Considerations For Using FMTs in a Domestic Disaster

A series of catastrophic events in the past decade highlights the complexities and pitfalls involved in coordinating the international health and medical response to those in need. ¹⁹ Planning for a catastrophic disaster has become an increasing priority of the federal government. The focus on developing crisis standards of care, in which usual health care operations are no longer possible because of an extreme demand placed on limited medical resources, is a significant feature of such planning. ^{20 , 21} While the US has significant resources in the health and medical sector, the ability to mobilize such resources in a rapid fashion and place them in the immediate response to a catastrophic event are very limited. These restrictions are primarily due to the existing limitations of federal disaster medical response capabilities,Reference Hanfling ²² and the inability to rapidly mobilize and organize the thousands of spontaneous medical response volunteers that might be needed to lend assistance under such circumstances.Reference Hanfling ²³

Current federal plans identify programs and agencies having key roles in response to a catastrophic event. The National Disaster Medical System consists of 80 deployable teams; 55 of these are disaster medical assistance teams (DMATs), which are primarily focused on the delivery of emergency-level care and the reconstitution of chronic care needs; and 3 are international medical surgical response teams.Reference Toner, Waldhorn and Franco ²⁴ Additional resources, such as those from the US Public Health Service,Reference Pafford ²⁵ deployable Department of Defense (DoD) medical capabilities, and academic health centers, would be used during a catastrophic response. Other private resources would respond under an ad hoc process of convergent volunteerism, Reference Cone, Weird and Bogucki ²⁶ but would largely be disorganized and only marginally integrated into the official, coordinated government-led response. Even if such practitioners volunteer to respond, or become convergent volunteers who are drawn to respond to a regional catastrophe, it remains unclear how they will integrate into Incident Command System operations under its current structure.

Therefore, while significant medical resources exist across the US, their ability to rapidly contribute to the acute response to a large-scale event would likely fall short in face of a catastrophic disaster. Academic health centers and deployable DoD assets have assisted with medical response efforts in CHEs outside of the US, such as after the 2010 Haiti earthquake.Reference Babcock, Baer and Bayram ^{27 -} Reference Sarani, Mehta and Ashburn ³⁰ However, for response operations to a domestic catastrophe, it remains unclear who will supply additional medical assets, where such assets will be staged, and how they will be organized under current response frameworks. In the absence of a ready plan to integrate large numbers of domestic volunteers, or investments in significant resources to expand National Disaster Medical System capabilities, the advantage of integrating FMTs into response operations lies in the fact that such teams are organized and trained in providing acute medical support to disaster-affected regions. Unlike well-intentioned domestic volunteer counterparts, FMTs are equipped, trained, and supplied to provide the needed medical support under austere conditions. The combination of a sudden-onset catastrophic event with a recognized shortfall in the availability of an organized domestic medical response capability, in which the absence of trained medical providers might affect morbidity and mortality outcomes, could therefore trigger the use of FMTs.

Barriers to the Integration and Coordination of FMTs

The participation of well-equipped, well-staffed, and experienced FMTs in response to a large-scale domestic disaster could enhance the opportunity to save lives and reduce suffering. Allowing selected FMTs that are vetted, and whose capabilities and limitations are clearly understood before an event, to participate in the delivery of acute medical care to injured and dying American citizens should be considered as a potential mechanism to improve response capabilities. However, a number of significant challenges are related to the potential use of FMTs in response to a disaster event in the continental US. These include political concerns regarding the acceptance that such teams should be invited to respond to an event in the US, as well as the logistical challenges that will result from the arrival of FMTs.

The greatest perceived barrier to the integration of FMTs into a domestic response will likely focus on the adherence to accepted standards of care expected of health and medical providers delivering emergency care in the US. While bringing FMTs into the US to render care in a disaster might actually result in care not delivered to the level of expectations of US medical providers is a concern, we believe that doing so will likely result in improved rather than lowered, standards of care. These are events that will likely result in standards of care and emergency medical response that are fundamentally different than emergency medical response that occurs on a day-to-day basis.Reference Hanfling ²² Therefore, the expeditious utilization of FMTs could help support the acute medical response. By providing critical supplies, staffing, key resources, and the capability to manage the medical and surgical needs of the affected population, FMTs may provide services that might otherwise not be available during the acute phase of the disaster response.

As described in the Institute of Medicine's work on standards of care in disaster events, medical care will be delivered across the continuum from conventional to contingency to crisis surge response paradigms. ²⁰ Permitting and integrating FMTs should be considered only during catastrophic events, when all available domestic medical response resources have been committed to the response, and a gap in delivering medical care remains. The use of FMTs would occur within the context of the implementation of crisis standards of care.

Another significant challenge relates to the legal and regulatory framework as it pertains to the delivery of health and medical care. Medical providers, as licensed independent practitioners, or nonlicensed practitioners dependent on certification and registration, work in a highly regulated environment. ³¹ FMTs would likely only be permitted to deliver care in the US based on some measure of verification of their capabilities. However, licensing, credentialing, and verification cannot be accomplished in real time during a disaster. These issues must be addressed before an event, or a mechanism to address them in real time must be created. Because the granting of medical, nursing, and pharmacy licensure is a state's responsibility, state governments will likely have to permit the licensing and credentialing of FMTs during a CHE. Therefore, current planning for catastrophic disaster response should, to the extent possible, rely on pre-established international agreements, which are nonbinding instruments not subject to ratification. ³² Planning should also be based on a pre-event registry of foreign capabilities and credentials for proper integration of FMTs. Disaster response entities are mobilized at the request of, and to provide support to, local emergency management authorities. In the case of FMTs coming to the US, they will be tasked with specific mission assignments at the local or state level. Although states are ultimately charged with approving integration of FMTs, the federal government is constitutionally responsible for negotiating and entering into the international agreements likely to be required to make such integration possible. ³³

Finally, assuring the operational integration of FMTs will pose challenges, as these teams would be expected to operate within the existing National Response Framework. Concerns include team placement, scope of services, logistical support, language services, and coordination with local, state, and federal domestic emergency response assets. An additional consideration will be reliance on the United Nations and the World Health Organization (WHO) Global Health Cluster to provide a framework for international disaster response, similar to the current efforts that are modeled on the International Search and Rescue Advisory Group framework used by the international urban search and rescue (USAR) community. ³⁴ Initial exploration of integrating foreign response teams into a domestic catastrophic disaster response event occurred during the Federal Emergency Management Agency (FEMA)'s National Level Exercise, conducted in 2011. ³⁵ Specifically, the Israel Defense Forces’ search and rescue command staff worked in conjunction with the FEMA USAR incident support team to simulate the arrival of an Israeli search and rescue team to help respond to the exercise scenario, that is, a large-scale disruptive earthquake along the New Madrid Seismic Zone resulting in tens of thousands of casualties.

Overview of Existing Policies and frameworks

The US government supports several policies and frameworks regarding response to domestic and international CHEs (see online Appendix B). However, neither domestic nor international policies completely address the role and integration of FMTs, and current policies are piecemeal and incomplete. This situation can result in an inability to meet public health and medical needs, inhibit the opportunity to contribute meaningful data regarding the public health response, and limit reporting of useful information regarding the utilization of services and delivery of care. In some cases, lack of FMT coordination in the acute response could even exacerbate public health and medical problems.Reference Chu, Stokes, Trelles and Ford ^{11 ,} Reference Zoraster ^{36 -} Reference Redmond, Mardel and Taithe ⁴¹ In contemplating the potential use of FMTs in response to an event in the US, many provisions in existing policies could be adapted to more comprehensively address the integration of such teams in the domestic setting.

Recommendations for Improving Integration of FMTs in Domestic Operations

In spite of efforts organized under existing frameworks and policies, further pre-event planning is necessary to improve management and integration of FMTs during a domestic CHE. The following recommendations address how the US government and international community can advance the FMT working group's efforts and outline considerations regarding the utilization and integration of FMTs responding to a CHE occurring in the US.

1. 1. Encourage US government agencies to provide continued support for FMT working group efforts, specifically the development of a pre-event registry and an FMT classification planning process, as outlined in their recent concept paper. National governments should be encouraged to support the FMT working group in establishing a robust registry of FMT capabilities. This registry will provide the US government and other governing entities with a registry of medical assets. The registry will also promote high standards for medical assistance and uniform ethical guidelines for operating in foreign territories. The establishment of such a registry could ultimately lead to a classification system, which would promote internationally accepted standards regarding the capabilities and specializations of FMTs. Through this process, FMTs could deploy based on a predemonstrated assessment of specific capabilities. Because the proposed registry also calls for registrants to identify minimal service capabilities, much like those adhered to by international NGOs, the registry can eventually expand to include NGOs. This in turn can help standardize requirements for medical assistance from both governments and NGOs. The US government should support the creation of a registry and classification system and encourage the future integration of NGOs into the framework.

2. 2. While the federal government provides support to states for emergency response efforts, some states may find it necessary to enter into emergency assistance agreements with foreign governments. Select states and localities have explored waivers for medical licenses in emergency situations; however, for jurisdictions that lack such policies, federal support would be warranted to expedite medical response. Governors are currently permitted to request assistance from other states or the federal government through mechanisms such as the Emergency Management Assistance Compact (EMAC). All US states and territories have adopted EMAC, and some states have added legal provisions that also facilitate the use of foreign-licensed professionals. This arrangement is not true of all states via their adoption of EMAC but it could be a mechanism to permit foreign-licensed practitioners to assist in the event of a disaster. Some states may also find that foreign assistance is less expensive, timelier, or more readily available. For example, states bordering Canada or Mexico may find that cross-sharing critical resources, such as equipment or personnel, allows for a more timely response than awaiting assets from another US state. Select local jurisdictions also have mutual aid agreements with their international cross-border counterparts; these agreements address how to coordinate and command requests for assistance, address liability concerns, and conduct joint training. ⁵⁷

   The federal government should coordinate with states to encourage state laws that promote unilateral engagement with foreign governments and establish a process for temporary, rapid recognition of existing foreign licenses and certifications. Two provisions can serve as models for state governments when coordinating and integrating FMTs during disasters. Currently, when the President declares an emergency or disaster and the Secretary of Health and Human Services declares a public health emergency, the secretary has authorization to take actions that are not typically under the secretary's purview. Section 1135 of the Social Security Acts gives the secretary permission to modify or waive certain provisions under the Children's Health Insurance Program, Medicare, or Medicaid, to ensure sufficient health care is available and accessible to those enrolled in these programs. ⁵⁸

   Second, the Food and Drug Administration permits the interstate shipment and importation of unapproved new drugs, which are generally prohibited, in the event that the intended use of the drug is unapproved and for which effective treatment is unavailable domestically through clinical or commercial means. ⁵⁹ Congress should authorize states to waive or modify requirements for foreign medical assistance on the declaration of an emergency and activation of the IAS, provided these FMTs are invited to respond and have undergone the registry and classification process. For FMTs that have been vetted before the onset of the catastrophic event, their integration into an operational response that occurs under the auspices of federal response efforts would eliminate the need for urgent state-by-state amendments to existing state law, including those related to state-based licensing decisions.

3. 3. Adjust current guidance under the International Assistance System to more clearly address the integration of FMTs, from both foreign governments and international NGOs, in a domestic response. The executive branch should establish an interagency coordinating committee that can provide recommendations about how the IAS can more comprehensively address the role of FMTs in a domestic response effort (see online Figure). Such a committee should include USAID; DoD; Department of Health and Human Services; the departments of State, Justice, and Transportation; and several divisions of the Department of Homeland Security, including FEMA, Customs and Border Patrol, and Immigration and Customs Enforcement. This effort should be initiated immediately with the intent to utilize the recent FMT working group draft guidance as a catalyst to establish a registration and classification system. This kind of system would be required to support selected invitation of FMTs to respond to a catastrophic event in the US, if warranted.

4. 4. Identify how to coordinate planning and response to a catastrophic event within accepted international response frameworks. The US government will likely manage domestic response operations, yet it should identify how to address the role of the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), since OCHA coordinates international response efforts to disasters in foreign nations. Similar to work with the International Search and Rescue Advisory Group for search and rescue operations, the US government should coordinate with the United Nations Disaster Assessment and Coordination (UNDAC) unit within OCHA to set up a system that establishes operating standards for FMTs. This system should aim to create uniform standards among FMTs and response teams in a host country to ensure efficient integration of FMTs into domestic operations. As noted, these efforts should expand as well to address approaches to professionalizing NGOs so that such teams can also meet the standards necessary to integrate into overall operations. USAID and other relevant agencies should begin conversations with OCHA to predetermine what role the UNDAC will play in response to a CHE in the US, instead of reacting to the request for participation of the key international organizations as an event unfolds.

5. 5. Just as domestic assets address liability protection issues, foreign governments deploying medical responders to the US should also address liability concerns regarding their medical teams. All medical providers will be subject to some potential liability and, therefore, in the absence of criminal, malicious, or grossly negligent conduct, governments that dispatch FMTs should be responsible for all costs and liabilities associated with their teams. Beyond direct costs associated with receiving foreign medical assistance, the US government should not be accountable for any potential additional costs and liabilities associated with injuries, economic losses, and other claims borne by FMTs when responding to a disaster in the US. Congress, FEMA, and other federal agencies should develop a template and prescripted language for response policies and frameworks that clarify this responsibility for foreign donors.