Introduction

In 2002, in response to the devastation wrought on 9/11 and the ensuing attacks of anthrax through the mail system, President Bush created the USA Freedom Corps (USAFC) to promote opportunities for volunteers to serve their communities while strengthening homeland security. As part of the USAFC initiative, the President also established the Citizen Corps to function as a coordinating council for numerous new and existing volunteer programs that would promote and enhance community emergency preparedness. These volunteer programs included the Community Emergency Response Teams, Fire Corps, the Neighborhood Watch Program, Volunteers in Police Service, and the Medical Reserve Corps (MRC).

The MRC was created within the Office of the Surgeon General (OSG), in the U.S. Department of Health and Human Services (HHS), with the explicit mission to "establish teams of local medical and public health professionals who contribute their skills and expertise throughout the year and during times of community need" (MRC, 2007). The MRC Program consists of local physicians, nurses, dentists, veterinarians, epidemiologists, and other volunteers preidentified as a reserve resource for their communities, ready to address emergent threats as they arise and to address broader public health needs of the community (Hoard and Tosatto, 2005). OSG implemented MRC through a small demonstration grants program in 2002-2006. During the first 2 years of the demonstration project (2002 and 2003), 42 and 124 units were funded, respectively, typically with $50,000 annually (for 2 or 3 years) in federal grant funds provided directly to each MRC unit's local sponsoring organization (i.e., local health department, university, or hospital).

The MRC Program recognized from the outset that each local community had its own unique characteristics; thus, the initial guidance for these grants was purposefully broad—an acknowledgment that the local community could best assess its special needs, define its response, and implement its program activities through its own volunteers. Nonetheless, the MRC Program established six main goals to guide and shape the activities to be undertaken by the MRC units created under the demonstration project (Figure 1-1). At the federal level, the role of the MRC Program office was to foster communications among MRC units and help them share lessons learned, coordinate efforts across federal agencies, enhance program visibility and recognition, and build local unit capacity through leadership conferences and technical assistance.

The concept of using volunteers to address emergency needs following disasters is a long-standing one. For many decades, the American Red Cross has successfully organized mental health counselors and other professionals to provide acute support to communities that have suffered natural disasters. Moreover, the concept of using volunteer physicians, nurses, and other health care providers to provide medical care has been demonstrated successfully for large-scale public events (Feldman et al., 2004; Wetterhall and Noji, 1997), international relief efforts in response to the Asian tsunamis (Bridgewater et al., 2006) and other natural disasters, and severe acute respiratory syndrome (Shih and Koenig, 2006).

By contrast, the concept of identifying, recruiting, and sustaining health care providers as "volunteers-in-waiting" for service in their respective local (and more distant) communities is a more recent innovation in emergency medical response. The National Disaster Medical System (which currently falls under HHS, but during the period of the MRC demonstration project operated under the auspices of the U.S. Department of Homeland Security [DHS] ) maintains a cadre of Disaster Medical Assistance Teams (DMATs) for deployment to disaster areas. These are federal assets designed to provide a rapid, definitive care response until other federal, regional, or State resources can be mobilized. MRC units can be engaged in activities complementary to DMATs as a backup to local emergency response efforts during a disaster (Hoard and Tosatto, 2005). MRC units, unlike DMATs, may be mobilized not only for an emergency or disaster, but also to support other year-round public health activities (e.g., immunization clinics, health fairs).

The concept of volunteers-in-waiting involves a series of philosophical and operational challenges that must be faced at the local, State, and federal levels, and these dictate the need for close coordination across all those levels. Experiences both internationally (Bremer, 2003) and domestically—most notably 9/11 (Kapucu, 2006) and Hurricane Katrina (Crammer, 2005; Franco et al., 2006; Gavagan et al., 2006)—highlight the fundamental importance of coordination among multiple entities before, during, and after a disaster. Moreover, preplanning and coordination with existing emergency response protocols are especially critical for volunteers. The worst possible scenario for a volunteer is to arrive at a disaster site untrained, unprepared, and unconnected to any formally recognized, organized response effort at the local, State, or federal level. Such self-deployments, although well intentioned, are an impediment to rescue and relief efforts (Martinez and Gonzalez, 2001; Crippen, 2006; Campos-Outcalt, 2005).

Certainly, the lack of any coordinating structure to manage the multitude of self-deployed medical volunteers in the wake of 9/11 provided ample rationale for the creation of the MRC (Hoard and Tosatto, 2005). As both 9/11 and Hurricane Katrina so poignantly demonstrated, in the immediate aftermath of a disaster, many Americans are more than eager to help; however, capitalizing on those offers of assistance requires an organizational structure to manage and integrate them into existing emergency response systems. Without such a structure, medical volunteers may be turned away or assigned to duties that do not make the best use of their talents and skills (Franco et al., 2006). The promise of the MRC Program is that it will provide States and localities the kind of organizational scaffolding needed to effectively utilize the skills and talents of medical volunteers both in times of need and for broader public health concerns.

Return to Contents

1.1 Evaluation of the MRC Program during the Demonstration Project

To assess the conceptual underpinnings and execution of the MRC Program during the demonstration period, RTI International initiated an independent evaluation of the program in February 2005 with the three specific objectives of

• Evaluating the applicability and effectiveness of the MRC Program in assisting MRC units to meet program goals.
• Evaluating MRC performance over the past 3 years (2003, 2004, and 2005) as it relates to program goals and objectives, and
• Evaluating the effectiveness of the MRC Program office and contract services in supporting and assisting MRC units to meet program goals.

The evaluation consists of two main activities: (1) key informant interviews with MRC Program staff in OSG and other relevant federal agencies and (2) case studies of six MRC units. The first component, the key informant interviews with federal stakeholders, was previously presented in the Interim Report. Here we present the findings of both components.

The remainder of the report is organized as follows. In Chapter 2, we describe our methods for planning and conducting the key informant interviews, as well as the criteria used to select the six case study units. In Chapter 3, we present the findings of our federal stakeholder interviews and our case study unit interviews by evaluation question. In Chapter 4, we summarize the key issues and implications of the findings for MRC design and operations.

Figure 1-1. Six Goals of the MRC Demonstration Project

Goal 1. Demonstrate whether medical response capacity can be strengthened through MRC units consisting of a broad range of medical and health professionals. Goal 2. Demonstrate whether surge capacity can be created to handle emergency situations that have significant consequences for the health of the population. Goal 3. Demonstrate whether the MRC enables current and retired health professionals to obtain additional training needed to work effectively and safely during emergency situations. Goal 4. Demonstrate whether the MRC approach provides an effective organizational framework with a command and control system within which appropriately trained and credentialed volunteers can use their skills in health and medicine. Goal 5. Determine whether the MRC approach facilitates coordination of local citizen volunteer services in health and medicine with other response programs of the community/county/State during an emergency. Goal 6. Determine whether the MRC approach provides cadres of health professionals who contribute to the resolution of public health problems and needs throughout the year.

Return to Contents
Proceed to Next Section