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MMRS: If I’ve never heard of it…why should I care?

By John J. Shaw, DMD, Former coordinator of Capitol Region MMRS

On April 19, 1995, Timothy McVeigh filled a 20-foot Ryder truck with 5,000 pounds of fertilizer and ammonium nitrate.  Two days later, Americans were shocked by the TV coverage of death and destruction at the Murrah Federal Building in Oklahoma City . There were scenes of dazed and bloodied citizens, of frightened parents praying the building’s daycare center had miraculously survived the blast, and rescuers desperately searching for survivors. In the end, 168 died and 400 were injured.  The sight of bloodied or dead children heightened our sense of vulnerability, and the bombing touched us in an intensely intimate way.

In the harsh light of the inevitable criticism, questions were asked about our preparedness for violent attacks, and the answers were unsettling.  Elected officials vowed never to allow our cities to go unprotected again. Congressional investigators identified shortcomings in medical preparedness at the local level following the incident, and the fear that most cities were equally vulnerable. Legislation to make our cities safer was passed.

The Defense against Weapons of Mass Destruction Act of 1996 was designed to enhance the capabilities of communities to respond to acts of terrorism. Then in 1997, the Nunn-Lugar-Domenici Amendment to the National Defense Authorization Act, a far-reaching and powerful document, authorized funding for the first Metropolitan Medical Strike Teams (MMST). The MMST’s consisted of trained and well-equipped local volunteers from the medical and emergency management professions, who would serve as our cities’ first line of medical response in those desperate hours immediately following an attack. 

The MMST concept evolved into the current Metropolitan Medical Response System (MMRS), a more comprehensive mechanism that involves all response professions and functions as a planning entity with operational capabilities. The MMRS provides federal funding directly to local communities to ensure that response plans are comprehensive and inclusive.

By 2002, the MMRS had expanded to 124 cities representing 80% of our population. Large cities and small towns across the nation began to plan together and to share their response assets. The MMRS emerged as the premier planning entity for community health and medical response. For the first time, traditional emergency planners from fire and police were meeting with health departments and hospitals to develop effective community emergency response plans.

No two MMRS jurisdictions looked alike, a reflection of the superb ability of jurisdictions to meet local needs and to build on available local assets. But each shared a common capability in providing medical incident management plans and trained responders. 

In 2002, the Congress provided $50 million to the MMRS program, assigned additional planning responsibilities, and the federal government had a platform for the seamless integration of federal assets when locally deployed.

The Institute of Medicine concluded that:

“The importance of the MMRS program is no longer equivocal, questionable or debatable. The enhanced organization and cooperation demanded by a well-functioning MMRS program will permit a unified preparedness and public health system with immense potential for improved responses.”1

The MMRS program was a pioneer in forging close operational links among responders of all types. The combined MMRS jurisdictions represented an effective national infrastructure working at the local level, where many feel it counts the most.

The MMRS proved its worth following Hurricanes Katrina. After the devastation, the East Baton Rouge Parish MMRS was activated and successfully coordinated the triage and treatment of thousands of medical emergencies. 

East Baton Rouge Parish Mayor-President "Kip" Holden stated, "Without the relationships that were in place, the training and communications systems (that are) integral to the MMRS program, and the support of other MMRS jurisdictions throughout the country, the death count here would have been much greater. I watched this medical program work in our region when others failed across the state." 2   

Numerous additional testimonies cite the value of MMRS, yet today the MMRS program is fighting for its life. Sustainment funding has not been allocated since fiscal year 2005, and the proposed FY 2008 White House budget has zeroed it out again.  Despite its exemplary record of success, the MMRS program clearly has fallen into disfavor at the federal level.

How have the funding cuts impacted the local government level? Almost immediately, efforts to continue the outreach were reduced or eliminated, and hiring policies severely limited. Yet, despite drastic funding cuts and degradation of the program, the latest DHS grants continue to identify new and increasingly sophisticated objectives for the MMRS.  

According to Captain Michael Anderson, the MMRS National Program Manager at DHS, “Something has to give. There has been so much criticism inside the beltway about the inability of our nation to respond effectively to mass casualty disasters. Yet the MMRS program has essentially created 124 local medical incident management teams with proven capabilities. And now the MMRS jurisdictions are dealing with surge capacity and pan flu issues simply because there are no other agencies capable of organizing the way MMRS does. A zero budget for MMRS will only serve to quickly erode those critical relationships that MMRS has established and maintained at the local level for integrated, coordinated medical response planning, medical response operations and medical incident management.”3

Why is the MMRS program in trouble?  The answer to this question is enlightening.

On February 11, 2004, the Washington Post published an article entitled, “OMB Draws a Hit List of 13 Programs It Calls Failures”. In the article, the Office of Management and Budget was reported to have concluded: “...the Metropolitan Medical Response System has met its goal of helping 122 cities prepare local health authorities to cope with mass casualties from a terrorist attack, and its $50 million in annual funding should end.”4

The recommendation to terminate the program was based on two findings. First, Congress had intended only to provide a baseline level of funding to local communities. At the time of the OMB report however, only about 70 of the 124 MMRS jurisdictions had actually achieved the baseline.

The second OMB finding stated that the MMRS had failed to create tools to assess short-and-long term outcomes of the program, making it impossible to accurately determine the effectiveness of the work. Ironically, in recognition that it might not be possible to evaluate the accomplishments of one jurisdiction against another’s, national MMRS leaders asked for funding to initiate an MMRS Operational Readiness Assessment.  However, that request was sidetracked for the duration of 2004 by OMB.

MMRS jurisdictions create plans and procedures that are a reflection of local leadership, training, and locally available resources, giving each jurisdiction a distinctly local look. Given the MMRS mission, the local character of the jurisdictions is the best indicator of success, and is something to be celebrated, not criticized.

The OMB report of 2004 marked both the moment when the continuation of the MMRS program first became doubtful, and the start of a remarkable effort to ensure its survival. Rep. Ed Markey (D-MA), a strong supporter of the MMRS program, led a dramatic charge to ensure that the MMRS survived.5 Due to Rep. Markey’s dogged efforts, both the House and Senate disapproved the reallocation of funds, citing a need to preserve the baseline capabilities at the local level. That same year, the U.S. Conference of Mayors called on the Congress to “...authorize and fully fund the MMRS program.”6

Despite the vocal support coming from the Congress and from local elected officials, the stage was set for the ongoing, uphill struggle for the survival of the MMRS program.

In an extraordinary demonstration of belief in the value of local MMRS programs, individual MMRS leaders have traveled to Washington repeatedly during the last three years to create an increased awareness in Congress of the critical importance of the MMRS mission.  Congress responded in limited fashion.  From a high of $50 million in 2003, the MMRS funding has dropped to slightly more than $30 million, an amount that allows the jurisdictions to preserve many of their basic capabilities, but forced jurisdictions to seek additional funding sources.  In some cases this puts the MMRS in competition with other agencies for local preparedness dollars.

Bill Ginnow, the MMRS program manager in Hampton Roads, VA, stated: "Our ability to sustain and expand regional preparedness efforts to address increased risks have been hampered by several years of reduced federal funding. Without supplemental local funding, our program and capabilities would have been significantly diminished." 7

In 2007, the battle for the survival of the MMRS has taken another twist. In January, in response to lessons learned from the 2005 Gulf Coast response disaster, the forces of homeland security were once again realigned. Federal response assets formerly housed at DHS have been transferred to the Department of Health and Human Services (HHS) in an effort to bring all federal medical response capabilities under one roof.  The MMRS however remains at DHS, and is the only medical program left in that department. 

When all medical response teams were located under the DHS roof, the roles and responsibilities of each were clearly defined. The MMRS served as the principal planning agent at the local level, designing procedures to maximize the use of local resources. MMRS protocols assured that the federal responders would be incorporated into the local operational command smoothly and seamlessly. The relationship between the local planners and the federal responders had been tested successfully on numerous occasions.

MMRS’s role under DHS now seems unclear. If the MMRS is expected to continue as the principal planner for local health and medical response, then questions arise as to the authority of MMRS, a DHS agent, to coordinate and integrate HHS assets when they are deployed to the scene of an incident.

This apparent lack of direction for the MMRS program at the federal level, and the anticipation of zero funding for FY 2008, are the clearest indicators to date that the MMRS is in danger of collapse.  There are significant implications for our municipalities should the MMRS be allowed to fade away.

First, common sense dictates that planning is a task never completed.

Second, if the MMRS is eliminated, it would be reasonable to expect that our cities would have to find another way to continue the MMRS program, or risk the loss of all the work done by the MMRS. But is anyone watching?  Hopefully, responsible citizens would be wise to ask why our nation’s leaders want to discard a program with a proven track record in favor of starting over with a new, untried process.  

High level debate is needed.  The leaders face the daunting challenge of having to defend a program that over time has been praised at the local level while being labeled no longer useful at the federal level. The MMRS is fast becoming the orphan child of the homeland security industry.

Once again, Massachusetts ’ Rep. Ed Markey is preparing to lead the next charge to save the program.  Markey and other members of Congress are exploring legislation that would fund the MMRS program in FY 2008 at more than $60 million, an amount that MMRS program officers say will provide the funds needed to restore the baseline capabilities. It will also begin to finance the additional local MMRS responsibilities associated with pandemic flu planning.

So the battle to save MMRS is well under way. The MMRS, played out in 124 different locations nationwide, has enabled our cities to face the challenges of health and medical incident management with confidence. Armed with the encouragement of local elected leaders and the anticipated bipartisan support of the Congress, the Metropolitan Medical Response System program will continue to be the best single investment this nation has made in preparing our health providers and medical facilities to respond to mass casualty disasters. 

So, even if you have never heard of the program until now, there is a reason to care because your safety and that of your family is directly impacted by the MMRS program.


history references

1 Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System Program, Institute of Medicine, Washington, D.C., National Academy Press, 2002.

2 East Baton Rouge Parish Mayor-President "Kip" Holden,   personal communication with the author, February 28, 2007.

3 CAPT Michael B. Anderson, Acting National Program Manager, the Metropolitan Medical Response System, personal communication with the author, February 28, 2007.

4 Christopher Lee, OMB Draws a Hit List of 13 Programs It Calls Failures, The Washington Post, February 11, 2004, p.A29.

5 Rep. Ed Markey, Massachusetts Seventh District, letter to the Honorable Harold Rogers and the Honorable Martin Sabo, U.S. Congress, May 5, 2004.

6 Conference of Mayors, Metropolitan Medical Response, 2004 Adopted Resolutions, 72nd Annual Meeting, Boston .

7 William Ginnow, MS, RPh, Program Manager, Hampton Roads, VA Metropolitan Medical Response System, personal communication with the author, March 1, 2007.