<DOC>
[107th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:75758.wais]
A REVIEW OF FEDERAL BIOTERRORISM PREPAREDNESS PROGRAMS FROM A PUBLIC
HEALTH PERSPECTIVE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON
OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
__________
OCTOBER 10, 2001
__________
Serial No. 107-70
__________
Printed for the use of the Committee on Energy and Commerce
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
__________
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COMMITTEE ON ENERGY AND COMMERCE
W.J. ``BILLY'' TAUZIN, Louisiana, Chairman
MICHAEL BILIRAKIS, Florida JOHN D. DINGELL, Michigan
JOE BARTON, Texas HENRY A. WAXMAN, California
FRED UPTON, Michigan EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida RALPH M. HALL, Texas
PAUL E. GILLMOR, Ohio RICK BOUCHER, Virginia
JAMES C. GREENWOOD, Pennsylvania EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia SHERROD BROWN, Ohio
STEVE LARGENT, Oklahoma BART GORDON, Tennessee
RICHARD BURR, North Carolina PETER DEUTSCH, Florida
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
GREG GANSKE, Iowa ANNA G. ESHOO, California
CHARLIE NORWOOD, Georgia BART STUPAK, Michigan
BARBARA CUBIN, Wyoming ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois TOM SAWYER, Ohio
HEATHER WILSON, New Mexico ALBERT R. WYNN, Maryland
JOHN B. SHADEGG, Arizona GENE GREEN, Texas
CHARLES ``CHIP'' PICKERING, Mississippi KAREN McCARTHY, Missouri
VITO FOSSELLA, New York TED STRICKLAND, Ohio
ROY BLUNT, Missouri DIANA DeGETTE, Colorado
TOM DAVIS, Virginia THOMAS M. BARRETT, Wisconsin
ED BRYANT, Tennessee BILL LUTHER, Minnesota
ROBERT L. EHRLICH, Jr., Maryland LOIS CAPPS, California
STEVE BUYER, Indiana MICHAEL F. DOYLE, Pennsylvania
GEORGE RADANOVICH, California CHRISTOPHER JOHN, Louisiana
CHARLES F. BASS, New Hampshire JANE HARMAN, California
JOSEPH R. PITTS, Pennsylvania
MARY BONO, California
GREG WALDEN, Oregon
LEE TERRY, Nebraska
David V. Marventano, Staff Director
James D. Barnette, General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Oversight and Investigations
JAMES C. GREENWOOD, Pennsylvania, Chairman
MICHAEL BILIRAKIS, Florida PETER DEUTSCH, Florida
CLIFF STEARNS, Florida BART STUPAK, Michigan
PAUL E. GILLMOR, Ohio TED STRICKLAND, Ohio
STEVE LARGENT, Oklahoma DIANA DeGETTE, Colorado
RICHARD BURR, North Carolina CHRISTOPHER JOHN, Louisiana
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
Vice Chairman JOHN D. DINGELL, Michigan,
CHARLES F. BASS, New Hampshire (Ex Officio)
W.J. ``BILLY'' TAUZIN, Louisiana
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Baughman, Bruce P., Director, Planning and Readiness
Division, Federal Emergency Management Agency.............. 88
Brinsfield, Kathryn, Director of Research, Training, and
Quality Improvement, Boston Emergency Medical Services and
Deputy Medical Commander, National Disaster Medical
System's International Medical and Surgical Response Team-
East....................................................... 34
Heinrich, Janet, Director, Health Care--Public Health Issues,
U.S. General Accounting Office............................. 93
Lillibridge, Scott R., Special Assistant to the Secretary on
Bioterrorism Issues and for National Security and Emergency
Management, U.S. Department of Health and Human Services... 83
O'Leary, Dennis, President, Joint Commission on Accreditation
of Healthcare Organizations................................ 47
Peterson, Ronald R., President, Johns Hopkins Hospital, on
behalf of the American Hospital Association................ 42
Smithson, Amy E., Director, Chemical and Biological Weapons
Nonproliferation Project, Henry L. Stimson Center.......... 17
Stringer, Llewellyn W., Jr., Medical Director, North Carolina
Division of Emergency Management........................... 38
Waeckerle, Joseph F., Chairman, Task Force of Health Care and
Emergency Services Professionals on Preparedness for
Nuclear, Biological and Chemical Incidents, on behalf of
the American College of Emergency Physicians............... 26
Young, Frank E., former Head, Office of Emergency
Preparedness, U.S. Department of Health and Human Services. 53
Material submitted for the record by:
Ataxia: The Chemical and Biological Terrorism Threat and the
US Response, report by Amy E. Smithson and Leslie-Anne Levy 164
Bioterrorism: An Even More Devastating Threat, The Washington
Post, September 17, 2001................................... 191
Commissioned Officers Association of the U.S. Public Health
Service, prepared statement of............................. 192
Daniels, Deborah J., Assistant Attorney General, Office of
Justice Programs, Department of Justice, prepared statement
of......................................................... 103
Hospital Preparedness for Mass Casualties, report entitled... 107
Hospital Preparedness for Victims of Chemical or Biological
Terrorism, report entitled................................. 185
(iii)
A REVIEW OF FEDERAL BIOTERRORISM PREPAREDNESS PROGRAMS FROM A PUBLIC
HEALTH PERSPECTIVE
----------
WEDNESDAY, OCTOBER 10, 2001
House of Representatives,
Committee on Energy and Commerce,
Subcommittee on Oversight and Investigations,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:15 a.m., in
room 2322, Rayburn House Office Building, Hon. James C.
Greenwood (chairman) presiding.
Members present: Representatives Greenwood, Stearns, Burr,
Bass, Tauzin (ex officio), Deutsch, Stupak, Strickland, and
Rush.
Also present: Representatives Ganske and Buyer.
Staff present: Tom DiLenge, majority counsel; Peter Kielty,
legislative clerk; and Edith Holleman, minority counsel.
Mr. Greenwood. The hearing will come to order.
Good morning. We welcome you all and apologize for the
slight delay. The Chair recognizes himself for an opening
statement.
Today's hearing is part of this subcommittee's long-
standing interest and oversight of bioterrorism issues which
led to the unanimous passage of the Bioterrorism Prevention Act
of 2001 by the full committee just last week.
Today, we turn our attention to an acutely critical area,
our Nation's preparedness to deal with the threat of
bioterrorism. Since May of this year, members of the committee
and committee staff have been busy investigating the capacity
of Federal, State and local public health officials to respond
to these kinds of threats and dangers.
When this subcommittee announced 5 weeks ago its intent to
hold a hearing on September 11 to examine the effectiveness of
Federal bioterrorism preparedness from a local public health
perspective, a concern at that time was that too little
attention was being paid to improving the ability of our local
health care communities to detect, contain, treat and
effectively manage a terrorist attack using deadly biological
agents, or for that matter, any naturally occurring disease
outbreak or disaster with mass care consequences.
The evil that was visited on our country and the world on
September 11 has changed all of that. It is now clear that the
people who perpetrated this deed are unconstrained by any sense
of morality. The only restraint on their form of ideologically
inspired madness is the limit of the technology that they can
acquire. And though the weapons of choice on that day were
jetliners filed with innocent passengers and not anthrax or the
plague, September 11 prompted this Nation to seriously
reexamine how we prepare for all types of terrorist attacks,
including bioterrorism.
There is much anxiety. Some of it is fueled by the almost
daily stories on the networks and in our major newspapers
detailing our lack of preparedness for bioterror assaults.
Congressional committees are also busy holding hearings to
examine this potential threat and the efforts to combat it.
The detection of the anthrax bacterium in a Florida
workplace and in two workers at that site, one of whom already
has died, has raised the temperature on this issue even higher.
Nevertheless, while there is legitimate reason to be anxious,
it is the duty of Congress to confront and reduce that anxiety
by making sound public policy choices. And big questions remain
unanswered about how best this Nation should approach
bioterrorism defense.
Our mission today is to engage in a dialog with the public
health officials who would be in the vanguard of any response
to bioterrorism, so that we in Congress build the right kind of
working partnership between all levels of government, as well
as assemble the necessary Federal resources that will best
enable them to address this threat. I hope to accomplish
several objectives with continuing, indeed increasing,
importance.
First, as we embark upon what most likely will be an major
new Federal initiative to improve our bioterrorism
preparedness, I think it is critically important that Congress
hear directly from the health care front lines--the hospitals,
the physicians, the emergency medical personnel about how they
view the existing Federal preparedness programs and what some
of the past barriers have been to successful preparedness
programs in the health care community.
Too often the concerns and needs of these groups which will
constitute our first line of defense in any real bioterrorist
incident have been overlooked or ignored in our race to do
something about terrorism. Hopefully, our hearing today will
help to change that.
Second, and just as important, I believe it is essential
that we at all levels of government approach bioterrorism
preparedness from a broader public health perspective. This
makes good sense for several reasons, but most of all because
it will be difficult to justify the costs or sustain
accomplishments over the long run if we focus too narrowly on a
threat that many in the health care community may rightly
perceive as small when compared to the tremendous daily
challenges facing our health care systems.
While there is a considerable debate about the likelihood
of a mass casualty biological terrorist attack, there was near
universal agreement that our public health infrastructure
itself is in need of CPR.
What do we mean when we use the term ``public health''? The
basic elements are pretty straightforward: clean water, a
plentiful and uncontaminated food supply, clean air, wastewater
treatment, and the ability to respond and control epidemics.
Unfortunately, in recent decades, we have allowed the
capability of our public health departments, laboratories, and
hospitals to deal with major disease outbreaks to stagnate or
even deteriorate. Between 1981 and 1993, for example, State
public health budgets declined as much as 25 percent. To now
ask them to take up the additional burden of responding to
bioterrorism without substantial new resources and direction
would be to risk a breakdown of the entire system.
Last, we need to take a good, hard look at how we are
spending and will continue to spend Federal dollars in this
area to ensure better allocation of existing and future
resources devoted to this purpose. Everyone gives lip service
to the idea that our local communities are and will remain the
principal responders to terrorist events. Yet most of the
billions of dollars spent each year on combating terrorism
never finds its way beyond the Capital Beltway.
We need to change that reality, particularly given that all
of the Federal assets and specialty teams that have been
created for this purpose make two fundamental assumptions in
their response plans: first, that timely surveillance and
detection activities will be made at the local level; and
second, that the local response teams possess the resources and
capabilities to effectively manage an emerging crisis within a
critical 12 to 72 hours before Federal assistance arrives on
the scene.
As we will hear today, those are two big assumptions.
Before I conclude, I also want to announce that this
subcommittee plans to hold another hearing on this topic on
October 25 to explore the related and equally important issue
of public health surveillance and detection systems, and how
technological advances in these areas can help in our battle
against bioterrorism, as well as against naturally occurring
disease outbreaks.
I thank our witnesses today and now recognize the ranking
member of this subcommittee, Mr. Deutsch, for his opening
statement.
Mr. Deutsch. Thank you, Mr. Chairman.
Last Thursday, I had, I guess, just certain difficulty, as
this meeting was originally scheduled for September 11, with
meeting with the county chairperson of Palm Beach County, the
county chairperson of Broward County, and the mayor of Miami-
Dade County in the early afternoon. At that point, they were
actually up here in terms of the potential supplemental bill
and in terms of talking about issues related to it. And in the
course of our discussion, you know, we were talking about other
issues. And I was talking about our committee and our
jurisdiction.
As many of you are well aware, our committee has
jurisdiction over the CDC, and we were talking about issues of
threats of bioterrorism. And I proceeded to go through what I
was aware of at the time, the sort of plan that exists and how
good that plan is, and how CDC is supposed to move in
automatically and provide all sorts of resources.
And as it so happens, unbeknownst to me at the time, but
beknownst to the chairperson from the County of Palm Beach, an
anthrax case was diagnosed in Palm Beach County. And the three
heads of the three counties in South Florida, where the
population is close to 6 million people, they didn't go into
outbreak laughter, but they basically said that what I was
describing was not reality.
And it was not reality at that moment in Palm Beach County,
and it was not reality of what could exist in Broward or Miami-
Dade Counties. And, you know, we understand--and the Secretary
of HHS has been on television on several occasions since last
Thursday telling the American people, don't worry, relax, we
are ready, we can deal with this.
Based on this sort of empirical thing of the leadership of
the three counties in South Florida, I have real concerns, and
I expect that we will have testimony today that will
essentially substantiate that.
This issue, though, is obviously much different since
September 11. I think all of us are much more knowledgeable
about not just terrorism in general, but bioterrorism,
bioterrorism in particular. It is no longer theory; it is a
reality in many ways; and I think, just to put on the table at
the start of the hearing, chemical weapons were used over 10
years ago by both Syria and Iraq. And I think there is
absolutely no reason to think that terrorists don't have
available those weapons today; and the only restricting factor
could be a delivery system.
So we are no longer talking about some esoteric,
theoretical issue; we are talking about a practical issue. As
awful as the horrific events that occurred at the World Trade
Center were, I think all of us understand that the potential is
far in excess of those events in a direct attack.
Now, the good news is, there are things that we can do in
terms of intelligence and also in terms of public health to
prevent that. And that clearly has become the highest, or as
high a priority as any that this Congress faces.
I yield back the balance of my time.
Mr. Greenwood. The Chair recognizes for an opening
statement the chairman of the full committee, Mr. Tauzin.
Chairman Tauzin. Thank you, Chairman Greenwood, for holding
this very critical and timely hearing on how this Nation can
best prepare for the possibility, however small, of any kind of
major bioterrorist event. I believe this committee, as the
principal public health committee on this side of the Capitol,
must take the lead to ensure that the Nation can, in fact,
tackle this very difficult issue.
Given what we read in the newspapers, what we see on
television, the American people understandably are concerned
about the threat of bioterrorism. It is true that--as we will
hear today, that we need to do more. So we need to do more to
fully prepare our Nation for this kind of a possibility.
It is also true, after September 11, that we have all, I
think, underestimated the evil and the sophistication of our
enemies, unfortunately, at our own peril.
That said, we should not allow undue public concern or
worry to develop over what most experts believe is a relatively
remote threat and one that is technically very difficult to
carry out. That is why it is imperative that we approach this
issue in a very thoughtful and a very measured way. I am glad
to see that that is exactly the approach that you, as chairman,
and the subcommittee have agreed to take.
Let me expand quickly on three points that Chairman
Greenwood has raised. First, we need to start a serious public
debate about some of the big questions that he alluded to, the
questions that remain unanswered today: What are we preparing
for, and what is the measure of our preparedness? In other
words, what are we trying to achieve and how do we know when we
have achieved it? How do we know that we have reached the point
where we can assure the American public that we are prepared,
and that we are prepared not only to assure their safety, but
to react in the worst case?
Our staff hears over and over about the health care front
lines, that the people who operate those lines, what is not
happening, where direction is not being given, where guidance
from Federal experts to properly prepare for a bioterrorism
event might, in fact, be helpful.
We need to change that. We need to make sure the lines of
communications are clear and that people understand guidance
and direction in this area as clearly as anything else as we
face these threats.
Second, this is not, as some would think, just a question
of more money. There is a reason that today's hearing is before
the oversight committee. We have already spent at the Federal
level billions of dollars in this area and more than $200
million annually on health-related programs alone. Secretary
Thompson says he needs at least $800 million more for
bioterrorism preparedness, probably more in the future. That is
not small change, and it is incumbent upon this committee to
make sure that both existing funds and new funds are used in
the most effective and measured way.
Again, that means the big questions need to be addressed:
Where should we be spending our money for the most safety and
security?
And third, I want to echo Chairman Greenwood's comments
regarding the importance of really listening to our brethren in
local jurisdictions around the country, particularly those in
the health care community. As one of our witnesses today states
so well in her written testimony, it is the local emergency
medical personnel, the hospitals, the health department
administrators, the doctors and nurses and support staff in the
communities where we live who are going to be the people whose
actions and decisions will determine just how contained or how
damaging any bioterrorism incident ultimately will be.
There are people who will detect an outbreak and treat
their fellow citizens often putting themselves at risk as well
as, and they should not be ignored by the Federal Government
that so often focuses too much on itself when devising
responses to bioterrorism.
One final thought: Our full committee has been briefed very
deeply by Secretary Thompson on the nature of those potential
threats. We are not about to join the leakers around town who
talk about things we shouldn't talk about. But I want you to
know that as we went into that briefing, my concern levels and,
I think, the concern levels of every member of this committee
were extraordinarily high; all of us felt more assured after
that briefing than before we had it.
Secretary Thompson and his department are aggressively
working and private sector components of the effort to prepare
this country are aggressively working not only to beef up the
already deployed stocks of vaccines and other pharmaceuticals
that are important for us to be able to respond to any such
threat, but also to make sure that there are new quantities and
new, appropriate steps taken to protect our citizens not simply
from the advent of the incident, but equally important, to take
care of our citizens should the worst ever happen.
Now, look, I got a call from a doctor at home. I am sure
you all did. And people were calling them because they have
heard stories and they want to know about what they can do
personally to prepare themselves.
The best preparation we can all have in this area, as in so
many areas, is to be the best citizens we can be, to be on our
guard, to go about our lives and to conduct our businesses--as
the President said, to hug our children, but also to be on our
guard, to be good citizens and to be helpful and supportive of
the agencies of our government that are trying to make sure
nothing like this ever happens in this country again, or
anything like it should happen in the future.
And the second thing is to have what I have--what I am
beginning to have in greater degree: a great deal of faith in
the notion that everybody at this level is working day and
night to ensure that our preparedness is at its top, its best;
and the money we will allocate and spend will have been
directed, as the chairman said, to the most important places
where our country needs to be prepared.
This Nation has come together very well. And Mr. Chairman,
this hearing, I hope, will be another effort to make sure that
the country knows that its government is not sleeping, that we
will not rest until we are sure that the American public and
this Nation are as protected as we can make them and as
prepared as much as we can for the worst of circumstances,
should we ever experience them again.
Thank you, Mr. Chairman.
Mr. Greenwood. The Chair thanks the chairman for his
opening statements and for his presence, and recognizes for an
opening the statement the gentleman from Michigan, Mr. Stupak.
Mr. Stupak. Thank you for holding today's hearings on the
subject that I have been interested in working on for the past
few years. Bioterrorism has suddenly taken center stage, and we
welcome comments from today's participants on this topic.
Last year, Congressman Burr and I cosponsored a public
health and emergencies act, which was rolled into the health
omnibus bill. It is the logical next step to evaluate our
Nation's preparedness.
As a former law enforcement officer, I am well aware of the
logical difficulties in implementing a country-wide or county-
wide public health response; and I am eager to hear today's
witnesses and their advice on how best to build on what Mr.
Burr and I started last year.
I was especially pleased and gratified to see Secretary
Thompson recently invoking the law that Mr. Burr and I worked
so hard to pass last year, specifically relating to
bioterrorism. It is my understanding Secretary Thompson was
able to ship medical supplies and assistance to the victims of
the September 11 terrorist attack in New York City as easily as
he did because of the language that we inserted in our
legislation last year.
The logistical elements of coordinating our efforts are
staggering, to stay the least. Effective communications mean
establishing links among public law enforcement, local health
departments, clinics and hospitals, so that critical data in an
emergency situation can identify, contain, and respond to an
emergency efficiently. However, we lack the personnel and the
resources to do this.
For example, if a bioterrorism attack occurred on Friday
afternoon after office hours, there would be no one to report
it to until Monday morning. The way most health departments are
currently set up, that would be the situation.
No one wants to spread unnecessary fear or alarm, but I
have to question, just how organized is the Nation's public
health system to respond to bioterrorism? No hospital or
geographically contiguous group of hospitals can effectively
manage even 500 patients demanding sophisticated medical care
and supplies, as would be required in a case of the outbreak of
anthrax.
The Bush administration's head advisor on bioterrorism
testified yesterday morning in front of a Senate panel. He said
in the event of a contagious disease outbreak such as smallpox,
far fewer patients could be handled, testified the expert, Dr.
Donald Henderson, Director of Johns Hopkins's Center for
Civilian Biodefense Studies. That is a good fact to know and a
compelling factor to consider in our deliberations today.
Mr. Chairman, I thank you for holding this hearing and for
holding a future hearing on October 25, and I look forward to
hearing from our experienced panels of witnesses on this issue
today. Thank you.
I yield back the balance of my time.
Mr. Greenwood. The Chair thanks the gentleman and
recognizes for an opening the gentleman from New Hampshire, Mr.
Bass.
Mr. Bass. Thank you, Mr. Chairman; and I appreciate your
holding this important hearing. As the distinguished chairman
of the committee has mentioned, the issues here are what we are
preparing for and what measure of preparedness should we take.
Over 2 years ago, the Intelligence Committee had a public
hearing on this very subject. I had the pleasure of
participating in that hearing, and suffice it to say that there
has been awareness and action undertaken both on the military
and on the civilian side to prepare for this kind of
eventuality.
I think, however, it is important, as we consider the
issues here, not to scare people or create mass paranoia, but
to inform and educate the people so that we can be alert and
aware of what we need to look out for, not for Congress to
overreact--or government, for that matter--but develop and
implement good, effective public policy that will be in the
best interests of the American people.
This hearing is a good beginning. I look forward to hearing
the testimony from the distinguished witnesses.
I yield back.
Mr. Greenwood. The Chair thanks the gentleman and
recognizes the gentleman from North Carolina, Mr. Burr.
Mr. Burr. Thank you, Mr. Chairman.
We are here today to look at bioterrorism preparedness. We
are probably a little late, in all honesty. But what we find
when we examine the issue is, we find a number of entities
within the Federal Government, a number of different agencies
with funding and with efforts to address our preparedness--some
because of the oversight restrictions of committees that fund
duplicative programs, some where one committee might determine
that the money is directed in the right place. We see the
participation of other agencies in the same area.
And now, since September 11, we have begun to look at it in
its entirety and, in many cases, with a microscope.
Let me suggest, had we held this before September 11, we
would have highlighted one thing today, and we will at this
hearing: What we had put in place as it relates to the national
medical response network of four private sector entities that
could be called up at any time, given that there was threat of
a bioterrorism attack. Had we had the hearing before September
11, I am not sure that we would have looked as closely at our
response capabilities federally and locally like we do today.
So I think for the American people the benefit of us having
this hearing post-September 11 is tremendously advantageous.
Mr. Chairman, we have got a challenge. As a member of the
Intelligence Committee--Ms. Harman is on the Commerce
Committee--we understand the efforts that are under way, we
understand the challenges that we will place on health care
professionals in every community across this country.
The only way that Congress can fall down on their job is to
make sure that the resources that we make available do not get
to the entities that need the equipment and that need the
training to respond in a timely fashion to a threat that exists
somewhere in America.
Our ability to pinpoint that threat does not exist and will
not exist, but our capabilities to respond to the threat and to
minimize the effects exist today. If the Congress of the United
States can find a way to coordinate the resources, the existing
resources and the potential future resources, we will have a
tremendous opportunity with the confirmation of Governor Tom
Ridge in his newly designed post.
And, Mr. Chairman, I hope that we will learn a lot about
our health preparedness and our response capabilities today;
and I hope that all members will begin to think, and those
entities that are here to testify will begin to think, how it
is that we help design this new post for Governor Ridge, so
that he has the budgetary authority to make sure that the
dollars are directed where they can do the most good for the
threat that we perceive and for the comfort of the American
people.
Even though we are an oversight arm of the Commerce
Committee, we are limited to a great degree by the efforts of
Health and Human Services and to--to their dollars that they
spend on health. Given that there are eight Federal agencies
and eight committees of jurisdiction where we don't have
collaboration between oversight committees, the only way that
we can function with the degree of confidence that we need to
have to make sure that American people are, in fact, protected
and that our response capabilities are the best, is to make
sure that we have an entity within the Federal Government, like
Governor Ridge, who is in charge of making sure that every
agency is held accountable for every dollar that goes into our
preparedness and our response capabilities.
I look forward to the panel that the committee has before
us today. And with that, I yield back.
Mr. Greenwood. The Chair thanks the gentleman and
reiterates that this hearing was originally planned for July,
and we decided to wait for the GAO study. And of course, the
great irony is that we noticed the hearing for September 11.
The issues remain the same, only the urgency has changed.
The Chair thanks the gentleman and recognizes the gentleman
from Iowa, Mr. Ganske.
Mr. Ganske. Thank you, Mr. Chairman. I ask consent to
submit for the record my full statement.
Mr. Greenwood. Without objection.
Mr. Ganske. Which would be about 30 to 40 minutes and I am
sure----
Mr. Greenwood. I am sure there are no objections.
Mr. Ganske. I think some of the remarks that have been made
so far bear repeating briefly; and that is that we should not
scare people, but we need to be responsibly concerned about the
threat of bioterrorism, and it is something that this Congress
has been working on in the past few years.
A couple of years ago we passed a bill outlining a number
of ways in which to better combat a potential bioterrorism
attack. In that legislation, sums were authorized for Federal
expenditures. We need to fulfill those authorizations, and as
the chairman pointed out, probably expand those authorizations
and actual appropriations. Because we are dealing with the
situation, with bioterrorism, where the first line responders
will not be policemen or firemen, but they will be doctors and
nurses and hospitals and public health facilities; and there
are a number of things that we need do to bolster that public
health component.
For many years now, public health services have been not
funded, I think, at the levels that they should be. They need
to be better coordinated between Federal, State and local and
city units. That is something for Governor Ridge to work on and
for Congress to work on, too, in order to facilitate that.
We are going to hear something about smallpox and about
anthrax today. Smallpox, as a physician, I can tell you that
there is probably no one in this audience today who is
immunized against smallpox. The immunizations for that were
discontinued years ago, were effective for a period of time.
Then, we supposedly eliminated smallpox from the planet,
except that it was kept in two repositories, that were supposed
to be secure, both in the United States and in Russia. I think
it is fair to say that it is possible that there are smallpox
strains elsewhere in the world, for instance in Iraq, possibly
in other places in Russia.
There certainly is expertise among Russian scientists who
have worked on bioterrorism projects. That is available around
the world. And we know that the--we are facing increasing
levels of sophistication in terms of terrorist attacks, so
these are some things that we need to be concerned with.
Smallpox is extremely catchy, and it can be 30 percent
fatal in people who are not immunized. So we need to do things
about increasing supplies for vaccines, surveillance, things
like that.
Anthrax is a little harder to distribute, but it is more
fatal if you get it in the pulmonary form. I will be interested
in seeing or hearing testimony today about this strain in
Florida that, according to newspaper reports, can be traced to
an Iowa facility from the 1950's.
But I also want to talk about the bioterrorism attack in an
economic way, and that is something that I and members of the
Agriculture Committee have been concerned about for many, many
months, long before the September 11 attack; that is the foot
and mouth disease problem.
We have seen what has happened to agriculture in areas
around the world where--particularly Europe, where this has
hit. We have been concerned about proper USDA surveillance, CDC
surveillance, things like that for this disease. It is not
particularly harmful to humans, but the economic devastation on
our agriculture community could be incredibly, incredibly
devastating.
I know that there will be some farmers who will be
listening to my testimony right now that would probably not
want me talking about this, except for the fact that this has
now received front page and headline stories in major magazines
like Time magazine, so this is not something that is secret. We
need to be looking at ways to secure our agriculture in terms
of an economic attack on our country, as well.
And finally, I think that we can all hope and pray that we
do not see a massive epidemic. I think that with better
coordination, with better funding of our public health
services, we certainly could see some additional benefits in
our ways for our country, and I look forward to the testimony.
Thank you, Mr. Chairman.
[The prepared statement of Hon. Greg Ganske follows:]
Prepared Statement of Hon. Greg Ganske, a Representative in Congress
from the State of Iowa
Tuesday September 11th is forever seared into our minds. We will
never forget the images: airplanes flying into buildings and exploding,
people choosing to jump off buildings rather than burn to death,
buildings collapsing on rescuers, clouds of vaporized concrete, steel,
glass and thousands of humans rolling down the streets like a volcanic
eruption . . . the Stars and Stripes framed by the flaming crater that
was the pyre of 195 soldiers and civilians at the Pentagon. Our hearts
go out to the victims and their families.
We watched those images and they didn't seem real. The spectacle
almost disguised the human toll. At first the magnitude of this tragedy
made it hard for most Americans to grasp. But everyday the newspapers
now put faces on the victims and their families. The shock has worn off
and we are left with grief, the deepest grief. We read those obituaries
and find ourselves tearing up. I don't know about you, but I can only
read a few each day before I must stop.
We've learned the stories of the brave passengers on United Flight
93 who bid their loved ones farewell pledging that they were going to
go down fighting. Their plane crashed but those heroes saved many lives
in Washington--perhaps even my own. We are humbled by their courage and
their sacrifice! Ordinary Americans who in 45 minutes became heroes.
We remember the final recorded words of the men and women
hopelessly trapped above the fiery inferno of the World Trade Center--
messages of love to their families.
In Corinthians the Bible teaches; ``So we do not lose heart. Even
though our outer nature is wasting away, our inner nature is renewed .
. . for we know that if the earthly tent we live in is destroyed, we
have a building from God, a house not made with hands, eternal in the
heavens.''
Each of us will carry our own memories of 9/11. I will never forget
the sense of unity as 170 bipartisan members of Congress, not
Republicans or Democrats but Americans, stood on the front steps of the
Capitol in the lengthening evening shadows of that Tuesday to say a
prayer for our country and its victims . . . and then we sang America
the Beautiful. Our message then--and today--and tomorrow is that we are
one Republic, united we stand. Terrorists can challenge this nation's
spirit--but they cannot break it!
In righteousness, we are hunting down . . . to the ends of the
earth if necessary . . . the assassins of our brothers and sisters,
mothers and fathers, husbands and wives, and children. We will do what
is necessary to win this war that has been declared on us. The victims
deserve justice and our people deserve security. We are meting out
justice to these terrorists, and we do distinguish between terrorists
and those who harbor them and the rest of the Muslim world.
But Christians, Jews, and Muslims must all understand that the
Osama bin Ladens, are leading to the destruction of all religion and
society . . . if the Muslim fundamentalists don't realize that the war
will go on and on.
Take the radical Islamic-fundamentalist Taliban regime. This is a
government so oppressive that it executes little girls for the crime of
attending school. Girls, aged 8 and older, caught attending underground
schools are subject to being taken to the Kabul soccer stadium and made
to kneel in the penalty box while an executioner puts a machine gun to
the back of their heads and pulls the trigger. Spectators scattered
among the stands are then encouraged to cheer.
An Afghani woman was beaten to death recently by an angry mob after
accidentally exposing her arm. Osama Bin Laden's treatment of women is
so barbaric that he orders their fingernails and toenails pulled out if
they are painted. Women have almost no health care because male doctors
are forbidden to touch female patients and there are very few female
doctors. The beating, raping and kidnapping of women are commonplace.
A reporter for CNN recently told of meeting a family of three
little girls hidden under their scarves and garments while their father
stared into space. The girls had apparently not moved in weeks . . .
they had been made to watch as the Taliban militia shot their mother in
front of them and then stayed in their home for two days while the
mother's body lay in the courtyard. The reporter asked the girls what
the Taliban men did to them during those two days . . . they just wept
silently.
The Taliban is rounding up men from villages. Those that don't join
willingly are shot. There are news reports of mass graves--some
containing as many as 300 Afganis--scattered throughout the country.
The Taliban is taking more than a few pages from the Nazis. They
require all Hindus to carry a yellow sticker identifying them as
members of a religious minority. Hindus are required to put yellow
flags on their rooftops, as well. The Taliban also controls the heroin
trade and funds its domestic and international terrorism with drug
money.
So what do we do? Well, to quote from British Prime Minister Tony
Blair's magnificent speech: ``Don't overreact some say. We aren't.
Don't kill innocent people. We are not the ones who waged war on the
innocent. We seek the guilty. Look for the diplomatic solution. There
is no diplomacy with Bin Laden or the Taliban regime. State an
ultimatum and get their response. We stated the ultimatum; they haven't
responded. Understand the causes of terror. Yes, we should try, but let
there be no moral ambiguity about this: nothing could ever justify the
events of 11 September, and it is to turn justice on its head to
pretend it could. There is no compromise possible with such people, no
meeting of minds, no point of understanding with such terror. Just a
choice: defeat it or be defeated by it. And defeat it we must.'' These
are words worthy of Churchill.
I personally will never forget the smell of the smoldering crater
of the Pentagon or the smoke unfurling into the air of lower Manhattan
while at ``ground zero'' the firemen poured water onto the ruins of the
World Trade Center that is the grave of over 5,000 innocent people.
As I stood looking at the mass of twisted steel and concrete, my
thoughts turned to the words of a little girl's handwriting I had just
seen a victims' family center . . . the words, ``I miss you daddy!!
Love you, Jenny.'' It is indescribably sad.
So what do we do? Just what we are doing in Afghanistan now:
destroying the terrorists and their supporters. Our prayers are with
the brave men and women soldiers of our Armed Forces. It must be
galling to the Taliban that some of our bravest soldiers are women!
What else do we need to do? Well, if we didn't realize how
important airplane security and airport security was before September
11th, we sure do now. The safety and security of our aviation system is
critical to our citizens' security and our national defense.
The tragedy of September 11, 2001 requires that we fundamentally
improve airport and airline safety. That is why Congressman Rob Andrews
and I Introduced on September 25th the Aviation Security Act, H.R. 2951
which is the companion bill to that offered by Senators Hollings and
McCain. Our bills have bipartisan support in both the House and the
Senate. Our bill would make planes' cockpits secure; it would place
federal air marshals on more flights. It puts the FAA in charge of
airport security operations including increased training for airport
security personnel and anti-hijacking training for flight personnel.
The Aviation Security Act would improve the screening of flight
training so that a terrorist couldn't walk up to the counter, plunk
down $20,000 in cash and say, ``Teach me to fly a jet and, oh by the
way, I'm not interested in learning how to take off and land . . . just
teach me to steer the jet!''
Our bill would pay for this with a $1 charge on airline tickets.
When I talk to Iowans, none of them say this is too much to pay for
increased airline security. I don't want more families writing letters
like another one I saw at the victim's family center: ``Danny, I will
love you always--you will always be in my heart. Love Chris and your
son, Justin.''
So what do we do about other terrorist threats like the possible
bio-terrorist anthrax attack in Florida? First of all, we should not
panic. I am speaking as a Congressman but also as a physician.
Selecting and growing biologic agents, maintaining their virulence,
inducing the agents into forms that are hardy enough to be disseminated
and finding an efficient means of distribution is not easy for a nation
to do, much less terrorists.
However, the level of coordination and the profiles of the
terrorists associated with September 11, mean we must be prepared for
attempts at bio-terrorism. There are nations such as Iraq that might
help these terrorists in their evil plans. Clearly, we must try to root
out terrorist cells before they strike. Our intelligence services must
be bolstered and given the tools they need. Impoverished scientists
from countries like Russia that have worked on biological weapons must
be prevented from selling that knowledge to terrorists.
But it is important to understand that the first line of defense
against a biological attack will not be a fireman or a policeman. It
will be doctors and nurses; it will be the public health system because
the ultimate manifestation of the release of a biologic agent is an
epidemic. Smallpox and anthrax are most frequently mentioned as agents
of bio-terror.
Officially, only two stores of the smallpox virus exist, for
research purposes, in secure locations in Russia and the U.S. . . . but
there may be covert stashes in Iraq, North Korea and in other places in
Russia. People who were vaccinated before 1972 have probably lost their
immunity and routine inoculations were halted around the world in 1972.
Most people would therefore be at risk. Smallpox is very ``catchy'' and
about 30% fatal.
The first victims of smallpox would likely be the terrorists
themselves, but remember, these are people who commit suicide to spread
terror. Inhaled anthrax is fatal about 90% of the time, 20% of the time
if infection is from contact with animals. Its spores are resistant to
sunlight, but manufacturing sufficient quantities and then distributing
them widely by, say, crop-duster airplane, would be difficult.
Time Magazine even talks about a terrorist attack aimed at crops
and livestock that would be easier and less directly harmful to humans,
but economically very harmful. Foot-and-mouth disease can spread with
astonishing speed in sheep, cattle and swine. An outbreak in the U.S.
could be devastating to American agriculture.
So what can we do? First, we need better coordination between the
Defense Department, the State Department, the Agriculture Department,
the Centers for Disease Control, state public health programs and
directors, and the city-based Domestic Preparedness programs. This is a
job for the new Director of Homeland Security.
Second, we must make a systematic effort to incorporate hospitals
into the planning process. As of today I think it is accurate to say
that few U.S. hospitals are prepared to deal with community-wide
disasters for a whole host of financial, legal and staffing reasons.
There will be significant costs for expanded staff and staff
training to respond to abrupt surges in demand for care, for outfitting
decontamination facilities and rooms to isolate infectious patients.
There will be the costs of respirators and emergency drugs. The first
serious efforts to implement a civilian program to counter bio-
terrorism emerged in the spring of 1998 when Congress appropriated $175
million in support of activities to combat bio-terrorism through the
Department of Health.
But we must do more to integrate federal, state and city agencies:
1. We must educate family doctors and public health staff about the
clinical findings of agents,
2. We need to further develop surveillance systems of early detection
of cases,
3. We need individual hospital and regional plans for caring for mass
casualties,
4. We need laboratory networks capable of rapid diagnosis,
5. And we need to accelerate the stockpiling and dispersal of large
quantities of vaccines and drugs.
The Public Health Threats and Emergencies Act of 2000 provides for
increased funding to combat threats to public health and we should
provide that increased funding this year.
I recently visited Broadlawns Hospital in Des Moines. Public
hospitals like Broadlawns and public health agencies have not been
adequately funded in recent years. They need to be bolstered in order
to cope with a biological attack. Even if a catastrophic biological
attack doesn't occur, and we pray it doesn't, the investment will pay
dividends in other ways.
Finally, let me return to the question of understanding the causes
of Muslim fundamentalists' hatred of the United States. President Bush
asked in his September 20 address to Congress, ``Why do they hate us?''
And those of us in the audience and those at home listening to the
President--still stunned by the magnitude of the attack--wondered what
degree of poverty or political resentment or religious convictions
could lead anyone to revel in the deaths of so many innocent people?
Shortly after the attack I was asked by the Des Moines Register
newspaper's editorial board why I thought there was so much hatred of
us in the Middle East. In April I had visited Israel, Jordan and Egypt.
Our Congressional delegation met with the leaders of these countries
and the Palestinians, but also met with people from these countries who
weren't in government.
I told the editorialists that there was much envy of our wealth and
dislike of our Western culture, particularly the role of women as
equals. I also said it was clear that our support of Israel was
significant.
But this is an incomplete answer and I do think we need to reflect
a moment on what we hear when, for example, we hear the translation of
Osama Bin Ladin's screed. In the end, coping with Islamic anti-
Americanism has to be a component of our ``war on terrorism.''
As someone who has traveled rather extensively to third world
countries on surgical trips, let me say that not everyone regards the
United States as a greedy giant. Even critics in other countries of
America's foreign policy still often praise U.S. values of freedom and
democracy.
But extremism thrives in poverty. Cairo is now a city of 18
million. In the center of the old city is a huge cemetery called the
City of the Dead. Years ago the authorities gave up evicting people
from living in the crypts--today it is home for a million people! And
population explosion in these countries is unbelievable. The breakdown
of services such as garbage collection is something few Americans can
comprehend.
Since the early 1970s, the populations of Egypt and Iraq have
nearly tripled. As a result, per capita income in Arab states has grown
at an annual rate of 0.3%. The labor force in these countries is
growing faster than that of any other region in the world. This leads
to large pools of restless, young men with no jobs.
Globalization has accelerated the pace of economic and social
change that creates insecurity. Most Islamic states don't have
democratic governments to mediate these conflicts. Generals, kings,
leaders for life, and parliaments with no power lead to frustrated
people.
When people feel powerless and extremely deprive--either
economically, politically or psychologically--the ground is fertile for
terrorism.
This sense of deprivation is part of the public backlash in those
countries against globalization, modernization, and secularism. And the
United States, regardless of its relationship with Israel, is the
country most benefiting from globalization, it is the most modem and
the most secular nation on earth. Two thirds of Egyptians and four-
fifths of Jordanians consider a ``cultural invasion'' by the West to be
very dangerous, according to a 1999 survey.
So what can we do? First, there is no compromise with people that
celebrate killing 5,000 people and would celebrate even more if they
killed 50,000. We will hunt down and destroy these assassins of our
brothers and sisters, mothers and fathers and our children.
We must also understand the region better. We do need to help those
countries tackle their underlying economic woes. We had to fight a
Second World War because of the failure of the Treaty of Versailles,
but the Marshall Plan helped us secure a safe Europe after W.W. II.
President Bush is already starting in this direction with Pakistan. The
Jordanian Free Trade Agreement is also an important step, especially
symbolically.
Education in the region is a problem. Secondary school education is
low, illiteracy is high, and fundamentalist Islamic sects have filled
the void. Those fundamentalist sects educate, feed and clothe the poor
and they win converts to their hatred of the West.
In Egypt and Jordan the state forbids the teaching of jihad in
those schools. As a condition of U.S. foreign aid, Pakistan should do
the same. Many of the Taliban are products of those schools that teach
hatred of us.
The United States should do more to promote democracy in the Middle
East. This means promoting free and fair elections, judicial and
legislative reform and rule of law. An investment in these countries
could be well worth the cost. Consider that the Wall Street Journal is
estimating the World Trade Center Attack to be costing the American
economy over $100 billion!
This war that we are in is a fight for freedom and justice. Whether
it is our military, our intelligence agencies, our resolve to make
airports more secure and our public health system better, I see around
this country the will and resolve to win this war. Our parents fought
World War II. Each generation is called on to sacrifice and I see the
valor of my fellow countrymen in its soldiers, and firefighters and
policemen and nurses and ordinary Americans, who in 45 minutes became
heroes.
This is our generation's challenge. It is our turn to fight for
freedom and justice. We will do our duty.
Mr. Greenwood. The Chair thanks the gentleman for the
abbreviated version of his opening statement and recognizes the
gentleman from Florida, Mr. Stearns.
Mr. Stearns. Good morning and thank you, Mr. Chairman. Like
my other colleagues, I wanted to commend you for holding this
hearing today. Looking at the two panels, of course, we have
folks from the private sector and folks from the government, so
we will be able to get a good cross-section of answers on some
of our questions.
How should our Federal Government shore up our defenses
against enemies who would harm us not with bullets but using
bacteria or viruses in our streets, subway cars, crops or water
supply? We have had several what-if scenarios recently. In
Florida, of course, one individual contracted the anthrax
bacterium and now a coworker has also been tested positive for
anthrax as well.
The FBI and CDC, of course, do not believe there is any
relationship to the September 11 attack, but I think all of
America has felt a collective shiver upon learning this news
last week, and this occurrence, this so-called ``random
illness'' so soon after the September 11, was quite a concern.
I think the fundamental questions we have for those
panelists is, do we have preparedness? Are we prepared to deal
with this crisis in America? And do we even have a definition
that the public health community is working off of, State,
Federal, and local, in dealing with these types of viruses and
bacteria?
Also, do we have the resources that are properly placed for
both the State and local governments in the health care
communities to sufficiently help solve this problem and clear
up and provide specific guidance about how we are going to deal
with bioterrorism situations?
And so I think, Mr. Chairman, just airing those two ideas
about what constitutes preparedness and whether we have the
resources available in this country and at the State, Federal,
and local level, and do the health care communities have the
specific instructions on what to do, is extremely important. So
I commend you for putting this hearing together.
And to--ultimately, not to overreact but put in perspective
what we can do to prepare, and to make sure that all of us are
safe.
And I yield back, Mr. Chairman.
Mr. Greenwood. The Chair thanks the gentleman from Florida
and would note, on our second panel, we will hear from Dr.
Scott Lillibridge from to the Office of the Secretary,
Department of Health and Human Services, who will give us an
update on the Florida situation.
That concludes the opening statements.
[Additional statements submitted for the record follow:]
Prepared Statement of Hon. Ted Strickland, a Representative in Congress
from the State of Ohio
I would like to thank Chairman Greenwood and Ranking Member Deutsch
for holding this hearing on an issue that has always been important but
has added urgency after the September 11 attacks. On that day, we saw
the almost unimaginable happen. I am glad the Subcommittee is today
addressing what the needs of our country will be should a bioterrorism
attack causing an epidemic occur. In addition, I would like to thank
the witnesses for sharing with us their expertise about local
communities' readiness and needs.
First, I want to echo the sentiments of my colleagues who warn that
confronting the threat of bioterrorism with anything short of calm and
thoughtfulness will lead to a response that is both ineffective and
wasteful of taxpayer money. Bioterrorism agents are difficult to turn
into weapons of mass destruction and easily degrade in the environment:
simply, science does not currently hold the mechanisms needed to easily
create the threat of a likely bioterrorist attack. However, as science
advances, the risk of such an attack will increase, and our country
must be prepared. It is essential that our approach to deal with such
an act enhances the ability of our local agencies by giving them the
resources they need to monitor and respond to all public health
threats, including bioterrorism, flu epidemics, and other challenges to
the health of our entire population. And by coordinating the many
Federal programs that have a role in mitigating the effects of any
bioterrorism attack, we will improve our nation's ability to respond
and potentially save many lives.
As a representative of a rural district, I am particularly aware of
the workforce shortage concerns expressed by the hospitals in my
district and the effects of these shortages on our preparedness in the
event of a bioterrorist attack. This concern is also elevated because
as reservists who also serve their communities as physicians, nurses,
or specialists are called to military duty, many rural and other
hospitals already struggling with a workforce shortage may be further
challenged to have the staff they need to provide routine patient care.
From both the perspective of a bioterrorism threat and the long-term
needs of our nation's health care delivery system, it is essential that
we strengthen programs to encourage more people to serve as physicians
and nurses. It would surely be a tragedy if certain regions of the
country could not respond to a bioterrorism attack because its
hospitals lack health professionals.
In conclusion, I want to commend the successes of all members of
the health care community for their response to the September 11
attacks. Physicians, nurses, medical supply distributors, and mental
health care professionals were all integral parts of the quick response
that was needed. I look forward to the witnesses' testimony.
______
Prepared Statement of Hon. Bobby L. Rush, a Representative in Congress
from the State of Illinois
Mr. Chairman, thank you for holding this timely hearing on the
federal government's preparedness to deal with bioterrorism. The two
Florida anthrax cases which occurred so soon after the September 11
terrorist attacks have thrust the issue of bioterrorism to the
forefront.
I would like to begin my remarks by pointing out that it is due to
the vigilance of Florida state public health officers who detected and
reported the first case of anthrax in Florida on October 3 that the
federal government was able to spring into action. I commend them for
their good work.
This incident, whether the act of terrorism or merely a natural
case of this disease, underscores the necessity of having a strong
network of local public health departments. The same local public
health officials that we rely on to respond to naturally occurring
disease outbreaks are the same officials that are responsible for
bioterrorism preparedness and response. Local public health officials
are the front line soldiers in the war against domestic bioterrorism.
They will be the first to come into contact with those infected and
they are responsible for alerting the federal government of any
possible bioterrorist attack.
However, there are serious questions of whether the federal
government is adequately preparing local health departments for a
bioterrorist attack. Too often, we have inadequately funded local
public health efforts. The key to preparing for a bioterrorist attack
is not just in funding bioterrorist programs, but in creating a strong
overall public health system. Unfortunately, some federal dollars are
tied to narrow programs and do not address public health as a whole.
While the topic of this hearing is the federal government's
readiness for a bioterrorist attack, it is clear that the swiftness of
the federal governments response to an attack is inextricably tied to
the strength of our local departments of public health.
Thank you.
______
Prepared Statement of Hon. John D. Dingell, a Representative in
Congress from the State of Michigan
Today's hearing on the level of preparedness of our public health
system for a bioterrorism attack or a pandemic caused by an unknown
organism is particularly important because it focuses on the very
serious deficiencies in our public health system at the local, state
and federal levels. Improvements in our public health system can save
lives lost every day to such diseases as new strains of infectious
tuberculosis that are resistant to antibiotics, undetected hanta virus,
and gastrointestinal illnesses. They also will better prepare us for
potential biological attacks.
To date, the Federal Government's approach has been highly
fragmented and focused on training police, firefighters, and emergency
medical personnel. This has worked well for chemical disasters; it does
not for biological disasters. The first responders to a biological
attack will most likely be hospital emergency room personnel and
medical staff in clinics and doctors' offices. These people have been
almost totally ignored in response planning and training. It also
appears that there may not be sufficient stockpiles of antibiotics,
antidotes and other medical supplies to respond to a bioterrorism
attack because of the ``just-in-time'' inventory that hospitals,
pharmacies, and other health care facilities have implemented.
The fragility of the response system has been demonstrated by the
anthrax incident in Florida. Because of one case of anthrax, 700 people
are being tested and treated with antibiotics. There were not enough
antibiotics available from local sources to treat even 300 people so
the National Pharmaceutical Stockpile was activated. What would happen
if there were 50 cases of anthrax and 35,000 people to be tested and
treated in a very short time frame? The answer is clear: the system
would break down.
But we know how to fix our public health infrastructure. We know
that increased funding is required, as well as improved federal
direction and coordination. Now it is a simple and direct question of
political will, given greater urgency because of the implications of
the tragic events of September 11. We need money for training, for
developing new vaccines and antibiotics, and for developing stockpiles
of pharmaceuticals and other medical supplies. We need money for public
hospitals and community health centers. And we need leadership from the
Federal Government.
We must be prepared to defend all our citizens from domestic or
foreign enemies and from a variety of threats that now include
biological agents. Undue haste and panic are unwarranted and, in fact,
are counterproductive. But we need to begin significant and serious
efforts to rebuild our public health system, and I look forward to
working with my colleagues on them.
Mr. Greenwood. The Chair would call forward the our first
panel of witnesses. They are Dr. Amy E. Smithson, Senior
Associate of the Henry L. Stimson Center here in Washington;
Dr. Joseph Waeckerle, who is the Chairman of the Task Force of
Health Care and Emergency Services Professionals on
Preparedness for Nuclear, Biological and Chemical Incidents
with the American College of Emergency Physicians; Dr. Kathryn
Brinsfield, Associate Medical Director and Director of
Research, Training and Quality Improvement, Boston Emergency
Medical Services.
We have Dr. Lew Stringer, Medical Director of the North
Carolina Division of Emergency Management; Mr. Ronald R.
Peterson, President of the Johns Hopkins Hospital, on behalf of
the American Hospitals Association; and Dr. Dennis O'Leary,
President of the Joint Commission on Accreditation of
Healthcare Organizations; and Dr. Frank E. Young, former head
of the Office of Emergency Preparedness, Department of Health
and Human Services.
We thank all of the witnesses for your testimony today, in
advance, and for your patience in waiting for us to begin. You
are hopefully all aware that this committee is holding an
investigative hearing, and when doing so, we have the practice
of taking testimony under oath.
Do any of you have objection to testifying under oath?
Seeing no such objection, I would advise you that under the
rules of the House and the rules of the committee you are
entitled to be advised by counsel. Do any of you desire to be
advised by counsel during your testimony?
Seeing no such interest, I ask you then to please rise and
raise your right hand, and I will give you the oath.
[Witnesses sworn.]
Mr. Greenwood. We will recognize Dr. Smithson first for
your testimony. Welcome. You are recognized for 5 minutes to
offer your statement.
TESTIMONY OF AMY E. SMITHSON, DIRECTOR, CHEMICAL AND
BIOLOGICAL WEAPONS NONPROLIFERATION PROJECT, HENRY L. STIMSON
CENTER; JOSEPH F. WAECKERLE, CHAIRMAN, TASK FORCE OF HEALTH
CARE AND EMERGENCY SERVICES PROFESSIONALS ON PREPAREDNESS FOR
NUCLEAR, BIOLOGICAL AND CHEMICAL INCIDENTS, ON BEHALF OF THE
AMERICAN COLLEGE OF EMERGENCY PHYSICIANS; KATHRYN BRINSFIELD,
DIRECTOR OF RESEARCH, TRAINING, AND QUALITY IMPROVEMENT, BOSTON
EMERGENCY MEDICAL SERVICES AND DEPUTY MEDICAL COMMANDER,
NATIONAL DISASTER MEDICAL SYSTEM'S INTERNATIONAL MEDICAL AND
SURGICAL RESPONSE TEAM-EAST; LLEWELLYN W. STRINGER, JR.,
MEDICAL DIRECTOR, NORTH CAROLINA DIVISION OF EMERGENCY
MANAGEMENT; RONALD R. PETERSON, PRESIDENT, JOHNS HOPKINS
HOSPITAL, ON BEHALF OF THE AMERICAN HOSPITAL ASSOCIATION;
DENNIS O'LEARY, PRESIDENT, JOINT COMMISSION ON ACCREDITATION OF
HEALTHCARE ORGANIZATIONS; AND FRANK E. YOUNG, FORMER HEAD,
OFFICE OF EMERGENCY PREPAREDNESS, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Ms. Smithson. Thank you, Mr. Chairman. And I thank the
other members of the committee for their appearance here today,
because I hope we all become more educated about what is
obviously a very confusing subject for the American public and
for some of our policymakers.
In a continuing effort to separate fact from fiction, what
I would like to do is start with a topic that has been in the
news quite a lot lately. Let's talk crop dusters.
There are many people in this country that are under the
impression that crop dusters are suited to disperse biological
warfare agents. Quite frankly, that is not the case. Crop
dusters disperse materials in 100-micron particle sizes and
larger.
The size of a biological warfare agent particle needed to
infect the human lung is 1 to 10 microns. So let's hopefully
cut down on some of the apprehension about crop dusters as an
instrument of biological terror.
As far as the case in Florida is concerned, let's also get
right to it. Rubbing some type of an anthrax substance on a
keyboard is not a mass casualty dispersal attempt. So I hope
that even though the timing of these two things, the September
11 conventional attacks and a very unusual and possibly
criminal case in Florida, has put us all on edge that we will
be able to calm down and begin to consider the nature of this
threat in a bit more, shall we say, calm atmosphere. Because
there are important things that Washington needs to do to
prepare this country better for a biological disaster, and
quite frankly, this needs to be done regardless of whether or
not terrorists overcome the significant technical hurdles
involved in dispersing these materials in a way that would
cause massive casualties.
Mother Nature is out there and occasionally she wreaks
havoc with the human population. Not only are we talking about
emerging infectious diseases, but the increasing antibiotic-
resistant diseases that our public health officials on this
panel can speak to much better than I.
So this country needs to be prepared to deal with a
biological disaster regardless of whether or not terrorists
ever figure this out.
I would focus the remainder of my remarks on what I
consider to be the division of labor that needs to be achieved
between Washington and the rest of the country, the Federal
Government and the rest of the country.
There are several important missions for the Federal
Government. At the top of that list would be the need to
enhance our programs involved in the research and development
of vaccines and antibiotics. You will find a few remarks in
that regard in my written testimony. In addition, the other
thing that the Federal Government will need to provide is
emergency medical manpower in the event that there is some type
of significant disease outbreak in this country.
At present, in the survey that I did for Ataxia, which
encompassed officials from 33 cities across this country, it is
very clear that our hospital systems and health care systems
cannot handle the patient load of a regular influenza outbreak
season. So they are going to probably need in very quick order
outside medical assistance in order to cope with the incredible
burdens on the health care system that would result from a
major disease outbreak.
Now, there have been statements that 7,000 medical
personnel could be put on the spot in fairly short order. If
you are to examine the outcome of the mid-May 2000 Top Off
drill, you will see that the conclusion from the slated release
of plague in Denver is that 2,000 outside medical personnel
needed to be put on the ground within 24 hours or the local
health care system would collapse.
Well, I couldn't find anybody in any survey that felt like
the Federal Government could meet just the 2,000 goal, much
less the 7,000. I would recommend that Congress sponsor annual
medical mobilization exercises to see whether or not the
Federal Government can deliver what is on paper.
There are other roles that I would recommend for the
Federal Government, but most important the resources that are
spent on enhancing public preparedness have to get outside of
Washington, DC's Beltway. Right now, in this area, $8.7 billion
are being spent on readiness, but only $311 million is making
it outside of the Beltway. That is simply an unsuitable balance
of where the resources are being spent.
There are a few important things I would like to highlight
in terms of local readiness. If our health care systems are
going to be able to withstand the patient burden of a disease
outbreak, they need to have in place an agreement among
entities that are now competitors in most of our communities.
Hospitals are private entities. They need to have regional
hospital planning where there is a pre-agreed burden-sharing
arrangement so that some hospitals convert over to infectious
disease hospitals, others will take trauma patients, ladies
having babies and heart attack victims, because these things
will continue to occur, so those types of plans need to be
established.
And there were only a couple of cities that I surveyed for
Ataxia where this type of planning was even beginning. So I
would encourage you to support regional hospital planning
grants.
In addition to continuing to strengthen traditional public
health capabilities such as the improvements being made to our
laboratories, I would also encourage you to look at what may
give our physicians and our laboratories that heads-up early
warning that something is going wrong in the community, in the
health of their metropolitan community.
There are a few cities across the country that are engaged
in what is called syndrome surveillance, disease syndrome
surveillance. They are taking data that is available and
putting it to the purpose of giving us that heads-up. This is
another wise investment for Congress to make in the days ahead.
I thank you for your time, and would be glad to answer your
questions.
Mr. Greenwood. I am sure that we will have very many
questions. The surveillance aspect which you referred to last
will be the subject of a hearing on this subcommittee on
October 25.
[The prepared statement of Amy E. Smithson follows:]
Prepared Statement of Amy E. Smithson, Director, Chemical and
Biological Weapons Nonproliferation Project, Henry L. Stimson Center
When a major, complex problem comes to light, even the most learned
and experienced can find it tough to think calmly and rationally about
the reasonable, constructive steps that government should take to
address it. When the problem identified is as frightening and
potentially devastating as a bioterrorist attack, rationality can take
a backseat. In the last few years, indeed in the weeks since September
11th, countless government officials have extolled their terrorism
response capabilities, only to ask Congress in the next breath for just
a few million more dollars so they can better address the problem. A
few million here and a few million there soon adds up to serious money.
Already, the General Accounting Office and some nongovernmental
researchers like myself, have issued warnings about overlapping and
short-sighted terrorism preparedness programs.
The convening of this hearing is a positive sign that Congress may
soon begin to exercise more rigorously its oversight functions
regarding terrorism prevention and response programs. The appointment
of Governor Tom Ridge as Director of the new Office of Homeland
Security would seem to be a constructive step that could put improved
coordination and streamlining of the federal response bureaucracy on a
fast track, but that may not be the case if he is not given strong
budgetary authority. An initial review of section 3(k) of the Executive
Order establishing the Office of Homeland Security and the Homeland
Security Council does not appear to vest sufficiently strong budgetary
authority in this new office. As a matter of priority, the Office of
Homeland Security and Congress must work together to tame the unwieldy
federal bureaucracy and to get preparedness resources flowing to the
nation's cities and long-neglected public health system. To aid
Governor Ridge in his efforts, Congress should grant him czar-like
budgetary authority. Unless this occurs in tandem with a consolidation
of the number of congressional oversight committees, a few years from
now a great deal of money will have been spent with marginal impact on
reducing the threat of terrorism and mitigating the aftereffects of an
unconventional terrorist attack.
grasping for perspective in the aftermath of september 11th
Despite what you might have heard in recent weeks, there are
meaningful technical hurdles that stand between this nation's citizens
and the ability of terrorist groups to engage in mass casualty attacks
with chemical and biological agents. Between the misleading statements
that have been made about the ability of crop dusters to disperse
biological agents and the recent death of a 63-year old man in Florida
from inhalational anthrax, the public is understandably spooked about
the whole subject of bioterrorism. Facts often get overlooked in such
an atmosphere, but I will resort to them nonetheless. Crop dusters
disperse materials in a 100 micron or greater particle size, which is
significantly larger than what would be required for the effective
dispersal of a biowarfare agent. Another fact that has been glossed
over is that the sheer mechanical stresses involved in putting a wet
slurry of biowarfare agent through a sprayer can kill 95 percent or
more of the microorganisms, to say nothing of the sensitivity that some
agents have to environmental stresses once released. In order for an
aerosol spray of biological agent to infect a person, the agent must
arrive in the human lung alive, in a 1 to 10 micron particle size.
As for the developing situation in Florida, the investigation is
ongoing and conclusions cannot be drawn at this point. In the end, this
sad situation may fit into a pattern typical of past terrorist activity
with chemical and biological substances. Data compiled by the Center
for Nonproliferation Studies at the Monterey Institute of International
Studies show that over the past 25 years instances where subnational
actors actually used a chemical or biological substance relate mostly
to disgruntled workers, domestic disputes, or others with some type of
vendetta against political figures or rivals. The substances of choice
tended to be household, industrial chemicals and the scope of intended
harm included one or a few individuals, not dispersal at public
locations or in a manner where mass casualties could result. In 96
percent of these cases where terrorists used chemical or biological
substances, three or fewer people were injured or killed. Difficult
though it may be, one should not jump to the conclusion that what has
occurred in Florida is related to the horrific events of September
11th. In the headquarters building of American Media Inc., anthrax was
reportedly found on an individual's computer keyboard, a dispersal
approach that does not enable mass casualties. Should the investigation
reveal that the perpetrator(s) who introduced Bacillus anthracis into
this building employed a dry, microencapsulated form in the requisite
microscopic particle size, then concern would be warranted. That would
indicate that a subnational actor had indeed scaled technical obstacles
that other terrorists had previously been unable to overcome. Greater
detail about terrorist activities with chemical and biological
substances can be found in Chapter 2 of Ataxia: The Chemical and
Biological Terrorist Threat and the US Response, which is available on
the internet at: www.stimson.org/cwc/ataxia.htm.
When one retreats from the hyperbole and examines the intricacies
involved in executing a mass casualty attack with biowarfare agents,
one is confronted with technical obstacles so high that even terrorists
that have had a wealth of time, money, and technical skill, as well as
a determination to acquire and use these weapons, have fallen short of
their mark. Chapter 3 of Ataxia addresses this point at some length,
examining the lessons that should be learned from the very terrorist
group that got the hyperbole started, Aum Shinrikyo. To summarize,
although the results of the cult's 20 March 1995 sarin gas attack were
tragic enough--12 dead, 54 critically and seriously injured, and
several thousand more so frightened that they fled to hospitals--Aum's
large corps of scientists hit the technical hurdle likely to stymie
other groups that attempt to follow in its wayward path toward a
chemical weapons capability. They were unable to figure out how to make
their $10 million, state-of-the-art sarin production facility work and
therefore were unable to churn out the large quantities of sarin that
would be needed to kill thousands. As for Aum's germ weapons program,
it was a flop from start to finish because the technical obstacles were
so significant.
the compelling need for disease outbreak readiness
No matter where one comes out in the debate about whether
terrorists can pull off a biological attack that causes massive
casualties, the fact of the matter is that the debate itself is moot.
One need only consult public health journals to understand that it is
only a matter of time before a strain of influenza as virulent as the
one that swept this country in 1918 naturally resurfaces. Further
confirmation of a looming public health crisis can be secured through a
steady stream of reports from the World Health Organization and the
National Institutes of Medicine, which describe how an increasing list
of common diseases (e.g., pneumonia, tuberculosis) are becoming
resistant to antibiotics. These public health watchdogs are also
justifiably worried about the array of new diseases emerging as mankind
ventures more frequently into previously uninhabited areas. Microbes
have an astonishing capability to humble the human race: scourges such
as plague, polio, and smallpox have devastated generations past. Even
with everything that is in the modern medical arsenal, public health
authorities will find it difficult to grapple with disease outbreaks in
the future. Rapid global travel capabilities will facilitate the
mushrooming of communicable diseases through population concentrations
and will in turn hinder use of the traditional means of containing a
contagious disease outbreak, namely quarantine.
An even grimmer picture materializes when one consults those on the
forefront of health care in America. The best medical care in the world
can be found in this country, but US hospitals are at present poorly
prepared to handle an epidemic. To illustrate the point, US hospitals
already have difficulty handling the patient loads that accompany a
regular influenza season. Ambulances wait for hours in emergency
department bays, unable to unload patients until bed space is
available. The press of genuinely ill and worried citizens clamoring
for medical attention in the midst of a plague or smallpox epidemic
would so far outstrip a normal flu season that local health care
systems would quickly collapse.
Ataxia, the afore-mentioned report that I released last October
with my co-author, Leslie-Anne Levy, presents a series of
recommendations on how to improve federal terrorism preparedness
programs. Ataxia is based largely on interviews with first responders
from 33 cities in 25 states conducted over a period of 1\1/2\ years, so
this report is steeped in candor and the common-sense wisdom borne of
experience. Drawing from this research and the feedback that continues
to come my way in the aftermath of Ataxia's publication, I would like
to address a few issues critical to an effective response to a major
disease outbreak, whether caused intentionally or naturally. Those
issues could be listed as the ability to detect an eruption of disease
promptly, the need to establish response plans among regional health
care facilities that could be quickly activated, and the ability of the
federal government to provide timely delivery of emergency supplies of
medicine and medical manpower. Any response, however, would be thrown
off track if there is not a clear agreement on lines of authority, so I
will start there.
leadership in confronting disease outbreaks
How many FBI special agents or Federal Emergency Management Agency
(FEMA) officials know off the top of their heads the appropriate adult
and child dosages of ciprofloxacin for prophylaxis in the event of a
terrorist release of anthrax? Darned few, if any. No, the FBI excels at
catching criminals and FEMA at providing mid- and long-term recovery
support to communities stricken with all manner of disasters. An
outbreak of disease is first and foremost a public health problem, so
let's not be confused about who should be calling the shots in an
epidemic--public health officials. Yet, this simple fact is certainly
not reflected in what is taking place with regard to bioterrorism
preparedness, inside or outside the beltway.
Inside of Washington's beltway, concepts of crisis and consequence
management not only linger, they predominate. With an apparent lack of
budgetary authority and proposals circulating anew to have the Justice
Department retain a leadership and coordination role despite the Bush
administration's earlier appointment of FEMA in this capacity, it is
fair to say that Governor Ridge's office will have difficulty presiding
over the tug of war about which federal agency should lead the federal
component of unconventional terrorism response. In America's cities,
counties, and states there is also a fair amount of jostling as to who
exactly would have the authority to make certain decisions during an
epidemic. Only a handful of states, unfortunately, have untangled the
cross-cutting jurisdictions left over from more than a century of
contradictory laws passed as authorities scrambled to deal with the
different diseases that were sweeping the country. Prompt, decisive
action could make a lifesaving difference in the midst of an outbreak,
but the experience of various terrorism exercises and drills gives
ample reason to believe that precious time would be squandered as
local, state, and federal officials squabbled over who has the
authority to do what. These circumstances beg for a clear vision and a
firm hand to untangle this mess and put the people who know the most
about disease control and eradication--public health officials--
unquestionably in charge of any biological disaster, whether natural or
manmade. FEMA, the FBI, the Pentagon, and other federal and local
agencies should be playing support roles, not reshaping and second-
guessing the directions of public health professionals as they manage
the crisis and consequences of a major eruption of disease.
addressing problems of disease outbreak detection and overall medical
readiness
Perhaps the first challenge facing the health care community would
be figuring out that something is amiss. Many diseases present with
flu-like symptoms, and the physicians and nurses who could readily
recognize the finer distinctions between influenza and more exotic
diseases are few in number indeed. Thus, in a spot test conducted in
mid-February 2000 in Pittsburgh, Pennsylvania, only one out of 17
doctors correctly identified smallpox after hearing a case history and
being shown photographs of the disease's progression. Smallpox, it
should be recalled, presents in a most visible manner, with pustules
covering the body. That sixteen doctors would not correctly diagnose
smallpox can be attributed to the success of public health authorities
in eliminating scores of diseases in America. Subsequently, medical and
nursing schools concentrated training on ailments that health care
givers are more likely to see.
In another illustration of the problem, there have been far too
many reports in recent weeks of physicians prescribing antibiotics for
patients worried about a possible bioterrorist attack. Of all people,
physicians should understand how such prescriptions could backfire, not
just in adverse reactions to the antibiotics if citizens begin self-
medicating their children and themselves when they come down with the
sniffles, but in the lessened ability of those very drugs to help their
patients in a time of true medical need.
The exotic disease recognition problems are not limited to the
medical community. In the nation's laboratories, microbiologists and
other technicians who analyze the samples (e.g., blood, throat
cultures) that physicians order to help them figure out what ails their
patients are much more likely to have encountered exotic diseases in
textbook photographs rather than under their microscopes. Thanks to the
laboratory enhancement program initiated by the Centers for Disease
Control and Prevention, the ability to identify out-of-the-ordinary
diseases more rapidly is on the rise in several dozen laboratories
across the country. However, such is not the case in the 158,000
laboratories that serve hospitals, private physicians, and health
maintenance organizations are the backbone of disease detection in this
nation. In conjunction with the Centers for Disease Control and
Prevention and the Association of Public Health Laboratories, the
American Society of Microbiology is developing protocols to assist
clinical microbiology laboratories in identifying bioterrorist agents.
Although the protocols have yet to be published, volume number 33 in
the Cumulative Techniques and Procedures in Clinical Microbiology
series addresses bioterrorism issues and is available from the American
Society of Microbiology. As of yet, there is no national guideline
requiring private laboratories to enhance their ability to identify
such diseases, a component of the preparedness framework that should be
weighed carefully by public health authorities.
To date, the domestic preparedness training program, now
administered by the Justice Department, has managed to draw some
medical and laboratory personnel, mostly emergency department
physicians and nurses, into the classroom in the cities where training
is being provided. To enhance the disease detection and treatment
skills of the medical community nationwide, however, a different
strategy is required. If a long-term, systemic difference is to be made
in the skills of medical and laboratory personnel, then more
comprehensive instruction in medical, nursing, microbiology, and other
pertinent schools is required. Knowledge of exotic diseases should be
required to obtain diplomas, and the topic should become a mainstay of
the refresher courses offered to maintain professional credentials.
Those involved in setting the curricula for pertinent schools should
waste no time in heeding the long-standing warnings of the Institute of
Medicine and the World Health Organization and adjusting their course
offerings, requirements, and other professional activities accordingly.
With modern data collection and analysis capabilities, however, one
need not rely solely on the ability of laboratories and medical
personnel to pick up the telltale early signs of a disease outbreak. In
a few areas in the United States, public health and emergency
management officials are teaming to test concepts to get a head start
on detection. The concept focuses on early signs of syndromes (e.g.,
flu-like illness, fever and skin rash) that might indicate the presence
of diseases of concern. They are compiling historical databases to
supply a baseline of normal health patterns at various times of the
year, against which contemporary developments can be measured. Since
people feeling ill tend to take over-the-counter medications, consult
their physicians, or request emergency medical care, some areas are
beginning to track the status of health in their communities via select
Emergency Medical Services call types (e.g., respiratory distress,
adult asthma); sales of certain medications (e.g., over-the-counter flu
remedies); reports from physicians, sentinel hospitals, and coroners
about select disease symptoms or unexplained deaths; or some
combination of these markers. Once a metropolitan area has compiled
data to understand normal patterns activity patterns at various times
of the year, abnormal activity levels can be detected. For instance,
when EMS calls rise above the expected rate in the fall season, public
health officials and emergency managers would get the earliest possible
indication that something was amiss, which would enable them to cue
medical personnel and laboratories to search more diligently for what
might be causing a possible disease outbreak. This concept of syndrome
surveillance will be key to allowing public health officials to get the
jump on prophylaxis or whatever other control measures might be in
order.
Nationwide, syndrome surveillance is being done in several
locations, drawing in no small part upon the path breaking work done by
New York City's Department of Public Health and Office of Emergency
Management. Their efforts are summarized in box 6.7 of Ataxia, which
again is available online so that policy makers and public safety and
public health officials around the United States and elsewhere can have
the benefit of the composite knowledge of the individuals who shared
their expertise and experiences with me.
What is now called for is a more systematic approach to
institutionalizing syndrome surveillance across the nation. A model for
syndrome surveillance should be refined and then made available
nationally, along with funds to allow metropolitan areas to conduct the
necessary historical analysis and establish the computer database,
communications, and other components needed to put syndrome
surveillance in place. Again, the data and the computing capabilities
are available, it is just a matter of harnessing them for the purposes
of early disease outbreak recognition. In their own ways, the Kennedy-
Frist and the Edwards-Hagel bills address these matters. Coordination
of congressional action is called for so that the most readiness can be
gained for taxpayers' dollars.
the need for regional hospital planning
The next challenge facing a metropolitan area in the midst of a
major disease outbreak would be contending with the flood of humanity
that would seek health care services. As already noted, hospitals would
be quickly overwhelmed, so it will be critical for regional health care
facilities to have a pre-agreed plan that divides responsibilities and
locks in arrangements to bring emergency supplies in the interim until
federal assistance can arrive. In the era of managed health care,
hospitals compete with each other for business and rely on just-in-time
delivery of supplies, keeping an average of two or three days supplies
in inventory. Since community-wide hospital planning has fallen by the
wayside, precious time could be wasted if hospitals lack prior
agreement as to which facilities would convert to care of infectious
disease cases--particularly important if a communicable disease is
involved--and which ones would attend to the other medical emergencies
that would persist throughout an epidemic. Business competitors, in
other words, must convert within hours to work as a team.
This regional hospital plan must also contend with how to handle
the overflow of patients and provide prophylaxis to thousands upon
thousands of people. Whether the approach involves auxiliary facilities
near major hospitals, the conversion of civic or sporting arenas to
impromptu hospitals, or the use of fire stations or other neighborhood
facilities to conduct patient screening and prophylaxis, such a plan
needs to be put in place. Other factors that regional hospital planning
must address are how to tap into local reserves of medical personnel
(e.g., nursing students, retired physicians), how to break down and
distribute securely the national pharmaceutical stockpile, and how to
enable timely delivery of emergency supplies of everything from
intravenous fluids to sheets, tongue depressors, and food.
federal roles in biodisaster preparedness
Washington's willingness to fund regional hospital planning as well
as programs that institute disease syndrome surveillance nationally
will be critical to biodisaster readiness. In addition, the federal
government has important roles to play in the development and
production of essential medicines, in the provision of medical manpower
during an emergency, and in general mid- to long-term recovery disaster
recovery assistance. With regard to the latter role, FEMA's
capabilities have risen steadily over the last decade and little, if
anything, would need to be added to its existing capabilities and
regular Stafford Act assistance activities.
Long before the current concerns about bioterrorism, I was at a
loss to explain how the federal government could have known about the
extent of the Soviet Union's biowarfare program--including the
production of tons of agents such as smallpox and antibiotic resistant
plague and anthrax--as early as 1992 and not kicked this nation's
vaccine research, development, and production programs into a higher
gear until 1997. The extent of the problem is illustrated by the fact
that only one company is under contract to produce the anthrax vaccine,
no company currently produces the plague vaccine, and it was not until
recently that steps were taken to meaningfully jumpstart smallpox
vaccine production. Such matters should have been promptly addressed if
only to enable protection of US combat troops, not to mention producing
enough vaccine to cover the responders on the domestic front lines,
namely the medical personnel, firefighters, police, paramedics, public
health officials, and emergency managers who would be called upon to
aid US citizens in the event of a biological disaster.
As for the effort that was mounted, many nongovernmental experts
have been taken aback at the structuring and relatively meager funding
of the Joint Vaccine Acquisition Program. With a $322 million budget
over ten years, this program aims to bring seven candidate biowarfare
vaccines through the clinical trials process. Giving credit where it is
due, one must acknowledge that this program as well as Defense Advanced
Research Projects Agency-sponsored research into innovative medical
treatments are making headway. However, the federal government must
find ways to shrink the nine to fifteen year timeline that it takes to
bring a new drug through clinical trials to the marketplace. Food and
Drug Administration officials are already wrestling with how to adjust
the clinical trials process for testing of new vaccines and additional
bumps are to be expected on the road ahead.
Next, the National Institutes of Health and the pharmaceutical
industry, not the Defense Department, are this country's experts at
clinical testing and production of medications. My point is not that
the Defense Department should not have a role--perhaps even a lead role
since the candidate vaccines originated with the US Army Medical
Research Institute for Infectious Diseases--but these other important
players need to be at the table if an accelerated program is to be
achieved. As I noted, Governor Ridge will have his hands full, no
matter which direction he turns. Moreover, close congressional
oversight of this particular aspect of the nation's biological disaster
readiness is warranted.
On the chemical side of the house, by the way, the picture is
similarly discouraging. The Pentagon now turns to one company for
supply of the nerve agent antidote kits, known as Mark 1 kits, that the
Health and Human Services Office of Emergency Preparedness has
encouraged cities participating in the Metropolitan Medical Response
System program to purchase. Many a city is still waiting to receive the
Mark 1 kits ordered long ago, and when they do, these kits will have a
considerably shorter shelf life than the kits made available to the
military.
emergency medical manpower needs during a major disease outbreak
Secretary of Health and Human Services Tommy Thompson stated on
September 30th in an interview with ``60 Minutes'' that his department
has ``7,000 medical personnel that are ready to go'' in the event of a
bioterrorist attack. While that statement may be true in theory, in
practice it may not hold. Somewhat lost in the late 1990s rush to soup
up federal teams for hot zone rescues was the one major non-FEMA
federal support capability that would clearly be needed after an
infectious disease outbreak and perhaps after a chemical incident as
well--medical assistance. The National Disaster Medical System was one
of several improvements made to federal disaster recovery capabilities
over the last decade, a time during which the federal government
demonstrated that it could bring appreciable humanitarian and
logistical assets to bear after natural catastrophes and conventional
terrorist bombings. While these events flexed the muscles of the FEMA-
led recovery system, including the deployment of Disaster Medical
Assistance Teams, they did not even approach the type of monumental
challenge that a full-fledged infectious disease outbreak would
present. Prior to Secretary Thompson's recent statement, officials from
the Health and Human Services Department and the Pentagon have also
stated that they could mobilize significant medical assets quickly.
Yet considerable skepticism exists that these two departments
combined could have met the medical aid requests made from Denver after
the release of plague was simulated during the mid-May 2000 TOPOFF
drill, much less a call for even more help. During that hypothetical
event, health care officials quickly found their medical facilities
sinking under the patient load and concluded that 2,000 more medical
personnel were needed on the ground within a day to prevent the flight
of citizens that would have further spread the disease. Getting that
number of physicians and nurses to a city and into hospitals and field
treatment posts would be a tremendous logistic achievement. No one that
interviewed for Ataxia, including members of the Disaster Medical
Assistance Teams and other medical and public health professionals,
felt that the federal government could deliver 2,000 civilian medical
professionals within the required timeframe. For its part, the Pentagon
has yet to articulate clearly or commit to civilians at the federal or
local level just how much medical manpower it could deliver and in what
timeframe.
Quite frankly, the time has come for the Pentagon to stop being coy
about what medical assets it could bring bear in a domestic emergency.
Articulation of this capability, even if it needs to be done in
classified forums, is necessary for sound planning on the civilian
side. Furthermore, there have been no large-scale dress rehearsals to
confirm whether civilian or military medical assets could muster that
many medical professionals that quickly, or even over a few days. Even
so, the 2,000 figure from the Denver segment of TOPOFF seems almost
quaint when compared to one US city's rough estimate that 45,000 health
care providers--many of whom would have to be imported--would be
required to screen and treat its denizens.
The only way to find out whether the federal government is truly up
to the most important role it may have to perform after a bioterrorist
attack or a natural disease outbreak is to hold a large-scale medical
mobilization exercise. Despite the expense, Congress should mandate a
realistic test of how much civilian and military medical assistance can
be delivered, how fast. Unlike TOPOFF, where federal assets were pre-
picked and pre-staged, the terms of the exercise should specify that
teams deploy as notified. While the general nature and identity of the
exercise location(s) would certainly be known beforehand and the
timeframe of the drill agreed within a window of several months, local
officials should trigger the onset of the exercise. In short, dispense
with the tabletop games that allow everyone the comfort of claims of
what they could do and see what a real exercise brings. A genuine and
probably sobering measure of federal capabilities could be taken, and
the lessons of the exercise could inform the structure of federal and
local plans and programs.
conclusions
One need not resort to hyperbole when it comes to how difficult it
would be for major US cities to handle a pandemic; the truth is
sobering enough. Even though the basic components of the ability to
handle a disease outbreak--hospitals, public health capabilities at the
federal, state, and local levels, and a wealth of medical
professionals--are already in place, there is ample room for
improvement. The pragmatic steps that the federal government should
take are clear. Mr. Chairman, Members of the Committee, Washington can
take the smart route to enhance biodisaster preparedness nationwide or
it can continue to go about this in an expensive and inefficient way.
The keys to biodisaster readiness are as follows:
<bullet> The sufficiency of existing federal programs, response teams,
and bureaucracies needs to be assessed and redundant and
spurious ones need to be eliminated. In the interim until an
assessment of the sufficiency of existing assets is made, a
government-wide moratorium on any new rescue teams and
bureaucracies should be declared, with the exception of the
enhanced intelligence, law enforcement, and airport security
measures that are being contemplated.
<bullet> Defense Department programs related to the development and
production of new vaccines and antibiotics need to be put on a
faster track and incorporate expertise in such matters from
outside the Pentagon.
<bullet> The federal government should continue to revive the nation's
public health system, an endeavor that involves sending funds
to the local and state levels, not keeping them inside the
beltway. In addition, the federal government should fund
regional hospital planning grants and additional tests of
disease syndrome surveillance system, followed by plans and
funds to establish such capabilities nationwide.
<bullet> Appropriate steps should be taken to see that physicians,
nurses, laboratory workers, and public officials benefit from
training that is institutionalized in the nation's universities
and schools.
<bullet> Last, but certainly not least, Washington needs to develop a
plan to sustain preparedness over the long term. Drills at the
local and federal levels are necessary because plans that sit
on the shelf for extended periods of time are often plans that
do not work well when emergencies occur.
I will wrap up with one more essential task to which each
individual member of Congress must attend. Since September 11th, I have
received numerous calls from offices on both sides of the Hill and both
sides of the aisle, asking me to brief them on these issues and to help
fashion legislation that would put Representative ``X's'' or Senator
``Z's'' stamp on the legislation that is taking shape. While I have
responded as quickly as possible to such requests, they are in some way
indicative of the problem that Washington faces if it is to craft
meaningful, cost-effective preparedness programs.
With all due respect, I would point out that while the attacks of
September 11th occurred in New York City and Northern Virginia, they
were attacks on this nation as a whole. Those who risked their lives
that day to save the lives of others were not thinking about themselves
or their future, they were selflessly acting in the interests of
others. Put another way: this is no time for pet projects, whether they
be to benefit one's home district constituents or a particular branch
of government. This is not about job employment, it is about saving
American lives. The future well-being of each American, I would
contend, is equally important.
On behalf of the local public health and safety officials who have
shared their experience and common sense views with me, I urge Congress
to waste no time in passing legislation that brings the burgeoning
federal terrorism preparedness programs and bureaucracies into line and
points them in a more constructive, cost-effective direction. The key
to biodisaster preparedness lies not in bigger budgets and more federal
bureaucracy, but in smarter spending that enhances readiness at the
local level. Even if terrorists never strike again in this country,
such investments would be well worthwhile because they would improve
the ability of hometown rescuers to respond to everyday emergencies.
Mr. Greenwood. Dr. Waeckerle.
TESTIMONY OF JOSEPH F. WAECKERLE
Mr. Waeckerle. Good morning.
Mr. Greenwood. You are recognized.
Mr. Waeckerle. Good morning to all of the members and my
fellow panelists. I am Joe Waeckerle; I am a Board certified
emergency physician in Kansas City, practicing. I have been
involved in this area for the last 8 or 9 years as a consultant
to the FBI, the Defense Science Board and CDC and Office of
Emergency Preparedness.
I also serve as the task force chair, as you spoke to
earlier. I am passionate about domestic preparedness and have
spent too much time in the area, as we all must now.
America has been targeted. America has been attacked and
America has suffered, and we all mourn as we should. But we
need to do more than mourn to better protect our country and
honor those who have suffered and died. We need to be prepared
and, especially, prepared against biologic weapons.
We are extremely vulnerable. Numerous analyses of the
escalating risks to America and the considerable deficiencies
have been presented before you and other Members of Congress,
both internal, external and from distinguished people, like Dr.
Smithson to my right. They have demonstrated considerable
deficiencies which the government has appropriately addressed,
but there are many that still linger.
Careful consideration of the lingering major deficiencies
are obvious points of interdiction requiring urgent reform that
we can address, and I hope to do so for some today.
The failure to recognize biowarfare is a national threat
that has resulted in a lack of a comprehensive national
strategy. I therefore ask Congress to demand a specific
comprehensive and sophisticated strategy of deterrence and
defense against bioweapons. This currently does not exist and
has not trickled down to the local community.
The failure to mandate and implement a centralized Federal
authority has resulted in a void in leadership which, as you-
all alluded to, is remarkable and causes fragmented,
uncoordinated, redundant and inefficient planning and
preparation.
Please authorize and fund a central Federal management and
oversight group, whether it be in Governor Ridge's office or
another, so that we can develop and implement a comprehensive
deterrent and defense strategy, and we can have better
communication and cooperation and integration between the
Federal family and the local first responders who will be the
first people to protect our country.
I will not discuss planning or detection deficits, you will
discuss those, but I will tell you that I served on the Defense
Science Board's recent task force, and that report was given to
you, I believe, 2 weeks ago. It is remarkably well done. I
apologize for saying so. And I urge you to look at it.
I would like to talk about three other issues.
The failure to maintain our public health system: Not
having a public health infrastructure in this country has
severely retarded our ability to detect, identify and
investigate epidemiologic--appropriate epidemiologic studies.
The Congress, therefore, must ensure that the public health
system be retooled with appropriate capabilities and capacities
for biowarfare, and be linked to emergency and other health
care professionals so we have better detection and better
notification.
This is an added value to the natural epidemics and
infections occurring today that it will benefit such retooling.
The failure to engage hospitals in this endeavor is a severe
problem.
Hospitals are certainly financially frail. There is
overcrowding. There are too few beds, too light staff, and too
little supplies and resources due to financial frailty. There
is no surge capacity. Congress must recognize that emergency
departments and their hospitals are the critical component of
the infrastructure of biodefense, along with public health, and
must take steps to necessarily fortify their abilities.
Finally, the failure to engage emergency health care
professionals has resulted in the lack of awareness of national
strategy, a lack of clinical acumen of the bioagents and a lack
of understanding of their vital roles.
Patients will come to the emergency departments, as you
correctly pointed out. The ER is where we always go. That will
be the incident scene in contrast to the tragedies in New York
City. The first responders will now be emergency physicians,
emergency nurses and emergency medical technicians. So they
must be able to detect and diagnose and notify our system and
implement treatment quickly. Unfortunately, we are not prepared
to do such, as our task force pointed out.
Also, because of that, we may be not only the first
responders, but the second victims, further destroying the
infrastructure of our health care in this country. Congress
must therefore authorize and implement an overall plan for
providing, sustaining and monitoring appropriate educational
experiences for these essential emergency care professionals.
An overarching strategy that our task force recommends you
consider is to no longer fund private contractors through DOD
or DOJ, but to allow HHS or the new office to directly partner
with the professional organizations of all health care
professionals, who communicate, educate, monitor and regulate
their own members on a day-to-day basis.
Don't reinvent the wheel. The wheel is there.
In conclusion, to deter or mitigate any terrorist action
against our country or our people, Congress must provide the
leadership, financial support and organizational and logistical
support requisite to developing a comprehensive national
strategy, preparation and response.
Certainly such preparation is costly, both financially and
personally to all of us. However, America must remain resolute.
For what is the price of our freedom, of our country's well-
being and our citizens' lives?
Thank you for the opportunity.
[The prepared statement of Joseph F. Waeckerle follows:]
Prepared Statement of Joseph F. Waeckerle, Chairman, Task Force of
Health Care and Emergency Services Professionals on Preparedness for
Nuclear, Biological, and Chemical Incidents, The American College of
Emergency Physicians
introduction
Chairman Greenwood and members of the Subcommittee, good morning. I
am Dr. Joseph F. Waeckerle, Editor in Chief of the Annals of Emergency
Medicine, the Journal of the American College of Emergency Physicians.
I am a Board of Emergency Medicine certified physician, and the
Chairman of the American College of Emergency Physicians' Nuclear,
Biological, and Chemical Task Force. I am here today testifying on
behalf of the American College of Emergency Physicians (ACEP), which
represents more than 22,000 emergency physicians and their more than
one hundred million patients.
I want to thank you for the opportunity to appear before you today
to discuss the readiness and capacity of the federal programs to
provide needed health related services in the event of a biological
terrorist attack.
The focus of the nation since September 11 has been on the tragic
and senseless loss of lives caused by terrorists willing to fly air
planes into buildings. I want to talk to you today about the new
weapons of war that have emerged in our modern world which perhaps
represent the greatest long-term threats to our national security.
Preeminent among them are biological warfare agents. To date, our
nation has had very little experience with threatened bioweapon use.
What experience we have had has involved small, isolated events not
indicative of the true potential devastation of bioagents.
The use of biologic agents as weapons of war could approximate the
lethality of a nuclear explosion, can decimate a large population, and
thereby destabilize a nation. It can inflict psychological and economic
hardship and political unrest by attacking small populations in
multiple sites over a protracted period. America's citizens, national
security and international stature are at risk should a bioweapon be
used.
america's state of readiness
There have been numerous analyses of the escalating risks to
America and the considerable deficiencies in our responses to the
threat of any weapon of mass destruction much less biologic warfare.
Internal reports from the Federal government (Defense Science Board,
Defense Threat Reduction Agency, General Accounting Office), external
assessments by august panels such as Hart-Rudman and the Gilmore
commission, and private testimonies including the Smithson report and
individuals before Congress repeatedly warn of the serious deficiencies
in our planning and preparation. Authorities have acted on these
deficiencies, but we must decisively improve much more. Careful
consideration of the existing strategies and response protocols reveals
major deficits that are obvious points of interdiction.
national strategy deficit
A comprehensive national strategy must be predicated on an in-depth
analysis of threats and risks. By identifying credible threats,
available assets, and resultant vulnerabilities, a cogent national
strategy can be generated. To date, the approach has centered on an
``all-hazards'' approach. Most of our nation's hospitals have policies
to respond to hazardous materials (HAZMAT) incident, which are
inadequate for responding to some chemical agents and nearly all
biologic agents. Certainly, conventional weapons are and should be our
main focus. Current planning has also focused on chemical weapons with
many federal agencies and departments specifically addressing these
threats. This is appropriate to a degree because there are currently
about 850,000 facilities in the US using hazardous or extremely
hazardous materials. Better preparation for possible hazardous
materials incidents whether they are the result of industrial accidents
or perpetrated by terrorists is beneficial to our country.
Many governments and civilian authorities rightly believe that
biologic agents suitable for warfare are readily available. The
dissolution of the USSR has led to the cessation of funding for their
once formidable bioweapons facilities and financial hardship for the
employees. As such, security is minimal and personal motivation to
survive, much less profit, is utmost, so bioagents may be ``on the
market.'' Compared with conventional weapons, research and development
of bioagents are economically feasible today for many other nations as
well. Research and development is now where once only a few had the
capability and resources to pursue these avenues. As a result, many
nations/states have aggressively and successfully pursued their own
biowarfare research and development.
There is also legitimate scientific application of microbiology,
which could be used to develop biologic agents. The pharmaceutical
industry, beverage industry, and others pursue research in biology to
benefit mankind. Because of the overlapping assets used for producing
legitimate products and bioweapons, it is extremely difficult to
estimate and regulate research and development activities to prevent
legitimate research from falling into the wrong hands. Today, any
bidder may easily procure samples of bioagents from a variety of
sources both legitimate and illicit.
Even if only small samples of a bioagent are available, technologic
advancements make it possible for nations or organizations to culture
and harvest adequate quantities of an agent relatively inexpensively
and virtually anywhere. Bioagents can also can be easily stored and
transported. Dissemination, which may be most problematic in using
these agents, is now more easily accomplished as well.
For those individuals seeking to gain competency in this area,
knowledge is readily available. Educational opportunities are offered
in the formal education process including high school, college, and
graduate level courses and informally through widespread availability
of knowledge via the Internet. In addition, motivated researchers using
advanced techniques can now build engineered pathogens that are even
more suitable for biowarfare.
The list of agents that could be used in a biological attack is
formidable and growing. Legitimate and nefarious researchers have
scrutinized the naturally occurring agents as to what clinical and
biologic effects are most requisite. Also, newly engineered bioagents
are now more than ever viable threats against which the US is
vulnerable because they are custom built as weapons.
The capability is there, and today's world fosters malcontents,
extremists and malicious opportunists that view the United States with
hostility. These groups include nation/states, groups, and
individuals--both domestic and international--that are motivated by
political, social, economic, religious, or criminal intent. Nations who
could not challenge the United States because of the high cost of
conventional warfare now have the capability through the use of
biologic weapons to challenge our dominance as the sole remaining
superpower. Individuals and groups of zealots, extremists and criminals
also view the recent availability of bioagents as an opportunity to
wage asymmetric warfare in order to exert influence and manipulate the
system for their own gain.
Some authorities have argued that moral constraints will limit the
use of such particularly lethal weapons (weapons of mass destruction)
especially if civilians are exposed. However, the September 11 assaults
on America have shown the contrary.
The inevitable conclusion is that the availability of biowarfare
agents and supporting technologic infrastructure, coupled with the fact
that there are many who are motivated to do harm to the US means that
America must be prepared to defend her homeland against biological
agents. Denial of this threat or the excuse that this threat is too
difficult to plan for is no longer tenable.
Although the probability of a bioattack is difficult to measure,
the consequences are high. Biowarfare is a multidimensional problem due
to the diversity of bioagents each with particular threat
characteristics, plethora of vulnerable targets and varied routes of
dissemination. As such, there is no typical presentation, no easily
recognizable signature to allow easy detection or identification,
limited treatment options and a disturbing array of sequelae. A
biological attack on America will impose unparalleled demands on all
aspects of our government and our societal infrastructure that must be
met.
The consequences of poor preparation are not tenable.
Considerations for the use of potential biological weapons are the sine
qua non of future defense readiness. Biological weapons are such
formidable weapons of uniqueness and complexity that a specific defense
strategy is essential. The triumvirate of research, preparedness and
response issues pertinent to biowarfare are central to the formulation
of a robust strategic blueprint. Congress must demand a specific,
comprehensive and sophisticated strategy of deterrence and defense.
command, control and communication deficits
The United States must designate and give adequate authority to a
central office to coordinate the various agencies involved in emergency
response. A single line of authority is traditional in the Defense
Department and law enforcement for good reason. Yet the United States
has a multitude of federal agencies and departments with vested
interests in WMD preparation, and there is no authority structure. The
result is efforts in formulate and implement a national strategy are
fragmented, uncoordinated, redundant and inefficient. Unfortunately,
the absence of unity not only decays the Federal effort it undermines
the critical partnership between Federal authority and State and local
authorities.
Communication is also a major problem in domestic preparation
today. Due to the lack of an overreaching authority, there is little
communication among active Federal participants in domestic
preparedness. Equally disturbing, the lack of communication among the
Federal families trickles down to the state and local communities. As a
result, preparation for the possible use of WMD especially biological
weapons without Federal assistance is not achievable for most
communities in America. Our communities desperately need guidance and
support but little communication results in little progress. This is an
unacceptable outcome given the risks.
Until authority is mandated, centralized and implemented, turf
battles, egos, pettiness and power and money struggles will preclude
effective use of our dollars and prevent a collaborative and integrated
preparedness process on a national level or local level. Congress
should authorize and fund a centralized Federal management and
oversight office.
planning deficits
Any response to a weapon of mass destruction on American soil will
first be local and community-based perhaps for an extended period of
time. This means that communities must have plans that are well
conceived and effectively coordinated. Although a general plan in most
communities today, the local response is currently not well informed,
not well financed, not well trained or drilled, and not properly
integrated into the overriding federal response. Federal authorities
must ensure coordinated ventures with the local communities but they
must first cooperate among themselves to do so.
Furthermore, current disaster preparedness programs in US
communities are often insufficient in their design in that they are
generally inappropriate for specific preparation and response against
biowarfare. A biological agent incident requires a vastly different
response with regard to management and personnel and resources needed.
The multi-agency, multi-jurisdictional character of the many
uncoordinated strategies being delivered by the Federal family to the
local community makes success against biowarfare a remote possibility.
Congress must direct the centralized the federal management and
oversight office to provide preparedness and response, education,
guidance, and financial support directly to State and local
communities.
response deficits
The cornerstone of the Nation's response will lie in the medical
and public health communities. It is critical they be actively involved
in the threat-assets-risk analysis and subsequent national and local
preparation efforts. They are essential to controlling disease
outbreaks through appropriate and timely detection and identification,
investigation and management.
Detection and Identification Deficits
The United States must establish, strengthen, and expand
sophisticated surveillance systems that are integrated with the public
health systems and the nation's emergency departments. Efforts to
detect bioagents in the environment before people become infected
currently face significant technical obstacles. This is unfortunate
because the best defense is to detect the agent prior to its infecting
individuals. Likewise, the current technology has not matured to the
point that rapid and reliable diagnostic testing of individuals is
available. The absence of such capabilities will significantly impede
timely response and appropriate management.
At present, the detection of a disease outbreak depends on alert
clinicians--or human surveillance. However, most health care
professionals are not trained to recognize the symptoms of most of
diseases from bioweapons agents nor do they have any experience with
these agents. Patients may only exhibit non-specific flu-like symptoms
during the early stages of their infection, and clinicians probably
would recognize an outbreak only after a number of patients presented
with highly unusual symptoms or died of unusual circumstances.
The United States must improve the partnership between health care
system and public health agencies. Physicians are not prone to
reporting puzzling cases of illness to health officials. Moreover, few
public health departments have the personnel or resources to conduct
real-time disease reporting or provide expert advice.
The absence of real-time surveillance and simple, quick and
reliable diagnostic testing further complicates matters. It will be
difficult for clinicians to determine the location and scope of the
attack. Infected individuals could move about without overt
manifestations during the incubation period of infection. Depending on
the agent, contagion could be spread unknowingly, further amplifying
the peril. The ability to determine who is actually infected so needs
treatment and who is not infected so needs only reassurance is
paramount. Potentially, the ``worried well'' may overwhelm the health
care system just as it needs to be entirely focused on the truly
infected. The inability to distinguish the infected victims also does
not allow appropriate disease containment.
Complicating this, most hospital and commercial labs cannot
definitively identify the bioweapons pathogens of greatest concern,
such anthrax or smallpox. There are also serious concerns about the
capacity of laboratories to cope with increased demands, and the
capacity of hospital emergency departments that are already operating
at critical capacity to respond. The CDC has been working with state
public health laboratories to augment their abilities and capacities
and foster a national laboratory system.
Congress must support public and private research for the
development of real-time alerting and tracking surveillance systems
with analytical capabilities as well as rapid and reliable diagnostic
tests for bioagents.
Investigation Deficits
Suspicion that a bioterrorist attack has occurred will provoke
public health officials to begin an immediate investigation.
Epidemiologic investigations are essential to managing outbreaks of
contagious disease. However, the U.S. public health infrastructure is
fragile and in much need of rebuilding as has been previously reported.
State and local health departments often lack sufficient professional
staff, office support and equipment, and the laboratory capacity to
perform the basic public health functions much less respond to a large-
scale incident.
As noted above, the absence of real-time electronic surveillance
systems is a serious problem. These systems could provide information
and analysis of data from key testing and monitoring sources thereby
allowing up-to-date understanding of an incident. Better understanding
will result in more focused and presumably more successful
interventions.
Congress must ensure that the public health system be retooled with
the appropriate capabilities and capacities needed for biowarfare, and
be linked to emergency healthcare systems.
management deficits
Personnel Deficits
The United States must train emergency healthcare personnel to
recognize and treat victims of a biologic attack, as well as to report
incidents. This is vital to our nation's preparedness for a successful
response to a bioagent, medical personnel and medical resources are
paramount. Local civilian medical systems--both out-of-hospital and
hospital--are the critical human infrastructure. These professionals
will be integral in recognizing a bioagent and minimizing the
devastation. As in any emergency, concerned or infected patients may
come to the ``ER'' seeking medical help. Emergency physicians and
nurses and emergency medical technicians will therefore be the ``first
responders.'' Thee first and most critical line of defense for
detection, notification, diagnosis, and treatment of a bioincident.
However, this may be delayed if the treating emergency physicians and
nurses do not have the clinical knowledge and high index of suspicion
to recognize the features of a biologic attack and activate a response.
Emergency physicians and nurses along with other health care
professionals in current preparedness programs. Emergency health care
professionals need to be integrated and educated. These professionals,
in turn must understand the need to become active participants in the
preparedness arena. This specifically includes understanding of local
disaster plans, including incident command systems and hospital
disaster plans.
An overall plan must be implemented for providing, sustaining, and
monitoring appropriate educational experiences for these emergency
health care professionals in the field of biologic warfare. Unless this
training is forthcoming, a critical link in the management of a
bioincident will be missing.
To that end ACEP's Task Force of Health Care and Emergency Services
Professionals on Preparedness for Nuclear, Biological, and Chemical
Incidents assessed the needs, demands, feasibility, and content of
training for emergency physicians, nurses, and paramedics for nuclear/
biological/chemical (NBC) terrorism. The task force recommended that
training programs and materials need to be developed and incorporated
into these professionals' formative education and into their continuing
education. The task force developed the core content essentials for
incorporation into
Educational programs and recommended that each of the three groups
be trained relative to their particular job responsibilities and
anticipated levels of involvement.
It was suggested that a multidisciplinary oversight panel of
content experts, educational specialists, and representatives of major
professional organizations representing each of the three audience
groups implement these educational strategies. The oversight panel
would be tasked with the responsibility for the consistency, quality,
and updating of the products developed. Additionally, the oversight
group would work to establish partnerships with organizations and
institutions to assist with the implementation of the recommendations
discussed in this report. The multi disciplinary oversight group is an
integral part in the development of each recommendation for each of the
target audiences. They also formulate and manage formal plan for
evaluating each educational product. To support the work of the
oversight group, a national clearinghouse or repository should be
established to collect relevant information, including articles, books,
reports, research, instructional materials, and other media.
An important overarching strategy to support the proposed
recommendations is to work with national professional organizations and
associations to increase all health care professionals' understanding
of the necessity of this type of education.
Working through national professional organizations and
associations, Congress must authorize an implement an overall plan for
providing, sustaining, and monitoring appropriate educational
experiences for emergency healthcare professionals in the field of
biologic warfare.
Hospital Deficits
Unfortunately, civilian health care facilities are not, in general,
integrated into a community or regional disaster response system.
Hospitals tend to be autonomous, competitive institutions so most are
not committed to cooperative efforts that would be needed during a
community-wide disaster. Furthermore, hospitals do not possess or
regularly exercise requisite communications networks.
Hospital capacity and capability are very real dilemmas today. Many
American hospitals are financially frail. They have responded to
financial pressures by cutting staff, reducing inventory and
eliminating money-losing operations. ``Just-in-time''' staffing and
supplies flow models now govern the number of personnel working and the
resources available on a given day. These cost-cutting measures have
reduced hospitals' flexibility; they have no surge capacity in the face
of sudden or sustained stress. As a result, it would not take many
casualties presenting for evaluation and specialized treatment to
overwhelm the hospital system of a large American city. Nowhere is this
more evident than in the emergency departments where overcrowding, and
lack of critical resources are the norm.
Staffing issues are also challenging. Although many if not most,
physicians and nurses hold hospital privileges at several facilities so
this will be available to only one institution. Hospital staff
privileges requirements and state licensing restrictions are barriers
to doctors and nurses from outside the community assisting. Further
complicating the local shortage, many health care professionals are
committed to military duty as reservists or have volunteered to serve
on medical assistance teams or at emergency operations centers.
In addition to professional staff, hospital operations depend on a
wide array of skills--the absence of lab technicians, security guards,
food service, or housekeeping personnel would significantly affect the
efficiency and effectiveness of the whole institution. Furthermore, a
significant proportion of a hospital's staff may fail to report to work
in the midst of an epidemic due to fear of a deadly, contagious
bioagent.
Congress must recognize that hospitals and their emergency
departments are critical components of the infrastructure of America's
biodefense system, and must take these steps necessary to fortify their
ability to respond.
Medical Treatment Deficits
For almost all of the bioagents thought to represent a serious
threat, the speed with which appropriate medical treatment is
administered is critical, i.e. early detection. Different bioweapons
agents will require different medical treatment and in some cases there
are scant scientific and clinical data available to support treatment
decisions. The effectiveness of existing antibiotics and vaccines to
prevent or limit the severity of diseases caused by bioweapons
pathogens is quite limited as well. For some bioagents, antibiotic
treatment is effective but in some cases only if given before symptoms
begin or become severe. In other instances, the mainstay of care is
supportive which can be very labor intensive.
Currently, there are no effective vaccines for many important
bioweapons agents. When available, some vaccines have undesirable
features and in other cases, existing vaccine supplies are limited.
Special populations, such as children, pregnant women, and immune-
compromised persons may be a particular risk or have contraindications
for specific therapies. The possibility of bioengineered weapons
resistant to traditional therapies must also be considered.
It is clear that there is major shortfall in the readily available
capacity of drugs and vaccines. It is also clear that there are many
vaccines yet to be developed. This is due to the lack of existing
commercial partners interested in undertaking the production, minimal
excess capacity within the drug and vaccine industry even if there were
interested parties, and the regulatory and technology transfer issues
that need to be overcome in order to rapidly manufacture critical
supplies.
In addition, there is a lack of a coherent acquisition strategy for
national pharmaceutical and vaccine stockpiles. The federal government
has recognized that the availability of necessary vaccines and
antibiotics is a critical component of an effective bioterrorism
response and has taken steps to create a National Pharmaceutical
Stockpile (NPS) of medicines and supplies. However, significant
logistical problems were encountered in the handling and distribution
of the supplies during Operation Topoff that must be remedied.
Congress should direct the centralized federal management and
oversight office to partner with private industry interested in
undertaking the research, development, and production of necessary
pharmaceuticals; maintaining some surge capacity. Congress should also
address the regulatory and technology transfer barriers that impede
rapid development and availability of critical supplies.
conclusions
The United States homeland is vulnerable. We are a free society;
our greatest right is our greatest liability. We are an inherently
trusting and tolerant people so we are not overly suspicious. We are
peace loving; we do not act offensively but only respond when provoked.
Finally and fortunately, we have had essentially no first hand
experience with any form of modern warfare waged in our country until
recently
An attack against the homeland using a biological weapon would
severely test us. Foremost, the ability to mitigate the consequences of
a bioterrorist attack is directly tied to the deficits of the civilian
medical and public health systems. The importance of limiting
casualties and minimizing interference with daily life is obvious. In
addition, failure to deliver adequate medical care or to execute
appropriate public health measures could lead to loss of public
confidence in the government's ability to protect our citizens, raise
the possibility of profound, even violent, civil disorder, and possibly
diminish America's position internationally.
Americans must now commit to not allow such heinous acts to occur
in our country. We must all vow to become involved. Our goal is to
deter or mitigate any terrorist action against our people or our
country. Federal authorities must provide the leadership, the financial
investment and the organizational and logistical support requisite to
develop a comprehensive national strategy, solid domestic preparedness
and appropriate response plans. Health care professionals and state and
community leaders must pledge dedication and involvement. Such
preparation is very costly, financially, and personally. There is never
enough time. But American must remain resolute, for what is the price
of our freedom, of our country's well-being, of our lives.
Mr. Greenwood. Thank you very much for your testimony, Dr.
Waeckerle.
Dr. Brinsfield, you are recognized for 5 minutes.
TESTIMONY OF KATHRYN BRINSFIELD
Ms. Brinsfield. Mr. Chairman, members of the subcommittee.
My name is Kathryn Brinsfield. I am the Director of Research,
Training, and Quality Improvement for Boston Emergency Medical
Services, a practicing Emergency Medicine physician, and the
Deputy Medical Commander of the National Disaster Medical
System's International Medical and Surgical Response Team-East.
As the youngster on this panel, I would like to thank you
for inviting me here to speak me on this topic.
On March 20, 1995, Sarin was released in the Tokyo subway
system. The incident started at 7:55 a.m. And the last patient
was treated before noon.
On September 11, 2001, the terrorist events at the World
Trade Center killed over 6,000. The last live victim was
rescued within 36 hours. All disasters are local. And terrorist
disaster response is a local response.
Federal programs have helped prepare localities for dealing
with these disasters, but there is still more to do. While
Federal response provides important relief in the forms of
specialized experience, credentialed personnel and supplies,
the ability of a locality to rescue, treat, transport and
provide definitive care to its own citizens weighs the balance
between life and death. This holds true for bioterrorism,
although in nontraditional ways.
Treatment and stabilization of a bioterrorist event is
dependent on recognition that an event is under way, and
recognition is dependent on the ability of local responders in
the local public health office.
In Boston, we are lucky to have a strong Public Health
Commission with Cabinet-level input into the operations of the
city. This has allowed our local CDC office to take the lead in
organizing a citywide hospital volume surveillance system which
has, 2 years running, detected the onset of influenza in the
State prior to laboratory isolation.
Our recent exposure to the West Nile virus proved that
incident command training for public health professionals pays
off and that the public health director can act as incident
command with police, fire, EMS and other city agencies
participating in a unified command structure.
In bioterrorism, the ability to respond is dependent on the
education and equipment of the prehospital personnel and
hospital providers.
In Boston, we are also fortunate to have an Emergency
Medical Service with strong city support. This has allowed us
to train all of our EMTs and paramedics in hazardous materials
and bioterrorism. Even though the training materials are
provided free to agencies, training and salary costs are not.
Annual recurring training and fixed costs supported by the city
are close to a half million dollars for a small agency alone.
For every 1,000 people exposed to anthrax, the cost of
treating the victims prior to the arrival of a national
pharmaceutical stockpile is $25,000.
In Boston, we are lucky to have funding through the HHS
Office of Emergency Preparedness MMRS program. We are also
fortunate to have the support of local hospital pharmacies and
pharmacy colleges, who agreed to rotate the stock of
antibiotics and provide pharmacists for us.
We also have a strong Conference of Boston Teaching
Hospitals, which has a long history of working together to
improve the health care in the city. Those relationships proved
invaluable in pulling hospitals and physicians into the
terrorism planning process through Emergency Medical Services
over the last 5 years.
In Boston, we consider ourselves fortunate to have been one
of the initial cities trained under the Domestic Preparedness
program. Although not perfect, the DP program did several
things well. It required all city public safety agencies to sit
at the table and submit a unified training and equipment plan
before training would be scheduled.
Second, it trained the personnel locally, allowing city
workers to brainstorm at the breaks and in the sessions and
meet people that they may be working with in the event of a
disaster.
It provided adequate awareness training.
And it allowed instructors and students to share
information and gain knowledge of other cities' plans.
Unfortunately, the program failed by its stand-alone nature
and its sometimes ``foster child'' status among the various
Federal agencies who have been responsible for its
implementation. New programs need strong, clear Federal
leadership that reflects interagency cooperation at the
national level.
In a bioterrorist incident, the emergency department and
medical clinic providers are truly first responders. In the
initial DP bioterrorism tabletop exercise, cities were
encouraged to do an anthrax hoax letter drill, testing the fire
department HAZMAT response. In Boston, we went against the tide
and held a tabletop with seven hospitals and all public safety
agencies that tested our ability to respond to a pneumonic
plague event.
As the events of September 11 have unfolded, many who were
previously skeptical are now requesting training. Let's not
lose this opportunity. Based on the Boston experience, I
recommend that new programs: Should include a lessons-learned
format; Should include hospitals in addition to city public
health and safety agencies; Standardized funded training and
protective equipment should be provided for hospital-based,
public health, EMS, as well as police and fire personnel.
Money should be tied to a universal citywide approach to
the disaster. This would require several Federal agencies to
either work together or outside their usual funding schemes. I
believe this consolidation on the Federal level is critical to
avoid a splintering of response on the local level.
In closing, I share with the committee that I was proud and
honored to be a member of the Massachusetts 1 Disaster Medical
Assistance Team that responded to the World Trade Center.
Although, as a health care provider, it was frustrating to have
so few live victims to treat, our mission to treat the rescuers
was rewarding and awe-inspiring.
Nonetheless, I will be very happy if I never again find
myself working across the street from 6,000 dead.
It is clear there's only so much the medical response
community can do in an event of this size. My thoughts and
hopes are with the law enforcement agencies that can prevent
these tragedies.
[The prepared statement of Kathryn Brinsfield follows:]
Prepared Statement of Kathryn Brinsfield, Director of Research,
Training, and Quality Improvement, Boston Emergency Medical Services
Mr. Chairman, members of the subcommittee, my name is Kathryn
Brinsfield, MD, MPH. I am the Director of Research, Training, and
Quality Improvement for Boston Emergency Medical Services, a practicing
Emergency Medicine physician, and the Deputy Medical Commander of the
National Disaster Medical System's International Medical and Surgical
Response Team-East. I would like to thank you for inviting me here to
speak on this topic.
On March 20, 1995, Sarin was released in the Tokyo Subway system.
The incident started at 7:55 am; the last patient was treated before
noon.
On September 11, 2001, the terrorist events at the World Trade
Center killed over 6,000 and injured fewer than 2,000. The last live
victim was rescued within thirty-six hours.
All disasters are local.
Terrorist disaster response is a local response.
Federal programs have helped prepare localities for dealing with
these disasters but there is still more to do.
<bullet> Ensure that significant funding goes directly to localities so
we can have the flexibility to plan our response based on our
unique needs
<bullet> Enable local health and public safety agencies to work
together with hospitals to coordinate a response
<bullet> Coordinate among agencies at the federal level to ensure
unified interagency guidance, materials and funding.
<bullet> Follow-up Domestic Preparedness training with concrete
information and lessons learned based planning guides.
From floods to fires to bombings, the initial minutes and hours of
a disaster largely determine the number of victims that will survive.
While federal response provides important relief in the forms of
specialized experience, credentialed personnel and supplies, the
ability of a locality to rescue, treat, transport and provide
definitive care to its own citizens weighs the balance between life and
death.
This holds true for bioterrorism, although in nontraditional ways.
Treatment and stabilization of a terrorist event is dependent on
recognition that an event is underway, and recognition is dependent on
the ability of local responders and the local public health office.
In Boston, we are lucky to have a strong Public Health Commission,
with Cabinet level input into the operations of the city, and strong
funding and support. This has allowed our local CDC office to take the
lead in organizing a citywide hospital volume surveillance system,
which has two years running detected the onset of influenza in the
state prior to laboratory isolation. If this type of system can detect
influenza, it should be able to detect the flu like illness that may be
a harbinger of bioterrorism. In addition, we have been able to develop
a consortium of Boston hospital based infectious disease and emergency
medicine providers, poison control center representative, and zoo
veterinarian, who meet quarterly, and have the ability to share
information and alerts over the Internet. Our recent exposure to the
West Nile Virus proved that Incident Command training for public health
professionals pays off, and that the Public Health Director can act as
Incident Command with Police, Fire and other city agencies
participating in a Unified Command Structure.
Many localities are not so lucky, and rely on antiquated
information systems, scarce personnel, and minimal recognition from the
public safety agencies.
In bioterrorism, the ability to respond is dependent on the
education and equipment of the prehospital personnel and hospital
providers.
In Boston, we are also fortunate to have an emergency medical
service with strong city support. This has allowed us to train all of
our Emergency Medical Technicians and Paramedics to the hazardous
materials operations level and domestic preparedness EMS-technician
level. Even though the training materials, and sometimes the training,
are provided free to agencies, training costs are not. We are also
fortunate to have respiratory protective equipment provided. Annually
recurring training and fit testing costs supported by the city are
close to a half million dollars a year for our small agency alone. In
an anthrax exposure for 1000 people, assuming the National
Pharmaceutical Stockpile arrives and can be unloaded in seventy-two
hours, the cost of antibiotics that must be on hand in a city to
immediately treat exposed victims is 25,000 dollars. In Boston, we are
lucky to have funding through the HHS Office of Emergency Preparedness
MMRS program. We are also fortunate to have the support of the local
hospital pharmacies, who have agreed to rotate this stock of
antibiotics for us, so that they do not out-date, wasting our
investment if no event happened in two years time. However, training
and fit testing costs are renewable and supported by federal funding;
while these costs may be small compared to a federal budget, they are
large costs for local agencies.
We are also fortunate to have a strong Conference of Boston
Teaching Hospitals, which has a long history of working together to
improve health care in the city. This organization supports a hospital
disaster committee and hospital EMS committee. These relationships
proved invaluable over the last five years, in pulling hospitals and
physicians into the terrorism planning process through EMS. In
addition, we applaud the local hospital CEO's, who have been long
sighted enough to recognize the importance of this issue, and provided
funds for the construction of decontamination areas and staff training
in the emergency departments.
Many private and hospital based EMS agencies do not have the
funding or support to receive the necessary training or equipment, or
to stockpile the necessary antibiotics. Many hospitals do not work in
this type of collaborative environment, and are not able to participate
in citywide planning. Few physicians receive any training in
bioterrorism. Emergency Department and hospital overcrowding is a very
real issue that will only be exacerbated in an event of any magnitude.
Future preparedness funding should take these things into account.
In Boston, we consider ourselves fortunate to have been one of the
initial cities trained under the Domestic Preparedness program.
Although not perfect, the DP program did several things well.
First, it required all city public safety agencies to sit at the
table, and submit a unified training and equipment plan before the
training would be scheduled. Second, it trained the personnel locally,
allowing city workers to brainstorm at the breaks and in the sessions,
and meet people they may be working with in the event of a disaster.
Third, it provided an adequate awareness training of terrorism.
Finally, it allowed instructors and students to share information, and
gain knowledge of many other cities' plans.
Unfortunately, the program failed by its stand-alone nature, and
its sometimes ``foster child'' status among the various federal
agencies who, at one time or another, have been responsible for its
implementation. New programs need strong, clear federal leadership that
reflects interagency cooperation at the national level.
Domestic Preparedness was an awareness level program, and should
have been followed by more concrete information and coordinated
planning guides. Every locality is different, but every locality can
learn some lesson from each other. Planning guides were produced
separately by various agencies, and no other effort took into account
the need for fire, police, and emergency medical personnel to
collaborate on a single city plan.
At the time the program was started, the importance of
bioterrorism, and the delayed manner in which it would appear was not
appreciated. We now realize that in a bioterrorist incident, the
Emergency Department and Medical Clinic providers are truly the first
responders. In the initial DP bioterrorism tabletop exercise, cities
were encouraged to do an anthrax hoax letter drill, testing the fire
department HAZMAT response, but ignoring the hospitals and public
health system. In March of 1999 in Boston, we went against the tide and
held a tabletop with seven hospitals, all public safety agencies, and
several state and federal agencies participating that tested our
ability to respond to a Pneumonic Plague event.
As the events of September 11th have unfolded, many who were
previously skeptical are now requesting training. Let's not lose this
opportunity. Based on the Boston experience, I recommend that
<bullet> New programs should include a lessons learned format, with
concrete references and examples to help localities plan.
<bullet> New programs should be planned to include hospitals in
addition to city public health and safety agencies
<bullet> Standardized, funded training and protective equipment should
be provided for hospital based, public health, EMS, police and
fire personnel.
<bullet> Monies should be tied to a universal, citywide approach to the
disaster. This would require several federal agencies to either
work together or outside their usual funding schemes. I believe
this consolidation on the federal level is critical to avoid a
splintering of response on the local level.
In closing, I share with the committee that I was proud and honored
to be a member of the Massachusetts 1 Disaster Medical Assistance Team
that responded to the World Trade Center. Although as a health care
provider it was frustrating to have so few live victims to treat, our
mission to treat the rescuers was rewarding and awe-inspiring.
Nonetheless, I will be very happy if I never again find myself
working across the street from 6000 dead. It is clear there is only so
much the medical response community can do in an event of this size. My
thoughts and hopes are with the law enforcement agencies that can
prevent these tragedies
Thank you.
Mr. Greenwood. Thank you very much, Dr. Brinsfield.
Dr. Stringer, you're recognized for 5 minutes for your
statement.
TESTIMONY OF LLEWELLYN W. STRINGER, JR.
Mr. Stringer. Good morning, Mr. Chairman, members of the
committee. Thank you for allowing me to be here today.
I have long experience in emergency management as a local
EMS Medical Director, commanding officer of the disaster
medical team in North Carolina. I am the Medical Director of
the North Carolina Division of Emergency Management, and for
the last 10 years I've served as the Medical Director for ESF-8
or the U.S. Public Health Service's response to many natural
and now man-made disasters.
Back in 1995 when the initiatives on weapons of mass
destruction was started, I was one of about 16 people that Dr.
Frank Young brought to the Office of Emergency Preparedness to
look at what was it from the health side that Federal ought to
do. Two things we came up with.
No. 1, as you've heard before, it's local. So we felt that
we needed to coordinate, train and equip a unified local
medical response team which is now known as the Metropolitan
Medical Response System.
The second thing was to form some federally sponsored
medical teams known as the National Medical Response Team for
weapons of mass destruction. They would be highly trained,
highly equipped, fast to go and assist the local community in
such an event.
All of these have gotten started. 120 cities, as you know,
have been picked for Nunn-Lugar-Domenici training courses. Of
those, as of December 2000, 68 cities have been completed, and
37 more have been started. After the Nunn-Lugar-Domenici
training, then the Office of Emergency Preparedness for the
U.S. Public Health Service gives an award or a contract of
approximately $600,000 to each city to finish their training.
Remember, the first one was trained to train only, to
finish that training, to develop a team, to have a unified
training program, a plan that included even the health
departments and the hospitals and to purchase the equipment. As
of September 1, 2001, 97 cities have been partly--correction--
97 cities have received or are in the process of receiving
these grants. Of those 97, 49 are considered to be partially or
fully functional.
Disturbing thing to me is, of those 49, not but 26 have
purchased their medications. In my opinion, it's going to be
another 5 or 6 years before all 120 cities truly are
functional, ready to roll.
But what about the other communities in this country that
are not funded, that are not trained? The Office of Justice
program has instituted 1999, 2000, 2001 monies to help the
States and the communities that weren't included in this, try
to get their training and equipment. The assessment part was
extremely confusing that they required us to fill out. Only
four States have turned in their assessments and three are
planned. North Carolina, we've been working on this for a year
and a half, and it's going to be the end of this year before we
can even turn our paperwork in. It's too restrictive.
When questions are asked of OJP, you get many different
answers. There was not enough funding to the States to assist
the locals with trying to efficiently develop their needs
assessment and what their problems were and where we needed to
go. You don't get your 2000 and 2001 monies till the assessment
and 3-year plan is turned in. Many areas in my State won't get
any money, and the cities that we determine that are high risk
are not going to get what they need.
We need more money. We need to get the 2000 and 2001 funds
turned loose to the State now. We need to let the States decide
what's needed and where and not tie our hands with so many
restrictions. I think States know how to best help their
communities.
As far as the health and the health initiatives, you've
heard today the first responders are cops, firemen, HAZMAT and
EMS. They're also docs and nurses. We've got to include the
hospitals and the health care system in this training, in the
equipping and in the planning for not just bioterrorism but for
just handling a pandemic. It's got to happen.
There's not much in the way of Federal initiatives for the
health care community; and the health care community, as you've
heard, on a day-to-day basis functions in the crisis mode. As
the Medical Director of North Carolina State Emergency
Management, I can tell you now they have decided that they need
not to consider this a ``hope-not'' plan, but they need to get
some help. They are very concerned, as everyone in this country
is.
CDC has developed an excellent program on bioterrorism.
It's a template that the hospitals can start with and work
with.
Also, the Office of Emergency Preparedness has a health
care WMD training program at the Noble Training Center at Fort
McCullen, which is just getting off the ground; and I think
it's going to go a good job with that. It needs some more
support. It's going to be like Emmitsburg for FEMA.
The four national medical response teams, which are the
only assets that are available within the Federal Government's
Office of Emergency Preparedness to go and assist communities
in time of an NBC event, are inadequately funded. They're
highly trained professional medical personnel who do around 100
extra hours of training in addition to their requirements for
their job a year at no payment at all. We have consistently
asked for more funding for maintenance and readiness of the
four response teams to go help the local community, but there's
been very little increased support for us.
Since there are just four teams in the Nation like this, I
think it would be rather cheap insurance to improve the funding
so that we can at least name four entities that can get off the
ground or go by ground in less than 4 hours response, any time,
day or night, to help a community.
I've heard 7,000 quoted medical professionals that NDMS has
that could go help people. They need job protection, sir. Right
now, they have none. They need to know that they can leave when
they are activated to go help, and they need to know that I
have got a job when they get home, which does not happen at
present. Please pass House bill 2233 to give these people some
job protection.
After reading about, hearing about all the money that
Congress has been appropriating these activities, in my job as
both the local, State and Federal responder, I just don't
understand where all the money has gone.
Thank you for allowing me to be here.
[The prepared statement of Llewellyn W. Stringer, Jr.
follows:]
Prepared Statement of Llewellyn W. Stringer, Jr. Medical Director,
North Carolina Division of Emergency Management
Mr. Chairman and Members of the Committee, thank you for inviting
me here today to discuss the issue of Weapons of Mass Destruction
Preparedness. I am Dr. Lew Stringer, Medical Director of the North
Carolina Division of Emergency Management. I have a long history of
emergency management experience that ranges from services as a local
EMS Medical Director for 27 years, Director of the Special Operations
Response Team a disaster organization in North Carolina and involvement
with the National Disaster Medical System through the Office of
Emergency Preparedness, USPHS since 1990.
In 1995, because of concerns regarding Weapons of Mass Destruction
(WMD) in the US, I was one on sixteen people asked by the Office of
Emergency Preparedness, USPHS, to advise and develop strategies to deal
with the consequence management of a WMD event. PDD 39 and the Nunn-
Lugar-Demenici initiative were enacted during this time. Our group
concluded that from the consequence management side, a WMD event was
primarily a local issue. Local agencies needed to be trained, organized
in a uniform manner and equipped to deal with the initial response in
order to save lives. Mutual aid agreements needed to be in place with
surrounding communities and state agencies should be immediately
involved. The state agencies should respond to assist the ``locals'' in
dealing with this complex and unusual emergency event that would
rapidly overwhelm most local communities. Our group concluded that law
enforcement, fire, HAZMAT, EMS, hospitals, Public Health, and local
emergency management had to be brought together to assess additional
training, organizational and equipment needs. These agencies needed to
develop a plan. And, they needed assistance from the federal
government.
Our committee named this new local entity the Metropolitan Medical
Response Team, MMRT. In 1997, the first MMRT was formed in Washington,
D.C. From that team concept, came the resource material to be used by
OEP/USPHS for the other cities in the system. 120 of the largest cities
in the US were selected to receive the Nunn-Lugar-Demenici training
grants administer by DoD and then to receive the grants administered by
the OEP/USPHS to organize and equip these MMST's. They are now known as
Metropolitan Medical Response Systems, MMRS. It was our recommendation
that several regional specialized medical response teams be formed and
equipped by the National Disaster Medical System, OEP/USPHS to respond
rapidly to assist communities affected by the WMD event. These teams
were founded as Nation Medical Response Team, NMRT/WMD. I developed the
first SOP for the NMRT's early in 1996. There are four teams. I am the
commander of the NMRT/WMD East, in Winston-Salem, N.C.
As of December 21, 2000, of the 120 designated MMRS cities/
metropolitan areas, DoD had completed the training for 68 cities and
had begun the training of 37 additional cities before the program was
turned over to the Office of Justice Program (OJP) to administer. After
a city completed the NLD Domestic Preparedness Program ``Train the
Trainer'', OEP/USPHS contracts with the city's metropolitan area,
providing a $ 600,000 grant for the development of plans, additional
training, and equipment purchases to give the metropolitan area a
unified multi-discipline team capable of responding to a terrorist
event. According to OEP/USPHS, as of September 2001, 97 cities have
received or in the process of receiving funding from OEP. OEP states
that 49 cities are fully or partially functional. Only 26 cities have
purchased the pharmaceuticals necessary to treat the victims. It is my
opinion, looking at information I have received from several federal
agencies, that it will be 5-6 years before all 120 cities are fully
functional.
In 1999, OJP initiated a nationwide assessment of vulnerability,
threat, risk, capabilities, and needs. Each state with their local
jurisdictions was to complete this assessment and develop a long-range
plan that was to include federal funding for the purchase of needed
equipment. I have been told, that by September 2001, only four (4)
states (give names) have turned in their completed assessment making
them eligible for the 2000-2001 monies. Funding is not released until
the completed assessment along with a three-year strategic plan is
returned to OJP.
It has taken my state of North Carolina 1 + years to complete the
assessment and the 3-year plan. I have found the assessment to be
complex and difficult to complete. NC does not have the resources to
collect the data in a timely fashion. Local jurisdictions needed help
in amassing the information. There is much diversity within the state,
large cities and small rural counties made completing complicated.
The plan for North Carolina includes:
1) Equipping our 6 regional HAZMAT response teams, our highway patrol,
and our state disaster team
2) Assisting financially our largest cities or highest risk cities
(metropolitan area affecting 20 counties). Of our 100 counties,
80 counties will receive no financial assistance. Charlotte,
NC, the second largest banking center in the US, will not
receive funding through our plan, because they received
separate financing from Congress.
In an explosive, chemical or nuclear event, victims are
concentrated in that area. First responders will rescue, decontaminate,
treat, and transport victims to health care facilities. With a
biological event, victims will not likely be concentrated in any one
area. Victims will receive most of their treatment at health care
facilities. In this biological scenario, health care workers will be
the first responders.
Until the horrendous events at the World Trade Center and the
Pentagon and in the past history of disasters, victims have self-
triaged to health care facilities bypassing the EMS system. In our
present structure, ONLY law enforcement, fire, HAZMAT and EMS are
considered First Responders by the federal government and eligible for
funding in WMD Preparedness. This shortfall was pointed out to Congress
in the 2000 Gilmore Report. The Noble Training Center, OEP/USPHS at
Fort McCullen in Alabama is the only federally funded WMD training
support for health care workers that I know in existence today.
CDC has an excellent program, well received by the states, to
assist states and local communities with a WMD event:
1) The National Pharmaceutical Stockpile, NPS, delivered on site in 6-
12 hours.
2) State grants to improve and upgrade laboratories and improve
reporting of disease patterns. These grants assist state and
local public health services to upgrade labs for agent
identification, develop Bio-terrorist planning, implementation
of the electronic surveillance programs of the Health Alert
Network, and collect epidemiological information.
The health care community has been a difficult player to bring to
the WMD planning table. Sadly, the health care systems operate in a
``crisis mode'' of staffing and financial problems on a daily basis.
Several health care facility managers in my state of North Carolina
have told me, ``I have no time or finances for a hope not activity''.
This attitude must change. (We) in emergency management must help the
health care system with planning, training and equipment to enable
these dedicated individuals, be prepared to safely receive and
effectively treat WMD victims.
I look at the support provided by the OEP's National Disaster
Medical System for the four National Medical Response Teams for WMD.
The 4 teams, staffed by volunteers who have to train without pay,
receive limited funds for additional equip purchases and maintence.
This funding is not enough to maintain the NMRT's proper readiness
state to respond to assist state or local communities. It would be
proper, in my opinion, to increase the funding for the NMRT program.
I believe that the health care system must be funded and supported
to become an active player in order to resolve the consequences of a
WMD event. I am concerned that many cities will not be able to
effectively manage the consequences of a WMD event for the next 4-5
years. I have pointed out to you that in my state of North Carolina,
like many other states, little or no training or equipment is in place
to respond to a WMD event if it occurred today.
As a state and a local emergency management official, I understand
that it will be the state and local governments that will respond and
manage the consequences of such an event for many hours and even after
the federal assets arrive.
I have read about all of the money appropriated by Congress to the
many federal agencies for WMD Preparedness. Frankly, I wonder and do
not understand where all that money has gone?
Mr. Greenwood. Well, thank you, Dr. Stringer. We thank
Congressman Burr for bringing you and your expertise to the
attention of the committee and assure you that a large part of
our effort here is to find out exactly where all the money is
going and how well it's being spent.
Mr. Peterson you're now recognized for 5 minutes for your
statement as well. Thank you.
TESTIMONY OF RONALD R. PETERSON
Mr. Peterson. Mr. Chairman, good morning. Thank you.
I am Ron Peterson, President of The Johns Hopkins Hospital
and Health System in Baltimore. I'm here today on behalf of the
5,000 hospitals, health systems, networks and other health care
provider members of the AHA. We appreciate the opportunity to
present our views on an issue of great concern to hospitals and
communities across America, namely the readiness for a
potential terrorist attack utilizing chemical or biological
weapons.
On September 11, hospitals in New York, New Jersey,
Connecticut, Virginia, Washington, DC, Maryland and
Pennsylvania all relied on their training and experience.
Shortly after the crash at the Pentagon, Secretary Tommy
Thompson called to tell us that we might receive casualties at
The Johns Hopkins Hospital. We immediately activated our
disaster control centers at our three hospitals, ceased
elective surgeries at all three hospitals and began to identify
candidates for early discharge to increase capacity.
Our Baltimore Regional Burn Center was placed in a high
state of readiness. That afternoon we sent burn supplies to the
Washington Hospital Center and to Walter Reed Hospital.
Some of our emergency physicians with Oklahoma City
experience were called on by FEMA to assist at the Pentagon,
and we sent teams to augment the Red Cross blood drive across
from the White House.
Our health care workers, like others, grieved when they
could not do more, but our emergency plans were in place and
worked effectively. We were ready.
But now we must plan for the extraordinary. To help
America's hospitals with this planning, the AHA has created a
disaster readiness site on its Web page engaged in frequent
communication about biological and chemical preparedness and
sent two advisories on hospital readiness. Our recommendations
have included the following:
First, hospitals must be more highly integrated in the
local public safety infrastructure with police, fire, EMS and
public health.
Hospitals need to increase inventories of drugs and
antibiotics to combat the effects of chemical and biological
weapons.
Hospitals need to increase the supplies of ventilators and
respirators, gloves, gowns and masks, the basic ingredients
needed to treat victims of a mass disaster, as well to protect
health care workers.
Hospitals need to establish better communications with
public safety entities to coordinate care.
Hospitals must improve surveillance and detection to watch
for potential biological outbreaks.
Hospitals also need backup water supplies, auxiliary power,
sources and increased fuel storage.
We need our hospitals to be secure and safe and be able to
lock down if necessary.
Hospitals need to enhance their current decontamination
capability, and hospitals may need to filter and otherwise
modify the air circulation systems of buildings that are
designated to receive patients that might be infected with
contagions so that infections are not spread through the air.
The Federal Government can provide financial assistance to
help ensure that hospitals and local agencies are able to
respond to potential attacks. These funds would help meet the
challenges outlined above, including inventories of drugs and
equipment.
Now, at The Johns Hopkins Hospital and Health System, we
are aggressively pursuing the recommendations that I've just
addressed. The Johns Hopkins Hospital alone will need to spend
at least $7 million to prepare for these kinds of attacks. As
an example of the expense that we will incur, we plan to
purchase 1,000 powered air purifying respiratory masks at a
unit cost of $300 dollars, a total of $300,000. That figure
will get those masks to just one-seventh of our total employee
population, those who are most likely to come in contact with
infected patient. We will add 50 ventilators to our ventilator
fleet, for a total price tag of $1.5 million. We will stock 4
days worth of vital antibiotics and other medication antidotes
to treat 100 victims at a cost of about $600,000. These are but
three practical examples that buildup cumulatively to the
number, the $7 million figure that I suggested. These are three
of about a dozen major categories.
In order to meet the challenges I've outlined, hospitals
also need staff support. You should be aware that right now
American hospitals are facing a severe workforce shortage,
particularly for skilled help. For example, hospitals
nationwide have 126,000 vacancies for registered nurses. This
shortage cuts right to the heart of communities across America
and our ability to be ready for any need.
Legislation has been introduced to address the workforce
shortage, and we urge its passage.
You have our commitment, Mr. Chairman, to work with you to
address the many challenges hospitals will face as they prepare
for what was once the unthinkable. Our Nation's nurses, doctors
and other health care workers are caring, committed,
compassionate people who are devoted to their communities. They
answered the call on September 11, and they stand ready to do
so again.
Thank you, sir.
[The prepared statement of Ronald R. Peterson follows:]
Prepared Statement of Ron Peterson, President, The Johns Hopkins
Hospital and Health System, on Behalf of the American Hospital
Association
Mr. Chairman, I am Ron Peterson, President of The Johns Hopkins
Hospital and Health System in Baltimore, Maryland. I am here today
representing the American Hospital Association (AHA) and it's nearly
5,000 hospitals, health systems, networks, and other providers of care.
We appreciate this opportunity to present our views on an issue that is
dramatically affecting hospitals and communities across America:
readiness for a potential terrorist attack utilizing chemical,
biological or radiological (CBR) weapons.
September 11 introduced a new consciousness to the collective
American mind. We find ourselves faced with the task of preparing for
new threats that once seemed unimaginable. Among those threats is the
potential use of CBR against our citizens.
hospital disaster plans
To answer these and other threats, hospitals nationwide, like those
that directly responded to the September 11 tragedies, have disaster
plans in place that have been carefully developed and tested. The plans
are multi-purpose and flexible in nature because the number of
potential disaster scenarios is large. As a result, hospitals maintain
an ``all-hazards'' plan that provides the framework for managing the
consequences of a range of events. Hospitals conduct at least two
drills a year: one may be focused on an internal event, such as a
complete power failure. Another must be focused on an external event,
such as a major highway crash, a hurricane or an earthquake. A hospital
near an airport, for example, might focus on responding to an airplane
crash, while a hospital near a nuclear plant or an oil refinery would
focus on responding to the consequences of incidents at those sites. It
is important to remember that all incidents are local, and that local
agencies and organizations must work together so that response
mechanisms are tailored to the needs of their community.
A good example of how hospitals worked with their communities to
prepare for a wide range of possibilities was the change of the
calendar to the year 2000. Throughout 1999, hospitals across the nation
engaged in a major preparedness effort: Y2K readiness. While Y2K was
easier to address than mass casualty readiness, because it had a known
time . . . midnight of December 31 . . . and place . . . the hospital .
. . the consequences were unknown. Hospitals were ready.
Mass casualty preparedness is similar, because the possibilities
are many. But it is also different because of its uncertainty. No one
can accurately predict when an incident will occur, where it will
occur, or what will be its cause and consequences. That is why the all-
hazards plan, tailored to suit the needs of each individual hospital
and its community, has provided an excellent framework for doctors and
nurses forced into action by a wide range of events. Nowhere was this
better reinforced than on September 11.
september 11: hospital reaction
When hospitals in New York received the call to expect thousands of
injured patients, triage teams were immediately set up, rehabilitation
centers were transformed into auxiliary emergency rooms, and hundreds
of off-duty nurses and doctors swarmed the hospital to offer
assistance. Hospitals in New Jersey and Connecticut were also at the
ready. In Washington, readiness paid off as regional hospitals in
Virginia, the District of Columbia and Maryland launched into their
disaster modes. And in Pennsylvania, facilities in the southwest part
of the state were ready to provide care for victims of the airplane
crash there. When the emergency plan went into effect, everyone was in
their place, doing their jobs. Nurses, doctors, and others, working
side by side, communicating effectively, relying on teamwork and
training to assist the incoming wounded.
Different cities, different hospitals, hundreds of miles away from
each other, each responding efficiently to a direct hit of terrorism.
Each reacted in a positive, planned manner that not only saved lives,
but also proved that America's health care heroes are dedicated, caring
professionals who are ready for the worst of circumstances. The health
care professionals and volunteers at all the sites were prepared to
treat far more patients than actually came to them. Death tolls were
simply too high, and health care workers grieved that they couldn't do
more.
learning tools
It is important to realize each incident is used to improve our
preparedness. Disaster managers use the term ``after action analysis''
to describe the types of activities that are conducted to study what
happened, what worked and what did not. The AHA and its state, regional
and metropolitan associations work with our member hospitals to share
throughout the field critical information that can be derived from
responses to events. The following are important facts that we already
know:
<bullet> By definition, a mass casualty incident would overwhelm the
resources of most individual hospitals. Equally important, a
mass casualty incident is likely to impose a sustained demand
for health care services rather than the short, intense peak
customary with many smaller scale disasters. This adds a new
dimension and many new issues to readiness planning for
hospitals.
<bullet> Hospitals, because of their emergency services and 24-hour a
day operation, will be seen by the public as a vital resource
for diagnosis, treatment, and follow up for both physical and
psychological care.
<bullet> To increase readiness for mass casualties, hospitals have to
expand their focus to include planning within the institution,
planning with other hospitals and providers, and planning with
other community agencies.
<bullet> Traditional planning has not included the scenario in which
the hospital may be the victim of a disaster and may not be
able to continue to provide care. Hospital planners should
consider the possibility that a hospital might need to
evacuate, quarantine or divert incoming patients.
<bullet> Readiness could benefit from exploring the concept of
``reserve staff' that identifies physicians, nurses and
hospital workers who are retired, have changed careers to work
outside of health care, or now work in areas other than direct
patient care (e.g., risk management, utilization review). The
development of a list of candidates for a community-wide
``reserve staff'' will require that we regularly train and
update the reserves so that they can immediately step into
various roles in the hospital, thereby allowing regular
hospital staff to focus on taking care of incident casualties.
<bullet> Hospital readiness can be increased if state licensure bodies,
working through the Federation of State Medical Boards, develop
procedures allowing physicians licensed in one jurisdiction to
practice in another under defined emergency conditions. Nursing
licensure bodies could increase preparedness by adopting
similar procedures or by adopting the ``Nursing Compact''
presently being implemented by several states.
bioterrorism
The threat of chemical, biological and radiological agents has
become a focus of counterterrorism efforts because these weapons have a
number of characteristics that make them attractive to terrorists.
Specifically, biological agents pose perhaps the greatest threat.
Dispersed via the air handling system of a large public building, for
example, a very small quantity may produce as many casualties as a
large truckful of conventional explosives, making acquisition, storage
and transport of a powerful weapon much more feasible. Some CBR agents
may be delivered as ``invisible killers,'' colorless, odorless and
tasteless aerosols or gases.
The distinguishing feature of some biological agents--such as
plague or smallpox--is their ability to spread. The victim may even
become a source of infection to additional victims. The effects of
viruses, bacteria and fungi may not become apparent until days or weeks
after initial exposure, so there will be no concentration of victims in
time and locale to help medical personnel arrive at a diagnosis.
Exposure to biological agents may cause a variety of symptoms,
including high fever, skin blisters, muscle paralysis, severe
pneumonia, or death, if untreated.
hospital readiness
Because September 11 redefined the meaning of disaster, hospitals
are now upgrading their existing readiness plans to meet the new needs
of their communities. Since the risk of chemical and biological attacks
is now an obvious concern, hospitals are reassessing their current
plans. The AHA so far has sent two Disaster Readiness Advisories to all
of America's hospitals with information and resources to help them in
this effort.
The following are among the key items that we believe need to be
addressed to help hospitals as they update their disaster plans to meet
the challenges of a threat that, until recently, seemed hypothetical:
an attack using chemical, biological or radiological agents.
Medical and pharmaceutical supplies--Hospitals must be properly
stocked with antibiotics, antitoxins, antidotes, ventilators,
respirators, and other supplies and equipment needed to treat patients
in a mass casualty event.
Communication and notification--There is a need for greater
coordination of public safety and hospital communications, the ability
of different entities to communicate with each other on demand. In
addition, alternative and redundant systems will be required in case
existing systems fail in an emergency.
Surveillance and detection--Improving hospital laboratory
surveillance and the epidemiology infrastructure will be critical to
determining whether a cluster of disease is related to the release of a
biological or chemical agent. The ability to rapidly identify the agent
involved is vital.
Personal protection--Hospital supplies of gloves, gowns, masks,
etc. would quickly be used up during an attack, and equipment like
canister masks is rarely kept in adequate numbers to meet demands of a
large casualty attack.
Hospital facility--Among the capabilities hospitals will need in
the event of an attack: lockdown ability; auxiliary power; extra
security; increased fuel storage capacity; and large volume water
purification equipment.
Dedicated decontamination facilities--Hospitals need a minimal
capability for small events and the ability to ramp-up quickly for a
larger event.
Training and drills--Staff training is needed at all levels for all
types of potential disasters. Additional disaster drills beyond the two
per year required by JCAHO, particularly community-wide drills, would
enhance the level of hospital readiness.
Mental health resources--Mass casualty events trigger escalated
emotional responses. Hospitals must be ready to treat not only patients
exhibiting these symptoms, but others, such as family members,
emergency personnel and staff.
communication/transportation issues
To truly solidify response readiness, the federal government should
help establish an emergency communication and transportation strategy.
During the recent attacks, street closings and clogged roads impeded
EMS workers as they tried to reach the affected areas, and hindered
quick access to hospitals. No-fly zones were implemented to prevent
other air attacks, but those zones hindered med-evac helicopters and
other air transports that shipped blood and bandages to hospitals in
dire need. Hospitals need assistance from Federal Aviation
Administration officials to keep the skies open to critical medical
aircraft.
In addition, any biochemical attack will require the coordination
of local, state and federal agencies. In response, the Centers for
Disease Control and Prevention have invested in and upgraded state-of-
the-art labs to identify and monitor reports of suspicious cases of
illness across the country. Working in conjunction with state and local
epidemiologists, they will communicate their findings to government
agencies.
readiness resources
Realistically, America can never afford to prepare every hospital
in the country for every possibility of attack. However, the federal
government can provide assistance to help ensure that hospitals and
their local agencies are best able to respond to potential attacks.
These funds would be earmarked to meet the challenges outlined above,
including inventories of the necessary drugs and equipment needed to
help victims of terrorist attacks. Communities need the funding to
assist their hospitals and expand their emergency relief teams, as well
as to establish or implement new systems of readiness.
hospital challenges
There is no more important strategy in this domestic war on
terrorism than to help our hospitals reach a state of readiness. But if
America's hospitals are to enhance their readiness for a new world of
possibilities, they must have in place the people they need to do the
job. However, America's hospitals are experiencing a workforce shortage
that will worsen as ``baby boomers' retire. Currently, our health
systems have 126,000 open positions for registered nurses, for example.
The United States Department of Health and Human Services predicts a
nationwide shortage of 400,000 nurses by 2020. There also are shortages
of other key personnel, such as pharmacists. This shortage cuts to the
core of America's health care system, because dedicated, caring people
are the heart of health care.
Fortunately, Congress has recognized the importance of this issue.
Legislation has been introduced that can help hospitals attract and
maintain the health care workforce that is needed to ensure that our
patients receive the right care, at the right time, in the right place.
For example, the Nurse Reinvestment Act (S.706/H.R. 1436) offers the
right step to ensure health care professionals avert the collision
course we face with lack of hospital staff.
conclusion
The United States has been thrust into a new era. Our hospitals
have always been ready for the foreseeable. Now we must plan for the
previously inconceivable. Hospitals are upgrading existing disaster
plans, and continue to tailor their disaster plans to suit the
individual needs of the community in the face of new threats.
America can be comforted that, as we have witnessed over the last
few weeks of our national tragedy, highly trained, caring doctors,
nurses and other professionals are the heart of our health care system.
They perform heroic, lifesaving acts every day. And, in the face of the
unexpected, they can be depended on to rise to the needs of their
communities.
The AHA has worked closely with the administration on this
important issue, especially with Sec. Thompson. We look forward to
working with Congress as we help ensure that the people we serve get
the care they need in any and all circumstances.
Mr. Greenwood. Thank you very much for your remarks.
Dr. O'Leary you're recognized for 5 minutes for your
opening statement, please.
TESTIMONY OF DENNIS O'LEARY
Mr. O'Leary. Thank you, Mr. Chairman.
I'm Dennis O'Leary, President of the Joint Commission on
Accreditation of Healthcare Organizations. We appreciate the
opportunity to testify on the ability of this country's
infrastructure to deal with acts of bioterrorism.
The medical and public health systems deserve particularly
close examination. Their effective integration would not only
enhance our terrorism response capacity, it would also expand
our ability to deal with a broad range of public health threats
such as emergent infectious diseases and epidemics. It is my
intent to make a case for the development of integrated
community approaches to preparedness that flow from Federal
leadership.
The Joint Commission has long accredited most of this
country's hospitals. We also evaluate and oversee home care
agencies, ambulatory care centers, behavorial health programs,
nursing homes, clinical laboratories, and managed care plans,
among other health care delivery entities.
The scope of our involvement in the health care delivery
system places us in a unique position to both set expectations
for readiness across the entire spectrum of provider services
and to measure adherence to these expectations. For many
decades, the Joint Commission has required that accredited
health care organizations meet established disaster
preparedness standards, but several years ago we decided to
develop new standards that would expand the ability of
individual health care organizations to deal with rare events
through broad engagement with their community.
First, we have shifted the focus of the standards from
simple emergency preparedness to emergency management. Now
health care organizations are expected to address four specific
phases of disaster planning: mitigation, preparedness, response
and recovery. This means planning as to how an organization
would lessen the impact on its services following an emergency,
how organization operations might need to be altered in the
heat of the crisis and how to return the organization to normal
functioning once a crisis has passed.
Second, the new standards require accredited organizations
to take an all-hazards approach to planning. Organizations must
develop a chain of command approach that is common to all
hazards which are credible threats in their community. This
planning starts with a vulnerability analysis against an
unconstrained list of extreme events, including terrorism, and
then critically appraises their probability of occurrence,
their risk to the organization and the community and the
capacity for responding to each potential threat.
The last new requirement is the expectation that each
health care organization annually participate in at least one
community-wide practice drill relevant to its vulnerability
analysis. Large-scale drills can be extremely instructive in
plotting out the typical effects of bioterrorism over a period
of weeks and in identifying unanticipated planning gaps.
Because these drills are time-consuming and expensive to
conduct, government financial incentives should be used to
leverage ongoing engagement in such activities.
We as a Nation are not unprepared to deal with
bioterrorism, but our Nation's public health and medical
systems could be better prepared than they are today. To that
end I would like to offer a series of recommendations for
upgrading our system capabilities.
First, more medical care workers must be trained to become
familiar with pathogens that may be used in bioterrorism, aware
of the symptoms they produce, knowledgeable about their route
of transmission and alert to the possibility of their use.
The reality is that most practicing physicians would not
recognize a case of anthrax, tularemia or smallpox, nor would
they know what kinds of specimens to collect for testing, how
to handle such specimens or which clinical laboratories possess
the expertise to detect the rare agents that could be used as
terrorist weapons.
Second, it is essential that a single integrated system of
response be created that will be effective in addressing a full
range of diseases and rare events, whether of terrorists or
natural origins. This system should be a blueprint for action
that is also scalable to the extent of the emergency and to the
settings that are involved. The framework should be community-
wide and utilize common concepts so that it is transportable.
Third, a public health surveillance system should be
established that can promptly detect naturally occurring
epidemics as well as terrorist activity. The rapidity with
which a rare disease or terrorist weapon is recognized at the
provider level and communicated to the public health experts
will largely determine the extent of its spread and the overall
mortality rate. A surveillance system should be designed for
the routine collection of automated data and presenting
symptoms and laboratory findings that points of delivery system
entry. Monitoring the data would provide an early warning
system for potentially disastrous trends that might otherwise
go undetected.
Finally, it is essential that the national funding policies
which have progressively reduced the elasticity of the medical
system to respond to peak demands be reevaluated. For more than
two decades, public policymakers have taken clear steps to
reduce the excess delivery system capacity, but we are entering
a new era that requires a reexamination of fiscal public policy
on emergency preparedness. We are not advocating an unfettered
buildup of delivery system capacity but rather a strategic
reassessment of the resources needed to assure necessary system
elasticity in the face of national or local crises.
In conclusion, local emergency management requires
government support that goes well beyond the availability of
vaccines, antibiotics and medical technology. There are
definitive needs for investment in the conduct of risk
analyses, in the development of community infrastructures, in
the training of key health personnel and an information
gathering, monitoring and dissemination; and, in the end,
government must set national priorities for resource deployment
and ensure that emergency management efforts are carried out
effectively at the local level.
It is essential that this country start to address the
identified needs with all due haste. In this regard, the Joint
Commission stands ready to commit additional resources toward
meeting our collective national readiness goals.
Thank you.
[The prepared statement of Dennis O'Leary follows:]
Prepared Statement of Dennis O'Leary, President, Joint Commission on
Accreditation of Healthcare Organizations
I am Dr. Dennis O'Leary, President of the Joint Commission on
Accreditation of Healthcare Organizations. We very much appreciate the
opportunity to testify on this critically important ``Review of Federal
Bioterrorism Preparedness Programs from a Public Health Perspective.''
The tragic events of September 11, 2001 have served as an unwelcome
catalyst for focusing on this country's ability to deal with acts of
terrorism. All aspects of our nation's infrastructure have received
renewed, and in some cases, heightened attention to their particular
vulnerabilities and response capabilities. The medical care and public
health systems perhaps deserve exceptional attention because they will
assuredly be the centerpiece of any response to--and therefore be
severally strained by--any terroristic event involving substantial
illness or injury to multiple individuals. However, these systems also
deserve close examination because our citizens can reap significant
benefits from strengthening this interface even if bioterrorists do not
strike. The value of a well-integrated medical and public health
infrastructure transcends terrorism and expands our capacity to deal
with a broad range of public health threats, such as emergent
infectious diseases and epidemics.
I am here today to speak specifically about how the Joint
Commission fits into the framework for bioterrorism preparedness and
how we see ourselves playing a continuing, significant role in
facilitating the readiness of our nation's health care organizations to
respond to untoward events. I will be raising for consideration some
vulnerabilities in the current ability of the medical system to respond
effectively to bioterrorism and making suggestions about solutions. It
is my intent to make a strong case for the development of system-wide,
integrated community approaches to preparedness that flow from federal
leadership. And I want to underscore that a strong nexus between the
medical and public health systems is critical to improving and
maintaining our preparedness.
For those of you who are not familiar with the Joint Commission, we
are the nation's predominant health care standard-setting and
accrediting body. The Joint Commission is a not-for-profit, private
sector entity that was founded in 1951, and is dedicated to improving
the safety and quality of care provided to the public. Our member
organizations are the American College of Surgeons; the American
Medical Association; the American Hospital Association; the American
College of Physicians-American Society of Internal Medicine; and the
American Dental Association. In addition to these organizations, the 28
member Board of Commissioners includes representation from the field of
nursing, and public members whose expertise covers such diverse areas
as ethics, public policy, and health insurance.
The Joint Commission accredits approximately 18,000 health care
organizations, including a substantial majority of hospitals in this
country. Our accreditation programs also provide quality oversight for
home care agencies; ambulatory care centers and offices whose services
range from primary care to outpatient surgery; behavioral health care
programs; nursing homes; hospices; assisted living residencies;
clinical laboratories; and managed care entities. The Joint Commission
is also active internationally and, in fact, has provided consultation
services on bioterrorism preparedness overseas.
The scope of our involvement in the health care delivery system
places us in a unique position to both set expectations for readiness
across the entire spectrum of provider services and to measure
adherence to those expectations. However, leadership and resource
commitments at the federal, state and local levels are also essential
to any effective bioterrorism response capacity.
the joint commission's standards on emergency management
For many decades, the Joint Commission has required that its
accredited health care organizations meet established disaster
preparedness standards. Not surprisingly, these standards have focused
on natural disasters such as tornadoes, floods, hurricanes and
earthquakes; and on certain uncommon accidents such as power plant
failures, chemical spills or fire-related disasters. Organizations have
been required to develop internal response plans and conduct periodic
staff drills to determine that these plans actually work. During on-
site surveys, our surveyors review these plans as well as the results
of the staff drills.
Several years ago, in a move that now seems prescient, the Joint
Commission decided to develop new standards that would broaden the
ability of individual healthcare organizations to deal with rare
events. At that time, we had become concerned that the medical system
was inadequately prepared to deal with the rare threat of bioterrorism,
and perhaps equally unprepared for the greater possibility of
infectious outbreaks arising from an increasing global inventory of
virulent infectious agents. Regardless of the source of the threat,
readiness for managing biological events has certain common elements.
The Joint Commission's accreditation standards were modified in
three important ways, all of which infused the concept of community
involvement into the preparedness process. First, we shifted the focus
of the standards from simple emergency preparedness to emergency
management. That modification may not sound significant, but it has far
reaching implications. Now, health care organizations are expected to
address four specific phases of disaster planning: mitigation,
preparedness, response, and recovery. This means engaging in planning
as to how an organization would lessen the impact to its services
following an emergency; how organization operations might need to be
altered during the heat of the crisis; and how to conduct consequency
management to return the organization to normal functioning once a
crisis has passed.
Further, emergency management requires that when organizations are
addressing each of the four phases of disaster planning, they must
broaden their preparedness and their perspectives to take into account
how the community around them may be affected during a rare event.
``Community'' may be viewed as the population at large, the other
medical institutions in the area, and/or relevant community structures
and agencies. This more outward and proactive way of thinking should
better position health care organizations to play an effective role in
bioterrorism preparedness.
Second, the new standards, which were effective on January 2001,
require accredited organizations to take an ``all hazards approach'' to
planning. What this means, is that organizations must develop emergency
management plans that contain a chain of command approach that is
common to all hazards deemed to be credible threats--an approach that
also can be easily integrated into their community's emergency response
structure. Hospitals must start this aspect of planning by considering
a wide variety of threats that could befall their community, including
terrorism. Hospitals, for example, are now required by these new
standards to do a hazard vulnerability analysis that starts with an
unconstrained list of extreme events, and then critically appraises
their probability of occurrence, their risk to the organization and the
capacity for responding to each potential threat. Inherent in this
analysis is having an understanding what the community itself, rather
than just the health care organization, considers to be a realistic
threat.
While this vulnerability analysis is obviously important, the
abilities of the individual organizations, and indeed of communities,
to prepare for and respond to the full array of potential threats is
seriously constrained by the major cost restraints in most health care
organizations. This will obviously lead to important priority judgments
about risk that will condition future response capabilities. There is
also a risk of fragmented priority setting--healthcare organizations
and communities may view the risk differently between and among
themselves, leading to uncoordinated preparedness. To do their jobs
effectively, individual health care organizations should take their
lead from responsible federal and state government authorities. This is
rather problematic at present because the United States has not
articulated its own national threat and risk assessment. As stated in
the recent GAO report on Homeland Security, ``a threat and risk
assessment is a decision-making tool that helps define the threats, to
evaluate the associated risk, and to link requirements to program
investments.'' It is clearly essential that governmental agencies
involved with assessing the threats from bioterrorism communicate their
analyses down to the local level so that the medical system has a
blueprint for appropriate action and can construct a reasonably
consistent strategy of preparedness throughout the United States.
The last new requirement of the standards is the involvement in at
least one annual community-wide practice drill by those health care
organizations whose all hazard risk assessment identifies credible
community threats. These drills must evaluate the interoperability of
the response structures developed by the health care organization and
the community. Responding to a bioterrorism attack will require
unprecedented communication, coordination, and attention to chain of
command structures. Therefore, these drills, if effectively executed,
are time consuming and expensive to conduct. Moreover, thorough mock
attacks must consider how the effects of bioterrorism would typically
play out over a period of weeks, constantly changing the landscape of
issues and decision making for health care leaders. Given the
complexity and cost of these essential drills, we believe that
governmental financial incentives should be considered as a means of
leveraging on-going engagement in such activities.
Drills also can be extremely instructive. Large-scale ones such as
TOP-OFF have elucidated unanticipated planning gaps and have exposed
the need for unconventional thinking in times of emergency. To
elaborate, we rightly consider our hospitals the first place to go when
people are severely ill. In fact, in this country we go to great
lengths to ensure that everyone has access to hospital emergency care.
Yet in the throes of a biological disaster, we may not want to admit
everyone who arrives at the hospital door. First, if individuals are
infected with a virulent pathogen, they will then infect physicians,
nurses and other staff, and thus limit the availability of critical
medical personnel. Under such circumstances, it may be prudent to keep
the hospital free from contamination by setting up off-campus isolation
units and treatment modalities outside of the hospital that are
overseen by properly protected staff. This would permit the hospital
itself to remain a safe haven for management of other injuries and
illnesses.
Further, if--in the face of a biological threat--everyone were
accepted into the hospital for evaluation, there is a real risk of
overwhelming facility capabilities. Experience with drills has shown us
that even the largest hospitals would be unable to handle the onslaught
of people who are concerned that they may have the dreaded agent. This
raises the real potential need for off-site evaluation and triage of
individuals in a fashion different from the usual conduct of emergency
services.
The new Joint Commission accreditation standards for emergency
management represent a significant step toward improving the nation's
readiness for a biological emergency, but national leadership in the
area of risk analysis will be necessary to convince many organizations
that bioterrorism threats are worthy of their serious attention. The
Joint Commission is participating in an Agency for Healthcare Research
and Quality funded project with Science Applications International
Corporation to investigate the linkages among key entities in response
to a bioterrorism event. This project will not be completed until next
year, so I am unable to share any final results with you. However, as
part of our contribution to the project, we conducted a survey of a
sample of hospitals to assess their community linkages for purposes of
mounting a bioterrorism response. Among the obstacles identified by
those hospitals which did not have effective community linkages were
the lack of community awareness of the issue and therefore, interest in
planning; and inadequate funding for bioterrorism planning, training
and resources at both the community and organizational levels.
vulnerabilities in the medical and public health care readiness
Much additional progress needs to be made. Given the outstanding
training we provide to our medical and public health personnel in this
country, and given our scientific know-how, state-of-the-art
technology, and high level of health care spending, it is reasonable
for the American public to expect that this country is ready to respond
to the worst of disasters that terrorists could bring to our doors.
This perception has been reinforced by the admiral way in which New
York City medical and public health personnel handled themselves in the
face of the massive disaster last month. But is should be pointed out
that the medical care and public health systems were not tested for the
level of stress that would result from a bioterrorist event, because
sadly there were many more deaths from the World Trade Center calamity
than there were persons needing medical attention.
Some people believe that the health care delivery system--if faced
with a bioterroism event--will somehow be able to accommodate the
thousands of ill, injured and worried well who will seek health care in
that situation. The unfortunate truth is that we have much to do before
such a belief can be fulfilled. This is not intended as an alarmist
statement, but there are some stark realities that must be faced about
the current capacity and integration of our public health and medical
care systems and the readiness of governmental agencies to assume
authoritative leadership roles.
To that end, I would like to offer a series of recommendations for
upgrading our system capabilities and for weaving together a tighter
response fabric among responsible parties. This fabric should be
pattern recognizable to all those who comprise the cloth, because its
essential elements will be comprised of effective coordination,
communication, cooperation, chain of command, and capacity building.
<bullet> More medical care workers must be trained to become
familiar with pathogens that may be used in bioterrorism, aware of the
symptoms they produce, and alert to the possibility of their use.
Medical personnel must also become knowledgeable about routes of
transmission, the transmission vectors for various biologic agents and
the effective therapeutic approaches to these agents. The reality is
that most physicians would not recognize a case of anthrax, tularemia,
or smallpox that presented to them in the emergency room or in their
office. Nor would they know what kinds of specimens to collect for
testing, how to handle such specimens or which clinical laboratories
possess the expertise to detect some of the rare agents that could be
used by terrorists. Such education is essential to a prompt response to
any bioterrorism attack.
<bullet> It is essential that a single, integrated system of
response be created that will be effective in addressing a full range
of diseases and rare events whether of terrorist or natural origins.
Because it will serve multiple purposes, a single system is less likely
to wither from inattention or nonuse. This system should be a blueprint
for action that is also scalable to the extent of the emergency and to
the settings that are involved. The framework should be community-wide
and utilize common concepts so that it is transportable. For example,
we should be reliance upon a consensus-based ``chain of command''
construct that has interoperability common to all states. This would
make emergency management plans quickly and easily understood by all
who are engaged in emergency activities. The system should be
periodically tested and evaluated for its currency and feasibility.
<bullet> Community or state-wide capacity analyses of preparedness
that include available medical facilities and delivery sites must be
carried out. We are pleased that the CDC is working to identify the
core capacities that state and local health departments must have in
order to be adequately prepared for a biological attack. However, this
evaluation needs to be expanded to include the core capacities of the
medical infrastructure within each geographic area. This should lead to
a gap analysis that addresses issues of supplies at hand, which
additional personnel may be needed, transfer agreements during times of
system overload, and other identified medical system vulnerabilities.
Such assessments should be integrated into any other assessments being
undertaken by state and local authorities.
<bullet> A medical/public health surveillance system should be
established to promptly detect naturally occurring epidemics as well as
terroristic activity. The rapidity with which a rare disease or
terrorist weapon is recognized at the provider level and communicated
to public health experts will largely determine the extent of its
spread and the overall mortality rate. With today's technology, the
reporting system should not rely upon an astute clinician to pick up
the telephone and know whom to call about an unusual case, or number of
cases. Rather, a surveillance system should be designed for the routine
collection of automated data on presenting symptoms at points of
delivery system entry and of health care utilization and laboratory
data. Such information should be provided to public health officials
for ongoing surveillance. Public health epidemiologists might then be
able to detect ``spikes'' in the data and take investigatory action if
warranted. A system of this nature could also communicate
electronically with CDC and could be used in time of bona fide
bioterrorism to inform decision-makers about disease spread.
<bullet> Issues of national supplies and their disbursement need to
be evaluated and resolved. Determinations as to how much vaccine,
pharmaceuticals, medical equipment and other supplies are needed for
stockpiling should be made at the national level after a credible
threat and vulnerability analysis. Equally important is how supplies
are prioritized for distribution and how fast they can be deployed. It
may be that there is no effective way to expeditiously distribute to
localities the massive amount of supplies that may be needed if there
is as large-scale bioterrorist attack, especially if the transportation
infrastructure is also affected. The practicalities of needing to act
quickly require considerations as to when regionalized supplies are
preferable, who will have the authority to disburse them, and what
criteria will be used to make dispersal decisions.
<bullet> It is essential that the national funding policies which
have progressively reduced the elasticity of the medical system to ramp
up to a peak demand be re-evaluated. For more than two decades, public
policy makers have taken clear steps to reduce excess delivery system
capacity (e.g., hospital beds). During this time many emergency
departments and satellite clinics have closed. But we are entering a
new era that requires a reexamination of fiscal public policy on
emergency preparedness. We are not advocating an unfettered build-up of
delivery system capacity, but rather a strategic reassessment of the
resources needed to assure necessary system elasticity in the face of
national or local crises.
The Joint Commission stands ready to work with many others on the
aforementioned recommendations, because we believe that our
organization has a key role in the strategic planning for medical and
public health systems' response to terrorism.
conclusion
It is said that all health care is local. That maxim ultimately
applies to emergency management. Indeed, local readiness planning will
need to be scaled and tailored to the characteristics and capabilities
of individual communities. However, it is equally important that there
be strong leadership at the federal and state levels that directs
particular attention to the issues raised in our testimony. The
resources needed to support effective emergency management at the local
level are not simply vaccines, antibiotics, and medical technology.
There are definitive needs for government investment in the conduct of
risk analyses, in the development of community infrastructures, in the
training of key health care personnel, and in information gathering and
dissemination. And in the end, government must set national priorities
for resource deployment and assure that emergency management efforts
are carried out at the local level.
We as a nation are not unprepared to deal with bioterrorism and
natural disaster and epidemics, but our nation's public health and
medical systems could be better prepared than they are today. We
therefore need to start addressing the identified needs with all due
haste. In this regard, the joint Commission standards ready to commit
its own resources to work alone and with others to meet our collective
national readiness goals.
Mr. Greenwood. Thank you very much, Dr. O'Leary.
Dr. Young for 5 minutes.
TESTIMONY OF FRANK E. YOUNG
Mr. Young. Mr. Chairman, thank you very much for the
ability to be here today. I would like to submit my testimony
for the record and summarize some points that have not been
made completely by my other colleagues.
Mr. Greenwood. That will be fine. Your full statement will
be made a part of the record.
Mr. Young. Thank you. I'm particularly pleased to testify
with two of my colleagues, Dr. Lew Stringer and Dr. Kathy
Brinsfield, who were in my command when we served and began, as
Dr. Stringer outlined, the entire approach to bioterrorism. I'd
like to remind this committee that this is not an old issue
that we are regrinding over and over again but an issue that we
have been trying to address since 1995, and I've provided for
the committee a copy of the first biological and chemical
terrorism study that was conducted at that time. It was then
that Dr. Stringer and others joined together to build a local
system.
I'm also releasing for the first time as attachment 2 the
letter that was submitted to President Clinton on May 6, which
is the result of an ad hoc committee that I chaired in response
to looking at bioterrorism, and you will note that most of the
things that were spoken of today are outlined there in 1998 as
well.
The budget is the ultimate instrument of policy, as you
know, sir. These requests have been made year upon year upon
year. Dr. Stringer knows the many times that I have come before
Congress pleading for funds and the many times in which they
were not answered. Now is the time to act, and I urge your
dispatch to be matched with a passion of the day, with the
actuality of the funding.
I have a number of urgent recommendations that I would like
to bring to your attention that cobble together the needs that
I believe are necessary to fix the system.
First, develop a command and control system for public
health that interfaces seamlessly with the Office of Homeland
Defense and integrates the State and local regional activities.
Nothing is more important than the ability to communicate well.
At a time of disaster, it is not the time to exchange business
cards for the first time. We must know each other, and we must
trust each other.
Second, you can see the problem displayed in Florida of the
lack of laboratory facilities to rapidly diagnose infectious
agent. I'm a microbiologist. It is not necessary to do, as we
did there, to look for 48 hours at culture and sensitivities.
There must be rapid diagnostic materials made available that
can detect these pathogens in hours to minutes, not days to
weeks. The laboratory facilities at USAMRIID and at CDC are
woefully inadequate for high containment work, as are the
laboratories around the Nation.
FDA has been urged in 1998 to finalize a regulation that
would enable new drugs for bioterrorism agents to be approved
based on suitable animal tests. That regulation was posted in
1999 and is languishing to this date. It is a simple thing to
finalize. All the comments are in. I urge you, see to that.
The augmentation of the mass casualty response teams can be
built by, one, augmenting the National Guard medical systems,
which are in a poor state of repair; creation of disaster
responders through the Commissioned Corps of the Public Health
Service that would be able to respond at a moment's notice to
augment the local teams. At the moment, just as Lew pointed
out, with the State and local teams you have to get permission
to deploy. You need to be able to be up and out the door in 4
hours or less. Otherwise, you are ineffective.
Next, to train people locally with the capacity to manage
the medical consequences of weapons of mass destruction; to
train medical and environmental health personnel through
distance learning so that it would be possible to understand
how these systems should work. There is an excellent course at
USAMRIID that has trained over 50,000 people for this purpose;
and I would urge that that be continued, funded and made
available to the Nation.
Develop an integrated system of field hospitals and
identify structures within communities whereby patients could
be brought in. As pointed out by the President of Johns
Hopkins, it is difficult to bring in large numbers of
contaminated people within the hospital system. There are only
five field hospitals in DOD and less than one to two adequate
field hospitals in the HHS and few scattered around the Nation.
You need to make sure that we have those hospital facilities,
portable hospital facilities that can be used at time of
crisis.
There is a need to be sure that all types of therapies are
developed, including immunotherapies that are just-in-time
immunotherapies; and I've given information on one novel
approach in Appendix 3.
It is important to protect our health responders with the
adequate equipment and clothing and ability to find them in the
event that they are incarcerated in rubble or other material,
and I've given you information on that in Appendix 4.
Death management is critical. I was there in Oklahoma City,
and I managed that from a medical standpoint. That was small in
comparison to New York City. My heart goes out to the many
people that are trying to deal with the large number of dead
people there. It is a special activity. We do have disaster
mortuary teams. They have been overstressed.
I now serve as a pastor. It was interesting that--to me
when the call came to testify I was preparing my Sunday
materials on the good Sermon on the Mount, Matthew 5:1-15; and
I want to urge you with every fervor that I can to make a team
of trained chaplains, grief counselors and other professionals
that can go in and make an impact in the lives of people when
they are suffering. I know a call went out, but when the call
went out, there was ``send as many people as you can who are
not trained and not experienced.'' and I've seen the difficulty
in counseling individuals dealing with large-scale deaths, and
we need to be prepared, and that type of training needs to be
done as well.
Media communications are key, Mr. Chairman. We have seen a
lot of talking heads and experts that are nonexperts. I've been
in weapons of mass destruction for a quarter of a century, and
it is important for me to emphasize that I'm one of the young
and retired people of the field that is no longer extant within
the United States. We need to train people in this expertise
and have people nursed and rehearsed and capable of bringing
public messages.
Let me give you an example. In the Midwest flood, it
involved five States, some of you know, from Michigan. I was
there on the ground. The State health departments could not
decide how long to boil water. Some said, 3 minutes. Others
said 1 minute. Others said 30 seconds. Then there came a
concern about hepatitis. And they said if these fools can't
tell us how long to boil water, we can't believe them on
infectious hepatitis.
We've got to have a message that is similar, that is
accurate, that's done by experts and coordinated across the
land. To do less is not appropriate.
Finally, Mr. Chairman, it's up to you. The budget is the
ultimate instrument of policy. To not act and bring these
medicines as we have been shouting for to the local communities
for years represents, in my pastoral opinion, a sin.
Mr. Chairman, I'd be happy to answer any questions I can.
[The prepared statement of Frank E. Young follows:]
Prepared Statement of Frank E. Young, Former Director, Office of
Emergency Preparedness, National Disaster Medical System, Vice
President Reformed Theological Seminary, Metro Washington
introduction
Dear Mr. Chairman and members of the Committee: Thank you for the
opportunity of testifying before your committee concerning the
``Federal Preparedness for Bioterrorism from a Public Health
Perspective''. As a microbiologist and a physician focusing on
infectious disease, I have been involved in research on non-pathogenic
and pathogenic organisms related to those used in bioterrorism for over
a quarter of a century. In government I participated in the defense
from the effects of organisms involved in bioterrorism since 1984 when
I served as Commissioner of the Food and Drug Administration to 1996
when I completed my service as Director of the Office of Emergency
Preparedness and the National Disaster Medical System. From 1993-1996,
I represented the Department of Health and Human Services on the
Council of Deputies of the National Security Council, coordinated the
Emergency Support Function 8 for Health and Medical response in the
Federal Response Plan and participated in many training exercises to
test response to disasters caused by weapons of mass destruction. My
testimony will focus on the reality of the threat, the two basic types
of threats, the requirements for effective management; the progress
made to date and additional needs for enhancement of our capabilities.
The call to testify before your Sub-committee came while I was
preparing for an adult ministries class in the church where I serve as
associate pastor. It was a remarkable kaleidoscope of ideas as I
pondered the attributes of a Christian disciple from the Sermon on the
Mount I taught last Sunday to my church (the Gospel of Matthew 5:1-15)
as compared with terrorism-the essence of evil. The sinfulness of
mankind is revealed in the wanton destruction of civilian life. None of
the major world religions preach the violent slaughter of innocent
people.
the threat
Most experts in bioterrorism would agree that the threat is smaller
than the use of bombs and bullets, but this low probability event is of
high consequence. While a large number of microorganisms could be
utilized, the more plausible organisms are summarized in attachment
1.<SUP>1</SUP> Of these, anthrax is the easiest to prepare and
disseminate particularly in confined spaces. It also, under appropriate
conditions, can produce the highest morbidity and mortality. A
comprehensive analysis of the current threats can be obtained from the
excellent publication of the Institute of Medicine and National
Research Council entitled ``Chemical and Biological Terrorism: research
and development to improve civilian medical response''.
---------------------------------------------------------------------------
\1\ D.R. Franz et al. Clinical Recognition and management of
patients exposed to biological warfare agents, JAMA 278: 399-411
---------------------------------------------------------------------------
Two general types of release can be perfected. First and easiest,
is the release of organisms in an enclosed environment such as a
building, subway or ship. Small amounts of microbes are required, the
dispersal conditions are not so rigorous and the agent recycles in the
air system until it settles out. The agent is also less exposed to
harsh environmental conditions. This type of release is designed more
to produce terror than a large kill. Second, the organisms can be
released as an aerosol into the atmosphere through a spray such as a
crop duster airplane, or a truck with an insect sprayer (fogger). The
sprayers are more difficult as they require a dispersal agent to keep
the particles below 10<greek-m> to ensure particles are inhaled into
the lungs. Effective release is highly dependent on climatic
conditions. It is important to note that the Aum Shinriko was
unsuccessful in causing death form an aerosol release.
Fortunately the United States has excellent medical capacity to the
management of infectious disease. However, there is limited hospital
surge capacity. The growth of managed care, cost containment
procedures; reduction in hospital beds and reduction in hospital staffs
has limited markedly the excess capacity of the health system in
responding to large-scale emergencies. A visit to a metropolitan
emergency room on a Saturday evening will show the strain on resources
required for daily needs let alone an emergency. Systems need to be
developed to make beds rapidly available.
The primary issues to be addressed are: intelligence to minimize
surprise and interdict the terrorists; crisis response to mobilize
investigative forces and consequence management. Frequently crisis and
consequence management occur at the same time. Bioterrorism events will
likely be discovered after a number of people have become sick or died
therefore rapid response is of the essence. With appropriate commitment
of resources and organization skills illness and death can be reduced
60-to100 fold but deaths will occur at the initial site of release and
continue until the infectious agent(s) are brought under control.
requirements of a robust system for defense against bioterrorism
1. An integrated Federal, State and local civil response system.
2. A single command and control system at the Federal level
3. A robust Public Health infrastructure that includes the military and
civilian sectors.
4. Rapid diagnosis tests for the most common threat agents.
5. Enhanced reference laboratory capabilities including sufficient
numbers of BSL 2-4 containment facilities in both USAMRIID and
CDC
6. Surge capacity of the medical system.
7. Stockpiles of therapeutic agents.
8. Training of medical response system with particular emphasis on
local response capacity using both exercises and distance
learning
9. A regulatory system within FDA that can evaluate therapeutics using
surrogate markers and sufficient resources to accomplish the
reviews expeditiously.
progress since the gulf war
During the Gulf War, I had the responsibility for training the
local fire-rescue and emergency response system for a possible anthrax
attack. We had little of the above listed capacity. Together with
William Clark, presentations were made on the various biologic agents
and with the support of the Assistant Secretary for Health, James
Mason, I stored sufficient medicine inside the beltway to treat 51,000
people for 48 hours with antibiotics. Liaison was established with both
FBI and FEMA. The system was totally inadequate.
Following the Gulf war, The Public Health Service (PHS), through
the Office of Emergency Preparedness which I directed sought the
support of FEMA for the first Federal bioterrorism training exercise
(CIVIX 93) that simulated an anthrax attack on a large metropolitan
subway system. This exercise revealed widespread weaknesses in the
response system at all levels. It also demonstrated the need to include
military assets at USAMRIID and the research capacity of DARPA to
develop certain applied research projects. However, attempts to obtain
adequate funds to address the deficiencies were unsuccessful within the
Administration and Congress.
The attack of the Aum Shinriko on the Tokyo subway system in 1995
with sarin led to middle of the night discussions during which I
reported rapidly to Mr. Richard Clarke, National Security Council that
the agent was most likely sarin based on the symptoms. The difficulties
involved in preparing to defend against a coordinated attack on the
United States and other countries are well described in the recent
publication by Miller, Engelberg and Broad.<SUP>2</SUP> The magnitude
of the Aum Shinriko operations and the discovery that they experimented
unsuccessfully with anthrax provided a wake up call to our nation. In
the aftermath of the incident, there was a great deal of activity led
by Richard Clarke that culminated in PDD 39, and the designation of the
PHS as the lead Federal Agency in consequence management for biologic
agents. Broad Federal cooperation occurred in the meetings that I
chaired and assignments were completed on time. Trust and close working
relationships are required for success. We all recognized that we
should not exchange business cards for the first time at the site of a
disaster. The planning actions of representatives from American Red
Cross, DOD, DOJ, EPA, FBI, FEMA, PHS, VA, and USDA resulted in the
completion of the integrated Health and Medical Services Support Plan
for the Federal response to terrorism in September 1995. Unfortunately,
adequate funds for implementing this plan were not forth coming despite
appeals both to the then Principle Deputy Assistant Secretary for
Health and her staff and in the PHS and the Congress. There were two
initiatives that were seminal and have had a marked impact on training
nationally. First, the Secretary of DHHS made monies available for the
first time to local communities enabling both local and integrated
Federal, State and local training exercises to occur. Second, the
Metropolitan Washington response agency (Council of Governments) wrote
to President Clinton describing the inadequate preparation of the
region. Subsequently, the Office of Emergency Preparedness with the
advice of State and local health personnel developed a concept of
Metropolitan Medical Strike Teams to augment the capability of local
public safety, public health, fire rescue, hazmat and medical emergency
responders to be able to address successfully biological and chemical
terrorism.
---------------------------------------------------------------------------
\2\J. Miller, S. Engelberg and W. Broad Germs, Biological Weapons
and America's Secret War Simon and Schuster, New York 2001, pg151-152
---------------------------------------------------------------------------
The next major change in the preparedness system resulted from a
concern by President Clinton. He concluded that there was weakness in
the current response to bioterrorism based on world conditions and
requested briefing from non-governmental experts. During the meeting
with the President and selected senior staff, the Attorney General, the
Secretary of Defense and the Secretary of DHHS, a comprehensive
analysis of the current statue of preparedness and recommendations for
improvement were presented. The President requested that the analysis
be submitted expeditiously. The document with the attached budget is
submitted as attachment 2. Particularly relevant was the focus on
emergency response and research. The DOD, DHHS and DOJ were requested
to examine their programs, propose enhancements to overcome the noted
deficiencies and submit an appropriate budget. The positive response of
the departments led to substantial improvements.
progress since may 1998
The increased budget for the PHS has resulted in substantial
improvements. However the most significant recent event was the
appointment of Governor Tom Ridge as Director of Home Defense. If he is
successful in developing a coordinated approach to the threat of
terrorism in general and bioterrorism in particular, it will greatly
improve the response. A coordinator in HHS for all of the former PHS
agencies with budget authority and coordination responsibility could
aid the Director's efforts.
Training has been greatly strengthened through the provision of
funds to the States. The concept of Metropolitan Medical Strike Teams
has been continued though renamed (Metropolitan Medical Response
System). A total of 97 systems have been funded in cities or locales.
Coordination between Federal and State and local public health agencies
has been heightened through monies for joint training exercises. The
National Disaster Medical System has been enhanced through additional
development of teams that can respond to both chemical and
bioterrorism.
The public health infrastructure at the local, State and Federal
level is still not sufficiently robust. For example at the Federal
level, the containment facilities and staff trained to study highly
infectious pathogens at the BSL 2- 4 level in USAMRIID are inadequate
to meet the needs for contained management of highly infected cases and
research of pathogens. They need to be doubled in size. Similarly, the
facilities at the Centers for Disease and Prevention and NIH are
inadequate. Other regional facilities need to be developed. The public
health laboratories, while able to diagnose bacterial infections, have
insufficient facilities for viral diagnosis. Finally, there is
insufficient graduate training in this field. The most experts who were
involved in the bioterrorism field like myself are retired!
Most telling is the inability to diagnose infectious agents
rapidly. The recent fatal case of anthrax in Florida is illustrative.
It took at least 48 hours for the diagnosis. Probably classical culture
and antibiotic sensitivities were employed. This is simply
unacceptable. To have effective treatment to reduce toxemia, it is
imperative to make the diagnosis more expeditiously through
immunological means. Adequate laboratory facilities are required to
meet emergency requirements. Anthrax may not always be easily diagnosed
clinically, as textbook cases are rare in real life. Additionally,
although USAMRIID and CDC and other state laboratories can do careful
epidemiological work through plasmid determination or bacteriophage
sensitivities, these too need to be done in hours not days. Public and
private sector research and development and expeditious evaluation by
FDA is required to meet these needs. Similarly, rapid detection of
other an agents that could be used in bioterrorism is imperative.
Great progress has been made in developing stockpiles of
antibiotics and other medical supplies. However the supply of vaccines
against anthrax and smallpox remains insufficient. The production of
vaccines needs to be accelerated and Federal facilities may be
necessary if the private sector cannot respond adequately. Because most
people will not be immune and antibiotic resistant strains can be
utilized, there is a need for just in time therapy to neutralize toxin
and microbial agents in bioterrorism. The Biotechnology Company Elusys
on whose Board of Directors I serve is developing one such promising
approach. This therapy can neutralize the anthrax toxin after exposure
and when used in combination with antibiotics should be highly
effective (attachment 3).
Surge capacity of the medical system has been enhanced but only
marginal progress has been made since 1998. This is a highly
significant though correctable deficiency.
Research on pathogenic model systems for the common infectious
agents has proceeded but remains inadequate.
The ad hoc committee that reported to the President emphasizes the
need for regulations to facilitate the development of therapeutic
agents and diagnostic agents for organisms that cannot be tested in
human volunteers. Because there are insufficient natural cases of
infections with agents like smallpox and anthrax, it is imperative to
evaluate these in appropriate animal models. Additionally, it was
recommended that a special division be formed and funded to provide the
personnel to expeditiously determine the safety and efficacy of such
therapies. FDA proposed a rule Docket No. 98N-0237 ``New Drug and
Biological Drug Products; Evidence Needed to Demonstrate Efficacy of
New Drugs for use against Lethal of Permanently Disabling Toxic
Substances When Efficacy Studies in Humans Ethically Cannot Be
Conducted'' (FR Vol. 64: 53960-53970). The comment period closed
December 20,1999, comments have been posted on the FDA web site however
the rule is languishing. This rule is important because it would enable
FDA to approve for marketing on the basis of appropriate well-
controlled animal studies.
urgent recommendations
When I managed the emergency medical system there were difficulties
in: understanding what to do, convincing the government to fund the
infrastructure, and developing a system to coordinate the major
agencies in PHS, DOD, VA FBI and FEMA. Much progress has been made
since 1995 in addressing the response to terrorism with weapons of mass
destruction. Funds can now be allocated to enhance the response system
thereby saving many lives. Although there are especial nuances among
them, the response to biological terrorism must be viewed in concert
with an all hazards response system. Based on past professional
experience, I urge the following recommendations for immediate
implementation.
1. Develop a command and control system for Public Health that
interfaces seamlessly with the Office of the Director of Home
Defense and integrates all of the relevant organizations in the
civilian agencies of government, the military and the private
sector.
2. Enhance the rapid diagnosis system through the development of rapid
immunological procedures. The recent delays in identifying the
organism in Florida illustrate this need. Local laboratories
can be overwhelmed by requests for mass screening. Therefore,
it is necessary to ensure that communities have access to
containment laboratories and surge capacity to meet large
diagnostic loads.
3. Finalize the FDA regulation on Drugs to treat diseases where ethical
considerations prevent the use of human subjects. The proposed
regulation is Docket No. 98N-0237 ``New Drug and Biological
Drug Products; Evidence Needed to Demonstrate Efficacy of New
Drugs for Use Against Lethal of Permanently Disabling Toxic
Substances When Efficacy Studies in Humans Ethically Cannot Be
Conducted (FR Vol. 64: 53960-53970). Provide 2-million dollars/
year for FDA to meet this critical mission.
4. Augment the mass casualty response system through:
<bullet> Augmentation of the medical systems in the National Guard
to enable them to rapidly deploy to the disaster site.
<bullet> Creation of a dedicated health disaster personnel system
with 750 officers within the Commissioned Corps of the
Public Health Service under the direction of the Secretary
and the Surgeon General. While these physicians, nurses,
epidemiologists and support personnel can work in agencies
while not deployed their primary responsibility is to the
emergency management
<bullet> Support training of individuals capable to manage the
medical consequences of weapons of mass destruction both in
the military and civilian sectors.
<bullet> Training of medical and environmental health personnel
through distance learning and exercises to ensure each
community can respond appropriately. The excellent course
at USAMRIID has trained over 50,000 people
<bullet> Develop a similar civilian training program for all
hazards
<bullet> Develop an integrated system of field hospitals and
identified facilities that can be used for mass casualty
management. DOD has only approximately 5 such units and the
equipment for field hospitals in DHHS is inadequate to meet
the civilian need specially since the military units may be
on deployment.
<bullet> Augment the containment facilities in hospitals to ensure
that the hospital will not be rendered useless through
needless contamination.
<bullet> Ensure that the emergency response teams can be protected
through proper equipment and protective clothing. One
recent development is a shirt developed through a research
grant from DARPA that can determine heart rate, respiratory
rate, temperature, blood oxygenation and locate people
under 60-80 feet of rubble through geopositioning and two
way communications (attachment 4). This would enable
trapped workers to be located
<bullet> Provide sufficient training in containment and
decontamination of infectious agents within the
environment. The emergency response capacity of EPA should
be enhanced.
5. Ensure sufficient medicines to respond to mass casualties through
stockpiles at strategic locations. Where supplies are
insufficient the Federal government should support research
into new therapies and production of just in time
immunotherapies and vaccines.
6. Mass death management. The events in Oklahoma City and the World
Trade Center have taught us how difficult it is to identify
bodies. Massive deaths from a major terrorist attack require
sensitive treatment of the remains of loved ones.
7. Development of a reserve system of grief counselors and chaplains
that can be trained through distance education and local
exercises. As a Pastor, I can attest that at a time of mass
casualties, the faith and the emotional well-being of the
victims may be fragile and in need of significant support.
8. Media communications must be accurate and informative. Public Health
officials should be trained and exercised in communication. The
confusion of facts in the recent Florida anthrax case is an
example of this need.
9. Support genomic research to enable rapid analysis of novel organisms
including those with mutations to antibiotic resistance and
genetically engineered toxin production.
10. Support development of ``just in time immune therapies'' to treat
the potential threat agents
summary
While the threat of bioterrorism is a significant, it can be
overcome through coordinated civil defense, a robust public health
system and research on the genomes and mechanism of pathogenicity of
threat agents. Of particular need are methods of rapid diagnosis,
enhanced containment facilities and new modalities of therapy. It is
important to note that the proposed measures will strengthen our
response to emerging pathogens as well as meet the threat of
bioterrorism. Thus funds to address the issues identified in this
testimony will be well spent.
Mr. Greenwood. Thank you, Dr. Young; and let me assure you
that this committee hears your prayers.
The Chair recognizes himself for 5 minutes for questioning.
If I were to dispatch any one of you to a city, Washington
DC, Philadelphia back in my State of Pennsylvania, Los Angeles,
wherever, and said to you I want you to go there and I want you
to report back to me as to the preparedness of that city for a
bioterrorist event, the question that I have for you is, would
you know where to find the checklist? Do you think that we have
developed or that you have access to a comprehensive definition
of what would make a city prepared against which those local
officials can measure themselves so that you could report back
that, in fact, the preparations are adequate?
And let me ask any or all of you who wish to comment. We'll
start with Dr. Smithson.
Ms. Smithson. This is exactly what I had in mind when I
fanned out across the country in reviewing individuals from
various response disciplines, and you'll see that in chapter 6
of the Ataxia. They feel that they're much better prepared to
deal with a chemical disaster and that they've got a much
further way to go when it comes to responding to a biological
disaster.
Now I separate those two responses because they're very
different things. And you'll also see in that narrative their
key points about what is entailed in biological disaster
preparedness, from detection to training, institutionalization
of this training across the various response disciplines. Not
just hopping from city to city, but it's got to be in all of
our universities, nursing and medical schools, as well as the
other response disciplines.
Mr. Greenwood. Let me just make sure I'm clear about my
question. My question is, is do we know what constitutes
preparedness? In other words, is there a universally accepted
checklist that you could take to the city of Philadelphia and
say, training of EMTs, check; training of ERs, check; supplies
of vaccines, check; et cetera? Do we have an agreed-upon--not
even getting to the question yet of are we prepared, and we
know very well that we have a long way to go in that regard, do
we have a definition that's agreed to within the profession, if
you will, that would enable us to measure our cities in terms
of their preparedness? Dr. Waeckerle.
Mr. Waeckerle. Thank you, sir. There are components of what
you asked for available through certain previous workings of
the Nunn-Lugar-Domenici Act, some through DOJ, OJP, some
through DOD, and some through HHS and CDC. As Dr. Smithson
alluded to, most are related to chemicals, but there is no
protocol, templates or ability to bring anything from the
Federal level to the local community for all hazards that we
currently face available to any city in America. The MMRS
effort is as close as I am aware to get to that currently, but,
as they admitted in testimony in the GAO report, they still
focus more on chemicals, and we need to have a great deal more,
especially for biologics.
Mr. Greenwood. Did you want to----
Ms. Smithson. The MMRS effort has basically focused on
allowing the cities to make their own plans, and that's put----
Mr. Greenwood. That doesn't seem to me to be adequate
because we can't assume that every city has the expertise to do
that, to know what constitutes readiness.
Ms. Smithson. They have some of the expertise there, but it
forces all these cities to push the same rock up the same hill
independently. While there's resistance at the local level to
having a model, there ought to be some type of a model out
there for them to follow; and I would say that perhaps New York
City's biodisaster readiness efforts would be the model that,
most of the places where I went, they were following that
model.
Mr. Greenwood. Thank you.
Mr. Young. Mr. Chairman.
Mr. Greenwood. Let me go to Dr. Stringer. We'll go from
left to right.
Mr. Stringer. There have been excellent examples of unified
planning and working together with the MMRSs. The MMRS has done
one thing for emergency management. It's brought the health
departments and the hospitals to the table, as the Superfund
law did in 1986, and required them to come to the LAPCs. So
they're all working together. They even know each other now.
That's a start, sir, because, before, that didn't exist,
and most communities--some will not agree with me on that, but
I think that's probably overall true--each city is allowed to
do it the way they sort of think it ought to be best for them.
There have been a couple models that are excellent out there
that the OEP has tried to provide to the cities, and I think
many of them are using--they're not all starting from scratch,
but they do have the right to have what's best for them, which
may not be the example of what's in the next city, say even in
that State, that was approved on MMRS.
Mr. Greenwood. Thank you, sir.
Dr. Young.
Mr. Young. Mr. Chairman, I think it's important to realize
that when we started the program we wanted to recognize, as Dr.
Stringer said, the local capability, but Dr. Lederberg and I
were asked by Dr. Hamburg and through her from Mayor Guiliani
to go with him the first month of his office and brief him on
bioterrorism. I also briefed the Mayor of Boston.
So the answer to your question specifically, in those
cases, all the appropriate officers of the city government were
in the room and plans were developed, and that was the
beginning of this local team approach. A single unified plan
for bioterrorism and chemical terrorism does exist, and that
Lew Stringer was helpful in developing for the Olympics that we
had in Georgia. Because at that time we had both helicopters,
response teams, outside and you noticed how rapidly, when the
bomb went off, there was response within that area with teams.
They were prepositioned, supplied and equipped; and I believe,
Lew, those lists and the supplies, equipment and plans still
exist in the Office of Emergency Preparedness.
Mr. Stringer. That has been one of the initiatives that
started the equipment catch list that most cities have in
talking about whether it's a thousand or 10,000 patients or X
number of thousand--the same equipment.
Mr. Greenwood. Thank you. Let's see. Dr. O'Leary.
Mr. O'Leary. Yeah. I think the issue is that--others have
said more than a checklist issue. It is a plan issue. And I
don't think we can assume that there is one single model. I
think that we are talking about cities, we're talking about
suburban communities and may be talking about rural areas.
These things can happen anywhere, and the models, the templates
will not be used unless they are adaptable to the realities of
these communities, and there is a crying need to develop these
so that they are going to actually be usable.
Second, I would comment that a plan itself is not
sufficient, that we have to make sure that these plans are
being tested and carried out. It is a functionality that we
should be evaluating; and there is, I think, eventually a case
to be made for some third-party oversight of these. That could
be done by State agencies, it could be done at a national
level, but I don't think we can assume because they have a plan
that it's working. I think the public will want some external
validation that these plans are working, and that a checklist
is part of that.
Mr. Greenwood. I understand. Mr. Peterson.
Mr. Peterson. Although I think you're hearing that we can't
give you comfort that there is one uniform, elegant approach
that's being deployed, it's my observation that one of the
things that's going on is that we have a serious effort under
way for folks to be talking to each other.
I know at our local level, the Mayor of Baltimore has been
very actively involved in convening the appropriate agencies,
hospitals and so forth and, in turn, has communicated via video
conference, teleconference with other mayors of large cities to
share best-demonstrated practices. So you should glean from
this the sense that there is a lot of collegial activity under
way, but I think it is fair to say--I would agree with all of
my colleagues here at the panel that, in fact, there is not one
uniform approach that's being deployed across all of the
jurisdictions.
Mr. Greenwood. Thank you. My time has long since expired.
The Chair recognizes the ranking member, Mr. Deutsch, for 5
minutes to inquire.
Mr. Deutsch. Thank you, Mr. Chairman.
You know, maybe I'm looking at it differently than people
on the panel. And we can talk about the incident in Florida, of
whether it is a criminal case or a case of bioterrorism, and we
could talk about definitional terms, but obviously something is
happening, and it's very much I think on the minds of Americans
and not just Americans, people around the world. Dr. Simpson,
you, you know, talked about it specifically, and if you can
maybe elaborate in terms of the response that's actually going
on now, in terms of CDC, in terms of the local health agency,
in terms of HHS, in terms how they are responding to the cases
of anthrax that have been disclosed in Florida. You know, are
they doing a good job? Should they be doing more? What should
they be doing? If you're able to do that.
I mean, because I guess we've talked about the theory of
bioterrorism. We've talked--you know, we've had all of you talk
about the theory of response. As far as I'm concerned, there is
a potential bioterrorism incident that is occurring right now
in the United States of America. You can describe it as a
criminal act. I think it's still open of whether or not it's
bioterrorism, whether it's related to September 11, we don't
know. My understanding is that, you know, 700 additional people
have been tested.
Again, one of the issues that Dr. Young mentioned, which is
I guess really frustrating, is that there still seems to be a
24/48 hour incubation period before we know if there are any
additional cases. So that's not the case; it is the case.
That's what CDC said to us yesterday in a nonclassified
briefing that they gave Members and staff. But we have
something going on.
And I will tell you that, you know, we can really get into
this, what the definition of terrorism is. I will tell you, I'm
going to submit this to the record--I wasn't aware of this
until this morning--a letter that was sent by American Media,
which is the company where the two cases were uncovered, and
their building has been basically cordoned off.
A letter that was sent from that office to an office in
Montreal, the building in Montreal was evacuated. The entire
building was evacuated. People in that building were tested for
anthrax, and at least we're getting reports at this point--and
this is a local company in Florida. I represent Florida, and
I'm familiar with the company--that at this point they are
having problems distributing their newspaper because people are
afraid that their newspaper is covered with anthrax, and in
fact people apparently--we're getting reports that people are
apprehensive of going into supermarkets where their newspapers
are distributed for fear of getting anthrax. So, I mean, you
know, we have a public health crisis right now. I mean, if you
can respond. I mean, because--just respond in terms of what's
going on now, if you can.
Ms. Smithson. This country was viciously attacked on
September 11, and in much of what I have seen in the media in
the succeeding weeks with regard to bioterrorism, we've been
traumatized all over again. I have to echo Dr. Young's remarks
in that regard. There have been a lot of people on TV saying
things that I don't recognize to be technically true.
With regard to the case in Florida, first of all, it is
clear, at least as far as I understand from people that I've
talked with and involved with the investigation, that this was
a substance on a computer keyboard. If this were an attempt at
mass casualty terrorism, the delivery method would have been
much, much different.
Second of all, I think that it would be appropriate for me
to actually turn your question about the response over to
others who have been involved in that system, but, before I do,
I would encourage you to look at what terrorists have actually
been doing with these substances and to perhaps keep your mind
open that this is the type of case that would be a grudge or a
vendetta or a disgruntled worker.
We've had disgruntled workers sprinkling Shigella on the
breakfast donuts in a hospital not so long ago, so occasionally
individuals do turn to these substances to harm other people.
Mr. Deutsch. There is no question about disgruntled
employees is also the theory. All of us have become experts in
theorizing and movie writers over the last couple of weeks, but
I guess, you know, first of all, in terms of the job of this
committee, you know, we have continuously been told that this
is a very difficult substance to obtain. We're now told that
this is a substance which is nonnaturally occurring, so, you
know, it is in a very limited capacity. So, you know, there are
very smart, very vicious people out there; and I don't doubt
it's possible that this is a case of a disgruntled employee,
but this is a real case going on.
No. 1, you know, if the only substance--and we're not aware
of this at this point in materials of this committee. If the
only location of that anthrax in that building was on the
keyboard, you might have more information than any of us have
right here; and, if that's the case, I'd be happy for you to
elaborate on it. So that would be No. 1.
No. 2, though, there's still the issue of how it became
inhaled. If it was on a keyboard, the person who died inhaled,
which again apparently is a very, very bizarre, you know,
unusual case of anthrax. I mean, there have been many cases of
the--through skin?
And I still question, just--you know, we have a situation
that now this occurred last Thursday. We still don't know. I
mean, today is Wednesday. You know, it goes back to the
question Dr. Young mentioned. If you have the response which is
Cipro or whatever in terms of preventing mass casualties, then,
you know, we're almost a week later, and again my understanding
is that once you got it, you got it. I mean, you can do
prophylactic antibiotics, but you can't do it afterwards.
Dr. Brinsfield, do you want to respond?
Ms. Brinsfield. Although I'm certainly not the most expert
in this of people in this room, anthrax is a naturally
occurring organism that occurs throughout the world. It is not
as difficult to obtain as it is to aerosolize and cause a mass
casualty incident.
The other thing that I think is important to say is that
when you define terrorism as the creation of fear, you know,
maybe we have to look at ourselves and wonder what we're doing
to stop that spread of fear. The idea that they decontaminated
an entire building based on one letter sent to them is a
colossal waste of money, time and the public's attention; and
it just really I think behooves us to look at controlling how
people know about this and how they respond to prevent the
creation of fear.
Mr. Deutsch. If I can just respond, and obviously not
having as much medical training as anyone or disaster training
as anyone on the panel, I'll tell you that one of the problems
is misinformation, not just in terms of pundits but
misinformation in terms of the government. We're getting
reports back, and they almost become circular. We get reports
that it's naturally occurring. Now we're getting reports that
apparently it was not naturally occurring anthrax, which seems
to be the latest situation. Then we're getting reports that it
can't be, you know, ascertained, the aerosol issue, but this
gentleman clearly had inhaled anthrax. Right. So he--but
apparently you can't get it by taking your finger and touching
your nose. I mean, there's 5,000 spores that you would have to
get into your nose and breathe in. So, you know, you're the
experts here, and you can't tell me anything--or you can try.
Again, I know time is up, but the last two responses. Yes,
Dr. Waeckerle.
Mr. Waeckerle. I guess there are two issues here. The first
issue is I'm reluctant to speculate on information that is
tenuous with Dr. Lillibridge behind me and knows the answers to
these questions, but I will tell you that--to some of the
questions. I don't want to put Scott on the spot here, but--
well, I do, but it's okay. But I do think that there's two
issues that have come about that you bring up that are terribly
important.
The first issue is how do we effectively communicate with
the media as the authorities--the knowledgeable authorities
that our citizens look to for reasonable, rational and accurate
information? And I believe that this hierarchy that we've asked
you to create in these management protocols, whether they be
local or national, should address that specifically.
The second issue that you bring up is an incredibly
important issue that I believe your committee attends to, and
that is the dealings with the pharmaceutical industry and the
availability of drugs and vaccines. And there are significant
problems with drugs and vaccines that are available for this
type of an organism and the capacity to produce them, the
research and development of them and the technical barriers and
legislative barriers that the pharmaceutical industry must face
with regard to these.
So there are some issues that I think you've brought up
that are terribly important that I hope you pursue, sir.
I do think that the answer to some of your questions, which
I believe some of us can speculate on about not having the
accurate information, we could talk to you about the inhalation
of spores or what happens when you touch your nose or what
happens if you open an envelope and smell it or what happens or
how you spread it, but--and there is accurate information, and
there also as I understand it maybe some laboratory diagnostic
tests now that may be available in some areas that are not
available to all the local communities. So I would hope that
you'll get some answer from Dr. Lillibridge and others on that.
Mr. Greenwood. The time of the gentleman has expired.
Dr. Young, very briefly, if you have a comment.
Mr. Young. Yeah. I was working with spore farmers while
Scott Lillibridge was still in knickers. So I want to try to
answer a little bit on your question directly.
First of all, it's important to note that you can
aerosolize spores. They will last a long period of time, but
you do have to get the amount up into the nose. But the second
point that's most critical is to get accurate diagnostic
information and to get it fast.
There's two parts to the case. One is related to any
criminal activity, and the other is looking at what the
organism is, per se. The most important thing for the American
people to know is that it takes a significant dose of the
organism to get the disease. You're not going to get the
disease from a few spores on the keyboard, and you're not going
the get the disease from a few spores on letters. Will you find
it in both places and anytime people handle it? The answer is
yes.
One time I wanted to get an organism from a Japanese worker
in Japan who didn't want to send it who was a spore farmer. I
got his letter. I put it in pen. assay broth, incubated it, and
I had his organism because he had scratched his face, his nose
and elsewhere, and I could get the strain from there.
Finding the organism in a place does not mean disease.
Having disease does not mean an epidemic. We've got to be very
careful with the language we use.
Mr. Deutsch. You know, if I can ask one final question with
a show of hands, not with an answer. If I gave each of you
letters from the American Media company right now, if I gave
you copies of the National Inquirer right now that were
published at that facility, would you just open them
automatically, or would you try to get responses? I mean, just
show of hands, all of you. Would open them automatically?
Mr. Greenwood. The time of the gentleman has expired.
Some would argue that the tabloids are toxic by definition.
I recognize the gentleman from North Carolina, Mr. Burr,
for 5 minutes.
Mr. Burr. Mr. Chairman, one of the things that is certain
is the definition of experts has changed since September 11,
given the host of individuals that we've seen on and the fact
that they're not always as consistent as the next one. I want
to thank each one of you for very thoughtful and very
informative testimony.
Dr. Smithson, let me turn to you real quickly, if I could.
You talked a little bit about the vaccine and antidotes that
were needed. We've certainly had a number of news reports of
late as it relates to anthrax vaccines, the slow start that the
Michigan company has that--not only transitioning that business
that was owned by the State but receiving the approvals from
the FDA relative to production outside of the military of the
vaccine.
There have been a number of commissions on terrorism.
Several of them, if not all of them, have come to the
conclusion that the vaccine manufacturing and potentially the
antidote manufacturing must be done in a Federal manufacturing
facility to assure us in some way, shape or form that we have
the vaccines available and in the right supply. Would you like
to comment on whether that function should be Federalized or
not?
Ms. Smithson. It's not just limited to the anthrax vaccine.
The plague vaccine is not being manufactured anywhere at
present, as far as I understand. And even on the chemical side
of the house, we just have one company in the United States
that makes Mark 1 kits. We've got to keep, you know, looking
across the spectrum at our manufacturing capabilities, and I
think there should be serious consideration given to
Federalizing some of these manufacturing capabilities, not just
for the supplies that might be needed to vaccinate our soldiers
but for the supplies that would be needed to get to the front
lines at home, to our first responders at home.
Mr. Burr. Is it your belief that the private sector cannot
fulfill that function?
Ms. Smithson. I think we need a public-private partnership
in this, and there needs to be a Washington-led effort, in
combination with the U.S. pharmaceutical industry, to bring
that about.
Mr. Burr. Let me----
Ms. Smithson. Surge capacity----
Mr. Burr. Let me suggest to all of you that there's a very
fine line there between a Federal entity and a partnership, and
I know that I think in your testimony I think Dr. Young alluded
to the fact. We have a budget currently of about $322 million
over 10 years that was to address the joint vaccine acquisition
program. Given the fact that a new pharmaceutical runs in the
neighborhood of about a quarter of a billion dollars from start
to finish, $322 million looks like a drop in the bucket for the
funding of an entire vaccine program. Would you agree?
Ms. Smithson. Yes, indeed I would.
Mr. Burr. The current timeframe, if I remember correctly,
is somewhere between 9 and 15 years, relative to the FDA
approval of a vaccination.
Ms. Smithson. And that timeframe does not address the fact
that the clinical trials in these cases must deal with diseases
that are lethal. So that's why the FDA is having such a
difficult time wrestling with this.
Mr. Burr. Dr. Young, you referenced to a date, 1999 or--I
can't remember what it was--where the FDA was directed I think
to put together a final regulation or a set of procedures, a
directive that they receive, and they still haven't put that
together.
Mr. Young. That's affirmative, and there has been dialog
with the docket branch trying to speed that along.
Mr. Burr. Ambassador Bremer in, I believe, 2000 when the
National Terrorism Commission gave their report--let me read
you one of the bullets: A terrorist attack involving a
biological agent, deadly chemicals or nuclear or radiological
material, even if it succeeds only partially, could profoundly
affect the entire Nation. The government must do more to
prepare for such an event.
Dr. Stringer, have we done anything different since that
report came out before September 11?
Mr. Stringer. I think there's a lot more interest in WMD
preparedness, WMD training, funding from every level of this
country. I just hope it won't go away when the televisions go
away, because that's been the frustrating thing since 1995 when
we started this, trying to get adequate funding for any of the
initiatives.
Mr. Burr. The General Accounting Office on October 10 of
this year put out a report. Let me read you just a section of
it. It said: Federal spending on domestic preparedness for
terrorist acts involving WMDs has risen 310 percent since
fiscal year 1998, to approximately $1.7 billion in fiscal year
2001, and may increase significantly after the events of
September 11. However, only a portion of these funds were used
to conduct a variety of activities related to research on and
preparedness for the public health and medical consequences of
bioterrorist acts.
Dr. Young, can you shed any light on where the hell this
money is going?
Mr. Young. Well, I've been trying to track the same thing,
Mr. Burr, but I think I can give you two points. One, the funds
were set out in regards to the teams that Lew spoke of. That
was a major initiative, about 600,000 for 1997, soon to be 120
teams. There have been exercises that went from the Federal
level down to the local level, and that consumed a significant
amount of the public health monies.
There's another point that I think ought to be added, and
when you read the note that--or the letter that I sent to the
President with the other committee, you can see the emphasis on
research. One of the things that I've been concerned with is
just-in-time therapy, and I've given you some information in
Appendix 3 of just such an approach, because not everyone will
be vaccinated, and there are therapeutics under development
that can intervene and detoxify and remove the viruses.
Those types of efforts in research needs to be coordinated.
DARPA has done some research in that way. FDA has a little bit.
NIH has, CDC, but there is not a global look as to what type of
research is done.
This is, in a sense, a war. There needs to be a focus, in
my opinion, just as we did in World War II, to look at the kind
of research that's needed, fill the gaps, and support the
grants and contracts to do that.
Mr. Burr. Well, clearly, there's a renewed interest in
fulfilling that mission.
Dr. Stringer, let me ask you one last question. As one of
four national medical response teams, the pharmaceutical
inventory that you must have to be able to be deployed and to
address a potential casualty in a city of 100, 200, 300,000
people must be massive. Do you have such a drug inventory?
Mr. Stringer. We carry on board the trucks a thousand
patient doses and then a stockpile, an additional up to 10,000.
Then there's the--coming behind, the national pharmaceutical
stockpile with a lot larger footprint.
Mr. Burr. But from a standpoint of that national
pharmaceutical stockpile, that's not at SORD or the other
three?
Mr. Stringer. No, sir.
Mr. Burr. Medical response----
Mr. Stringer. They're in secured locations across the
country. They can be in within 12 hours, and it was sort of
neat to see in New York they didn't get there in 12 hours. It
was a much shorter timeframe, which we're all proud of.
Mr. Burr. We're extremely fortunate.
Mr. Stringer. The birds weren't flying that day.
Mr. Burr. Well, we were extremely fortunate also that this
happened in New York, which may have been the best city as far
as their preparedness.
I will ask one last question with the chairman's
indulgence.
I made a statement during my opening statement that
Governor Ridge has to have the budget authority and oversight
responsibilities for every penny that is directed toward
response and preparation for bioterrorism.
Is there anybody who disagrees with me on that, on this
panel?
I will show that there are no hands raised. Everybody is in
agreement that that budget authority needs to be extended.
I yield back.
Mr. Greenwood. The Chair recognizes the gentleman from
Michigan, Mr. Stupak, for 5 minutes.
Mr. Stupak. Sorry I missed some of this, but I ran down to
do a press conference, because once again--for the last 5 years
we are trying to do a food safety bill, and actually it is in
this GAO study about how food safety or foodborne incidents can
result in terrorism in this Nation. And we put in new authority
there for the Secretary.
So I am--just a little reminder to everybody on the panel.
I hope that they take a look at our legislation, and we can
move it along, because it is a major concern in this country.
Our imports of food have gone up 200 percent in the last 5
years, yet we inspect only 1 percent of food coming into this
country. So you can see it could lead to some real problems if
the right substances were added to our food. So we should take
a look at it.
But we are talking a little bit about money here, and it
came up quite a bit, and if you take a look at what is going
on--Mr. Peterson, you mentioned that Johns Hopkins will spend
up to $7 million, you said. Will you be reimbursed for any of
that, for any kind of program through the Federal Government,
State or local?
Mr. Peterson. Right now there is no direct source for
reimbursement other than through our ongoing patient revenues.
But that is a budgetary item on the expense side of the ledger
of budgetary impact for which we did not have a plan.
Mr. Stupak. Sure, you didn't have a plan. What will it cost
you a year to maintain that, supplies and things you need?
Mr. Peterson. We have not been able to determine that. But
that is a one-time startup situation.
To your very point, there will be ongoing costs to
replenish consumables. Probably, if I had to guess, at least a
quarter to a third of that number.
Mr. Stupak. You're a big hospital complex. I am sure $7
million is not insignificant. But how about regional hospitals
around the Nation?
Take northern Michigan where I am from, we are hundreds of
miles apart from a regional hospital. How would they be able to
do it? Just be prepared like you are?
Mr. Peterson. I think the point is that there will probably
be different needs at different hospitals. And the other point
that I would make is that I do endorse the notion that was
suggested earlier in the day, which is that we do need to
engage in a more regional approach. There needs to be some
rational planning that goes on so each and every hospital is
not engaged in duplicative activities.
Mr. Stupak. You mentioned the nurses shortage. The
legislation that is pending before Congress is good
legislation. Any other suggestion you would make on that
legislation to increase nurse availability throughout the
United States?
Mr. Peterson. I think anything we can do to provide
incentives for young women and men to enter the health fields
is a good investment, a good thing to do for this country.
It is not just nurses. We have evidence that there are many
other skilled categories of workers in health care for which
there is a growing scarcity.
Mr. Stupak. Thanks.
Dr. Smithson, you had mentioned money in your opening
statement, and I missed it--something about $1.7 billion or
something--but very little gets outside of the Beltway. Could
you explain that again? I missed part of that.
Ms. Smithson. The Federal funds being spent this year on
readiness are $8.7 billion, with $311 million getting to the
local level in training, equipment and planning grants.
If we are to look at the public health sector and the
hospital end, even a small fraction of that $311 million makes
its way there.
Mr. Stupak. Thanks.
Dr. Waeckerle, you participated in OPERATION TOP OFF, you
mentioned, in Denver.
Mr. Waeckerle. I was asked to oversee it. I didn't
participate in it, sir.
Mr. Stupak. It is my understanding that the FBI was in
charge of the crisis management and FEMA was in charge of the
consequences management. So where did the public health
officials come in? Did they have to go through FEMA and FBI to
do anything?
Mr. Waeckerle. One of the panels has unanimously
recommended that you have a central authority with command and
control and the ability to communicate vertically and
horizontally, if you will allow military terms, because as
you--you probably know already that that was a disaster. And
that was one of the major lessons learned from OPERATION TOP
OFF.
And, in fact, there were open disagreements as to who was
in charge at what point in time, and they adversely affected
the drill and, theoretically, they would adversely affect any
real events that might occur in this country. And that is why
we have implored you all to look at the authority and command
and control and communications issues.
Mr. Stupak. Okay.
Dr. Brinsfield----
Mr. Waeckerle. I just had one suggestion for your law, and
I apologize to my colleague for interrupting.
One of the great issues that the hospitals face in this
country are credentialing and staff privileging issues, as well
as State licensure issues. If we wish to supplement an
institution's nursing staff or radiology staff or physician
staff--and while I apologize, I haven't read your bill in
detail, I hope that you have addressed the fact that we have to
somehow create States that border on each other working
together, so that they can share licensing, credentialing
issues, as well as hospital and regions doing that; so we can
have surge capacity and supplement from an unaffected region to
an affected region of our country with critical health care
personnel. And I hope that that is addressed.
Thank you.
Mr. Stupak. Thanks. If I may have one more question.
Mr. Greenwood. We will have a second round. But the Chair
has been very indulgent.
Mr. Stupak. Okay. You said the domestic preparedness
program failed because of its stand-alone nature and the lack
of follow-up. Could you just elaborate a little bit on that for
me?
Ms. Brinsfield. I think that it did several things well. I
think one of the things that it failed with was that its
oversight changed over the time that it was put out, and that
it was a single program and a single day training, and there
was no follow-up.
So, in Boston, we received that awareness level of training
over 5 years ago, and there was no training that came as a
secondary follow-up to move ahead.
Mr. Stupak. Thank you.
Mr. Greenwood. The Chair thanks the gentleman.
The gentleman from Iowa, Mr. Ganske, is recognized for 5
minutes.
Mr. Ganske. Thank you, Mr. Chairman. Appreciate the
testimony of the panel.
Last night, when I gave a floor statement on this issue, I
talked a little bit about the problems with different agents;
and then I asked the question, what can we do?
And this is--these were my thoughts last night. I am glad
the panel is in agreement with them.
First, we need better coordination between the Defense
Department and the State Department, the Agriculture
Department, the CDC, the State public health departments and
directors, the city-based domestic preparedness programs. And
that is a job that I gather this entire panel feels would be
appropriate for the new Director of Homeland Security to
address.
Second, we must make a systematic effort to incorporate
hospitals into the planning process.
I appreciated your testimony, Mr. Peterson, because I think
it is accurate to say that there are few, if any, hospitals
today that are prepared to deal with a community-wide epidemic
of the type that we could envision for a whole host of
financial, legal and staffing reasons, some of which you
entered into, and went on to say there will be significant
costs for expanded staff and staff training to respond to
abrupt surges in demand for care--as you mentioned, outfitting
decontamination facilities, rooms to isolate infectious
patients, cost of respirators and emergency drugs.
The first serious efforts to implement that civilian
program to counter that was in 1998 when Congress started to do
this. But then I went on to say that we had to do more to
integrate Federal, State and city agencies.
First, we have to educate the physicians of public health
staff about the clinical findings of agents--not that easy
because, as all of you know, the beginning symptoms on those
are nonspecific upper respiratory, GI. We need to develop
further surveillance systems for early detection of cases.
We need individual hospital and regional plans, as you have
mentioned, for caring for mass casualties. As you have
mentioned, Dr. Young, we need laboratory networks capable of
rapid diagnosis; I think that is really, really important. And
we need to accelerate stockpiling and dispersal of large
quantities of vaccines and drugs.
I recently visited Broadlawns Hospital in Des Moines, Iowa,
which is a public health hospital. We talked about some of
these things. For years we have neglected our public health
hospitals. We need to correct that.
But I just want to finish by making a--a generalized
comment. You were here today making these points, and I would
say that one of the main, overall reasons that you are making
those points is because under the HMO model of health care in
this country we have wrung out of the health care system any
redundancy in the quest for efficiency.
And I see everyone on this panel nodding their head.
There is no room for the surge of an epidemic in the health
care system today, because of the HMOs contracting with the
health system. Some of us would argue that they have gone too
far in certain circumstances.
So my point is this: Because of the way that we have
financed health care in this country and because of the cost-
cutting measures with managed care, we will be facing increased
Federal costs.
And I think everyone on this panel before us, and probably
every one of the Congressmen and Congresswomen here today,
would agree that Congress will be appropriating significantly
increased dollars to cover those problems, which you and I and
others have outlined.
So one way or another--you know, the costs are there, and
they will have to be paid for. If they aren't paid for through
the private health care system, they are going to be covered
hopefully through the government.
And with that I will yield back.
Mr. Buyer [presiding]. We thank the gentleman.
Mr. Strickland is recognized for 5 minutes for inquiry.
Mr. Strickland. Thank you, Mr. Chairman, and thanks to the
members of this panel.
As I have listened to you today and looked at your
testimony, I have heard over and over again the admonition from
you that you need more resources. And putting that in the
context of--I just can't help but think of actions that we have
taken in this Congress over the last few months.
We have talked--all of us, people in both parties, so I am
not being partisan here--we have talked over and over again
about the surplus this country has. Well, there may have been
an accounting surplus in a budgetary sense, but it is evident,
I think to all of us now, that we have been woefully neglectful
in terms of dealing with the real needs of our population.
We have neglected to fund these kinds of activities as we
should have, and now we are trying to play catch-up.
And so I want to thank you. I think you are all incredible
in terms of the message that you are bringing to us today.
Mr. Peterson, I have here an article from the American
Journal of Public Health, and there is a study discussed here
regarding the preparedness of hospitals to deal with certain
terrorist incidents and so on. The conclusion is, hospital
emergency departments generally are not prepared in an
organized fashion to treat victims of chemical or biological
terrorism.
Now, you have stated that hospitals must be properly
stocked with antibiotics, antitoxins, antidotes, ventilators,
respirators and other equipment. You have talked about what you
have done at Johns Hopkins. But the question I would ask, would
you give us an idea of the volume you are suggesting?
Who do you think is going to pay for it? And who is going
to make sure that such supplies and the like are in place? How
do we guarantee that what you are saying needs to be done is
actually done? And how do we pay for it?
Mr. Peterson. First of all, let me respond by saying, I
think it is important to recognize that at the individual
hospital level, it is important that we attempt to do two
things. One is to introduce a rational way of thinking about
what any one hospital needs to prepare for. And what I mean by
that is that the hope, of course, is that if any one hospital
or hospitals in the region are dealing with a catastrophic
happening that help will be on the way at some point after the
first couple of days.
Let me use that frame of reference so that as we are
thinking about what our responsibility is at the local
individual hospital level.
You heard me suggest that perhaps we need to have a stock
to handle 4 days' worth, and I use that because we think it is
our responsibility to be able to go for a couple of days. And
we would plan for that. We would spend for that.
Beyond that, it is our hope that help would be on the way.
So one way of responding to you is that the--the order of
magnitude of planning that is done at any one institution, I
think needs to recognize that in a catastrophic situation,
there would need to be augmentation of what any one institution
could do either in a physical way of thinking of it or in a
fiscal way of thinking of it. But I would repeat that I would
endorse the notion of some regionalization in how we think
about utilizing hospitals and their resources.
Now to how do we pay for it: It strikes me that given the
reality that was suggested with respect to how the system has
been reimbursed for services over the last several years, we
have been squeezed not just by the managed care phenomena, but
it is also fair to say that both medical assistance programs
and Medicare programs over the last few years have also placed
a squeeze on hospitals. So, in general, hospitals are working
with very, very slim margins, can barely manage their current
missions in that regard.
So I would have to take the point of view that we sit
before you and suggest, we do need some help. I don't know that
I can suggest to you that we should turn to the Federal
Government for 100 percent of that which we need to gear up to
do it, but I do think that we need to have some consideration
in the form of some direct grants.
Perhaps there can be a Federal reserve fund of some sort
that is developed. But--we can't do it alone, but we have a
responsibility to temper that which we do.
So what I tried to do today is provide for you, for a
fairly large hospital, a realistic depiction of what we think
we have to do at our local level; and I don't think that number
is unrealistic for the size of our hospital.
So I am not going to suggest that you multiply $7 million
times 5,000 hospitals. I don't mean to scare you in that sense.
But I do think that it is illustrative of one large hospital's
requirement, and I think it is a fairly responsible position
that we are taking in that regard.
Mr. Strickland. Mr. Chairman, may I ask Dr. O'Leary one
quick question?
Mr. Buyer. Yes.
Mr. Strickland. Dr. O'Leary, in your opinion, how would
your organization make local hospital planning for possible
disasters, such as we are discussing today, a part of the
accreditation process?
Mr. O'Leary. It is part of the accreditation process now,
as I mentioned in my testimony. It is part of the process now.
Mr. Strickland. It has been suggested to me that I ask
whether or not that includes having adequate supplies in place
in terms of the things we have talked about.
Mr. O'Leary. Well, the assessment that we have to make,
which is a--you know, it is all-hazards analysis and what are
the vulnerabilities and gaps, then identify the needs that have
to be fulfilled.
One of the things I think that we--our standards are
promoting is an engagement of hospitals with communities, but--
which is a broader statement of the need for integration
between the medical care and public health systems which is, we
are well short of that reality in a number of communities
around the country.
The fact that planning identifies needs does not
automatically mean that these needs are going to be fulfilled.
I think that is the kind of problem that--we can't mandate
that, but we can certainly advocate for adequate funding to
provide the supplies and the Federal guidance in terms of
direction for both risk analysis and setting priorities for
deployment of those resources.
Mr. Strickland. Thank you.
Mr. Buyer. You know, in response to Mr. Strickland's
comment about neglectful, I am not so certain who he was
targeting the comment to, but I do know, as a people, as a
society, there were things that we were--we weren't prepared
for.
I can't blame Congress when I look back on this post-
Oklahoma City.
You know, Bill Clinton and I did not exchange Christmas
cards. But I can tell you that I have to compliment him because
he began to help focus the country on weapons of mass
destruction. He appointed the then-CINC of SOUTHCOM, General
Hugh Shelton, as his Chairman of the Joint Chiefs of Staff,
someone who operated in the dark world of Special Operations.
That was very wise of him to do that.
When--when Senators Nunn and Lugar then passed their
measures to focus the country on preparedness for weapons of
mass destruction, you know, DOD takes up the program, we shift
it over to the Department of Justice, yet States and localities
don't prepare their plans.
There is Federal money available, but they don't even do
it. Only four States have done that today. So even--even here
as the Federal Government prepares a program and says, you
know, offer us your plan, we will help you in your training and
preparedness for your medical readiness, it wasn't even done.
So maybe it was the country, Mr. Strickland, when I think
about that. I even remember Joe Biden, Senator Biden, and I,
who don't always agree on things were at a conference committee
under the antiterrorism bill. And we tried to change
wiretapping from the rotary phone to the person, and we
couldn't even get it out of conference.
Now the judiciary passes it in a flash fire.
Mr. Strickland. Can I respond, sir?
Mr. Buyer. Sure.
Mr. Strickland. I wasn't directing that comment to anyone.
As I said at the beginning, this is a matter that all of us, I
think, have to assume some responsibility for.
But the fact is that we haven't in the past been thinking
as we should have been thinking. And I think we have all
learned a great deal in the last few days and weeks. And
growing out of that learning, I hope comes a change of policy
and setting of priorities these folks can help us with.
Mr. Buyer. I can even tell you--gosh, I have to look back
almost maybe 24 to 28 months ago as chairman of the Military
Personnel Subcommittee--taking the Top Secret briefings,
talking to General Zinni about the ever-present threat of
anthrax and then authorizing the anthrax vaccine with regard to
our soldiers. Very controversial.
I had--in the last election, I had billboards against me
for having done that. Can you imagine? And now, I am getting
the, how come other people can't get the shots? Now, isn't that
a change?
And there was--something was brought up by Mr. Burr earlier
in a comment--Dr. Smithson, you made--about public-private
arrangements. That is what we have with BioPort.
Ms. Smithson. It is not working so well.
Mr. Buyer. We held a hearing on that issue. We cannot find
a pharmaceutical company that is willing to take that program
at risk. Are you familiar?
And I suppose if--if we are going to mandate that, do, you
know, a population, then you would have all kinds of people
saying, oh, yes, we would like that public arrangement. But
when we don't have it, then we--I can tell you the conclusion
was a sole-source contract in a public-private arrangement,
i.e., an anthrax vaccine.
I just wanted to share that with you, what we have been
doing with regard to our hearings.
I do have a--my question for you is, you took a lot of time
to prepare your testimonies. I read them last night. But let's
sort of concentrate it. Give me a one, two. And we will go
quickly down the line of the one or two most productive things
Congress could do right now. Just give me two bullets.
Dr. Smithson.
Ms. Smithson. Get the money outside of the Beltway to the
local response entities.
Two, and I am going to kind of make this a duo. Please make
grants for regional hospital planning and institute early
warning disease syndrome surveillance across this country.
Mr. Waeckerle. To paraphrase the distinguished Member of
Congress, I am just a country doc from Kansas City; I am not
real familiar with all of the politics. But I will tell you
this, we have been clamoring for years to have a central
authority to manage the money and get it to the local
community. We have to have a central authority. It cannot go
through 50 different Federal agencies, who are redundant and
don't even talk to each other.
The second thing is, the money needs to get to the local
resources. But we have to rebuild the local resources--the
hospitals, the emergency health care personnel associated with
them, and the public health infrastructure--at the local level.
Thank you.
Mr. Buyer. Thank you.
Ms. Brinsfield. I think if I have to choose two, it would
be to make sure that training and equipment and protective
equipment makes it to the local level, mostly to the emergency
medical personnel, the hospital personnel and public health
personnel that are really lacking that right now.
And the second, these needs to be a coordinated response
and it needs to stay coordinated to prevent the agencies, on
the local level, from splintering.
Mr. Stringer. The funds should go to the States to
coordinate regionally in the State, county, city efforts. Get
it out of the Beltway.
Second, job protection for the Federal response personnel
so that they have a job when they come home. I have a real
problem with that, I think this country would be hard pressed
if you tried to find 7,000 immediately.
Mr. Peterson. Local hospitals stand prepared to do their
part, but are at this point in history, deserving of some
additional fiscal relief to assist in the local planning that
does need to go on.
However, having said that, the hospital community would
welcome the introduction of a more coordinated approach. We
would stand prepared to participate willingly and would
welcome, in fact, the opportunity to, if you will, to take
direction.
We think there is an indication at this point in time for
more planning that is actually centrally promulgated.
Mr. O'Leary. It is pretty clear that we need a national
coordinated and integrated plan of response. I don't think that
we can count on our communities to come up, and being isolated
with the priorities, there needs to be guidance from the
Federal Government. I think Mr. Ridge has the opportunity to do
that.
And then we ought to create the models for planning within
these communities and hold these communities accountable for
making sure that necessary plans actually work. That is one.
Second, you know, it is easier for me to say than some of
the other panelists, but our medical care delivery system is
starving. This is not just on the bioterrorism. We see
understaffing, we see it in emergency overcrowding. It is time
to wake up to this issue. And it doesn't mean that we need to
return to where we were in the 1970's and 1980's, but we need
to think strategically about how to reintroduce resources in
this system that permit us a surge capacity. That is real.
Mr. Young. To develop a central command and control at the
Federal level that extends to the State and local, with each of
the entities integrated and able to work together. They should
have control of resources, personnel, training, supplies, and
the ability that Lew mentioned on protection of jobs.
I would also urge that Congress to have a single command
and control on hazard response and that there be a single
oversight committee, not multiple ones that bring individuals
as witnesses at different times.
That is my first recommendation, single command and control
administration and Congress.
Second, a rapid diagnostic capability that has the capacity
through development of new tests from research to identify in
minutes to hours by immunological means rather than culture and
sensitivities. We have done that on cerebral spinal fluid, for
meningococcal infections, pneumonococcal infections and others.
This is a no-brainer and not that difficult to do.
Linked with it, a whole concept of just-in-time therapies
which not only include antibiotics and vaccines, but
immunotherapies that can be used to interdict toxemia, and
viremia at the time it is occurring in a nonimmune population.
Those two issues would go a long way toward solving--and
Mr. Chairman, you may not have seen, but I did put the letter
to the President in 1998 which led to the kickoff of the
terrorism response. And I would go on record that Mr. Clinton
has done a remarkable job in bringing bioterrorism and chemical
terrorism to the fore, and echo what you said in that the
Nation is indebted to him.
Now is the time to take the next step.
Mr. Buyer. Thank you.
Before I yield to Mr. Rush, I want to thank all of you on
how you answered Mr. Deutsch's question, so there is not a
panic out there with regard to the anthrax. I really respect
the way you answered that question.
Mr. Rush.
Mr. Rush. Thank you, Mr. Chairman.
I also want to add my voice of congratulations and
commendations to all of the panelists in what I have been able
to ascertain. This has been a very, very important and cogent
hearing, and I appreciate all of your comments.
I must say to you that I was a bit tardy coming to this
hearing because I was upstairs. I had a meeting with a major
hospital in my area--the president; and they were concerned
because there is an effort by the VA to close a hospital, major
VA hospital in my city. And ironically we were meeting at the
same time, and it just clearly indicates to me the kind of
disjointed approaches that we take in the Congress and as the
Federal Government in regards to the whole area of public
health and the public health system.
It's indeed contradictory at worst--at best, rather, for us
to--the VA in this climate to be entertaining closing down a
hospital dedicated to veterans. And so I just wanted to say
that.
I wanted to ask a question. It seems to me that over--since
I have been a Member of Congress, and even prior to that as a
member of the city council in the city of Chicago, there has
been almost a total breakdown in the public health system
across the board. In my area, hospitals have closed down,
hospitals that have served the inner city communities; and
cost-cutting policies have reduced medical care and--medical
facilities to medical resources to a large portion of our
Nation's citizens.
And I am--I--last--I believe it was about a week ago, the
Nightline Show, I saw this enactment of what would happen if in
fact a bioterrorist would invade the city with some chemicals
and what would happen. I saw the buildup in terms of the
afflicted citizens and how they responded, and I saw how the
medical profession, the hospitals, started out with a steady
stream to the point where they became overrun with victims.
And it really, again, is kind of--it really clearly
indicated to me that there is a problem in terms of
preparedness in response to this type of unfortunate event,
that if it had--would occur in our--in one of our major
American cities.
And so, Dr. Peterson, my question to you is, how can we
balance concerns over cost with the need to be prepared for
public health emergency? I mean, is there a way that we can--
that you suggest that we try to figure out? How do we deal
with--certainly cost is a reality.
Mr. Peterson. As I suggested earlier, I think it--it starts
with the requirement that we who are currently responsible for
running the Nation's hospitals, that we need to take the
responsibility to have a rational approach to what we are doing
at the local level.
And that is why--and I don't mean to be repetitive, but I
would suggest that we need to take, along with governmental
entities, a leadership role in training, to rationalize how we
do our preparedness planning as it relates to this kind of a--
of a possible incident. And, therefore, I do not believe that
it is prudent for each and every hospital to go out and assume
that they have to--to be prepared at a level that is consistent
with perhaps what a Johns Hopkins, if I may use the name of my
own institution, would do.
So that is the first point.
We do need to balance, as you suggest in your statement, in
your question, the reality that we are starting at a baseline
that unfortunately is much lower from a fiscal health
perspective than any of us would like. And so, therefore, I
can't disagree with what has been said among my colleagues on
the panel or what has been said by the members of the
committee, that indeed we don't have much surge capacity today.
So I think what we need to be about, we are trying to do at
our local level is, we are trying to be as responsible as we
can. I have authorized a certain amount of, if you will,
overspending beyond my budget authority, and it is my hope that
we will be able to solicit some consideration from the Federal
Government to have some relief. We think some relief is
indicated, but we have to take responsibility to not go
overboard in what we are doing.
We are trying to be as prudent as we can in our response.
But we have to do more now that we better appreciate, that we
as a hospital community appreciate a little bit more subsequent
to September 11, what we may be dealing with.
I have to suggest to you that if you go back in time, only
a couple of years ago and maybe even before September 11, for
many of us the notion of bioterrorism was certainly not on the
front burner. It needs now to be on the front burner and there
are some different things that one must do to prepare for that
eventuality that then--in contrast to what one does for other
types of disasters.
So that is the way I would respond to you, sir. And I think
that we are dealing with a--a terribly complex balancing act,
given where we are starting from a fiscal point of view.
Mr. Rush. Mr. Chairman, the doctor wants to respond to my
question also.
Mr. Waeckerle. Thank you. I would like to make two
comments, because I think this is incredibly important, that we
need to discuss this for your benefit.
First of all, it would be hypocritical for us as health
care professionals to come to ask you if we didn't commit. And
I think, Mr. Peterson, the American College of Emergency
Physicians and everybody here can promise you that we will
commit, too. This is a partnership.
But I think what we are trying to ask you to do is just--
the people trying to do the job, and to add a job on top of it
is the reason that I want a central authority to oversee and
manage everything--is all of the money that Dr. Smithson is
taking about is available to us, but it never gets to us.
If you get the money to the health care professionals, the
hospitals, to the public health, to the professional
organizations that train the nurses and the doctors and the
EMTs, and you bypass the bureaucracy that heretofore has
plagued us, it becomes a much more efficient and much more
effective process; and I believe will garner a greater gain
than any of us ever dreamed of.
And that is a challenge we all face together.
Mr. Rush. Dr. Smithson.
Ms. Smithson. Actually, in her testimony, Dr. Brinsfield
illustrated how a Federal-local partnership might work with
regard to an emergency cache of pharmaceuticals. Under the MMRS
program the cities were given moneys to purchase
pharmaceuticals, but what the locals have to figure out how to
do is put that pharmaceutical cache in a bubble so that it is
replaced before the dates of expiration. That costs money, and
that needs to be a commitment on the local level.
So for each of those different areas, we need to figure out
how to share that Federal and local burden.
Washington can go about this the ineffective and costly way
or they can go about this the smart way in giving the locals
the money to do the planning that would allow them to overcome
some of those surge capacity problems, so that the hospitals
can have a game plan for how to meet a surge of patients that
need isolation capability by simply transforming wards to that
type of patient care, as opposed to building new isolation
capacity.
There are near-term solutions that are cost effective, as
opposed to some of these other things that may be considered in
the long term as advisable. There are ways to get about this.
Mr. Greenwood. The time of the gentleman has expired.
The gentleman from Florida, Mr. Stearns, is recognized for
5 minutes.
Mr. Stearns. Thank you, Mr. Chairman. The question I have
is for Dr. Young and perhaps Dr. O'Leary.
In my hometown we have two major hospitals. And in this
world of free market, these hospitals will start to grapple
with these problems and they will start to develop individually
their own disaster plan dealing with terrorism; they won't be
consulting, hospital to hospital, with other groups.
Do you think there is a potential for double-counting of
the hospitals doing the same thing and perhaps not knowing what
one hospital is doing, or the other? Is there some way perhaps
to have the staff and supplies brought together from the two
hospitals? And should this be done on a national level so that
hospitals and physicians and everybody cross-pollinates on this
in the event of a crisis?
And how could it be done, I guess?
Mr. Young. That is an excellent question, sir. The reason
that I think Boston and New York did so well is that they
focused on working together among the hospitals, as Mr.
Peterson said. I personally went up to Boston, met with a
variety of hospitals and the public health and medical facility
managers and also with the EMS and the MDMS teams. That was a
very helpful catalyst. It brought us all together, and we began
regional planning. And Boston made the commitment that they
would go out and work with the regional hospitals and try to
build a network.
What I would suggest, sir, is, just as we have talked
about, that there be regionalization, that the local people
have the ability to design their own system within guidelines,
and that we reward and design the system so that if you work
together and really don't each do your own competitive thing,
you get even more resources, rather than each person trying to
do their own work. I have found that where we have taken that
approach, in Boston, in New York, and in other places that I
personally visited that it went quite well and we saw the
people rise up together.
In fact, in New York City it was interesting. In the
meeting that the Mayor convened, as I described, many of the
people hadn't met each other before. Their responsibilities
were not outlined. And Dr. Letterberg and I walked through the
various scenarios. And Dr. Peggy Hamburg, who was then
Commissioner of Health, later became Assistant Secretary in the
Department of Health and Human Services, went out then and
organized the region.
Mr. Stearns. How should this originate today in my home
community or in my congressional district? Should I, as a
Federal elected officer, try to organize something like this;
or should the Federal Government institute a program, or
Governor Ridge provide designees that would come down to each
congressional district to develop a whole consultation program
much like that you did in Boston and New York?
I mean, how should this originate on a national basis?
Mr. Young. I would recommend, based on past experience,
that it come out of the new Department of Homeland Protection
and that there be actual visits within the communities.
Mr. Stearns. By someone from the Homeland?
Mr. Young. By someone from the Homeland Department in this
area of public health.
Mr. Stearns. To give them guidelines and to tell them what
to do?
Mr. Young. That is right. And to start coming--just going
there is an event of forcing action.
I don't think in a lot of places all of the individuals
would have gathered and planned if we didn't have an event.
When we first developed the concept of the metropolitan medical
strike teams, Lew, Susan Briggs from Boston and a number of the
other commanders were there, and then we took that program from
them out to the States.
Now, with this new organization, I think it would be highly
effective if there was a way to go into the regions. If you
were there, sir, that would give it an added, heightened view.
Mr. Stearns. Maybe congressional-wide consultation to talk
about how hospitals and emergency facilities and physicians
would act and use the guidelines from the--Governor Ridge's
office to debrief everybody.
Mr. Young. I would definitely think so. And I would be
interested in what Mr. Ganske says, as a physician. But I would
think that the joint action of Congress and the administration
could go a long way toward dispelling fear and mobilizing the
Nation to meet this.
Particularly, it brings together the medical, the public
health communities, the local communities that manage
emergencies and the teams that are there. And if the Congress
would join that, I think it would be another way to get the
proper attention from the media.
Mr. Stearns. Mr. Chairman, before I close, I have got a
question for Dr. O'Leary.
You can answer that one, but I just wanted to--you
indicated in your testimony that disaster planning is part of
the accreditation process, if I understand it.
Mr. O'Leary. That's correct.
Mr. Stearns. Have you told the staff--told the committee
what your success rate has been? I understand that you have
18,000 health care organizations. What has been the success
rate of these hospitals you inspect in terms of disaster
planning?
Mr. O'Leary. Well, the--I would like to come back to the
original question. The degree of compliance with the disaster
planning standards is actually quite high.
But we do have new standards in place--they went in place
last January--which moved to the issue that you raised
initially with Dr. Young. And that is the need to engage
communities as part of the planning process.
Hospitals are not solos in this process, and while they--
they may compete with each other in various communities, they
can also collaborate; and I think many of them actually do. Our
standards create the expectation in this engagement with
community that ``community'' is other hospitals, it is public
health agencies, fire fighters, policemen. It is everybody in
the community.
And I think it is--it is too early for us to answer your
question as to how effectively they are doing that. But you
will not be surprised that we are paying a lot of attention to
that issue in our survey process.
I think the question you may be getting at is, we have a
system of accountability for hospitals, but we do not have a
system of accountability for our communities. The hospitals are
like nodes around a command center. But the command center is
not well defined yet, nor is it accountable. And I think that
is an issue that merits the consideration of the Congress and
the new Homeland Security agency, to determine how that
accountability will be played out once an appropriate model and
planning is in place, because that really is a crucial issue.
That is a complimentary aside. The hospitals are only a
piece of the puzzle. There is a bigger puzzle.
Mr. Greenwood. The time of the gentleman has expired.
We thank all of the--the committee thanks all of the
panelists for being here with us these last 3 hours. We are
wiser for your testimony and your responses to questions, and
we will do our best to implement your suggestions.
We now excuse you and again thank you for your service. You
are welcome to stay for the balance of the hearing.
Mr. Greenwood. We now call the second and final panel
forward, beginning with Dr. Scott Lillibridge, Special
Assistant for Bioterrorism, Office of the Secretary, Department
of Health and Human Services; Mr. Bruce Baughman, Director of
the Planning and Readiness Division of the Federal Emergency
Management Agency; and Ms. Jan Heinrich, Director of Health
Care and Public Health Issues for the U.S. General Accounting
Office.
You are aware that the committee is holding an
investigative hearing and that, when doing so, we have had the
practice of taking testimony under oath. I need to ask you, do
any of you have any objection to giving your testimony under
oath?
No?
Seeing no objection, the Chair advises you that pursuant to
the rules of the House and pursuant to the rules of this
committee, you have the right to be advised by counsel. Do any
of you choose to be advised by counsel?
Okay. In that case, would you please rise and raise your
right hand.
[Witnesses sworn.]
Mr. Greenwood. You may be seated.
Dr. Lillibridge, you are recognized for your statement.
Thank you for being with us.
TESTIMONY OF SCOTT R. LILLIBRIDGE, SPECIAL ASSISTANT TO THE
SECRETARY ON BIOTERRORISM ISSUES AND FOR NATIONAL SECURITY AND
EMERGENCY MANAGEMENT, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES; BRUCE P. BAUGHMAN, DIRECTOR, PLANNING AND READINESS
DIVISION, FEDERAL EMERGENCY MANAGEMENT AGENCY; AND JANET
HEINRICH, DIRECTOR, HEALTH CARE--PUBLIC HEALTH ISSUES, U.S.
GENERAL ACCOUNTING OFFICE
Mr. Lillibridge. Thank you, Mr. Chairman.
I would like to thank the previous panelists. I learned a
lot. And I would like to thank Dr. Frank Young for introducing
me to the preparedness issues around terrorism. He put me on
airplanes, had me eat bad food and sent me all over the world.
Mr. Greenwood. Were you indeed in your knickers during that
time?
Mr. Lillibridge. I was indeed, perhaps, in my knickers at
that time and have developed a few gray hairs since then.
Mr. Chairman and members, I am Scott Lillibridge, Special
Assistant to the Secretary on Bioterrorism Issues, National
Security and Emergency Management Issues; and I appreciate the
opportunity to appear before you today to discuss the
Department of Health and Human Services' role in State and
local government preparedness to respond to acts of terrorism,
particularly those involving bioterrorism.
Clearly, preparedness and response issues are the order of
the day. State and local health programs comprise the
foundation of an effective national strategy for preparedness
and emergency response. No doubt about that. Preparedness must
incorporate not only the immediate responses to threats, such
as biological terrorism, but also must encompass the broader
components of public health infrastructure which provide the
foundation for immediate and effective emergency response and
long-term sustained response.
Those capabilities include the following--we have heard
many of these today:
Clearly, a well-trained public health workforce; Laboratory
capacity to produce timely and accurate results for diagnosis;
Disease detective work or epidemiology and surveillance; and
Secure, accessible communication systems both to and from local
health departments, to State health departments and from States
back to Federal entities like CDC. CDC has used funds provided
by the past several Congresses to begin the process of
improving the expertise, facilities and procedures of State and
local health departments to respond to biological and chemical
terrorism.
For example, over the last 3 years, the agency has awarded
more than $130 million in cooperative agreements to cover fifty
States and at least one territory and four major metropolitan
health departments as part of its overall bioterrorism
preparedness and response program. This program is new since
1999--fiscal year 1999.
We must continue to work with our State and local health
systems as part of our ongoing preparedness efforts,
incorporating many of the components that we have heard today,
in terms of their vital importance in responding to disease,
epidemics and large-scale outbreaks of activities such as what
is occurring in Florida.
The Health and Human Services Office of Emergency
Preparedness is also working on a number of fronts to assist
local hospitals and medical practitioners to deal with the
effects of biological, chemical and other terrorist acts. Since
fiscal year 1995, for example, OEP has been developing local
Metropolitan Medical Response Systems.
Through contractual relationships, the MMRS system uses
existing emergency response systems, emergency management and
medical and mental health providers, public health departments,
law enforcement, fire departments, and EMS and National Guard
to provide an integrated, unified response to a mass casualty
event, drawing them into a centralized planning activity and
bringing public health and medical folks to the table for the
first time.
As of September 30, 2001, OEP has contracted with 97
municipalities to develop MMRS systems, and the fiscal year
2002 budget includes funding for an additional 25 MMRS systems.
MMRS has continued to expand--or refine and expand our
medical preparedness at the most local level by requiring the
development of local capacity for mass immunization, mass
prophylaxis, the capability to distribute and stockpile
ingredients and local capacity to increase our ability to do
mass care.
I would like to mention a few indications from lessons
learned from previous responses such as the recent TOP OFF
exercise. This occurred in May 2000. This national drill
involved scenarios related to a weapons of mass destruction
attack against our population. However, the exercise that
simulated a plague outbreak in Denver still applies today to
many things that have come to light during this hearing. This
exercise, of course, involved FEMA, the Department of Justice,
HHS, Department of Defense and many other vital community
sectors that would play a role in an actual response.
Several things emerged, and we are still working toward
these entities. For example, improving the public health
infrastructure remains a critical focus of bioterrorism
preparedness and response, and such preparedness is
indispensable for reducing the Nation's vulnerability to
terrorism related to infectious agents.
Second, we need to increase our current and very limited
surge capacity in our health care system through issues ranging
from local planning to local health care system expansion
activities to rapidly expand in the face of an emergency.
Those two things are certainly things that have come up
both in this hearing and the previous hearing over the past
week.
I would like to just use some plain talk to talk about some
of the things that Secretary Thompson has been thinking about
in leading this preparedness effort in Health and Human
Services, our Department.
First of all, it seems important as this new Office of
health--Homeland Security develops that we begin to have strong
linkage from HHS to OHS, our Office of Homeland Security, and
that we are in the process of identifying people in our
Department who can work with Governor Ridge as he begins this
new endeavor.
Also the Secretary is in the process of enhancing our
ability to manage a one-department response in a way that we
never have tried in the past. For example, getting different
agencies with different agendas, harmonized to a centralized
emergency response activity has been a very, new phenomenon for
our Department and as a consequence, the manifestation of my
coming to Washington was one of those activities, but only one
of the most visible.
Other things have been involving key leadership and
training, information, briefings, actually reaching out to the
other interagency intelligence briefings and all of the kinds
of things that you do for a serious one-department emergency
response capability.
The second thing that was mentioned was the development of
more response teams or rapid response teams, and we are working
with CDC and our commission core readiness force to have
additional capacity to put into an emergency should that
develop.
Training remains important, and we have recently
consolidated an interagency agreement with FEMA to expand
cooperative training activity between HHS and FEMA and have
worked with entities like Noble Army Hospital at Ft. McClellan,
Alabama, and conducted regional and distance-based learning.
In conclusion, I would like to mention that the Department
of Health and Human Services is committed to ensuring the
health and medical care of our citizens, and we have made
substantial progress to date in enhancing the Nation's
capability to respond to a bioterrorism event. Priorities
include, in conclusion, strengthening our local and State
public health capacities, continuing to enhance our national
pharmaceutical stockpile, and helping support our local
hospitals and medical professionals to expand their vital surge
capacity.
With that, Mr. Chairman, I will conclude my prepared
remarks, and I would be pleased to answer any questions that
you or members of the subcommittee may have.
[The prepared statement of Scott R. Lillibridge follows:]
Prepared Statement of Scott R. Lillibridge, Special Assistant to the
Secretary for National Security and Emergency Management, Department of
Health and Human Services
Mr. Chairman and Members of the Subcommittee, I am Scott R.
Lillibridge, Special Assistant to the Secretary of HHS for National
Security and Emergency Management. I appreciate the opportunity to
appear before you this morning to discuss, from a Public Health
perspective, the Department of Health and Human Services (HHS) role in
preparedness to respond to acts of terrorism involving biological
agents.
What has HHS been doing to prepare for this kind of event? Our
efforts are focused on improving the nation's public health
surveillance network to quickly detect and identify the biological
agent that has been released; strengthening the capacities for medical
response, especially at the local level; expanding the stockpile of
pharmaceuticals for use if needed; expanding research on disease agents
that might be released; developing new and more rapid methods for
identifying biological agents and improved treatments and vaccines;
improving information and communications systems; and preventing
bioterrorism by regulation of the shipment of hazardous biological
agents or toxins.
preparedness and response
State and local public health programs comprise the foundation of
an effective national strategy for preparedness and emergency response.
Preparedness must incorporate not only the immediate responses to
threats such as biological terrorism, it also encompasses the broader
components of public health infrastructure which provide the foundation
for immediate and effective emergency responses. These components
include:
<bullet> A well trained, well staffed, fully prepared public health
workforce;
<bullet> Laboratory capacity to produce timely and accurate results for
diagnosis and investigation;
<bullet> Epidemiology and surveillance, which provide the ability to
rapidly detect heath threats;
<bullet> Secure, accessible information systems which are essential to
communicating rapidly, analyzing and interpreting health data,
and providing public access to health information;
<bullet> Communication systems that provide a swift, secure, two-way
flow of information to the public and advice to policy-makers
in public health emergencies;
<bullet> Effective policy and evaluation capability to routinely
evaluate and improve the effectiveness of public health
programs; and
<bullet> Preparedness and response capability, including developing and
implementing response plans, as well as testing and maintaining
a high-level of preparedness.
The CDC has used funds provided by the past several congresses to
begin the process of improving the expertise, facilities and procedures
of state and local health departments to respond to biological
terrorism. For example, over the last three years, the agency has
awarded more than $130 million in cooperative agreements to 50 states,
one territory and four major metropolitan health departments as part of
its overall Bioterrorism Preparedness and Response Program. In
addition, CDC currently funds 9 states and 2 metropolitan areas
specifically to develop public health preparedness plans for their
jurisdictions. Many of these states and cities have participated in
exercises to test components of their plans. We must continue to work
with our state and local public health systems to make sure they are
more prepared. This will require the interaction of state departments
of health with state emergency managers to fully integrate the state's
capacity to effectively distribute life-saving medications to victims
of a biological or terrorism event.
HHS is also working on a number of fronts to assist local hospitals
and medical practitioners to deal with the effects of biological,
chemical, and other terrorist acts. Since Fiscal Year 1995, for
example, HHS has been developing local Metropolitan Medical Response
Systems (MMRS). Through contractual relationships, the MMRS uses
existing emergency response systems--emergency management, medical and
mental health providers, public health departments, law enforcement,
fire departments, EMS and the National Guard--to provide an integrated,
unified response to a mass casualty event. As of September 30, 2001,
OEP has contracted with 97 municipalities to develop MMRSs. The FY 2002
budget includes funding for an additional 25 MMRSs (for a total of
122).
MMRS contracts require the development of local capability for mass
immunization/prophylaxis for the first 24 hours following an identified
disease outbreak; the capability to distribute materiel deployed to the
local site from the National Pharmaceutical Stockpile; local capability
for mass patient care, including procedures to augment existing care
facilities; local medical staff trained to recognize disease symptoms
so that they can initiate treatment; and local capability to manage the
remains of the deceased.
lessons learned from preparedness exercises
An indication of the Nation's preparedness for bioterrorism was
provided by the congressionally mandated Top Officials (TOPOFF) 2000
Exercise, held in May 2000, and the recent Dark Winter exercise, which
was held earlier this year. Both of these drills involved scenarios
related to a weapons-of-mass-destruction-attack against our
populations. Part of the TOPOFF exercise simulated a plague outbreak in
Denver, while the Dark Winter exercise simulated a release of smallpox.
Lessons from TOPOFF
While much progress has been made to date, a number of important
lessons learned from TOPOFF have begun to shape our plans about
bioterrorism preparedness and response in the health and medical area.
They are as follows:
<bullet> Improving the public health infrastructure remains a critical
focus of the bioterrorism preparedness and response efforts.
<bullet> Local health care systems should expand their health care
capacity rapidly in the face of mass casualties.
<bullet> Local communities will need assistance with the distribution
of stockpile medications and will greatly benefit from
additional planning related to epidemic response.
<bullet> Ensuring that the proper legal authorities exist to control
the spread of disease at the local, state and Federal level and
that these authorities can be exercised when needed. This will
be important to our efforts to control the spread of disease.
Lessons from Dark Winter
The issues that emerged from the recent Dark Winter exercise
reflected similar themes that need to be addressed.
<bullet> The importance of rapid diagnosis--Rapid and accurate
diagnosis of biological agents will require strong linkages
between clinical and public health laboratories. In addition,
diagnostic specimens will need to be delivered promptly to CDC,
where laboratorians will provide diagnostic confirmatory and
reference support.
<bullet> The importance of working through the governors' offices as
part of our planning and response efforts--During the exercise
this was demonstrated by Governor Keating. During state-wide
emergencies the federal government will need to work with a
partner in the state who can galvanize the multiple response
communities and government sectors that will be needed, such as
the National Guard, the state health department, and the state
law enforcement communities. These in turn will need to
coordinate with their local counterparts. CDC is refining its
planning efforts through grants, policy forums such as the
National Governors Association and the National Emergency
Management Association, and training activities. CDC also
participates with partners such as DOJ and FEMA in planning and
implementing national drills such as the recent TOPOFF
exercise.
<bullet> Better targeting of limited smallpox vaccine stocks to ensure
strategic use of vaccine in persons at highest risk of
infection--It was clear that pre-existing guidance regarding
strategic use would have been beneficial and would have
accelerated the response at Dark Winter. As I mentioned
earlier, CDC is working on this issue and is developing
guidance for vaccination programs and planning activities.
<bullet> Federal control of the smallpox vaccine at the inception of a
national crisis--Currently, the smallpox vaccine is held by the
manufacturer. CDC has worked with the U.S. Marshals Service to
conduct an initial security assessment related to a future
emergency deployment of vaccine to states. CDC is currently
addressing the results of this assessment, along with other
issues related to security, movement, and initial distribution
of smallpox vaccine.
<bullet> The importance of early technical information on the progress
of such an epidemic for consideration by decision makers--In
Dark Winter, this required the implementation of various steps
at the local, state, and federal levels to control the spread
of disease. This is a complex endeavor and may involve measures
ranging from directly observed therapy to quarantine, along
with consideration as to who would enforce such measures.
Because wide-scale federal quarantine measures have not been
implemented in the United States in over 50 years, operational
protocols to implement a quarantine of significant scope are
needed. CDC hosted a forum on state emergency public health
legal authorities to encourage state and local public health
officers and their attorneys to examine what legal authorities
would be needed in a bioterrorism event. In addition, CDC is
reviewing foreign and interstate quarantine regulations to
update them in light of modern infectious disease and
bioterrorism concerns. CDC will continue this preparation to
ensure that such measures will be implemented early in the
response to an event.
<bullet> Maintaining effective communications with the media and press
during such an emergency--The need for accurate and timely
information during a crisis is paramount to maintaining the
trust of the community. Those responsible for leadership in
such emergencies will need to enhance their capabilities to
deal with the media and get their message to the public. It was
clear from Dark Winter that large-scale epidemics will generate
intense media interest and information needs. CDC has refined
its media plan and expanded its communications staff. These
personnel will continue to be intimately involved in our
planning and response efforts to epidemics.
<bullet> Expanded local clinical services for victims--DHHS's Office of
Emergency Preparedness is working with the other members of the
National Disaster Medical System to expand and refine the
delivery of medical services for epidemic stricken populations.
HHS will continue to work with partners to address challenges in
public health preparedness, such as those raised at TOPOFF and Dark
Winter. For example, work done by CDC staff to model the effects of
control measures such as quarantine and vaccination in a smallpox
outbreak have highlighted the importance of both public health measures
in controlling such an outbreak. The importance of both quarantine and
vaccination as outbreak control measures is also supported by
historical experience with smallpox epidemics during the eradication
era. These issues, as well as overall preparedness planning at the
federal level, are currently being addressed and require additional
action to ensure that the nation is fully prepared to respond to all
acts of biological terrorism.
conclusion
The Department of Health and Human Services is committed to
ensuring the health and medical care of our citizens. We have made
substantial progress to date in enhancing the nation's capability to
respond to a bioterrorist event. But there is more we can do to
strengthen the response. Priorities include strengthening our local and
state public health surveillance capacity, continuing to enhance the
National Pharmaceutical Stockpile, and helping our local hospitals and
medical professionals better prepare for responding to a biological or
terrorist attack.
Mr. Chairman, that concludes my prepared remarks. I would be
pleased to answer any questions you or members of the Subcommittee may
have.
Mr. Greenwood. Thank you very much, Dr. Lillibridge.
Mr. Baughman, you are recognized for your testimony.
TESTIMONY OF BRUCE P. BAUGHMAN
Mr. Baughman. Thank you, Mr. Chairman.
I am Bruce Baughman, Director of Planning and Readiness
with the Federal Emergency Management Agency. It is my pleasure
to represent Director Albaugh at this important hearing on
bioterrorism. The mission of FEMA is to reduce loss of life and
property and to assist in protecting our Nation's critical
infrastructure from all hazards. When disaster strikes, we
provide a management framework and funding for responding
units.
The Federal response plan is the heart of that framework.
It reflects the labor of interagency groups that meet in
Washington from all 10 of our FEMA regions to develop a
capability to respond as a team, the Federal community
responding as a team. This team is staffed by 26 departments
and agencies, including the American Red Cross, and is
organized into interagency functions based upon the authority
and the expertise of the member organizations, and the needs of
our counterparts at the State and local level, health and
medical, is headed by HHS under our plan.
Our plan is designed to support, not supplement, State and
local response structures. Since 1992, the plan has been a
proven framework for managing major disasters and emergencies,
regardless of cost. It works. It worked in Oklahoma City, it
worked at the World Trade Center.
However, biological terrorism would present some unique
challenges and has already. With an undetected attack, first
responders would be doctors, hospital staff, animal control
workers, instead of police, fire and emergency medical service
personnel. Connections between these nontraditional first
responders and the larger Federal response is not routine. The
Department of Health and Human Services is the critical link
between the health and medical community and the larger Federal
response.
FEMA works closely with public health service as the
primary agency for health and medical function under the
Federal response plan. We rely on them to bring the right
experts to the table when we meet to discuss potential
biological threats, how they spread, and the resources and
techniques that would be needed to control them.
We are making progress. As Scott mentioned, Exercise TOP
OFF in May 2000 involved a chemical attack on the East Coast
followed by a biological attack in the Midwest. We have
incorporated the lessons learned in that exercise into our
response procedures. The procedures--the process is active and
ongoing. It takes time and resources to identify, develop, and
incorporate these changes into the system.
In January 2001, the FBI and FEMA jointly published U.S.
Government's interagency domestic concept of operation for
terrorism, or CONPLAN, with the Departments of Health and Human
Services, Defense and Energy and the Environmental Protection
Agency. Together, the CONPLAN and the Federal response plan
provide the framework for managing the response to causes or
consequences to a terrorist act. It was recognized, however, at
that time that these plans were inadequate to adequately
address a biological incident.
On May 8, the President asked the Vice President to oversee
the development of a coordinated national effort regarding
domestic preparedness. The President also asked the Director of
FEMA to create an Office of National Preparedness to coordinate
all Federal programs dealing with preparedness for and response
to the terrorist use of weapons of mass destruction. In July,
the Director formally established the office at FEMA
headquarters with elements in each one of the 10 FEMA regional
offices.
On September 21 in the wake of the horrific terrorist
attacks, the World Trade Center and the Pentagon, the President
announced the establishment of the Office of Homeland Security
in the White House headed by Governor Ridge. The office will
lead, oversee, and coordinate a national strategy to safeguard
the country against terrorism and respond to attacks that may
occur. It is our understanding that the office will coordinate
a broad range of policies and activities related to prevention,
deterrence, preparedness and response.
This office includes a Homeland Security Council comprised
of key departments and agency officials, including the Director
of FEMA. We expect to provide significant support to this
office in our role as the lead Federal agency for consequence
management.
Mr. Chairman, you convened this hearing to ask about our
preparedness to work with State and local agencies in the event
of a biological attack.
Terrorism presents tremendous challenges. We rely heavily
on the Department of Health and Human Services to coordinate
the efforts in the health and medical community and to address
biological hazards. They need your support to increase the
national inventory of response resources and capabilities.
FEMA needs your support to ensure that the system the
Nation uses 65 times a year to respond to major disasters and
emergencies has the tools and the capacity to adapt to a
biological attack or any other weapon of choice.
Thank you, Mr. Chairman.
[The prepared statement of Bruce P. Baughman follows:]
Prepared Statement of Bruce P. Baughman, Director, Planning and
Readiness Division, Readiness, Response, and Recovery Directorate,
Federal Emergency Management Agency
introduction
Good morning, Mr. Chairman and Members of the Subcommittee. I am
Bruce Baughman, Director of the Planning and Readiness Division,
Readiness, Response, and Recovery Directorate, of the Federal Emergency
Management Agency (FEMA). Director Allbaugh regrets that he is unable
to be here with you today. It is a pleasure for me to represent him at
this important hearing on biological and chemical terrorism. I will
describe how FEMA works with other agencies, our approach to dealing
with acts of terrorism, our programs related to terrorism, and new
efforts to enhance preparedness and response.
background
The FEMA mission is to reduce the loss of life and property and
protect our nation's critical infrastructure from all types of hazards.
As staffing goes, we are a small agency. Our success depends on our
ability to organize and lead a community of local, State, and Federal
agencies and volunteer organizations. We know who to bring to the table
and what questions to ask when it comes to the business of managing
emergencies. We provide an operational framework and a funding source.
The Federal Response Plan (FRP) is the heart of that framework. It
reflects the labors of interagency groups that meet as required in
Washington, D.C. and all 10 FEMA Regions to develop our capabilities to
respond as a team. This team is made up of 26 Federal departments and
agencies and the American Red Cross, and organized into interagency
functions based on the authorities and expertise of the members and the
needs of our counterparts at the state and local level.
Since 1992, the Federal Response Plan has been the proven framework
time and time again, for managing major disasters and emergencies
regardless of cause. It works during all phases of the emergency life
cycle, from readiness, to response, recovery, and mitigation. The
framework is successful because it builds upon the existing
professional disciplines and communities among agencies. Among Federal
agencies, FEMA has the strongest ties to the emergency management and
the fire service communities. We plan, train, exercise, and operate
together. That puts us in position to manage and coordinate programs
that address their needs. Similarly, the Department of Health and Human
Services (HHS) has the strongest ties to the public health and medical
communities, and the Environmental Protection Agency (EPA) has the
strongest ties to the hazardous materials community. The Federal
Response Plan respects these relationships and areas of expertise to
define the decision-making processes and delivery systems to make the
best use of available resources.
the approach to biological and chemical terrorism
We recognize that biological and chemical scenarios would present
unique challenges. Of the two I am more concerned about bioterrorism. A
chemical attack is in many ways a large-scale hazardous materials
incident. EPA and the Coast Guard are well connected to local hazardous
materials responders, State and Federal agencies, and the chemical
industry. There are systems and plans in place for response to
hazardous materials, systems that are routinely used for small and
large-scale events. EPA is also the primary agency for the Hazardous
Materials function of the Federal Response Plan. We can improvise
around that model in a chemical attack.
With a covert release of a biological agent, the ``first
responders'' will be hospital staff, medical examiners, private
physicians, or animal control workers, instead of the traditional first
responders such as police, fire, and emergency medical services. While
I defer to the Departments of Justice and HHS on how biological
scenarios would unfold, it seems unlikely that terrorists would warn us
of a pending biological attack. In exercise and planning scenarios, the
worst-case scenarios begin undetected and play out as epidemics.
Response would begin in the public health and medical community.
Initial requests for Federal assistance would probably come through
health and medical channels to the Centers for Disease Control and
Prevention (CDC). Conceivably, the situation could escalate into a
national emergency.
HHS is a critical link between the health and medical community and
the larger Federal response. HHS leads the efforts of the health and
medical community to plan and prepare for a national response to a
public health emergency. FEMA works closely with the Public Health
Service, as the primary agency for the Health and Medical Services
function of the Federal Response Plan. We rely on the Public Health
Service to bring the right experts to the table when the Federal
Response Plan community meets to discuss biological scenarios. We work
closely with the experts in HHS and other health and medical agencies,
to learn about the threats, how they spread, and the resources and
techniques that will be needed to control them. By the same token, the
medical experts work with us to learn about the Federal Response Plan
and how we can use it to work the management issues, such as resource
deployment and public information strategies. Alone, the Federal
Response Plan is not an adequate solution for the challenge of planning
and preparing for a deadly epidemic or act of bioterrorism. It is
equally true that, alone, the health and medical community cannot
manage an emergency with biological causes. We must work together.
In recent years, Federal, state and local governments and agencies
have made progress in bringing the communities closer together.
Exercise Top Officials (TOPOFF) 2000 in May 2000 involved two
concurrent terrorism scenarios in two metropolitan areas, a chemical
attack on the East Coast followed by a biological attack in the
Midwest. We are still working on the lessons learned from that
exercise. We need time and resources to identify, develop, and
incorporate changes to the system between exercises. Exercises are
critical in helping us to prepare for these types of scenarios. In
January 2001, the FBI and FEMA jointly published the U.S. Government
Interagency Domestic Terrorism Concept of Operation Plan (CONPLAN) with
HHS, EPA, and the Departments of Defense and Energy, and pledged to
continue the planning process to develop specific procedures for
different scenarios, including bioterrorism. The Federal Response Plan
and the CONPLAN provide the framework for managing the response to an
act of bioterrorism.
synopsis of fema programs
FEMA programs are focused mainly on planning, training, and
exercises to build capabilities to manage emergencies resulting from
terrorism. Many of these program activities apply generally to
terrorism, rather than to one form such as biological or chemical
terrorism.
Planning
The overall Federal planning effort is being coordinated with the
FBI, using existing plans and response structures whenever possible.
The FBI is always the Lead Agency for Crisis Management. FEMA is always
the Lead Agency for Consequence Management. We have developed plans and
procedures to explain how to coordinate the two operations before and
after consequences occur. In 1999, we published the second edition of
the FRP Terrorism Incident Annex. In 2001, the FBI and FEMA published
the United States Government Interagency Domestic Terrorism Concept of
Operations Plan (CONPLAN).
We continually validate our planning concepts by developing plans
to support the response to special events, such as we are now doing for
the 2002 Olympic Winter Games that will take place in Utah.
To support any need for a Federal response, FEMA maintains the
Rapid Response Information System (RRIS). The RRIS provides online
access to information on key Federal assets that can be made available
to assist state and local response efforts, and a database on chemical
and biological agents and protective measures.
In FY 2001, FEMA has distributed $16.6 million in terrorism
consequence management preparedness assistance grants to the States to
support development of terrorism related capabilities, and $100 million
in fire grants. FEMA is developing additional guidance to provide
greater flexibility for states on how they can use this assistance.
FEMA has also developed a special attachment to its all-hazards
Emergency Operations Planning Guide for state and local emergency
managers that addresses developing terrorist incident annexes to state
and local emergency operations plans. This planning guidance was
developed with the assistance of eight Federal departments and agencies
in coordination with NEMA and the International Association of
Emergency Managers.
FEMA and the National Emergency Management Association (NEMA)
jointly developed the Capability Assessment for Readiness (CAR), a
self-assessment tool that enables States and Territories to focus on 13
core elements that address major emergency management functions.
Terrorism preparedness is assessed relative to planning, procedures,
equipment and exercises. FEMA's CAR report presents a composite picture
of the nation's readiness based on the individual State and Territory
reports.
FEMA's Comprehensive Hazardous Materials Emergency Response
Capability Assessment Program (CHER-CAP) helps communities improve
their terrorism preparedness by assessing their emergency response
capability. Local, State, and Tribal emergency managers, civic leaders,
hospital personnel and industry representatives all work together to
identify problems, revise their response plans and improve their
community's preparedness for a terrorist event. Since February 2000, a
total of 55 communities have been selected to participate, initiated,
or completed a sequence of planning, training, and exercise activities
to improve their terrorism preparedness.
Training
FEMA supports the training of Federal, State, and local emergency
personnel through our National Fire Academy (NFA), which trains
emergency responders, and the Emergency Management Institute (EMI),
which focuses on emergency planners, coordinators and elected and
appointed officials. EMI and NFA work in partnership with State and
municipal training organizations. Together they form a very strong
national network of fire and emergency training. FEMA employs a
``train-the-trainer'' approach and uses distance-learning technologies
such as the Emergency Education Network via satellite TV and web-based
instruction to maximize our training impact.
The NFA has developed and fielded several courses in the Emergency
Response to Terrorism (ERT) curriculum, including a Self-Study course
providing general awareness information for responding to terrorist
incidents that has been distributed to some 35,000 fire/rescue
departments, 16,000 law enforcement agencies, and over 3,000 local and
state emergency managers in the United States and is available on FEMA
internet site. Other courses in the curriculum deal with Basic
Concepts, Incident Management, and Tactical Considerations for
Emergency Medical Services (EMS), Company Officers, and HAZMAT
Response. Biological and chemical terrorism are included as integral
parts of these courses.
Over one thousand instructors representing every state and major
metropolitan area in the nation have been trained under the ERT
program. The NFA is utilizing the Training Resources and Data Exchange
(TRADE) program to reach all 50 States and all major metropolitan fire
and rescue departments with training materials and course offerings. In
FY 2001, FEMA is distributing $4 million in grants to state fire-
training centers to deliver first responder courses developed by the
NFA.
Over 112,000 students have participated in ERT courses and other
terrorism-related training. In addition, some 57,000 copies of a Job
Aid utilizing a flip-chart format guidebook to quick reference based on
the ERT curriculum concepts and principles have been printed and
distributed.
NFA is developing a new course in FY 2002 in the Emergency Response
to Terrorism series geared toward response to bioterrorism in the pre-
hospital recognition and response phase. It will be completed with the
review and input of our Federal partners, notably HHS and the Office of
Justice Programs.
EMI offers a comprehensive program of emergency management training
including a number of courses specifically designed to help
communities, states, and tribes deal with the consequences of terrorism
and weapons of mass destruction. The EMI curriculum includes an
Integrated Emergency Management Course (IEMC)/Consequences of
Terrorism. This 4\1/2\ day course combines classroom training, planning
sessions, and functional exercises into a management-level course
designed to encourage communities to integrate functions, skills, and
resources to deal with the consequences of terrorism, including
terrorism. To foster this integration, EMI brings together 70
participants for each course that includes elected officials and public
health leaders as well as representatives of law enforcement, emergency
medical services, emergency management, and public works. The course
provides participants with skill-building opportunities in
preparedness, response, and recovery. The scenario for the course
changes from offering to offering. In a recent offering, the scenario
was based on an airborne anthrax release. Bioterrorism scenarios
emphasize the special issues inherent in dealing with both infectious
and noninfectious biological agents and stresses the partnerships
between local, state, and Federal public health organizations.
Exercises
In the area of exercises, FEMA is working closely with the
interagency community and the States to ensure the development of a
comprehensive exercise program that meets the needs of the emergency
management and first responder communities. FEMA is planning to conduct
Phase II of a seminar series on terrorism preparedness in each of the
ten FEMA Regional Offices. In addition, exercise templates and tools
are being developed for delivery to state and local officials.
new efforts to enhance preparedness and response
In response to guidance from the President on May 8, 2001, the FEMA
Director created an Office of National Preparedness (ONP) to coordinate
all federal programs dealing with weapons of mass destruction
consequence management, with particular focus on preparedness for, and
the response to the terrorist use of such weapons. In July, the
Director established the ONP at FEMA Headquarters. An ONP element was
also established in each of the ten FEMA Regional Offices to support
terrorism-related activities involving the States and localities.
On September 21, 2001, in the wake of the horrific terrorist
attacks on the World Trade Center and the Pentagon, the President
announced the establishment of an Office of Homeland Security (OHS) in
the White House to be headed by Governor Tom Ridge of Pennsylvania. In
setting up the new office, the President stated that it would lead,
oversee and coordinate a national strategy to safeguard the country
against terrorism and respond to attacks that occur. It is our
understanding that office will coordinate a broad range of policies and
activities related to prevention, deterrence, preparedness and response
to terrorism.
The new office includes a Homeland Security Council comprised of
key department and agency officials, including the FEMA Director. FEMA
expects to provide significant support to the office in its role as the
lead Federal agency for consequence management.
conclusion
Mr. Chairman, you convened this hearing to ask about our
preparedness to work with State and local agencies in the event of a
biological or chemical attack. It is FEMA's responsibility to ensure
that the national emergency management system is adequate to respond to
the consequences of catastrophic emergencies and disasters, regardless
of cause. All catastrophic events require a strong management system
built on expert systems for each of the operational disciplines.
Terrorism presents tremendous challenges. We rely on our partners in
Department of Health and Human Services to coordinate the efforts of
the health and medical community to address biological terrorism, as we
rely on EPA and the Coast Guard to coordinate the efforts of the
hazardous materials community to address chemical terrorism. Without
question, they need support to further strengthen capabilities and
their operating capacity. FEMA must ensure that the national system has
the tools to gather information, set priorities, and deploy resources
effectively in a biological scenario. In recent years we have made
tremendous strides in our efforts to increase cooperation between the
various response communities, from fire and emergency management to
health and medical to hazardous materials. We need to do more.
The creation of the Office of Homeland Security and other efforts
will enable us to better focus our time and effort with those
communities, to prepare the nation for response to any incident.
Thank you, Mr. Chairman. I would be happy to answer any questions.
Mr. Greenwood. Thank you, Mr. Baughman. We appreciate your
testimony.
Ms. Heinrich, you are recognized for yours.
TESTIMONY OF JANET HEINRICH
Ms. Heinrich. Mr. Chairman and members of the subcommittee,
I appreciate the opportunity to be here today to discuss our
ongoing work on public health preparedness for a domestic
bioterrorist attack. We recently released a report, that you
referred to, on Federal research and preparedness activities
related to the public health and medical consequences of a
bioterrorist attack on the civilian population.
I would like to begin by giving a brief overview of the
findings in our report and then address weaknesses in the
public health infrastructure that we believe warrant special
attention.
We identified more than 20 departments and agencies as
having a role in preparing for or responding to the public
health and medical consequences. These agencies are
participating in a variety of activities from improving the
detection of biological agents and developing new vaccines to
managing the national stockpile of pharmaceuticals.
Coordination of these activities across departments and
agencies is fragmented, as we have heard in the first panel
today. The chart we have prepared--I draw your attention to
this--gives examples of efforts to coordinate these activities
at the Federal level as they existed before the creation of the
Office of Homeland Security. We, too, feel that this office
holds great promise.
I won't walk you through the whole chart, but as you can
see, a multitude of agencies have overlapping responsibilities
for various aspects of bioterrorism preparedness. Bringing
order to this picture will be a challenge. We do need
coherence.
Federal spending on domestic preparedness for terrorist
attacks involving all types of weapons of mass destruction has
risen 310 percent since fiscal year 1998 to approximately $1.7
billion in fiscal year 2001.
Funding information on research and preparedness of a
bioterrorist attack, as reported to us by the Federal agencies,
was difficult to ascertain. We identified increases year to
year from generally low levels, or zero levels, in 1998. For
example, HHS-CDC's bioterrorism preparedness and response
program first received funding in fiscal year 1999; its funding
has increased from approximately $121 million at that time to
approximately $194 million in fiscal year 2001.
While many of the Federal activities are designed to
provide support for local responders, inadequacies in the
public health infrastructure at the State and local level may
reduce effectiveness of the overall response effort.
Our work has pointed to weaknesses in three key areas--
training of health care providers, communication among response
parties, and capacity of hospitals and laboratories.
I think we heard very concrete examples of the problems
with training, the problems with communication and also the
lack of capacity, both laboratories and hospitals, very
eloquently on the first panel, so I'm not going to repeat that;
only to say in conclusion, although numerous bioterrorism-
related research and preparedness activities are under way in
the Federal agencies, we remain concerned about weaknesses in
public health and medical preparedness at the State and local
levels and, of course, the coordination at the Federal levels.
Thank you. I'd be happy to answer any questions.
[The prepared statement of Janet Heinrich appears at the
end of the hearing.]
Mr. Greenwood. Thank you, Ms. Heinrich. Appreciate your
testimony.
The Chair recognizes himself for 5 minutes. Let me address
my first question to Dr. Lillibridge, and actually it may be
appropriate for Mr. Baughman to respond as well. And Ms.
Heinrich, if you'd like to respond, you may as well.
In your testimony, you talked about the number of
metropolitan areas that have participated in your department's
preparedness programs, how much money you've given out, the
goals that have been set; but I'm not sure that we get a clear
sense so far as to whether we're meeting those goals. And I
think you were present when I asked the previous panel
whether--if I were to ask them to go out and inform this
committee as to whether or not a particular city or
metropolitan area was in fact prepared, would they even know
the right list of questions or the right checklist to compare
the efforts against.
And what do we know about and how do we measure the
preparedness of cities? Could you respond to that, Dr.
Lillibridge?
Mr. Lillibridge. Yes, sir. Let me mention two things that
we're working on, and we certainly share your concerns about
municipal preparedness.
One of the things that we began to do in HHS is, after the
first year or two of the grant cycle, when it became clear that
this threat was going to continue and we'd be engaging in a
long-term preparedness process, began to look at what core
capacities really equal response and hone down on that. And
through a 6-month process we've come to the conclusion in the
key areas of epidemic preparedness and response the kind of
things that help lead us to capacities that could be measurable
at the State and local level as you begin to look at this--and
we intend to anchor those or at least link those to our grant
process in the near future. Those were developed in concert
with public health, medical folks, people in the public health
guilds and workers in disease detective work or epidemiology at
the State and local level.
Mr. Greenwood. Mr. Baughman, did you want to comment?
Mr. Baughman. I think that probably HHS has done a good job
in getting guidance out to the participating cities for
guidance as to what an MMRS ought to be and how they ought to
be able to react to a biological event. I think what we've done
a poor job on is getting guidance out to area hospitals and
health care providers as to how they detect and treat these
types of things in a rapid--and I think you heard that from the
first panel also.
Mr. Greenwood. But it seems to me if--if I could refine my
question, if I were the mayor of Philadelphia and I had the
ultimate responsibility for the lives of people in that city, I
would want to be able to ask my cabinet, Are we ready? And that
would mean somebody would need to tell me how the hospitals--
you know, the hospitals, check; first responders, check;
vaccines, check; communications system, check; command and
control, check.
And if the mayor of Philadelphia called me after this
hearing and said, How do I--what tool do I use to measure the
preparedness of the city of Philadelphia, how should I respond
to him?
Mr. Baughman. There are a number of checklists out there.
The Office of Justice Programs has in fact put out guidance as
to how you evaluate plans, what you ought to be looking for
when you're evaluating those plans. I'm not sure that those
plans have been adequately vetted through the community to get
the expert input that they need to have on them.
Mr. Greenwood. Ms. Heinrich.
Ms. Heinrich. I'd just like to say that we've certainly
been looking for such a list, and measurable indicators.
To remind you, we are going to be starting--we are starting
the second phase of our work, which is to assess the
preparedness at the local and State level. It's part of the
mandate that we have to do this work. And what we've found is
that there's--there are a lot of different checks that seem to
focus on this from an all-hazards approach, a chemical approach
or a biological approach, and it seems as though there are
differences, depending on how you view what the threat is.
Mr. Greenwood. The Washington Monthly's cover is--this is
from May 2000--``Weapons of Mass Confusion: There's Anthrax in
Your Subway. Who Are You Going to Call?'' and think that's what
we're seeing here is that we do have that issue.
I'm going to yield 5 minutes to the gentleman from Florida,
Mr. Deutsch.
Mr. Deutsch. Thank you, Mr. Chairman.
You know, I think that's a good lead-in to a question that
in a sense everyone on the previous panel talked about, which
is the need for a centralized location, and none of you
testified to that need, where everyone on the other panel
mentioned it.
Do you have thoughts? Is there disagreement of a
centralized location to be coordinating this? Dr. Lillibridge?
Mr. Lillibridge. Let me begin. After engaging in nearly 3
years of national preparedness, individually with local
communities, States and regionally, it's clear that we could
benefit from central coordination of certain activities.
Clearly, having a forum, an office or a centralized leadership
to coordinate issues of implementation, budget and interagency
things, I believe is going to be extremely important. Our
department is quite excited about supporting the new Office of
Homeland Security and Governor Ridge in his effort.
Mr. Deutsch. So would that theoretically, with the central
location at this point--I mean, the Office of Homeland
Security?
Mr. Lillibridge. We would be glad to coordinate through
that, and that--as information becomes known and how that's
going to roll out and be implemented. We're standing by,
identifying staff and looking at issues that could really
benefit from that kind of central coordination.
Mr. Baughman. I'd like to mention, though, there's two
areas of coordination. There is, one, coordinating the various
Federal programs that are going down to State and local
government; and I think that everybody is in favor of a
centralized need, central location. It's one of the reasons
that we--lacking anything else, we set up, at the request of
the President, an office of national preparedness.
Again, if Homeland Security takes on that responsibility,
that's a central location. Regardless of where it is, that
function is needed.
The other part is preparing the Federal community to
respond to a situation like the World Trade Center. We have
been the central coordinating agency, working with the
Federal--various Federal agencies to bring together the
existing arsenal of Federal response assets to respond, and I
think we've done a pretty good job at that.
But the other one, the central location for coordination of
the various Federal agency programs, that's needed.
Ms. Heinrich. The GAO has gone on record as being very much
in favor of a central coordinating office, but more than
coordination, it speaks to several principles, a couple of
examples being budget control and also the whole issue of
command and control.
We don't think that anyone knows yet exactly what the
President is thinking about in terms of inclusion of agencies
under the Homeland Security office. I think there are a lot of
unknowns there at this time.
Mr. Deutsch. Let me go back to the questions I asked the
first panel, and hopefully you could provide some additional
information, and maybe get into a couple of specifics.
First off, Dr. Lillibridge, is there a test available on
anthrax beyond this 24/48-hour incubation period?
Mr. Lillibridge. Sir, we have a number of things to draw
down to look at. The assay--the issue of assay development
could be discussed at length, but let me in short--in the
application of public health at the State and local level, we
have a system of 81 laboratories that we support at CDC,
throughout the States, that have been trained and received
reagents--those are the things to conduct the test--and test
assays from CDC and other Federal entities to have in place to
do rapid diagnoses at different levels.
Case in point, the Florida experience that we currently
spoke of on the earlier panel, the--it's important to note that
those resources were used on the first day of admission to get
a presumptive positive and trigger the public health response
and that that test was reconfirmed at CDC, but that capacity
and that lab training and those lab tests were already in the
State, and Florida has that also arrayed regionally.
Dr. Young alluded to the issue of advancing laboratory
technology. There are many things we must do and stay focused
on because there are many more agents. There's opportunities to
push local diagnosis locally more rapidly, and I think those
are going to be things that we'll work on in the future.
Mr. Deutsch. Let me try to be more specific. I mean,
yesterday we were on a conference call, with CDC saying they're
testing 700 additional people in Florida. They said that it's
going to be 24 to 48 hours before it's determined whether there
are additional cases of anthrax in Florida. I mean, is that the
best we can do?
Mr. Lillibridge. You can do several ranges of tests, but
the test that was selected to do for those folks that were
potentially exposed, that they brought back for prophylaxis,
was a culture. That requires that bacteria be grown in culture
plates; that does take several days.
You could do presumptive tests on those people on their
nasal swabs right away, but you would still have a presumptive
test that would need a bacterial culture confirmation.
Mr. Deutsch. So the presumptive tests on those 700 people
have not been done?
Mr. Lillibridge. What they're doing are the gold standard
tests, the culture. They're already on medical prophylaxis----
Mr. Deutsch. Let me ask a follow-up question on this.
Is it a case--until those cultures grow, we don't know if
this is a case that is limited to two people at this point in
time?
Mr. Lillibridge. Good point. Being colonized is not the
same as being infected or being a case, and the people who have
positive nasal swabs may not be cases in terms of being--having
clinical disease. They may be colonized or they may have
external contact in their nasal cavity.
It does help us confirm that they were in a place where
they might have been exposed; if it turns out, it may help
guide the investigation to determine where the source of the
exposure may have been.
Mr. Deutsch. Right. So the second gentleman which--it's
unclear whether or not he in fact has developed anthrax. He
just was exposed.
In other words, the nasal cavity, there were anthrax spores
in his nasal cavity; is that correct?
Mr. Lillibridge. Correct. I was at CDC as early as this
morning. It's been about--information is about 3 or 4 hours
dated now, but as of that time, he was getting better. He was
not considered a case of anthrax. He was considered a surface
exposure of his nasal swab, which indicated that he had been in
an area, perhaps, where there had been some contact with----
Mr. Deutsch. And the limitation of him is that--again, my
understanding is it would take 5,000 spores sort of as an
average, or as minimum, to actually acquire the disease?
Mr. Lillibridge. You need a substantial exposure, as Dr.
Young said.
One of the interesting things about this--or at least some
of the good news is that if this was a massive exposure, there
should be lot of people sick or earlier presentations of
pulmonary anthrax. We are not finding that, and we are--still
have one confirmed case, and we are doing everything possible
to conduct a dual law enforcement and a public health
investigation.
Mr. Deutsch. At this point in time, do we know if that--I
mean, the press is reporting that that particular strain came
from a lab in Iowa. Is that accurate?
Mr. Lillibridge. Well, what we do know is that the strain
from the man's nose and the patient who died and the keyboard
from the patient who died are identical. We think that it--it's
similar to--it has been reported to be similar to other
strains. However, the confirmation on that was not available as
of the time I came in.
I'd like to mention one thing, just to allay the public--
one issue that's extremely important is that the sensitivity of
this bacteria was such that it was sensitive to penicillin,
doxycycline and ciprofloxacin, and possibly several other
drugs. The significance of that is, it doesn't--that is not the
hallmark of an engineered bioweapon.
Mr. Deutsch. Right. Because a bioweapon, that is why cipro
is the only one that works on the bioweapons in the Russian
labs. Is that correct?
Mr. Lillibridge. Well, you stack your therapy against what
you think will work best, and it's one of the newer and more
powerful antibiotics. You would start with that, wait for
sensitivity in testing to come back, and then shift to
something you were sure it was sensitive to.
Mr. Deutsch. Where would someone get anthrax to use? I
mean, let's just assume it's a case of a disgruntled employee
who has, you know, put it on someone's keyboard. I mean, where
would someone get anthrax?
Mr. Lillibridge. Well, as mentioned in the previous panel,
it's ubiquitous. It's in the soil. You could----
Mr. Deutsch. Right, but this is a non--you know, not
naturally occurring. So this is in someone's lab in Iowa or
something. I mean, so it didn't come from the soil is what
we're being told at this point in time.
Mr. Lillibridge. Well, one of the things we're looking into
is trying to nail down where the source is, by location, and
then get more information about where that might have come from
in terms of, was it a package? Was it an exposure of an
airborne variety? Or was it some sort of occupational thing?
Mr. Deutsch. You're telling us now and you're confirming
that it was on a keyboard that the gentleman who passed away
used? Is that accurate?
Mr. Lillibridge. We have--it's consistent for us to
understand that it was found in three locations. One, the
environment; the keyboard is second; a man's nose----
Mr. Deutsch. The keyboard of the gentleman who passed away?
Mr. Lillibridge. The keyboard of the gentleman who passed
away.
Mr. Deutsch. And again I guess I'm trying to ask a very
basic question.
If it's there and, at this point, we're saying that it's
not a naturally occurring form, someone put it there. I mean,
is that a fair assumption that someone put it there?
Mr. Lillibridge. No. It is----
Mr. Deutsch. It's not a fair assumption?
Mr. Lillibridge. It's the assumption that all we know is
that at this point in the investigation--I don't have all the
elements of the criminal component, but that there's an
environmental swab that was positive. There was a nasal swab in
a second person, and the first index patient, or the first
person who contracted the disease and died, had the same,
similar pathogen.
Now, in the context of knowing that and beginning to
examine patients and looking through the potentially exposed
folks, you begin to look at people who might be sick, who were
in the area or who traveled the same pathway.
Mr. Greenwood. It's theoretically possible that it could
have--anthrax could have been in the victim's body first and
the keyboard second?
Mr. Lillibridge. It is theoretically possible, depending on
how the original person was exposed.
Mr. Deutsch. And it would have dropped out of his passages
and ended up on the keyboard, I mean, and at what levels?
I mean, let me just tell you, we're in the mood of passing
out things. This is local papers from south Florida, which I
represent. I don't represent the location where the hospital
is, but it's close enough, and the county is just directly
bordering Palm Beach County.
I mean, you know, what the press accounts are--are, you
know, out of a bad movie scene. I mean, people, you know,
calling up HAZMAT, you know, dozens of times in south Florida
yesterday whenever they see, you know, a packet of dust or an
envelope of dust and things like that.
And, again, I know you're trying to be as helpful as
possible, but you're not clearing up a heck of a lot. You're
not clearing up a heck of a lot. And I mean, if you're the guy
at HHS that is supposed to be in charge of bioterrorism--
whether we're calling this a criminal act or bioterrorism, I
think we need to at least be thinking of it as potential
bioterrorism at this point, contrary to what the Secretary
originally said.
And whether it's a testing ground, I mean, of--you know,
what the, you know, people who were living in this neighborhood
were doing--again, this is just weird that----
Mr. Buyer. Mr. Chairman, we've got a vote coming on. We've
been very patient here.
Mr. Greenwood. The time of the gentleman has expired.
The gentleman from North Carolina, Mr. Burr--Mr. Buyer.
Mr. Buyer. I think we could probably clear this up really
quick for the gentleman from Florida.
Obviously we know that there are specific strains of
anthrax. We know what type of strains of anthrax have been
weaponized by certain countries in the world. Once you culture
this particular anthrax, we will know whether or not this was
an anthrax of a strain that was from a weaponized form from
another country. So at some point in time, an answer is going
to be made there, I want to share with the gentleman from
Florida.
Now, obviously, I don't want to ask you this question,
because you can't answer this question in a public forum. I see
a nod by the doctor in the back. It's correct, isn't it?
Mr. Lillibridge. Well, I can tell you what I know as of
this time, and let me just review the pathway.
As this--as more information becomes known--and they're
double-checking and looking at different ways to do strain
identification, all that information is not back yet, so it
would be presumptive or premature to make prognostications,
whether it came from a foreign state or whether it was a
bioterrorism attack.
We do know the following: It wasn't large scale; the
sensitivity looks relatively modest and not weaponized; it was
a sensitive strain; and indeed there will be tests to look at
different types of patterns, to locate it geographically and
perhaps to locate it to somebody else's library or to look for
a specific lab.
If that information were available today, I would tell you.
I do not have that information, because----
Mr. Deutsch. I will tell you, CNN is reporting it came from
a lab in Iowa, not from an overseas lab----
Mr. Greenwood. The time belongs to the gentleman from
Indiana.
Mr. Lillibridge. I would have to have our lab people talk
with the CNN lab people.
Mr. Buyer. The only reason I asked the question for
clarification is that, because these strains are identifiable,
there will be an opportunity to sort of track this thing down.
I only brought this up because the gentleman is harping on this
question between--the difference between criminality or
bioterrorism, and we do have an ability to identify.
I want to go to this question to you: With regard to the
GAO report on bioterrorism, it noted, under current law that
Federal grant monies cannot go to private entities, such as
hospitals, for bioterrorism preparedness activities. Do we need
to change that, or do you recommend we change that? What is
your counsel to us?
Mr. Lillibridge. Well, I would recommend the following,
that--and the Secretary has asked for resources to begin
hospital preparedness activities that would require some things
that would--may require resources or structural changes in
hospitals that would include enhancing medical capacity,
developing alternative care, dealing with a wider range of
infected patients.
And I think--in summary, that answer--I think we ought to
look, work with you on that. That may be part of the solution.
Mr. Buyer. Okay. I yield the balance of my time to the
gentleman from North Carolina.
Mr. Burr. Doctor, let me go to the heart of what you said.
The Secretary has asked for additional resources. Everybody has
asked for additional resources.
You know, America is in a position where they want to
respond. One of the functions, if not the primary function on
this committee right now, is to determine, what do we need to
fix prior to injecting new funds?
We've alluded to a lot of numbers, $1.7 billion for fiscal
year 2001; and I think, another place, we estimated that some
small portion of that actually made its way to response and
preparation and equipment and training.
I think it's extremely easy for Congress to throw more
money in it and for us to turn around a year, 2 years, 5 years
down the road, and for Dr. Stringer to tell us that the threat
is every bit as great and his response is every bit as
challenging and for everybody that was on the first panel to
say, look at all the things that are broken.
Do we have somebody who is going to come with concrete
suggestions as to what we need to fix legislatively, or what
can be fixed rulemaking-wise that changes the outlook of our
capability to respond effectively?
Mr. Lillibridge. Yes, sir.
Let me mention that we've mentioned some of the things--
some of the targets have been brought up today by different
panels and myself about key elements of the public health
infrastructure. We've talked about some of the hospital surge
capacity.
But let me turn then to something--the legislative issues
that are high on our agenda that--I understand our department
is working with this committee on several things. But high on
our agenda includes food safety, things that we might have to
do to improve our ability to respond. We're looking at issues
around the select agent legislation that's been out there and
are looking at a way to enforce certain high-priority agents
that have come to light that are of public health importance,
and a way to expedite--I think somebody mentioned earlier the
FDA process of looking at key pharmaceuticals or vaccines that
may need to be----
Mr. Burr. And I think all of us would agree with all the
points you just made.
Will you be coming to us with the suggestions as to how you
want them changed, whether you can do them internally, whether
we need to do them legislatively?
Mr. Lillibridge. We will be coming----
Mr. Burr. The hair on the back of my neck goes up when you
talk about changes at the Food and Drug Administration, because
I don't think you understand how big an undertaking that is.
Mr. Lillibridge. Sir, we agree it's a big undertaking, but
we will be coming to work with you on that. Secretary Thompson
made that clear at his last hearing, and it's my----
Mr. Burr. And trust me, I have more confidence in his
capabilities than I do in practically everybody else's in
Washington. But I also know that the task that he has before
him is one of the biggest tasks he has ever faced, and I don't
think he understands--and I don't think we understand, by the
way--everything that we're all going to have to do.
I just know that the answers and the questions that were
raised by the first panel, the warnings that were given to us
by terrorism committees that were chartered by this Congress
and prior Congresses, the reports to the President, the
warnings that were out there--we knew this existed. This threat
was there, and we did a poor job at preparing ourselves for
what happened in Florida and potentially what could happen
elsewhere. We all need to get on the same page.
A last question, and then the chairman can go where he
wants to.
Mr. Greenwood. I thank the gentleman.
Mr. Burr. That was a compliment.
To all three of you, should Governor Ridge have the budget
authority over all bioterrorism dollars that are placed at
these different agencies within the Federal Government?
Mr. Lillibridge. Sir, I don't know if our department has
made a statement on that or has an opinion.
Mr. Burr. This is a tremendous opportunity for you.
Mr. Lillibridge. And so, at risk of getting out in front of
our department on this issue, I would say that they have to
have some capability to weigh in on budget issues, whether
that's budget authority or whether that's participating in
budget decisions or participating in planning, whereby things
are implemented as a result of the budget.
Mr. Burr. Would you agree that if there's over a billion
dollars of appropriated dollars out there--and I guess $1.7 is
this year's number, and $300 million actually makes it into the
stream of purchasing equipment, training, people to respond--
that that percentage is pitiful?
Mr. Lillibridge. Well, I'll agree that the preparedness
effort that has been lined out should include a general
consideration for equipment, specialized personnel, hospital,
public health and all the things we mentioned.
Mr. Burr. Mr. Baughman?
Mr. Baughman. Our director met with Governor Ridge last
Friday. We're in the process--we're in ongoing dialog with
Governor Ridge's office as to what he needs to succeed. I can't
get into the particulars right now. The director, I'm sure, has
his own ideas and I think will be forthcoming with those.
But certainly I think we would agree that as far as Federal
programs, dealing with first responder training, there does
need to be a central point of coordination, and I think we
realized that when we set up 2 months ago our Office of
National Preparedness.
Ms. Heinrich. I would just say that at this point in time
OMB does try to do some coordination, or at least
identification of dollars that are spent in terrorism, overall.
They have not--they have not tried to coordinate or actually
reduce duplication, but only to identify the dollars.
From GAO's perspective, I think, again we feel that there
are some areas that overlap in terms of jurisdiction, and,
therefore, accountability isn't as clear as it could be or
should be.
Mr. Burr. You're being a lot more generous than the GAO
report as it relates to the duplication, aren't you?
Ms. Heinrich. Well, I'm----
Mr. Burr. The report was much more specific, that we just
don't have any coordination of programs, and in most cases,
can't find where that money went, can we?
Ms. Heinrich. We had a difficult time really identifying
all the dollars; and as we said, we used the reports from the
various agencies and departments. They had difficulty, because
for bioterrorism, there isn't a particular line item, and they
also used different--different forums. Some appropriations,
some dollars, were expenditures.
Mr. Burr. Let me read you what the report said: ``over 40
Federal departments and agencies have some role in combating
terrorism''----
Mr. Greenwood. I just would like to inform the gentleman
that the time on the floor for voting has expired, so----
Mr. Burr. We had better leave.
Mr. Greenwood. We had better leave.
Mr. Burr. [continuing] ``and coordinating their activities
is a significant challenge. We identified over 20 departments
and agencies as having a role in preparing for or responding to
the public health and medical consequences of a bioterrorist
attack.'' I'll stop there.
I'll only make the statement that, you know, I would feel
much more comfortable if we had one agency doing it, and I
think that is the decision. Are we going to have one office
coordinating it? We may still have 40, but are we going to have
somebody that is responsible versus 40 different entities?
I thank the chairman for his time.
Mr. Greenwood. The Chair thanks the panelists for your
testimony and for your help and excuses the abrupt conclusion
of our hearing, but we've got to go see if we can put our votes
in the record.
[Whereupon, at 1:40 p.m., the subcommittee was adjourned.]
[Aditional materal submitted for the record follows:]
Prepared Statement of Deborah J. Daniels, Assistant Attorney General,
Office of Justice Programs
Chairman Greenwood, Mr. Deutsch, and Members of the Subcommittee: I
am pleased to testify on behalf of the Office for Domestic Preparedness
(ODP) within the Office of Justice Programs. When others from OJP have
testified before Congress previously about domestic preparedness, they
were able to talk about our programs and preparations in the context of
the threat of a potential catastrophic terrorist attack. Sadly, we no
longer have the luxury of time on our side and the attack is no longer
merely potential.
The Office for Domestic Preparedness (formerly the Office for State
and Local Domestic Preparedness Support) was created within the Office
of Justice Programs in1998 when Congress authorized the Attorney
General to assist state and local public safety personnel in acquiring
the specialized training and equipment necessary to safely respond to
and manage domestic terrorism incidents, particularly those involving
weapons of mass destruction (WMD). Congress recognized that these state
and local personnel are typically first on the scene of any emergency,
would likely be the first to respond in the event of a terrorist
attack, and need to be as well-prepared and well-equipped as possible
for these potentially catastrophic incidents. As was demonstrated so
dramatically and tragically on September 11, Congress was right. New
York City Police, Fire and Emergency Services personnel were first on
the scene at the World Trade Center. Arlington County, and other
Virginia, Maryland and District of Columbia emergency personnel were
immediately on the scene at the Pentagon. Local personnel were first at
the Pennsylvania crash site.
Over the past three years, ODP has worked to provide coordinated
training, equipment acquisition, technical assistance, and support for
national, state, and local exercises to fulfill its mission of
developing and implementing a national program to enhance the capacity
of state and local agencies to respond to domestic terrorism incidents.
OJP and ODP remain committed to reaching as many first responders--
firefighters, emergency medical services, emergency management agencies
and law enforcement--as well as public officials in as many communities
as possible to prepare them for the wide range of potential threats.
ODP's activities are concentrated in the areas of training and
technical assistance, equipment, planning, and exercises.
Since 1998, ODP has provided training to over 77,000 emergency
responders in 1,355 jurisdictions in all 50 states and the District of
Columbia, and has completed over 2,000 deliveries of technical
assistance to state and local response agencies.
ODP's Training and Technical Assistance Program provides direct
training and technical assistance to state and local jurisdictions to
enhance their capacity and preparedness to respond to domestic
incidents. Training is based on National Fire Protection Association
standards, and provides emergency responders with a comprehensive
curriculum in the areas of WMD awareness, technician, operations, and
terrorist incident command. All courses go through a rigorous pilot and
review process where federal, state, and local subject matter experts
examine the course materials to ensure accuracy and compliance with
accepted policies and procedures. Courses are brought directly to
jurisdictions and taught by an ODP mobile training team or are
conducted at a specialized facility, such as OJP's Center for Domestic
Preparedness in Anniston, Alabama. Internet, video and satellite
broadcast training courses round out the ODP curriculum.
Last year, ODP assumed responsibility for the Nunn-Lugar-Domenici
(NLD) Training Program. The NLD Program identified the nation's 120
largest cities to receive training, exercises and equipment monies to
enhance their capacity to respond to WMD incidents. Prior to the
program's transfer from the Department of Defense, 68 of the 120 cities
received all elements of the NLD Program, and 37 others received only
the training component. ODP will complete delivery of the program to
these 37 cities, and deliver all program elements to the remaining 15
designated cities. As part of the NLD Program, these 52 cities will
receive a biological weapons tabletop exercise, and the 15 cities will
also receive briefings on the U.S. Public Health's Metropolitan Medical
Response System.
The National Domestic Preparedness Consortium (NDPC) is the
principal vehicle through which ODP identifies, develops, tests and
delivers training to state and local emergency responders. The NDPC
membership includes OJP's Center for Domestic Preparedness, the New
Mexico Institute of Mining and Technology, Louisiana State University,
Texas A&M University, and the Department of Energy's Nevada Test Site.
Each consortium member brings a unique set of assets to the domestic
preparedness program. ODP also utilizes the capabilities of a number of
specialized institutions in the design and delivery of its training
programs. These include private contractors, other federal and state
agencies, the National Terrorism Preparedness Institute at St.
Petersburg Junior College, the U.S. Army's Pine Bluff Arsenal, the
International Association of Fire Fighters, and the National Sheriffs'
Association.
ODP provides targeted technical assistance to state and local
jurisdictions to enhance their ability to develop, plan, and implement
a program for WMD preparedness. Specifically, ODP provides assistance
in areas such as the development of response plans, exercise scenario
development and evaluation, conducting of risk, vulnerability,
capability and needs assessments, and development of the states' Three-
Year Domestic Preparedness Strategies.
Working with Congress, ODP has implemented a program in all 50
states, the District of Columbia, and the five U.S. territories to
develop comprehensive Three-Year Domestic Preparedness Strategies.
These strategies are based on integrated threat, risk, and public
health assessments, conducted at the local level, which will identify
the specific level of response capability necessary for a jurisdiction
to respond effectively to a WMD terrorist incident. Once these plans
are assembled and analyzed, they will present a comprehensive picture
of equipment, training, exercise and technical assistance needs across
the nation. In addition, they will identify federal, state and local
resources within each state that could be utilized in the event of an
attack. ODP anticipates receiving the majority of these strategies by
December 15, 2001. Following their submission, ODP will work directly
with each state and territory to develop and implement assistance
tailored to the specific needs identified in the plans. Last month, the
Attorney General wrote to the governors stressing the urgency of
completing these assessments, and has directed ODP to place the highest
priority on analyzing and processing these strategies and assisting
states in meeting identified needs as quickly as possible.
To date, only one state, Utah, which has heightened needs and
awareness in preparation for the 2002 Winter Olympics, has completed
its plan and received its allocated equipment funds. ODP has approved
the plans for Rhode Island, South Carolina and Hawaii, and these states
are now eligible to draw down funds. Florida and Pennsylvania have
recently submitted their plans, which are currently being reviewed.
States received a total of $54 million in initial planning and
equipment funds from FY1999 under this program and are scheduled to
receive an additional $145 million in aggregated FY2000 and 2001
equipment funds as plans are completed. Each state will, in turn,
distribute funds to jurisdictions within the state, as well as to state
agencies, for use in implementing the state's strategy. Currently,
equipment funding is limited to personal protection (such as protective
suits), chemical and biological detection devices, chemical and
biological decontamination equipment, and communications equipment.
Under the FY1998 and FY1999 County and Municipal Agency Equipment
Program, large local jurisdictions received approximately $43 million
in equipment funding. From 1998 through 2001, OJP has provided a total
of $242 million in equipment grants for 157 local jurisdictions and the
50 states, the District of Columbia and the five U.S. territories.
Experience and data show that exercises are a practical and
efficient way to prepare for crises. They test crisis resistance,
identify procedural difficulties, and provide a plan for corrective
actions to improve crisis and consequence management response
capabilities without the penalties that might be incurred in a real
crisis. Exercises also provide a unique learning opportunity to
synchronize and integrate cross-functional and intergovernmental crisis
and consequence management response. ODP's National Exercise and State
and Local Domestic Preparedness Exercise Programs seek to build on the
office's training, technical assistance, and equipment program
activities.
The State and Local Domestic Preparedness Exercise Program aids
states and local jurisdictions in advancing domestic preparedness
through evaluation of the authorities, plans, policies, procedures,
protocols, and response resources for WMD crisis and consequence
management. The program provides funding and technical assistance to
states and local jurisdictions to support local and regional
interagency exercise efforts. ODP also provides guidance and uniformity
in design, development, conduct, and evaluation of domestic
preparedness exercises and related activities. A number of state and
local agencies have requested exercise assistance in bioterrorism
response as part of this program.
In May 2000, at the direction of the Congress, ODP conducted the
TOPOFF (Top Officials) exercise, the largest federal, state and local
exercise of its kind, involving separate locations and a multitude of
federal, state and local agencies. TOPOFF simulated simultaneous
chemical and biological attacks around the country and provided
valuable lessons for the nation's emergency response communities. The
bioterrorism scenario conducted in Denver, Colorado, involved state and
local health, fire and HAZMAT agencies, as well as the CDC, the U.S.
Public Health Service and other federal agencies.
ODP has begun planning for the congressionally-mandated TOPOFF 2
exercise, which will be conducted in Spring 2003. TOPOFF 2 will
incorporate lessons learned from the first exercise into its planning
and design. TOPOFF 2 will be preceded by a series of preparatory WMD
seminars and tabletop exercises crafted to explore relevant issues.
In addition to its National Exercise and State and Local Domestic
Preparedness Exercise Programs, ODP, in collaboration with the
Department of Energy, is establishing the Center for Exercise
Excellence at the Nevada Test Site. The center will deliver a WMD
Exercise Training Program for the nation's emergency response community
to ensure WMD exercise operational consistency nationwide. During
FY2001, the National Guard Bureau agreed to support the center with
funding to exercise its Civil Support Teams in conjunction with state
and local emergency responders.
All ODP programs and policy development include consideration of
and response to potential bioterrorism, in addition to the full range
of weapons of mass destruction.
In keeping with its congressionally-mandated mission, ODP has
primarily focused program efforts on meeting the needs of traditional
first responders, which include fire, HAZMAT, and law enforcement
personnel, and has relied on the medical and public health communities
to train their traditional constituencies, such as emergency medical
technicians and hospital personnel. However, ODP has also actively
worked with and supported other federal agencies in their efforts to
provide this training and assistance.
ODP initiated an effort to bring together all of the federal-level
training representatives to formalize the coordination processes
already in effect and to capitalize on the diverse expertise and
specialized training delivered by the respective federal agencies. The
resulting Training Resources and Data Exchange (TRADE) working group
includes representatives from the United States Fire Administration's
National Fire Academy, the Federal Bureau of Investigation, the Federal
Emergency Management Agency, the Environmental Protection Agency, the
Department of Energy, the Department of Health and Human Services, and
the Centers for Disease Control and Prevention. The TRADE group has
identified and initiated work on several immediate tasks, including the
development of agreed-upon learning objectives by discipline and
competency level for federal training efforts, a joint course
development and review process, joint curriculum assessment and review,
and coordination of training delivery resources in accordance with
state strategies.
Since 1998, ODP and the U.S. Public Health Service (PHS) have been
engaged in active coordination of their domestic preparedness efforts
and assistance programs for state and local emergency responders. In
FY2001, several joint program efforts were initiated: a cooperative
effort to integrate implementation of the Nunn-Lugar-Domenici Domestic
Preparedness Program (NLD DP) and the Public Health Service's
Metropolitan Medical Response System (MMRS) program; review and
revision of the hospital training component of the NLD DP Program; a
joint project to enhance awareness of MMRS initiative and the National
Disaster Medical System, which are critical to the effective delivery
of health and medical consequence management resources; and a
partnership effort among ODP, PHS, and the National Domestic
Preparedness Consortium to assist management and oversight of PHS'
Noble Training Center in Anniston, Alabama, and to provide for joint
development, review and delivery of WMD courses for medical personnel.
In October 2000, ODP held a formal program coordination meeting
with the CDC. This meeting laid the foundation for cooperation between
these agencies on a multitude of issues, and has resulted in continued
follow-up communications and meetings, involvement of CDC subject
matter experts in ODP course development and review, and better
coordination of the two agency's programs.
In the future, ODP will continue to actively coordinate its
programs with other federal agencies to ensure that the highest quality
of training and technical assistance is provided to the broad spectrum
of the nation's emergency response community while also making certain
duplication of federal resources in these areas does not occur.
These joint endeavors will present a unified federal effort in the
eyes of the public safety community and greatly enhance federal
domestic preparedness efforts and the capacity of the nation as a whole
to respond safely and effectively to incidents of terrorism involving
WMD, including biological agents.
Once again, thank you for the opportunity to describe OJP efforts
in this vitally important area.
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