This series spotlights the importance of addressing the specific needs of children before, during and after disasters. Children represent almost one quarter of the American population and can be significantly impacted by disasters and traumatic events. Based on this fact, the series will discuss a variety of issues, strategies and developments relating to children and disasters with the goal of providing emergency managers with valuable tools and knowledge to plan effectively for America’s most vulnerable.
Last fall we launched a series on children and disasters, offering an overview of the issue’s history since Hurricane Katrina laid it bare in 2005 and introducing some of the organizations that have continued to advocate for the needs of children in emergencies in the years since. Now we turn our attention to the current landscape: where does the issue of preparation for children before, during and after disasters stand today?
As we discussed previously, the National Commission on Children and Disasters was created in 2008 to delve deeply into the needs of children before, during and after disasters. Following its submission of a set of detailed findings and recommendations to President Barack Obama and Congress in 2010, the Commission was sunset, leaving a loose coalition of pediatric associations and non-profits to advocate for enactment of its recommendations.
In 2013, as part of the Pandemic All Hazards Preparedness Act (PAHPA) re-authorization, language was inserted to create a longer-standing Federal Advisory Committee that could continue to carry forward the issues specific to children in disasters. In 2014, the U.S. Department of Health and Human Services (HHS), to meet its statutory obligations under the PAHPA reauthorization, established the National Advisory Committee on Children and Disasters (NACCD). This committee was created to advise the Secretary of HHS and the Assistant Secretary for Preparedness and Response (ASPR) on issues related to the medical and public health needs of children relative to disasters. It is worth noting that, unlike the National Commission on Children and Disasters, which made its recommendations directly to the President and Congress, the NACCD is an internal committee to HHS; it is governed by the rules and regulations of the Federal Advisory Committee Act.
In November 2015, the NACCD released a series of recommendations to the ASPR centered on coalition-building, workforce development, and medical countermeasure readiness. While the full report extensively details the current state, gaps, mitigation strategies, best practices, and recommendations for each area, we have highlighted some of its more noteworthy points.
- Coalition-building. Noting that “[p]ediatric disaster coalitions, incorporated into overall disaster planning and management, are now recognized as a most effective mechanism to match resources to needs during catastrophic events and thereby provide the best outcomes for pediatric victims and their families,” the NACCD recommended several actions aimed at fostering such a coordinated multidisciplinary response.
Recommendations included developing practical guidance on establishing and managing regional pediatric disaster coalitions while removing the still-prevalent silo approach that often omits non-profits, human services agencies and other key players. Other recommendations promoted increased education and funding, as well as an expansion of the definition of “first responder” for disaster preparedness to encompass others qualified to give care, such as school nurses and childcare providers.
- Workforce development. Asserting that “the current culture of preparedness in healthcare is reactive instead of proactive,” the NACCD identified the root of the issue to be the disconnect between the state and federal government entities who establish response vision and policy and the local entities who are actively engaging and responding when crises occur. Local responders are expected to operationalize the policies enacted by the state and the feds, often with little to no funding, while simultaneously maintaining readiness for the next emergency. Furthermore, while pediatric preparedness information is available, it is often targeted exclusively to physicians and nurses, omitting other key responders like school nurses, paramedics and pharmacists.
The NACCD also points out that non-pediatric physicians’ residencies do not usually include any pediatric disaster response training. Therefore, the NACCD recommended that everyone with a role to play in caring for children impacted by disaster must be adequately trained for the task and that pediatric disaster training standards for both medical and non-medical responders should be developed. They also suggested incorporating pediatric-specific standards into the Healthcare Preparedness Capabilities guidance and assessment of pediatric preparedness in Hospital Preparedness Program applicants and grantees. Additionally, access to mental health resources, crisis counseling, and Incident Command System training for doctors, nurses, and childcare providers were encouraged.
- Medical countermeasures. While the ability of the U.S. to administer pharmaceuticals to children in emergency situations has improved dramatically in the past ten years, gaps stubbornly persist. The NACCD honed in on a variety of issues, including adult auto-injector modification for emergency pediatric use, guidance and training on emergency dosing, alternative drug delivery systems, off-label drug options, and standardization of pediatric medications and supply stocks.
Furthermore, the NACCD observed that some drugs have not yet received FDA approval for pediatric use because the necessary studies and research have not been undertaken. This renders an understanding of off-label use for children all the more critical because there may not be a formally approved drug for pediatric use in certain chemical, biological, radiological, and/or nuclear situations.
Finally, the NACCD acknowledged the ethical issues that can arise when treating children in disaster situations. For example, children cannot provide consent for medications and must rely on parents or guardians to provide consent for them. Even more challenging is the question of children participating in clinical trials, which would be necessary for the completion of the research previously mentioned.
The Current State of Pediatric Preparedness
Although we see progress on the children’s preparedness front, we also see continued inaction by policymakers and funders alike. The science of what matters in preparedness for children is actually much clearer than that of communities as a whole, but we continue to muddy the waters by building capacity while ignoring capability. Grant guidance for preparedness programs continues to omit specific, significant language surrounding effective preparedness relating to the needs of children during and after disasters, allowing a great deal of wiggle room for communities to spend funds on non-child-related readiness efforts. Funding is in danger of further erosion as Congress and the Trump Administration identify new priorities and develop different policies in support of those priorities. Unfortunately, the prevalent policy and funding philosophy of preparedness for our children has become, “if it happens, we will fund.” It has been said that “strategy lacking resources is rhetoric,” and that is evident in our national approach to this critical issue.
The breadth of gaps and issues identified above provide a small glimpse into the complicated nature of the challenges facing policymakers when it comes to emergency preparedness for children. Issues impacting the broad question of effective care for children in disasters encompass a dizzyingly wide range of considerations: from psychological first aid and medical dosing challenges to standardizing pediatric supply requirements on ambulances, incorporating schools into disaster planning, facilitating emergency social services for families, protecting children from opportunistic sexual predators during the chaos that often follows a crisis and more. Yet, despite these many challenges, we must face such obstacles head on. Even if policymakers do not often agree, everyone can agree that children and their families deserve our very best efforts to prepare for their wellbeing.