Fast Facts

The catastrophic destruction caused by Hurricanes Irma and Maria overwhelmed the U.S. Virgin Islands and Puerto Rican governments and resulted in a large federal disaster response.

The Department of Health and Human Services led federal public health and medical services efforts. Among other things, it provided medical personnel and facilities and evacuated critical care and dialysis patients.

We identified shortcomings in HHS’s efforts, such as insufficient staffing at emergency operations centers that contributed to confusion over the status of evacuated patients. We made 7 recommendations, including that HHS ensure adequate staffing.

HHS’s Disaster Medical Assistance Team Setting Up a Temporary Medical Clinic in Puerto Rico, October 2017

A team of people organizing boxes of supplies

A team of people organizing boxes of supplies

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Highlights

What GAO Found

The catastrophic destruction encountered as a result of Hurricanes Irma and Maria proved overwhelming to the U.S. Virgin Islands and Puerto Rican governments and resulted in a large federal disaster response, complicated by losses of power, communication, and health care infrastructure. The Department of Health and Human Services (HHS) led the federal public health and medical services response and undertook numerous actions to address the needs in the territories—including evacuating critical care and dialysis patients from the U.S. Virgin Islands and Puerto Rico and providing medical personnel and facilities.

However, GAO identified several shortcomings in HHS's leadership. While the scale, location, and timing of these storms complicated response efforts, the deficiencies GAO identified were in many cases a function of preparedness policies, or lack thereof. As a result, they could adversely affect future large-scale responses unless addressed. For example, as the lead agency, HHS is responsible for ensuring that appropriate planning activities are undertaken, including monitoring the federal ability to provide core public health and medical services response capabilities. However, GAO found that

HHS did not have a full understanding of the capabilities and limitations of its support agencies, including the Departments of Defense, Homeland Security, and Veterans Affairs. Consequently, HHS's needs were not always aligned with the resources that its support agencies could provide, resulting in some deployed resources not being properly and efficiently utilized. For example, HHS requested Department of Defense medical teams, but these teams specialized in trauma and surgical care, not the chronic and primary care needed.

HHS lacked plans for the territories that accounted for the chronic and primary care needs in isolated communities. This care was greatly needed, given that many, especially the elderly, could not easily access hospitals.

Example of Downed Power Lines in Puerto Rico, November 2017

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Why GAO Did This Study

Hurricanes Irma and Maria hit the U.S. Virgin Islands and Puerto Rico within two weeks of each other in September 2017, causing catastrophic damage. HHS is responsible for leading the federal public health and medical services response during a disaster, such as these hurricanes. As part of its lead federal role during these hurricanes, HHS called upon support agencies, including the Departments of Defense, Homeland Security, and Veterans Affairs, to assist with the public health and medical services response.

GAO was asked to review the federal public health and medical services response to Hurricanes Irma and Maria in the U.S. Virgin Islands and Puerto Rico. This report examines HHS's actions and leadership of this response, among other things. GAO reviewed documentation on the preparedness for, and response to, the hurricanes. It also interviewed federal and territory officials and interviewed or received written responses from eight nonfederal stakeholders involved in the response, such as nongovernmental organizations. GAO identified these stakeholders through research and referrals.

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Recommendations

GAO is making seven recommendations, including that HHS develop agreements with support agencies that include response capability and limitation information, and develop response plans for providing care in isolated communities. HHS disagreed with two of the seven citing, among other things, territory responsibility for plans. GAO clarified the intent of the two recommendations and believes that all seven are warranted.

Recommendations for Executive Action

Agency Affected Recommendation Status
Office of the Assistant Secretary for Preparedness and Response
Priority Rec.
This is a priority recommendation.
ASPR should develop a response personnel strategy to ensure, at a minimum, a lead ASPR liaison officer is consistently at the local emergency operations center(s) during an emergency support functions (ESF) #8 response and another liaison, if not more, is at strategic location(s) in the area. (Recommendation 1)
Open
ASPR agreed with this recommendation. ASPR officials told us in May 2019, and reiterated in March 2021, that they have an incident response framework that includes a long-term goal of creating an incident response team that will establish an initial ESF#8 presence at local emergency operations centers and manage resources and capabilities. If implemented, this strategy may allow ASPR to provide more liaisons on the ground during a response and address the staffing deficiency we identified. However, ASPR officials have not provided us with evidence that this team has been used successfully to ensure at least one liaison is consistently stationed at emergency operations centers. Given the challenges ASPR encountered in the U.S. Virgin Islands, we plan to keep this recommendation open until we receive additional information.
Office of the Assistant Secretary for Preparedness and Response As ASPR finalizes its federal patient movement framework, the agency should exercise the framework with its National Disaster Medical System (NDMS) partners to ensure that patients evacuated through NDMS will be consistently tracked from the start of their evacuation. (Recommendation 2)
Open
HHS officials concurred with this recommendation. As of March 2021, ASPR officials stated that implementation of this recommendation is still in progress.
Office of the Assistant Secretary for Preparedness and Response ASPR should put controls in place to ensure data on all NDMS evacuated patients are complete and accurate. (Recommendation 3)
Open
HHS officials concurred with this recommendation. As of March 2021, ASPR officials stated that they have hired a nurse consultant into NDMS who is the lead for the case management program. The consultant is in the process of developing procedures and training for case managers. Officials explained that their plan is to develop case managers within NDMS and not become dependent on the US Public Health Service as those resources are not part of ASPR and not always available when needed. In addition, officials stated that the contract for the Joint Patient Assessment and Tracking System will be opened for competition in 2021. We will review ASPR's efforts once they are completed.
Office of the Assistant Secretary for Preparedness and Response ASPR Region II should revise its Incident Response Plans for the territories to include strategies for providing chronic and primary care in isolated communities. These strategies could include the incorporation of Federally Qualified Health Centers and other local health clinics as part of a response. (Recommendation 4)
Open
HHS stated in 2019 and reiterated in March 2021 that it does not concur with this recommendation. In its comments on the draft report, HHS stated that while ASPR has federal plans in place that guide federal response, each state and locality is responsible for developing its own individual plans. However, according to a lead ASPR Region II official, these plans are internal agency plans that serve as a playbook for HHS officials during an ESF#8 response. As we reported, these plans do not account for the provision of chronic and primary care in isolated communities. Accordingly, we believe our recommendation is warranted.
Office of the Assistant Secretary for Preparedness and Response
Priority Rec.
This is a priority recommendation.
ASPR should work with support agencies to develop and finalize memorandums of agreement that include information on the capabilities and limitations of these agencies to meet ESF#8 core capabilities. (Recommendation 5)
Open
In its comments on the draft report and subsequently in March 2021, ASPR officials stated they do not concur with this recommendation. In its comments, HHS proposed the continued use of interagency liaison officers at the HHS emergency operations center, as they can provide real-time updates on available resources during a response. We agree that HHS should continue this practice in future responses. However, as is evidenced by the capabilities misalignment identified in our report, this action was not adequate during the response to Hurricanes Irma and Maria in the U.S. Virgin Islands and Puerto Rico. Further, as we reported, ASPR officials acknowledged that more needs to be done to better understand the resources available from its support agencies. We maintain that it is essential for ASPR to take steps to ensure it has a sufficient understanding of each ESF#8 support agency's potential capabilities and limitations. As we have reported, taking such action is needed to help ensure that future ESF#8 responses are more efficiently and effectively coordinated.
Office of the Assistant Secretary for Preparedness and Response ASPR should develop a strategy demonstrating how it ESF#8 core capabilities can be provided through HHS and ESF#8 support agencies if DOD's capacity to respond is limited. (Recommendation 6)
Open
HHS officials agreed with this recommendation. As of March 2021, ASPR officials stated that they continue to work on implementing this recommendation.
Office of the Assistant Secretary for Preparedness and Response ASPR should take steps to ensure the perspectives of key external parties are incorporated in the development of HHS's after-action reviews, following future ESF#8 activations. (Recommendation 7)
Open
HHS officials agreed with this recommendation. As of March 2021, ASPR officials stated that they continue to work on implementing this recommendation.

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