
Group is collaborating with the agency's National Preparedness Directorate to incorporate
children's needs into FEMA's disaster planning documents, including the Comprehensive
Planning Guide 101 and the National Response Framework.14
Making children a priority will have important implications at all levels of government for
training, equipment, supplies, and exercises, since priorities drive investment and resource
allocation decisions. Not enough attention has been paid nor resources devoted to
improving Federal and especially non-Federal disaster capabilities for children. The bedrock
of the Nation's disaster planning and management system lies at the State and local levels.
First responders to any disaster are not likely to be FEMA, HHS, or other Federal entities. If
requested at all, Federal support may not arrive for several hours or days after the disaster.
States and localities supported by Federal emergency preparedness grants should develop
disaster capabilities that meet the needs of children. However, a disproportionately small
amount of the total Federal funds appropriated for State and local disaster management is
specifically allocated to support development of capabilities to assist children. DHS worked
closely with the Commission to develop and release a Supplemental Resource regarding
children in disasters within its FY 2010 Homeland Security Grant Program guidance.15 The
guidance provides States with specific examples of eligible uses of funding to benefit
children, such as supplies, planning, and training; however, the guidance does not require
States to expend grant funds to address the needs of children.
The Commission recommends that specific emergency preparedness capabilities for
children be developed and integrated into existing capabilities that are supported by Federal
emergency preparedness grants. States and jurisdictions would then have greater means to
develop disaster capabilities that meet the needs of children. Grantees should assess their
performance in meeting the needs of children during exercises and drills, and include
performance evaluations in their After Action Reports and improvement and corrective
action plans. Based on briefings with national organizations representing State and local
governments and knowledge derived from field visits, the Commission developed a list of
basic disaster capabilities for consideration by elected officials and emergency managers
The Commission also recommends that congregate care settings, such as schools, child
care, juvenile justice, and child welfare facilities, along with local child serving agencies be
included in planning, training, and exercises. Likewise, State child serving government
agencies should be incorporated into State-level efforts. The Government Accountability
Office (GAO) asserted that children would be better protected if State and local disaster
plans incorporated child welfare, education, and other agencies that serve children.16 The
Commission believes that integrating these State and local agencies and facilities in State
and local planning efforts is essential to ensure that States and communities are prepared to
address the needs of children.
The Commission recommended in its Interim Report that children's needs be addressed in
relevant target capabilities, preparedness training, and exercises, with specific target
outcomes and performance measures.17 FEMA intends to integrate children's issues into the
2011 National Level Exercise (NLE).18 The concept for the NLE is a major earthquake within
the New Madrid seismic zone impacting eight Midwest States.19 Among the overarching
exercise objectives are evacuation and shelter-in-place, mass care (sheltering, feeding, and
related services), medical surge, and long-term recovery.20 Since no single jurisdiction or
response discipline will be capable of handling an event of this magnitude, the Commission
recommends that the NLE test the capabilities of cooperative efforts among jurisdictions and
pre-event mutual aid agreements to address children's needs, especially in the context of
additional health and mental health care for children and evacuation of unaccompanied
children across State lines. The earthquake in Haiti demonstrated the need to ensure
capabilities around quickly reuniting unaccompanied children with their families and
accommodating a potential surge of orphans resulting from a mass casualty event.21 Echoing earlier concerns regarding serious gaps in preparedness, the Commission also
recommends that exercises test capabilities and training around more common and realistic
events faced by State and local responders, rather than just catastrophic events.
Finally, in order to institute accountability and track national progress toward
implementation of the Commission's recommendations and the improvement of capabilities
for children, Congress should require the Administration to prepare and submit an annual
report on children and disasters to appropriate Congressional committees. Additionally, the
Commission recommends that the Executive Branch require relevant agencies to
incorporate measurable goals into their multi-year strategic plans and an evaluation
framework to monitor performance and impact of investments related to children and
disasters, particularly with regard to grant programs.
| Recommendation 1.2: The President should accelerate the development and
implementation of the National Disaster Recovery Framework with an explicit emphasis
on addressing the immediate and long-term physical and mental health, educational,
housing, and human services recovery needs of children.
As supported by the findings of a 2009 GAO report on recovery efforts following Hurricane
Katrina,22 key to any recovery effort is the prompt restoration of critical services for children
and families, including housing, health and mental health, education, child care and
nutrition services, and safe recreation areas, which are discussed in greater detail later in
this report. In the Interim Report, the Commission recommended the prompt development
of a National Disaster Recovery Strategy that specifically addresses the needs of children in
long-term recovery from disasters.
The Commission's field visit to Iowa, to gather findings and lessons learned from the longterm
recovery efforts of Iowa's 2008 floods and tornados, also underscored the need for
improved long-term recovery planning. In particular, it was clear to the Commission that
the recovery efforts in Iowa were hindered by the absence of a pre-existing national, State,
or local long-term disaster recovery plan. Other key findings from the field visit included
the critical need for a central point of coordination at the Federal and non-Federal level for
recovery programs and services, specifically for children and families, and the pressing
need for Federal disaster assistance programs designed to support long-term recovery of
children and families.
The Post-Katrina Emergency Management Reform Act of 200623 requires the development of
a "National Disaster Recovery Strategy"24 to coordinate long-term recovery resources
following major disasters. This strategy document, now named the National Disaster
Recovery Framework (NDRF), is designed to be a companion document to the National
Response Framework. The Commission and Congress have urged the Administration to
accelerate the development of this document. A Long-Term Disaster Recovery Working
Group was formed in 2009, and a first draft of the NDRF was released on February 5,
The Commission provided comments on the draft, based in part on its findings from the
Iowa field visit and a field visit in Louisiana in January 2009.26 Among other suggestions,
the Commission cited a need for: 1) the appointment of a Federal Disaster Recovery
Coordinator who reports directly to the President; 2) an office residing in the White House
or a Federal agency to help build recovery capacity across the country; 3) the incorporation
of school and child care recovery as a major theme and element in the framework; and 4)
leadership and operational guidance on how States and communities can reestablish forprofit
and nonprofit health care practices. In addition, the Commission commented that the
NDRF should recognize the need for Federal agencies to: proactively educate States about
available resources; assist in holistic long-term needs assessments for children and families;
reduce the burden of paperwork; create greater flexibility in grant guidance, reimbursements, and regulations; and help identify ways to address unmet needs in States and localities.
In addition, the Working Group intends to develop an NDRF Annex with Recovery Support
Functions (RSFs),27 which are critical to specifying the roles and responsibilities of Federal
and non-Federal partners and fostering new interagency collaborations. The Commission
urges that the RSFs be developed in collaboration with State, tribal, and local jurisdictions,
especially those with recent long-term recovery experiences and lessons learned. These
jurisdictions will inform Federal agencies where there are significant gaps in funding,
resources, and coordination that require new capabilities and capacities at the Federal
level. Also, States and localities may have recovery planning models and best practices that
could be shared nationally throughout this effort. For example, Iowa established a Rebuild
Iowa Office to coordinate State-wide disaster recovery efforts and provide a centralized
entity to address issues such as housing, public health and health care, infrastructure,
economic and workforce development, education, and hazard mitigation.28
The NDRF and a report to the President were scheduled to be delivered by June 1, 2010. At
the time of this report's publication, finalization of the documents is on hold due to Federal
response and recovery efforts following the oil spill disaster in the Gulf of Mexico. The
Commission urges the Administration and Congress to move swiftly to provide necessary
additional authority and funding to undertake new recovery responsibilities, particularly as
they relate to children and families. The Commission also recommends that the
Administration and Congress ensure that disaster recovery assistance programs for children
and families are more responsive to the needs identified by States and communities who
will receive the assistance.
| Recommendation 1.3: DHS/FEMA should ensure that information required for timely and
effective delivery of recovery services to children and families is collected and shared with
- Government agencies and non-governmental organizations should collect information
on children and families necessary to identify and support their immediate and longterm
- DHS/FEMA should expand information sharing with appropriate government agencies
and non-governmental organizations to enable the delivery of recovery services
- DHS/FEMA should pre-identify and credential additional local and out-of-State
voluntary and non-governmental organizations and networks that provide disaster
assistance to children and families.
A major barrier to the timely and adequate provision of services for children and families
after a disaster is the limited collection and sharing of information on disaster survivors
among government agencies and organizations providing disaster relief and service
delivery. The Children's Health Fund, in its report on disaster case management following
the Gulf Coast hurricanes, reported that FEMA's inability to share client-level data, based
upon regulations and policies derived from FEMA's interpretation of the Privacy Act,29 resulted in information being given to HHS for case management work that was insufficient
for providing health and human services to individuals and families.30 More recently, during
its January 2010 Iowa field visit, the Commission learned of instances where insufficient or
uncoordinated sharing of information impeded the delivery of services to children and
families. For example, following the spring 2008 floods in Iowa, the administrator of the
State-level Crisis Counseling Assistance and Training Program (CCP) was denied basic
information from FEMA, including the addresses of affected homes, despite CCP being a
FEMA-funded program. According to the administrator, outreach efforts would have been
much more efficient had they been given access to this information.31 Iowa officials also
indicated that the inability to share information between the various agencies and
organizations providing case management services presented difficulties for both case
managers and clients.32
Information collection and sharing can: 1) provide more complete identification of the
unique needs of children and families; 2) create a more accurate composite picture of the
needs of children and families within the communities affected by the disaster; and 3)
ensure that children and families are offered and provided continuous services during the
entire recovery process.
For the purpose of providing more comprehensive data on children to FEMA and its Federal
and non-Federal partners, the Commission recommends that FEMA collect information, in
the disaster recovery assistance intake process, identifying the ages of children in an
applicant's household and any health, mental health, physical, nutritional, and educational
needs. In the current process, FEMA collects information for the purpose of determining
eligibility for FEMA-specific assistance. FEMA does not request specific information on
children and only requires the applicant to indicate the number and type of dependents in
the applicant's household.
The Commission also recommends that FEMA pre-identify and credential additional local
and out-of-State voluntary and non-governmental organizations and networks that provide
disaster assistance to children and families to enable the organizations to obtain access to
the information they need to provide recovery assistance.33 FEMA had, until recently, shared
limited information with specific voluntary and non-governmental organizations for the
purpose of preventing the duplication of monetary benefits to survivors. FEMA modified its
information sharing policies and procedures to enable sharing of information with
government agencies and members of the National Voluntary Organizations Active in
Disaster (NVOAD) or members of FEMA or State-recognized Long Term Recovery
Committees.34 Other local and out-of-State voluntary and non-governmental organizations
would benefit from access to information that helps them identify survivors in need.
Although FEMA often plays a key role in information collection and sharing, in many cases,
FEMA will not have information on survivor children and families for weeks or months after
a disaster.35 Therefore, the collection and dissemination of data among State, tribal, local,
and non-governmental agencies is also critical since the initial response in any event will be
handled by local and State agencies.
Finally, the Commission determined that, in some instances, schools can be a useful source
for providing immediate information on children and families following a disaster. Upon
request of the Commission, ED clarified earlier information-sharing guidance to schools
under the Family Educational Rights and Privacy Act36 that was issued in response to
questions surrounding the H1N1 influenza pandemic. The updated guidance37 assists school
officials in determining what information may be shared and with whom in response to
natural and man-made disasters.
The Commission recognizes that the privacy of children and families' personal information
must be protected when personally identifiable information is being collected and released
to agencies and organizations delivering recovery services in the aftermath of a disaster. The
Commission urges Federal, State, tribal, and local agencies to be cognizant of privacy laws
and relevant disaster and emergency waivers, and to have pre-disaster information-sharing
agreements and policies in place.
| Recommendation 1.4: DHS/FEMA should establish interagency agreements to provide
disaster preparedness funding, technical assistance, training, and other resources to State and local child serving systems and child congregate care facilities.
State and local child serving systems and child congregate care facilities must be adequately
prepared to protect children in disasters. Children spend a significant amount of time under
the care or custody of these various systems and facilities, which include schools,38 child
care and early education,39 child welfare, and juvenile justice.40 However, as identified in
other chapters of this report, gaps in disaster preparedness are prevalent in these settings.
Federal agencies such as the DOJ Office of Juvenile Justice and Delinquency Prevention
(OJJDP), ED, and the Administration of Children and Families' Child Care Bureau (CCB) and
Children's Bureau (CB) provide some assistance to support the disaster preparedness efforts
of their State and local partners. However, these Federal agencies lack the funds and
disaster planning expertise to substantially support the disaster preparedness efforts of their
State and local partners.
The Commission recI aommends that DHS/FEMA, as the primary Federal agency charged with
enhancing our Nation's disaster preparedness,41 play a leading role in supporting and
improving disaster preparedness of State and local child serving systems and child
congregate care facilities. DHS/FEMA should establish interagency agreements (IAAs) with
OJJDP, ED, CCB, and CB. The IAAs would specify formal commitments of each agency to
provide funding, expertise, and other resources to support innovative, collaborative
programs to improve disaster preparedness capabilities of State and local child serving
systems and child congregate care facilities. The IAAs would also facilitate increased interagency
and inter-governmental planning and coordination, including joint training and exercises involving emergency management officials and officials from child serving systems at the State and local level.
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