<DOC>
[109th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:36035.wais]
PROTECTING THE HOMELAND: FIGHTING
PANDEMIC FLU FROM THE FRONT LINES
=======================================================================
JOINT HEARING
before the
SUBCOMMITTEE ON PREVENTION OF NUCLEAR AND BIOLOGICAL ATTACK
joint with the
SUBCOMMITTEE ON EMERGENCY
PREPAREDNESS, SCIENCE, AND TECHNOLOGY
of the
COMMITTEE ON HOMELAND SECURITY
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
FEBRUARY 8, 2006
__________
Serial No. 109-61
__________
Printed for the use of the Committee on Homeland Security
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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__________
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COMMITTEE ON HOMELAND SECURITY
Peter T. King, New York, Chairman
Don Young, Alaska Bennie G. Thompson, Mississippi
Lamar S. Smith, Texas Loretta Sanchez, California
Curt Weldon, Pennsylvania Edward J. Markey, Massachusetts
Christopher Shays, Connecticut Norman D. Dicks, Washington
John Linder, Georgia Jane Harman, California
Mark E. Souder, Indiana Peter A. DeFazio, Oregon
Tom Davis, Virginia Nita M. Lowey, New York
Daniel E. Lungren, California Eleanor Holmes Norton, District of
Jim Gibbons, Nevada Columbia
Rob Simmons, Connecticut Zoe Lofgren, California
Mike Rogers, Alabama Sheila Jackson-Lee, Texas
Stevan Pearce, New Mexico Bill Pascrell, Jr., New Jersey
Katherine Harris, Florida Donna M. Christensen, U.S. Virgin
Bobby Jindal, Louisiana Islands
Dave G. Reichert, Washington Bob Etheridge, North Carolina
Michael T. McCaul, Texas James R. Langevin, Rhode Island
Charlie Dent, Pennsylvania Kendrick B. Meek, Florida
Ginny Brown-Waite, Florida
______
SUBCOMMITTEE ON PREVENTION OF NUCLEAR AND BIOLOGICAL ATTACK
John Linder, Georgia, Chairman
Don Young, Alaska James R. Langevin, Rhode Island
Christopher Shays, Connecticut EdwarD J. Markey, Massachusetts
Daniel E. Lungren, California Norman D. Dicks, Washington
Jim Gibbons, Nevada Jane Harman, California
Rob Simmons, Connecticut Eleanor Holmes Norton, District of
Bobby Jindal, Louisiana Columbia
Charlie Dent, Pennsylvania Donna M. Christensen, U.S. Virgin
Peter T. King, New York (Ex Islands
Officio) Bennie G. Thompson, Mississippi
(Ex Officio)
______
SUBCOMMITTE ON EMERGENCY PREPAREDNESS, SCIENCE, AND TECHNOLOGY
Dave G. Reichert, Washington, Chairman
Lamar S. Smith, Texas Bill Pascrell, Jr., New Jersey
Curt Weldon, Pennsylvania Loretta Sanchez, California
Rob Simmons, Connecticut Norman D. Dicks, Washington
Mike Rogers, Alabama Jane Harman, California
Stevan Pearce, New Mexico Nita M. Lowey, New York
Katherine Harris, Florida Eleanor Holmes Norton, District of
Michael McCaul, Texas Columbia
Charlie Dent, Pennsylvania Donna M. Christensen, U.S. Virgin
Ginny Brown-Waite, Florida Islands
Peter T. King, New York (Ex Bob Etheridge, North Carolina
Officio) Bennie G. Thompson, Mississippi
(Ex Officio)
(II)
C O N T E N T S
----------
Page
STATEMENTS
The Honorable John Linder, a Representative in Congress From the
State of Georgia, and Chairman, Subcommittee on Prevention of
Nuclear and Biological Attack.................................. 1
The Honorable James L. Langevin, a Representative in Congress
From the State of Rhode Island, and Ranking Member,
Subcommittee on Prevention of Nuclear and Biological Attack.... 2
The Honorable Dave Reichert, a Representative in Congress From
the State of Washington, and Chairman, Subcommittee on
Emergency Preparedness, Science, and Technology................ 4
The Honorable Bill Pascrell, Jr., a Representative in Congress
From the State of New Jersey, and Ranking Member, Subcommittee
on Emergency Preparedness, Science, and Technology............. 5
The Honorable Bennie G. Thompson, a Representative in Congress
From the State of Mississippi, and Ranking Member, Committee on
Homeland Security.............................................. 6
The Honorable Donna M. Christensen, a Delegate in Congress From
the U.S. Virgin Islands........................................ 50
The Honorable Bob Etheridge, a Representative in Congress From
the State North Carolina....................................... 52
The Honorable Nita M. Lowey, a Representative in Congress From
the State if New York.......................................... 57
The Honorable Edward J. Markey, a Representative in Congress From
the State of Massachusetts..................................... 59
The Honorable Eleanor Holmes-Norton, a Delegate in Congress From
the District of Columbia....................................... 55
Witnesses
Mr. Ernest Blackwelder, Senior Vice President, Business Force,
Business Executive for National Security:
Oral Statement................................................. 30
Prepared Statement............................................. 32
The Honorable David B. Mitchell, Secretary, Department of Safety
and Homeland Security, State of Delaware:
Oral Statement................................................. 16
Prepared Statement............................................. 18
Ms. Frances B. Phillips, RN, MHA, Health Officer, Anne Arundel
County, Maryland Department of Health:
Oral Statement................................................. 23
Prepared Statement............................................. 26
Dr. David C. Seaberg, Department of Emergency Medicine,
University of Florida:
Oral Statement................................................. 36
Prepared Statement............................................. 38
Dr. Tara O'Toole, Chief Executive Officer and Director, Center
for Biosecurity, University of Pittsburgh Medical Center:
Oral Statement................................................. 8
Prepared Statement............................................. 11
PROTECTING THE HOMELAND: FIGHTING PANDEMIC FLU FROM THE FRONT LINES
----------
Wednesday, February 8, 2006
u.s. House of Representatives,
Committee on Homeland Security,
Subcommittee on Prevention of Nuclear
and Biological Attack,
joint with the
Subcommittee on Emergency Preparedness,
Science, and Technology,
Washington, DC.
The subcommittees met, pursuant to call, at 2:11 p.m., in
Room 2237, Rayburn House Office Building, Hon. John Linder
[chairman of the Subcommittee on Prevention of Nuclear and
Biological Attack] presiding.
Present: Representatives Linder, Reichert, Rogers, Dent,
Langevin, Pascrell, Thompson, Markey, Lowey, Norton,
Christensen, and Etheridge.
Mr. Linder. [Presiding.] The Committee on Homeland
Security's Subcommittee on Prevention of Nuclear and Biological
Attack and the Subcommittee on Emergency Preparedness, Science
and Technology will come to order.
The subcommittees are meeting today to hear testimony on
protecting the homeland in fighting pandemic flu on the
frontlines. I would like to welcome and thank our distinguished
panel of witnesses for appearing today before this joint
hearing of these two subcommittees.
Imagine this scenario. On September 29, seven deaths were
reported in Washington. By October 2, there had been a total of
35. By the middle of October, 60 to 90 people were dying each
day.
By then, the city's commissioners had taken drastic steps,
first closing the schools, then prohibiting any large indoor
public gatherings, including church services. The Red Cross
nurses were caring for the sick, who were flooding area
hospitals, or worse, suffering unattended in their homes.
Disposal of bodies became a particular problem. On October 12,
the U.S. Capitol shut its door to visitors.
Ladies and gentlemen, this is an account of life in the
fall of 1918 here in Washington, D.C., reported in The
Washington Post. The United States, like most of the rest of
the world, was gripped with a pandemic of Spanish influenza.
With over 50 million deaths worldwide, it was the third-largest
epidemic in recorded history, and the largest since the Middle
Ages.
Today, the possibility exists that the world may face yet
another deadly outbreak, this time from an avian influenza
strain known as H5N1. While the virus has not yet evolved into
a form easily transmissible between humans, should it acquire
that capability, it is similar to the 1918 pandemic. Estimates
show that between 30 million and 384 million people worldwide
would be afflicted.
To combat this potentially devastating scenario, President
Bush announced on November 1 of last year a national strategy
for pandemic influenza, which provides a framework for U.S.
government planning efforts.
The goals of the national strategy are: first, to stop,
slow or otherwise limit the spread of a pandemic to the United
States; second, to limit the domestic spread of a pandemic and
mitigate disease, suffering and death; and third, to sustain
infrastructure and mitigate the impact of a pandemic to the
economy and society.
I look forward to working with the executive branch to
implement this initiative in the coming months.
The national strategy recognizes, however, that preparing,
implementing and responding to a pandemic cannot be viewed as a
purely federal responsibility. Our nation must have a system in
place at all levels of government and all sectors of society to
address the pandemic threat.
Medical countermeasures such as vaccines and antiviral
drugs are vital. At present, the strategic national stockpile
only has approximately 3 million bulk courses of an unfinished
H5N1 vaccine. The vaccine has not even yet been filled in
vials. Antivirals like Tamiflu are limited as well. There are
only enough doses on hand to cover about 1 percent of the U.S.
population.
Furthermore, effectiveness of the H5N1 vaccine and
antiviral drugs in preventing and mitigating the effects of the
strain of the influenza that sparks a pandemic are unknown. In
the absence of an effective vaccine or antiviral, nonmedical
countermeasures and intervention strategies are critical.
Surveillance and early warning systems are essential tools
for the non-medical-based pandemic strategy that will afford us
more time to intervene and implement control measures to
mitigate the virus' spread.
Strengthening our public health infrastructure will
increase our ability to identify, diagnose and treat those
needing care, deliver information quickly to those local, state
and national health officials and physicians to be of most
help, as well as improve our overall surge capacity.
Extending efforts to most of these areas will certainly not
be a waste. It will instead provide benefits beyond preventing
and preparing for and responding to an influenza pandemic.
Clearly, if we are successful in implementing these strategies,
our nation will be better equipped to face the threat of
biological terrorism.
I am now pleased to yield for an opening statement to my
friend from Rhode Island, Mr. Langevin.
Mr. Langevin. Thank you, Mr. Chairman.
I would like to welcome our witnesses here today.
This hearing is on a very important topic. Influenza
pandemic is looming, and we need to know how prepared we are.
Just a few months ago, Hurricanes Katrina and Rita struck
the Gulf Coast. Response on nearly every level was disgraceful.
In the case of these hurricanes, we had several days of
warning. We should have been better prepared and ready to
respond.
In the case of a potential avian flu outbreak, we have
already had at least 1 year of warning and we probably have at
least another year to get ready. There really is no excuse for
failing to be prepared.
The Spanish flu epidemic of 1918 to 1920 is believed by the
CDC and other health experts to be a similar model of what we
can expect in an H5N1 outbreak. The Spanish flu killed
approximately 675,000 Americans and more than 20 million people
around the world.
Based on such a model, an epidemic of H5N1 avian influenza
could cause nearly 2 million deaths in the U.S. and up to 300
million deaths worldwide. That epidemic was nearly 90 years
ago. Our knowledge of viruses has increased dramatically and we
have many more tools at our disposal.
Last month, Secretary Leavitt was in Rhode Island to
promote the administration's response plan. While I appreciate
the fact that he is reaching out to states early, the message
from the meeting was that states need to fight the pandemic on
their own, with minimal federal assistance. Well, the flu does
not abide by state lines. We need a well-coordinated national
response if we are to be successful in slowing the spread of
disease and saving the lives of Americans.
Our goals must be realistic. We will not be able to keep
avian flu from our shores if it is to mutate into easy human-
to-human transmission. Unfortunately, people will get sick and
many could die. We must control the spread of the disease
enough to ensure that our health care system is not overwhelmed
and that our economy is not crippled.
I am concerned that the president's national strategy on
pandemic influenza could fail us because it puts too much
emphasis on vaccines and antivirals. The national strategy,
which was released in November, proposes $7.1 billion to
prepare for avian flu, 85 percent of which is focused on
vaccines and antivirals that the U.S. does not currently have
the capacity to produce.
At the same time, the national strategy provides only $251
million to detect and contain outbreaks and $644 million to
ensure that all levels of government are prepared to respond to
a pandemic outbreak. Even if cell-based vaccine production
technology were available today, the time from virus isolation
to vaccine production would be approximately 6 months. During
that time, no vaccine would be available. Using the present
technology, it would take between 14 to 18 months to
manufacture a vaccine.
An antiviral such as a Tamiflu will present a slightly more
optimistic story because they can be produced today. However,
the production process is difficult and takes approximately 6
to 8 months. Moreover, Tamiflu only treats the symptoms of the
flu, rather than preventing the spread of the virus, and it
must be taken within a few days of initial infection in order
to have any effect at all.
I am interested to hear from our witnesses today if they
feel the president's plan is a good one, or if they agree that
it relies too much upon drugs and not enough on simple public
health practices such as hand washing and limiting social
contact. We know that these methods, if practiced correctly,
can be effective.
I know that people such as our witnesses are trying their
best to prepare for a pandemic. One thing that would be
important is consistent and steady leadership, though, from the
federal government.
I am concerned that the national response plan might not be
executed properly because the White House and the Department of
Health and Human Services have created separate plans and
people do not know which plan to follow. So I am interested to
hear to whom you are looking to for guidance, and what kind of
leadership and cooperation you are receiving from the
Department of Homeland Security, as well as the Department of
Health and Human Services.
Ladies and gentlemen, right now, we have time to do what is
right, and to do this right overall in terms of response and
our planning. I am pleased to see that we are taking oversight
responsibility seriously by ensuring that we are prepared.
Mr. Chairman, I want to commend you for convening this
hearing today.
Thank you very much, Mr. Chairman. I yield back my time.
Mr. Linder. I thank the gentleman.
The Chair now recognizes the chairman of the Subcommittee
on Emergency Preparedness, Science and Technology, the
gentleman from Washington, Mr. Reichert, for the purpose of
making an opening statement.
Mr. Reichert. Thank you, Mr. Chairman.
Welcome. Thank you for taking time out of your schedules to
be with us this afternoon. I am looking forward to hearing from
you. We appreciate your appearance before us today at this
joint hearing on our nation's preparedness to deal with a
potential avian flu pandemic.
Before we start, I would like to commend my colleagues,
Chairman John Linder and Ranking Member Jim Langevin on the
Subcommittee on Prevention of Nuclear and Biological Attack,
for their hard work on this complex and pressing issue. I
appreciate your willingness to hold this joint hearing with the
Subcommittee on Emergency Preparedness, Science and Technology,
which I chair with the able assistance of my good friend Mr.
Pascrell.
As a former sheriff from the Seattle area, I approach this
issue from the perspective of a first responder. Avian flu may
never strike the United States, but if it does, this country
must be prepared. Pandemics affect every sector of our society,
not just our nation's health care system. It has the potential
to severely disrupt our way of life, cause devastating loss of
life, and have staggering effects on the international economy.
As usual, we will rely heavily on the nation's law
enforcement, firefighters, emergency medical services and other
health service workers to serve on the frontlines at grave
risk. These dedicated, caring men and women will not only be
required to care for the sick. They will also be required to
ensure the continuation of essential services, maintain public
order, distribute drugs and medical supplies, food, water and
enforce quarantines and isolations.
Given the unique nature of a pandemic, the federal
government will not be able to respond to every hot spot.
Unlike a natural disaster, even one as catastrophic as
Hurricane Katrina, a pandemic knows no geographical or temporal
bounds. It can spread around the globe in the course of months
or years, usually in waves, and affect communities of all sizes
and compositions.
That is precisely why our nation needs to ensure that every
level of government is adequately prepared. It is my hope that
this hearing will give the subcommittees a better sense of
state and local government and private sector pandemic flu
preparedness and how the federal government can support such
efforts.
I want to thank again the witnesses for their testimony
today, and our colleagues on the Prevention Subcommittee for
holding this joint hearing with us. Thanks.
Mr. Linder. I thank the gentleman.
The Chair now recognizes the ranking minority member of the
Subcommittee on Emergency Preparedness, Science and Technology,
the gentleman from New Jersey, Mr. Pascrell, for the purpose of
making an opening statement.
Mr. Pascrell. Thank you, Mr. Chairman.
I want to preface my remarks, my opening statement with
some questions I would ask the panel, and thank you for your
service to your country.
I want to preface the following questions. We know that the
national response plan declares that the Department of Homeland
Security is the lead agency, and that the Secretary of Homeland
Security is the principal federal officer if an incident of
national significance is declared. Do you have clear lines of
communication with the department so that you will know what
the Secretary is advising in such a case?
My next question--and you are going to have your testimony,
but I would like you to keep this in mind when you are
presenting it. From all we have seen so far, the
administration's national strategy for pandemic influenza is
highly tilted towards pharmacological countermeasures, vaccines
and antivirals, and 85 percent of the funding requested in
support of the plan goes to these measures. Do you agree with
that approach?
And finally, what do you feel is the proper role for the
federal government in providing resources for pandemic
preparedness and response? What are your expectations from us?
I want to thank Chairman Linder and Chairman Reichert for
holding the hearing. The threat of a global influenza pandemic
is real. It is not exaggerated. There is no hyperbole that I
have seen. The possible effects of an actual outbreak could be
catastrophic.
Another very real fear exists, the fear that we still
remain completely unprepared. Hurricane Katrina exposed our
complete lack of coordination and preparedness to address a
catastrophic storm, even when we had several days notice. The
pandemic flu scenario is affording us much more time to
prepare, but as of today it appears that the nation is poised
to repeat a grave error by not heeding the lessons learned from
Katrina.
For example, while the president released his national
strategy for pandemic influenza in November 2005, the plan
contains no operational details; makes very broad mention of
vaccines and antivirals, foreign and domestic monitoring, and
response and mitigation. Agency-specific additions to this plan
were to be completed by each federal agency by February 1,
2006.
Mr. Chairman, those plans are not available yet. This is an
inauspicious start, to say the least.
Allegedly, the overriding plan could be followed in the
case of a declared incident of national significance, including
certain biological events like a pandemic flu, is the national
response plan. But the level of knowledge and familiarity of
the different entities responsible for pandemic influenza
response within the national response plan varies widely. Many
state and local entities have simply never read the document,
even though they are expected to develop plans that complement
the document.
Interestingly, 8 days ago, the GAO, the Government
Accountability Office, released its preliminary observations
regarding preparedness and response to Katrina and Rita, and
found that the Department of Homeland Security failed to
implement the NRP or designate a key federal point of contact.
This is a real problem. I am not convinced that there is
appropriate leadership in place to address the issue. Its
current state is simply unacceptable for everybody on this side
of the table.
We know the dangers are enormous. Don't take my word for
it. On October 27, 2005, Health and Human Services Secretary
Michael Leavitt said the following: ``If the pandemic hits our
shores, it will affect almost every sector of our society, not
just health care, but transportation systems, workplaces,
schools, public safety and more. It will require a coordinated
government-wide response, including federal, state and local
governments and it will require the private sector and all of
us as individuals to be ready.''
We are not ready, but we can do better as a nation. I am
thankful that the two subcommittees within the Homeland
Security Committee are taking on this issue. We need to examine
and explore the ways best to consolidate and coordinate the
actions of the federal, state and local actors. We need to
ensure that a lack of federal leadership is remedied, and
examine how best to combat problems of strained resources.
We have a good panel before us, and I welcome them. I am
very interested in hearing from our witnesses about their
dealings with DHS, as well as their preparation, coordination,
and incident command plans to address what many describe as an
event certain to happen.
I thank the chairman.
Mr. Linder. I thank the gentleman.
The Chair now recognizes the ranking member of the full
committee, the gentleman from Mississippi, Mr. Thompson, for
the purpose of making an opening statement.
Mr. Thompson. Thank you very much, Mr. Chairman.
I would like to welcome our witnesses here today, and I
look forward to their testimony.
I am pleased that these two subcommittees are turning their
attention to the issue of pandemic flu preparedness and
response. I am also looking forward to the hearing in the full
committee on this subject, which as I understand at this point
will feature Secretary Chertoff and Secretary Leavitt as
witnesses.
In a full-scale pandemic situation, federal, state, local
and private entities will all need to cooperate effectively for
a response to be successful. The thousands of state and local
health departments are working hard to plan for pandemic flu,
but they have been hampered by a lack of money and guidance
from the federal government.
In the president's national strategy for pandemic
influenza, the bulk of federal research funding is going for
drug research and vaccines. The president requested only $100
million for state and local preparedness. While Congress
appropriated $350 million in the emergency appropriation this
past December, it still pales in comparison to the $6 billion
that the president requested for vaccines and antivirals.
I am also concerned that the various flu response plans
that are being developed by federal agencies do not complement
the national response plan, which is supposed to guide the way
we manage domestic emergencies. We have many questions to
answer. Who is in charge of response operations at the federal,
state and local levels? Who gets vaccines first? Where should
we urge citizens to wear masks or stay home? When should we
close schools? How will hospitals handle the surges of
patients?
As I have spoken in recent months to local physicians,
hospital administrators, public health officials and first
responders, it has become clear to me that we do not yet have
the answers to these questions. I hope this hearing will help
us begin to answer them. Although we cannot be certain, many
experts predict we have a year or longer before a full-scale
outbreak of avian flu may occur. In that time, we must ensure
that a coherent nationwide response is ready, and that is and
will be properly executed when we need it.
Thank you, Mr. Chairman.
Mr. Linder. I thank the gentleman.
We are pleased to have before us a distinguished panel of
witnesses on this important topic.
Let me remind the witnesses that their entire written
statement will be made part of the record. We would ask you to
keep as best you can your testimony to no more than 5 minutes.
Dr. Tara O'Toole is the chief executive officer and
director of the Center for Biosecurity at the University of
Pittsburgh Medical Center. She has served on numerous
government advisory committees, including panels of the Defense
Science Board, the National Academy of Engineering's Committee
on Combating Terrorism, and the National Academy of Science's
Working Group on Biological Weapons.
Secretary David Mitchell is the secretary of the Department
of Safety and Homeland Security in the state of Delaware.
Secretary Mitchell has over 3 decades of law enforcement
experience. Prior to his recent appointment, he was
superintendent of the Maryland State Police.
Ms. Frances Phillips is a health officer in Anne Arundel
County, Maryland. In addition, she is the vice chair of the
Bioterrorism and Emergency Preparedness Committee of the
National Association of County and City Health Officials, and
past president of the Maryland Association of County Health
Officers.
Mr. Ernest Blackwelder is the senior vice president of the
Business Executives for National Security, or BENS. Mr.
Blackwelder oversees the organization's Business Force
activities, including operations in New Jersey, Georgia,
Missouri, Kansas, Iowa, Nebraska and California. Prior to
joining BENS, Mr. Blackwelder was chief operating officer of
ArsDigita, an Internet software and professional services firm.
Dr. David Seaberg is with the Department of Emergency
Medicine at the University of Florida. He serves as the
president of the Florida College of Emergency Physicians. He
also serves on the board of directors for the American College
of Emergency Physicians and the Emergency Medicine Learning and
Resource Center.
We thank you all for being here.
Dr. O'Toole?
STATEMENT OF DR. TARA O'TOOLE
Dr. O'Toole. Thank you, Mr. Chairman. It is a pleasure to
be with you today.
I am going to address three specific issues amongst the
panoply of very serious and scary matters you outlined in your
opening remarks. I am going to talk about the health care,
specifically hospitals' response to a possible pandemic and
what that would mean, and what it is going to take to get
through it without collapsing our health system and endangering
the faith of the American people, not to mention their lives.
I am then going to talk a little bit about disease
containment, and the prospects for protecting the well, for
stopping the spread of disease in a flu pandemic; and finally
the very important topic of engaging the people as
collaborators in our response to flu.
Before I do that, I am going to say a few words about the
current situation. We have no idea on a scientific basis when
or if a pandemic might break out. We do not know why 1918
happened. We do not understand the genetics of that virus,
which we have now replicated. We do not understand why it was
so virulent or why it spread or why it literally popped up out
of nowhere. So we cannot predict when or if the avian flu that
is now endemic through Eurasia will become transmissible.
But it is very important to understand that the current
situation is historically unprecedented. There are now millions
and millions of wild birds throughout Southeast Asia and Asia,
and today we learn that there are poultry outbreaks of H5N1 in
Nigeria, who are carrying this very lethal virus as they
migrate around the world. The more birds that carry the virus,
the greater the chances that this virus would become
transmissible. It might happen a year from now. It might happen
tomorrow. There is absolutely no way of predicting.
Hopefully, we will be given the gift of time to get
prepared, but whenever it happens, getting through this is
going to be a traumatic event for America and an existential
event for some countries and certainly for some economies. We
are only going to get through this intact if everybody works
together. That is all sectors, not just public, but also
private at all levels.
How do we do that? Let's talk about hospitals, because they
are the linchpin of the U.S. health care system in many ways,
and they are where Americans expect to go if they or their
family are very sick. It is true that there are a lot of things
to worry about beyond hospitals and health care, but the irony
of the situation is that hospitals and health care, because
they are a private sector enterprise, have been left out of
most emergency preparedness, bioterrorism preparedness, or flu
preparedness exercises in thinking.
That is hard to believe, but that is the case. Most
hospital administrators have not read the flu plan, and they
are not going to. In most hospitals, the person in charge of
disaster preparedness is a low-level assistant professor who
has this as an add-on assignment. Hospitals are already very
overburdened. They have responded to the financial pressures of
the last decades by cutting staff, by going to just-in-time
supply chains, et cetera, et cetera.
The first thing to know, and this is not going to change,
in all likelihood, is that if a 1918-type pandemic broke out in
America, most Americans would have no access to the health care
system. I am not just talking about hospital admissions. I am
talking about the ability to talk to or to visit a physician.
We have to educate the American people to this reality, and we
have to organize ourselves so that the health care system we
have can be as expandable and as agile as possible. That is
going to take a lot of work.
Let me give you some specifics. CDC has put out a computer
model that allows each hospital to calculate how much it would
have to surge in a 1918 pandemic or in a smaller 1968-type
pandemic. Let me give you the figures for the Atlanta metro
region if we had a 1918-type flu. All of the hospitals together
in Atlanta would have to increase their current pre-epidemic
hospital bed capacity by 300 percent just to care for flu
patients. Now, beds are not the problem. The real problem is
the staff to take care of the patients in the beds. This 300
percent does not include the people that you would need to take
care of heart attacks and patients not related to flu. Atlanta
would have to increase its intensive care unit capacity by 700
percent. It would need nearly four times as many ventilators as
it is using today just to care for flu patients.
This is not feasible. You cannot get there from a kind of
marginal, incremental increase over what we have done.
Hospitals can probably get prepared to surge maybe 20 percent
over their current capacity. But what we are talking about here
is a fundamental shift in how we deliver health care and what
we mean by health care.
Within your purview, within the purview of the Department
of Homeland Security, lies the National Disaster Medical System
and the DMAT, the Disaster Medical Assistance Teams. These are
going to be of very little use in a pandemic. There is a
terrific report out that was commissioned by Secretary Ridge
that critiques the NDMS and the DMAT quite carefully and
accurately, that is worth your while, done by a Dr. Lowell. The
essence of it is that we have a very fragmented federal
response system when it comes to health care. We have to get
that much more coherently organized.
We definitely need to plan, but I would suggest that there
is no way we are going to be able to come up with explicit
protocols and procedures for how we would react to a pandemic.
We are not going to know when we are going to close schools in
advance. We are not going to know who is going to get the
ventilators. What we have to do, and what the main point of
planning is, as we have learned in all of the emergency
preparedness done so far, is that we have to start talking with
each other.
In an emergency, the NDMS, which is intended to transport
patients from the disaster area to another region that has
available hospital beds, is not going to make sense. We are not
going to be transporting contagious people around the country,
besides which everyone is going to be overloaded or fearful of
being overloaded and unlikely to be willing to accept new
patients.
Now, flu is very, very contagious. We are not going to be
able to stop the spread of a transmissible flu if it breaks
out. This notion that if we see it early, if we catch the first
30 people who are spreading it from person to person, and then
fly lots of Tamiflu in and give it to the one village that was
first the victim of this transmissible gene, is worth pursuing
because we ought to do anything we can to quench this pandemic,
but has a very low probability of success. We are probably not
going to see this breakout if it happens in Kurdish Iraq or in
the Urals somewhere until it is well under way, and then it
will be everywhere.
There are some important things to know about flu. Every
disease spreads slightly differently and the public health
measures you use to control the spread of disease differ from
one pathogen to the next. You can be contagious with flu before
your symptoms. In fact, you usually are. In fact, in a normal
flu season, half of the people who are infected are never
symptomatic, but can spread the disease. So it is going to be
almost impossible to actually contain the disease or to stop
the spread.
What we want to do is slow it down so the consequences are
spread out over time and we have a better chance of responding.
We need the cooperation of the American people in succeeding
with this. They have to understand that if they get sick, they
need to stay home. Provisions have to be made to make that
possible, which means a whole bunch of things, from the
capacity for employees to work from home, to delivering food to
the doorstep, to keeping good movies on television so you can
keep the teenagers from going to the mall. A lot of the action
is going to happen at a very local level.
We have to keep as many people as possible out of the
hospitals so the hospitals can tend to the very ill. At some
point, the hospitals will become overrun and we are going to
have to shift to this complete paradigm change in health care.
That ought to be a decision that is made by leaders of the
community, not just elected officials. New organizations are
going to have to be formed that will make it possible for very
competitive hospitals who on a normal day would try and steal
each other's patients, to work together and make joint
decisions that are going to mean life and death for their
communities.
It is quite possible that interventions intended to prevent
the spread of disease will make things worse. It is quite
possible that we could worsen the CBO's estimates of a 5
percent drop in GDP if we were to have a 1918 pandemic, by
trying to stop travel; by trying to limit the flow of goods; by
basically doing things that mess around with the economy, but
are not going to get you much in terms of stopping the spread
of disease.
So all elected officials have to be very informed about how
flu spreads and what works and what does not work with respect
to public health interventions.
Mr. Linder. Doctor, if you go on too long, I will have to
stop you, before my glee at what you are speaking about just
overwhelms me. We will be back with questions for you.
Dr. O'Toole. Could I say one thing?
Mr. Linder. Sure.
Dr. O'Toole. We can do this. We have absolutely
extraordinary scientific and technological prowess that we are
not using well. We have a huge coast-to-coast health care
system that we can organize, and we have a private sector that
I think is willing to pitch in, but we need a better vision of
how we get through it.
[The statement of Dr. O'Toole follows:]
Prepaed Statement of Tara O'Toole, MD, MPH
Mr. Chairman, distinguished members of the committee, thank you for
the opportunity to appear before you today to discuss the nation's
preparedness to deal with a possible influenza pandemic.
My name is Tara O'Toole. I am the Director and CEO of the Center
for Biosecurity of the University of Pittsburgh Medical Center and a
professor of medicine at the University of Pittsburgh Medical School.
The Center for Biosecurity is a non-profit, multidisciplinary
organization which includes physicians, public health professionals and
biological and social scientists located in Baltimore. The Center is
dedicated to understanding the threat of large-scale lethal epidemics
due to bioterrorism and to natural causes. My colleagues and I are
committed to the development of policies and practices that would help
prevent bioterrorist attacks or destabilizing natural epidemics, and,
should prevention fail, to mitigating the destructive consequences of
such events.
Last year, my colleagues and I had the privilege of participating
in this committee's retreat at Wye River, where we held an interactive
table-top based on Atlantic Storm, a ministerial exercise conducted in
January 2005 which was designed to illuminate the kinds of issues that
world leaders would confront in the wake of a bioterrorist attack using
smallpox.
Over the past 18 months, the Center for Biosecurity has focused its
attention on the threat of pandemic influenza and the capabilities
needed to respond to such an event. I will focus my testimony on two
aspects of pandemic response: containing the spread of influenza and
the role of hospitals in pandemic preparedness and response. First,
however, I will describe the current situation with respect to H5N1 and
the potential impacts on hospitals were a flu pandemic to occur in the
next year or two.
Background: The Likelihood and Implications of Pandemic
Influenza
Current Situation--
The current situation in Asia and parts of Europe--namely, the
infection of millions of wild, migratory birds and poultry with the
H5N1 strain of influenza, and the infection of over 100 people--is
unprecedented. H5N1 is an especially virulent type of flu against which
no humans have immunity. More than half of all humans known to be
infected have died. H5N1 is clearly endemic in wild birds, and cannot
now be eradicated. Moreover, as the birds migrate to winter feeding
grounds, they are spreading the virus into wild and domestic birds
across Asia and into Europe. The World Health Organization (WHO) warned
in 2005 that the evidence point towards the likelihood of an influenza
pandemic, which could sicken one of four people on the planet, and kill
millions.
Recently, bird flu has been found in domestic poultry in Turkey and
in Kurdish Iraq. Peregrine falcons in Saudi Arabia have also been
infected. Infection with avian flu continues in domestic flocks across
wide expanses of Indonesia, and southeast Asia. At least XXXX human
cases of bird flu have been confirmed, although no human-to-human
transmission has been observed.
Potential Impacts--
The WHO estimates that once the next human pandemic begins, it will
be found on all continents (but not necessarily in every country)
within three months and will spread across the world within 12 months.
Recurrent outbreaks would be expected over subsequent winter and spring
seasons. The specific pattern of spread is impossible to predict and
will depend on the properties of the pandemic strain (how lethal, how
contagious, how closely it could move around the planet).
The Congressional Budget Office (CBO) has estimated that in a 1918
scale pandemic, about 90 million people would become sick and 2 million
would die in the US alone [Congressional Budget Office, ``A Potential
Influenza Pandemic: Possible Macroeconomic Effects and Policy Issues'',
Dec. 8, 2005]. The CBO estimates that a pandemic of this scale would
lower real GDP by about 5%compared to the level it would have reached
had there not been a pandemic. The CBO notes that ``Improving the
capacity of the health care system to care for many people in all parts
of the country who are sick at the same time stands out as a priority.
. . .'' [CBO, page 2].
There is no scientific way to predict whether an influenza pandemic
will occur this year or next or several years from now or how severe it
will be. That there will be an influenza pandemic in this century is
certain; flu pandemics have occurred throughout history, about three
times each century. The ``good news'' is that there is much that can be
done to mitigate the death, suffering and economic and social
disruption caused by epidemics--if preparations are made in advance. Of
course the preparations that could be put in place were a pandemic to
occur in the next few months would differ considerably in scale and
scope from what could be accomplished if we had 18 months or years to
get ready. My colleagues and I are deeply concerned that the current
pace and intensity of pandemic preparedness activities, including the
search for effective vaccines, are still very inadequate given the
possible consequences of this threat.
Importance of Vaccine--
Having adequate amounts of an effective vaccine changes everything.
Global supplies of a pandemic vaccine and the ability to distribute it
could transform these grim scenarios decisively. Today, there are more
than 20 projects to develop a vaccine against H5 type influenza viruses
underway, pursued by private sector biopharma companies and the NIH but
results to date have been disappointing. The recent Congressional
appropriation for flu vaccine research and development is welcome and
necessary, but still falls far short of what is warranted by the nature
of this threat. The scientific basis of the effort is sound, but there
is, as yet, no national strategy to pool America's prodigious
scientific and pharmaceutical industry capacity in the context of an
overall strategic plan. I realize this issue is beyond the usual scope
of this committee, but the matter is of such overriding importance that
all of Congress should be aware of the situation.
Caring for the Sick During a Flu Pandemic or Mass Casualty Bioattack
US Health Sector is Unprepared to Meet Surging Pandemic Health Care
Needs
In the event of a 1918-scale flu pandemic, most Americans would be
unable to access the health care sector because demand will exceed
supply by large factors that cannot be bridged by incremental, marginal
increases in health care capacity.
Hospitals would be flooded with desperately ill people seeking
care. Most hospitals routinely operate at or near full capacity,
however and have limited ability to rapidly increase services. During
an epidemic, the health care workforce would be greatly reduced. Health
care workers would face a high risk of infection because of contact
with infected patients; many would need to stay home to care for sick
relatives, and in the absence of vaccine, others might fear coming to
work lest they bring a lethal infection home to their families The
provision of critical, non-flu medical services would be adversely
impacted in most communities. .
In addition, because hospitals have adopted just-in-time supply
chains, there would be an almost immediate shortage of critical
supplies such as ventilators, masks and gowns, antibiotics, etc. The
shortages of supplies and staff would likely worsen over time as
critical components of supply chains are lost due to attrition and
absenteeism in the US and overseas. (During the 2003 SARS outbreak, a
single Ontario teaching hospital used 18,000 N95 masks per day).
All three TOPOFF exercises convincingly demonstrated that hospitals
are among the most fragile components of mass casualty response.
Hospitals have little money of their own to spend on stockpiling
supplies or planning for catastrophes. The US health care delivery
sector is financially pressured, and highly competitive. One third of
US hospitals do not meet operating costs; among non-profit hospitals
which are in the black, operating margins average only 3%. In a
pandemic, hospitals would be forced to close clinics, cancel surgery
and defer most money making services to care for the volume of flu
victims. Many hospitals may be forced to close down due to lack of
staff and/or lack of revenue.
Hospitals do not have the funds to pay for pandemic preparedness
planning or to purchase stockpiles of equipment or train staff. Federal
funds for hospital preparedness began only in FY 2002 and have remained
at low levels. The federal appropriation for FY 2006 was only enough to
cover the salary of a single nurse at each of the country's
approximately 5000 hospitals for one year.
Within the medical community, there are widespread expectations
that the military would quickly provide significant resources
(personnel, mobile hospitals, equipment) during a mass casualty event.
The military maintains that its medical resources are limited and that
force support needs would be the priority.
CDC Flu Surge Projections: Pandemic Demands Would Overwhelm Most
Hospitals
It is important to have a clear picture of what the pressures of
pandemic flu would mean. CDC has create ``Flu Surge'', a software
program that allows one to project the patient demands that would be
levied on hospitals of different types and sizes if the pandemic attack
rates and severity of illness mimicked those of 1918.
For example, in a 1918 type pandemic, in the Atlanta metro area,
that region would require 300% of its current (pre-epidemic) hospital
bed capacity to care for flu patients (and the necessary clinical staff
to care for this increase in patients); 700% of Atlanta's pre-epidemic
Intensive Care Unit capacity and nearly four times as many ventilators
to care just for the flu patients.
These demands do not take into account the resources that would be
required to meet normal ongoing critical medical needs (care of heart
attack victims, etc.).
The US lacks a national strategy for providing health care surge
capacity in mass casualty emergencies.
The NDMS, DMAT teams and uniformed public health service would be
of little practical use in such an emergency. These organizations lack
the necessary operational scale and skill sets and will be needed in
their home communities.
In a large-scale flu pandemic or bioterror attack, the National
Disaster Medical System (NDMS) and the Disaster Medical Response Teams
(DMATs) would be of little practical use. An analytic report of the
Department of Homeland Security's readiness to respond to national
medical emergencies (January 2005) stated:
``A National healthcare system-wide strategy for providing
surge capacity does not exist. . .Numerous Federal programs
(e.g. NDMS, Commissioned Corp Readiness Force, and the Medical
Reserve Corps program) exist to enhance surge capacity, but
they are fragmented and not incorporated into the national
response effort.''
[Lowell, J. ``Medical Readiness Responsibilities and
Capabilities: A Strategy for Realigning and Strengthening the
Federal Medical Response'', Jan. 3, 2005; accessed at http://
wid.ap.org/documents/dhsmedical.pdf, 2/3/06.]
NDMS was designed to identify empty hospital beds beyond the area
affected by an emergency to which casualties could be sent. However, in
a pandemic, all areas of the country would be affected more or less
simultaneously, or to fear that they will be hit next.
Moreover, the crucial need is not for hospital beds, but for
medical staff to care for the patients in the beds. The central premise
of NDMS--that empty hospital beds imply the capacity to care for
patients--is outdated. Similarly, the deployment of Disaster Medical
Support Teams (DMATs), which consist of volunteers from around the
country, would be impractical in contexts in which team members are
needed in their home communities.
Following 9/11, the Medical Reserve Corp (MRC) was founded. This
component of the Citizen Corps is located within the office of the
Surgeon General in HHS. Still considered a pilot program, the MRC
currently has 55,000 volunteers in 330 local MRC units who are intended
to supplement local medical resources in times of need. MRCs have no
uniform structure and volunteers are not necessarily medical
professionals.
The US health care sector is highly fragmented, competitive and
largely private. In most locales, there is no ``Organizing Authority''
with the capacity to establish a regional pandemic plan that would
obligate hospitals to collaborate in a manner designed to optimize
health care delivery during a pandemic.
Aside from a handful of cities such as New York, Minneapolis and
Seattle, there are no well defined or practiced plans for mobilizing
hospitals, HMOs and other sources of patient care during a mass
casualty emergency. Public health agencies typically have not taken on
this task, nor do most public health agencies have the personnel, funds
or legal power to direct, manage or coordinate hospitals in crisis.
The ability to identify and contact health care professionals and
support staff is essential to hospitals' capability to respond to
emergencies. There is an urgent need to create regional data bases of
health care workers that would allow rapid identification of and
contact with professionals with certain credentials and skill sets.
Further, provisions to credential clinicians at multiple hospitals in a
region (ahead of an emergency), and to ensure that professionals and
the institutions in which they work have adequate liability protection
are essential. Some states have established Mutual Aid pacts or other
provisions with neighboring jurisdictions to address such concerns. Yet
few regions have successfully built the data bases needed, or solved
all the legal problems to ensure that qualified health care
professionals can practice across state and institutional lines in
times of emergency.
Collaboration among hospitals and other patient care institutions
will require near-real time ``situational awareness''. Yet most
hospitals do not have electronic connections with other hospitals in
their region or links to their local or state public health agencies.
This will make it difficult for decision-makers to understand which
hospitals are able to receive patients, where vital equipment is
located or needed, what supplies are running low or where the public
should be told to take those who are desperately ill.
The Federal government has failed to propose a coherent strategy
for pandemic hospital response; has failed to adequately fund even
minimal hospital preparedness activities. Responsibility and
accountability for hospital preparedness within DHS and HHS are
diffuse, confused and grossly under funded and understaffed.
The HHS Pandemic Flu Plan contains a lengthy list of items
associated with hospital preparedness. However, the FY06 appropriation
for pandemic preparedness contains no funds for hospitals. Accordingly,
it would not be possible for any hospital to implement everything
suggested by the HHS list, partly because of cost and partly because
individual hospitals lack the authority to accomplish much of what is
recommended.
It is unclear who in the federal government--or indeed which
agency--is in charge of medical response in a mass casualty emergency.
The HHS missions and skill base more closely match the need than do the
assets currently found in DHS. The National Disaster Medical System
(NDMS), transferred to DHS upon its creation, had its management
personnel reduced from 144 to 57, leaving the NDMS without a staff
physician, medical planner or logistician [Lowell, ibid. p. 6].
Containing the Spread of Disease During a Flu Pandemic
Not All Interventions to Prevent Disease Spread are Worth the Costs
Most disease containment interventions are logistically difficult
to implement, of imperfect or uncertain effectiveness, and may have
significant adverse economic and social consequences. It is important
that decision-makers understand the ``return on investment'' of various
interventions.
When considering possible interventions to stop or slow the spread
of influenza--or of any contagious disease--it is important to consider
both the possible benefits of the intervention as well as the costs.
The interventions that are likely to produce a reasonable ``return on
investment'' are likely to differ, depending on the specific disease
and the context. It is critical that elected officials understand how
flu spreads and carefully consider the trade-offs involved in various
disease containment measures. Some public health interventions will
cause more harm than good.
Influenza is a highly contagious disease. In normal flu seasons,
each infected victim passes the infection to at least two others. What
makes flu so contagious however is the speed at which people are
infected. One becomes contagious within 24 to 72 hours after being
infected. Thus, flu can spread from one person to the next before
symptoms occur. In normal flu seasons as many as half the cases may
never show any symptoms but can still be contagious. Infectious
pandemic flu patients can be expected as well.
This means that screening interventions--for example, screening
airline passengers for fever or for cough and other symptoms--will not
be effective. This was apparent during the SARS outbreak of 2003. Both
Canadian and Chinese authorities, in careful studies, concluded that
such screening was of no value although requiring a great deal of time,
effort and cost.
Possible Interventions to Control the Spread of a Contagious Disease:
Vaccine--having sufficient supplies of an effective pandemic flu
vaccine changes everything. An effective vaccine is by far the single
most important component of pandemic preparedness. If available in time
and in sufficient quantities vaccine would make a decisive difference.
Therapies which can be used in treatment--Tamiflu is proposed for
use although little information is yet available regarding its actual
effectiveness. Given within 36 hours after symptoms begin, it would be
expected to reduce growth of the virus and perhaps reduce the
likelihood of a fatal outcome. However, virus resistance to this drug
is expected and supplies of the drug are limited
Therapies which may prevent spread--Tamiflu decreases the amount
(``load'') of virus in the patient's throat and hence may prevent
disease and, as well, diminish the likelihood of transmission.
Prevention with this drug, however, would require daily administration
of the drug throughout the course of an epidemic. The quantities of
drug required and the cost, let alone complications of the drug itself
recommend against its general use.
Isolation of sick individuals--This is an essential component of
all influenza containment strategies. Especially in health care
settings, isolation of infected patients is critically important to
limiting disease spread. However, health care workers are at special
risk and thus, appropriate isolation of infected patients and use of
``barrier controls'' (gowns, face masks, gloves) and hand-washing are
essential.
It would also be highly desirable to isolate individuals who are
sick with flu but not so desperately ill that they need to be
hospitalized. It is likely that many people will remain at home, though
some communities are making provisions to equip sports arenas and other
large spaces with beds to accommodate those who cannot be cared for at
home. To the extent possible, patients should be encouraged to stay at
home from the first signs of illness and to stay out of close contact
with others until they are no longer contagious.
The resources needed to enforce compulsory isolation or quarantine
are enormous and the likelihood of failure is high. Cooperative rather
than compulsory measures are to be preferred.
There are significant challenges associated with isolation of
infected persons, whether they are restricted to their homes or
isolated in some central facility. Arrangements must be made to provide
people with food and medical services (including medicines for chronic
illnesses
Quarantine--Historically, quarantine referred to sequestration of
large groups of people who are without symptoms--some of whom may have
been infected with a disease, some not--until it was certain that all
who might have been infected were past the point of being able to
spread the illness. Large scale quarantine requires vast resources,
most likely including the use of force. Experience shows that it has
seldom proved to be effective and, in some cases, has led to
suppression of reports of disease and of persons fleeing or escaping
the restricted area. Rarely does it succeed in limiting spread of the
disease.
Social Distancing--this involves voluntary avoidance of close
contact (3-6 feet) with others. Social distancing could include
cancellation of schools or large public gatherings such as sports
events or business conventions. It could also include asking employees
to work from home, urging people to avoid coming within 3 feet of
others, forgoing handshakes and other forms of direct contact.
Use of Personal Protective Equipment--such as masks, respirators,
gowns, gloves.
These are of value for use of health care personnel in preventing
their acquisition of infection. Masks are of uncertain value for public
use.
Possible Congressional Actions to Improve US Hospital
Response During a Pandemic or Mass Casualty Situation
<bullet> The Secretary of HHS is the nation's leader on pandemic
preparedness and Secretary Leavitt's commitment to this issue is
evident and commendable. Given the breadth and urgency of preparedness
activities, it seems essential that someone be appointed who can be
fully devoted to overseeing flu preparedness strategy across all
agencies. The federal government must clearly identify someone who is
knowledgeable and has both authority and resources to assume direction
of pandemic preparedness programs and to enlist appropriately trained
staff to address the array of problems posed by a potentially
catastrophic pandemic. Of special importance are the problems posed by
the need to provide medical care to an unprecedented number of victims.
<bullet> In spite of the often heroic efforts of individual, highly
expert federal employees, the federal agencies do not now include the
full range and depth of talent and experience required to develop and
implement a pandemic flu plan or a strategic defense against
bioterrorist attacks. There is a pressing need to immediately acquire a
staff of 50-100, including senior professionals and executives who
could assist in establishing pandemic response policies and programs.
<bullet> There should be a federal/state task force charged with
designing a plan to deliver medical care during a pandemic or mass
casualty event. This group should focus on options for dealing with
surges in medical demand comparable to those predicted by Flu Surge
models for a 1918 type pandemic. Every effort should be made to work
directly with the hospital community as well as with governors and
mayors to address these urgent problems. HHS should be directed to work
with hospital and health care leaders as well as local officials on the
state and local level and members of Congress to devise ``organizing
authorities'' that could effectively coordinate medical services during
mass casualty emergencies. Funds to institute such authorities should
be appropriated
<bullet> HHS should distinguish which specific pandemic
preparedness are the responsibility of individual hospitals, and for
what functions states or the federal government are accountable and
create mechanisms to fund and oversee these functions.
<bullet> The Congress should appropriate sufficient funds, on an
ongoing basis, to allow hospitals to execute specific, clearly
identified and measurable preparedness activities. It should charge HHS
with responsibility for designing processes, possibly in collaboration
with the Joint Commission on Accreditation of Health Care
Organizations, for ensuring that these activities are implemented and
adequate.
<bullet> It would be highly useful for the Administration and the
Congress to orchestrate a public ``call to service'' to the medical
care community, to clearly communicate the gravity of the threat of
mass casualty events and the need for immediate action on the part of
hospitals, health care organizations and providers.
<bullet> Federal financing to spur the development of hospital
electronic medical records should be considered a national security
priority. Federal funds should be contingent on hospitals linking
health information systems to other hospitals in their region and to
public health authorities.
<bullet> Congress should immediately consider the possibility of a
large-scale pandemic and hold public hearings on the need to enforce
``eminent domain'' type authorities over health care assets should such
a crisis arise as well as mechanisms to ensure that people who lack
health insurance are not denied care or shunted to public or not-for-
profit hospitals.
<bullet> Congress should establish legal provisions to ensure that
hospitals who must forgo routine revenue flows to care for mass
casualty victims will remain financially viable throughout the crisis.
<bullet> The single most important preparation in coping with a
pandemic is education of the public. It will be critical that people
understand what they can do to protect themselves and others during a
pandemic. In particular, members of the public need to clearly
understand that in a pandemic many people will find it difficult to
access the health care system and should not expect to visit their
doctors unless absolutely necessary.
<bullet> The Congress--and elected officials--should be educated on
the basic facts about flu and participate in a nation-wide education
campaign to prepare the public for a potential epidemic. In particular,
leaders should acquaint themselves with the potential advantages and
downsides of various interventions intended to contain the spread of
flu and be prepared to explain why certain measures are necessary or
unfounded. There will be great temptation to ``do something'' in the
emergency. The probable benefits and longer term costs of such measures
should be clearly articulated to the public and the cost-benefit of
instituted measures should be carefully monitored.
<bullet> Employers should be encouraged and incentivized to plan
for a major pandemic and in particular to prepare to enable employees
to work from home and to avoid the workplace if they are ill. People
should be encouraged to prepare to voluntarily remain at home--get
themselves out of circulation--at the first sign of flu like symptoms
or if they know they were in close contact with someone with flu.
Mr. Linder. Thank you very much.
Dr. O'Toole. Thank you. Sorry to be so long.
Mr. Linder. Secretary Mitchell?
STATEMENT OF THE HONORABLE DAVID B. MITCHELL, SECRETARY,
DEPARTMENT OF SAFETY AND HOMELAND SECURITY, STATE OF DELAWARE
Mr. Mitchell. Thank you, Mr. Chairman.
Chairman Linder, Chairman Reichert, ladies and gentlemen of
the committee, I bring greetings on behalf of Governor Ruth Ann
Minner from the First State, the state of Delaware. She brings
her greetings, and I, along with my governor, thank you for the
opportunity to discuss this most important topic with you here
today.
We in Delaware are not unfamiliar with the concept of H5N1
bird flu. There are two issues here. One is avian flu, and one
is pandemic flu. On any given day, today for example, on the
Delmarva peninsula, we have 110 million chickens. In fact,
Sussex County, Delaware, is the greatest poultry producer of
any of the counties in the United States. We did in fact have
an outbreak of avian flu several years ago, and we were very
successful. It was a low-grade flu that infected two poultry
farms. We were very successful in containing that. I have to
say, that thanks to Secretary Mike Scuse, one of my colleagues,
and DDA in the state of Delaware, were very sophisticated in
our preparation for that. Our relationship with the poultry
industry, I have to say, is second to none.
When it comes down to pandemic influenza, fighting from a
homeland security perspective, one of our accomplishments in
Delaware was to prepare for what some say may happen, others
say will happen, with the enactment of our Emergency Health
Powers Act. It gives the Division of Public Health and the
Department of Safety and Homeland Security the authority to
obtain quarantine and isolation orders in an expedited manner.
It also contains provisions protecting the due process
rights of individuals who are subject to a quarantine or an
isolation order. By ``isolation,'' I am saying that in fact we
know you are infected with H5N1 bird flu, and so we will, if
necessary, isolate you, if necessary against your will, for the
better good of our community. By ``quarantine,'' I am saying
that you have been exposed, and I am not sure if you have it,
but we will isolate you until that determination is made.
That type of isolation and quarantine has been tested in
our Third Circuit of the federal judiciary. It has passed
muster constitutionally, provided that there is a due process
opportunity, which raises all kinds of issues. How do you bring
someone before a member of the judiciary if they are infected
with H5N1 bird flu? Well, I had that discussion with our
Supreme Court and other members of the bench in Delaware just
last week. We proposed to do it by video, but even that brings
up all kinds of issues about whether or not. We certainly do
not want to contaminate an inmate population. We are working
through these issues, in fact, as we speak.
The Intrastate Mutual Compact that we have is another major
accomplishment. It gives us the opportunity across
jurisdictional lines within our state and between states, to
help one another out. With our proximity being that close to
Maryland, New Jersey and Pennsylvania, we do rely on each
other, as well as in the great state of Virginia.
With regard to federal funding, resources have supported
many of our objectives, including effective communications. We
heard, as we know in Katrina, the issue, as is often the case
in any crisis, is our ability to talk to one another. Thank you
for your federal support to our 800 MHz system. We do have
coverage that is about 99 percent effective throughout our
great state. Our in-building coverage is about 66 percent, well
on its way to becoming 85 percent in compliance, so that we
will have not only coverage outside of any structure, but
inside of any structure. When I say ``coverage,'' I am talking
about transportation systems talking with the police,
firefighters, emergency responders and others.
We also have benefited from your support to the Delaware
Information and Analysis Center, which is a hub that collects
not only intelligence from our local officers up through and up
to the Department of Homeland Security, but it receives
information from the Department of Homeland Security and our
federal resources that we disseminate locally. It is our hub
where have situational reports given the threat that we face,
that we would put that information out daily and so forth.
We hope that enhancing the federal-state partnership will
be the order of the day. Our line of communication with the
Department of Homeland Security, I have to say, is very clear.
I have an outstanding relationship with my colleagues on the
federal level, and we are very fortunate. I cannot speak for
all the other states, only for the state of Delaware, probably
because of our proximity, that we are in contact so frequently.
But we need to continue to foster and support that
partnership. Our federal partners need to continue to hold
public meetings and summits to keep the lines of communication
open. Delaware looks forward to a federal partnership that
highlights best practices. That is something the federal
government can do, tell us what best practices are occurring
where, so that we can consider on a local level what might work
in our state, recognizing that one size does not necessarily
fit all.
We also need continued federal funding to increase our
ability to gather accurate information and to disseminate that
information, in fact, to the public. Our success depends on
that coordination and cooperation. We are here to extend a hand
to continue that partnership with our federal allies. We
support the president's vision as to whether or not 85 percent
should go to the issue of pharmaceuticals. That is an issue
that is well beyond my realm of expertise.
I am here to say that our line of communications is open;
that we have an outreached hand; we look forward to continuing
to work with our federal partners.
We thank you for the opportunity to be here today.
[The statement of Mr. Mitchell follows:]
Prepared Statement of the Honorable David B. Mitchell, J.D.
INTRODUCTION
Good afternoon, Chairman King and members of the Subcommittees. I
am David B. Mitchell, Secretary of the Delaware Department of Safety
and Homeland Security. On behalf of Governor Ruth Ann Minner, I am
honored to be here today to address the important issue of homeland
security as it relates to pandemic influenza. I would like to thank you
for your support of the many initiatives now in place that have
enhanced homeland security and emergency preparedness at the federal
and state level.
The most recent concern of avian influenza mutating into a form
that leads to a human pandemic is a topic not unfamiliar to Delaware,
since we are a leading poultry producing state. I would like to open my
statement today with an explanation of Delaware's experiences with
avian influenza prevention and response in our animal or poultry
population. I will then move on to discuss with you our response to
human pandemic influenza and how we can enhance our federal-state
partnership and allocate resources wisely.
Each year, Delaware poultry growers produce approximately 240
million chickens. Tyson Foods, Inc., Perdue Farms, Inc., Mountaire
Farms, Inc., and Allen Family Foods are the major poultry companies
with growers or facilities in Delaware. However, there are also
numerous other smaller commercial and non-commercial poultry producers
in Delaware. On any given day, there are approximately 110 million
chickens on the Delmarva Peninsula. As one of the largest poultry
producing states in the nation, the risk of exposure to avian influenza
within the poultry industry is high. Of even greater significance is
the risk of exposure within the human population of an influenza
pandemic. The avian influenza virus presents two potential crises with
serious consequences to the State of Delaware. First, an outbreak of
the avian influenza virus within the State's poultry population may
have a severe negative impact on Delaware's economy. Secondly, and of
greater significance, is the possibility of an influenza pandemic which
would have grave consequences for the public health in Delaware.
In recognition of its unique situation, the Delaware Department of
Safety and Homeland Security (DSHS) and its Divisions, Delaware
Emergency Management Agency (DEMA) and the Delaware State Police (DSP),
have succeeded in creating close partnerships and working relationships
with the Delaware Department of Agriculture (DDA), the Department of
Health and Social Services and its division, the Division of Public
Health (DPH), local law enforcement, the Delaware National Guard and
the Dover Air Force Base in an effort to develop a seamless
preparedness and emergency response plan.
AVIAN INFLUENZA--IMPACT ON DELAWARE'S POULTRY INDUSTRY
In February 2004, the DDA and several Delaware agencies joined
forces to contain a low pathogenic avian flu virus identified in flocks
at two Sussex County farms. At the time of the initial outbreak, the
DSHS, through its Division, DEMA, already had in place the Delaware
Emergency Operations Plan (DEOP) for emergencies arising from natural
or human-made disasters. The DDA immediately implemented its emergency
support functions under the DEOP and another division of DSHS, the
Delaware State Police, came in to support the DDA in its efforts to
contain the avian flu virus. Further, the Delmarva Poultry Industry
Inc. (DPI), a nonprofit industry association, had already created an
emergency disease task force in response to an avian influenza outbreak
that occurred in the early 1980s in Lancaster, Pennsylvania. A
Memorandum of Understanding creating a partnership between the DDA, DPI
and other states within the Delmarva Peninsula enabled the DDA to also
convene the DPI's Emergency Disease Task Force. Because the outbreak
did not involve a bird-to-human or human-to-human transmission, DDA
acted as the managing agency. The Delaware State Police, in conjunction
with local private security officers, was immediately mobilized to
assist the DDA in setting up a quarantine of the infected farms,
setting up a barrier to prevent reporters and other curiosity seekers
from trespassing onto the farm, and providing lines of communications
between the DDA, the press and the public about the status of the
crisis.
Despite the quarantine order and admonitions by the DDA and the
Delaware State Police that it was necessary to stay away from the
infected farms to prevent spread of the virus, reporters attempted to
enter the quarantined area through any means available. Some flew
helicopters to gain access to the farms; others trespassed at night
with night vision equipment to photograph poultry, houses and growers.
Through coordination between DSHS, DDA and DPI, efficient
implementation of the DEOP, and effective communications between DDA,
the Delaware State Police, DPI and the public, Delaware successfully
quarantined the two farms and contained the virus.
Delaware's success in containing the virus in 2004 has earned it
national attention as a leader in how to respond to avian influenza as
it pertains to poultry. Under the DDA's poultry regulations, all
commercial or non-commercial premises where live poultry is kept must
be registered with geo-referenced coordinates of all chicken coops.
Vehicles, crates, coops and footwear used for sale or transfer of
poultry out of state must be in a completely clean condition prior to
leaving or returning to Delaware and is subject to inspection. The DDA
requires all poultry growers to maintain detailed records of their
poultry.
Producers are required to participate in several testing programs
to ensure their flocks are free from any potentially hazardous forms of
avian influenza. Thanks to a partnership between the DDA and the
University of Delaware, the DDA is able to conduct onsite testing of
every flock and receive test results within 3 to 4 hours. At present,
the test can quickly identify the potential harmful ``H'' factor of the
avian flu, but additional testing must be conducted in order to
identify the ``N'' factor. Any flock found to have avian influenza is
immediately depopulated and disposed of onsite in an environmentally
acceptable manner and the coops disinfected for reuse.
Delaware is one of five states to implement an Indemnity Program
which utilizes state and federal funds to reimburse poultry producers
for flocks lost due to depopulation by DDA. This permits the State of
Delaware to immediately respond to the threat of the spread of an avian
flu virus without delays and, as an additional benefit, encourages
poultry growers to report an infected flock in a timely manner. The
continued success of its program is dependent upon efficient
recognition and reporting of an emergency poultry disease. Because
Delaware is one of the largest poultry producing states in the nation,
continued funding from the federal government is necessary to ensure
that Delaware can continue its research to completely and expeditiously
identify a highly pathogenic avian flu virus with the potential to
mutate to a form adaptable for human to human transmission. Further,
federal funding is also necessary to ensure the viability of Delaware's
Indemnity program. From a homeland security perspective, fighting the
pandemic influenza from the frontlines includes, in large part,
preventing the spread of avian influenza through the development of
strict regulations, rigorous testing and an effective emergency
response plan as it pertains to Delaware's poultry industry.
PANDEMIC INFLUENZA_FIGHTING FROM A HOMELAND SECURITY PERSPECTIVE
The U.S. Department of Health and Human Services' (HHS) Pandemic
Influenza Plan recognizes the important role that Homeland Security and
state and local law enforcement agencies have in the overall success of
the plan and offers detailed guidance to local law enforcement
regarding their involvement in the execution of their state and local
pandemic influenza plans.
In September 2005, with the guidance of the HHS Pandemic Influenza
Plan, Delaware completed its Pandemic Influenza Plan. In recognition of
the important role of the Department of Safety and Homeland Security
and State and local law enforcement play in a pandemic influenza
situation, DSHS and state and local law enforcement agencies, with the
Delaware National Guard, DEMA and other state agencies have conducted
extensive drills, table top exercises and incident command training
geared towards early, quick and effective response to a pandemic
influenza event and allocation of resources in the most effective and
efficient manner.
In November 2005, more than 100 participants gathered to take part
in a Pandemic Influenza Table Top Exercise tackling tough issues like
isolation and quarantine, continuity of essential services and
businesses, medical surge capacity, infrastructure security, mass
fatality and public education. The exercise was a great opportunity for
Delaware's agencies to coordinate their individual roles, exchange
information and concerns, network and review emergency plans. Delaware
will hold its Pandemic Influenza Summit on February 21, 2006 with
Governor Ruth Ann Minner and other local and federal representatives,
including keynote speaker U.S. Surgeon General Richard Carmona. The
Summit will give Delaware the opportunity to discuss Delaware's
Pandemic Influenza Plan and to exchange information with its federal
partners to ensure the continued development of a seamless, flexible
and practical preparedness and emergency response plan.
A. The Emergency Health Powers Act
The Department of Safety and Homeland Security, Delaware State
Police, DEMA, Division of Public Health, Delaware National Guard, and
the Dover Air Force Base are actively working together to develop an
effective quarantine and isolation plan. One of Delaware's
accomplishments has been the enactment of the Emergency Health Powers
Act, which gives the Division of Public Health and the Department of
Safety and Homeland Security the authority to obtain quarantine or
isolation directives and orders in an expedited manner during an
influenza pandemic. Prior to a Declaration of a State of Emergency by
Governor Ruth Ann Minner, the Public Health Authority under DPH may
obtain a quarantine or isolation order if it has been established that
a person or persons pose a significant risk of transmitting a disease
to others with serious consequences. Once a State of Emergency has been
declared, the Public Safety Authority under DSHS has the authority to
obtain quarantine and isolation orders. Both the Public Health
Authority and the Public Safety Authority have the ability to request
that an order be granted on an ex parte basis and both have the
authority to issue directives permitting state and local law
enforcement to detain the person or persons pending the issuance of an
isolation or quarantine order. Further, the Emergency Health Powers Act
contain important provisions protecting the due process rights of
individuals who are subject to a quarantine or isolation order, such as
ensuring that persons quarantined or isolated under an ex parte order
receive a hearing within 72 hours.
Currently, the Delaware Department of Safety and Homeland Security
and Division of Public Health are working with Delaware's state courts
to create form petitions for ex parte quarantine and isolation orders
to help expedite the process of obtaining orders under which law
enforcement can legally act. The goal is to create petitions easily
recognizable to a judge or clerk of the court as urgent. Furthermore,
both agencies are working with the courts to establish a judge-on-call
who can act as the primary responder to an emergency petition to
quarantine or isolate as well as a set policy and procedure for
responding to an influenza pandemic.
Although the judges in Delaware are not considered first
responders, they play an important role in determining what legal
authority law enforcement has to enforce a quarantine or isolation
order and to the extent of that legal authority. It is further expected
that judges will continue to play a role during a pandemic as they will
be asked to issue other orders, such as orders of contempt against
those persons who violate the quarantine or isolation orders or to
determine law enforcement's authority to, for instance, restrict travel
across State borders. Currently, efforts are being made to protect
judges from being exposed to the virus when they are called upon to
preside over hearings related to quarantine and isolation orders. For
example, Delaware is looking at the possibility of conducting hearings
from a remote location through videoconferencing or providing judges
with protective gear when conducting such hearings.
B. The Delaware Emergency Operations Plan and Pandemic Influenza
Plan
The Incident Command System has been incorporated into the Delaware
Emergency Operations Plan. The Department of Safety and Homeland
Security and the Delaware State Police are the primary agencies in
command of security and law enforcement and in charge of communications
when there has been a declaration of a state of emergency. Delaware's
Pandemic Influenza Plan, issued in September 2005, also provides that
the Delaware State Police shall act as a supporting agency in the way
of crowd control, traffic control for vaccination clinics, enforcement
of quarantine and isolation orders and directives, and transportation
of shipments of vaccines to designated receiving sites. Until there has
been a declaration of a State of Emergency, the Delaware State Police
shall only act as a supporting agency to the local jurisdiction in
which a quarantine or isolation order has been issued by the Division
of Public Health. The Delaware State Police will only assist when help
is requested by that local jurisdiction. DSHS, the Delaware State
Police and local law enforcement also have the ability to enter into
mutual aid agreements if the emergency escalates.
1. The Intrastate Mutual Aid Compact
As part of Delaware's incident command training and its efforts to
minimize local jurisdictional lines during an emergency, Delaware
recently enacted the Intrastate Mutual Aid Compact which creates a
system of intrastate mutual aid between participating political
subdivisions and fire, rescue and emergency medical service provider
organizations in Delaware. The Compact provides for mutual assistance
in the prevention of, response to, and recovery from, any disaster that
results in a formal state of emergency in a participating political
subdivision. The Compact has also created a committee to review the
progress and status of statewide mutual aid, assist in developing
methods to track and evaluate activation of the system and to examine
issues facing participating political subdivisions and fire, rescue,
and emergency medical service provider organizations regarding
implementation.
From a homeland security perspective, the Intrastate Mutual Aid
Compact permits state and local law enforcement to cross in-state
jurisdictional lines to provide or receive aid from neighboring local
jurisdictions and promotes integration and intra-operability between
state and local law enforcement resources as a cohesive and fluid
process.
Once there has been a declaration of a State of Emergency, the
Delaware State Police creates a task force comprised of representatives
from each of the local law enforcement agencies, which then convenes to
coordinate emergency law enforcement response, allocation of resources,
communications and assignments of personnel. It is imperative that
intra-operability, information gathering, analysis and dissemination
between agencies and the public be transparent, fluid and efficient.
Delaware recognizes that intra-operability between first responders and
other necessary emergency personnel is key to the success of any
emergency preparedness plan. Federal funds are always necessary to
assist Delaware in acquiring and maintaining state-of-the-art
technology which would promote continuity of operations during an
emergency involving the containment of a lethal virus or disease.
STATE ALLOCATION OF FEDERAL RESOURCES
Federal funding and resources have supported many of Delaware's
main homeland security objectives including effective communication
between first responders, information gathering, analysis and
dissemination, intra-operability between local jurisdictions, agencies
and the business and private sector, and public education and
awareness. Funding received from the federal government has also
enabled the Department of Safety and Homeland Security to make
significant strides in the development of an ``all hazards'' approach
to our preparedness and emergency response plans. Funding at the
federal level is necessary to ensure that Delaware can continue to
develop plans which are flexible enough to adapt to different types of
emergencies, yet specific enough to effectively and efficiently respond
to those emergencies. Finally, fighting the pandemic influenza from the
frontlines means maintaining a strong focus on prevention and response.
Delaware must place its efforts in preventing the virus from entering
its State borders and on ensuring success in the execution of an
immediate, effective and proficient emergency response plan.
DSHS understands the importance of being able to equip Delaware's
first responders and state and local law enforcement with the tools
necessary to successfully fight an influenza pandemic from the
frontlines. A substantial amount of federal funds Delaware has received
has been allocated to the purchase of decontamination equipment,
protective suits and masks, communications equipment, all terrain
vehicles for rescue and recovery in extremely rough terrain, chemical
detection kits, security cameras and night vision equipment. State and
local law enforcement agencies are working with the Delaware Division
of Public Health to ensure that they, as first responders, and their
families receive antiviral vaccinations that should offer protection
against the virus. Further, the DSHS, in conjunction with DEMA and the
Delaware State Police are designated as the primary agencies for
keeping the lines of communication open between agencies and the public
and disseminating accurate information to the agencies and the public
as a pandemic unfolds.
The Department of Safety and Homeland Security is using state of
the art telecommunications technology to create a 24 hour, 7 day a
week, center from which information and intelligence data may be
received, analyzed, processed, and disseminated to the private and
public sector in a consistent and reliable manner. The Delaware
Information Analysis Center (DIAC) will be key in maintaining open
lines of communication between state and local law enforcement and
other first responders. It will also serve to expand DSP's intelligence
capabilities allowing a host of law enforcement agencies including the
FBI, State and local police to share information regarding possible
terrorist and bioterrorist threats. As part of the DIAC, DSHS is
developing a geographical information system (GIS) and looking at the
option of installing global positioning system (GPS) and automatic
vehicle locator (AVL) devices in all modes of transportation used by
first responders.
As a result of federal funding, Delaware has been able to enhance
its 800 MHz Digital Trunked Radio System to improve intra-operability
for all state, county and local government agencies, fire, police and
emergency medical services and to improve communications within
buildings through the use of vehicular repeater systems. Currently,
there are over 40 different agencies on the system, using approximately
12,000 mobile and portable radios and making over 115,000 calls on a
typical day. The 800 MHz System also provides interoperability in the
jurisdictions surrounding Delaware that have systems which are
compatible with Delaware's system. Delaware's goal is to enhance the
system to resolve current system deficiencies. This $52 million project
will provide in-building coverage throughout the State, through the use
of tower sites, bi-directional amplifiers, and vehicular repeater
systems. It will also expand the number of dispatch consoles from 54 to
123 while standardizing and improving redundancy within and between all
911 Centers, upgrade the radio systems platform to extend its
lifecycle, enhance intra-operability with agencies that are not on the
800 MHz system today, such as Public Works, and enhance
interoperability with jurisdictions surrounding the State who use
systems which are not compatible with Delaware's system. The State
would like to also expand the microwave network that connects the radio
system so that it can support the traffic and reliability needs for
other telecommunications services requirements in the state. While the
$52 million allocated for this project will help to upgrade systems
currently being used by Delaware for emergency response, additional
federal funding over the next 5 to 7 years will be necessary to meet
the prevention and emergency response needs of Delaware as it strives
to keep pace with ever evolving technology.Sec.
Delaware has also been involved in other projects to enhance the
state's ability to stay informed of events as they unfold throughout
the state and to allocate resources where they are most needed.
Recently, Delaware State Police and Kent County Emergency Services
purchased new high-tech Mobile Command Centers which have been fully
customized with state of the art technology and telecommunications to
assist those who need help as quickly as possible at the scene of an
emergency. Additionally, the Delaware State Police enhanced their
medical transport service with the purchase of new aircraft to provide
24-hour, 7-day a week emergency helicopter transport statewide.
Educating the public prior to the onset of this crisis is crucial.
The Department of Safety and Homeland Security is providing an all
hazards personal preparedness message to Delawareans by promoting the
U.S. Homeland Security Ready campaign. Residents are encouraged to
create a plan, make a kit and know potential threats. DEMA also
provides personal preparedness training in communities statewide
through its Citizen Corps program. Delaware has earmarked the Phase 1
Federal Pandemic Influenza funds it has received for public education.
The Division of Public Health has implemented a public outreach program
to educate Delawareans about pandemic influenza and personal
preparedness. One component of the program is a series of public
informational meetings hosted in communities throughout the state.
Public Health officials will also provide citizens with information on
assembling a personal emergency kit with the essential items including
health supplies, food and water. Brochures have been created for the
special needs population in Delaware on how to prepare for and respond
to general emergencies. The brochure advises people with disabilities
and other special needs to maintain a contact list of medical
suppliers, pharmacies, doctors, family members and friends they can
rely on during an emergency. It also provides information on how to
create an emergency preparedness kit.
ENHANCING THE FEDERAL-STATE PARTNERSHIP
Delaware will continue to look to the federal government for
guidance and support during the development of its plans to manage an
influenza pandemic. It is important that our federal partners continue
to hold public meetings and summits to keep the lines of communication
open. Public meetings are needed in each state to share information
with local residents. Delaware looks forward to a federal partnership
to highlight best practices. It is vital that we learn from each other.
Sharing expertise and lessons learned can save states valuable time and
money. Delaware also needs federal funding to implement these best
practices, which may include the purchase of state-of-the-art equipment
and technology or the institution of innovative programs designed to
prepare its agencies, the private and business sector and its citizens
for a worst case emergency scenario. Fiscal restraints should not
interfere with the States ability to take appropriate safety measures
to protect its citizenry. In the face of the varying messages from
different facets of the media, federal funding and support continue to
be necessary to increase Delaware's ability to gather accurate
information and disseminate that information to the public. Our
citizens rely on state officials to provide them with timely accurate
information. Providing funds to develop the Delaware Information
Analysis Center and 800 MHz System will promote accurate dissemination
of information to the public and enhance rumor control. Finally,
support from our federal partners should come in the form of ongoing
joint summits and federal and state exercises and drills. Exercises
help states form invaluable relationships with state and federal
contacts important in emergencies. Experiences gained during drills and
exercises will prove beneficial in the event of emergency.
The success of the Delaware Pandemic Influenza Plan, and any other
pandemic influenza plan, depends on the cooperation and coordination
between law enforcement and other agencies on the national, state, and
local level. Effective forms of communication and accurate
dissemination of information as the pandemic progresses will lessen the
chance of overstating or understating the risks inherent in this type
of a crisis. One thing is for certain: we must stay ahead of the H5N1
avian flu virus. Constant preparation, planning, testing, and
development of Delaware's Emergency Operating Plan and Pandemic
Influenza Plan will result in an effective and meaningful preparedness
and emergency response plan to the pandemic flu.
Mr. Linder. Thank you, Secretary Mitchell.
Ms. Phillips?
STATEMENT OF FRANCES B. PHILLIPS, HEALTH OFFICER, ANNE ARUNDEL
COUNTY, MARYLAND DEPARTMENT OF HEALTH
Ms. Phillips. It is my pleasure, Chairman Linder and
Chairman Reichert and distinguished members, to address you
today on the vital role that local health departments and our
community partners play on the frontlines in pandemic influenza
planning and response.
Local health departments hold the potential to minimize the
impact of a pandemic, and in fact local public health action
can determine the initial and perhaps ultimate impact of such a
crisis in the United States.
What I would like to do is very briefly describe what it is
that local health departments across the country are now doing,
and the crucial link between this public health work and our
public safety agencies. I will base my remarks on my experience
in Anne Arundel County.
As you may know, Anne Arundel County is in the Baltimore-
Washington corridor, a county in Maryland, home to just over
500,000 county residents, as well as our historic capital,
Annapolis. Our county is also home to many very important
federal landmarks, such as the United States Naval Academy,
Fort Meade Army base, the National Security Agency, and other
federal installations, the Chesapeake Bay Bridge, and of
particular interest for this topic is the Baltimore-Washington
Thurgood Marshall International Airport.
In my experience, over 13 years as a health officer in Anne
Arundel County, our department has faced a number of local
public health crises, certainly ranging from the full
mobilization on 9/11, and then the subsequent anthrax attack in
2001. We have had severe weather emergencies, smallpox
preparedness, as well as the SARS emergency in 2003.
We have also dealt with more moderate public health crises,
including hepatitis, tuberculosis, and West Nile outbreaks, as
well as the national seasonal flu vaccine shortage in 2005. And
then on a day-to-day basis, we face urgent public health issues
such as well water contamination, respiratory outbreaks in
nursing homes, and meningitis cases among schoolchildren.
I had the opportunity in 2004 to have a very rewarding
opportunity, I should say, to serve as an interim fire chief
for my county. In making this appointment, the County Executive
reflected on the number of instances in our county where the
health department and the fire department jointly addressed
local emergencies, and how both agencies share a common
commitment to the protection of the public safety of our
residents. I found in my tenure with this large metropolitan
fire department, I found more in common between the two
agencies than that which is different.
With regard to pandemic planning, not only must we take an
all-hazards approach, but we must definitely plan for the
integration of local, state, federal and nongovernmental
response agencies. Fundamental to this organization, this
integration, is the shared command and management framework
which the National Incident Management System provides. This is
the common underpinning across public health and public safety.
In my department, with a staff of over 850, every single
person in my health department has been trained in basic
preparedness, using the NIMS model, some much more skilled than
the basic level. Readiness for the possibility of a 24/7
emergency call-up is a condition of employment in my health
department. So every school nurse, for example, every
addictions counselor, every restaurant inspector has a basic
understanding of what their role would be in an emergency. We
have both exercises, and we have had real-time experience with
this call-up.
I would like to name just four areas of unique local public
health activity with regard to pandemic preparedness. The first
has been mentioned, and that is disease surveillance. We need
and we have a system across the country of surveillance so that
when an astute clinician either diagnoses or suspects a case,
that suspicion can be reported to a public health authority
able to interpret and to respond on that report. That is the
basic infrastructure and local health departments are the boots
on the ground, so to speak, with regard to our nation's
surveillance system. Every year, my department receives 4,000
communicable disease reports, which then trigger over 2,100
disease investigations.
A different kind of surveillance is demonstrated by an
incident that occurred within the last 2 weeks at BWI airport.
On a commercial carrier, the pilot radioed ahead that there was
a sick passenger on board and that that passenger had had
extensive Southeast Asian travel. What occurred at the point of
landing was a very rapid response where, taking isolation for
caution, the patient was evacuated to a nearby hospital for
emergency evaluation. Within the hour, about two dozen state,
local, federal and representatives of the commercial carrier
were convened, and a response plan initiated.
Surveillance is one. The second unique role that I would
like to briefly mentioned, and has been mentioned, community
awareness and self-sufficiency. Pandemic is going to involve
all sectors, as has been said. It is a pan-societal crisis. In
my department, we have been briefing over the past several
months every sector in our county, certainly our other public
safety and other county agencies. We have been working very
closely with personnel from the Naval Academy, from Fort Meade,
from NSA, working on their contingency plans; our school
systems, our hospitals, our church and faith-based
organizations, and I have to say our business community. Large
employers in our county are very anxious to understand more
about pandemic influenza preparedness so that they can put
forth their continuity of operations plans.
Thirdly, community infection control. When we think about
an outbreak of this kind of infection, certainly the issue of
isolation and quarantine comes forward. As has been mentioned,
many states have beefed up the legal underpinnings to take some
unprecedented actions with regard to ordering individuals and
to taking control of private property. At my level, we are
right now working on an inventory of alternative housing for
individuals who would need to be in respiratory isolation, as
well as working on the social and the medical support that
these people would need to stay homebound.
We had a little bit of experience with this with the SARS
emergency. We had some people who were in a voluntary home
isolation. We had 100 percent compliance, but we certainly
believe that that may not be the future with pandemic and we
need to rely on our public safety partners for security.
Lastly, mass vaccination and medication distribution. The
role of local health departments, when a vaccine is available,
an effective vaccine, is to take delivery of that vaccine and
to distribute it to all county residents. In our county, we
have not had, of course, the experience with pandemic, but last
year in 2005, with the flu vaccine crisis, we had a situation
where thousands and thousands of residents were very anxious
for their flu shots. We mobilized, with the help of our EMS and
our police department. High-school-based mass clinics, using
all of our staff, were able to vaccinate on two Saturdays,
6,800 people at a rate of 670 doses an hour.
In conclusion, as far as federal leadership, I do commend
the federal government for this proactive approach and
engagement on the issue of pandemic flu. I have submitted some
written recommendations with regard to the federal role.
Suffice it to say that it is key that there is a collaboration
at the very highest levels of the federal government, because
for us on the ground it is very important that that
collaboration result through state and local grantees in a
reinforced and consistent message. I urge the Department of
Homeland Security, for example, to engage with us, local public
health practitioners, as they go forward with their pandemic
flu plan.
So on behalf of the National Association of City and County
Health Officials and our membership, I commend you for your
leadership on this topic. Thank you.
[The statement of Ms. Phillips follows:]
Prepared Statement of Frances B. Phillips
It is my pleasure, Chairman Linder, Chairman Reichert, and
distinguished Members, to address you today concerning the vital role
of local health departments and their community partners in homeland
security on the front lines in pandemic influenza planning and
response.
The combined efforts of local health departments and our colleagues
in first response will determine the initial, and in many ways, the
ultimate impact of an influenza pandemic in the United States. In my
presentation, I will describe how local health departments are planning
our response to a worldwide influenza outbreak, with an emphasis on how
the success of those plans relies on the crucial linkages that have
been built between local public health departments and a range of
community partners.
For nearly 13 years I have directed a large local health department
serving a population of about 500,000, including residents of our
historic state capital, Annapolis. Anne Arundel County is also home to
many national landmarks such as the U.S. Naval Academy, Fort Meade Army
Base, the National Security Agency and other federal installations and
the Chesapeake Bay Bridge. In terms of pandemic flu, the landmark about
which I am most concerned is the Baltimore Washington Thurgood Marshall
International Airport. Collectively, these landmarks have resulted in a
relatively high ``vulnerability index'' of security threats to the
county.
Heightened awareness of the potential vulnerabilities is something
all the response entities in our jurisdiction share. For years, we have
been engaged with our police, fire and rescue, emergency management and
other counterparts in planning and exercising for local emergencies. As
in the rest of the country, this type of cooperative work intensified
after September 11, 2001, building on the mutual understanding that we
all have our part to play in any unfolding emergency.
In 2004, I had the unique and rewarding opportunity to serve as
Acting Fire Chief for an interim period in my county. In making this
decision, the County Executive reflected on the number of instances in
which both fire and health departments had jointly addressed local
emergencies, and how a common commitment to protecting the safety of
county residents was central to the appointment. So often we hear about
the differences that exist among the emergency disciplines--but this
core mission that we share is key.
I found more that was common to public health during my tenure with
this large metropolitan fire department than was different. There were
areas where each agency could--and did--benefit from an exchange of
expertise. For example, learning from public health's proficiency in
prevention and outreach to diverse communities, including those with
special needs, was a gain for the fire department. Likewise, the fire
department's expertise in incident management and chain of command
accountability has proven to be of great utility within the health
department in a range of emergency situations.
My department, with a staff of about 850, has experienced a wide
array of emergencies, just in recent years. We have had direct
experience mobilizing emergency operations in the face of the 9/11
attacks and subsequent anthrax attacks of 2001, severe weather
situations, tuberculosis and hepatitis outbreaks and the SARS emergency
of 2003. We have also faced more moderate, but nonetheless challenging
events, such as the West Nile Virus outbreak and the national flu
vaccine shortage of 2005. And of course, on a daily basis we are
confronted with localized but urgent public health issues such as well
water contamination, respiratory outbreaks in nursing homes and
meningitis cases among school children. All of these experiences are
vital to building a workforce prepared to respond in the face of a
prospect as daunting as pandemic influenza. My remarks today are based
on lessons learned from these real world events.
Pandemic Influenza Preparedness Must be Integrated into All-Hazards
Preparedness
Local emergency preparedness is based on an `all-hazards' approach.
This approach requires communities to assure the essential capabilities
necessary to respond to a wide range of emergencies: intentional or
naturally occurring infectious disease outbreaks; chemical, explosive
or radiologic accident or attack; weather-related disaster; or other
emergency.
Since 2001, with the elevated awareness of the country's
vulnerability to intentional attacks with biological agents, there has
developed a better understanding of public health's unique role in
protecting the homeland in this kind of scenario. Whether the
communicable disease threat is a novel influenza virus, smallpox,
anthrax, West Nile Virus, SARS, or other emerging pathogen capable of
causing widespread illness and death, there are a core of universal
public health response capabilities for which local health departments
across the country are planning, training and exercising.
However, those health departments do not and cannot stand alone.
All planning and response must be integrated with other local entities,
most notably public safety first responders, but also state, federal
and non-governmental partners. Fundamental to such integration is a
shared command and management framework. With its strong foundation in
the Incident Command System, the broader National Incident Management
System (NIMS) developed under Homeland Security Presidential Directive
5 provides this common underpinning for all public health and public
safety preparedness. Over time, adoption of NIMS will continue to
facilitate the integration of language, mental models and even certain
cultural aspects of public safety by public health professionals.
Pandemic influenza planning is a section of our county's Health/
Medical Annex--the ``ESF (Emergency Support Function) #8 Chapter''--
within the county's all-hazards plan. This is typical and it
demonstrates the integration of the influenza response into an all-
hazards approach. Although it is located in the Health/Medical Annex,
which contains the core response elements for a disease outbreak, the
roles in executing the response span the gamut of other emergency
disciplines, as they do for any other targeted scenario within an all
hazards plan.
Key Elements of Front Line Pandemic Influenza Preparedness
1. Disease Surveillance
The purpose of a strong surveillance system is to create time in
which to intervene and eliminate or mitigate threats. In local public
health, practical disease surveillance means a system by which
clinicians in private practice or in hospital settings can detect and
report a novel flu virus or a suspect case to a public health authority
capable of receiving, interpreting and responding to such a report.
Ultimately, the country may reach a point where electronic medical
records and associated systems will enable automatic reporting of
diseases or suspicious symptoms, but such capability will be immensely
challenging in this intensely diverse and complex national environment.
We cannot wait, nor can we depend solely on technology when so much is
at stake. Our greatest strength is in our American workforce--our
astute clinicians, our trained healthcare professionals, our alert
hospitals--and the effective partnerships that are forged between this
community and capable local public health departments. It is important
not to underestimate the immediate and important utility of this model
of disease surveillance.
Local health departments are the `boots on the ground' elements of
our nation's disease surveillance system. In my department, we receive
4000 communicable disease reports each year from our partner hospitals
and physicians. Typically, these reports involve infectious diseases
such as tuberculosis, AIDS, or measles. These reports generate over
2100 disease investigations conducted by public health, with our staff
conducting patient interviews, performing contact tracing and, where
indicated, beginning prophylactic treatment of persons who have been
exposed.
One less typical but important example of public health
surveillance recently occurred when the flight crew on a commercial
aircraft bound for BWI airport reported a sick passenger returning from
extensive travel in Asia. Upon arrival, the individual was immediately
transported to a nearby hospital for evaluation. Within the hour,
nearly two dozen local, state and federal agency personnel, along with
representatives of the carrier, had been alerted and a response plan
initiated.
2. Community Awareness and Self-Sufficiency
As the BWI incident demonstrates, planning with a broad range of
partners meant than when a real situation arose, the right people were
there quickly. In the specific case of pandemic influenza, there is a
continuing need for not only governmental, but also corporate and
community sectors to be informed about pandemic influenza and to
understand their potential roles in a response.
At a local level, the health department is regarded as the source
for reliable and practical information, specific to the community. For
months my department has conducted continual `customized' education
sessions on avian and pandemic influenza to all sectors, beginning with
our police, fire, emergency management and pubic works departments. We
have held ongoing briefings with the Naval Academy, Ft. Meade and NSA
personnel; our school system, hospitals, and nursing homes. The
business sector, faith-based and community-based organizations have all
sought our information and guidance on preparing for a major flu
outbreak.
My department serves a key consultant to county government and
several large corporations in developing their continuity-of-operations
plans to address prolonged and widespread absenteeism. We have a cadre
of trained presenters, as well as a very active website, public sector
cable television channel and strong media relationships to assist with
these broad communications efforts.
We are not alone in conducting such education. Across the country,
some innovative partnerships between public health departments and the
private sector are emerging. Whether it is educating their employees
through distributing information on preventive measures or volunteering
to coordinate points of dispensing on corporate campuses, some
companies are showing interest in playing a part in the larger
response.
There is a tremendous desire for information regarding pandemic
influenza across all sectors and a great deal of work ahead for local
health departments in spreading the word, but this effort will be worth
the return if we can reduce panic and increase creative response
options if the need ever arises.
3. Community Infection Control
Over the past several years, the legal foundation required for
public health to adequately protect the public in a catastrophic health
emergency has been significantly strengthened in many states. Both
state and local health departments have closely examined our respective
responsibilities to isolate or quarantine persons; to control private
property or otherwise intervene in private activities. All these would
be unprecedented actions, requiring enormous pre-planning. In my
county, for example, we are developing an inventory of alternative
housing suitable for persons requiring respiratory isolation. We are
identifying sources for the medical and social supports should large
numbers of people be confined at home. These partners will be a major
part of the success of any critical effort to minimize the spread of
disease.
Our experience with placing a few SARS suspects in home isolation
has been instructive. We experienced 100% compliance, but recognize a
pandemic circumstance could be radically different. In such situations,
we may call on our public safety partners to assist with security. We
recognize the importance of making sure they are educated about risks
and are knowledgeable about what prophylaxis is available and the need
for any personal protective equipment.
4. Mass Distribution of Vaccines and Medications
Timely development of an effective vaccine, in sufficient quantity
to immunize the population against a novel virus, is a huge challenge
that the Federal government has taken important steps to confront.
Local health departments are responsible on the ground for accepting
delivery of the Strategic National Stockpile in which such a vaccine or
anti-viral medications would be stored. Mindful that we do not now have
the ability to manufacture sufficient quantities of such
countermeasures, we must still have in place all the planning, staffing
and public information systems necessary to promptly distribute them to
all priority populations in the county.
While we've not experienced a pandemic, local health departments
have had parallel experiences and exercises that have tested our
ability to provide mass vaccine and medication distribution. In our
case, in October 2001, we rapidly mobilized mass clinics to distribute
ciprofloxacin to U.S. Postal Service or U.S. Senate employees
potentially exposed to anthrax while working. During the 2004 seasonal
flu vaccine shortage, with delayed shipments causing the public to
become extremely anxious to get their flu shots, our department gave
over 6800 doses in two days, at a rate of 670 doses an hour.
This effort demonstrated the value of a thoroughly trained and
responsive public health workforce. In my department, every staff
person, from school nurse to addictions counselor to restaurant
inspector, is required to be trained, at a minimum, in basic emergency
preparedness using the NIMS model.
Yet again, we could not have managed this mobilization without the
full support of our police and fire departments, who provided security,
essential traffic control, and necessary emergency medical transport
capacity at the high school-based mass clinics. These are no minor
feats in a mass setting, especially in a real life situation where
emotions are running high and the chance of panic is never far away.
The public already has benefited greatly from the collaboration between
public health and public safety agencies. Only through a highly
coordinated and very broad ``pan-social'' approach will we achieve
maximum homeland security in the face of an influenza pandemic.
Federal Leadership
It is a positive step that so many in this country are paying
attention to pandemic influenza before we find that threat a reality.
We often tend to focus on the last event, but in this case the focus
has been on being proactive--a fact which is evidenced by the very
existence of this hearing. Your leadership on this issue is
appreciated.
However, there doesn't always appear to be the same sort of
cooperation and coordination occurring at the Federal level among the
various agencies involved in pandemic influenza preparedness as there
is even in Anne Arundel County. Leadership questions in the event of a
biological attack have been debated by Federal agencies in the press.
Should the Department of Homeland Security (DHS) be at the forefront or
should the Department of Health and Human Services (HHS) play the
leading role? If DHS is in charge, how will they draw on public health
expertise and resources to guide the Federal response?
The same question frequently arises when setting up an incident
command at the local level for a biological incident. Is the public
health officer the incident commander? The answer is sometimes yes,
sometimes no. The answer depends on the health department, it depends
on the community and it depends on the event. The decision should be
made based on a clear understanding of needs and capabilities. Most
often at the local level, the understanding is that if public health is
not the incident commander in a public health emergency, whoever does
assume that role will rely heavily on the public health officer to
provide the guidance and situational awareness necessary for decision-
making.
Thus far, the Department of Homeland Security has made progress in
understanding and integrating public health in fits and starts. Initial
efforts toward fulfilling HSPD-8 showed limited understanding of what
public health even was and how it would mount a response in an
incident. As I described above, pandemic influenza response will
require much more than medical care and hospital beds. To its credit,
DHS later reached out to public health practitioners for input on
documents like the Universal Task List and the National Preparedness
Goal. DHS and HHS appear to have improved their communication somewhat,
but there is still much room for improved coordination between these
two agencies.
For example, the interdisciplinary cooperation I have described
that will be so valuable in the event pandemic influenza arrives in
Anne Arundel County appears not to be a high priority in the current
Federal approach. Congress has appropriated some much-needed additional
funds, $350 million, for local and state health departments, and new
guidance for those efforts is on its way. Yet, little discussion is
taking place regarding the non-CDC grantees vital to the success of a
pandemic influenza plan. Can DHS grantees use their funds for
collaboration on this sort of planning? Should they be required to do
so?
Federal agencies need to collaborate at the highest level of
government to send coordinated and reinforcing messages to all grantees
at state and local levels that multidisciplinary cooperation is a high
priority. Through the structure of grant programs and the guidance
provided, DHS and HHS can either facilitate local efforts in that
regard or hinder them with inconsistent guidance. Both agencies should
include local public health practitioners, the ones who will be key
responders on the ground, in their consultations. It is not enough for
DHS to rely exclusively on HHS for public health input.
Another way that those at the Federal level can help to make our
national response to emergencies like pandemic influenza more unified
is to remember the professional diversity of their audience when
rolling out national programs. Local emergency response agencies are
being required to absorb and integrate a continual stream of new
initiatives, ranging from NIMS and the National Response Plan to the
Target Capabilities and the National Preparedness Goal. Training
courses are introduced through FEMA and the Emergency Management
Institute. Yet the local audiences grappling with all these new
programs--while continuing their day-to-day workload serving their
communities--need to understand just how these programs are relevant to
their roles in an emergency. When a federal contractor with a fire
service background conducts a basic Incident Command System training
for public health workers, the concepts are correct, but the anecdotal
examples don't resonate. In terms of public health, there are a wealth
of solid examples of departments that have integrated ICS into even
their day-to-day operations. Courses that reference those familiar
experiences are more likely to have an impact. Unfortunately, such
courses are hard to find.
Finally, while much time is spent asking local and state emergency
personnel to understand how the national plan is structured, we need to
remember that no matter how serious the emergency, the response always
begins locally. And in the case of pandemic influenza, the
effectiveness of that early response will determine how the emergency
unfolds. Standardization is important to the extent that it can be
realized, but national plans also must support a response in every
corner of this diverse country. A one-size-fits-all approach simply
will not be successful.
Whether pandemic influenza or some other disaster afflicts our
nation, there is no shortage of dedicated Americans at every level of
government working hard on homeland security. Continuing to promote,
support, and build local partnerships among public health, health care,
public safety, emergency management, and a host of private sector
partners will only improve our ability to protect the health and safety
of our communities.
Mr. Linder. Thank you very much, Ms. Phillips.
Mr. Blackwelder?
ERNEST BLACKWELDER, SENIOR VICE PRESIDENT, BUSINESS FORCE,
BUSINESS EXECUTIVES FOR NATIONAL SECURITY
Mr. Blackwelder. Good afternoon, Chairman Linder, Chairman
Reichert, ranking members, distinguished members of the
committee. It is an honor to be here today to address some of
the ways in which the private sector can help our country
better prepare for and respond to pandemic influenza.
I am here on behalf of Business Executives for National
Security, or BENS, a national nonpartisan, nonprofit
organization, comprised of more than 500 business executives
committed to volunteering their time and talents to improve the
nation's security.
Mr. Chairman, when facing the threat of pandemic flu or any
catastrophic event, businesses have two kinds of
responsibilities. First is saving themselves, and the second is
helping their communities. Self-preservation or business
continuity planning includes developing emergency response
capabilities to protect employee health and safety, as well as
taking steps to make business operations resilient enough to
survive a catastrophic event. Business preparedness helps
protect critical infrastructure, ensure availability of
urgently needed goods and services, and strengthen economic
stability.
Businesses are creating contingency plans to help reduce
their economic risk in the event of pandemic flu, including
stockpiling supplies, improving virtual work programs such as
telecommuting, implementing travel restrictions, cross-training
employees, reallocating work activities, and reconfiguring
shifts, to limit exposure to coworkers.
While business continuity planning is critical, there
remain huge gaps in our preparedness and response capabilities
nationwide that neither business nor government can fill alone.
Increasingly, communities recognize the need to bring the best
of business and government together to meet these challenges.
Three years ago, BENS began to leverage private sector
resources and know-how to work in concert with state and local
government to strengthen regional homeland security and
disaster response capability. I would like to share some of the
lessons we have learned and the promise they hold for saving
lives.
Through regional public-private partnerships we call the
Business Force, BENS has mobilized businesses to help state and
local government on a pro bono basis to prepare for and respond
to catastrophic events.
Mr. Chairman, I would like to describe four Business Force
initiatives that illustrate the potential for American
businesses to work in partnership with government, specifically
to address the threat of pandemic flu.
The first involves mobilizing business volunteers to assist
in the dispensing of the strategic national stockpile. In July
of last year, BENS worked in partnership with state and local
public health leaders in Georgia and the metro Atlanta region
to mobilize 1,200 private sector volunteers for a live
bioterrorism exercise. Our members facilitated a 9-month design
effort, during which business volunteers helped state and local
health officials modify their existing exercise plans to
incorporate significant business participation. That exercise
included utilizing corporate facilities as a point of
dispensing, or POD.
Following the exercise, BENS members worked with state and
local public health leaders to create a model that calls for
large employers in a given urban area to dispense vaccines or
medications to their employees and their families, with the
understanding that a predefined group of employees would then
volunteer to go to designated public schools and help treat the
general population. This model has the potential to provide a
substantial portion of the thousands of volunteers that would
be needed in any major urban area in the wake of a biological
or chemical attack.
Furthermore, this model can be modified for use in an
influenza pandemic by tapping the expertise of the private
sector in such areas as logistics, supply chain management,
human resources, and in fact creating a public-private sector
disease management and monitoring program.
The second initiative is what we call the Business Response
Network, Web-based regional databases of pledged business
resources that state and local emergency management leaders and
public health officials can call upon during a catastrophe.
Both 9/11 and Hurricane Katrina highlighted the need to create
in advance a system that effectively utilized the overwhelming
offers of support from the private sector. The total value of
business resources we have registered to date is about $700
million, but the potential exists to register tens of billions
of dollars in pledged business resources nationwide.
Now, some of the search capacity requirements of the
pandemic, including facilities, transportation, and
communications equipment, can be identified and pre-pledged,
while other needed supplies might be solicited on the fly
during an event. The Business Response Network is an efficient
and effective tool for doing both.
The third initiative is the Workplace Sentinel Program.
BENS has recently partnered with the New Jersey Public Health
Department to design a Web-based reporting system that will
enable large employers to report spikes in absenteeism to state
and local epidemiologists.
Finally, in addition to building these three specific
capabilities, business and government leaders must learn to
communicate effectively and make sound decisions during an
event. To this end, BENS is facilitating the integration of
business representatives into state and local emergency
operation centers and intelligence and information fusion
centers.
Mr. Chairman, business does not have all the answers, but
it is clear, especially during times of crisis, that our nation
needs the vast resources, expertise and capabilities of the
private sector. We cannot overstate the value of building trust
and creating a study bridge between business and government in
advance. BENS will continue to work with our government
partners to strengthen prevention, preparedness and response
capabilities.
Mr. Chairman and members of the committee, thank you for
your courtesies. I look forward to your questions.
[The statement of Mr. Blackwelder follows:]
Prepared Statement of Ernest A. Blackwelder
Good afternoon, Chairman Linder, Chairman Reichert, Ranking
Members, and distinguished Members of the Committee. It is an honor to
appear before you today, to address some of the ways in which business
and the private sector can help our country better prepare for and
respond to the threat of a pandemic influenza.
My name is Ern Blackwelder. I am here on behalf of Business
Executives for National Security (BENS)--a national, non-partisan, non-
profit organization comprised of more than 500 business executives--
committed to volunteering their time and talents to improve the
nation's security.
Since its inception in 1982, BENS has worked on nuclear non-
proliferation initiatives and the application of best business
practices into Pentagon support functions. With the turn of the
century, BENS' focus expanded to include the growing threats of
terrorism. After 9-11, our members agreed there would be important
roles for the private sector in homeland security as well and quickly
recognized the wisdom of an all hazards approach.
When facing the threat of pandemic flu, or any catastrophic event,
the business community has responsibility in two important areas.
The first is business continuity planning--a term that often
includes developing emergency response capabilities to help ensure
employee health and safety, as well as making sure that the business
survives a catastrophic event. Business preparedness also serves to
protect critical infrastructure, ensure availability of urgently needed
goods and services, and strengthen economic stability. These challenges
would be especially severe in a flu pandemic, where companies could
experience absenteeism rates of up to 30 or 40 percent for up to
several months.
Pandemic flu business continuity plans encompass a wide variety of
activities like hand washing and social distancing, stockpiling
supplies, monitoring and assisting the sick, improving virtual work
programs such as telecommuting, implementing necessary travel
restrictions, cross-training employees, reallocating work activities
and reconfiguring shifts to limit disease spread. Large companies
typically employ business continuity professionals, while smaller
companies often ask operations managers to perform this function along
with their other responsibilities.
In December 2005, HHS Secretary Leavitt and DHS Secretary Chertoff
co-signed a letter to business leaders containing a checklist to assist
companies with pandemic flu business continuity planning
(www.pandemicflu.gov and www.cdc.gov/business). In addition to advising
businesses on how to prepare themselves for a pandemic, the Secretaries
asked businesses to coordinate with external organizations to help
their communities. I will focus the remainder of my prepared remarks on
this second responsibility of business during times of crisis: that of
providing civic leadership--sharing resources and expertise for the
benefit of the community and the nation.
While business continuity planning is critical, there are huge gaps
in our preparedness and response capabilities nationwide that neither
business, nor government can fill alone. We saw those gaps on 9-11, and
more recently with Hurricane Katrina. Increasingly, communities
recognize the need to bring the best of business and government
together to meet these challenges.
Three years ago, BENS began to leverage private sector resources
and know-how to work in concert with state and local government to
strengthen regional homeland security and disaster response capability.
I'd like to share some of the lessons we've learned and the promise
they hold for saving lives.
Through regional public private partnerships we call the Business
Force, BENS has mobilized member businesses on a pro bono basis to help
state and local government leaders prevent, prepare for, and respond to
catastrophic events--including acts of terrorism, natural disasters, or
public health emergencies. These partnerships can help reduce loss of
life and economic disruption from such events by implementing specific
preparedness and response initiatives that tap the expertise and
resources of the private sector and build trust between business and
government.
Through early collaboration with state and local public health
leaders and with the Center for Disease Control (CDC) in Atlanta, we've
identified four Business Force initiatives of particular value in
addressing the threat of a flu pandemic, or other public health
emergencies. They include:
1) mobilizing business volunteers to assist in the dispensing
of the Strategic National Stockpile;
2) building Business Response Networks--web-based registries of
pledged business resources that can be called upon by public
officials in response to a catastrophic event or public health
crisis;
3) launching the Workplace Sentinel program--enlisting large
employers to report anomalous rates of employee absenteeism to
provide public health officials early indicators of disease;
and
4) integrating business into state and local emergency
operations and intelligence fusion centers.
Strategic National Stockpile (SNS) Dispensing
BENS worked in partnership with state and local public health
leaders in Georgia and the Metro-Atlanta region to mobilize 1,200
private sector volunteers for a live bio-terrorism exercise in July
2005. Our members facilitated a nine-month design effort, during which
business volunteers helped state and local public health officials
modify their exercise plans to incorporate significant business
participation. During the exercise, business volunteers served as both
patients and logistics observers at three dispensing sites--two public
schools and a private manufacturing facility.
The Atlanta exercise illustrated that local public health
districts, responsible for dispensing the SNS, used approximately 40
percent of their personnel to process a patient volume equal to less
than five percent of the patient volume expected following an actual
airborne anthrax attack. In other words, had this been an actual
attack, public health would have had about 10 percent of needed
personnel. Similar shortfalls exist under other biological or chemical
attack scenarios, although specific personnel requirements would vary.
Following the exercise, BENS worked with state and local public
health leaders to create a model that calls for large employers in a
given urban area to dispense vaccines or medications to their employees
and families, with the understanding that a pre-defined group of
employees would then volunteer to go to designated public schools to
assist in dispensing to the general public.
This model has the potential to provide a substantial portion of
the thousands of volunteers that would be needed in any urban area in
the wake of biological or chemical attack. Furthermore, this model can
be modified for use in an influenza pandemic by tapping the expertise
of BENS members and staff--in areas such as logistics, volunteer
recruitment, and building trust between business and government
partners--to create a public-private disease monitoring and management
program.
Beyond Georgia, public health leaders have expressed interest in
implementing this model in each of the regions where BENS has
operations--including the states of California, Kansas, Missouri and
New Jersey, and the Kansas City and Santa Clara County urban areas
selected for emergency preparedness pilots by the Centers for Disease
Control and Prevention (CDC).
Business Response Network (BRN)
Hurricane Katrina demonstrated how a catastrophic event can
overwhelm government's ability to respond. Katrina also highlighted the
need to create, in advance, a system for effectively utilizing the
overwhelming offers of support from the private sector. BENS has
implemented a web-based system to meet this need called the Business
Response Network, or BRN. The BRN is a regional web database of pledged
business resources (warehouse or office space, trucks, equipment,
skilled personnel, etc.) that emergency management and public health
leaders can call upon in a catastrophe or public health emergency.
(www.businessresponsenetwork.org)
BENS has implemented permanent BRN's in New Jersey, Missouri and
Kansas, and a temporary BRN for the state of Massachusetts prior to the
2004 Democratic National Convention. The total value of business
resources registered to date is approximately $700 million; however,
the potential exists to register tens of billions of dollars in pledged
business resources nationwide. Multiple state BRN's could be
coordinated through the states' mutual aid program known as EMAC
(Emergency Management Assistance Compact). The EMAC system currently
applies to public sector resources, however BENS is exploring
opportunities to include private sector resources as well.
BENS builds the BRN at the state or regional level for two reasons:
1) state and local governments have primary accountability for first
response under the National Response Plan; and 2) it is easier to build
trust between business and government at the state and local level.
Until there is a uniform federal standard, concerns about liability
protection must be addressed at the state and local level, where laws
vary widely. While some businesses may not participate in their state's
BRN due to liability concerns, many others have chosen to participate--
even with imperfect Good Samaritan laws. These companies recognize that
sitting on the sidelines will only lead to higher casualties and
greater risk--to the economy, their communities, and their businesses.
The BRN system applies to ``all hazards'', but would be especially
useful in the event of a pandemic, given its potential scope and
duration. Some of the surge capacity requirements of a pandemic--
including facilities, transportation, or communications equipment--can
be identified and pre-pledged, while other needed supplies might be
solicited on-the-fly during an event. The BRN provides an efficient and
effective tool for doing both.
Workplace Sentinel
BENS has recently partnered with New Jersey public health leaders
to design a web-based reporting system that will enable large employers
to report spikes in absenteeism that can alert state epidemiologists.
This system, which is planned for implementation in mid-2006, calls for
each company to establish a baseline absenteeism rate. When absenteeism
exceeds a certain number of standard deviations above baseline,
companies will report that information online. Employer data will be
anonymously aggregated by county, and then forwarded to state and
affected county public health agencies to help identify causes and
determine appropriate response.
Business Integration into Emergency Operations and Information Fusion
Centers
The SNS Dispensing, BRN and Workplace Sentinel initiatives can all
be implemented and exercised in advance, to dramatically improve the
response to any catastrophic event or public health emergency. In
addition to building these specific capabilities, business and
government leaders must learn to communicate effectively and make sound
decisions during a crisis. To this end, BENS is facilitating the
integration of business representatives into state and local Emergency
Operations Centers and Intelligence/Information Fusion Centers.
Establishing a formal business presence at these centers and
performing exercises to test the effectiveness of business-government
communication will strengthen teamwork and build trust--making it
easier to work together effectively during a crisis. BENS is developing
pilot programs in Georgia, Metro Kansas City, New Jersey, and in Los
Angeles and Orange Counties, and has also been asked to support
implementation of similar initiatives in other states.
Mr. Chairman, there is no single model, nor comprehensive program
that will fill all the nation's needs in the event of pandemic flu. It
is clear, however, that especially during times of crisis, our nation
needs the vast resources, expertise, and capabilities of the private
sector. BENS is highly confident in the value of building trust and
creating a sturdy bridge between business and government, and we will
continue to work with our government partners to strengthen prevention,
preparedness and response capabilities.
Mr. Chairman, I look forward to answering your questions.
BENS
BUSINESS FORCE
Business Executives for National Security
Programs and Regions
----------------------------------------------------------------------------------------------------------------
Initiative Description NJ GA KC SF LA MA
----------------------------------------------------------------------------------------------------------------
ASSETS
----------------------------------------------------------------------------------------------------------------
Business Response Network * Businesses make needed resources X X X X X X
(e.g., trucks, warehouses, people
with certain skills) available on a
pro bono basis via web database
----------------------------------------------------------------------------------------------------------------
VOLUNTEERS
----------------------------------------------------------------------------------------------------------------
Strategic National Stockpile Partnership * Businesses assist in distribution X X X X X
and dispensing of vaccines and
other medical supplies in a major
medical emergency
----------------------------------------------------------------------------------------------------------------
Emergency Preparedness Training * BENS recruits companies to create X X
Community Emergency Response Teams
(CERTs)
----------------------------------------------------------------------------------------------------------------
INFORMATION
----------------------------------------------------------------------------------------------------------------
Intelligence/Information Fusion * Business assist government in X X X X X
implementation of Fusion Centers
that include active participation
of the private sector
----------------------------------------------------------------------------------------------------------------
Critical Infrastructure Protection * Business assists government in X X X
implementing critical
infrastructure risk assessment
tools, and provide advise on
protecting critical infrastructure
----------------------------------------------------------------------------------------------------------------
Public TV/Radio Partnership * BENS recruits companies to X
receive satellite ``datacasting''
feeds during times of crisis
----------------------------------------------------------------------------------------------------------------
Knowledge Portal * BENS creates a ``knowledge X X
management portal'' to facilitate
sharing of best practices between
state government and business
----------------------------------------------------------------------------------------------------------------
Agricultural Early Warning System * Agricultural businesses report X X
animal sickness or contamination to
public health agencies (early
stage)
----------------------------------------------------------------------------------------------------------------
STRATEGIC SUPPORT
----------------------------------------------------------------------------------------------------------------
Exercises * BENS designs and conducts X X X X
exercises to identify program
opportunities and to ensure that
each program is operational. Also
hosting a major TOPOFF3 exercise in
New Jersey
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Ad Hoc Projects * Operating Groups of senior X X X X
business and government leaders in
each region enable collaboration on
an as-needed basis (e.g., response
to flu vaccine shortage; serving on
state homeland security committees)
----------------------------------------------------------------------------------------------------------------
* Regions
NJ: New Jersey--started February 2003
GA: Georgia--started October 2003
KC: MidAmerica (Missouri, Kansas, Nebraska, Iowa, based Kansas
City)--started October 2004
LA: Los Angeles and Orange Counties--management agreement
Homeland Security Advisory Council began January 2006
SF: San Francisco Bay Area--start-up planned for 2005
MA: Massachusetts--DHS project for Democratic National
Convention in 2004
Mr. Linder. Thank you, Mr. Blackwelder.
Dr. Seaberg?
Dr. Seaberg. Mr. Chairman and members of the subcommittees,
I want to thank you for allowing me to testify today on behalf
of the American College of Emergency Physicians. ACEP is the
largest specialty organization in emergency medicine, with over
23,000 members.
Emergency departments act as our nation's health care
safety net. Unlike any other health care provider, the
emergency department is open for all patients who seek care, 24
hours a day, 7 days a week, 365 days a year. We provide care to
anyone who comes through our doors regardless of their ability
to pay.
At the same time, when factors force an emergency
department to close, it is closed to everyone and the community
is denied a vital resource. As the frontline of emergency care
in this country, emergency physicians are particularly
sensitive to the devastating impact an avian flu pandemic would
have on our patients and our communities. According to CDC
estimates, a medium-level pandemic in the U.S. could affect
between 13 percent and 35 percent of the population, with an
economic impact between $71 billion and $166 billion.
As I mention in my written statement, avian influenza could
proliferate rapidly throughout the United States. As the virus
spreads exponentially from person to person, the strain will
cripple our nation's emergency departments, which are already
operating at or over critical capacity.
Over the last decade, emergency department visits have
risen by 26 percent. However, the number of emergency
departments have decreased by 14 percent. Additionally,
hospitals have lost over 103,000 staff beds and 7,800 intensive
care unit beds. As a result, fewer beds are available for
admissions from the emergency department. Once the emergency
departments have filled all their beds, there is no reasonable
way to expect that the stressed systems will be able to
suddenly create the surge capacity necessary to effectively
manage an event.
When crowding becomes so severe, ambulances must be
diverted to other hospitals, reducing patient safety. In a
study that was just released on Monday, an ambulance is
diverted to a different hospital on average every minute in the
United States. These findings show a clear lack of capacity in
the emergency medical care system.
Protection of a disaster, act of terrorism or epidemic will
only be effective if appropriate preparations have been made at
all levels. In most disasters, the emergency department is the
frontline. History has shown that during a disaster, nearly 80
percent of patients simply go to the nearest emergency
department, bypassing ambulance transport. Even if hospitals
had sufficient warning of a pandemic outbreak, most emergency
departments have limited isolation units. Once the emergency
physicians and nurses have contracted the disease, their
ability to provide care for their patients would be severely
diminished.
Since 9/11, we have appropriately spent billions on
preparedness, but emergency departments have received virtually
none of that support. Lack of overall capacity may lead to a
breakdown of the health care safety net when we need it most.
If we are unable to effectively respond to a disaster or
pandemic, people will suffer needlessly and some will die. We
must take steps now to avoid a catastrophic failure of our
medical infrastructure, and we must take steps now to create
capacity, alleviate overcrowding, and improve surge capacity in
our nation's emergency departments.
We present this 10-point plan to achieve these goals. One,
we must increase the surge capacity of our nation's emergency
departments by ending the practice of boarding admitted
patients in emergency departments because no in-patient beds
are available.
Two, we must collect and monitor real-time data for
syndromic surveillance, hospital and emergency department
capacities, and ambulance diversion status.
Three, homeland security agencies need to understand that
emergency departments are part of the community's critical
infrastructure.
Four, we must require hospitals and communities that are
severely affected by a disaster to postpone elective admissions
until the crisis has abated.
Five, command and control of disaster medical response must
be more coordinated across federal, state and local agencies.
Six, we must develop and refine national medical
preparedness priorities and standards that are consensus-driven
and evidence-based.
Seven, we must provide federal and state funding to
compensate hospitals and emergency departments for the
unreimbursed cost of meeting the critical public health and
safety net roles, to ensure that emergency departments remain
open.
Eight, we must establish a sustainable funding mechanism
for disaster preparedness for hospitals, emergency departments,
and emergency management that is tied to national benchmarks
and deliverables.
Nine, Congress should continue to include emergency
physicians and nurses in any definition regarding first
responders to disaster.
And ten, Congress should pass H.R. 3875, the Access to
Emergency Medical Services Act, which provides incentives to
hospitals to reduce overcrowding and provides reimbursement and
liability protection for EMTALA-related care.
Let me close by assuring you that in any local, regional or
national disaster epidemic, the nation's emergency physicians
and emergency nurses will be there to do their jobs, as was
evident during Hurricane Katrina. Every day, we save lives
across America. Please give us the capacity and the tools we
need to be there for you when you need us, today, tomorrow and
when the next major disaster strikes the citizens of this great
country.
Thank you.
[The statement of Dr. Seaberg follows:]
Prepared Statement of David C. Seaberg, M.D., C.P.E., F.A.C.E.P.
Introduction
Mr. Chairmen and members of the subcommittees, I want to thank you
for allowing me to testify today on behalf of the American College of
Emergency Physicians at this joint hearing entitled, ``Protecting the
Homeland: Fighting Pandemic Flu From the Front Lines.''
ACEP is the largest specialty organization in emergency medicine,
with over 23,000 members who are committed to improving the quality of
emergency care through continuing education, research, and public
education. ACEP has 53 chapters representing each state, as well as
Puerto Rico and the District of Columbia, and a Government Services
Chapter representing emergency physicians employed by military branches
and other government agencies.
Emergency departments act as our nation's health care safety net.
Unlike any other health care provider, the emergency department is open
for all patients who seek care, 24 hours a day, 7 days a week, 365 days
a year. We provide care to anyone who comes through our doors,
regardless of their ability to pay. At the same time, when factors
force an emergency department to close, it is closed to everyone and
the community is denied a vital resource.
As the frontline of emergency care in this country, emergency
physicians are particularly sensitive to the devastating impact an
avian flu pandemic would have on our patients and our communities. To
put this in perspective, I would like to share with you the findings of
the Centers for Disease Control and Prevention:
``In the absence of any control measures (vaccination or
drugs), it has been estimated that in the United States a
'medium-level' pandemic could cause 89,000 to 207,000 deaths,
314,000 to 734,000 hospitalizations, 18 to 24 million
outpatient visits, and another 20 to 47 million people being
sick. Between 15% and 35% of the U.S. population could be
affected by an influenza pandemic, and the economic impact
could range between $71.3 and $166.5 billion.''\1\
---------------------------------------------------------------------------
\1\ Centers for Disease Control and Prevention. January 17, 2006
``Pandemic Flu: Key Facts''
---------------------------------------------------------------------------
As this statement indicates, if the avian flu pandemic, which has
been the focus of world attention over the past several months, should
begin spreading from human to human and then reach our shores, the
consequences to the United States would be catastrophic. What makes a
potential avian influenza pandemic so deadly is that, like some
biologic agents, it would be transmissible from person to person and
could spread rapidly in an urban environment or through mass
transportation. Optimally, treatment must be initiated as quickly as
possible, although contracting avian flu would not result in obvious
characteristics that would distinguish it from the normal flu
initially. Therefore, detecting it, even when symptoms occur may be
difficult.
The state of readiness in our nation's emergency departments and
the ramifications of patients who have been infected with the avian flu
virus appearing at hospital emergency departments around the country
are what I will explore in my testimony today.
Patient X
Let me give you an example of what could be a typical avian
influenza outbreak scenario. Patient X unknowingly contracts the avian
flu while on a business trip in Europe immediately prior to boarding a
plane for Atlanta. Not only will this person infect the passengers of
this plane and anyone else who comes into contact with this individual
at one of the busiest airports in the world, but the passengers who
have final destinations outside Atlanta will also carry the infection
to other passengers, and so on, as the disease begins to spread
exponentially. Of course, it will take several days for this person to
feel sick enough that they go to their local emergency department.
This infected patient now sits in a typically overcrowded emergency
department spreading the infection to everyone else in the waiting room
and they, in turn, will either eventually be admitted to the hospital
or treated and released to go home and spread the infection to their
family and neighbors. Even once they are admitted to the hospital, the
majority of patients still remain in the emergency department (also
known as ``boarding'' a patient in the emergency department) waiting
for an inpatient bed for more than four hours, with nearly 20 percent
of those patients waiting in the emergency department for more than
eight hours,\2\ which would continue to expose these infected
individuals to other emergency department patients, as well as patients
throughout the hospital due to the high-volume of air recirculation.
---------------------------------------------------------------------------
\2\ General Accounting Office. GAO-03-460. March, 2003 ``Hospital
Emergency Departments: Crowded Conditions Vary among Hospitals and
Communities.''
---------------------------------------------------------------------------
While it is common practice to ensure a patient who enters the
emergency department with a cough or fever wears a mask while waiting
to be treated, it may take over an hour before a triage nurse has an
opportunity to see that individual if the emergency department just
received multiple ambulances and the waiting room is already saturated.
In addition, the patient may require oxygen treatment and a nebulizer,
making the use of a mask irrelevant, and it was the use of nebulizers
that caused SARS to spread so rapidly through emergency rooms in 2003.
Without sufficient warning, emergency physicians and nurses would
be unprepared to place arriving avian flu patients in isolation until
it was too late. Since most hospitals only have one isolation unit,
there would be no way to isolate the next patient infected with avian
flu. By this time, the emergency physicians and nurses have also been
in contact with avian flu and, unless they have been previously
inoculated, would be at high-risk of contracting the disease
themselves, potentially diminishing their ability to provide care for
incoming patients.
Overcrowding and Lack of Surge Capacity
As the disease begins to spread rapidly among the population, the
strain will cripple America's 4,000 hospital emergency departments as
the majority of the nation's emergency departments are already
operating either at or over critical capacity. Emergency department
visits rose more than 26 percent in a decade--from 89.8 million in 1992
to 114 million in 2003. At the same time, the number of emergency
departments decreased by 14 percent.\3\ In addition, between 1990 and
1999, hospitals lost 103,000 staffed, inpatient medical/surgical beds
and 7,800 Intensive Care Unit (ICU) beds.\4\ As a result, fewer beds
are available for admissions from the emergency department. Once the
emergency departments have filled all of their beds, there is no
reasonable way to expect that these stressed systems will be able to
suddenly create the surge capacity necessary to effectively manage a
pandemic, natural disaster, terrorist attack or other mass-casualty
event.
---------------------------------------------------------------------------
\3\ Centers for Disease Control and Prevention Advance Data from
Vital and Health Statistics ``National Hospital Ambulatory Medical Care
Survey: 2003 Emergency Department Summary.'' No 358. May 26, 2005.
\4\ ``Emergency Departments: An Essential Access Point to Care,''
AHA Trendwatch 3, no. 1 (2001): 1-8.
---------------------------------------------------------------------------
When crowding becomes so severe that patient safety could be
jeopardized, ambulances must be diverted to other hospitals,
potentially causing precious time to be lost. In 2001, two-thirds of
emergency departments diverted ambulances to other hospitals. Because
overcrowding is most severe in areas with large populations (where the
potential spread of infectious disease poses the greatest risk), nearly
one in 10 hospitals reported being on ambulance diversion 20 percent of
the time (more than four hours per day).\5\
\5\ General Accounting Office. GAO-03-460. March, 2003 ``Hospital
Emergency Departments: Crowded Conditions Vary among Hospitals and
Communities.''
Need for Effective Syndromic Surveillance
Knowing about an avian flu outbreak elsewhere in the world or here
in the United States could significantly improve preparations and
reduce diagnosis time. For this reason, it is essential that our nation
have a real-time syndromic surveillance system linking emergency
departments across regions with state public health departments and
nationally with the Centers for Disease Control and Prevention to serve
as an early warning system for epidemics. Existing data collection
systems are currently limited in their capacity and ability to provide
information to health authorities and the public. Until such time that
we do have an effective means of data collection and dissemination,
emergency physicians and nurses will serve as critical components of
the nation's human syndromic surveillance system.
Planning and Preparedness
Detection of a disaster, act of terrorism or epidemic will only be
effective if appropriate preparations have been made at all levels of
government and the private sector. In most disasters, the emergency
department is the frontline. History has shown that during a disaster,
such as 9/11 or the anthrax scare here in the nation's capital, nearly
80% of patients simply go to the nearest emergency department,
bypassing ambulance transport. In fact, only a small percentage of
patients are actually managed by EMS. Emergency department personnel
are the forgotten first line of response in disasters.
Since 9/11 we have appropriately spent billions on preparedness.
But emergency departments have received virtually none of that support.
Policymakers and the public have assumed that the nation's emergency
departments will be able to meet their vital safety net function.
However, lack of overall capacity may lead to a breakdown of the health
care safety net when we need it most. If we are unable to effectively
respond to a disaster or pandemic, people will suffer needlessly and
some will die.
The private sector also will play an important role before and
during an avian flu pandemic. In addition to providing goods and
services to the public and medical personnel, workplace policies that
diminish the potential spread of infectious diseases are critical.
Establishing an ethic of infection control in the workplace that
includes options for working offsite while ill, systems to reduce
infection transmission and worker education are vital.
ACEP Recommendations
We must take steps now to avoid a catastrophic failure of our
medical infrastructure and we must take steps now to create capacity,
alleviate overcrowding and improve surge capacity in our nation's
emergency departments.
My colleagues and I at the American College of Emergency Physicians
present this 10-point plan to achieve these goals and we urge Congress
to enact these measures in order to effectively manage a pandemic,
natural disaster, terrorist attack or other mass-casualty event.
1. We must increase the surge capacity of our nation's
emergency departments by ending the practice of ``boarding''
admitted patients in emergency departments because no inpatient
beds are available. This will require changing the way
hospitals are funded to allow for inpatient and intensive care
unit surge capacity to manage this burden.
2. We must implement protocols to collect and monitor real-time
data for syndromic surveillance, hospital inpatient and
emergency department capacities and ambulance diversion status.
Collection of this data is vital to developing appropriate
protocols.
3. Homeland Security agencies on the Federal, State, and Local
levels need to understand that hospitals and Emergency
Departments are part of the community's Critical
Infrastructure. We can not have response and recovery in a
disaster without fully functioning, protected, and connected
health resources.
4. We must require hospitals and communities that are severely
affected by a natural or man-made disaster, or even a severe
influenza outbreak, to postpone elective admissions until the
crisis has abated. We must develop a way to compensate those
facilities for their loss of revenue.
5. Command and control of disaster medical response must be
more coordinated across federal, state and local agencies and
departments.
6. We must establish a committee of stakeholders and disaster
medicine experts from the public- and private-sectors and
academic institutions to develop and/or refine national medical
preparedness priorities and standards. We must change the
national preparedness culture to one which is consensus-driven
and evidence-based.
7. We must provide federal and state funding to compensate
hospitals and emergency departments for the unreimbursed cost
of meeting their critical public health and safety-net roles to
ensure these emergency departments remain open and available to
provide care in their communities.
8. We must establish a sustainable funding mechanism for
disaster preparedness for hospitals, emergency departments and
emergency management that is tied to national benchmarks and
deliverables.
9. To ensure emergency physicians and nurses play a primary
role in disaster planning and are considered in any national
allocation of resources and protective measures, Congress
should continue to include them in any definitions regarding
first responders to disasters, acts of terrorism and epidemics.
10. Congress should pass H.R. 3875, the ``Access to Emergency
Medical Services Act,'' which provides incentives to hospitals
to reduce overcrowding and provides reimbursement and liability
protection for EMTALA-related care.
Conclusion
While adopting crisis measures to increase emergency department
capacity may provide a short-term solution to a surge of patients
suffering from the flu, ultimately we need long-term answers. The
federal government must take measures necessary to strengthen our
resources and prevent more emergency departments from being permanently
closed. In the last ten years, the number and age of Americans has
increased significantly. During that same time, while visits to the
emergency department have risen by tens of millions, the number of
emergency departments and staffed inpatient hospital beds in the nation
has decreased substantially.\6\ This trend is simply not prudent public
policy, nor is it in the best interest of the American public.
---------------------------------------------------------------------------
\6\ Centers for Disease Control and Prevention Advance Data from
Vital and Health Statistics ``National Hospital Ambulatory Medical Care
Survey: 2003 Emergency Department Summary.'' No 358. May 26, 2005.
``Emergency Departments: An Essential Access Point to Care,'' AHA
Trendwatch 3, no. 1 (2001): 1-8
---------------------------------------------------------------------------
Let me close by assuring you that in any local, regional or
national disaster or epidemic, the nation's emergency physicians and
emergency nurses will be there to do their jobs, as was evident during
Hurricane Katrina. If the avian flu pandemic were to spread throughout
America before appropriate safety measures could be implemented, then
it's reasonable to expect a 20% loss of emergency department personnel
due to death or disability. America's emergency departments are already
operating at or over capacity. This loss of emergency department
personnel is unsustainable and would cripple this nation's health care
safety net and the quality of patient care would be severely
jeopardized.
Every day we save lives across America. Please give us the capacity
and the tools we need to be there for you when you need us. . . today,
tomorrow and when the next major disaster strikes the citizens of this
great country.
Mr. Linder. Thank you, Dr. Seaberg.
I want to thank each of you for your hopeful and uplifting
comments.
Dr. Seaberg, do the emergency rooms have paperless
activities so that they can be on computer and let that
information go immediately to the Board of Health or something
when you see a spike?
Dr. Seaberg. There are very few emergency departments right
now that are on paperless systems, probably less than 10
percent in the country right now. None of those systems that I
am aware of are right now hooked up to the health department.
There are some states that are looking at developing this, but
currently there are very few paperless systems across the
country.
Mr. Linder. Dr. O'Toole, is that what we need?
Dr. O'Toole. Yes.
Mr. Linder. I understand Pennsylvania is working toward
that, in testimony we had, I believe, yesterday.
Dr. O'Toole. Yes, some hospitals, about 15 percent of
hospitals have electronic records in one way or another. Many
of them are not as robust as one would wish, and very, very few
of them have links to public health. As we spend money, we
ought to try and invest in solutions instead of stopgaps
wherever possible.
Much better than surveillance systems designed for this
disease or that disease, or this problem and that problem,
would be a true integrated electronic health network to take
care of patients on a routine day, but would also give you
real-time situational statistics during an epidemic. That is
going to be a ways off.
Mr. Linder. Secretary Mitchell, who has the authority to
instigate quarantines in Delaware?
Mr. Mitchell. As the point person, I have the overall
command of an emergency such as what we are discussing.
Mr. Linder. That rests with you?
Mr. Mitchell. Yes, it does rest with me. However, we would
petition the court in cases where we could. That is not where
we are that concerned. We are concerned where someone comes in
to an emergency room, and heaven forbid, and there are many
undocumented workers here, as you know. If they are diagnosed
with bird flu and told that they are going to have to be
quarantined, they are probably going to leave the hospital
immediately and they are probably going to disappear.
Which brings up the case, it is almost like an arrest-
without-warrant situation. When can a police officer detain
without a judicial order? We can, in Delaware, provided that a
physician, based on clear and convincing evidence, says that
that patient in fact is infected and is a danger to the health
of our community. Based on that clear and convincing evidence,
a police officer can detain against one's will.
Mr. Linder. Ms. Phillips, do you have that same power?
Ms. Phillips. We have a slightly different arrangement in
the state of Maryland. Two years ago, the legislature enacted
the Catastrophic Health Emergency Powers. The power to
quarantine and isolate individuals rests with the governor, who
may designate that authority to the state health secretary to
issue the quarantine and isolation orders. It is the role of
the local health department to carry out those orders, to find
suitable arrangements for these individuals, and to provide the
support necessary for their term of either isolation or
quarantine.
Mr. Linder. I am impressed by the training that you do with
your 800 people. Most of us think of local health departments
as being sort of sleepy backwaters. Is it your experience that
many counties across the country are doing what you are doing?
Ms. Phillips. It is. From my work nationally with NACCHO, I
am seeing that there is a tremendous infusion of an
understanding of NIMS, incident command, and the kinds of
infrastructure that we take for granted on the public safety
side, to the public health community. The kinds of
opportunities for a clear chain of command and accountability
during in an emergency are clearly advantages that the public
health community is picking up, as well as the 24/7 response.
What we do not share with the public safety folks is three
shifts. Public health typically is a one-shift-a-day operation
so that we are drawing on a workforce that in a sustained
emergency would be very stretched.
Mr. Linder. Dr. O'Toole, I do not want to sound like a
cliche, but is it true that this is not a matter of if, it is a
matter of when?
Dr. O'Toole. There is no scientific way to answer that. I
am very worried. I think it would be the height of
irresponsibility to bet on a miracle. In 1918, the mortality
rate was 1 to 2 percent. We are seeing a mortality rate of
about 50 percent right now. Even if it drops down to half that,
and there is no reason to suppose it would, we are talking
about quite a cataclysmic event.
If I could, I would like to say a couple of things about
quarantine. ``Quarantine'' should be banned from use as a word
because it is a very confusing word. It comes from the 1400s.
It had to do with taking ships that you thought were coming
from plague-infested waters and putting them in a corner of the
harbor until everybody on the ship was either dead or still
living, until they were not contagious. I do not think, aside
from that special situation of possibly seeing the first
village that gets transmissible flu, I do not think it is
possible to implement a quarantine in the modern world.
Secondly, I do not think you are going to want to, if what
you are going to do is take people who may have been exposed,
but are not yet sick, and house them together until they are
through the incubation period. The way to think about disease
containment is as a return on investment judgment. Even if you
could quarantine Annapolis, where I live by the way, would you
really want to? Is that how you are going to want to be
spending your resources in an epidemic? Probably not.
Sam Nunn said something very wise during a bioterrorism
exercise years ago, when he was being urged to federalize the
National Guard. He said, there is no force on earth that can
make the American people do something they do not believe is in
their own best interest and the best interest of their
families. It is very important to keep that in mind. If this
breaks out, we are not going to have time to use video to go
through due process and so forth. We are going to have one out
of four Americans infected. It is going to be overwhelming.
The other thing that I would mention is a recent Harvard
study that shows that in surveys, Americans are much more
willing to be isolated at home or in the type of facility Ms.
Phillips talked about, if they cannot stay at home, if it is
not compulsory. If it is compulsory, they get a lot less
willing to participate. We saw that in China during SARS. When
Beijing authorities decided things were so bad in one big
apartment complex they were going to quarantine it, keep
everybody in. Before they could get the police over there,
everybody had fled, worsening the situation.
So we should not talk about quarantine. We should talk
about isolation. We should be, especially you all in leadership
positions, should be very precise in use of your terms as a way
of educating Americans so that they understand what would be
expected of them.
Mr. Linder. Thank you. My time has expired.
Mr. Langevin?
Mr. Langevin. Thank you, Mr. Chairman. I want to thank you
again for convening this hearing.
I want to thank all of our witnesses who testified. It has
been very enlightening.
Let me begin with Dr. O'Toole, if I could. You said, if I
heard you right--and I guess I can speak for the whole panel--I
should say that I did not hear a real ringing endorsement of
the national response plan, so hopefully you will have a chance
to comment further.
Dr. O'Toole, you said that, as I heard it, that most
hospital administrators have not read the national response
plan and they are not going to. Can you discuss this further?
How do we get them more engaged?
Further, you stated in your testimony that there has
traditionally been a wide gulf between the public health
community and the medical care provider community. Can you
elaborate on that and in what ways that gulf can be bridged?
I would also like to hear from Ms. Phillips and Dr. Seaberg
after your answer.
Dr. O'Toole. I think what Secretary Leavitt is doing in
going from state to state is a good start in getting the
attention of hospital authorities. It has been our experience,
and we have worked on hospital response issues for about 4
years now in the context of bioterrorism.
We are deeply involved in flu response with hospitals right
now as well. It has been our experience that the hospitals do
not necessarily think of themselves as part of the national
response plan. They do not think of themselves as part of an
incident command system. They certainly do not think of
themselves as being under the orders of the public health
system on most days.
So what you are talking about is a different cultural
attitude about what their mission and responsibilities are. One
of the problems with the pandemic flu plan that the president
set forth, which I do think is a good beginning, although I do
not think it spends nearly enough on vaccine or nearly enough
on everything else, is the list of things hospitals should do.
The problem is it is an overwhelming list. There is not a
hospital in the country that could actually implement
everything on that list. It is not prioritized. There are some
things on that list that are not within the purview of an
individual institution, such as fix all the legal problems
involved with sharing staff at your other hospitals.
What we need is a prioritized, very specific list that says
every hospital in America has to be able to do the following.
And then you need to send money. Okay? Hospitals do not have
the funds to do this. Really, truly, they do not. It is not
going to happen unless we figure out some kind of coherent
system for getting the money and getting it to them, not in
just one tranche, but over time.
I would suggest, though, back to the invest in solutions,
not stopgaps, we have to make that list of what they have to do
specific enough so that you can enforce against it. You have to
hook it not just to the carrot of money, but to some kind of
stick that they will pay attention to, because these people are
very busy trying to survive until next week.
On your public health care sector gulf, I think that is
improving because of the efforts of people like Ms. Phillips
and others, and because of the growing awareness of flu and
bioterrorism. It is still a very big gulf. They really have
very different jobs. These are very different cultures. Neither
community actually has the resources to do a lot of outreach,
the kind of table-tops, the kind of exercises that Mr.
Blackwelder was talking about. Anything that gets people in the
same room is a good thing, but it is going to take time. My
choice for what to invest in first would be electronic health
records that have an immediate connection to public health.
Mr. Langevin. And you do not feel that right now the public
reporting system in the public health system is robust enough
to get real-time monitoring?
Dr. O'Toole. It is not even close. Most emergency
departments have to go through each shift with a pencil and
figure out, well, what did we see that Fran might be interested
in, and then call it in. Since 9/11, in those entities that
actually dealt with anthrax, that has gotten a little bit
better and there are more electronic exchanges of information.
But then, most public health authorities have to go through and
say, am I going to investigate this or not. I mean, half of
what got called in as emergencies did not warrant an
investigation. It is a very laborious process right now.
The problem has been misconstrued to some extent. I do not
think detection is as big a problem as management in the
situation we are in during an epidemic. For that, we need real-
time electronic health records.
Mr. Langevin. I agree.
Ms. Phillips?
Ms. Phillips. Yes, a couple of points to follow up on the
surveillance discussion.
In Maryland, we have a beginning of a system that links
what is happening in hospitals, particularly emergency rooms,
with the public health sector, with the emergency responders,
the EMTs. It is very basic, but it is an electronic system, so
that in my office I can see the volume of activity in the
emergency rooms in my county. I can see the volume of patients
coming in who are likely to need ventilators. But I do not get
anything close to the kinds of surveillance indicators that I
would need to understand what is going on in terms of
interpreting that.
I do believe that our system is a little bit ahead because
of our experience with anthrax in Maryland. We have a ways to
go on surveillance. So right now the surveillance system we
rely on is the relationships between hospitals, the physicians,
and the public health system and telephone and fax and
postcards. So that is what we are working with.
Coming back to the issue of the plan, from a public health
perspective, the direction, the guidance that we get on
pandemic flu planning comes from the CDC. So that is a pipeline
that, as you know, has released a document in December, I guess
it was January, that was extremely welcome to all public health
agencies across the country, to look at the federal guidance on
planning for a pandemic.
I want to emphasize that in my remarks, I did try to
emphasize that the role locally that I play is really a bridge
with the public safety folks. I do not see through their
pipeline, which is our state emergency management agency, FEMA,
as well as the Department of Homeland Security on a federal
level, I do not see that level of pandemic flu preparation
training. So that I am the one now to do all of this work with
our 600 firefighters and our 700 police officers.
So the request, I guess, that I made as far as coordination
at the top level is that the kind of guidance that CDC is
pushing out to the public health community be replicated on the
public safety side so that we get some assistance. Right now,
it is based on coordination and it is working at a local level,
but it is working against some of those barriers as far as
funding.
Mr. Reichert. [Presiding.] The gentleman's time has
expired.
The Chair recognizes himself for 5 minutes.
Thank you again for being here. I want to just make a
couple of comments, and I have a few questions.
The point that you were making, Ms. Phillips, is one that I
struggled with as a sheriff in trying to work with public
health officials back in Seattle, and the law enforcement
community not understanding their role in this new
responsibility. I know that the secretary can identify with
that same struggle.
What I hear, though, is really some good things are
happening. There has been a lot of progress made in building
partnerships. We have business represented here, where in the
past when I was first assigned to a police car was handle the
burglary, do not talk to the people, and just take care of
business and on you go. Those so-called separations and silos
were all in effect, and everybody had their own
responsibilities. Now, today, we realize we all have to work
together. So all of us are here.
What I have noticed, though, in your testimony, all of you
together, first I would like to address a couple of frightening
things that I heard. First, Dr. O'Toole, you said that the
surge capacity would increase, for beds, by 300 percent, if we
were hit by it?
Dr. O'Toole. If you use the CDC models on what it would
take to deal with a 1918-type pandemic, and you plug in the
current number of beds, in the Atlanta metro region, just as an
example, then you need 300 percent of your current beds.
Mr. Reichert. And 700 percent increase in patients.
Dr. O'Toole. A 700 percent increase in ICU capacity.
Mr. Reichert. ICU capacity.
Dr. O'Toole. And you would need four times as many
ventilators as one has on hand now.
Mr. Reichert. And a 20 percent surge is acceptable?
Dr. O'Toole. Well, I think a 20 percent surge is a
reasonable goal that you could ask hospitals to strive for. It
is a stretch.
Mr. Reichert. And then Dr. Seaberg says there is a 26
percent average increase of patients, and a 14 percent drop in
hospital emergency rooms. Is that correct?
Dr. Seaberg. That is correct.
Mr. Reichert. And then the last statement that you made,
Dr. O'Toole, was, and you asked Chairman Linder, can I just say
one more thing, and you said, we can do this. If you could just
maybe explain for a couple of minutes some of your thoughts
along the lines of, with those big numbers, how can we do this?
Dr. O'Toole. Well, first of all, the way to solve the
problem is to get a vaccine. I know that is not directly within
your purview, but everybody ought to understand that we are not
doing what we ought to be doing if you really think vaccine is
the answer, as I do. That would transform everything, if we had
an effective vaccine, and we had enough and we had it in time.
But suppose we do not have a vaccine. If we do not have a
vaccine, then going to the hospital will not help you get
through the flu in most cases. We are not going to have enough
Tamiflu. It is not clear that Tamiflu is even going to be
effective if we did have it on hand. So what you are talking
about for most people is what we all do with flu. You go home
and you go to bed; you take fluids; you rest; et cetera, et
cetera. And you do not run around contaminating other people.
What we need to do is get that message across so that the
people who seek medical care are those who are the desperately
ill, and there are three or four ways that people are going to
be desperately ill with flu, as far as we understand it. I can
go into that, but you do not really care.
Those are the people who ought to go into hospitals.
Everyone else ought to either stay at home, or if they cannot
stay at home for whatever reason, they ought to be cared for in
the type of facilities Ms. Phillips was describing, you know,
gymnasiums where they are basically getting home care. It is
not going to be alternative hospital care. As we saw in
Katrina, a hospital is not just doctors and nurses and beds. It
is a significant infrastructure. It is gases, oxygen, et
cetera, et cetera. It is a whole infrastructure that you are
not going to replicate in a gymnasium or a sports arena.
Mr. Reichert. Is this process taking place today?
Dr. O'Toole. No.
Mr. Reichert. Nowhere?
Dr. O'Toole. There is no master plan.
Mr. Reichert. Does anybody on the panel have a comment?
Dr. Seaberg. This is not occurring. The problem with the
federal response is it takes time to coordinate that. So what
is going to happen is initial response is all going to have to
be local. Compared to police, fire and public health, the
hospitals and health care workers are clearly the weakest link
in any health care response to this, without a doubt. They have
not been prepared. Health care workers and hospitals have been
unwilling to participate due to lack of funds. My hospital
alone is nearly $1 million for a 1-hour training course.
So the number-one concern, if you asked health care
workers, is surge capacity. We can barely handle what we have
now, let alone a pandemic. In Florida, we are looking at ways
to perhaps retrofit non-clinical space such as auditoriums,
cafeterias, conference rooms, so that they can be surged up to
clinical space, because until all this is set up by public
health and federals, I am sorry, they are going to be coming to
the hospital. The worried well will be coming to the hospital
and to the emergency departments.
So we need to look at creating non-clinical space into
clinical space. We need to reduce overcrowding, and H.R. 3875
is a step in the right direction. We need to train the hospital
and health care workers to more long-term pandemic scenarios.
And then we need to take these lessons learned, the best
practices and lessons learned, and disseminate. We are spending
a lot of money in each state to train people, but at least in
the health care workforce, these lessons are not being
disseminated. You have each state creating standard core
competencies for hospitals. We should have national core
competencies that everyone trains to. Yet, we are working on
that through the American College of Emergency Physicians, but
we do not have that yet. We need to have better coordination
between federal, state and local.
Mr. Reichert. Thank you.
My time has expired. The Chair recognizes the ranking
member of the Subcommittee on Emergency Preparedness, Mr.
Pascrell.
Mr. Pascrell. Thank you, Mr. Chairman.
Dr. O'Toole, what is the main reason we have not developed
the necessary vaccines?
Dr. O'Toole. It is hard and it is expensive. There are
about 20 companies, as well as NIH, trying to develop a
pandemic flu vaccine. There are not many expectations that they
are going to make money out of that.
Mr. Pascrell. Is there a sense of urgency?
Dr. O'Toole. I think there is a sense of urgency, but I do
not think that has been translated into a strategic approach to
how the world could get together and make a vaccine that works
and in sufficient quantities. For example, there are things we
ought to be doing in parallel that we are doing in serial. We
just found out that the H5N1 vaccine that NIH has been working
so hard on, we discovered last summer requires an enormous
amount of the antigen, which is the stuff that gets grown in
eggs that we have a very limited supply for and we cannot make
more.
We were hoping that adding an adjuvant, which is a kind of
immune booster to that vaccine would allow us to make more
doses. It did not work. We should have done the adjuvant
studies simultaneously with the antigen studies. We are doing a
lot of things that we ought to do in a more organized fashion.
We are kind of running the H5N1 trials, as far as I can tell,
and one of the peculiarities, it is very hard to get the
science. It is taking months and months to publish it. There
ought to be a much more real-time exchange of information among
the scientists involved.
As far as we can tell, it is being run pretty much like a
normal research process. People are working hard, do not get me
wrong, but with more money and more organization that is beyond
the reach of the people in charge right now, we could do
better.
Mr. Pascrell. Let's take the example of Tamiflu. Let's take
that example, since you brought it up. I think it is a good
example. We knew very early on that there was some hope and
possibilities. Whether at this particular time in history,
February 8, we think maybe Tamiflu is not the answer. Anyway,
the companies who make Tamiflu, particularly there is one major
company, had no real signal from the federal government, as I
understand it, to move forward with the research and
development.
Am I mistaken, Dr. O'Toole?
Dr. O'Toole. I think it is more complicated than that,
unfortunately.
Mr. Pascrell. Okay.
Dr. O'Toole. We need a very robust process for figuring out
what we are going to invest in scientifically. One of the
truisms of vaccines and drugs is that they are really difficult
to make. You have to get a long way into a very expensive
process before you know if it is going to work or not. Last
August, the New York Times said the problem is solved; the H5N1
vaccine that NIH is making works. All right?
Now, the government thus far has been very reluctant to
invest gigantic sums of money, and we are talking billions of
dollars here, in stuff that we might not need and might not
work. What we need is a more open and much more robust process
for understanding what is out there that might work.
Mr. Pascrell. Yes, but what do we need to do that? We have
heard that before, Dr. O'Toole. Let's get to the point. Let's
get to the meat and potatoes here.
Dr. O'Toole. Okay, let's do.
Mr. Pascrell. What are you suggesting we are not doing now
in order to facilitate this research so that we avoid
duplicity, so that we avoid research that is going to come up
with nothing. What do we need?
Dr. O'Toole. The government needs to form a process that
engages the intellectual firepower of the private sector, of
the bio-pharma community and the university researchers.
Mr. Pascrell. Isn't that what NIH is supposed to be doing
or the Center for Disease Control supposed to be doing?
Dr. O'Toole. No, it is not what they are doing.
Mr. Pascrell. Then what are you calling for, another
agency? Are you calling for, what?
Dr. O'Toole. What I would call for is first of all put
somebody in charge of pandemic preparedness across the
agencies.
Mr. Pascrell. Okay. That would be one thing that would
advance this.
Dr. O'Toole. That would be one thing that would advance
this, because you can see it is very complicated. There are
things that are definitely in the lane of more than one agency.
DHS and HHS are the big players. So is DOD.
Secondly, you have to find ways to really engage the
private sector. The U.S. government at the federal level does
not at this point have the talent it needs in sufficient
numbers to handle this problem. That is not to say that people
are not working their hearts out and are not competent. They
are. Okay? But we do not have in the federal government in 2006
a lot of biopharmaceutical experts. We do not have a lot of
epidemiologists. We do not have people with the skill sets we
need. This is a new problem. You have to hire about 100 people.
You also have to pick off what the problems are that you
need to focus on. One person cannot do hospital preparedness
and public health preparedness and build a vaccine. It is too
hard. I think Secretary Leavitt has done a great job, but he is
one guy and he has a huge portfolio beyond the flu. This is
really big. We have to do something that is very extraordinary
and very non-routine here.
Mr. Pascrell. Okay. You answer I think is very clear, very
focused--if I may conclude, Mr. Chairman?
Mr. Reichert. Yes, sir.
Mr. Pascrell. It is very clear, very focused. I gather from
all these hearings, we do not have a sense of urgency. And
secondly, we do not have a sense of direction, which is just as
important. I mean, you could be, let's do this; we have to get
this done right away, and not have any direction once they are
going.
You have provided very clear direction. Is the federal
government listening? I do not know. We are listening. We need
to do something different than what we have been doing. We
should be further down the line, is what I am saying. I do not
know if you agree or disagree with me. We should have been
further down the line. We are doing a disservice to the
American people. I have heard all of these discussions before.
We are doing a disservice to the American people. We are not
moving the ball forward. We are relying on past strategies to
deal with the major problems that exist right now.
Mr. Reichert. The gentleman's time has expired.
Mr. Pascrell. Thank you, Mr. Chairman.
Mr. Reichert. The Chair recognizes the gentlelady from the
Virgin Islands, Ms. Christensen.
Mrs. Christensen. I did not realize I was up already.
I want to thank the chairs of the subcommittees for holding
this hearing because health care has not really gotten the kind
of attention that it has needed since this committee has been
formed and actually since the department has been formed.
I have had the opportunity to be very much involved with
the Katrina efforts, in trying to restore the health care
infrastructure there. It has been a nightmare. If we did not
believe the state of unreadiness of our health care system to
withstand a natural disaster or a manmade disaster, I think we
have seen it in full swing.
I had a lot of questions, some of which have been answered.
I have heard several of you say that we need one person who is
directing, a director of pandemic, or something like that, I
think you called it, Dr. O'Toole. We have an assistant
secretary at the Department of Health and Human Services for
Emergency Preparedness and Response. I believe his name is Mr.
Simmons. What has his role been with Delaware, with Maryland,
or with the University of Pittsburgh Medical Center?
It seems to me that there is someone at the department that
should be filling it. There is a position that is filled at
that department and I would like to know what your experience
has been with that office.
Ms. Phillips. I do not know that particular position. I do
know that the unit within CDC that is responsible for pandemic
flu guidance is, I guess they are working very hard; we are
waiting for the guidance, with respect to the funding. There
has been a lot of discussion about the funding for development
of pharmaceuticals. I suppose the other 15 percent of that pie
goes to the preparedness, in terms of certainly distributing
the pharmaceuticals, as well as a lot of the other planning
work.
The difficulty from a public health perspective, and also
public safety perspective, is that that is not something you
buy. That is not a piece of heavy equipment. That is staff.
That is a workforce. And so the problem with categorical
funding that is about to come down, I suppose, is that it is
short term and it is categorical, so that it is very tough in
my department to take a grant, a small grant that is time
limited, and to hire staff on that. Really, when you think
about the response to get a vaccine from the strategic national
stockpile, and then administer it to the population, that is
not something I can buy though a contract arrangement as a one-
time-only.
I did ask a ranking individual at CDC, how is it that a
local health department can take this categorical one-time-only
funding and best use it. I was told two things. I was told to
buy a plan and to do a drill. You know, I feel that the kind of
relationships that we need locally to sustain an all-hazards
response is not something that an external contractor can
provide for us.
Mrs. Christensen. I was going to ask you, because you
talked about the importance of the federal, local, state
collaboration. I was wonder. I was going to ask you what your
experience has been in terms of having that collaboration. You
have gone through several events, as you mentioned at the
beginning of your opening statement. What was your experience
relating to the federal government, or coordinating with the
federal government? What improvement might you have seen since
that time?
Ms. Phillips. We do look to the CDC. We look to the CDC for
standardized, authoritative guidance on infectious disease.
Mrs. Christensen. When you are in the middle of an
anthrax--
Ms. Phillips. When we are in the middle of an event, we go
to that Web site. We pull of what is the most recent, the
clinical protocols for testing for avian flu or for influenza
type-A. We look to that.
Mrs. Christensen. Do they back you up, to work with you?
Ms. Phillips. We have had experiences where CDC, yes, where
CDC does send special officers. In the BWI incident that I
mentioned, we had quarantine officers that were involved with
us with regard to the commercial carrier. So CDC has tremendous
capabilities, as does our state, but oftentimes there is that
lag of time between the time we get the notification and the
time that we can get effective assistance.
Mrs. Christensen. Go ahead.
Dr. Seaberg. The Department of Homeland Security has also
recently nominated a medical director, who is also looking at
the medical aspects of disaster. Particularly, we saw with
Katrina that there was a lack of communication and coordination
with national FEMA, national NDMS, and the local and state
response. So he is looking at trying to coordinate that
response much better, and also looking at the areas of hospital
training.
Mrs. Christensen. Mr. Blackwelder, we have met, probably,
or some people from BENS had breakfast with us. I was really
impressed. I have had the experience of talking with you and
also been a Project Impact recipient in my district, which is
basically what you are doing.
There were some experiences. After Katrina, for example,
you offered communications vehicles that were turned down, and
then they wanted to buy them from you. We are now approaching 6
months afterwards. Have there been some discussions with the
federal government?
I know from experience how important it is setting up the
business expertise, or the coordination before-hand, even being
able to expand the personnel for administering medication or
whatever. Has there been any discussion since we met back a few
months ago?
Mr. Blackwelder. Yes. We have been in discussions with the
Department of Homeland Security and the CDC. They are
interested in expanding this kind of capability. Frankly, we
are moving as fast as our resources allow us to move. We do
believe we are just scratching the surface, really, in terms of
mobilizing the business community. I gave some examples. We
have partnerships in place in five regions around the country.
For example, when I spoke about response during Katrina, we
did not have any kind of partnership in place there, nor did
anybody else. So what you saw post-Hurricane Katrina was a
pretty disjointed and haphazard business response effort.
Literally thousands of businesses that wanted to help and tried
to help, could not plug into the system. We know in major
catastrophes, particularly in the case with pandemic flu, that
there is not enough surge capacity in the government anywhere,
federal, state or local, to meet the need.
We also know that business is willing to help. And finally,
we know that business cannot plug into the system at game time.
You cannot just show up on the field without having practice,
without having gotten to know the players, without having
written some plays and practiced them. So this is what we are
trying to do as fast as we can.
It is important, we find, to build these kinds of teams and
to do this kind of practicing at the state and local level. DHS
and CDC are supporting what we are doing. We make sure that we
are integrating with the national response plan and NIMS. We
provided input to the private sector portion of the NRP, but
really these relationships and the kind of trust that needs to
be built between business and government needs to happen at the
state, local and regional level. That is really where the
action is.
Mr. Reichert. The gentlelady's time has expired.
The Chair recognizes the gentleman from North Carolina, Mr.
Etheridge.
Mr. Etheridge. Thank you, Mr. Chairman.
Let me thank you for being here. I think you have
recognized that the committee is interested, the public
frightened, and looking for answers. Let me ask you to comment.
I am going to try to zero in very quickly in 5 minutes.
If we go back to 1918 and the pandemic, as bad as it was,
the world was an entirely different place. People did not
travel like they travel today. They lived in rural areas.
Communication, at best, was newspapers; no TV; no Internet; all
the stuff we see today.
Yesterday, I had the opportunity to participate with some
of my colleagues in a table-top exercise, along with
administration officials, on this very issue. It focused on the
federal response to the emerging flu pandemic. Most of the
participants agreed that we are not prepared. We are not ready.
A number of things came out of it, one of which is education,
communication, coordination, a focus on what we are going to
get to, the very things you have talked about, because the
first thing that is going to happen is somebody is going to
have a TV camera in someone's face and they will have to answer
the question.
So I have a couple of questions, and I will get to them,
because I think that is the critical piece. You know, we picked
up today what is happening in Nigeria. That will be on the news
tonight, and no one will really be paying attention yet, but
some are. I am frustrated that we cannot get the federal
officials working with the state officials in coordination
across agencies.
I was state superintendent of schools for the state of
North Carolina before my service here. One of the real
challenges we had was getting people to work together across
disciplines. That is not easy.
You can appreciate that, Mr. Mitchell.
The key is you have to make it happen. I think we have to
do it here, because lives are at stake, and a lot of lives
possibly.
Do you feel the information the public gets through the
media about the impending situation, number one, is accurate?
Number two, what are your most trusted sources of information?
I am only going to ask a couple of you that, because I will
not have time. Ms. O'Toole, I want to ask you first how you
would respond, and Mr. Mitchell, since you have statewide
responsibilities.
Dr. O'Toole. Well, it depends on which media.
Mr. Etheridge. I agree with that, but there is so much out
there, we have to try to reach.
Dr. O'Toole. Yes. It has been very difficult to get
information about what is happening on the ground. For example,
it takes the WHO about 10 days using the best labs on the
planet to figure out if the sick person in Turkey actually has
H5N1. So there is a lag period between when you see something
happening.
Mr. Etheridge. The first information to close-out.
Dr. O'Toole. Closing that gap would be helpful in general.
What the public is not getting from the media is what they need
to do to protect themselves and their family in a crisis.
Generally, people do not listen to that kind of information
until the crisis is upon them. That is a tenet of public health
education. You have to be ready to go the moment something
breaks. Anything we can do beforehand in workplaces and in
schools, and indeed in the U.S. Congress. I hope you all go
home and tell your constituencies what you know. It would help.
We have to be ready to actually just kind of cover the
media if this really happens. People have to know what they
need to do themselves.
Mr. Etheridge. Mr. Mitchell?
Mr. Mitchell. The information I rely on comes from our
state health secretary and our director of public health, Gus
Rivera. That information comes to us in Homeland Security on a
daily basis. On the statewide response, we are working very
well together, between Homeland Security, as well as the
Departments of Health and Agriculture.
We are not relying so much on a federal response, if you
will, as much as we are what do we need to do for ourselves. Of
course, the federal response in the way of financing is very
generous and very helpful, and very necessary in planning and
getting information out to the community, about 30 days worth
of food supplies so that you can self-quarantine in your home;
basic hygiene measures that we should all be doing nonetheless;
as well as encouraging the business community in particular to
consider telecommuting, and for all of our state agencies for
telecommuting. How do we maintain our state operations and how
do we maintain commerce from remote locations, if you will.
Mr. Etheridge. Thank you.
I think all of you heard, and I don't think anyone
disagrees, during the Katrina exercises that there was a
disaster. People worked hard. There's no question there was at
all levels, and we do not need to go there.
What level of confidence do you have that the appropriate
agencies now are refocusing, because they are doing so many
other things, but this issue is so critical that we are paying
attention to things we ought to be paying attention to? I know
we are here having a hearing. We want to get it moving, but
that the resources that are being put in the right pots, so
that we get the biggest bang for the buck. Dr. O'Toole, you
have already indicated we probably are not doing that.
So tell us what we need to do very quickly. You have shared
some ideas. What do we need to be doing now to be prepared?
There are those who would say, well, you know, we are spending
all this money and we may not need it. Well, in our national
defense, during the Cold War, we spent a lot of money on
nuclear weapons and a lot of other things and never used them,
thank God, but we had them there just in case. If we never have
this, that would be a great benefit to the American people.
Mr. Blackwelder. I offer three things that the government
can do to mobilize more of the private sector, where after all
over 80 percent of the critical infrastructure resides. The
first is to improve and make more consistent Good Samaritan
laws, to protect liability of people who help. Now, we know
that business is willing to help despite that fact that Good
Samaritan laws are imperfect, but we also know that some are
sitting on the sidelines because of that fact. So I think
strengthening and making more consistent Good Samaritan laws is
one thing.
Second, I encourage state and local government and business
leaders to build these kinds of partnerships and create these
kinds of relationships in advance. We know that with just
modest investments, one or two full-time people to manage these
sorts of public-private partnerships can deliver huge returns
on investment.
The third thing is just to continue to encourage DHS and
the CDC and HHS to make business an integral part of their
strategic planning process.
Mr. Reichert. The gentleman's time has expired.
The Chair recognizes the gentlelady from the District of
Columbia, Ms. Norton.
Ms. Norton. Thank you very much, Mr. Chairman.
I appreciate that you called this hearing. We are working
on this issue. I am particularly appreciative to today's
witnesses because they have come from the various points of
view that we most need to hear from. I am very concerned about
the public response to the possible epidemic. It is as if they
think we are crying wolf, and you are beginning to hear them
say, you know, nothing is going to happen, and even some
pundits and members of the press are saying this. I think post-
Katrina, we are doing exactly what we should do.
I am not convinced. I must say I am very concerned after
hearing your testimony. One of my major questions, having heard
your testimony, is I do not for a moment think that we are
remotely prepared to do what would be needed if in fact
something that would be called an epidemic, as opposed to if
one or two cases broke out. I just have no question about it,
from your testimony and from other testimony in a number of my
other committees.
I am particularly interested, frankly, in what Dr. O'Toole
or one of you called alternative institutions, because the
notion of piling it on the hospitals or on clinics, I do not
think anybody thinks would work.
I must say, Dr. O'Toole, you focused me on a question that
I have had for some time, just on the basic science. This plan
focuses on that. I am not critical of that. I am critical of
our failure to deal operationally, but I am not critical of the
federal government focusing on the vaccine, because that is
really the only institution that can do that. That is what your
federal government is for.
So I think they have to begin there. And then they have to
look at what has happened with flu. You know, the flu we have
right now, the flu that we have every year. We don't have any
vaccine for that. So here we are talking about a vaccine for
what is an unknown disease, and you expect the citizens of the
United States to believe that we, the United States, can
develop a vaccine for something that no one ever heard of until
a couple of years ago.
No wonder there is lack of confidence in the public in our
capability. Well, 30,000 people die every year. We know they
are going to die every year and we still do not know what to do
about it. We had some of the same problems to arrive this year,
just in distribution of that flu vaccine after what we had last
year, and we are trying to convince the public that we can not
only develop a vaccine, but we can distribute it, and do not
worry, we are starting early, so you see the evidence of it.
They will look at flu, the flu that their mother-in-law
gets; the flu that they keep their children from getting, to
measure whether or not we can do that. You know what? I think
Congress ought to look there, too.
And I heard Dr. O'Toole talking about electronic health
retrievals. You know, we are ground zero there, too, so that is
like beginning with the vaccine. Everybody considers that a
frontier idea.
Let me begin by asking this. The Spanish flu we all go back
to as the marker. I cannot understand this coming pandemic, or
if it will really be avian flu or something else that we really
are not talking about. It ought to be much worse now. We have a
global economy, everything moving at lightning speed. That is
not what you had in 1918, the Spanish flu.
Moreover, this should be facilitated by the fact that birds
fly everywhere, and yet nobody has seen it here, and frankly
the average American says, I hope you all work on something
that I am really interested in, like the flu we get every year.
So I do not understand why this is a first priority, as
opposed to some other viruses that could come around the
country. I do not understand, for example, whether or not this
virus is anything like the AIDS virus. Did it linger in animals
for some time and slowly move to human beings? Now, of course,
it is a real epidemic. I do not understand how avian flu, which
so far a bird gets, we can find no proof, no evidence of how it
has even moved to the human being, or if after it moves to a
human being, it has been spread to other human beings.
So my concern is of the viruses that may be coming around
the world, this is the one, if it hasn't been here yet, and if
the flu that comes here every year, we cannot do anything
about, I am still not sure why this is at the top of the list
of the various kinds of viruses that could come, much as I
believe we are correct to focus on this. I wish you would help
me understand, you know, it has been since 1918, why we haven't
gotten something already, and the question I pose.
My time is already up. Please, Dr. O'Toole. I would also
like to get something on alternative institutions, what kind of
alternative institutions.
Mr. Reichert. The gentlelady's time has expired.
Ms. Norton. I am sorry. Could she at least be able to
answer the question? I will not open my mouth again.
Could I say that I did not realize I was taking all the
time to ask a question, because I heard others, and I did not
realize I was taking any more time than they were. But if I
could ask the indulgence of the Chair, if she could just
answer.
Mr. Reichert. Dr. O'Toole?
Dr. O'Toole. The question is why worry, and why worry about
this, and why worry to the point where we are talking about
spinning up the entire government and everybody else to get
ready.
We do not know why the 1918 pandemic happened, but here is
what we do know. Influenza viruses of all different types
circulate in wild birds all the time. They normally do not hurt
the birds. Every once in a while because of the genetic
propensity of the virus to re-assort its genes, you get a flu
virus that is new and that has the ability to make humans sick.
If it is a completely new virus to which we have no previous
exposure and hence no immunity, you get a pandemic. Sometimes
they are not a huge deal. In 1957 and 1968, we saw new types of
flu. It was a pandemic and killed a lot of people, but did not
perturb the world in a fundamental way.
What is different here is that we have never seen, first of
all, a new flu virus. This is a new flu virus we have never
seen before, this H5N1, that makes birds this sick. It kills
chickens in 24 hours and it is killing a lot of wild migratory
fowl as well. So we have never seen one this virulent and we
have never seen it in this many birds, who are spreading it to
poultry that are in contact with humans.
There are hundreds of millions of poultry in Asia who are
in contact with these wild birds who are carrying H5N1, and
those hundreds of millions of poultry are in direct contact in
Asia and in the Urals, for example, with humans. They are
backyard birds. If this were just happening in large blocs
under corporate control, as is the case in Delaware, we could
imagine controlling it. But we are not going to get rid of this
H5N1 that is now in the wild birds, and there is no way really,
practically to stop the wild birds from commingling and
sickening the chickens.
So the are gazillions of copies of this virus now literally
flying around the planet, and this is a virus which normally,
under normal circumstances, moves its genes around, takes new
genes from other viruses that are circulating in the birds and
in humans, and re-assorts and makes new viruses. If this virus
learns how to transmit, we are talking about a pathogen that
kills 50 percent of the people that it infects. Remember in
1918, only 2 percent of infected people died. And as you point
out, Congresswoman, everybody is moving around faster, further,
et cetera, et cetera, and more routinely.
So there is that possibility of a calamity. We do no know
what it would take to make H5N1 transmissible, but it is
moving. It is evolving and it is changing as we speak. So
people who understand flu and who watch it are worried. I will
only say that we could control seasonal flu. We just don't, but
that is within achievable horizons.
Mr. Reichert. Thank you.
The Chair recognizes Ms. Lowey.
Ms. Lowey. Thank you, Mr. Chairman.
I also want to thank the ranking member as well, Mr.
Chairman, for organizing this very important hearing.
To segue from Dr. O'Toole's comments, some of us that serve
on another committee, Labor HHS, the one that funds CDC and
NIH, have been concerned about this for a very long time and
have been expressing our strong feeling that this is an urgent
situation.
I remember a hearing in October 2004 where we had people
testify and we talked about the fact that if in fact we
expanded our seasonal vaccine supply, we would have the
capacity to manufacture in this country additional vaccine
which would address the avian flu. Of course, we didn't and we
knew this, and I am sure the experts knew this before.
Not being a physician, I believe the physicians who have
been briefing us, we knew this in 2004, October. We have been
talking about it, many of us, since. And the process is moving
so slowly. I want to congratulate this panel for what you are
doing locally in sounding the alarm. I just wish more people
would listen.
Dr. Seaberg, even addressing the surge issue, I believe you
talked about that. In the president's pandemic plan, as you
probably know, there is no money for surge capacity. This was
discussed in the New York Times article.
Many of us also served on this committee when BioShield was
passed. In fact, there was another article, I believe it was
the New York Times, talking about Stewart Simonson, the man who
oversees Project BioShield. Before he was appointed to that
position, he was a lawyer for Amtrak. There had been some
questioning about his capability by both Republicans and
Democrats. The example that was discussed on 60 Minutes was
that a company, it is not important to even mention it, a
biotech company was authorized to make a product that would
deal with radiation. The company went ahead expecting to
produce 10 million doses, and Stewart Simonson authorized
100,000 doses. The company went broke, et cetera, et cetera, et
cetera.
For those of us who have been asking Dr. Fauci and Julie
Gerberding about Tamiflu and vaccines and they are working on
both, I said if Tamiflu is important, if you really think it
will mitigate the disease by shortening the disease, then why
are we covering 1 percent of the population, when England is
covering 22 percent; France, 20 percent; and Canada, 17
percent? And now we are trying to push the companies to
manufacture more. And yet, as someone mentioned here, this
company did not even get the signal for it to go ahead and
manufacture. So now they won't even be ready to cover all the
population by 2007.
So we have had some real problems. There is a lack of
funding. The localities complain about unfunded mandates in the
latest plan that has been produced by the administration. They
are asking localities to pay for 25 percent of the Tamiflu.
Now, is health going to depend upon where you live? Or does the
federal government have a responsibility, if they are sending a
signal that this is a good thing, to make sure that we are
producing enough on the federal level.
It seems to me, we still do not know who is in charge. I
have had many, many, many meetings, in addition to the
hearings, on this issue; Homeland Security for some things; CDC
for other things. We saw what happened with Katrina when no one
was in charge. The military told us they were able to move the
equipment in, but once it was in there, it was like Paul Revere
brought back again. You heard stories of people throwing
bottles down to tell people, others who were in charge, where
to go.
So I don't even know if I have a question at this point. If
I am expressing frustration, having worked on this for a long
time, sounding the alarm for a long time, I just appreciate
what you are doing on the local level. I also want to say, if I
have a minute or so left, I do not know where I am.
Mr. Reichert. You are on yellow.
Ms. Lowey. I am on yellow.
I also serve on the Foreign Operations Committee. In this
area, I support the president 100 percent. Fight it over there,
and we are not fighting it over there adequately. There is not
adequate surveillance. We are not working with the governments
adequately to compensate the farmers to do adequate culling.
They are paid such low wages anyway that we could certainly
replace their income.
So whether it is producing antivirals, whether it is the
local plans in place. You are all exceptions. There have been
many articles, which I do not have time to quote here, talking
about how inadequate the planning is on the local level,
because they are not getting adequate direction from the feds
on communication, on surge capacity, on interoperability.
So, once again, thanks to the chairman.
I hope we can continue to work with you, and I hope that we
can replicate your successes across the country, because there
is sure a lot needed. I do believe this is coming, if not now,
I hope it never does, but we should be ready and treat this as
a national security issue, because frankly we do not use all
the bombers that the military makes, but we all vote for that
defense bill. We should be providing exactly what is needed.
Thank you very much.
Mr. Reichert. The Chair thanks the gentlelady for her
statement.
The Chair now recognizes the gentleman from Maine, Mr.
Markey.
Mr. Markey. Massachusetts.
Mr. Reichert. I am sorry. Massachusetts.
Mr. Markey. You know what? Maine was part of Massachusetts
until the compromise of 1820, when letting Missouri be a slave
state, we also broke off the top of Massachusetts, called it
Maine and had two more anti-slave senators.
[Laughter.]
We are proud of it.
According to the Department of Homeland Security's budget
in brief, released earlier this week, the department's
preparedness director is the focal point to build our nation's
preparedness to respond effectively to attacks, major
disasters, and other emergencies. Clearly, a bird flu pandemic
would be a major disaster and public health emergency for our
country, with an estimated 2 million deaths in the United
States alone.
Earlier this week, the Bush administration submitted its
fiscal year 2007 budget request to Congress. It seeks $3.4
billion, which represents a cut of $621 million compared to the
funding level enacted in fiscal year 2006. This funding cut
includes a $613 million reduction in funding preparedness
grants and training for first responders and emergency
officials in communities across the country.
Dr. O'Toole, given the current lack of preparedness for a
bird flu pandemic that you described in your testimony, should
the federal government be cutting emergency preparedness grants
to state and local emergency personnel by $613 million over the
next year?
Dr. O'Toole. No, but it should reorganize those grants.
Mr. Markey. Excuse me?
Dr. O'Toole. It should reorganize those grants.
Mr. Markey. Even if you organize it, can you do a good job
if you are taking $613 million away from emergency
preparedness?
Dr. O'Toole. I do not know what that $600 million is,
Congressman Markey. I suspect it is a bad idea.
Mr. Markey. Okay. Let me ask, has anyone else focused on
the $613 million cut the Bush Administration is proposing in
emergency grants? Yes, sir, could you please?
Mr. Mitchell. Yes, we certainly are in Delaware. The money
for law enforcement and terrorism, and so forth, has been cut.
We are in the law enforcement arena feeling it very
desperately, frankly. It is money that should not be cut.
Mr. Markey. Okay, thank you. I agree with you. I just think
that the Bush administration is nickel and diming homeland
security, cutting emergency preparedness even as we are
identifying that it is already an area of weakness. They are
cutting it even further at the local and state level.
Now, the Bush administration's budget also cuts Medicare
payments to hospitals. In my home state of Massachusetts, the
Bush administration would cut Medicare payments to hospitals in
my state by $213 million over the next 5 years. Dr. Seaberg,
how would that affect the local community's ability to respond
in the event of a pandemic flu?
Dr. Seaberg. Well, it would again increase the overcrowding
of emergency departments. You would have less physicians
wanting to take care of Medicare patients, and their only
alternative is going to be coming to the emergency departments.
I am in the response business. I believe avian flu is a serious
threat, as is influenza, smallpox. I am in the response
business primarily, and I need to decrease my overcrowding in
the emergency department. I have to have better surge capacity
in the hospitals.
Mr. Markey. So Medicare cuts will undermine actually your
ability to respond. Is that what you are saying?
Dr. Seaberg. It could, yes.
Mr. Markey. Okay.
How about you, Ms. Phillips, do you agree with that, that
cuts in Medicare funding will undermine hospitals' abilities to
be able to respond?
Ms. Phillips. Actually, the Medicare cuts are not ones that
in public health that we have focused on.
Mr. Markey. That's okay. Then this weekend The Washington
Post reported that because our emergency departments are so
overcrowded nationwide, an ambulance has to be diverted to a
different hospital every minute in our country. Now, a couple
of years ago there was an accident on Route 93 in my district.
It basically overcrowded the emergency room, just a very small
accident. This is in greater Boston, the medical capital of the
United States.
Dr. Seaberg, in your testimony you described the challenges
currently faced by the approximately 4,000 emergency
departments. In your opinion, about how many of those 4,000
emergency departments are prepared today to respond to a
pandemic flu outbreak in their communities?
Dr. Seaberg. None.
Mr. Markey. None.
Dr. Seaberg. In a small disaster, a car accident, you know,
I had one 2 weeks ago--
Mr. Markey. No, I am talking about a pandemic. How many are
prepared to respond today--
Dr. Seaberg. None.
Mr. Markey. Okay.
Now, the president's budget set aside $2.3 billion to help
prepare for pandemic flu. However, he has not specified how he
would like that money to be used. Clearly, the $350 million
provided last year is not enough, by your testimony. How much
of this money to the states, the cities, and towns need to have
in order to be prepared in the event of a pandemic in the view
of Dr. Seaberg?
Dr. Seaberg. I cannot give you an exact estimate. I may be
able to get that information for the record. But right now, we
can barely handle what comes in our departments today. We are
overcrowded. Hospitals are at capacity. We cannot handle what
we have today, let alone a pandemic.
Mr. Markey. Okay. Now, after September 11 and the anthrax
attacks, Congress passed the Public Health Security and
Bioterrorism Preparedness and Response Act. This bill
authorized $1.6 billion for states and towns to prepare for a
public health emergency. In January of 2004, GAO found that
while this Act improved our country's preparedness, we are
still not prepared. Ranking Member Thompson and I have asked
GAO to study the barriers to preparedness and provide
recommendations to help us ensure that the funds provided for a
pandemic influenza do more to improve our nation's safety.
What do you think caused the Public Health Preparedness Act
to fall short of its goal of preparing the public health system
for a national emergency? Do you have any questions that you
think the GAO should look at with regards to our public health
preparedness?
Secretary Mitchell, would you please respond to that, and
the Ms. Phillips?
Mr. Mitchell. Suffice it to say that we in the state of
Delaware have enormous needs. On the one hand, we are a small
state, only 800,000 people. On the other hand, we are large
enough and we are within a metropolis of a four-state area that
we are a great risk. The funding is needed to address the
issues. How it is planned to be spent I think needs a lot of
state and local coordination and recommendation. That is what
we are about doing as we speak.
Mr. Markey. Ms. Phillips?
Ms. Phillips. Yes, I would like to make three points very
quickly. First of all, the experience that we have had,
unfortunately some of those grants have been very categorical,
so we have been focusing on smallpox, and then we stopped
smallpox. I would like to think that in the future it would be
a more sustained, all hazards approach, rather than each agent
by agent.
Secondly, as I mentioned before, if it is not continuous
funding, if I do not have confidence that I can meet a payroll
with that grant next year, then I cannot hire the staff who
will be on the other end of the call when a physician or
emergency room makes a communicable disease report.
Thirdly, a lot of problems have arisen with the
jurisdictional specificity of some of this money. My county
straddles Baltimore in the northern part and D.C. in the
southern part. I am only one health department, but I am in two
metropolitan areas and it is very tough to juggle zip codes as
to which resident gets which grant funding.
Those are three areas that I would like to see streamlined.
Mr. Markey. I thank each of you. You are like latter-day
Paul Reveres warning us that the bird flu is coming. I hope
that the Bush administration listens to you. I do not think
they can be cutting by $613 million emergency preparedness at
this time. I think it is a bad decision, a terrible decision. I
am going to make sure the Congress votes on restoring that
money to the Bush budget. I just think it should be an
additional $600 million, not less.
We thank you so much for your guidance today.
Mr. Reichert. Thank you, Mr. Markey. The gentleman's time
has expired.
Mr. Pascrell, you have an additional question?
Mr. Pascrell. Thank you, Mr. Chairman.
I have quickly two questions. I want to associate myself
with the questions and answers of the gentleman from
Massachusetts, soon to be a state, but within the United
States.
[Laughter.]
Dr. Seaberg, I want to thank the panel for your boots-on-
the-ground responses because I look at it this way. Either the
administration is in denial or they are playing with dire
cynicism. I do not know which it is. This is all A, B, C, and D
of the question. What are your protocols for epidemiological
reporting? What are your protocols?
Dr. Seaberg. We are part of the state Department of Health.
They right now just collect our total census information, as of
right now. We are going to look eventually to include
diagnoses, now that we have an electronic medical record. Other
than that, our information on epidemics and so forth comes
through the state department of health through emails and other
ways.
Mr. Pascrell. Have you been asked by the CDC to report flu
symptoms to them?
Dr. Seaberg. We have not at this point been asked to report
flu symptoms.
Mr. Pascrell. Do you test patients presenting flu-like
symptoms like H5N1?
Dr. Seaberg. Obviously, if we suspect that, we would report
it to our local department of health.
Mr. Pascrell. Do you by law have to do that? Or are you
doing this simply because--
Dr. Seaberg. If we think it is avian flu, there is
mandatory reporting for certain infectious disease in Florida,
yes.
Mr. Pascrell. And isn't there a relatively inexpensive
urinalysis test, $20, that should be available to inform you,
and therefore inform CDC as to what is going on?
Dr. Seaberg. For avian flu?
Mr. Pascrell. Yes.
Dr. Seaberg. We do not have that. We do have the regular
influenza test. We do not have avian flu.
Mr. Pascrell. And by the way, did you get your stockpile
that you were supposed to get for that?
Dr. Seaberg. Vaccines?
Mr. Pascrell. Yes, regular flu?
Dr. Seaberg. Well, we have our supplies, our hospital did.
Mr. Pascrell. And it was adequate?
Dr. Seaberg. Yes. Actually, the department of health did
get an adequate supply in Alachua County.
Mr. Pascrell. Can I ask one more question, Mr. Chairman?
Mr. Reichert. Yes, sir.
Mr. Pascrell. One more question of Dr. O'Toole. Dr.
O'Toole, what tools do we have to limit the influx of disease
into our country from abroad? And how effective to you think
these measures are?
Dr. O'Toole. I do not think we have any effective tools. I
think that for flu, not for all diseases, but for flu,
screening incoming airline passengers is going to be very
expensive and very low-yield.
I also think that it does not make a lot of sense to screen
airline passengers without screening people coming in via boats
or over the border from Mexico or Canada, et cetera, et cetera.
I think to do fever checks at all border crossings would have a
very profound effect on commerce.
If we are contemplating doing airline fever screening, for
example, which again I do not think will work on flu because
half of them are going to be contagious before they have a
fever, but if we are contemplating doing that, before we do
something that would be that intrusive of commerce, I think the
CDC should really put together the evidence that says this
makes sense. I have not seen that evidence. We have gone
looking for it. We do not think it is there.
I think because of how fast flu moves and because of the
way the world works now, once it is out, it is going to be out.
It is going to be pretty much everywhere within a few months.
We are going to have a very limited time to respond. Then what
we want to do is try and slow the spread of disease, and if we
can keep people from getting sick. That is really going to
depend on mass cooperation. It is going to depend upon doing
things at the local level.
Again, we ought to think of all of this as return on
investment.
Mr. Pascrell. Mr. Chairman, I thank you very much.
Mr. Chairman, I would contend that this is even more
evidence that chapter 12 of the 9/11 Commission's report on
global strategy must be taken into account when we are trying,
and every day there are examples. If we are not in
communication. If we are not at the table with these nations,
when we are not going to do what we have to do.
I would think, Mr. Chairman, that that chapter 12 should be
taken almost from memory by every member of Congress and
anybody who is in the public realm to protect us. We cannot
protect the citizenry of this country unless we have good
relationships with the countries, or try to have good
relationships with these countries, until they understand, too,
how serious the subject is that we are talking about.
Mr. Markey. Would the gentleman yield?
Mr. Pascrell. Yes.
Dr. Seaberg. Mr. Chairman, could I make one correction to
my testimony? If we do have laboratory-confirmed information,
that is reportable to the state. I misspoke.
Mr. Pascrell. By law?
Dr. Seaberg. Yes.
Mr. Reichert. Mr. Pascrell's time has expired.
Mr. Markey is recognized.
Mr. Markey. I thank the chairman very much.
Dr. O'Toole, I am actually on this subject preparing
legislation that would encourage countries to comply with the
World Health Organization's international health regulations
and establish an annual country-by-country report on the degree
to which nations are complying with the regulations'
requirements, including prompt notice to the World Health
Organization of diseases such as bird flu, SARS, and other
diseases.
Do you think such legislation could be helpful as a public
health tool?
Dr. O'Toole. Yes. If we can find a way to get countries to
actually enforce and practice the international health
regulations, which obliges them to report disease outbreaks,
that would be very helpful. The rub, of course, is that it
takes time to confirm, usually more time than the media needs
to put it on the airwaves.
Secondly, confirmation of a big disease outbreak is
automatically an economic threat, a hit, really. So countries
are understandably very reluctant to say we have a problem
until they can prove they have a problem, and then there is a
lot of national price, et cetera, et cetera, involved.
So it is complicated getting it to happen, but that is what
needs to go on. Everybody had to understand we are all in it
together.
Mr. Markey. You know, we are in a world now of trade and
travel and tourism. In China and many other countries, they
want desperately to be given entry to the World Trade
Organization. They say it is central to their development. And
yet, the more obviously that we trade with China and other
countries, the higher the risk that diseases from those
countries will come to our country and to the West generally.
So you wind up in a situation where many of these countries
want the benefit of free trade, the benefit of global tourism,
but do not want the concomitant responsibility as a member of
the World Health Organization to then report promptly diseases
which could be much more easily transmitted across our world
than could before this era of the World Trade Organization. So
we now are in a situation where 2 million people cross
international boundaries every day, and a lot of it because of
this speeded-up world trade.
So what recommendations would you have, Dr. O'Toole or
anyone else on the panel, to build some teeth into a
requirement that these members who are participants in this
global trading regime now accept their responsibility to notify
immediately, notwithstanding their national pride. They do not
have too much pride to join the World Trade Organization. They
do not have too much pride to send their products to our
country. But you are saying that they have too much pride that
they do not want to admit that they have a disease which can
affect us and others in the West.
So what recommendations do you have to us so that we can
ensure that they understand their concomitant responsibility to
give us the public health notice?
Dr. O'Toole. That is me, Congressman?
Mr. Markey. Yes, please, or anyone else.
Dr. O'Toole. I would suggest two things. First of all, any
hammers or sticks that you have that you think would actually
work I think are certainly worth contemplating. I think if we
built a rudimentary international disease surveillance system
that was grounded in the health care and public health care and
laboratory network, we would have to build the laboratory
network, around the world, word would get out really quickly,
regardless of what the governments wanted or tried to prohibit,
because of the Internet and because of things like ProMED.
We knew a lot about what was going on in China with SARS
before the Chinese government told us. We know a lot about bird
die-offs in western China in spite of the government saying
nothing is happening, again because of the Internet. So if we
build the surveillance system so that we can see the disease
outbreaks, which we cannot in most parts of the world today,
until they are really a forest fire, I think the tourist
industry will make its own decisions.
Mr. Markey. All right. Well, again, what you are saying is
that the Internet can serve as an early warning system, but
when you have situations where Microsoft is agreeing to
cooperate with the Chinese government not to allow anything on
their Internet on penalty of crime, then I think that is,
honestly, a pretty weak place to be dependent, where time is of
the essence in a public health situation, where this disease
can spread so rapidly. So we need other drivers, other hammers
here, that will put it through.
Yes?
Mr. Mitchell. In Delaware, we have a situation where
because of our poultry industry we want immediate reporting. We
made a decision to indemnify each grower that if a flock is
infected, the state will buy the flock. So it takes out the
economic scare, if you will, of losing a flock and so forth.
Mr. Markey. So are you saying that we should insist that
countries adopt policies that they will promise to indemnify
any farmers or others who are affected by this?
Mr. Mitchell. I am saying that in Delaware, that is what we
did to encourage reporting, and also that we do not publicly
report which poultry farm has an infection. We report that
there is an infection, but we do not by law, and it was passed
by our General Assembly. Whether or not that would work in
another country, I do not know.
The issue of the government telling our government, a
foreign government telling our government about a disease is
one issue. Whether or not farmers in that country are telling
their government about a disease is another.
Mr. Reichert. The gentleman's time has expired.
Mr. Markey. Thank you, Mr. Chairman.
Mr. Langevin. I want to thank you all for your testimony.
This has been a long afternoon, but a fruitful discussion and
your input has been invaluable.
Just briefly, we had a discussion earlier, I think Dr.
O'Toole, you were mentioning the work that CDC was doing in
terms of trying to make a vaccine for the H5N1 virus. It is my
understanding, and I just want to clarify it for the record,
that what is going to be most effective, and one of the
constraints that we have in terms of making vaccine is that we
actually have to wait until the vaccine mutates to easy human-
to-human transmission before we can actually make a vaccine
that is effective for H5N1. Is that a correct understanding?
Dr. O'Toole. Maybe. It is possible. We and others are
trying to make vaccines right now against H5N1. It may be that
H5N1 ends up mutating into a pandemic and that the pandemic
strain is close enough to the vaccine that we created today
that it will still have some cross-reactivity.
Mr. Langevin. But we do not really know that?
Dr. O'Toole. We do not know that that will be the case.
There are other strategic options that have a basis in science,
such as trying to create a flu vaccine that would be good
against all sub-types of flu. This would solve Congresswoman
Norton's problem of every year we have to make a new flu
vaccine. That science ought to be very heartily supported. It
is getting minimal amounts of money right now.
There are a variety of scientific strategies you could
conceive of to speed up the process and to put your bets on
more than one square, which we are not doing right now in what
I would consider a robust fashion. But you are generally right.
That is definitely a problem.
Mr. Langevin. Thank you all.
Mr. Reichert. Thank you.
I want to thank the witnesses and thank the members for
their questions.
Members may have additional questions for the witnesses,
and we will ask that you respond to them in writing. The
hearing record will be open for 10 days.
Without objection, the subcommittee stands adjourned.
[Whereupon, at 4:33 p.m., the subcommittee was adjourned.]
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